Expansion of all quality treatment is needed to address Scotland’s drug crises

In this blog post, Scottish Drugs Forum’s CEO, David Liddell, writes on our public health crises and the role of treatment within them.

There has been some confused public debate recently on the role of treatment in responding to two related public health crises – the high rate of problem drug use in Scotland and the high rate of drugrelated deaths.   

Almost all problem drug use in Scotland is poly-drug use.  People use a range of substances along with a ‘main’ drug.  We know that the estimated number of people who have a drug problem involving opiates (mainly heroin) and / or benzodiazepines (drugs like Valium) is around 60,000 and, broadly speaking, this has not significantly changed in over two decades. 

That population is not static.  Since 2000, around 13,000 people have died as a result of a drug overdose and at least that number again will have died of other drugrelated causes.  Some people who have had an opiate or benzodiazepine problem will have moved on to using other substances which are not included in these estimates – stimulants like cocaine or alcohol, for example; others will have resolved their problem drug use and will be using substances in a way that is defined as unproblematic or be abstinent from substances. No one knows the numbers of people who have moved on from problem opiate / benzo use in these ways, but we do know that each of them has been replaced by someone else with an opiate / benzo problem. 

One way to protect people from the risk of overdose deaths is to ensure that they are in treatment. For people with an opiate-based problem that usually means some form of medication assisted treatment (MAT) – substituting street drugs with diamorphine, methadone or buprenorphine. In Scotland, we have around 35% of the people who could benefit from treatment actually in treatment. In the rest of the UK, that figure is around 60%. This statistic goes some way to explain Scotland’s high drug death figures. 

Anyone who uses or works in Scotland’s treatment services will know that they are busy.  They only have around half the capacity they really require. It is a sobering thought that busy as they are, they should have at least twice as many people using them.  Scotland’s treatment system is just far too small to meet the challenge we face.   

Recently an old ‘debate’ has been resurrected about the role of residential rehabilitation.  In this debate, a focus on whether the number of residential rehabilitation beds is higher or lower than it previously was replaces any proper discussion about the treatment system.  As it happens, the number of people going into residential rehabilitation in Scotland has never been higher than about 650, in 2004, and may now currently be around 300 or fewer. Both of these figures are actually insignificant in terms of the tens of thousands of people who have a drug problem.  The debate, then, is really a spat about whether the number of services is too small or far too small.  

The reduction in residential rehabilitation places is not the cause of the rise in Scotland’s drug deaths – it cannot be as the figures simply do not add up.  Nor would, say, doubling the number of rehab places be a solution to fatal overdoses.  What is needed is an expansion in the number of people in treatment and all kinds of treatment, whatever form it takes. 

Residential rehabilitation services, like all services, need to be of a high quality.  Residential service providers will concede that not everyone is suitable or ready for their service.  People need to be prepared for participation and adequately supported.  

Sometimes people seem to have a very particular view of the transformative nature of residential rehab. Residential treatment needs to be backed up with supports after the programmeThere is a significant risk of relapse and fatal overdose for people exiting treatmentAlthough there are success stories, of course, there are people who die within a year of rehab; including people who initially seem to be ‘doing well’.  Once someone leaves residential rehabilitation, their needs are somewhere to live, something to do, an income and a positive social network that will support them unconditionally. They also need access to effective health services  

It is worth noting that we have a very narrow view of residential treatment in Scotland and we could learn a lot from colleagues in other countriesThe integration of employability and other supports and the provision of housing are good examples of common practice abroad that are under-developed here.  Also, the possibility of residential services for people who are on medication assisted treatment is precluded here and yet exists as part of a range of services elsewhere.  

It is unhelpful to frame a debate around medication assisted community-based treatment versus abstinence-based residential rehab as if these were ideological positions or in competition for funding. As a sector, services in Scotland – as well as people lobbying for various stakeholder groups – should instead be rallying around some key messages and clearly stating: 

  • We need to have more people with a drug problem in treatment  
  • We need to expand the range of treatment choices for all – including a wider choice of residential rehabilitation and crisis intervention services; and a wider range of MAT options including Heroin Assisted Treatment and slow release morphine 
  • We need people in treatment to have access to effective mental health services and psychological support 
  • We need to expand each element of the treatment sector 
  • We need to improve the quality of the treatment experience of people with a drug problem 
  • We need adequate in-treatment and posttreatment supports for people with a drug problem 

SDF operates from this consensus and welcomes discussion and debate on this basis.