New or Novel Psychoactive Substances ( NPS) imitate the effects of illegal drugs and are commonly (although misleadingly) referred to as 'legal highs'. Over the last decade the use of NPS has expanded in Scotland. Current data sources and anecdotal reports have identified a number of vulnerable or potentially at risk groups. This report presents results of mixed methods research on NPS use among five key target populations: vulnerable young people, people in contact with mental health services, people affected by homelessness, people who inject drugs ( PWID) and men who have sex with men ( MSM).
Qualitative interviews were undertaken with 33 people who had taken NPS. Over half of participants belonged to two or more target groups. Four focus groups were run with front line staff working with people who use NPS across Scotland, and attended by 42 practitioners. Key themes from qualitative analysis of the interviews and focus groups were used to inform the design of two surveys: one for service users  (the NPS survey), and one for staff (the staff survey). 424 service users and 184 front line workers completed the surveys.
Findings are presented on patterns of NPS use, motivations for and consequences of use, and treatment and legislative responses.
|Patterns of NPS Use: Key Findings|
|Various service data sets were explored, including specialist drug service data and national data sets, in an attempt to derive prevalence estimates within vulnerable populations across Scotland, but none were sufficiently robust.
However, local estimates for NPS use among people who inject drugs were derived in two parts of Scotland from data from injecting equipment providers. From analysis of existing needle exchange data for NHS Greater Glasgow and Clyde ( GGC) and NHS Lothian, we estimate that there are 190 (confidence interval 114-265)  injecting NPS users in NHS GGC and a further 673 (confidence interval 562-784) NPS injectors in the NHS Lothian area.
Use of NPS was widespread in the survey sample with 59% (n=252) of respondents reporting that they had ever used NPS. Of those, 74% (n=185) reported having used NPS within the last six months.
Poly-substance use amongst the sample was very high. Only one person reported being a sole NPS user, with 99% (n=251) of NPS users also reporting traditional drug use. The most commonly used NPS were synthetic cannabinoids (41%, n=104) and benzo-type NPS (41%, n=102), while approximately one fifth reported taking stimulant-type NPS (21%, n=53) and mephedrone (19%, n=48).
Preferred route of administration varied by substance. Smoking was most common for synthetic cannabinoids (98%, n=91), whereas oral (66%, n=57) and sublingual (under the tongue) (28%, n=24) were most common for benzodiazepine-type NPS. Stimulant-type NPS were more commonly taken by snorting (51%, n=25) or injecting (33%, n=16).
|Motives: Key Findings|
|There were a wide range of reasons reported for people using NPS. The key motives related to ease of access, curiosity and influence of peers, as well as pleasure, price and potency. Legal status did not appear to be a key motivator for use.
Other specific motivations were associated with particular groups of respondents. For example MSM were more likely to highlight improving sex as a key motivator for use. Those with a history of benzodiazepine use were more likely to highlight substitution from prescribed drugs as a key motivator for use.
Reasons for not trying: Reasons for not trying NPS were explored in the qualitative interviews only. These generally related to awareness of the harms from observing NPS use among their peers.
Reasons for trying: The key reasons for trying NPS related to price, curiosity and ease of access, including being offered through peers.
Reasons for stopping: The key reasons for stopping use of NPS reported in the study related to 'not liking it' or in relation to specific harms that individuals had experienced, for example having a negative impact on mental or physical health.
Reasons for continuing to use: The reasons for continuing to use NPS overlapped with reasons for trying and in particular around ease of access. In addition, motives for continuing also related to pleasure and compulsion. More functional reasons for continued use related to people using in an attempt to self-manage underlying mental health problems or dependency and a desire to avoid going into withdrawal.
|Consequences of Use: Key Findings|
|The surveys identified multiple harms associated with the consequences of using NPS. The negative consequences of use can broadly be described in terms of mental and physical health harms and social harms.
Positive effects were identified by some. This was generally when under the influence of NPS, and negative after effects were often described. Use of NPS by MSM for chemsex saw half of respondents report no negative after effects for mental health (n=15/29) or social consequences (n=15/29). Those who reported benzodiazepine-type NPS use also identified positive effects on managing sleep and mental health, with 91% (n=52) reporting that use helped them sleep and 81% (n=47) stating that use reduced their anxiety.
Mental Health harms
Across all NPS users who had used in last 6 months, 25% (n=47) identified anxiety, 12% (n=22) paranoia and 20% (n=38) depression as key mental health harms. There was also a significant impact reported on underlying mental health conditions and use of NPS to reduce mental health symptoms.
A range of physical harms were reported. Physical harms varied because of the variations in the type of NPS people were using. The negative impact on sleep through NPS use was the most commonly reported physical health harm. Across
all NPS users who had used in last 6 months 20% (n=37) reported problems with sleep. Co-ordination problems were also reported by 20% (n=38) of the sample and appeared to be particularly prevalent among those who reported use of benzodiazepine-type NPS. Population-specific harms were identified such as chemsex harms among MSM, injecting NPS among PWID, and unsupervised opiate detoxification among opiate users.
Wider social harms
Financial issues: Money and debt were highlighted as major issues. 60% (n=105) of respondents to the NPS survey said they had spent more money than they planned to on NPS. 39% (n=89) reported that they borrowed money to pay for NPS.
Missed appointments: Missing appointments was reported by 60% (n=104) of the overall NPS survey sample and highlighted a potential consequence of NPS use that could lead to significant further harms, including potential sanctions by the Department of Work and Pensions.
Education and Employment: While this was identified as a significant harm in the staff survey, it did not feature highly among the harms reported in the NPS survey. It was however recognised as a greater issue by MSM than for other vulnerable populations.
Loss of tenancy: Staff perceived loss of tenancy as a social harm amongst people who use NPS (49%, n=90). Although it was reported less frequently in the NPS survey approximately 20% (n=35) of those who responded to a question on problems caused by NPS use, reported losing a tenancy as a result of NPS use.
NPS use and relationships: The majority of NPS survey respondents reported negative effects on their relationships with family following on from NPS use, something that was also identified by the staff survey. A quarter (26%, n=45) reported struggling with caring commitments.
|Treatment and Psychoactive Substances Act: Key Findings|
| Contact with services: 36% (n=69) of all NPS users were not in contact with drug services at all for any issue  . Overall contact with services was high, which was not surprising given the nature of the population and the fact that a large proportion were recruited through services. However only 11% (n=26) of NPS survey respondents reported being in contact with one or more services specifically in relation to their NPS use. People in contact with mental health services reported the highest level of contact with services regarding their NPS use (20%, n=18).
Use of emergency services: While the vast majority of vulnerable people in the study chose not to discuss their NPS use specifically with the services they were in contact with, there was a higher level of use of emergency services. 32% (n=77) had called an ambulance for someone else and 23% (n=55) had an ambulance called for them as a result of NPS use. 26% (n=63) of NPS users had attended A&E as a result of NPS use.
Provision of information and support: Sources of information on NPS consisted primarily of talking to family and friends (32%, n=70). 31% (n=67) had not tried to source any information on NPS prior to use. 16% (n=34) had talked to a drug service and 16% (n=35) accessed information leaflets. 16% (n=34) had obtained information on NPS from TV documentaries.
This low uptake of obtaining information from services was explained by a perception among those surveyed that in general workers knew little about NPS. This perception was borne out by services who felt that it was hard to 'keep up to date'.
Providing support - client disclosure of NPS use: Only a small proportion of those surveyed said they had discussed their NPS use with services. This contrasted with services, with 75% (n=131) of staff reporting that they ask service users about NPS use at first presentation. This suggests that there is considerable under-reporting of NPS, making effective engagement by services challenging. Qualitative focus group feedback suggested that how questions about NPS use are asked can affect disclosure of use from clients.
Client service relationship: The qualitative interviews and focus groups suggested that improving the provision of credible information and building trust were key to improving disclosure and enabling services to respond more effectively.
Improving services: There were a range of views on what service developments were required from respondents to the NPS survey. Those who had used NPS were asked what one option was the most important service to offer. Responses included:
The Psychoactive Substances Act ( PSA): The Act came into force after most of the survey work had been completed and therefore findings are largely focused on the likely impact. 57% (n=141) of those surveyed felt it would have no impact, this being highest among MSM with 74% (n=28) of this group believing it would have no impact on their NPS use. Over a quarter (29%, n=73) of all respondents to the NPS survey said they would move or return to traditional drugs.
45% (n=112) of the NPS survey sample said they bought NPS from shops and clearly this will have changed following the closure of 'head shops'. Staff anticipated a shift to online buying to a greater extent than those who reported using NPS.
|Key Learning Points|
| Prevalence estimates of NPS use among vulnerable populations
1. Database tools such as DAISy should be adapted and in the case of needle exchange data collection, standardised, to include specific questions relating to NPS use, this may include individual NPS names or categories. Training for frontline workers in how best to apply these tools should be incorporated in this process.
In order to develop more robust estimates of NPS use there needs to be an improvement in data collection within services. The new database for drug and alcohol services currently being developed (Drug and Alcohol Information System - DAISy) provides an opportunity to collect reliable data provided staff are enabled to undertake thorough initial assessments and adequately record these. Similarly needle exchange data has the potential to provide useful prevalence data, again provided staff are appropriately equipped to encourage accurate disclosure of NPS use.
Motives for use
2. Motives for use should be identified in assessments and reviews with service users and used to inform care plans undertaken by support services and frontline staff.
A better understanding of motives for NPS use and the ways they vary by population group and type of NPS can inform interventions by services. In particular there may be benefits of targeted interventions for people who intend to continue using, reduce use, or want to stop. Consequences of use
3. Mental health harms: Greater partnership working between substance use and mental health services and a review of care pathways for those with substance use and mental health difficulties should be considered.
Given the reported mental health impacts of NPS use better collaboration and partnership working between mental health services and drug services may help to improve care for this population. A review of care pathways for those with substance use and mental health difficulties would assist in improving the treatment response for service users. Further research would also help to better understand the complex effects of NPS use on mental health, both in relation to specific substances and mental health conditions.
4. Physical harms : Assessments within key services should cover a range of physical health areas including sleep management.
The most common reported physical harm across the majority of NPS types was sleep problems. Dedicated resources or information on sleep management could be useful to explore. Taking account of the range of other physical harms reported and given the low levels of reported disclosure of NPS use, assessments within key services which cover a range of health areas could assist in opening up a dialogue regarding NPS use and related harms. Such assessments may also encourage better disclosure of NPS use.
5. Social harms: Multi-agency and flexible working approaches such as assertive outreach should be continued and developed to support people with the range of social harms experienced.
NPS use had a significant impact on a range of aspects related to the ability to cope with daily living including finance, maintaining appointments and tenancies. NPS use can result in the most vulnerable populations experiencing significant harm, which puts them at great risk. Approaches should be explored which protect such vulnerable individuals and highlight the need for multi-agency and flexible working to support people with a range of different issues.
6. Frontline services should consider providing basic NPS training for all staff, as well as training in a variety of health based topics and assessment for support staff.
The lack of expertise and ability to keep up to date with knowledge on NPS within services was reported by both NPS users and staff. In relation to workforce development, a minimum requirement in terms of improving practice is the provision of basic NPS training for all staff. Linked to this would be the provision of at least annual updates on new NPS trends. Training in a variety of health based topics and assessment would also assist in being able to identify NPS use and harms.
7. Health board and ADP areas should review possibilities for service developments or adaptations to existing services to respond to those who use NPS.
Specialist treatment for NPS including detox was identified as important for staff and service users alike. Development and expansion of the remit of established treatment services including use of specialist workers could be explored to meet this need. Services should explore how they might adapt to attract less traditional client populations who use NPS. This could include exploring specific clinics, opening outwith standard hours and changing service branding. Services should also consider developing the skills and expertise of one member of staff who can keep up to date with new developments and provide advice and assistance to other staff.
8. Multi agency and targeted responses should be explored for the different populations using NPS.
There was considerable cross over between the target populations of this study, although MSM and vulnerable young people were largely separate groups. Multi-agency responses are required for those groups experiencing multiple disadvantages. There is a need for specific service developments within key services that MSM are likely to use, for example, sexual health services and targeted MSM health provision where it exists. Similarly services for vulnerable young people should explore how best to address NPS and wider substance use among their young people.
Information on NPS to users
9. Information resources in a variety of formats are required to reach the different populations who use NPS.
The lack of access to information sources on NPS was evident. Reliable and credible sources of information on NPS need to be developed which can be made accessible to those from vulnerable populations who use NPS.
Psychoactive Substances Act
10. Monitoring of the impact of the Psychoactive Substances Act ( PSA) on vulnerable populations should be undertaken by ADPs, health boards and services with a particular focus on increased overdose risk.
There were a range of views on the potential impact of the new legislation but no real clarity on its likely impact. It will be important to track the impact of the PSA particularly in relation to changes in supply routes that might have specific effects on vulnerable populations who use NPS. For example there may be increased risk of overdose for opioid users who also use NPS, who return to opioid use and may have reduced tolerance. Alcohol and Drug Partnerships and Naloxone coordinators should be alerted to the potential for increased overdose risk so that appropriate action can be taken, including supply of Naloxone to vulnerable populations.