Guidance

National intelligence network on drug health harms briefing: September 2018

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. Chemsex and PHE’s HIV Prevention Innovation Fund

Chemsex is the use of drugs before or during sexual activity to sustain, enhance, disinhibit or facilitate the experience. Chemsex often involves the use of crystal methamphetamine, GHB/GBL and mephedrone, and sometimes injecting these drugs (known as slamming). It can have an adverse impact on people’s health and wellbeing.

PHE established a national HIV Prevention Innovation Fund to support new approaches to prevention that could be replicated elsewhere and are focused on engaging at-risk or under-served communities. Summaries of presentations of two chemsex-related projects supported by the fund follow.

1.1 Chemsex –harm reduction and cultural competency

Peter Sheath (Addaction)

Chemsex Open Access Support Team (COAST) is an outreach service run by Addaction for men who have sex with men and use drugs during sex. The service, which is based in Liverpool but is not restricted to that area, provides information about where to go for sexual health support and testing, how to minimise harms (including safer injecting techniques) and where to access clean injecting equipment. COAST also provides one-to-one therapy sessions which support mental health and wellbeing.

COAST has seen over 150 clients for brief harm reduction interventions, while engaging 35 people in more long-term, intensive psychosocial interventions.

COAST has found widespread poor injecting practice leading to injury,, so promoting safer injecting practices for people engaged in chemsex is especially important and can be delivered alongside first aid training.

The service has also delivered training on chemsex to Addaction staff, GPs, sexual health clinics, HIV nurses, Mersey Care NHS Foundation Trust, emergency services and commissioners across the UK. COAST has formed good local partnerships which have allowed the team and the services it provides to function more effectively.

Cultural competency is very important for the LGBT and chemsex community. Staff need to understand the chemsex terms being used, so they can communicate effectively with their clients. Also, staff should avoid expressing personal judgements as this could jeopardise effective and meaningful clinical interventions.

1.2 Chemsex – online support

George Halfin (Terrence Higgins Trust)

The Friday/Monday project is a partnership between Terrence Higgins Trust and London Friend to provide online, video group work and counselling to gay and bisexual men struggling with issues relating to sex, drugs and alcohol.

The project includes a Life Check quiz to highlight what leads to risky behaviour. Results are sent by email, with a motivational email following a month later.

Using video conferencing means the project has a wide geographical reach. Nearly half of those who have registered (and just under a third of people signed up for counselling) are from outside London.

Providing counselling and group work in this way has proved to be convenient for the project and its clients. It lets people get help when they may be apprehensive about, or incapable of, physically attending a service. And for many, having the sessions in the privacy and safety of their own home made them feel more comfortable and better able to communicate.

The project also found higher client retention for online counselling or group work than with face-to-face sessions. Although delivering online services requires the same level of administration as face-to-face services, the online platform enables greater flexibility and responsiveness without some associated costs and travel time.

2. The IONA study

Professor Simon Thomas (National Poisons Information Service)

The IONA (Identification Of Novel psychoActive substances) study aims to develop methods of screening, analysis and quantification for new and emerging NPS in biological samples (from urine, oral fluid and blood) from consenting participants who have presented to emergency departments with severe suspected NPS toxicity. In data analysed between March 2015 and December 2017, NPS and conventional drugs of misuse were present in samples from 235 (57%) and 351 (85%) participants respectively, with both present in 186 (46%).

The most common NPS identified were synthetic cannabinoid receptor agonists (SCRAs), identified in around 60% of participants. These SCRAs were mainly 5F-ADB and FUB-AMB (also known as AMB-FUBINACA).

There have been reductions in confirmed exposures to all NPS and especially SCRAs since 2016, but there have also been increases in the prevalence of 5F-ADB and FUB-AMB. These drugs are also more commonly identified in homeless participants.

Over the same time there have been increases in cocaine and diazepam, and diazepam has been the most commonly identified conventional drug.

There is currently a low prevalence of novel opioids (including fentanyl analogues) detected among opioid users.

3. Cannabis

According to the Crime Survey for England and Wales, cannabis is the most commonly used drug in the UK: 7.2% of adults aged 16 to 59 said they used it in the last year (which is around 2.4 million people). Numbers of people entering treatment for cannabis have fallen slightly in the past 3 years but there are additional complications due to the increasing strength of cannabis available. The following 2 summaries relate to cannabis-related psychosis and treatment.

3.1 What drives the association between cannabis use and psychosis?

Dr Marta Di Forti (Medical Research Council clinician scientist, King’s College London and consultant adult psychiatrist, South London and Maudsley NHS Foundation Trust)

People who use cannabis have an increased risk of psychosis, an effect attributed to the active ingredient THC (tetrahydrocannabinol). There has recently been concern over an increase in the concentration of THC appearing in cannabis available in many countries.

A recent study also showed that people with a first episode of psychosis were over 5 times more likely to have smoked higher-potency cannabis (skunk) on a daily basis, than a healthy control group. There was no evidence that the choice of smoking skunk was influenced from any genetic factors for schizophrenia.

People who continue to use cannabis after onset of psychosis also have adverse outcomes, including higher relapse rates, longer hospital admissions, and more severe symptoms, compared to those who stop using or never use it.

These findings suggest that reducing cannabis use could be an important target to improve outcomes for patients with psychosis. The findings also raise important public health implications, given the increased availability and use of high-potency cannabis.

3.2 Cannabis treatment

Dr Luke Mitcheson (PHE and South London and Maudsley NHS Foundation Trust)

The latest annual statistics from the National Drug Treatment Monitoring System (NDTMS) show that the majority of 18 to 24 year-olds coming into treatment (54%) presented with cannabis as a problem drug. A 2015 study by Freeman and Winstock showed that frequent use of high-potency cannabis (like skunk) predicted more severe dependence (based on days of use per month) and this effect became stronger as age decreased. By contrast, using low-potency cannabis (grass and resin) was not associated with lower dependence (days of use per month).

High-potency cannabis was distinct from low-potency varieties by its marked effects on memory and paranoia.

Skunk is associated with an increased severity of dependence, especially in young people. It is also associated with negative effects (memory, paranoia), but also positive characteristics (best high, preferred type), which may be important when considering clinical or public health interventions focusing on cannabis potency.

Interventions for cannabis treatment include motivational interviewing, followed up with cognitive behavioural therapy. People with severe psychiatric illness might need a more harm reduction focussed approach, which promotes non-using days or using only at a particular time of day. Contingency management could also be considered.

4. PHE update

Pete Burkinshaw, Steve Taylor and Eamonn O’Moore (PHE Alcohol, Drugs, Tobacco and Justice Division) and Stephanie Migchelsen (PHE National Infection Service) updated the network on recent PHE activity related to drug-related health harms.

Drug-related deaths

The latest official Office for National Statistics (ONS) drug-related deaths statistics for England and Wales, for registrations in 2017, have been published. PHE published a blog in response to the figures, which remain high compared to 2012 but are lower than last year for drug misuse deaths and heroin deaths. A detailed review of the statistics and what they say will be covered at the next national intelligence network meeting, scheduled for Friday 2 November.

ONS have also published their findings from the “deep dive” into coroners’ records commissioned by PHE in 2016. The study investigated deaths related to drug misuse in 2014 and 2015 using available coroners’ records and recommends action for ONS, PHE, Chief Coroner and the Coroners’ Society, the Ministry of Justice and General Register Office to potentially improve reporting and help prevent future drug-related deaths.

Fentanyl

Guidance has been published with advice for local authorities on how to respond to potential potent opioids. This is accompanied by a modelling tool for every local authority on how much naloxone they should be providing.

PHE has published advice to protect first-responders from exposure to fentanyl. The advice outlines what law enforcement, fire, rescue, paramedic and emergency department personnel, need to know when encountering fentanyl and what action they should take.

Hepatitis C

The National Strategic Group on Viral Hepatitis (NSGVH) and PHE are engaging with drug service providers and commissioners about hepatitis C testing and referral to treatment in community drug services. Problems were identified with dried-blood spot test reporting but discussions are in place to resolve this. Positive test results should be fed into the operational delivery network (ODN) multi-disciplinary teams, so the ODN can take on the responsibility of ensuring patients enter appropriate care.

Xanax

Since 2017, data from hospitals and the National Poisons Information Service, and reports from local areas via PHE centre teams, point to an increase in the use of and harm from alprazolam (usually referred to by the brand name Xanax). Seizures data suggests a large number of alprazolam tablets are available in the UK with hugely variable strength: some can be far stronger than expected while others may not contain any alprazolam at all. PHE has published a blog.

Prison to community continuity of care

PHE has published a toolkit with recommendations to improve continuity of care from prison to community drug treatment. The 2017 evidence review of drug treatment in England highlights the risk of relapse and reoffending for substance-misusing prisoners and their vulnerability to drug-related death in the first few weeks following release.

Crack cocaine

The Home Office and PHE are undertaking a rapid enquiry on crack use to improve national and local understanding of the reasons behind the recent increases in crack use. The enquiry will inform appropriate responses and support local attention and action on the issue of increased crack use, and the possible causes. PHE and Home Office staff are interviewing service users, drug workers and police officers in 6 local areas.

Changes to medicine supply and availability

A supply issue with buprenorphine led to price increases and these may continue after the summer. PHE recognises the severe financial problems that continuing supply problems and elevated prices cause for the drug treatment sector, and continues to press for solutions.

The price of sugar-containing methadone solution fell over the last 18 months to much less than the sugar-free formulation, causing a risk that some treatment providers would switch from the latter to the former. This prompted concerns about giving unnecessary sugar to people who might have poor diets and possibly triggering a shortage. But prices have now been more or less equalised so that the decision about which formulation to prescribe should only be a clinical one.

Lofexidine, which is commonly used to help with the physical symptoms of opioid withdrawal, is not currently being supplied to the UK due to manufacturing problems. The out of stock period is likely to last for a few months at least, but the impact should be relatively small. Services have already agreed clinical protocols using appropriate alternatives.

Current shortages of 5 and 10 mg injections of diamorphine are having some impact but this is a minimal problem as higher dose formulations are the mainstay of any diamorphine prescribed as opioid substitution treatment.

Survey of people who inject drugs

PHE have published the annual data tables from, and a Health Protection Report on, the Unlinked Anonymous Monitoring (UAM) survey of people who inject drugs (PWID).

The survey measures the prevalence of antibodies to HIV, hepatitis C and hepatitis B as well as levels of risk and protective behaviours in the PWID population in England, Wales and Northern Ireland. There are also tables for the 9 PHE regions.

Findings from the survey will be covered at the next national intelligence network meeting on Friday 2 November but, in brief, the headlines from the survey show that for people who inject drugs:

• hepatitis C remains the most common infection among people who inject drugs (over a half have antibodies to hepatitis C)
• hepatitis B infections remain low (17%)
• HIV prevalence remains low and stable at less than 1%
• over half (53%) had recently injected crack
• less than 1 in 5 recently shared needles and syringes but nearly 2 in 5 injected drugs into higher risk sites on the body (such as the groin and hands)