Written evidence submitted by
Amira Guirguis MPharm, MRPharmS and Christine Heading PhD, FRPharmS.

Both are pharmacists associated with North West London. AG is currently involved in research work focusing on chemical identification of new psychoactive products; CH has worked academically in the field of substance misuse over many years.

Summary

This brief submission highlights four features of the misuse of psychoactive substances. No specific recommendation is made to the committee, since the purpose of the briefing is to inform discussion. 

From the many perspectives on the topic, the features have been selected because they have special relevance to harm reduction for established users. Each feature is described with supporting evidence drawn from published literature.

The following points are highlighted:

• Users of NPS are not a homogenous group
• Patterns of use of substances can be simple or sophisticated
• Reported administration routes include mouth, nose and injection.
• Harm reduction strategies (such as needle exchange) have a place in reducing the overall damage caused by NPS misuse.

1. Introduction and purpose of this submission

The text below identifies some issues relevant to usage patterns of individuals using psychoactive substances that in turn must influence strategies for harm reduction and treatment. The purpose of so doing is to inform the discussions of the committee, by highlighting some of the less-frequently discussed issues. Conversations with colleagues and other relevant professionals have suggested to us that these issues need to be more widely recognised than they seem to be.

The term new psychoactive product (NSP) is used to include products containing active ingredients that may be newly created molecules or be substances that have only become misused over recent years.

2. Scope and Information sources

The identified features are expanded below, drawing on information from UK sources, the European Monitoring Centre for Drugs and Drug Addiction and peer reviewed literature. The EMCDDA collates information from across Europe on usage patterns and harm associated with drug misuse including NPS. Trends, substances in use and usage patterns in other European countries can differ from those currently seen in the UK, but this collated information helps to provide an overview of the problem. Overall, the information available regarding NPS is patchy, incomplete and fragmented, and the examples cited here are merely illustrative. Additionally, it should be emphasised that some usage information has been drawn from user-reports and reliability is therefore low.

3. Highlighted features

3.1 User characteristics

It is useful to remember that users of NSP are as diverse as users of traditional substances of misuse. Reports have specifically identified user groups including students, lesbians, gay bisexual and transgender (LGBT), heroin users, all age ranges, clubbers, homeless population, prisoners, as well as users of substance misuse and the ‘needle and syringe exchange schemes’. The European Drug Report 20151 describes users as being “as diverse as school students, party-goers, psychonauts, prisoners and injecting drug users”.

3.2 Patterns of use

Linked to the diversity of users, patterns of use can range from using a single product on a solitary or occasional basis, to sophisticated use of cocktails of products with a specific purpose in mind. NPS products sold may contain a single or multiple active ingredients. In 2014, the Home Office Forensic Early Warning System (FEWS) reported that of samples analysed that contained NPS, about 91% were identified as mixtures of either two or three different active components. The proportion of controlled drugs in the products varied with source2. Post mortem analysis not infrequently reveals that more than one psychoactive substance has been used3. 

Usage patterns are believed to include deliberate use of combinations of drugs with stimulant, hallucinogenic or sedative properties4. As early as 2011/12, the crime survey for England and Wales (CSEW) reported that ketamine users generally have high rates of simultaneous poly-substance use5.

Some NPS are thought to be used as cheaper or more available alternatives for traditional addictive drugs such as heroin for example6 but, on the basis of their known pharmacology and evidence of usage patterns, several NPS are themselves thought to be addictive. Examples include ethylphenidate7, methoxetamine8 and cathinones1.

3.3 Routes and modes of administration

As with traditional substances of misuse, many modes of administration are used. The UK Project NEPTUNE has reported that NPS are usually snorted, smoked, injected, ingested, ingested via bombing (placed in paper, made like a ball and ingested) or dissolved in alcohol9. The fact that several NPS are used by injection, introduces the additional problems of harm such as infection, necrosis, spread of disease etc. Specific examples of injected products include e.g. cathinones including mephedrone6, methoxetamine10 and 25I-NBOMe11.

3.4 Harm reduction

Injection of traditional substances of misuse has long been known to be associated with harm beyond that of the substance itself. Strategies such as needle and syringe exchange facilities are proven to reduce harm. The European Drug Report 20151 identifies “needle and syringe exchange programmes based in low-threshold services” as an important response to the challenges posed by NPS.

Harm reduction via provision of sexual health services has also been highlighted by the EMCDDA1, particularly in the context of hepatitis and HIV transmission. As well as the established need of for infection control amongst those injecting substances, ketamine for example, has been linked to pronounced sexual health risks12. The provision of sexual health services and advice present an opportunity for harm reduction.

4. Conclusion

By stressing the diversity amongst users and of products used, along with the overlap with issues associated with misuse of more traditional substances, the above may be of value to the Committee.

References

1 http://www.emcdda.europa.eu/edr2015

2 Home Office. (2014). Annual Report on the Home Office Forensic Early Warning System (FEWS). A system to identify New Psychoactive Substances in the UK Forensic Early Warning System. UK: FEWS.

3 http://www.emcdda.europa.eu/publications/risk-assessment/methoxetamine

4 http://www.emcdda.europa.eu/publications/risk-assessment/MDPV

5 Home Office, Crime survey England and Wales 2011. 2012.

6 http://www.emcdda.europa.eu/topics/pods/synthetic-cathinones-injection

7 Soussan C, Kjellgren A.  "Chasing the high" - experiences of ethylphenidate as described on international internet forums. Subst Abuse. 2015 Mar 5;9:9-16. doi: 10.4137/SART.S22495. eCollection 2015.

8 Kjellgren A, Jonsson K. Methoxetamine (MXE)--a phenomenological study of experiences induced by a "legal high" from the internet J Psychoactive Drugs. 2013 Jul-Aug;45(3):276-86.

9 Abdulrahim D. & Bowden-Jones O, on behalf of the NEPTUNE Expert Group. Guidance on the management of acute and chronic harms of club drugs and novel psychoactive substances. Novel Psychoactive Treatment UK Network (NEPTUNE). London, 2015

10 http://www.emcdda.europa.eu/publications/risk-assessment/methoxetamine

11 http://www.emcdda.europa.eu/publications/risk-assessment/25I-NBOMe

10  Mitcheson, L., et al., Sexual health risk among dance drug users: cross-sectional comparisons with nationally representative data. International Journal of Drug Policy, 2008. 19(4):304-310.