Research and analysis

Cover letter from ACMD with advice on synthetic cathinones (accessible)

Updated 12 February 2025

ACMD Chair: Prof Owen Bowden-Jones

Synthetic cathinones working group Secretary: Lydia Chaloner and Oli Gibson

1st Floor (NE), Peel Building
2 Marsham Street
London
SW1P 4DF

Rt Hon Dame Diana Johnson DBE MP
Minister of State (Minister for Policing, Fire and Crime Prevention)
2 Marsham Street
London
SW1P 4DF

3 February 2025

Dear Minister,

RE: ACMD Report – ‘Synthetic Cathinones – An Updated Harms Assessment’

The ACMD was commissioned in May 2023 by the previous Minister of State for Crime, Policing and Fire to provide an updated harms assessment of 3’,4’- Methylenedioxy-α-pyrrolidinohexiophenone (MDPHP) and other synthetic cathinones under the Misuse of Drugs Act (MDA) 1971.

The ACMD is pleased to enclose its report, which considers the harms and control of synthetic cathinones and includes recommendations to reduce their harms across the UK. These include recommendations on appropriate domestic controls under the MDA, the 2001 Regulations and the Misuse of Drugs (Designation) Order 2015, following a thorough review of the evidence available. The ACMD is grateful to national and international experts who provided their expertise to this review.

The ACMD last reviewed cathinones in 2010, following a period in which synthetic cathinone use in the UK had increased significantly. At that time, these substances were often considered to be cheap and legal alternatives to more established stimulant-type illicit drugs such as cocaine and amphetamines. The outcome of this 2010 harms assessment resulted in a recommendation to categorise these compounds as Class B under the MDA and for a generic definition of these compounds to be included in the Act.

Since control of synthetic cathinones in 2010 via the MDA, there has been an observed increase in use and harms from these compounds, especially over the first half of the last decade. Additionally, large numbers of new synthetic cathinones have been detected in illicit markets in the UK and elsewhere. The generic definition in the MDA has been successful in capturing the majority of these in Class B.

Of particular concern, reports suggested that 3’,4’-Methylenedioxy-α- pyrrolidinohexiophenone (MDPHP) and related drugs (types of synthetic cathinones sometimes sold as “Monkey Dust”) have been linked to violent incidents and adverse health effects, with health and social harms primarily concentrated in and around Staffordshire. The ACMD has therefore considered carefully whether these specific compounds are more harmful than other synthetic cathinones and may therefore need separate classification under the Misuse of Drugs Act 1971.

The ACMD also considered specific synthetic cathinones that are causing health and social harms but are not captured by current generic definition for cathinones, updating the information available about their pharmacology and health or social harms.

The following conclusions were reached after review of synthetic cathinones by the ACMD Working Group:

1. Conclusions

Use of synthetic cathinones has been declining in the UK in recent years, mainly driven by a reduction in prevalence of mephedrone use since 2010. The number of deaths involving mephedrone has been falling since 2015. Since then, there has been an increase in the proportion of deaths involving other cathinones, but absolute numbers of deaths remain low compared to those involving other substances of misuse such as heroin or cocaine and have not increased recently.

Other than mephedrone, the synthetic cathinones most commonly involved in drug-related deaths in the UK over the last 5 years have been MDPHP, α-PHP and α-PVP, all pyrrolidino-cathinones, as well as dibutylone. Involvement of these compounds in drug-related deaths could reflect their toxicity or their frequency of use, however, their detection in cases of drug- related death does not mean that they are the cause of death, as other compounds are almost always identified alongside them.

There are pharmacological reasons to suggest that pyrrolidino-cathinones may have more marked psychostimulant effects and abuse liability compared to other cathinones such as mephedrone. These include the potency of their actions as DAT and NET inhibitors with their associated low SERT:DAT ratios and their increased lipid solubility, which may increase penetration into the brain. While a low SERT:DAT ratio may not be a consistently reliable indicator of high abuse liability, there is also accumulating evidence that some pyrrolidino-cathinones display increased re-enforcing effects in primates, which is consistent with more severe dependence liability. The animal research studying cathinone toxicology, however, is incomplete.

Very limited human data exists from which to draw reliable conclusions about the relative toxicity of pyrrolidino-cathinones compared to other cathinones. Comparisons in humans are problematic because observed toxicity may be influenced by other factors besides the specific cathinone involved, such as the dose of the product used, the purity of the preparation, the route of administration and the effects of other substances as multiple exposures are common. In relation to dose, it is not possible to know if producers are diluting appropriately these more potent drugs with excipients to ensure that dosing delivers appropriate amounts of the cathinone needed to obtain the desired effects without causing toxicity. There are reports of pyrrolidino-cathinones producing marked psychostimulant effects, but these are also described with other cathinones, and it is not possible to demonstrate with certainty that the risk of adverse outcomes from human use is higher with pyrrolidino- cathinones. Data provided for this report by UK stakeholders suggests a disproportionately high representation of pyrrolidino-cathinones in post- mortem (PM) toxicology cases compared with drug seizure or submitted sample analysis. Interpretation is difficult, however, because the numbers involved are relatively small, seizure or submitted samples counts do not necessarily reflect prevalence of population use, and deaths where compounds are detected at PM may be caused by co-used drugs.

There are particular concerns about synthetic cathinone use in North Staffordshire and the surrounding areas, where the use of ‘monkey dust’ is commonly reported and associated with antisocial behaviour, with substantial effects on local communities. From the limited testing performed, ‘monkey dust’ has been found to contain various pyrrolidino- cathinones, specifically MDPHP, α-PiHP or α-PHP, sometimes with other substances of misuse.

Drug-related deaths involving pyrrolidino-cathinones are much more common in North Staffordshire and surrounding areas than elsewhere in the UK and deaths in that geographic area account for most drug-related deaths in the UK involving a pyrrolidino-cathinone, with the compounds most commonly involved being MDPHP, α-PHP and α-PVP. The reason for this high local concentration of use and harms in relation to these compounds remains unclear.

2. Legislative options

Synthetic cathinones appearing in illicit drug markets, including the pyrrolidino-cathinones found in ‘monkey dust’, are almost all currently classified under the MDA as Class B. In view of their involvement in ‘monkey dust’ preparations and the effects of these substances on local communities, as well as their association with suspected drug-related deaths in the UK, it is appropriate to consider the arguments in favour of for and against changing classification to Class A for selected examples.

The lower sentencing for possession and supply offences (Table 7 in the report) for Class B compared with Class A drugs means that criminal enterprise involving the former is effectively lower risk and high yield and there may be insufficient deterrent. Courts use Criminal Sentencing Guidelines, which specify the factors they should use in considering appropriate sentences. These are often less severe than the maximum penalties shown in Table 7 (in the report). Reclassification of some or all synthetic cathinones to Class A would ensure greater sentencing powers for the court, potentially providing an increased deterrent for would-be offenders, focusing particularly on those within supply chains. It is not clear, however, how great the deterrent would be, especially for those importing or supplying synthetic cathinones alongside Class A drugs such as heroin or cocaine.

It has been suggested that a higher classification under the MDA might also increase the priority for action by police and Border Force, not just in areas where synthetic cathinone use is prevalent, and this may help disrupt supply chains. Law enforcement tasking processes, from local to regional, are driven by a monthly Tasking and Coordination Group with threats evaluated using the Management of Risk in Law Enforcement (MoRILE) tool. This is a purist and evidential approach to prioritisation, supporting location of a priority grading and tasking a response to an appropriate owner, such as a local police force, Regional Organised Crime Units or the National Crime Agency. A MoRILE score is an ongoing cyclical review process which involves scores determined by a range of factors including impact and harm (to victim, community or environment), threat (intent, capability, geographic, frequency and volume), confidence and organisational position (priority, reputation, resourcing). Reclassification of a drug from Class B to Class A would not specifically influence MoRILE scoring. Classification of a drug may be a factor in determining operational priority, but other key factors determining the impact of the threat on the region (such as harm and scale) are also considered.

One aspect factored in by MoRILE scoring is the geographic impact of a threat. Work has been conducted in Stoke to assess MoRILE scoring, comparing operations involving ‘monkey dust’ with those involving Class A drugs to identify how scores are impacted by current classification. This demonstrates that in Staffordshire, ‘monkey dust’ features highly in drug assessments and above most Class A drugs because of the vulnerability of people using it and the harms it produces for individuals and the community. These include behavioural effects in people using ‘monkey dust’, the more regular supply/demand requirements associated with its short duration of action, and intermittent incidents of higher physical harm, violence, sexual assaults and/or exploitation.

A drug impacting a single force area or contained geographic area, however, is less likely to be adopted at a regional or national level and would likely be owned locally. This is an important consideration because of the localised nature of ‘monkey dust’ use. Police and partners recognise MDA Class A drugs as a greater overall threat and risk than those in Class B, and there is a public expectation that police focus on the greater risk to communities.

Arguments against reclassification of some or all synthetic cathinones to Class A also include:

a) The risk they pose to public health is limited and has been declining overall. Use and harms associated with synthetic cathinones has become less common across the UK in recent years. Although pyrrolidino-cathinones have caused significant problems in and around North Staffordshire, their use appears uncommon elsewhere, especially when compared with other substances.

b) cquisitive crime, with the main societal impact restricted to antisocial behaviour and the use of policing and healthcare resources to deal with this. If reclassification resulted in increased supply costs, the risk of acquisitive crime to fund drug purchases could increase. The removal of legal and cost differentials could encourage some synthetic cathinone users and their suppliers to switch to potentially more hazardous Class A compounds, such as cocaine.

c) Reclassification may increase stigma for people using these drugs, discouraging them from seeking social or medical support. Their further criminalisation may present additional barriers to accessing services such as housing.

d) Reclassification of some (but not all) synthetic cathinones to Class A would require changes to the generic text so that the descriptions of chemical structures and modifications are specific to each class. While this may be possible, it makes the legislation increasingly complex, and this may be confusing for people who use drugs, enforcement agencies, the public and other stakeholders.

e) Reclassification would not affect MoRILE scoring and as such would not necessarily increase the priority for action by police forces, especially in places where use of reclassified compounds was not common.

f) There is a risk that reclassification of some compounds would impact on their possible future use in research, including in the development of new medicines.

There are a few synthetic cathinones detected in the UK or Europe that are not captured by the current generic text and are therefore not controlled via the MDA. Very limited information is available on the pharmacology or health harms associated with these compounds and currently their prevalence in the UK is low. Two have been recorded in drug-related deaths, although it should be noted that this does not necessarily mean that they caused or contributed to the death. One compound, α-D2PV, has pharmacological similarities to diphenidine and has caused clinical toxicity. This compound should, therefore, be considered for classification via the MDA.

3. Other options

More widely, a public health approach, in line with the National Drug Strategy and the recommendations of the Home Affairs Select Committee (2023), is more likely than changes to legislation to impact synthetic cathinone use. This should include early identification of vulnerability, assisting people out of poverty and a joined-up rehabilitation landscape, including referrals into effective treatment across a broad range of public agencies, not just law enforcement. This would also help to reduce the repeat offending cycle within which many individuals find themselves. Structural factors, and inequalities, and their links to substance abuse (Addison, 2023) should not be overlooked. The available research (McCormack and others, 2023a) and the responses from stakeholders to our Call for Evidence suggest that services, including access to accommodation, mental health support and ambulance response services are compromised by stigma and organisational resource challenges.

With the links between homeless populations and the use of ‘monkey dust’, the Housing First model may offer a way forward to address synthetic cathinone-related harms. Housing First places people experiencing long-term homelessness in accommodation, rather than offering housing as a reward for adhering to treatment and support plans (Tsemberis and others, 2004). It acknowledges that people have the right to a home, and that recovery is not linear, making compassionate allowances for when someone regresses on their recovery journey. The Housing First model can be framed as a health intervention by preventing further deterioration (Wood and others, 2019) and providing the conditions needed to begin recovery from long-term homelessness. The model is typified by smaller caseloads for support staff and holistic intervention. Evaluations of Housing First in England have reported promising results in terms of tenancy sustainment (Homeless Link, 2015), outcomes relating to mental and physical health, alcohol and substance misuse (Bretherton and Pleace, 2015), and cost effectiveness (Pleace and Bretherton, 2019). A meta-analysis identified studies that evidenced decreases in drug use for Housing First customers and strong evidence supporting significant improvement of their mental health (Spyropoulos and others, 2022). The ACMD has previously reported on the effectiveness of this model and recommended that strategies and plans across the UK should specifically address the needs of people who use drugs and are experiencing homelessness by recommending evidence-based housing provisions, such as Housing First. This will enable collaboration across departments and agencies to ensure these interventions have a chance to succeed (ACMD, 2019).

Improved access to mental health and drug treatment services are needed, with availability of appropriate routes of referral to each, both in the community and in (or leaving) prisons, and these should include services suitable for young people. While there are no substitute licensed medicinal drugs effective for treating people who use synthetic cathinones, talking therapies (for example, interventions deriving from the cognitive behavioural approach) may be effective and further evaluation of this approach for synthetic cathinone users is needed to gain a more nuanced understanding of their effectiveness. Evidence submitted to this review suggests that having a dedicated worker providing talking therapies may be effective in addressing issues, but more research is needed to produce a robust evidence base on which to plan effective interventions.

Supporting local authorities to better resource the services they commission for co-occurring mental health and drug and/or alcohol use could help to address the challenges the police are facing when working with synthetic cathinone users.

The DIVERT early intervention programme is an interesting approach that could be used for young people arrested in connection with the use of synthetic cathinones and other substances. DIVERT aims to educate and inform them to make informed choices about their drug use. Young people can engage with the programme by asking to see a locally based DIVERT specialist Custody Intervention Coach while in the custody suite. The coaches focus on long-term personal plans, which can include training, education and employment, and access to other services and a supportive environment community through sport, music and more (Bounce Back, 2024). Evaluations of DIVERT programmes have, however, produced mixed results, without consistent reductions in rates of re-arrest (College of Policing, 2021). There are, however, methodological challenges to evaluations and ongoing refinement, and further evaluation of DIVERT interventions appears necessary.

The ‘Safer Streets’ imitative is a programme that aims to reduce serious harm and increase public confidence in policing and in the criminal justice system, with priorities including combatting knife crime and violence against women and girls. It involves putting increasing numbers of police officers, Police Community Support Officers (PCSOs) and special constables into neighbourhood policing roles. One important aim of the initiative is to tackle anti-social behaviour with an improved neighbourhood policing response. There are advantages to the provision of resources from this initiative towards areas where drug use and associated antisocial behaviour and other criminality is prevalent.

Guidance regarding Drug Treatment Orders by the Court at the point of sentencing to mandate people who use synthetic cathinones to engage with rehabilitation programmes may be useful and should be explored further.

Parents have reported that having public health messaging around ‘monkey dust’ would be helpful for safeguarding conversations with their children (McCormack and others, 2023a).

Creating safe spaces for people to go to when in drug and mental health crisis may also help to reduce harms, especially if there is improved access for mental health support (McCormack and others, 2023b). Such actions would be costly and would require additional government funding.

There is a need for appropriate services in affected communities for those affected by sexual violence besides the national online or telephone support services such as Victim Support, Rape Crisis helpline, Survivors Trust and National Male Survivor helpline and online service. These should include adequate resources and trained sexual assault referral centres.

Greater levels of surveillance in neighbourhoods more affected by ‘monkey dust’, including the increased use of CCTV and foot patrolling, may help residents to feel safer and could assist with obtaining greater numbers of immediate prosecutions as a measure to safeguard a community; however, displacement of drug dealing may well occur (McCormack and others, 2023a; Page and Griffin, 2023).

Increasing policing at community level would seemingly benefit the flow of intelligence gathering and likelihood of prosecutions to better safeguard the local community (McCormack and others, 2023a; Page and Griffin, 2023). However, greater surveillance requires appropriate resourcing; police are already finding policing synthetic cathinone-related issues to be time consuming and resource intensive.

Research is needed to develop better field testing so that police forces and other services can more easily identify synthetic cathinones. The current limited understanding of the compounds involved in illicit drug preparations, such as ‘monkey dust’, limits the ability to identify patterns that might be present, which could be useful to those working with people using the drugs, to law enforcement and to healthcare providers. Eurofins Forensic Services screen most of their samples using simple colour tests such as the Marquis Reagent, which is currently approved for use by the Evidential Drug Identification Testing (EDIT) process used by police. Methylenedioxy-cathinone derivatives, such as MDPHP, give a bright yellow colour change with this test. This, however, is not specific and several methylenedioxy-cathinones give the same yellow colour change, while this is not observed for other cathinones, such as α-PVP. Testing confirms that it is the methylenedioxycathinones that react and not an associated cutting agent, such as caffeine. Suitable verification testing will be required by the Home Office or Defence Science and Technology Laboratory (DSTL) prior to this colour change being allowed to indicate a methylenedioxy-cathinone for use by the police. Its introduction to the EDIT process or similar testing could be used under appropriate testing conditions. This is being considered by the Forensic Science Regulator’s Drug Test Kit working group.

It remains essential that there is close monitoring of the use of NPSs in the UK and their adverse health effects. The involvement of NPSs in drug- related deaths is a particularly important measure reflecting serious health harms. Because of this, the ACMD has made recommendations in several previous reports aimed at strengthening the quality and consistency of PM forensic analysis, as it is essential that analysis can detect recently encountered NPS if their impact is to be tracked. The ACMD is aware of and supports the current work of the Office for Health Improvement and Disparities (OHID) and Public Health Scotland in developing relevant data sets, including drug seizure data, submitted sample analysis, emergency department (ED) presentations and PM toxicology, as well as their ongoing work with coroners and forensic toxicologists to enhance the standards of PM toxicology testing.

It is also important that the UK can monitor the emergence of NPSs in Europe, as there is a high risk that compounds appearing in neighbouring countries will also appear in the UK. There are also advantages to joint working with neighbouring countries to avoid duplication of effort in assessing risks associated with these compounds. The current lack of joint working with the European Union Drugs Agency (EUDA) and of access to their European New Drugs Database (ENDD) disadvantages UK stakeholders involved with tracking NPSs and responding to their associated public health challenges, restricting information on use in Europe and requiring duplication of work on chemistry, pharmacology, toxicology, and health and social harms.

Based on the evidence available, the ACMD has made the following recommendations:

4. Recommendations

No recommendation on its own, including changing classification under the Misuse of Drugs Act 1971, is likely to be sufficient to substantially reduce the harms associated with use of synthetic cathinones, particularly where use and harms are localised to specific regions.

The ACMD has the following recommendations, which the government should consider as a package of interventions. These include:

a) Changes to the Act by revision of the generic text for cathinones.

b) Improved health and social care for those with drug use disorders involving synthetic cathinones and other substances.

c) More effective use of law enforcement and the criminal justice system to direct drug users to health and social care services, with expansion of policy initiatives, such as Safer Streets.

d) Improved education and training for users, the public and healthcare professionals.

e) Increased monitoring, surveillance and research funding in relation to synthetic cathinones and other novel psychoactive substances.

These recommendations build on advice provided by the ACMD in previous reports across several of these topics, including ‘Commissioning impact on drug treatment’ (ACMD 2017), ‘Drug-related harms in homeless populations and how they can be reduced’ (ACMD 2019a), ‘Ageing cohort of drug users’ (ACMD 2019b) and ‘Custody-community transitions’ (ACMD 2019c).’

Changes to the Misuse of Drugs Act 1971

(A) Synthetic cathinones currently captured by the UK generic text:

The ACMD acknowledges the evidence that some synthetic cathinones are of particular concern because they are (a) highly potent as DAT and NET inhibitors, (b) may have greater reinforcing properties compared to cocaine and methamphetamine, and (c) can be associated with more severe health harms than others, including increased risks, clinical reports of severe or prolonged behavioural disturbances and of dependency. These adverse effects in users are disproportionately highly represented in post-mortem (PM) toxicology cases compared with drug seizure or submitted sample analysis.

Adverse effects associated with their use may also cause significant harms to local communities. The specific pyrrolidino-cathinones involved, such as MDPHP, MDPHP, α-PHP, α-PVP and α-PiHP, have been most frequently encountered in North Staffordshire and its environs as components of ‘monkey dust’ preparations. These compounds are also detected more commonly there in drug-related deaths. The ACMD has therefore considered carefully whether these compounds require a higher classification within the MDA.

Recommendation 1: All synthetic cathinones captured by the UK generic text remain Class B (MDA) and Schedule 1 (MDR) materials.

While there is some evidence of increased health harms with some specific synthetic cathinones, this evidence is incomplete and there is a particular paucity of evidence of increased harms in humans compared with other compounds in Class B including amphetamines and desoxypipradrol.

The ACMD is particularly concerned about the health and social harms associated with pyrrolidino-cathinones in North Staffordshire and its environs; however, the evidence indicates that this is a localised problem. The overall public health impact of synthetic cathinone misuse across the UK has been declining, and the numbers of drug-related deaths associated with pyrrolidino- cathinones remains low and is not increasing.

Classification of implicated cathinones as Class A would increase sentencing powers for courts and may increase the priority for action by police forces nationally and by Border Force. The impact of this in deterring import, supply or use of these compounds in North Staffordshire and elsewhere is uncertain, however, especially as many suppliers and users are already involved with other Class A substances.

There are potential disadvantages of making specific compounds Class A, including further increasing stigma for users and potentially restricting their access to health and social care support, including housing.

It is also important to avoid the unintended reclassification of compounds with potential legitimate use, including medicines in development, as Class A compounds, because of the potential adverse impacts this may have.

The ACMD is unanimous in considering that the disadvantages of reclassification outweighed any possible advantages and believes that the ongoing problems with synthetic cathinones reported from North Staffordshire would be more effectively addressed by a public health, rather than a criminal justice approach, as detailed in the further recommendations below.

The available information on the pharmacology and health harms of dibutylone was also studied carefully. This compound was not considered to be sufficiently pharmacologically distinct or associated with increased health harms compared to other non-pyrrolidinocathinones to merit changing its current classification under the MDA.

(B) Synthetic cathinones not currently captured by the UK generic text:

Recommendation 2: Following appropriate consultation, the UK generic text for cathinones in the MDA should be updated, so that selected psychoactive cathinones that are not currently captured by the current text are included as Class B, Schedule 1 compounds.

The generic text for synthetic cathinones has been successful in capturing the great majority of synthetic cathinones encountered over the last 14 years.

There are, however, some synthetic cathinones outside the scope of the generic text for which there is some evidence of psychoactivity and that have been encountered in the UK and/or Europe. The prevalence of use of these compounds in the UK is currently low and the evidence of harms associated with them is currently weak. Nevertheless, the advice is that there is sufficient evidence that one of these, α-D2PV, has the potential to cause health or social harms commensurate with classification in Class B because of its pharmacological similarity to diphenidine. There is also a potential future risk from compounds structurally related to α-D2PV, which is where the third carbon atom of the sidechain is incorporated into a cyclic structure. For this reason, adjustment of the current generic text to include such compounds in Class B is considered the most appropriate approach.

There are other synthetic cathinones detected in the UK or in Europe that are not captured by the current generic text, but the ACMD’s advice is that there is currently inadequate evidence of prevalence in the UK, psychoactivity or risk of health or social harms for control under the MDA to be justified at present. Psychoactive examples are currently subject to the provisions of the PSA (2016).

Proposed updated text, with an explanation, for the generic control of synthetic cathinones is provided in Annex D in the report.

It is essential to avoid the unintended classification of compounds with potential legitimate use, including medicines in development, as Class B compounds. A consultation with appropriate stakeholders is therefore necessary before changes to legislation are made. These should include academia and the chemical and pharmaceutical industries.

Should it not be possible to draft generic text without risking capture of compounds for which there may be a potential legitimate use, the specific cathinone of current concern could be controlled as Class B by name. This compound is α-D2PV.

Lead: Home Office

Measure of outcome: The inclusion of the described compounds in Class B of the Misuse of Drugs Act 1971 and Schedule 1 of the Misuse of Drugs Regulations 2001, following appropriate consultation.

Improved health and social care for those with drug use disorders involving synthetic cathinones and other substances

Poverty and social deprivation are major factors underlying drug use, including use of synthetic cathinones, and this also applies to affected communities in North Staffordshire and its environs. Measures to address social deprivation more generally are likely to result in reduced drug use and less antisocial behaviour, but detailed recommendations are beyond the scope of this specific review.

A joined-up public health approach is needed to address the complex needs of people with drug use disorders involving synthetic cathinones, as well as other substances.

These compounds are often used with other illicit substances, including strong opioids or crack cocaine. Affected people also commonly have underlying mental health conditions, sometimes arising from previous trauma. They need timely and barrier-free access to effective drug treatment and mental health provision, involving clear referral pathways that avoid the risk of clients falling between different services.

In view of the association between homelessness and the use of synthetic cathinones, provision of appropriate housing should be considered a priority.

Recommendation 3: Healthcare commissioners, local authorities and other social care partners, NHS Mental Health Trusts, and other providers of mental health and/or drug treatment services should review local services and their referral pathways to ensure that they adequately encompass those consuming synthetic cathinones. Specifically, these services and their staff should be aware of the latest evidence on harms, as contained in this report, and their care pathways must be accessible and able to provide high-quality care for those living with relevant mental health and drug use disorders.

In line with the National Drugs Strategy, adequate and appropriate drug treatment and mental health referral pathways are required to provide necessary care, including with resourcing, to meet locally relevant demand. These services need to be responsive to clients with complex needs, including those with drug use in the context of complex mental health issues. Services should be able to provide evidence-based and holistic care, including to those with multiple needs, and there should be clear referral pathways according to that need. High-quality collaboration, appropriate information sharing, and liaison between different services is essential. These referral pathways should be available without unnecessary barriers to those working in primary care, secondary care (including emergency departments), social services, the police, and the courts, and should adopt a facilitatory, patient-first approach, centred on the needs of the individual requiring care.

Service providers should consider the appointment of dedicated healthcare workers who can provide appropriate therapies to those with drug use disorders, including those affected by synthetic cathinone use. These should be informed by the latest evidence on harms and treatments, such as that contained in this report. They should also consider the establishment of safe spaces for those in crisis, with access to relevant mental health support.

Appropriate services encompassing physical and mental health needs should be available for those affected by, or vulnerable to, sexual and other forms of direct and indirect violence, harm, and exploitation.

This builds on recommendation 3 of the previous ACMD report ‘Drug-related harms in homeless populations and how they can be reduced’ (ACMD 2019a), which encourages evidence-based approaches to engage and retain homeless people in proven treatments. It is also consistent with recommendations provided in the ACMD report ‘Commissioning impact on drug treatment’ (ACMD, 2017), that it remains essential to maintain and protect budgets for drug and alcohol misuse services and to strengthen links between local health and social care systems and drug misuse treatment.

Leads: Department of Health and Social Care, working with NHS England and the Association of Directors of Public Health, Office for Health Improvements and Disparities, Joint Combatting Drugs Unit, local authorities and Integrated Care Board (ICB); Integrated Joint Boards; Regional Partnership Boards; or Health and Social Care Trusts that variously commission mental health and drug treatment services across the devolved nations.

Measure of outcome: Demonstration of clearly defined services supported by dissemination of relevant information, such as that provided in this report, and published referral criteria and pathways that establish working relationships which genuinely put individuals at the centre of their care. ICBs, or their equivalents noted above, would seem appropriate owners of this role, though they might wish to delegate them in certain circumstances to provider organisations.

Recommendation 4: The ‘Housing First’ model should be used to tackle homelessness in deprived communities, including amongst those with drug use disorders such as synthetic cathinone use. Adequate resource should be made available to allow this to happen.

Tackling drug use by homeless people is unlikely to be successful while they remain without appropriate accommodation. Dealing with their homelessness should be considered a priority.

The Housing First model provides permanent housing associated with open- ended support, allowing other issues, including drug use, to be addressed from a stable home platform. The ACMD has previously reported on the effectiveness of this model and recommended that strategies and plans across the UK should specifically address the needs of people who use drugs and are experiencing homelessness by: recommending evidence-based housing provisions, such as Housing First; enabling collaboration across departments and agencies to ensure these interventions have a chance to succeed (ACMD, 2019).

There continues to be a need for the Housing First model to be widely available, but especially in areas where homelessness associated with drug use is prevalent. This requires adequate resource, which usually comes from local authority commissioning, public health and adult social care or charitable sources. Government should consider the current resource available for Housing First programmes and ensure that this is sufficient for these programmes to be effective in these areas.

Continuation or extension of the Rough Sleeping Drug and Alcohol Treatment Grants should be considered to support homeless drug users by provision of accommodation together with drug and alcohol treatment and other support, such as access to mental health and substance dependence workers and peer mentors.

Leads: Ministry of Housing, Communities and Local Government; local authorities; housing associations; Department of Health and Social Care; OHID; equivalents in devolved administrations.

Measure of outcome: Establishment or enhancement of Housing First programmes in areas affected by synthetic cathinone use.

Law enforcement and the criminal justice system

Recommendation 5: Drug users in contact with the criminal justice system should be directed towards appropriate health and social services using established referral pathways, when this is appropriate.

Contact with the criminal justice system offers an opportunity to direct drug users towards appropriate services, with the aim of dealing with potentially reversible factors underlying their drug use and criminal or antisocial behaviour. This may result in contact with drug treatment services or actions to address social issues.

Support programmes for young people under arrest, such as the DIVERT programme, should be available. Their impact on subsequent criminal behaviour should be monitored.

For drug users involved with minor crimes who are encountering the police, and whose pattern of drug use or degree of dependency is sufficient for this to be clinically appropriate, referral to drug treatment services should be considered as an alternative to arrest for those who are willing to engage with these services and can demonstrate consistent attendance. This is already done by several police forces.

Courts should consider increasing the use of Drug Rehabilitation Requirements with or without Mental Health Treatment Requirements within community sentences for offenders with drug use disorders involving synthetic cathinones who have been assessed as suitable (because of regular drug use associated with dependency) and who consent to this approach.

Following on from previous advice (recommendation 2) provided by the ACMD ‘Custody-community transitions’ report (ACMD 2019c), it remains important to reduce the proportion of people who leave prison with unsettled or unknown accommodation on the first night of release and increase the proportion of people who have an assessed need for drug treatment on release who enter treatment in the community within 4 weeks of release.

Leads: Home Office; police forces; courts; prison services.

Measure of outcome: Establishment of support programmes in police stations. Increased referral to drug treatment services from the police. Increased numbers of community sentences with Drug Rehabilitation Requirements involving synthetic cathinone users.

Recommendation 6: The government should establish an appropriately managed fund, possibly within the ‘Safer Streets’ initiative, to support local policing and/or public health initiatives in communities that are particularly affected by drug use.

Adequate resourcing is needed to support local policing initiatives in communities affected by drug use, with the aim of protecting and reassuring local people. The precise measures needed, and the resource required, should be considered locally, but might include fixed resources such as additional CCTV and street lighting. It may also be useful for funds to be available to support local public health initiatives aimed at reducing harms associated with drugs in areas where prevalence is particularly high.

Police and Crime Commissioners have already had the opportunity to bid for resources via the Safer Streets fund launched in 2023. The extension of this fund or the establishment of a further fund to support local initiatives in communities affected by drug use should be considered, not just for fixed infrastructure but potentially also for additional surveillance and, where justified, the employment of staff. This initiative should not be confined to areas affected by synthetic cathinone use, but also those affected by other illicit drugs.

Leads: Home Office; Police, Fire and Crime Commissioners; OHID; local authorities and equivalents in devolved administrations.

Measure of outcome: Establishment of an appropriate fund and distribution to affected communities.

Education and training

Recommendation 7: More detailed information on the effects of synthetic cathinones should be made available to people who use drugs, the public and staff who may encounter drug users, including those working in health, social care housing and criminal justice settings.

The public facing website Frank already contains information on synthetic cathinones, including reference to ‘monkey dust’. This information should be updated to include information on the content of ‘monkey dust’ preparations and more detailed information on cathinones other than mephedrone, including potential adverse effects of pyrrolidino-cathinones. Information should also be provided in an appropriate format for younger people and for those engaging in chemsex. This information should also be provided by other information sources, including the DAN 24/7 telephone helpline in Wales.

Health professionals can register to access information and clinical management advice about potentially toxic substances, including illicit drugs, via the TOXBASE® website. Currently, a search for ‘monkey dust’ on TOXBASE® takes the user to a general page on unknown drugs of misuse.

This should be updated to provide more specific information on the contents of ‘monkey dust’ preparations. Information should also be provided on MDPHP, which currently does not appear to have a specific entry on the website.

Employing organisations such as NHS Trusts and Boards, local authorities and the police should review training provided for staff who may come into contact with people who use drugs. They should ensure that this includes information on the drugs that are commonly used in their local area, the active constituents of street drug products (such as ‘monkey dust’) and their potential adverse health effects. They should also be familiar with appropriate referral pathways and management of people who use drugs. Training should be designed to reduce stigmatising attitudes of staff towards people who use drugs, including those who use synthetic cathinones. Training should be reviewed regularly and updated to include new and locally emerging substances.

This advice builds on advice about staff training (Recommendation 2) provided in the earlier ACMD report ‘Ageing cohort of drug users’ (ACMD, 2019b).

Leads: Talk to Frank website; Dan 24/7; National Poisons Information Service; UK Health Security Agency; NHS Trusts and Boards; local authorities and their devolved equivalents; police forces.

Measure of outcome: Availability of appropriate online information. Delivery of updated information and training by responsible agencies.

Monitoring, surveillance and research

Recommendation 8: More detailed and regular analysis of the contents of ‘monkey dust’ and other commonly encountered NPS preparations should be carried out to monitor their contents and, when possible, purity.

Currently, there is limited information available on the contents of ‘monkey dust’ preparations in circulation. Police forces in affected areas should establish a programme of regular and systematic analysis of seized ‘monkey dust’ preparations to track their contents and, when possible, purity. Resource should be made available to allow this to happen.

Leads: Home Office; police forces in affected areas.

Measure of outcome: Reporting the content of seized ‘monkey dust’ preparations at least annually.

Recommendation 9: The development of improved field testing of street drugs, including ‘monkey dust’ preparations, should be funded with the aim of detecting different synthetic cathinones.

It would be helpful to police forces to have methods of field testing available that can identify synthetic cathinones in seized materials and differentiate them from other illicit drugs. Materials containing synthetic cathinones could then be sent for more detailed forensic analysis to identify the specific compounds involved. This would be a more cost-efficient approach than sending all samples for detailed analysis. It would facilitate criminal prosecution of offenders and the identification of those needing drug treatment and rehabilitation in relation to synthetic cathinone use. It would also provide more detailed analytical information, so that problem compounds and patterns of use could be identified at an earlier stage.

Funding should be provided to develop improved field testing of illicit drug product including “monkey dust” preparations, to detect different synthetic cathinones. This should align appropriately with Evidential Drug Identification Testing (EDIT) and testing for public and social health purposes. This could involve development of a simple colour tests using the Marquis Reagent described in paragraph 16.13 (in the report).

Leads: Home Office; National Police Chief’s Council; police forces in affected areas.

Measure of outcome: Development and roll out of an effective field-testing methodology to identify synthetic cathinones.

Recommendation 10: Research should be funded to study the appropriate management of stimulant use disorders including those associated with synthetic cathinones.

There is currently some uncertainty about the optimum management and effectiveness of drug use disorders involving stimulants, including synthetic cathinones, including the role of talking therapies.

Research funding organisations such as the National Institute for Health and Care Research (NIHR) should consider this area for funding, possibly via the Health Technology Assessment (HTA) programme.

Leads: NIHR; HTA Programme

Measure of outcome: Inclusion in the HTA funding programme or an alternative.

Recommendation 11: Research should be undertaken to compare the pharmacology and human health harms of individual cathinones that are currently prevalent in the UK.

This review has identified evidence gaps that have made it difficult to make robust comparisons between the pharmacology of different stimulants, including different types of synthetic cathinone. There is also a lack of comparative information on the adverse human health effects of these compounds, including their acute toxicity and their ability to induce drug dependence.

It would be useful to develop expertise and research capacity within the UK for the study of the pharmacology and human health effects of different stimulants, including those that may emerge in the future. Research on the relationship between findings in animal studies and effects in humans is also required.

UK funding bodies such as the Medical Research Council (MRC) and NIHR should consider these areas of research for future funding.

Leads: MRC; NIHR.

Measure of outcome: Availability of research funding.

Recommendation 12: Research should be funded to better understand the reasons for the high prevalence of use of pyrrolidino- cathinones in North Staffordshire and its environs.

Evidence obtained for this review has demonstrated that use of pyrrolidino- cathinones, especially as constituents of ‘monkey dust’, is highly concentrated in North Staffordshire and its environs. The reason for this is unclear and it would be useful to have information about this in order to better plan appropriate responses in areas affected and elsewhere.

Local authorities and police forces should consider funding research to better understand the underlying reasons for the increased use of synthetic cathinones in areas of high prevalence.

Leads: Local authorities and police forces in areas of high prevalence.

Measure of outcome: Local availability of research funding.

Recommendation 13: In the event of changes being made to the legal status of synthetic cathinones, research should be funded to examine the impact of these changes on their availability and on health and social harms associated with these and related compounds in the UK.

There is currently little information available on the impact of different levels of legal control on the health and social harms of drugs of misuse. As a result, there remains uncertainty about the effects of increasing the level of classification for compounds already controlled via the MDA.

Should such a change be enacted now or in the future, research should be conducted to examine the impact of this on the availability of these and related compounds and on drug-related health and social harms. This should include monitoring related drug seizures and human health harms including drug-related deaths. This research should not be restricted to synthetic cathinones as there is a need to monitor for the possible displacement towards other related compounds, such as amphetamines and cocaine.

Lead: Home Office

Measure of outcome: Publication of a review of the impact of legal changes within 5 years of implementation of any change in legislation.

Recommendation 14: Government should discuss developing a closer working relationship with the European Union Drugs Agency to facilitate better sharing of information about illicit substances in circulation in the EU and UK.

The current lack of joint working between the UK and EU in the area of drug misuse is a significant disadvantage to both sides, as it has resulted in a loss of data sharing and the need to duplicate work of mutual importance. Drafting this report, for example, has been made more difficult and time consuming due to lack of access to resources held by EUDA, including the ENDD. This restricts the information available to UK stakeholders about drugs in circulation within the EU. This is an important disadvantage because of the high risk that these substances may also appear here. Work to establish the chemistry, pharmacology, and health harms of drugs of misuse and especially NPS would be greatly assisted by access to the resources already held on the ENDD, which the UK no longer has access to.

There would be significant mutual advantages to the negotiation of a memorandum of understanding to underpin joint working on drug issues and access to information held by each side.

Lead: UK government.

Measure of outcome: Establishment of a formal working arrangement between the UK and EUDA.

We would welcome the opportunity to discuss this report in due course.

Yours sincerely,

Professor Owen Bowden-Jones
Chair of the ACMD

Professor Simon Thomas
Chair of NPS Committee