Threading the shifting sands of drug abuse is a balancing act for medical staff, community workers and policy-makers — and for drug-users themselves.
Several years ago, the spotlight was trained on new psychoactive substances (NPS). The Criminal Justice (Psychoactive Substances) Act 2010 was introduced to address the ‘head shop’ trade in unregulated psychoactive substances and works in conjunction with the ongoing controlling of identified harmful substances under misuse of drugs legislation.
“The Act, which came into effect in August 2010, made it a criminal offence to advertise, sell, supply, import or export a psychoactive substance (not otherwise excluded), knowing or being reckless that it was for human consumption,” stated a Department of Health spokesperson. “The Act does not contain any offence for simple possession for personal use of these substances, as it is targeted at those involved in trading in NPS.
“Under the Act, a psychoactive substance is defined as a substance that has the capacity to stimulate or depress the central nervous system, resulting in hallucinations, dependence or significant changes to motor function, thinking or behaviour.”
Through misuse of drugs legislation and regulations, over 200 substances (‘legal highs’) were controlled by means of statutory instruments in May 2010 and a further 60 in November 2011. Substances were controlled either by individual names or generic definition.
These measures seem to have made an impact. In 2014/15, prevalence of last-year use of NPS had declined significantly to 0.8 per cent from 3.5 per cent in 2010/11, according to the latest prevalence survey on drug use in Ireland. The data was launched earlier this month by the National Advisory Committee on Drugs and Alcohol (NACDA), which operates under the aegis of the Department of Health.
Nevertheless, a significant increase in lifetime prevalence for cannabis use (25.3 per cent to 27.9 per cent), ecstasy (6.9 per cent to 9.2 per cent), and crack (0.6 per cent to 1.1 per cent) over the same period was reported in the survey, prompting concerns that some people who bought from head shops may have merely ventured onto the back streets and ‘cyberstreets’ for their ‘fix’.
In July 2016, further legislative measures were passed to tackle drug abuse. The Misuse of Drugs (Amendment) Act 2016 brought zopiclone and zaleplon under the scope of drugs legislation in an attempt to aid law enforcement activities. It also controls the benzodiazepine phenazepam, a number of NPS that Ireland must control under EU and UN obligations, and two substances found in the head shop drug ‘Clockwork Orange’.
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He warned that pregabalin, given its abuse potential, will fill the void created by these controls
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Additionally, associated regulations will place further controls on scheduled benzodiazepines and z-drugs.
Controlling the substances in the legislation is part one of a two-step process. Regulations and various orders are required to allow legitimate users (eg, patients with a prescription, health professionals) to possess the substances.
“Work on drafting the regulations is at an advanced stage. Until the new regulations are made, rules under existing medicinal legislation apply to z-drugs and phenazepam,” a Department spokesperson told the <strong><em>Medical Independent</em></strong> (<strong><em>MI</em></strong>).
<h3><strong>Void</strong></h3>
Yet the void created by controls on certain drugs is invariably filled by others. Prescription drug pregabalin, which is licensed for epilepsy, neuropathic pain and generalised anxiety disorder, seems to be the latest example of this phenomenon.
In recent months, this licensed medication has been frequently discussed and referenced at a special Department of Health sub-committee that tracks drug abuse trends.
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<strong>Minister of State Catherine Byrne</strong>
<strong><em>MI</em></strong> obtained partially-redacted meeting minutes and emails sent to the Early Warning and Emerging Trends (EWET) subcommittee of the NACDA under Freedom of Information legislation.
Representatives from the Departments of Health and Justice, HSE, the State Laboratory, Forensic Science Ireland (FSI), Health Research Board (HRB), Health Products Regulatory Authority (HPRA), National Poisons Information Centre, Medical Bureau of Road Safety (MBRS), An Garda Síochána and community drug services sit on this forum.
In June 2016, pregabalin and gabapentin were the subject of a rare clinical advisory notice issued by this subcommittee. The advisory warned doctors, pharmacists, and doctors and nurses in emergency departments of the need for “vigilance” when prescribing or dispensing these drugs. This was due to the risk of addiction and potential for illegal diversion and medicinal misuse.
“Over the past two years, the EWET has received a number of anecdotal reports on the misuse of pregabalin and to a lesser extent the misuse of gabapentin,” read the advisory. “Recently, this evidence has been bolstered with evidence-based reports about the misuse of these medicines for recreational use and through their appearance in post-mortem toxicology screening tests.”
HSE PCRS dispensing data over the past five years has shown a “dramatic and continued increase” in the volume of dispensed pregabalin, “suggesting that those who are misusing these drugs may be sourcing them through legal as well as illegal channels”.
The sub-committee’s May meeting minutes showed that the State Laboratory reported cases showing pregabalin as having risen “dramatically”. Most cases involved a level “many times greater than would be expected if it was being used therapeutically”. The State Laboratory conducts analyses for the presence of alcohol and drugs to assist coroners to determine cause of death, eg, in cases of overdose.
At the meeting, the Ana Liffey Drug Project also noted pregabalin as one of the most prescribed drugs over recent years, “with the number of prescriptions almost doubling each year”. Director of the Project Mr Tony Duffin stated that clients were mixing these tablets with others, such as zopiclone, and almost taking them by the handful.
Reference was also made to the HSE National Drug Treatment Centre stressing the need for additional resourcing to meet the needs of both pregabalin and zopiclone testing.
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<h3><strong>SNAPSHOT: Drug trends in 2016</strong></h3>
Potency of ecstasy tablets was noted to have increased (State Laboratory, May 2016 EWET sub-committee meeting).
There continued to be large number of cases showing a high blood level of zopiclone. Phenazepam was showing up in samples from the south west, while etizolam has been seen in a sample from Dublin (State Laboratory, May 2016 EWET sub-committee meeting)
Forensic Science Ireland (FSI) had notifications of new drugs including indications of clephedrone, nitrazolam and fluorofentanyl. Fluorophenmetrazine and MPHP (4-methyl-alpha-pyrrolidinobutiophenone, related to pyrovalerone) were first encountered by the FSI on 10/5/16. (FSI, May 2016 EWET sub committee meeting).
The majority of cases handled by FSI are still cannabis, with no significant change in cocaine, diamorphine, MDMA, amphetamine or methamphetamine cases. They are also seeing large numbers of benzodiazepines and zopiclone cases. (FSI, May 2016 EWET sub-committee meeting).
FSI saw an increase in the number of cases containing etizolam, which were mainly coming from the Dublin area (FSI, May 2016 EWET sub-committee meeting).
The Medical Bureau of Road Safety (MBRS) reported that there had been a 35 per cent and 33 per cent decrease in specimens positive for cocaine and benzodiazepines, respectively. The decrease may be attributed to the latest media campaign highlighting the risks of drug-driving (MBRS, February 2016 EWET sub-committee meeting).
The HSE National Drug Treatment Centre found an increase in positive results for cocaine, from 6.1 per cent in 2014 to 8.2 per cent in December 2015. The figures for positive benzodiazepine results had decreased over the last year (HSE, February 2016 EWET sub-committee meeting).
The State Laboratory found that substances being presented as crystal meth had turned out to be a-PVP and not methamphetamine. The FSI had also seen a-PVP being sold as crystal meth (State Laboratory and FSI, February 2016 EWET sub-committee meeting).
Other matters raised have included “‘snow-blow’ in Clondalkin”. Partially-redacted correspondence sent to the sub-committee in June noted feedback that cocaine in Clondalkin, west Dublin, was being cut with snow-blow as a bulking agent. There were reports of fit-like seizures after injecting and the substance “going jelly-like” in the syringe.
Difficulties experienced by the State Laboratory in receiving a viable sample in order to confirm the substance involved in a particular case was referenced in the May meeting minutes. This was under a section on 25I-NBOMe. The minutes noted that, especially in non-fatal incidents, admission samples may never be taken. The Department of Health was working with HSE Acute Hospitals on the matter.
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<h3><strong>Major concern </strong></h3>
At a meeting of the EWET subcommittee in February, Ms Siobhan Stokes, Principal Biochemist at the HSE National Drug Treatment Centre Laboratory, expressed “major concern” relating to pregabalin, as its “use/dangers are being under-reported, as it can be overlooked when other drugs are found in a sample”.
Chief Pharmacist in HSE Addiction Services Dr Denis O’Driscoll reported at the same meeting that when additional controls come into force on benzodiazepines and z-drugs, there could be “a knock-on effect” for addiction services, “especially if over-prescribing is reduced and individuals present with an addiction to these drugs”, noted the minutes.
“He warned that pregabalin, given its abuse potential, will fill the void created by these controls. He raised his concern that the group has been discussing the misuse of pregabalin over the last couple of years but that no developments had been progressed to address the issue.”
A study into the potential for misuse of pregabalin was conducted by researchers at the HSE National Drug Treatment Centre Laboratory in Dublin between June and August 2014. It found that of 440 people, 39 tested positive for pregabalin, representing 9.2 per cent of the total sample, indicating that the misuse of pregabalin is a “serious emerging issue”. Only 10 patients from this group had been prescribed the drug, according to the findings, which were published in the <em>Irish Medical Journal</em> (November/December 2015).
Pregabalin has not just been a talking point in Ireland. Last January, the UK’s Advisory Council on the Misuse of Drugs recommended that pregabalin — as well as gabapentin — should be controlled under misuse of drugs legislation as Class C substances.
According to 2014 data from the PCRS, pregabalin was the 22nd-most prescribed product in the GMS and the 11th-most prescribed product under the Drug Payment Scheme (DPS).
At the recent launch in Hawkins House of the <em>Prevalence of Drug Use and Gambling in Ireland and Drug Use in Northern Ireland</em> bulletin, <strong><em>MI</em></strong> asked Minister of State for Communities and National Drugs Strategy Catherine Byrne if pharmaceutical companies had lobbied her to ensure pregabalin did not become a controlled drug under Irish misuse of drugs legislation.
Minister Byrne said: “They haven’t lobbied me anyway, unless they’ve lobbied the Department, but I don’t think so.”
A Department spokesperson later confirmed: “The pharmaceutical industry have not been in contact with the Department of Health in relation to the addition of medications to the schedules of the Misuse of Drugs legislation within the specified time frame (2015 to date).”
No decision has been taken to place additional controls on pregabalin or gabapentin in Ireland, according to the Department. “Any decision in this regard will be taken in consultation with relevant stakeholders. It should be noted that while there are concerns and reports that suggest that abuse of these medicines is on the increase, legitimate use of these medicines provides valuable, effective treatment options for a number of medical conditions, including epilepsy, generalised anxiety disorder and neuropathic pain.”
Lyrica is the brand name of Pfizer’s pregabalin product. A spokesperson for Pfizer told <strong><em>MI</em></strong> that it updated the EU product labelling for Lyrica in July 2014, to add the risk of dependence and misuse to the existing summary of product characteristics warnings for abuse and withdrawal symptoms. This followed a review of the scientific evidence and discussion with the European Medicines Agency. “It is important to note, this caution applies to the specific population of patients with a history of substance abuse.”
The majority of pregabalin prescriptions in Ireland are for the treatment of neuropathic pain, according to Pfizer.
“Pfizer actively works with healthcare professionals to ensure that information about Pfizer medicines, including licensed indications, prescribing information and safety information is understood,” added its spokesperson.
Pfizer did not comment on its position should pregabalin be proposed as a controlled drug in Ireland.
<div style=”background: #e8edf0; padding: 10px 15px; margin-bottom: 15px;”> <h3><strong>Cocaine ‘on the way back’, warns emergency medicine consultant</strong></h3>
Cocaine is “on the way back” as the economy improves, according to Dr Fergal Hickey, Consultant in Emergency Medicine at Sligo University Hospital and communications officer with the Irish Association for Emergency Medicine (IAEM).
He warned that many people erroneously believe cocaine is safe due to its depiction in popular culture.
Dr Hickey underlined that cocaine is potentially lethal, particularly when mixed with alcohol. When alcohol and cocaine are consumed concurrently, it leads to the formation in the body of the chemical cocaethylene, which is both potentially life-threatening and can have long-term psychiatric consequences.
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<strong>Dr Fergal Hickey</strong>
He said “far more” public education is required on the risks of drug-taking. He believes people are not making “informed decisions”.
As little as half an ecstasy tablet, for example, “can kill you” due to an idiosyncratic reaction which is impossible to predict. There is also a dose-related risk.
Dr Hickey added that the narrative around legalising medicinal cannabis is also problematic in lulling people into a false sense of security over the safety of cannabis. Herbal cannabis, which is now the majority form of cannabis, is very potent, can be toxic and have long-term neuropsychiatric effects, he outlined.
He said there are no discernibly new, stand-out trends confronting staff in Irish emergency departments (EDs), but drug-related admissions remain an ongoing problem.
Consultants and staff in EDs see the results of planned and unplanned drug cocktail consumption. Many illicit drugs are mixed with various substances “to make sale more profitable”, said Dr Hickey. These include rat poison, talcum powder, household bleach and local anaesthetics. “It is cut with all kinds of things, including bleach. Nobody would voluntarily drink bleaches, unless you were mad,” he said.
These agents can cause problems in themselves, said Dr Hickey. There is also no way for people to know the potencies of illicit drugs they are purchasing.
Often, patients present having ingested a cocktail of drugs and it is unclear what they have taken. Some may present with a toxic psychosis, which is “difficult to deal with”.
A toxicology sample may be taken but treating doctors “may not get a definitive answer for a week”. There are bedside kits that can detect certain substances but these are of limited use and as “people synthesise newer agents, these detection systems can’t keep up”.
It is difficult to identify and track trends in drug admissions to EDs countrywide because there is no national ED information system. “There should be a national ED information system, but that request has fallen on deaf ears for many years. You couldn’t run a corner shop on that basis,” remarked Dr Hickey.
Dr James Gray, Consultant in Emergency Medicine at Tallaght Hospital, Dublin, commented: “We have noticed over the years that the incidence of the old drug ‘staple’ heroin use has been constant, with little by way of fluctuation, whereas use of synthetic highs remains difficult to quantify. The established drugs like cocaine and related sympathomimetics have declined marginally with the demise of the so-called Celtic Tiger. The trend will rise no doubt once the economy continues to improve.”
He said synthetic agents are very unpredictable in terms of quality, duration of high, level of high and duration of comedown. “Also, synthetic agents are constantly evolving so the rogue chemists are always one step ahead of both the medical profession in terms of capacity to identify and detect, as well as the legislation. Importantly, routine toxicology/laboratory screening will not detect synthetic new agents, which poses problems for epidemiological study data.”
The overall prevalence rate for last-year use of any illegal drug was 8.9 per cent in 2014/5, compared with 7 per cent in 2010/11.
Lifetime usage of cannabis (24 per cent) is considerably higher than any other form of drug. The second-most commonly used drug is ecstasy (7.8 per cent), with lifetime usage of cocaine (including crack) and cocaine powder at 6.6 per cent and 6.4 per cent, respectively.
Meanwhile, in the 10-year period 2004-2013, a total of 6,002 deaths by drug poisoning and deaths among drug users met the criteria for inclusion in the National Drug-Related Deaths Index (NDRDI) database. Of these deaths, 3,519 were due to poisoning and 2,483 were deaths among drug users (non-poisoning).
The annual number of poisoning deaths increased from 361 in 2012 to 387 in 2013. Polydrugs accounted for 60 per cent of poisoning deaths.
Alcohol was involved in 35 per cent of poisoning deaths, more than any other specific drug. Alcohol alone was responsible for 15 per cent of poisoning deaths, while methadone was implicated in a quarter of poisonings (93; 24 per cent), according to HRB data.
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<h3><strong>‘Mammy’s little helper’</strong></h3>
GP and addictions specialist Dr Patrick Troy suggests that controlling the medication in this fashion would not be such a good idea.
“No, it is not necessary for it to be a controlled drug. Really, what you need is doctors to be very, very much aware that this is actually being abused all over the country,” he said. According to Dr Troy, the recipients of this message should include not only GPs, but junior doctors who may commence patients on the drug in hospitals.
Dr Troy noted that when benzodiazepines first came on the market, they were considered benign — or ‘mammy’s little helper’ — but later their abuse potential became clear. Pregabalin could well be “the next benzodiazepine problem that we have”, he warned.
Drug scheduling can be a double-edged sword, suggests drug trends researcher Mr Tim Bingham.
“There are always going to be unintended consequences. Whenever you schedule a drug, and you can go back through… 30 or 40 years of drug policy and history in Europe, you can see there has always been a direct correlation between scheduling a substance and something else coming on to the market,” he said.
In communities bombarded by street-selling of benzodiazepines, for example, it is “very obvious why some sort of scheduling needed to take place”. It does reduce dealing but something is “always going to take its place”.
Mr Bingham said the bigger question is why people are resorting to abusing these drugs in the first place.
He shares the view of previous Minister for National Drugs Strategy Aodhán Ó Ríordáin in believing that Ireland should look to Portugal’s approach. The Iberian country considers possession and use of small quantities of drugs to be a public health rather than criminal justice issue.
Currently, a new national drugs strategy is being drawn up under the watch of Minister Byrne and is expected to be finalised early next year.
“Ideally, you would be looking at some sort of personal decriminalisation, where the person would not necessarily be criminalised for carrying a drug,” said Mr Bingham.
“I very much like the Portuguese model, where there would be some sort of intervention. I mean, drugs are always going to be around, so I would be looking at that type of approach, ideally where you would have services set up to actually engage with people… You see, if you start dealing with or working with people from a very early stage who are recreational users, they are less likely to go on to be more chaotic later on.”
