Emergency department toxicology: ASSIST

Between August and November 2022, 169 detections of 30 different illicit drugs were identified by the ASSIST pilot. More than one substance was detected in 82% of attendances. The most commonly detected drug category was depressants (58%), followed by stimulants (27%). The most commonly detected drug was cocaine (13%), followed by desmethyldiazepam (11%).

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 analysis of standard of care clinical data for severely ill patients attending the ED due to illicit drug toxicity.

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 or hospital)

The pilot enables full toxicological analysis through the biorepository. 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 three-month follow up period.

Toxicology analysis of surplus serum samples

Surplus serum samples are left over blood samples, that were taken as part of usual care. The chart below shows the most common drug categories detected in toxicology analysis of surplus serum samples between 17 August 2022 and 16 November 2022. The results are shown as the total number of detections, broken down by top five drug categories and then broken down further by drug name.

This chart shows the number of detections of drug types within QEUH ED. They are grouped into five main categories of effect, with depressant, stimulant, opioid, cannabinoid and other on the y-axis and the number of detections along the x-axis. The most common category was depressant, with 98 detections. This included 88 detections of benzodiazepines and 10 detections of gabapentinoids. The second most common category was stimulant, comprised of 22 detections of cocaine and 11 detections of other stimulants. There were 21 detections of opioids, 15 detections of cannabinoids, and two 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 November 2022), 273 discreet ED attendances related to illicit drug use were identified.

Drug type and category

Complete toxicology and clinical data are available for 38 attendances, with results described below. Results from the remaining attendances will be available in the next report.

• There was a total of 169 detections of 30 different illicit drugs found through the biological detection of the drug or its metabolite.
• The following drugs were most commonly detected:
  • cocaine: 22 (13%)
  • desmethyldiazepam: 17 (10%)
  • cannabis: 15 (9%)
  • etizolam: 14 (8%)
  • temazepam: 14 (8%)
• Depressants were the most common drug category, detected 98 times, making up 58% of all detections.
  • Benzodiazepines were detected 88 times (52%). 12 different types of benzodiazepines were detected.
  • Gabapentinoids were detected 10 times (6%), three gabapentin and seven pregabalin.
• Stimulants were the second most common drug category, detected 33 times, making up 20% of all detections.
  • The most common stimulant was cocaine, detected 22 times (13%).
  • There were four detections for amphetamine, three for methamphetamine and two for MDMA. Mephedrone and MDA were each detected once.
• Opioids were the third most common drug category, detected 21 times, making up 12% of all detections.
  • Codeine, methadone and dihydrocodeine were each detected four times. Dihydromorphine, buprenorphine and morphine were detected twice. There were two detections of morphine (a metabolite of heroin and other opioids).

Polydrug use

• Polydrug use is a prevailing feature with 31 tests (82%) detecting more than one illicit drug or metabolite, even after legal substances (such as alcohol) and known prescribed medicines (including prescribed benzodiazepines and opioids) are removed.
• The number of illicit drugs detected for each attendance ranged between one and 12, with a mean of four.
• 48% of cases positive for a benzodiazepine also tested positive for an opioid. 100% of cases positive for an opioid also tested positive for a benzodiazepine.
• 59% of cases positive for a benzodiazepine also tested positive for cocaine. 73% of cases positive for cocaine also tested positive for a benzodiazepine.

Further findings

Complete clinical data is available for 134 attendances, with results described below.

• 96 were male (72%) and 38 were female (28%).
• Just over half were 16 to 34 years old.

• 109 patients were in hospital for 24 hours or less (81%).
• ED outcome records show that five patients were admitted to an intensive care unit. 24 were admitted to a ward or high dependency unit. 10 were transferred to a psychiatric unit. 75 were discharged home and 20 were recorded as ‘other’ (including discharged to police custody, self-discharge and unknown).
• Clinical severity outcome (after 28 days) recorded that 120 patients recovered and 3 patients died. 11 outcomes were recorded as ‘other’ including ongoing inpatient stay, disabled and unknown.

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

Forensic toxicology testing for controlled substances

The total number of deaths testing positive for controlled substances via Forensic Medicine and Science (FMS) toxicology testing was 16% lower in Q3 of 2022 (1 July 2022 to 30 September 2022) than in Q2 (1 April 2022 to 30 June 2022).
In Q3 of 2022, the most commonly found drugs or drug types were opioids (74%) and benzodiazepines (50%). Heroin/morphine was detected in 35% of deaths and there was a continued reduction in detections for etizolam (17%) and methadone (25%).

Background

This analysis is based on toxicology testing data completed at post-mortem.

This testing was performed by the Forensic Toxicology Service based within FMS at the University of Glasgow, on behalf of the Crown Office and Procurator Fiscal Service.

The range of substances routinely analysed by this service is extensive and includes the detection of alcohol, prescribed medicines and controlled drugs.

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

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

The chart shows the percentage of forensic toxicology cases testing positive for specific individual opioids (heroin/morphine, methadone, buprenorphine and fentanyl) and benzodiazepines (diazepam, etizolam and clonazolam). 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 Q3 2022 (1 July to 30 September), 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 2022, when the presence of these substances in toxicology cases both decreased. Both substances have continued to decrease and in Q3 of 2022 the percentage of cases testing positive for methadone was approximately equal to the percentage of deaths testing positive for diazepam, with etizolam falling below this level. 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 has become the most common substance present. 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 diazepam, fentanyl or buprenorphine present remained relatively stable throughout the time series.

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Forensic toxicology cases testing positive for specific opioids and benzodiazepines

Summary

Historic trend

• In total, 2,172 deaths occurred in 2021 where controlled drugs were found present via FMS toxicology testing, which was 2% higher than in 2020 (2,136).
• The most commonly found drug types were opioids and benzodiazepines. The percentage of deaths with these drugs present increased during the time period when the initial COVID-19 restrictions were in place (Q2 of 2020) and remained high throughout 2020 to Q2 of 2021, but has been decreasing since Q3 of 2021.
• The specific drugs most commonly present throughout the time series (from Q1 of 2020 to Q2 of 2022) were etizolam, methadone and heroin/morphine, with etizolam and methadone both increasing sharply in Q2 of 2020.
• Although there was a gradual reduction in deaths where methadone was found present, etizolam presence remained high throughout 2020 and early 2021 before sharply decreasing in Q3 of 2021.
• The percentage of deaths involving diazepam, other opioids, gabapentin/ pregabalin or cocaine have remained relatively stable over time.

Update

• The total number of deaths testing positive for controlled substances via FMS toxicology testing was 16% lower in Q3 of 2022 (1 July 2022 to 30 September 2022) than in Q2 (1 April 2022 to 30 June 2022) and 9% lower than in Q3 of 2021.
• In Q3 of 2022, the following drugs or drug types were most commonly detected:
  • opioids: 329 (74%)
  • benzodiazepines: 221 (50%)
  • gabapentin/pregabalin: 152 (34%)
  • cocaine: 130 (29%)
• Following a continued reduction in cases testing positive for etizolam (from 35% in Q1 to 17% in Q3) and methadone (from 34% in Q1 to 25% in Q3), the most commonly found substance was heroin/morphine (35% in Q3 of 2022).
• In Q3 of 2022, the percentage of cases testing positive for etizolam fell below diazepam (24% in Q3 of 2022), which remained relatively stable.
• There were no deaths positive for clonazolam via FMS testing in Q3 of 2022, in comparison to a peak of 12% of deaths in Q3 of 2021.
• Other toxicology sources suggest the ‘street’ benzodiazepine market continues to diversify, with substances such as bromazolam increasingly in use. The decrease in benzodiazepine detections described above may be due to these emerging compounds not being included in testing during this time period. These data will develop further as bromazolam (and other new or emerging drugs) are added to toxicology screening in the coming months.

Additional information

PHS was provided with these data by FMS, University of Glasgow.

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.

The data above are for deaths occurring in the west, east and parts of the north of Scotland. Apart from a very small number of cases analysed at the University of Glasgow, post-mortem toxicology testing for deaths occurring in Aberdeen and the far north of Scotland is conducted by a similar service at the Aberdeen Royal Infirmary (ARI). Results from the ARI are not included in the analysis above.

Glossary

Drug seizures in Scottish prisons

Synthetic cannabinoids were the most prevalent drug type in the Scottish Prisons Non-Judicial Drug Monitoring Project during April, detected in 50% of samples. In contrast, benzodiazepines were the most prevalent in May, detected in 27% of samples.

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 chart below shows the five drug types most commonly detected in drug seizures in Scottish prisons between 1 September 2020 and 31 May 2022, based on the percentage of all samples tested.

The chart shows the percentage of SPS drug seizures broken down by drug type (synthetic cannabinoids, benzodiazepines and synthetic cannabinoids mixture, benzodiazepines, gabapentinoids, cocaine and opioids). The percentage of samples is on the y axis and the date, between September 2020 and May 2022, on the x axis. An overall decreasing trend is observed in the percentage of synthetic cannabinoids detected between September 2020 and March 2022, before a spike in April and decrease in May 2022. An increasing trend is observed in benzodiazepine samples in the most recent month.

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Drug seizures in Scottish prisons: drug type

The second chart shows the four sample types most commonly seized in Scottish prisons between 1 September 2020 and 31 May 2022, based on the percentage of all samples tested.

The chart shows the percentage of SPS drug seizures broken down by sample type (card, paper, powder and tablet). The percentage of samples is on the y axis and the date, between September 2020 and May 2022, on the x axis. An overall decreasing trend in the percentage of paper samples is observed between September 2020 and January 2022 before increasing until April and falling again in May. An increasing trend is observed in paper and tablet samples in the most recent months.

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Drug seizures in Scottish prisons: sample type

Summary

Historic trend

• Synthetic opioids were the most common substances seized throughout the time series, followed by benzodiazepines. However, both were highly variable over time:
  • The percentage of seizures testing positive for synthetic cannabinoids decreased markedly between July 2021 (57%) and January 2022 (15%). Overall, an average of 47% of seizures in 2021 tested positive for synthetic cannabinoids compared with 19% between January and March 2022.
  • The percentage of seizures testing positive for benzodiazepines fluctuated throughout 2021 with an average of 45% per month for the year (ranging from 21% to 48%). The percentage then decreased and remained stable from January to March 2022 (average of 22%).
• Opioid detections increased at the start of 2022, averaging 17% per month from January to March 2022 compared to 4% in 2021.
• Paper samples were the most common sample types seized in 2021, accounting for an average of 53% of samples per month. This fell to an average of 26% per month from January to March 2022. Increasing trends in the percentage of powder (average of 17% per month) and tablet (35% per month) samples were observed from January to March 2022.

Update

Please note, that data for the full time period (April to June 2022) were not available. This update provides analysis of samples seized in April and May 2022 (63 samples).

For the most recent time period (1 April 2022 to 31 May 2022):

• The three most commonly detected drugs were ADB-BUTINACA (synthetic cannabinoid), ADB-HEXINACA (synthetic cannabinoid) and etizolam (benzodiazepine).
• Synthetic cannabinoids were the most common drug type, detected in an average of 30% of seizures. This was lower than the same time period in 2021 (50%).
• Benzodiazepines were the second most common drug type, detected in an average of 29% of seizures. This was higher than the same time period in 2021 (24%).
• A continuing increasing trend in the percentage of powder and paper samples was observed in April (39% paper, 38% powder). Paper samples decreased in May (11% compared to a monthly average of 53% in 2022). An increase in tablet samples was also observed (38%).

Further findings

A small number of samples (31) were tested between June and September 2022, with these broadly following previously observed trends. 58% of samples tested positive for synthetic cannabinoids and 32% for benzodiazepines.

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.

Glossary