Scotland’s failed war on addiction

Scotland’s drug deaths crisis reflects a moral abdication of responsibility by those charged with running Scottish society and finding solutions to the very real problems it faces, writes Carlton Brick.

Retaining moral judgments about drug use and accepting the stigma directed towards drug use, if not drug users, may be an important part of an effective approach aimed at tackling the use of illegal drugs in society. (1)

Scotland is in the grip of a chronic drug addiction crisis. Drug deaths have increased substantially over the last 20 years, with almost five times as many deaths in 2020 compared to 2000. In 2020, 1,339 drug-related deaths were registered in Scotland: 5 per cent more than in 2019 and the largest number since records began in 1996. Scotland’s drug death rate is the highest in Europe and over three and a half times as large as the rest of the UK.

Methadone accounts for almost 50 per cent of all Scotland’s drug related deaths; a figure which has almost tripled since 2015. This is more than double the rate of the United States. Methadone is prescribed by doctors wanting to wean addicts off heroin and this comprises a key part of the Scottish government’s harm reduction strategy.

According to SNP government’s experts, stigma and social prejudice prevent adicts getting the help they need. Others point out that since 2007, the SNP has slashed addiction service budgets by 55 per cent. There is little doubt that Scotland is in the midst of a tragic addiction crisis. However, simply throwing more money at the problem is not a solution. Rather than being a resources problem, Scotland’s drug deaths crisis has become a moral problem.

In recent years, tensions have emerged between the governments of the UK and Scotland over how to view and deal with drugs. Unlike health, drug law is not a devolved issue. And whereas the UK government seemingly favours a criminal justice approach to dealing with drugs, the Scottish administration has opted for a public health centred approach. However, this apparent difference is not as clear cut as first presented. Both governments approach the problem largely through the purview of ‘harm reduction’. Yet in the case of Scotland, advocates steadfastly argue against the idea of abstinence and prohibition as appropriate approaches to drug treatment, with disastrous results.

Both advocates of and opponents of SNP drug policy point to the fact that there are specific demographic and regional deprivation factors that influence the pattern of drug deaths in Scotland. Statistics suggest that the majority of drug-related deaths occur between males aged between 35 and 54. Individuals living in the most economically deprived areas are 18 times more likely to die from a drug-related death than those not.

However, these factors alone cannot explain the high rates of drug related fatalities as a percentage of the Scottish population. Indeed, as recent academic research has identified, the rapid increase in opioid related deaths in Scotland is both ‘remarkable’ and ‘worrisome’. When comparing opioid related death rates across the UK as a whole, research suggests that there are ‘… no clear regional differences…’ and the role of demographics and deprivation as key drivers of the Scottish opioid crisis is limited (2). The key distinction between Scotland and the rest of the UK is policy.

The Scottish government has become enthralled to the idea of harm reduction as an end in itself, rather than as part of a more comprehensive strategy that places the problem of addiction at its centre. Policy has largely jettisoned any assumption that with opportunity and support, an addict might overcome their addiction. Indeed, in April 2021, Scottish First Minister Nicola Sturgeon suggested that public discussion on the ‘rehabilitation’ of addicts was largely a distraction and that too much time had been wasted debating the issue.

The retreat from recovery

A core element of the Scottish government’s harm reduction strategy has been to complement methadone management with national campaigns aimed at educating the wider Scottish public on the plight and hardships faced by the country’s substance abusers. One such endeavour has been the recently rejuvenated campaign to challenge the stigma of addiction. Originally launched in December 2020 as part of the Scottish Drug Deaths Taskforce, the campaign points to the stigma faced by addicts as a principal cause of the country’s high drug death rate. According to campaign literature ‘…many who could benefit from treatment can be discouraged from doing so by language, attitudes and behaviours that appear judgmental…’. and ‘…tackling stigma could make a significant contribution to reducing drug-related deaths in Scotland.’

Based on a series of posters and television adverts, the national campaign suggests that terms such as ‘user’, ‘addict’, ‘drug abuse’ or ‘drug user’ should not be used to describe individuals with substance abuse issues. Moreover, the campaign adverts continue:

Substance use has been seen as a lifestyle choice or the result of poor decisions. It’s also been described or viewed as a mistake or the result of moral weakness. This is stigmatising and unhelpful. It shows a connection between drug or alcohol use and personal failures. This allows substance use to be linked to character or morals. Viewing this as just a personal issue adds to stigma. A drug or alcohol problem is a health condition. People should receive help and support, not judgment. Let’s end the stigma of addiction.

The SNP view is that the discrimination experienced by drug addicts, rather than their actual addiction, is responsible for the annual increase in drug deaths.

In reality, the Drug Deaths Taskforce campaign has little to do with helping drug addicts. It is a deliberate attempt to forcibly reengineer the common norms and values that shape wider Scottish society. Far from promoting tolerance and respect, the campaign sets out to stigmatise the belief held by many ordinary people that individuals are responsible for what they do, and if their actions are harmful to themselves or others, they have a responsibility to desist from such behaviour.

In July 2020, under the then stewardship of Professor Catriona Matheson, Professor of Substance Use at the University of Stirling, the Taskforce published its stigma and drug abuse strategy. Ironically, Matheson resigned in January 2022 because she felt the government was dragging its feet on this issue. Subtitled ‘We all have a part to play’, the strategy argues that the commonly held belief that addicts should be encouraged to abstain from taking drugs is no longer an acceptable view to hold. According to the Taskforce, the idea of abstinence is itself discriminatory because it stigmatises those drug addicts who fail to quit. Government policy on addiction, the Taskforce argues, is undermined ‘by the common perception among service staff and others that abstinence is the purpose of treatment… a notion based in stigma… and is a key driver of drug-related deaths.’

The Taskforce goes on to suggest that a ‘hierarchy of stigma’ exists in Scotland which informs the deeply ingrained prejudice against drug users. ‘Public discourse, political discourse, criminal justice discourse, public health discourse, media coverage’ all apparently contribute to a climate where those ‘with a drug problem often have a perception of themselves that simply reflects the prejudices of others that are based in their stigmatisation.’ In other words, as long as public opinion on addiction is shaped by attitudes that are fundamentally opposed to substance abuse, discrimination against drug addicts will continue.

According to the SNP’s experts, this stigma is systemic in Scottish society and is a form of discrimination on a par with racism and sexism. As such, the Scottish government has set itself the task of re-educating local communities, and the Scottish population more broadly, in how their stigmatised options are discriminatory and perpetuate social inequality and, ultimately, drug deaths.

However, the view that underpins this outlook is highly cynical and dangerous. The focus upon harm reduction, at the expense of recovery and rehabilitation, and the targeting of so-called stigmatising views against addicts, endorses an idea that addiction is socially acceptable and, in fact, should be respected by wider society. It provides a technocratic managerial solution – albeit dressed up in the language of therapy – to what is in fact a fundamentally moral question about the individual’s responsibility to wider society and their ability to contribute purposefully to that society – in this case the addict’s willingness to exercise personal responsibility for their condition.

The retreat from moral responsibility

Scottish policy is often justified on the grounds that it is more compassionate and socially just than approaches adopted south of the border. However, as noted above, harm minimalization has characterised both medical and government approaches to drug addiction in the UK – in particular the adoption of methadone as a ‘therapeutic’ substitute for heroin – since at least the 1980s (3) (1).

Initially introduced by the Conservative government in an effort to control the spread of HIV infection, strategies such as needle exchange and outreach education on safer injecting techniques had, by the late twentieth century, become common practice in dealing with the UK drug problem. In 2002, the Home Office issued guidance stating that ‘All problematic drug users must have access to treatment and harm minimization services both within the community and through the criminal justice system’. This now included the introduction of ‘methadone maintenance’ as a principal strategy in treating addiction. Outlined in the Government White Paper ‘Tackling Drugs to Build a Better Britain’ and guidelines on clinical management provided by the Department of Health in 1999 signalled that the UK approach to drugs had become predominantly public health centred (4). Drug addiction was now something to be managed rather than something to be cured.

Indeed, as Fitzpatrick argues, this new ‘public health’ approach is informed by minimising the emphasis upon abstinence in favour of more instrumentalised outcomes such as harm reduction and addiction management (3). The objective is not to encourage users to become drug free, but to replace a dependence upon an illicit substance with long-term maintenance on methadone. Moreover, the issue of drug addiction treatment is largely removed from the realm of the medical expert and relocated in the realm of the academic researcher and policy expert. This has had disastrous consequences as evidenced by the high levels of Scottish opioid deaths.

When used within a context that centres a meaningful notion of recovery, predicated upon the ideal of abstinence and supported by professional medical treatment, methadone has a valuable role to play. But as already noted, the turn towards de-medicalised harm reduction approaches in the 1980s and 90s all but negated abstinence as a worthwhile endeavour, favouring instead the much more instrumentalised notion of addiction management.

Evidence suggests that some aspects of harm reduction strategies do reduce an addict’s exposure to harm. However, as McKeganey notes, harm reduction is far less successful in treating the more pressing harm of addiction (1). As the case in Scotland clearly shows, a policy predicated solely upon ‘safely’ maintaining a patient’s addiction, without addressing the principal problem of addiction itself, means very little if the end result is premature death. McKeganey has gone as far to characterise the contemporary focus upon harm reduction as morally ambivalent (1). Scottish drug policy represents a complete abdication of both moral and social responsibility on the part of government, policy makers, and the wider research community, to deal with the very real problem of addiction in a way that is meaningful to the addict themselves.

Not only does the addict swap one addiction to a dangerous and deadly substance with another, they also become increasingly more dependent upon the state. The fetishization of harm reduction strategies negates the idea that the addict does in fact have agency and is responsible for the choices they themselves make. Harm reduction policies undermine the possibility of the drug user being able to own the rehabilitation process and overcome their addiction. It subordinates the actual interests of the addict and drug abuser, which is to get better, to the instrumentalised managerial logics of the spreadsheet. The management of addiction in Scotland has become an end in itself rather than a means to an end, albeit, as the drug death figures testify, a profoundly dysfunctional end.

Conclusion

The attempt by Scotland’s political and policy elites to stigmatise the view that substance abuse is in fact anti-social and unacceptable, undermines the moral responsibility the individual addict has to wider society to take responsibility for their drug problem. In this respect, Scotland’s approach to substance abuse does little for actual addicts, except condemn them to death. For the powers that be, the real value of this outlook lies in the way it serves an elite project to delegitimise the organic relationship between the individual and the disciplining role of wider community norms. It reflects the technocratic elite’s increasingly pessimistic view of the capacity for individuals to take control of their lives. It also reveals their deep contempt for Scottish society.

The Scottish government’s weaponization of addiction serves as the basis through which an increasingly technocratic and unaccountable political class delegitimises the moral and restitutive capacity of shared social norms. Legislative attempts to normalise addiction, through the undermining of liberal values such as individual responsibility and agency, seem to be readily accepted by politicians, policy makers and academic experts alike. Might this not be the real cause of Scotland’s drug crisis?

References

(1) McKeganey, N. (2011) Controversies in Drugs Policy and Practice. Palgrave MacMillan.
(2) van Amsterdam J; van den Brink W. and Pierce M. (2021) ‘Explaining the Differences in Opioid Overdose Deaths between Scotland and England/Wales: Implications for European Opioid Policies’ in European Addict Research. (27).
(3) Fitzpatrick, M. (2001) The Tyranny of Health Doctors and the Regulation of Life Cycle. Routledge.
(4) Department of Health. (1999) Drug Misuse and Dependence: Guidelines on Clinical Management. Stationery Office.

Carlton Brick is a lecturer in Sociology at the University of the West of Scotland.