How can Scotland's shameful drugs death crisis finally be fixed?

The release of the drugs death numbers have become an annual cavalcade of hand-wringing, with promises of vast sums of funding and renewed political will sitting ill at ease with ignominious numbers that belie a tragedy of almost unimaginable scale. Following the announcement of the latest drug misuse death statistics, which showed that 1,172 people had died across Scotland last year - an increase of 121 compared to 2022 - the health secretary said the data was “hugely concerning,” and underlines why the Scottish Government “will continue to do all we can to reduce harm and deaths caused by drugs.”

We have been here before. Several times over. There is little wonder many are feeling fatigue around the response.

Three-and-a-half years have passed since the Scottish Government declared the issue as an emergency and instigated a grand “national mission” to tackle it once and for all. A year has gone by since the then-drugs minister, Elena Whitham, suggested the “tide was turning.” Yet still the death toll creeps stubbornly upwards.

For the best part of a generation now, successive devolved administrations have failed to arrest the trend, save for occasional, incremental decreases. After adjusting for age, the rate of drug misuse deaths stands 4.2 times as high in 2023 than it was in 2000, and Scotland continues to have the highest rate of recorded drugs deaths in Europe. Each year brings all too familiar stories of people trapped in a cycle of addiction, excluded by treatment and care services, and struggling to obtain the support they need simply to stay alive. 

So what exactly needs to change? It is the million dollar question with a complex, multifaceted answer. Problem drug use, after all, is a symptom of a broader malaise inextricably linked to other policy areas, such as housing and mental health, a reality underscored by the grim fact that people living in the most deprived areas of the nation are more than 15 times as likely to die than those in the least deprived areas. 

The support charity, Turning Point, has been among those to call for a rethink of how Scotland addresses the social and structural issues that contribute to the risk of harm facing drug users while they are living, and not just after they have died. “The rise in drug related deaths might be better understood as part of the wider rise in deaths of despair,” it explained. 

But there are undoubtedly several key areas where more can, and should, be done to reduce deaths. Chief among them is the provision of residential rehabilitation beds, an issue the Scottish Government has talked up a great deal. Sadly, its actions have fallen way short. 

When then first minister Nicola Sturgeon announced her government’s new national mission to reduce drug related deaths and harms in January 2021, later admitting that they had “took our eye off the ball,” a key focus was the expansion of capacity in, and use of residential rehabilitation, ensuring it is “available for everyone who wants it.” It committed £100 million to the goal, setting a target of increasing the number of statutory funded residential rehab placements by 300 per cent so that by 2026, at least 1,000 people a year would be publicly funded for their placement. 

The semantics of that pledge raised eyebrows at the time - the talk was of increasing placement funding, as opposed to beds - and with the benefit of hindsight, such scepticism has been justified. Out of that headline £100m figure, only £38m is dedicated to increasing bed capacity. Indeed, since the government launched its ‘mission’, the actual number of beds across Scotland has risen by just 32. 

Even at that, an evaluation published in February by the quango, Public Health Scotland contained several caveats that have gone largely unreported. Those 32 beds can only be accessed by specific demographics; either individuals with children, those who can access NHS Lothian services. In short, there has been no increase in bed capacity for individuals without children living in other health board areas. 

On the day the latest drug misuse death statistics were published last week, health secretary Neil Gray eventually said - after a robust line of questioning from Sky News - that while the target set by the government’s national mission was to provide residential enough rehab beds to treat 1,000 people a year, the actual expansion would only increase the number of actual beds by 140.  

The scale of that increase has angered some campaigners, who believe it is nowhere near sufficient in order to make inroads into a persistent crisis. Annemarie Ward, chief executive of Faces & Voices of Recovery UK, an addiction advocacy and recovery charity, warned that the “gross underestimation” by the government was not simply a failure, but a “deep betrayal.”

She explained: “Rehabilitation isn’t a quick fix, it’s a long-term process that demands substantial investment in time, resources, and care. By setting such a low target, the government is effectively declaring that the lives of those struggling with addiction are not worth the necessary commitment.

“The broader picture exposes a systemic failure in Scotland’s approach to addiction treatment. The focus appears more on managing numbers than on genuinely addressing the crisis. The idea that 140 beds could suffice in a country where 50,000 people are in addiction treatment each year is a damning indictment of the government's seriousness in tackling this issue.”

Indeed, the most recent official statistics indicate that for all the urgency that accompanies the political rhetoric surrounding drug misuse deaths, there has been no progress at all in the provision of statutory-funded residential rehab placements. 

An interim monitoring report by Public Health Scotland shows that between 1 October 2023 and 31 March this year, 461 such placements were approved across Scotland. That is 16 fewer than the number of placements approved in the previous six months, and only the same number as those approved between October 2022 and March 2023. 

Other charities who are heavily involved in support and policy issues around drug-related harms point to other problematic areas where the Scottish Government has again fallen short on its promises. 

The Scottish Drugs Forum (SDF), for example, advocates the use of Naloxone, drug checking, safer drug consumption, and medication assisted treatment (MAT) services as the “core part” of any overdose prevention strategy. But the latter solution, it points out, is still some considerable way from being fit for purpose. 

Over three years have passed since the Scottish Government, in collaboration with the Drug Deaths Task Force, published the MAT standards, a framework designed to provide consistent access to effective treatment, regardless of individual circumstance. The reality is altogether different. 

Research published last week by the SDF, based on multiple interviews with people engaging with treatment services, highlighted the standards had not been fully implemented, even allowing for a revised schedule which set a deadline of March this year. Its report found that some participants endured delays of up to several months for an appointment, with many experiencing stigma and left wanting more frequent contact with MAT services.

“The primary aim of all treatment should be the empowerment of people in treatment,” said Kirsten Horsburgh, the SDF’s chief executive. “This would be achieved by successful implementation of all ten MAT standards, o\f which there is some way to go.” 

“The treatment services need to be capable of change and be supported to change.  That requires more radical change in practice and a clearer vision that the MAT standards implementation remains a priority.” 

Then there is the threat posed by certain drugs. As reported by The Scotsman last week, policing forensics experts have warned that a dangerous and extremely potent new synthetic opioid known as nitazenes poses a “substantial risk” hospitalisation, and death, with fears that a cluster of overdoses, as has been seen in Ireland, could exert a “significant strain” on Scotland’s already stretched emergency services. 

While opioids such as heroin, morphine remain the most common drugs connected to deaths, the datasets published by the National Records of Scotland point to a deeply worrying increase in deaths involving nitazenes, up from just one to 23 in the space of 12 months. In Ms Ward’s view, a spike of that level is indicative of “a failure in monitoring” the proliferation of such new substances. “It suggests that authorities are lagging behind in addressing emerging threats,” she said.

The data also raises searching questions about the impact of methadone. There were 514 deaths involving the drug last year, compared to just 389 linked to heroin and morphine. The statistics do not detail how many of those people were actively undergoing treatment, but such a high number invites scrutiny of the opioid substitution therapy strategy. 

That is an issue seized upon by Andrew McAuley, a professor in public at Glasgow Caledonian University and expert in injecting drug use and related harms, who noted that methadone has been proportionately more involved in deaths than heroin since 2020.

“The data tells us nothing about whether this is prescribed or diverted medicine,” he explained on X. “The research base for the protective effect of methadone remains very strong, including in Scotland. But we need to better understand why in-treatment mortality rates are increasing.”

There is hope that steps already being taken will have an impact. After years of legal wrangling, it was announced last week that a £2.3m drugs consumption facility - the first of its kind in the UK - will open in Glasgow’s east end in mid-October, capable of accommodating up to 30 service users at a time.

That will help problem drug users in Scotland’s biggest city, but in the likes of Dundee, Inverclyde, North Ayrshire, and East Ayrshire, where the rate of drug misuse death is above the national average, the future is fraught - just as it has been for the past two decades.