Textbook of Clinical Management of Club Drugs and Novel Psychoactive Substances: NEPTUNE Clinical Guidance

355 Pages·2022·3.839 MB·English

by  Dima Abdulrahim, Owen Bowden-Jones

Textbook of Clinical
Management of Club Drugs
and Novel Psychoactive
Substances
Published online by Cambridge University Press
Published online by Cambridge University Press
Textbook of Clinical
Management of Club Drugs
and Novel Psychoactive
Substances
NEPTUNE Clinical Guidance
Dima Abdulrahim
ProgrammeManagerandPrincipalResearcherfortheNEPTUNEProject,CentralandNorthWestLondonNHSFoundationTrust
Owen Bowden-Jones
ConsultantAddictionPsychiatrist,CentralandNorthWestLondonNHSFoundationTrust
Published online by Cambridge University Press
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Informationonthistitle:www.cambridge.org/9781009182133
DOI:10.1017/9781009182126
©TheRoyalCollegeofPsychiatrists2022
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................................................................................................................................................................................................
Everyefforthasbeenmadeinpreparingthisbooktoprovideaccurateandup-
to-dateinformationthatisinaccordwithacceptedstandardsandpracticeat
thetimeofpublication.Althoughcasehistoriesaredrawnfromactualcases,
everyefforthasbeenmadetodisguisetheidentitiesoftheindividualsinvolved.
Nevertheless,theauthors,editors,andpublisherscanmakenowarrantiesthat
theinformationcontainedhereinistotallyfreefromerror,notleastbecause
clinicalstandardsareconstantlychangingthroughresearchandregulation.
Theauthors,editors,andpublishersthereforedisclaimallliabilityfordirector
consequentialdamagesresultingfromtheuseofmaterialcontainedinthis
book.Readersarestronglyadvisedtopaycarefulattentiontoinformation
providedbythemanufacturerofanydrugsorequipmentthattheyplantouse.
Published online by Cambridge University Press
Contents
Acknowledgements vi
Part I Introduction and Background 8B Amphetamine-typeStimulants:An
Overview 146
1 AnIntroductiontoClubDrugsandNovel
9 ‘Ecstasy’:MDMA(3,4-Methylenedioxy-N-
PsychoactiveSubstances 1
Methylamphetamine),MDMAAnaloguesand
2 PsychosocialInterventionsforClubDrugsand DrugswithSimilarEffects 165
NovelPsychoactiveSubstances 22
10 Methamphetamine 202
11 SyntheticCathinones 240
Part II Drugs with Primarily Depressant
ff
E ects
Part IV Drugs with Primarily
3 Gamma-Hydroxybutyrate(GHB)andGamma- Hallucinogenic Effects
Butyrolactone(GBL) 37
12 HallucinogenicDrugs 267
4 NewBenzodiazepineNovelPsychoactive
Substances 65
Part V Synthetic Cannabinoid Receptor
5 SyntheticOpioidNovelPsychoactive
Substances(Fentanyland Agonists
Non-fentanyl) 78
13 SyntheticCannabinoidReceptor
6 KetamineandOtherNovelPsychoactive
Agonists 299
SubstanceswithDissociativeEffects 101
7 NitrousOxide(N O) 131
2 Part VI Concluding Remarks
Part III Drugs with Primarily Stimulant 14 Conclusion 329
ff
E ects
8A IntroductiontoStimulantClubDrugsand
NovelPsychoactiveSubstances 143
Index 330
v
Published online by Cambridge University Press
Acknowledgements
The authors would like to express their gratitude to The authors would like to thank the Health
the EU Action Against Drugs and Organised Crime Foundation for supporting the development of the
(EU-ACT)(aprojectfundedbytheEuropeanUnion NEPTUNE work through unrestricted educational
andimplementedbyFIIAPPInternationalandIbero- grants.
AmericanFoundationforAdministrationandPublic The authors would also like to thank the multi-
Policy)foranunrestrictedqualityimprovementgrant disciplinarygroupsofexpertsandexpertsbyexperience
usedtoproducethispublication. fortheirinvaluablesupportinthedevelopmentofwork.
The authors would like to extend particular thanks to
Paul Dargan, David Wood, Jonathan Dewhurst, Sarah
Finley, Fabrizio Schifano, Christopher Whitely, and
LukeMitcheson.
vi
Published online by Cambridge University Press
Introduction and Background
PartI
Chapter An Introduction to Club Drugs and Novel
1
Psychoactive Substances
1.1 Introduction and Background Novelpsychoactivesubstanceshavebeenfoundin
most of Europe and North America, as well as
Thisdocumentprovidesaneweditionandanupdate
Oceania, Asia and South America, and in a number
tothe2015NEPTUNEguidanceontheclinicalman-
of African countries. To some extent, however, NPS
agement of harms resulting from acute intoxication
are primarily a North American and European phe-
and from the harmful and dependent use of ‘club
nomenon. Although NPS affects all regions of the
drugs’and‘novelpsychoactivesubstances’(NPS).
world, there are diverse regional patterns, in terms
Theguidanceisevidence-basedandisaresponseto
of both the type and number of NPS reported by
thegapinknowledgeandexperienceinthemanagement
individual countries. The NPS situation also differs
ofthesedrugs.Thereisevidencethatcliniciansoftenfeel
bycountryfromoneyeartothenext.4
poorlyequippedtoassessandmanagetheharmsofNPS
andreportthatmoreeducationonemergingdrugsand
misuse patterns is needed.1 It has alsobeennoted that 1.2 NEPTUNE Aims and Guidance
continued education on NPS is fundamental for the Development
provision of improved harm reduction services, which
canenhanceoverallcareforNPSserviceusers.2
1.2.1 Objectives of NEPTUNE
Patterns of drug use continue to be dynamic. At
the time of publication of this second edition, the This document is the 2022 update of the 2015 guid-
quantity and range of drugs available to people is anceontheharmsandmanagementofNPSandclub
wider than ever. Recreational users typically use drugs, developedby NEPTUNE (Novel Psychoactive
awiderepertoireofsubstances: Treatment UK Network). This edition has been
(cid:129) ‘Traditional’drugscontinuetobethemostused funded and supported by EU-Action Against Drugs
(dependingoncountry,bute.g.cannabis,cocaine, andOrganisedCrime(EU-Act).5
amphetamines). Theaimoftheguidanceistoimproveconfidence,
(cid:129) Novelpsychoactivesubstances(NPS)areused competence, and skills of clinicians in the detection,
alongwiththesetraditionaldrugs,buthavenot assessment,andmanagementoftheharmsassociated
replacedthem. withtheuseofNPS.
(cid:129) Increaseofnon-medicaluseofprescriptiondrugs. Specificareasaddressedinclude:
Thisdocumentfocusesonthehealth-relatedharmsof (cid:129) Detection/identification.Recognisingthe
clubdrugsandNPSandtheirclinicalmanagement. significantpsychological,physical,andsocialrisks
The use of substances referred to as ‘club drugs’ whichcanbeassociatedwithclubdrugsandNPS,
has been well established for many decades. It andequippingprofessionalstobeableto
includes illicit substances, e.g. cocaine and amphet- recogniseproblematicuse,associatedharms,and
amine,aswellasNPS. dependence.
TheuseofNPSisarelativelymorerecentglobal (cid:129) Assessment.Assessmentoftheproblemsrelated
phenomenon, with 120 countries and territories totheuseofclubdrugsandNPS,includingthe
from all regions of the world having reported one assessmentofbothdirectandindirectharms.
ormoreNPStotheUnitedNationsOfficeonDrugs (cid:129) Management.Clinicalmanagementofacuteand
and Crime (UNODC) Early Warning Advisory on chronicharmsrelatedtotheuseofclubdrugsand
NewPsychoactiveSubstances.3 NPS–basedonthebestavailableevidence.
1
Published online by Cambridge University Press
Introduction and Background
PartI
Chapter An Introduction to Club Drugs and Novel
1
Psychoactive Substances
1.1 Introduction and Background Novelpsychoactivesubstanceshavebeenfoundin
most of Europe and North America, as well as
Thisdocumentprovidesaneweditionandanupdate
Oceania, Asia and South America, and in a number
tothe2015NEPTUNEguidanceontheclinicalman-
of African countries. To some extent, however, NPS
agement of harms resulting from acute intoxication
are primarily a North American and European phe-
and from the harmful and dependent use of ‘club
nomenon. Although NPS affects all regions of the
drugs’and‘novelpsychoactivesubstances’(NPS).
world, there are diverse regional patterns, in terms
Theguidanceisevidence-basedandisaresponseto
of both the type and number of NPS reported by
thegapinknowledgeandexperienceinthemanagement
individual countries. The NPS situation also differs
ofthesedrugs.Thereisevidencethatcliniciansoftenfeel
bycountryfromoneyeartothenext.4
poorlyequippedtoassessandmanagetheharmsofNPS
andreportthatmoreeducationonemergingdrugsand
misuse patterns is needed.1 It has alsobeennoted that 1.2 NEPTUNE Aims and Guidance
continued education on NPS is fundamental for the Development
provision of improved harm reduction services, which
canenhanceoverallcareforNPSserviceusers.2
1.2.1 Objectives of NEPTUNE
Patterns of drug use continue to be dynamic. At
the time of publication of this second edition, the This document is the 2022 update of the 2015 guid-
quantity and range of drugs available to people is anceontheharmsandmanagementofNPSandclub
wider than ever. Recreational users typically use drugs, developedby NEPTUNE (Novel Psychoactive
awiderepertoireofsubstances: Treatment UK Network). This edition has been
(cid:129) ‘Traditional’drugscontinuetobethemostused funded and supported by EU-Action Against Drugs
(dependingoncountry,bute.g.cannabis,cocaine, andOrganisedCrime(EU-Act).5
amphetamines). Theaimoftheguidanceistoimproveconfidence,
(cid:129) Novelpsychoactivesubstances(NPS)areused competence, and skills of clinicians in the detection,
alongwiththesetraditionaldrugs,buthavenot assessment,andmanagementoftheharmsassociated
replacedthem. withtheuseofNPS.
(cid:129) Increaseofnon-medicaluseofprescriptiondrugs. Specificareasaddressedinclude:
Thisdocumentfocusesonthehealth-relatedharmsof (cid:129) Detection/identification.Recognisingthe
clubdrugsandNPSandtheirclinicalmanagement. significantpsychological,physical,andsocialrisks
The use of substances referred to as ‘club drugs’ whichcanbeassociatedwithclubdrugsandNPS,
has been well established for many decades. It andequippingprofessionalstobeableto
includes illicit substances, e.g. cocaine and amphet- recogniseproblematicuse,associatedharms,and
amine,aswellasNPS. dependence.
TheuseofNPSisarelativelymorerecentglobal (cid:129) Assessment.Assessmentoftheproblemsrelated
phenomenon, with 120 countries and territories totheuseofclubdrugsandNPS,includingthe
from all regions of the world having reported one assessmentofbothdirectandindirectharms.
ormoreNPStotheUnitedNationsOfficeonDrugs (cid:129) Management.Clinicalmanagementofacuteand
and Crime (UNODC) Early Warning Advisory on chronicharmsrelatedtotheuseofclubdrugsand
NewPsychoactiveSubstances.3 NPS–basedonthebestavailableevidence.
1
https://doi.org/10.1017/9781009182126.001 Published online by Cambridge University Press
AnIntroductiontoClubDrugsandNovelPsychoactiveSubstances
(cid:129) Harmreduction.Interventionsaimedatpreventing (cid:129) Newpopulationsintreatment(includingnew
morbidityandmortalityamongindividuals patternsofdruguseandcontextsofharm);
presentingtoclinicalsettings,includingmeasuresto (cid:129) New harms (some club drugs are associated
reducetheharmsofclubdrugsandNPSfor with harms not previously linked to illicit
individualsandcommunitiesandtohelppatients drug use, e.g. ketamine-related ulcerative
achieveandsustainrecoveryandwell-being. cystitis);
Thisdocumentprovidesguidance,notguidelines.The (cid:129) Newmanifestationofdrug-relatedharmswhich
implementationofNEPTUNEatnationallevelsmust arefamiliartoclinicians(e.g.dependenceand
takeplacewithintheprinciplesofnationalandinter- withdrawalassociatedwithgamma-
national guidelines, national and local protocols, as hydroxybutyrate(GHB).
wellastheinternationalstandardsandbroadprinciples NEPTUNE therefore aims to improve clinicians’
forthetreatmentofsubstancemisusedisorders.6,7 knowledge of the specific issues relating to NPS and
The implementation of NEPTUNE learning into to support evidence-based practice at local levels. It
clinical practice must adapt the learning to take into also aims to help improve clinicians’ confidence in
accountfactorsspecifictotheregion,countryorsector working with patients who use NPS, by providing
where they are implemented. This includes the needs, thefollowing:
priorities, legislation, policies, systems of healthcare (cid:129) ‘Technical’knowledge(whatthedrugsareand
delivery and resources of the various countries.
howtheywork);
Adaptationshouldbecarriedoutwithoutundermining (cid:129) ‘Cultural’knowledge(whoisusingthem,andhow);
the validity of the evidence-based training. Local and
(cid:129) ‘Clinical’knowledge(howtoclinicallymanage
national protocols, including prescribing protocols,
bothacuteandchronicpresentations).
shouldbeused.
For up-to-date information, it is also recom-
1.3 Target Audience for the Guidance
mended that clinicians contact the Poisons Centres
intheirregion,whereavailable.Thesearespecialised
units that advise on, and assist with, the prevention, 1.3.1 Primary Audience
diagnosis,andmanagementofpoisoning.Theirstruc-
Thisguidanceisaimedprimarilyataclinicalaudience
ture and function varies around the world; however,
andmostspecificallyclinicianswhomanagephysicaland
at a minimum, a poisons centre is an information
mentalhealthproblemsassociatedwithharmfulor/and
service. Some centres may also include a toxicology
dependent drug use and ensuing acute or chronic
laboratoryand/oraclinicaltreatmentunit.8
problems.
These will include clinicians working in spe-
1.2.2 Why Produce Guidance on Club
cialist drug treatment and recovery services, as
Drugs and Novel Psychoactive Substances?
well as in emergency departments. The document
is also relevant to professionals working with
The underlying principles of good clinical practice in
populations at risk of drug-related harms and
relationtotheusersofclubdrugsandNPSarethesame
associated poorer treatment outcomes, such as
asforharmfulanddependentdrugmisuseingeneral.
Clinicians’existingexperienceofthetreatmentof mental health services, prison health services, pri-
mary care, sexual health services, HIV treatment,
othercommonlyuseddrugs(suchasheroin,alcohol
hepatology and others.
orcannabisforexample)isveryrelevanttothetreat-
mentofclubdrugsandNPS.
1.3.2 Other Audiences
However,goodassessmentandmanagementofthe
harms of club drugs and NPS must also consider the
Although not directly aimed at them, this docu-
particularchallengesposedbynoveldrugsandaddress
ment is also a resource for funders/commissioners
themdirectly.Theseincludechallengesposedby:
and policy-makers in developing local, national or
(cid:129) Newdrugs(rapidlychangingprofileandever- regional services. It also provides patients and
increasingnumbersofsubstances,withpoorly carers with information on what interventions
understoodharms); should be available.
2
https://doi.org/10.1017/9781009182126.001 Published online by Cambridge University Press