Guidance

National intelligence network on drug health harms briefing: May 2019

Updated 13 January 2020

This briefing is based on a meeting of the national intelligence network (NIN) on the health harms associated with drug use. The NIN is made up of representatives from drug treatment services, local authority public health and commissioning teams and national professional and membership bodies. Network meetings are chaired by Dr Michael Kelleher, consultant addictions specialist and clinical lead for Lambeth Addictions at the South London and Maudsley NHS Foundation Trust.

1. Crack cocaine use and treatment

National statistics for substance misuse treatment show significant increases in the number of people in treatment for crack cocaine problems, with a 44% increase since 2016 to 4,301 in 2018. This increase in treatment demand reflects increasing prevalence estimates for crack cocaine users, which show a statistically significant 8.5% rise from 2011 to 2012 and 2016 to 2017 (166,640 to 180,748).

1.1 Investigation into the increase in crack use

Pete Burkinshaw (Public Health England)

The Serious Violence Strategy committed the Home Office and Public Health England (PHE) to conduct an investigation into the increases in crack use and to consult with service users and providers to understand more about who currently uses crack.

Findings from the published report include:

• increasing crack use had mainly taken place among existing heroin users, who have now also started to use crack daily
• there is a ‘hidden’ group of crack users who have not been in treatment, including some women and younger people
• the main driver of the increase in crack use was aggressive marketing by dealers (for example, crack being given free to heroin users or as part of a deal)
• crack is widely available and delivery can be “quicker than a pizza”
• crack is sold in smaller quantities to make it more affordable
• there was a perception that purity of crack had increased while heroin purity had fallen
• there is less stigma associated with crack use than there used to be, partly due to the way it is marketed by dealers
• a lack of resources had made it difficult for the police to prioritise small scale drug-dealing
• ‘county lines’ drug dealing operations had not been the only factor in the increase in crack use, because use had also increased in areas where county lines were not prevalent

There is a real need for good, well-supported local treatment systems that can respond to both the increasing numbers and the specific needs of crack users. This requires local authorities to understand the levels of unmet need, which will vary substantially between different areas.

Strong local partnerships can provide effective links between treatment, prevention and the criminal justice system, for example through greater availability of arrest referral schemes and improved monitoring of Drug Rehabilitation Requirements, and make sure that people get the support they need.

1.2 Helping people with crack cocaine addiction

Professor John Marsden (Institute of Psychiatry, Psychology and Neuroscience, King’s College London)

Unlike for heroin, there is no approved treatment medication for cocaine use disorder. Instead, psychosocial interventions have been used to build and sustain change people’s motivation. These have mostly been cognitive behavioural therapy but there is scope for using other interventions like memory-focused cognitive therapy (MFCT).

Preliminary evidence from a trial of MFCT for cocaine use disorder in South London has shown that this intervention is associated with reduced craving and increased abstinence. The trial also showed that the procedures involved are safe and able to be used.

‘Conditioned cocaine cues’ can be a range of triggers from someone’s personal environment, such as a memory, an image or a sensation, that they associate with their cocaine use. The long-lasting effects of these cues were highlighted in the trial, with some promising findings. MFCT could also be included as part of a toolkit of psychosocial interventions, offered alongside opioid medication for opioid use disorder.

2. Secondary distribution and hepatitis C testing uptake among people who use image and performance enhancing drugs

Professor Vivian Hope (Public Health Institute, Liverpool John Moores University)

A review to update guidance on needle and syringe programmes (NSPs) and research on anabolic steroids found that some NSPs report seeing more people who inject image and performance enhancing drugs (IPEDs) than people who inject psychoactive drugs. Two related areas of interest are the secondary distribution (where people who use NSPs distribute injecting equipment to friends and other people who inject IPEDs) and factors associated with hepatitis C testing uptake among people who inject IPEDs.

2.1 Secondary distribution

IPEDs are often used cyclically meaning that people who use them only access NSPs a few times each year. Also, a recent study shows that secondary distribution of injecting equipment obtained from NSPs is common among people injecting IPEDs. All of this adds up to infrequent, or a complete lack of, contact between people who inject IPEDs and NSPs. This is a concern because the potential opportunities for harm reduction and other interventions become limited. One potential solution is for NSPs to target those collecting equipment on behalf of others as potential peer educators for sharing harm reduction messages. But further alternative ways of communicating safer injecting practices among people who inject IPEDs need to be explored.

2.2 Hepatitis C testing

Despite some misconceptions, people who inject IPEDs are at risk of bacterial and blood-borne viral infections. There is evidence about the risks for these infections from the way people use steroids. Yet only a third of people using IPEDs ever report having been tested for hepatitis C. A recent report suggests that because previous studies of people who inject IPEDs have focused on recruitment from needle and syringe programmes, there may have been a potential over-estimate of hepatitis C virus testing uptake. Therefore, the proportion of IPED users who are aware of their hepatitis C virus status is possibly lower than previously thought. People injecting IPEDs need targeted hepatitis C virus testing interventions. Services that want to increase testing uptake will need to reach people who are not using needle and syringe programmes and those without a history of psychoactive drug injection or imprisonment.

3. Public Health England update

Pete Burkinshaw, Steve Taylor, Laura Pechey and Rob Wolstenholme (PHE) updated the network on recent PHE activity related to drug-related health harms

3.1 Buprenorphine

PHE has again written to directors of public health to update on the buprenorphine availability and price issue that has continued.

In January, NHS Prescription Services moved 2mg and 8mg buprenorphine tablets from category M of the Drug Tariff to category A, at higher prices than the previous Drug Tariff prices and even higher than the concessionary prices. This change means that a continuing increased cost for drug treatment providers and their commissioners is likely.

The National Institute for Health and Care Excellence (NICE) published a PHE-commissioned evidence summary on depot buprenorphine. They were only able to review one published study but also took some expert clinical advice. NICE concluded that depot buprenorphine has a place for some people, especially those who are unable to have a daily pick-up or supervised consumption.

3.2 Naloxone

A change to legislation means that drug services can now supply a formulation of naloxone for nasal administration without prescription on the same terms as injectable naloxone.

The availability of nasal naloxone is now reflected in PHE, Medicines and Healthcare products Regulatory Agency and Department of Health and Social Care guidance on naloxone provision.

3.3 Opioid Substitution Treatment Good Practice Programme (OST GPP)

PHE has launched the Opioid Substitution Treatment Good Practice Programme (OST GPP) to focus on implementing existing clinical guidance, in particular the ‘orange book’, and supporting evidence-based service delivery through practical and user-friendly tools and resources covering pharmacological and psychosocial treatment interventions.

For the year ahead, PHE will develop a range of products and pilot them for 6 months before implementing them by the end of March 2021.

3.4 Reporting Illicit Drug Reactions (RIDR)

Reporting Illicit Drug Reactions (RIDR), the national system for reporting the unexpected or severe adverse effects of NPS and other drugs, has now received over 400 reports.

Reports to RIDR about harms caused by alpha-PVP, a synthetic cathinone, have helped advise clinicians on dealing with adverse reactions caused by the substance.

The RIDR dashboard provides an up-to-date summary of the latest clinical messages and intelligence on NPS and other drug health harms.

3.5 Substance misuse treatment for young people: statistics 2017 to 2018

PHE published national statistics for young people (16 and 17 year olds) in treatment at the end of 2018. There were nearly 16,000 young people in specialist substance misuse services in 2017 to 2018 – a 5% decrease from 2016 to 2017, and a continuation of the downward trend over recent years (35% down since 2008 to 2009). Almost 9 out of 10 cited cannabis as a problem substance.

3.6 Substance misuse treatment in secure settings: statistics 2017 to 2018

The latest national statistics for substance misuse treatment in secure settings showed that prisons treated the majority of adults for opiate use, while young offender institutions treated 75% of people for problems with non-opiates.

Almost 1 in 10 adults in treatment said they had a problem with NPS, although this is the proportion of adults entering treatment with problematic NPS use and unrepresentative of the prevalence in the whole secure settings population.