National Drugs Mission Plan: 2022-2026

3. The challenge we face

Scotland has one of the highest drug death rates in the developed world. With 1,330 drug misuse deaths in 2021^[2], this represents a marginal decrease on the record high of 2020 and still 4.6 times as many deaths compared with 2000. Drug deaths are now recognised as one of the biggest contributors to Scotland's falling life expectancy^[3].

3.1 High prevalence of people with drug problems

The most recent estimates of drug prevalence from Public Health Scotland (formerly ISD Scotland)^[4] estimated that the number of individuals with problem drug use (routine/prolonged use of illicit opiates and/or benzodiazepines) in Scotland during 2015/16, aged 15-64 years old, was 57,300 (95% CI = 55,800 – 58,900). Expressed as a percentage of the population, the rate of problem drug use in 2015/16 was 1.62% (95% CI = 1.58% – 1.67%). While there are methodological and definitional differences data suggests that Scotland has a far higher rate of problem drug use than England (1.62% compared with 0.74%) and other European countries.

3.2 Increasingly complex needs

The average age of a drug death has increased from 32 in 2000 to 44 in 2021. Analysis by Public Health Scotland^[5] identified evidence of a cohort effect of drug users now in their late 30s and 40s, especially among males living in the most deprived areas of Scotland.

Many in this group have been using drugs for many years, in some cases decades, and commonly have complex co-morbidities and needs.

While this group are the largest we must also be mindful of the needs of all demographics and equalities groups, particularly the disproportionate increase in drug deaths among women and new and concerning trends of increasing harms experienced among younger people aged under 25.

3.3 Polydrug use and changing drugs market

Most drug deaths involve more than one substance. Of the 1,330 drug misuse deaths in 2021 in Scotland, more than one drug was present in 93% of cases.

This reflects a wider trend of polydrug use seen in other data sources. Of particular concern is the increase in use of 'street' benzodiazepines such as fake Xanax (alprazolam) and etizolam and gabapentinoids such as pregabalin and gabapentin, which are often consumed alongside opioids to enhance their effects. Both of these types of drugs are associated with respiratory depression and may increase the risk of overdose when consumed alongside opioids. Gabapentinoids may also reduce user's opioid tolerance. Cocaine has also been implicated in an increasing number of deaths and hospital admissions in recent years.

3.4 Rising drug harms

Along with the increased drug deaths we have seen a corresponding increase in harms with around 15,000 drug-related hospital admissions each year. Polydrug use has been a contributing factor and an increase in harms among younger people under 25 is of particular concern.

3.5 Poverty and deprivation

A key underlying factor for drug deaths is poverty. In 2021, people in the most deprived areas were 15 times as likely to have a drug-related death as those in the least deprived areas. While drug deaths are unacceptably high across the country some areas – particularly the cities and deindustrialised communities – have a particularly acute challenge.

3.6 Covid Recovery

The Covid-19 pandemic affected the whole of Scotland – including people with drug problems. While drug and alcohol treatment services were considered essential services and remained open throughout the Covid-19 lockdown periods there was still a drop in specialist referrals. The impact of lockdowns undoubtedly had an impact on how people used drugs and were able to access the services and support they need. Our approach aligns with the Scottish Government covid recovery strategy which sets out actions to address systemic inequalities made worse by Covid^[6].

Despite these significant challenges, much has already been achieved and this plan takes learning from the past, builds on gains made, expands tried and tested initiatives and supports creative new ones that have been shown to work in other, similar jurisdictions to ensure that no one gets left behind and that people who use drugs have the support and assistance they need to live full, active and healthy lives at all stages of their journey.