Wasting time on ‘phoney debates’ has hampered action on Scottish drug deaths

The rate of people dying from a drug overdose death in Scotland remains the highest in Europe and the latest statistics from the National Records of Scotland confirm that.

Each year the publication of these statistics confirms the human tragedies that affect families and communities every day. There is a peak in media, political and public interest and our organisation, Scottish Drugs Forum (SDF), receives a few dozen media requests from Scotland and further afield.

The usual question is why Scotland is in this situation. There are many possible answers – they shouldn’t contradict each other as there are historical, social, economic and even political reasons why Scotland has high levels of substance use. But there can only be one answer to why we have failed to further reduce drug-related deaths, and that is that we have failed to do what is evidenced to reduce them elsewhere.

The evidence base is clear that there are a range of effective interventions. These include measures to reduce fatal outcomes by providing naloxone and safer-consumption facilities; to reduce the risk of overdose occurring by maximising the number of people in opiate substitution treatment; and to reduce vulnerability by integrating care with mental health and mainstream health services.

We should be doing all of these things, at the necessary scale, across the whole of Scotland.

We have wasted a lot of time on phoney debates in Scotland. In that process, we have lost sight of the evidence and attached the stigma associated with drug use and experiencing drug problems to treatment and treatment services. The way methadone – a medication on the World Health Organization’s List of Essential Medicines that is also the WHO’s recommended treatment for opiate dependency – is talked about in the media and political discourse in Scotland is a shameful disgrace. Treatment services, often under-staffed and under-resourced and provided in some of the poorest physical environments, reflect this stigma.

To improve matters, we have managed to build a consensus that treatment should be improved. This led to the development of the Medication Assisted Treatment (MAT) Standards and a target to increase the number of people in treatment by nine per cent. These measures were to be delivered by April this year. The system has struggled to implement the necessary change and targets have slipped.

New SDF research published this week shows us why services have not become more accessible and acceptable to people experiencing drug problems. The research fieldwork, which received funding from the Scottish Government, was undertaken by people with their own lived experience of substance use, who observed and interviewed people using treatment services repeatedly, at intervals, as they progressed through the system.

The issues some people faced illustrate why Scotland attracts a lower proportion of people experiencing drug problems into treatment. 

People are still having to wait to get into treatment despite the standards demanding that they should be able to start on the day they present for treatment. In the circumstances in which people present, this is not a delay but a missed opportunity as people can then disengage and not return for months. 

Once in treatment, there is often a lack of a person-centred approach. The research shows many people want a positive therapeutic relationship with services. They appreciate the significant difference that building trust with service staff makes.

However, for some, this is impossible due to changes of worker, the worker not having the time or irregular contact. This gap in service provision, for some people, leads to them consuming more drugs and increasing their risk. Some people being treated for opiate dependency then report that they have started using stimulants like cocaine. 

The report shows very mixed responses. It is obvious that the system works for some people, sometimes. Often this seems to be about individual staff making extra effort. Last year we did some research on the workforce in drug services and found alarming levels of burn out. This should be a concern.

The latest report on MAT Standards implementation coded 30 local areas covering Scotland against nine measures. Of these 270 data points, full implementation and monitoring of a MAT standard had been achieved on just four occasions. Clearly, a system which itself is resistant or incapable of change will struggle to inspire and support change in the people it serves.

For many people experiencing drug problems, the experience is one of disempowerment. By the time they present at treatment services, many people report feeling desperate. They may say that their lives are dominated or controlled by drugs. But their day to day lives are shaped by the actions of drug dealers and organised crime groups, by the police and criminal justice system, the benefits system and sometimes antagonistic relationships with other services, including housing.

Some have also lost contact with all or most of their families and have no positive social network that is not related to buying and using drugs. 

It’s clear that, for all the range of need that services identify, or people presenting for treatment may request, the fundamental need is for empowerment. Services should not view the people they work with as having chaotic lives that the service provider should be controlling. Service provision and treatment should be a process of empowerment based on a therapeutic relationship.

Austin Smith is head of policy, practice and communication at Scottish Drugs Forum, a member-based charity whose mission is to improve Scotland’s approach to drug-related issues