Emergency department toxicology: ASSIST

Between February and May 2023, the ‘A Surveillance Study in Illicit Substance Toxicity’ (ASSIST) emergency department pilot made 448 detections of 48 different illicit drugs, in samples from 100 patients. The most detected drug category was depressants (60%), followed by opioids (17%). The most detected individual drug was cocaine (11%), followed by bromazolam and etizolam (both 8%).

Background

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

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

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

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

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

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

Toxicology analysis of surplus serum samples

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

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

The total number of samples included for surplus serum sampling for the first 9 months of the ASSIST study was 291. Many of these involved multiple positive detections (total of 1471 detections), therefore the total number of detections listed below is greater than the total number of samples.

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

Detections presented are for the substance only. If a metabolite 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.

All prescribed medications are removed from the detections list. For example, if methadone is detected but the individual is prescribed methadone, it will not be included.

This stacked bar chart shows the number of detections of drug types within QEUH ED. The drugs are grouped into five main categories of effect, with depressant, opioid, stimulant, cannabinoid and other, on the y axis and the number of detections along the x axis. The most common category was depressant, with 880 detections. This included 756 detections of benzodiazepines and 103 detections of gabapentinoids. The second most common category was opioid, with 255 detections, 71 of these were of morphine. The third most common category was stimulant, with 194 detections. 151 of these were of cocaine. There were 118 detections of cannabinoids, nine of these were of synthetic cannabinoids. There were 26 detections of other drugs.

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Toxicology analysis of surplus serum samples: drug category

Summary

For the most recent time period (17 February to 16 May 2023):

• 317 individual ED attendances related to illicit drug use were identified.
• 100 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 100 individual samples with toxicology:

• There was a total of 448 detections of 48 substances (found through the biological detection of the drug or its metabolite).

Of the 448 detections, the following drugs were the most common:

• cocaine: 49 (11% of detections, 49% of samples)
• bromazolam: 37 (8% of detections, 37% of samples)
• etizolam: 37 (8% of detections, 37% of samples)
• desmethyldiazepam: 34 (8% of detections, 34% of samples)
• cannabis (tetrahydrocannabinol): 34 (8% of detections, 34% of samples)
• diazepam: 25 (6% of detections, 25% of samples)

Note: desmethyldiazepam is a benzodiazepine, and also a metabolite of other benzodiazepines such as diazepam. 

This stacked bar chart shows the percentage of detections of drug types within QEUH ED across three time periods - 17/08/22 to 16/11/22, 17/11/22 to 16/02/23 and 17/02/23 to 16/05/23. The drugs are grouped into six categories other depressant, bromazolam, etizolam, opioid, cocaine and other, on the y axis and the time period along the x axis. The most common category was other depressant with 45%, 49% and 43% across the time periods. The second most common is opioids with 17,18 and 17% across the time periods. An increase in bromazolam detections has been seen across the time period, increasing from 4% in the first quarter to 8% in the most recent.

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Toxicology analysis by drug type: per quarter

For the most recent time period (17 February to 16 May 2023):

• Depressants were the most common drug category, making up 60% of all detections (267 times):
  • Benzodiazepines were detected 228 times (51% of all detections).
  • In total, 14 different types of benzodiazepines were detected, including bromazolam (8%, 37 detections) and etizolam (8%, 37 detections).
  • Bromazolam detections have increased over the study, from 4% between August and November 2022, to 8% in the most recent time period.
  • Gabapentinoids were detected 34 times (8%). 11 of these were gabapentin and 23 were pregabalin.
• Opioids were the second most common drug category, making up 17% of all detections (75 times).
  • There were 25 detections of morphine (an opioid and metabolite of heroin and other opioids). There were 17 detections for codeine and 15 for methadone.
• Stimulants were the third most common drug category, making up 14% of all detections (52 times).
  • The most common stimulant was cocaine, making up 11% of all detections (49 times).

Further findings

Complete clinical data are available for 317 attendances for the most recent time period (17 February to 16 May 2023): 

• 230 were male (73%) and 87 were female (27%).
• Over half were over 35 years old, with 29% aged 35 to 44 years.
  • A decrease in the number of patients aged 34 and under was observed, from 54% in the first two quarters of the study, to 46% in the most recent time period.

This stacked bar chart shows the percentage within QEUH ED across three time periods - 17/08/22 to 16/11/22, 17/11/22 to 16/02/23 and 17/02/23 to 16/05/23. Age is grouped into six categories (16 to 24, 25 to 34, 35 to 44, 45 to 54,over 55 and age unknown) on the y axis and the time period along the x axis. The most common category age group is 25 to 34 in the first two quarters at 34%. The most common age groups in the most recent quarter are 25 to 34 and 35 to 44 years at 29% each.

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Attendances by age

•  ED outcome records show that: 
  • 109 (34%) patients were discharged home 
  • 93 (29%) were admitted to a ward 
  • 43 (14%) self-discharged 
  • 31 (10%) were taken into police custody 
  • 15 (5%) were admitted to an intensive care unit, high dependency or critical care unit 
  • 26 (8%) were recorded as 'unknown' or 'other'. 
• Clinical severity outcome (after 28 days) recorded that: 
  • 313 patients were discharged 
  • less than five patients died 
  • less than five patients were ongoing inpatient admissions 
  • one outcome was '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

Post-mortem toxicology testing for controlled substances

From October to December 2022, the most common drug types detected in post-mortem toxicology were opioids (75%) and benzodiazepines (62%). The most common drugs detected were heroin/morphine (38%), followed by diazepam (35%). Bromazolam (a new ‘street’ benzodiazepine) was detected in 15% of deaths.

This indicator update provides complete data for Q4 of 2022 (1 October 2022 to 31 December 2022), revising the partial Q4 information included in RADAR quarterly report 3.

Background

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

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

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

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

The data presented below is a revision of the previous RADAR publication, which included data for the period 1 October to 30 November 2022 only. The revised information presented in this report now also includes tests for deaths occurring in December 2022 and therefore completes the reporting period for Q4 of 2022 (1 October to 31 December 2022). More recent data are not yet available due to the transition of testing to SPA FS and the complexities of establishing a new service within a different organisation.

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

The first chart below provides an indication of controlled drugs found present at post-mortem in deaths occurring between 1 January 2020 and 31 December 2022.

The chart shows the percentage of forensic toxicology cases testing positive for controlled substances (opioids, benzodiazepines, gabapentin and pregabalin, cocaine). The percentage of toxicology cases is on the y axis and the calendar year and quarter of death, between Q1 of 2020 and Q4 of 2022, is on the x axis. The percentage of deaths that tested positive for opioids increased from Q1 to Q2 of 2020, but otherwise remained relatively stable over the time series. A sharp increase in the percentage of deaths where benzodiazepines were present occurred between Q1 and Q2 of 2020. This percentage remained high throughout 2020, before gradually falling from Q1 of 2021 onwards. The percentage of deaths where gabapentin and pregabalin was present remained relatively stable across the time series, though an isolated increase was observed in Q2 of 2021. The percentage of deaths where cocaine was present increased markedly during Q2 of 2020 but was otherwise relatively stable over the time series.

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Forensic toxicology cases testing positive for controlled substances

The second chart provides an indication of specific opioids and benzodiazepines found present at post-mortem in deaths occurring between 1 January 2020 and 31 December 2022.

The chart shows the percentage of forensic toxicology cases testing positive for specific individual opioids (heroin/morphine, methadone and buprenorphine) and benzodiazepines (diazepam, etizolam, clonazolam and bromazolam). The percentage of toxicology cases is on the y axis and the calendar year and quarter of death, between Q1 of 2020 and Q4 of 2022, is 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. Since Q3 of 2021, etizolam and methadone detections have decreased. Heroin/morphine remained relatively stable and has been the most common substance since Q3 of 2021. In Q4 of 2022 diazepam reached similar levels to heroin/morphine, after a marked increase in detections. Deaths with clonazolam present increased in Q2 of 2020, peaking in Q3 of 2021, before falling to zero in early 2022. Deaths with buprenorphine present remained relatively low and stable throughout the time series. Data included for the first time in Q4 of 2022, shows that 15% of deaths tested positive for bromazolam.

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Forensic toxicology cases testing positive for specific opioids and benzodiazepines

Summary

Historic trend

• In total, 1,942 deaths occurred in 2022 where controlled drugs were found present in post-mortem toxicology, which was 11% lower than in 2021 (2,179) and 10% lower than in 2020 (2,147).
• The most commonly detected drug types were opioids and benzodiazepines.
• The percentage of deaths with benzodiazepines present remained high throughout 2020 to Q2 of 2021, before a decreasing trend between Q3 of 2021 and Q3 of 2022. The decrease in benzodiazepine presence could be partly due to a lack of testing for new and emerging drugs.
• The specific drugs most commonly present throughout the time series (from Q1 of 2020 to Q2 of 2022) were etizolam, methadone and heroin/morphine. Etizolam and methadone detections both increased sharply in Q2 of 2020, before both reducing in Q3 2021, etizolam most notably.
• Tests positive for clonazolam peaked at 12% of deaths in Q3 of 2021, before decreasing to zero in Q3 of 2022.
• Since Q2 of 2020 there has been a gradual reduction in the percentage of deaths where methadone was detected.
• The percentage of deaths involving diazepam, other opioids, gabapentin and pregabalin or cocaine has remained relatively stable over time.

Update

For the most recent time period (1 October to 31 December 2022):

• The total number of deaths testing positive for controlled substances was 478. Many of these deaths involved multiple positive detections, therefore the total number of detections listed below is greater than the total number of deaths.
• The following drugs or drug types were most commonly detected:
  • opioids: 358 (75%)
  • benzodiazepines: 296 (62%)
  • gabapentin and pregabalin: 174 (36%)
  • cocaine: 136 (28%)
• Heroin/morphine remained the most commonly detected substance, with 38% of cases testing positive (from 35% in Q3). Methadone was detected in 29% of cases (from 25% in Q3).
• Diazepam detections increased markedly to 35% of cases (from 25% in Q3). Etizolam was detected in 17% of cases (from 18% in Q3).
• Due to expanded toxicology testing, there were new detections of the following substances (detected for the first time when testing was outsourced to other laboratories):
  • Bromazolam (a new 'street' benzodiazepine) was detected in 15% of deaths (70).
  • Desalkylgidazepam (a new 'street' benzodiazepine, also known as bromonordiazepam) was detected in 1% of deaths (4).
  • Protonitazene (a nitazene-type opioid) was detected in 1% of deaths (<3).

Additional information

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

The data above are for deaths occurring in the west, east and parts of the north of Scotland. It does not include a small number of cases in the far north and north-east of Scotland where post-mortem toxicology testing is conducted by the Aberdeen Royal Infirmary (ARI).

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.

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

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

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

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

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

Glossary

Drug seizures in Scottish prisons

Benzodiazepines were the most prevalent drug type detected in the Scottish Prisons Non-Judicial Drug Monitoring Project between January and March 2023, detected in 21% of samples, with bromazolam being the most prevalent benzodiazepine detected. Synthetic cannabinoids were the second most prevalent, detected in 19% 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 shows the number and type of samples seized in Scottish prisons between 1 January 2021 and 31 March 2023.

The chart shows the percentage of SPS drug seizures broken down by sample type (e-cigarette, paper or card, tablet, powder and other). The percentage of samples is on the y axis and the date, between January 2021 and March 2023, is on the x axis. Sample types are highly variable over the time period. Paper or card detections decreased across the time series with an average of 73% per month being detected in 2021, compared to 23% per month in 2022. There were low detections of e-cigarettes until June 2022, when they made up over half of the seizures that month. Between July to November, an average of 32% of the samples per month were e-cigarettes. This briefly decreased to 5% in December 2022, before increasing and remaining relatively stable at 24% per month between January and March 2023. Powder samples remained relatively stable, with approximately 19% per month being detected in 2022, peaking at 50% in December.

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Drug seizures in Scottish prisons: sample type

The chart below shows the three most detected drug types from seizures in Scottish prisons between 1 January 2021 and 31 March 2023. This is based on the percentage of samples tested each month and includes raw data and 3-month moving averages.

The chart shows the percentage of SPS drug seizures broken down by drug type (synthetic cannabinoids, benzodiazepines and opioids). The percentage of samples is on the y axis and the date, between January 2021 and March 2023, is on the x axis. Synthetic cannabinoids are the most prevalent drug throughout the time series. The percentage of seizures testing positive for synthetic cannabinoids was on average 43% per month in 2021, decreasing to 33% per month in 2022. The second most common drug type detected is benzodiazepines. The percentage of seizures testing positive for benzodiazepines fluctuated throughout 2021 with an average of 38% per month, before decreasing and remaining relatively stable in 2022 (average of 26%).

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Drug seizures in Scottish prisons: drug type

Summary 

Historic trend

• The number of seizures analysed fluctuated in 2021, ranging from a low of 23 in June and peaking at 134 in September. Between January and December 2022, the average number of seizures analysed remained relatively stable with an average of 35 per month, ranging from a low of 10 in June and peaking at 52 in March. The number of seizures is not indicative of a change in the total number of drug seizures each month in Scottish prisons, as this project only analyses non-judicial (or non-attributable) samples.
• Sample type data were highly variable over time, but changes were observed in sample type detections during 2022:
  • Paper and card detections decreased, making up an average of 24% of samples per month in 2022, compared to an average of 73% per month in 2021. This is thought to be due to changes to prison rules that mean prisoners now receive photocopied correspondence rather than original items.
  • E-cigarette detections increased from June 2022 onwards, making up an average of 30% of samples per month.
• Synthetic cannabinoids were the most common substances detected, followed by benzodiazepines. Drug type seizure data were highly variable over time, so the following narrative is based on the 3-month moving average:

• The percentage of seizures testing positive for synthetic cannabinoids was on average 42% per month in 2021. Percentages varied throughout 2022; between January and April 2022 the percentage remained relatively stable (average of 27% per month), increasing to 43% between May and September. The percentage decreased for the remainder of the year, averaging 26% per month.

• The percentage of seizures testing positive for benzodiazepines fluctuated throughout 2021 (monthly average 38%), before decreasing and remaining relatively stable from January to December 2022 (monthly average 26%).

Update

This update provides analysis of 101 samples tested in the most recent time period (1 January to 31 March 2023):

Sample type

• An increasing trend in the percentage of e-cigarette and tablet sample types was observed:
  • The most common sample types were e-cigarettes and tablets (each accounting for 27% of samples).
  • Synthetic cannabinoids were detected in 30% of the e-cigarettes analysed.

Drug type

• The three most detected controlled drugs were cannabis, bromazolam (benzodiazepine) and pregabalin.
• Benzodiazepines were the most common drug type.
  • They were detected in an average of 21% of seizures per month (average of 27% during the same time period in 2022).
  • 69% of benzodiazepine samples contained bromazolam. View our bromazolam alert.
• Synthetic cannabinoids were the second most common drug type.
  • They were detected in an average of 19% of seizures per month (average of 33% during the same time period in 2022).
• Cannabis was the third most common drug type.
  • Cannabis was detected in an average of 7% of seizures per month (average of 2% during the same time period in 2022).

Further information 

Between January and March 2023, this drug analysis project detected the following drugs for the first time in prisons in Scotland, demonstrating a constantly evolving drugs market: 

• dipentylone (cathinone, stimulant)
• MDMB-INACA (synthetic cannabinoid)

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 funded directly by SPS since February 2021.

Why we use a 3-month moving average 

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

Glossary