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The Risk of Violence Associated With Novel Psychoactive Substance Misuse in Patients Presenting To Acute Mental Health Services - Ps
The Risk of Violence Associated With Novel Psychoactive Substance Misuse in Patients Presenting To Acute Mental Health Services - Ps
DOI: 10.1002/hup.2606
1
Highgate Mental Health Centre, Camden and
Islington NHS Foundation Trust, London, UK Abstract
2
College Lane Campus, University of Novel psychoactive substance (NPS) availability is increasing at a phenomenal rate and so is their
Hertfordshire, Hatfield, UK associated misuse. Currently, the harms associated with NPS misuse are unclear. This report
Correspondence presents the initial findings of a continuing study looking into the impact of NPS misuse on
Dr. Abu Shafi, Highgate Mental Health Centre, admissions to an acute mental health facility in London. Violence preadmission and violence
Camden and Islington NHS Foundation Trust,
during admission have been found to be significant in NPS misusers compared to non‐NPS
Dartmouth Park Hill, London N19 5EX, UK.
Email: abu.shafi@nhs.net substance misusers. Our findings have important consequences for acute mental health,
emergency, and public health services. NPS misusers require specific assessment and risk
management to reduce the risk of violence towards others.
KEY W ORDS
Hum Psychopharmacol Clin Exp. 2017;32:e2606. wileyonlinelibrary.com/journal/hup Copyright © 2017 John Wiley & Sons, Ltd. 1 of 4
2 of 4 SHAFI ET AL.
health signs and symptoms in susceptible users (Brady & Sinha, 2007), TABLE 1 Demographics of sample
and NPS misuse has been specifically associated with the presentation No NPS
of severe mental, behavioural, and physical signs and symptoms Total sample NPS use use
Variable (442) (58) (384)
(Zanda, Fadda, Chiamulera, Fratta, & Fattore, 2016).
At the end of 2015, there was growing anecdotal evidence at the Age (years) 43.7 (15.4) 36.2 (9.8) 44.9 (15.8)
Camden and Islington NHS Foundation Trust that substance misusers Gender (male) 244 43 201
were being admitted with a clinical presentation of acute psychosis, A&E presentation 256 32 224
thought disorder, disturbed perception, agitation, and aggression that Police involvement 184 29 155
were far more extreme and severe in comparison than observed Sectioned 191 30 161
previously. Patients were admitting to the use of “legal highs.” Initial Opiate use 55 18 37
observations were reported (Shafi, Gallagher, Stewart, & Metastasio, Cocaine use 99 29 70
n.d.). A research group was created in January 2016 to compare and Amphetamine use 44 22 22
analyse the effect of NPS use with non‐NPS substance misuse on Cannabis use 112 21 91
the mental health of patients being admitted with deterioration in their Alcohol use 160 32 128
mental state. The aim of this group was to study the particular Polysubstance misuse 38 15 43
characteristics of NPS misusers and to explore if there were similarities Previous violence 164 41 123
and differences between them and non‐NPS misusers. Forensic history 145 35 110
Substance misuse 44 14 30
Psychosis 228 33 195
2 | METHODS Mania 54 4 50
Depression 44 3 41
All admitted patients were initially screened for substance misuse. The Anxiety disorder 19 2 17
admission notes were then further data‐mined from the electronic
Personality disorder 57 9 48
medical record by five researchers (PG, AB, HC, TC‐J, and KM) and
Dual diagnosis 43 14 29
their results checked by another researcher (AS). A database was PICU 50 20 30
created and admission criteria for analysis selected, including process Seclusion 28 8 20
of admission, current diagnosis, use of recreational substances,
Rapid tranquilisation 70 26 44
investigations, treatment, violence preadmission, violence during
Antipsychotic 347 45 302
admission, length of stay, and readmission. We report on the database Mood Stabiliser 64 11 53
results obtained from March to September 2016.
Antidepressant 108 9 99
Benzodiazepine 167 38 129
Statistical analysis was completed using Stata IC version 12.1. Aside Admission length (days) 40.8 (32.7) 50.4 (33.5) 39.4 (32.4)
from admission length, there were no missing data. Where the patient Readmission 47 8 39
TABLE 2 Associations with NPS misuse similar. Use of any illicit substance or alcohol was also associated with
Variable Probability Effect size violence during admission. These factors were incorporated into the
logistic regression. After adjustment for these factors, the strength of
Age (years) <.001 −8.66 (−12.86 to −4.46)
association was again reduced but remained significant: OR 15.98,
Admission length (days) .016 11.05 (2.05 to 20.05)
95% CI [7.05, 36.20]. There was no statistically significant interaction
Gender (male) .003 1.61 (1.18 to 2.20)
between the factors evaluated.
A&E presentation .167 0.88 (0.50 to 1.53)
Admission length was noted to be significantly associated with
Police involvement .162 1.48 (0.85 to 2.57)
both use of the MHA during admission and violence (both during or
Sectioned .162 1.48 (0.85 to 2.58)
prior to admission). Patients under section or those who had been
Opiate use <.001 4.22 (2.20 to 8.10)
violent had considerably longer admissions. Use of any illicit
Cocaine use <.001 4.47 (2.51 to 7.96)
substances by themselves did not have any significant association;
Amphetamine use <.001 10.05 (5.08 to 19.91)
with the exception of amphetamines, illicit substances and alcohol
Cannabis use .043 1.82 (1.02 to 3.28)
demonstrated a reduction in admission length, albeit nonsignificant.
Alcohol use .002 2.46 (1.41 to 4.31)
Diagnostic category had a notable effect on admission length:
Polysubstance misuse <.001 4.26 (2.39 to 7.59)
Psychosis and mania diagnoses were associated significantly with a
Violence preadmission <.001 14.70 (7.43 to 29.08)
longer admission. Comparatively, depression, anxiety, and personality
Violence during admission <.001 20.23 (10.13 to 40.41)
disorders were associated with significant reduction in admission
Previous violence <.001 5.10 (2.78 to 9.33)
length. After adjustment for violence prior to admission, there was
Forensic history <.001 3.78 (2.13 to 6.68)
no longer a significant relationship between use of NPS and admission
PICU <.001 6.19 (3.21 to 11.95)
length, although the effect of longer admissions remained present
Seclusion .017 2.90 (1.21 to 6.94)
(effect size 6.07, 95% CI [−3.90, 16.03]). Notably, there was significant
Rapid tranquilisation <.001 6.28 (3.43 to 11.50)
interaction between violence prior to admission and reported NPS use,
Antipsychotic .855 0.94 (0.48 to 1.83)
with the presence of both significantly prolonging admission (effect
Mood stabiliser .300 1.46 (0.71 to 3.00)
size 28.45, 95% CI [6.50, 50.40]).
Antidepressant .094 0.53 (0.25 to 1.12)
Forty‐seven of the admissions examined resulted in a subsequent
Benzodiazepine <.001 3.76 (2.10 to 6.72)
admission within the follow‐up period. Factors influencing readmission
Substance misuse <.001 3.67 (1.81 to 7.45)
at 90 days were examined. Notably few factors showed a strong
Psychosis .475 1.23 (0.70 to 2.13)
association with readmission. Use of MHA during the admission
Mania .176 0.48 (0.17 to 1.39)
(p = .012, OR 0.41, 95% CI [0.21, 0.82]) and presence of a psychotic
Depression .189 0.45 (0.13 to 1.49)
diagnosis (p = .028, OR 0.49, 95% CI [0.26 to 0.92]) were both
Anxiety disorder .711 0.75 (0.17 to 3.35)
associated with reduced likelihood of readmission. Comparatively,
Personality disorder .564 1.26 (0.58 to 2.72)
presence of dual diagnosis (p = .025, OR 2.51, 95% CI [1.12, 5.64])
Dual diagnosis <.001 3.89 (1.91 to 7.93)
and personality disorder (p = .002, OR 3.08, 95% CI [1.51, 6.29]) were
Readmission .404 1.41 (0.63 to 3.20)
associated with a greater instance of readmission.
carers and relatives of NPS misusers. The prison services have European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
reported a rise in mortality associated with NPS misuse (Prisons and Health responses to new psychoactive substances 2016. http://www.
emcdda.europa.eu/system/files/publications/2812/TD0216555ENN.
Probation Ombudsman Independent Investigations, 2016). pdf (accessed 20th Sep 2016).
The findings suggest NPS users having a longer length of stay in European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) EU
hospital and a higher readmission rate compared to non‐NPS early warning system. Alert 8 February 2016. http://www.emcdda.
substance misusers. This has implications for bed utilisation and europa.eu/system/files/publications/2873/2016.4528_WEB.pdf
(accessed 20th Sep 2016).
service delivery within an already strained resource environment and
Gray, R., Bressington, D., Hughes, E., & Ivanecka, A. (2016 Mar). A system-
limited mental health beds, especially intensive care beds that are
atic review of the effects of novel psychoactive substances ‘legal highs’
reserved for those who present with the most severe deterioration on people with severe mental illness. Journal of Psychiatric and Mental
of mental health, which NPS misusers are. Resource planning will be Health Nursing, 1.
critical in the future if NPS users are found to be consistently utilising Home Office. Psychoactive substances bill. http://www.legislation.gov.uk/
ukpga/2016/2/contents/enacted/data.htm (accessed 20 Sep 2016).
beds for longer inpatient stays and being readmitted more quickly.
Martinotti, G., Lupi, M., & Acciavatti, T. (2014). Novel psychoactive
With limited acute mental health beds available, and a rise in NPS users
substances in young adults with and without psychiatric comorbidities.
presenting with acute mental deterioration, care pathways will need to Bio Med Res Int, 2014, 815424.
be identified to manage these patients appropriately and safely. Prisons and Probation Ombudsman Independent Investigations. 2016
The study also suggests that admission assessments need to be Sep 23. http://www.ppo.gov.uk/wp‐content/uploads/2016/09/PPO‐
improved due to the current lack of knowledge and understanding of amends‐NPS‐prison‐death‐figure‐news‐release.pdf. (accessed 10th
October 2016)
NPS misuse. This has led to the development of a 10‐question NPS
Shafi, A., Gallagher, P., Stewart, N., & Metastasio, A. Psychoactive Sub-
risk assessment and management tool to support health care stances Act 2016‐unknown unknowns. E‐letter to the editor. The
professionals with their assessments and risk planning. This tool is British Journal of Psychiatry.
currently being validated, but initial feedback has been very positive. Stanley, J. L., Mogford, D. V., Lawrence, R. J., & Lawrie, S. M. (2016 May 1).
Health care professionals require more education and support in the Use of novel psychoactive substances by inpatients on general adult
psychiatric wards. BMJ Open, 6(5), e009430.
management of NPS misuse as this was frequently reported to our
Toftdahl, N. G., Nordentoft, M., & Hjorthoj, C. (2015). Prevalence of sub-
research group.
stance use disorders in psychiatric patients: A nationwide Danish
The findings reported are, to the best of our knowledge, population‐ based study. Social Psychiatry and Psychiatric Epidemiology,
amongst the first to be published on this particular subject, and it 51, 125–140 https://doi.org/10.1007/s00127‐015‐1104‐4.
is our opinion that they should be shared and disseminated as early United Nations Office on Drugs and Crime (UNODC). Global Smart Update
2016. http://www.unodc.org/documents/scientific/Global‐SMART‐
and widely as possible to alert professionals to the current risks
Update‐2016‐vol‐16.pdf (accessed 16 Sep 2016).
posed by NPS misuse and to encourage similar studies and collabo-
UNODC Early Warning Advisory (EWA) on New Psychoactive Substances
ration in the future. (NPS) https://www.unodc.org/LSS/Page/NPS (accessed 16 Sep 2016).
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