Austin Smith, Policy Officer at Scottish Drugs Forum, discusses the link between poverty, problem drug use and Scotland’s high and increasing rate of drug-related deaths.

Austin Smith Policy Officer at Scottish Drugs Forum discusses the link between poverty, problem drug use and Scotland’s high and increasing rate of drug-related deaths.

The latest drug related deaths statistics were met with concern and some outrage but sadly there was little real surprise.  A seventh year of record drug overdose deaths offered statistical proof that Scotland remains the place in Europe you are most likely to die of a drugs overdose – by far. 

This year the National Records of Scotland made clear the link between poverty and drug-related deaths.  To illustrate the clear link the report stated:

In 2020, after adjusting for age, people in the most deprived areas were 18 times as likely to have a drug- related death as those in the least deprived areas (68.2 per 100,000 population compared with 3.7).

That ratio has almost doubled in 20 years. In the early 2000s, those in the most deprived areas were around 10 times as likely to have a drug-related death as those in the least deprived areas.

This drew some media coverage and some comment from politicians and commentators. Yet it should come as no surprise.  To become aware of the link between poverty and problem drug use, people only have to walk around Scotland’s city centres or former council housing estates, or pay a visit to the more deprived areas of Scotland’s towns.  If you live there, you know already.  It is a concern that some media commentators and social media personalities seem to have been unaware of this link or have previously failed to report on it.

The media and commentators are not the only people to choose to marginalise poverty as an issue. Perhaps Scots are so used to it that, even when we see it, we do not recognise its significance or maybe we think that it is not even noteworthy.  The fact is that when the UK left the EU it ranked second in terms of the extremity of its income inequality, exceeded only by Lithuania.  The UK is a country defined by income inequalities. Deprivation and relative poverty are its defining features.  And Scotland is little different.  That is the reality we have to face, articulate and change.

It is also important to realise that some of Scotland’s health statistics are very poor –A recent paper by an Edinburgh GP, Dr Catriona Morton, is worth quoting

The male life expectancy in Greendykes and Niddrie, where our practice is sited, is just 58 years. Men in Tanzania (which has 3 million orphans and ranks as one of the poorest countries in the world) have a life expectancy of 61 years. In Europe, again in terms of life expectancy, Scotland stands between Cyprus and Albania which have per capita GDPs of around $29,000 and $13,000 respectively. Since the late 1970s, Scotland has had the highest mortality among working-age men and women in Western Europe.”

Of course, these shocking statistics are partly driven by drug overdose deaths.

Scottish Drugs Forum and others have been emphasising the link between poverty and problem drug use for years.  As far back as 2007, SDF collected all the evidence of the link between problem drug use and poverty and published it.  Understanding this link is key to understanding Scotland’s public health problems of the last four decades involving problem drug use.  It is crucial if we are to reduce drug-related deaths.

It is also important to understand that, contrary to the views of some newspaper columnists, this is not the sole useful insight.  It is crucial that we understand and address the needs of the group of people who are the majority of people who die from overdoses- people, mainly men, who use opiates as part of a pattern of polydrug use and who somewhere are now between their late thirties and sixty years old.  It is hugely significant that the average age of death increases by almost a year each year as it proves that there is indeed an ageing group of people at very high risk of fatal overdose.  It is also important that we realise that over 90% of people who die are using combinations of substances, including, in almost all cases, opiates. 

The link between problem drug use and poverty is stark and demonstrated in both the statistics and the lived experience of people with a drug problem.  Unfortunately, the link is complex and there are several perspectives that need to be taken into account.  These may best be described by comparing the situations of people who live in deprived areas and those who live in more affluent areas.

It is generally recognised that there is a link between adverse childhood experiences and problem drug use.  While adverse childhood experiences can, and do, happen to all children, they occur in higher rates in children who are poor than those who are not.  Death of a parent is more likely; incarceration of a parent is more likely; witnessing violence is more likely; neglect is more likely.  

But the link to what goes on with families and within the home is only part of the picture.  The lack of power and control people have over their lives and the lack of support that people have in trying to make positive change keeps people where they are.  Before people develop a drug problem they may have been failed by several systems – the economic system, the education system, the care system, the health system, the criminal justice system.

When people have adverse events and circumstances, they develop mental health issues.  Engaging with supports and services is more difficult for the poor.  There are fewer services.  Even universal services like primary care offer far fewer GPs in poor areas than rich areas – even though levels of poor physical and mental health are higher.  It could also be argued that some people living in poverty will find it harder to engage with services because of the processes involved in operating the system. For example, to see a specialist a person has to persistently and consistently articulate their heath problem and their concern about it; keep appointments and travel to a specialist facility etc.  That can be hard for any of us especially when we are perhaps seriously ill but it may prove impossible for some whose day to day lives are a challenge and sometimes desperate.

So let’s imagine a young person in their late teens who has had some experimental use of drugs socially with a group of peers and has, for unrelated reasons, developed some mental health issue.  If that person can engage with services, they may get a diagnosis, some medication or therapy and advice that will allow them an insight into their condition and how to live with it or even overcome it.  For another person who cannot easily relate to and engage with services, that may be something that can be addressed by the use of street drugs.  Ironically, in the short term, both may be on exactly the same medication. 

Of course, another significant issue is the unemployment or underemployment of people in deprived communities.  A lack of structure provided by employment, a lack of a sense of self-worth through doing useful work and a lack of money because of low wages or benefits all combine to make life less tolerable. 

People in deprived communities live with more chronic health problems and so families have more caring responsibilities This may make prioritising yourself and, for example, focusing on developing a career, more difficult.  It also means that escaping one’s situation and ‘moving on’ is more challenging. 

With more difficult lives, fewer opportunities to change one’s life and a lack of empowerment and control, life can become intolerable or tolerable only when blunted by substances.  A short term solution may become a long term situation when a person develops a dependency on substances or is self-medicating for underlying health problems. 

The vast majority of people who die from a drugs overdose have had a drug problem and are likely to have had that problem, in some form, for many years.  At the time of their death, they are likely not to be in treatment and, if they are, they are likely to be on substitute medication at a dose which makes ‘topping up’ with street drugs at some point almost inevitable.  All their life, they may have been engaged by services – education, family social work, police, criminal justice social work, prison, harm reduction services, drug treatment services.  In their own way these services may have helped keep the person alive but ultimately their overdose death has not been prevented. 

And of course, they have their own family and social network.  These people too will have, most likely many times, supported them and prevented their death.  These people are hugely impacted by their loss.  They, in turn, have their own trauma.  For some an overdose death results in another child with another adverse childhood experience with an incalculable cost.  Much time and effort has been wasted trying to demonstrate a genetic tendency to addiction when the real family link is clear – poverty makes trauma more likely and more difficult to avoid and resolve.  Poverty is a root cause of problem drug use and overdose deaths and in recognising this and addressing it Scotland could make a significant step in preventing the deaths that mark it out as very unusual a particular case.