Rapid Action Drug Alerts and Response (RADAR) quarterly ​report
April 2024 (correction 4 June 2024)

About this release

Our quarterly report

The Drugs Team at Public Health Scotland (PHS) has compiled this RADAR quarterly report of drug-related indicators.

The objective of this report is to monitor drug-related harms, service usage and toxicology data, in order to provide an early warning of emerging drug trends and identify actions to reduce and prevent drug harms and deaths.

View a printable version of this report.

Update

The suspected drug death section in this publication was revised on 4 June 2024 to include updated data for January and February 2024 due to data quality and completeness issues. This means that the number of suspected drug deaths occurring in the period covered by this report was higher than previously stated. The revisions are as follows:

• January 2024: number of deaths was revised from 96 to 103
• February 2024: number of deaths was revised from 86 to 95
• December 2023 to February 2024: number of deaths was revised from 278 to 294

Updates are defined by ^R or (R).

Acknowledgements

This report reflects the collective efforts of different organisations and hundreds of people in frontline and supporting roles who record, organise, analyse and interpret information from a range of sources and services.

We gratefully acknowledge the continued commitment and effort of all those involved.

Data and reporting period

RADAR's emphasis is on reporting drug-related information as rapidly as possible, for the purpose of public health surveillance. This means that data may not be fully validated and may be subject to change. Further analysis of these data will be made available in our Accredited official statistics publications on substance use.

Observed changes in indicators may reflect genuine trends in behaviours but may also be influenced by factors such as the configuration of services, or data quality and completeness issues.

Different time periods may be reported across the different indicators. In all cases, the most recently available data are used. Most charts show Scotland-level data based upon a two-year time series. Location and time series can be customised in the RADAR dashboard (external website).

The next release of this publication will be 30 July 2024.

Dashboard

Data for most of the harm and service indicators in this report are published in our new RADAR dashboard (external website).

In the dashboard, the time series can be adjusted and the data can be filtered by NHS board.

This dashboard supersedes the substance use section of the COVID-19 wider impacts dashboard (external website), which has now been decommissioned.

For optimal viewing and interaction, we recommend accessing the dashboard using a computer with a large screen. Accessing via a mobile phone may reduce the functionality.

Main points

• Drug-related harms remained high in Scotland.
• The following changes were observed compared to the previous reporting period (reported in quarterly report 6 – January 2024):

For harm indicators:

• • suspected drug deaths: 17% increase^R
  • naloxone administration incidents: 14% decrease
  • emergency department attendances: 12% decrease
  • drug-related hospital admissions: 24% decrease

For service indicators:

• • drug treatment referrals: 10% decrease
  • injecting equipment provision: transactions - stable, number of needles and syringes - 6% decrease
• Patterns of polysubstance use remain the key driver of harms. The combinations most associated involve benzodiazepines (most commonly diazepam and bromazolam), cocaine and opioids.
• Cocaine played an increasing role in harms.

Alerts

• A public health alert about nitazene-type opioids was updated in December 2023. Based on the latest post-mortem toxicology testing, nitazenes were detected in 38 deaths (from the first detection in June 2022 to 31 December 2023).
  • PHS alert: nitazene-type opioids in Scotland
  • SDF synthetic opioid resources (external website)
• A public health alert about new benzodiazepines was published in July 2023 and remains current. Bromazolam is currently the most common 'street benzo' detected in Scotland.
  • PHS alert: new benzodiazepines - bromazolam

Harm indicators

• Between December 2023 and February 2024, the average weekly number of Scottish Ambulance Service naloxone administration incidents decreased (from 72 to 68). The total number of incidents was 14% lower than in the same period in 2021/22 and 10% higher than in 2022/23.
• Between December 2023 and February 2024, drug-related attendances at emergency departments were 12% lower than in the previous period. The number of attendances was 7% higher compared to the same period in 2021/22 and similar to 2022/23.
• Between October and December 2023, drug-related hospital admissions were 24% lower than in the previous period. The total number of admissions was 26% lower than the same period in 2021 and 7% higher than in 2022. These data should be interpreted with caution, as the number of admissions may be affected by issues accessing urgent care and by the capacity of hospital services.
• Between December 2023 and February 2024, there were 294 suspected drug deaths. The number of deaths was 10% higher than the same period commencing in December 2021 (268) and similar to the same period commencing in December 2022 (285).^R

Toxicology indicators

• Between November 2023 and February 2024, the most frequently detected drug in the ASSIST hospital toxicology project was cocaine (11%) followed by desmethyldiazepam, temazepam and bromazolam (all 10%). Nitazenes made up 1% of detections (detected eight times, down from 16 in the previous quarter).
• Between October and December 2023, the most common drug types detected in post-mortem toxicology were opioids (70%) and benzodiazepines (58%). The most common individual drug detected was cocaine (36%), followed by heroin/morphine (29%), methadone (29%), diazepam (27%) and bromazolam (22%). Nitazenes were detected in 2% of deaths (12).
• Limited Scottish Prison Service drug analysis data for August to October 2023, showed the most common drug type was synthetic cannabinoids.

Service indicators

• Between November 2023 and February 2024, the average weekly number of referrals to specialist drug treatment services was relatively stable, aside from a seasonal fluctuation seen in previous years. The total number of referrals recorded in this period (5,351) was broadly similar to the same period commencing December 2022 (5,150) and 2021 (5,458).
• Between October and December 2023, the average weekly number of injecting equipment provision transactions, and needles and syringes distributed remained relatively stable. During this time period, the number of transactions was similar to the same period in 2021 and 6% higher than in 2022. The number of needles and syringes distributed was 16% higher than the same period in 2021 and similar to 2022.
• Between October and December 2023, opioid substitution therapy (OST) doses supplied per month was stable and similar to the same period in 2021 and 2022. The average monthly number of methadone doses supplied continued to decrease while the number of injectable buprenorphine doses increased over time.

Reporting trends

• Between January and April 2024, 43 trend reports were received by RADAR.
• The majority of reports related to benzodiazepines, cocaine, heroin and polydrug use.
• Other commonly reported concerns related to synthetic opioids (nitazenes), cannabinoids (cannabis and synthetic cannabinoids), ketamine and MDMA.
• Trend reports can be viewed on our dashboard (external website).

Implications

The harm caused by drugs is a significant public health issue for Scotland. The illicit drugs market is evolving and increasingly toxic substances are being detected with greater frequency, most notably nitazenes and xylazine.

The risk of harm and death are increased in the context of polysubstance use, stigma and exclusion.

The increasing frequency of cocaine involvement in drug harms indicates the need for appropriate evidence-based prevention, harm reduction and treatment measures to reduce this risk.

The results of limited drug checking from Scotland indicate that contamination of illicit drugs with toxic substances is common. This finding emphasises the importance of timely and accurate hospital toxicology and forensic post-mortem toxicology services, as well as accessible drug checking.

Alerts

Current alerts

Nitazenes

A public health alert about nitazene-type opioids was published in January 2023. This alert was further updated in December 2023 to include provisional data on detections of nitazene-type opioids in deaths in Scotland. Based on provisional post-mortem toxicology testing, nitazenes were detected in 38 deaths (from the first detection in June 2022 to 31 December 2023).

Bromazolam

A public health alert about new benzodiazepines was published in July 2023. Bromazolam is the most common drug detected in ‘street benzos’. Bromazolam produces strong sedative and sleep-inducing effects. As a result, there is a substantial risk of overdose.

Trends

Police drug trends bulletin

This bulletin contains photos of drugs.

This update provides information on new synthetic drugs – nitazene-type opioids and xylazine.

This information has been provided by Police Scotland’s Statement of Opinion (STOP) Unit to raise awareness of drug appearance and to demonstrate some of the substances present in Scotland's drugs market.

Xylazine

Xylazine is a non-opioid veterinary tranquiliser, not approved for human use. Xylazine (often known as ‘tranq’) is used on its own, but more commonly it is found in combination with opioids. This may increase the effects experienced but also increases the risk of harms.

Limited research has been conducted on the effects of xylazine on the human body, but anecdotal reports indicate that users experience effects similar to opioids and other depressants (analgesia, decreased breathing, decreased heart rate, nausea, unconsciousness).

The supply and importation of xylazine is controlled by the Psychoactive Substances Act 2016. In February 2024, the Advisory Council on the Misuse of Drugs (ACMD) recommended xylazine be added to class C of the Misuse of Drugs Act 1971.

Police Scotland have encountered a small number of recoveries of diamorphine that contained xylazine both in the east and west of Scotland. One recovery of 925 grams was made in the west of Scotland and is depicted below. The seizure of light brown powder with grey flecks was analysed and found to contain diamorphine (heroin), bromazolam, metonitazene, protonitazene and xylazine.

Nitazenes

As of 20 March 2024, the following fifteen synthetic opioids have been added as class A drugs to the Misuse of Drugs Act 1971:

• metonitazene
• protonitazene
• isotonitazene
• butonitazene
• flunitazene
• metodesnitazene (metazene)
• etodesnitazene (etazene)
• N-pyrrolidino-etonitazene (etonitazepyne)
• N-piperidinyl-etonitazene (etonitazepipne)
• N-pyrrolidino protonitazene
• ethyleneoxynitazene
• N-desethyl protonitazene
• N-desethylisotonitazene
• N-desethyl-etonitazene
• brorphine

There are several operation and threat assessment groups that have been set up throughout Scotland and the UK to monitor the threat, including Project Housebuilder run by the National Crime Agency (NCA).

To date, Police Scotland have had 16 cases in which nitazene-type opioids have been found.

RADAR intelligence and reports

43 reports were validated by RADAR between 5 January and 4 April 2024.

43 reports were validated by RADAR between 5 January and 4 April 2024.

So far, RADAR has received over 200 reports of drug-related information and harms through the reporting form and mailbox.

A summary of key trends is shown below. Validated intelligence reports to RADAR can be found on the dashboard (external website).

Please note, many of these reports have not been confirmed by toxicology and should be considered anecdotal.

Trends by primary drug type

In the latest period (5 January to 4 April 2024):

• The most common drugs or drug types reported were:
  • benzodiazepines
  • cocaine
  • heroin
  • new synthetic opioids, including nitazenes
  • MDMA (ecstasy)
• Most concerns were related to adverse effects.

Synthetic drugs

RADAR is assessing the harms related to new synthetic drugs, including bromazolam, nitazene-type opioids and xylazine.

Reporting drug harms

Please encourage people and services in your area to share information on trends, incidents and harms related to drugs, such as:

• adverse effects including overdose and wounds
• routes of administration
• new substances or patterns of use
• testing data.

The information in the regional breakdown can be used by local areas for their own drug trend surveillance.

Anyone can make a report by using our reporting form or by emailing phs.drugsradar@phs.scot.

Harm indicators

Naloxone administration by Scottish Ambulance Service

The average weekly number of naloxone administration incidents decreased between December 2023 (72) and February 2024 (68). The total number of incidents during this time period (879) was 14% lower than in the previous period (1,020). The number of incidents was similar to the same period commencing in December 2021 (914) and 10% higher than in the same period commencing in December 2022 (801).

Background

Naloxone is a medicine used to prevent fatal opioid overdoses. These data relate to the number of incidents in which naloxone was administered by Scottish Ambulance Service (SAS) clinicians.

While these data count multiple overdose patients at the same incident separately, multiple naloxone administrations to the same patient at the same incident are not counted separately.

The chart below shows the weekly number of SAS naloxone administration incidents from 6 December 2021 to 3 March 2024.

An interactive version of this chart can be found in the RADAR dashboard (external website). The dashboard also allows users to download the data and filter by NHS board.

The chart shows the number of emergency naloxone incidents by the Scottish Ambulance Service. The number of incidents is on the y axis and the date, between 6 December 2021 and 3 March 2024, is on the x axis. An uneven slightly decreasing trend was observed from December 2021 until April 2022. Following an isolated increase in April 2022, the number of naloxone incidents followed a gradual decreasing trend from May to December 2022. An increasing trend was observed from January to May 2023. Between June and August 2023, the average weekly number of naloxone incidents remained broadly stable at around 93 per week, after which the weekly number of incidents followed a generally decreasing trend to January 2024, although an isolated increase was observed in week beginning 30 October (108).

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Naloxone administration by Scottish Ambulance Service

Summary

Historic trend

• Until winter 2021, the average weekly number of SAS naloxone administration incidents was similar to previous years, which have generally been characterised by lower numbers of incidents during winter months and higher numbers during summer months.
• During 2022, the normal seasonal pattern was less pronounced than in previous years and, despite an increase in April, followed a gradual decreasing trend from May to December 2022.
• An increasing trend in the average weekly number of incidents was observed from January (60) to May 2023 (79).
• Between June and August 2023, the average number of incidents remained broadly stable (96), before generally decreasing to November 2023 (76). An isolated increase was observed in the week beginning 30 October (108).

National update

For the most recent 13-week period (4 December 2023 to 3 March 2024):

• 879 SAS naloxone incidents were recorded, at an average of 68 per week. Weekly numbers of incidents remained broadly stable, ranging between 56 and 86, although an isolated decrease was observed in the week beginning 1 January (44).
• The total number of incidents was 14% lower than in the previous 13-week period (4 September to 3 December 2023) when 1,020 incidents were recorded, at an average of 78 per week.
• The number of incidents was similar to the same period commencing in December 2021 (914, weekly average 70) and 10% higher than in the same period commencing in December 2022 (801, weekly average 62). 

Local update

For the most recent period (4 December 2023 to 3 March 2024), naloxone administration incidents decreased across most mainland NHS boards, compared to the previous period:

• Incidents decreased in eight areas: NHS Lothian (10%), NHS Ayrshire and Arran (10%), NHS Dumfries and Galloway (12%), NHS Lanarkshire (15%), NHS Tayside (16%), NHS Greater Glasgow and Clyde (22%), NHS Highland (24%) and NHS Fife (37%).
• Incidents increased in NHS Borders (42%) and NHS Forth Valley (58%).
• Incidents were broadly stable in NHS Grampian. 

To analyse these data further, please visit the RADAR dashboard (external website).

Additional information

PHS was provided with these data by SAS.

Information on take-home naloxone distribution can be found in the National Naloxone Programme Scotland quarterly monitoring bulletin, published by PHS.

Scotland's Take-Home Naloxone Programme

The national Take-Home Naloxone Programme was launched by the Scottish Government in 2011 to prevent fatal opioid overdoses.

Naloxone is a medicine that can temporarily reverse the effects of an opioid overdose. It can be given to anyone who is non-responsive and displaying the signs of an overdose (such as unconsciousness, shallow breathing, snoring, blue lips, pale skin and pin-point pupils).

Anyone in Scotland can carry naloxone. It can be accessed through most local drug services or pharmacies, and it can also be delivered to your home through the charity Scottish Families Affected by Alcohol and Drugs (external website).

Naloxone is very easy to administer. You can learn more about administering naloxone in a free e-learning module 'Overdose Prevention, Intervention and Naloxone (external website)' created by the Scottish Drugs Forum.

Drug-related attendances at emergency departments

Between December 2023 and February 2024, the number of drug-related attendances at emergency departments (1,009) was 12% lower than in the previous time period. The number of attendances was 7% higher compared to the same period commencing in December 2021 (945) and similar to the same period commencing in December 2022 (1,044).

Background

A drug-related emergency department (ED) attendance is an attendance for a drug intoxication or overdose, either alone or combined with alcohol intoxication.

The chart below shows the weekly number of drug-related ED attendances between 29 November 2021 and 3 March 2024.

An interactive version of this chart can be found in the RADAR dashboard (external website). The dashboard also allows users to download the data and filter by NHS Board.

The chart shows the number of drug-related emergency department attendances in Scotland. The number of attendances is on the y axis and the date, between 29 November 2021 and 3 March 2024, is on the x axis. An overall decreasing trend was observed from November 2021 to April 2022, with the lowest levels in the week beginning 4 April (53). Attendances then increased sharply, peaking at 123 in the week beginning 16 May. Attendances decreased and remained broadly stable at 82 per week between June 2022 and March 2023. Between April and June 2023, the number of attendances gradually increased before a peak of 142 in the week beginning 19 June. From July 2023 to February 2024, an overall decreasing trend was observed, in spite of large variations in the number of attendances per week.

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Drug-related attendances at emergency departments

Summary

Historic trend

• A decreasing trend was observed from November 2021 to April 2022, from an average of 73 attendances per week in November 2021, to the lowest level in the series in the week beginning 4 April 2022 (53).
• Attendances then increased sharply and peaked in the week beginning 16 May 2022 (123) before decreasing and remaining stable until March 2023 (weekly average 82).
• Between April and June 2023 attendances generally increased, with the highest weekly levels in the series observed in the week beginning 19 June (142).
• From July to November 2023, an overall decreasing trend was observed in the number of attendances per week (from 94 to 76).

National update

For the most recent 13-week period (4 December 2023 to 3 March 2024):

• 1,009 emergency department attendances were recorded, at an average of 78 per week. This was 13% lower than the previous 13-week period (4 September to 3 December 2023, 1,142 attendances, weekly average 88). 
• Attendances were 7% higher than the same period commencing in December 2021 (945 attendances, weekly average 73) and similar to the same period commencing in December 2022 (1,044 attendances, weekly average 80).

Local update

For the most recent period:

• Attendances decreased in five NHS boards compared to the previous period: NHS Lanarkshire (14%), NHS Lothian (16%), NHS Greater Glasgow and Clyde (17%), NHS Ayrshire and Arran (23%) and NHS Highland (43%).
• Attendances increased in two areas: NHS Borders (35%) and NHS Grampian (67%).
• Attendances were broadly stable in the other mainland boards.

To analyse further, please visit the RADAR dashboard (external website).

Additional information

These data are taken from our Accident and Emergency Activity Data.

Due to the quality of the data available, it is not possible to accurately report total attendances for specific conditions using the national Accident and Emergency dataset. The diagnosis or reason for attendance can be recorded in a variety of ways, including in free text fields and not all NHS boards submit this information. The numbers presented in this report are based on an experimental definition of drug-related ED attendances and have not been subject to extensive quality assurance. Therefore, they are provisional and may be subject to change in future releases. Further details can be found in the metadata and the Accident and Emergency Activity Data.

Drug-related acute hospital admissions

Between October and December 2023, 1,942 drug-related hospital admissions were recorded, 24% lower than the previous quarter (2,561). Admissions were 26% lower than the same period in 2021 (2,438) and 7% higher than in 2022 (1,798).

Background

The data used in these statistics relate to all inpatient and day-case admissions to general acute hospitals (excluding maternity, neonatal, geriatric long stay and admissions to psychiatric hospitals) where drug use was recorded as a diagnosis at some point during the patient’s hospital stay. Data are presented by date of admission.

The chart below shows the weekly number of drug-related admissions to Scotland’s general acute hospitals from 27 September 2021 to 31 December 2023.

An interactive version of this chart can be found in the RADAR dashboard (external website). The dashboard also allows users to download the data and filter by NHS board.

The chart shows the number of drug-related hospital admissions in Scotland’s general acute hospitals. The number of admissions is on the y axis and the date, between 27 September 2021 to 31 December 2023, is on the x axis. Following a decreasing trend from October 2021 to April 2022, admissions briefly increased in April and May 2022 (peak of 201 admissions during the week beginning 16 May), before following an uneven decreasing trend from June to December 2022. Admissions increased between January and July 2023, reaching a peak in week beginning 10 July (221), remaining relatively stable until September before following a decreasing trend until December 2023.

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Drug-related hospital admissions

A further chart showing the top five drug types associated with admissions is available on the RADAR dashboard (external website).

Summary 

Historic trend 

• There was a decreasing trend in the weekly number of drug-related hospital admissions from October 2021 to April 2022. Admissions briefly increased between April and May 2022, before following an uneven decreasing trend between June and December 2022.
  • The decrease seen in 2022 should not necessarily be interpreted as a reduction in harms. Hospital admissions may have been affected by issues accessing urgent care services and by the capacity of hospital services.
• Admissions then increased, from 119 in the week beginning 26 December 2022, to 221 in the week beginning 10 July 2023.
• Between July to September 2023, the most common drug category recorded was opioids (45% of admissions), followed by cocaine (20%).

National update

For the most recent period (2 October to 31 December 2023):

• 1,942 drug-related hospital admissions were recorded, at an average of 149 per week. This was 24% lower compared to the previous 13-week period (2,561 admissions, weekly average 197).
• Admissions generally decreased throughout this period, from 162 in the week beginning 2 October 2023, to 104 in the week beginning 25 December 2023.
• The total number of admissions was 26% lower than in 2021 (2,438, weekly average 188) and 7% higher than in 2022 (1,798, weekly average 138).
• Opioids continued to be the most common substance type. These were recorded in an average of 47% of admissions per month, which was broadly consistent over the time series. There was a slight decrease in the average monthly cocaine admissions recorded (17%) compared to the previous 13-week period.

Local update

For the most recent period (2 October to 31 December 2023), the number of drug-related hospital admissions decreased across most mainland NHS boards, compared to the previous quarter:

• Admissions decreased in six areas: NHS Ayrshire and Arran (9%), NHS Greater Glasgow and Clyde (15%), NHS Forth Valley (28%), NHS Lothian (29%), NHS Grampian (30%) and NHS Dumfries and Galloway (39%).
• Admissions were broadly stable in two areas: NHS Borders and NHS Tayside.
• Due to completeness levels for the most recent time period being below 90%, NHS Fife, NHS Highland and NHS Lanarkshire have been excluded from the above narrative. The data can be found on our dashboard. Caution is advised when interpreting local trends for these boards and comparing to other areas.

To analyse further, please visit the RADAR dashboard (external website).

Additional information 

These data have been extracted from our Scottish Morbidity Records (SMR01 acute).

The data presented on drug type are based on ICD-10 diagnostic codes and are not confirmed by toxicology analysis, therefore patterns in substance type should be interpreted with caution.

The most recent Official Statistics on drug-related hospital care, includes a range of further information on drug types and patient demographics. For details, see our information on drug-related hospital statistics (DRHS). Please note, our DRHS dashboard presents data by date of discharge, so figures will differ to those shown above.

Suspected drug deaths

The total number of suspected drug deaths between December 2023 and February 2024 was 294, averaging 25 per week. The average weekly number of deaths was roughly stable between December 2023 (24) and February 2024 (24). The total number of deaths (294) was 17% higher than the previous period (251), 10% higher than the same period commencing in December 2021 (268) and similar to the same period commencing December 2022 (285).(R)

Background

A suspected drug death is a death where controlled drugs are suspected of being involved. Suspected drug-death figures are based on reports, observations and initial enquiries from police officers attending scenes of death.

The details of these events are recorded by Police Scotland and shared with Public Health Scotland (PHS).

Following further investigation, these suspected drug deaths are either confirmed as a 'drug-related death' or determined 'not to be a drug death'. This can take several months.

Suspected drug-death figures are used to provide a timely indication of trends and to detect any potential recent changes or clusters of harm to inform prevention activity. These figures are different to those published by the National Records of Scotland (NRS: external website) and do not provide a robust indication of the numbers of drug-related deaths occurring each year.

The chart below shows the weekly number of suspected drug deaths in Scotland from 22 November 2021 to 25 February 2024.

An interactive version of this chart can be found in the RADAR dashboard (external website). The dashboard also allows users to download the data.

The chart shows the weekly number of suspected drug deaths in Scotland on the y axis and the date, between 22 November 2021 to 25 February 2024, on the x axis. Between December 2021 and the end of February 2024, the average weekly number of deaths fluctuated considerably but remained within a range of 17 to 31 per week.

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Suspected drug deaths

Summary 

Historic trend 

• Between December 2021 and November 2023, the average weekly number of suspected drug deaths fluctuated considerably but remained within a range of 17 to 31 per week.

Update 

For the most recent period (December 2023 to February 2024):

• There was a total of 294 suspected drug deaths, 17% higher than the previous period (251). This was 10% higher than the same period commencing in December 2021 (268) and similar to the same period commencing December 2022 (285).
• There were 96 deaths in December, 103 in January and 95 in February.
• The average weekly number of deaths remained broadly stable throughout December 2023 (24), January 2024 (26) and February 2024 (24).
• An average of 25 deaths were recorded per week. This was 19% higher than the previous period (21),14% higher than the same period commencing in December 2021 (22) and similar to the same period commencing in December 2022 (24)

To analyse these data further, please visit the RADAR dashboard (external website).

Additional information 

Data on suspected drug deaths are provided by Police Scotland.

The Scottish Government produce a quarterly report (Suspected drug deaths in Scotland (external website)) that presents Police Scotland data on suspected drug deaths and describes the age, sex and geographical location of deaths in each quarter. The analysis in this RADAR release is provided for the purpose of real-time detection and prevention of harms and is not comparable with the Scottish Government publication.

The information above is management information and not subject to the same validation and quality assurance as accredited official statistics. The data provided in this release should not be viewed as indicative of the annual deaths reported by NRS.

Accredited official statistics on drug-related deaths are published annually by the NRS during the summer and provide information broken down by age, sex, substance implicated and geographical area. The latest NRS publication (external website) reported that there were 1,051 drug-related deaths in Scotland in 2022. This was a 21% decrease compared to 2021 (1,330).

Detailed information on drug-related deaths is presented in the National Drug-Related Deaths Database, which is published by PHS every two years. The latest PHS drug-related deaths report describes deaths that occurred in 2017 and 2018, with trend data from 2009.

Toxicology indicators

Emergency department toxicology: ASSIST

Between November 2023 and February 2024, the ‘A Surveillance Study of Illicit Substance Toxicity’ (ASSIST) emergency department project made 496 detections of 40 different illicit drugs, in samples from 88 patients. The most commonly detected drug category was depressants (67% of detections), followed by opioids (13%). The most commonly detected individual drug was cocaine (11%), followed by desmethyldiazepam, temazepam and bromazolam (all 10%).

Background

The ASSIST study is conducted by the emergency department (ED) at the Queen Elizabeth University Hospital (QEUH) in NHS Greater Glasgow and Clyde (GGC). This project has been funded by the Scottish Government since August 2022.

The aim of the study is to monitor drug trends and associated clinical features through the use of prospective surveillance of ED attendances due to acute illicit drug toxicity. For the most unwell patients, the study performs full toxicological analysis through the biorepository-approved surplus sampling.

The study allows drug profiling and the identification of emerging drugs or changing trends to inform appropriate harm reduction measures and public health responses.

Data collection

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. Surplus serum samples are leftover blood samples, which were taken as part of usual care.

Each ED attendance is counted once in these data. If the same person presented more than once, each attendance would be a separate data point.

Drug detections presented here are of ‘illicit drugs’ only and were not prescribed to the individual.

Illicit drug definition

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 (e.g. if methadone is detected but the individual is prescribed methadone, it will not be included)
• drugs administered to the individual as part of treatment (by ambulance staff or in hospital).

Toxicology analysis of surplus serum samples

Detections presented are for the substance only. If a metabolite (compound produced when a drug breaks down in the body) is detected, it will be presented as the substance only. If the metabolite and substance are detected, it will also be presented as the substance only.

However, if a drug and a metabolite are both detected but the metabolite could also be a drug, we have included both as it is not possible to say which has been used, if not both.

Data from the study are presented in quarters, based on the date of ED presentation, and are provided in the table below:

Results

The first chart shows the most common drug categories detected in toxicology analysis of surplus serum samples between 17 August 2022 and 16 February 2024 (Q1 to Q6).

The results are shown as the total number of detections. They are broken down by the top five drug categories and presented by study quarter.

This stacked bar chart shows the percentage of detections of drug types within QEUH ED across six quarters - Q1 to Q6. The drugs are grouped into five categories (depressant, opioid, stimulant, cannabinoid and other (including dissociative and psychedelic drugs)). Percentage of detections by category is on the y axis and the time period is on the x axis. The most common category was depressants with 57%, 62%, 60%, 64%, 66% and 67% across the time series. The second most common was opioids with 17%, 18%, 16%, 16% ,15% and 13% across the time series.

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ASSIST hospital toxicology analysis: drug categories by study quarter

Summary

Historic trend

Between 17 August 2022 and 16 November 2023:

• The most commonly detected drug type was depressants, making up 62% of all detections, followed by opioids (17%). The most commonly detected individual drug was cocaine (11%).
• 72% of attendances were male and 28% were female.
• 76% of attendances were aged 44 and under. The most common age category was 25 to 34 years (30%), followed by 35 to 44 (27%) and 16 to 24 (19%).
• The most common outcomes were discharged to home (39%), ward (28%) and police custody (11%).

Update

For the most recent period (17 November 2023 to 16 February 2024):

• 288 individual ED attendances related to illicit drug use were identified.
• 88 attendances qualified for surplus sampling toxicology testing (as they were categorised as having a higher clinical severity of toxicity as per research inclusion criteria).

Drug type and category

Among the 88 samples analysed:

• There were 496 detections of 40 individual substances (found through the biological detection of the drug or its metabolite).
• The average number of drugs detected per sample was six.

Of the 496 detections, the following drugs were the most common:

• cocaine: 55 (11% of detections, 63% of samples)
• desmethyldiazepam: 50 (10% of detections, 57% of samples)
• temazepam: 50 (10% of detections, 57% of samples)
• bromazolam: 49 (10% of detections, 56% of samples)
• etizolam: 38 (8% of detections, 43% of samples)
• oxazepam: 38 (8% of detections, 43% of samples)
• cannabis (tetrahydrocannabinol): 25 (5% of detections, 28% of samples)
• diazepam: 22 (4% of detections, 25% of samples)
• morphine: 19 (4% of detections, 22% of samples)

Please note: desmethyldiazepam, temazepam and oxazepam are all benzodiazepine drugs but can also be found as a metabolite of diazepam and other benzodiazepines.

The chart below shows the most common depressant drug detected in toxicology analysis of surplus serum samples between 17 August 2022 and 16 February 2024 (Q1 to Q6). The percentages are of all detections.

This line chart shows the percentage of detections of specific depressant drugs within QEUH ED across six quarters - Q1 to Q6. Percentage of detections is on the y axis and the time period is on the x axis. The most common depressant drug in Q1, Q2, Q5 and Q6 was desmethyldiazepam (Q1; 10%, Q2; 8%, Q5; 11%, Q6; 10%). The most common depressant drug in Q4 was bromazolam (Q4; 10%). This was the third quarter in which xylazine was detected.

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ASSIST hospital toxicology analysis: depressant drugs by study quarter

Depressants were the most common drug category, making up 67% of detections (334).

• Benzodiazepines were detected 296 times (60% of all detections):
  • In total, 12 different types of benzodiazepines were detected, including bromazolam (10%) and etizolam (8%).
  • Desmethyldiazepam made up 10% of all detections, down from 11% in Q5.
• Gabapentinoids were detected 30 times (6% of all detections, from 5% in Q5). Of these detections, 14 were gabapentin and 16 were pregabalin.
• There were four detections of xylazine (1%).

This line chart shows the percentage of detections of specific opioid drugs within QEUH ED across six quarters - Q1 to Q6. Percentage of detections is on the y axis and the time period is on the x axis. The most common opioid drug across the time series was heroin/morphine (Q1: 4%, Q2: 5%, Q3: 6%, Q4: 5% , Q5: 5% and Q6; 4%). Nitazenes were detected for the first time in Q4 (seven detections) and increased to 2% of detections (16 detections) in Q5. They were detected 8 times in Q6. Detections of noscapine decreased from 3% in Q1 to 0% in Q5 and increased to 1% in Q6.

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ASSIST hospital toxicology analysis: opioid drugs by study quarter

Opioids were the second most common drug category, making up 14% of detections (90).

• There were 19 detections of heroin/morphine (4%), 7 for methadone (1%) and six for codeine (1%).
• There were eight detections of nitazenes (1%).

Stimulants were the third most common drug category, making up 12% of detections (58).

• The most common stimulant was cocaine, making up 11% of detections (55).

Further findings

Complete clinical data were available for 288 attendances for the most recent period (17 November to 16 February 2024):

• 71% of attendees were male (205) and 30% were female (83).
• 19% (55) of attendees were aged 16 to 24 years and 22% (63) were aged 25 to 34.
• 58% of attendees were aged 35 years and over, with 34% (97) aged 35 to 44, 19% (55) aged 45 to 54 and 5% (14) aged 55 years or older.

This stacked bar chart shows the percentage of QEUH ED ASSIST attendees by age group across six time periods - Q1 to Q6. Percentage of attendees is on the y axis and the time period is along the x axis. The most common age group in Q1, Q2 and Q4 was 25 to 34 years (34%, 34% and 29% respectively). In Q3, patients aged 25 to 34 years and 35 to 44 were equally common (both 29%). The most common age group in Q5 and Q6 was 35 to 44 years (30% and 34% respectively).

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Attendances by age

ED outcome records show:

• 119 (41%) patients were discharged home
• 74 (26%) were admitted to a ward
• 42 (15%) were taken into police custody
• 34 (12%) self-discharged
• 15 (5%) were admitted to an intensive care unit, high-dependency unit, critical care unit or died
• less than five were recorded as ‘unknown’ or ‘other’.

Clinical severity outcome (after 28 days) recorded:

• 270 patients were discharged following the attendance
• less than five patients either died or remained an inpatient following the attendance
• outcomes for 13 patients were ‘unknown’.

Additional information

Public Health Scotland (PHS) was provided with these data by QEUH, NHS 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 (external website). 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 (external website).

Post-mortem toxicology testing for controlled substances

In Q4 of 2023, the most common drug types detected in post-mortem toxicology were opioids (70%) and benzodiazepines (58%). The percentage of deaths where cocaine was detected remained stable at 36% (37% in Q3 of 2023). It continued to be the most commonly detected individual substance, followed by heroin/morphine (29%), methadone (29%), diazepam (27%), and bromazolam (22%).

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, the COPFS commissions 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. It is not limited to deaths involving controlled drugs and includes suicides and natural deaths where there is no previous medical history.

Post-mortem toxicology testing is carried out by two services in Scotland:

• The Scottish Police Authority Forensic Services (SPA FS) covers deaths occurring in the west, east and parts of the north of Scotland.
• The Department of Clinical Biochemistry at NHS Grampian covers deaths in the far north and north-east of Scotland.

The inclusion of data on deaths in the far north and north-east of Scotland (the areas covered by NHS Grampian) from January 2022 onwards, means that the figures presented after that point cover the whole of Scotland and are different from publications released before October 2023.

This report includes two new periods of data:

• Remaining outstanding data for September 2023, completing data for Q3 of calendar year 2023; and
• 1 October to 31 December 2023, representing data for Q4 of 2023. This period is the most recent data discussed below.

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.

The charts below show the prevalence of controlled substances detected in deaths which were subject to post-mortem toxicology screening. Drug detections were assigned to specific time periods based on the calendar year quarter of death. As indicated by the line on the chart, data for 2020 and 2021 are based on deaths in the west, east and parts of the north of Scotland. From January 2022, the data include all areas in Scotland. Throughout the time series, the sum of the percentages for each quarter exceeds 100% due to the widespread detection of multiple substances in deaths (multiple controlled drugs were detected in 96% of deaths in Q4 2023).

The first chart below provides an indication of controlled drugs detected at post-mortem, in deaths occurring between 1 January 2020 and 31 December 2023.

The chart shows the percentage of forensic toxicology cases testing positive for controlled substances (opioids, benzodiazepines, gabapentin and pregabalin, cocaine). The percentage of cases is on the y axis and the calendar year and quarter of death, between Q1 of 2020 (1 January to 31 March) and Q4 of 2023 (1 October to 31 December), is on the x axis. The most commonly detected drug types were opioids and benzodiazepines. The percentage of deaths positive for opioids has gradually decreased since Q2 of 2020, to 70% in Q4 of 2024. Benzodiazepines were present in 74% of deaths in Q2 of 2020, but have gradually decreased over time, and have been present in 51% to 61% of deaths in each quarter since Q2 of 2022. Since Q1 of 2022, the percentage of deaths involving gabapentin and pregabalin has been relatively stable, averaging 31% per quarter. The percentage of deaths where cocaine was present increased markedly during Q2 of 2020 (to 38%), but otherwise remained relatively stable to Q1 of 2023 (averaging 29%). Detections recently increased from 29% of deaths in Q1 of 2023 to 36% of deaths in Q4 of 2023.

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Forensic toxicology cases testing positive for controlled substances

The following charts provide an indication of specific opioids and benzodiazepines detected at post-mortem, in deaths occurring between 1 January 2020 and 31 December 2023.

The chart shows the percentage of forensic toxicology cases testing positive for specific opioids (heroin/morphine, fentanyls, methadone, buprenorphine and nitazenes). The percentage of cases is on the y axis and the calendar year and quarter of death, between Q1 of 2020 (1 January to 31 March) and Q4 of 2023 (1 October to 31 December), is on the x axis. Heroin/morphine has been the most commonly detected opioid since Q3 of 2021 – the percentage of deaths testing positive for heroin/morphine followed a gradual decreasing trend from 43% in Q1 of 2020 to 29% in Q4 of 2023. Methadone detections reached 45% in Q2 of 2020, after which they gradually decreased to 23% in Q3 of 2022. Since then, methadone detections have slightly increased (29% in Q4 of 2023). Deaths with buprenorphine present remained relatively low and stable throughout the time series (averaging 6%). There was a gradual increase in the percentage of cases where fentanyls were detected from 1% in Q1 of 2022 to 5% in Q4 of 2023 nitazene-type opioid substances (detected for the first time in Q1 of 2022) have increased slightly but remained uncommon, detected in 2% of deaths in Q4 of 2023.

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Forensic toxicology cases testing positive for specific opioids

The chart shows the percentage of forensic toxicology cases testing positive for specific benzodiazepines (diazepam, etizolam, clonazolam and bromazolam). The percentage of cases is on the y axis and the calendar year and quarter of death, between Q1 of 2020 (1 January to 31 March) and Q4 of 2023 (1 October to 31 December), is on the x axis. Diazepam has been the most commonly detected benzodiazepine since Q2 of 2022. Diazepam detections were stable for most of the time series, averaging 24% until Q3 of 2022, when there was a marked increase to 35%. Diazepam was detected in 27% of deaths in Q4 of 2023. Bromazolam (detected for the first time in Q1 of 2022) has increased sharply and was detected in 22% of deaths in Q4 of 2023. Etizolam was the most common benzodiazepine detected for some time, averaging 51% between Q2 of 2020 and Q2 of 2021. Since then, etizolam detections have decreased to 6% in Q4 of 2023. Temazepam detections were relatively stable (averaging 5%) until Q1 of 2022. Detections then increased and remained stable (9% in Q4 of 2023). Deaths with clonazolam present increased and peaked at 12% in Q3 of 2021, before falling to low levels from early 2022 (2% in Q4 of 2023).

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Forensic toxicology cases testing positive for specific benzodiazepines

Summary

• The most commonly detected drug types were opioids and benzodiazepines, averaging 71% and 58% respectively between January 2022 to December 2023.
• The most commonly detected individual drug in the last three quarters was cocaine (averaging 37%). Before Q2 of 2023, the most common individual drug was heroin / morphine.
• Multiple drugs were detected in 629 (96%) of 654 deaths in Q4 of 2023.
• The following drugs or drug types were most commonly detected in deaths from Q4 of 2023:
  • opioids: 458 (70%)
  • benzodiazepines: 380 (58%)
  • cocaine: 235 (36%)
  • heroin/morphine: 189 (29%)
  • methadone: 189 (29%)
  • gabapentin and pregabalin: 188 (29%)
  • diazepam: 175 (27%)
  • bromazolam: 143 (22%)

Stimulants

• For the third quarter in a row, the most commonly detected drug was cocaine.
• The percentage of deaths where cocaine was detected was relatively stable until Q1 of 2023 (averaging 29%), with the exception of an isolated increase in Q2 of 2020 (38%). Detections recently increased from 29% of deaths in Q1 of 2023 to 36% of deaths in Q4 of 2023.

Opioids

• The percentage of deaths where opioids were detected has gradually decreased from a peak of 82% in Q2 of 2020, to 70% in Q4 of 2023:
• Heroin/morphine detections decreased from a peak of 45% in Q2 of 2020 to 29% in Q4 of 2023 (35% in Q3).
• Methadone detections reached 45% in Q2 of 2020, before gradually decreasing to 23% in Q3 of 2022. Since then, methadone detections have increased slightly (29% in Q4 of 2023).
• Buprenorphine detections remained low and stable (detected in an average of 6% of deaths throughout the time series).
• There was a gradual increase in the percentage of cases where fentanyl-type opioids were detected, from around 1% prior to Q2 of 2022, to 5% in Q4 of 2023.
• Nitazene-type opioids (detected for the first time in Q1 of 2022) have increased slightly but remained uncommon, detected in 2% of deaths (12) in Q4 of 2023 (also 2% in Q3 (12)).

Depressants

• Benzodiazepines were present in 74% of deaths in Q2 of 2020, but have gradually decreased over time, and have been present in 51% to 61% of deaths in each quarter since Q2 of 2022.
• Diazepam has been the most commonly detected benzodiazepine since Q2 of 2022. Since then, detections have fluctuated between 25% and 35%. Detections decreased to 27% in Q4 of 2023 (from 35% in Q2).
• Detections of bromazolam increased sharply throughout 2022, replacing etizolam as the most commonly detected ‘street’ benzodiazepine from Q1 of 2023 onwards. Bromazolam was detected in 22% of deaths in Q4 of 2023.
• Etizolam was the most common benzodiazepine detected for some time, before detections fell to 6% of deaths in Q4 of 2023.
• Temazepam detections were relatively stable (averaging 5%) until Q1 of 2022, when there was an increase to 9%. Since then, the percentage of temazepam detections have remained broadly similar (9% in Q4 of 2023).
• Clonazolam detections increased and peaked at 12% in Q3 of 2021, before decreasing to low levels from Q1 of 2022. In Q4 of 2023, clonazolam detections were 2% (from <1% in Q3 of 2023).
• Since Q1 of 2022, the percentage of deaths involving gabapentin and pregabalin has been relatively stable, averaging 31%.
• Xylazine (detected for the first time in Q3 of 2023) was detected in less than 1% of deaths (3) in Q4 of 2023 (from 1% (5) in Q3 of 2023). However, this is likely to be an undercount and should be interpreted with caution, as detections of xylazine in Q4 of 2023 may be subject to change once further testing information becomes available.

More detailed descriptions of historical changes can be found within our previous reports.

Additional (provisional) data

It is important to note that the information presented within this section is based on incomplete data. It is therefore provisional and subject to change once further toxicology data becomes available.

Data presented within this report has been based on the latest and most complete period for which toxicology data were available. However, in this section, more recent data (partial data for January 2024) is included to provide an early indication of emerging trends or detections of new substances.

Where available, provisional data received for January 2024 indicated the following:

• Deschloroetizolam (a ‘street’ benzodiazepine) was detected for the first time.
• There were a small number of nitazene and xylazine detections, but these continued to be relatively uncommon (<5).

Additional information

PHS was provided with post-mortem toxicology testing data for deaths occurring in the west, east and parts of the north of Scotland by Forensic Medicine and Science at the University of Glasgow and SPA FS.

In late 2022, post-mortem toxicology services for the west, east and parts of the north of Scotland were transferred from the University of Glasgow to the Scottish Police Authority Forensic Services (SPA FS). During the period of transition, tests were completed by other laboratory testing sites in the UK. Although testing has now been moved to SPA FS, these testing sites continued to provide support in 2023 and data from both SPA FS and outsourced sites have been included in this report.

Data on deaths occurring in the far north and north-east of Scotland from January 2022 onwards, was supplied by the Department of Clinical Biochemistry at NHS Grampian.

The table shows the total number of deaths testing positive for controlled substances, for each calendar year and quarter.

New drugs (e.g. bromazolam, desalkylgidazepam, nitazene-type opioids and xylazine) were detected for the first time when screening was expanded or testing was outsourced to other laboratories. These drugs may have been present before this time but were not being tested for. Data for substances including nitazenes and bromazolam are considered to be more robust and reliable from January 2023 onwards. Xylazine is not currently routinely tested for. These data will develop further as new or emerging drugs are added to routine toxicology screening by the SPA FS and NHS Grampian.

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 it does not include consideration of wider causes of death.

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 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.

Additionally, it is important to note that small numbers of detections for specific substances may result in large percentage differences between quarters. Where it is felt that data should be interpreted with caution due to small numbers, the number of detections has also been provided for context.

As some of the data received from other laboratory testing sites 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.

Similarly, as date of death was unavailable for those tests conducted by the Department of Clinical Biochemistry at NHS Grampian, the date when the case was received from the Crown Office and Procurator Fiscal Service has been used instead.

These 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.

Drug seizures in Scottish prisons

The Scottish Prisons Non-Judicial Drug Monitoring Project is a collaboration between the Scottish Prison Service and the Leverhulme Research Centre for Forensic Science at the University of Dundee (external website). The 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'.

Analysis of the drug seizures in Scottish prisons from November 2023 to January 2024 is ongoing and is not included in this report. We anticipate the updated data will be available for the next release in July 2024.

Since the last quarterly report, we have received data for a limited number of samples for the latest period (1 August to 31 October 2023):

• 33 samples were tested. 27 contained an illegal substance and six contained nicotine.
• Synthetic cannabinoids were the most prevalent drug type. They were detected in 36% of samples (12), compared to 33% between January and July 2023.
• MDMB-INACA was the most common synthetic cannabinoid (four detections), followed by MDMB-4en-PINACA (three).
• In the latest period, only two samples contained a benzodiazepine (diazepam, alprazolam). Please note that due to the limited number of samples received for testing since August 2023, these detections do not fully represent all benzodiazepine seizures in this reporting period. Between January and July 2023, benzodiazepines were detected in 16% of samples, with bromazolam being the most common.
• The most common sample type was powder (30%), followed by tablets and e-cigarettes (both 24%). Synthetic cannabinoids were detected in 50% of e-cigarettes.

Complete data to July 2023 are available in a previous quarterly report.

Service indicators

Specialist drug treatment referrals

Between November 2023 and February 2024, the average weekly number of referrals to specialist drug treatment services was relatively stable, aside from a seasonal fluctuation seen in previous years. The total number of referrals (5,351) recorded in this period was 10% lower than in the previous period (5,934). The number of referrals was broadly similar to the same period commencing December 2021 (5,458) and 2022 (5,150).

Background 

Specialist drug treatment referrals occur when a person comes into contact with services designed to support their recovery from problematic drug use.

Figures shown are for referrals relating to either drug use or co-dependency (people seeking help for both drug and alcohol use). Figures include new referrals for treatment and referrals between services.

The chart below shows the weekly number of referrals to specialist drug treatment services between 8 November 2021 and 11 February 2024.

An interactive version of this chart can be found in the RADAR dashboard (external website). The dashboard also allows users to download the data and filter by NHS board.

This chart shows the number of referrals to drug treatment services in Scotland on the y axis and the date, between 8 November 2021 and 11 February 2024, on the x axis. In December and January each year, a seasonal reduction in referrals occurs. Throughout 2022, there was a fluctuating, but gradual, decrease in the average weekly number of referrals. After the seasonal reduction in December 2022, referrals returned to a weekly average of approximately 450 per week in January 2023. A relatively stable trend was evident in 2023, with referrals ranging between 400 and 500 per week. After the seasonal reduction in December 2023, the average weekly number of referrals ranged from 400 to 450 until February 2024.

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Specialist drug treatment referrals

Summary

Historic trend

• Throughout 2022, there was a fluctuating, but gradual, decrease in the average weekly number of referrals.
• Following the seasonal reduction in December 2022, referrals returned to a weekly average of approximately 450 per week in January 2023.
• Referrals were broadly stable in 2023, ranging between 400 and 500 per week.

National update

For the most recent 13-week period (13 November 2023 to 11 February 2024): 

• Following the seasonal reduction in December 2023, the average weekly number of referrals ranged from 400 to 450 until February 2024.
• 5,351 specialist drug treatment referrals were recorded, at an average of 412 per week. This was 10% lower than the previous 13-week period (14 August to 12 November 2023) when 5,934 referrals were recorded, at an average of 456 per week. 
• The number of referrals was broadly similar to the same period commencing in December 2022 (5,150) and 2021 (5,458).

Local update

For the most recent period: 

• The weekly number of referrals increased in six mainland NHS boards compared to the previous period: NHS Fife (10%), NHS Tayside (10%), NHS Forth Valley (14%), NHS Lanarkshire (18%), NHS Borders (27%) and NHS Highland (29%).
• Referrals decreased in three areas: NHS Grampian (7%), NHS Lothian (8%) and NHS Ayrshire & Arran (12%).
• Referrals were broadly stable in the other mainland boards.

To analyse these data further, please visit the RADAR dashboard (external website).

Additional information

These data are taken from the Drug and Alcohol Information System (DAISy) and its predecessor, the Drug and Alcohol Treatment Waiting Times (DATWT) database.

PHS publishes further information on waiting times for people accessing specialist drug and alcohol treatment services. The latest data can be viewed in our National drug and alcohol treatment waiting times report which also includes a new interactive drug and alcohol treatment waiting times dashboard (external website).

Additionally, for more information on initial assessments for specialist drug and alcohol treatment services in Scotland, visit our new report: Drug and Alcohol Information System (DAISy): Overview of initial assessments for specialist drug and alcohol treatment 2021/22 and 2022/23.

For details of drug treatment services in your area, visit the Scottish Drug Services Directory website (external website).

The Medication Assisted Treatment (MAT) standards (external website) is an improvement programme to strengthen access, choice and support within the drug treatment system in Scotland.

Opioid substitution therapy

From October to December 2023, the average number of opioid substitution therapy (OST) doses supplied per month was stable and similar to the same time period in 2021 and 2022. The average monthly number of methadone doses supplied continued to decrease while the number of injectable buprenorphine doses increased over time.

Background

The data used in these statistics relate to the number of average daily quantity (ADQ) doses for OST drugs dispensed in the community in Scotland. OST drugs include methadone, oral buprenorphine and injectable buprenorphine. Methadone and oral buprenorphine are usually taken once every day. Injectable buprenorphine is long-acting and is administered once every week or month (depending on the formulation).

The chart below shows the average total monthly number of ADQ doses supplied for OST medications in the community between 1 October 2021 and 31 December 2023.

The stacked area chart shows the three-month rolling average number of doses supplied for OST medications in the community between October 2021 and December 2023. The number of doses per month is on the y axis and the calendar month is on the x axis. There was a gradual decrease in the average monthly total number of OST doses supplied over the time series, which is likely associated with a decreasing trend in the number of methadone doses supplied.

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Average total number of OST doses per month

The chart below shows trends in the monthly number of ADQ doses supplied for specific OST medications in the community between 1 October 2021 and 31 December 2023.

The chart shows monthly trends in the number of doses supplied for specific OST medications in the community between October 2021 and December 2023. The number of doses per month is on the y axis and the calendar month is on the x axis. Methodone was the most commonly prescribed throughout the time series. Methadone prescriptions were stable at an average of approximately 592,000 prescriptions between October 2021 and April 2022 before following a decreasing trend to approximately 493,000 doses per month between October and December 2023. Injectable buprenorphine was first licensed for use in Scotland in early 2020. The average total number of doses supplied has increased steadily since then, to approximately 123,000 per month between October and December 2023, making it more common than oral buprenorphine since November 2023. The average monthly number of oral buprenorphine doses supplied was roughly stable over time, with approximately 116,000 oral buprenorphine doses prescribed per month between October and December 2023.

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Number of doses per month for OST medications

Summary

Historic trend

• There was a gradual decrease in the average monthly total number of OST doses supplied. This was likely to have been associated with a decreasing trend in the average monthly number of methadone doses supplied, which reduced by 15%, from 595,200 between October and December 2021, to 504,100 between July and September 2023.
• The average monthly number of oral buprenorphine doses supplied fell by 8% between October to December 2021 (123,400) and July to September 2023 (113,700).
• Injectable buprenorphine was first licensed for use in Scotland in early 2020. The average monthly number of doses supplied increased more than two-fold, from 49,400 between October and December 2021, to 115,600 between July and September 2023.

Update

Data from PHS's Prescribing Information System was subject to delay in recent RADAR reports. This has now been rectified and data are available approximately three months in arrears. While data for most medications up to December 2023 have been successfully validated, October to December 2023 data for injectable buprenorphine remain provisional and may be subject to change in future reports. We anticipate the data for this period to be validated for the next release of this report in July 2024.

For the most recent period (1 October to 31 December 2023):

• The average total monthly number of OST doses supplied was approximately 732,000. This was roughly the same as in the previous quarter (July to September 2023; approximately 733,400 doses) a slight decrease compared to the same period in 2021 and similar to the same period in 2022.
• The average monthly number of methadone doses supplied was approximately 493,100. Equivalent figures for oral buprenorphine and injectable buprenorphine were 116,100 and 122,800, respectively.
• The number of methadone doses was approximately the same as in the previous quarter, 17% lower than the same period in 2021 and 10% lower than in 2022.
• The number of oral buprenorphine doses supplied was approximately the same as the previous quarter, 6% lower than the same time period in 2021 and similar to the same period in 2022.
• The number of injectable buprenorphine doses was 6% higher than in the previous quarter, 148% higher than the same period in 2021 and 47% higher than the same time period in 2022.

Additional information

These data have been extracted from the Prescribing Information System (PIS) and the Hospital Medicines Utilisation Data Manual (HMUD) (external website).

The data shown on methadone and oral buprenorphine, and the majority of injectable buprenorphine data, relate to prescriptions dispensed to individuals from a community pharmacy in Scotland, where a request for reimbursement of costs was processed. The time period reflects the month for which reimbursement was claimed. This is regarded as the most comprehensive and reliable way of reporting community prescribing data. There can be a lag of approximately three months from a prescription being written to reimbursement data becoming available.

As a consequence of the direct administration of injectable buprenorphine within clinics, some NHS boards do not request the reimbursement of costs for all of the OST treatments they provide. Data for approximately 28% of injectable buprenorphine doses supplied in Scotland are held in the HMUD and have been combined with the community prescribing data to provide a comprehensive account of OST supply over time.

To analyse information on methadone and oral buprenorphine dispensing by NHS board or by Alcohol and Drug Partnership, visit the RADAR dashboard (external website).

What is average daily quantity (ADQ)?

When comparing use between medicines and over time, it is common to use World Health Organization (WHO) defined daily doses (DDDs). The DDD is defined as the usual average daily maintenance dose used in adults for the main therapeutic use of the medicine. The WHO DDD is a global average and may not be representative of the doses used in clinical practice at a more local level. This is particularly the case for methadone, where the WHO DDD of 25 milligrams (mg) daily is between one-half and one-third of the normal maintenance dose used in Scotland.

We have therefore replaced DDDs with ADQs, which are more representative of the daily maintenance doses used within Scotland. These values have been developed through a combination of prescription analyses and by consultation with the Specialist Pharmacists in Substance Management group. The ADQs agreed are:

• methadone (oral): 65 mg
• buprenorphine (oral): 13 mg
• buprenorphine (injection): 3.4 mg

Glossary

For detailed definitions on the terms used above, visit the RADAR dashboard (external website).

Injecting equipment provision

The average weekly number of injecting equipment provision (IEP) transactions, and needles and syringes distributed, remained relatively stable between October and December 2023. During this time period, the number of transactions was similar to the same period in 2021 and 6% higher than in 2022. The number of needles and syringes distributed was similar to the same period in 2021 and 2022.

Background 

IEP is a form of harm reduction that helps to reduce the transmission of blood-borne viruses among people who inject drugs. These data relate to the number of needle and syringe transactions at IEP sites and the total number of needles and syringes distributed.

The chart below shows the weekly number of IEP transactions from 4 October 2021 to 31 December 2023.

An interactive version of this chart can be found in the RADAR dashboard (external website). The dashboard also allows users to download the data and filter by NHS board.

The chart shows the number of transactions at injecting equipment provision sites in Scotland. The number of transactions is on the y axis and the date, between 4 October 2021 and 31 December 2023, is on the x axis. In December and January each year, a seasonal reduction in transactions is observed. Between October 2021 and December 2022, outwith the seasonal reduction, the number of transactions varied but was broadly stable between 2,600 and 3,450 per week. After the seasonal reduction in January 2023, the number of transactions fluctuated until the end of June 2023 (3,277), following an overall increasing trend. Between July and November 2023, the number of transactions was stable between 2,900 and 3,200 per week. In December 2023, a seasonal reduction in the number of transactions was observed (2,446 in the week beginning 25 December 2023).

Close

Injecting equipment provision: transactions

Further charts showing the weekly number of needles and syringes distributed, and the ratio of needles and syringes per transaction, are available on the RADAR dashboard (external website).

Summary

Historic trend

• The average number of transactions remained broadly stable (approximately 3,000 per week) from February 2022 to September 2023.
• For each indicator, seasonal fluctuations were observed during December and January each year.
• Between October 2021 and September 2023, the average number of needles and syringes distributed was broadly stable (approximately 37,000 per week).
• The ratio of needles and syringes distributed was stable from October 2021 to September 2023, at an average of 14.2 needles and syringes distributed per transaction.

National update

For the most recent period (2 October to 31 December 2023):

IEP transactions

• 38,221 transactions were recorded, at an average of 2,940 per week.
• This was similar to the previous period (3 July to 1 October 2023) when a total of 39,376 transactions were recorded (weekly average 3,029).
• The number of transactions was similar to the same period in 2021 (38,073, weekly average 2,929) and 6% lower than in 2022 (36,191, weekly average 2,784).

Needles and syringes distributed

• 471,780 needles and syringes were distributed, at an average of 36,291 per week.
• This was 6% lower than the previous period when a total of 504,464 needles and syringes were distributed, at an average of 38,805 per week.
• The number of needles and syringes distributed was similar to the same period in 2021 (481,381, weekly average 37,029) and 2022 (471,583, weekly average 36,276).

Ratio of needles and syringes distributed

• There was a weekly average of 13.3 needles and syringes distributed per transaction.
• This was slightly lower than in the previous time period (14.0) and the same periods in 2021 (14.0) and 2022 (14.3).

Local update

For the most recent period, the ratio of needles and syringes distributed per transaction varied across mainland NHS boards, compared to the previous period:

• The ratio increased in three areas: NHS Lanarkshire (7%; ratio 14.4), NHS Forth Valley (28%; ratio 20.3) and NHS Borders (67%; ratio 16.0).
• The ratio decreased in four areas: NHS Tayside (5%; ratio 18.2), NHS Greater Glasgow and Clyde (10%; ratio 9.2), NHS Ayrshire and Arran (14%; ratio 20.4) and NHS Dumfries and Galloway (14%; ratio 6.7).
• The ratio was stable in NHS Grampian (ratio 18.8) and NHS Lothian (ratio 22.3).

To analyse these data further, please visit the RADAR dashboard (external website). 

Additional information

These data are taken from the Needle Exchange Online 360 database (neo360).

The 11 mainland NHS boards use neo360 routinely, but due to missing data for part of the time period presented, NHS Highland is excluded from the transaction data, and both NHS Fife and NHS Highland are excluded from the needle and syringe and ratio figures.

For details of injecting equipment providers in your area, visit the Scottish Needle Exchange Directory (external website).

Contact

General enquiries

If you have an enquiry relating to this publication, please email:

• Nicole Jarvie | Principal Information Analyst | phs.drugsteam@phs.scot
• Vicki Craik | Public Health Intelligence Adviser | phs.drugsradar@phs.scot

Reporting a drug harm

To make a report to RADAR and share information such as trends, incidents and harms related to drugs you can either:

• fill in our reporting form
• email phs.drugsradar@phs.scot

Media enquiries

If you have a media enquiry relating to this publication, please contact the Communications and Engagement team.

Requesting other formats and reporting issues

If you require publications or documents in other formats, please email phs.otherformats@phs.scot.

To report any issues with a publication, please email phs.generalpublications@phs.scot.

Further information

RADAR

Find out more about RADAR – Scotland's drugs early warning system.

Data and intelligence

View our wider drug data and intelligence.

Public health information

Visit Scottish Public Health Observatory (ScotPHO) for further drug-related public health information.

Metadata

The remaining metadata for this document has been split into sections as there are some differences between the indicators.