Cynulliad Cenedlaethol Cymru

Ymchwiliad i sylweddau seicoweithredol newydd (“cyffuriau penfeddwol cyfreithlon”)

Tystiolaeth gan Bwrdd Iechyd Prifysgol Aneurin Bevan – LH 15

Response to the Health and Social Care Committee inquiry into new psychoactive substances (“legal highs”) - Aneurin Bevan University Health Board.

Dr Gillian Richardson , Director of Public Health, Julia Osmond, Principal in Public Health. 16.10.14

1. We welcome this opportunity to contribute to the National Assembly for Wales inquiry on New Psychoactive substances (NPS). The issue of whether it is legal or illegal to use a drug can result in confusion regarding its safety. The fact that a NPS is legal does not mean that it is safe. This is commonly mis-understood by the public. A more realistic term possibly would be ‘not yet made illegal as new substance of unknown composition’, ie) will probably be made illegal when chemical composition worked out and class of drug identified.

2. These drugs are often affordable and easily accessible. In many cases, these substances have been designed to mimic Class A drugs, often producing the same or similar effects as drugs such as cocaine or ecstasy, but are structurally different enough to be currently classified as illegal substances under the Misuse of Drugs Act 1971.

3. The European Monitoring Centre for Drugs and Drug Addiction define a New Psychoactive Substance as

'a new narcotic or psychotropic drug, in pure form or in preparation, that is not controlled by the United Nations drug conventions, but which may pose a public health threat comparable to that posed by substances listed in these conventions' (1)

4. With the major exception of mephedrone which was classified as a Class B drug in April 2010, many new psychoactive substances are legal to use and buy from the internet, in “head shops” (astore that sells drug-related paraphernalia(2) from street dealers and friends.

5. How to raise awareness of the harms associated with the use of NPS among the public and those working in the relevant public services.

This would be best achieved through a national social marketing campaign targeted at young people and young adults. Professional education of Educational Welfare Officers, Head Teachers and Teachers - through INSET day training - School Counsellors, School Nurses and Youth workers would also be beneficial.

Looked after children are particularly vulnerable and foster carers, care home workers and children and young people’s Social workers would also benefit from training.

Additional training in the Health Sector for General Practitioners Practice Nurses and A and E staff is also essential. In ABUHB training supported by Police is to be offered at GP and Practice Nurse CPD events, and is to be offered to A and E departments.

6. A person buying NPS is unlikely to be sure of what he or she is buying. It is also the case that the seller is unlikely to know what he or she is selling. NPS vary considerably and are often designed to mimic more ‘traditional drugs’. The chemical composition and potential affects are often unknown. This can be true of even the manufacturer as substances can be mutated into another drug along the supply chain by the adding of unknown cutting agents or other drugs.

7. 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 effectiveness of data collection and reporting on the use of legal highs in Wales and their effects.

8. (These aspects are interdependent as surveillance is ‘information for action’. Lack of information on drug use patterns in the community hampers ability of services to plan and respond.)

9. Services in Wales face a considerable challenge in dealing with impacts of NPS. There are numerous types of NPS being produced it is not possible to chemically analyse each substance in a timely fashion to provide enough information for them to be classified as illegal. Within each NPS drug category the number of substances are continually rising (3), as can be seen in Figure 1.

10. A significant concern about NPS use is that if an unknown drug is taken resulting in adverse effects and there is a need for medical attention, health professionals are often unable to provide an appropriate intervention to counteract the effects of the unknown drug.

In an attempt to address this issue WEDINOS (Welsh Emerging Drugs and Identification of Novel Substances) has been designed to collect and test substances. Appropriate evidenced-based harm reduction information for individuals who misuse substances and interested professionals is disseminated via their website (http://www.wedinos.org/).

Samples are donated to WEDINOS anonymously. A code, known only to the donor is allocated, providing information about the substance being analysed free of charge, on the WEDINOS website.

9. The media have raised concern that this service supports sellers and manufacturers of NPS by providing them with analytical information about their ‘product’.

Though it can be argued that the service has the potential to be abused, it has to recognised that it has a valuable role in contributing to our knowledge base, including how it is used and types of NPS available. This information is necessary to inform primary prevention and secondary prevention (harm reduction) interventions wherever possible.

11. The WEDINOS facility is accessed more frequently in the ABUHB area than elsewhere in Wales. Between October 2013 and June 2014, some 237 samples were submitted. This compares with, Betsi Cadwaladr , 61 samples; Powys Teaching, 5; Cwm Taf, 39; Cardiff and the Vale, 69; Abertawe Bro Morgannwg, 69; and Hywel Dda, 18 during the same time period.

12. It is unclear why there is increased numbers of samples in the Gwent area. This could be due to high levels of professional involvement/awareness or greater prevalence of NPS use in the ABUHB area. We suspect the former.

13. The analysis of recent samples submitted to WEDINOS from the ABUHB area show at least 40 different substances were identified either in combination or in isolation.

14. In addition to this as well as taking NPS orally, there is increasing experimentation with alternative modes of administration such as intravenous use. This potentiates the effect of the drug and also increases the risk of the spread of blood borne viruses between users if needles are shared. In June 2014, there were two separate hepatitis C outbreaks confirmed in injecting mephedrone users in South Wales (4). Of the powders submitted for analysis to the WEDINOS project between October 2013 and June 2014, 4% would have been administered intravenously,indicating that 1 in 25 people injected NPS.

15. The full scale and impact of the use of NPS is not fully understood. There is no universal surveillance system in Emergency Departments in Wales which captures this information on a routine basis. There is also no standard ICD 10 coding definition which can be used to log diagnosis due to the number of different sorts of NPS. It is reasonable to suggest that numbers recorded of those affected is likely to represent just the ‘tip of the iceberg’.

16. A look-back exercise to try to quantify impact of use of NPS in Torfaen area alone on A and E attendances in Gwent during 2013, showed 63 residents presented with mephedrone – like substance use. This equates to an average of 5.25 presentations each month. Of these 63 people, 47 were under the age of 30, with 14 of them being between the ages of 15 and 20 years.

17. The number of people in Gwent presenting for assessment and or treatment, where the primary drug is classified as ‘other substances’ has risen gradually since 2009/2010 as illustrated in Figure 2. These might include substances not know at the assessment or which are not in the drug list so could include NPS. In many instances more than one substance will also be used.

18. The Welsh National Database for Substance Misuse (WNDSM) was established in 2005. It contains guidance on the common data sets and data definitions regarding substance misuse for those seeking treatment by SM services (5).

Figure 2: Welsh National Database for Substance Misuse (WNDSM) Assessment Analysis All Ages.

Primary assessment data for substance misuse services illustrates that the age groups where “other drugs” are the principal reason for assessment for drug service use are 12-24 years of age.

Figure 3WNDSM Assessment Analysis, 12-17 years of age. Gwent

The age profile for NPS use in the Gwent area, is similar to that of the rest of south Wales, the main users of NPS being teenagers and young people.

Figure 4WIDSM Assessment Analysis by Substance and Age Group From 2012 to 2014.

19. The possible legislative approaches to tackling the issue of legal highs, at both Welsh Government and UK Government level.

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.

20. Building health public policy

Reducing the harm associated with use of NPS should be regarded as a priority whether this is achieved through education or enforcement. A clear legislative framework needs to be developed by national government within which local agencies can operate. Collaborations between these agencies are of upmost importance. Action to identify and ban dangerous substances should be prompt and tools developed to enable this. Consistent messages regarding the risks and consequences of NPS which can be tailored to meet local need are necessary. The Director of Public Health Report for Gwent will this year include a section on NPS as an emerging threat.

If we are to ensure early identification of trends of NPS use and effective interventions the promotion of greater information sharing should be promoted locally. The development of better data collection methods to reduce gaps in knowledge is vital along with the need to engage with individuals who use NPS.

21.Creating supportive environments

Due to the legal status of NPS implementation of drug enforcement legislation to reduce supply and use is not an option. However, an alternative approach is the use of consumer protection legislation. An example of this is local authority departments such as trading standards taking action against suppliers such and ‘head shops’ and related businesses that sell NPS. This can result in NPS being seized and criminal investigations being pursued. There are also issues with this approach such as the need to be able to test a product on sale to establish if consumer protection law is being breached. This approach requires financial resources however.

For NPS which have already been classified as illegal, intervention is more straight forward, action can be taken to disrupt sales through known routes such as internet sales, closing websites offering sales of banned substances. Substances sold as NPS often contain controlled drugs as well should this be found to be the case drug enforcement legislation can be implemented as being in possession of, or supplying controlled drugs is an offence.

Interventions should focus on environments where young people congregate. A number of third sector organisations have worked with the organisers of university events and social gatherings such as clubs, parties and music festivals to not only raise awareness of the potential effects of NPS and provide support if and when necessary.

22.Strengthening community action

Statutory services such as the Police and health services should work collaboratively with local communities to identify their needs and how restricting both the demand for and the supply of NPS can both be addressed. Raising awareness of NPS amongst the public is paramount, with education being delivered at a local/community level, allowing campaigns to be tailored to meet the needs of specific groups.

The idea that drug taking is an acceptable activity and an inevitable part of growing up needs to be challenged within certain communities. Tolerance of substance misuse should be challenged.

23.Development of personal skills

Prevention and education based interventions should focus on increasing individuals self efficacy and to promote/empower the choice not to take unknown, potentially harmful substances. It is important that we focus not only on substance misuse itself, but also on the root causes of the behaviour, helping people to develop necessary skills and values and building resilience in relation to risk taking behaviours.

Though use of NPS is not only the preserve of young people, use among this age group is very concerning. Resource should be targeted on resilience and skill development for this group through schools, youth services and non statutory services for young people. Ideally this would begin at primary school with age appropriate messages being communicated. Information should be made available to parents to enable them to support their children. Programmes such as the charity Care for the Family’s ‘How to Drug proof your Kids’ training days for parents should be promoted and expanded.

The key message should be that because a substance is labelled ‘legal’ it does not mean that it is guaranteed safe. The content of the package are not necessarily ‘what it says on the tin’.

Although emphasis should be on prevention, a priority should be reducing harm for those who do use NPS. The WEDINOS system provides up to date information on the health effects of NPS, this should be used to enable harm reduction information to be publicised, increasing public awareness of the health risks and dangers of taking NPS.

24.Re-orientation of services

Substance Misuses services provide specialist treatment for people with problems relating to NPS and other substances. Data from the WEDINOS system should be used in conjunction with service utilisation data to inform future service planning.

However many recreational NPS users would not consider themselves ’substance misusers’ and would certainly not approach traditional services that they may see as associated with users of ‘hard drugs’. Drop in clinic facilities for teenagers/young people wishing to discuss health issues including NPS are needed.

There are a number of professionals and organisations with whom those who use NPS will come into contact (for example primary care, accident and emergency department, and housing staff). It is important that these professionals are equipped with knowledge about NPS and where support and treatment can be accessed.

The DAN 24/7 website is useful. Messages need ‘post marketing surveillance’ to ensure they remain relevant and hit the mark.

25. International evidence on approaches taken to combat legal highs in other countries.

The US has developed a system for temporarily banning new substances that are being classified. However classification is always one step behind production, and so a new approach is being piloted in New Zealand which has decriminalised NPS through the Psychoactive Substances Bill 2013. This enables regulation and licensing of a tightly controlled market for recreational drugs including safeguards, testing and regulation of new substances. Drug manufacturers must prove the product has ‘low risk of harm’ and pay research costs and fees to register. In effect all NPS are therefore illegal until proven to be low risk. This is at variance with EU and US approaches which are not proving effective, so international interest in effectiveness of New Zealand’s approach is high. (7)

References

(1) United Nations Office on Drugs and Crime. World Drug Report, [Internet] 2013 [cited 7 September 2014]. Available from: http://www.unodc.org/unodc/secured/wdr/wdr2013/World_Drug_Report_2013.pdf

(2) Oxford Dictionaries Language Matters, [Internet] 2014 [cited 15 September 2014]. Available from: http://www.oxforddictionaries.com/definition/english/head-shop

(3) European Monitoring Centre for Drug and Drug Addictions. European Drug Report Trends & Development, [Internet] 2014 [cited 26 August 2014]. Available from: http://www.emcdda.europa.eu/attachements.cfm/att_228272_EN_TDAT14001ENN.pdf

(4) Smith, J and Lyons, M Dr. “New hepatitis C diagnoses amongst mephedrone injectors – summary report and actions July 2014” Health Protection. Public Health Wales. Cardiff

(5) Welsh Government. The Welsh National Database for Substance Misuse (WNDSM) and Treatment Outcome Profile (TOP). [Internet] 2014 [cited 28 September 2014]. Available from: http://wales.gov.uk/topics/people-and-communities/safety/publications/wndsm/?lang=en

(6) Gwent Police “Location of Mephedrone Dealing Based on Intelligence Submitted Between August and November 2012” in (2013) p109 Substance Misuse Interim Needs Assessment for Consultation Gwent Area Planning Board.

(7) New Zealand’s regulation of new psychoactive substances; A response to the futility of trying to ban such substances as they appear

BMJ 2014;348:g1534