Rapid Action Drug Alerts and Response (RADAR) quarterly ​report
January 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.

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 April 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, but a decrease was observed during autumn 2023 compared with the previous reporting period (summer). Levels remain higher than in the spring (reported in quarterly report 4 – July 2023).
• The following changes were observed compared to the previous reporting period (reported in quarterly report 5 – October 2023):

For harm indicators:

• • naloxone administration incidents: 17% decrease
  • emergency department attendances: 13% decrease
  • drug-related hospital admissions: stable (2% decrease)
  • suspected drug deaths: 19% decrease

For service indicators:

• • drug treatment referrals: 8% decrease
  • injecting equipment provision: stable (transactions - 4% decrease, number of needles and syringes - 2% decrease)
• The pattern of drug use associated with most harms was polysubstance use involving benzodiazepines (most commonly diazepam and bromazolam), cocaine and opioids. Cocaine played an increasing role in drug-related harms.

Alerts

• A public health alert about nitazene-type opioids (published in January 2023) was updated in December 2023 to include provisional data on detections of nitazenes in deaths in Scotland. Based on post-mortem toxicology testing, nitazenes were detected in 25 deaths (to 30 September 2023).
  • PHS alert: nitazene-type opioids in Scotland
• Scottish Drugs Forum (SDF) worked with service providers and other partners to launch a multi-agency alert and develop information resources for people at risk of overdose due to the introduction of synthetic opioids, including nitazenes into the drug supply.
  • SDF synthetic opioid resources (external website)
• A public health alert about new benzodiazepines was published on 5 July 2023 and remains current. Bromazolam is currently the most common 'street benzo' detected in Scotland.
  • PHS alert: new benzodiazepines - bromazolam

Harm indicators

• Between September and November 2023, the average weekly number of Scottish Ambulance Service naloxone administration incidents decreased (from 84 to 75). The total number of incidents was 19% lower than in the same period in 2021 and 14% higher than in 2022. These figures do not take account of naloxone administration by members of the public, service workers, or other emergency responders such as police officers.
• Between September and November 2023, drug-related attendances at emergency departments were 13% lower than in the previous time period. The total number of attendances recorded was similar to the same period in 2021 and 2022.
• Between July and September 2023, drug-related hospital admissions were similar to the high in the previous period. The total number of admissions was 16% lower than the same period in 2021 and 20% 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 September and November 2023, there were 267 suspected drug deaths. The number of deaths was 8% lower than in the same period in 2021 (290) and 6% lower compared to 2022 (285).

Toxicology indicators

• Between August and November 2023, the most frequently detected drugs in the ASSIST hospital toxicology project were desmethyldiazepam (11% of detections), followed by cocaine (11%), temazepam (10%) and bromazolam (10%). Nitazenes made up 2% of detections (detected 16 times, up from seven in the previous quarter).
• Between July and September 2023, the most common drug types detected in post-mortem toxicology were opioids (67%) and benzodiazepines (59%), based on partial data available for September (provisional Q3 2023). The most common individual drug detected was cocaine (38%), followed by heroin/morphine (35%), diazepam (30%), methadone (25%) and bromazolam (24%). Xylazine was detected in post-mortem samples for the first time.
• Scottish prison drug analysis data were not available for the latest period.

Service indicators

• Between August and November 2023, the average weekly number of referrals to specialist drug treatment services varied widely within an overall decreasing trend. The total number of referrals recorded in this period was 8% lower than in the previous period. The number of referrals was 6% lower than the same period in 2021 and 6% higher than in 2022.
• Between July and September 2023, the average weekly number of injecting equipment provision transactions, and needles and syringes distributed remained relatively stable. During this period, both the total number of transactions, and number of needles and syringes distributed, were lower than in the same period in 2021 (13% and 9% respectively) and similar to 2022.
• Data for opioid substitution therapy is not available for the most recent period. Between April and June 2023, 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 October and December 2023, 53 trend reports were received by RADAR.
• The majority of reports related to benzodiazepines, cocaine and polydrug use.
• Other commonly reported concerns relate to heroin, novel synthetic opioids (fentanyl and nitazenes), tapentadol and carisoprodol tablets (‘somas’ and ‘red apples’), ketamine and MDMA.
• Trend reports can now be viewed on our dashboard (external website).

Actions

• 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.
• These developments increase the risk of harm and death, particularly in the context of polysubstance use, stigma and exclusion. They emphasise the importance of timely and accurate hospital toxicology and forensic post-mortem toxicology services, as well as accessible drug checking.
• A system-wide approach that prevents drug harms and supports people affected into treatment, care and recovery remains critical. Harm reduction interventions are a key part of a systems-wide approach.

Alerts

Scottish Drugs Forum has worked with service providers and other stakeholders to develop information resources for people at risk of overdose due to the introduction of synthetic opioids, including nitazenes into the drug supply.

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 post-mortem toxicology testing, nitazenes were detected in 25 deaths (to 30 September 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 detections of MDMA and 'tusi', and legal changes related to nitrous oxide.

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.

MDMA

The STOP Unit continues to see recoveries of both MDMA crystal and tablets (ecstasy) on a regular basis. MDMA is a class A controlled drug within the provisions of the Misuse of Drugs Act 1971.

The below are images of MDMA tablets recovered in August 2023 by events venue security staff in the West of Scotland. Some of these tablets have been reported to be linked to the deaths of young people.

2-CB

2-CB tablets were also seized in the West of Scotland. 2-CB is a psychedelic. It is a class A controlled drug within the provisions of the Misuse of Drugs Act 1971.

Nitrous oxide

On 8 November 2023, nitrous oxide was classified as a class C controlled drug within the provisions of the Misuse of Drugs Act 1971, having previously been governed under the Psychoactive Substances Act 2016.

Nitrous oxide is also known as 'laughing gas'. It is a colourless gas that is commonly found in metal pressurised canisters, known as chargers or tanks. The gas is released into a balloon using a dispenser, nozzle or cracker and then inhaled.

'Tusi'

'Tusi,' also known as 'tusibi', 'tuci', and 'pink cocaine', is a pre-mixed combination of drugs. The composition of 'tusi' varies widely in the illicit market. It may include a variety of drugs such as MDMA, 2-CB, LSD, ketamine, cathinones and cocaine, mixed with pink food colouring.

This is a drug that has been in and around the illicit drugs market for some time, however, it is not very common. Some Drug Trend Monitoring Groups in Scotland have reported that they have seen a rise in this commodity recently. The STOP Unit will continue to liaise with partner agencies on any emerging trends and recoveries.

RADAR intelligence and reports

53 reports were validated by RADAR between 5 October 2023 and 4 January 2024.

So far, RADAR has received over 150 reports of drug-related information and harms received 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 October 2023 to 4 January 2024)
• The most common drugs or drug types reported were:
  • benzodiazepines
  • cocaine
  • heroin
  • new synthetic opioids including nitazenes
  • tapentadol and/or carisoprodol tablets ('somas' and 'red apples')
  • ketamine
  • MDMA (ecstasy)
• Half of reports mentioned polydrug use – the use of more than one substance at a time.
• The most commonly reported concerns were related to adverse effects, overdose and deaths.

Key trends

RADAR is currently assessing the harms related to cocaine and ketamine, 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 the mailbox.

Harm indicators

Naloxone administration by Scottish Ambulance Service

The average weekly number of naloxone administration incidents decreased between September (84) and November 2023 (75). The total number of incidents during this time period (1,017) was 17% lower than in the previous period (1,220). The number of incidents was 14% higher than the same period in 2022 (890) and 19% lower than in 2021 (1,249).

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 September 2021 to 27 November 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 emergency naloxone incidents by the Scottish Ambulance Service. The number of incidents is on the y axis and the date, between 6 September 2021 and 27 November 2023, is on the x axis. An uneven decreasing trend was observed from September 2021 until April 2022. Following an isolated increase in April 2022, the number of naloxone incidents again followed a gradual decreasing trend from May to December 2022. An increasing trend was observed from January to June 2023. Between June and August 2023, the average weekly number of naloxone incidents remained broadly stable at around 96 per week. A sharp decrease in weekly incidents was observed between 11 September (94) and 25 September (65), followed by a sharp increase in week beginning 30 October (108). A decreasing trend in the number of naloxone incidents was observed throughout November 2023.

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Naloxone administration by Scottish Ambulance Service

Summary

Historic trend

• Until winter 2021/22, 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.
• In spring 2022, the trend diverged from 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 the end of May 2023 (79).
• Between June and August 2023, the average number of incidents remained broadly stable (96).

National update

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

• 1,017 SAS naloxone incidents were recorded, at an average of 78 per week. Weekly numbers of incidents generally decreased throughout this period, although an isolated increase was observed in week beginning 30 October (108 incidents).
• The total number of incidents was 17% lower than in the previous 13-week period (5 June to 3 September 2023) when 1,220 incidents were recorded, at an average of 94 per week.
• The total number of incidents was 19% lower than the same period in 2021 (1,249, weekly average 96) and 14% higher than in 2022 (890, weekly average 68).

Local update

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

• Incidents increased in NHS Fife (8%) and NHS Dumfries and Galloway (44%).
• Incidents decreased in eight areas: NHS Lothian (10%), NHS Greater Glasgow and Clyde (19%), NHS Forth Valley (23%), NHS Grampian (23%), NHS Ayrshire and Arran (23%), NHS Borders (25%), NHS Highland (31%) and NHS Lanarkshire (33%).
• Incidents were broadly stable in NHS Tayside.

To analyse 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.

Police Scotland have also trained and equipped all operational officers up to and including the rank of Police Inspector with intra-nasal naloxone kits. New data published by Police Scotland (external website) brings the total number of administrations by the police (since naloxone was first provided to officers as part of a national test of change in March 2021) to at least 353. This should be taken into consideration when interpreting the data shown above.

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 September and November 2023, drug-related attendances at emergency departments decreased by 13%, compared to the previous time period. A total of 1,138 attendances were recorded in this period, similar to the same period in 2021 (1,130) and 2022 (1,101).

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 30 August 2021 and 3 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 emergency department attendances in Scotland. The number of attendances is on the y axis and the date, between 30 August 2021 and 3 December 2023, is on the x axis. An overall decreasing trend was observed from August 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. The number of 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 to November 2023, an overall decreasing pattern 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

• An overall decreasing trend was observed in drug-related attendances at EDs between October 2021 and April 2022, with the lowest weekly levels in the time series observed in the week beginning 4 April (53).
• Drug-related ED attendances increased sharply and peaked in May 2022, to 123 in the week beginning 16 May.
• Attendances decreased and remained stable from June 2022 to March 2023, averaging 82 per week.
• Between April and August 2023 attendances generally increased, averaging 98 per week.

National update

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

• 1,138 ED attendances were recorded, at an average of 88 per week. This was 13% lower than the previous 13-week period (5 June to 3 September 2023, 1,313, weekly average 101).
• Attendances were similar to the same periods in 2021 (1,130, weekly average 87) and 2022 (1,101, weekly average 85).

Local update

For the most recent period (4 September to 3 December 2023), most mainland NHS boards saw a decrease in the number of drug-related ED attendances, compared to the previous period:

• Attendances increased in two areas: NHS Borders (13%) and NHS Ayrshire and Arran (34%).
• Attendances decreased in eight areas: NHS Greater Glasgow and Clyde (5%), NHS Forth Valley (7%), NHS Lanarkshire (10%), NHS Tayside (14%), NHS Lothian (15%), NHS Fife (27%), NHS Dumfries and Galloway (47%) and NHS Grampian (64%).
• Attendances were broadly stable in NHS Highland.

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

Additional information

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

Diagnosis and reason for attendance can be recorded in a variety of ways, including in free text fields. Therefore, the numbers presented in this report only give a high-level indication of attendances over time.

Drug-related acute hospital admissions

Between July and September 2023, 2,423 drug-related hospital admissions were recorded, similar to the previous quarter (2,484). Admissions were 16% lower than the same period in 2021 (2,889) and 20% higher than in 2022 (2,021).

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 28 June 2021 to 1 October 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 28 June 2021 to 1 October 2023, is on the x axis. Following a long-term-decreasing trend from July 2021 to April 2022, admissions briefly increased in April and May 2022 (peak of 200 admissions during the week beginning 16 May), before following an uneven decreasing trend from June to December 2022. Admissions increased between January and June 2023, reaching a peak in week beginning 10 July (219), before following a decreasing trend until October.

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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 long-term decreasing trend in the weekly number of drug-related hospital admissions from June 2021 to April 2022. Admissions briefly increased between April and May 2022, before following an uneven decreasing trend between June and December 2022. Admissions then increased, from 118 in the week beginning 26 December 2022, to 209 in the week beginning 26 June 2023.
• The long-term decreasing trend in drug-related hospital admissions observed in 2022 differed from previous years, which have generally been characterised by lower numbers of admissions during winter months and higher numbers during summer months. 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.
• Between April to June 2023, the most common drug category recorded was opioids (47% of admissions), followed by cocaine (19%).

National update

For the most recent period (3 July to 1 October 2023):

• 2,423 drug-related hospital admissions were recorded, at an average of 186 per week. This was similar to the previous 13-week period (2,484 admissions, weekly average 191).
• Admissions generally decreased throughout this period, from 204 in the week beginning 3 July 2023, to 144 in the week beginning 25 September 2023.
• The total number of admissions was 16% lower than in 2021 (2,889, weekly average 222) and 20% higher than in 2022 (2,021, weekly average 155).
• Opioids continued to be the most common substance type. These were recorded in an average of 45% of admissions per month, which was broadly consistent over the time series. Admissions recording cocaine remained stable (20%).

Local update

For the most recent period (3 July to 1 October 2023), the number of drug-related hospital admissions varied across mainland NHS boards, compared to the previous quarter:

• Admissions increased in four areas: NHS Greater Glasgow and Clyde (11%), NHS Grampian (18%), NHS Ayrshire and Arran (22%) and NHS Borders (60%).
• Admissions decreased in two areas: NHS Dumfries and Galloway (11%) and NHS Tayside (27%).
• Admissions were broadly stable in three areas: NHS Forth Valley, NHS Lothian and NHS Lanarkshire.

Due to completeness levels below 90% for the most recent time period for both NHS Fife and NHS Highland, the boards 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.

The most recent Accredited 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 average weekly number of suspected drug deaths remained stable between September (19) and November 2023 (19), averaging 21 per week. The total number of suspected drug deaths between September and November 2023 was 267. The number of deaths was 8% lower than in the same time period in 2021 (290) and 6% lower compared to 2022 (285).

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 30 August 2021 to 26 November 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.

The chart shows the weekly number of suspected drug deaths in Scotland on the y axis and the date, between 30 August 2021 to 26 November 2023, on the x axis. Between September 2021 and the end of November 2023, the average weekly number of suspected drug deaths fluctuated considerably but remained within a range of 17 to 30 deaths per week.

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Suspected drug deaths

Summary 

Historic trend 

• Between September 2021 and August 2023, the average weekly number of suspected drug deaths fluctuated considerably but remained within a range of 17 to 30 deaths per week.

Update 

For the most recent period (September to November 2023):

• There were 80 suspected drug deaths in September, 105 in October and 82 in November.
• There was a total of 267 suspected drug deaths, 19% lower than the previous period (330). This was 8% lower than the same period in 2021 (290) and 6% lower than in 2022 (285).
• The average weekly number of suspected drug deaths decreased throughout September and remained broadly stable through October and November 2023.
• There was an average of 21 suspected drug deaths recorded per week. This weekly average was 13% lower than the previous period (24), and similar to the same periods in 2021 and 2022 (both 22).

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 August and November 2023, the 'A Surveillance Study of Illicit Substance Toxicity' (ASSIST) emergency department project made 715 detections of 36 different illicit drugs, in samples from 131 patients. The most detected drug category was depressants (66% of detections), followed by opioids (15%). The most detected individual drug was desmethyldiazepam (11%), followed by cocaine (11%), temazepam (10%) and bromazolam (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. The study uses 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 November 2023 (Q1 to Q5).

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 five quarters - Q1 to Q5. 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% and 66% across the time series. The second most common was opioids with 17%, 18%, 16%, 16% and 15% 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 August 2023:

• The most commonly detected drug type was depressants, making up 61% of all detections, followed by opioids (17%). The most commonly detected individual drug was cocaine (11%).
• 73% of attendances were male and 27% were female.
• 50% of attendances were aged 34 and under. The most common age category was 25 to 34 years (31%), followed by 35 to 44 (26%) and 16 to 24 (19%).
• The most common outcomes were discharged to home (39%), ward (29%) and police custody (10%).

Update

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

• 332 individual ED attendances related to illicit drug use were identified.
• 131 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

Of the 131 samples analysed:

• there was a total of 715 detections of 36 substances (found through the biological detection of the drug or its metabolite).
• the average number of drugs detected per sample was six.

Of the 715 detections, the following drugs were the most common:

• desmethyldiazepam: 80 (11% of detections, 61% of samples)
• cocaine: 79 (11% of detections, 60% of samples)
• temazepam: 73 (10% of detections, 56% of samples)
• bromazolam: 71 (10% of detections, 54% of samples)
• oxazepam: 59 (8% of detections, 45% of samples)
• diazepam: 47 (7% of detections, 36% of samples)
• etizolam: 42 (6% of detections, 32% of samples)
• cannabis (tetrahydrocannabinol): 36 (5% of detections, 27% of samples)
• morphine: 33 (5% of detections, 25% of samples)
• gidazepam: 32 (4% of detections, 24% 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 November 2023 (Q1 to Q5). The percentages are of all detections.

This line chart shows the percentage of detections of specific depressant drugs within QEUH ED across five quarters - Q1 to Q5. Percentage of detections is on the y axis and the time period is on the x axis. The most common depressant drug across the time series with the exception of Q4 was desmethyldiazepam (Q1; 6%, Q2; 5%, Q3; 8%, Q4: 7% and Q5; 8%). This was the second 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 66% of detections (473).

• Benzodiazepines were detected 422 times (59% of all detections):
  • In total, 14 different types of benzodiazepines were detected, including bromazolam (10%) and etizolam (6%).
  • Desmethyldiazepam made up 11% of all detections, up from 8% in Q5.
• Gabapentinoids were detected 36 times (5% of all detections, from 7% in Q4). Of these detections, 11 were gabapentin and 25 were pregabalin.
• There were seven detections of xylazine (1%).

This line chart shows the percentage of detections of specific opioid drugs within QEUH ED across five quarters - Q1 to Q5. 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% and Q5: 5%). Nitazenes were detected for the first time in Q4 (seven detections) and increased to 2% of detections (16 detections) in Q5. Detections of noscapine decreased from 3% in Q1 to 0% in Q5.

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ASSIST hospital toxicology analysis: opioid drugs by study quarter

Opioids were the second most common drug category, making up 15% of detections (108).

• There were 34 detections of heroin/morphine (5%), 22 of methadone and 19 of codeine (3% of detections respectively).
• The presence of noscapine (a compound found in opium) can suggest exposure to opium-derived substances. There were no detections in Q5, down from 11 in Q4.
• There were 16 detections of nitazenes (2%).

Stimulants were the third most common drug category, making up 13% of detections (90).

• The most common stimulant was cocaine, making up 11% of detections (79).
• The second most common stimulant was MDMA, which was detected in seven samples (1%).

Further findings

Complete clinical data are available for 332 attendances for the most recent period (17 August to 16 November 2023):

• 70% of attendees were male (234) and 30% were female (98).
• 18% (60) of attendees were aged 16 to 24 years and 27% (90) were aged 25 to 34.
• 54% of attendees were aged 35 years and over, with 30% (98) aged 35 to 44, 16% (53) aged 45 to 54 and 8% (28) aged 55 years or older.

This stacked bar chart shows the percentage of QEUH ED ASSIST attendees by age group across five time periods - Q1 to Q5. 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 was 35 to 44 years (30%).

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Attendances by age

ED outcome records show:

• 134 (40%) patients were discharged home
• 82 (25%) were admitted to a ward
• 44 (13%) were taken into police custody
• 28 (8%) self-discharged
• 28 (8%) were admitted to an intensive care unit, high-dependency unit, critical care unit or died
• 16 (5%) were recorded as 'unknown' or 'other'

Clinical severity outcome (after 28 days) recorded:

• 313 patients were discharged following the attendance
• seven patients either died or remained an inpatient following the attendance
• outcomes for 10 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 provisional data for Q3 of 2023, the most common drug types detected in post-mortem toxicology were opioids (67%) and benzodiazepines (59%). The percentage of deaths where cocaine was detected continued to increase to 38% (from 36% in Q2 of 2023), making it the most commonly detected individual substance, followed by heroin/morphine (35%), diazepam (30%), methadone (25%) and bromazolam (24%).

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, or where there was suspicion of involvement of controlled drugs.

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:

• 1 June to 30 June 2023, completing data for Q2 of calendar year 2023; and
• July to September (complete period for 1 July to 31 August 2023, with inclusion of available partial data for September 2023), representing data for Q3 of 2023. This period is the most recent data discussed below and is referred to as 'provisional Q3 2023' throughout.

Remaining outstanding data for deaths occurring in September, which will complete the period Q3 of 2023, will be included in the next RADAR publication. More recent data are not yet available due to the overall time it takes to complete toxicology testing and the transition of testing to SPA FS.

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 first chart below provides an indication of controlled drugs detected at post-mortem, in deaths occurring between 1 January 2020 and the most recent time period for which data are available (provisional Q3 2023). 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.

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 provisional Q3 of 2023, is on the x axis. The percentage of deaths positive for opioids increased, from 78% in Q1 of 2020 to 82% in Q2 of 2020, but gradually decreased to 67% in Q3 of 2023. A sharp increase in the percentage of deaths where benzodiazepines were present occurred between Q1 and Q2 of 2020. This percentage remained high throughout 2020, before gradually falling from 73% in Q4 of 2020 to 51% in Q3 of 2022. Since then, benzodiazepine detections have increased, to 59% in Q3 of 2023. Following an isolated increase to a peak of 42% in Q2 of 2021, the percentage of deaths involving gabapentin and pregabalin followed a decreasing trend to Q2 of 2022 (27%), before gradually increasing again to 35% in Q3 of 2023. The percentage of deaths where cocaine was present increased markedly during Q2 of 2020 (to 38%) and also more recently in Q3 of 2023 (to 38%), but otherwise remained relatively stable over the time series (averaging 30%).

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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 where controlled drugs were detected, occurring between 1 January 2020 and the most recent time period for which data are available (provisional Q3 2023).

The chart shows the percentage of forensic toxicology cases testing positive for specific individual 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 provisional Q3 of 2023, is on the x axis. Heroin/morphine has been the most common substance since Q3 of 2021 – the percentage of deaths testing positive for heroin/morphine was relatively stable over the time series (averaging 37%). Methadone detections increased sharply to 45% in Q2 of 2020 but have been gradually decreasing since then (25% in Q3 of 2023). There was a gradual increase in the number of cases where fentanyls were detected from 1% in Q1 of 2022 to 5% in Q3 of 2023. Deaths with buprenorphine present remained relatively low and stable throughout the time series (averaging 6%). 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 Q3 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 individual 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 provisional Q3 of 2023, is on the x axis. Diazepam has been the most commonly detected benzodiazepine since Q2 of 2022. Diazepam detections remained relatively stable for most of the time series, averaging 24% until Q3 of 2022. A marked increase (to 35%) was observed in Q3 of 2022 and, in spite of fluctuations, detections have remained high (30% in Q3 of 2023). Bromazolam (detected for the first time in Q1 of 2022) has increased sharply and was detected in 24% of deaths in Q3 of 2023. Etizolam was the most common benzodiazepine detected for some time, averaging 51% between Q2 of 2020 and Q2 of 2021. Since then, there has been a gradual reduction in etizolam detections to 8% in Q3 of 2023. Deaths with clonazolam present increased in Q2 of 2020, peaking at 12% in Q3 of 2021, before falling to low levels from early 2022.

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Forensic toxicology cases testing positive for specific benzodiazepines

Summary

Historic trend

• The most commonly detected drug types were opioids and benzodiazepines.
• The percentage of deaths where opioids were detected have been gradually decreasing from a peak of 82% in Q2 of 2020, to 72% in Q2 of 2023:
  • Heroin/morphine and methadone were the most common opioids detected.
  • Methadone detections increased sharply from 28% in Q1 of 2020, to 45% in Q2 of 2020, before decreasing to 30% in Q2 of 2023.
  • There has been a small but gradual increase in the number of cases where fentanyl-type opioids were detected, from around 1% prior to Q2 of 2022, to 4% in Q2 of 2023.
  • Deaths with buprenorphine present remained relatively low and stable throughout the time series (averaging 6%).
  • Nitazene-type opioids (detected for the first time in Q1 of 2022) increased but remained uncommon, with 7 (1%) cases detected in Q2 of 2023.
• The percentage of deaths where benzodiazepines were detected increased sharply between Q1 and Q2 of 2020, remaining high before gradually falling from 73% in Q4 of 2020, to 51% in Q3 of 2022. A gradual increase (to 61% in Q2 of 2023) has been observed since then.
  • Diazepam has been the most commonly detected benzodiazepine since Q2 of 2022, remaining relatively stable until Q4 of 2022, when detections increased markedly (to 35%) and remained high (35% in Q2 of 2023).
  • Bromazolam (detected for the first time in Q1 of 2022) has increased sharply (21% in Q2 of 2023), replacing etizolam as the second most common benzodiazepine detected from Q1 of 2023.
  • Etizolam was the most common benzodiazepine detected for some time, averaging 51% between Q2 of 2020 and Q2 of 2021. Since then, there has been a gradual reduction in etizolam detections (13% in Q2 of 2023).
  • Clonazolam detections peaked at 12% in Q3 of 2021, decreasing to 1% in Q2 of 2023.
• The percentage of deaths involving other opioids and benzodiazepines have remained relatively stable over time
• Following an isolated increase to a peak of 42% in Q2 of 2021, the percentage of deaths involving gabapentin and pregabalin followed a decreasing trend to Q2 of 2022 (27%), before gradually increasing again to Q2 of 2023 (34%).
• The percentage of deaths with cocaine present was relatively stable over the time series (average 30%), with the exception of an isolated increase in Q2 of 2020 (38%) and an increase to 36% in Q2 of 2023.

Update

For the most recent time period (complete period for 1 July to 31 August 2023, with inclusion of available partial data for September 2023):

• The total number of deaths testing positive for controlled substances was 603. Many of these deaths involved multiple positive detections, therefore the total number of detections is greater than the number of deaths.
• The following drugs or drug types were most commonly detected:
  • opioids: 402 (67%)
  • benzodiazepines: 357 (59%)
  • cocaine: 227 (38%)
  • heroin/morphine: 211 (35%)
  • gabapentin and pregabalin: 210 (35%)
  • diazepam: 183 (30%)
  • methadone: 149 (25%)
  • bromazolam: 142 (24%)
• The percentage of deaths where opioids were detected decreased to 67% (from 72% in Q2):
  • Heroin/morphine detections remained stable at 35% (also 35% in Q2).
  • Methadone detections decreased to 25% (from 30% in Q2).
  • Fentanyl-type opioids remained relatively stable, detected in 5% of deaths (4% in Q2).
  • Nitazene-type opioids increased, but remained uncommon, detected in 2% of deaths (11) (from 1% in Q2 (7)).
• The percentage of deaths where benzodiazepines were detected decreased slightly to 59% (from 61% in Q1):
  • Diazepam detections decreased to 30% (from 35% in Q2).
  • Bromazolam continued to increase and was detected in 24% of deaths (from 21% in Q2).
  • Etizolam has continued to decrease and was detected in 8% of deaths (from 13% in Q2).
• The percentage of deaths where cocaine was detected continued to increase to 38% (from 36% in Q2), making it the most commonly detected individual substance.
• The percentage of deaths involving gabapentin and pregabalin was relatively stable at 35% (from 34% in Q2).
• For the first time in post-mortem toxicology testing, there were detections of xylazine (a veterinary medicine with sedative, analgesic and muscle relaxant properties). This substance was detected in 1% of deaths (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 (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, as they have only recently emerged in drug markets. 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. 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 August to October 2023 is ongoing and is unable to be included in this report.

We anticipate the updated data will be available for the next release of this report in April 2024. Data to July 2023 are available in the previous quarterly report.

Service indicators

Specialist drug treatment referrals

Between August and November 2023, the average weekly number of referrals to specialist drug treatment services varied widely within an overall decreasing trend. The total number of referrals (5,664) in this time period was 8% lower than in the previous period (6,131), 6% lower than in the same period in 2021 (6,008) and 6% higher than in 2022 (5,354).

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 16 August 2021 and 19 November 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.

This chart shows the number of referrals to drug treatment services in Scotland on the y axis and the date, between 16 August 2021 and 19 November 2023, on the x axis. In December and January each year, a seasonal reduction in referrals occurs. Referrals decreased throughout June and July 2021, and then remained broadly stable to January 2022 (400 to 480 referrals per week). 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 fluctuating, downward trend has been evident since then, with referrals ranging between 400 and 500 per week.

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Specialist drug treatment referrals

Summary

Historic trend

• Referrals decreased throughout June and July 2021 and then remained broadly stable to January 2022 (400 to 480 referrals per week, apart from the seasonal decreases in December and January).
• Throughout 2022, there was a fluctuating, but gradual, decrease in the average weekly number of referrals.
• Following the seasonal reduction in December 2022, the number of referrals returned to a weekly average of approximately 450 per week in January 2023. A fluctuating, downward trend has been evident since then, with referrals ranging between 400 and 500 per week.

National update

For the most recent 13-week period (21 August to 19 November 2023):

• 5,664 specialist drug treatment referrals were recorded, at an average of 436 per week.
• This was 8% lower than the previous 13-week period (22 May to 20 August 2023) when 6,131 referrals were recorded, at an average of 472 per week.
• Referrals were 6% lower compared to the same period in 2021 (6,008, weekly average 462) and 6% higher than in 2022 (5,354, weekly average 412).

Local update

For the most recent period (21 August to 19 November 2023), the number of weekly referrals decreased across most mainland NHS boards, compared to the previous period:

• Referrals decreased in seven areas: NHS Lanarkshire (6%), NHS Greater Glasgow and Clyde (7%), NHS Highland (7%), NHS Lothian (12%), NHS Dumfries and Galloway (17%), NHS Forth Valley (17%) and NHS Ayrshire and Arran (18%).
• Referrals were broadly stable in the other mainland NHS 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 (external website).

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.

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

Opioid substitution therapy

From April to June 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 April 2021 and 30 June 2023.

The stacked area chart shows the three-month rolling average number of doses supplied for OST medications in the community between April 2021 and June 2023. 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. The chart below shows trends in the monthly number of ADQ doses supplied for specific OST medications in the community between 1 April 2021 and 30 June 2023.

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Average total number of OST doses per month

The chart shows monthly trends in the number of doses supplied for specific OST medications in the community between April 2021 and June 2023. Methadone was the most commonly prescribed, at approximately 540,000 doses per month between April and June 2023. Buprenorphine was less frequently prescribed. The average monthly number of oral buprenorphine doses supplied was roughly stable over time, with approximately 119,000 oral buprenorphine doses prescribed per month between April and June 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 102,000 per month between April and June 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 10%, from 603,600 between April and June 2021, to 542,300 between January and March 2023.
• The average monthly number of oral buprenorphine doses supplied was broadly stable between April to June 2021 (123,100) and January to March 2023 (118,200).
• 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 27,300 between April and June 2021, to 88,200 between January and March 2023.

Update

OST prescribing data for July to September 2023 has been delayed due to changes in the primary data source for PHS's Prescribing Information System. We anticipate that data for July to September 2023 will be available for the next release of this report in April 2024.

For the most recent period (1 April to 30 June 2023):

• The average total monthly number of OST doses supplied was approximately 750,900. This was roughly the same as in the previous quarter (January to March 2023; approximately 748,700 doses) and similar to the same period in 2021 and 2022.
• The average monthly number of methadone doses supplied was approximately 530,700. Equivalent figures for oral buprenorphine and injectable buprenorphine were 118,700 and 101,500, respectively.
• The number of methadone doses was approximately the same as in the previous quarter, 12% lower than the same period in 2021 and 7% lower than in 2022.
• The number of oral buprenorphine doses supplied was approximately the same as the previous quarter and similar to the same period in 2021 and 2022.
• The number of injectable buprenorphine doses was 15% higher than in the previous quarter, 272% higher than the same period in 2021 and 54% higher than in 2022.

Additional information

These data have been extracted from the Prescribing Information System (PIS) (external website) 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 numbers of injecting equipment provision (IEP) transactions, and needles and syringes distributed, remained relatively stable between July and September 2023. During this time period, both the number of transactions, and number of needles and syringes distributed were lower than in the same period in 2021 (13% and 9% respectively) and similar to 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 5 July 2021 to 1 October 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 5 July 2021 and 1 October 2023, is on the x axis. An overall decreasing trend was observed from July 2021 to January 2022. Between February 2022 and December 2022, the number of transactions was broadly stable before a large decrease in January 2023. The number of transactions increased in February and fluctuated until the end of June 2023, following an overall increasing trend. Between July and September 2023 transactions were relatively stable. A seasonal dip in transactions in December and January was observed in each year.

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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

• There was an overall decrease in the average weekly number of IEP transactions from July 2021 to January 2022. The average number of transactions remained broadly stable (approximately 3,000 per week) from February 2022 to June 2023.
• An overall decreasing trend in the average weekly number of needles and syringes distributed was observed from July 2021 to January 2022. Between January 2022 and June 2023, the average number of needles and syringes distributed has been broadly stable (approximately 37,000 per week).
• The ratio of needles and syringes distributed was stable from July 2021 to June 2023, at an average of 14 needles and syringes distributed per transaction.
• For each indicator, seasonal fluctuations were observed during December and January each year.

National update

For the most recent period (3 July to 1 October 2023):

IEP transactions

• 39,376 transactions were recorded, at an average of 3,029 per week.
• This was similar to the previous period (3 April to 2 July 2023) when a total of 37,959 transactions were recorded (weekly average 2,920).
• The number of transactions was 13% lower than the same period in 2021 (45,221, weekly average 3,479) and similar to 2022 (38,644, weekly average 2,973).

Needles and syringes distributed

• 504,464 needles and syringes were distributed, at an average of 38,805 per week.
• This was similar to the previous period when a total of 494,660 needles and syringes were distributed, at an average of 38,051 per week.
• The number of needles and syringes distributed was 9% lower compared to the same period in 2021 (554,021, weekly average 42,617) and similar to 2022 (492,782, weekly average 37,906).

Ratio of needles and syringes distributed

• There was a weekly average of 14 needles and syringes distributed per transaction.
• This was equal to the previous period and the same period in 2022 (14), and similar to 2021 (13).

Local update

For the most recent period (3 July to October 2023), the ratio of needles and syringes distributed per transaction varied across mainland NHS boards, compared to the previous period:

• The ratio increased in two areas: NHS Forth Valley (6%) and NHS Tayside (27%).
• The ratio decreased in three areas: NHS Grampian (5%), NHS Lanarkshire (7%) and NHS Greater Glasgow and Clyde (9%).
• The ratio was stable in four areas: NHS Ayrshire and Arran, NHS Borders, NHS Dumfries and Galloway and NHS Lothian.

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 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.