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SCOTTISH ADVISORY COMMITTEE ON DRUG MISUSE: Psychostimulant Working Group Report
CHAPTER 2: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
SUMMARY
EXTENT OF THE PROBLEM
At present there are limited data available on the scale of psychostimulant use in Scotland, particularly among those users not seeking treatment.
Trends in cocaine use in Scottish data are less consistent than those from England which show a clear increase in the use of cocaine in the second half of the 1990s. In Scotland there does appear to be an increase in the use of cocaine, but at a lower level.
Increased cocaine use reported in the Health Education Population Survey (HEPS) and an increase in the number of new referrals to the Scottish Drug Misuse Database using stimulants.
The demographics of those reporting cocaine use alone are markedly different from those who use opiates either as a primary or secondary drug.
The figures for Aberdeen and surrounding area are particularly high and reflect an established crack/cocaine market in the area.
COCA Scotland note changing habits and use of crack/cocaine from area to area and scene to scene within the same city/town with injecting of crack/cocaine more prevalent in the north of Scotland than elsewhere.
Police reports of increased seizures of cocaine may reflect a real increase in availability.
PREVENTION
The 'all drugs' approach, i.e. all drugs are harmful and use of them should be discouraged, of the Scottish Executive's communications strategy is appropriate - singling out stimulants for separate treatment at the national level would not be helpful (in part because there is a danger of encouraging use).
More specific information on the dangers of using amphetamines, cocaine and crack cocaine is appropriate at local level.
Specifically targeted information should be available to drug services, health professionals, service users, needle exchanges, employers, the police and prison service.
Similar information should be available in settings where users who are not currently seeking treatment are likely to be found, such as pubs and clubs.
ADVERSE EFFECTS OF USE
Health problems
Dependence on psychostimulants is associated with general health problems such as reduced appetite and poor nutrition resulting in increased susceptibility to illness and infection.
Some of the adverse physical effects of psychostimulant abuse are related to the route by which they are taken.
Injecting psychostimulants carries additional risks including abcesses, septicaemia and chronic infection of the heart lining and valves. Sharing needles carries the risks of hepatitis, HIV and AIDS.
Psychiatric problems can occur with psychostimulant use, especially with chronic use and during "binges".
Neuro-psychological tests on chronic psychostimulant users show cognitive impairments, some of which may be persistent, that may adversely affect the ability to make decisions and thus the outcome of treatment.
Amphetamines
Amphetamines are a group of chemically related synthetic stimulants that are generally produced illicitly. Some may be pharmaceutical products that are diverted onto the illicit market.
The commonest types of amphetamines tend to be swallowed, injected or snorted. A variety of amphetamine known as "ice" can be smoked, though this is still currently rare in Scotland.
Amphetamine abuse can result in high blood pressure, abnormal heart rhythms, stroke and uncontrolled rise of the body temperature, all of which may be fatal.
Anxiety during use and depressive symptoms after using are common.
Amphetamine psychosis may develop with chronic or high dose consumption of amphetamines.
Maternal use during pregnancy may harm the fetus but the research evidence is limited.
Cocaine
There are two basic types of cocaine: cocaine hydrochloride which is snorted or injected and the alkaloid of cocaine (freebase or crack) which is usually smoked.
Cocaine use can be linked to virtually every type of heart disease. Death or disability may result from abnormal heart rhythms, heart attack or high blood pressure causing a stroke. With chronic use the cardiovascular system is prematurely aged.
Cocaine may cause seizures or unmask epilepsy and can cause an uncontrolled rise in temperature that may be fatal.
Snorting of cocaine can result in nose bleeds, loss of sense of smell, and nasal septum perforation. Smoking can cause a variety of respiratory problems including respiratory failure and "crack lung".
The injecting of heroin together with cocaine ("speedballing" or "snowballing") is a highly dangerous practice that is becoming more prevalent in Scotland.
Cocaine is often taken with alcohol forming a third substance, cocaethylene, which has longer lasting effects and is more toxic, especially to the cardiovascular system, than cocaine alone.
Psychiatric problems include anxiety and panic attacks. These may persist even after stopping cocaine use. Depressive symptoms are common following stopping the drug and may be persistent and severe enough to lead to suicide.
With heavy or chronic use a psychosis may develop with paranoid features, auditory hallucinations, anxiety and agitation. The individual may become confused (excited delirium), violent and require detention for treatment. This usually resolves over a few days but may be more persistent.
Maternal use during the pregnancy can cause premature delivery, low birth-weight, post-natal withdrawal symptoms and cognitive and behavioural disorders in later life.
PLANNING SERVICES
There is limited evidence about how drug services should be designed to meet the needs of stimulant users, and what there is comes from England and the USA.
Most stimulant users perceive drug services, as they are currently configured, to be the preserve of opiate users.
Psychostimulant users are not a homogeneous group who also use other drugs/alcohol- some are opiate users who also use psychostimulants; others are primary stimulants users; a few only use stimulants.
CONCLUSIONS
Whilst there is no current or anticipated epidemic of stimulant use in Scotland, there are indications that the use of cocaine and crack cocaine has increased recently and is expected to continue to increase.
The message of prevention at the national level should continue to be that all drugs are harmful. To be effective with stimulant users, local communication strategies, and other prevention work aimed at discouraging stimulant use, need to take account of the fact that stimulant users may be difficult to reach and have a very different profile from opiate users.
There is an urgent need for information on the dangers of crack/cocaine use for service providers and users in Scotland. A range of channels and techniques need to be used to reach the different target audiences.
The health consequences of psychostimulant use should not be underestimated. There are serious physical and psychiatric problems associated with the use of these drugs that may be compounded by the use of alcohol or opiates at the same time.
Information on stimulant use, its consequences and the range of possible treatment options is currently very limited in the training of health care (and other) professionals.
There is a need for services to be more responsive and accessible to stimulant users across Scotland, although there is considerable variation across the country and specific stimulant services are urgently needed in cocaine and crack cocaine hot spots
Whether existing services should adapt or new services be set up would be a matter for local decision. Resources would need to be redirected to allow this.
There is already a significant level of unmet need among stimulant users that should be addressed without delay. The number of individuals who seek help because of cocaine use is small, but there is undoubtedly need for an increased number of treatment places available to stimulant users.
To be accessible to stimulant users, services and interventions will need to be tailored to their specific needs, profile and characteristics, which are very different from those of opiate users.
Continuous monitoring of stimulant use across and within Scotland is important to ensure that services are able to meet the demands of this group. Experiences from elsewhere suggest that this may include local needs assessment exercises.
Consideration needs to be given as to whether new sources of data may be necessary, given the number of users who do not go to treatment services.
There is a need for further evaluation and research, at least at a UK level, to examine the effectiveness of services models and specific interventions to address the needs of stimulant users in Scotland and elsewhere. Evidence of the effectiveness is currently limited.
As part of a broad strategy to address stimulant use, it is important for the police to take steps to curtail availability and to increase enforcement.
RECOMMENDATIONS
PREVENTION
1. The Scottish Executive should make available without delay specifically targeted information on the dangers of crack/cocaine use to drug services, health professionals, service users, needle exchanges, employers, the police and prison service, using information resources already available from the Piper and Blenheim Projects, COCA and Mainliners.
2. The Scottish Executive should work with Drug Action Teams (DATs) to develop local communication strategies covering psychostimulants that tailor health messages to different audiences and use different methods and general outlets such as libraries, sports centres/gyms and websites.
3 Information made available through local communication strategies for users about the damaging health consequences of psychostimulant use should stress the risks associated with the route by which stimulants are taken and the psychiatric problems associated with bingeing.
4. Local information strategies should include information for users on the risks of contracting blood borne viruses associated with the injection of crack and cocaine and on the dangers of contracting sexually transmitted diseases as a result of risk-taking sexual activity, so that they can make informed decisions and reduce associated harm.
5. The Lord Advocate's guidance, which is currently under review, should ensure that needle exchanges are able to supply enough sets of injecting equipment to meet the increased need of crack and cocaine injectors.
6. All agencies involved in drugs education should highlight the dangers of cocaine and crack cocaine use.
7. Employers should review their workplace drug policies to include reference to psychostimulant use.
AVAILABILITY
8. The Scottish Drug Enforcement Agency should take action without delay to make key messages from its recent unpublished report more widely available and advise on action to be taken by the police and other agencies to reduce availability of psychostimulants in Scotland and to strengthen enforcement.
9. The Scottish Executive should consider and act on the outcomes of a Customs and Excise Research project that will quantify recreational drug misuse, particularly crack cocaine, across the UK.
10. Each local health care co-operative should undertake a survey to assess the impact of the SIGN Guideline No 52 on the primary care management of attention deficit disorder and hyperkinetic disorder.
TREATMENT
11. Service planners and providers should ensure that treatment interventions are designed for stimulant users based on existing evidence of their effectiveness.
12. Service planners must consider increasing substantially the number of treatment places for both cocaine and crack users.
13. Opiate services should also take account of their clients' cocaine and crack use.
14. The Scottish Executive should review the Models of Care for stimulant users being developed in England by the National Treatment Agency with a view to developing similar standards for use in Scotland.
15. The Effective Interventions Unit (EIU) should include in its forthcoming report on the integrated care of drug users a section on access to treatment for psychostimulant users.
16. The Scottish Prison Service should give consideration to developing the COCA advice to prison workers to reflect Scottish conditions.
17. Maternity services should be aware of the possible adverse effects of maternal stimulant use on the fetus and new-born.
PLANNING SERVICES
18. Drug Action Teams (DATs) across Scotland, and their constituent agencies, should establish and develop drug services that are geared to meet the needs of an existing and emerging (and potentially large) group of cocaine and crack users
19. Cocaine 'hot spots' such as Glasgow, Aberdeen and Edinburgh should have basic stimulant drug services in place.
20. DATs should commission local needs assessments before services are planned.
21. In planning services for psychostimulant users DATs and agencies should address the needs of four categories of users:- youthful experimenters; regular stimulants users; problematic stimulant users; and opiate/stimulant co-users.
22. DATs and service providers must recognise the disinclination of problem stimulant users to use services and take measures to over come this.
23. The EIU should provide, as soon as possible this year, a guide on psychostimulants for (DATs), service planners and providers drawing on the findings from this report. This should include information about the range of health consequences of stimulant use and their seriousness and the characteristics of some stimulant users. (Draft is at Annex G)
24. Criminal justice initiatives such as Drug Treatment and Testing Orders and Drug Courts should take steps to address the treatment needs of psychostimulant users and Arrest Referral Schemes should be able to refer stimulant users to appropriate services.
TRAINING
25 NHS Education should ensure that substance misuse is included in the curriculum for all health care professionals as a matter of urgency.
26 The Scottish Executive should explore with relevant professional bodies the inclusion of substance misuse in the undergraduate curricula for doctors, pharmacists and nurses as a matter of urgency.
27 The Scottish Executive should include in its review of initial teacher education the need to incorporate stimulants as part of health education.
28. The Scottish Executive should bring forward proposals to enhance professional social work education by ensuring that stimulant use is included in substance misuse training.
29 The Scottish Social Services Council should include substance misuse in its curricula and in its programme of professional development as a matter of urgency.
30. Scottish Training on Drugs and Alcohol (STRADA) should develop a module about psychostimulant use for specialist drugs workers and health professionals.
31 STRADA should develop training modules on psychostimulant use which should be available to front line staff in the police, prison service, community education, teaching, housing, employment services, social work etc.
RESEARCH AND EVALUATION
32 Service commissioners should ensure that services designed to meet the needs of psychostimulant users are rigorously evaluated. This may include both process (to examine how services are best designed and delivered) and outcome evaluations (to assess the impact of the service). Support for such evaluations in Scotland should be a commitment for future work of the Scottish Executive Drugs Misuse Research Programme.
33 Service providers should ensure that approaches to treatment (pharmacological / psychological and psychosocial) are rigorously evaluated to help build on the existing evidence base and inform the future development of services at national and local levels.
34 The EIU should, as soon as possible, disseminate widely current and future research on psychostimulants, including the aforementioned guide for DATs which draws on the key findings of the this report.
35 The EIU should watch for relevant research evidence from other countries.
STATISTICS
36. The Information and Statistics Division of the Common Services Agency (ISD) should make available data that will help with local needs assessment.
37 ISD should consider whether there is a need for analysis linked to DAT needs assessment work.
38 ISD should continue to monitor trends in use of psychostimulants.
39 ISD should consider developing some more detailed local monitoring in areas of high use of psychostimulants.
40. ISD should consult a range of additional data sources that could provide supplementary evidence of psychostimulant use, such as NHS data on psychiatric morbidity; A&E admissions etc.
RESOURCE IMPLICATIONS
41 Resources should be made available by the Executive, NHS Boards and local authorities to:-
improve existing service to address the needs of psychostimulant users;
introduce specific services targeted at regular and problematic psychostimulant users;
produce and disseminate information as part of the communication strategy;
undertake research and evaluate new and existing service provision; and to
improve data collection to include specific questions on psychostimulant use.
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