Last month, the CNWL Club Drug Clinic launched an app about non-medical use of prescription drugs. The app, ATOMIC, is designed to help clinicians know more about this emerging issue. The SSA caught up with Professor Owen Bowden-Jones to find out more.

SSA: The ATOMIC app is focused on the non-medical use of prescription drugs. Why is this important and why now?

Prof. Bowden-Jones: “That’s a good question. About two years ago, people attending the club drug clinic began telling us that they were increasingly adding prescription medications to the illegal drugs that they used. The most common pattern was the use of a benzodiazepine, such as diazepam, to reduce the unwanted effects of stimulant use, but others told us about using codeine or tramadol for their psychoactive effects, or ADHD medications to assist with concentration.

We asked people coming to the club drug clinic where they were sourcing the medications from and how commonly they thought prescription medications were being used. The response was ‘pretty much everyone uses them, they’re so easy to get hold of, we either buy them online or the dealer sells them alongside everything else’.

Obviously, we are only describing the experience of our clinic and others may be seeing different patterns, but I have been surprised by how normalised prescription drug use has become in our clients and the perception among people who use them of them being safe. I would encourage all front-line clinicians working with people who use drugs to consider assessing non-medical prescription drug use as part of a standard practice.”

How had those patients started using prescription drugs?

“Interestingly, there appeared to be two patterns of use. The first pattern is the addition of prescription medications to an existing drug using repertoire. For example, someone may be using ketamine, cocaine and alcohol and then add in a prescription medication. This is usually to enhance to overall psychoactive effect, or to reduce unwanted effects.

The second pattern involves people who have been legitimately prescribed medication for a medical problem such as an anxiety disorder, chronic pain, insomnia or ADHD. The prescriber has then, often against the wishes of the patient, stopped the medication. The medication is usually stopped in line with the recommendations of local or national clinical guidelines. The patient is often frustrated and angry with the decision to stop the medication and seeks a supply elsewhere, either buying online/from a street dealer or by using medication diverted from others.

We particularly see this second pattern with benzodiazepines in people experiencing anxiety disorders or depression. They come to the Club Drug Clinic asking for help because, although they feel they are legitimately self-medicating, they are also aware that without supervision, their use of the medication has spiralled out of control.

As we have seen greater numbers of people using prescription medications, we decided to find out how much information was available for clinicians about non-medical use of prescription medications. To our surprise there was not that much and so Dima Abdulrahim and I successfully applied for funding from the Health Foundation to develop an evidence-based learning resource. That has now turned into the ‘Addiction to Medication: Improving Care’ or ATOMIC app.”

“It’s an evidence-based mobile learning application, it is completely free, and you can download it onto your mobile phone, iPad or your computer. It works on all platforms, so you don’t need to have a particular type of phone.”

Very Blondie, I like it! So, what kind of challenges do people using prescription drugs present for clinicians?

“There are a couple of things that are interesting about people’s use of prescription medicines. Most striking is the perception of safety. In general, people using prescription medications perceive them as less harmful than drugs such as cocaine and ketamine. We often hear people say “if my doctor can prescribe them, then they must be safe”.

Exploring this further, people assume that the products they are using are produced by pharmaceutical companies and so are quality assured. In particular, they often state that there are “no impurities, because they are medicines”. This is interesting, because many of the products available online and from street dealers are counterfeit medications, produced in the same uncontrolled manner as other illegal drugs. People using these drugs often report marked variability in psychoactive effect between doses, as well as poor quality tablets which “crumble” or obviously incorrect packaging.  Despite clearly not being a legitimate product, people still seem to hold on to the idea that it is somehow safer. Counterfeit medications can pose a serious health risk. Recent analysis from WEDINOS has shown high levels of substitution of more potent, novel psychoactive benzodiazepines or other illegal drugs into counterfeit prescription medications. Essentially, many people will not know what they are taking or in what strength, so the perception of safety needs to be challenged.”

Are there similar assumptions among clinicians about prescription drug use compared with illicit drug use?

“I think the first problem there is that many clinicians, particularly outside of substance misuse services, don’t ask about non-medical use of prescription medications. Asked about drug use, a person may report their use of cannabis or ketamine but won’t mention the diazepam and codeine they are sourcing online because they see them as medications, often for a legitimate medical problem.

Clinicians will also be challenged by drugs that they are less familiar with. Medications like methylphenidate are often initiated by specialists and the potential harms, particularly when used without supervision, may be unfamiliar to most clinicians. Many clinicians may also be unfamiliar with some of the ways prescription medicines are misused. Sometimes tablets are crushed, snorted or injected, so they’re not always consumed in the way that they are intended.

We are also seeing some people using prescription medicines in a more unconventional way. A good example of this is something called lean. Lean is a mixture of a codeine and promethazine-based cough syrup and a fizzy drink. Sometimes over-the-counter medications containing dextromethorphan are used. Lean is typically used by younger people and it is not yet clear whether this is a fad, or if it will become established.”

So how does the ATOMIC app work?

“It’s an evidence-based mobile learning application, it is completely free, and you can download it onto your mobile phone, iPad or your computer. It works on all platforms, so you don’t need to have a particular type of phone.

Dima and I began by undertaking a review of the literature to make sure that the app is based on the latest available evidence.

The app content is divided into four modules. The first is an overview of non-medical use of prescription drugs, including the epidemiology and some of the broader challenges. The second module focuses on benzodiazepines, which is the drug we’ve seen the most of at the Club Drug Clinic. The third module covers primary depressant drugs, including opioids such as tramadol and codeine. It also looks at the gabapentinoids, over-the-counter mixtures and unusual combinations such as lean. The final module focuses on stimulant medicines such as methylphenidate and other amphetamine-based medicines and other stimulants like modafinil.

Each module has a before and after assessment and a certificate of completion for your CPD folder.”

Does ATOMIC take people through assessment and treatment principles?

“Yes, it covers both acute and longer-term harms, where the evidence is available. It also looks at acute harms and their management and management of longer-term harms with each module following the same structure. We hope it’s easy to navigate; in fact, we’ve based the structure on the NEPTUNE e-learning modules which we produced a couple of years ago and that have been completed by thousands of people with very positive feedback.

The app is based on the principles of Continued Professional Development (CPD). We used the feedback from the NEPTUNE e-learning to inform how we structure the ATOMIC app and have include lots of interactive elements to support learning.”

Do you get a certificate on completion?

“Again, we took this learning from the Neptune e-learning modules. There is an MCQ [multiple-choice questionnaire] at the end of each module and following this you receive a certificate at successful completion.”

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