Culture change required

Chapter 2

2.1 Our principles

A big cultural shift is required in Scotland to tackle the harms associated with drug use. Change takes time, but it can be delivered through collaboration and continued engagement.

We believe three principles for change are central to this cultural shift:

  1. this is everyone’s responsibility;
  2. broad culture change from stigma, discrimination and punishment towards care, compassion and human rights is needed; and
  3. families and people with lived or living experience should be at the heart of the development and delivery of services.

Our recommendations and actions therefore are broad-reaching to encompass the societal barriers encountered by people with experience of problem drug use.

2.2 Core values

We have identified 12 core values to underpin the required cultural shift.

  • Person-centred support – Every person with a substance use issue is entitled to holistic, personcentred, co-designed care and support that is focused on their needs and is respectful and responsive to them.
  • Choice – The treatment and care received by people who use drugs must be based on informed choice.
  • Families need support – Separate, ring-fenced family support pathways that are not dependent on access to services for the person who uses drugs should be available for all families to help them manage and overcome any harms they experience as a result of their loved one’s drugs use.
  • Families as support – Services must recognise that families play a critical role in supporting the care of people who use drugs and should ensure that family-inclusive practice is embedded in their work.
  • Peers – Peers play a vital role in all aspects of the care system, both as a support network for a person receiving care and as part of the workforce. Local areas and services must consider how they can most effectively support peers throughout their care pathways.
  • Stigma, discrimination and negative culture must be tackled – A pronounced and sustained culture change in services and a shift in public attitudes are needed to tackle stigma and discrimination.
  • Trauma-informed services and care – Care systems must be trauma-informed at service and workforce levels.
  • Rights-based approach – A human rights-based approach puts people’s rights to life, health, support, treatment and recovery at the core of service design.
  • Relationship-based care – An effective relationship among services, those working in them and people who use drugs is a central factor of any effective intervention.
  • No wrong door – People must be able to get the right care, in the right place at the right time, no matter where or when they first seek help.
  • Aftercare – The transition from treatment can be a high-risk period for drug-related deaths, so it is vital that everyone completing treatment is fully supported to continue their progress.
  • Consistency – Delivering a full range of treatment options successfully and consistently in all areas would help to remove the current “postcode lottery” of service delivery.

These values and principles should be realised through nationally agreed guidance and standards for drug services. This is explored in more detail in Chapter 4.

2.3 Lived and living experience

We welcome the introduction of the National Collaborative. We hope it will ensure that families and those with lived and living experience can drive the integration of a human rights approach to policy-making, service design and service delivery.

What needs to change

People should be empowered through involvement in their own care. Their knowledge and experience are important parts of ensuring services meet their users’ needs and support a person-centred, human rights-based approach.

We are clear that people with lived and living experience should be included in all aspects of the development and implementation of policies and programmes that influence service design.

Action 11. All responses to problem substance use must be co-produced or co-developed with people with lived and living experience.

Peers – those with lived and living experience of problem drug use – also play a vital role in ongoing care and support. They are often the people who first respond to near-fatal overdose and can refer people into the appropriate support pathway. Peers need their own ongoing specific support.

Action 12. ADPs should ensure that specific psychological and wellbeing support is provided for people with lived and living experience.

Supporting others can be an important part of individual recovery. People with lived and living experience, however, can encounter barriers such as stigmatising behaviour and discriminatory policies when they investigate options in volunteering, training and education or when transitioning into paid employment.

Generalised criteria for volunteering, being accepted onto an educational course or a work placement can include being substance-free for a specified time. Individuals can sometimes struggle to pass vetting processes due to past criminalisation. This reinforces the idea that they are “different” and less valued than others or require more significant monitoring.

Such stigmatising behaviour and practice should be challenged and removed. People with lived and living experience should be supported to take opportunities to volunteer, enter training or education and seek paid support roles. Barriers such as lack of finance or low educational attainment should be identified and appropriate support put in place.

Of course, not every person with lived and living experience will want to work in the sector. For some, doing so can be a triggering experience. Appropriate employability support that provides pathways to careers in other sectors should always be available.

Action 13. The Scottish Government should work to ensure that barriers to accessing opportunities such as volunteering, training, education or employment are removed for people with lived and living experience wherever possible.

2.4 Families

Families are often at the frontline of Scotland’s drug death emergency. They witness the harms experienced by their loved ones and may experience harm themselves.

In developing our recommendations on families, we have built on a report from our Family Reference Group which has outlined a number of key changes that families would like to see. We have published this as an appendix to this report.

What needs to change

Families highlighted to us the need for family-inclusive practice in all aspects of the care system and in the justice system.

The framework for families affected by substance use published in December 2021 (9) focuses on improving holistic family support. It re-emphasises the importance of families as partners in supporting their loved one’s treatment and recovery. It also stresses that families need and deserve support in their own right and recognises the need to support children affected by family substance use.

We support this whole-family approach and call on the Scottish Government to implement the framework’s actions as soon as possible.

Action 14. The Scottish Government should continue to support the whole-family approach and implement the actions set out in the framework at pace.

Families should be key partners in work to develop early intervention strategies. They should be able to access support and advice as soon as they have any concerns about a family member and should also be able to access early support for themselves. Support and information for families should be available consistently across the country.

Not every family is able to be part of an early intervention. Every service nevertheless should start from the principle of involving family members and supporting them even when they do not have direct involvement in the individual’s care and support.

Support and training on a family-inclusive approach should be provided for people working in services. This will help to ensure that engaging an individual’s family in their treatment is effectively managed and supported.

Action 15. The Scottish Government and chief officers should ensure that family-inclusive practice is embedded across the public sector, with mandatory training provided for the workforce.

Action 16. ADPs should ensure that specific, ring-fenced support, including psychological and wellbeing support, is available for family members. This should not be dependent on the person who uses drugs accessing support.

2.5 Stigma kills people

We heard this time and again from members and partners. It is something that must be understood and taken seriously.

Reframing the societal approach towards people who use drugs, their families and those who work in drug support services is not about encouraging drug use. It is about reducing trauma, supporting people and ultimately saving lives.

We published A Strategy to Address the Stigmatisation of People and Communities Affected by Drug Use (21) in July 2020. The strategy outlines the types of stigma that may be experienced, the groups who may be affected, and how other factors may compound the experience of stigma.

Many people who use drugs face such factors. In addition, gender, race, comorbidities, engaging in transactional sex, being a parent, religion, disability, homelessness, unemployment, involvement in the criminal justice system and low educational attainment are issues that bring their own stigma. That stigma is increased when co-existing with problem drug use.

People with experience of problem drug use may be more likely to have experienced trauma. This can result in fear and anxiety towards engaging with services, where they may experience additional stigma and negative treatment.

Ultimately, stigma reinforces trauma and prevents people from disclosing their drug use and seeking support and treatment.

What needs to change

Like all members of society, people with lived and living experience of problem drug use, either themselves or through family, should be recognised as individuals with the same rights as everyone else. Fear, judgment, punishment and shame must be replaced by compassion, connection and communication.

Action 17. The Scottish Government should develop and rapidly implement a national stigma action plan, co-produced with people with lived, living and family experience and built on the Taskforce stigma strategy.

This is everyone’s responsibility

A significant cultural change like this needs to be multi-directional and cannot simply be imposed from above. It can be driven and supported by consistent challenging of damaging and stigmatising language and behaviours and promotion of a caring, compassionate and human rights-based approach.

What needs to change

Evidence shows effective ways to tackle stigma include protest, advocacy, education, contact with the stigmatised group, peer programmes and media campaigns.

Protest and advocacy reflect a formal objection to negative portrayals of people with drug problems or lived and living experience. Journalists, politicians, community leaders and professional groups can be engaged through protest and advocacy.

People should be empowered to protest against negative treatment of, and attitudes towards, people with problem drug use, their families and workers in the sector. Legal changes can support this – we propose some in this report – but everyone can protest against judgemental attitudes, shame, victimisation, exclusion and inequity.

Education-based campaigns use facts to address stigma by confronting negative beliefs and incorrect information.

Contact with people with lived and living experience is vital to improving understanding of the realities for people with substance use issues and has been shown to be effective in Scotland.

While peer programmes and advocacy can be an important part of recovery for many, it is not the responsibility of a person with lived or living experience to educate others unless they choose to do so, in which case they should be compensated for their work accordingly.

Media campaigns can have a role in addressing negative perceptions. Changing the attitudes of the general public is a long-term project that requires sustained effort. The application of a communication science approach should ensure that messaging is targeted, consistent and sustained.

Following the publication of our stigma strategy and its recommendations, the Scottish Government ran a media campaign during winter 2021/22. An evaluation was conducted and, alongside the views of people with lived and living experience, its results should be taken into account when designing further campaigns.

We are disappointed, however, that the media campaign remains the only action

taken forward on stigma since the publication of our strategy more than two years ago. We hope the work of the National Collaborative will help to accelerate action on stigma.

The development and implementation of a stigma action plan should be prioritised and sustained and consistent actions to challenge stigma should be taken by all services and stakeholders.

Action 18. The National Collaborative should inform and support the development and implementation of the action plan and hold the Scottish Government and partners to account for delivery.

Stigma within services

Seeking support should be an attractive and welcoming option for people where they and their families are treated with kindness, respect and are involved in choices about their own care.

Stigma exists within the workforce and has negative consequences for service delivery to people who use drugs.

Stigma tends to manifest through staff holding negative perceptions of people who use drugs or blaming them for their substance use and its consequences. It is not necessarily expressed verbally, although this could be the case, but is present in how services and staff view and treat people who use drugs.

People who use drugs are aware of stigma and recognise when they are being negatively perceived in health settings. The impact includes:

  • receiving inadequate treatment for problems such as pain;
  • barriers (perceived or actual) being put up for people who use drugs to access services; and
  • people who use drugs being reluctant to engage with services because of being stigmatised.

Evidence suggests that stigma is more commonly observed in staff in non-drug specialist services.

What needs to change

People who use drugs want a workforce that is empathetic, non-judgemental and positive about change being possible. Services should be flexible, non-punitive and involve people who use drugs in setting goals and care planning.

Staff should have good knowledge of substances and be aware of specific issues that affect some people who use drugs. These include co-morbidity with mental health issues, trauma and abuse for women, specialist support needs for older people, and barriers to accessing services for people who identify as LGBTI+.

Training on stigma, substances and the effects of substance use and the harms associated with it should be given to all levels of the workforce (see the workforce section of Chapter 4).

Health and social care practitioners, general practitioners and medical students have stated that they do not feel sufficiently skilled to work effectively with people who use drugs. This in part appears to be because drugs and addiction training are not embedded in core preparation for these professionals.

Some staff have also reported that they need more training in trauma, specifically around the disclosure of trauma by service users. This has implications for the delivery of the MAT Standards. Standard 6 relates to Psychological Support and sets out that services will “ensure the service culture and environment is psychologically-informed”. Standard 10 is on Trauma-informed Care and affirms that understanding trauma needs and working to address them should be embedded in drug services.

Services must actively promote opportunities for anyone – people who use drugs, families, communities and the workforce – to be able to challenge stigma and stigmatising behaviour, processes or environments. Formal complaints pathways for stigma experienced within services should be in place.

Services should also consider the development of stigma-free spaces in which people with problem drug use can openly discuss local and national responses to drug use, emerging issues and personal experiences. This would support people’s involvement in identifying their own priorities and determining what actions will be taken. It would also encourage effective communication with service leaders.

Increased contact and engagement with people with lived and living experience of drug use is clearly shown to improve attitudes towards, and treatment of, people who use drugs. Improving awareness and understanding of personal experience helps to overcome prevailing stigmatising narratives. It is important that links are developed and maintained between statutory services, peer support workers and recovery communities to foster this engagement.

Action 19. All services that support people who use drugs should have a defined, collaborative improvement plan for tackling stigma, based on national and local strategies. It should include a full critical review of their service to identify and proactively counter any systemic stigmatising practices.


Stigma towards the workforce

Working in drug services should be a valid and appealing career choice, with a fully supported workforce providing appropriate care and support. Stigma, however, can be directed at those who work in drug support services.

What needs to change

Action should be taken to challenge stigma associated with working within the sector. This can be done by increasing understanding of what working on the frontline entails and improving public awareness of the value and importance of the work. Addressing negative perceptions of problem substance use would also change how working within the sector is viewed.

When the culture changes to valuing people who use drugs in the same way as all other individuals, those who work to support them will also be valued and appreciated as providing essential support to people in need. This should be incorporated into the national action plan.


Public attitudes

People deserve to live in a society without discrimination and stigmatisation and have the right to be treated with respect, dignity and empathy. This is not limited to people with experience of drug dependency, but it should not exclude them either.

What needs to change

While evidence shows public opinion tends generally towards sympathy for those with problem drug use, fear of having people with lived and living experience of problem drug use within the community persists.

This is significantly lessened when people have personal familiarity with an individual who has experienced drug dependency. Greater engagement with communities and a sharing and celebration of positive stories would help to familiarise the public with people who have experience of drug use and the realities of their lives.

Recovery communities should continue to actively participate in community events and initiatives. This will increase their visibility to the wider public. They should also extend invitations to meet and gather with community groups. Equally, community organisations should seek to include local recovery communities in their events and initiatives.

Local and national events celebrating recovery and lived and living experience educate and promote the benefits that people with lived and living experience bring to their local communities and wider society. They help to replace ignorance, fear and stigma with compassion and connection.

Stigma in the media

Positive stories of drug recovery in the media are regularly tainted by a stigmatising image that changes readers’/viewers’ perspectives. Language is used to emphasise the “horror” of drug-use situations.

Most people agree that the language and imagery used in the media is inappropriately negative and damaging towards people who use drugs. This suggests that the media is not reflecting prevailing social attitudes and is negatively impacting public opinion.

What needs to change

The narrative around problem drug use needs to change. Nationally and locally, all opportunities should be taken to provide the media with a more positive story of treatment and recovery, respect for individuals, families and communities and the contributions the sector makes to wider society.

Media portrayal of substance use and recovery could be changed through proximity to people with lived or living experience. Recovery communities should work with local media to spread their stories of hope and optimism.

We endorse the approach recommended by Scottish Families Affected by Alcohol and Drugs (SFAD) and the Scottish Recovery Consortium (SRC) in their joint research programme, Rewriting the Media’s Portrayal of Addiction and Recovery (22). It provides six recommendations for journalists and editors:

  • use positive imagery;
  • adopt people-first language;
  • use your article as an opportunity to educate;
  • always include support service information;
  • learn about lived experience and the impact of stigma; and
  • include more positive stories reflecting recovery, support, and lived/living experiences

Action 20. Ofcom, media outlets and commissioning editors should use the SFAD and SRC guidelines for journalists and work with organisations representing people who use drugs and their families to develop guidance on reducing stigma and discrimination in reporting, documentaries and fiction. Scottish Government should support these organisations to deliver this action.


Structural stigma

The issue of a “drugs crisis” has been politicised. Too often, politicians use drugrelated death statistics as a political football.

Each drug-related death represents the loss of a person who had friends and families. The people they leave behind should be able to expect a meaningful and sustained focus on these deaths and an effective response. Instead, they may see their loved one’s death cited as a statistic or used in a polemic on drug use.

What needs to change

The harmful impacts of structural stigmatisation go beyond the surface narrative and have a deeper impact on how people with experience of problem drug use are treated.

Negative assumptions about problem drug use lead to a lack of investment in the sector. The result is reduced services, services being located in poor accommodation, services without privacy (such as in community pharmacies) and increased caseloads for fewer staff. Workers are unable to invest the time required to fully support their clients, and some will experience burnout as a result.

Structural stigmatisation can also result in arbitrary decisions being made about treatment without involving individuals or understanding what they need or want.

Action 21. The Scottish Government and chief officers should mandate that our Stigma Charter is adopted by all public bodies and services and all other organisations should be encouraged to adopt it. The uptake of this adoption should be recorded and reported publicly, with appropriate and defined sanctions for public bodies and services that do not adopt it.


2.6 No wrong door

Experience of problem substance use can be a result of, or lead to, long-term support needs that cross multiple sectors and services.

People with multiple needs do not necessarily fit the care and service systems that are in place. They should not be rejected on these grounds.

Providing a phone number or website address is not sufficient. Services need to be joined up, with defined contacts and pathways through which service providers can reach out. Sufficient resources and relevant training are needed within services to support this.

People can present to services and be turned away without a plan for support because of siloed service design and lack of partnership-working. They can be refused help because they have mental health needs or be denied support with non-drug-use issues until they are in treatment for, or abstinent from, drug use.

These barriers, with no clear pathway to accessing support, can result in people giving up on seeking out services. This reinforces the narrative that people who use drugs cannot be helped and are not as valued as others.

What needs to change

There should be no wrong door to entering support. All services to which people present should ensure no one is turned away without ensuring that supportive contact is made.

Action 22. People should not be turned away from services because they have additional support needs that are outwith the service’s remit. They should be linked with appropriate services and be supported to address their own needs.

Every service contact with someone who uses drugs should be maximised. Each interaction offers an opportunity to provide interventions and support and facilitate entrance into treatment pathways.

Action 23. ADPs should ensure that people with multiple and complex needs are not simply passed on to other services. A single lead professional should, with the patient’s consent and involvement, take a coordinating role in developing and overseeing a holistic care package.

We acknowledge that there may be instances in which medical interventions are contra-indicated when a person has drugs in their system. Support, however, should not be conditional on receiving treatment for problem drug use, or being abstinent from drugs.

For people with mental health problems, trauma or adverse past experiences, the use of substances can be a coping mechanism. Asking a person to remove drugs without providing support and guidance can lead to further trauma.

Pathways and processes for dual support need to be put in place, with therapeutic approaches – pharmacological, psychological, or both – to tackle co-occurring substance use and mental health problems, such as mood disorders, distress and trauma.

Action 24. Service providers in all sectors and ADPs should ensure that support, including for mental health, is not conditional on people receiving treatment for their dependency, recovery or abstinence.

Recognising the stigma and negative attitudes held towards people who use drugs, some individuals may not wish to seek treatment or support in their local area. In such cases, people should be supported to access services in other localities, with no barriers to access or funding.

Action 25. ADPs and services should work effectively across boundaries to ensure that individuals have choice over what services they access and where.

2.7 Supporting the whole person with holistic care

Services must really listen to people who use drugs and their families and inspire trust through their openness and transparency.

They must provide them with necessary non-prejudiced information so they can make informed decisions about their care and care plan. Respect, choice and dignity are central to supporting people who may feel they have lost all three because of multiple complex health and social issues.

Currently, there are significant barriers to providing this level of service for people with drug dependency.

A big part of the challenge is that problem drug use does not have parity with other health conditions. Implementation of the actions we call for in Chapter 1 on removing punitive exemptions from legislation would go a long way to creating this long-overdue equivalence.

In the meantime, there are other actions that services in Scotland can take to ensure a holistic approach to supporting people who use drugs is adopted.

What needs to change

Services need to see people as whole individuals rather than component parts to be supported in isolation.

More co-ordinated, cross-sectoral and holistic approaches are needed across treatment services for substance use and mental and physical health services. This should also be the case for social support services such as benefits, employment, legal and financial advice, and housing.

Housing First is an evidence-based model in which provision of immediate safe housing is not dependent on abstinence from substances. At the end of March 2022, it was present in 24 local authorities. The evidence to date is positive.

Some of the principles of the Housing First Framework could be applied as best practice by other services. This would help them develop a person-centred, holistic approach to service provision that seeks to proactively remove barriers to support.

Action 26. The Scottish Government should continue to support Housing First and expand coverage to all local areas in Scotland. Learning from the model can be used to support the design of other support services.

We funded a number of tests of change in local areas. The aim was to introduce approaches to offering integrative support for people. These are ongoing, with final reviews expected early in 2023. Changes that have been shown to work in local areas and which tie-in with local needs should be implemented.

Action 27. The Scottish Government should gather the evidence from Taskforce projects that continue beyond July 2022 and share these with local areas to inform local strategic plans. Effective changes to support joint working and improve and save lives should be implemented.

2.8 Dismantling hierarchies of service provision

Research into the challenges facing the workforce suggested that an increased reliance on volunteers “may be unable to match the expertise and training that was lost” due to funding cuts.

While it cannot be denied that services were reduced and experience and training was lost, this also highlights a gulf between perceptions of statutory services, third sector services and peer-led services, including recovery communities.

People working in third-sector agencies and volunteer groups report that their contributions are seen as being less valuable than those from statutory services or nationally commissioned organisations. This is supported by the Dundee Drug Commission’s two-year review, which highlighted an unequal system of control and decision-making between statutory and third-sector services. Our own engagement with services and the evidence review of Scotland’s alcohol and drug workforce led to similar conclusions.

The situation is not helped by short-term funding arrangements that do not provide third-sector organisations with the same level of security as those in the statutory sector. Forward-planning and creating a stable workforce are challenging undertakings with short-term funding.

The contribution volunteers make to services should never be underestimated. Many volunteers and peer workers have experience of their own or a family member’s drug use. The fact that they have not undertaken professional training should not diminish the importance of the specialist support and advocacy they provide.

In Chapter 4, we recommend the implementation of joint commissioning and joint working across the sector. It is clear, though, that without a shift in culture in all parts of the sector, it will be difficult to fully implement this and realise the potential benefits.

What needs to change

Leaders in organisations across the sector should drive change towards collaboration and partnership-working and away from competition, judgement and exclusion. Perceived hierarchies of service provision with statutory services at the top and third-sector services some way down the order should be dismantled.

Positive relationships and partnerships should be built from a shared foundation of reducing harm and saving lives.

Multiple pathways for support, recovery and stabilisation exist. While people have different needs that may require different approaches from different agencies, this should not dissuade organisations from making a commitment to work together.

Action 28. The Scottish Government and ADPs should support the improvement of partnership-working across the sector, including between statutory and third-sector services, and with recovery communities. This should be backed by fair, transparent and sustainable funding to ensure services are delivered in the most effective way by the right partners.