'The feeling of crisis has come back.' The 'known unknown' of novel psychoactive substances

The clue is in the name: novel psychoactive substances (NPS). The emergence of new drugs is not in itself unique. However, the speed and scale by which these substances – intended to mimic the effects of traditional drugs controlled under legislation – have emerged has left police, health professionals and policymakers, for the most part, on the back foot.

“It’s a known unknown, if you like,” says Dr Brian Kidd, a clinical senior lecturer in addiction psychiatry for NHS Tayside. “We know it’s there. We know that it’s queering the pitch. We know that there are times when we’ve got patients who suddenly go off the road and we don’t understand what’s happened and now we’re thinking, ‘I wonder if they’ve taken a legal high?’ and that is what’s becoming apparent. And we’re behind that curve.”

Treatment services that have become mostly opiate-oriented are not set up particularly well to respond to the population using NPS, Kidd suggests, despite clinicians being well versed in what to do with drugs they’re based on.

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“A lot of the chemicals that are being used, we’re not experienced in dealing with,” adds Dr David McCartney, clinical lead for Lothians & Edinburgh Abstinence Programme. “They’re causing harms that are unusual for us to see around mental health, physical health and infections, and they are also challenging to treat. We can’t test for them, there are withdrawal syndromes associated with them, and people can become very difficult to manage because of the behaviours associated with their use and when withdrawing from them.”

A&E departments and mental health services are feeling the effects too. Pragmatic medical approaches are being taken in response. “But it’s a fact that most of these substances can be quite idiosyncratic in their presentation and what might affect or not affect one person can profoundly affect somebody else,” adds Dr Alastair Ireland, clinical director for emergency medicine for the north sector in Glasgow.

What is most worrying is the specific way in which the problem has manifested itself in Scotland’s capital. “Edinburgh is very unique in Scotland in that we’ve got this quite significant cohort of people who are injecting NPS, whereas in other parts of Scotland the tendency is to be using them in different ways but not injecting,” says McCartney. Against that backdrop, health professionals, together with police, went to the Advisory Council on the Misuse of Drugs in April, amid an increase in the number of intravenous drug users using a product known as ‘Burst’.

The UK Government has since put in place a 12-month banning order for five substances. Shops have been revisited and products containing the banned compounds have not been seen on shelves, though law enforcement is realistic about its impact. “The banning orders are firefighting really,” says Detective Inspector Stevie Russell of Police Scotland’s specialist crime division.

“You’re slowing them [producers] down because they’re stopping that [particular product] but there’s that many different chemical structures and compounds they can change that, by changing one slight bit of it, it takes it right outside of the banning order. They just morph into something else.”

In recent weeks, the new Conservative administration set out its answer. The Psychoactive Substances Bill seeks to mirror legislation in Ireland by introducing a blanket ban on production, distribution, sale and supply. Reaction has been mixed.

For the police, which has been, as Russell puts it, “trying to come up with obscure ways of dealing with the problem in front of us”, any legislation is welcome. Yet the need for a system akin to New Zealand’s, which places the onus on manufacturers to prove their products pose a low risk of harm, continues to be underlined. “For what is right in front of us, what we can actually see, transferring the burden of proof would make things a damn sight easier for us,” adds Russell.

Though legislation will not stop drug use, McCartney believes it will prove helpful in potentially changing the way in which they’re used. “They’re too available at the moment in Edinburgh,” he adds. Kidd appears more skeptical. “That is not the response that’s going to have the impact that we need to have. What it is probably going to mean is the inevitable increase of criminalisation of people who are using intoxicants.”

Deaths in Scotland where NPS were found present in the body have increased from four in 2009 to 113 in 2013, while those in which it has been implicated have risen from three to 60 over the same period. Though NPS will undoubtedly continue to attract attention as legislation passes through Westminster, it is but one part of a much larger story given fewer than five per cent of all drug-related deaths over the last five years on record have seen such substances implicated.

Even so, Dr Roy Robertson, chair of the National Forum on Drug-Related Deaths, believes it is contributing to a growing recognition that Scotland has entered a “new phase of injecting”. A longstanding recommendation of the forum’s – supervised drug consumption rooms and injectable ‘medical’ grade heroin – was made once again in their latest annual report published last month, albeit broadened out to form part of a ‘coordinating centre for services for injectors’.

With almost two-thirds of individuals who suffered a drug-related death in 2013 not being treated for their problem drug use at the time of death, the intention behind the call remains to get people into and keep them in treatment. According to Robertson, the current Scottish Government minister and his two predecessors have all said they have no objection in principle – a perspective that has not necessarily been communicated publicly – but rather, funding has inhibited health boards.

“The feeling of crisis has come back and it does feel like it did in the early 1980s,” says the Muirhouse-based GP. “And I keep thinking it’ll be temporary, people can’t be that reckless that they’ll go on injecting things quite so damaging – but there is no sign of it stopping. Here we are three or four years into a major epidemic of injectable novel psychoactive substances and it’s not going away and so everybody is recognising that.

“Our problem here of injectables has the potential to reignite the HIV epidemic, if it isn’t happening already – we don’t know that, it could be happening already and we haven’t measured it. There are certainly little pockets of HIV in Glasgow and other places. It feels [like] familiar territory and coming back to the question of injecting rooms, supervised consumption and heroin, that really is another reason why you want to get that in place so you’ve got a capacity to deal with people who are injecting and are injecting recklessly and sharing needles, to try and prevent that HIV and Hepatitis C happening again.”

Less contentious has been the introduction of the first-ever performance target for drug treatment, which culminated in 95 per cent of the 4,033 people who attended an appointment for drug treatment in the final three months of 2014 waiting three weeks or less. That, of course, only tells part of the story. In NHS Tayside, for example, the substance misuse service was designed to manage 1,500 people. The current caseload is almost double that.

As part of their 2008 Road to Recovery strategy, the Scottish Government is working on ways of measuring quality of care given access now appears to have been addressed. “On the ground, I think that presents a very significant challenge to beleaguered services,” adds Kidd, who chaired the recently disbanded Drugs Strategy Delivery Commission, the independent group tasked with overseeing the strategy. “Caseloads in my service average about 100, so a nurse will be responsible for 100 patients. When I started working in the field of addictions as a consultant in 1996, my entire service in Forth Valley, which consisted of six full-time nurses, had a caseload of 98. 

“The ability to meet the needs of individuals and deliver well-tailored high quality care becomes less. It’s stack ‘em high, sell ‘em cheap [and] ultimately, what you can achieve becomes more and more limited in those circumstances.”

The prevalence of problem drug use hasn’t declined since 2006. Drug-related deaths, which now sit at 16 per 100,000 in Scotland compared to 12 almost a decade ago, are among the highest in Europe. Beneath those headline figures, though, the landscape is changing. Estimated prevalence in both the 15-24 and 25-34 year old age groups is down as rates appear to be increasing in the 35-64 age category.

There has been a wider shift within the drug and alcohol field, however, suggests Addaction Scotland director Andrew Horne. “I would think the number one presentation coming into services now is alcohol use,” he says. “There is still a lot of older heroin users but we’re not seeing young people come in with heroin problems, we’re seeing them come in really with alcohol problems at a younger and younger age group all of the time.”

Off the back of work with Asda in Dundee, which has seen the charity work in every secondary school across the city, as well as run information stalls within stores, a similar scheme is expected to launch in Glasgow from next month. That will work with pupils in the final two years of primary school as well as second and fourth year of high school around alcohol and drugs. Addaction is also to work with the Children’s Hearing System to provide more intensive support for young people throughout the city who have demonstrated high-risk behaviour relating to alcohol and drugs.

Six years on from Scotland’s alcohol strategy being published, there are some positive signs. Having made alcohol brief interventions subject to a HEAT standard, a target to carry out just over 60,000 ABIs was exceeded by more than 40,000 in the last year on record. “It remains the first programme of its type in the world and there had been research evidence on the effectiveness of this for 20-plus years before we implemented it, so there is a lot of envy actually around the world of the Scottish programme,” says Dr Peter Rice, chair of Scottish Health Action on Alcohol Problems.

Minimum pricing continues to be caught in a legal wrangle, much to the frustration of Rice. Even so, alcohol-related mortality rates have fallen by more than a third since their peak in 2003. Hospital admissions for alcohol-related conditions have seen a similar downward trend since 2007-08.

However, with the exception of increased awareness of the harm caused by alcohol, surveys suggest public knowledge and attitudes around alcohol haven’t really budged in the last ten years. “In a way, I am not so worried about the attitudes as if we see the behaviours and the outcome measures improving, which we have really very substantially, that for me is the most important thing,” says Rice.

Even so, with a survey earlier this year suggesting that children’s recognition of Foster’s lager exceeded the likes of Ben & Jerry’s ice-cream, the SHAAP chair believes alcohol marketing, and the sports sponsorship that sits within it, needs to be critically thought through. “We’re in a situation where lager brands are more familiar to children than ice-cream brands and that’s not a good thing.”