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The latest report from RADAR, Scotland’s drugs early warning system, highlights the emergence of new benzodiazepines and opioids, but how does this effect harms?

In this blog post, Vicki Craik from the Drugs Team at Public Health Scotland, explains how the drugs market is changing and what impact that may have on public health in Scotland.

After a decrease in drug-related deaths in 2022, harm indicators have been trending upwards in 2023, as shown in our most recent RADAR quarterly report.

Most notably, drug-related hospital admissions were up 26% and emergency department attendances increased by 13%.

This can be influenced by many factors; but one potential area is ongoing changes to the drug supply, including the types and potency of drugs in circulation.

New drugs on the RADAR

In Scotland, we continue to see the harm caused by established drugs such as heroin, diazepam and cocaine. In our latest report, cocaine was the most common drug detected in hospital and post-mortem toxicology. However, a range of new drugs are now also being detected.

Analysis of seizures in Scottish prisons detected a new cannabinoid (MDMB-INACA) and a stimulant (dipentylone). The ASSIST study in Glasgow has detected several uncommon drugs in the latest quarter, including protonitazene and metonitazene (opioids), xylazine, meprobamate, bromazepam and lormetazepam (depressants) and 4-CEC and n-ethylpentylone (stimulants).

Some of these drugs are ‘new psychoactive substances’ (NPS); drugs that have been newly developed or were developed years ago but have recently resurfaced. They can have similar effects to traditional drugs, but are often more potent and toxic, and may increase the risk of overdose.

Why are new drugs appearing?

In 2022, 41 new drugs were reported to the European Monitoring Centre for Drugs and Drug Addiction, about one every nine days.

Their development is often a by-product of a control approach towards a specific chemical structure. By changing the chemical structure, a new drug can circumvent legal controls. This can create a cycle whereby a new drug emerges, use increases, the drug is banned, another new drug emerges, use increases, that drug is banned, and so on.

Based on RADAR’s data, PHS has issued two alerts on new drugs detected in Scotland.

  • Bromazolam after popular benzodiazepines (etizolam and alprazolam) were internationally controlled in 2021.
  • Nitazenes after restrictions around fentanyls and their ingredients were tightened.

Another reason can be the ease of production. Drugs derived from a natural source (like heroin) require land for growing and processing. Laboratory produced synthetic drugs are not grown on a farm and so production is quicker and cheaper.

Synthetic drugs are also often more potent (a highly potent drug produces effects at lower quantities). They take up less space and are easier and cheaper to transport, and harder for law enforcement to detect.

What’s the threat?

These new and emerging drugs will likely continue to form a greater part of Scotland’s drugs market.

Scotland has a long history of benzodiazepine use and these substances continue to change. Bromazolam has only recently been detected, but has now replaced etizolam as the most commonly found street benzodiazepine. In the most recent post-mortem toxicology data, bromazolam was detected in 23% of deaths. It is likely that other new benzodiazepines will follow.

Currently, the use and detections of synthetic opioids have been low. In the latest post-mortem data, nitazenes were detected in 1% of deaths and fentanyls were detected in 3%, in comparison to 33% for heroin/morphine. There is a growing concern that Scotland could follow the trends seen across the globe, where more synthetics have crept into the supply - especially if the supply of heroin is disrupted. This is a real possibility as in 2022, the Taliban banned the growing of opium (a plant used to make heroin) in Afghanistan, the main source of Scotland’s heroin supply. This resulted in the cultivation of opium in Helmand falling from more than 120,000 hectares in 2022, to less than 1,000 hectares in 2023.

What harms are we likely to see?

While less heroin in Scotland might initially sound positive, without a reduction in demand, people will look for alternatives. Reduced availability of heroin could boost the popularity and availability of synthetic opioids; the devastating impact of these are evident in North America.

If synthetic opioids are increasingly used, it’s likely we will see an increase in harms and overdoses. Many of these new drugs are mis-sold and people may not always know what they are taking. Small doses of some of these drugs can cause an overdose, even in the healthiest of individuals, putting a large population at high-risk.

What can we do?

Reducing drug harms in Scotland is complex and challenging. It requires a comprehensive and multi-faceted approach.

Keeping people and health professionals informed about emerging drugs, their potential harms, and how to effectively respond using the outputs of RADAR is one approach. At a service level, the collective response must be as innovative as the drugs reaching our communities. This includes boosting surveillance through timely and accurate drug checking, hospital toxicology and forensic post-mortem toxicology. Scotland must then use this to inform and adapt our approach to provide relevant and effective interventions that can save lives.

View our latest RADAR quarterly report

View our new RADAR digital dashboard that presents drug harms trends across Scotland

Last updated: 01 November 2023