1. NPS Intravenous Use in the UK: Current Situation and Experiences Catherine Crawford, UK Focal Point

2. 2 Prevalence of NPS use / IV NPS use in the UK Outbreaks of infections associated with IV use Edinburgh / the Lothians South-west Wales Responses Outline

3. Mephedrone and NPS use in the UK Emergence of mephedrone in the UK in 2008; controlled under the Misuse of Drugs Act in 2010 All NPS last-year use in 2014/15: 2.8% (16-24); 0.9% (16-59) (primarily SCRAs) However, injecting of mephedrone/NPS has increased 3 Crime Survey of England and Wales. Home Office, 2015. Last year use of mephedrone in England and Wales

4. Increasing use of stimulants amongst PWID 4Presentation title - edit in Header and Footer 4Shooting Up: Infections among people who inject drugs in the UK, 2014. Public Health England, 2015. 5.9% of IV drug users reported injecting mephedrone in the last month in 2014 8.9% of IV drug users reported injecting mephedrone in the last year in 2014

5. Injection of stimulants by patients in treatment 5Data from TDI Standard Tables submitted to the EMCDDA, 2012-2015

6. Injection of mephedrone and NPS in the UK Rise in IV use of mephedrone noticed around 2012 Users then (and now) two distinct groups: Established / experienced heroin users Recreational stimulant users moving to injecting Geographically distinct pockets of users Problems highlighted when associated with disease outbreaks Ethylphenidate injection in Edinburgh / the Lothians Hepatitis C / HIV in south-west Wales 6Shooting Up: Infections among people who inject drugs in the UK, 2014. Public Health England, 2015.

7. IV ethylphenidate use in Edinburgh 7

8. 8Data from Health Protection Scotland Skin and soft tissue infections in the Lothians InfectionNo. of cases % of all cases Streptococcus pyogenes and/or Staphylococcus aureus 20193.9 Other soft tissue infections104.7 No growth but clinical signs of infection 31.4 Total214100

9. IV ethylphenidate use in Edinburgh All patients had used ‘Burst’ or ‘Blue Stuff’ (ethylphenidate) in the week before illness No other drug implicated Drug bought in shops in 6 different areas of Edinburgh Short-lived high, highly addictive (multiple dosing up to 30x per day) Does not dissolve well, leaving residues and clogging filters, therefore likely that solid material was injected leading to injection site damage High levels of equipment sharing Significant increase in numbers of needles provided by needle exchange services during outbreak Issues isolated to the Lothian region Not sufficient evidence to conclude contaminated drugs, contaminated preparation or person-to-person transmission was responsible 9Data from Health Protection Scotland

10. IV NPS use in Wales 10

11. IV NPS use in Wales 11Data from Public Health Wales Individuals accessing NSP services with primary NPS use

12. Localised increase in HCV infection Prevalence of HCV in injecting population: Cardiff and Vale: 2006: 38% 1 2011: 28% 2 2014: 36.6% 2 Swansea 2006: 42% 1 2014: 71.7% 2 Plus investigating cluster of HIV cases amongst mephedrone users, first cluster amongst IDUs 14 years 12 1.Craine et al, 2009. Epidemiology and Infection; 137: 1255-1265. 2.Hope et al. Unlinked Anonymous Monitoring Survey. Health Protection Agency / Public Health England

13. Responses Edinburgh / Lothians Increased BBV testing Harm reduction advice issued Targeted communication Legislation controlling ethylphenidate Forfeiture order – headshops relinquished stock of NPS Wales Increased accessibility of sterile equipment Information and awareness raising Training (e-learning and face-to-face) Increased BBV detection (DBS / clinics) and revising surveillance systems Prevalence estimate of problematic and injecting drug use Welsh Assembly Health and Social Care Committee: service redesign 13Data from Health Protection Scotland, Public Health Wales

14. Psychoactive Substances Act Will be an offence to produce, supply or offer to supply any psychoactive substance if likely to be used for psychoactive effects Exemptions include nicotine, alcohol, caffeine and medicinal products (and drugs already controlled by main drugs legislation) No possession offence (consumption of drugs per se not illegal in UK) except for in prisons Expected to be most effective at combatting visible outlets – ‘headshops’ and surface web websites Expected to come into force this spring 14

15. Acknowledgements Data from Scotland: Andy McAuley, Health Protection Scotland Data from Wales: Josie Smith, Public Health Wales 15