Swiss expert's 'Death sentence' warning over waiting lists as Scotland awaits new drug strategy

"My brother in law died on Christmas Day. He took a combination of drugs and alcohol with methadone on Christmas Eve.

"He died in his sleep. My sister found him in the morning. She was pregnant at the time with their fourth child," he says.

Growing up surrounded by addiction, in the East End of Glasgow, he took drugs himself for 25 to 30 years, before finally getting clean a few years ago.

Scotland's staggering rate of drug deaths is no surprise to Sammy. "I heard about someone overdosing almost daily. When it happened to me, it was like an occupational hazard."

Substantially different? Scotland's drug death crisis in numbers

Had he died, he knows there are people who would view it as no great loss, that people like Sammy have chosen the risks of drug use.

"I don't know anyone who made a choice to live that sot of life. It is a way of coping", he says. "There were times when I woke up in hospital and thought it would have been easier if I hadn't recovered."

Imagine a building collapsed in Scotland once a year, killing hundreds of people. Worse: every year a bigger building fell, taking more lives with it. There would be public enquiries, taskforces, immediate action.

Not so with Scotland's drug deaths. In July when the latest figures came out, showing 934 Scots lost their lives to drugs in 2017, there were a few days headlines and we moved on.

This year, most expect we will lose 1000 people to drugs for the very first time. A trend which has seen deaths more than double from 2006 to 2016 (from 421 to 867) shows no sign of abating. But why are more people dying from drugs?

There are plenty of theories: an ageing population of drug users in poor health, increased "poly drug use", poverty and de-industrialisation. Writers from Carol Craig to Loki have theorised that early trauma – so called Adverse Childhood Experiences – have led many Scots to self-medicate away their pain.

Read more: 'Poverty Safari' author Loki sounds alarm over soaring drug deaths

A bigger question is why Scotland is an unenviable global leader in the field of fatal overdose and drug-related death.

According to World Health Organisation statistics we have the second highest rate of death, per head of the population, trailing behind only Ukraine.

Partially, Scotland is more assiduous at recording lives lost to drugs than many other countries. Rules on how such deaths are recorded and attributed mean our statistics are more robust than in many parts of the world.

But other European countries are equally diligent. And our record is woeful compared to many of them. From Sweden to Portugal, France to Finland, Ireland to Austria, our near neighbours all report less than half the rate of deaths, we do.

In England, where deaths are recorded in much the same way as in Scotland, many, many fewer lives are lost. Scotland sees around two and half times as many people die, as the rest of the UK.

Read more: Drug deaths in 2017 reached record levels

Andrew Horne, director of the charity Addaction in Scotland says we simply have more people using drugs. "The bottom line is that there are a lot of people at risk. We have more people using drugs per head of the population than in most parts of the world," he says.

Combine that with a historic ambivalence about the most effective means of keeping drug users alive: opiate replacement therapy (ORT), usually with methadone, and you have a recipe for problems. "The obvious intervention is to get more people into treatment," Mr Horne says.

Only about 40 per cent of Scotland's estimated 60,000 drug users are in treatment, compared with 60 per cent in England. And when people do register with drug services, we are not good at keeping them there.

Despite controversies over methadone, the evidence is it is this, or alternatives such as Buprenorphine which works to keep people alive. "ORT is the evidence-based treatment," Horne says, "there really isn't another one."

But many of those working on the frontline agree a lack of realistic, holistic support, is where Scotland falls down.

"We need much more of a sort of drop-in availability. Instead there is still a culture of punishment in many services," Horne adds. "If people don't behave – they continue too use illegal drugs, say, or miss appointments, instead of trying harder to keep people in treatment, we withdraw or reduce it."

It is hard to overstate how damaging an ill-fated emphasis on recovery was. A Scottish Government misstep, it saw the direction of Scotland's drug strategy changed towards abstinence, with services urged to push people towards a narrowly-defined "recovery" and a drug-free life. Those who succeeded became 'recovery champions'.

The problems with this are multiple. Those who spend time with drug users know the lives of many are chaotic. They are not ready to simply walk away from drug use, and those who do often relapse.

"We made abstinence almost saintly, celebrating those in recovery," one worker told me. But the corollary was that drug services became less keen to offer harm reduction advice and help, increasing the risk and stigma facing people whose problems were more acute.

Meanwhile for successful quitters the fall if they did relapse became greater with their public identity now so tied up with abstinence .

"We have operated under too narrow a definition of what abstention is," says Scottish Drugs Forum director David Liddell. "It has been about being 'clean' when it should be about quality of life.

"You might have someone on methadone for 20 years, who has children doing well at school and who is working, and who uses heroin occasionally at the weekend. Or someone who has been off drugs for 3-4 years, but has attempted suicide, has underlying mental health issues, has lost the care of their child and all connections with their family. Which one is in recovery?"

Substantially different? Scotland's drug death crisis in numbers

e praises the Housing First model now being promoted and funded by the Scottish Government around the country, which will allow people with addiction problems to be given a home while they are still tackling their dependency. But it has to go hand in hand with better help."People can take a long time to turn their lives around and too many are dying before they reach that point."

The politics of drugs also influence what is offered. We are uncomfortable with giving people with addictions too much choice. Heroin assisted treatment (HAT), now slowly inching its way towards reality in Glasgow, is a case in point.

When it does arrive, it is likely to be offered to dozens of users. Mr Liddell says, especially in light of city's stalled plans for a safer injection room, it should be offered to hundreds.

This is supported by Dr Thilo Beck, of the Arud Centres for Addiction Medicine in Switzerland

He is cautious about the WHO figures, but says it is still clear Scotland's problem is acutely worse than in Germany, France and England.

Switzerland used to have a high death rate too, but cut the annual number of deaths from drugs from 419 in 1992 to 152 in just 15 years.

"We had the same problem as you in the 1990s," Dr Beck says. "The only thing that helped was integrating various services. Maintentance and treatment are really important, but it also takes housing, employment programmes, and drug consumption rooms."

He is aghast that Glasgow's plans for a pilot safer injecting scheme are being blocked at Westminster. "Then you had better leave the UK!", he says, adding: "For that reason, anyway, it would make sense."

Any public opposition has faded away as such rooms in Switzerland have become ubiquitous, he says. "People like them because it takes away the public nuisance. The police tolerate it because they see it works."

He also warns against the lengthy waits Scottish patients face before they can access methadone treatment. "When someone walks in to see you that is when you need to prescribe methadone. We have people on the programme in 20 minutes. You can't have a three month waiting list. That is a death sentence," he adds.

People need help with not just housing but other underlying problems: from childhood trauma and abuse to bereavement and mental health problems. They may need help with restoring contact with their children, they may have been struck off benefits, or been evicted, one worker told me. "Once they are stabilised you need to address those issues too. That doesn't happen enough: it barely happens at all."

Essentially, people trapped on drugs need hope. If you look at the miserable, stigmatised, lonely life of an addict and wonder what kind of life it can be, you are not alone. "There is a massive issue of social isolation. Some people are ambivalent about whether they survive or not," David Liddell says.

For Sammy Deans, eventually, a drug treatment and testing order set him on a slow path to 'recovery'. Prior to that, services hadn't helped him. "During the whole time I took drugs, I never once had access to counselling," he claims. "They always wanted you to stay abstinent. But that was impossible. I was self-medicating the trauma in my life, I've I'd been able to achieve abstinence, I wouldn't have needed the counselling."

But politically, we have been uncomfortable providing the medication and other supports drug users need, reluctant in a way we would never be with those suffering from diseases such as heart disease or diabetes.

After an ill-advised cut to the budgets of Scotland’s alcohol and drug services, the Scottish Government recently reinstated the £17m in funding which had been taken from local Alcohol and Drugs Partnerships as part of a £20m “investment” in services.

But it was notable that it was not Scotland’s harrowing drug death figures which prompted this change. Instead ministers were responding to a report which set out clearly the predicted costs to the public purse – the NHS, courts, prisons and crime – likely to be incurred by leaving addiction untreated.

Besides improving the health and wellbeing of drug and alcohol-dependent people, the Scottish Government said, the funding would lead to “a reduction in future demand on high tariff services”.

The Scottish Government is now putting the finishing touches to a revised drug and alcohol strategy, which has been subject to extensive consultation with the sector. But the danger is it will end up being a fudge, an unambitious attempt to please everyone.

Roy Robertson, the Muirhouse GP who is also Edinburgh University's professor of addiction medicine, believes it is not the answer we need. "Our problem with the draft strategy is that it really doesn't recognise the urgency and the extent of the problem," he says. "there is a feeling that we haven't got a grip of just what a crisis we are facing."