Written evidence submitted by Royal College of Psychiatrists
Submission to: Home Affairs Select Committee Psychoactive Substances inquiry
1 September 2015
1.1 The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom.
1.2 The College aims to improve the outcomes of people with mental illness, and the mental health of individuals, their families and communities. In order to achieve this, the College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. Nationally and internationally, the College has a vital role in representing the expertise of the psychiatric profession to governments and other agencies.
1.3 We are pleased to respond to this inquiry and are happy to participate in any further discussion.
Groups affected by a ban on NPS/education/change in legal status
2.1 It is known (National Treatment Agency for Substance Misuse, 2012) that so far (or at least up to 2012), the UK’s heroin and crack users had not switched to using Novel Psychoactive Substances (NPS) – instead, a new population of users has emerged.
2.2 Identifying who will be affected by the ban on psychoactive substances is challenging as NPS describes a range of different substances with strikingly different effects. NPS can be stimulating, sedating, hallucinogenic or dissociative. These different effects appeal to different groups of users and as such there is no ‘typical’ NPS user. Instead, this population appears to be composed of a mosaic of different social groups including students, people who identify themselves as ‘clubbers’, prison populations, young professionals, so-called ‘psychonauts’ and lesbian, gay, bisexual and transgender (LGBT) communities.
2.3 Many of these people are reported to be reluctant to approach traditional drug treatment services for help as these services are perceived to cater for ‘problem’ alcohol, heroin and crack users only.
2.4 Although they do not form the majority of people presenting for drug treatment, NPS users do represent a diverse group that require intervention now.
2.5 NPS users draw on a range of health services, including emergency and urgent care departments, acute care hospitals, mental health services and sexual health clinics. These forums therefore present useful sites and opportunities to educate people both about the dangers of NPS but also the change in their legal status.
Legitimate researchers – a group who must not be affected by the Bill
2.6 In its originally presented form, there was considerable scope for the Bill to affect legitimate research.
2.7 Substances originally exempted in the Bill include "Investigational medicinal products" as defined by the Medicines for Human Use (Clinical Trials) Regulations 2004. These regulations must be adhered to by all clinical trials of investigational medicinal products.
2.8 The ban on Psychoactive Substances as set out in the original Bill also relates only to psychoactive substances that are actually consumed by humans. Therefore research that does not involve the human consumption of a psychoactive substance (i.e. preclinical trials) would not be banned under these provisions of the Bill.
2.9 However, there are some experiments involving humans that sit outside The Medicines for Human Use (Clinical Trials) Regulations 2004. Some 'biologicals' and early stage pharmacological 'tools' - proteins, or manipulated chemical compounds - would fall outside of this definition as they cannot be classified as 'investigational medicinal products'.
2.10 This is concerning as physiological experiments on humans, for example all studies in human neuroscience looking at issues such as attention, consciousness, memory, use substances, sometimes psychoactive but not medicines, and therefore would be illegal under the original provisions in the Bill.
2.11 The RCPsych therefore supported an amendment tabled by Baroness Meacher in June 2015 which would ensure that all research, including using humans consuming substances not captured by the Medicines for Human Use (Clinical Trials) Regulations 2004, would remain legal, enabling vital work to progress the understanding of neuroscience to continue.
2.12 Without this or a similar amendment, it would also likely be the case that laboratory suppliers would be wary in supplying some requested compounds for neuroscience research because of their potential to have a psychoactive effect in humans. This would potentially mean that vital new medicines may not be developed.
2.13 This amendment was debated on Tuesday 30 June 2015 at Committee Stage of the Bill in the House of Lords. In response to the points raised by Baroness Meacher, the Minister emphasized that:
“the Government attaches a high priority to bona fide scientific research and to not putting in place unnecessary regulatory barriers that in any way impede research in the UK. We are actively ensuring, in accordance with our original intention, that any interaction between the provisions of the Bill and those conducting or supporting bona fide research into psychoactive substances is removed. As a priority, we are establishing how we best achieve this, perhaps through the drafting of further exemptions in the Bill.”
2.14 The RCPsych welcomes this commitment from the Minister. We propose that an initial starting point for defining ‘bona fide’ research should be the involvement of the research community and other stakeholders.
Evaluation
2.15 In order to ensure that legitimate research is not affected by the proposed Bill, it will be necessary to conduct a detailed evaluation of its impact.
2.16 The RCPsych believes that a thorough evaluation of the proposed new law should be conducted on an annual basis by the Secretary of State. This should include information on the impact of the Bill on (1) the use, treatment and non-treatment of users of controlled drugs and banned substances (including the services providing such treatment), (2) scientific research and (3) law enforcement. This should be included as a legislative requirement ‘on the face’ of the Bill, utilising the above wording or similar.
Current treatment provision – six steps to improvement
3.1 The current need for treatment of NPS and club drugs appears to be increasing. Consequently, while some commentators note that ‘time will tell’ about the future demand for such treatment (National Treatment Agency for Substance Misuse, 2012), inaction is not an option. This briefing therefore outlines six steps to address NPS harm:
3.1.1 Step 1: Widen the front door. Many club drug and NPS users do not see traditional drug services as meeting their needs, but being more suited for heroin and crack users. Services need to work to change this attitude by making the needs of NPS and club drug users ‘core business’ and placing them on an equal footing with alcohol and opiate treatment.
3.1.2 Step 2: Support the front line. Many front line healthcare staff do not have sufficient knowledge or skills to manage harm related to NPS and club drug use. Drug service staff need to be educated about these drugs and given skills to intervene and provide appropriate treatment, to help people recover and bring about improvements in their lives. At the same time, non-drug service staff – in settings which will see NPS users such as accident and emergency or sexual health clinics – should also receive training.
3.1.3 Step 3: ‘Connect’ the front line. Arguably because of their negative perceptions of existing drug services, NPS users draw on a range of health services, including emergency and urgent care departments, acute care hospitals, mental health services and sexual health clinics. Such non-specialist services need to establish much better links with drug services so that specialist support and expertise can be shared, onward referrals can be made more effectively and intelligence and insight can be exchanged. A clinical network supporting the analysis of clinical data relating to NPS could support this ambition. Furthermore, a clear need exists to also develop recovery and support pathways so that NPS users can achieve sustainable improvements.
3.1.4 Step 4: Watch all horizons for harm. New NPS are emerging all the time and their harmful effects are poorly understood. Patterns of use are also rapidly changing. Therefore data on the harm from NPS should be recorded not only from drug and alcohol services, but also accident and emergency/acute care settings, primary care, prison settings, sexual health services and mental health services. This will require national monitoring systems to be revised and reworked to achieve this.
3.1.5 Step 5: Promote research into NPS. Given the robust body of evidence supporting treatment interventions for ‘established’ drugs such as heroin, research funders should rebalance and prioritise new funding programmes into interventions for NPS users.
3.1.6 Step 6: Empower users through education. Many users and the general public have little idea about emerging NPS or their potential for serious harm. However, existing information on promoting positive health and reducing the harm associated with these drugs is of varying quality. Consequently, preventing initiation of NPS use through access to reliable information is a priority.
3.2 It is clear that NPS are evolving and will continue to change for the foreseeable future, as will the contexts of use, behaviours and individuals using and selling them. Consequently, it is vital that the UK’s existing drug services keep pace with this new trajectory, as well as continuing to meet the existing demands of more established substance misuse problems associated with alcohol, heroin and crack cocaine.
3.3 [Please see One New Drug a Week (Royal College of Psychiatrists, 2014) for further information on each of these six steps
https://www.rcpsych.ac.uk/pdf/FR%20AP%2002_Sept2014.pdf]
Evaluation
3.4 It is vital that any action to counter a shift to conventional banned substances (or other substances with deleterious health implications such as alcohol) is evidence-based.
3.5 The RCPsych believes that a thorough evaluation of the proposed new law should be conducted on an annual basis by the Secretary of State. This should include information on the impact of the Bill on (1) the use, treatment and non-treatment of users of controlled drugs and banned substances (including the services providing such treatment), (2) scientific research and (3) law enforcement. This should be included as legislative requirement ‘on the face’ of the Bill, utilising the above wording or similar.
Proportionality
4.1 Current proposals do not include an element of proportionality. This not only does not reflect the evidence that there is a spectrum of harm related to NPS use, but may present practical difficulties in terms of law enforcement if agencies have difficulty prioritising their efforts in line with a scale of harm.
Evaluation
4.2 In order to establish whether enforcement agencies are effectively enforcing the proposed new laws, detailed evaluation will be necessary.
4.3 The RCPsych believes that a thorough evaluation of the proposed new law should be conducted on an annual basis by the Secretary of State. This should include information on the impact of the Bill on (1) the use, treatment and non-treatment of users of controlled drugs and banned substances (including the services providing such treatment), (2) scientific research and (3) law enforcement. This should be included as legislative requirement ‘on the face’ of the Bill, utilising the above wording or similar.