Correspondence

Letter from the Minister of State for Crime, Policing and Probation to the Chair of the Advisory Council on the Misuse of Drugs (accessible version)

Updated 27 April 2022

Professor Owen Bowden-Jones
Chair, Advisory Council on the Misuse of Drugs
2 Marsham Street
London
SW1P 4DF

27 April 2022

Dear Professor Bowden-Jones

The ACMD’s report ‘An assessment of the harms of gamma-hydroxybutyric acid (GHB), gamma-butyrolactone (GBL), and closely related compounds’.

Thank you again for your report of 20 November 2020 on GHB and related substances. On the 30 March 2021, the Home Secretary accepted Recommendation 3 (that GHB, GBL and 1,4-butanediol (1,4-BD) be moved from Class C to Class B of the Misuse of Drugs Act 1971) and Recommendation 4 (that GBL and 1,4-BD are placed under Schedule 1 of the Misuse of Drugs Regulations 2001, so that industrial users will require a controlled drugs licence). Initial steps have been taken to implement the legislative changes, and in light of evidence from industry on the impact of these changes further work is ongoing to finalise the approach to legislation. In my initial letter, the Home Secretary committed to a further response on the remaining recommendations.

I recognise the importance of the joined-up approach to GHBRS outlined in your report. Following on from my initial response, the Home Office has worked closely with the Department for Health and Social Care (DHSC), and the Office for Health Improvement and Disparities (OHID) to provide a comprehensive response to the remaining recommendations in advance of the introduction of the regulations. I set out each recommendation and the Government’s response below.

The Home Office is responding to the ACMD’s advice on behalf of the UK Government in respect of reserved matters. The Home Office has consulted with the Devolved Administrations in the preparation of this response, and their views on the matters which fall within their competence (including, in particular, healthcare, data collection and analysis, and post-mortem toxicology) are set out in an annex. In some cases, the Devolved Administrations have also provided comments on reserved issues, as presented in the annex.

Recommendation 1: To improve current service level data collection and reporting

Part 1: To improve current service level data collection and reporting in the following ways:

• Ensure that sexual health services report relevant sections as required in GUMCAD V3 with financial support afforded to those services that require adaptation of electronic patient systems.
• For the PHE National Drug Treatment Monitoring System (NDTMS):

a. service reporting of sexual orientation to remain above 95% field completion; and

b. to make publicly available, on an annual basis, the sexual orientation for individuals in treatment for GHBRS, crystal methamphetamine, ketamine and mephedrone (note: all four relevant chemsex drugs are included to give an indication of chemsex needs and ensure that data for GHBRS does not need to be limited by PHE for the reasons of disclosure control).

The Government accepts this recommendation and can confirm the sexual orientation field completion rate in the National Drug Treatment Monitoring System (NDTMS) has remained above 95% for those starting treatment in recent years. Going forward, the Office for Health Improvement and Disparities (OHID) will report problematic substances by sexual orientation in NDTMS annual reports from 2021/22 reporting year onwards. Furthermore, OHID successfully piloted the behavioural specification of GUMCAD (including questions on recreational drug use) with multiple software providers of electronic patient record management systems at sexual health services and commenced implementation of this specification in April 2019. However, implementation of the software upgrades required to collect, extract and report the newly specified behavioural data was severely delayed as a result of staff redeployment and service reconfiguration in response to COVID-19. As a result, the deadline for implementation of the April 2019 behavioural specification of GUMCAD was extended. It is noted that funding for software system upgrades is determined locally in accordance with local commissioning plans.

Part 2: To improve current service level data collection and reporting in the following ways:

• For the Crime Survey for England and Wales (CSEW) to collect data frequently from all individuals on: 2. GHBRS use; and 3. sexual orientation.

The Government agrees with the ACMD’s recommendation. Questions on respondents’ sexual orientation are already included in the CSEW. Due to the small proportion of respondents in each year who identified themselves as gay, lesbian or bisexual, data from a number of survey years would need to be combined to look at drug use among these groups. The Home Office will continue to discuss carrying out this type of analysis with the Office for National Statistics. Questions about GHBRS use will be added from April 2022 onwards to check whether prevalence has changed since it was last asked about in 2011/12.

Part 3: To improve current service level data collection and reporting in the following ways:

For the UK Government to provide sufficient funding to enable provision and analysis of The Gay Men’s Sex Survey (GMSS) for at least five years. As this has previously been funded as part of an EU grant this recommendation is in line with the UK Government’s commitment that research in the UK will not suffer as a result of EU-exit.

The OHID agrees in principle with this recommendation and are exploring funding options for the survey. The OHID has agreed to update the ACMD on its progress at the earliest opportunity.

Recommendation 2: Testing for GHBRS should be routinely undertaken in all cases of unexplained sudden death.

Where testing is not possible (for example, not enough sample, financial, or other reason) then a clear statement should be included in the toxicology report stating that GHBRS testing has not been carried out. Where a blood sample is positive for GHBRS, if possible, this should be confirmed in another sample type, for example, urine.

This recommendation is beyond the remit of Government as it is ultimately the responsibility of Coroners, who, as judicial office holders, are independent in the discharge of their statutory functions. Coroners are funded by individual local authorities and make decisions in each individual case about the nature of the toxicological examination required. Nevertheless, Home Office officials have raised this matter with both the Ministry of Justice and the Office of the Chief Coroner in order that it can be considered as appropriate.

Recommendation 5: Better integration of drug treatment and sexual health services

Commissioning (including at regional/local level as indicated by need) of open access, competent, culturally appropriate, substance use and sexual health services to address the inter-related harms and psychosocial aspects of health due to GHBRS use, including in the context of sexualised drug use. Integrated treatment models currently (as at 2020) exist in the UK and these should be examined to understand best practice.

In high demand areas, the closer integration of drug treatment and sexual health services, including co-location, should be further explored for effectiveness, underpinned by models of joint funding and commissioning. In areas of lower demand/capacity, commissioners and providers should ensure expert referral pathways between services.

Further research into effective service access should be conducted, particularly in areas of high prevalence, including A&E and primary care. It is noted that this recommendation applies to GHBRS but could also apply to chemsex drugs in general.

The government recognises the need for referral pathways between sexual health clinics and treatment services and for staff in each type of service to be competent in treating GHBRS users, including in the context of sexualised drug use and the chemsex scene. While the appropriateness of joint commissioning and the extent to which services should be integrated are to be determined locally in accordance with local need, OHID published guidance on for Local Authority public health commissioners on “Substance misuse services for men who have sex with men involved in chemsex”, which protected best practice in collaboration between substance misuse and sexual health services.

In its initial response to Part Two of Dame Carol Black’s Review of Drugs, the Government has committed to drafting commissioning quality standards to support any future enhancement of the treatment and recovery system and this will cover integration with sexual health services.

Recommendation 6: Education

Develop a specialist education pathway for frontline staff in the health and social care system who come into contact with GHBRS users. These staff include those within the SHS, SMS, and emergency departments (overdose and withdrawal). The specialist education pathway should provide staff with relevant training on GHBRS-related harms in order to better equip them in managing complex cases and provide essential information on drug use, cultural competence and understanding. This should help to deliver a higher quality and non-judgemental service, working towards reducing harm and alleviating some of the stigma associated with the use of GHBRS. A skilled workforce should also enable improved engagement at the first point of contact with the SHS/SMS.

To review and update the chemsex e-Learning module of the Sexual Health and HIV training to ensure that the content reflects the importance of not just drug knowledge but also covers cultural competence and creating a safe environment for open discussion about risks and sexual behaviour.

In addition, for the inclusion of GHBRS within postgraduate programmes and speciality nurse training, Diploma of genitourinary (GU) Medicine, and speciality training curricula.

The Government agrees that frontline staff in the health and social care system who encounter people using GHBRS should have the appropriate level of knowledge about these substances.

In its initial response to Part Two of Dame Carol Black’s review, the Government has committed to the Department of Health and Social Care (DHSC) working with Health Education England (HEE) to develop a workforce strategy, training requirements and occupational standards for staff, as well as devising an urgent comprehensive strategy on the future need of the workforce. Appropriate training on GHBRS and other chemsex drug use will be considered as part of this.

Educational materials covering GHBRS are already available for the substance misuse workforce and staff working in other relevant sectors. This includes e-learning and clinical guidance published as part of Project NEPTUNE and on FRANK.

Recommendation 7: Treatment interventions

Chronic harms (sexual trauma and stigma)

Services involved in the management of people who use GHBRS should provide comprehensive assessments and evidence-based psychological and social support to individuals within a key worker/client context. These should be tailored to the individual requirements of the service user according to their specific needs, for example, issues related to age, ethnicity, cultural context, diversity and social isolation. For those individuals with more complex needs all relevant services should have commissioned, clear and timely pathways to care.

Non-acute presentations to support services (for example, elective withdrawal)

The TOXBASE® clinical guidelines for GHBRS intoxication and withdrawal, which are used by emergency department staff, should be emphasised to be of value for non-acute services, such as elective detoxification presentations. Support services should access TOXBASE® guidelines directly or adapt the content to the local service need.

The Government agrees that this is good practice. Services involved in the management of people who use GHBRS are supported to provide quality care as described in this recommendation by existing guidelines. OHID will consider the Council’s view on this topic when drafting the commissioning quality standards referenced above.

OHID will consider whether there is a need to address GHBRS intoxication and withdrawal in clinical guidelines for drug treatment when these are next updated. Local support services are currently able to obtain clinical information relating to GHBRS through partnership working with local acute services where they have identified a local need for them to do so.

PHE has previously published guidance on for Local Authority public health commissioners on ‘Substance misuse services for men who have sex with men involved in chemsex’, covering comprehensive assessment, care pathways and collaboration between substance misuse and sexual health services. OHID will continue to promote good practice in this area.

Recommendation 8: Information and support

To ensure the availability and promotion of information and support to those who are at highest risk of harms associated with GHBRS. This should utilise reliable and up-to-date sources of information that are already available on physical, mental and social harms, including sexual harms and consent in a chemsex setting. The information should, where necessary, be individualised and accessible (for example, in appropriate languages).

The Government accepts this recommendation and OHID will update all relevant published Government information on GHBRS, which includes the relevant page on FRANK, to reflect the reclassification of GHBRS, reflecting the harms associated with it. OHID has also reviewed the rest of the relevant content on FRANK to ensure it is up to date and appropriate for the audience, and has contacted the charities that are responsible for information on the other websites identified to ensure that they are aware of the report and this recommendation.

I would like to thank the ACMD once again for their detailed and thoughtful recommendations on this complex matter.

Rt Hon Kit Malthouse MP

Annex: Responses of the Devolved Administrations to the ACMD’s recommendations

Recommendation 1: Data collection and reporting

To improve current service level data collection and reporting in the following ways:

Part 1

• Ensure that sexual health services report relevant sections as required in GUMCAD V3, with financial support afforded to those services that require adaptation of electronic patient systems.
• For the PHE National Drug Treatment Monitoring System (NDTMS):
• service reporting of sexual orientation to remain above 95% field completion; and
• to make publicly available, on an annual basis, the sexual orientation for individuals in treatment for GHBRS, crystal methamphetamine, ketamine and mephedrone (note: all four relevant chemsex drugs are included to give an indication of chemsex needs and ensure that data for GHBRS does not need to be limited by PHE for the reasons of disclosure control).

GUMCAD and NDTMS only apply to England.

Scottish Government: The Scottish Government is supportive of this recommendation and would be happy to collaborate on the collecting and reporting of this data.

Wales: Where possible The Welsh Government are happy to collaborate on the collecting and reporting of this data.

Northern Ireland: The Department of Health Northern Ireland (DoH NI) is supportive of the recommendation and would be happy to collaborate on the collection and reporting of data on a UK basis, and locally, where practicable. It is likely that additional resources may be required to put in place all the ACMD recommendations.

Part 2

For the Crime Survey for England and Wales (CSEW) to collect data frequently from all individuals on:

• GHBRS use
• sexual orientation

The CSEW is a reserved matter for England and Wales. Scotland and Northern Ireland have separate surveys on crime.

Scottish Government: The Scottish Government recognises the importance of collecting data on emerging substances of misuse and continues to review the questions asked, and the drugs asked about, in the Scottish Crime and Justice Survey (SCJS). The SCJS team are also in discussion with the Scottish Health Survey to potentially move the drugs module to the health survey in future.

Wales: No comments.

Northern Ireland: The Department of Health Northern Ireland (DoH NI) is supportive of the recommendation and would be happy to collaborate on the collection and reporting of data on a UK basis, and locally, where practicable. It is likely that additional resources may be required to put in place all the ACMD recommendations.

Part 3

For the UK Government to provide sufficient funding to enable provision and analysis of The Gay Men’s Sex Survey (GMSS) for at least five years. As this has previously been funded as part of an EU grant this recommendation is in line with the UK Government’s commitment that research in the UK will not suffer as a result of EU-exit.

The GMSS only collects data in England, and is a devolved matter.

Scotland: The Scottish Government are supportive of this recommendation.

Wales: The Welsh Government are supportive of this recommendation.

Northern Ireland: The Department of Health Northern Ireland (DoH NI) is supportive of the recommendation and would be happy to collaborate on the collection and reporting of data on a UK basis, and locally, where practicable. It is likely that additional resources may be required to put in place all the ACMD recommendations.

Recommendation 2: Testing

Testing for GHBRS should be routinely undertaken in all cases of unexplained sudden death. Where testing is not possible (for example, not enough sample, financial, or other reason) then a clear statement should be included in the toxicology report stating that GHBRS testing has not been carried out. Where a blood sample is positive for GHBRS, if possible, this should be confirmed in another sample type, for example, urine.

In Wales, the coroners service is a reserved matter, where in Scotland and Northern Ireland it is a devolved matter.

Scotland: The testing of GHB is relatively simple and a test which is carried out fairly frequently. As GHB is an endogenous substance and susceptible to being produced in the body after death, they use a cut-off of 50mg/L in blood to report a positive result. If they find a positive in blood, they will always test a urine sample (if available) to differentiate between post production and ingestion of GHBRS.

If required to test all casework for GHB, this would require a significant increase in resource is not necessarily required.

With regards to stating on the report that they have not been tested for GHBRS the tox lead does not think this would be sensible or necessary. There are hundreds of substances they will not have tested for, and it would be impracticable to start listing all of these on every report.

Wales: As part of our National Board for the Prevention of Drug Related Poisonings we will be working with Coroners in Wales with regards to toxicology testing. Any cross-government work would be welcomed.

Northern Ireland: The Coroners Service for Northern Ireland are content with this recommendation but would defer to the Forensic Service for Northern Ireland.

Recommendation 5: Better integration of drug treatment and sexual health services

Commissioning (including at regional/local level as indicated by need) of open access, competent, culturally appropriate, substance use and sexual health services to address the inter-related harms and psychosocial aspects of health due to GHBRS use, including in the context of sexualised drug use. Integrated treatment models currently (as at 2020) exist in the UK and these should be examined to understand best practice.

In high demand areas, the closer integration of drug treatment and sexual health services, including co-location, should be further explored for effectiveness, underpinned by models of joint funding and commissioning. In areas of lower demand/capacity, commissioners and providers should ensure expert referral pathways between services.

Further research into effective service access should be conducted, particularly in areas of high prevalence, including A&E and primary care. It is noted that this recommendation applies to GHBRS but could also apply to chemsex drugs in general.

Healthcare policy is a devolved issue.

Scotland: The Scottish Government agrees with this recommendation. The Scottish Government understands the importance of data-sharing between services, and for services to be integrated.

We need to work together across Scotland to ensure help and support for those who need it. That means that individuals with problem drug use who are in contact with other services – including sexual health services – need to be a priority for these services. Contacts across these services need to be a better gateway into drug services.

Wales: This would form part of the work carried out and overseen by Area Planning boards (APBs). In addition, on our harm reduction website there is an e-learning module with regards to sexual health. SMaSH (Substance Misuse and Sexual Health) is a training programme which aims to provide learners with the skills, knowledge and confidence required to identify potential risk behaviours and promote health and wellbeing relating to sex, drugs and alcohol throughout an individual’s life.

Northern Ireland: DoH NI is supportive of this recommendation in principle.

A new commissioning framework will be developed for alcohol and drug service provision as part of the new substance use strategy. This recommendation will inform that work, while obviously priority will be given to services and pathways for the substances most prevalent within the region to maximise the added value of available resources.

We will continue to liaise with other administrations as new materials are developed and will consider implementation in Northern Ireland based on an assessment of need and availability of resources.

Recommendation 6: Education

Develop a specialist education pathway for frontline staff in the health and social care system who come into contact with GHBRS users. These staff include those within the SHS, SMS, and emergency departments (overdose and withdrawal). The specialist education pathway should provide staff with relevant training on GHBRS-related harms in order to better equip them in managing complex cases and provide essential information on drug use, cultural competence and understanding. This should help to deliver a higher quality and non-judgemental service, working towards reducing harm and alleviating some of the stigma associated with the use of GHBRS. A skilled workforce should also enable improved engagement at the first point of contact with the SHS/SMS.

To review and update the chemsex e-Learning module of the Sexual Health and HIV training to ensure that the content reflects the importance of not just drug knowledge but also covers cultural competence and creating a safe environment for open discussion about risks and sexual behaviour.

In addition, for the inclusion of GHBRS within postgraduate programmes and speciality nurse training, Diploma of genitourinary (GU) Medicine, and speciality training curricula.

While some avenues of this recommendation are devolved policies, services such as FRANK and NEPTUNE are UK-wide. Otherwise, the DAs are responsible for establishing their own specialist education pathways for frontline staff.

Scotland: GHB is a small issue in Scotland in comparison to other drugs. The drugs education charity CREW 2000 receive very few requests regarding information for GHB, most of it being with regards to chemsex. The ‘COVID-19 and Drugs Market’ survey showed that GHB-GBL was the least common of all drugs reported with only 4% of respondents in Scotland reporting using it. CREW 2000 can, however, provide information about GHB and other drugs as required.

Wales: Our national harm reduction website: https://www.harmreductionwales.org / provides e-learning on chemsex. In addition, there is information held on our national helpline website DAN 24/7. On our harm reduction website there are links to other relevant bodies such as BASSH, NEPTUNE and RCGP training

Northern Ireland: DoH NI is supportive of this recommendation.

We will continue to liaise with other administrations to identify best practice on improving education in this area.

Recommendation 7: Treatment interventions

Chronic harms (sexual trauma and stigma)

Services involved in the management of people who use GHBRS should provide comprehensive assessments and evidence-based psychological and social support to individuals within a key worker/client context. These should be tailored to the individual requirements of the service user according to their specific needs, for example, issues related to age, ethnicity, cultural context, diversity and social isolation. For those individuals with more complex needs all relevant services should have commissioned, clear and timely pathways to care.

Non-acute presentations to support services (for example, elective withdrawal)

The TOXBASE® clinical guidelines for GHBRS intoxication and withdrawal, which are used by emergency department staff, should be emphasised to be of value for non-acute services, such as elective detoxification presentations. Support services should access TOXBASE® guidelines directly or adapt the content to the local service need.

Responsibility for this function in Scotland, Wales and Northern Ireland is devolved.

Scotland: The Scottish Government is supportive of this recommendation in principle.

We will continue to liaise with other administrations, learning from examples of what works to reduce drug-related harms and save lives.

Wales: This would be Public Health Wales and the Welsh Government Substance Misuse Team, which work with our Area Planning Boards

Northern Ireland: DoH NI is supportive of this recommendation in principle.

We will continue to liaise with other administrations on new treatment interventions and learning developed around them and will consider implementation in Northern Ireland based on an assessment of need and availability of resources.

Recommendation 8: Information and support

To ensure the availability and promotion of information and support to those who are at highest risk of harms associated with GHBRS. This should utilise reliable and up-to-date sources of information that are already available on physical, mental and social harms, including sexual harms and consent in a chemsex setting. The information should, where necessary, be individualised and accessible (for example, in appropriate languages).

While healthcare policy is a devolved issue, some policy issues such as FRANK are UK-wide.

Scotland: GHB is a small issue in Scotland compared with other drugs. The drugs education charity CREW 2000 can provide information about GHB and other drugs.

Wales: PHW has developed and launched the harm reduction website https://www.harmreductionwales.org /

This website provides harm reduction advice, e learning and evidence. In addition, we also have a national helpline, DAN24/7 where people can access relevant information on a range of topics

NI: DoH NI is supportive of this recommendation. With these substances, overdose including fatal overdose is a real concern – due to the steep dose/effects curve and concurrent use of other sedatives including alcohol. Awareness of this will be limited so there is a need to ensure frontline staff are aware in order to give targeted harm reduction advice. Of the many incident reports reviewed over the past few year, there is a significant increase in references to polysubstance use.