Psychoactive challenge

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Knowing enough about each novel psychoactive compound that emerges in time to help clients can feel like an impossible task. Kevin Flemen gives a pragmatic approach to staying ahead

Anyone trying to keep abreast of novel psycho­active compounds (NPCs) will know what a daunting task this can be. My inbox is constantly refilling with bulletins inform­ing me of new compounds, along­side emails from frontline workers asking about substances that their clients are experimenting with. As with any new development, a flurry of new responses emerges. In an echo of the period after the crack strategy was published, some agencies are creating ‘NPC worker’ posts. Elsewhere, commentators are using use the emer­g­ence of NPCs as evidence for stricter laws or as proof of the failure of prohibition, according to their ideology.

Closer to the coalface, one can spend thankless hours reading through forum accounts of people’s latest psychedelic experiments, while their peers, with varying levels of knowledge, discuss the finer points of pharmacology.

In much the same way that an incautious worker can get drawn in to the chaotic presentation of their client, so the researcher exploring NPCs can get so swept along in the novelty, uncertainty and confusion that they lose sight of some pragmatic responses. I’ve found myself in this situation, chasing the illusory white rabbit in numerous forum threads. Over the past few months in training sessions, another set of responses has started to emerge, which can offer a useful approach:

 

1. Acknowledge ignorance

We need to be very cautious about thinking we know more than we do. From the lab that thinks it is making drug X, to the end user who believes they have bought a specific drug, there are layers of uncertainty. The lab, the web retailer, the head shop and the end user cannot be certain what they are making, selling or using.

Even if they could be certain, it doesn’t help us that much because we don’t know enough about how most NPCs will work in the short, medium and long term. 

The snag for most people involved in this fast-moving scene is that we tend to crave facts. Whether posting to a website, writing a leaflet or offering training, we want to proffer knowledge. We then run the risk of creating an illusory sense of knowledge, when actually what we largely offer is conjecture and speculation. 

The primary message to everyone contemplating use or who is already using is the extent of the ‘unknowns’. It is not a failing not to know; it is a failing to not acknowledge that we don’t know.

 

2. Work symptomatically

Given the colossal uncertainty as to what an individual has taken (or what combinations they have used) and how little we know about specific compounds, trying to ascertain what a person has used, or thinks they have used, may not be that helpful. Instead, a primary question should be ‘how do you feel?’ rather than ‘what have you taken?’

If, for example, a person presents to club outreach workers saying that they have just used AMT, how do they know that’s what they have had? Is this based on what the website/head shop/dealer/mate said? Without previous experience to compare it to, or an objective reference point, how can they know that this is what AMT feels like? And even if it is AMT, what else have they had? 

Alongside this uncertainty, we may struggle to gain any objective evidence of what has been used. Newer drugs may not show up in tests or may give misleading positive results.

So it is much more useful – and important – to lead with an exploration of symptoms. Management of panic, high pulse rate, elevated temperature, delusion, blood pressure – these will be much more important in the short term than trying to identify exactly what the person has used. 

 

3. Share knowledge

Having successfully managed a presenting situation (eg in a crisis) it is then wholly appropriate to try to identify what was used. It will be useful to ascertain the name of the substance, its appearance, packaging, route, dose and other substances used. But until confirmed by analysis, the identity of the substance should be treated as uncertain. 

Without toxicology we can cascade what we know – that substance sold or bought as X, which looked like this and was taken like this, possibly caused these effects.

If we have toxicology results and it says that the substance in question wasn’t X but contained Y, then we can also brief the field to say that the substance sold and packaged as X was found to contain Y and had these effects.

If tests do show that substance X did, in truth contain X, then we now know a bit more about X than we did before – that it may be linked to these side effects. 

Importantly, all such information cascades must be clear as to the evidence underpinning assertions, mindful that they may be of limited geographic relevance, and that they are time limited and can become obsolete.

 

4. Cluster drugs… 

A model that I have found useful in training sessions has been to provide a detailed framework of drug families, so that people can locate newer drugs against more familiar comparisons. If we then at least start from the basis that our new drug shares the same risks as its nearest neighbours, we can start to engage with the substance and refine the information as more knowledge emerges. So by locating newer compounds such as etizolam or ethylphenidate alongside more familiar compounds such as diazepam or amphetamine, you can provide common sense advice on tolerance, overdose, mixing and withdrawal.

 

5. …but use caution

Having extolled the virtues of clustering by drug families, there are of course limits to it. This includes the dramatic differences in dose range between older, adulterated drugs and newer drugs that may be stronger and purer. It can only provide a foundation. Newer drugs may turn out to be safer, or more hazardous and this should be acknowledged. A key area where a ‘clustering’ approach works less well is general drugs education literature. Saying, for example, that ‘6-APB is similar to ecstasy’ is something of a double-edged sword. While it could inform useful harm reduction, it also runs the risk of popularising and effectively advertising a new drug.

 

6. Keep sight of skill sets

One of the key benefits of locating newer compounds within a comprehensible framework is that it allows workers to see how their existing knowledge and skills can be applied. In the face of a flurry of new drugs, some people seem paralysed by abbreviations and slang names. But those same workers were skilled at working with people who had cravings, were bingeing on cocaine, or who were experiencing bad ecstasy-related comedowns. Reinforcing that their skills are transferable to newer compounds can leave workers empowered and more confident in engaging with them.

 

7. Review popularity

Not everything becomes popular. It is certainly the case that there’s been a veritable slew of new drugs coming to market as reported by international and European monitoring, but very few of those drugs will ever appear on the UK market and fewer still will gain popularity. So time and energy can be wasted researching and preparing for some NPCs that will never become an issue.

Throughout the distractions of the new, the less new is becoming more and more popular. Mephedrone has become a fixture of some regional drug markets, but elsewhere the most widely reported newer compounds have been gabapentin and pregabalin. So amid the coverage of NPCs, we need to be aware of less high profile compounds that are gaining ground.

 

8.  Keep sight of fundamentals

It’s important not to lose sight of some fundamentals here. NPC use rose in part and peaked because the ‘right drug’, 4-MMC, arrived at the right time – pre-austerity, with a market typified by poor quality cocaine and MDMA.

We don’t have a good evidence base in relation to use, but there is some evidence that while a small number of people are dabbling with NPCs, the majority, given a choice, will gravitate back towards the ‘classics’ of cocaine, MDMA, cannabis and speed.

Those who are experiencing the biggest problems and need targeted interventions are:

• multiply vulnerable people, including young people for whom NPCs are just the latest, most available ways to be altered

• young naive users who are able to source potent compounds with little information or skills for harm reduction.

 

9. Get tech savvy

The internet plays a critical role in the emergence of NPCs and in changes to existing drug markets. It is therefore essential that workers keep their knowledge of evolving technologies as up-to-date as their awareness of new drugs. This includes being confident and familiar with undertaking primary research online in a number of arenas (such as drug discussion forums), and able to critically assess the value of the information. 

It is no longer enough to rely on one or two authoritative sources of information as they are all too often woefully behind the curve. In turn, the need to be able to roam the web means that organisations that restrict access to websites based on catch-all search terms (such as ‘drugs’) must review and change their policy. Expecting workers to stay abreast of NPCs while restricting net access is akin to expecting someone to navigate from London to Glasgow with only a sextant and a mappa mundi. 

 

Beyond pragmatism

There are of course many interventions beyond these pragmatic suggestions that need to be explored in relation to NPCs. The way substances are analysed and tested and how this information is shared with the wider field and end users is a significant challenge and the legislative framework and regulation of sale needs wholesale review. Retaining outreach, educative and harm-reduction interventions for people using NPCs is essential, even while other parts of service align themselves with delivering recovery-orientated services.

While these greater systemic issues will get addressed slowly, there is much that we can do now, with what we do know and the skills we do have. DDN

 

Kevin Flemen runs KFx, a drugs information and training services and has delivered training sessions about NPCs around the UK. For more information and resources go to www.kfx.org.uk