Rapid Action Drug Alerts and Response (RADAR) quarterly report
October 2023
A Management Information Statistics publication for Scotland
- Published
- 24 October 2023
- Type
- Statistical report
- Author
- Public Health Scotland
Toxicology indicators
Emergency department toxicology: ASSIST
Between May and August 2023, the 'A Surveillance Study of Illicit Substance Toxicity' (ASSIST) emergency department project made 810 detections of 52 different illicit drugs, in samples from 157 patients. The most detected drug category was depressants (63%), followed by opioids (15%). The most detected individual drug was cocaine (11%), followed by bromazolam (10%) and temazepam (8%).
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 assess the feasibility of prospective surveillance of ED attendances due to acute illicit drug toxicity, using 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.
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
The total number of surplus serum sample results available for the first 12 months of the study was 448. Many of these involved multiple positive detections, therefore the total number of detections (2,281) is greater than the total number of 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.
Results
The first chart shows the most common drug categories detected in toxicology analysis of surplus serum samples between 17 August 2022 and 16 August 2023.
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.
Summary
Historic trend
Between 17 August 2022 and 16 May 2023:
- The most detected drug category was depressants, making up 60% of all detections, followed by opioids (17%). The most detected individual drug was cocaine (10%).
- 73% of attendances were male and 27% were female.
- 51% were aged 34 and under. The most common age category was 25-24 (32%), followed by 35-44 (27%) and 16-24 (19%).
- The most common outcomes were discharged to: home (41%), ward (26%) and police custody (11%).
Update
For the most recent time period (17 May to 16 August 2023):
- 372 individual ED attendances related to illicit drug use were identified
- 157 surplus serum samples with toxicological analysis results are presented.
Drug type and category
Of the 157 samples analysed:
- there was a total of 810 detections of 52 substances (found through the biological detection of the drug or its metabolite)
- the average number of drugs detected per sample was five.
Of the 810 detections, the following drugs were the most common:
- cocaine: 91 (11% of detections, 58% of samples)
- bromazolam: 85 (10% of detections, 54% of samples)
- temazepam: 64 (8% of detections, 41% of samples)
- desmethyldiazepam: 61 (8% of detections, 39% of samples)
- etizolam: 54 (7% of detections, 34% of samples)
- oxazepam: 52 (6% of detections, 33% of samples)
- diazepam: 46 (6% of detections, 29% of samples)
- pregabalin: 44 (5% of detections, 28% of samples)
- cannabis (tetrahydrocannabinol): 42 (5% of detections, 27% 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.
Depressants were the most common drug category, making up 63% of all detections (511).
- Benzodiazepines were detected 449 times (55% of all detections).
- In total, 30 different types of benzodiazepines were detected, including bromazolam, temazepam, diazepam and etizolam.
- Bromazolam detections increased from 8% of all detections in the previous quarter, to 10% in the most recent period. The number of bromazolam-positive samples increased, from 37% of samples in the previous quarter, to 54% in the most recent period.
- There was also an increase in detections of gidazepam (28, 3% of detections), flubromazepam (16, 2% of detections) and clonazolam (10, 1% of detections).
- Gabapentinoids were detected 56 times (7%). Of these detections, 12 were gabapentin and 44 were pregabalin.
- There was a small number of detections (< 5) of zopiclone, zolpidem, xylazine and meprobamate.
Opioids were the second most common drug category, making up 15% of all detections (126).
- There were 44 detections of morphine (an opioid and metabolite of heroin and other opioids). There were 29 detections for codeine and 19 for methadone.
- There was a small number of detections (< 5) of protonitazene, tapentadol, metonitazene, tramadol and buprenorphine.
Stimulants were the third most common drug category, making up 13% of all detections (104).
- The most common stimulant was cocaine, making up 11% of all detections (91 times). The number of cocaine-positive samples increased, from 49% of samples in the previous quarter, to 58% in the most recent period.
- The second most common stimulant was amphetamine, detected 7 times (1%).
- There was a small number of detections (< 5) of MDMA, methamphetamine, 4-CEC (cathinone) and n-ethylpentylone (cathinone).
Further findings
Complete clinical data are available for 372 attendances for the most recent period (17 May to 16 August 2023):
- 73% were male (272) and 27% were female (100).
- 19% (69) were aged 16 to 24 and 29% (107) were aged 24 to 34.
- Just over half were aged 35 and over, with 24% (89) aged 35 to 44, 20% (74) aged 45 to 54 and 7% (27) aged 55 years or older.
ED outcome records show:
- 131 (35%) patients were discharged home
- 131 (35%) were admitted to a ward
- 35 (9%) were taken into police custody
- 34 (9%) self-discharged
- 21 (6%) were admitted to an intensive care unit, high-dependency unit or critical care unit
- 20 (6%) were recorded as 'unknown' or 'other'
Clinical severity outcome (after 28 days) recorded:
- 354 patients were discharged
- nine patients either died or remained an inpatient
- outcomes for nine 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. 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.
Post-mortem toxicology testing for controlled substances
From April to May 2023, the most common drug types detected in post-mortem toxicology were opioids (72%) and benzodiazepines (60%). The most common individual drugs detected were cocaine (37%) and diazepam (37%), followed by methadone (35%) and heroin/morphine (33%). Bromazolam (a new benzodiazepine) was detected in 23% of deaths.
Background
All sudden or unexpected deaths in Scotland are investigated by the Crown Office and Procurator Fiscal Service (COPFS) to determine the cause of death and the need for criminal proceedings. To inform these decisions, the COPFS commissions post-mortem toxicology and pathology services across Scotland.
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 analysis in this report 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.
New data included in analysis
For the first time in a RADAR quarterly report, data are available for the whole of Scotland. Previous reports only included data on deaths in the west, east and parts of the north of Scotland (the areas covered by SPA FS).
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 those shown in previous publications.
Reporting period
This report includes two new periods of data:
- 1 January to 31 March 2023, representing Q1 of calendar year 2023
- 1 April to 31 May 2023 (most recent data discussed in the ‘Update’ section), representing partial data for Q2 of 2023.
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.
Controlled drugs detected at post-mortem
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 new or emerging drugs are added to toxicology screening.
The first chart provides an indication of controlled drugs detected at post-mortem, in deaths occurring between 1 January 2020 and 31 May 2023.
As indicated by the dotted vertical 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 (Q1), the data include all areas in Scotland.
Opioids and benzodiazepines
The next two 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 31 May 2023.
Summary
Historic trend
- In total, 2,425 deaths occurred in 2022 where controlled drugs were detected in post-mortem toxicology across Scotland.
- 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 81% in Q2 of 2020, to 69% in Q1 of 2023:
- Heroin/morphine and methadone were the most common opioids
- Methadone detections increased sharply from 28% in Q1 of 2020, to 45% in Q2 of 2020, before decreasing to 25% in Q1 of 2023.
- There has been a small but gradual increase in the number of cases where fentanyl-type opioids were detected, from around 1% before Q2 of 2022, to 6% in Q1 of 2023.
- Deaths with buprenorphine present remained relatively low and stable throughout the time series (averaging 6%).
- Nitazene-type opioids were first detected in Q2 of 2022. Routine testing on all samples from across Scotland was available from early 2023. In Q1 of 2023, nitazenes were detected in <1% of deaths.
- The percentage of deaths where benzodiazepines were detected increased sharply between Q1 and Q2 of 2020. They remained high before gradually falling from 72% in Q1 of 2021, to 50% in Q3 of 2022. A slight increase was observed in Q1 of 2023.
- Diazepam has been the most commonly detected benzodiazepine since Q2 of 2022 and, although there was a slight increase in Q4 of 2022, has remained relatively stable since Q1 of 2020.
- Bromazolam (detected for the first time in Q3 of 2022) has increased sharply, replacing etizolam as the second most common benzodiazepine detected in Q1 of 2023.
- Etizolam was the most common benzodiazepine detected for some time, increasing sharply in Q2 of 2020, before decreasing in Q3 2021. Since then, there has been a continued reduction in etizolam detections.
- Clonazolam detections peaked at 12% in Q3 of 2021, decreasing to 1% in Q1 of 2023.
- The percentage of deaths involving other opioids, gabapentin and pregabalin, or cocaine has remained relatively stable over time.
Update
For the most recent time period (1 April to 31 May 2023):
- The total number of deaths testing positive for controlled substances was 380. 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: 273 (72%)
- benzodiazepines: 228 (60%)
- cocaine: 142 (37%)
- diazepam: 140 (37%)
- methadone: 132 (35%)
- gabapentin and pregabalin: 131 (34%).
- The percentage of deaths where opioids were detected was relatively stable at 72% (from 69% in Q1):
- Methadone detections increased to 35% (from 25% in Q1), replacing heroin/morphine as the most commonly detected opioid.
- Heroin/morphine remained stable, detected in 33% of cases (from 32% in Q1).
- Fentanyl-type opioids were detected in 3% of deaths (from 6% in Q1).
- Nitazene-type opioids were detected in 1% of deaths (from <1% in Q1).
- The percentage of deaths where benzodiazepines were detected increased to 60% (from 54% in Q1):
- Diazepam detections increased to 37% (from 29% in Q1).
- Bromazolam continued to increase sharply and was detected in 23% of deaths (from 18% in Q1).
- Etizolam remained stable and was detected in 12% of cases (from 12% in Q1).
- The percentage of deaths where cocaine was detected increased to 37% (from 29% in Q1), also making it the most commonly detected substance, alongside diazepam.
- The percentage of deaths involving gabapentin and pregabalin remained relatively stable at 34% (from 32% in Q1).
Additional information
Toxicology services
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 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 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.
New drugs
New drugs (bromazolam, desalkylgidazepam and nitazene-type opioids) 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.
Scope
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.
Date of death analysis
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:
- Date of the case being received or sent to other labs for toxicology testing.
- 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 COPFS has been used instead.
The dates listed 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
Synthetic cannabinoids were the most prevalent drug type detected in the Scottish Prisons Non-Judicial Drug Monitoring Project between April and July 2023, detected in 48% of samples. Benzodiazepines and steroids were the second most prevalent, both detected in 9% of samples, with bromazolam being the most prevalent benzodiazepine.
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 non-attributable samples seized in Scottish prisons between 1 April 2021 and 31 July 2023.
The chart below shows the five most detected drug types from seizures in Scottish prisons between 1 April 2021 and 30 June 2023. This is based on the percentage of samples tested each month and uses 3-month moving average figures.
Summary
Historic trend
- The number of seizures analysed varied widely between April and December 2021, ranging from 23 in June, to 134 in September. In 2022, the monthly average remained relatively stable at 35. During Q1 of 2023, the monthly average number of seizures was 50.
- Sample-type data were highly variable over time. Changes were observed in sample-type detections during 2022 and 2023:
- Paper and card detections decreased, from a monthly average of 73% in 2021, to 24% in 2022, to 6% in Q1 of 2023. 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 in 2022. This fell slightly to 25% in Q1 2023.
- Drug-type data were highly variable over time, so the following narrative is based on averages:
- Synthetic cannabinoids were the most common substances detected, followed by benzodiazepines.
- In 2021, the percentage of seizures testing positive for synthetic cannabinoids was on average 42% per month. Percentages varied throughout 2022, averaging 33% per month, with higher percentages observed during the summer months. In 2023, monthly averages increased between January and March, from 19% to 33%.
- The percentage of seizures testing positive for benzodiazepines fluctuated throughout 2021 (monthly average 38%), before decreasing and remaining relatively stable in 2022 (monthly average 26%). In 2023, monthly averages decreased between January and March, from 30% to 15%.
Update
This update provides analysis of 113 samples tested in the most recent time period (1 April to 31 July 2023):
Sample type
- The most common sample type was e-cigarette (37% of samples).
- The percentage of e-cigarettes fluctuated across the time period, from 18% in April to 70% in June.
- Synthetic cannabinoids were detected in 57% of the e-cigarettes analysed.
- Paper or card detections were the second most common sample type detected (16% of samples).
- The percentage of paper or card detections fluctuated, from 6% in April to 47% in June.
Drug type
- The three most detected controlled drug types were synthetic cannabinoids, benzodiazepines and steroids.
- Synthetic cannabinoids were the most common drug type, detected in an average of 44% of seizures per month – similar to the average of 41% observed during the same time period in 2022.
- Benzodiazepines and steroids were the second most common drug types.
- 80% of benzodiazepine samples contained bromazolam. View our bromazolam alert.
- Benzodiazepines were detected in an average of 9% of seizures per month – lower than the average of 21% during the same time period in 2022.
- Steroids were detected in an average of 9% of seizures per month – similar to the average of 10% during the same time period in 2022.
Further information
Between January and July 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 the SPS and the 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 the SPS since February 2021.