THIS WEEK’S report on drug related deaths in Scotland gives food for thought on one of the largest public health disasters since devolution started. Like all things on matters of public health the caveat to this statement is, “it’s complicated”.
While overall drug related deaths have begun to fall, and this is encouraging, the numbers are nonetheless ghastly. A serious bone of contention I have had for a while with the narrative is that it shows Scotland a rank outlier against the rest of the UK and therefore Holyrood alone is to blame. This is only partially true.
As with GERS figures published last month, the idea is that Scotland is doing badly in the UK when the reality is everywhere is doing badly except London and the South East. Regional figures for income, benefit dependency, deprivation and mortality are on a par with Eastern Europe, and that region is making rapid gains on all fronts. We are not.
This matters for those supporting the UK as a whole because huge disparities within England cannot be lightly dismissed as SNP bad. The SNP does not govern the North East of England, nor Wales or Northern Ireland. Something much bigger and deeper is going on.
Drug use and drug related deaths correlate very strongly with deprivation and lack of social mobility that are two sides of a coin we can call economic failure. Figures for Northern England are also very poor and similar patterns emerge there. The reason drug related deaths are such an issue in Scotland is that even when adjusting for regional disparities in deprivation we are still doing far worse than regions in England and Wales that are poorer.
Data from the National Records for Scotland show some alarming patterns yet as always in the nationalist-unionist singularity of Holyrood, no one seems to be using data to develop policy that could help the situation.
Much has been said of the heroin centre in Glasgow where addicts use heroin with supervision, the so called Shooting Gallery, and of the roll out of the Naloxone programme where addicts can be given reversal agents by those close to them or by ambulance crews. Arguments made for and against them ignore the obvious. The situation is parlous and the priority has shifted to firefighting, to at least stopping drug users from dying this month, this year, and away from tackling long term addiction. Some defence can be mounted for these services in that they are at least trying to act in a damage control manner in the immediate term which given the situation is not unreasonable.
I am a believer that drugs per se are not addictive but have addictive potential in those predisposed and that social mobility and economic growth for all are the best preventers of addiction in the first place. That is ultimately for another day.
I can see five areas of concern in the data on drug deaths in Scotland and these should focus minds on how we can act quickly to reduce the risk of immediate death while we develop a better way of tackling addiction longer term.
The first is the vast majority of drug deaths are accidental. This matters because accidents can be prevented. This point cannot be overemphasised, in that these deaths could be avoided if risk factors were mitigated.
The second is the degree to which methadone was a driver in those deaths. Methadone, a synthetic opioid, is the mainstay of addiction management in Britain. Putting aside the arguments against maintenance and for abstinence for a moment, we should explore why methadone overdose happens. The first is that in recent years and especially through COVID there has been a move away from supervised dosing in pharmacies and towards self dispensing at home, where addicts have a week or more supply of the drug they take themselves. In an ideal world this would not be an issue but many addicts live chaotic lives, miss doses, and take other substances all of which increase the risk of overdose. Missed doses and an attempt to catch up on those doses is especially serious given methadone has a long half life in the body and tolerance fades within days. A double dose is an overdose and once taken the addict is then mixing the doses and half lives of other substances. A fatal cocktail for too many.
The fourth is the use of street benzos, or sleepers that are taken along with methadone. The vast majority involved etidazolam and bromazolam. Heard of those? Me neither, we don’t use them in healthcare in the UK yet since 2020 their use boomed. Diverts from prescribed diazepam or Valium exist too. We must mention here my personal bugbear, and that is the explosion of legal use of pregabalin and gabapentin since 2000. Pushed by big pharma for all sorts of ailments related to pain the sheer volume dished out across the NHS means some finds its way onto the street. I am quietly informed there is quite a market for those in high doses to earn a side income passing on some of their medication to dealers.
Put simply, mixed overdoses of different drugs of different durations are lethal. They are the mainstay of drug related deaths.
The fifth is the Cocaine crisis that has swept every little town and big city in Scotland. Like opium in Victorian China it is nowhere and everywhere. It has become so serious that deaths from cocaine have jumped from 50 to 400 a year over the past ten years. All too often taken with alcohol this is an especially toxic combination. Cocaethylene is the drug no one can buy… because we make it. Alcohol and cocaine actually combine chemically in the liver to create a drug that has two particular features. It is toxic to the heart and it drives extreme violence. Much of what is seen in A&E and in police stations attributed to alcohol or cocaine is in fact cocaethylene toxicity. Broken jaws, brain haemorrhage, the dreaded “coke stroke” and heart attacks in those over 40 make quite a night on the hospital ward tiles.
We have the data, now what to do with it? It isn’t easy. Every doctor I know has their own opinions and heaven help anyone offering advice who is not a renowned expert… not that I am saying medical experts are egotists… oh, heaven’s no.
I can think of a few things we could do in Scotland. Ultimately I feel Holyrood is simply playing a poor set of cards badly and that UK level action on drugs is needed. I personally feel cash benefits given to addicts with structure in their lives is a complete disaster and cannot be anything else. Nothing is more price inelastic than a drug one is addicted to so a cash based system essentially funds and prolongs addiction. There, I’ve said it. Benefits to addicts need to be different because they act and think differently.
Back in Scotland I’d propose prospective MSPs to think through the following.
1. Mixed overdoses involving methadone are the biggest killer here and it should prompt random if not weekly testing of methadone users for co-substance use and positive tests should prompt a return to supervised daily dosing for as long as the issue remains. We can proactively seek out those at risk of mixed overdose by using methadone collection as a screen for mixed drug and alcohol use.
2. All methadone users over 35, according to literature, are at higher risk of death, certainly men over 45 are. It may be prudent to return everyone in this group to a much smaller supply of methadone issued at home, else to return to supervised dosing for them.
3. Cocaethylene can be tested for and for those arrested by police can be checked for its presence… it can only be created when taking alcohol and cocaine within a short time frame. Those testing positive can have that result used in sentencing guidelines, a small but easy deterrent to recreational use of both.
4. A full review of off licence use of gabapentin and pregabalin in the NHS, to reduce potential supply. The rates of use have grown vastly in recent years and I believe we are close to stage we were at with overuse of OxyContin 10 years ago and Valium 30 years ago.
The data shows huge differences in death rates across Scotland, with most of Scotland actually well within the UK average for death rates: Glasgow and Dundee are positively frightening. This seems to be largely down to the sheer number of addicts in those cities rather than any specific policy failings locally.
In conclusion Scotland has a lot of drug related deaths for three reasons:
i. A lot of people use drugs and many are addicted and this is decades in the making. Much but not all of use is driven by relative deprivation compared to the UK as a whole.
ii. Cocaine use has boomed and we have barely begun to consider it a serious public health issue over and above antisocial weekend partygoers. It’s much bigger than that and much more widely used by non-addicts. A true recreational toxin.
iii. Public health measures continue to fail though deaths are slowly falling, with the drift to greater rates of home prescription and longer times between deliveries meaning large volumes are in the homes of people worst placed to regulate that. For the record over 600,000 litres of methadone have been given out in Scotland between 2009 and 2013 alone.
We need to move quickly away from simply saying methadone is good or bad and we need to recognise the serious impact of illegal street benzos and cocaine that now make a considerable contribution to overall death rates. We need to know we can test for the co-use of alcohol and cocaine and we can use that to determine stricter sentences and penalties for its involvement in crime. We know who is at greatest risk of accidental deaths and we need to do more to pre-empt mixed overdoses with stricter pharmacovigilance and routine testing for co-use of non opioid drugs.
The rest, as they say, is politics…
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