Emergency department toxicology: ASSIST

Between August 2022 and February 2023, the ASSIST emergency department pilot made 1,022 detections of 52 different illicit drugs in samples from 190 patients. More than one illicit substance was detected in 87% of attendances. The most commonly detected drug category was depressants (60%), followed by opioids (18%). The most commonly detected individual drug was cocaine (10%), followed by desmethyldiazepam (a benzodiazepine and metabolite of diazepam) (9%).

Background

The ASSIST (A Surveillance Study in Illicit Substance Toxicity) pilot, conducted by the emergency department (ED) at the Queen Elizabeth University Hospital (QEUH), aims to assess the feasibility of prospective surveillance of ED attendances due to acute illicit drug toxicity.

The study collects anonymised data through the analysis of standard of care clinical data for patients attending QEUH ED due to illicit drug toxicity and surplus serum sample toxicology testing.

The use of the term ‘illicit drug’ encompasses any substance that is controlled. It excludes:

• legal substances such as alcohol, nicotine, caffeine and paracetamol
• medications recently prescribed to the individual
• drugs administered to the individual as part of treatment (by ambulance staff or in hospital)

The pilot enables full toxicological analysis through the biorepository approved surplus sampling. This allows drug profiling and the identification of emerging drugs or changing trends, to inform appropriate harm reduction measures and public health responses.

This pilot will run in the QEUH ED in Glasgow from August 2022 to August 2023, followed by a 3-month follow-up period.

Toxicology analysis of surplus serum samples

Surplus serum samples are left-over blood samples, which were taken as part of usual care. Drug detections presented here are of ‘illicit drugs’ only and were not prescribed to the individual.

The chart below shows the most common drug categories detected in toxicology analysis of surplus serum samples between 17 August 2022 and 16 February 2023.

The results are shown as the total number of detections. They are broken down by top five drug categories and then broken down further by drug name.

This bar chart shows the number of detections of drug types within QEUH ED. The drugs are grouped into five main categories of effect, with depressant, opioid, stimulant, cannabinoid and other, on the y axis and the number of detections along the x axis. The most common category was depressant, with 613 detections. This included 528 detections of benzodiazepines and 69 detections of gabapentinoids. The second most common category was opioid, with 180 detections, 46 of these were of morphine. The third most common category was stimulant, with 140 detections, 102 of these were of cocaine. There were 73 detections of cannabinoids, two of these were of synthetic cannabinoids. There were 14 detections of other drugs.

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Toxicology analysis of surplus serum samples: drug category

Summary

For the most recent time period (17 August 2022 to 16 February 2023), there were 481 individual ED attendances related to illicit drug use identified. 190 attendances qualified for surplus sampling toxicology testing (as they were categorised as ‘more unwell’ as per research inclusion criteria).

Drug type and category

Of the 190 individual attendances:

• There was a total of 1,022 detections of 52 substances (found through the biological detection of the drug or its metabolite).

Of the 1,022 detections:

• The following drugs were the most common:
  • cocaine: 102 (10%)
  • desmethyldiazepam: 91 (9%)
  • temazepam: 84 (8%)
  • etizolam: 76 (7%)
  • cannabis (tetrahydrocannabinol): 73 (7%)

Note: desmethyldiazepam and temazepam are benzodiazepines and also metabolites of other benzodiazepines such as diazepam.

• Depressants were the most common drug category, detected in 60% of all detections (613 times):
  • Benzodiazepines were detected 528 times (52% of all detections).
  • In total, 17 different types of benzodiazepines were detected, including bromazolam (53 detections), gidazepam (31) and flubromazepam (27).
  • Gabapentinoids were detected 69 times (7%), 29 of these were gabapentin and 40 were pregabalin.
• Opioids were the second most common drug category, detected in 18% of all detections (180 times):
  • There were 46 detections of morphine (an opioid and metabolite of heroin and other opioids). There were 32 detections for codeine, 21 for methadone, 16 for dihydrocodeine and five for buprenorphine.
• Stimulants were the third most common drug category, detected 140 times, making up 14% of all detections. The most common stimulant was cocaine, detected 102 times (10%).
  • There were 16 detections for amphetamine, eight for MDMA, six for MDA (a stimulant and also a metabolite of MDMA) and four for methamphetamine.

Polydrug use

Of the 190 attendances, for which complete toxicology and clinical data are available, polydrug use is a prevailing feature:

• 165 samples (87%) had more than one illicit drug or metabolite detected, even after legal substances (such as alcohol) and known prescribed medicines (including prescribed benzodiazepines, gabapentinoids and opioids) were removed.
• The number of illicit drugs detected per sample ranged between one and 16, with a mean of five.
• Benzodiazepines were detected in 155 samples (82%), with more than one type of benzodiazepine detected in 117 of these samples. Detections ranged between one and eight, with a mean of three.
• Of the benzodiazepine positive samples, 51% were also positive for an opioid and 46% were also positive for cocaine.
• Of the opioid positive samples, 87% were also positive for a benzodiazepine.
• Of the cocaine positive samples, 81% were also positive for a benzodiazepine.

Further findings

Complete clinical data are available for 481 attendances, with results described below:

• 351 were male (73%) and 130 were female (27%).
• Over half were 16 to 34 years old.

• ED outcome records show that:
  • 215 patients were discharged home
  • 118 were admitted to a ward
  • 58 were taken into police custody
  • 28 were transferred to a psychiatric unit
  • 24 self-discharged
  • 20 were admitted to an intensive care unit
  • 10 were admitted to a high dependency or critical care unit
  • Eight were recorded as ‘unknown’ or ‘other’
• Clinical severity outcome (after 28 days) recorded that:
  • 455 patients were discharged
  • Eight patients died
  • Six were ongoing inpatient admissions
  • 12 outcomes were recorded as ‘unknown’ or ‘other’

Additional information

Public Health Scotland (PHS) was provided with these data by QEUH, NHS Greater Glasgow and Clyde (GGC).

The ASSIST trial is registered with Clinical Trials UK (ID: NCT05329142).

Ethical approval has been granted by the West of Scotland Research Ethics Service (IRAS ref: 313616, REC ref: 22/WS/0047) and surplus sampling methodology through Biorepository Ethics (ref: 22/WS/0020).

The West of Scotland Safe Haven research database hosts the electronic clinical data under IRAS ref: 321198 or REC ref: 22/WS/0163.

This study is sponsored by NHS GGC Research and Innovation and is funded by the Scottish Government.

The testing has been carried out by the LGC Group. LGC analyse pseudonymised samples using mass spectrometry and screen against a database of over 3,500 analytes. This testing can detect drugs and metabolites, but this analysis does not imply that specific drugs were implicated in harms.

Further information on the study can be found at Clinical Trials UK.

Glossary

Post-mortem toxicology testing for controlled substances

In October and November 2022, the most common drug types detected in post-mortem toxicology were opioids (75%) and benzodiazepines (63%). The most common drugs detected were heroin/morphine (37%) and diazepam (37%). Bromazolam (a new ‘street’ benzodiazepine) was detected in 14% of deaths.

Background

All sudden or unexpected deaths in Scotland are subject to investigation by the Crown Office and Procurator Fiscal Service (COPFS) to determine the cause of death and the need for criminal proceedings. In order to inform these decisions, COPFS commission post-mortem toxicology and pathology services across Scotland.

This analysis is based on data from toxicology testing conducted at post-mortem for sudden and unexplained deaths or where there was suspicion of involvement of controlled drugs.

The majority of testing was performed by the Forensic Toxicology Service based within Forensic Medicine and Science (FMS) at the University of Glasgow, on behalf of COPFS. In late 2022, post-mortem toxicology services were transferred from the University of Glasgow to Scottish Police Authority (SPA) Forensic Services.

During this period, post-mortem tests were completed by other laboratory testing sites in the United Kingdom. Data from those sites have been included in this report and cover the most recent period reported. Future testing will be completed within a laboratory based within SPA Forensic Services.

The range of substances routinely analysed is extensive and includes the detection of alcohol, prescribed medicines and controlled drugs. The data within this report will develop further as other new or emerging drugs are added to toxicology screening in the coming months.

The first chart below provides an indication of controlled drugs found present at post-mortem in deaths occurring between 1 January 2020 and 30 November 2022.

The chart shows the percentage of forensic toxicology cases testing positive for controlled substances (opioids, benzodiazepines, gabapentin and pregabalin, cocaine). The percentage of toxicology cases is on the y axis and the calendar year and quarter of death, between Q1 2020 (1 January to 31 March) and 30 November 2022, on the x axis. The percentage of deaths that tested positive for opioids increased from Q1 to Q2 of 2020, but otherwise remained relatively stable over the time series. A sharp increase in the percentage of deaths where benzodiazepines were present occurred between Q1 and Q2 of 2020. This percentage remained high throughout 2020, before gradually falling from Q1 of 2021 onwards. The percentage of deaths where gabapentin and pregabalin was present remained relatively stable across the time series, though an isolated increase was observed in Q2 of 2021. The percentage of deaths where cocaine was present increased markedly during Q2 of 2020 but was otherwise relatively stable over the time series.

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Forensic toxicology cases testing positive for controlled substances

The second chart provides an indication of specific opioids and benzodiazepines found present at post-mortem in deaths occurring between 1 January 2020 and 30 November 2022.

The chart shows the percentage of forensic toxicology cases testing positive for specific individual opioids (heroin/morphine, methadone, buprenorphine) and benzodiazepines (diazepam, etizolam, clonazolam and bromazolam). The percentage of toxicology cases is on the y axis and the calendar year and quarter of death, between Q1 of 2020 (1 January to 31 March) and 30 November 2022, on the x axis. The percentage of deaths that tested positive for etizolam and methadone increased sharply in Q2 of 2020 and remained high until Q3 of 2021 when a sharp decrease occurred. Similar patterns were observed for both drugs. Etizolam presence was higher than for methadone throughout the time series, until Q2 of 2022, when the presence of these substances in toxicology cases both decreased. Although there has been a slight increase in October and November 2022 for both substances, the percentage of cases testing positive for etizolam remains below methadone. The percentage of deaths where methadone was present was consistently lower than for heroin/morphine. Although both decreased gradually throughout 2021 and 2022, heroin/morphine remained relatively stable and became the most common substance present since Q3 of 2021. However, a marked increase in the percentage of cases testing positive for diazepam in October and November 2022, has meant that diazepam has jointly become the most commonly found substances, alongside heroin/morphine. Although very few deaths with clonazolam present were observed across most quarters in the time series, increases occurred in Q2 of 2020 and, more notably, in early 2021, remaining uncharacteristically high at the end of 2021. However, the percentage of deaths where clonazolam was detected decreased in early 2022 to lower levels. Percentage of deaths with buprenorphine present remained relatively low and stable throughout the time series. Data included for the first time in October and November 2022 indicate that 14% of deaths tested positive for bromazolam in this time period.

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Forensic toxicology cases testing positive for specific opioids and benzodiazepines

Summary

Historic trend

• In total, 2,179 deaths occurred in 2021 where controlled drugs were found present via FMS toxicology testing, which was 2% higher than in 2020 (2,147).
• The most commonly found drug types were opioids and benzodiazepines. The percentage of deaths with these drugs present remained high throughout 2020 to Q2 of 2021, before a decreasing trend between Q3 of 2021 and Q3 of 2022.
• The specific drugs most commonly present throughout the time series (from Q1 of 2020 to Q2 of 2022) were etizolam, methadone and heroin/morphine. The percentage of etizolam and methadone detections both increased sharply in Q2 of 2020, before both reducing in Q3 2021, etizolam most notably.
• Deaths positive for clonazolam peaked at 12% of deaths in Q3 of 2021, before decreasing to zero in Q3 of 2022. The increase in deaths where clonazolam was found present indicates that, rather than a reduction in street benzodiazepine deaths, a shift towards alternative substances may have occurred.
• Since Q2 of 2020 there has been a gradual reduction in the percentage of deaths where methadone was found present. The percentage of deaths involving diazepam, other opioids, gabapentin and pregabalin or cocaine has remained relatively stable over time.

Update

For the most recent time period (1 October 2022 to 30 November 2022):

• The total number of deaths testing positive for controlled substances was 326. Many of these deaths involved multiple positive detections, therefore the total number of detections listed below is greater than the total number of deaths.
• The following drugs or drug types were most commonly detected:
• opioids: 246 (75%)
• benzodiazepines: 207 (63%)
• gabapentin and pregabalin: 124 (38%)
• cocaine: 99 (30%)
• Heroin/morphine remained the most commonly detected substance, with 37% of cases testing positive (from 35% in Q3). Methadone was detected in 29% of cases (from 25% in Q3).
• Diazepam detections increased markedly to 37% of cases (from 25% in Q3), making it was the most commonly detected substance alongside heroin/morphine. Etizolam was detected in 20% of cases (from 17% in Q3).
• Due to expanded toxicology testing, there were new detections of the following substances (detected for the first time when testing was outsourced to other laboratories):
• Bromazolam (a novel ‘street’ benzodiazepine) was detected in 14% of deaths (45).
• Protonitazene (a nitazene-type opioid) was detected in 1% of deaths (<3).

Additional information

PHS was provided with these data by FMS, University of Glasgow and SPA Forensic Services.

The data above are for deaths occurring in the west, east and parts of the north of Scotland. It does not include a small number of cases in the far north and north-east of Scotland where post-mortem toxicology testing is conducted by the Aberdeen Royal Infirmary (ARI). Nitazene-type opioids have been added to toxicology testing at the ARI and retrospective sampling has resulted in the identification of nitazene-type opioids in deaths. Further details will be added to RADAR reports and alerts once available.

Detailed interpretation of the levels of drugs found present, drug interactions, co-morbidities or other factors relating to death are outside the scope of this analysis. This analysis does not imply that specific drugs were implicated in deaths nor that deaths were classified as ‘drug-related’ and does not include consideration of wider causes of death.

New drugs (bromazolam and protonitazene) were detected for the first time when testing was outsourced to other laboratories. These drugs may have been present before this time but were not being tested for, as they have only recently emerged in the drugs markets. These data will develop further as bromazolam, nitazenes and other new or emerging drugs are added to routine toxicology screening by the SPA Forensic Services.

It should be noted that increases observed in specific substances within this report may be due to differences in toxicology test approaches (e.g. detection of concentration levels of a particular drug) between outsourced laboratories and previous FMS screening. This may result in increases in substance detection. Further data will be required and monitored to determine the impact of any differences in toxicology screening across laboratories.

As part of the interim period, prior to post-mortem tests being completed at SPA Forensic Services, other laboratories testing data from around the UK have been included in this report (September 2022 to November 2022). As these data did not include date of death, other date variables have been used as a proxy to improve data completeness and enable the inclusion of these deaths within this report. Two separate date variables have been used to approximate date of death information, where this information was unavailable:

1. Date of the case being received or sent to other labs for toxicology testing.
2. Date of toxicology test being completed.

The dates listed above have been used in the analysis as they are considered to provide a close approximation to the month and year of death. It is anticipated that missing information on date of death will be improved over time, as further information becomes available.

Glossary

Drug seizures in Scottish prisons

Synthetic cannabinoids were the most prevalent drug type detected in the Scottish Prisons Non-Judicial Drug Monitoring Project between June to December 2022 (detected in 35% of samples). Benzodiazepines were the second most prevalent, detected in 27% of samples, with bromazolam being the most prevalent benzodiazepine detected.

Background 

The Leverhulme Research Centre for Forensic Science (LRCFS) is currently undertaking research with the Scottish Prison Service (SPS). The Scottish Prisons Non-Judicial Drug Monitoring Project tests drug seizures made across the Scottish prison estate in order to understand the changing characteristics of synthetic drugs, including synthetic cannabinoids, often referred to as ‘spice’. 

The first chart shows the number and type of samples seized in Scottish prisons between 1 September 2020 and 31 December 2022. 

The chart shows the percentage of SPS drug seizures broken down by sample type (e-cigarette, paper or card, tablet, powder and other). The percentage of samples is on the y axis and the date, between September 2020 and December 2022, on the x axis. Sample types are highly variable over the time period. Paper or card detections decreased across the time series with an average of 73% per month being detected in 2021 compared to 23% per month in 2022. There were low detections of e-cigarettes throughout the study. Over half of seizures were e-cigarettes in June 2022. Between July to November, an average of 32% of samples per month were e-cigarettes before a decrease to 5% in December 2022. Powder samples remained relatively stable with approximately 19% per month being detected in 2022, peaking at 60% in December.

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Drug seizures in Scottish prisons: sample type

The second chart shows the three most detected drug types from seizures in Scottish prisons between 1 September 2020 and 31 December 2022. This is based on the percentage of all samples tested and is presented with a month moving average.

The chart shows the percentage of SPS drug seizures broken down by drug type (synthetic cannabinoids, benzodiazepines and opioids) and presented alongside the three-month moving average. The percentage of samples is on the y axis and the date, between September 2020 and December 2022, on the x axis. Synthetic cannabinoids are the most prevalent drug throughout the time series. The percentage of seizures testing positive for synthetic cannabinoids was, on average, 43% per month in 2021, decreasing to 27% between January and May 2022. The second most common drug type detected is benzodiazepines. The percentage of seizures testing positive for benzodiazepines fluctuated throughout 2021 with an average of 39% per month, before decreasing and remaining stable from January to May 2022 (average of 28%). Opioid detections have remained relatively stable remaining between 0% and 11% across the time series.

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Drug seizures in Scottish prisons: drug type

Summary 

Historic trend  

• The number of seizures analysed fluctuated in 2021, ranging from a low of 23 in June and peaking at 134 in September. Between January and May 2022, the average number of seizures analysed remained relatively stable with an average of 40 per month. 
• Sample type data were highly variable over time, but changes were observed in sample type detections during 2022:
  • Paper/card detections decreased, making up an average of 30% of samples per month in 2022, compared to an average of 73% per month in 2021. This is assessed to be due to changes to prison rules that now allows SPS to photocopy general correspondence, with recipients being given photocopies rather than original items. 
• Synthetic cannabinoids were the most common substances detected, followed by benzodiazepines. Drug type seizure data were highly variable over time, so the following narrative is based on the 3-week moving average: 
  • The percentage of seizures testing positive for synthetic cannabinoids was on average 42% per month in 2021. Between January and May 2022, the percentage was variable, averaging at 30% per month. 
  • The percentage of seizures testing positive for benzodiazepines fluctuated throughout 2021 with a monthly average of 38%, before decreasing and remaining stable from January to May 2022 (monthly average of 29%). 

Update 

This update provides analysis of samples seized from June to December 2022 (205 samples). For the most recent time period (1 June 2022 to 31 December 2022): 

Sample type 

• An increasing trend in the percentage of e-cigarette and powder sample types was observed: 
  • Over half of seizures were e-cigarettes in June 2022. In July to November, e-cigarettes made up an average of 32% of samples per month before decreasing to 5% in December. 
  • Synthetic cannabinoids were detected in 41% of the e-cigarettes analysed.  
  • Powder samples have remained relatively stable with a monthly average of 19% between January and November 2022, before increasing to 60% in December. 

Drug type 

• The three most detected controlled drugs were ADB-BUTINACA (synthetic cannabinoid), bromazolam (benzodiazepine) and etizolam (benzodiazepine).
• During recent months, bromazolam overtook etizolam as the most detected benzodiazepine in prison seizures. In the most recent time period 39% of benzodiazepine samples contained bromazolam, versus 35% containing etizolam. 

Drug type seizure data were again highly variable from June to December 2022, so the following narrative is based on the 3-week moving average: 

• Synthetic cannabinoids were the most common drug type, detected in an average of 38% of seizures per month: 
  • The detection of synthetic cannabinoids has been fluctuating in recent months, increasing to 50% of seizures in July 2022 before falling to an average of 28% in October and November 2022. 
  • Detections of synthetic cannabinoids were on average 41% per month during the same time period in 2021. 
• Benzodiazepines were the second most common drug type, detected in an average of 25% of seizures per month: 
  • Figures followed an increasing trend between July and November (approximately 27% per month) and peaked at 40% in December 2022. 
  • Detections of benzodiazepines were on average 37% per month during the same time period in 2021. 

Further information 

Between September and December 2022, this drug analysis project detected the following drugs for the first time in prisons in Scotland, demonstrating a constantly evolving drugs market: 

• ADB-5’Br-BUTINACA (synthetic cannabinoid)  
• bromonordiazepam (desalkylgidazepam, benzodiazepine) 
• nitrazepam (benzodiazepine) 

Metonitazene (a nitazene-type opioid) was detected twice in August 2022. For further information on nitazenes, please see our latest alert.  

From preliminary findings for seizures obtained in January 2023, dipentylone (cathinone, stimulant) was detected for the first time in Scottish prisons. 

Additional information 

PHS was provided with these data by SPS and LRCFS. 

The Scottish Prisons Non-Judicial Drug Monitoring Project is a collaboration between the SPS and the LRCFS at the University of Dundee. 

An initial pilot project ran between September 2018 and January 2021. The project has been directly funded by SPS since February 2021. 

Why we use a 3-month moving average 

As these data are highly variable over time, the 3-month moving average has been included in the graph to account for this variability and provide an average line. 

Glossary