What happens as opioid abusers hit middle age? "What your body tolerates at 18 it doesn't tolerate at 38 or 48."
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Tony Nugent was clean for almost seven years before he relapsed.
He found that heroin, cruel to the young, is even less forgiving with age.
Nugent had been using the drug on and off since he was 19, but overdosed the first time he shot up again. He has overdosed three more times since last year.
"I've nearly died four times," said Nugent, who turns 43 this month. "It's getting harder for me to recover as I get older."
Still, he considers himself lucky, especially living in what is now being called the "drug-death capital of the world."
Last year there were 1,187 drug-related deaths in Scotland, a record, and a staggering increase of 27 per cent from the year before. Overdoses are more common in Scotland, by some measures, than even in the United States.
Older, long-term opioid users account for much of the problem. Things are expected to only get worse.
"We're seeing diseases that you would associate with old age in a lot of these middle-aged men with a long history of drug use," said Carole Hunter, the lead pharmacist for Glasgow Addiction Services. "What your body tolerates at 18 it doesn't tolerate at 38 or 48."
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Drug deaths are not new in Scotland. More than two decades ago, the gruelling life of addiction in Edinburgh was the subject of the novel-turned-film Trainspotting.
What is new is how many people are dying.
"I remember there was outrage when the headlines said 'One Death Every Day From Drugs,'" said Andrew McAuley, a senior research fellow on substance use at Glasgow Caledonian University, referring to a national investigation into drug deaths in 2003. "That seems like glory days. We're four times that now."
There are almost 60,000 drug users in Scotland with routine and prolonged use of opioids or benzodiazepines. Many also suffer from physical and mental health issues, putting them at greater risk of dying from an overdose.
Nugent is one of them. He has been treated for deep-vein thrombosis, hepatitis C and skin abscesses. Lately, he said, he had been urinating blood.
"Scotland looks perhaps more like the US than many of the countries to which we usually think of as having more progressive drug policy," said Corey Davis, an attorney at the National Health Law Program. "It has a higher baseline rate of both drug and alcohol misuse, chronic underinvestment in public health and less of an interest in adopting interventions like supervised consumption spaces."
The United States is three decades into its own opioid crisis, and with its drug users aging, experts might do well to look at how Scotland responds. The United States has a much larger number of overall drug users, many of them are turning to deadlier drugs like fentanyl, and, in general, they have less access to drug treatment than users in Scotland.
"There are lessons to be learned internationally as many countries grapple with this," said Jeffrey Samet, a professor at Boston University who specialises in substance use disorders.
A path to trouble
Scotland was not always the "sick man of Europe."
Until around 1950, life expectancy there was on par with most of Western Europe, or better. But after World War II, things in Scotland improved more slowly than in any other Western European country.
The reasons behind Scotland's drug crisis are varied: Economic policies left areas deeply impoverished. Treatment services were neglected. Drugs became deadlier.
"The jigsaw is complex," said McAuley, the Glasgow researcher. "It's our history, it's the way we consume drugs, it's the chronic underfunding and underperforming treatment services we have. Underline that with austerity and welfare cuts in recent years, and you've got the perfect storm for this to happen."
Many of Scotland's struggles grew out of social and economic policy changes made in the late 1970s, according to David Walsh, a researcher at the Glasgow Center for Population Health who has studied at Scotland's high mortality. The conservative government in London at the time considered industrial cities like Glasgow to be "declining" and pushed for rapid economic restructuring.
Scotland's leaders made contentious policy decisions at home, too. In Glasgow in particular, said Walsh, officials prioritised commercial development and clearing slums, relocating entire communities to isolated public housing estates that were poorly maintained.
"There's a very clear relationship between socioeconomic factors and health," Walsh said. "Evidence shows people can turn to alcohol and drugs to cope with difficult circumstances."
As far-reaching changes hit Scotland, heroin flowed into Europe. A supply route linking Afghanistan to Iran opened up in the 1980s, making the drug more available — and affordable — than ever. In Scotland, this produced what came to be known as the "Trainspotting" generation.
"Before 1980, our police drug squad said there were maybe 50 people in Edinburgh using heroin and we knew them all," said Roy Robertson, a professor of addiction medicine at the University of Edinburgh. "Then around 1980 there was this wave of drugs and that availability stimulated the epidemic."
Strides, and stumbles
For years, Scotland made strides in curbing drug deaths.
Needle exchanges were introduced in the 1980s and naloxone, the lifesaving overdose medication, has been in widespread use since 2011. Opioid-substitute therapies like methadone — which is tightly regulated in the United States — are free and available at most pharmacies through the nationalised health care system.
But in 2016 the Scottish government cut funding to alcohol and drug prevention services by more than 20 per cent, from 69 million pounds (about $130 million) a year down to 54 million pounds. The funding has since been restored, and the Scottish government pledged an additional 20 million pounds, starting this year.
"What would you expect to happen to a country with an opiate addiction problem if you progressively remove treatment? The death rate would steadily go up," said John Strang, a professor at King's College London who has researched addiction treatment for over 30 years.
About 40 per cent of users in Scotland are currently in treatment, according to Dr. Lesley Graham of the National Health Services of Scotland. In England that figure is closer to 60 per cent. The challenge for Scotland is to get more people into treatment — and to keep them there.
When Daniel Hamilton arrived at the Edinburgh Access Practice on a Monday afternoon, he did not think he would leave that day with a prescription for methadone, the opiate substitute used to curb heroin cravings. In his hometown, Perth, getting a prescription can sometimes take months, he said. (A review of cases from the National Health Service found that the median wait for treatment in the region was eight weeks.)
"You could get a bad batch of heroin and die by then," he said.
The Edinburgh Access Practice is trying to get people into treatment faster and start addressing the issues behind their drug use. Its staff includes a mental health team as well as social workers and housing and employment specialists.
But facilities like this one are rare. Experts say Scotland needs to scale up and improve access to existing services, and then introduce approaches like heroin-assisted treatment centers or supervised drug consumption facilities.
"We've managed to keep a lot of the aging cohort alive through our current drug treatment services, but they get to a certain point where that blanket is not enough," McAuley said. "They need respiratory care, they need mental health care, they need help with housing, employment, welfare and a whole host of other things."
Controlled substances like heroin, however, fall under the British government's jurisdiction, and conservative lawmakers have resisted proposals for more progressive drug policy.
"The UK government has been clear that there is no legal framework for the provision of drug consumption rooms and there are no plans to introduce them," the Home Office said in a statement.
Scotland's public health minister, Joe FitzPatrick, lamented that position.
"I know the instinct from the U.K. government is that they don't want to be seen in any way to be condoning illegal drug use," he said. "But people are dying. We need to do things that at first feel difficult."
Scotland has largely managed to avoid America's deadliest opioid, fentanyl: Only 12 deaths last year involved any trace of the drug.
Health officials can do little but hope that remains the case.
"If fentanyl does come here, it will be kind of endgame type stuff," McAuley said.
Nugent said he had not seen fentanyl in Glasgow yet. He is more worried about the influx of "street Valium," or etizolam. "People are dying with one bad pill," he said. Etizolam was found in nearly half of all drug deaths in Scotland last year.
Nugent said he steered clear of it, but his best friend, James Muir, is less cautious. Muir is homeless in Glasgow; Nugent planned to check himself into a rehab center this fall.
He worries about what will happen to Muir when he's gone.
"I don't know what's going to become of him," he said. "I hope that someone will look after him the way I do."
Written by: Allison McCann and Mary Turner
Photographs by: Mary Turner
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