Drug-related harms decreased during the most recent quarter (September to November 2024). However, intelligence suggests the drug supply remains highly toxic and unpredictable, requiring ongoing vigilance and a heightened response. Significant disruptions and adaptations in the heroin and benzodiazepine markets, appear to be influencing levels and patterns of harm.

Key points

• Benzodiazepines: A decrease in bromazolam detections was observed in post-mortem and seizure toxicology sources. There was a slight increase in emergent benzodiazepines detected during this period including clonazolam and desalkylgidazepam.
• Heroin: Adulteration of heroin with synthetic substances, including nitazenes and xylazine, continued to be reported through RADAR reports and WEDINOS. These adulterants increase the risk of overdose and adverse effects and were associated with unpredictable reactions, including rapid onset overdose and difficulty reversing overdoses with naloxone.
• Cocaine: Cocaine remained the most frequently identified substance in both post-mortem toxicology and the ASSIST project, highlighting its leading role in harms.

Data update

The following changes were observed compared to the previous reporting period (reported in quarterly report 9 – October 2024).

For harm indicators:

• naloxone administration incidents (September to November 24): 30% decrease
• emergency department attendances (September to November 24): 10% decrease
• suspected drug deaths (September to November 24): 10% decrease
• drug-related hospital admissions (July to September 24): 8% decrease

For service indicators:

• drug treatment referrals (August and November 24): stable
• injecting equipment provision (July to September 24): 2% increase in transactions, 2% increase in number of needles and syringes distributed
• opioid substitution therapy (July to September 24): 2% decrease

Alerts

• The legal status section in our public health alerts were updated in January 2025 to reflect changes to the Misuse of Drugs Act (1971) (external website).
  • PHS alert: nitazenes
  • PHS alert: xylazine
  • PHS alert: bromazolam 

Harm indicators

• Between September and November 2024, the number of Scottish Ambulance Service naloxone administration incidents was 30% lower than the previous quarter. Incidents were 24% lower than the same period in 2022 and 34% lower than in 2023.
• Between September and November 2024, drug-related attendances at emergency departments were 10% lower than the previous quarter. Attendances were 14% lower than the same period in 2022 and 16% lower than in 2023.
• Between July and September 2024, drug-related hospital admissions were 8% lower than the previous quarter. Admissions were similar to the same period in 2022 and 20% lower than in 2023.
• Between September and November 2024, there were 215 suspected drug deaths. The number of deaths was 10% lower than the previous quarter (238), 20% lower than the same period in 2022 (268) and 15% lower than in 2023 (254).

Toxicology indicators

• Between September and November 2024, the most frequently detected drug in the ASSIST hospital toxicology project was cocaine (13%), followed by desmethyldiazepam (12%) and temazepam (10%). N-desethyl etonitazene was detected for the first time in the study.
• Between July and September 2024, the most common drug types detected in post-mortem toxicology were opioids (73%) and benzodiazepines (54%). Cocaine continued to be the most commonly detected individual drug (34%), followed by heroin/morphine (31%), diazepam (23%) and methadone (23%). Nitazenes increased slightly, being detected in 4% of deaths (25). Nitazenes have been detected in a total of 105 deaths (to 30 September 2024).
• Synthetic cannabinoids continue to be the most prevalent drug type detected in the Scottish Prisons Non-Judicial Drug Monitoring Project.

Service indicators

• Between August and November 2024, the average weekly number of referrals to specialist drug treatment services was relatively stable. The total number of referrals recorded (6,578) was 7% higher than the same period in 2022 (6,166) and 5% lower than in 2023 (6,910).
• Between July and September 2024, opioid substitution therapy doses supplied per month was 7% lower than the same period in 2022 and similar to 2023. The average monthly number of methadone doses supplied continued to decrease while injectable buprenorphine doses increased over time.
• Between July and September 2024, the average weekly number of injecting equipment provision transactions was similar (2% higher) to the previous quarter, similar to the same period in 2022 and 6% lower than 2023. The number of needles and syringes distributed was similar (2% higher) to the previous quarter, 6% lower than the same period in 2022 and 7% lower than in 2023.

Reporting trends

• Between 5 October 2024 and 4 January 2025, 97 trend reports were received by RADAR.
• The majority of reports related to heroin and benzodiazepines.
• Trend reports can be viewed on our dashboard (external website).

Implications

• The harm caused by drugs is a significant public health issue for Scotland and there is a high likelihood of sudden, localised spikes of drug-related harms. For information on responding to a drug harm incident see: Guidance on the management of clusters of drug related harms.
• Contamination of illicit drugs with toxic substances is both common and widespread across drug types. There remains an urgent need for hospital toxicology and accessible drug checking services across the country.
• The changes in the types of benzodiazepines detected, specifically the reduction in bromazolam and the emergence of novel benzodiazepines, followed international control.
  • In 2024, bromazolam was included in the Convention on Psychotropic Substances (1971). These measures are likely to contribute to disruptions in the availability and accessibility of bromazolam.
  • Given the dominance of bromazolam within the Scottish drug supply over the past 18 months, a reduction in availability is of concern. There is a risk that previously unseen and highly toxic benzodiazepines may emerge to dominate the supply in the near future.
  • There remains an urgent need for evidence-based benzodiazepine harm reduction and polysubstance treatment support interventions.
  • Toxicology services and Public Health Scotland should continue to collaborate to support timely identification and risk assessment of the health impact of emergent ‘street benzos’.
• There is a mixed picture of availability and widespread contamination of the heroin supply with both nitazenes and xylazine. It is unclear whether these changes are because of global supply changes or market adaptation.
• Cocaine continued to play a leading role in drug harms. Further work is needed to deliver harm reduction and treatment support. Injecting cocaine carries the highest risk of harm. Scaling up access to evidence-based interventions, including access to safer consumption facilities and provision of inhalation devices should be considered across Scotland.
• People use drugs in different ways and for different reasons, understanding the specific context and nature of drug use amongst people at risk or affected is critical to an effective response. The risk of harm is increased in the context of stigma and exclusion and these factors should be considered when preventing or responding to a drug harm incident.
• There is a risk that as the availability or perceived quality of substances changes, the types of drugs that contribute to harms changes. There is an urgent need for coordination to improve Scotland's ability and agility in responding to polysubstance use and a continually evolving drug market. A focus is needed on development, implementation and evaluation of measures to prevent and reduce the harms of polysubstance use.
• A system-wide approach that prevents drug harms and supports people affected to access treatment, care and recovery remains critical.