Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel ...

355 Pages·2015·2.15 MB·English

Novel Psychoactive Treatment UK Network
NEPTUNE
Guidance on the Clinical
Management of Acute
and Chronic Harms of
Club Drugs and Novel
Psychoactive Substances
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This publication of the Novel Psychoactive Treatment UK Network (NEPTUNE)
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is protected by copyright. The reproduction of NEPTUNE guidance is authorised,
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provided the source is acknowledged.
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© 2015 NEPTUNE (Novel Psychoactive Treatment UK Network) 2015
Club Drug Clinic/CAPS
Central and North West London NHS Foundation Trust (CNWL)
69 Warwick Road
Earls Court
SW5 9HB
http://www.Neptune-clinical-guidance.com
http://www.Neptune-clinical-guidance.co.uk
The guidance is based on a combination of literature review and expert clinical
con sensus and is based on information available up to March 2015. We accept no
responsi bility or liability for any consequences arising from the use of the information
contained in this document.
The recommended citation of this document is:
Abdulrahim D & Bowden-Jones O, on behalf of the NEPTUNE Expert Group. Guidance on the Management
of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances. Novel Psychoactive
Treatment UK Network (NEPTUNE). London, 2015.
NEPTUNE is funded by the Health Foundation, an independent charity working to
improve the quality of health care in the UK.
Editorial production and page design by Ralph Footring Ltd, http://www.footring.co.uk
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NEPTUNE (Novel Psychoactive
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Treatment UK Network): N
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Expert Group members
NEPTUNE Expert Group
Dr Owen Bowden-Jones Neptune Chair
Clinical and programme lead
Consultant Psychiatrist and Lead Clinician for Club Drug Clinic,
Addictions Directorate, Central and North West London NHS
Foundation Trust
Honorary Senior Lecturer, Imperial College, London
Dr Dima Abdulrahim NEPTUNE Programme/ Manager Secretariat
NEPTUNE Lead Researcher
Central and North West London NHS Foundation Trust
Dr James Bell Consultant Physician
South London and Maudsley NHS Trust
Dr Nigel Borley Consultant Urologist
Chelsea and Westminster NHS Trust
Dr Steve Brinksman GP Birmingham
Clinical director of Substance Misuse Management in General Practice
(SMMGP)
Ms Emma Crawshaw Service Delivery Manager
Crew 2000, Edinburgh
Ms Laura Day Project worker
Crew 2000, Edinburgh
Ms Annette Dale-Perera Director of Addiction and Offender Care
Central and North West London NHS Foundation Trust
Mr Mark Dunn Clinical Nurse Specialist
Club Drug Clinic, Central and North West London NHS Foundation
Trust
Ms Stacey Hemmings Assistant Psychologist
Club Drug Clinic, Central and North West London NHS Foundation
Trust
Mr Salvo Larosa Club Drug Clinic, Central and North West London NHS Foundation
Trust
David MacKintosh Director
London Drug and Alcohol Policy Forum
Dr Luke Mitcheson Consultant Clinical Psychologist
South London and Maudsley NHS Foundation Trust
Public Health England
Mr Monty Moncrieff Chief Executive
London Friend
Prof David Nutt Edmond J Safra Professor of Neuropsychopharmacology Director of
the Neuropsychopharmacology Unit in the Division of Brain Sciences. 
Imperial College London
Dr John Ramsey Analytical toxicologist
Director
TICTAC Communications Ltd
St George’s, University of London
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Expert Group members iv
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Dr John Roche Consultant Psychiatrist
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Leeds and York Partnership NHS Foundation Trust
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Prof Fabrizio Schifano Chair in Clinical Pharmacology and Therapeutics
University of Hertfordshire E
and Consultant Psychiatrist (Addictions)
Mr David Stuart Substance Use Lead, GUM/HIV
56 Dean Street,
Chelsea Westminster Hospital NHS Foundation Trust
Dr Ann Sullivan Consultant Physician in HIV and Genito-urinary Medicine
Chelsea and Westminster Hospital NHS Foundation Trust
Dr Tim Williams Consultant Psychiatrist
Avon and Wiltshire Mental Health Partnership NHS Trust
Dr Christopher Whiteley Trust Deputy Head of Psychology
Consultant Clinical Psychologist
South London and Maudsley NHS Foundation Trust
Dr Adam Winstock Consultant Psychiatrist and Addiction Medicine Specialist, SLAM NHS
Trust
Senior Lecturer, Kings College London
Director, Global Drug Survey
Dr David Wood Consultant Physician and Clinical Toxicologist and Service (Clinical)
Lead for Medicine, Guy’s and St Thomas’ NHS Foundation Trust and
King’s Health Partners, London, UK
Senior Lecturer, King’s College London, UK
Dr Dan Wood Consultant Urologist in Adolescent and Reconstructive Surgery
University College Hospitals, London
Other contributors
Dr Marta Boffito Head of Clinical Trials, St. Stephen’s Centre (SSAT)
Consultant Physician, Chelsea and Westminster Foundation Trust
Imperial College London
Ms Lindsey Hines PhD student
Addictions Department, Institute of Psychiatry, Psychology and
Neuroscience
Kings College London
Mr Josh Hulbert Project
Administrator & EU Coordinator
Independent Scientific Committee on Drugs
Dr Duccio Papanti Psychiatrist Trainee
Department of Medical, Surgical, and Health Sciences
University of Trieste, Italy
Observers
Mr Pete Burkinshaw Skills and Development Manager
Public Health England
Dr Mark Prunty Senior Medical Officer for Substance Misuse Policy
Department of Health
Mr John McCracken Drugs Programme Manager
Department of Health
Ms Melanie Roberts Drug Strategy – Reducing Demand Team
Home Office
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Acknowledgements
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NEPTUNE was hosted by Central and North West London NHS Foundation Trust
(CNWL).
We would like to acknowledge the generous support of the Health Foundation, which
has funded the NEPTUNE work.
We are very grateful for the independent peer reviews on the draft of this report
by Dr Paul Dargan (Consultant Physician, Clinical Toxicologist and Clinical Director
at Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London)
and Dr Jonathan Dewhurst (Consultant Addiction Psychiatrist at Greater Manchester
West Mental Health NHS Foundation Trust).
We would like to thank Dr Christopher Whitely and Dr Luke Mitcheson for writing
the Chapter 2, ‘Psychosocial interventions for club drugs and novel psychoactive
substances’.
We would like to thank Dr Sarah Finley (Consultant in Emergency Medicine) and staff
at the Chelsea and Westminster Hospital Emergency Department for their support in
developing and testing the GHB/GBL care bundles. We would also like to thank Claire
Whitelock and Nick Prideaux-Brune for their input.
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Contents
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Contents listing is hyperlinked
Part I: Introduction, background and overall principles 1
Chapter 1. Introduction 2
1.1. This document 2
1.2. Novel Psychoactive Treatment UK Network (NEPTUNE): project aims and guidance
development 4
1.2.1. Objectives of the NEPTUNE Project 4
1.2.2. Aims of the NEPTUNE clinical guidance 4
1.3. Target audience for the guidance 6
1.3.1. Primary audience 6
1.3.2. Other audiences 6
1.4. The process of developing the guidance: method for the literature review 6
1.4.1. General inclusions and exclusions in the guidance 8
1.4.2. Substances and drug groups covered by this guidance 8
1.5. An overview of club drugs 9
1.5.1. Old drugs, new drugs and ‘legal highs’ 9
1.5.2. New markets and user communication about drugs 12
1.6. Club drug use in the UK 14
1.6.1. Overall drug use 14
1.6.2. Club drug and NPS use 14
1.6.3. Drug-using repertoires and poly-drug use 15
1.6.4. Club drug users and contexts of use 15
1.6.4.1. Clubbers and night-time economy 15
1.6.4.2. Lesbian, gay, bisexual and transgender populations 16
1.6.4.3. ‘Psychonauts’ 17
1.7. Overview of the effects and harms of club drugs 17
1.7.1. How drugs work 17
1.7.2. Toxicity and other harms 17
1.7.3. Mortality related to the use of club drugs 19
1.8. Response to club drug use 21
1.8.1. Policy response to club drug and NPS use 21
1.8.2. NPS and drug-related presentations to hospitals and treatment 21
1.8.3. Principles underlying the assessment and management in target settings of the harms
associated with the use of club drugs and NPS 22
1.8.3.1. Emergency departments 22
1.8.3.2. Sexual health services 22
1.8.3.3. Substance misuse treatment services 24
1.8.4. Overview of the interventions for the screening, identification and management of drug
harms in the target settings 24
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Chapter 2. Psychosocial interventions for club drugs and novel
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psychoactive substances 30
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2.1. Stepped care 32
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2.2. Identification of NPS use and its severity 33
2.3. Settings for the delivery of PSIs 34
2.3.1. Settings for lower-intensity PSIs 34
2.3.2. Settings for higher-intensity PSIs 35
2.4. Lower-intensity PSIs 36
2.5. Higher-intensity PSIs 39
2.5.1. Structured drug treatment 39
2.5.2. Formal psychological treatment 40
2.6. Residential psychosocial treatment 42
2.7. Mutual aid 43
2.8. Models for specific psychosocial approaches 44
2.8.1. Motivational Interviewing 44
2.8.2. Network and environmental therapies 44
2.8.3. CBT-based relapse prevention 45
2.8.4. Contingency management 45
2.8.5. Psychodynamic therapy 45
Part II: Central nervous system depressants 48
Chapter 3. Gamma-hydroxybutyrate (GHB) and gamma-butyrolactone (GBL) 49
3.1. Street names 49
3.2. Legal status 49
3.3. Quality of the research evidence 49
3.4. Brief summary of pharmacology 49
3.5. Clinical and other uses 50
3.6. Prevalence and patterns of use 51
3.7. Routes of ingestion and frequency of dosing 52
3.8. Desired effects of GHB/GBL for recreational use 53
3.9. Mortality 54
3.10. Acute harms 54
3.10.1. Acute GHB/GBL toxicity 54
3.10.1.1. The features of acute GHB/GBL toxicity 56
3.10.1.2. Acute withdrawal 58
3.10.2. Poly-drug use and drug interactions 58
3.10.3. GHB and HIV antiretroviral therapy 59
3.11. Clinical management of acute toxicity 59
3.11.1. Identification and assessment 59
3.11.2. Clinical management of overdose and acute toxicity 60
3.11.3. Treatment outcome 61
3.11.4. Acute withdrawal following detoxification 62
3.12. Harms associated with chronic use 62
3.12.1. Dependence 62
3.12.2. The GHB/GBL withdrawal syndrome 63
3.12.2.1. Predictors of withdrawal 63
3.12.2.2. Rapid onset and duration of withdrawal syndrome 63
3.12.2.3. Individual variations and unpredictability of the withdrawal syndrome 63
3.12.2.4. GHB/GBL withdrawal symptoms 64
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3.13. Management of harms from chronic use 65
3.13.1. Clinical management of dependence 65 U
3.13.1.1. Identification and assessment of GHB/GBL dependence and withdrawal 65
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3.13.1.2. Psychosocial and pharmacological support 66
3.13.2. Clinical management of withdrawal 66 E
3.13.2.1 Medical complications reported during withdrawal 68
3.13.3. Medically assisted elective or planned withdrawal and detoxification 68
3.13.4. Aftercare and supporting recovery 68
3.14. Public health and safety 69
3.15. Harm reduction 69
3.15.1. Supporting patients undergoing outpatient medically assisted GHB/GBL withdrawal 69
3.15.2. Advice for users S-T-A-Y-I-N-G S-A-F-E on GHB/GBL 69
Chapter 4. Ketamine and methoxetamine 78
4.1. ‘Dissociative’ drugs 78
4.2. Street names 79
4.3. Legal status 79
4.4. Quality of the research evidence 79
4.5. Brief summary of pharmacology 79
4.6. Medical uses of ketamine 80
4.7. Prevalence and patterns of use 81
4.7.1. Prevalence of use in the UK 81
4.7.2. Ketamine use and high-risk sexual and injecting behaviours 83
4.8. Routes of ingestion, dosing and frequency of dosing 84
4.8.1. Ketamine 84
4.8.2. Methoxetamine 85
4.9. Desired effects for recreational use 85
4.9.1. Ketamine 85
4.9.2. Methoxetamine 86
4.10. Mortality 87
4.11. Acute ketamine toxicity 88
4.11.1. Features of acute ketamine toxicity 88
4.11.2. Acute withdrawal 90
4.11.3. Poly-drug use: complicating factors for acute toxicity 90
4.12. Management of ketamine-related acute harms 91
4.12.1. Identification and assessment of acute toxicity 91
4.12.2. Clinical management of acute toxicity 91
4.12.3. Outcome of treatment for acute toxicity 93
4.13. Harms associated with chronic ketamine use 93
4.13.1. Ketamine dependence 93
4.13.2. Ketamine withdrawal 93
4.13.3. Other harms of chronic use of ketamine 94
4.13.3.1. Ketamine-induced damage to the urinary tract 94
4.13.3.2. Gastrointestinal toxicity 95
4.13.3.3. Diabetic ketoacidosis (DKA) 96
4.13.3.4. Drug interaction in HIV treatment 96
4.13.3.5. Neurobehavioural, psychiatric and psychological effects 96
4.13.3.5.1. Cognitive impairment and memory impairment 96
4.13.3.5.2. Depression 97
4.13.3.5.3. Neurological effects 97
4.13.3.6. Social harms 98
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4.14. Management of harms related to chronic ketamine use 98
4.14.1. Numbers in specialist drug treatment for ketamine-related harms and dependence 98 U
4.14.2. Identification and assessment 98
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4.14.3. Psychosocial and pharmacological support 98
4.14.3.1. Psychological support 98 E
4.14.3.2. Pharmacological interventions for dependence and withdrawal 99
4.14.3.3. Aftercare and support 99
4.14.4. Management of urinary tract problems 99
4.15. Public health and public safety 100
4.15.1. Viral and bacterial infections 100
4.15.2. Accidents and assaults 101
4.16. Harm reduction 101
Chapter 5. Nitrous oxide 109
5.1. Street names 109
5.2. Legal status 109
5.3. Quality of the research evidence 109
5.4. Brief summary of pharmacology 109
5.5. Clinical and other legitimate uses of nitrous oxide 110
5.6. Prevalence and patterns of use 110
5.7. Routes of ingestion and frequency of dosing 111
5.8. Desired effects of nitrous oxide for recreational use 112
5.9. Mortality 113
5.10. Acute harms 113
5.10.1. Acute toxicity 113
5.10.2. Acute withdrawal 114
5.10.3. Poly-drug use and drug interactions 114
5.11. Clinical management of acute toxicity 114
5.11.1. Identification and assessment of acute toxicity 114
5.11.2. Clinical management of acute toxicity 115
5.12. Harms associated with chronic use and dependence 115
5.12.1. Dependence 115
5.12.1.1. Withdrawal 115
5.12.2. Other harms – vitamin B12 deficiency 116
5.13. Management of harms related to chronic use 116
5.13.1. Psychosocial and pharmacological support 116
5.14. Harm reduction and public health 117
Part III: Stimulants 120
Chapter 6. Cocaine, synthetic cocaine derivatives and piperazines 121
6.1. Cocaine: an overview 121
6.2. Legal status and pharmacology 122
6.3. Prevalence, patterns of use, desired and unwanted effects and routes of ingestion 122
6.4. Mortality 123
6.5. Acute harms 124
6.5.1. Acute toxicity 124
6.5.1.1. Cardiovascular disorders 125
6.5.1.2. Cerebrovascular disorders 128
6.5.1.3. Cocaine-induced psychosis 128
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6.6. Management of cocaine-related acute harms 129
6.6.1. Hospital presentation with acute cocaine intoxication 129 U
6.6.2. Management of cocaine-induced cardiovascular disorders 129
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6.6.3. Management of cocaine-induced psychosis 130
6.6.4. Discharge and onward referral 131 E
6.7. Chronic use and dependence and their clinical management 131
6.7.1. Cocaine dependence and its management 131
6.7.2. Access to cocaine-dependence treatment in the UK 132
6.8. Synthetic cocaine derivatives 132
6.9. Piperazines 133
Chapter 7. Amphetamine-type substances (ATS): an overview 140
7.1. Pharmacology 141
7.2. Medical and other legitimate uses of amphetamines 142
7.3. Prevalence and patterns of use 142
7.4. Routes of ingestion and dosing 143
7.5. Desired and unwanted subjective effects of ATS 144
7.6. Mortality 145
7.7. Acute harms 145
7.7.1. Features of acute toxicity 146
7.7.2. Serotonin syndrome 147
7.8. Management of the acute harms associated with use of ATS 149
7.8.1. Identification and assessment of acute toxicity 149
7.8.2. Management of serotonin syndrome 150
7.9. Harms associated with chronic use of ATS 152
7.9.1. Dependence and withdrawal 152
7.9.2. Physical and psychiatric/psychological harms from chronic use 153
7.10. Management of harms associated with chronic use 154
7.10.1. Identification and assessment of ATS use and dependence 154
7.10.2. Stepped care for ATS users 154
7.10.3. Psychosocial and pharmacological support for the management of dependence 155
7.10.3.1. Psychosocial interventions 155
7.10.3.2. Pharmacological interventions 157
7.10.4. Management of amphetamine psychosis 157
7.10.5. Aftercare and support 158
7.11. Public health and safety and harm reduction 158
Chapter 8. Methamphetamine 164
8.1. Street names 164
8.2. Legal status 164
8.3. Quality of the research evidence 164
8.4. Brief overview of pharmacology 165
8.5. Clinical and other legitimate uses of methamphetamine 166
8.6. Prevalence and patterns of use 166
8.7. Routes of ingestion and dosing 168
8.8. Desired effects for recreational use and unwanted effects 168
8.9. Mortality 169