Understanding The Patterns Of Use, Motives, And Harms Of .
Understanding the patterns ofuse, motives, and harms ofNew Psychoactive Substancesin ScotlandHEALTH AND SOCIAL CAREsocialresearch
Understanding the patterns of use, motives, and harmsof New Psychoactive Substances in ScotlandFinal Report to the Scottish GovernmentNovember 2016Katy MacLeod1*, Lucy Pickering2*, Maria Gannon2, Sharon Greenwood2, DaveLiddell1, Austin Smith1, Lauren Johnstone1, George Burton11Scottish Drugs Forum; 2 University of Glasgow* This was a collaborative research project between Scottish Drugs Forum andGlasgow University, led by Katy MacLeod and Lucy Pickering.
ContentsAcknowledgements . iGlossary: Abbreviations & Terms . iiGlossary: Drug Wheel Categories . iiiGlossary: NPS Categories . ivExecutive Summary . vBackground. vMethods . vFindings . vPatterns of NPS Use: Key Findings . vMotives: Key Findings .viConsequences of Use: Key Findings . viiTreatment and Psychoactive Substances Act: Key Findings . viiiKey Learning Points . x1. Introduction . 11.1Background to the Study . 11.2The Legal Context of NPS in Scotland . 21.3Aims and Objectives of the Study . 21.4Study Population . 31.5Defining NPS . 42. Methods . 72.1Ethics and Research Governance Permissions . 72.2Prevalence Estimates . 72.3Qualitative data. 82.4Quantitative Data . 113. NPS Use among vulnerable populations in Scotland . 183.1Quantitative survey and „risk‟ groups . 183.2People who inject drugs . 203.3Mental health service users . 213.4Vulnerable young people . 223.5Homeless people . 223.6Men that have sex with men (MSM) . 233.7Service Provider Survey Results . 233.8Discussion . 26
4. Motives for NPS Use . 274.1Introduction . 274.2Trying NPS . 274.3Not Trying and Stopping Use . 344.4Continuing to Use NPS . 374.5Discussion . 405. Consequences of Use . 425.1Introduction . 425.2Positive Effects . 425.3Negative Effects . 435.4Mental Health Harms . 445.5Physical Health Harms . 495.6Social Effects . 535.7NPS Use and Relationships . 555.8Population-Specific Harms . 585.9Discussion . 616. Treatment and Legislative Responses . 636.1Introduction . 636.2Contacts with Services . 636.3Providing Information and Support . 676.4Improving Services . 726.5The Psychoactive Substances Act . 766.6Discussion . 797. Discussions and conclusions . 827.1Prevalence. 827.2Motives for use . 837.3Consequences of use . 837.4Improving practice . 867.5Service developments . 877.6Engaging vulnerable populations . 887.7Information on NPS to people who use NPS . 897.8Psychoactive Substances Act . 907.9Study limitations . 917.10Closing remarks . 92References Cited . 93Appendices . 103
A. Technical Appendix 1: NEO Data . 103B. Technical Appendix 2: Prevalence estimate . 108C. Interview Participant Demographics . 109D. Qualitative Data Collection: Topic guides . 110E. Focus Group demographics . 113F. Online Surveys . 114NPS Survey . 114NPS Survey Draw . 114Staff survey . 114
AcknowledgementsThis report would not have been possible without the hard work and contributionsof many people. Firstly, we would like to take this opportunity to acknowledge all683 participants who took part in interviews, focus groups, or completed the onlinesurvey – without your contribution, we would not have been able to do thisresearch. Thank you for taking the time to contribute.Secondly, we would like to thank Saket Priyadarshi, John Campbell, and JoMcManus from NHS Greater Glasgow and Clyde, and Jim Sherval and ConLaffery from NHS Lothian for clinical considerations guidance, access to injectinginformation data sets and general advice, and Gregor Hodge for insights into NPSand opiate use.In addition to this we give special thanks to our other local collaborators who wereessential in gaining NHS ethical permissions across Scotland.Marie Wilson, NHS Ayrshire and Arran; Susan Walker, NHS Borders; JackieDavies, NHS Dumfries and Galloway; Steve Walker, NHS Fife; Elaine Lawlor,NHS Forth Valley; Fraser Hoggan, NHS Grampian; Debbie Stewart, NHSHighland; Pauline Izat, NHS Lanarkshire; Karen Smith, NHS Shetland; RussellGoldsmith, NHS Tayside; Karen Peteranna, NHS Orkney.Many thanks also go to the services across Scotland who hosted the researchteam and displayed study information, those staff who participated in focus groupsand to Mark Adley for use of the drug wheel. Finally, particular thanks go to theScottish Drugs Forum Peer Researcher Team, who were involved with recruitmentand data collection for the NPS survey:David Barbour, Martin Boyle, Pauline Farrow, Nicola Middleton, RaymondMoffat, Ian Murray, Derrick Percival, Sandy Strang, Gary Trotter, Zoe Wilson.Finally, we would like to thank the Research Advisory Group: Vicky Carmichael,Fiona Fraser, Peter Whitehouse, and Alistair Greig - for their advice and support inconducting this research. We would also like to add an extra special thank you toIsla Wallace (also from Research Advisory Group) for consistently providingexcellent guidance and encouragement to all members of the research team –thank you.This report is dedicated tothe memory of:Zoe Wilson(1974 – 2016)i
Glossary: Abbreviations & TermsA&EADPBBVBenzosBZPAccident and EmergencyAlcohol & Drug PartnershipBlood-Borne VirusesBenzodiazepineAlso known as party pills. Tablets containing benzylpiperazine (apiperazine which produces empathogenic and stimulant effects)Comedown To lose the effects of a drug and return to a normal or more normalstateChemsex The use of drugs, often illegal ones, to increase pleasure during sexChemsIn the context of chemsex, the use of crystal methamphetamine,mephedrone, and/or GHB/GBLDRDDrug Related DeathsEMCDDA European Monitoring Centre for Drugs and Drug AddictionGGCGreater Glasgow and ClydeHeadshop A retail outlet selling a range of NPS or „legal highs‟ and otherparaphernalia used for consumption of drugs such as cannabisIEPInjecting Equipment ProviderIDUInjecting Drug UserMDAMisuse of Drugs Act 1971MSMMen who have Sex with MenNEETNot in Education, Employment, or TrainingNPSNew (or Novel) Psychoactive SubstancesOn tickTo buy drugs, usually with the agreement to pay laterORTOpiate Replacement TherapyParty pills See BZPPSAPsychoactive Substances Act 2016PWIDPeople/Person Who Inject DrugsSALSUSScottish Schools Adolescent Lifestyle & Substance Use SurveySCJSScottish Crime and Justice SurveySDFScottish Drugs ForumSDMDScottish Drug Misuse DatabaseSlamming Injecting during chemsexTCDOTemporary Class Drug OrderUNODCUnited Nations Office on Drugs and Crimeii
Glossary: Drug Wheel CategoriesThis report utilises The Drugs Wheel to categorise substances into comparablegroups. This tool, developed by Mark Adley, was developed in response to therapidly expanding number of psychoactive substances available. More informationon this tool can be found at www.thedrugswheel.com. A visual presentation of thewheel is found within the „Introduction‟ section of this report. The table belowpresents a breakdown of the categories, providing common effects and examplesfor each.NameCommon Effects1Example(s)“Stoned”, calm, munchies, chilled out, floaty,Cannabinoids giggly, sensual, paranoid, dry mouth, anxiety,lazy, mental health issues.CannabisDepressants“Buzzing”, euphoric, confident, relaxed, risktaking, withdrawal, unconsciousness, coma,vomiting, ut of body”, euphoric, floaty, disconnected,relaxed, numb, scared, unable to move, in a“hole”.Ketamine, Salvia,Methoxetamine“Loved up”, connectedness, warmth,Empathogens understanding, sweating, arousal, mood swings,depression.MDMA (ecstasy),PMA, MDAIOpioids“Invincible”, confident, pain-free, safe, euphoric,constricted pupils, addiction, hallucinations,withdrawal, overdose.Heroin, Tramadol,MorphinePsychedelics“Trips”, spiritual connection, heightened senses,visual or auditory hallucinations, anxiety, panic,mental health issues.LSD, 5-MeO-DALT,AMTStimulants“Uppers”, increased energy, increased heartrate, euphoria, dilated pupils, paranoia, anxiety,sexual arousal, sexual impotence, comedowns.Amphetamine,Cocaine,Mephedrone1All common effects taken from Adley (2016) The Drugs Wheel. Available WheelCategories 2 0.pdf [last accessed: 26/7/2016]iii
Glossary: NPS CategoriesThroughout this report, NPS types will be linked to Drug Wheel categories. Thetable that follows sets out the categories we discuss, the corresponding DrugWheel category, and some commonly used names.NameDrug WheelCategoryCommonly Used NamesSyntheticCannabinoidsCannabinoidBombay Blue, Annihilation, Clockwork Orange,Doctor Green Thumb, Exodus, Herbal Haze,Joker, Sensate, Pineapple Express, Spice,Herbal IncenseBenzodiazepinetype NPSDepressantPhenazepam, Etizolam, Diclazepam,Flubromazolam, FlubromazepamStimulant-type NPS StimulantGogaine, Ching, Mr. White, Columbiana, CharlySheen, Dust till Dawn, Ivory Wave, Blue Stuff,Bath Salts, SniffMephedroneStimulantMagic, Bubbles, M-Cat, Meow Meow, EP, Burst, Ocean BurstSalviaDissociativeSalvia, Sally Div
Executive SummaryBackgroundNew or Novel Psychoactive Substances (NPS) imitate the effects of illegal drugsand are commonly (although misleadingly) referred to as „legal highs‟. Over thelast decade the use of NPS has expanded in Scotland. Current data sources andanecdotal reports have identified a number of vulnerable or potentially at riskgroups. This report presents results of mixed methods research on NPS useamong five key target populations: vulnerable young people, people in contactwith mental health services, people affected by homelessness, people who injectdrugs (PWID) and men who have sex with men (MSM).MethodsQualitative interviews were undertaken with 33 people who had taken NPS. Overhalf of participants belonged to two or more target groups. Four focus groups wererun with front line staff working with people who use NPS across Scotland, andattended by 42 practitioners. Key themes from qualitative analysis of theinterviews and focus groups were used to inform the design of two surveys: onefor service users2 (the NPS survey), and one for staff (the staff survey). 424service users and 184 front line workers completed the surveys.FindingsFindings are presented on patterns of NPS use, motivations for andconsequences of use, and treatment and legislative responses.Patterns of NPS Use: Key FindingsVarious service data sets were explored, including specialist drug service data andnational data sets, in an attempt to derive prevalence estimates within vulnerablepopulations across Scotland, but none were sufficiently robust.However, local estimates for NPS use among people who inject drugs werederived in two parts of Scotland from data from injecting equipment providers.From analysis of existing needle exchange data for NHS Greater Glasgow andClyde (GGC) and NHS Lothian, we estimate that there are 190 (confidenceinterval 114-265)3 injecting NPS users in NHS GGC and a further 673 (confidenceinterval 562-784) NPS injectors in the NHS Lothian area.Use of NPS was widespread in the survey sample with 59% (n 252) of2Participants for the survey were recruited primarily through services including homeless drop ins. Toincrease reach, participants were also recruited online. The majority of surveys were by clients of services,however a small proportion were completed online by individuals not necessarily in contact with services.3A confidence interval gives an estimated range of values which is likely to include the true value.v
respondents reporting that they had ever used NPS. Of those, 74% (n 185)reported having used NPS within the last six months.Poly-substance use amongst the sample was very high. Only one person reportedbeing a sole NPS user, with 99% (n 251) of NPS users also reporting traditionaldrug use. The most commonly used NPS were synthetic cannabinoids (41%,n 104) and benzo-type NPS (41%, n 102), while approximately one fifth reportedtaking stimulant-type NPS (21%, n 53) and mephedrone (19%, n 48).Preferred route of administration varied by substance. Smoking was mostcommon for synthetic cannabinoids (98%, n 91), whereas oral (66%, n 57) andsublingual (under the tongue) (28%, n 24) were most common forbenzodiazepine-type NPS. Stimulant-type NPS were more commonly taken bysnorting (51%, n 25) or injecting (33%, n 16).Motives: Key FindingsThere were a wide range of reasons reported for people using NPS. The keymotives related to ease of access, curiosity and influence of peers, as well aspleasure, price and potency. Legal status did not appear to be a key motivator foruse.Other specific motivations were associated with particular groups of respondents.For example MSM were more likely to highlight improving sex as a key motivatorfor use. Those with a history of benzodiazepine use were more likely to highlightsubstitution from prescribed drugs as a key motivator for use.Reasons for not trying: Reasons for not trying NPS were explored in thequalitative interviews only. These generally related to awareness of the harmsfrom observing NPS use among their peers.Reasons for trying: The key reasons for trying NPS related to price, curiosity andease of access, including being offered through peers.Reasons for stopping: The key reasons for stopping use of NPS reported in thestudy related to „not liking it‟ or in relation to specific harms that individuals hadexperienced, for example having a negative impact on mental or physical health.Reasons for continuing to use: The reasons for continuing to use NPSoverlapped with reasons for trying and in particular around ease of access. Inaddition, motives for continuing also related to pleasure and compulsion. Morefunctional reasons for continued use related to people using in an attempt to selfmanage underlying mental health problems or dependency and a desire to avoidgoing into withdrawal.vi
Consequences of Use: Key FindingsThe surveys identified multiple harms associated with the consequences of usingNPS. The negative consequences of use can broadly be described in terms ofmental and physical health harms and social harms.Positive effects were identified by some. This was generally when under theinfluence of NPS, and negative after effects were often described. Use of NPS byMSM for chemsex saw half of respondents report no negative after effects formental health (n 15/29) or social consequences (n 15/29). Those who reportedbenzodiazepine-type NPS use also identified positive effects on managing sleepand mental health, with 91% (n 52) reporting that use helped them sleep and 81%(n 47) stating that use reduced their anxiety.Mental Health harmsAcross all NPS users who had used in last 6 months, 25% (n 47) identifiedanxiety, 12% (n 22) paranoia and 20% (n 38) depression as key mental healthharms. There was also a significant impact reported on underlying mental healthconditions and use of NPS to reduce mental health symptoms.Physical harmsA range of physical harms were reported. Physical harms varied because of thevariations in the type of NPS people were using. The negative impact on sleepthrough NPS use was the most commonly reported physical health harm. Acrossall NPS users who had used in last 6 months 20% (n 37) reported problems withsleep. Co-ordination problems were also reported by 20% (n 38) of the sampleand appeared to be particularly prevalent among those who reported use ofbenzodiazepine-type NPS. Population-specific harms were identified such aschemsex harms among MSM, injecting NPS among PWID, and unsupervisedopiate detoxification among opiate users.Wider social harmsFinancial issues: Money and debt were highlighted as major issues. 60%(n 105) of respondents to the NPS survey said they had spent more money thanthey planned to on NPS. 39% (n 89) reported that they borrowed money to payfor NPS.Missed appointments: Missing appointments was reported by 60% (n 104) ofthe overall NPS survey sample and highlighted a potential consequence of NPSuse that could lead to significant further harms, including potential sanctions by theDepartment of Work and Pensions.Education and Employment: While this was identified as a significant harm inthe staff survey, it did not feature highly among the harms reported in the NPSvii
survey. It was however recognised as a greater issue by MSM than for othervulnerable populations.Loss of tenancy: Staff perceived loss of tenancy as a social harm amongstpeople who use NPS (49%, n 90). Although it was reported less frequently in theNPS survey approximately 20% (n 35) of those who responded to a question onproblems caused by NPS use, reported losing a tenancy as a result of NPS use.NPS use and relationships: The majority of NPS survey respondents reportednegative effects on their relationships with family following on from NPS use,something that was also identified by the staff survey. A quarter (26%, n 45)reported struggling with caring commitments.Treatment and Psychoactive Substances Act: Key FindingsContact with services: 36% (n 69) of all NPS users were not in contact withdrug services at all for any issue4. Overall contact with services was high, whichwas not surprising given the nature of the population and the fact that a largeproportion were recruited through services. However only 11% (n 26) of NPSsurvey respondents reported being in contact with one or more servicesspecifically in relation to their NPS use. People in contact with mental healthservices reported the highest level of contact with services regarding their NPSuse (20%, n 18).Use of emergency services: While the vast majority of vulnerable people in thestudy chose not to discuss their NPS use specifically with the services they werein contact with, there was a higher level of use of emergency services. 32%(n 77) had called an ambulance for someone else and 23% (n 55) had anambulance called for them as a result of NPS use. 26% (n 63) of NPS users hadattended A&E as a result of NPS use.Provision of information and support: Sources of information on NPS consistedprimarily of talking to family and friends (32%, n 70). 31% (n 67) had not tried tosource any information on NPS prior to use. 16% (n 34) had talked to a drugservice and 16% (n 35) accessed information leaflets. 16% (n 34) had obtainedinformation on NPS from TV documentaries.This low uptake of obtaining information from services was explained by aperception among those surveyed that in general workers knew little about NPS.This perception was borne out by services who felt that it was hard to „keep up todate‟.4Not all respondents answered each question. Where answers are missing these have been excludedfrom the analysis so figures that describe the same population may have different base sizesviii
Providing support - client disclosure of NPS use: Only a small proportion ofthose surveyed said they had discussed their NPS use with services. Thiscontrasted with services, with 75% (n 131) of staff reporting that they ask serviceusers about NPS use at first presentation. This suggests that there is considerableunder-reporting of NPS, making effective engagement by services challenging.Qualitative focus group feedback suggested that how questions about NPS useare asked can affect disclosure of use from clients.Client service relationship: The qualitative interviews and focus groupssuggested that improving the provision of credible information and building trustwere key to improving disclosure and enabling services to respond moreeffectively.Improving services: There were a range of views on what service developmentswere required from respondents to the NPS survey. Those who had used NPSwere asked what one option was the most important service to offer. Responsesincluded: Detox/rehab (27%, n 66)Specialist services for NPS (15%, n 38)Information provision (13%, n 33)Specialists within services (13%, n 31)Service providers identified some similar themes on what they would like to offer inthe staff survey, particularly the development of local specialist services for NPS(47%, n 87), specialists within a service (45%, n 82) and information leaflets(40%, n 73).The Psychoactive Substances Act (PSA): The Act came into force after most ofthe survey work had been completed and therefore findings are largely focused onthe likely impact. 57% (n 141) of those surveyed felt it would have no impact, thisbeing highest among MSM with 74% (n 28) of this group believing it would haveno impact on their NPS use. Over a quarter (29%, n 73) of all respondents to theNPS survey said they would move or return to traditional drugs.45% (n 112) of the NPS survey sample said they bought NPS from shops andclearly this will have changed following the closure of „head shops‟. Staffanticipated a shift to online buying to a greater extent than those who reportedusing NPS.ix
Key Learning PointsPrevalence estimates of NPS use among vulnerable populations1. Database tools such as DAISy should be adapted and in the case of needleexchange data collection, standardised, to include specific questions relating toNPS use, this may include individual NPS names or categories. Training forfrontline workers in how best to apply these tools should be incorporated in thisprocess.In order to develop more robust estimates of NPS use there needs to be animprovement in data collection within services. The new database for drug andalcohol services currently being developed (Drug and Alcohol Information System– DAISy) provides an opportunity to collect reliable data provided staff are enabledto undertake thorough initial assessments and adequately record these. Similarlyneedle exchange data has the potential to provide useful prevalence data, againprovided staff are appropriately equipped to encourage accurate disclosure ofNPS use.Motives for use2. Motives for use should be identified in assessments and reviews with serviceusers and used to inform care plans undertaken by support services andfrontline staff.A better understanding of motives for NPS use and the ways they vary bypopulation group and type of NPS can inform interventions by services. Inparticular there may be benefits of targeted interventions for people who intend tocontinue using, reduce use, or want to stop.Consequences of use3. Mental health harms: Greater partnership working between substance useand mental health services and a review of care pathways for those withsubstance use and mental health difficulties should be considered.Given the reported mental health impacts of NPS use better collaboration andpartnership working between mental health services and drug services may helpto improve care for this population. A review of care pathways for those withsubstance use and mental health difficulties would assist in improving thetreatment response for service users. Further research would also help to betterunderstand the complex effects of NPS use on mental health, both in relation tospecific substances and mental health conditions.4. Physical harms: Assessments within key services should cover a range ofphysical health areas including sleep management.x
The most common reported physical harm across the majority of NPS types wassleep problems. Dedicated resources or information on sleep management couldbe useful to explore. Taking account of the range of other physical harms reportedand given the low levels of reported disclosure of NPS use, assessments withinkey services which cover a range of health areas could assist in opening up adialogue regarding NPS use and related harms. Such assessments may alsoencourage better disclosure of NPS use.5. Social harms: Multi-agency and flexible working approaches such as assertiveoutreach should be continued and developed to support people with the rangeof social harms experienced.NPS use had a significant impact on a range of aspects relate
On tick To buy drugs, usually with the agreement to pay later ORT Opiate Replacement Therapy . Sensate, Pineapple Express, Spice, Herbal Incense Benzodiazepine-type NPS Depressant Phenazepam, Etizolam, Diclazepam, Flubromazolam, Flubromazepam Stimulant-type NPS Stimulant . participants were also recru
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