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Novel psychoactive substances: identifying and managing acute and chronic harmful use

BMJ 2017; 356 doi: (Published 25 January 2017) Cite this as: BMJ 2017;356:i6814
  1. Derek K Tracy1 2,
  2. David M Wood3 4,
  3. David Baumeister5
  1. 1Oxleas NHS Foundation Trust, London
  2. 2Cognition, Schizophrenia and Imaging Laboratory, Department of Psychosis Studies, the Institute of Psychiatry, Psychology and Neuroscience, King’s College London
  3. 3Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
  4. 4School of Life Sciences and Medicine, King’s College London, London, UK
  5. 5Department of Psychology, the Institute of Psychiatry, Psychology and Neuroscience, King’s College London
  1. Correspondence to: D K Tracy derek.tracy{at}

What you need to know

  • Most standard urinary drug tests have limited sensitivity and specificity to novel psychoactive substances (NPS)

  • Discuss risks and encourage reduction in the frequency and quantity of harmful NPS use, but be cautious with benzodiazepines or opioids where sudden discontinuation can lead to physical withdrawal

  • Offer referral to drug and alcohol treatment services or other professionals, such as psychiatry, sexual health, or social services when appropriate

Identifying and managing acute drug related harms and problematic substance misuse cuts across medical specialties. Data suggest that clinicians are seeking readily accessible information on novel psychoactive substances (NPS), incorrectly known as “legal highs.” Clinicians may encounter acutely disturbed or unwell patients, individuals with harm or dependency related to chronic NPS use, and those reporting incidental consumption that might require psychoeducation and monitoring. Such assessments will have more successful and meaningful outcomes if clinicians are aware of the spectrum of NPS available and how they might affect their patient.

The linked clinical update1 describes the different classes of NPS and their effects. This article provides practical advice to the non-specialist on how to approach an assessment of individuals using NPS, including examples of acute and chronic use.

Exploring NPS use

A sensitive, non-judgmental approach is essential. Key aspects of the history are applicable in all scenarios. Boxes 1 and 2 cover specific issues relevant to emergency and longer term presentations. Patients may be concerned about being criticised for using drugs, and they might be uncertain of, but worried about, the potential harms and available services for those using NPS. Individuals can also be fearful of legal consequences of disclosure, and the principle and limits of confidentiality should be discussed. Adopt an empathic line of questioning, such as “I can imagine it might be difficult or worrying to talk about drug/NPS use. My role is to try understand …

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