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Annex 1: Context of New Psychoactive Substances (NPS) Summary

1. PURPOSE
Summarise the current thinking and latest research into NPS in the UK, to provide
background context for Medway NPS Need Audit. This will include:
Current policy position in UK on NPS
International policy in EU / USA & Australia
Key points from recent research conducted in UK with people who use NPS
about their
(i) Motivations
(ii) Patterns of use
(iii) Need for support
2. KEY POINTS
NPS DEATHS RISING AS DRUG DEATHS FALL
NPS accounts for 2% of drug related deaths in UK (2012) however NPS deaths
rose by 79% from 2011 whilst drug related deaths fell by around 7% over same
period1. Deaths involving new psychoactive substances (legal highs) such as
mephedrone increased by 79% from 29 in 2011 to 52 in 2012. The total number
of drug-related deaths in 2012 was 2,597.

The number of NPS products is rapidly expanding


The number of new psychoactive substances reported by Member States to the
United Nations Office on Drugs and Crime rose by 51% from 166 at the end of
2009 to 251 by mid-2012. This exceeds the total number of psychoactive
substances (234) currently controlled by the international drug conventions.
For every new psychoactive substance that is banned, there is another one ready
to be launched to take its place
From the documentary Legally High: True Stories, Dr Zee

1 ONS table 3 Number of deaths related to drug misuse by sex and underlying cause,
England and Wales, deaths registered between 19932012

Use is more prevalent outside of major towns & cities


Consumption of new psychoactive substances appears to be more prevalent
outside major towns and cities, in areas where it is more difficult to acquire
conventional drugs.
Current NPS epidemic is likely to increase
The Home Affairs Select Committee (Dec 2013) concluded that there is currently
an epidemic of psychoactive substances and it is highly likely that the creation of
new psychoactive substances will continue to increase in the future unless
immediate action is taken.
Education & Information are crucial to prevent deaths
They recommend that Education of young people is crucial in order to prevent
further deaths from psychoactive substances. schools and colleges extend the
current educational sessions they run on drugs policy with effective evidencebased sessions.
The way to protect young people was to emphasise the dangers of new
psychoactive substances, rather than banning them, a view shared by the British
Medical Association.
The Angelus Foundation
NHS England should issue guidance to local Clinical Commissioning Groups.
Home Affairs Select Committee
The Police are not yet responding to this emerging issue
Chief Constables and other law enforcement agencies are failing to understand
the impact of psychoactive substances
Home Affairs Select Committee
The Home Affairs Select Committee (Dec 2013) were deeply concerned
that there is not enough data collated by each local police area regarding the
usage and effect of these types of substances. We recommend that police forces
start a process of data collection immediately in order to have established, within
6 months, the challenges they face locally. This will enable them to develop an
effective strategy in tackling the problems presented by psychoactive substances,
both in pursuing those who are selling substances which may contain illegal drugs
and also producing an appropriate education strategy for potential users.
Introduce a New Legislative Model separate to illicit drugs
The Select Committee recommended Home Office should introduce a new
legislative model, taking into account the benefits of other systems in use abroad.
The new model should shift the evidential responsibility, of proving the safety and

the non-narcotic purpose of a substance, onto the seller for all new psychoactive
substances. It should also be specifically related to the new psychoactive
substances problem and not impinge on current legislation which controls illicit
drugs.
We take very seriously the global threat posed by new psychoactive substances
Government Response to Select Committee (May 2014)

3. New Psychoactive Substances Policy Research


Cannabinoids Misuse of Drugs Act 1971
https://www.gov.uk/government/news/new-drug-description-to-help-ban-familyof-legal-highs
2009 Cannabinoid controls included named compounds and materials related to
the drugs in circulation
2013 This list was expanded to include a broader range of emerging materials
Nov 2014 Advisory Council of Misuse of Drugs (ACMD) recommended a revised
general description to control a third generation of synthetic cannabinoids.
Summary: Efforts have been made to illegalise synthetic cannabinoids, but their
fast evolution and the development of new materials and combinations means
that regular updating of their definition is required.
Tryptamines
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3
18693/UpdateGenericDefinitionTryptamines.pdf
June 2014 Recommendation to class tryptamines as Class A drugs under the
Misuse of Drugs Act
New Zealand: Has a general control for simple tryptamines where certain
substances are banned but others are not
USA: Several simple tryptamines are named as Schedule 1 hallucinogens and then
related materials are controlled by virtue of USs analogue controls
Overall: The main consensus seems to be that the UK wishes to ban NPS but
there are problems with keeping definitions up to date as new materials and
combinations are continuously being developed to try and evade the law.
2011 Recommendations report
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/1
19139/acmdnps2011.pdf
Provides a general overview and recommendations for government from ACMD,
such as encouraging source countries to halt manufacture and placing the burden
of proof on the supplier to prove that it is safe for its intended purpose. A good
summary of the key points is provided in the executive summary.

New Psychoactive Substances in England: a review of the evidence


https://www.gov.uk/government/publications/new-psychoactive-substances-inengland-a-review-of-the-evidence
Does not provide much information on policy, but gives a good overview of
evidence and research into NPS prevalence, motivation for use and health and
social effects.
Government response to expert panel report on NPS
https://www.gov.uk/government/publications/response-to-expert-panel-reporton-the-new-psychoactive-substances-review
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3
07865/New_psychoactive_substances_and_prescription_drugsPRINT.pdf
Good reading, lays down good background on where the government stand on
this issue and the challenges they face in tackling the issue, as well as their
attempts to do so.
2014 News story
https://www.gov.uk/government/news/so-called-legal-highs-linked-to-deaths-tobe-banned-in-uk
Following the publication of an expert review of new psychoactive substances in
October, the government is developing proposals for a blanket ban across the
whole of the UK.
2014 Written statement to parliament from the Home Office
https://www.gov.uk/government/speeches/drugs-policy
Proposed range of actions:
- blanket ban instead of substance by substance basis
- base legal controls on future cannabinoids on their effects on the brain
instead of their chemical structure
- strengthen training of front-line NHS staff to deal with the effects of NPS
use
- Publish new guidance by Public Health England for local authorities
May 2014 Status report on NPSs and Club drugs
http://www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Policy/Busi
nessAsUsual.pdf
Lots of information on definitions, effects, current legislation and some
information on what other countries are doing:
- UK: Generic Ban a compound along with chemically similar compounds
- USA: Analogue Ban a compound along with other compounds that have
a similar effect irrespective of its pharmacy
- Ireland & Poland: Blanket ban All head shops closed, all substances
banned

New Zealand: Regulated market The onus is placed on the manufacturer


to demonstrate that a product poses minimal risk before it is allowed to be
sold.

Evidence review from the Scottish Government


http://www.scotland.gov.uk/Resource/0045/00457682.pdf
Provides general information and evidence gaps, as well as responses from
around the world:
- Japan: Legislation to prohibit advertising, supply and production, but
provision for personal use does not constitute an offence
- New Zealand: Legislation to control the manufacture and sale of new
restricted substances of which there is not yet enough evidence of potential
harm to prohibit them completely. Onus placed on manufacturers to prove
their products pose a low risk of harm prior to receiving approval for legal
production and sale
- Republic of Korea: Legislation to control several NPS, which has been
strengthened by the addition of a new temporary scheduling system that
allows the Korean Food and Drug Administration to temporarily schedule
NPS for a year
- USA: Legislation controls the manufacture, importation, possession, use
and distribution of certain substances. Temporary scheduling of NPS
possible. Federal Analogue Act set up to control substances not specifically
listed in the Controlled Substances Act, but the term analogue drug has
come under criticism
EU Policy
http://ec.europa.eu/justice/anti-drugs/files/nps_report_2014_en.pdf
Lots of information on various EU-funded programmes, many of which aim to
increase knowledge of NPS, improve training of relevant staff members, and other
local measures to reduce their use
International Drugs Comparison
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3
68489/DrugsInternationalComparators.pdf
Provides information about what various countries are doing about different
drugs. There is a section on NPS:
- UK: Forensic Early Warning System, FRANK, Advisory Council on the
Misuse of Drugs all gather intelligence that can then be used to inform
legislation and clinical management/treatment
- USA, Republic of Ireland, New Zealand same information as above
Australian policy May 2014
http://www.druginfo.adf.org.au/drug-facts/legal-highs
Blanket ban on possession and sale of any substances that have a psychoactive
effect, other than alcohol/tobacco/food in several regions. Other regions/states in

Australia have banned specific substances with new ones being added to the list
and the specific substances vary from region to region.
Information on policy in Australia and New Zealand
http://www.adf.org.au/policy-advocacy
Same as above, more detail

4. Understanding NPS Use in UK


The drug Benzylpiperazine (BZP) worked as a tipping point from use of other
drugs to new psychoactive drugs (NPS). In the late 90s, a heroin drought swept
over Australia and New Zealand, and opium in Thailand was removed and
Methamphetamine labs took their place. Crystal meth created major problems in
regions and BZP was promoted as a safe alternative. From then, orders across the
world were made online.
The drug landscape has had a paradigm shift, and a lot of it is due to the internet.
The internet has discussion forums for information exchange, patent searches,
wholesale purchase of chemicals and products and retail sales for drugs online,
the latter is a part of the so called Dark Web.
NPS identification in 2010-2013:
EU reporting
UK reporting
to EMCDDA
to EMCDDA
2010
41
16
2011
49
13
2012
74
13
2013
81
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EMCDDA = European Monitoring Centre for Drugs and Drug Addiction
Mephedrone is a NPS and came about the drought of MDMA in 2008.
Mephedrone replaced MDMA and became popular in the UK as it was both legal
and strong. It was banned in 2010 after UK media fire-storm of deaths and
governments not doing enough.
Other NPSs are:
Synthetic cannabinoids: Clockwork Orange, Black Mamba and Exodus
Damnation.
- Stimulant-type drugs: e.g. BZP, mephedrone, MPDV, NRG-1, benzo Fury,
MDAI and ethylphenidate.
- Hallucinogenic: e.g. 25i-NBOMe, Bromo-Dragonfly.
- Opiate: AH-791
The UK bans compounds along with any chemically similar compounds (Generic
ban). Other control responses are the Misuse of Drugs Act, Trading standards,
consumer laws, general product safety and Intoxicating Substance Supply Act.
Moreover, the NPS review panel recommend a blanket ban on synthetic
cannabinoids (?), commission research into prevention and treatment approached,
improve data collection and sharing of information and development of the
workforce.
-

The health harms of NPS are:


Overdose and temporary psychotic states and unpredictable behaviours.


Hallucination and vomiting, confusion leading to aggression and violence
Intense comedown that can cause users to feel suicidal
Increase in mental health issues including psychosis, paranoia, anxiety,
psychiatric complications
Concerns over mephedrone injecting more frequent, more sharing

Some UK data:
-

600,000 aged 16-59 have a lifetime experience of mephedrone of which


about 300,000 are aged 16-24 (BCSEW 2013)
12,000 15 year olds have tried mephedrone in the last year (Smoking,
drinking, drug use 11-15 - 2013)
Only 30% of 13 year olds had heard of legal highs. Of those who listed
what they thought were legal highs, only 18% got it right the rest were
naming illegal drugs. (DfE longitudinal lifestyle study)

NPS deaths (in UK):


Mention of
cathinones including
mephedrone
12
11
30
34

2010
2011
2012
2013

GBL
63
GBL = gamma-Butyrolactone

Only cathinones
including
mephedrone
4
3
11
6
34

Profile of users:
-

Clubbers are not interested in NPS


More in areas of poverty and deprivation
There is a range of outlets
Young, vulnerable, youth offenders
Homeless and other vulnerable adults, including adult offenders
Limited knowledge of NPs amongst everyone: users, sellers, workers,
academics, parents, teachers etc.
According to Shapiro, relatively few people buy NPS online. People do not
want to wait, but want drugs immediately.

4. New Psychoactive Substances and the individuals who use them:


(i) Motivations
- Factors influencing use of Mephedrone (NPS): purity, lack of long- or shortterm harms and having good ratings from peers or internet (Freeman,
Morgan, Vaughn-Jones, Hussain, Karimi & Curran, 2012).
- Men who have sex with men use NPS to sustain and enhance sexual
experiences.
- Initiation to mephedrone (NPS) is based on several consumption decisions
e.g. exposure, widespread user availability, curiosity, peer use and
competitive pricing (van Hout & Brennan, 2011).
(ii) Patterns of use
- 2010 student survey on use of NPS: 31.4% (of 446 participants) reported
use (Corazza, Simonata, Corkery, Trincas & Schifano, 2014).
- National survey in Scotland (2012-2013): mephedrone (NPS) used by 1.6%
of all 16-24 year olds in the last year (Fraser, 2014).
- NPS users are typically: clubbers, men who have sex with men, students,
members of the LGBT community. Users are predominantly people who are
employed and have established networks.
- NPSs are recreationally used in night clubs, at house parties and music
festivals.
- Studies have found that mephedrone (and other NPSs) are added to the
existing drug repertoire as a supplement to cocaine and ecstasy (Moore,
Dargan, Wood & Measham, 2013; van Hout & Brennan, 2011), rather than
replacing other drugs.
- A widespread level of ignorance among users as to exactly what they are
using.
- Drugscope on local pattern of use (May 2014):
o Folkestone: Trend towards pills and powders.
o Canterbury: limited use of NPS, but increase of synthetic
cannabinoids
o Maidstone: increase of use over last 12 months (like Canterbury),
focus on stimulant powder and pills.
(iii) Need for support
- NPS users reluctant to attend drug services which they believe to be
primarily for heroin and cocaine users (Bowden-Jones, 2013).
- Need of raising awareness of the harm of NPSs. Educating the general
population, but most importantly children and young adults.
- NPS users present to various health care systems (hospitals, sexual health
clinics, mental health services) which complicates the analysis of information
across complex systems (Bowden-Jones, 2013). Hence, need of local
clinical network and sharing of information.
- Drug staff needs competence, knowledge and credibility, then users will
engage (Bowden-Jones, 2013), including cultural competence.

-
-
-
-

Building resilience: target risk factors e.g. truancy, offending and negative
home environments.
Treatment shall be individualised, and include health and psychological
support, rather than just treatment of drug misuse.
Local authorities should collect data on the usage of NPSs.
Further research into treatment effects, pattern of use, motivation,
pathways of use and setting of use.

5. References
Bowden-Jones, O. (2013). Legal highs and other club drugs: why the song and
dance? The Psychiatrist, 37(6), 185-187. doi: 10.1192/pb.bp.113.042713
Corazza, O., Simonato, P., Corkery, J., Trincas, G., Schifano, F. (2014). Legal
highs: Safe and legal heavens? A study on the diffusion, knowledge and
risk awareness of novel psychoactive drugs among students in the UK.
Rivista di Psichiatria, 49(2), 89-94.
DrugScope. Business as usual? A status report on new psychoactive substances
(NPS) and club drugs in the UK. May 2014.
http://www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Polic
y/BusinessAsUsual.pdf
Faculty if Addictions Psychiatry, Royal College of Psychiatrists: One new drug a
week: Why novel psychoactive substance and club drugs need a difference
response from UK treatment providers. FR/AP/02. 2014.
http://www.rcpsych.ac.uk/pdf/FR%20AP%2002_Sept2014.pdf
Fraser, F. (2014)The Scottish government. New psychoactive substances
Evidence Review. Scottish Government Social Research.
http://www.scotland.gov.uk/Resource/0045/00457682.pdf
Freeman, T.P., Morgan, C.J.A., Vaughn-Jones, J., Hussain, N., Karimi, K., Curran,
H. (2012). Cognitive and subjective effects of mephedrone and factors
influencing use of new legal high. Addiction, 107(4), 792-800. doi:
10.1111/j.1360-0443.2011.03719.x
Government. Drugs: New psychoactive substances and prescription drugs. May
2014.
https://www.gov.uk/government/uploads/system/uploads/attachment_data
/file/307865/New_psychoactive_substances_and_prescription_drugsPRINT.
pdf
Moore, K., Dargan, P.I., Wood, D.M., & Measham, F. (2013). Do novel
psychoactive substances displace established club drugs, supplement them
or act as drugs of initiation? The relationship between mephedrone, ecstasy
and cocaine. European Addiction Reserach, 19, 276-282. doi:
10.1159/000346678
Public Health England: New psychoactive substances: A toolkit for substance
misuse commissioners. Nov 2014. http://www.nta.nhs.uk/uploads/nps-atoolkit-for-substance-misuse-commissioners.pdf

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Van Hout, M.C., & Brennan, R. (2011). Plan food for thought: a qualitative study of
mephedrone use in Ireland. Drugs: Education, Prevention and Policy, 18(5),
371-381. doi: 10.3109/09687639.2010.537713

6. Relevant Recommendations from the DrugScope NPS Expert


Group
Wider recommendations relating to intervention and treatment, prevention
and education and information sharing
Recommendation 3.1: Undertake research in key areas
3.1.1 Develop and improve what is currently known about NPS use across the
three strands of the Drug Strategy, including information about patterns
and motivations of use, harms, and data collected from enforcement
agencies. This should be considered in both health and wider nonhealth
settings, relating to the general population; specific settings and
subgroups; and (potential) problem users including those in touch with
criminal justice and health services.
3.1.2 Commission research into effective prevention and treatment
interventions for NPS.
3.1.3 Develop effective preventative campaigns informed by the findings of
recommendation 1.1 and including forensic, toxicological and social
research data.
Recommendation 3.2: Improve the collection of data and the detection of
NPS
There is a need to establish prevalence, evidence and harms associated with NPS.
This can be achieved through the following actions and in relation to the three
tiers of users in the general population; specific subgroups; and (potential)
problem users in touch with criminal justice and health services:
3.2.1 Develop detection and data collection tools across criminal justice and
health services, and other relevant settings, for example, schools and universities.
3.2.2 Develop understanding of patterns of NPS use in the general population,
and in specific subgroups in a range of nonhealth settings.
58 New Psychoactive Substances Review Report of the Expert Panel
Potential Pilot: to pilot a detection tool in areas of high prevalence and with
known subpopulations, including a sexual health service, A&E waiting room,
criminal justice system and a nighttime economy setting.
3.2.3 Develop internet tools to monitor internet activity around NPS. 3.2.4 Record

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health and social harms related to NPS by utilising professional networks and
other
early warning systems.
Potential Pilot: to develop and pilot an alert system for clinicians on NPS and
drugsoutreach workers on NPS and drugrelated adverse reactions and
harms (similar to the MHRA yellow card system for medication adverse
reactions).
3.2.5 Understand local markets, including through headshops, retail outlets,
prisons and local police assessment.
Recommendation 3: Enhance the sharing of information on NPS
Sharing information at both local and national levels is essential in helping to
achieve a reduction in the demand and supply of drugs and in promoting
comprehensive and effective interventions. The sharing of information on NPS can
be enhanced through the following actions:
3.3.1 Local areas should already have a network of practitioners in place through
which information can be shared, and should establish one if not already in place.
Potential Pilot: Promote the development of local intelligence networks using
a model such as DrugWatch.
. 3.3.2 Develop a national network of professionals to help record health harms
and share information about NPS and other drugs (link to 2.2.3).
. 3.3.3 Local and national networks should be used to disseminate effective
practice, for example, project NEPTUNE information.
. 3.3.4 FEWS and DEWS should be used to support networks more widely,
where appropriate.
. 3.3.5 Ensure FRANK continues to develop as a trusted and sober brand,
through clear cooperation, partnership and joint learning with NGOs,
schools, local public health systems, festival promoters, local media and
other agencies.
. 3.3.6 Work with internet service providers to avoid internet filters that may be
developed to target NPS sales inadvertently blocking sites that provide
advice and support aimed at reducing harms.
Recommendation 3.4: Skills and Workforce: developing competence and
support
In order to tackle NPS and drug use effectively we need a competent and
confident workforce supported with appropriate, evidencebased tools for
assessment and intervention, including:
. 3.4.1 Develop an evaluated programme to ensure that every local area is able
to provide an identification and brief advice approach in line with evidence
of effectiveness. This will ensure that all staff that come in contact with
people using NPS, for example health, law enforcement and education,
have access to some basic skills to help identify problematic use and
provide brief advice.
. 3.4.2 Staff working in the drugs field should already have the competence to

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work with the five main drugeffect types/presentations (i.e. stimulant,


hallucinogenic, dissociative, sedative or opioidlike, and cannabislike), and
should apply these skills to people using NPS.
3.4.3 Given the diversity of the populations using NPS, all staff should be
culturally competent in working with specific groups, with additional training
provided as appropriate for local populations.
Potential Pilot: Identify the training necessary to ensure that all appropriate
healthcare staff (not just drugs workers) are able to identify NPS and drugs
issues in their patients.
Recommendation 3.5: Expanding the toolkit
Practitioners and public health staff require appropriate, evidencebased
information and tools for prevention, education, assessment and intervention. The
current toolkit can be expanded through the following actions:
. 3.5.1 It is essential that NPS are addressed as part of a curriculum that helps to
build young peoples resilience, whilst noting the limited evidence base on
effective programmes. This would be best achieved by Personal, Social,
Health and Economic education becoming a statutory subject, which would
secure appropriate curriculum time, generate evidence based tools, raise
awareness and drive quality.
. 3.5.2 Schools and other educational settings should continue to be provided
with advice and support on evidencebased practice.
. 3.5.3 Schools should be supported with information on the resources that are
available to ensure that their drugs policies are in line with best practice
and reflect the NPS landscape.
. 3.5.4 Guidance and/or toolkits should continue to be developed to support
local responses and the commissioning of evidencebased prevention
across the life course.
. 3.5.5 Support should also be given to local authorities and other
commissioners i.e. Police and Crime Commissioners, to assist planning and
commissioning using multiagency assessments, evidencebased
prevention tools and resources such as the Joint Strategic Needs
Assessment support pack, to ensure NPS are considered and addressed in
local needs assessments and that pathways are always available.
. 3.5.6 Develop and share evidencebased tools with clinicians for the
assessment and management of NPS harms.
Potential Pilot: This could be achieved by piloting particular tools in areas of
high prevalence, for example the nighttime economy setting.
3.5.7 NPS users should be involved in developing targeted publicity
campaigns. Potential Pilot: Targeted, segmented social marketing campaigns,
focused on reducing harms
in highrisk groups and settings, within the context of the wider health and
social care agenda.
3.5.8 A mechanism should be developed to allow users to easily assess harms
posed by drugs including NPS.

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Potential Pilot: Develop and pilot an online selfassessment tool to allow


users to assess harms. This should be short, confidential and signpost
relevant pathways.

7. LOCAL INSIGHTS
Three areas of Kent were chosen to demonstrate the fragmentary nature of NPS
distribution and use:
Folkestone
There are two head shops; one is an old school hippy-style shop selling posters, tshirts, paraphernalia and so on. They dont sell to under 18s and are in dialogue
with KCA and are willing to share information. The second is less discerning and
does serve young people in consequence of which it is monitored by police and
trading standards. The current trend is now towards pills and powders as opposed
to synthetic cannabinoids, but there is also increased use by young people of
drugs more associated with adult use specifically, Blues (valium and
phenazepam), Gaba (gabapentin) and Trixies (trihexyphenidil).
Canterbury
Here there are two head shops: as in Folkestone, one is old school and does
demonstrate a degree of responsibility towards its customers, the other one is
Skunkworks. NPS use has been limited, although with the last year, there has been
an increase in synthetic cannabinoids, but also AMT (legal DMT) and NBOMe
(formerly legal LSD). The user reports gathered in this area concerning smoking
blends of various types are generally negative: chest pain, shortness of breath,
loss of consciousness, co-ordination problems, unpleasant visuals, intense anxiety,
fear of dying but theyre viewed as cheaper and legal. Some local drug
workers believe that media reports about synthetic cannabinoids being stronger
than cannabis could be tending to promote use.
Maidstone
The workers reported that this town has a proliferation of head shops; three
established (including Skunkworks) plus pop up shops, all in close proximity of
each other within the town centre. Like Canterbury, local workers report a steady
increase in reported use over the past 12 months. Initially this focused around
stimulant pills and powders such as Charley Sheen (a cocaine-like drug), but
recently smoking mixtures are dominating the conversations in sessions with some
groups of young people.
PROFILES
Three main user groups of NPS were identified: teenagers (13-18), students and
clubbers, and gay men (particularly gay clubbers). In addition to these there are
smaller user groups which include: older age groups (30 years plus), heroin users

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and so-called psychonauts (people who experiment with mind-altering chemicals


and keep records of their experience). The Insight Project also found that NPS
are usually sourced from: head shops (including online); friends; dealers; and in
pubs and clubs. For some gay men they are also sourced at chem-sex parties,
through niche websites and male escorts. Often these drugs are consumed with
peers at social events/ situations (for example, clubs and festivals) and tend to be
mixed with other illegal drugs.

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