National Mission on Drugs: Annual Monitoring Report 2023-2024

9. Outcome 5: Quality of life is improved by addressing multiple disadvantages

9.1 Summary

Outcome 5: Quality of life is improved by addressing multiple disadvantages

• Adults who had used drugs in the last 12 months had a mental wellbeing score of 46.3 in 2023. Small increase since the start of the National Mission.
• People in the most deprived areas are 15.3 times more likely to die of a drug death compared to people in the least deprived areas in 2023. Broadly unchanged since the start of the National Mission.
• Drug-related mortality and hospital stays remain concentrated in the most deprived areas and people who have used drugs continue to report lower wellbeing. There is positive activity at the ADP level, but more insight is needed directly from people using services.

9.2 Background

People with problem substance use often experience multiple disadvantages, complex needs and/or other comorbidities and require support from a range of services specific to their individual needs. The effects of deprivation, homelessness, trauma, and co-occurring mental health problems on a person are known to be compounding factors that can greatly impact quality of life and the harms associated with substance use.^[69] National and local initiatives aimed at addressing these disparities include agreeing formal joint working protocols at an ADP level to support people with co-occurring substance use and mental health diagnoses to receive mental health care; the development of trauma-informed workforce and services; and the implementation of the MAT standards.

There are a range of individual policies and initiatives introduced as part of the National Mission to address the wider holistic needs of people who use drugs. Assessing the extent to which progress is being made in improving people’s quality of life and attributing this to any interventions associated with the National Mission, including any aimed at addressing multiple disadvantages, is not possible in the context of this quantitative monitoring report. Short of attribution, it is possible to explore individual outcome measures (such as wellbeing) and rates of harms associated with disadvantage, as well as activities at ADP level that address this outcome.

9.3 Headline metrics

9.3.1 Headline metric: Mental wellbeing score for adults who have used drugs

Mental wellbeing provides an indication of an individual's ability to cope with the stresses of life, realise their own potential, work productively and make contributions to their community.^[70] Many factors can impact mental health and wellbeing, including social, cultural, political, environmental and economic factors such as living conditions, social support, physical health and other factors which are linked with problem substance use and drug-related harms. There is a significant association between higher levels of deprivation and lower wellbeing.

In 2023, adults who had used any drug in the last 12 months reported lower mental wellbeing than those who had not used drugs (mean WEMWBS scores of 46.3 and 49.4 respectively) (Figure 11). Similar patterns were recorded among males (46.6 and 49.6 respectively) and females (45.8 and 49.2 respectively).^[71] The increase in mental wellbeing score amongst adults who reported using any drug in the past 12 months (0.9 points) was greater than the increase reported for adults who had not used drugs in the past 12 months (0.3 points).

Figure 11: Mental wellbeing was lower among adults who reported drug use in the last 12 months

Mean WEMWBS scores, age-standardised, 2021 and 2023, adults aged 16 years+ who reported any drug use in the last 12 months and adults who did not report having used any drugs in the past 12 months

People who had used drugs

46.3

(2021: 45.4)

People who had not used drugs

49.4

(2021: 49.1)

Source: Scottish Health Survey 2023, Scottish Government, November 2024.

The mean mental wellbeing score of men who reported using drugs in the last 12 months has increased slightly from 45.0 in 2021 to 46.6 in 2023. The mean mental wellbeing score for women reporting using drugs has remained unchanged (2021: 45.8, 2023: 45.8).

Questions on drugs were included in the Scottish Health Survey for the first time in 2021 having previously been included in the Scottish Crime and Justice Survey. These questions will be included biennially and will provide a measure of how mental wellbeing among adults who have used drugs in the past 12 months changes over time.

9.3.2 Headline metric: Ratio of drug death rate in the most deprived areas to rate in the least deprived areas

The age-standardised drug death^[72] rate for people living in the most deprived areas of Scotland^[73] was 15.3 times higher than in the least deprived areas in 2023 (53.7 and 3.5 per 100,000 respectively) (Figure 12). This is a slight decrease compared to 2022 (when the ratio was 15.9) and in line with 2021. The drug death deprivation ratio was highest in 2019 at 19.6.

Source: Drug-related deaths in Scotland 2023, National Records of Scotland, August 2024

The ratio of the drug death rate in the most deprived areas to that in the least deprived areas of Scotland is slightly lower than before the start of the National Mission but the association of deprivation with drug deaths remains much greater than with other causes of death.

9.4 Supporting metrics

9.4.1 Supporting metric: Ratio of drug-related hospital stay rate in the most deprived areas to rate in the least deprived areas

In 2022/23 (the most recent data available), the drug-related hospital stay rate for people who live in the most deprived areas^[74] was 12.3 times higher than for those in the least deprived areas (456.5 and 37.1 per 100,000 respectively) (Figure 13). This is a decrease from 2022 when the rate was 15.2. Just under half (48%) of the patients with a drug-related hospital stay lived in the most deprived areas in Scotland.

Source: Drug-related hospital statistics - Scotland 2022 to 2023, Public Health Scotland, April 2024

The ratio of the drug-related hospital stay rate for people living in the most deprived areas to the rate for those living in the least deprived areas has narrowed since the start of the National Mission.

9.4.2 Supporting metric: Number of drug deaths amongst people experiencing homelessness

There were an estimated^[75] 100 people experiencing homelessness who died a drug death^[76],[77] in Scotland in 2023, an increase of 11 (12%) since 2022 when there were 89 such deaths. This increase is consistent with the increase in all drug deaths in Scotland between 2022 and 2023 (see section 4.3.1). In 2023, 41% of all homeless deaths were due to drugs, an increase on 2022 (36%) but a smaller proportion than in 2021 (51%).

Source: Homeless Deaths 2023, National Records of Scotland, November 2024

9.4.3 Supporting metric: Number of homeless households with a drug or alcohol dependency support need

In 2023/24, there were 3,474 households^[78] assessed as homeless or threatened with homelessness where drug or alcohol dependency support needs were identified (Figure 15)^[79]. This is an increase of 308 households (10%) compared to 2022/23 when there were 3,166 such households and is higher than any year since 2019/20. Prior to 2023/24 there had been a gradual decline in the number of households with a drug or alcohol dependency support need since before the start of the National Mission. However, this should be interpreted in the context of both the overall number of homeless households and the number of those households with any support needs - homeless households with a drug or alcohol dependency support need has been stable at 10-12% of all households assessed as homeless over the time period of analysis here.

Source: Homelessness in Scotland 2023-24, Scottish Government, September 2024

9.4.4 Supporting metric: Percentage of ADP areas with formal joint working protocols with mental health services

Nearly nine in ten (87%) ADPs reported that they had formal joint working protocols in place to support people with co-occurring substance use and mental health diagnosis to receive mental health care^[80]. This was a 28-percentage point increase from last year’s survey (59%)^[81].

Nearly all (97%) ADP areas had arrangements in place within their area for people who present at substance use services with mental health concerns for which they do not have a diagnosis. In 97% of areas, ADPs reported professional mental health staff within substance use services, such as psychiatrists, community mental health nurses etc. In 80% of areas ADPs reported pathways for referral to mental health services or other multidisciplinary teams and in 67% of areas there are formal joint working protocols between mental health and substance use services specifically for people with mental health concerns for which they do not have a diagnosis. In 17% of ADP areas dual diagnosis teams were reported. Other arrangements included the provision of mental health assessments for patients who are presenting with mental health problems, the organisation of joint appointments where cooccurring mental health and problem substance use is identified, and triage of appointments jointly between drug and alcohol services and mental health, with professionals meeting to discuss cases.

9.4.5 Supporting metric: Percentage of ADP areas undertaking activities to implement trauma-informed approach

All ADPs reported a range of activities which have been undertaken in ADP-funded or supported services to implement a trauma-informed approach^[82].

Over nine in ten (93%) ADPs reported that services were engaging with people with lived/living experience, which was an increase from 76% of ADPs who reported this last year. A similar number (93%) reported training the existing workforce (compared to 100% last year). Around six in ten ADP areas reported that working groups (60%) and staff recruitment (63%) were approaches being taken to implement a trauma-informed approach, a decrease on last year's survey (79% and 83% respectively). Most (63% of ADP areas) reported provision of trauma-informed spaces/accommodations. Other activities that were reported included the implementation of trauma-informed principles in local recovery hubs, training specifically aligned with MAT standards 6 and 10, and trauma “walk through” events with staff and lived/living experience forums.

9.5 Discussion

Drug-related mortality and hospital stays remain concentrated in the most deprived areas and people who have used drugs continue to report lower wellbeing. There is positive activity at the ADP level, but more insight is needed directly from people using services.

Evidence from the Scottish Health Survey shows that the mean mental wellbeing score for people who reported using drugs in the last 12 months was lower than for those who had not used drugs. This is demonstrated in the data from both 2021 and 2023. However, the small sample size for people who report drug use in Scottish Health Survey means that it is difficult to rely on this as a means for measuring progress and drawing conclusions.

Metrics clearly show the continued association between deprivation and drug harms, with age-standardised drug death rates being more than 15 times higher in the most deprived areas than the least deprived areas. The drug death deprivation ratio reduced slightly in 2023 but remains very high, with the association of deprivation with drug deaths higher than any other causes of death. Drug-related hospital stay rates were more than 12 times greater for those in the most deprived areas compared to those in the least deprived areas. This ratio is lower than before the National Mission but remains high.

Indicators relating to homelessness and drug related harm are similar to last year, with drug deaths amongst people experiencing homelessness having increased proportionally with the increase in overall drug deaths. The proportion of homeless deaths which were due to drugs remained high (41%), but at a lower level than at the start of the National Mission. The number of homeless households with a drug or alcohol dependency support need increased compared with 2022/23 figures to the highest level since 2019/20. However, this is within the context an overall increase in the number of homeless households and the number of households with a support need. This highlights a significant demand for substance-use related support among people experiencing homelessness.

In terms of activity at ADP level to support this outcome, indicators show improvement, with an increase in the number of ADPs reporting that they had formal joint working protocols in place to support people with co-occurring substance use and mental health conditions to receive medical care. Almost all ADPs reported having arrangements in place within their area for people who present at substance use services with mental health problems for which they do not have a diagnosis. Like last year, all ADPs reported a range of activities undertaken in ADP-funded or supported services to implement a trauma informed approach, including engaging with people with lived/living experience, providing training and implementing working groups. While these indicators are based on self-reported evidence from ADPs and do not necessarily reflect the experiences of service users themselves or direct outcomes, they demonstrate positive progress towards ADP level provision of services to support this outcome. Considerations for how evidence directly from people with lived/living experience could be included in National Mission monitoring are discussed in the data development section of this report.

It is challenging to draw firm conclusions on progress towards this outcome based on available data. The burden of drug-related mortality and hospital stays remains heavily concentrated in Scotland’s most deprived areas and is a significant concern for populations experiencing homelessness. Adults who have recently used drugs continue to report lower mental wellbeing than those who have not used drugs, but it is difficult to draw strong conclusions on any changes over time based on the data available. While there is evidence of positive activity at an ADP level, more insight is needed directly from people with lived and living experience. Additionally, evidence of the experiences and engagements with wider services beyond those specifically targeting drugs and alcohol (such as GP and other healthcare, accessing social security and wider social work), would be valuable to understand wider quality of life for people who use substances.