Drug use: 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 Public Health Scotland (PHS) publication Drug-Related Hospital Statistics Scotland 2021/22 presents information on hospital activity relating to illicit drug use in Scotland in the period from 1996/97 to 2021/22. The topics covered include: the number of hospital stays, the number and characteristics of patients, substances used and geographical variations. These data are published in a dashboard and full report.

Key points:

In 2021/22:

• There were 12,474 drug-related hospital stays. The European Age-sex Standardised Rate (EASR) of drug-related hospital stays was 235 stays per 100,000 population. This rate decreased for the second consecutive year, from a peak of 283 per 100,000 population in 2019/20.
• The highest substance-specific stay rate (106 per 100,000 population) was for opioids (drugs similar to heroin). This rate decreased for the second consecutive year, from a peak of 141 per 100,000 population in 2019/20.
• The highest patient rate (412 per 100,000 population) was observed among people aged 35-44 years. This rate decreased for the second consecutive year, from a peak of 517 per 100,000 population in 2019/20.
• Approximately half of the patients with a drug-related hospital stay lived in the most deprived areas in Scotland.
• Between May 2021 and March 2022, the number of stays each month was approximately one quarter lower than the average number of stays in the same months of 2018 and 2019. This period of lower-than-expected stays partly coincided with the COVID-19 restrictions in place from December 2021 to January 2022, however the reasons for the sustained decreases are not yet fully understood.
• The rate of stays for drug poisoning/overdose decreased to 32 stays per 100,000 population, from a peak of 42 stays in 2020/21. This was the first decrease in overdose stay rates since 2012/13 (22 stays per 100,000 population).
• Drug-related hospital stay rates decreased sharply since 2019/20 among people aged under 45 years but have remained fairly stable in patients aged 45 years and older. People aged 45 years and over were more likely to have been admitted to hospital multiple times for drug-related causes and stayed in hospital for longer than people aged under 45.

Maternity and Neonatal Discharges

 The publication Births in Scotland (year ending 31st March 2023) is based on maternity data (SMR02) and neonatal discharges (Scottish Birth Record) collected by PHS. This publication was revised in 2017 and no longer includes detailed information on drug use during pregnancy. However, equivalent data for 2011/12 to 2022/23 have been provided by the PHS Pregnancy, Birth and Child Health team (Tables (45Kb)).

Table 4 of the Excel workbook provides information about the data quality and completeness of SMR02 data on drug use during pregnancy. Improvements in the quality and completeness of SMR02 data on drug use have been observed since 2018/19. However, the results below should be interpreted with caution as some NHS Boards continue to have high percentages of missing or unknown data and issues with the quality of the known data have also been identified.

Key points:

In 2022/23:

• Drug use was recorded in 1.8% (805) of 44,557 maternities in Scotland. This was equivalent to a rate of 18.1 maternities with drug use recorded per 1,000 maternities, an increase from 2021/22 (787, 16.7 per 1,000 maternities). The 2022/23 rate of maternities with drug use recorded was lower than in 2011/12 (19.7 per 1,000 maternities), when the highest rate in the time series provided was observed (Table 1).
• Where maternal drug use was recorded, the drugs often recorded as being used during pregnancy were cannabis (483, 10.8 per 1,000 maternities), opiates/opioids (131, 2.9 per 1,000 maternities), cocaine (119, 2.7 per 1,000 maternities) and sedatives (51, 1.1 per 1,000 maternities) (Table 1).
• Recorded rates of opiate/opioid use during pregnancy has consistently decreased over the time series from 9.7 per 1,000 maternities in 2011/12 to 2.9 per 1,000 maternities in 2022/23. Recorded rates of cocaine use more than doubled between 2016/17 (74, 1.4 per 1,000 maternities) to 2019/20 (170, 3.5 per 1,000 maternities), but have since decreased slightly. In 2022/23, rates of cannabis use (483, 10.8 per 1,000 population) were at their highest across the observed time series (Table 1).
• The rate of maternities with drug use recorded was highest in the under 20 age group (62.7 per 1,000 maternities) and lowest in the 40 and over age group (9.2 per 1,000 maternities) (Table 2).
• The rate of maternities where drug use was recorded was five times higher in the most deprived neighbourhoods in Scotland (deprivation quintile 1: 31.0 per 1,000 maternities) than in the least deprived neighbourhoods (deprivation quintile 5: 6.1 per 1,000 maternities). In 2022/23, the rate of maternities with recorded drug use in the most deprived communities (31.0 per 1,000 maternities) was the highest observed since 2011/12 (32.3 per 1,000 maternities) (Table 3).
• A total of 113 (0.3%) of 45,061 babies born in Scotland were recorded as having been affected by maternal use of drugs. This rate decreased steadily over time from 6.9 per 1,000 live births in 2011/12 to 2.5 per 1,000 live births in 2022/23 (Table 5). 

Supporting information about the data sources used and content presented in these tables can be found in the annual 'Births in Scotland' technical document and the latest ‘Data Quality Assurance Assessment of SMR02’ report.

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 2022/23.

Key points:

In 2022/23: 

• There were 330 IEP outlets in Scotland. This was a 3% increase compared to 2021/22. 
• There were 132,447 attendances reported by IEP outlets, 9% fewer than in 2021/22 (146,137). There has been a gradual decrease in attendances each year since 2014/15 (328,329 attendances). 
• Approximately 2.3 million needles and syringes were distributed. This was 5% lower than in 2021/22 (approximately 2.5 million) and continues the decreasing trend observed over the last seven years (2015/16: approximately 4.7 million). 
• Wipes or swabs (approximately 2.1 million), foil (approximately 1.8 million) and citric acid or vitamin C (approximately 1.7 million) were the most distributed items of other injecting equipment. The numbers of foil items increased by 4% compared to the previous year, whilst fewer items of wipes or swabs, and citric acid or vitamin C were distributed than in 2021/22 (approximately 2.2 million wipes or swaps and 1.8 million citric acid or vitamin C). 
• Following the implementation of COVID-19 mitigation measures (for example, temporary changes in the availability of IEP services due to staff absence and asking service users to attend IEP services less often), an increase in the number of needles and syringes distributed per attendance was seen in 2020/21 (16.8). The number of needles and syringes distributed per attendance continued to be roughly the same in 2021/22 (16.7) and 2022/23 (17.6).

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 (PWID).  The annual HPS Surveillance Report: Hepatitis C antibody positive cases in Scotland (results to December 2018) was published in July 2019.

Key Points:

• In Scotland in 2018 (the last complete year where data was available), there were 1,423 new cases of HCV diagnosed. This figure compares to 1,814, 1,591, and 1,511 new cases of HCV diagnosed in 2015, 2016 and 2017 respectively and was the lowest number of new hepatitis C antibody diagnoses since 1996.
• In Scotland, people infected with HCV tend to live in or near major urban centres. In 2018, of the 1,423 people diagnosed with hepatitis C, 34% (478) resided in Greater Glasgow and Clyde NHS Board area and 17% (121) resided in the NHS Lothian area.
• In total, two-thirds (953, 67%) of people diagnosed with hepatitis C in 2018 were male and 35% (492) were aged between 30 and 39 at time of diagnosis.
• Of all people diagnosed with hepatitis C up to 2018 (43,080), Scottish Index of Multiple Deprivation (SIMD) category was known for 35,973 individuals. Of these individuals, 50% resided in the 20% most deprived neighbourhoods in Scotland (SIMD quintile 1).
• It is estimated that, by the end of 2018, there were 21,000 individuals living with chronic Hepatitis C in Scotland, 10,500 of which have been diagnosed.
• During the financial year 2018/19, there were 2,609 individuals initiated onto hepatitis C treatment.

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. The annual NESI publication was published in April 2022, covering seven surveys at the Scotland level from 2008/09 to 2019/20 (Report  Tables).

The NESI 2019/20 survey was suspended in March 2020, due to restrictions in conducting face-to-face research as a resulting from the start of the COVID-19 pandemic. Recruitment had yet to commence in three NHS Boards (Dumfries and Galloway, Borders and Grampian), and so the 2019/20 survey was limited to the eight remaining mainland NHS Boards and related entirely to the pre-pandemic period.

Key points:

• The average age of the NESI sample in 2019/20 was 41 years. This has increased year-on-year since 2008-09 (33 years), suggesting an ageing cohort of PWID (Table 1.1).
• Heroin remains the most prevalent drug injected, with 89% of those interviewed in 2019/20 reporting injecting it in the past six months. The injection of cocaine and ‘speedballs’ (mixing heroin and cocaine together) have both increased in recent years. In 2019/20, 37% of the sample reported injecting cocaine compared to 29% in 2017/18, while for ‘heroin and cocaine’ this was 14%% in 2019/20 compared to 9% in 2017/18 (Table 1.1).
• In 2019/20, 11% of participants reported recently (in the past six months) using a needle/syringe that had been previously used by someone else. This was an increase from 7% in 2015/16. The percentage of participants reporting sharing other injecting equipment (spoons/cookers, filters, water) in the past six months decreased from 26% in 2017/18, to 19% in 2019/20 (Table 1.2). 
• In 2019/20, uptake of hepatitis B virus (HBV) vaccination had further decreased to 68%, down from 77% in 2015/16. Uptake of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) testing has continued to increase. HCV testing increased from 35% in 2008/09 to 58% in 2019/20, whilst HIV testing increased from 30% to 52% over the same time period (Table 1.3).
• In 2019/20, 70% of respondents who self-reported as HCV positive (or who self-reported as clear of HCV after therapy) had received antiviral therapy for their infection, compared to 28% in 2015/16, and 50% in 2017/18 (Table 1.4).
• The prevalence of HCV antibodies in 2019/20 remained high at 55% among all participants, and 59% among people currently injecting drugs (Table 1.5).
• HCV antibody prevalence among individuals who recently commenced injecting is an indicator of recently acquired HCV infection. Among recent onset injectors (less than one year since started injecting), the prevalence was 26% (2017/18: 17%), among those who started injecting within the last three years it was 31% (2017/18: 23%) and among those who started injecting within the last five years it was 33% (2017/18: 26%) (Table 1.5).
• The presence of HCV RNA (ribonucleic acid) and absence of HCV antibodies is regarded as a further indicator of recent HCV infection. By this measure, the estimated incidence of HCV among PWID in 2019/20 was 12.4 new infections per 100 person years, a decrease from 14.1 in 2017/18. HCV incidence had previously reached a low point of 6.1 per 100 person years in 2011/12 having decreased from 13.3 in 2008/09. Findings should be interpreted with caution as confidence intervals overlap (Table 1.5).
• Between 2015/16 and 2019/20 chronic HCV prevalence among NESI participants decreased from 37% to 19%. In 2019/20, 48% of individuals with a chronic HCV infection accurately self-reported their diagnosis. This was a decrease compared to previous years (2015/16: 56% and 2017/18: 60%) (Table 1.5).
• Between 2011/12 and 2019/20 HIV prevalence among NESI participants increased from 0.3% to 3.1%. In 2019/20, 42% of individuals with an HIV infection accurately self-reported their diagnosis. This was a decrease compared to previous years (2015/16: 46% and 2017/18: 69%) (Table 1.5).

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 (PWID) are described in the Shooting Up 2023 Report and associated data tables.

Key points:

• In Scotland, there were known to be 22 laboratory cases (provisional data) of acute hepatitis B diagnosed in 2021, approximately the same as in recent years (Table 2). 

HIV

HIV, 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 people who inject drugs (PWIDs) decreased following the introduction of harm reduction measures in the early 1990s, but has increased in recent years following an outbreak of HIV in Glasgow in 2015 (see HPS website section on HIV and AIDS). Additional analysis of HIV information in PWIDs has been provided by HPS (HIV in People Who Inject Drugs 2018  (27Kb)).

Key points:

• Up to 31 December 2018 , a total of 9,377 HIV infections in individuals were reported in Scotland. Of these, 1,673 (18%) were in people who inject drugs (Table B5.4).
• Of the total number of people with HIV infections, 54% (5,072) were presumed to have been infected in Scotland. Among people who inject drugs this percentage was higher, with 88% (1,476) presumed to have been infected in Scotland (Table B5.4).
• Of all people who inject drugs with HIV infection reported in Scotland, 570 (34%) were presumed alive and living in Scotland as of 31 December 2018 (Table B5.4).
• There have been 969 deaths among people who inject drugs with HIV infection reported in Scotland (including those infected outwith Scotland) as of 31 December 2018 (Table B5.4).
• As at 31 December 2018, of all people who inject drugs  infected with HIV, 85% (1,414) lived in the Lothian, Greater Glasgow and Clyde and Tayside NHS Board areas (Table B5.5).
• The median age of people who inject drugs diagnosed with HIV in 2018 was 39 years (Table B5.6).
• Of the 320 new HIV cases reported by NHS Boards in Scotland in 2018, 15 (5%) were in people who inject drugs, a decrease from 2015 (15%). From 2006 to 2014, the percentage remained relatively stable ranging from 3% to 7%, before increasing to 15% in 2015 (the highest recorded over the time series) (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.

HPS reported an outbreak of wound botulism among people who had a history of injecting drugs between December 2014 and June 2015 in Scotland. The epidemiological evidence linked the source of the contaminated heroin to Glasgow and molecular typing of clostridium botulinum type B.

A total of 40 confirmed and probable cases were recorded during the outbreak, making this the largest outbreak of wound botulism among PWID in Scotland to date. The outbreak affected PWID mainly in NHS Greater Glasgow and Clyde (63%) and neighbouring NHS boards (Lanarkshire, Forth Valley, Fife and Ayrshire and Arran). The majority of cases were in males (68%) and the mean age among males and females was 44 years and 38 years respectively.

All cases were presented with classical symptoms of oculomotor and bulbar palsy. Symptoms ranged from mild facial weakness and blurring of vision to descending paralysis and respiratory distress. Twenty cases also suffered from at least one gastro intestinal related symptom. All cases were promptly treated with trivalent botulinum antitoxin. Surgical debridement was performed on 18 cases (45%) and all received antibiotics. The respiratory function of 22 (55%) cases deteriorated requiring them to be placed on a ventilator. There were four deaths during the outbreak with botulism considered a contributory cause in two.

The most common bacterial infections linked to PWID 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 people do not practice good hygiene whilst injecting. Infections from these bacteria can cause abscesses to form around injecting sites and can then be transferred to others by sharing injecting equipment. Further risks involve the transfer of bacteria normally found in the mouth into the blood of PWID. This occurs when, during the preparation of the injecting material, people crush tablets in their mouths before injecting or clean injecting sites using saliva. These practices were associated with a large outbreak of streptococcus milleri in Scotland in the early 1990s. A survey of PWID attending needle exchange sites in Scotland in 2019 and 2020 (pre COVID-19) found that 22% had experienced an abscess, sore or open wound during the past year (Shooting up, 2023, Data tables - Table 4e)

Drug-related deaths

The annual report Drug-Related Deaths in Scotland in 2022 was published by National Records of Scotland on 22 August 2023. This is a National Statistics publication reporting on drug-related deaths in 2022 and earlier years, broken down by underlying cause of death, selected drugs, age and sex. It includes figures for NHS Board areas and for Council areas (Tables 673 kb).

Key points:

• Based on the definition used for these statistics, 1,051 drug-related deaths were registered in Scotland in 2022; a decrease of 21% (279 deaths) compared to 2021. This was the lowest number of drug-related deaths since 2017 (Table 1 – summary).
• Males accounted for 66% (692) of drug-related deaths in 2022. Drug-related deaths among males decreased by 27% between 2021 (933) and 2022 (Table 4 - age group and sex).
• Almost two thirds of drug-related deaths were among people aged 35-54 years (660, 63%). People aged under 35 years and 55 years and over comprised 19% (198) and 18% (193) of drug-related deaths respectively (Table 4 - age group and sex). The average age of drug-related deaths has increased from 32 in 2000, to 45 in 2022.
• In 2022, the NHS Greater Glasgow & Clyde area had the highest age-adjusted rate of drug-related deaths over the 5-year period from 2018 to 2022 (34.0 per 100,000 population), followed by Ayrshire & Arran (29.5) and Tayside (26.2) (Table HB4 – ASMRs).
• In 2022, after adjusting for age, people in the most deprived 20% of communities in Scotland (SIMD quintile 1) were 16 times more likely have a drug-related death than people in the least deprived areas (SIMD quintile 5) (52.4 compared to 3.3 deaths per 100,000 people). In the most deprived areas, the rate of drug-related deaths fell from 64.3 per 1000,000 people in 2021, to 52.4 per 100,000 in 2022.
• All drug-related deaths were subject to toxicology screening and pathology examination to determine which substances had been consumed prior to death and, of those, which substances were implicated in death. Most drug-related deaths involved the consumption of multiple substances. In a total of 220 (21%) cases, only one drug (and maybe alcohol) was thought to have been implicated in death (Table 8 – only one drug implicated).
• Of the 1,051 drug-related deaths, opiates or opioids (including heroin/morphine and methadone) were implicated in 867 (82%) deaths. Examining individual opioid drugs, methadone was implicated in, or potentially contributed to, 474 (45%) deaths in 2022, a decrease from 2021 (635 deaths, 48%), and heroin/morphine was implicated in, or potentially contributed to 419 (40%) of deaths. This represents an increase from 2021, where heroin/morphine was implicated in 480 (36%) of deaths. (Table 3 – drugs reported).
• Of the 1,051 drug-related deaths in 2022, benzodiazepines (such as diazepam and etizolam) were implicated in 601 (57%) of deaths. Of these, 505 deaths (48% of all drug-related deaths) were associated with ‘street’ benzodiazepines, a decrease from 2021 (842 deaths, 63%). Etizolam was implicated in 382 (36%) deaths in 2022, a decrease from 2021 (772 deaths, 58%) (Table 3 – drugs reported).
• The rate of drug-related deaths in Scotland was 2.7 times higher than the UK average in 2021 (the most recent year that data is available for the UK). In 2021, in Scotland the rate of drug-related deaths was 27.1 deaths per 100,000 people, compared to 10.0 deaths per 100,000 across the UK as a whole.

Drug-related deaths – comparison to other countries

On 22 August 2019, National Records of Scotland (NRS) published a note comparing Scotland’s drug-related death data with those of other countries (Tables). There are two main sources of comparison:

1. Other UK countries: Data for England and Wales is taken from the Office of National Statistics (ONS) publications for 2016 and 2017 and 2018, and for Northern Ireland taken from the Northern Ireland Statistics and Research Agency (NISRA) publication for 2007 to 2017. Note that figures for Northern Ireland for 2018 are not yet published. NRS has assumed that the figures for 2018 will be the same as for 2017 to allow an estimate for the whole of the UK in 2018. Given that Northern Ireland contributes about 3% of all drug deaths in the UK in 2016 and 2017, it is expected that such estimates will have only a small margin of error.
2. Other European countries using the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) publications which appeared in 2018 and 2019.

• Based on the UK Drugs Strategy definition (used in NRS’s National Statistics) Scotland’s 2018 drug-related death rate (218 per million population) was 3.4 times that of the UK (63 per million population) (Table 2).
• The ONS use a ‘wide’ definition of ‘drug poisoning deaths’, that includes deaths from poisoning by drugs which are not controlled under the Misuse of Drugs Act (such as aspirin, ibuprofen, and paracetamol). Under this definition Scotland’s 2018 drug-related death rate (241 per million population) was 2.8 times that of the UK (87 per million population) (Table 3).
• For comparison between European countries the EMCDDA uses a ‘drug-induced death’ definition that covers only deaths directly caused by illegal drugs in those aged 15 to 64, and the rate per million population aged 15-64. Scotland’s 2018 drug-induced death rate was 295 per million population. For Scotland in 2017 (the most recent year for which widely comparable figures were available) the drug-induced death rate was 229 per million population aged 15-64. This was higher than any other European country, the next highest being Estonia with 130 deaths per million population (Table 1).

The eighth report from the National Drug-Related Deaths Database (NDRDD) for Scotland, on deaths which occurred in 2017 and 2018 (and trends since 2009) was published in July 2022 (Tables ). 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 2018 NDRDD cohort comprises 1,209 people, of which 1,154 people were considered to be ‘non-intentional deaths’ and are reported in the main body of the report.
• In 2018 most DRDs continued to be among men (73%), although the percentage of female deaths increased between 2009 (21%) to 2018 (27%) (Table 1a).
• The mean age of people who had a DRD increased from 35 years in 2009 to 42 years in 2018 (Table 1c).
• Over half (55%) of the individuals who died lived in the 20% most deprived neighbourhoods in Scotland (Deprivation quintile 1) (Table 2).
• Most people who had a DRD lived in their own home (77%). Fifty-eight percent lived alone all of the time. The percentage of people in these categories increased over the time series (2009 to 2018) (Tables 3 and 4).
• In 2018, 566 children lost a parent or parental figure as a result of DRD (Table 5).
• Most DRDs (87%) were among people previously known to use drugs; 72% of which were known to have used drugs for at least eleven years, and 57% were known to have injected drugs (Table 7 and 8).
• In 2018, 478 (41%) people who had a DRD had been prescribed an Opioid Substitution Therapy (OST) drug (mainly methadone) at the time of death. The percentage of people prescribed an OST at the time of death increased since 2009 (Table 10a).
• In 2018 and across the time series combined, the percentage of females who had a DRD and were previously known to use drugs (83%) was lower than the percentage of males (89%). However, across the time series combined, among those known to use drugs, females (65%) were more likely than males (62%) to inject drugs, and were also consistently more likely than males to be prescribed an OST at the time of death (45% compared to 41% in 2018) (Tables 7c, 8c and 10e).
• In 2017, 70% of people who had a DRD had a medical condition recorded in the six months before death, falling to 63% in 2018. Reported recent medical ill health among DRDs has increased since 2009 (46%) (Table 14a).
• In 2017 and 2018, 63% of people who had a DRD had a recent psychiatric condition recorded in the six months prior to death. The percentage of DRDs with recent psychiatric ill health has increased since 2009 (40%) (Table 16a).
• In 2017, 76% of individuals (83% of those whose death was opioid-related) were in contact with a service with the potential to address their problem drug use or deliver harm reduction interventions in the six months before death (2018: 67%, of which 73% were opioid-related) (Tables 32a and 32c).
• Over half of DRDs (52%) occurred when others were present at the scene of the overdose. The percentage of deaths where others were present at the scene of overdose (and potentially able to intervene) was lower where individuals lived alone all of the time (34%) or were aged 45 or over (44%), than in relevant comparison groups. (Tables 39a and 39e)
• Where known, take-home naloxone (THN) supply has increased over time (29% of 2018 DRDs). Among people who had previously been supplied with THN, 59% had naloxone available at the scene of death (Tables 45a and c).
• In 2018, almost all (95%) DRDs occurred after the consumption of multiple substances (Table 46a).
• Heroin/morphine (51%), methadone (51%) and etizolam (51%) were the most common substances found at post-mortem in 2018. Since 2016, the percentage of deaths found with Heroin/Morphine has decreased (62%), whilst there were increases for deaths involving methadone (46%) and etizolam (33%) (Table 46a)
• Opioids (methadone, heroin, morphine or buprenorphine) were implicated in over three quarters (77%) of DRDs (Table 50a).
• In 2018, gabapentin and/or pregabalin were implicated in 17% and 18% of deaths respectively. Implication of these drugs has increased over time (2011: 1% and 0% respectively), potentially due to their use to enhance the effects of opioids (Table 50a).
• The presence of diazepam at post-mortem has decreased sharply from 66% in 2015 to 36% in 2017, while presence of etizolam (a benzodiazepine-type Novel Psychoactive Substance (NPS)) increased sharply (51%, compared to 9% in 2015) (Table 46a). Etizolam was twice as likely as diazepam to be implicated in deaths where it was found present (97% vs. 49%) (Table 53a).
• NPS-related deaths have continued to increase sharply between 2015 and 2018 due to the number of deaths involving benzodiazepine-type NPS (etizolam and diclazepam). In 2018, only one death involved the use of stimulant-type NPS (e.g. mephedrone) (Table 54a).
• In 2017 and 2018, most OST prescribing at time of death was well established (had been prescribed for one year or more – 83% and 74% respectively), via supervised consumption (80% and 85% respectively), and within recommended therapeutic dose guidelines (64% and 59% respectively) (Tables 57a, 56a, and 55a).
• The percentage of individuals prescribed OST, and had heroin/morphine present at death in 2017 (53%) and 2018 (49%) has decreased since 2016 (62%, the highest recorded), decreased from 62% in 2016 (the highest recorded), and was similar to the percentage observed among people not on OST (2017: 58% and 2018: 53%) (Table 58b).
• Prescribing of gabapentin or pregabalin within 90 days of death increased from 5% of people who had a DRD in 2009 to 28% in 2018 (Table 63)

Drug-Related Deaths among People Experiencing Homelessness

In November 2023, National Records of Scotland (NRS) published a report Homeless Deaths 2022 relating to deaths in Scotland among people experiencing homelessness (Tables). It should be noted that NRS has designated these as official statistics in development (formerly called experimental statistics) and urges users to take note of the limitations of these statistics.

• In 2022, an estimated 244 deaths of people experiencing homelessness were registered in Scotland. This was similar to 2021 when an estimated 250 deaths of homeless people were registered. (Table 1).
• In 2022, almost three quarters of estimated homeless deaths were among males (178 deaths, 73%) (Table 2).
• In 2022, the most common age group among estimated homeless deaths 35 to 44 years (70 deaths, 29%). The most common age group at death was 35 to 44 years for females (26) and 45 to 54 years for males (54) (Table 2).
• Of the 244 estimated homeless deaths registered in 2022, 89 (36%) were recorded as drug-related. This was a decrease from 2021, when 51% (127) of homeless deaths were recorded as drug-related (Data Fig 5).
• Comparison of NRSs statistics on homeless deaths and on drug-related deaths suggests that 8% (89/1,051) of drug-related deaths registered in Scotland in 2022 were among homeless people compared with 10% (127/1,330) of drug-related deaths in 2021. 

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 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 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 DRDs 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 2016 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 affect the substance users’ risk of ‘double dosing’.