Understanding the patterns of use, motives, and harms of new psychoactive substances in Scotland

Footnotes

1 All common effects taken from Adley (2016) The Drugs Wheel. Available at: http://www.thedrugswheel.com/downloads/TheDrugsWheelCategories_2_0.pdf [last accessed: 26/7/2016]

2 Participants for the survey were recruited primarily through services including homeless drop ins. To increase 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.

3 A confidence interval gives an estimated range of values which is likely to include the true value.

4 Not all respondents answered each question. Where answers are missing these have been excluded from the analysis so figures that describe the same population may have different base sizes

5 UNODC (2013) The Challenges of New Psychoactive Substances.

6 EMCDDA (2015) NPS in Europe An update from the EU Early Warning System March 2015

7 EMCDDA (2016) Health Responses to New Psychoactive Substances.

8 UNODC (2016) World Drug Report.

9 Wyckmans et al (2015) 'Novel Psychoactive Substances: a worldwide problem that requires an adequate approach'.

10 Seddon (2014) 'Drug policy and global regulatory capitalism: The case of new psychoactive substances ( NPS)'.

11 SCJS (2016) Scottish Crime and Justice Survey 2014/15: Drug Use.

12 SALSUS (2016) Drug use Report 2015

13 SALSUS (2016) Technical Report 2015.

14 SCJS (2016) Scottish Crime and Justice Survey 2014/15: Drug Use

15 NRS Scotland (2016) Drug Related Deaths in Scotland - 2015.

16 Ibid

17 The PSA came into force on the 26 ^th May 2016, which fell during the quantitative survey phase of data collection (which ran from 28 ^th April to 10th June 2016).

18 Fraser (2014) New Psychoactive Substances - Evidence Review.

19 Gillies, A. (2015) Closing the Evidence Gaps on the Prevalence and Harms of New Psychoactive Substances in Scotland.

20 Lafferty et al (2016) 'The Experience of an Increase in the Injection of Ethylphenidate in Lothian, April 2014 - March 2015'.

21 SDF et al. (2016) Chemsex, starting the conversation

22 Stanley et al (2016) 'Use of Novel Psychoactive Substances by Inpatients on General Adult Psychiatric Wards'.

23 Van Hout, M.C. and Bingham, T. (2012) 'A costly turn on: patterns of use and perceived consequences of mephedrone based head shop products amongst Irish injectors'.

24 New Psychoactive Substances Act 2016.

25 Wallace (2016) New Psychoactive Substances ( NPS): results of a questionnaire on the definition of NPS, proposals to establish a forensic centre for excellence, and improving data collection and information sharing

26 EMCDDA (1996) Estimating the Prevalence of Problem Drug Use in Europe

27 ISD (2016) Estimating the National and Local Prevalence of Problem Drug Use in Scotland 2012/13

28 Gillies (2014) Mapping Current and Potential Sources of Routine Data Capture on NPS in Scotland

29 Heyerdahl, F, Hovda, K, Giraudon, I, et al (2014) 'Current European data collection on emergency department presentations with acute recreational drug toxicity: gaps and national variations'

30 This includes young homeless people, care leavers, looked after and accommodated young people, and NEETs (those not in education, employment or training).

31 This was because R&D access was not granted in time for inclusion in the qualitative stages of the study.

32 Chen et al (2013) 'Service Use and Barriers to Mental Health Care among Adults with Major Depression and Comorbid Substance Dependence'; Lloyd et al (2013) 'Factors Influencing Mortality among Alcohol and Drug Treatment Clients in Victoria, Australia: The Role of Demographics and Substance Use Characteristics'; Thompson et al (2013) 'Substance-Use Disorders and Poverty as Prospective Predictors of First-Time Homelessness in the United States.

33 Braun & Clark (2006) 'Using Thematic Analysis in Psychology'

34 For more information on The Drugs Wheel, please see the Glossary at the start of this document, or visit www.thedrugswheel.com

35 Researchers recruited by SDF who have past lived experience of drug use and were formerly or currently representative of the research target group, MSM, PWID, in contact with mental health services, homeless. Due to ethical agreements, vulnerable young people were not recruited as researchers and at request of services, staff researchers were used for vulnerable young person recruitment.

36 Participants for the survey were recruited primarily through services including homeless drop ins. To increase 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.

37 Many participants fell into more than one population, thus figures here will not total 100%, or the total number of respondents (n=424).

38 p<0.001

39 p<0.001

40 p<0.001

41 O'Brien, K Chatwin, C, Jenkins, C and Measham, F (2015) 'New Psychoactive Substances and British Drug Policy: A View from the Cyber-Psychonauts Drugs: Education, Prevention and Policy 22(3): 217-223.

42 e.g. for women, BME communities, LGBTQI+ groups.

43 Participants for the survey were recruited primarily through services including homeless drop ins. To increase 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.

44 Sublingual is under the tongue administration

45 For benzodiazepine-type NPS, sublingual (under the tongue) was the most common 'other' selection, 24 out of 29 responses

46 Number of respondents varied by drug type question which is indicated by n=

47 A confidence interval gives an estimated range of values which is likely to include the true value

48 The method used to produce population estimates from a single data set is known as truncated Poisson. Details on this method can be found in the technical appendix to this report (Appendix A).

49 Substances prepared for injection should be filtered to remove impurities from the substance

50 Missed hits is a term used for missing the vein in an intravenous injecting episode and can be a factor in developing infections and swelling

51 Citric acid is one method for breaking down drugs such as heroin in to an injectable form. As stimulant-type NPS are generally water soluble, they do not require use of an acid to prepare for injection. Using citric acid when it is not required can contribute to irritation at the injecting site.

52 Combining only traditional drug use figures from 51-75% and 76-100% as described in Fig.4.2 to total 65%

53 Combining figures from only NPS use figures from 51-75% and 76-100% as described in Fig.4.2 to total 12%

54 Numbers of respondents varied by question which is indicated by n=

55 Peter, Young Person, Homeless

56 Colin, Mental Health Service User

57 Nick, Homeless

58 Moira, PWID

59 Jessica, PWID and Mental Health Service User

60 Claire, PWID, homeless, and mental health service user

61 Luke, Vulnerable Young Person

62 Daniel, Vulnerable Young Person

63 Note on prison deaths: any death in prison custody may lead to a Fatal Accident Inquiry ( FAI) under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 however the decision to hold an FAI is a matter for the Lord Advocate/Procurator Fiscal. No cause of death is recorded where a death has not yet been determined following FAI. No determination has been made that has recorded NPS as having contributed to or been the cause of a death in a Scottish prison.

64 Tiffany, mental health service user

65 Michael, mental health service user

66 Hugh, MSM

67 Kevin, PWID

68 As described in Chapter 3, the most extensively used substances during last chemsex encounter were reported as alcohol, followed by GHB/ GBL, mephedrone, cannabis and cocaine at much lower rates. Two participants reporting using ecstasy-type NPS and two using ketamine-type NPS.

69 Lothian Focus Group

70 GGC Focus Group

71 Samuel, vulnerable young person

72 Luke, vulnerable young person

73 Hugh, MSM

74 Note: mephedrone has been classified under the Misuse of Drugs Act 1971 since April 2010.

75 Graeme, MSM

76 GGC Focus Group Participant

77 Daniel, Vulnerable Young Person, Homeless

78 Colin, Mental Health Service User

79 See Chapter 6: Treatment and Legislative Responses

80 Daniel, Young Person, Homeless.

81 Kimberley, PWID, Mental Health Service User

82 Andrea, Mental Health Service User, PWID

83 Claire, Mental Health Service User, Homeless, PWID

84 See Chapter 6: Consequences of Use

85 Colin, Mental Health Service User

86 Paula, Mental Health Service User, Homeless

87 Hugh, MSM

88 Samuel, Vulnerable Young Person, Mental Health Service User

89 Tiffany ( PWID),

90 Sheridan & Butler (2010) ''They're Legal so They're Safe, Right?': What did the Legal Status of BZP-Party Pills mean to Young People in New Zealand?'

91 Winstock & Ramsey (2010) 'Legal Highs and the Challenges for Policy Makers'.

92 See, for example, Bourgois (2010) Righteous Dopefiend; Hopwood et al (2015) 'Drugs, Sex and Sociality: Factors Associated with the Recent Sharing of Injecting Equipment among Gay and Bisexual Men in Australia'; Latkin et al (2010) 'Social Norms, Social Networks, and HIV Risk Behavior among Injecting Drug Users'

93 Bourne et al (2014) The Chemsex Study

94 Ibid.

95 Stuart, D et al (2016) 'ChemSex: Data on Recreational Drug Use and Sexual Behaviour in MSM from a Busy Sexual Health Clinic in London'

96 SDF, UK Drugwatch (2014) Etizolam briefing

97 Pétursson,H. (1994) The benzodiazepine withdrawal syndrome

98 Clinical Knowledge Summaries (2015) NICE guidelines 'Benzodiazepine and Z-Drug Withdrawal; Nielsen (2013) 'Benzodiazepine Withdrawal after Long-Term Use'; Silverman (2016) 'Controlled Substance Management: Exit Strategies for the Pain Practitioner'.

99 Clinical Knowledge Summaries (2015) NICE guidelines 'Benzodiazepine and Z-Drug Withdrawal; Nielsen (2013) 'Benzodiazepine Withdrawal after Long-Term Use'; Silverman (2016) 'Controlled Substance Management: Exit Strategies for the Pain Practitioner'.

100 Debbie, Homeless

101 Peter, Vulnerable Young Person.

102 Luke, Vulnerable Young Person

103 Kevin, PWID

104 Alistair, Mental Health Service User

105 Samuel, Vulnerable Young Person, Mental Health Service User

106 Alexander, MSM

107 Staff could select more than one NPS therefore percentages do not equal one hundred.

108 Kimberley, PWID, Mental Health Service User

109 Claire, Homeless, Mental Health Service User, PWID

110 Gary, Homeless, Mental Health Service User

111 Lothian Focus Group

112 Luke, Vulnerable Young Person

113 Alistair, Mental Health Service User

114 Moira, PWID

115 Andrea, Mental Health Service User, PWID

116 Nick, Homeless

117 p<0.05

118 Overall figure from whole sample taking account of the cross over between different risk groups

119 Alistair, Mental Health Service User

120 Statistically significant for all groups

121 John, Mental Health Service User, PWID

122 Nick, Homeless Person

123 Luke, Vulnerable Young Person

124 Moira, PWID

125 With the exception of interviews with MSM, this was spontaneously raised by participants.

126 Thomas MSM

127 Jessica, Mental Health Service User, PWID

128 Kimberley, PWID

129 Lothians Focus Group

130 The emergence or re-emergence of anxiety

131 NICE guidelines 'Benzodiazepine and Z-Drug Withdrawal; Nielsen (2013) 'Benzodiazepine Withdrawal after Long-Term Use'; Silverman (2016) 'Controlled Substance Management: Exit Strategies for the Pain Practitioner'.

132 See Vandrey, Smith, McCann, Budney & Curran (2011) 'Sleep Disturbance and the Effects of Extended-Release Zolpidem during Cannabis Withdrawal' on sleep disruption in cannabis withdrawal. See also Bonn-Miller, Babson & Vandrey (2014) 'Using Cannabis to Help you Sleep: Heightened Frequency of Medical Cannabis Use among those with PTSD' on the use of cannabis to promote sleep, and elevated use of cannabis among individuals experiencing post-traumatic stress disorder.

133 NRS Scotland (2016) Drug Related Deaths in Scotland - 2015.

134 Merrall, E. L. et al. (2010), 'Meta-analysis of drug-related deaths soon after release from prison.'

135 Lafferty, C. et al. (2016) The experience of an increase in the injection of ethylphenidate in Lothian April 2014-March 2015

136 Roy, K.M. et al. (2007) Hepatitis C virus infection among injecting drug users in Scotland: a review of prevalence and incidence data and the methods used to generate them. Epidemiology and Infection

137 Number of respondents varied per question which is indicated as n=

138 Some of the target groups have cross over with other groups e.g. homeless and in contact with mental health services and so are therefore reported under both groups

139 p<0.01

140 p<0.05

141 Alexander, MSM

142 Michael, Mental Health Service User

143 Samuel, homeless, vulnerable young person

144 Paula, homeless, mental health service user

145 Kieran, Mental Health Service User

146 GGC Focus Group

147 Nicola, PWID

148 GGC Focus Group

149 SCJS (2016) Scottish Crime and Justice Survey 2014/15: Drug Use.

150 Lothian Focus Group

151 GGC Focus Group

152 Highlands Focus Group

153 Lothian Focus Group

154 Andrea, Mental Health Service User, PWID

155 Claire, homeless, Mental Health Service User, PWID

156 Keiran, mental health service user

157 Wampold (2015) 'How Important are the Common Factors in Psychotherapy? An Update'; Zilcha-Mano (2016) 'New Analytic Strategies Help Answer the Controversial Question of Whether Alliance is Therapeutic in Itself'.

158 Staff could select numerous options therefore the percentages will not total 100%

159 Graeme, MSM

160 GCC Focus Group

161 James, vulnerable young person

162 Peter, vulnerable young person

163 Tiffany, Mental Health Service User

164 p<0.05

165 This totals 127% as participants were invited to tick multiple boxes.

166 Kieran, Mental Health Service User

167 p<0.05

168 Home Office (2016) Psychoactive Substances Act 2016: Guidance for Retailers; BBC (2016) 'Legal Highs Ban Comes into Force across UK';

169 p<0.01

170 Tiffany, Mental Health Service

171 Gary, Homeless, Mental Health Service User

172 GGC Focus Group

173 Soussan & Kjellgren (2016) 'The Use of Novel Psychoactive Substances: Online Survey about their Characteristics, Attitudes and Motivations'.

174 Newcombe, R (2010) 'Wobbled Up' The illicit use of diazepam in Redcar.

175 Zoe Slote Morris & Maria Gannon (2008) Drug misuse treatment services in Scotland: predicting outcomes

176 Dolliver (2015) 'Evaluating Drug Trafficking on the Tor Network: Silk Road 2, the Sequel'; Martin (2014) Drugs on the Dark Net: How Cryptomarkets are Transforming the Global Trade in Illicit Drugs.

177 Martin (2014) notes that where vendors do sell less pure substances, they often state this explicitly, and clearly distinguish between 'high-grade' and 'sociable' standard drugs, with this distinction reflected in the price.

178 Leffler, Smith, de Armas & Dorman (2014) 'The Analytical Investigation of Synthetic Street Drugs containing Cathinone Analogs'; Miserez, Ayrton & Ramsey (2014) 'Analysis of Purity and Cutting Agents in Street Mephedrone Samples from South Wales'.

179 SCJS (2016) Scottish Crime and Justice Survey 2014/15: Drug Use.

180 SALSUS (2016) Drug use Report 2015

181 Winstock, A (2012) Global Drug Survey 2012

182 David B. Rosengren (2009) Building Motivational Interviewing Skills: A Practitioner Workbook

183 Winstock, A (2012) Global Drug Survey 2012

184 Home Office (2014) New Psychoactive Substances Review, report of the expert panel

185 Stanley et al (2016) 'Use of novel psychoactive substances by inpatients on general adult psychiatric wards'; see also, Martinotti, Lupi, Acciavatti, Cinosi, Santacroce, Signorelli, Bandini, Lisi, Quattrone, Ciambrone, Aguglia, Pinna, Calo, Janiri& di Giannantonio (2014) 'Novel Psychoactive Substances in Young Adults with and without Psychiatric Comorbidities '.

186 Bootzin, R., Stevens, S. (2005) 'Adolescents, substance abuse, and the treatment of insomnia and daytime sleepiness'

187 Fraser, F. (2014) New Psychoactive Substances - Evidence Review

188 Mental health network (2014) The future's digital mental health and technology

189 Tennant, R. (2015) No Light at the End of the Tunnel: Tracking the impact of Welfare Reform across Glasgow

190 Novel Psychoactive Treatment UK Network (2015) NEPTUNE Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances

191 Public Health England (2015) Substance misuse services for men who have sex with men involved in chemsex

192 Peer worker research team, St George's University of London (2015) Introducing peer workers in to mental health services: An organisational toolkit

193 Bowden Jones. O. (2014) One new drug a week 'Why novel psychoactive substances and club drugs need a different response from UK treatment providers'

194 Slote Morris, Z & Gannon. G. (2008). 'Drug misuse treatment services in Scotland: predicting outcomes'.

195 NEPTUNE (2016) Club Drug Use Among Lesbian, Gay, Bisexual and Trans ( LGBT) People.

196 Newcombe, R (2010) 'Wobbled Up' The illicit use of diazepam in Redcar.

197 A prison resource was created in partnership with Polmont YOI, SDF and Crew which is utlised in some prisons via groupwork or prison TV/Radio system.