Simply blaming an ageing cohort or pre-devolution economic policies for Scotland\u2019s shameful levels of drug-related deaths won\u2019t cut it anymore, say Barry Sheridan and Iain McPhee. For more than a decade drug-related deaths (DRDs) in Scotland have increased, with the available evidence indicating poor alcohol and drug service outcomes in comparison to the UK and the rest of Europe. Between 2007 and 2019 the Scottish Government cut budgets for alcohol and drug services from \u00a3114m to \u00a353.8m per year. In this article we explain how Scottish Government funding and policy decisions, centralising service provision, and closing third sector service providers \u2013 while relying on unpaid volunteers in recovery \u2013 has contributed to increased risk of DRD among marginalised communities. In assessing evidence that challenged the Scottish Government narrative that DRD increases were attributable to a legacy of UK government economic policies before Scottish devolution in 1999, or that increased DRDs could be explained by an ageing cohort, we reviewed the 2009 Audit Scotland report on drug and alcohol service provision. This report was published after the Scottish Government published the Road to recovery strategy in 2008 \u2013 this strategy concentrated on drug-free recovery, with a clear focus on the concept of recovery capital. The adoption of a narrow individualised conceptual approach to measuring recovery has clearly failed to reduce DRDs. The strategy largely ignored structural and environmental risk factors for problematic drug use, and increased risk of DRDs. The analysis in our paper published in Drugs and Alcohol Today uses the 2009 Audit Scotland report Drugs and alcohol services to make comparisons with the 2019 update report (see box opposite). The 2009 report made six recommendations on treatment effectiveness \u2013 setting clear national minimum standards for a range of services, clear accountability of service governance, assessment of local need, service specifications on quality requirements, clear criterion on demonstrating treatment effectiveness, and, finally and most importantly, to use the Audit Scotland 2009 checklist to help improve delivery and impact of drug and alcohol services using a joined up consistent approach. The 2019 report did not follow up on the recommendations in the 2009 report but chose to focus on naloxone provision, needle provision, and framing increases in DRDs as linked to an ageing cohort. The 2019 report indicates a 71 per cent increase in DRDs since 2009 and suggests that the average annual funding for services by the Scottish Government was \u00a373.8m for 2018-19. These statements require deeper analysis and explanation. Naloxone Naloxone has an impact on people who experience an overdose of opiates. However, a large number of DRDs are \u2013 from autopsy and toxicology reports \u2013 poly-drug users, which reduces the effectiveness of naloxone in preventing overdose. Needle provision The uptake of syringes is not an indication that needles are provided to the target population, i.e. those most at risk of DRDs \u2013 poly users of opiates and benzodiazepines. The existing data indicates that a large percentage of service providers distribute injecting equipment to non-problematic drug injectors and will include people injecting performance enhancing substances. The Misuse of Drugs 1971 Act has been used by the Scottish Government as an excuse for not implementing a proposed safe injection facility (SIF). Evidence indicates that drug related deaths are more prevalent in urban communities characterised by deprivation. Therefore the proposed first SIF site, Glasgow city centre, will have little impact on the target group (people not frequenting Glasgow city centre to buy drugs) most at risk of DRD. We believe that there should be multiple SIFs at the sites where the deaths are occurring. Ageing cohorts In an advanced nation such as Scotland we should not consider being over 35 part of an ageing cohort. In other areas of public health, such as heart disease, obesity, or diabetes, being 35 or over would not be posited as a major contributing factor to explain a rise in death. For the Scottish Government to attribute increased DRDs to a legacy of Westminster pre-devolution economic policies is shameful. We cannot attribute the stark increases in DRDs to the economic policies of the UK government more than twenty years ago or to an ageing cohort. Thirty percent of drug related deaths occur among an age group who entered the labour market post-devolution in 1999, when economic policies were devolved to the Scottish Parliament. Drug-related deaths have increased by 470 per cent since 1996. Around half of DRDs occur in the most deprived communities, while 4 per of deaths occur in the most affluent areas. Using the WHO burden of disease formula, the rates of DRDs within deprived communities are similar to the prevalence rates for heart disease and strokes. There would be a national outcry if the same number of deaths occurred in the population for any other health-related mortality factor. Funding Examining the Scottish Government data on alcohol and drugs services funding indicates that there has been more than a 50 per cent cut in funding to services since 2007-08. The 2019 report suggests that an annual funding of \u00a373.8m per year is being made available to services. However, the actual figure is \u00a353.8m per annum \u2013 the additional \u00a320m accounts for \u00a310m per year allocated over two years to the Drug Deaths Taskforce. There is little evidence that monies allocated to the Drug Deaths Taskforce have significantly impacted on reducing deaths in the communities where drug deaths are occurring. Recommendations made in 2009 by Audit Scotland were ignored. If these recommendations were acknowledged by the Scottish Government and implemented, they may have improved outcomes and prevented unnecessary drug related deaths. In short, cutting funding, centralising services, and ignoring accountability for making these cuts and changes to service provision, increased risk factors. We cannot change the policy and funding decisions that have been made. But we recommend that a meaningful and collaborative approach is taken by statutory and non-statutory agencies beyond addiction services to implement effective system changes recommended in the 2009 Audit Scotland report. No longer can services be designed to suit the needs of the organisations that commission, provide and evaluate their own services. Specialists, non-specialists, and communities (beyond recovery communities and families) must be at the heart of this collaborative approach, adopting an inclusive, honest, and open dialogue. This dialogue has to begin by admitting that current specialist alcohol and drugs services no longer have the legitimacy to offer solutions. Only then can we prevent further increases in DRDs that impact greatest on the most marginalised communities in Scotland. Drugs and alcohol services \u2013 then and now 1. The HEAT standards used by Scottish Government concentrate on only one measure, that of treatment waiting times. The 2009 Audit Scotland report indicates that no clear minimum standards of treatment outcome efficacy were used, and this remains the situation in 2020. 2. There remains no clear separation between service provider and service purchaser, thus poor service performance in 2009 was unaccountable. This is still the case in 2020. 3. There are no measures in place to assess local need informing local decision making in 2020. All decisions remain top down and centralised. We accept that the NHS (ISD) DAISy tool is due to be implemented in December 2020 and will be helpful in assessing individual risk factors, however this has taken seven years to design. It will not fully assess local need \u2013 the tool records data on those individuals who access services, not on those at risk who do not. 4. Voluntary sector services are commissioned on short-term contract cycles negating the opportunity to allow commissioned services to adopt a long-term approach. Longer contracts would, we believe, allow these services to deliver better treatment outcomes where DRDs are occurring. 5. There is a lack of robust information on opiate replacement therapy, unit treatment costs and treatment outcome information. This local and national data is available in England but not in Scotland, meaning that the Scottish Government is unable to develop information that could improve service provision, performance management, accountability, and service outcomes. A de-professionalisation of the sector has occurred due to severe funding cuts and encouraging low or unpaid volunteers to provide recovery support. While we welcome the current emphasis on developing recovery communities who offer a vital resource, they should not be a low-cost replacement for skilled workers. 6. The 2009 Audit Scotland checklist was not mentioned in the 2019 Audit Scotland report, relating to governance. Performance and evidence-based services were not discussed in the 2019 Audit Scotland report. Click here to view AUDIT Scotland ten years on.