The wider context
Chapter 1
1.1 Our principles
1. Drug-related deaths are preventable and we must act now.
2. Scotland and the Scottish Government must focus on what can be done within our powers.
1.2 Drug deaths in Scotland
Scotland has the highest drug-death rate in Europe.
National Records of Scotland (NRS) reported 1,339 registered drug-related deaths in Scotland in 2020 (1). This was 5% more than in 2019 and the largest number since records began in 1996.
Drug-related deaths have increased more rapidly in Scotland than in England and Wales over the last 20 years. Rates are considerably higher here than in the rest of the UK.
1.3 What is the cause of Scotland’s higher rates?
Some characteristics of the profile and behaviours of people who use drugs and their patterns of use add complexity to the nature of our challenge in Scotland. We have concluded that four key issues are prominent.
High-risk drug use
Ninety-three percent of people who died from a drug-related death in Scotland in 2020 had more than one drug present in their body at death (1). Combinations of opioids, cocaine and benzodiazepines put people at particularly high risk.
A high-risk group
Chronic and multiple complex disadvantage – poor physical and mental health, unemployment, unstable housing, involvement with the criminal justice system and family breakdown – can predispose people to high-risk drug use. Multiple disadvantage is more common is Scotland due to the legacy of economic and social challenges from the 1980s. Opportunities to support people to address such issues may have been missed in the past because of lack of adequate service funding and access to treatments. Those most at risk can have a pattern of near-fatal overdose incidents leading ultimately to a fatal outcome.
Concentrated social deprivation
Deprivation is linked to adverse social and health circumstances, including poor mental and physical health, high exposure to trauma and increased incidence of adverse childhood experiences. All of these are recognised risk factors for drug use (2). In 2020, people in the most deprived areas in Scotland were 18 times more likely to die of a drug-related death than those in the least deprived. This rate has almost doubled in 20 years, from around 10 times more likely in the early 2000s (1).
Stigma
People who use drugs are highly stigmatised. Many feel that the healthcare system often sees only the drug problem and does not recognise the person. This perception dissuades many from accessing services.
The challenges of treating problematic drug use have been well documented in recent years through reports by, for example, the Health and Social Care Committee (3), the Scottish Affairs Committee (4), the Dundee Drug Commission (5), the Royal College of Physicians of Edinburgh (2) and Professor Dame Carol Black (6).
1.4 The response in Scotland
The Scottish Government has launched a coordinated suite of measures to tackle the drug-deaths crisis in Scotland.
The Scottish Drug Deaths Taskforce
The Scottish Drug Deaths Taskforce was established by Scottish Ministers in July 2019. We were asked to examine the key drivers of drug deaths and advise on changes in practice or in the law that could help to save lives and reduce harm.
The Taskforce met 23 times and we developed a programme of evidence-based actions. We were supported in our work by four subgroups focusing on specific areas of challenge:
- Public Health Surveillance – this subgroup developed a high-level framework for the drugs surveillance system, with priorities for implementation;
- Multiple and Complex Needs – the subgroup examined evidence on how to support people who were most vulnerable to overdose and commissioned tests of change to build the evidence base in this area;
- Medication Assisted Treatment – 10 national standards were developed by the subgroup to optimise the use of medication assisted treatment (MAT) (10), which helps to reduce the use of drugs and risk of deaths (the subgroup now continues as the MAT Implementation Support Group, reporting to the Scottish Government); and
- Criminal Justice and the Law – the subgroup looked at how to improve and accelerate access for people into health and social care services from the criminal justice system and considered the impacts of legislation on provision of public health harm-reduction services.
The focus of the Taskforce moved away from commissioning to adopting a more advisory role after the creation of the National Mission in January 2021. We established some short-term working groups in this phase to explore specific issues at pace, including drug law reform, women, and benzodiazepines. We have also been supported in our development of the recommendations by three reference groups – Lived Experience, Family and Frontline – and a number of working groups.
Our publications include:
- One Year Report (July 2020) (11);
- MSP Briefing (March 2021) (12);
- MAT Standards Informed Response for Benzodiazepine Harm Reduction (August 2021) (13);
- Drug Law Reform (September 2021) (14);
- response to the UK Government’s Naloxone Consultation 2021 (October 2021) (15);
- Women’s Report (December 2021) (16); and
- Update Briefing (December 2021) (17).
The Government granted the Taskforce £9 million to invest in 2020/21 and £5 million in 2021/22 to “Support innovative projects, test new approaches and drive forward specific work to improve the quality of services”. The funding was used to support initiatives, some of which are ongoing, to help reduce drug-related deaths.
Action 1. The Drug Policy Division of the Scottish Government should work with ongoing Taskforce projects and feed any learning into Scotland’s National Mission.
Taskforce impacts
The issues that drive the drug death crisis in Scotland are long-term and structural. Such challenges take many years to change. It therefore is not possible for us to show in a statistically significant way what direct impact the Taskforce has had.
We do know, however, that the initiatives we have launched and supported to date, which are based on our six evidence-based strategies, have made significant improvements (see Table below).
In addition, every local area in Scotland has been supported to expand its treatment and support offer by focusing on evidence-based innovative interventions.
We were determined that no one would need to wait for our final report to be published to see change happen. We already have made over 100 recommendations that are now being progressed by the Scottish Government and partners. These recommendations have been condensed and updated in this, our final report.
| Initiatives (based on Taskforce six evidencebased strategies) | Impacts |
|---|---|
| Securing targeted distribution of naloxone | The distribution of naloxone in Scotland has increased dramatically and the reach of take-home naloxone is growing; the distribution of naloxone in justice settings has also been targeted |
| Having an immediate response pathway for non-fatal overdose | The number of ADPs reporting that they have an immediate response pathway for non-fatal overdose has been increasing – every area now offers this support |
| Optimising MAT | The MAT Standards have been adopted by the Scottish Government and are being rolled out across Scotland to improve access, choice and care and to ensure that MAT is safe and effective |
| Targeting people most at risk | The Benzodiazepine Working Group has developed interim guidance that is being taken forward by the MAT Implementation Support Team and the Scottish Government to support clinicians prescribing benzodiazepines to manage individuals’ dependency on risky street versions |
| Optimising public health surveillance | A high-level framework for the public health surveillance system has been developed |
| Ensuring equivalence of support for people in the criminal justice system | Local pathways have been developed to ensure that individuals engaged in the justice system have the opportunity to access treatment and support throughout their justice journey |
1.5 Legal challenges
The subject matter of the key piece of legislation, The Misuse of Drugs Act 1971 (19) (the 1971 Act), is reserved to the UK Government, and is not within the competence of the Scottish Parliament.
This imposes significant legal restrictions on what the Scottish Government can and cannot do.
Our focus clearly is on advising the Scottish Government on actions it can take to reduce the unacceptable level of drug-related deaths in Scotland. It is inescapable, however, that some actions we want to see implemented require a response from the UK Government.
We therefore call on the UK Government to consider and address the issues we raise in this report that fall within its competence.
Despite this, responsibility for the treatment and prevention of drug problems is devolved to the Scottish Parliament. Many improvements to services and practices could be made without wholesale changes to primary and secondary legislation.
While we believe legislative change is required, more should – and can – be done in Scotland under current constitutional arrangements.
What needs to change
We held an engagement exercise on Drug Law Reform (20) that demonstrated support for wholesale change.
Specific legislative changes to enable further harm-reduction activity were suggested. These included:
- introducing supervised drug consumption facilities;
- reclassifying naloxone; and
- enabling the provision of drug paraphernalia through services to facilitate safer drug consumption.
We concluded that a review of legislation is urgently needed to support a public health approach in Scotland.
Action 2. The UK Government should amend the Misuse of Drugs Act 1971 and Misuse of Drugs Regulations 2000 to allow for the legal provision of a wider range of drug paraphernalia through harm-reduction and treatment services. This is essential to enabling safer drug consumption.
Action 3. While the Scottish Government is unable to amend the Misuse of Drugs Act 1971 and Misuse of Drugs Regulations 2000, it should explore all options to support their amendment as suggested by the Taskforce.
The engagement exercise highlighted a need for changes to regulations controlling the dispensing, prescribing and supply of controlled drugs. It also emphasised the need for regulations to control the supply of pill presses, which are involved in the mass production of street benzodiazepines.
Action 4. The UK Government should review the regulations on dispensing and prescription forms for controlled drugs to take account of clinical and technological advances since implementation in 2001.
Action 5. The Scottish Government should work with the UK Government to deliver progress on the regulation of pill presses, including developing a suitable licensing system to reduce related harm.
The Equality Act 2010, (Disability) Regulations 2010, states that “addiction to alcohol, nicotine or any other substance is to be treated as not amounting to an impairment”, unless as a result of the administration of medically prescribed drugs or other treatment. We previously asked for a transparent review of this legislation. However, due to further engagement, we are now asking for a removal.
The exemption is stigmatising and discriminatory. It prevents people from receiving reasonable adjustments that may assist their engagement with treatment and ongoing recovery. Such adjustments would be available to a person with a mental health condition but are intentionally blocked to people with dependency, removing opportunities for tailored support.
Our conclusions on this topic are similar to those of the Scottish Affairs Committee in 2019, which stated it was unacceptable that drug dependence be excluded from the Equality Act despite being recognised as a health condition and called for an immediate review. To date, however, the UK Government has been unwilling to review the exemption.
Action 6. The UK Government should urgently remove the exemption set out in S3.1 of the Equality Act 2010, (Disability) Regulations 2010, and make drug dependency part of the protected characteristic of disability.
Action 7. The Scottish Government should do everything within its powers to hasten the removal of the exemption set out in S3.1 of the Equality Act 2010, (Disability) Regulations 2010 and make drug dependency part of the protected characteristics of disability.
Work is underway to incorporate into Scots Law the right of every person to the highest attainable standard of physical and mental health through the new Human Rights Bill. It is critical that the Bill does not create similar discrimination to the Equality Act 2010 by separating the treatment of drug dependency from that of other health conditions.
Action 8. The Scottish Government should ensure, as part of the Human Rights Bill and/or National Collaborative work to develop a Charter of Rights, that the right to the highest attainable standard of physical and mental health is accessible and enforceable for people who use drugs, removing any discriminatory separation between drug dependency and other health conditions, as currently exists in the Equality Act 2010.
We found tentative support in our Drug Law Reform engagement exercise for a move towards decriminalisation or a regulated market. Stakeholders emphasised, though, that regulating, legalising or decriminalising the drug market is a complex issue. It requires engagement and consultation on a wide scale across society.
The evidence is that unacceptable and avoidable stigma and discrimination towards drug use are increased by criminalising people. People who use drugs commonly have multiple complex needs and experience serious disadvantage. Action is therefore needed to tackle the underlying causes of drug use, including poverty and inequality. People who use drugs need to be treated with respect, helping them not only to survive, but also to thrive. These themes are reflected throughout this report.
We have heard that the 1971 Act is outdated and that the law needs to be reformed to support harm-reduction measures and the implementation of a public health approach.
Action 9. The UK Government should undertake a root and branch review of the Misuse of Drugs Act, reforming the law to support harm-reduction measures and implement a public health approach.
Action 10. If the UK Government are not willing to reform the Misuse of Drugs Act, it should commit to exploring all available options openly with the Scottish Government to enable Scotland to take a public health approach.
Our final recommendations
Our final report was broken down into 4 chapters.
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