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Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances NEPTUNE

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Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances NEPTUNE Novel Psychoactive Treatment UK Network NEPTUNE Guidance on the Clinical Management of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances NEPTUNE This publication of the Novel Psychoactive Treatment UK Network (NEPTUNE) is protected by copyright. The reproduction of NEPTUNE guidance is authorised, provided the source is acknowledged. © 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 NEPTUNE NEPTUNE (Novel Psychoactive Treatment UK Network): 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 Bricksman 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 Ofender 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 Moncrief 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 NEPTUNE Expert Group members iv Dr John Roche Consultant Psychiatrist Leeds and York Partnership NHS Foundation Trust Prof Fabrizio Schifano Chair in Clinical Pharmacology and Therapeutics University of Hertfordshire 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 Bofto 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 Ofcer 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 Ofce NEPTUNE Acknowledgements 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 draf 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 staf 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. NEPTUNE Contents 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 efects 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 NEPTUNE Contents vii Chapter 2. Psychosocial interventions for club drugs and novel psychoactive substances 30 2.1. Stepped care 32 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 efects 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.
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