Drugs Deaths: National Drugs Mission Clinical Advisory Group minutes March 2024

Attendees and apologies

• Marion Bain, Co-Chair – Deputy Chief Medical Officer
• Adrian MacKenzie, MAT Standards Clinical Lead, Healthcare Improvement Scotland
• Professor David Lowe, Clinical Director Health Innovation (Scot Gov) and Consultant Emergency Medicine NHS GGC
• Duncan Hill, Specialist Pharmacist in Substance Misuse, NHS Lanarkshire
• Kirsty Nelson, Parish Nurse, Queen's Nurse
• Hazel Torrance,    Head of Forensic Toxicology Service, Scottish Police Authority
• Roy Robertson, Professor of Addiction Medicine at the University of Edinburgh and Retired General Practitioner
• Dr Ryan McHenry, Clinical Research Fellow and Registrar in Emergency, Pre-Hospital and Retrieval Medicine
• Susanna Galea-Singer, Clinical Lead and Consultant Psychiatrist / Chair of the Education Committee / Co-Chair Faculty of Addictions Psychiatry
• Tara Shivaji, Consultant in Public Health Medicine, Public Health Scotland
• John Harden, Co-Chair – Deputy National Clinical Director
• Chanpreet Blayney, Consultant Psychiatrist at NHS Greater Glasgow and Clyde
• Mandy Ramsay, Head of Clinical and Care Governance, Turning Point Scotland
• Maggie Page, Scottish Government
• Alison Crocket, Scottish Government
• Deanna Francis, Scottish Government
• Georgie Alford, Scottish Government
• Michael Crook, Scottish Government
• Louise Wilson, Scottish Government
• Paul Sutherland, Scottish Government

Items and actions

Welcome and Introduction

The Chair welcomed members and attendees to the fourth meeting of the National Mission Clinical Advisory Group. 

Board Governance

The minute of the second meeting on 06 December 2023 was approved.

Members were advised that previous meeting minutes have now been published online on the Scottish Government website.

Presentation: RADAR Update.

Tara Shivaji (Public Health Scotland) delivered an epidemiology update on the  RADAR (Rapid Action Drug Alerts and Response) early warning system.

Points to note

• The early warning system was set up at the start of the COVID pandemic and collects risk knowledge to allow Public Health Scotland and the Scottish Government to monitor and alert and to recognise any unexpected levels of harm. 
• It will communicate risk information that has been detected to allow national and community response capabilities to be enhanced.
• The use of real time data presents both opportunities and challenges noting the increased uncertainty vs speed of information.
• Xylazine has been detected in Scotland and the numbers are expected to increase when widespread testing begins in Spring 2024, although the upward trend could be due to broadening testing rather than purely increasing prevalence.  
• The indicators of harm continues to be high as drug use trends are changing.

Scenario Planning/ Presentation: The emergence of synthetic opioids and the potential impact that we may face in the next 12 months.

Hazel Torrance (Head of Forensic Toxicology Service, Scottish Police Authority) and Dr Ryan McHenry (Clinical Research Fellow and Registrar in Emergency, Pre-Hospital and Retrieval Medicine) delivered short presentations on Toxicology and Emergency Medicine in the context of synthetics.
Points to note

Toxicology

• Heroin shortages are leading to the increase in use of synthetic opioids which is an emerging concern reflected in a number of academic papers in the last year.
• Nitazenes are soon to be named on the Misuse of Drugs Act 1971 as class A drugs.
• Nitazenes have been detected in many forms of drugs; powder, tablets and paper tabs since June 2022 and detected (alongside other drugs) in 40 post-mortem cases across Scotland since June 2022.
• There are still many gaps in knowledge, for example on dosage, purity, stability and interaction with other drugs.
• There were questions over the stability and half-life of nitazenes, in some cases, after periods of time it is no longer detectable in samples.
• Nitazenes are currently found in a small proportion of post-mortem toxicology testing but this is increasing.

Emergency medicine

• Attendance levels to Emergency Department are stable but still remain high. The levels are highest amongst the prison population. 
• The reported A&E attendances in RADAR are likely to be a significant underestimate due to recording challenges
• Presentations at Emergency Departments have become more complex and more likely to require admission, or ICU care.
• These are less predictable toxidromes and present different clinical pictures in terms of the care each individual will require.
• The overriding message is that the drug take population are striving for something different and it is important to use all available data to gain and understanding of what is driving drug taking trends.
• So what? – We must understand why it is better to know what a patient has taken if the treatment remain unchanged.
•  A lot of information can be found in community research from a wider spectrum of patients who aren’t dying from an overdose.

Discussion 

Maggie Page outlined the policy approach being taken by the  Scottish Government and key areas of clinical consideration.   

Points to note

Naloxone

• All community pharmacies are now carrying Naloxone and some distribute take-home, noting this is a good distribution route.
• Naloxone is available through the Scottish Ambulance Service has increased significantly. They have now changed policy to now carry 2 doses instead of one. Turning Point staff now carry 2 kits as do their homelessness staff. It was noted that naloxone take home availability differs in areas of the country, there is now an opportunity to establish a standardised approach with this.
• Debate on whether more than one naloxone kit is required, or whether take home naloxone should be increased to 2 kits. There is rapid review literature from the US around the effectiveness of naloxone on synthetic opioids and fentanyl which recommends that more than one dose of Naloxone is required for higher doses or more potent synthetic opioids.
• However, it is difficult to categorise who would require more than one dose of Naloxone, as this would be dependent on individual tolerance.
• Clinical advice suggests to administer first dose and wait to see if it is effective before giving additional doses.  
• Naloxone can only be effective if people/patients carry it and we need to have naloxone in places where drug users would present for help, such as Naloxone boxes (similar to defibrillator boxes) in area of drug use or in all licensed premises.
• A drone delivery pilot is underway that can transport Naloxone rapidly to remote locations. 

 
Testing strips 

• We should be very careful using testing strips at point of care and be aware of their limitations as won’t always pick up the presence of new low dose drugs and can sometimes produce false positive and false negative results.
• The primary purpose of testing strips was as an engagement tool to improve behaviours and start the conversation and informal evidence supports that they have improved behaviours.
   

Drug Checking

• There are challenges using point of care testing for new low dose drugs as they may be harder to detect. Nitazenes, in particular, may appear in different forms when testing.
• Debate on whether the majority of users test before use and it was flagged that there is a risk users could use this to test for a more potent dose to take.
• Any checks made available to users should only be to test the quality of the substance and not to indicate the strength or potency. 
• Drug checking won’t necessarily help us to find out information on potency and concentration level in fatal and non-fatal events.

 

Pragmatic Approaches 

• Need to inform and communicate with the wider public, and not only the drug or injecting population, regarding nitazenes and their emerging prevalence across drugs.
• The orange guidelines– which were initially written for heroin treatment – must be updated and rewritten to include synthetics.
• Services have traditionally been tailored for opioids but as substances are changing, they must be widened to accommodate all people who go to special services for prescribing.
• A number of options were discussed for engaging with the drug using community more effectively, including: Community Psychiatric Teams, front door to care, emergency departments, clinical governance and introducing community pharmacy prescriptions reviews.
• Consideration must be given to how many Drug Related Deaths were seen in the Emergency Department in months before and whether this data is this recorded.

Barriers to address 

• There are still  significant gaps between Community and Statutory services and it was noted that information sharing is still weak.
• To improve communications, we must have a single patient record, continuous recounting of the same issues can cause unnecessary additional trauma for patients.
• We need a joined up approach, as it is difficult to users refer to services when the substance in question is not an opiate, noting that in Dundee, crack cocaine is the biggest issue. 
• It was questioned whether MAT standards should now be broadened to include all substances. 
• People are less likely to present for Opioid Substitution Therapy if they are using many different types of drugs.
• There are concerns that that Primary Care may be at capacity and therefore not keen to take on anymore work or do not see it as their responsibility.

Discussion of focus of next meeting: 

• Suggestion – To look at what challenges face policy makers and how the CAG can help policy makers and to explore where the groups advice can feed into policy decisions?

AOB & Close

• Roy Roberston’s paper was flagged.

The next meeting is scheduled to take place 19 June 2024 at 1.00 pm.- 3:00 pm. This meeting will be in-person in St. Andrews House.

Subsequent meetings as follows: 

Wednesday 18th September 2024 1 pm – 3 pm

Wednesday 11th December 2024 1 pm – 3 pm

(Scheduled to be in-person meetings in St Andrews House and are subject to short notice change)