As he retires from his role as the Scottish Drug Forum’s CEO, Dave Liddell reflects on a sector that’s in many ways unrecognisable from the one he started out in.
‘There were maybe 20 services, mostly two people and a dog,’ says outgoing Scottish Drugs Forum CEO Dave Liddell of Scotland’s drugs sector in the mid ‘80s. ‘There were no local planning structures or anything, so you had almost a blank sheet to develop policies and ideas.’
He’s retiring this month, having worked at SDF since it was set up in 1986 – the longest job he’d had before ‘was about 18 months,’ he says, so his tenure has safely beaten that record. He’d previously trained as a biochemist, then become a social worker before going to work for SCODA, the forerunner of DrugScope.
Parts of Scotland were already in the grip of a serious heroin problem when SDF was set up, and he was one of the people calling for the establishment of needle exchanges. ‘There was a complete lack of knowledge in terms of the development of anything like that, but obviously HIV drove those changes so even the Tory government at the time had to agree to needle exchanges being developed.’
‘Dungeons of Death’
The arguments were not dissimilar to later debates around naloxone and the current back and forth over consumption rooms. ‘It’s like all these things – there’s a period where they’re completely controversial, then they become mainstream and no one remembers the time when you were pilloried for suggesting them,’ he says. ‘I remember we had a conference in 1996 on drug consumption rooms with a speaker over from the Netherlands – the headline in one newspaper was “Dungeons of death”.’
The whole debate around drugs has moved on significantly, with a growing recognition that many people with a drug problem will have underlying trauma or other mental health issues. ‘We’ve obviously still got a huge way to go, but we have made progress. Incremental change is mostly the way things happen, particularly in controversial areas.’
Looking back at the biggest changes he’s seen over almost four decades in the sector, the current level of service provision is a ‘huge one’, he says. ‘I think we forget that we have pretty well-developed provision of help and support. We’ve just been through so many epochs – from the abstinence approach in the mid ‘80s to HIV and public health and the move towards harm reduction.’ Then came the ‘whole focus on recovery, particularly abstinent recovery. I think we suffered significantly from that in terms of a narrow focus. We’ve obviously come through that now, but at some considerable cost.’
In the Scottish context while there’s more money in the system there’s now another issue which is ‘one of bureaucracies and the numbers of policy folk involved’, he says. ‘I guess the difference from ’86 is that we could produce a paper or run a conference on anything, and there was no one to tell us we couldn’t. Now it’s so cluttered, and that’s the bit I won’t miss – it becomes quite a lot harder to achieve anything because of the slowness. We’ve made quite good progress with medication-assisted treatment and same-day prescribing – all that stuff is brilliant and I think we can say we were significant drivers of that, particularly in the early stages, but it’s become very hard to see the wood for the trees just because of the number of people involved.’
It mirrors a wider problem in the system with the move to much larger providers and the potential that the therapeutic relationship might suffer as a result, he believes. ‘It can sometimes be hard to provide a really individualised service. In the peer research we do, people name a particular person who’s helped them to get better.’ When someone who presents to a service gets seen by a different person each time, it not only means those vital relationships can’t be built but also risks re-traumatising people, he states.
There can also be a failure to recognise why ‘people find it difficult to trust services when their whole lives they’ve been failed by everyone around them’, he says. ‘We’ve thankfully moved through the punishment model, where if you miss two or three appointments you get kicked out or your methadone cut, but it’s the problem of people having to navigate such a complicated system.
‘The population we’re trying to help have very specific needs about engagement with services that are different to the general population. We’ve almost set up services in the general health service model, and then failure to attend appointments means you’re pushed out. To me it’s about building that trusting therapeutic relationship over the long term, and that’s the bit we still haven’t got to, sadly.’
Over the last decade the sector in Scotland has been dominated by the shocking rates of drug-related deaths. There was a tiny fall in 2021, and while the provisional figures for the last quarter of 2022 showed an increase (DDN, April, page 5) the prediction is that figures for the whole year will be down. Does he think we may finally be turning a corner? ‘My view is that we probably are,’ he states. ‘But I think that because the numbers have been so tragically high, a fall at some point is inevitable – that could not go on at that level. I’d like to think that the responses like naloxone and medication-assisted treatments are starting to have an impact, but the reality is even if it goes down it’s still colossal.’
At the end of 2020 when the highest-ever figures came out, SDF described it as a national tragedy and a national disgrace, and it wasn’t long after that Nicola Sturgeon used similar language and admitted her administration had taken its ‘eye off the ball’. ‘That was the first time the government had owned the problem at that high level,’ he says. ‘It became a political issue that couldn’t be ignored.’
The sheer scale of the deaths has perhaps also helped to change people’s attitudes and go some way to challenging stigma, he believes. ‘I think it may have led to more compassion for people with drug problems overall, and we’ve tried to explain to the wider population that drug problems tend to be a symptom of underlying issues. We do a lot of stigma training ourselves, and you still see stigma even within the addiction services let alone other services like housing. Our view is that’s the place to start. It links back to those issues around being trauma-informed and building therapeutic relationships. There’s nothing new in any of that, but it’s slow to change.’
While the sector is full of dedicated and compassionate staff, some can be hamstrung by structures they work in that make change difficult to deliver, he says. ‘Some of the challenges of service delivery are very difficult to change overnight. You have areas that have got additional monies for medication-assisted treatment, but a year or two on they still haven’t spent that money. The lesson is always I guess that government thinks it can kick local areas to deliver, but the accountability lines are not always there to do that.’
So what is he most proud of during his time at SDF? ‘Certainly our influence in terms of the amount of resource going into the sector,’ he says. ‘More specifically, the peer research programme that we’ve been running for 25 years. When we first started that programme the notion that we could have volunteers who were still using and they could interview people who were still using was very, very controversial – that you would listen to the views of people who were still using drugs. That’s quite hard to imagine now, but it was absolutely the case. What’s interesting now is that peer research has become mainstream in the Scottish context, and I might argue that because of our track record we’re probably still doing it better than most. The other one would be the addiction worker training programme – the positive outcomes of those who completed it are 85 per cent into employment. We’ve probably had 300 or more folk through that programme, and obviously there’s opportunities to do more around that.’
And then there’s SDF’s influence on policy and strategy over the years. ‘It’s gone up and down. Sometimes you’re in the tent and sometimes you’re out, and the membership has often criticised us for being either too close to government or too far away. So that balance is quite tricky. But one of the things we’ve often done is saved government from doing something that could have made the situation worse, and that can be entirely unseen as an outcome because it’s behind the scenes. What we’ve had is that longevity and corporate memory, which is completely lacking in government because the civil servants change every three years – the number of times we’ve had “new” approaches that aren’t new at all. And the other thing is that we’ve stuck to our principles all the way through in terms of our approach. We’ve never wavered.’
So will he miss it? ‘I will, for sure, in terms of the cut and thrust of all of it. I’m planning on doing quite a bit of travelling – one of my granddaughters lives in Prague. Someone said to me, “don’t agree to anything in the first four months of your retirement”. I’ve had a couple of offers, but if they’re writing funding applications I think I’ll have to give it a miss.’ DDN