Drug misuse: health harm

Drug use can lead to a wide range of health problems. In addition to causing physical problems, drug use can lead to a wide range of mental health problems. This section summarises information from a number of sources including discharge data from hospitals, primary care consultations, drug-related deaths, maternity data and neonatal discharges and survey data from the Needle Exchange Surveillance Initiative. 

Drug-related general and psychiatric hospital discharges

The ISD publication Drug-Related Hospital Statistics Scotland 2015/16 reports on hospital discharges relating to drug misuse. It includes information on inpatient and day case discharges by general acute and psychiatric specialties in Scotland, where drug misuse was mentioned in the records at some point during the patients’ hospital stay. The most recent publication includes a section on combined general acute and psychiatric stays and data tables are published using an interactive electronic dashboard.

Key points:

  • The number and rate of drug-related general acute stays increased steadily over time (41 to 143 stays per 100,000 population between 1996/97 and 2015/16), while psychiatric stays remained roughly the same (28 to 29 stays per 100,000 population between 1997/98 and 2014/15).
  • In the most recent available year’s data, around six in ten drug-related general acute stays were due to opioids (drugs similar to heroin) while approximately half of drug-related psychiatric stays were associated with ‘multiple/other’ drugs.
  • The number and rate of younger people admitted to hospital for drug misuse has remained relatively stable over time, while admissions among older drug users have increased (for example, among 40-44 year olds, a fifteen-fold rise from 20 to 291 patients per 100,000 population between 1996/97 and 2015/16 (general acute)).
  • In the most recent available year’s data, around half of patients with either a general acute or psychiatric stay in relation to drug misuse lived in the 20% most deprived areas in Scotland.
  • In 2014/15, 3,297 patients (61 new patients per 100,000 population) were treated in hospital (general acute/psychiatric combined) for drug misuse for the first time.

Primary care consultations

Practice Team Information is a scheme that collects consultation data from general medical practices in Scotland. Data are collected from a sample of practices covering 6% of the Scottish population and include every face-to-face contact between a patient registered with the practice and a member of the practice team. This sample is broadly representative of the Scottish population in terms of age, sex, deprivation and urban/rural mix and allows consultation estimates to be produced for Scotland.

The latest figures on numbers of drug-related consultations, patients seen for drug-related conditions and their co-morbidities, their age and gender and deprivation can be found in GP consultations Drugs 2012/13.xls (81Kb). The tables present figures with 95% confidence intervals (CIs). This section reports on estimated values, which are derived from a sample of GP practices. The confidence intervals provide a range of values, for which it can be said with a 95% probability that the true value lies within. The confidence intervals are included to indicate the accuracy of these estimates.

Key points:

  • Table B3.1 shows that there were an estimated 24,810 patients (95% confidence interval 19,800-29,820) consulting their GP about drug misuse in 2012/13. The numbers appear to have decreased over the last ten years; in 2003/04 the estimated number of patients with drug-related consultations was 32,640 (95% confidence interval 26,250-39,030), although this change was not statistically significant.
  • These patients had an average of 8.3 consultations in 2012/13, compared with 3.9 consultations for all patients seeing their GP (Table B3.1).
  • The largest number of patients with a drug-related consultation was in the 25-44 year age group (an estimated 18,170 out of an estimated 24,400 patients), and around twice as many males were seen compared to females (Table B3.2).
  • Males aged 18-44 with drug-misuse consultations were more likely to consult their GP regarding psychological signs and symptoms (20%) and anxiety disorders (15%) than all males within this age group (11% and 7% respectively). Females with drug-misuse consultations (aged 18-44) were also more likely to consult their GP regarding psychological signs and symptoms (26.9%), diseases of the upper respiratory tract (23%) and anxiety disorders (21%) compared to all females within the same age group (14%, 8% and 9% respectively) (Table B3.3).
  • An estimated 49% of the patients with a drug-misuse consultation lived in an area classed as in the most deprived SIMD quintile versus 4% living in the least deprived areas (Table B3.4). 

Maternity and Neonatal Discharges

The publication Births in Scottish Hospitals (year ending 31st March 2016) (Tables) is based on maternity data (SMR02) and neonatal discharges (SMR11, Scottish Birth Record) collected by ISD. This publication includes a section on drug misuse during pregnancy. Care should be taken when comparing numbers over time as recording of drug misuse data items has improved over the last five years (these items were made mandatory in April 2011).

Key points:

  • In 2015/16, drug misuse was recorded in 1% (707) of a total of 53,720 maternities in Scotland. Opioid misuse was recorded in almost half of those cases (42%, 299) (Table 14.2).
  • In 2015/16, the rate of maternities with drug misuse recorded was 13 per 1,000 maternities (707). This rate has been approximately the same since 2013/14 (13.6), but had previously been on a downward trend (1,129 (20 per 1,000 maternities) in 2011/12) (Table 14.2).
  • The rate of maternities with drug misuse recorded varied across NHS Boards, from 27 per 1,000 maternities for NHS Lothian during the period 2013/14 to 2015/16, to 6 per 1,000 for NHS Greater Glasgow & Clyde. Differences in data completeness between NHS Boards was thought to contribute to some of this variation (Table 14.1).
  • The rate of maternities where drug misuse was recorded was almost six times higher in the most deprived category (SIMD quintile 1: 22 per 1,000 births) than in the least deprived category (SIMD quintile 5: 4 per 1,000 births) in 2015/16 (Table 14.4).
  • In 2015/16, of the 718 births (from 707 maternities) to mothers where drug misuse was recorded, 78% (563) were reported as having a full-term normal birthweight, compared to 90% of all births. Around 11% of births where drug misuse was recorded were pre-term, higher than the percentage recorded among all births (8%) (Table 14.3).
  • The rate of babies affected by maternal use of drugs (where the baby was affected by, or had withdrawal symptoms from, maternal use of drugs of addiction) was 5 per 1,000 live births for the period 2013/14 to 2015/16. When compared to a similar aggregated rate of maternities where drug misuse was recorded (13 per 1,000 maternities for the period 2013/14 to 2015/16), it can be seen that just under one third of babies where maternal drug misuse was recorded were affected by, or had withdrawal symptoms from, maternal use of drugs (Table 14.5).

More information about SMR02 data can be found at http://www.isdscotland.org/births and data about SMR11 and the Scottish Birth Record can be found at http://www.isdscotland.org/Products-and-Services/Scottish-Birth-Record/.

Injecting Equipment Provision

Injecting Equipment is provided free of charge across Scotland from community pharmacies and from other services, known as agencies. The purpose of this harm reduction intervention is to promote safe injecting practice and reduce the risk of Blood Borne Virus transmission (particularly Hepatitis C and HIV) amongst People who Inject Drugs. The following main points have been taken from Injecting Equipment Provision in Scotland 2015/16.

Key points:

  • In 2015/16 there were a total of 287 Injecting Equipment Provision outlets in Scotland, of which 219 (76%) were located in pharmacies, and the remaining 68 were part of other services (e.g. specialist drug treatment providers).
  • In 2015/16, nearly 328,000 attendances were reported by outlets, approximately the same as in 2014/15. Eight of 12 participating NHS Boards reported increases in attendances between 2014/15 and 2015/16, while decreases were reported by four NHS Boards.
  • Where gender of the client was reported, 79% of attendances were made by males.
  • Over 4.7 million needles and syringes were reported to have been distributed by participating outlets in 2015/16.
  • Nationally, it was estimated that an average of 77 needles and syringes were distributed per problem drug user in 2015/16.
  • The number of outlets distributing items of sterile injecting equipment other than needles and syringes has increased over time. In 2015/16, wipes or swabs and citric acid or vitamin C were most commonly distributed (approximately 4.5 million and 3.7 million items respectively).

Blood Borne Viruses

Hepatitis C

In resource-rich countries, the hepatitis C virus (HCV) is mainly transmitted by the sharing of injecting equipment among People Who Inject Drugs (PWIDs). Health Protection Scotland (HPS) estimated in 2006 that 50,000 persons have been infected with HCV in Scotland; thus, around 1% of Scotland's population has been infected with HCV. The annual report is published in the HPS Weekly Report vol. 49.

Key Points:

  • In Scotland in 2014 (the last complete year where data was available), 2,014 new cases of HCV were laboratory confirmed.
  • In Scotland, those infected with HCV tend to live in or near major urban centres. Of all laboratory confirmed hepatitis C infections up until December 2014 (37,596), 39% of infected persons (14,751) resided in Greater Glasgow and Clyde NHS Board area and one-third (12,314, 33%) in Lothian, Grampian and Tayside NHS Board areas.
  • In total, two-thirds of infected persons (25,080, 67%) were male and the majority (20,443, 54%) were aged between 20 and 40.

Additional information on Hepatitis C in Scotland is available from the Hepatitis C in the UK report produced by Public Health England (Report).

Key Points:

  • It is estimated that in 2014 around 36,700 people in Scotland (0.7% of the population) were chronically infected with hepatitis C; thus, the prevalence of this infection is nearly twice that for England (160,000 adults or 0.4% of the adult population). However, the estimated prevalence has decreased since the previous estimate of 39,000 in 2008-2009. This is due to more people leaving the infected population (through treatment, mortality and migration) than are joining it (through infection/migration).
  • In Scotland, the number of new hepatitis C diagnoses has remained stable over the last three years, at around 2,000 per annum. Of the 36,700 people estimated to be living with chronic hepatitis C infection, approximately 15,500 (42%) had not been diagnosed.
  • Incidence of infection among PWIDs in Scotland, was estimated at 10 infections per 100 person years during 2013/14.  This was an increase from 2011-12 (6.1 per 100 person years) and around the same level as in 2010 (9.9 per 100 person years).

NESI

The aim of the Needle Exchange Surveillance Initiative (NESI) is to measure and monitor the prevalence of blood-borne viruses and injecting risk behaviours among people who inject drugs (PWID) in Scotland. The initiative was initially funded by the Scottish Government as part of the Hepatitis C Action Plan, which stated that efforts to prevent hepatitis C virus (HCV) in Scotland must focus on preventing transmission of the virus among PWID (HCV prevalence in NHS Boards and Alcohol & Drug Partnerships is included as one of the indicators in the ScotPHO Drugs Profiles).  More recently, however, the initiative has been funded under the auspices of the Scottish Government’s Sexual Health and Blood Borne Virus Framework. NESI provides information to evaluate and better target interventions aimed at reducing the spread of infection amongst PWID. 

Key points:

  • The average age of the Needle Exchange Surveillance Initiative (NESI) sample has increased year-on-year since 2008-09, suggesting an ageing cohort of people who inject drugs (PWID).
  •  Heroin remains the most prevalent drug injected, but there are signs that injection of psychostimulants, notably cocaine and ‘legal highs’, have increased in recent years.
  •  Sharing of needles/syringes and other equipment (spoons/cookers, filters, water) are stable but reported re-use of one’s own needle/syringe has increased, especially among psychostimulant users.
  • Uptake of hepatitis B virus (HBV) vaccination, and hepatitis C virus (HCV) and HIV testing are at their highest levels since the NESI surveys began in 2008-09.
  • Over a quarter of respondents who self-reported as HCV positive (or who self-reported cleared after therapy) had received antiviral therapy for their infection.
  • The prevalence of HCV antibodies in 2015-16 remains high at 58%.
  •  The estimated incidence of HCV among PWID in 2015-16 is 11.4 per 100 person years; this, and other indicators of recently acquired infection (i.e. prevalence among recent onset injectors), suggest incidence of HCV may have increased since 2011-12.
  • 63% of respondents accurately reported their HCV status (comparing self-reported with dried blood spot testing), the highest level since 2008-09, suggesting that an increasing proportion of the HCV-infected PWID population are being diagnosed.
  • Over half of those testing positive for HIV antibodies in 2015-16 reported that they were unaware of their infection.

Hepatitis B

In Scotland, hepatitis B infection is usually acquired in adulthood, with sexual activity and injecting drug use being the most commonly reported routes of infection.  UK trends in the transmission of hepatitis B among People Who Inject Drugs (PWIDs) are described in the Shooting Up 2016 Report and associated data tables.

Key points:

  • In Scotland, there were known to be 459 laboratory cases of both chronic and acute hepatitis B diagnosed in 2015, a decrease from 494 in 2014. The total number of hepatitis B infections has risen since 2005 but there was considerable variation across years.
  • Infection with hepatitis B is preventable through vaccination. Among injectors attending a needle exchange programme in Scotland during 2015/16, 77% reported uptake of the hepatitis B vaccine.

HIV

HIV (Human Immunodeficiency Virus), the virus that leads to AIDS (Acquired Immune Deficiency Syndrome), can be acquired by sharing needles, syringes or other drug injecting equipment with someone who is infected. The number of diagnoses among PWIDs decreased following the introduction of harm reduction measures in the early 1990s and has remained relatively low since (see HPS website section on HIV and AIDS). Additional analysis of HIV information in PWIDs has been provided by Health Protection Scotland (HIV in People Who Inject Drugs 2015 (33Kb)).

Key points:

  • From 1985 until 31st December 2015, a total of 8,365 HIV infections in individuals were reported in Scotland. Of these, 1,573(19%) were in known PWIDs (Table B5.4).
  • Of the total number of HIV infections, 56% (4,655) were presumed to have been infected in Scotland. Among known PWIDs, 88% (1,392) were presumed to have been infected in Scotland (Table B5.4).
  • Of all PWIDs with HIV infection reported in Scotland, 571 (36%) were presumed alive and living in Scotland as of 31st December 2015 (Table B5.4).
  • There have been 914 deaths among PWIDs with HIV infection reported in Scotland (including those infected outwith Scotland) as of 31st December 2015 (Table B5.4).
  • Between 1985 and 31st December 2015, 85% (1,344) of all PWIDs infected with HIV lived in the Lothian, Tayside and Greater Glasgow and Clyde NHS Board areas (Table B5.5).
  • 71% (1,109) of PWIDs diagnosed with HIV up to 31st December 2015 were male (Table B5.4). The median age of PWIDs diagnosed with HIV in 2015 was 36. (Table B5.6).
  • Of the 362 new HIV cases reported by NHS Boards in Scotland in 2015, 55 (15%) were in known PWIDs. This percentage was the highest recorded in the last 11 years; prior to this the percentage remained relatively constant, with an average of 5% of new infections from 2005-2014 occurring among known PWIDs (Table B5.8).

Bacterial Infections

Anthrax is an acute infectious disease caused by the bacterium Bacillus anthracis and is very rare in Europe.  The source of anthrax outbreaks among PWIDs is thought to be contamination of heroin or cutting agents during production or handling of the drug. An outbreak report was produced by HPS following infections of PWIDs in Glasgow in 2009 and 2010.

Key points:

  • Between December 2009 and October 2010, an outbreak of anthrax occurred among PWIDs in Scotland.  During this time period, there were 47 laboratory confirmed infections (with a further 72 probable and possible cases; 119 in total) of which 14 were fatal.  There were a further five linked cases in Germany and England in the same time period, three of which were fatal. 
  • Within Scotland, cases were reported in ten out of the 14 health boards, mainly centred in the Greater Glasgow and Clyde, Lanarkshire and Tayside health board areas.
  • Further sporadic cases continue to occur in Scotland, with four confirmed cases in 2012 and one so far in 2013.

Other infections that have been shown to have links with injecting drug use include Clostridium botulinum. There was an outbreak in Scotland which caused botulism among injecting drug users between December 2014 and May 2015 with over forty clinically confirmed cases who all injected heroin sourced from the Glasgow area. There were four deaths in this outbreak (botulism was a contributory cause in two of those cases). The majority of cases (98%) presented with bulbar palsy (a form of paralysis that affects the muscles in the head) and over half (58%) were ventilated for respiratory paralysis (although most did not require long-term support). All cases were promptly treated with antitoxin, half had wounds cleaned out (debridement) and all received antibiotics Shooting Up, 2015.

The most common bacterial infections linked to PWIDs are infections from individual’s own bacterial flora on their skin (e.g. Staphylococcus and Streptococcus species). These infections are most likely to occur when users do not practice good hygiene whilst injecting. Infections from these bacteria can cause abscesses to form around injecting sites and can then be transferred between drug users who share injecting equipment. Further risks involve the transfer of oral microbial infections into the blood of the users when, during the preparation of the injecting material, drug users crush tablets in their mouths before injecting or clean injecting sites using saliva. This is thought to have led to an outbreak of Streptococcus milleri in Scotland leading to groin abscesses in the early 1990s. A survey of injecting drug users attending needle exchange sites in Scotland in 2013/14 found that 28% had experienced an abscess, sore or open wound during the past year (Shooting Up, 2015).

Drug-related deaths

The annual report Drug Related Deaths in Scotland 2015 was published by National Records of Scotland on 17 August 2016. This is a National Statistics publication showing statistics of drug-related deaths in 2015 and earlier years, broken down by cause of death, selected drugs reported, age and sex. It includes figures for NHS Board areas and for Council areas.

Key points:

  • Based on the definition used for these statistics, 706 drug-related deaths were registered in Scotland in 2015; 93 (15%) more than in 2014. This was the largest number ever recorded, and 370 (110%) more than in 2005.
  • Sixty nine per cent (484) of drug-related deaths in 2015 were among males. The largest number of drug-related deaths was among those aged 35-44 (249 or 35%).
  • In 2015, the NHS Board areas where most drug-related deaths occurred were Greater Glasgow & Clyde (221 or 31%) and Lothian (100 or 14%).
  • When comparing the annual average for 2011-2015 with that for 2001-2005, the percentage increase in the number of drug-related deaths was greater for females (153%) than for males (56%). As was the case in the previous report, the largest absolute increase was for 35-44 year olds, the next largest was for people aged 45-54. There was a fall in the number of drug-related deaths of people aged under 25.
  • Of the 706 drug-related deaths in 2015, heroin and/or morphine were implicated in, or potentially contributed to, the cause of 345 deaths (49% of the total); methadone was implicated in, or potentially contributed to, 251 deaths (36%); benzodiazepines (e.g. diazepam) were implicated in, or potentially contributed to, 191 deaths (27%); cocaine, ecstasy-type drugs and amphetamines were implicated in, or potentially contributed to, 93, 15 and 17 deaths respectively; whereas alcohol was implicated in, or potentially contributed to, 107 of the drug-related deaths.
  • In 2015, there were 112 deaths where Novel Psychoactive Substances (NPS) were present, compared with 114 in 2014. In 2015, NPS were implicated in 74 deaths, compared with 62 in 2014. Benzodiazepine-type NPS were most frequently found to be present and most often implicated in these deaths. In only a small proportion (3 out of 74 deaths) were NPSs the only substances implicated in the death. 

The sixth report from the National Drug-Related Deaths Database (NDRDD) for Scotland presents data on deaths which occurred in 2014 (and trends since 2009) was published in March 2016. The NDRDD was established to collect detailed information regarding the nature of drug-related deaths and the health and social circumstances of individuals who have died. This report analyses a specific cohort of drug-related deaths in Scotland on which National Statistics have already been published by National Records of Scotland (NRS), providing insights into the lives of these individuals and highlighting potential areas for intervention.

Key Points:

  • The 622 drug-related deaths reported by the NDRDD are largely a subset of the 613 deaths registered in 2014, on which summary statistics were previously published by NRS. Of the 622 drug-related deaths reported by NDRDD, 575 were classed as non-intentional – these are the main focus of the report and the following points.

  • Around three quarters (76%) of drug-related deaths were among males. The average age of individuals increased from 34 in 2009 to 39 in 2014, reflecting the ageing profile of problem drug users.

  • Most drug-related deaths (54%) were among long-term (i.e. more than 10 years) drug users. The percentage of drug-related deaths who were long-term drug users increased over time.

  • Female drug-related deaths increased by 54% from 2009 to 2014, in comparison with a 28% increase among males.

  • Around half (53%) of those who died lived in the 20% most deprived neighbourhoods in Scotland, similar to previous years.

  • 37% (196) of those who died were a parent or carer to a child. 310 children lost a parent or carer to a drug-related death.

  • Nearly two thirds (63%) had a medical condition and 60% had a psychiatric condition recorded in the six months before death. Recent medical and psychiatric ill health increased over time.

  • 70% of those who died had recently been in contact with a service (drug treatment, hospital, police or prison) which may have identified them as being at risk of drug-related death.

  • Around one third (29%) were prescribed an Opioid Replacement Therapy (ORT) drug (predominantly methadone) at the time of death. The percentage prescribed an ORT drug increased over time.

  • In almost all cases (96%) multiple drugs were present in the body at death and in 69% of cases multiple drugs were deemed to be implicated in death, indicating polydrug use.

  • Heroin (58%), anti-depressant (46%) and gabapentin (17%) presence at post mortem increased in 2014. Diazepam (70%) and methadone (40%) presence was lower than in most previous cohorts.

  • Three out of four individuals had opioids (methadone, heroin, morphine or buprenorphine) implicated in their death.

  • Heroin/morphine was the drug most commonly implicated in death, increasing from 40% in 2011 to 52% in 2014. Deaths where methadone was implicated in death fell from 54% to 36% over the same time period.

  • Unlike previous years, the number of deaths related to Novel Psychoactive Substances increased only slightly in 2014 (112).

The role of benzodiazepines in drug-related deaths

Benzodiazepines are amongst the most widely prescribed psychotropic drugs in the world. Over the last 30 years, Scotland has had a strong relationship with the misuse of benzodiazepines; from temazepam, diazepam, and triazolam in the mid-1980s, to the ‘New’ or ‘Novel’ Psychoactive Substances (NPS) such as etizolam and phenazepam in the 2010s.

Reflecting their prominence within the illicit drug market in Scotland, the vast majority of Drug-Related Death (DRD) cases since the introduction of the National Drug-Related Death Database (NDRDD) in 2009 have had benzodiazepines present in post-mortem toxicology. However, benzodiazepines are often regarded by the reporting pathologist as not implicated in DRDs where they were present.

Owing to a lack of research on benzodiazepines, the National Forum on Drug-Related Deaths commissioned work addressing why benzodiazepines are common in DRDs and what role they play in such deaths, particularly at the high doses often reported.  This Report presents the findings of a systematic review of evidence in relation to the use and misuse of benzodiazepines and highlights significant gaps in knowledge; in particular;

  • The increasing availability of unregulated benzodiazepines of unknown content and quality. There are more than 30 benzodiazepine-type drugs available but only 16 are currently legislated for in the Misuse of Drugs Act 1971. Furthermore, the increased availability of ‘street benzos’ and emergence of benzodiazepine-type NPS has increased the complexity of substance use and related harms (self-medicating, unwitting use of more potent drugs, variability in potency and concentration and easier access to larger quantities of supply).
  • The excessive use of benzodiazepine-type drugs by people self medicating with prescribed and/or illicit benzodiazepine-type drugs and the metabolic and physical effects of such ‘mega doses’. As benzodiazepine-type drugs share metabolic pathways with opioids and other drugs that are commonly found in DRDs, further study is required to analyse how ‘mega doses’ of benzodiazepines increase blood concentrations of opioid and other drug concentrations.
  • Polydrug use is common among substance users with benzodiazepine-type drugs rarely found as single agents in DRDs. There is a lack of studies assessing ‘benzo burden’ and prescribing patterns in non-fatal overdoses. It is suspected that substance users in and out of treatment are at higher risk of developing multimorbidity and thus receive multiple medicines (polypharmacy). Parallel to an ageing cohort of people using illicit drugs, it is clear that the role of polydrug use and polypharmacy will continue to have an increased risk of drug-drug and drug-disease interactions and further increases the risk of adverse effects.
  • The risks of short-term and long-term mental health and cognitive problems associated with routine and excessive benzodiazepine-type drug use. Although benzodiazepine-type drugs can be effective for alcohol and substance withdrawal, longer-term use is associated with greater depressive symptoms. Cognitive impairment and central nervous system (CNS) depression are well known side effects of benzodiazepine use, with higher doses being associated with increased side effects. Cognitive impairment is of concern as it may effect the substance users’ risk of ‘double dosing’.

Please note: If you require the most up-to-date data available, please check the data sources directly as new data may have been published since these data pages were last updated. Although we endeavour to ensure that the data pages are kept up-to-date, there may be a time lag between new data being published and the relevant ScotPHO web pages being updated.