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National Assembly for Wales - Health and Social Care Committee Inquiry into new psychoactive substances (“legal highs”)

The Royal College of Psychiatrists in Wales is pleased to respond to this inquiry. We represent a number of Psychiatrists in Wales, specialising in the assessment and treatment of people with complex medical and social needs arising out of addictions or addictive behaviour. We are increasingly treating more people who present with problems associated with legal highs.

Our response is coordinated by Dr Raman Sakhuja, Consultant Psychiatrist and Chair of the Faculty of Addictions. The response below follows the Committee’s terms of reference. For further information on our views of Legal Highs, the Royal College of Psychiatrists’ Central Addictions Faculty published a report into Legal Highs earlier this month One new drug a week: Why novel psychoactive substances and club drugs need a different response from UK treatment providers.

How to raise awareness of the harms associated with the use of legal highs among the public and those working in the relevant public services

1. The Faculty is aware that the use of NPS has grown over the recent years with more people being referred into specialist services with problems of NPS use and misuse. On average, one new NPS is made available for sale each week on the European and online market, with these being potentially available to users in the UK via online retailers (European Monitoring Centre for Drugs and Drug Addiction, 2012).

2. Statistics from the Global Drug Survey, 2014 paint an alarming picture, particularly in terms of the biggest users of research chemicals and legal highs. The United Kingdom trails only the US in the percentage of users of legal highs in the past 12 months. 22% of respondents from the UK said they had bought drugs on the internet.

3. Raising awareness of the use and misuse of these substances is a crucial first step in improving the management of this trend. The Faculty of Addictions believes that raising awareness of these needs to be achieved at various levels:

· There must be greater public education of harms associated with these drugs. One source of current information on these new trends is the internet, which is largely an unregulated source leading to debatable authenticity of information. It is important that the information is clinically sound, scientific and accurate. This remains a challenge for the future as the speed of introduction of drugs generally outweighs the speed of the scientific and health care community to validate that information. But wherever possible, public health campaigns facilitated by relevant Addiction experts can be a useful strategy.

· Since there is an increasing trend of using NPS, including a new cohort of users which are not part of ‘traditional’ cohort of heroin or stimulant users (Faculty report, 2014), raising awareness amongst existing and new service users of the harms associated with these drugs becomes important.

· People using these substances can present at various points of healthcare systems including Emergency departments, Primary Care, Secondary Care including Mental Health services, Voluntary substance misuse services and specialist and statutory NHS services in Wales. Raising awareness and educating these groups becomes logically crucial to enable improved management of a variety of presentations.

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

4. The current specialist prescribing services in Wales dealing with substance misuse are generally funded for the ‘traditional’ drugs- such as Opiates and alcohol related problems. Over the years, however, the trends of substance misuse have been changing and so are the challenges (Sakhuja, 2012) There is an increase in alcohol referrals, prescribed medication dependence, Over-the-counter medication dependence along with NPS (Fig 1). The Faculty believes that the current services do not have the capacity to deal with this increasing demand (Faculty report, 2014)

Fig 1: Mephadrone- referrals for treatment, reproduced from NHS Wales Informatics service & Welsh Government (2014)

5. There are difficulties in keeping up with the fast pace of the NPS market. Another problem we face is that most users of NPSs do not present at services (Faculty Report, 2014), though some of our established clients will admit to some use. Maintaining or even attaining first hand clinical experience is difficult. It raised the question as to what, if any, clinical services should be offered over and above what is available already. We do not and cannot know what is coming to current services with the drug groups on the Welsh National Database for Substance Misuse (WNDSM). If any specific services are set up they need to be part of research program given the unknowns.

6. WEDINOS (the Welsh Emerging Drugs and Identification of Novel Substances Project) is used to analyse substances brought in to Substance Misuse Services, although its main intention at the outset was to be used in relation to A&E presentations and matching substances taken with clinical presentation. We would like to see how successfully this has been done across Wales. We would also like to see WEDINOS carry more public health information and link into other credible information sources.

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

7. The Faculty is aware that data collection for NPS within specialist services across Wales is variable. The Faculty, however, is not aware of how best this data collection gets transferred into meaningful data for clinical service development both at a national and at a local level. The Faculty recommends that current service provider databases should be analysed and a standardised way of reporting be developed. The Faculty of Addictions in Wales can help with the analysis and the clinical components of the database requirements. To be efficient, it may be useful to be able to trace the referral pathway or the patient journey, thus integration of databases becomes important as useful interventions ranging from raising awareness, harm minimisation strategies to specialist pharmacological and psychological support can be charted and put in place by this integration and process mapping.

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

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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

8. With the changing trends, the Faculty of Addictions in Wales fully supports the RCPsych Addictions Faculty report One new drug a week recommendations which include:

a. Making NPS and club drugs part of ‘core business’ of service delivery

b. Raising awareness and educating the front line staff in primary care, secondary care, emergency departments and wider substance misuse services of the harms associated with these drugs and clinical management of these harms.

c. Due to the varied nature of presentations at different parts of healthcare, it is crucial to improve the links of the non- specialist services and specialist services. This can be achieved by increasing the Liaison role of Addiction specialists within the various healthcare settings.

d. The rising trends necessitates the involvement of Addiction specialists and other stakeholders to carry out research in the effects, harms and management of clinical problems associated with NPS

e. The Novel drugs may require Novel treatments and with the rise in demand and lack of capacity necessitates resource allocation to specialist services to be able to meet the demand- both for research and for developing novel treatment strategies.

References

1. Royal College of Psychiatrists, Addictions Faculty Report- One New Drug a week, 2014

2. Winstock, Adam. Reflections on the results of the world’s biggest ever drug survey, 2014 http://www.globaldrugsurvey.com/facts-figures/the-global-drug-survey-2014-findings/

3. Sakhuja, R. Addiction Psychiatry in Wales- Current status and future challenges. RCPsych Newsletter, 2012

4. NHS Wales Informatics Service, Welsh Government (2014) Clients Entering Treatment for Club Drugs (2005/6 to 2012/13). Welsh Government.