Deprivation a Driving Factor of Drug-Related Deaths

Scotland continues to face the most severe drug-related mortality crises within the UK and across Europe (see Scotland Drug-Related Deaths Scandal this website) with significant disparities between the rates in socially deprived and affluent groups.  Analysis of data from the National Records of Scotland reveals that drug-related deaths (DRD) have increased substantially over two decades, with deaths rising from 292 in 2000 to 1,172 in 2023 with the greatest rise in the most deprived group SIMD Q-1.

Analysis of age standardised drug-related death rates (ASR) in Scotland reveals a stark and persistent relationship between socioeconomic deprivation and the drug-related death rate.  See notes  below for details on Age Standardised Rates and SIMD Quintiles.

Figure 1: Scotland Age Standardised Drug-Related Death Rates
Yearly Drug-Related Death Rates (ASR)  for Scotland as a whole and for SIMD quintiles Q-1
to Q-5.  ASR normalised per 100,000 population.

The Relationship Between SIMD Deprivation and Drug-Related Deaths

As measured by the Scottish Index of Multiple Deprivation (SIMD) grouped by quintiles, the data clearly demonstrates that individuals residing in the most deprived areas (SIMD Q-1) experience significantly higher rates of drug-related deaths  compared to those in the least deprived areas (SIMD Q-5) see Figure 1.

Over the period from 2001 to 2023, the average ASR for SIMD Q-1 was approximately 34.66 per 100,000 population, while for SIMD Q-5, it was around 2.54 per 100,000 population. This indicates that, on average, the most deprived quintile has an ASR that is nearly 13.6 times higher than the least deprived quintile. This ratio has fluctuated over the years, reaching as high as 19.57 in 2019 and 18.51 in 2020, highlighting a widening gap in certain periods.

Looking at the trends, the ASR for SIMD Q-1 has generally shown an upward trajectory over the two decades, with notable increases in recent years. For instance, the ASR for SIMD Q-1 rose from 16.6 in 2001 to 53.7 in 2023, peaking at 68.5 in both 2019 and 2020. In contrast, while the ASR for SIMD Q-5 has also seen some increases, it has remained relatively low, ranging from 1.2 in 2004 to 4.2 in 2021. This widening absolute gap underscores the disproportionate impact of drug-related deaths on the most vulnerable communities.

The overall Scottish ASR adjusted rate  (Figure 1: Scot-ASR black line) also shows a rising trend from 6.2 in 2001 to 22.1 in 2023, with the highest rate recorded in 2020 at 25.2. This national trend is heavily influenced by the rates in the most deprived areas, suggesting that addressing deprivation is crucial for reducing the overall burden of drug-related deaths in Scotland.

Unadjusted Drug-Related Death Rates

Looking at unadjusted death rates, over a ten year period from 2014 to 2023 just over half of all drug-related deaths came from the 20% of the population living in deprived areas (SIMD Q-1) see Figure 2.

Drug Use is Also a Problem in Scotland

This web page reports on drug-related deaths, however, the high death rate is a surrogate measure for and points to a problem of high drug use in Scotland and especially in the most deprived areas.  This results in a cycle of deprivation and problematic drug use.  Homelessness, poverty, inequality, involvement in the criminal justice system are both drivers of and driven by problematic drug use, and all of these combine to compound the effect of each issue.

Figure 2: Unadjusted Drug-Related Death Rates
Yearly Drug-Related Death Rates for SIMD quintiles Q-1 to Q-5

Factors Contributing to Social Deprivation and Drug-Related Death Rates

The high rates of drug-related deaths in Scotland, particularly among those in deprived areas, are not solely attributable to drug use itself but are deeply intertwined with a complex web of social determinants of health. These determinants create a fertile ground for problematic drug use and exacerbate its harms.

Research indicates that social determinants play a significant role in shaping substance use patterns [1]. Factors such as age, sex, marital status, immigrant status, race/ethnicity, education, income, and mental health are independently associated with the use of illicit substances, opioids, problematic alcohol levels, and combined substance use. For instance, individuals under 29, those without a partner, and those with affective disorders have been found to report higher use of individual and multiple substances [1].

Poverty and inequality are consistently highlighted as primary drivers of problematic drug use and related deaths in Scotland. People in the most deprived areas are significantly more likely to die from drug misuse compared to those in the least deprived areas [2]. This is not merely a correlation; poverty can lead to a ‘snowball effect’ where individuals are exposed to environments and circumstances that increase their vulnerability to drug use [3].

Key contributing factors include:

• Socioeconomic Disadvantage: Half of the people who died from drug-related causes in Scotland in 2020 lived in the 20% most deprived neighborhoods [4]. This underscores how concentrated disadvantage creates environments where drug use can become a coping mechanism for the stresses of poverty, unemployment, and lack of opportunities.
• Mental Health and Trauma: Poor mental health and a sense of hopelessness are significant factors, particularly among women who use drugs [5]. Adverse Childhood Experiences and trauma are also strongly linked to problem drug use, as individuals may turn to substances to self-medicate unresolved psychological pain [6].
• Poly-drug Use and Changing Drug Market: The increasing prevalence of poly-drug use (the use of multiple substances) significantly contributes to the risk of fatal overdose. In Scotland, opiates and opioids, often in combination with benzodiazepines (particularly street benzodiazepines), are frequently implicated in drug misuse deaths [7, 8]. The emergence of new psychoactive substances and synthetic opioids further complicates the landscape, increasing the unpredictability and lethality of drug use [9].
• Lack of Access to Support and Treatment: While not explicitly a social determinant, inadequate access to timely and effective treatment and support services exacerbates the problem. Stigma associated with drug use also acts as a barrier, preventing individuals from seeking help and leading to unnecessary suffering and overdose deaths [10].
• Social Isolation: Increased social isolation, as observed during events like the COVID-19 pandemic, can complicate efforts to prevent drug use and contribute to higher overdose rates [11].

These factors collectively create a challenging environment, particularly for those already experiencing social deprivation, making them more susceptible to the harms associated with drug use.

Scottish Government Initiatives to Reduce Drug-Related Deaths

In response to the escalating crisis of drug-related deaths, the Scottish Government launched “the National Mission on Drug Deaths: Plan 2022-2026”. This comprehensive strategy signifies a paradigm shift, moving away from a criminal justice approach to one firmly rooted in public health principles [12]. The Mission is supported by an additional £50 million in government funding per year (but is it enough) over the lifetime of the current Parliament (2021 to 2026) [12].

Vision and Objectives:

The overarching vision of the National Mission is to reduce drug deaths and improve the lives of those impacted by drugs, including their families and communities. This aligns with the broader Scottish Government commitment to improving population health. The plan outlines several key objectives:

• Preventing people from developing problem drug use.
• Reducing harms from the consumption of drugs.
• Getting more people into high-quality treatment and recovery services.
• Addressing the needs of people with multiple and complex needs.
• Supporting families and communities affected by problem drug use.

By focusing on these key areas, the Scottish Government aims to create a comprehensive and compassionate system that not only reduces drug-related deaths but also improves the overall well-being of individuals, families, and communities affected by drug use.

Notes

SIMD
Every four years (approximately) the Scottish Government publishes data which provides a set of relative measures of Scotland’s deprivation. The process takes into account many factors contributing to deprivation: health, income, education, employment, housing, crime and access for rural communities to services and isolation. The published data is called the Scottish Index of Multiple deprivation which is abbreviated to SIMD.  See simd2020-overall-deprivation-map/

Quintiles
The SIMD data is collected for 6,976 small defined areas, smaller than council wards, with a median population of around 750 people.  In order to describe the data in publications it is often grouped into equally sized bands.  When the data is grouped into 5 bands the sets are referred to as quintiles, which is what is used on the page. SIMD Quintile 1  (SIMD Q-1) refers to the most deprived group (20% or about 1,400 of the SIMD local areas) and SIMD Quintile 5 (SIMD Q-5) is the least deprived group.

References and Data:

Data Sources

Main Page for data on drug related deaths
https://www.nrscotland.gov.uk/publications/drug-related-deaths-in-scotland-in-2023/

Link to Download master data file from source above
https://www.nrscotland.gov.uk/media/i5jduiff/drug-related-deaths-23-data.xlsx

References

[1] The social determinants of substance use associated with deaths of despair: Individual risks and population impacts.
https://www.sciencedirect.com/science/article/abs/pii/S0091743522003772

[2] Drug-related deaths in Scotland in 2023.
https://www.nrscotland.gov.uk/publications/drug-related-deaths-in-scotland-in-2023/

[3] Problem drug use in Scotland – Scottish Affairs Committee.
https://publications.parliament.uk/pa/cm201919/cmselect/cmscotaf/44/4405.htm

[4] Analysis reveals families and communities impacted by drug-related deaths in Scotland.
https://publichealthscotland.scot/news/2024/october/analysis-reveals-families-and-communities-impacted-by-drug-related-deaths-in-scotland/

[5] Why are drug-related deaths among women increasing in Scotland?
https://pmc.ncbi.nlm.nih.gov/articles/PMC7612287/

[6] Problem drug use in Scotland – Scottish Affairs Committee.
https://publications.parliament.uk/pa/cm201919/cmselect/cmscotaf/44/4405.htm

[7] Drug crisis in Scotland – Wikipedia.
https://en.wikipedia.org/wiki/Drug_crisis_in_Scotland

[8] [PDF] Drug-related deaths in Scotland MSP Briefing.
https://sdf.org.uk/wp-content/uploads/2024/05/Drug-related-deaths-in-Scotland-MSP-Briefing.pdf

[9] Drug and drink deaths in Scotland still among Europe’s worst.
https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2024/10/31/drug-and-drink-deaths-in-scotland-still-among-europe-s-worst-despite-new-funding

[10] Poverty, homelessness, and social stigma make addiction more deadly.
https://www.health.harvard.edu/blog/poverty-homelessness-and-social-stigma-make-addiction-more-deadly-202109282602

[11] Social Infrastructure and Recent Surges in Opioid-Related Deaths.
https://poverty.umich.edu/2020/09/08/social-infrastructure-and-recent-surges-in-opioid-related-deaths-amid-the-pandemic/

[12] National Mission on Drug Deaths: Plan 2022-2026, Scottish Government.
https://www.gov.scot/binaries/content/documents/govscot/publications/strategy-plan/2022/08/national-drugs-mission-plan-2022-2026/documents/national-mission-drug-deaths-plan-2022-2026/national-mission-drug-deaths-plan-2022-2026/govscot%3Adocument/national-mission-drug-deaths-plan-2022-2026.pdf