Guidance

National intelligence network on drug health harms briefing: August 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. Group A streptococcal infection in prisons, people who inject drugs and people who are homeless or live in hostels

Dave Leeman (Public Health Specialist Registrar, Public Health England (PHE) National Infections Service)

Download the Group A streptococcal infection in prisons presentation.

The National Infections Service (NIS) has seen an increase in cases of Group A streptococcus (GAS) infections in people in prison, people who use drugs and people who are homeless or live in hostels. GAS is a bacterium which can colonise the throat, skin and anogenital tract. In some recent clusters of infections there have been co-infections with staphylococcus aureus (MRSA and MSSA).

The NIS has recorded around 1,000 cases dating back to the beginning of 2018. Two-thirds of these have been recorded as people who inject drugs. About a third of all cases have been recorded as hospitalised and there have been a small number of deaths.

PHE has co-ordinated an incident management response to gather information about the demographics and drug use of those infected. This involved 2 questionnaires, one for prisons and one for community settings.

Active case finding is driving up the number of infections PHE has recorded and is adding to the overall picture to help understand who is at risk and who to target with effective infections advice.

It’s not yet clear how important the use of shared injecting equipment is in the spread of infection, or if the drugs that people are injecting have been contaminated. But staff should provide infection control advice to all people who inject drugs accessing services, including:

• cleaning hands before injecting
• using sterile equipment
• cleaning sites before injecting
• seeking medical advice for wounds

Services can also make sure they notify local health protection teams about clusters of 2 or more linked cases of GAS infection and help to complete the questionnaires with people identified by local health protection and forensic epidemiology service teams.

2. Substance misuse and psychiatric crisis

Dr Nicky Kalk (Locum Consultant Psychiatrist in Addictions, King’s College Hospital Alcohol Care Team)

Download the substance misuse and psychiatric crisis presentation.

Dr Nicky Kalk presented data from the South London and Maudsley NHS Foundation Trust’s centralised ‘place of safety’.

Mental health professionals can assess people’s needs at a ‘place of safety’ or a ‘136 suite’. These are places, such as hospitals and prisons, where police can take people under section 136 of the Mental Health Act if they have a mental illness and are in need of care.

About 1,300 people were recently transferred and assessed by South London and Maudsley NHS Foundation Trust at their centralised place of safety. They found that 62% were intoxicated, mainly with alcohol, cocaine or cannabis.

Also, 64% of detentions were preceded by suicidal behaviour, and suicides were associated with recent alcohol use. Staff were more likely to discharge people intoxicated with alcohol even if they were still suicidal. The use of cannabis and synthetic cannabinoids, whether the person had psychotic symptoms or not, greatly increased the odds of physical violence from them in detention.

Analysis of post-mortem data from 2012 to 2016 held by the toxicology unit at Imperial College London looked at cases where there were suspected violent suicides.

Patients who tested positive for cocaine had higher blood alcohol concentrations and there appears to be a link between higher alcohol use, cocaine use and violent suicide. The prevalence of cocaine use immediately before suicide peaks in 25 to 34 year olds and then decreases markedly in older age groups. Results suggest that staff should treat psychosis and addiction at the same time.

3. Developing and enhancing the drug early warning system and trend analysis in Greater Manchester

Michael Linnell (Co-ordinator of Greater Manchester drugs early warning system)

Download the drug early warning system in Greater Manchester presentation.

Every area should have a local drug information system (LDIS), which uses consistent and efficient processes for sharing and assessing drug information and issuing warnings. They can help make sure high-quality and relevant information rapidly reaches the right people.

PHE’s LDIS guidance provides local authorities with information and advice to support them to do this, and suggests systems and approaches that local areas may choose to adopt or adapt to inform their local systems.

The LDIS for Greater Manchester, in partnership with DrugWatch UK, has recently produced information briefings on Spice, alprazolam and ‘THC-vapes’.

The Manchester Emergent Substance Use Survey, co-ordinated by Manchester Metropolitan University and commissioned by Manchester City Council, aims to gather up-to-date information on changing trends in substance use. The findings from the survey will inform the Greater Manchester LDIS and provide recommendations to the council about developing and providing substance use services.

4. Public Health England update

Steve Taylor, Ellen Heinsbroek and Rob Wolstenholme (Public Health England) updated the network on recent PHE activity related to drug-related health harms.

4.1 Alerts-type information

PHE receives a range of information and intelligence from local areas, police and other networks which is assessed for action based on principles outlined in the LDIS guidance (covered above).

Over the last 3 months, Spice often reported as being “stronger” than previously in circulation and containing the synthetic cannabinoids 5F-MDMB-PICA or 4F-MDMB-BINACA, has been implicated in overdoses in Blackburn, Newcastle, Bristol, Greater Manchester and Sheffield. There has not yet been any confirmatory evidence that these compounds are more hazardous than others.

In May PHE issued an alert about hospitalisation and deaths linked to consumption of 2,4-dinitrophenol (DNP) (a ‘fat burner’) and advice on the rapid treatment needed in cases of suspected DNP poisoning.

4.2 Report Illicit Drug Reactions (RIDR)

PHE updates the dashboard summary of information collected through RIDR every quarter. Drug and alcohol treatment providers can promote RIDR by sharing the dashboard which they can download from the website.

4.3 Publications since the last NIN

PHE published a collection of evidence and guidance to help healthcare professionals identify, prevent or reduce drug-related harms from the misuse of illicit drugs and medicines – as part of the All Our Health framework. This framework uses evidence to guide healthcare professionals in preventing illness, protecting health and promoting wellbeing. The information helps front-line health and care professionals identify, prevent or reduce drug-related harm and identify resources and services available in your area that can help people with drug misuse.

PHE also published 2 case studies on co-existing substance misuse and mental health issues. The first case study shows how joining up mental health, alcohol and drug misuse services in a Derby hospital provided better support for people with addiction and mental health problems.

The second looks at how a a service for young people in North Yorkshire works with other agencies to focus on their emotional wellbeing, substance misuse and mental health needs.

4.4 Botulism

Since the beginning of the year there have been 4 confirmed cases and 1 probable case of botulism in Scotland, including a death.

Some cases in the South of England and the Midlands were also reported in October and November but the geography suggests they are unlikely to be linked.

4.5 Heroin assisted treatment

PHE is convening a group of clinical experts to support us as we collate existing evidence and guidance on heroin assisted treatment (HAT), building on the latest clinical guidelines and the earlier evidence on which the guidelines draw. The new guidance, due later this year, will clarify clinical and operational aspects for those considering setting up a HAT service.

5. Scotland

Vicki Craik (Emerging Trends and Training Coordinator, Crew)

The market for cocaine in Scotland has become more established in the past couple of years leading to an increase in use. Some services are reportedly seeing more people presenting to services in more vulnerable and unpredictable states. There have also been links made between increased cocaine prevalence and increased public order offences, in particular at football matches.

The HIV outbreak in Glasgow has been associated with a big increase in cocaine injecting and the most significant change in the market appears to be strength. Street purity of cocaine was averaging 15% a few years ago but now it is close to 70%. The cost, however, has remained stable at £50 a gramme.

Etizolam use is still higher than other benzodiazepines. This category of drugs are implicated in over 60% of drug-related deaths in Scotland.

Synthetic cannabinoid receptor agonists (SCRAs) in Scotland are still almost only used in prisons and have not become prevalent in other groups, like they are in other parts of the UK.