Follow up on the Government’s response to the ACMD report (Accessible) | Daily News Byte

By email only to ACMD@homeoffice.gov.uk

6 December 2022

Government response to 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 to which the Government has committed to provide further feedback in response to the Council from October 2020. This covers the following topics:

1. Research to study the 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 professionals in the appropriate therapeutic use of strong opioids

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

5. (a) research to monitor the spread of fentanyl and b) analysis of non-adopted 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 the consultation on the extension of retrospective controls to cover simple forms of ANPP, the immediate predecessor of 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 provide this updated response.

Recommendation 1

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

Both 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), agreed with this recommendation, although there may be a sufficient case for undertaking research. . making

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

Another key commitment, set out in the recent cross-government drugs strategy, is the Addiction Healthcare Mission. Backed with £30m of funding, the Office for Life Sciences is delivering the mission, initially focusing on opioids and cocaine, and aims to enhance the UK-wide research environment and promote innovative approaches to reducing harm and death caused by these addictions.

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

Recommendation 2

Government departments should thoroughly review international drug strategy approaches to fentanyl markets, in particular, the North American experience, and consider prohibition controls that may apply 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 forthcoming NICE guidance on the management of chronic pain.

Since the government’s response in October 2020, the DHSC has called for opioids to be made more widely available and has met with representatives from the Faculty of Pain Medicine to discuss how to do this.

Opioids Aware is the Faculty’s most accessed resource (although user data is not currently collected by the Faculty or centrally) and a link is placed on its homepage to increase visibility. The Opioids Aware Resource is also included as part of further resources in the ‘All Our Health’ guidance on illicit drugs and drug abuse and musculoskeletal pain. This is available on both GOV.UK and eLearning for Healthcare platforms. E-Learning for Healthcare Platforms (elfh) is a Health Education England program in partnership with the NHS and professional bodies.

NICE guidance on chronic pain, developed in partnership with the Royal College of Physicians, was published in April 2021. These guidelines recommend that opioids should not be initiated to manage chronic primary pain and this will be reflected in government professional training. Response in October 2020.

Recommendation 4

a) Toxicology analysis of all death samples related to drug poisoning should include analysis for fentanyl and fentanyl analogs because non-systematic detection hinders our ability to understand trends in drug deaths.

b) Toxicology reports of all deaths related to drug poisoning should include a clear statement as to whether fentanyl and/or its analogs were included in the test. If fentanyl and/or its analogs have not been tested this should be specified as important. This would enable meaningful monitoring of trends in fentanyl-related deaths.

The UK Government agreed in principle to this recommendation in its October 2020 response. Ultimately, the recommendation is beyond the scope of government because 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 about the nature of toxicology tests required in each individual case. Consequently, it is not feasible for the government to require coroners to adopt a specific approach to toxicology.

However, the Government acknowledges that ACMD’s recent report reviewing the evidence on the use and harm of 2-benzyl benzimdazole (‘Nitazen’) and piperidine benzimidazolone (‘Brorphine-like’) opioids has recommendations that are broadly relevant to the post. – Mortem toxicology.

Recommendation 5

Research to monitor the local and national prevalence of fentanyl and fentanyl analogs should be assigned to:

(a)(i) seizure of drugs including heroin preparations and counterfeit drugs;

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

b) Additional funding should be made available for the Defense Science and Technology Laboratory Forensic Early Warning System (DSTL FEWS) program to enhance the attack analysis capability of non-adoptive police and border forces.

Recommendation 5(a)(i): OHID agrees that monitoring the local and national prevalence of fentanyl and fentanyl analogs in drug addiction is important, but that more appropriate research is needed in this area.

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

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

Recommendation 5(a)(ii): OHID is keen to monitor non-fatal episodes of heroin toxicity requiring hospital treatment, as currently done through the “Identification of Novel Psychoactive Substances” (IONA) study, and options for further research. Considering. beyond the term of the present contract. IONA’s data has been and will continue to be shared with ACMD.

IONA, or the successor project, is a research project suitable for non-fatal episodes of heroin poisoning that require hospital treatment. It is OHID’s assessment that this does not require additional new research separately.

Recommendation 5b): The government started collecting samples of cocaine and diamorphine in 2020 following ACMD’s recommendation. As of 2020, 480 samples containing cocaine and 175 samples containing diamorphine have been analyzed. Ocfentanil is the only new synthetic opioid discovered under the FEWS project since 2020 and was detected in one sample during the 2020/21 financial year. His identity 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. In addition, the Home Office will continue to work across government with relevant departments and agencies to monitor the risk of fentanyl and synthetic opioids.

Recommendation 8

Following consultation with the research community, the Home Office should extend retrospective controls to cover simpler forms of ANPP (see Annex 6), which is the immediate precursor to fentanyl. It is recommended that paragraphs (i) to (v) of the text of the existing general control on fentanyls also apply to the preceding legislation, i.e. the entry for the ANPP be amended to cover:

Any compound……derived from ANPP by structurally modified in any of the following ways, namely:

• (i) by replacing the phenyl part of the phenethyl group by any heterocycle, whether further substituted into the heterocycle or not;
• (ii) by substitution of 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 of the aniline ring with alkyl, alkyl, alkylenedioxy, halogen 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 to also regulate benzyl analogues of fentanyl as precursors (see Annex 7), the new regulation described above should be further expanded by adding a paragraph:
• (i)(a) “the replacement of a phenyl group by a benzyl group;” And by extension of para (ii):
• (ii) by substitution of 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 impact of the recommendation on research and pharmaceuticals and further consideration of these responses is required. As explained in the Government’s initial response in October 2020, there are many complexities about how to capture this in legislation that will need to be considered in the wider context of the Government’s management of retrospective drug controls. The Home Office will update ACMD when we have more information on the matter.

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

The Rt Hon Chris Philp MP

Minister of State for Crime, Policing and Fire