The road to recovery: a new approach to tackling Scotland's drug problem

Chapter 1: Making a Fresh Start

Scotland has a long-standing and serious drug problem. The dedicated efforts of many front-line workers to tackle the problem have had some success, but very significant challenges remain.

Recent work by experts in the field now points to a new way forward. Based on this fresh vision the Scottish Government believes it is time for a step change in how we tackle Scotland's drug problem.

This document sets out why and how the Government plans to work with all concerned to implement this programme of reform.

This Chapter sets out:

• a picture of the drug problem in Scotland, and the harms it causes;
• a description of the Scottish Government's new way of working, and how it relates to tackling drug use;
• an overview of how Scotland has tackled problem drug use to date, and the challenges we now face; and
• in light of all the above, the Government's key priorities for tackling drug use.

DRUG USE IN SCOTLAND TODAY

The scale of the drug problem in Scotland today is unacceptably high. It is a significant driver of economic underperformance, crime, risk to children and health inequalities.

1. An estimated 52,000 people are problem drug users. ¹ Put another way, almost 1 in 50 of our population aged between 15 and 54 are experiencing or causing medical, social, psychological, physical or legal problems because of their use of opiates, such as heroin and benzodiazepines. Although this represents a decline in the number of problem users since 2000 (when the comparable figure was 56,000), it is still notably higher than that for England. Although the use of different methodologies and definitions makes exact comparisons difficult, Scotland's rate of problem drug use also seems to be much higher than other similar European countries such as Ireland, Finland or Denmark.

2. The most commonly used illegal drug in Scotland remains cannabis: 1 in 3 adults in Scotland have taken cannabis at some point in their lives, 1 in 10 in the past year. Cocaine is now the next most commonly used, with a significant increase in its use over the last 10 years: 4% of adults in Scotland reported having used cocaine in the past year in 2006, compared with only 1% in 1996. The third most commonly used drug is ecstasy, with 3% of adults reporting they had used it in the past year in 2006, compared with 2% in 1996. ² The Government is committed to tackling recreational drug use through improved education, information and enforcement of the law. Recreational drug use today can become problem drug use tomorrow. As examined in Chapter 3, services need to respond to changes in drug consumption patterns. In addition, as a society, we need to remain vigilant. If trends towards greater cocaine use accelerate, a more fundamental change in our response may be required. Although users of cannabis and cocaine are not included in the estimated 52,000 problem drug users, this does not mean that use of these drugs cannot cause problems - it is the economic, health and social consequences of drug use that should concern us, not the choice of drug.

3. There is also a growing trend towards poly-drug use, that is, the use of more than one drug at the same time: typically around 2 in 5 current drug users report taking 2 or more different illegal drugs together. This kind of drug use has increased health risks for the user. Consuming alcohol while under the influence of drugs is even more common, with 4 in 5 current drug users having done this. ³

4. Encouragingly, there appears to have been a significant drop in the reported use of drugs by both 15 and 13 year olds in the last 8 years. Between 2004 and 2006 prevalence of drug use among 15 year old boys declined from 21% to 14%, and among 15 year old girls declined from 20% to 12%. Prevalence among 13 year olds also halved. However, there is no room for complacency, given that the same survey also reports that a quarter of all 15 year olds had used drugs in the last year. ⁴

5. Patterns of drug use change. New drugs appear, and trends in drug use change. Organised criminals are not concerned about which drug or even which commodity they traffic, as long as it brings profit and power. The trafficked drug of choice can change quickly, and on a large scale. For now, crack cocaine use appears to be geographically concentrated in parts of Scotland whereas in England its use has become more widespread. Cannabis strains are reported to be stronger and there has been a huge increase in cannabis being grown in Scotland. ⁵ Methamphetamine, which has had a devastating impact in North America and Australia, has not significantly hit Scotland, but we need to remain vigilant.

6. People who use drugs undermine their potential to lead rich and fulfilling lives. They put at risk their relationships, their chances of employment and their health. People with problem drug use - especially those who inject - are at hugely increased risk of contracting serious blood-borne viruses such as HIV and Hepatitis C. A recent report demonstrated that over 85% of Hepatitis C sufferers in Scotland contracted the disease from sharing needles, syringes or other paraphernalia. ⁶ Despite concerted efforts by professionals on the front line there were 421 drug-related deaths in Scotland in 2006 - the highest ever. ⁷

7. Drug problems in a family, especially parental drug problems, can have devastating effects. According to research taken in 2000, an estimated 40-60,000 children in Scotland, about 1 in 20, are affected by the drug problem of one or more parent. ⁸ One immediate effect of this can be the risk of emotional or physical abuse; in the long term it can seriously harm the well-being and life chances of the child, including their health, educational attainment and future employment prospects.

8. Other family members also bear the cost - financial, emotional and social - of having a person with problem drug use in the family. In many cases, a grandparent or other member of the family may take on the responsibility of caring for the child of a problem drug user, often at a stage of life when they are less able to cope with the strains it involves.

9. In short, problem drug use ruins lives.

10. Problem drug use is one of the most significant contributors to health inequalities. Its negative impact on health and well-being produces inequalities between individuals and communities, reducing the chances and choices for many. Drug users can also face many barriers to obtaining treatment and other services.

11. There are also significant economic and social costs associated with problem drug use. Many people who have a drug problem are unemployed and are not therefore enjoying the health and economic benefits that come with employment. In 2006-07, 67% of new clients in drug treatment services reported that they were unemployed, compared to less than 5% for the country as a whole. ⁹ In most cases the individuals will be in receipt of benefits from the Government, which has implications for the public purse, as well as impacting on Scotland's labour productivity and, in turn, its sustainable economic growth.

12. Illegal drug use and dealing severely affect the quality of life in local communities. This can make local communities unattractive and unsafe places in which to live and work. In a 2007 survey, 76% of people saw drug use as a 'big problem' in their community. ¹⁰ Some people with problem drug use commit crime to fund their habits. The average cost of heroin addiction is around £238 per week ¹¹ and it has been suggested that one-third to over a half of all acquisitive crime is related to illegal drug use.

13. There is research to show that the average economic and social cost per problem drug user in England and Wales is around £50,000 per year. ¹² (This includes the costs to the victims of crime, costs to the criminal justice, health and social care systems, and the costs of drug-related deaths.) There is no reason to assume this figure would be significantly different for Scotland. This suggests that the total economic and social costs of problem drug use in Scotland amount to around £2.6bn per annum. Scotland specific research has been commissioned to refine the estimated cost further and will report later in 2008.

DRUG USE AND THE NATIONAL PERFORMANCE FRAMEWORK

Drug use has a significant negative impact on Scotland's well-being as a nation. Tackling problem drug use effectively is important to the achievement of the national outcomes identified by Government.

14. As the evidence above makes clear, problem drug use has a significant negative impact on many aspects of Scotland's well-being and success as a nation. In particular, it impacts directly on the 15 National Outcomes identified by the Scottish Government as part of the National Performance Framework.

15. Our Purpose as Scotland's Government is "to focus the Government and public services on creating a more successful country, with opportunities for all of Scotland to flourish, through increasing sustainable economic growth." ¹³ Economic growth is a concern for everyone because it dramatically affects the way we live, our job opportunities, incomes and the aspirations of our young people.

16. The Government's Economic Strategy sets out how we will support businesses, community partners and individuals and how, together, we will deliver the Purpose. It takes momentum from the challenging targets we have set to track progress in boosting Scotland's economic growth, productivity, population and labour market participation, and in delivering the desired characteristics of growth - solidarity, cohesion and sustainability.

17. The Purpose is also supported by five strategic objectives - to make Scotland wealthier & fairer, smarter, healthier, safer & stronger and greener. These are, in turn, supported by 15 national outcomes which describe in more detail what the Government wants to achieve over a ten-year period.

18. The national outcomes are as follows:

• We will live longer, healthier lives
• We realise our economic potential with more and better employment opportunities for our people
• Our children have the best start in life and are ready to succeed
• Our children are successful learners, confident individuals, effective contributors and responsible citizens
• We have improved the life chances for children, young people and families at risk
• We live our lives safe from crime, disorder and danger
• We have strong, resilient and supportive communities where people take responsibility for their own actions and how they affect others
• We live in a Scotland that is the most attractive place for doing business in Europe
• We are better educated, more skilled and more successful, renowned for our research and innovation
• We have tackled significant inequalities in Scottish society
• We live in well-designed, sustainable places where we are able to access the amenities and services we need
• We value and enjoy our built and natural environment and protect it and enhance it for future generations
• We take pride in a strong, fair and inclusive national identity
• We reduce the local and global environmental impact of our consumption and production
• Our public services are high quality, continually improving, efficient and responsive to local people's needs

19. Progress on the outcomes is measured through 45 national indicators. Together, these outcomes and indicators make up the National Performance Framework. An approach based firmly on the national outcomes enables us to focus on and maximise the contribution that tackling drug use can make to their achievement.

20. The importance of tackling problem drug use to the achievement of the national outcomes is reflected in the fact that the set of 45 national indicators includes the following:

"reducing the estimated number of problem drug users in Scotland by 2011."

21. The National Performance Framework also underpins the new relationship established between the Scottish Government and local government, through the Concordat agreed in November 2007. The package of measures contained in the Concordat includes the introduction of "Single Outcome Agreements" ( SOAs). Under the Concordat, an SOA will be developed between central government and the local authority or Community Planning Partnership ( CPP) in each area of Scotland.

22. Through the identification of local outcomes clearly aligned with the national outcomes, each SOA would set out the contribution to be made in that area to achievement of the national outcomes and, ultimately, to Scotland's well-being and success as a nation. So, just as the National Performance Framework helps focus action to tackle drug misuse at a national level, the SOAs can help us identify the contribution tackling drug use makes to the achievement of local outcomes. SOAs for 2008-09 are in the process of being agreed between Government and local partners.

23. Since a disproportionate impact on the national outcomes stems from what we describe as problem drug misuse, we now look in more detail at how we have tackled this in the past, and at the challenges that face us in 2008.

SCOTLAND'S RESPONSE TO PROBLEM DRUG USE

Action to tackle problem drug use in Scotland has evolved significantly over the last 20 years, with considerable increases in investment in recent years in particular. But recent work by experts suggests that a fresh approach is required if we want to address fully the needs of people with problem drug use, to help them recover and rebuild their lives.

24. To understand the challenges we currently face in tackling problem drug use, we need to reflect on how we have sought to tackle it in the past.

25. Heroin dependency and injecting drug use on a large scale became recognised as a problem in the early 1980s. At that time, the limited drug treatment services were primarily focused on abstinence, for those who were motivated to change their behaviour. However, the discovery of HIV among a large number of injecting drug users, firstly in Edinburgh and then in Dundee, led to a change in this approach. ¹⁴ A strong emphasis was placed on substitute prescribing, to reduce injecting; and needle and syringe exchanges were set up. The 1990s saw this 'harm reduction' approach extended to include social behaviours - in particular the relationship between treatment and reduced criminal activity. Funding for treatment increased significantly. Methadone became established as the main form of substitute prescribing: there are now 22,000 people receiving methadone prescriptions at any one time. ¹⁵

26. Public and political controversy over the use of methadone led to the Scottish Advisory Committee on Drug Misuse ( SACDM) being commissioned to review the place of methadone in treatment in Scotland. The report, written by a sub-group containing a wide range of expert and academic opinion, Reducing Harm, Promoting Recovery, was published in July 2007. ¹⁶ Its key conclusions were that, while methadone had an essential part to play in tackling problem drug use, it could not be the whole solution; and across Scotland as a whole there was a significant lack of services which could enable problem drug users to recover - to move on from their addiction towards a drug-free life as a contributing member of society. At the same time, there was a significant lack of information about the outcomes being achieved by the services provided.

27. July 2007 also saw the publication of the Stocktake of Alcohol and Drug Action Teams ( ADATs - local partnerships to tackle drug use). ¹⁷ The Stocktake had been commissioned by the previous administration to consider the performance of ADATs, and their capabilities to deliver future priorities on drugs and alcohol. The Stocktake team concluded that a partnership approach, as demonstrated by ADATs, remained essential to effective action, and that many ADATs had done excellent work; but that there were serious shortcomings in a number of ADATs. Generally, there was a need for greater clarity in their remit and function, and for a more effective relationship between ADATs and central government.

28. In March 2008, SACDM published a further report on the issue of recovery. The Essential Care report built on the earlier methadone review to identify the wider range of non-medical aspects of care which are essential to promote recovery. ¹⁸ The report also strongly advocated a person-centred approach, with support designed to address the person, rather than the addiction.

29. Within the field there is, therefore, an increasing recognition that we need to move on, to develop a broader approach to tackling problem drug use. Since coming into office in 2007, the Scottish Government has sought to explore with SACDM and others the implications and practicalities of moving towards an approach to tackling problem drug use in Scotland based firmly on recovery.

OUR KEY PRIORITIES IN TACKLING DRUG USE

The Scottish Government has sought to develop a fresh consensus on how best we can tackle Scotland's drug problem. One year into that process, and based on that emerging consensus, this document now proposes a set of key priorities for action, and a programme of work associated with each.

30. Over the past year, the Scottish Government has engaged with and sought the views of a wide and diverse range of key experts, practitioners and service users, as well as the main political parties in the Scottish Parliament. We sought throughout to build consensus on the way forward, building on the reports published by SACDM and others in the past year.

31. Based on our belief that there is now an emerging consensus, we put forward the following as key priorities:

• better prevention of drug problems, with improved life chances for children and young people, especially those at particular risk of developing a drug problem, allowing them to realise their full potential in all areas of life;
• to see more people recover from problem drug use so that they can live longer, healthier lives, realising their potential and making a positive contribution to society and the economy;
• having communities that are safer and stronger places to live and work because crime, disorder and danger related to drug use have been reduced;
• ensuring that children affected by a parental drug problem are safer and more able to achieve their potential;
• supporting families affected by drug use; and
• improving the effectiveness of delivery at a national and local level.

32. Subsequent chapters of this document set out a Programme of Action in pursuit of these priorities,
as follows:

• Chapter 2 sets out a programme of cross-cutting work, involving all arms of the Scottish Government and the public services, to prevent drug use by tackling the factors associated with drug use, as well as improving education and information;
• Chapter 3 sets out a new vision to support people with problem drug use based on promoting recovery;
• Chapter 4 sets out specific action to make our communities stronger and safer, by maximising the contribution made by the police, the Scottish Crime and Drug Enforcement Agency ( SCDEA), the courts, the Scottish Prison Service ( SPS) and the Crown Office and Procurator Fiscal Services. Much of this action will also contribute to other key priorities;
• Chapter 5 sets out specific action to protect and support children affected by substance misuse, to help them realise their full potential;
• Chapter 6 sets out a new approach to ensuring effective delivery, based on partnership at a national level, more effective partnership working at a local level, a stronger focus on outcomes and better use of evidence; and
• finally, the Action Plan summarises the next steps in taking forward this new approach to tackling drug use in Scotland.

33. What this strategy proposes is, ultimately, a significant programme of reform of how we tackle Scotland's drug problem. The challenge facing us all is to ensure that the work we take forward, at all levels, amounts to a successful response to this challenge.

34. The Scottish Government commits to working in partnership with all concerned, in as consensual a way as possible, to help us make the greatest difference we can. We invite all those involved to join in this enterprise: to put Scotland on the road to recovery.