National Mission on Drugs: Annual Monitoring Report 2023-2024

6. Outcome 2: Risk is reduced for people who use harmful drugs

6.1 Summary

Outcome 2: Risk is reduced for people who take harmful drugs

• 4,505 ambulance service naloxone administrations in 2023/24. Increase of 12% since 2022/23. At a lower level than before the start of the National Mission.
• 182 drug-related hospital stays per 100,000 in 2022/23. Decrease of 23% since 2021/22. Downward trend since before the start of the National Mission.
• There are some indications of improvement in provision of services that aim to reduce risk for people who use opioids. However, interpretation of the data relating to the impact of harm reduction services is challenging, particularly within the context of evolving risks. Data development relating to non-opioid drug related harm will inform this.

6.2 Background

Targeted harm reduction interventions are vital at various stages of a person’s recovery journey and are known to reduce the likelihood of a drug death. Naloxone is a medicine used to prevent fatal opioid overdoses and is now carried by all Scottish Ambulance Service (SAS) staff and all front-line Police Scotland officers. Both SAS naloxone administration data and data on drug-related hospital stays provide an insight into the level of acute harms associated with problem drug use experienced by people in the community. Rapid Action Drug Alerts and Response (RADAR) reports from Public Health Scotland also provide regular updates on a range of harm indicators.

Other community-based initiatives to reduce risk are wide-ranging and are aimed at promoting safer drug consumption practices and reducing the harms caused by injecting drug use including blood borne viruses, injection site injuries and infection, and overdoses. This includes the recently opened Thistle facility in Glasgow, the UK’s first safer drug consumption facility, which will be fully evaluated over the 3-year pilot period. Access to harm reduction is also a core part of the Medication Assisted Treatment (MAT) Standards.

6.3 Headline metrics

6.3.1 Headline metric: Number of ambulance service naloxone administrations

These data on the numbers of incidents in which naloxone was administered by Scottish Ambulance Service (SAS) clinicians provide an indication of numbers of suspected opioid overdoses. In 2023/24, there were 4,505 incidents^[20] in which naloxone was administered by SAS clinicians. This was 12% (482) more than in 2022/23 when there were 4,023 incidents^[21] (Figure 4). However, overall, SAS naloxone administration incidents are generally at a lower level now than they were before the National Mission was introduced.

Source: Rapid Action Drug Alerts and Response (RADAR) quarterly report, Public Health Scotland, January 2025

The latest surveillance data suggests that the number of SAS naloxone administrations has continued to fall. There were 2,094 SAS naloxone administration incidents over the first half of 2024/25, 16% (407) fewer than the same period of 2023/24.^[22]

Data on the administration of naloxone should be interpreted in the context of the significant activity undertaken in recent years to increase the distribution and carriage of naloxone in Scotland. The distribution of kits to people at risk has remained the priority, but further work targeting peers of people using drugs, family members and emergency services has also been undertaken with partners. This increased availability of naloxone and wider range of people who may be carrying and administering naloxone is likely to have had an impact on the number of SAS naloxone administrations. As at December 2024, there had been 581 naloxone administrations by Police Scotland.^[23]

6.3.2 Headline metric: Rate of drug-related hospital stays

During 2022/23 (the most recent data available), the rate of drug-related hospital stays was 182 per 100,000 population (Figure 5). ^{[24],[25],[26]} This is a decrease of 23% compared to 2021/22 (236 stays per 100,000). This is the third consecutive annual decrease from a high of 283 per 100,000 population in 2019/20. This reduction was driven primarily by falls in acute hospital stays and opioid related and sedative/hypnotics^[27] related stays.

Source: Drug-related hospital statistics Scotland 2022 to 2023, Public Health Scotland, April 2024

The majority of drug-related hospital stays are in general acute hospitals, where the rate has decreased for the third consecutive year from 245 per 100,000 population in 2019/20 to 151 stays per 100,000 population in 2022/23. In comparison, drug-related psychiatric hospital stays have remained relatively stable.

In 2022/23, the highest substance-specific stay rate was for opioids (81 per 100,000). This rate decreased for a third consecutive year. The highest patient rate was among people aged 35-44 years, and just under half of the patients (48%) with a drug-related hospital stay lived in the most deprived areas of Scotland.

Statistics for this metric for 2023/24 have not yet been published. However, RADAR reports management information data^[28] on the number of acute drug-related hospital admissions.^[29] This is a similar measure of drug-related hospital activity to the drug-related hospital stay statistics however admissions data are limited to acute hospital settings and may not fully capture all drug related diagnoses. Acute drug-related admissions show a broadly downward trend since mid-2023. Opioids remain the most common drug category recorded but there has been a gradual increase in admissions for cocaine (the second most common drug type recorded).

The continuing decreasing trend observed in drug-related hospital stays, mirrored in recent acute drug-related hospital admissions, may be suggestive of a decrease in harms. However, the drivers behind this trend are unclear and may be influenced by operational factors in hospital settings and caution must be taken when interpreting these metrics. It may be that people receive care in the community or attend the emergency department but are not admitted (for example due to actions as a result of the Scottish Government's NHS Recovery Plan 2021-2026, which aimed to develop alternative pathways of care in order to reduce the need for hospital admission). The PHS drug-related hospital admissions publication (expected Spring/Summer 2025) will provide further insight into recent trends.

6.4 Supporting metrics

6.4.1 Supporting metric: Number of new hepatitis C infections

There were 1,334 new diagnoses of hepatitis C antibody-positivity in Scotland in 2023 (Figure 6). This is an increase of 317 (31%) compared to 2022 (1,017 new diagnoses) and the highest total since 2019. 68% (908) of new diagnoses in 2023 were male, consistent with previous years. The distribution of diagnoses by age group in 2023 was slightly older than those in 2019, with over a quarter aged 50 years or older.^[30]

Source: Surveillance of hepatitis C in Scotland – Progress on elimination of hepatitis C as a major public health concern: 2024 update, Public Health Scotland, January 2025

The COVID-19 pandemic had a major impact on the delivery of hepatitis C prevention, testing/diagnosis and treatment services. Compared to 2019, the number of people tested for hepatitis C antibody (and/or PCR) in Scotland was 14% higher in 2023 highlighting the recovery made since the pandemic. Prevalence of chronic hepatitis C (i.e. active infection) further reduced from 37% in 2015-16 to 15% in 2022-23, contemporaneous with the scale-up of hepatitis C treatment in community settings among people who inject drugs. However the rate of decline has slowed, which may be attributable to fewer people being tested and treated for their hepatitis C during the COVID-19 pandemic. Considerable challenges remain in reaching hepatitis C elimination goals.

The Needle Exchange Surveillance Initiative (NESI) provides additional relevant context into the prevalence of blood-borne viruses specifically among people who use drugs in Scotland in relation to HIV. Uptake of HIV testing among NESI participants is stable. Forty-one individuals with HIV were detected in 2022/23, most within NHS Greater Glasgow and Clyde (the setting of an HIV outbreak that began in 2015), where the prevalence of HIV remains stable.^[31]

6.4.2 Supporting metric: Number of needles/syringes distributed per injecting equipment provision outlet attendance

No new ‘Injecting equipment provision in Scotland’ statistics are available to provide an update to this metric for 2023/24. However, this metric uses number of needles/syringes per visit as an indication of the number of injecting episodes and there are a number of other data sources that also provide some insight into this area.

The RADAR surveillance system publishes quarterly reports of drug-related indicators that include management information on injecting equipment provision (IEP) in Scotland. The average weekly number of IEP transactions, the average number of needles and syringes distributed per week, and the ratio of needles and syringes distributed per visit have all been broadly stable over recent years with the exception of some periods of seasonal fluctuation.^[32]

Data from the Drug and Alcohol Information System (DAISy) suggests that, among people starting specialist treatment for drug use, the percentage of people reporting having injected drugs in the month prior has decreased from 21% in 2021/22 to 17% in 2023/24.^[33]

NESI also provides insight into injecting risk behaviour among people who inject drugs in Scotland. Among respondents who had injected in the past six months, the proportion who reported injecting at least once a day has fluctuated over time but remains around 50%. The proportion that reported injecting four or more times a day has increased slightly, from 8-9% over the previous four surveys to 15% in 2022/23. The observed increase in cocaine injecting, which is known to have a shorter psychoactive effect and as such may lead to increases in injection frequency may account for the increase in those injecting very frequently.^[34]

6.4.3 Supporting metric: Naloxone programme reach

In 2023/24, the ‘reach’ of the National Naloxone Programme (percentage of people at risk of an opioid overdose who have been supplied with take home naloxone^[35]) was 76.2% (Figure 7). This is an increase of over five percentage points since 2022/23 (70.5%) and an increase of 26 percentage points compared to 2019/20 (50.2%). The reach of the National Naloxone Programme has continually increased since data collection began.

Source: National Naloxone programme Scotland - Quarterly Monitoring Bulletin January to March (Q4) 2023/24, Public Health Scotland, October 2024

6.4.4 Supporting metric: Percentage of ADP areas where MAT standard 4 has been fully implemented

PHS publish annual reporting on the implementation of MAT standards in their National Benchmarking Report.^[36],[37] However, the most recent 2023/24 report included changes in how assessments were undertaken since last year. Therefore, it is not possible to make direct year on year comparisons, and findings should be taken as a snapshot in time as opposed to a comparison progress report.

The aim of MAT standard 4 is to ensure that all people are offered evidence-based harm reduction at the point of MAT delivery, to minimise missed opportunities to reduce stigma. In 2023/24, the standard was assessed as fully implemented in 93% of ADP areas (sustained implementation in two ADP areas, fully implemented in 25 ADP areas and partially implemented in two ADP areas). All but one ADP area reported that blood-borne virus testing, injection equipment provision, naloxone and overdose awareness, and wound care were available for at least 75% of the case load at all MAT appointments as the benchmark for MAT 4. Limiting factors for availability included physical infrastructure and systems.

6.4.5 Supporting metric: Percentage of ADP areas offering specific harm reduction services

In 2023/24, in drug service settings (NHS, third sector and council):

• All ADP areas (100%) reported offering supply of naloxone.
• All but one ADP area (97%) reported offering hepatitis C testing.
• All ADP areas (100%) reported offering injecting equipment provision.
• All but one ADP area (97%) reported providing wound care.^[38]

This is in line with the previous year with the exception of wound care which was reported as offered in drug service settings in one fewer ADP area in 2023/24 than in 2022/23.

This supporting metric focuses on the availability of harm reduction initiatives in drug services specifically, but the survey also provides insight into the availability of harm reduction services more generally.

Supplies of naloxone

Supplies of naloxone were available in drug services in all ADP areas, followed by mobile/outreach services in 90% of areas. Since the 2022/23 survey, there was a reduction in ADPs reporting availability of naloxone across many services, including a 13% reduction in the number of ADPs where naloxone is supplied in community pharmacies and a 12% reduction in ADPs where it is supplied in women’s support services.

Hepatitis C testing

Hepatitis C testing was provided in drug services in 97% of ADP areas and in mobile/outreach services in 80% of areas. The number of ADPs reporting Hepatitis C testing being offered in many services has increased since 2022/23, such as in family support services and in community pharmacies, though a reduction in some, including in justice services and in peer-led initiatives.

Injecting equipment provision

Injecting equipment provision (IEP) was provided in drug services in all ADP areas and in mobile/outreach services in 93% of ADP areas. Across ADP areas there were both increases and reductions in the range of services IEP is provided in since the 2022/23 survey, including a reduction in ADP areas providing IEP in community pharmacies and in justice services, and an increase in ADPs reporting availability of IEP in both homelessness services and family support services.

Wound care

Wound care was provided in drug services in 97% of ADP areas, in hospitals in 83% of ADP areas and in general practice in 73% of ADP areas. Since 2022/23, there was an increase in ADPs reporting wound care availability in services including in family support services and in mental health services, and a decrease in wound care availability in some other services including in general practices and in mobile/outreach services.

6.5 Discussion

There are some indications of improvement in provision of services that aim to reduce risk for people who use opioids. However, interpretation of the data relating to the impact of harm reduction services is challenging, particularly within the context of evolving risks. Data development relating to non-opioid drug related harm will inform this.

Both ambulance service naloxone administrations and drug-related hospital stays show a downward trend which could suggest a reduction in drug related harms. However, there are limitations to consider when interpreting these data. The number of SAS naloxone administrations is likely to be impacted by the increased availability of naloxone in the community potentially reducing the need for it to be administered by the ambulance service. The level of drug-related hospital stays may be impacted by a range of barriers experienced by people accessing urgent care services as well as operational actions and the capacity of hospital services more generally. As PHS continues to develop its public health surveillance in relation to drug-related urgent care, it may be possible to explore the reasons behind the decreasing rate of drug-related hospital stays.

Other supporting metrics show a mix of findings related to this outcome. There was an increase in new hepatitis C infections in 2023 following a period of lower numbers newly diagnosed since 2020. Considerable challenges remain in reaching hepatitis C elimination goals.

While there are no official IEP statistics available for this most recent year, relevant management information suggests that provision of harm reduction equipment and engagement with IEP services has been broadly stable over recent years. Behaviours around injecting may be changing however, with a reduction in the percentage of people who report having injected drugs recorded amongst those starting specialist treatment. Conversely, among those who do inject, NESI found an increase in injecting frequency and suggested that this may be associated with an increase in cocaine injecting.

The reach of the National Naloxone Programme has continued to expand, with over three quarters of those at risk of an opioid overdose having been supplied with take-home naloxone. However, this metric does not provide any insight into community naloxone carriage or use.

MAT standard 4 (all people are offered evidence-based harm reduction at the point of MAT delivery) was assessed as fully implemented in the vast majority of ADP areas. The percentage of ADPs offering harm reduction initiatives (naloxone, hepatitis C testing, IEP and wound care) remains high in drug services and mobile/outreach services, however, there have been fluctuations in availability of these interventions in some other settings - including a reported reduction in ADPs where naloxone is supplied in community pharmacies. The reasons for this are an area for potential future investigation.

The metrics for this outcome are challenging to interpret, and while some metrics show stable or what could be interpreted as positive trends, there is need for further analysis and intelligence to provide the necessary context to understand the reasons underpinning any changes. This is particularly pertinent within the context of changing patterns of drug use behaviours and an evolving drug supply which may pose increasing risk for people who use drugs.