Novel psychoactive substances: synthetic cannabinoids - best practice treatment approaches

Dr George Ryan, Clinical Advisor, Criminal Justice, Public Health England, Alcohol, Drugs & Tobacco writes for SMMGP on training and treatment for NPS, in particular synthetic cannabinoids.

Background

The use of new psychoactive substances [NPS] in prisons has been recognised as an increasing problem for several years.

Successive Chief Inspectors of Prisons and the Prisons and Probation Ombudsman have drawn attention to the impact on prisons, prison staff and prisoners themselves from the use of NPS.

It is clear from seizure data [of drugs within prisons and of drugs being intercepted coming into prisons] and feedback from both staff and prisoners that synthetic cannabinoids [SC] are, by some distance, the single most used form of NPS in prisons.

An analysis of 400 seizures from 20 prisons revealed that 67% of seized samples were NPS—of these 99% were SC.

Why are SC popular in prison?

There are several reasons for the historical popularity of SC in prison:

• their undetectability by conventional onsite testing
• their perceived legal status
• their relative affordability, as a replacement for cannabis [even though effects can be very different from traditional forms of cannabis]
• the alleviation of boredom
• a form of self-medication
• pleasure and enjoyment

Some prisoners will continue to use SC as: they may enjoy using the drug and may be suffering no current apparent adverse effects from its use; and because the pleasure experienced from their use or their ability to cope better with being in prison by using SC will outweigh negative effects they may experience.

Some prisoners will continue to use SC because they are unable to tolerate the withdrawal symptoms when they attempt to reduce or stop the drugs.

Changes in the legislation, with the Psychoactive Substances Act becoming law in May 2016, the introduction of more effective testing and the rollout of the smoking ban in prisons may all have an impact on SC use in the future.

Prevalence of SC use in prisons

It is difficult to establish the exact nature of the prevalence of SC use in prisons.

In general terms, it is not at present widely used in women’s prisons, Young Offender Institutions and Immigration Removal Centres [IRC], but staff in these establishments are aware that this situation may change over time and may be affected by the current reconfiguration of the prison estate.

In male prisons there is considerable variation between the perceived prevalence of SC use, with staff in some establishments estimating 50% or more of prisoners using SC.

The use is currently low in high security establishments and appears to vary between open prisons.

Negative effects of SC use

The negative effects of SC use are wide-ranging and can be dramatic for individual prisoners in health and psychological terms and, since the advent of the Psychoactive Substances Act, criminal justice terms as well.

On an individual level NPS use is associated with debt, bullying and violence.

At an establishment level, NPS use can have a destabilising influence on the safe and effective functioning of a prison’s regime and routine, including an adverse impact on staff morale because of responding to the unpredictable and severe effects of NPS use by prisoners.

Physical health effects of SC use

A diverse and disturbing range of physical health effects have been attributed to NPS use.

Nausea, vomiting, sweating, chest pains, headache, convulsions, bizarre paralysis, fluctuating consciousness, confusion, disorientation and gait disturbance are among the more commonly described physical symptoms.

There is emerging evidence of SC causing significant cardiovascular effects such as myocardial infarction and cardiac arrest.

Symptoms and signs, such as levels of consciousness, pulse and blood pressure, may fluctuate wildly even in a matter of minutes, making management difficult and challenging for healthcare and other staff in attendance.

Combinations of symptoms, such as chest pain and paranoia, may make management of an acute situation more difficult.

Determining the precise cause for an individual’s presentation may be difficult, for example, an individual may have removed their clothes as a form of bizarre behaviour or in response to extreme sweating [which might, in itself be a medical emergency].

A quarter of acute presentations may resolve after six hours, but 30% may take up to two weeks to resolve.

Prisoners using SC may lose weight due to the direct effects of the drugs or because they sell their food to pay off debts owed because of their SC use.

Some prisoners report withdrawal from SC as being more difficult than withdrawing from opiates and these individuals will need considerable clinical and psychosocial support if they are to reduce or stop their SC use.

There is less clarity regarding longer term physical effects, but some prisoners seem to develop chronic gastrointestinal symptoms and individuals may develop long term health effects following severe, acute liver, kidney or cardiovascular damage.

There have been reports of individuals developing faecal and/or urinary incontinence due to their use of SC.

If an individual is suffering from urinary incontinence, it is essential to ask about past, current or future use of ketamine in view of the toxic effects of ketamine on the urinary bladder.

Prisoners may also suffer physical health consequences due to self-inflicted injuries whilst under the influence of SC or because of violence carried out by other prisoners under the influence of SC and because of being subjected to violence due to being in debt.

Mental health effects of SC use

The acute mental health effects of SC use are also manifold and often severe.

They include psychosis, hallucinations, bizarre behaviour, agitation, confusion, aggression, amnesia, paranoia, acute self-harm while intoxicated, anxiety and depression.

Amnesia may mean that a prisoner has no recall of how he was affected or behaving due to SC use.

In November 2016, the Prisons and Probation Ombudsman [PPO] reported that he had identified 64 deaths in prison that occurred between June 2013 and April 2016, where the prisoner was known, or strongly suspected, to have been using NPS before their death.

Whilst the PPO was careful not to make a causal link between NPS use and these deaths, it is striking that 44 of these deaths were self-inflicted, in some cases involving psychotic episodes potentially linked to NPS use, although these deaths need to be seen in the context of a significant rise in prison deaths in general.

Notes on a training programme

Prison staff who attended training based on Public Health England NPS Toolkit for Prisons described prisoners inflicting severe injuries on themselves whilst under the influence of SC, sometimes with fatal consequences.

Longer term mental health effects of SC use reported included psychosis and depression and bizarre forms of depersonalisation, with one prisoner describing how he had “lost his soul”.

The nature and duration of psychotic symptoms present a particular challenge when considering whether or not to initiate antipsychotic medication, further compounded by whether or not release is imminent.

An important feature of withdrawal is severe depression and suicidal ideation.

Staff from one IRC had a policy of putting individuals who had discontinued SC use on a mental health watch for a week, with special vigilance for suicidal ideation on days three to five after stopping SC use.

Debt, bullying and violence

SC were considered to be relatively affordable in prisons, despite costing ten times the community price.

However, a number of prisoners developed significant problems due to debt because of their SC use, with a range of potential negative consequences for them and their families.

Prisoners could be subjected to violence due to debt or coerced into inflicting violence on other prisoners, or on staff, to clear a debt.

A prisoner replacing an indebted prisoner in his cell might inherit his debt, with all the consequences which this implies.

A prisoner in debt might be forced to test a new or suspected bad batch of SC as a way of settling the debt.

It was commonly reported that prisoners would be given a spiked joint containing SC for purposes of entertaining other prisoners observing their response to using it.

Generally speaking, more vulnerable or older and frail prisoners would be targeted in this way.

Prisoners would play games, with forfeits or prizes, for the individuals most or least affected by the use of SC.

It is reported that the profitability of dealing in SC has motivated some prisoners to deliberately breach licence conditions so that they are recalled in order to smuggle SC into prisons. There has been at least one incident of a prisoner wielding a knife to defend a “throw over” of SC, such are the profits that can be made from dealing in SC in prisons.

Management of adverse effects of SC use

The management of acute and chronic adverse effects of SC use will depend on a number of variables, such as the location of a prison, staffing levels, staff experience, confidence and expertise, whether there is an in-patient Healthcare facility and so on.

Non-medical management

It is clear that a great deal of low key management, usually by prison officers—as they are often the first on the scene - is undertaken to defuse the effects of SC use by individual prisoners or groups of prisoners.

Asking an individual to step in or out of his cell, as appropriate, and giving advice and reassurance in a calm voice will often be sufficient to adequately manage many situations.

Even if an individual is displaying aggressive behaviour, staff will often take a wait and see approach, rather than resorting immediately to control and restraint.

Some prisons have observation cells where a prisoner can be safely accommodated and observed until his symptoms either settle or deteriorate to the point of needing transfer to hospital.

As the training programme progressed, there was increasing recognition of a de-escalation approach to acute presentations, with control and restraint being a last resort, even when an individual was agitated or aggressive.

In a similar way, a good deal of management of the chronic effects of SC use was of a non-medical pastoral nature by a wide range of staff and, on occasions, other prisoners.

Medical management of adverse effects of SC use

An important mantra which developed over the course of the training programme was “Treat what you see”.

Prison staff, across all domains, recognised that, rather than focusing on which drug or drugs may have been taken, it was better to clinically manage the presenting symptoms and to treat them, with or without the use of medication, appropriately.

In the vast majority of cases, management was supportive, with medical equipment being used very rarely and medication even more rarely.

Oxygen was frequently used, especially if SC had been mixed with opiates, with naso-pharyngeal tubes and suction devices being used infrequently.

There were occasional descriptions of the use of CPR and defibrillators—indeed as the training programme progressed there were more reports of prisoners suffering from acute cardiac symptoms, albeit in low numbers, due to SC use.

A clear and consistent finding over the six months of the training programme was that sedating medication was virtually never used to manage agitation or aggressive behaviour.

The reluctance to use sedating medication was based partly on not knowing what substances an affected prisoner might have taken and partly in consideration of not being able to reverse or manage any adverse effects of the sedating medication itself.

Having facilities such as an in-patient unit, stabilisation cells and other considerations such as staffing levels, staff competence and confidence, the impact of a bad batch and urban or rural locations were all relevant when deciding whether or not to send for an ambulance, as alluded to above.

A particularly challenging issue, to which there were no clear answers, was the interaction between SC and prescribed medications.

In response to this concern an advisory factsheet about such interactions was circulated by Public Health England in Spring 2016.

Psychosocial management of SC use

Psychosocial services were responding in a variety of ways to the challenges posed by SC use.

Initially, there was a sense of not knowing what to do, but, as time progressed, individuals and services adapted existing good, evidence-based practices to better manage individuals using SC.

Identifying an individual’s recovery trajectory and responding appropriately is an essential and fundamental requirement in the psychosocial management of SC use.

The FRAMES model (Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy), initially developed as a Brief Intervention for risky or harmful alcohol consumption is an effective means of sowing the seeds of engagement and retaining people in treatment. It can be used in a formal or intuitive way, which makes it particularly effective in the context managing SC use in prisons. 

As some people using SC did not consider their use to be problematic, at the very least they would be provided with harm reduction advice.

Due to the mental health effects of SC use, there was increased collaboration between mental health services, substance misuse services and health care services.

A consequence of this improved collaboration has been better practice relating to the management of dual diagnosis.

A key harm reduction message, especially in the period prior to release, is to suggest that individuals switch to traditional forms of cannabis once they are released [assuming that they have not suffered from adverse effects due to its use in the past].

A particular attraction for SC users in the community is its relatively low price.

Someone who has been paying ten times the community price while in prison can more easily afford to use traditional cannabis once they are released.

This advice can be further underpinned by practitioners being aware that 93% of SC users would rather be using traditional cannabis and by informing SC users of the significantly higher risk of experiencing adverse effects and hospitalisation from using SC compared to traditional cannabis.

Generally speaking, people who use SC in the community are more likely to be homeless and vulnerable, a group which will include many ex-prisoners.

Consequently, high quality harm reduction advice at the point of transition from custody to community is absolutely essential, and this advice needs to be maintained by community practitioners and services following release.

What’s in a name?

The unhelpful term “legal highs” is slowly dropping out of fashion and usage.

In general terms, most prisoners will refer to SC as “Spice” or “Black Mamba”.

While it is important to be aware of these terms and to use them to initiate a therapeutic conversation, it is important not to overuse them as this conveys the sense that SC are just one or two uniform or consistent products, when, in reality, there are numerous variations of SC.

SC users need to know that two identical looking packs of a particular brand might contain very different active ingredients, let alone different adulterants as well and there may even be variations within the same packet due to uneven spraying of the SC onto the “herbs” used to smoke the drug.

Effects of SC use on prison regime and routine

Apart from the effects on individual staff members of responding to the acute and chronic effects of SC use, there are systemic consequences on prison regimes to be considered in addition.

Responding to a wide range of adverse acute presentations and dealing with bullying and violence all place a strain on prison staff, in particular custodial staff.

The effects of a bad batch may mean several prisoners needing to be transferred to hospital, with each prisoner requiring an escort of two people.

There have been instances of 11, 12 or 13 prisoners needing transfer to hospital in a single day.

This means other prisoners are unable to attend medical appointments or take part in activities like gym, education or workshops.

Apart from the inconvenience and disruption that will occur consequently, prisoners affected, through no fault of their own, by such disruption will have an understandable sense of grievance of being deprived of important and meaningful activities.

There have been reports of prisons being brought to boiling point by accumulated frustration and grievance in such circumstances.

Effects of SC use on prison staff

Some prisoners will continue to use SC, despite experiencing adverse effects, because they are increasingly confident about the capability of prison staff to manage these incidents.

This can be a source of further stress, and demoralisation, for staff repeatedly attending prisoners suffering the acute effects of SC use.

Staff attending the training events occasionally described suffering symptoms [headache, disorientation, nausea] due to secondary exposure to SC.

Currently, very little is known about the likely short or long term impact of secondary exposure to SC, but staff should be advised to take all reasonable precautions to minimise the risk of prolonged exposure.

Responses to SC use

Criminal Justice responses

The Psychoactive Substances Act [PSA], which became law on May 26th 2016, means that possession and supply of NPS in prisons are criminal offences, with maximum sentences of up to two and seven years respectively.

It is important that prisoners are made aware that while personal possession of many NPS is not an offence in the community it is within a prison context.

However, SC are classified as Class B drugs and users need to be aware of this important distinction and of the potential penalties for possession and use of these drugs.

The availability of improved testing for NPS increases the likelihood of prisoners testing positive for NPS use and, thereby, suffering the Criminal Justice consequences of a positive test. Given that the non-detectability of SC is thought to have been a strong driver for its increased use in custody, prisoners need to made aware of this development and the increased risks and sanctions they may be facing.

Given the historical perceptions that NPS are “legal highs”, it is important that prisoners’ relatives are made aware of the potential penalties for conveying NPS, especially as they may be duped or coerced into smuggling NPS into prison on the basis that they are legal.

It is difficult to predict the long-term impact of the PSA at this relatively early stage of its implementation.

NPS use in the community

Community services face several challenges regarding the management of NPS use, especially the low numbers of NPS users entering treatment [2,728 or 0.9% of users entering treatment in 2015/2016] along with different patterns of NPS and Club Drug use in different localities.

Year

2013-2014

2014-2015

2015-2016

Numbers in treatment

301,944

295,244

288,843

New presentations

147,458

141,646

138,081

Club drugs

4,661[3.16]

5,532 [3.90]

6,105 [2.11]

NPS

320 [0.21]

1,154 [0.81]

2,728 [0.9]*

NDTMS data. Figures in brackets are percentage of new presentations.

25% of NPS users entering treatment will also be using opiates, 50% will have housing problems and 41% will have been referred to treatment by the prison or probation service.

Many users of SC in the community will find accessing services very difficult and services may need to be reconfigured to reach out to these vulnerable and frequently homeless individuals.

The price of SC varies quite significantly, costing £10 a gram in Leeds and in the homeless and hostel community in Manchester to as much as £30 to £60 a gram in central London.

One effect of the Psychoactive Substances Act is that many headshops have closed down-indeed many had closed in anticipation of the legislation taking effect.

However, in some areas street dealers have stepped in to replace the headshops and there is some evidence that this is introducing some SC users to traditional drugs of misuse such as heroin and crack.

Conclusion

SC continues to present a significant challenge to both prison and community services.

Prison staff, across all disciplines, have responded with increasing confidence and competence to this challenge and become increasingly adept at managing acute and chronic adverse effects on an almost daily basis.

Public Health England has developed a Toolkit to support the management of NPS use in prisons Public Health England NPS Toolkit for Prisons and has also produced a Thematic Analysis based on the training of prison staff to support the launch of the Toolkit.

The Thematic Analysis describes the experience of staff in secure environments in responding to NPS use and contains many examples of good practice which can be applied both in custodial and community settings. Comment GR: add link to Thematic Analysis.

There is increasing evidence of prison staff forming a therapeutic alliance with prisoners in establishing successful support groups and a robust network of peer mentorship and support.

Prisons are a repository of good practice and expertise which should not only be recognised, but emulated and adapted by other services and settings to ensure that the best possible care, in terms of prevention and management, is provided to service users not just in prison but also in community and hospital settings.

Resources and references:

Report Illicit Drug Reactions (RIDR) (PHE) Website with a new national system for healthcare professionals to report cases of harm with illicit substances. 

New psychoactive substances (NPS) in prisons-A toolkit for prison staff (PHE, November 2015-updated January 2017)

Thematic analysis of training for prison staff on new psychoactive substances (PHE, January 2017)

Harms of Synthetic Cannabinoid Receptor Agonists (SCRAs) and Their Management (Dr Dima Abdulrahim and Dr Owen Bowden-Jones on behalf of the NEPTUNE group, July 2016)

Spice: The Bird Killer: User Voice (May 2016)

HM Chief Inspector of Prisons for England Wales: Annual Report 2015-16

Changing patterns of substance misuse in adult prisons and service responses: Thematic report by HMIP December 2015

NDTMS Adult substance misuse statistics 2013-2014, 2014-2015, 2015-2016

Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances, March 2015 www.neptune-clinical-guidance.co.uk 

Drugs in prison: The Centre for Social Justice, March 2015.