National Assembly for Wales

Health and Social Care Committee

Inquiry into new psychoactive substances (“legal highs”)

Evidence from Public Health Wales – LH 17

Submission to the National Assembly for Wales’ Health and Social Care Committee Inquiry into New Psychoactive Substances
Author: Josie Smith, National Lead for Substance Misuse
Date: 20 October 2014	Version: 1
Publication/ Distribution: · Public (Internet)
Review Date: N/A
Purpose and Summary of Document: This document is the Public Health Wales submission to the National Assembly for Wales’ Health and Social Care Committee Inquiry into New Psychoactive Substances.

1 Introduction and summary

	We welcome the opportunity to give evidence to the Assembly Committee Inquiry into New Psychoactive Substances. Information from a number of sources in the UK, including Wales, suggests that new psychoactive substance (NPS) use is a growing public health issue.  Users of NPS are at risk of a number of serious adverse effects on health. Principally these are the direct physical, psychological and behavioural effects from the drugs themselves.  These harms reflect only the short term consequences of NPS use. It is not yet possible to predict the extent of future harm.  The approach being taken in Wales to harm reduction is the right one. It is multi disciplinary and focused on health. We wish to see it developed in three ways: Development of clear pathways for care and engagement – from early or initial contact with health and social services (for example ambulance, police, primary care, youth services and  clinical practitioners) to specialist substance misuse services (from low threshold and outreach community work through to treatment). Adaptation of specialist substance misuse services - to meet the needs of current drug and poly-drug users including NPS users, particularly those using synthetic cannabinoid receptor agonists (SCRAs) and stimulants.  Services are currently focussed mainly on more traditional drug use such as heroin but should provide support and treatment for all those experiencing problematic substance misuse. Increase expertise – there is a high level of knowledge and expertise in relation to NPS in some organisations in Wales. However we need to raise awareness in, and educate and train, professionals working with those who may use, or who consider using, NPS, as well as the wider population.
2	Raising awareness of the harms associated with the use of legal highs among the public and those working in the relevant public services Use of the term ‘legal highs’ is unhelpful. It implies that these substances are legal and as such ‘safe’.  Very often the substances are not legal or safe. Therefore, we prefer to use the term new psychoactive substances (NPS)[1]. There is no single way to raise awareness for people who use NPS or who work with people using NPS. This is because there are different types of NPS users. To communicate effectively we need to understand the attitudes, knowledge and behaviours of people using NPS.  There are three definable groups:
	Recreational and club/party goers This group mainly comprises adolescents and young adults who often use NPS on a recreational basis at weekends, festivals etc. They may become problematic or poly-drug users.  They tend to binge use NPS, often using a range of substances, over a number of days. As such they are regularly at risk of acute toxicity and are vulnerable to other harms related to intoxication including risky sex and transmission of sexually transmitted infections.  As they may have developed no or limited tolerance to substances, they are more vulnerable to high strength / high dose substances, including synthetic cannabinoids.  Often NPS are sold as a single named or branded product, such as an Ecstasy (MDMA) tablet, but the actual tablet may contain an entirely different chemical/s e.g. Para-methoxyamphetamine (PMA).  In 2012 a total of 17 deaths in the UK resulted specifically from PMA consumption which was purchased as Ecstasy.  Club/party goers will buy substances regularly, choosing substances for effect as well as perceived ‘legal status’.  Based on this understanding, peer reports of adverse effects and word of mouth appear to be more effective in initiating behavioural change than clinical information. Peer communication can be supported by: · The availability of information to ensure safer use of NPS in places where NPS are used (festivals, clubs etc) · The sharing of information on NPS using social and traditional media · Social marketing methods · The promotion of services such as WEDINOS (see Appendix 1) which provide objective analysis and profiling of substances “Psychonauts” ”Psychonauts’ actively experiment with mind altering chemicals and are keen to try entirely new substances. They often take exact measurements and keep records of experiences. They are highly active on the internet and social media and engage with online forum discussion regarding specific dose related experiences. On this basis, the best ways to communicate with ‘psychonauts’ are to: · Use the internet and social media e.g. WEDINOS minimises potential harm, particularly in respect of highly toxic substances, by identifying the self-reported effects from other users of entirely new substances.  · Engage them via online forums and discussion · Poly-drug users · Poly-drug users present the greatest public health challenge.   · They are people with a history of taking drugs including controlled substances such as heroin, cocaine, amphetamine and cannabis. They and may add NPS to the repertoire of drugs they use.  There is clear evidence of increased blood borne virus (BBV) transmission in the UK and Wales as a consequence of NPS use.   Increases have been recorded for HIV and Sexually Transmitted Infection (STI) transmission amongst ‘Chem-sex’ party goers where NPS and other drugs are taken over a prolonged weekend period. The parties are usually sex parties primarily between men who have sex with men.   The lack of knowledge of the content and strength of NPS may result in increased vulnerability to all users due to a lack of inhibition, unexpected effects and duration of effects.  The adoption of specific NPS alongside traditional controlled drugs has resulted in an increase in risk behaviour in relation to frequency of injecting from an average of three injections per day to upwards of 15-20 injections per day commonly reported. Over the past few years, mephedrone and other NPS use including other cathinones and synthetic cannabinoids have become more established amongst poly-drug users. Whilst work to estimate prevalence is ongoing, self-reported use amongst injecting drug users alone has more than doubled.    NPS use amongst poly-drug users is not restricted to those injecting.  The majority of NPS users do not inject. As such they are further removed from contact with the substance misuse services which provide sterile injecting equipment as well as harm reduction advice.  Taking the above into account, the most effective ways to raise awareness with, and to educate poly-drug users are to: Adapt specialist substance misuse services so they meet the needs of all substance users including young people and poly-drug users.  This will additionally require increased expertise amongst staff.  Target communications, proactive outreach and engagement via realigned substance misuse services
3	The capacity of local services across Wales to raise awareness of – and deal with the impact of – the harms associated with the use of legal highs.
	The primary issue relates to the range of services offered locally, rather than their capacity. Local services across Wales are well placed to raise awareness of the harms associated with the use of NPS using knowledge of local trends. However, existing substance misuse services tend to address the use of more traditional drugs. As such, they may suffer from the perception by NPS, and more broadly, stimulant and cannabis/SCRA users, that they have nothing to offer.  Therefore, NPS users may fail to engage with these services.  Adapting services, based upon evidence of the needs of the substance using population, would address this along with increasing levels of expertise amongst the staff.  In addition, the development of a clear pathway to services would support engagement and reduce harms. If they were adapted they could be engaging regularly with NPS users in the community.  Local knowledge along with increased expertise among staff should facilitate awareness raising amongst risk populations. Local services need to be supported by national information services such as DAN24/7 and WEDINOS. They can provide a unified and evidence based approach to ensure clear and relevant messages are tailored to the specific populations using NPS.
	4 The effectiveness of data collection and reporting on the use of legal highs in Wales and their effects
	There are a number of robust national data collection systems in place in Wales relating to the use of NPS, and a number of others in development: In response to the threat posed by NPS in Wales, Public Health Wales, with the support of the Welsh Government, developed the WEDINOS project in 2013. This enables data collection on the types of NPS being used in Wales, and on the harms experienced as reported by those using them. There are 71 contributing services across Wales including the four police forces in Wales, substance misuse services, housing and homelessness, youth services, education and emergency departments along with samples from NPS users. A quarterly report is produced and published online for all interested parties.  In addition, the website www.wedinos.org provides information from the National Poisons Information Service (NPIS) on toxicity and harms.  Whilst the system does not provide a prevalence estimate of all those using NPS, it does provide trend analysis of NPS in circulation and being used, by geographic area of residence. It also identifies the harms associated with the use of particular substances.  In addition, Public Health Wales is undertaking a prevalence estimate of problematic drug use that will include opioids, cocaine / crack cocaine and amphetamines and amphetamine-like substances (including NPS cathinones) from 2011/12 and up to 2020/21.  Previous prevalence estimates have focused on heroin and cocaine/crack use. This project is in development and going through ethical approval processes but should be in place for April 2015. · The Welsh National Database for Substance Misuse (WNDSM) allows for the indication of specific NPS use on referral to treatment services. However, secondary and tertiary drugs used are not well recorded and, as such, the extent of NPS use may be under reported at present.  NPS training for staff, as indicated above, may improve this. · The Harm Reduction Database Wales – NSP module - provides high quality data on all those injecting drugs, including named NPS, who are in contact with needle and syringe programmes across Wales.  Data from the last three years show a near fourfold increase in the number of people injecting mephedrone alongside other drugs (primarily heroin). · The Crime Survey for England and Wales relies on self reporting use of substances including some NPS. It does not distinguish between certain substances e.g. cannabis and synthetic cannabinoids. However, the majority of NPS users will not have contact with specialist treatment and related services. This represents a challenge in identifying the scale of NPS use and the nature of harms associated with their use.  Local needs assessments involving community field and outreach work, particularly amongst young people, should be undertaken regularly as part of the service adaptation to ensure that local knowledge regarding the scale and nature of NPS use is understood and fed into national data collection systems. In terms of recording clinical health harms, hospital admissions data is not able at present to record the harms (e.g. acute poisoning) by specific named NPS. This is because the patient often does not know what they have consumed and because coding for individual NPS is not possible.  This challenge could be addressed if data was collected when people attend emergency and unscheduled care services. If people were asked two questions - “Have you consumed any drugs other than your own prescribed medication today” and “Have you consumed any alcohol today” - the system could ‘flag’ patient records for further analysis in relation to substance misuse (drugs and alcohol) and related harms and outcomes.
	5 The possible legislative approaches to tackling the issue of legal highs, at both Welsh Government and UK Government level
	The UK Government has powers for the legislation of NPS.  There are a number of legislative approaches used within the UK at present. These include the use of Temporary Control Drug Orders (TCDOs), Trading Standards legislation and classification of NPS under the Misuse of Drugs Act (1971) and the Misuse of Drugs Regulations (2001).  Legislation is informed by the Advisory Council on the Misuse of Drugs (ACMD) and other scientific bodies.  Public Health Wales has supported the work of the ACMD and the European Early Warning System (European Monitoring Centre for Drugs and Drug Addiction) with findings from WEDINOS evidencing the harms related to specific NPS. There is a great deal of confusion in the population on the legal status of many drugs and the ongoing classification of new substances and existing prescription medication.  Within NPS user populations, the use of TCDOs and other legislation appears to have been less than effective.  There is concern amongst those working in the field that, whilst some extremely toxic substances should be controlled, the existing control structures and processes may lead individuals to experiment with new uncontrolled substances of which very little is known. This thereby potentially increases the possible acute and chronic health harms.    A recent example involved the NPS stimulants 5 and 6-APB.  Within five months of the implementation of a Temporary Class Drug Order (TCDO) being placed on the stimulants (phenethylamines) 5- and 6-APB, at least two new ‘legal’ derivatives had been notified.  These drugs mimic the effects of ecstasy and amphetamines.  5 and 6-APB have since been controlled as Class B drugs following scientific evidence of hospital admissions and a small number of deaths. Wedinos helps manage this issue by providing a system that identifies new substances and the actual and potential future harms associated with use. We believe that a harm reduction and health-centred approach is likely to be more effective than one based on criminal justice. If Wales were to adopt legislation prescribing health in all policies, this would be strengthened. We believe this should be achieved through the Wellbeing of Future Generations Bill with health included in its common aim.
6	How effectively a partnership approach to tackling the issue of legal highs in Wales is being coordinated, both within Wales and between the Welsh and UK Governments
	There are strong and well-established multidisciplinary partnerships within Wales to address the harms associated with NPS. These include the Substance Misuse Area Planning Boards and associated harm reduction groups.  Through the suggested development of multi-disciplinary pathways, adaption of services and increased expertise, effective partnership working should be further strengthened. At a national level, WEDINOS is an example of collaborative working with partners including criminal justice (police forces, probation and prison services), health (substance misuse, secondary care and ambulance/emergency departments), housing, education, youth services and local authorities. The partnership approach is essential to effective ongoing project management and development.  Wales and the Welsh Government is represented on all relevant UK-wide NPS boards and is an effective partner within the UK.
7	International evidence on approaches taken to legal highs in other countries
	NPS represent a global challenge to those working in substance misuse, particularly in relation to reducing harms.  Across Europe the majority of countries have adopted legislative approaches to a greater or lesser extent alongside prevention, awareness raising and harm reduction interventions.  The most effective approaches, from a public health perspective, are those that adopt a less punitive and more pragmatic approach, supporting those who are using or considering use of NPS.  The emphasis needs to be on the provision of accurate, timely and credible information, proactive engagement through relevant media, psychosocial interventions and low threshold early engagement with specialist substance misuse services.  Within Wales WEDINOS adopts such an approach and as such is attracting international attention in the form of collaboration requests and a direct contribution to the European Monitoring Centre for Drugs and Drug addiction.

Appendix 1 – WEDINOS (Welsh Emerging Drugs and Identification of Novel Substances) – project outline

In response to the changes in drug use trends, Public Health Wales, in conjunction with Cardiff & Vale Toxicology Laboratory, Llandough, and Cardiff University Pharmacology developed the WEDINOS project (Welsh Emerging Drugs and Identification of Novel Substances).  It is supported by the Welsh Government.

This national project provides a framework for the collection and testing of samples of new psychoactive substances and combinations of drugs, along with information regarding the symptoms users experienced, both expected and unexpected. 

Collation of these findings, along with identification of the chemical structure of the samples, will facilitate dissemination of pragmatic evidence based harm reduction information for those using new psychoactive drugs or considering use.  All relevant information will be available via the website: www.wedinos.org

A series of WEDINOS launch events were completed across Wales in September and October 2013 for all those using, or working with those using, New Psychoactive Substances. These include substance misuse service providers, the police, ambulance service, primary and secondary health care, youth and criminal justice leads, education and housing.  Further events will be arranged focussing on developing mechanisms whereby other relevant health care providers, including pharmacy and emergency departments, may contribute to the WEDINOS project. 

The WEDINOS project contributes to the wider UK and European Early Warning Systems in place to identify and monitor the changing trends in drug use. 

---

[1] The term “new psychoactive substances” has been legally defined by the European Union as a new narcotic or psychotropic drug, in pure form or in preparation, that is not scheduled under the Single Convention on Narcotic Drugs of 1961 or the Convention on Psychotropic Substances of 1971, but which may pose a public health threat comparable to that posed by substances listed in those conventions. (Council of the European Union decision 2005/387/JHA)