Correspondence

Followup government response to the ACMD report (accessible)

Updated 6 December 2022

Prof Owen Bowden-Jones,
Chair, Advisory Council on the Misuse of Drugs (ACMD)
Prof Simon Thomas,
Chair of the NPS Committee, ACMD
C/o 1st Floor,
Peel Building
2 Marsham Street
London
SW1P 4DF

By email only ACMD@homeoffice.gov.uk

6 December 2022

Follow-up Government response to the ACMD’s report on the misuse of fentanyl and fentanyl analogues

Further to the letter from the former Minister of State for Crime and Policing in October 2020, I have provided updated responses to recommendations 1 to 5 and recommendation 8 which the Government committed to respond further on in the response from October 2020 to the Council. These cover the following topics:

1. Research to study diversion and non-medical use of strong opioids

2. A review of international drug strategy approaches to fentanyl markets, in particular, the North American experience

3. Training of health professional in the appropriate therapeutic use of strong opioids

4. Toxicology analysis of samples of all deaths related to drug poisoning for fentanyl, and

5. (a) Research to monitor prevalence of fentanyl in i) drug seizures and ii) non-fatal heroin toxicity episodes; and b) analysis of unadopted Police and Border Force samples for fentanyl and fentanyl analogues under the Forensic Early Warning System.

The Government will respond to recommendation 8 separately, at a later date. This recommendation concerns a consultation on expanding the precursor controls to cover simple variants of ANPP, the immediate precursor to fentanyl.

The Home Office has worked with the Office for Health Improvement and Disparities (OHID) and the Department of Health and Social Care (DHSC) to produce this updated response.

Recommendation 1

Research should be commissioned to study diversion and non-medical use of strong opioids to identify trends, drug products involved and populations at risk.

The Department of Health and Social Care (DHSC) and its former executive agency Public Health England (PHE), now the Office for Health Improvement and Disparities (OHID), both agreed with this recommendation, provided that an adequate case to undertake the research can be made.

Following the Government’s response in October 2020, PHE, now the Office for Health Improvement and Disparities (OHID) has prioritised taking forward research projects identified by Dame Carol Black in her independent review of drugs.

Another key commitment, as set out in recent cross-government drugs strategy, is the Addiction Healthcare Mission. Backed with £30m funding, the Office for Life Sciences are delivering the mission, initially focussing on opioids and cocaine and aiming to enhance the UK-wide research environment and incentivise innovative approaches to reduce the harm and deaths these addictions can cause.

This particular area (research on diversion and non-medical use of strong opioids) has not been prioritised and no research requirements have been identified. OHID will keep this area under review.

Recommendation 2

Government departments should conduct a full review of international drug strategy approaches to fentanyl markets, in particular, the North American experience, and consider interdiction controls that can be applied to the UK situation.

Home Office officials have responded separately to the ACMD on this recommendation.

Recommendation 3

Ensure that health professionals are trained in the appropriate therapeutic use of strong opioids, as described in the ‘Opioids Aware’ resource and the forthcoming NICE guidance on management of chronic pain.

Since the Government’s response in October 2020, DHSC has sought to make Opioids Aware more widely available and has met representatives of the Faculty of Pain Medicine to discuss how to do so.

Opioids Aware is the Faculty’s most accessed resource (although user data is not currently collected by the Faculty, or centrally) and a link has been placed on its homepage to maximise visibility. The Opioids Aware resource has also been included as part of the further resources in the ‘All Our Health’ guidance on Misuse of Illicit Drugs and Medicines and Musculoskeletal Pain. This is available on both the GOV.UK and e-learning for healthcare platforms. The e-learning for healthcare platforms (elfh) are a Health Education England programme in partnership with the NHS and professional bodies.

The NICE guidance on chronic pain, developed in partnership with the Royal College of Physicians, was published in April 2021. The guidance recommends that opioids should not be initiated to manage chronic primary pain and this will be reflected in the professional training described in the Government’s response in October 2020.

Recommendation 4

a) Toxicology analysis of samples of all deaths related to drug poisoning should include analysis for fentanyl and fentanyl analogues as non-systematic screening hinders our capacity to understand trends in drug deaths.

b) Toxicology reports from all deaths related to drug poisoning should include a clear statement as to whether fentanyl and/or its analogues were included in the testing. Importantly it should be made explicit if fentanyl and/or its analogues have not been tested for.  This would enable meaningful monitoring of trends in fentanyl-associated deaths.

The UK Government agreed to this recommendation in principle in the reply of October 2020. Ultimately, the recommendation is beyond the remit of Government as Coroners are independent judicial office holders who 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. As a result, it is not possible for the Government to require coroners to adopt a particular approach to toxicology.

However, the Government recognises that the ACMD’s recent report A review of the evidence on the use and harms of 2- benzyl benzimidazole (‘nitazene’) and piperidine benzimidazolone (‘brorphine-like’) opioids contains recommendations that have a broad relevance to post-mortem toxicology.

Recommendation 5

Research should be commissioned to monitor the local and national prevalence of fentanyl and fentanyl analogues in:

a)(i) drug seizures, including heroin preparations and counterfeit medicines;

a)(ii) non-fatal episodes of heroin toxicity requiring hospital treatment;

b) Increased funding should be made available to the Defence, Science and Technology Laboratory Forensic Early Warning System (DSTL FEWS) programme to increase capacity to analyse un-adopted police and border force seizures.

Recommendation 5(a)(i): OHID agrees that monitoring of local and national prevalence of fentanyl and fentanyl analogues in drug seizures is important, but further bespoke research in this area is not required.

OHID produces analysis of substances including fentanyl and fentanyl analogues detected in seizures on a quarterly basis, which is shared with relevant stakeholders, in addition to more detailed analysis provided to the ACMD. OHID does not consider that there is sufficiently broad interest to warrant a specific publication analysing fentanyl and fentanyl analogues detected in seizures.

Since the interim response, OHID has discussed with the ACMD the information it monitors on fentanyls and other drugs detected in seizures and biological samples, and we understand that the ACMD is satisfied with OHID’s monitoring processes and with the information shared with ACMD. Arrangements for sharing relevant information with the ACMD can be formalised if this is desirable.

Recommendation 5(a)(ii): OHID is keen to continue monitoring non-fatal episodes of heroin toxicity requiring hospital treatment as is currently done through the “Identification of novel psychoactive substances” (IONA) study and is considering the options for further research beyond the current contract term. Data from IONA has been and will continue to be shared with the ACMD.

IONA, or a successor project, is the appropriate research project for non-fatal episodes of heroin toxicity requiring hospital treatment. It is OHID’s assessment that there is no need to commission additional new research separately from this.

Recommendation 5b): The Government began the collection of cocaine and diamorphine samples in 2020 following the recommendation by the ACMD. Since 2020, 480 samples containing cocaine and 175 samples containing diamorphine have been analysed. Ocfentanil is the only new synthetic opioid to be detected under the FEWS project since 2020 and was found in one sample during the financial year 2020/21. Its identification was confirmed during the financial year 2021/22.

The Home Office will continue to monitor unadopted samples for fentanyl, and fentanyl analogues and other novel synthetic opioids as well as new synthetic cannabinoids under the Forensic Early Warning System programme.  Alongside this, the Home Office will continue to work across government with relevant departments and agencies, to monitor the threat from fentanyl and synthetic opioids.

Recommendation 8

Following a consultation with the research community, the Home Office should expand the precursor controls to cover simple variants of ANPP (see Annex 6), the immediate precursor to fentanyl. It is recommended that paragraphs (i) to (v) of the text of the existing generic control on fentanyls be also applied in the precursor legislation, that is that the entry for ANPP be amended to cover:

Any compound……structurally derived from ANPP by modification in any of the following ways, that is to say:

• (i) By replacement of the phenyl portion of the phenethyl group by any heterocycle whether or not further substituted in the heterocycle
• (ii) By substitution in the phenethyl group with alkyl, alkenyl, alkoxy, hydroxy, halogeno, haloalkyl, amino or nitro groups
• (iii) By substitution in the piperidine ring with alkyl or alkenyl groups
• (iv) By substitution in the aniline ring with alkyl, alkoxy, alkylenedioxy, halogeno or haloalkyl groups
• (v) By substitution at the 4- position of the piperidine ring with any alkoxycarbonyl or alkoxyalkyl or acyloxy group
• [Note: para (vi) of the fentanyl generic refers to the propionyl group being replaced by another acyl group, but this feature is absent in ANPP and so is not required here] In order also to control the benzyl analogues of fentanyl as precursors (see Annex 7), the new control described above should be further expanded by adding a paragraph:
• (i)(a) “By replacement of the phenethyl group by a benzyl group;” And by expansion of para (ii) to:
• (ii) By substitution in the phenethyl or benzyl group with alkyl, alkenyl, alkoxy, hydroxy, halogeno, haloalkyl, amino or nitro groups”

The Home Office has consulted members of the scientific community about the effect of the recommendation on research and pharmaceuticals and further consideration of these responses is necessary. As explained in the Government’s initial response in October 2020, there are a number of complexities about how to capture this in legislation that will need to be considered in the wider context of the Government’s handling of drug precursor controls. The Home Office will update the ACMD when we have more information about this matter.

I thank the Council for their patience in waiting for the Government’s follow-up to the initial response and trust that my reply is helpful.

Rt Hon Chris Philp MP

Minister of State for Crime, Policing and Fire