Scotland has the highest drug-death rate in Europe. 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.
The Scottish Government has launched a coordinated suite of measures to tackle the drug-deaths crisis in Scotland. As part of this, the Scottish Drug Deaths Taskforce was established in July 2019 to identify measures to improve health by preventing and reducing drug use, harm and related deaths.
Context of the Taskforce
Two basic principles underpinned all our work:
- Drug-related deaths are preventable and we must act now.
- Scotland and the Scottish Government must focus on what can be done within our powers.
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.
Evidence shows that unacceptable and avoidable stigma and discrimination towards drug use are increased by criminalising people. We have heard that the Misuse of Drugs Act 1971 is outdated and needs to be reformed to support harm-reduction measures and the implementation of a public health approach.
Culture change required
A big cultural shift is required in Scotland to tackle the harms associated with drug use. Three principles for change are central to this cultural shift:
- this is everyone’s responsibility;
- broad culture change from stigma, discrimination and punishment towards care, compassion and human rights is needed; and
- families and people with lived or living experience should be at the heart of the development and delivery of services.
People with lived and living experience must be included in all aspects of the development and implementation of policies and programmes that influence service design. Families need and deserve support in their own right. Every service 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.
Many people who use drugs face stigma. Ultimately, stigma reinforces trauma and prevents people from disclosing their drug use and seeking support and treatment. Fear, judgment, punishment and shame must be replaced by compassion, connection and communication.
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.
Stigma exists within the workforce. Services should be flexible, non-punitive and involve people who use drugs in setting goals and care planning. Action should also be taken to challenge stigma associated with working within the sector.
People with multiple needs do not necessarily fit the care and treatment systems that are in place. All services to which people present should ensure no one is turned away without ensuring that supportive contact is made. Holistic support should not be conditional on receiving treatment for, or being abstinent from, problem drug use.
More co-ordinated, cross-sectoral and holistic approaches are needed across treatment services for substance use, mental and physical health services, and social support services.
Care system needed
Three principles for change must be integral to the care provided for every individual:
- parity of treatment, respect and regard with any other health condition must be ensured;
- services must be person-centred, not service-centric; and
- there needs to be national consistency that takes account of local need.
All services and elements of the care system should consider their accessibility and adaptability to meeting the needs of population groups who may face additional barriers. This includes people from black, Asian and minority ethnic communities, those who identify as LGBTQI+, disabled people, women and young people.
A sustained shift to a preventive approach in drugs policy and interventions is required to tackle structural inequality and poverty as root causes of drug dependency, with clear actions to increase prevention.
People should be supported to make informed decisions about their drug use and be able to access holistic support if their use becomes problematic. A trauma-informed workforce (across all areas of the public sector) is crucial to ensure those who have experienced trauma are able to access and engage in services.
Tackling the drug death crisis is everybody’s business. Workers in services outside the drug sector need to know how to help people who want to change or stop their drug use.
Many interventions have been taken forward in Scotland to help reduce the harm associated with using drugs. Being able to intervene quickly and effectively presents an opportunity to offer a range of options and perhaps eliminate risks of future overdoses.
Currently, many drug services do not operate in evenings or at weekends. We must provide emergency care 24/7 with out-of-hours referral points for people to access if needed.
Supervised drug consumption facilities are used in some countries. The UK Government should consider a legislative framework to support their introduction.
Our aim is for Scotland to have the most extensive naloxone network anywhere in the world. There is a crucial need for national coordination of naloxone delivery. We believe this could best be achieved through the appointment of a National Naloxone Coordinator.
Assertive outreach means that all people at high risk of drug-related harm are proactively identified and offered support. Navigators and peer support workers play a crucial role in this and need further support.
Licensed drug-checking services allow people to anonymously submit samples of psychoactive drugs for testing. Licensed facilities should be available widely across Scotland and be easily accessible at short notice.
Medication-assisted treatment (MAT) is protective against the risk of death. Full implementation of the MAT standards should be completed by May 2024.
Overarching treatment and recovery guidance, with defined and measurable standards, should be developed and implemented. The guidance should cover all types of drugs and the full spectrum of treatment and recovery support.
Residential services are highly intensive interventions. Wherever an individual lives in Scotland, they should be able to access crisis and stabilisation, detoxification and rehabilitation services at the point of need.
Leaving a service can be a time of high risk of overdose or drug-related death. Aftercare is therefore crucial to ensure that people remain stable in their drug use or recovery. Many residential rehabilitation services have positive links with local recovery communities. Local areas should be supported to ensure that thriving communities of recovery are linked to every drug treatment system.
The justice system should present a meaningful pathway to provide support for people who use drugs. Care between and in justice and community settings should be seamless. National guidelines should be developed to help resolve difficulties arising when implementing referral processes.
Alcohol and drug partnerships (ADPs) should proactively engage with justice services to detail what support is available in their area. They can then provide a gateway for vulnerable individuals who use drugs and have other complex needs.
Being held in police custody is often a crisis point in someone’s life. Holistic support should therefore be available for all people who use drugs when entering, being held in and leaving custody. Prison releases on a Friday or the day before a public holiday should be banned to give people a better chance to access support.
The aim should be to ensure that people who use drugs are better supported when they leave prison than when they entered. Appropriate support is needed before and throughout sentences, with reintegration support on release. People on remand should receive the same level of support as those serving a sentence. People who use drugs should also be provided with naloxone on liberation.
Co-ordination of the response
Two core principles underpin co-ordination:
- appropriate resource is required to bring about meaningful change, but it must be targeted to where it is most needed; and
- strong decisive leadership is essential to success.
The drug and alcohol sector should have comprehensive standards and guidance and be inspected against them. The sector should have clearly defined lines of accountability that ensure services are provided to meet the needs of individuals. Ultimate responsibility for ADPs’ responses to drug-related deaths and harms should sit with the chief officer.
A formal review process should be undertaken for every suspected drug-related death. These should start from the principle that every drug-related death is preventable.
Local leadership is vital to tackling drug-related deaths and harms. Local leaders should take a lead in ensuring that lived and living experience is at the heart of developing local services.
Fragmentation across policy areas in the Scottish Government is apparent, with little join-up between work on drugs policy and key policy partners such as mental health, justice, housing, poverty and inequality. Consideration should be given to establishing a cabinet subcommittee or joint ministerial group to drive change across the Scottish Government. A national outcomes framework would provide much needed accountability and scrutiny of the Scottish Government and local activity.
Surveillance should be central to the National Mission to improve and save lives. The data gathered should be aligned to the National Mission and should add value, with the objective of effecting change.
A National Co-ordinator for Drug-related Deaths role within Public Health Scotland would improve consistency and data-sharing and coordinate a review of the national drug-related deaths database.
All services should have a monitoring and evaluation plan in place. Services should evolve based on direct experience of delivering the service and embed a cycle of continuous quality improvement.
Digital inclusion should be a key goal when working with people who use drugs. Every person should have access to the necessary technology to enhance their engagement and improve their connectivity to support networks. Data-sharing must cease to be a barrier to the effective delivery of services. Partners must develop detailed information-sharing agreements to support the smooth transition of information around individuals’ cases.
Specific pathways for entry, progression and continuous professional development for the workforce in the sector should be in place to support all professionals to provide the highest standard of service and enhance their sense of value. A further rapid evidence review of the workforce should be undertaken to enable the Scottish Government to take immediate action to support recruitment and retention, while recognising that recruiting more staff without steps to improve retention will lead to further problems – the sector already has significant vacancies.
Anyone working with people who use drugs needs a core set of skills and experience. These should be focused on embedding care, compassion and empathy in service delivery. Training and improvement practice should be used to fully embed these competencies into practice.
Formalised pathways must be developed for people with lived and living experience to work in the sector. Appropriate training and development, as well as pay and career progression opportunities, should form part of these pathways.
A comprehensive and consistently reviewed action plan is needed to deliver on this critical investment in the workforce.
If Scotland is to deliver the change we have outlined – the change that is needed – the sector must be appropriately resourced. More importantly, the resource must be targeted where it is needed most and where it will have the greatest impact.
Significant additional funding will be required. The Scottish Government needs to set out a fully funded strategic plan that commits to fully resourcing the demand for services – not a return to the funding of the past, but an ambitious and radical commitment to making people’s lives better.
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