Drug-related harms in Scotland remain stable at a high level, highlighting the continued urgency of addressing this public health crisis. The stability at a national level masks substantial variability in local trends and occasions of clustering of harms. Ongoing risks and emerging trends require sustained attention.

Key trends

• Polysubstance use continues to drive the majority of harms, with high-risk combinations frequently involving cocaine, gabapentinoids, benzodiazepines (notably diazepam and bromazolam) and opioids.
• Emerging synthetic drugs such as potent nitazene-type opioids and xylazine are increasingly reported in harms.
• Cocaine continues to be the most common substance in both post-mortem toxicology and the ASSIST emergency department project.
• Contamination of drugs remains prevalent, with substances often not containing what the purchaser intended; this spans across drug types, including powders, vapes and pills (even in apparent medicines like those in blister packs).

Data update

The following changes were observed compared to the previous reporting period (reported in quarterly report 8 – July 2024).

For harm indicators:

• naloxone administration incidents (June to August 24): 7% increase
• emergency department attendances (June to August 24): 3% increase
• suspected drug deaths (June to August 24): 10% decrease
• drug-related hospital admissions (April to June 24): 5% increase

For service indicators:

• drug treatment referrals (May to August 24): 9% decrease
• injecting equipment provision (April to June 24): 3% increase in transactions, 3% decrease in number of needles and syringes distributed
• opioid substitution therapy (April to June 24): 2% decrease

Alerts

• A public health alert about nitazene-type opioids was published in January 2023. It was updated in July 2024, due to increasing detections in drugs mis-sold as heroin and diazepam.
  
  • PHS alert: nitazenes
• A public health alert about xylazine was published in May 2024, due to increasing detections, particularly in drugs mis-sold as heroin. Its use is associated with sedation, sudden collapse and severe wounds.
  
  • PHS alert: xylazine
• A public health alert about new benzodiazepines was published in July 2023 and remains current.
  • PHS alert: bromazolam

Harm indicators

• Between June and August 2024, the total number of Scottish Ambulance Service naloxone administration incidents was 7% higher compared to the previous quarter. Incidents were similar to the same period in 2022 and 20% lower than in 2023.
• Between June and August 2024, drug-related attendances at emergency departments were stable compared to the previous quarter. Attendances were similar to the same period in 2022 and 19% lower than in 2023.
• Between April and June 2024, drug-related hospital admissions were 5% higher compared to the previous quarter. The total number of admissions was similar to the same period in 2022 and 12% lower than in 2023.

• Between June and August 2024, there were 225 suspected drug deaths. The number of deaths was 10% lower than the previous quarter (249), 13% lower than the same period in 2022 (258) and 25% lower than in 2023 (301).

Toxicology indicators

• Between June and August 2024, the most frequently detected drug in the ASSIST hospital toxicology project was cocaine (13%), followed by desmethyldiazepam (11%) and temazepam (10%).
• Between April and June 2024, the most common drug types detected in post-mortem toxicology were opioids (70%) and benzodiazepines (56%). Cocaine continued to be the most commonly detected individual drug (37%), followed by heroin/morphine (32%), diazepam (28%), codeine (26%) and methadone (25%).
• Synthetic cannabinoids continue to be the most prevalent drug type detected in the Scottish Prisons Non-Judicial Drug Monitoring Project.

Service indicators

• Between May and August 2024, the average weekly number of referrals to specialist drug treatment services was relatively stable. The total number of referrals recorded in this period (6,337) was 5% higher compared to the same period in 2022 (6,031) and 10% lower than in 2023 (7,043).
• Between April and June 2024, opioid substitution therapy (OST) doses supplied per month was slightly lower compared to the same periods in 2022 and 2023. The average monthly number of methadone doses supplied continued to decrease while injectable buprenorphine doses increased over time.
• Between April and June 2024, the average weekly number of injecting equipment provision transactions was similar (3% higher) to the previous quarter, 5% lower than the same period in 2022 and similar to 2023. The number of needles and syringes distributed was similar (3% lower) to the previous quarter, 6% lower than the same period in 2022 and 7% lower than in 2023.

Reporting trends

• Between July and October 2024, 69 trend reports were received by RADAR.
• The majority of reports related to benzodiazepines, heroin, cocaine, synthetic opioids and polydrug use.
• 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.
• The risk of harm and death are increased in the context of polysubstance use, stigma and exclusion.
• Highly potent and toxic novel drugs such as nitazenes and xylazine continue to be detected in substances and among people who have experienced drug-related harms.
• 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 including specific interventions relevant for those who use cocaine and/or benzodiazepines.
• There is increasing recognition of the adverse health consequences associated with injecting-related injuries, vascular injury and soft tissue infections amongst people who use drugs. These harms and adverse effects should be considered as part of needs assessments when commissioning services and when planning workforce training. Further work may be needed to support the development of integrated approaches to prevention, treatment and physical rehabilitation of injuries and infections.
• Contamination of illicit drugs with toxic substances is both common and widespread. There continues to be an urgent need for timely and accurate hospital toxicology and forensic post-mortem toxicology services, as well as accessible drug checking.
• A standardised approach to hospital-based toxicology testing across Scotland is essential to identify substances never detected before, such as newer street benzodiazepines and other synthetic drugs, to ensure a proportionate and informed response to reducing harms.
• A system-wide approach that prevents drug harms and supports people affected to access treatment, care and recovery remains critical.