With the impact of synthetic drugs being realised across the UK, the APPG on Drugs, Alcohol and Justice dedicated its latest meeting to an escalating crisis. DDN reports.
Steve Rolles, senior policy analyst at Transform, summarised the situation. The opioid market had been changing rapidly since the Taliban’s ban on opium production and destruction of Afghan poppy fields – which had previously accounted for 95 per cent of heroin in the UK. As opium could be stored for ten years, tons had been stockpiled, but prices had jumped up in the last six months as the stockpilers cashed in. Alongside rising prices, purity had been falling and supply contraction was beginning to bite. Synthetic opioids were already filling the vacuum.
Fentanyls and nitazenes were of utmost concern as they were ‘incredibly dangerous’ – carfentanil was 10,000 stronger than morphine and just a tiny amount of any of these drugs could be fatal. The ‘cookie effect’ increased the risk with such strong drugs – they were never mixed evenly so strength was not uniform across the batch. Furthermore, ‘the market doesn’t just move to one drug – it mutates and becomes very messy,’ said Rolles. There were a ‘whole bunch of variations’ and the situation became confusing and chaotic. ‘I’m genuinely scared,’ he said. ‘I’ve worked with colleagues in Canada and the US and have seen what has happened… there has been an absolutely terrifying level of death.’
Market tilt
In Vancouver people weren’t able to get heroin that hadn’t been cut with fentanyl. An added complication was that people were actively seeking fentanyl – ‘they like the rush and the euphoria and they don’t want to go back to heroin. They don’t want to put the cat back in the bag. ’In New York City there were nine fentanyl deaths a day. ‘What’s stopping this from happening in the UK? Absolutely nothing. Dealers are thinking “why would we bother to ship from Afghanistan when we can manufacture a matchbox full?” The legislation tilts the market towards drugs that are easier to manufacture.’
Rolles could see drug-related deaths in the UK doubling, trebling or quadrupling in a few years, ‘or it could happen much faster’. There were already about three nitazene deaths a week and we were ‘looking down the barrel of a public health emergency’. Current planning was ‘woefully insufficient’ and there needed to be new money and political commitment. ‘I worry that we’ll have to have a big pile of dead bodies before anything happens,’ he said. ‘No one’s taking this as seriously as we should be.’
He recommended an emergency harm reduction plan that included drug-checking in every city and town, with test strips available for different drugs. Supervised drug consumption facilities should also be rolled out nationally and didn’t need to be multi-million pound units. Harm reduction advice needed to be realistic and relatable – and include housing environments for semi-supervised use, innovative prescribing options, and increased availability of naloxone.
In terms of political strategy, we had ‘to speak with a collective voice’ – experts together with people with lived experience – and avoid ‘partisan polarisaton’. We should lay out what was needed and how much it would cost, and act now. ‘We also need to be absolutely clear that there is no enforcement solution,’ he said. ‘Banning drugs and increasing sentences and border seizures are all entirely ineffectual… organised crime doesn’t care if it’s illegal.’
Escalating supply
‘The amount of drugs out there is escalating rapidly,’ said Dr Adam Holland, co-chair of the Drugs Special Interest Group at the Faculty of Public Health. Not only was there adulteration to consider, but also a whole market shift. ‘Synthetic’ was a very broad term that included substances such as MDMA, and there were at least 14 different drugs classified as nitazenes. As he pointed out, ‘You only detect the drugs you’re looking for – there are probably others out there we have not been looking for.’
Inappropriate doses occurred as people used the drugs in unexpected combinations – someone who had ordered benzos might have no opioid tolerance at all. The difficulties of unknown contents extended to medical emergencies as staff were unsure how to treat the patient appropriately. ‘There could be many more deaths related to these drugs than we’re aware of,’ he said.
Holland agreed with the call for more surveillance and testing. He also pointed to ‘a decade of underinvestment’ in drug services. ‘We need funding to be sustained and ideally increased,’ he said, and identified same-day and lower threshold prescribing, crack pipe provision, widespread naloxone, postal drug testing and supervised injecting as areas for immediate investment. ‘We need a central strategy – at the moment it is local initiatives happening where the Swiss cheese holes line up,’ he said. ‘We also need more support in wider health and social care to prevent trauma happening in the first place.’ Above all, he warned, ‘we can’t assume that we can carry on doing the same thing.’
Changing drug classification – nitazenes to class A, xylazine to class C – when they were already illegal was ‘clearly not a deterrent when there are such big profit margins’. The delay in coroner reports – up to two years – made it ‘impossible to respond in a timely fashion’. And we were missing many surveillance opportunities by not having enough testing. The ‘decade of disinvestment’ meant that urgent attention was needed.
Harm reduction
In the immediate term, drug services needed to rethink their offer for people who use drugs – whether benzos, crack, opioids – and offer more flexible prescribing options and harm reduction advice and equipment. More harm reduction services were a very necessary response, he said – more naloxone, more drug testing services (in-person checking and a UK-wide postal testing service) and the creation of spaces for supervised drug use, in OD prevention centres, high tolerance housing, and drug-use spaces in hospitals.
‘Our policy environment is not conducive to sensible responses,’ he said. But drug adulteration was going to get worse and emerging drugs were likely to exacerbate the drug-related death crisis. ‘How big does the pile of bodies have to get?’ he asked. ‘We need to go up a notch.’
Contamination
Abigail Wilson, lead clinical pharmacist at WithYou, gave a picture of the many challenges being faced by services who were encountering contamination with novel drugs. When people presented for treatment, nitazenes and xylazine were not showing up in urine or saliva screening tests, ‘as manufacturers haven’t caught up’.
She explained that test strips for substances could not be used in services without a Home Office licence, but they could be used by clients to test drugs themselves. This can lead to challenges with tests being completed accurately and can slow down the identification of trends, and she highlighted that tests are ‘not a tick in the box to say the drugs are safe’. Through a case study she explained that a client had tested negative but was in acute withdrawal. A further test by WEDINOS (the drug-testing and harm reduction service in Wales) confirmed nitazenes. ‘It’s so hard for our services to know what’s in a drug,’ she said. In another case study, the client thought they had taken ketamine, had overdosed, and was brought round by naloxone – so it turned out to be an opioid-related OD.
The obvious flaw in the system is not having more local access to testing. Other action points were to ‘get naloxone in every situation’, similar to how defibrillator boxes are placed and accessed; to talk to young people about avoiding risks; and to talk to the media to help them understand these issues. ‘When media outlets call xylazine a “zombie drug” people don’t access services.’ Also, talking about drugs as ‘potent’ and ‘high strength’ (instead of ‘dangerous’ and ‘harmful’) might make them seek it out. Using language mindfully was another tool in a toolbox that needed to be in use right now.
Read previous Drugs, Alcohol & Justice APPG reports here