H.E. Leigh Turner, UK Ambassador (Opening Remarks)
Thank you everyone for coming to consider this important issue.
New psychoactive substances are a global problem. There is growing international evidence of their public health harms, and an increasing interplay between NPS and traditional drug markets.
The United Kingdom is working with partners to adapt the international system to meet this challenge, including by establishing the International Action Group on NPS.
This informal group provides us with the forum we need share national best practice and to coordinate and drive the international response.
Significant progress has been made in recent years, including a more responsive international scheduling system and enhanced data collection, but as acknowledged in the outcome Document there is more to be done to address the health harms of these substances.
That is why the UK tabled resolution 60/4 last year, which promoted the implementation of key Outcome Document recommendations, with a particular focus on the health harms of these substances.
This event is an excellent opportunity to consider the steps that are being taken by the international community to achieve these goals.
I will now pass over to Katherine Merrifield, Joint-Head of the Drug and Alcohol Unit, UK Home Office, who will chair this event.
Dr Owen Bowden-Jones
Talking about Project NEPTUNE, a clinical response to NPS – founded in 2014 amidst a rapid rise of NPS in the UK with little information on these drugs and how to assess and manage the harms. Project NEPTUNE was an attempt to raise standards on treatment of NPS and dance culture drugs based on the available evidence. Where gaps existed in guidance, we developed expert consensus. The guidance was peer-reviewed. Hundreds of different drugs, and addressed the quality of the evidence available , the pharmacology, the clinical uses, the prevalence and routes of use, etc. Several guides have been released – including for LGBT populations and also on synthetic opioids. These have been very warmly received, 60,000+ downloads. It is also referenced in the UK national drug strategy and clinical guidance.
But even good guidance can get left on the shelf by busy clinicians – so Project NEPTUNE also looks at how to make guidance accessible and whether it is making a difference in practice. They developed seven e-learning modules (launched in January) and a series of clinical tools – all of which are also peer-reviewed. The modules have interactive content, including games. There has also been an independent evaluation of these modules in six pilot sites – and this has helped to improve the modules. Very good feedback received in the few weeks since the launch. Self-reported knowledge and confidence on the issue has increased. www.neptune-clinical-guidance.co.uk
Kirsten Mattison, Health Canada
In British Columbia, for example, overdose deaths have risen incredibly rapidly. More than 4,000 people died across Canada of overdose – including many cases of fentanyl and other opioids. These deaths have now become the most common cause of death in Canada, leapfrogging accidents. Canada’s laboratory and legal systems are well placed to identify and analyse substances, and the domestic legal framework allows for the control of groups of substances. They also have the legislative ability to put new substances under rapid, temporary control. Every NPS / fentanyl that they detect was already controlled in Canada, and was already known as a risk. But it has not been enough to stem the tide of this public health crisis. We understand that this North American crisis has not impacted other countries to the same extent, but it serves as a warning for the international community. We are still having a very technical discussion, and I worry that what we see in Canada is that we didn’t reach the general population and the younger population – and that NPS terminology still seems to substance users to be smart, flashy and cool, and we have not successfully communicated the public health risks associated with these substances. We do not have all of the answers, but are trying to extent our reach using communication specialists and people with lived experience to get the messages out.
Justice Tettey, UNODC Laboratory and Scientific Section
The UNODC Early Warning System is part of our research portfolio and is being used to protect health by getting red flags out there early. Many of you will recall surges in the 1990s, and will recognise that NPS is not new (1980s with benzodiazepines, 1990s with ATS, etc). But what was different with NPS, was we ended up with everything at the same time – not just one class of drug. And the numbers were astonishing. The trend has declined slightly for 2016. Looking at these NPS in terms of what they do to the body – we have stimulants, cannabinoid receptor agonists, hallucinogens, dissociatives, opioids and sedatives. The increase in opioids has continued, even in 2016. Assuming that the proposals are approved this week, there will be 11 opioids scheduled between 2015-2018, 13 stimulants and 10 cannabinoids. The Early Warning System is picking up more of the opioids.
The ideal Early Warning System will start with global monitoring of the markets, then alert regarding adverse threats, anticipate these threats etc. Over the years UNODC – with the mandate from several resolutions – have been able to develop a sophisticated system, offering global monitoring, knowledge, legislative responses, laboratory support, and risk assessments. The UK resolution allows the inclusion of adverse health affects into this system. How do we pick which ones are dangerous enough to meet the thresholds for the World Health Organisation review processes? The portal is being used a lot, and can give information about the substances on the market – but not which ones to worry about. In a few months, we will incorporate forensic toxicology data into the system, using data from labs in around 80 countries and a network of 2,000 members, providing a critical mass that allows to pick up the red flags and anticipate the threats. International cooperation is really important, including establishing national early warning systems (including several new ones across Latin America this year). In the summer, we will produce the first of the biannual threat assessment reports – answering the basic question ‘what do we need to worry about’. This will allow the UNODC Early Warning System to help countries to anticipate threats, reduce the associated risks, and inform the responses – and will be in a position to help address whatever the future crises might be.
Wil de Zwart, WHO Department of Essential Medicines and Health Products
The WHO ECDD examines the liability of abuse and harm, as well as the medical and scientific uses of a substance. There are several challenges: the high number of new substances requiring attention, for example. WHO is mandated by several CND resolutions – including 60/4 – to increase its surveillance and work in this area. The principles of the WHO NPS Surveillance System are: not to duplicate other work; strengthen connections with other organisations; collate and disseminate data from existing sources; and generate data through additional mechanisms. The model used is similar to the WHO Product Alert system, with information disseminated via the website – including on morbidity and mortality, and guidelines on prevention and treatment. You can also sign-up for notifications. Potential collaborations are with regulatory authorities, national poison centres, etc.
Question: What is the difference in the crisis in Canada and the USA?
Answer (Health Canada): There are definitely parallels, with increased rates of illegal prescribing, but essentially we have a contaminated drug supply, rather than seeing it as a transition to heroin. In Canada, a number of illicit drugs are being added to, or replaced with, fentanyls. But moving in a similar direction.
Question: Is the supply from diverted prescriptions or from illegal sources?
Answer (Health Canada): It is coming from illegal routes, and is being imported.
Question: I want to hear about the harm reduction approach, as well as just prevention and treatment.
Answer (Health Canada): Canada has been clear, especially since UNGASS, that our strategy includes harm reduction as a pillar, including for the emergency response to the crisis we are in. This includes making naloxone available for free, and without prescription, increasing the number of drug consumption facilities across Canada, good Samaritan legislation to protect those who intervene and report an overdose. This is an important piece, balanced with the other elements of the strategy.
Answer (Dr Bowden-Jones): I echo all of that. When we did the evidence review for Project NEPTUNE we did not find much on harm reduction strategies – so we recommend the same approaches as used for other drugs. Many of the people in the UK who are using NPS are unaware, they think that they are purchasing other drugs. This is a real challenge for us, in giving more specific harm reduction messages.
Answer (UNODC): We look at the origins of the current opioid crisis, we are not just looking at the harm reduction aspects in isolation but at the set of measures needed to take care of this special population, including treatment, in a wholistic approach.