Rapid Action Drug Alerts and Response (RADAR) quarterly report
October 2024
Management information
- Published
- 29 October 2024
- Type
- Statistical report
- Author
- Public Health Scotland
Toxicology indicators
Emergency department toxicology: ASSIST
Between June and August 2024, the ‘A Surveillance Study of Illicit Substance Toxicity’ (ASSIST) emergency department project made 669 detections of 43 different illicit drugs, in samples from 139 patients. The most commonly detected drug category was depressants (63% of detections), followed by stimulants and opioids (both 16%). The most commonly detected individual drug was cocaine (13%), followed by desmethyldiazepam (11%) and temazepam (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 collects anonymised patient data through the analysis of standard-of-care clinical data. For the most unwell patients, the study performs full toxicological analysis through the biorepository-approved surplus serum sampling. Surplus serum samples are leftover blood samples, which were taken as part of usual care.
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
- 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. For more definitions and inclusion criteria, see additional information below.
- Data from the study are presented in quarters, based on the date of ED presentation, and are provided in the table below.
| Quarter | Dates |
|---|---|
| Quarter 1 (Q1) | 17/08/2022 to 16/11/2022 |
| Quarter 2 (Q2) | 17/11/2022 to 16/02/2023 |
| Quarter 3 (Q3) | 17/02/2023 to 16/05/2023 |
| Quarter 4 (Q4) | 17/05/2023 to 16/08/2023 |
| Quarter 5 (Q5) | 17/08/2023 to 16/11/2023 |
| Quarter 6 (Q6) | 17/11/2023 to 16/02/2024 |
| Quarter 7 (Q7) | 17/02/2024 to 16/05/2024 |
| Quarter 8 (Q8) | 17/05/2024 to 16/08/2024 |
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 2024 (Q1 to Q8).
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.
Summary
Historic trend
Between 17 August 2022 and 16 May 2024:
- The most commonly detected drug type was depressants, making up 62% of all detections, followed by opioids (16%). The most commonly detected individual drug was cocaine (11%).
- 72% of attendances were male and 28% were female.
- 76% of attendances were aged 44 and under. The most common age category was 35 to 44 years (29%), followed by 25 to 34 (28%) and 16 to 24 (19%).
- The most common outcomes were discharged to home (38%), ward (28%) and police custody (12%).
Update
For the most recent period (17 May to 16 August 2024):
- 344 individual ED attendances related to illicit drug use were identified.
- 139 surplus serum samples were analysed for toxicology (as they were categorised as having a higher clinical severity of toxicity as per research inclusion criteria).
Drug type and category
Among the 139 samples analysed:
- There were 669 detections of 43 individual substances (found through the biological detection of the drug or its metabolite).
- The average number of drugs detected per sample was five.
Of the 669 detections, the following drugs were the most common:
- cocaine: 88 (13% of detections, 63% of samples)
- desmethyldiazepam: 74 (11% of detections, 53% of samples)
- temazepam: 64 (10% of detections, 46% of samples)
- bromazolam: 55 (8% of detections, 40% of samples)
- oxazepam: 46 (7% of detections, 33% of samples)
- etizolam: 37 (6% of detections, 27% of samples)
- diazepam: 35 (5% of detections, 25% of samples)
- morphine: 34 (5% of detections, 24% of samples)
- pregabalin: 33 (5% of detections, 24% of samples)
- clonazolam: 24 (4% of detections, 17% 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 August 2024 (Q1 to Q8). The percentages are of all detections.
Depressants were the most common drug category, making up 63% of detections (420).
- Benzodiazepines were detected 366 times (55% of all detections):
- In total, 15 different types of benzodiazepines were detected, including desmethyldiazepam (11%), temazepam (10%), oxazepam (7%), etizolam (6%), diazepam (5%) and clonazolam (4%).
- Bromazolam made up 8% of all detections, similar to 7% in Q7.
- Gabapentinoids were detected 44 times (7% of all detections, similar to Q7). Of these detections, 11 were gabapentin and 33 were pregabalin.
- There were no detections of xylazine, down from four in the last quarter.
The chart below provides an indication of specific opioids and nitazene drugs detected in toxicology analysis of surplus serum samples between 17 August 2022 and 16 August 2024 (Q1 to Q8). The percentages are of all detections.
Opioids were the second most common drug category, making up 16% of detections (110).
- There were 34 detections of heroin/morphine (5%, similar to Q7), 19 for methadone (3%) and 19 for codeine (3%).
- There were less than five detections of nitazenes, down from six in the last quarter.
Stimulants were the third most common drug category, making up 16% of detections (106).
- The most common stimulant was cocaine, making up 13% of detections (88). This stable compared to the previous quarter.
Further findings
Complete clinical data were available for 344 attendances for the most recent period (17 May to 16 August 2024):
- 79% of attendees were male (272) and 21% were female (72).
- 74% of attendances were aged 44 and under. The most common age category was 35 to 44 years (30%, 104 attendees), 22% (75) were aged 16 to 24 years and 22% (74) were aged 25 to 34.
- 26% of attendees were aged 45 years and over, with 18% (63) aged 45 to 54 and 8% (27) aged 55 years or older. Age was unknown for one attendance.
ED outcome records show:
- 126 (37%) patients were admitted to a ward – this was the highest percentage observed throughout the study (quarterly average 28%)
- 135 patients (39%) were discharged home
- 27 patients (8%) self-discharged
- 22 patients (6%) were taken into police custody
- 15 patients (4%) were admitted to an intensive care unit, high-dependency unit, critical care unit or died
- 19 were recorded as ‘unknown’ or ‘other’.
Clinical severity outcome (after 28 days) recorded:
- 337 (98%) patients were discharged following the attendance
- six patients either died or remained an inpatient following the attendance.
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).
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 (g. if methadone is detected for an individual prescribed methadone, it will not be included)
- drugs administered to the individual as part of treatment (by ambulance staff or in hospital).
Toxicology analysis
- 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 and the metabolite could also be a drug, the metabolite is included as it is not possible to say which has been used, if not both.
Post-mortem toxicology testing for controlled substances
In Q2 of 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%).
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.
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.
This report presents data on deaths covering the whole of Scotland, which became available from January 2022. It includes new data for the period from 1 April to 30 June 2024, representing Q2 of 2024.
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 charts below show the prevalence of controlled substances detected in deaths which were subject to post-mortem toxicology screening. Drug detections were assigned to specific time periods based on the calendar year quarter of death. Throughout the series, the sum of the percentages for each quarter exceeds 100%, due to the widespread detection of multiple substances in deaths.
The first chart provides an indication of controlled drugs detected at post-mortem, in deaths occurring between 1 January 2022 and 30 June 2024.
The following charts provide an indication of specific opioids and benzodiazepines detected at post-mortem, in deaths occurring between 1 January 2022 and 30 June 2024.
Summary
- The most commonly detected drug types throughout the series were opioids followed by benzodiazepines. Both have remained relatively stable averaging 71% and 57% respectively between Q1 of 2022 to Q2 of 2024.
- The most commonly detected drug was cocaine (averaging 36% between Q2 of 2023 and Q2 of 2024). Before Q2 of 2023, the most common individual drug was heroin/morphine.
- Multiple controlled drugs were detected in 573 of 598 deaths (96%) in Q2 of 2024. This is similar to previous quarters.
- The following drugs/drug types were the most commonly detected in deaths in Q2 of 2024:
- opioids: 421 (70%)
- benzodiazepines: 332 (56%)
- cocaine: 221 (37%)
- heroin/morphine: 194 (32%)
- gabapentin or pregabalin: 167 (28%)
- diazepam: 166 (28%)
- codeine: 153 (26%)
- methadone: 147 (25%)
Stimulants
- For the fifth quarter in a row, the most commonly detected drug was cocaine.
- The percentage of deaths where cocaine was detected was relatively stable until Q1 of 2023 (averaging 29%). Detections increased in Q2 of 2023 to 36% and have remained stable since (37% in Q2 of 2024).
Opioids
- The percentage of deaths where opioids were detected has remained relatively stable throughout the series, averaging 71%.
- Heroin/morphine detections have been gradually decreasing, from 36% in Q1 of 2022 to 32% in Q2 of 2024.
- Methadone was detected in 32% of deaths in Q1 of 2022 and has since generally fluctuated within a range of 25% to 29% of deaths.
- Buprenorphine detections remained low and stable throughout the series, detected in an average of 6% of deaths.
- Detections of fentanyl-type opioids have gradually increased, from 1% in Q1 of 2022 to 8% in Q2 of 2024. Fentanyl-type opioids are commonly used as medicines for pain relief.
- Nitazene-type opioid substances were first detected in Q1 of 2022 and have increased slightly, being detected in 3% of deaths (16) in Q2 of 2024. In Q2 of 2024, metonitazene was the most common nitazene detected, followed by protonitazene. Two nitazenes were detected in 10 deaths. Nitazenes have been detected in a total of 79 deaths (to 30 June 2024).
Depressants
- Benzodiazepines have remained broadly stable throughout the series, detected in an average of 57% of deaths.
- Diazepam has been the most commonly detected benzodiazepine since Q2 of 2022. Since then, detections have fluctuated between 25% and 35%.
- Detections of bromazolam increased sharply between Q3 of 2022 and Q3 of 2023, replacing etizolam as the most commonly detected ‘street’ benzodiazepine from Q1 of 2023 onwards. Bromazolam was detected in 20% of deaths in Q2 of 2024.
- Etizolam was the most common benzodiazepine detected in Q1 of 2022, after which detections have followed a decreasing trend to 6% of deaths in Q2 of 2024.
- Clonazolam detections remained low and stable throughout the series, detected in an average of 1% of deaths.
- Gidazepam/desalkylgidazepam was first detected in Q4 of 2022 and has gradually increased, being detected in 2% of deaths in Q2 of 2024.
- The percentage of deaths involving gabapentin or pregabalin has been relatively stable throughout the series, averaging 30%.
- Xylazine (detected for the first time in Q3 of 2023) detections remained stable compared to the previous quarter at 1% of deaths (5). Xylazine has been detected in a total of 23 deaths (to 30 June 2024).
More detailed descriptions of historical changes can be found within our previous reports.
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, was supplied by the Department of Clinical Biochemistry at NHS Grampian.
The total number of deaths testing positive for controlled substances, for each calendar year and quarter, are provided in table 1.
| Calendar year | Q1 | Q2 | Q3 | Q4 |
|---|---|---|---|---|
| 2022 | 566 | 631 | 535 | 710 |
| 2023 | 710 | 680 | 619 | 663 |
| 2024 | 692 | 598 |
A number of drugs were detected for the first time when screening was expanded or testing was outsourced to other laboratories. Table 2 provides information on the initial screening period new or emerging substances, from which limited testing data was available, and also when testing is considered to have become routine across Scotland.
| Substance | Initial testing (limited data available) | Routine testing (data across Scotland) |
|---|---|---|
| Nitazenes | Q1 of 2022 | Q1 of 2023 |
| Bromazolam | Q1 of 2022 | Q1 of 2023 |
| Deschloroetizolam | Q1 of 2023 | Q1 of 2023 |
| Xylazine | Q2 of 2023 | - |
'-' denotes information is not available.
Note that 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:
- 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 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
Synthetic cannabinoids continue to be the most prevalent drug type detected in the Scottish Prisons Non-Judicial Drug Monitoring Project.
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 non-attributable seizures (drugs that cannot be linked to a person or source) 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 December 2023.
The chart below shows the five most detected drug types from seizures in Scottish prisons between 1 April 2021 and 31 December 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 a low of 23 in June, to a high of 134 in September. In 2022, the monthly average remained relatively stable at 35. During 2023, numbers varied widely, ranging from a high of 60 in January to a low of 9 in December, with a monthly average of 40.
- 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 72% in 2021, to 23% in 2022, to 7% in 2023. This is thought to be due to changes to prison rules that mean prisoners now receive photocopied correspondence rather than original items.
- There were low numbers of e-cigarette samples until late 2022, when they made up an average of 30% of detections. Detections increased from a monthly average of 1% in 2021, to 18% in 2022, to 28% in 2023.
- Powder samples were low throughout 2021 (monthly average 4%), before increasing and remaining relatively stable at approximately 20% per month throughout 2022, increasing to 27% in 2023.
- The transition from synthetic cannabinoids in paper form to e-cigarette, powder or wax forms has introduced new methods of consumption. This variation in form and purity can make it challenging to achieve consistent dosing, potentially leading to unpredictable effects.
- Drug-type seizure data were highly variable over time, so the following narrative is based on 3-month moving averages:
- Synthetic cannabinoids were the most common substances detected.
- In 2021, the percentage of seizures testing positive for synthetic cannabinoids was on average 43% 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 July, from 12% to 61%, before decreasing for the remainder of the year to 22% in December.
- The percentage of seizures testing positive for benzodiazepines fluctuated throughout 2021 (monthly average 39%), before decreasing and remaining relatively stable in 2022 (monthly average 26%). In 2023, detections followed an uneven decreasing trend (monthly average 9%).
- Detections of opioids increased in late 2023 (average 33% in December), however small sample numbers should be taken into consideration when interpreting the data.
Update
Analysis of seizures from January to August 2024 is ongoing and not all data can be included in this report. We anticipate the updated data will be available for the next release in January 2025.
We have received data for a limited number of samples for 2024:
- 31 samples contained a controlled drug.
- Synthetic cannabinoids were the most prevalent drug type. They were detected in 12 samples, with ten samples containing two cannabinoids.
- MDMB-4en-PINACA was the most common synthetic cannabinoid (10 detections), followed by MDMB-INACA (8).
- In the latest period, three samples contained a benzodiazepine: two contained etizolam and one contained bromazolam. Please note that due to the limited number of samples received for testing for 2024, these detections do not fully represent all benzodiazepine seizures within this reporting period.
- The most common sample type was powder (17 samples).
Further information
In September 2023, this drug analysis project detected hexahydrocannabinol (HHC), for the first time in prisons in Scotland. HHC is a semi-synthetic cannabinoid, a compound that is derived from naturally occurring cannabinoids but is modified to enhance or alter the effects.
- HHC was detected four times between September 2023 and April 2024.
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.