As those who have participated in the KFx NPS training course over the past couple of years will know, the course spends some time looking at responses to Synthetic Cannabinoid Receptor Agonists (SCRAs, Spice, Mamba.)
For several months before the Psychoactive Substance Act
came in to force there was an urgent need to plan for what could happen
once the PSA was enacted.
The course stressed that there would
be dumping of residual stocks, as on-line suppliers and head-shops got
rid of prohibited stock and, as had happened with ever NPS before it, it
ended up sold via the street market.
The course also stressed that
agencies needed to prepare for what could happen yet. There was an
urgent need to get treatment protocols and pathways in place so that
those who had become dependent on SCRAs could access treatment. Agencies
needed to start this process before SCRAs were banned. The development
of care pathways and proactively engaging with dependent SCRA users was
an essential measure and given the looming enactment of the PSA, a
The risk of not acting ahead of the
prohibition was that dependent users, unable to access appropriate
treatment, would self-medicate using other substances. All too
predictably, this has started to happen in a number of areas. Numerous
participants on training courses across the UK have recounted cases of
dependent SCRA users drifting to heroin or other opiates to stave off
their opiate-esque withdrawal symptoms. The same trend was picked up by
Max Daly writing for Vice.
Concerned about the lack of tools and
resources for working with SCRA dependency, the existing Cannabis Dependency Toolkit on the KFx website was adapted to reflect SCRA
dependency. The SCRA Dependency Toolkit has proved popular with a number
of workers to prompt discussion about SCRAs and start the process of
addressing dependency and promoting change.
The area that still
needed to be addressed was how to respond effectively to physical
dependency, specially where pharmacological interventions were
The only significant report on the management and
treatment of SCRAs was produced by Project Neptune and the section on SCRAs republished separately in 2016.
The report has very little concrete information on treatment of withdrawal symptoms, saying only:
specific medications are indicated for SCRA harmful use or
dependence and no substitute prescribing is currently available.
Symptomatic management of withdrawal symptoms may be indicated in some
In the absence of clear direction, piecemeal resources
have emerged but haven’t been evaluated, reviewed or been shared with
wider audiences. Medical responses have included Buscopan or
phenothiazine for nausea. However misuse of Buscopan in custodial
settings has increased wariness of using antihistamines in such settings
and measures such as peppermint oil have been trialed.
one prison treatment prescriber used their initiative and used
Pregabalin with some success, until told by senior management not to
continue as the medicine was not licensed for this purpose. In other
settings, benzodiazepines (such as chlordiazepoxide) have been used.
a contemporary drugs field where centralized agencies work slowly to
national protocols and “evidence-based treatments” can take an age to
emerge, we have been left with too little concrete on offer.
resources like the BMJ's infograph on NPS don’t even make mention of
physical withdrawal symptoms, it can hardly be a surprise that GPs and
treatment workers may miss the link between presenting symptoms to SCRA
withdrawal and prescribe accordingly.
This ongoing void is
increasingly dangerous. Some drugs agencies have stated (both publicly
and to dependent users) that it would be easier to work with them if
they were using heroin as there would then be a clear treatment
protocol. Given such messages from helping agencies, it can hardly be
surprising that dependent, unsupported users have done just that.
numerous courses in Kent and elsewhere, and after discussion with a
number of agencies, there was a clear need for an additional resource to
complement the SCRA Dependency Toolkit. The initial idea was for a
Severity of Withdrawal index. This would follow on from the dependency
toolkit: for those identified as having a physical or psychological
dependency, a more detailed exploration of their symptoms could take
place. The second stage of this would be a tiered collection of
interventions ranging from holistic to inpatient treatment, with
potential pharmacological interventions for different presenting
On the back of one such discussion, as the tool was
being discussed, participants on courses were discussing potential
treatments. One we kept coming back to was Mirtazapine. It seemed that
it had the potential to address several key issues including craving,
sleep disruption, nausea, appetite loss, anxiety and neural pain. It
also had an advantage of being less prone to and risky from a misuse
point of view, especially when compared to Pregabalin which also could
be useful in managing several of the symptoms of SCRA withdrawal.
Index and Treatment suggestions are very much at a draft stage. What is
urgently required is that clinicians stop waiting for some
authoritative national guidance on SCRA treatment. Using the guidance
from Neptune, the only clinical guidance is “symptomatic management of
withdrawal symptoms may be indicated in some cases.” This should be used
as the rationale and argument for trialing appropriate pharmacological
In turn where measures have been successful (or
not) they need to be written up, even if it is only as a brief letter to
medical journals. Then and only then will the published evidence base
start to emerge. It requires agencies to take the lead and there should
be no need to wait any longer.
The draft SCRA Withdrawal Screening Tool and potential interventions can be downloaded here.
It is in draft form and all feedback and suggestions are gratefully received.