National Record for Scotland’s latest data revealed that drug deaths in Scotland are tragically on the rise once again, after two years of decline. The increase of 12% represents a shocking 1,172 lives lost to drugs last year. Each one of these deaths may have been preventable, and Scotland retains the shameful tag of being the drug death capital of Europe by rate – around three times higher than the next country on the list.
Each one of these 1,172 lives lost in just a year will have impacted thousands beyond those who died – sons, daughters, partners and loved ones. The trauma and suffering through generations is unthinkable, and action must be taken immediately to alleviate the suffering and stop the deaths.
The data worryingly revealed that synthetic benzodiazepine bromazalam was involved in 426 deaths, with testing for this substance unreliable for years prior, making a comparison on prevalence in the market difficult.
Nitazenes – a family of potent synthetic opioids – were involved in 23 deaths, up from 1 from the year prior. There should again be hesitancy around such comparisons given the veracity of testing.
People from the most deprived areas in Scotland were a shocking 15 times more likely to die from a drugs death than those from the least deprived areas. Increases in deaths related to cocaine are also on a sharp trajectory upwards highlighting the complexity of the crisis.
Context
Cranstoun work closely with Scottish Government and local councils to find solutions to the shameful level of drug deaths and there is sincere will to tackle the problem, but action is happening too slowly and attempts to find solutions have been knocked back at each turn.
Whilst the problems specific to Scotland are multi-faceted, with issues including poly-drug use, significant prevalence of novel and highly potent benzodiazepines, increased cocaine injection in recent years, and disproportionate levels of poverty – there is simply no excuse for the sheer number of deaths and lack of immediate action.
Positive work by campaigners, policy professionals, charities and Councilors are bringing us closer to implementing measures – such as an additional Overdose Prevention Centre in Edinburgh in addition to Glasgow – which will save lives but much more action is required to turn the tide.
The first sanctioned overdose prevention centre (OPC) in Scotland will finally open in October but one centre alone is not nearly enough. Now the go ahead has been given by Westminster, exploration of different models for delivery too must be considered as well, given the cost of the NHS delivering a highly medicalised model.
It is not just OPCs, but issues related to treatment numbers, deprivation and poverty, increased prevalence of potent synthetic drugs, medical assisted treatment (MAT) standards, a reticence to try alternative evidenced measures, and the continued criminalisation of people who use drugs which are causing preventable deaths to remain near record levels.
DAT (Diamorphine Assisted Therapy)
One example of missed opportunities relates to the further opening of a DAT facility in Dundee. A recent report published by the Alcohol and Drug Partnership for Dundee recognised the benefits of diamorphine assisted treatment, yet they declined the opportunity for such a facility to exist, giving reasons such as poly drug use. Poly drug use is undoubtedly an issue but DAT remains an effective tool in ensuring that the most at risk are being seen by a health professional daily. If someone overdoses in an OPC or DAT facility due to poly drug use, it is likely that their chance of survival is significantly higher than if they were alone.
Furthermore, a recent report by Professor Andrew McCauley for Public Health Scotland shows that whilst cocaine injections are reported as surging, heroin is still the most injected substance in Scotland. This compounds the need for services including same day prescribing of opioid substitutions (such as methadone or buprenorphine), DAT, and provisions for access to naloxone.
Medical Assisted Treatment standards & delays
It is with great relief that the first sanctioned overdose prevention centre in Scotland will open in just a few months, with an October 21st date finally set. Whilst this is encouraging news, the time it has taken to reach this is of enormous concern. It is not just OPCs that are taking longer than anticipated too.
Key targets set by the government are being missed (despite improvements in several areas), with no immediate plan on how to solve them and updates seemingly scarce. For example, mandatory Medical Assisted Treatment (MAT) standards for treatment providers were announced over two years ago and the April target set has now long passed, with Scotland still no closer to reaching this target.
This is one of several issues likely hindering people who use opiates from accessing treatment at the earliest point. Scotland has a significantly lower number of people in Opiate Substitution Therapy who would benefit from it compared to England – around 40% compared to 60%. Furthermore, research in The Lancet highlights how those who are not on Opioid Substitution Therapy (OST) are around three times more likely to die from drugs, than those who are receiving OST. This demonstrates the importance of same day prescribing and quick, easy access to such programmes for those who would like it.
Opportunities to engage more people in treatment are being missed. Solutions should include smarter use of the criminal justice system, more outreach programmes to reach those who would benefit from treatment and more harm reduction measures.
Additionally, the third sector in Scotland is unable to prescribe opioid replacement therapy. This leaves prescribing in the hands of the NHS alone, which given the strain it is under, may explain delays in getting people onto an opioid prescription. Delayed prescribing discourages people who use opiates from seeking treatment and is at least partly culpable for the issues in Scotland related to opioid deaths.
Criminal justice
Data provided by the Scottish Government shows that whilst more drug warnings are being issued by the COPFS, there are still scores of people being proceeded against for drug possession offences. This is despite the Scottish Government announcing in 2021 that it would essentially ‘de facto decrimalise’ the possession of controlled substances.
The SNP’s party position is aligned with this, however full decriminalisation of possession would require amendments to the Misuse of Drugs Act with powers reserved to Westminster.
The use of diversion schemes, namely pre-arrest schemes that do not require legislative change. The ability to issue drug warnings without sign off from the COPFS or whether pre-arrest schemes are in place is not immediately clear given contradictory information on the Scots Gov website.
Synthetic opioids and novel benzodiazepines
The number of people dying from drugs is even more concerning given the increased prevalence of synthetic drugs contaminating the drug supply, namely potent opioids such as nitazenes as well as novel benzodiazepine analogues (such as etizolam and bromazolam) and sedative xylazine (believed to be used to elongate the effects of synthetic opioids but which make propensity for overdose more likely).
Our CEO, Charlie Mack, recently returned from a visit to Vancouver in Canada, one of the epicenters of the synthetics drugs crisis. The teeth marks of the crisis remain incredibly visible, after an explosion of potent synthetics such as fentanyl wreaked havoc in various parts of Canada and the US. Both the US and Canada have called public health emergencies, and drug deaths have risen exponentially over the past few years.
We can take lessons – across the United Kingdom – for the lack of preparedness ahead of the crisis in North America, by adopting measures which will mitigate the level of crisis. Last year, Cranstoun published an 8 point plan in light of rising prevalence, though time is running out to implement measures which will save lives.
Thus far in response, the Scottish Government have taken steps for a multi-locality drug checking service pilot scheme, which should act as an evidence based measure to reduce the harm of synthetic opioids and the presence of other adulterants which may be contaminating the drug supply. It is additionally welcomed that a proposed site in Glasgow for testing will be in the same hub as the soon-to-open OPC. This joined up approach is what other areas, and the rest of the UK should be working towards, and there is great hope the evidence emerging from this pilot will result in a more cohesive approach across the country.
Over-medicalisation and lack of provision with third sector
Lastly, in addition to MAT standards improvements, the Scottish Government should further embrace the role of the third sector in treatment provision and service delivery. NHS-led delivery models for services such as DAT and OPCs are viewed by some as overly-medicalised, lacking the trauma-informed approach that is somewhat at odds with medical delivery of such services.
A comparison of third sector delivery against NHS delivery could be developed. A social model OPC in Edinburgh, and third sector delivery of DAT elsewhere in Scotland would provide an evidence base for which to evaluate and determine the best course of delivery.
Additionally, there is a significant difficulty in delivering MAT standards given prescribing restrictions for the third sector in Scotland. Given this is wholly in the hands of the NHS, there is unfortunate delays to prescribing which may explain the lower take up of treatment for people who use opioids.
Recommendations
Cranstoun believes that the Scottish Government must implement Cranstoun’s 8 point plan in response to rising drug deaths, and assist in preparations for a potentially worsening crisis.
There are green shoots of encouragement for action that is being taken, with pilot schemes for an OPC and drug checking set to open, whilst DAT in Glasgow is operational. There is still work to be done in developing a better framework for pre-arrest diversion schemes, improvements for MAT standards to ensure same day prescribing is available everywhere and mechanisms for encouraging more people into treatment.
Despite some good work and a clear positive will from the Scottish Government to tackle the issue, last week’s tragic figures lay bare the need for more action, quicker. The Scottish Government must do everything within its power to turn the tide, and until it is doing everything within the realms of its devolved powers, it is simply not good enough to point the finger at Westminster or anywhere else.
Our deepest sympathies and thoughts are with those who lost a loved one to a drug death in the past year.
This blog was originally published by Cranstoun. You can read the original post here.
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