8.Problem drug use can be defined in a number of ways. Official definitions tend to focus on the prolonged use of particular drugs. For example, NHS Health Scotland defines problem drug use as the “use of opioids […] and/or the illicit use of benzodiazepines, and implies routine and prolonged use as opposed to recreational and occasional drug use”. Under this definition, there is estimated to be between 55,800 and 58,900 people with problematic drug use in Scotland. This represents an estimated prevalence rate of approximately 1.62% of the population. However, problem drug use can also be defined more broadly as use of any drug which is causing medical, social, psychological, physical, financial or legal problems. We heard that there could be “thousands” of individuals covered by this broader definition which are not accounted for in official statistics.
9.Regardless of what definition is used, not all drug use is categorised as problem drug use. According to Aberdeenshire Alcohol and Drug Partnership, recreational drug use is fairly common, but only a minority of people, approximately 10%, develop problems.
10.A drug-related death is one in which poisoning from the toxic effects of a drug was implicated in, or potentially contributed to, the cause of death. The number of drug-related deaths in Scotland has risen almost year-on-year since records began in the mid-1990s, from 224 in 1997, to 1,187 deaths in 2018. The largest number of drug-related deaths were recorded in Greater Glasgow and Clyde (33% of the total), followed by Lothian (13%), Lanarkshire (11%) and Tayside (9%).
Source: National Records of Scotland, Drug-related deaths in Scotland in 2018, July 2019
Of the 1,187 drug-related deaths in 2018, opioids (such as heroin) were implicated in 86% of deaths. Benzodiazepines in 67% of deaths, methadone in 47% of deaths, and cocaine in 23% of deaths.
11.We explored why we have seen such a relentless increase in drug-related deaths in Scotland. Several key factors were identified, including:
a)An increase in poly-drug use (the consumption of two or more drugs at the same time). Dr Andrew McAuley, Glasgow Caledonian University, told us that benzodiazepines are being consumed “on top of their normal level of heroin, alcohol, methadone […] putting people much more at risk of overdose”. Of the 1,187 drug-related deaths in 2018, only 68 were cases in which only one drug was implicated in the death.
b)Increased strength and toxicity. Dr McAuley explained that the benzodiazepines consumed in Scotland are now “much more toxic” and are often “ten times as strong as the diazepam that people used to be taking”.
c)An ageing cohort. The average age of people who use drugs has been rising. Scotland now has an ageing cohort of middle-aged people who use drugs who began their drug use in the late 1980s. This particular cohort of people who use drugs is “ageing prematurely” due to “multiple comorbidity”. In other words, these individuals often experience additional health problems—such as respiratory, circulatory or cardiovascular disease—and are often therefore “physically and mentally more vulnerable”. Age is also a “proxy” for other relevant life circumstances which act as catalysts for health decline, such as “increasing social isolation, [and] bereavements in social networks”.
d)Rise in blood-borne viruses. An outbreak of HIV in Glasgow since 2015—the first HIV outbreak in over 30 years—has contributed to the increase in drug-related deaths in Scotland. This outbreak has been driven by high-risk methods of drug consumption such as sharing of injecting equipment. According to Turning Point Scotland, there were 228 newly diagnosed cases of HIV reported in Scotland in 2017. As many as 159 deaths in Scotland from HIV and Hepatitis C since 2015 could have been attributed to drug misuse. This is particularly concerning as it marks a reversal of earlier progress to reduce the rate of new infections, which addressed the HIV epidemics experienced by both Dundee and Edinburgh in the 1980s.
12.Scotland is in the midst of a drug death crisis. The relentless increase in drug deaths in Scotland is a tragedy that cannot be allowed to continue. We call on the UK Government to declare a public health emergency, and to work with the Scottish Government to take urgent and radical steps to halt Scotland’s spiralling drug crisis. Both Governments must be open to implementing innovative evidence-based solutions with the scale and urgency required by Scotland’s drug crisis.
13.As noted earlier, not all drug use is problematic. We therefore sought to explore why some peoples’ usage becomes problematic, while others’ does not. We heard there are a number of risk factors which make it more likely that an individual “will progress from initial use to repeated use, and then problematic use”, and that these factors can also act as a barrier preventing people from recovering from problem drug use. The main risk factors and structural drivers we explored are outlined below.
14.The single biggest structural driver of problem drug use is poverty and deprivation. Problem drug use is more prevalent “among people from more deprived areas [… and] from less advantaged backgrounds”. NHS Health Scotland told us that drug use disorders are 17 times more prevalent in Scotland’s most deprived areas, compared with the least deprived. It is not necessarily the case that poverty in itself is a direct driver of problematic drug use; however, those in poverty are more likely to be exposed to additional risk factors, such as unstable home life, unemployment, and adverse childhood experiences which increase the likelihood of a person being predisposed towards problematic substance use. Deprivation also make it less likely that a person will overcome their drug problems because “they have less access to factors that support recovery such as meaningful employment and suitable housing”, and having access to secure employment and housing are key protective factors against problem drug use.
15.Addaction told us that, in many cases, people experiencing social exclusion and disadvantage turn to drug use in early adulthood as a form of “escape”, to help them deal with the fact that they do not have access to the opportunities or resources available to the rest of society. Aberdeenshire Alcohol and Drug Partnership made a similar point, saying that drug-related deaths are often referred to as ‘deaths of despair’, because most relate to “people who have little hope for the future due [to] their experience of poverty [and] inequality of opportunity”. As such, “those experiencing hopelessness and despair are most at risk”, and these individuals tend to be amongst the poorest and most deprived in society.
16.We heard many examples of this from individuals with lived experience of problem drug use, including Colin Hepburn, who explained how his experience of poverty and deprivation whilst growing up caused him to turn to substance use:
The area that I was living in was being pulled down. It was an area of urban deprivation. There was high unemployment and crime. It seemed that nobody was working. Bear in mind that I grew up during the miners’ strike, you know. It was probably a sense of hopelessness throughout the area. There was no investment in the area. There was no community centre as such. For me looking back, it was a sense of no hope and no sense of purpose […] Just that: feeling heartbreak, feeling “what’s the point?” and I coped with that by using substances.
17.During public engagement events we heard numerous cases of individuals with lived experience whose problematic substance use developed as a result of self-medicating to treat chronic underlying health conditions. Those experiencing poverty and deprivation are more likely to develop long-term health issues and therefore, by extension, to self-medicate. We also heard that individuals from poorer backgrounds are more likely to be exposed to drugs in childhood in the first place (for example, in the home), and are therefore more likely to consume drugs later in life, and to experience problems and dependence. Vicki Craik, Crew 2000, explained:
When people are brought up in poverty it leads to the snowball effect of drugs. If the people around you are taking drugs in a problematic way, you are also likely to take them in a problematic way.
18.Dr McAuley also explained that the link between poverty and problem drug use was the reason why problem drug use is less prevalent in the middle classes; “whether it is income, employment, stable housing […] the middle classes are much less exposed to those factors and these are the factors that are more likely to drive people in the more deprived communities into problematic use”. This does not mean that recreational drug use (as opposed to problem drug use) is any higher in more deprived communities, compared to other groups.
19.The evidence we have heard suggests that reducing poverty and deprivation would alleviate the primary structural driver of problem drug use. Dr McAuley said:
It takes much larger forces to impact on income, wealth, housing, employment, but these are the structural forces that created the problem drug use cohort in the first place, and these are fundamentally the things that will address it in the future.
Dr Tweed, University of Glasgow, similarly recommended that the UK Government’s “absolute priority” should be reducing poverty and inequality, which would, in turn, help reduce problem drug use. Dr Budd, Edinburgh Access Partnership, Dr McAuley, and the Scottish Drugs Forum, amongst many others, all shared this view.
20.Poor mental health—often caused by traumatic experiences—is also a key risk factor amongst people who use drugs. Indeed, Turning Point Scotland told us that mental health is the most common issue present in people who access their support services. Adverse Childhood Experiences (ACEs)—stressful and/or traumatic events which occur in childhood—can be a factor which may predispose individuals towards developing problematic drug use later in life. Examples of ACEs include neglect, physical, sexual or emotional abuse, having a parent in prison, and having a parent with mental health problems within the home. Turning Point Scotland told us that “adults who experienced four or more adversities in their childhood, were […] eleven times more likely to have used crack cocaine or heroin”.
21.In adulthood, traumatic personal experiences of adversity might include witnessing or being a victim of violence, bereavement, military service in a combat zone, imprisonment, and homelessness. Homelessness, in particular, was a recurring theme throughout our inquiry. Dr Budd told us that rates of homelessness are increasing, and that it is both a consequence and driver of problem drug use. According to analysis by Turning Point Scotland, experiences of homelessness and difficulties with housing/accommodation were present in nearly 30% of individuals accessing their support services. Dr Budd explained that getting homeless people who use drugs into secure accommodation is the first part of the solution, as it then “enables them to start looking at some of the other underlying issues”.
22.People who have experienced traumatic experiences may turn to drugs as a way of coping with “overwhelming emotional and somatic sensations” caused by their experiences. For example, Addaction told us that “people misuse substances to address the traumatic stress they experience—including self-medicating to escape invasive memories, or make traumatic relationships more tolerable”.
23.We heard repeatedly that involvement with the criminal justice system is a risk factor for problem drug use. Dr Tessa Parkes, University of Stirling, explained that:
It is more challenging for people who experience problem drug use if they are criminalised in the criminal justice system to manage to pull out the recovery capital or the social resources to try to mitigate some of the harms.
There are many reasons for this, which will be explored in more detail in the next chapter. In short though, criminal justice interventions can lead to exposure to drugs in prison, loss of housing and employment, sever family and social support networks, and create barriers to future education and employment. The experience of incarceration can also be—in its own right—a traumatising experience, which individuals can attempt to treat through self-medication.
24.Social exclusion and weak family structure can also be a risk factor for problem drug use. Vicki Craik, Crew 2000, explained that social and familial support networks are a “protective factor”, which might support individuals who are potentially at risk of using substances problematically. Sharon Brand, a person with lived experience of problem drug use, explained how the sudden loss of family networks caused her to turn to drugs:
In the space of three weeks, I lost my grandparents. My grandmother and my dad emigrated and my support system left. Everything fell apart around us and I was associated with people who were using heroin. I succumbed to that after about a year.
25.The absence of social or familial structures often leads to social marginalisation, which can result in “people who feel that they have very little to benefit from or investment in the wider society, who feel rather left behind”. Dr Parkes explained that, as a result, these individuals often “go under the radar, and are harder for us as health service providers, social service providers, and friends and family members to bring back”.
26.Stigma is also a key structural driver, because it instils a fear in people from “coming forward” and seeking treatment for their substance use, due to fear of social judgement and shaming. As Dr Iain McPhee said, “the stigma associated with being a drug user, the way in which they are treated, and the way that they see themselves being treated in services, all exacerbate the drugs issue”. Some accounts suggested stigma towards problem drug use could be particularly prevalent in Scotland compared to other places. The Scottish Drug Forum told us that Scotland “often seems to have a comparatively judgemental, moralistic and stigmatising cultural attitude”. Evidence suggests that addressing stigma would help address problem drug use by encouraging individuals to “be more open to asking for help”. We explore this further in chapter 6.
27.People’s drug use often becomes problematic because of things beyond their control, rather than because of a proactive ‘decision’ to become dependent on substances. People who use drugs are a vulnerable group who require help and support, not prejudice and judgement. Both Governments must ensure that their approaches to problem drug use acknowledge and address the underlying causes, such as poverty and inequality, social marginalisation, trauma and the lack of strong family structures and support networks.
28.The drug-related death rate (per head of population) in Scotland is roughly three times that of the UK as a whole. A key question throughout our inquiry has been “why?”, and whether the drivers are different on either side of the border. The evidence we heard suggests that the structural drivers themselves are no different in Scotland, but that they are more severe, and their effects are therefore felt more keenly in Scotland, compared to the rest of the UK. The Scottish Drugs Forum explained:
Although none of these [factors] are unique to people in Scotland, it may be that Scotland has a higher rate of some or all of these issues than elsewhere.
Dr Priyadarshi said “it wouldn’t be accurate” to say that England has not experienced the same issues as Scotland. Indeed, drug-related deaths are also at an all-time high in England and Wales too. However, the structural changes which drive problem drug use have been felt more acutely in Scotland compared to the rest of the UK, and the prevalence of problem drug use is therefore disproportionately higher north of the border.
29.We heard accounts which suggested that there is a particular link between problem drug use and poverty and inequality caused by the UK’s socio-economic policies of the 1970s and 80s—notably de-industrialisation. Dr Saket Priyadarshi, NHS Greater Glasgow and Clyde, explained that the closure of Scotland’s industries—“everything from ship building, coal mining, steel industries and so on”—resulted in a loss of employment, and a loss of “meaning” in many Scottish communities. Dr McAuley added that these closures “may have impacted a population that was more dependent than others on those economies and industries”. Elinor Dickie, NHS Health Scotland, explained:
It appears that the policies in the ‘70s and ‘80s […] those changing socio-economic circumstances and the displacement of communities, disentangling their resilience, appears to have had a greater impact in Scotland.
Similarly, the Scottish Drugs Forum noted that economic changes between the 1960s and 1990s resulted in “dispossession and social displacement”, the legacy of which continues to manifest itself as ‘The Glasgow Effect’ today.
30.Another example of the drivers of problem drug use being more pronounced in Scotland is traumatising and adverse childhood experience, with the Scottish Drugs Forum noting that “Scotland has a far higher rate of children being removed from parental care by the state and being brought up in care than England”.
31.As we have seen, problem drug use has its roots in a complex mix of poverty and deprivation, stigma, mental health issues, and criminal justice interventions. Addressing this issue cuts across both governments’ responsibilities—the Scottish Government controls health and social care policy, while powers over the economy and welfare delivery are often shared or entirely within the UK Government’s control.
32.Dr Tweed, a clinical lecturer at the University of Glasgow argued there is a particular role for the UK Government in addressing economic inequalities and poverty as drivers of problematic drug use. The same point was made by the Scottish Drugs Forum, who told us that although the Scottish Government has control over the health service and social care, it has “more limited control” over Scotland’s economy and the distribution of wealth, which is key to addressing the longer-term effects of socio-economic change. Dr Parkes, University of Stirling, supported this point, adding that:
In terms of the most substantial levers that we have talked about, including socio-economic, they do not have all the levers to do so. They do not necessarily have the taxation [powers] to do that [via] welfare [systems].
33.We heard that the most effective approaches to addressing problem drug use have tended to be those which ‘join-up’ and integrate relevant policy areas. This is particularly difficult given the type of radical, whole-system change that could be required to address the root causes of Scotland’s drug epidemic. The importance and effectiveness of radical, whole-system change is evident in the case of Portugal, which was the most oft-cited example of the successful implementation of a public health approach. Numerous witnesses explained that decriminalisation in Portugal (which we explore further in chapter 5) went hand-in-hand with a number of equally important changes in other areas—including welfare, employment, education, as well as economic reform. These reforms were designed to tackle poverty and unemployment, thereby reducing structural health inequalities, social disempowerment, and marginalisation, which led to problem drug use. Dr Parkes explained:
They brought in not only expanded harm reduction and treatment but also an administrative response and minimum wage. They basically reformed the system around humanity, pragmatism and participation […] What we can see is that enhancing social and economic supports can go some way towards alleviating […] problem drug use because people are no longer excluded from society.
34.We heard of other successful interventions which are based on similar principles. For example, we heard that the Edinburgh Access [GP] Practice has taken an integrated approach to substance use treatment. Dr Budd explained that the Practice tries to bring all relevant services “under one roof”. For example, in addition to the usual GP and nurse services, the Practice also offers mental health and psychology services, hepatitis treatment clinics, housing advice surgeries, welfare rights advice drop ins, and legal advice clinics. The availability of these different services seeks to address each of the individual risk factors people who use drugs may be experiencing, and thereby address the underlying drivers and barriers to recovery.
35.However, our evidence suggests that the UK Government’s approach to problem drug use is not as integrated as it could be. Many witnesses argued that key Government departments are not proactively engaged with the health services, and that departments do not adequately consider the impact their policies have on people who use drugs. This can threaten the continuity of care which is essential to ensuring a stable path to recovery for people who use drugs. The Department for Work and Pensions (DWP) was a frequently cited example. For example, when asked whether there is any communication or involvement between the DWP and health services in relation to problem drug use, Dr Budd, replied “hardly”. He explained:
From my perspective, as a GP, there is very, very limited communication from the Department for Work and Pensions, and it would make a huge difference […] It would be a huge step forward for the Department for Work and Pensions to be working as a partner agency.
36.The DWP told us that in Scotland the Department is engaged with a number of key stakeholders, such as local authorities, the NHS, and other partners, in order to “maximise access to services which would benefit customers with addictions”, and that the Department has a network of “ever growing partnerships with specialist agencies” to support vulnerable people by addressing their complex barriers to employment.
37.The Home Office told us that it recognises the link between poverty and problem drug use; however, the minister did not expand on how this understanding has informed its drugs policy. The minister told us that he hopes to convene a comprehensive drug-death summit in Glasgow before Christmas, to bring together key stakeholders and governments at a local, national and regional level to create a fully integrated response to problem drug use. He said this summit would be informed by this Committee’s report, the work done by the Health and Social Care Committee and the Carol Black review, as well as advice from the Advisory Council on the Misuse of Drugs.
38.Addressing the root causes of problem drug use requires radical, whole-system change, rather than piecemeal reform. We welcome the planned cross-government summit in Glasgow and encourage the UK and Scottish Governments to be bold, imaginative and evidence-based. Both Governments must work together to implement an integrated, cross-departmental, and cross-government approach to drugs, which fully utilises the potential impact of joined-up policing, justice, employment, welfare, housing, physical and mental health policies and services. The UK Government must also ensure that all departments are proactively engaging with each other, the health services and third-sector organisations, in order to help address problem drug use in Scotland.
39.A key policy which the UK Government can influence which would address a key driver of problem drug use is the delivery of social security in Scotland—which is currently a shared responsibly. As discussed, poverty and inequality are the single biggest drivers of problem drug use, and social security policy plays a key role in this. As Dr Tweed said, “welfare reform has particular impacts on people who use drugs because they use public services, they often have precarious circumstances, needing support from benefits”. Some witnesses were particularly critical of the sanctions-based approach used by the DWP. A sanction is the reduction of welfare payments for a set period, in response to a failure to meet certain commitments (called ‘conditionality requirements’)—for example, for failing to attend a Job Centre meeting. Dr Budd was critical of this “adversarial system”, arguing that:
Sanctions just drive people further away from support and entrench them in a position of dependence and disability. Sanctions are a very negative and retrogressive approach to people who really need support now.
40.Elinor Dickie, NHS Health Scotland, Iain Clunie, SMART Recovery UK, Patricia Tracey, Turning Point Scotland, and Norma Howarth, Signpost Recovery, amongst others, agreed that sanctions-based approaches to welfare are a barrier to recovery. Norma Howarth argued that sanctions place “an incredible expectation” of autonomous responsibility and ability on service users which cannot always be managed by people with problem drug use:
To be able to access a system, to maintain appointments and to have the ability to engage in a system is quite complicated for our service users who skirt around quite a large, chaotic lifestyle. It is an expectation that is to their disadvantage.
Elinor Dickie used the example of sanctions for missed appointments to highlight the counterproductive effects of sanctions. We saw the impact of this ourselves during a visit to the Scottish Drugs Forum in June. We spoke to a person with current problematic drug use, who explained that sanctions for missing DWP appointments—often due to poor public transport infrastructure, or lack of concessionary access to travel—have left him unable to support himself financially, which caused him to relapse from recovery. This was also the view of the Scottish Government minister, Joe Fitzpatrick MSP, who argued sanctions often “create a whole new cycle”, which “pulls people away from treatment”.
41.The Department for Work and Pensions told us that sanctions are only applied when conditionality requirements are missed “without good reason”, that claimants are “given every opportunity to explain why they failed” to meet the agreed requirements, and that consideration is given for health conditions and disabilities. The Department added that in May 2019, 2.42% of Universal Credit claimants had a deduction from their welfare payment as a result of a sanction, and that claimants can appeal sanction decisions in an independent tribunal. We also note that since 2010 the UK’s unemployment rate has decreased significantly to levels last seen in the mid-1970s, reducing joblessness which our evidence suggests is a driver of problem drug use, and a barrier to recovery.
42.The welfare policies of the Department for Work and Pensions have a detrimental impact on people who use drugs, and often become a barrier for many people trying to enter recovery. The Scottish Government should also make full use of its existing powers to support people recovering from problem drug use. The UK Government must review the impact welfare sanctions have on people who use drugs, and outline steps it will take to make the welfare system less adversarial for people who use drugs who are trying to enter recovery.
9 NHS Scotland, Information Services Division, , March 2019
10 ; NHS Scotland, Information Services Division, , March 2019
11 ; NHS Scotland, Information Services Division, , March 2019
12 ; ; Scottish Government, Road to Recovery, 2008
14 Aberdeenshire Alcohol and Drug Partnership ()
15 Crew2000, , August 2019; National Records of Scotland, , July 2019
16 National Records of Scotland, , July 2019
17 Information Service Division (2019)
18 National Records of Scotland, , July 2019
19 National Records of Scotland, , July 2019
20 National Records of Scotland, , July 2019
21 National Records of Scotland, , July 2019
22 Scottish Drugs Forum ()
24 National Records of Scotland, , July 2019
30 BBC News, , 10 April 2019;
31 Turning Point Scotland ()
32 National Records of Scotland, , July 2019
33 BBC News, , 10 April 2019
37 NHS Health Scotland/NHS National Services Scotland ()
38 Addaction ()
39 Addaction ()
40 Addaction ()
41 Aberdeenshire Alcohol and Drug Partnership ()
42 Aberdeenshire Alcohol and Drug Partnership ()
50 ; Dr Emily Tweed ()
51 ; Scottish Drugs Forum ()
52 ; ; ;
53 Turning Point Scotland ()
56 Turning Point Scotland ()
57 Scottish Drugs Forum ()
59 Turning Point Scotland ()
62 Addaction ()
71 Scottish Drugs Forum ()
73 National Records of Scotland, , July 2019
74 Turning Point Scotland ()
75 Scottish Drugs Forum ()
76 Office for National Statistics, , 15 August 2019
82 Scottish Drugs Forum ()
83 Scottish Drugs Forum ()
85 Scottish Drugs Forum ()
90 ; Edinburgh Access Practice,
94 Department for Work and Pensions, UK Government ()
98 Department for Work and Pensions,
105 Department for Work and Pensions, UK Government ()
106 Department for Work and Pensions, UK Government ()
Published: 4 November 2019