13 February 2017

SCRA Dependency: the learned helplessness in treatment services

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 time-limited one.

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 indicated.

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:
“No  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 cases.”

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.

At least 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.

In 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. 

When 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.

Following 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 symptoms.

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.

The 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 interventions.

 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.