The British Association for Psychopharmacology guidelines for the management of substance dependence focus primarily on the pharmacological aspects of treatment. A group of international experts from a wide range of disciplines reviewed the current evidence in their field, considered the strength of the evidence and discussed the clinical implications at a consensus meeting. The guidelines focus on the pharmacological management of dependence on alcohol, benzodiazepines, ‘z-drugs’, γ-hydroxybutyrate (GHB), gabapentinoids, opioids, nicotine, cannabis and synthetic cannabinoids, cocaine, amphetamine and methamphetamine, dissociative drugs and their analogues. They are based on the available evidence and make recommendations to aid clinical decision making, as well as highlighting the gaps in the current evidence-base.

BACKGROUND:Safer smoking equipment interventions for people who smoke crack cocaine have been unevenly implemented globally with most harm reduction policy and practice focused on preventing opioid and injecting related harms. There is a need to synthesise the international evidence on safer inhalation equipment provision for crack and understand how, why, for whom, and in what context can such interventions improve engagement with services, promote safer use practices, and reduce harm. METHODS:Bibliographic databases (n = 8) and grey literature sources were searched for reports on the distribution of safer inhalation equipment among adults who use crack. Data synthesis was applied around a realist framework, focusing on contextual factors and mechanisms which influenced the interventions' outcomes. RESULTS:Evidence from 16 peer reviewed and 6 grey literature studies was included. Overall, acceptability of safer inhalation interventions and uptake (≈ 90% in some studies) was high. Evidence pointed towards reduced pipe sharing, decreased injecting, and improved engagement with health and social services. However, implementation was frequently hindered by resource, political, and logistical constraints. Five context-mechanism-outcomes were developed covering service accessibility, integrated provision, tailored provision, peer-supported behaviour change, and organisational resilience against criminalisation and funding cuts. Service engagement and the adoption of safer crack use practices were greater when supportive contexts activate key mechanisms such as perceived safety, ease of access, perceived relevance, and peer-supported learning. CONCLUSION:Although political, legal and funding constraints can impede implementation and optimal delivery, this review highlights the role of accessible, integrated and peer supported delivery models that services and policymakers can deploy to effectively reduce crack-related health harms and foster engagement with services.

Abstract Background The use of stimulants, such as crack-cocaine, is a global public health concern. Crack-cocaine use is increasing in the UK, but available data is focused on those who inject or also use opioids. To address this gap, characteristics of people using crack-cocaine in England, including respiratory problems among those who smoke, and variation in these by gender are described. Methods Adults self-reporting crack-cocaine use in the past 28 days, recruited by specialist services and peer networks in six sites during 2023, completed a self-report survey about demographic characteristics, drug use, crack use practices, health problems and service use. Bivariable analyses and logistic regression were used to explore gender-related differences in crack-cocaine use and crack-related respiratory problems. Results The participants’ (n = 731) median age was 42 years and 71% were men. Overall, 54% were stably housed, 71% had ever been imprisoned and 28% reported emergency department attendance in past 6 months. In the past 28 days, 99% had smoked crack-cocaine (44% shared pipes), with 30% injecting crack. Poly-sedative use was common including heroin (78%), pregabalin/gabapentin (41%), and benzodiazepines (28%), with 62% receiving opioid substitution therapy. Use of drugs normally smoked was common (90% tobacco, 62% cannabis and 25% spice). Women reported less polydrug use but more often vaped nicotine. Crack-related respiratory symptoms among those smoking crack were reported by 67% of women and 58% of men. In both men and women these symptoms were associated with increasing time since first crack-cocaine use and pregabalin/gabapentin use. In men they were also associated with food insecurity; smoking tobacco; temporary employment; and use in abandoned buildings or at friend’s place; reduced odds were associated with current heroin use and using with a close friend. Among women, having a respiratory symptom was also associated with sharing pipes. Conclusions Respiratory health problems are common among those smoking crack-cocaine, particularly among women. In combination with high poly-sedative use, this poses a mortality risk from respiratory depression. UK service provision is focused on prevention of opiate and injection-related risks. Services for people who use crack-cocaine and low-threshold respiratory care pathways require prioritisation to reduce avoidable morbidity and mortality.

Provision of equipment for the purpose of stimulant inhalation is prohibited under UK law. Crack cocaine use is prevalent and rising in England, where the SIPP (safer inhalation pipe provision) study piloted and evaluated a crack equipment and workforce training intervention. We report mixed method findings from the baseline component of the study, prior to intervention implementation. The aim of this paper is to situate quantitative findings regarding respiratory risk through qualitative exploration of crack inhalation practice in a context of stimulant equipment prohibition. In this paper we report descriptive findings from baseline survey data (n = 727) with a focus on thematic analysis of interview data (n = 33). Participants were recruited through drug treatment services and peer networks in six geographical locations in England, with survey eligibility criteria including crack use (injecting or smoking) in the past 28 days. Of the 733 participants who completed the baseline questionnaire, 727 (99

Background Crack cocaine use is increasingly prevalent in England, yet drug services are poorly equipped to support the needs of this population. Provision of stimulant inhalation equipment is prohibited, and workforce crack-related harm reduction knowledge is generally low. The Safe Inhalation Pipe Provision (SIPP) project piloted a crack inhalation equipment and training intervention in England. This paper explores how and in what way crack training and equipment provision influences engagement with drug service providers. Methods SIPP is a mixed-method study, comprising a before-and-after survey, service monitoring data, qualitative interviews, focus groups, and observations. Here we report qualitative data generated with people who use crack and providers at three intervention and three comparison group sites. We conducted a thematic analysis and report themes specific to contact and engagement with drug services. Results Prior to intervention implementation, little adequate crack-specific support was identified. SIPP equipment provision facilitated increased contact and/or disclosure of crack use with services. Workforce training enhanced communication and relationship-building opportunities, enabling disclosure of additional need and commensurate provision or linkage to health and social supports. The capacity for contact to facilitate engagement was impacted by organisational and structural constraints, and for some populations barriers to access remain entrenched. Conclusions Provision of crack inhalation equipment can facilitate new contacts with services among a highly marginalised population. Complementary workforce training helps to enable relationship building and engagement opportunity. Additional methods of provision, including through peer networks, are required to support people for whom barriers to service access remain. Trial registration ISRCTN12541454 https://doi.org/10.1186/ISRCTN12541454

In order to reach and maintain hepatitis C virus (HCV) elimination goals, it is imperative to reach marginalized people who do not engage with traditional testing and treatment. Peer-led interventions are effective in engaging such individuals. Studies have demonstrated community pharmacy as a low-threshold setting for HCV testing, but pharmacy teams’ competing demands are a barrier to maximizing potential. This pilot project aimed to assess whether a pharmacy-based peer-led model of HCV testing was implementable, deliverable, able to engage marginalized people, and overcome pharmacy staff constraints. We implemented a peer-led HCV testing service in one community pharmacy in the Midlands, England, providing four focused phases of testing, totalling 198 h, over two years. In total, 591 tests for antibodies or RNA were undertaken, identifying 24 active infections. Subsequent phases retested 20%, 16%, and 11% of those tested in combined preceding phases. In response to feedback, phases 3 and 4 included health screening (blood pressure, cholesterol, diabetes, and nurse-performed Fibroscans®). We demonstrate engagement and the ability to identify and refer those with abnormal results to appropriate healthcare. This pilot shows that peer-led testing in the pharmacy setting can be implemented and warrants further scale up and evaluation.

Background Co-use of benzodiazepines and/or ‘z-drugs’ along with opioids is linked to the rise in drug related deaths (DRD) in the UK. Understanding patterns of co-use could inform harm reduction strategies for reducing DRDs. This study explored how people co-use, including dosages, timings, methods of administration, use of other substances and desired effects sought. Methods Forty-eight semi-structured interviews across Glasgow in Scotland (n = 28), Bristol (n = 10) and Teesside (n = 10) in England with individuals who co-use illicit and/or prescribed opioids and benzodiazepines/z-drugs were conducted. Eighteen interviews were co-facilitated with qualitatively trained local peer researchers. Interviews were analysed using the Framework method. Results Six co-use patterns were generated: (1) co-use to aid sleep or come down, (2) curated co-use, opioid agonist therapy (OAT) only (3) morning and evening benzodiazepine doses with opioids throughout the day (4) co-use binges (5) co-use throughout the day, (6) benzodiazepine use throughout the day plus OAT. Patterns one to three reflected more controlled co-use with a focus on self-medicating to give confidence, manage anxiety, promote sleep and come-down from cocaine/ketamine. Patterns four to six involved greater poly-drug use, and less controlled co-use with a focus on seeking euphoria (“warm glow”, “gouching out”) or oblivion (to escape untreated mental health conditions and trauma). Patterns two, three, five and six involved daily co-use. People switched between patterns depending on available resources (e.g. finances) or changes to prescriptions (opioids or benzodiazepines). Near-fatal overdoses were reported by participants across all co-use patterns. Patterns four to six were conceptualised as presenting greater overdose risk due to less controlled co-use and more extensive polydrug use. Conclusions The patterns identified provide opportunities for future harm reduction strategies, tailoring advice to patterns of use, updated prescribing guidance and policies, and the need for better access to mental health care, for people who co-use benzodiazepines and opioids to reduce DRDs.

Many people who use illicit opioids have negative experiences when admitted to hospital, which is partly due to poor availability of opioid agonist therapy (OAT). We conducted a scoping review of interventions to increase access OAT to for hospital patients, with searches of MEDLINE, EMBASE, PsychINFO, and CINAHL for evaluations published before 29 July 2024. We followed a registered protocol (identifier: CRD42022313237). We included interventions in acute inpatient or emergency department settings, and extracted intervention characteristics, location, evaluation design and quality, and evidence for effectiveness. We included 57 studies; 50 from the United States, six from Canada, and one from the UK. Fifty-one were published in 2015 or later. We identified three intervention classes: (a) pathways to initiate OAT in emergency departments, entailing screening patients or training staff to identify withdrawal, initiating buprenorphine, and supported referrals (26 studies); (b) multidisciplinary 'addiction consult teams', which provide substance-related care across hospital departments, advise primary medical teams on issues such as pain relief and withdrawal management, and support patients with discharge and onward care (18 studies); and (c) Interventions that build capacity of general clinical teams to provide OAT to inpatients, including protocols to identify patients who need OAT, multidisciplinary patient review, and training/clinical education (13 studies). Most interventions included multiple components, and the most common were clinical education and measures to improve continuity of OAT after discharge, such as bridge prescriptions and supported referrals to community prescribers. Almost all studies concluded that interventions were effective, however evaluation methods were generally weak and most used before/after or case series designs. Efforts to improve OAT in acute hospitals emerged recently in North America and focus on addiction consult teams and initiation of buprenorphine in emergency departments. Although formal evaluation is weak, these models may represent starting points for national policy and larger research programmes.

Supervision of opioid agonist treatment (OAT) ensures that individuals take their correct daily dose to minimise withdrawal and craving, safeguard against diversion and overdose, and receive optimal benefit from OAT. There is an urgent need to develop effective interventions to increase medication adherence and technological solutions to streamline communication between pharmacies and prescribers. The authors have developed technology to deliver contingency management (CM) remotely by mobile telephone (mCM) and alert prescribers of missed doses. In a previous feasibility study, the authors found mCM was feasible to deliver and acceptable to patients, prescribers, and pharmacists but encountered difficulty recruiting patients starting methadone treatment. Since COVID-19, supervision guidelines have changed to focus on patients at risk of/not adhering to their medication. This study aims to assess the feasibility of conducting a future confirmatory trial to assess the clinical and cost-effectiveness of mCM to encourage adherence with supervised methadone or buprenorphine. It will use broader eligibility criteria, including patients receiving buprenorphine, and target a revised group of serial re-starters. Using a cluster randomised design, three drug services will be randomised 1:1:1 and 20 patients, attending seven pharmacies linked to each service, will be recruited (i.e. a total of N = 60). Each drug service providing supervised medication will be randomly allocated to deliver: (i) telephone-delivered text-message reinforcement with modest financial incentives; (ii) telephone-delivered text-message reminders; or (iii) no telephone text-messages. Prescribers will receive reports of patient attendance. Feasibility will be determined based on four progression criteria: the number of patients enrolled, the percentage of screened patients who are eligible, adherence to the telephone system, based on matches between sign-in at the pharmacy and pharmacy dispensing records and follow-up rates. We will also undertake qualitative assessments of clinicians’ perspectives on the revised eligibility criteria undertaken. This study will assess the feasibility of using mCM to target a clinically important group of patients non-adhering to their supervised medication. In the future, and if effective, mCM will encourage medication adherence among patients, enabling them to achieve an optimum dose and full benefit from OAT. ISRCTN33965312 (26/06/2023). This manuscript was submitted on February 27th, 2024. While recruitment was due to end on February 29th, we recruited our last patient on February 12th. The last patient/last visit took place on May 2nd, 2024.

Clinical pharmacists are the principal profession reviewing polypharmacy in English general practice. Pharmacists reviewing polypharmacy can encounter clinical uncertainty, thus affecting decision-making and the utility of medication reviews. Understanding factors and interventions that mitigate clinical uncertainty could improve polypharmacy medication reviews. This review’s objective was to explore how primary care clinical pharmacist decision-making can be improved when reviewing polypharmacy in the context of clinical uncertainty. A critical literature review was undertaken in key databases. Included articles explored polypharmacy, clinical uncertainty and medication review by primary care clinical pharmacists. Exclusion criteria included community pharmacy and monotherapy management. Quality assurance was conducted using Lincoln and Guba’s evaluative criteria. Contents of included papers were thematically analysed and conceptual models produced. 647 titles/abstracts were screened and 11 full-text articles included, encompassing focus group, interview, ethnography and intervention-development studies. Pharmacists expressed feelings of self-competence occurring alongside apprehension when reviewing polypharmacy. Relationships with patients, including shared decision-making, continuity of care and engagement can support medication reviews. Decision-making is impacted by environmental factors, with poor working relationships within organisations, working across several sites and time pressures hindering deprescribing. The absence of clinical and deprescribing guidelines for multimorbid patients contributes to clinical uncertainty. Multidisciplinary working mitigates clinical uncertainty and training interventions can support pharmacists to proactively deprescribe. Pharmacist, patient and environmental factors can influence pharmacists’ decision-making when experiencing clinical uncertainty during polypharmacy review. Clinical education, peer support and multidisciplinary working have roles in reducing clinical uncertainty and therefore optimising pharmacists’ reviews of polypharmacy.

Synthetic cannabinoids (SCs) are prevalent in prisons and among people who experience homelessness in the UK and can cause serious harms to people who use them. While it is currently not possible to test for SCs at the point of care (POC), a new method for doing so using fluorescence spectral fingerprinting has recently been developed. In this study, we aimed to outline the potential utility of POC SC testing in settings where SCs and SC use occur. This is a mixed-methods study. Professional stakeholders (n = 449) working or volunteering in healthcare, homeless, police, or prison services were invited to give their views on POC SC testing in an online survey with both quantitative and qualitative (free text) questions. Follow-up interviews were conducted with 35 survey participants and additionally with 25 people who use synthetic cannabinoids (PWUSC). Quantitative survey responses on the overall view of saliva- or drug-based detection of SCs were compared between the four groups using Kruskal-Wallis tests. Qualitative survey responses were analysed using content analysis and interviews were analysed using thematic analysis. SCs were perceived as prevalent in UK prisons and homeless communities, but stakeholders felt poorly equipped to tackle SC use and harms. The quantitative analyses revealed that all groups rated both saliva- and drug-based detection positively, but police and prison services were more positive towards both types of testing than healthcare and homeless services (all p’s < 0.001). The thematic and content analyses outlined several potential benefits of POC SC testing across all four settings, with the strongest support for use in prisons, particularly to reduce the ingress of SCs. Both PWUSC and professional stakeholders raised concerns that testing would be used in a punitive manner and highlighted the lack of treatment options for SC dependence and overdose as a major barrier to reducing harms. POC SC testing has the potential to support healthcare, homeless, police, and prison services in reducing the prevalence of SCs and improving the care of PWUSC. However, ethical application of the technology must be carefully considered to avoid causing undue harm to PWUSC, such as criminalisation and stigma.

IntroductionPre-exposure prophylaxis (PrEP) is an effective medication to reduce the risk of acquiring HIV. PrEP is available free of charge in the UK from sexual health clinics. Expanding PrEP delivery to community pharmacies holds promise and aligns with UK government goals to eliminate new cases of HIV by 2030. The aim of this scoping review was to describe the existing evidence about the barriers to and facilitators of community pharmacy oral PrEP delivery, for pharmacists and pharmacy clients, as aligned with the Capacity Opportunity, Motivation Behaviour (COM-B) Model.MethodsFive bibliographic and five review databases were searched from inception to August 2023. Literature of any study design was included if it discussed barriers and facilitators of community pharmacy PrEP delivery. Trial registrations, protocols and news articles were excluded.ResultsA total of 649 records were identified, 73 full texts were reviewed and 56 met the inclusion criteria, predominantly from high-income/westernized settings. Most of the included literature was original research (55%), from the United States (77%) conducted during or after the year 2020 (63%). Barriers to PrEP delivery for pharmacists included lack of knowledge, training and skills (capability), not having the necessary facilities (opportunity), concern about the costs of PrEP and believing that PrEP use could lead to risk behaviours and sexually transmitted infections (motivation). Facilitators included staff training (capability), time, the right facilities (opportunity), believing PrEP could be a source of profit and could reduce new HIV acquisitions (motivation). For clients, barriers included a lack of PrEP awareness (capability), pharmacy facilities (opportunity) and not considering pharmacists as healthcare providers (motivation). Facilitators included awareness of PrEP and pharmacist's training to deliver it (capability), the accessibility of pharmacies (opportunity) and having an interest in PrEP (motivation).DiscussionTo effectively enhance oral PrEP delivery in UK community pharmacies, the identified barriers and facilitators should be explored for UK relevance, addressed and leveraged at the pharmacy team, client and care pathway level.ConclusionsBy comprehensively considering all aspects of the COM-B framework, community pharmacies could become crucial providers in expanding PrEP accessibility, contributing significantly to HIV prevention efforts.

BackgroundMonitoring substance use and Substance Use Disorders (SUD) during global pandemics is essential, as individuals who engage in such activities may be at greater risk for infections as well as economic and social complications. This study aimed to describe the impact of COVID-19 on substance use and SUD, any changes that occurred in patterns of use, and services provided, the main challenges faced and if and how they had been overcome.MethodsA qualitative study consisting of face-to-face semi-structured interviews with a sample of SUD patients from 3 main addiction treatment centers in Jordan. Recruitment stopped once data saturation was reached. Interviews were transcribed and analyzed using NVivo-R1 software, and thematic analysis was undertaken.ResultsA total of 17 individuals were interviewed (male, aged 19-52 years). Five key themes emerged from a narrative analysis: Impact of COVID-19 on the availability of substances, the pattern of use, social life and its relation to SUD, impact on tobacco smoking, and finally on the user's health, awareness and hygienic measures.ConclusionsThis study provided in-depth information to inform, support, and customize the design of interventions to mitigate the negative effects of substance use and SUD-related outcomes in a rapidly changing pandemic.

BACKGROUND:There is little known regarding prescription and nonprescription medicine nonmedical use (abuse and misuse) in Iraq, with limited treatment. Pharmacists could be a valuable source of information in the absence of any national monitoring system. AIMS:This study aimed to explore Iraqi community pharmacists' perspectives on prescription and nonprescription medicine abuse/misuse, including motives for use and how often they encounter people whom they think are misusing or abusing medicines. METHODS:A cross-sectional survey was undertaken between November 2020 and February 2021. Community pharmacists in Iraq were asked to complete a prepiloted self-administered questionnaire, distributed through online social media platforms. RESULTS:300 pharmacists completed the questionnaire. The most commonly reported nonprescription drugs suspected of abuse/misuse were cough and cold medications (n = 80, 26.6%), topical corticosteroids (n = 54, 17.9%), and allergy products (n = 33, 11%). The most common reported prescription drugs suspected of abuse/misuse were systemic antibiotics (n = 111, 36.9%), gabapentinoids (n = 56, 18.6%), and moderate-weak opioids (n = 34, 11.3%). The most commonly method used by pharmacists to limit access to such drugs was responding that the requested medication was unavailable (n = 273, 51.7%), followed by advising on risks (n = 152, 33.2%). CONCLUSIONS:Prescription/nonprescription medicine abuse and misuse are suspected in community pharmacies in Iraq. Current methods for controlling the problem are likely to be ineffective in the absence of prescription drug enforcement. Pharmacists could have a more proactive role in managing this issue, networking with other pharmacists, and referring suspected users to support.

Background Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact. Methods The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms. Anticipated impact SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally. Conclusion People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform. Trial registration : ISRCTN12541454 https://doi.org/10.1186/ISRCTN12541454