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程序代写案例-1POLICY
时间：2021-11-04
1POLICY MEMORANDUM
To: Nicola Sturgeon, First Minister, The Scottish Government
From: (Do not Write your name in assignments)
Subject: Addressing Scotland's Opioid Overdose Crisis
Date: October 13, 2020
Scotland is in the midst of a public health crisis. Nearly 61,500 citizens use opioids.1
Approximately 0.30 per 1,000 Scottish citizens die of overdose annually.2 In 2017, a record of
934 people died from overdose, which is more than double the number from 2007. Last year,
Scotland experienced the greatest annual increase in overdose deaths—27% from 2018.3
Glasgow is the city with the highest number of overdose deaths.
In 2017, 20,700 emergency hospital visits resulted from drug overdoses, costing an estimated
£88.8m.4 Since then, data continues to show growth in drug-related hospital admissions, driving
the already-underfunded and overextended National Health Service's (NHS) expenditure through
the roof.5 Sum the non-health outcomes created by drug abuse and the cost is even greater.
Canada estimated the total cost for health and non-health outcomes created by drug abuse to be
$110b6 in 1995.7 Factoring in inflation, at current addiction and overdose rates, the Scottish crisis
costs roughly £125b per year.8
Long-term unemployment, financial instability, and psychological distress are major risk factors
for addiction.9 The 2008 economic crisis led to an alarming increase in substance abuse.10 A
1 “Rights, Respect and Recovery: Scotland’s Strategy to Improve Health by Preventing and Reducing Alcohol and
Drug Use, Harm and Related Deaths,” The Scottish Government (2018), pp. 1-65.
2 Ed Lowther and Steven Brocklehurst, “Scotland's Drug Death Crisis in Six Charts,” BBC News (February 26,
2020), https://www.bbc.com/news/uk-scotland-48853004.
3 Simon Jenkins, “Scotland Has a Drugs Problem – and It's Called Westminster,” The Guardian (July 19, 2019),
https://www.theguardian.com/commentisfree/2019/jul/19/scotland-drugs-problem-westminster-policy.
4 Notation “m” refers to “million”; Reevel Alderson, “Older Addicts Cost £51m in Hospital Stays, Report Says,”
BBC News (June 22, 2017), https://www.bbc.com/news/uk-scotland-scotland-politics-40370051.
5 See Appendix 1; “Rights, Respect and Recovery”; Nick Triggle, “10 charts that show why the NHS is in trouble,”
BBC News (May 24, 2018), https://www.bbc.com/news/health-42572110.
6 Notation “b” refers to “billion.”
7 Canada’s overdose rates in 1995 were similar to Scotland’s rates at present (see following citation); given the
political, institutional, and demographic similarities between Scotland and Canada, we can expect costs to be
translatable; D. Fisk, E. McCormack, and J. Rakfeldt, “Assertive Outreach: An Effective Strategy for Engaging
Homeless Persons With Substance Use Disorders Into Treatment,” The Homeless Hub (2006),
https://www.homelesshub.ca/resource/assertive-outreach-effective-strategy-engaging-homeless-persons-substance-
use-disorders.
8 In 1995, $110b CAD = £64,395,100.00 * inflation of GBP from 1995-2019 (sourced from Bank of England
Inflation Calculator) = £124,728,557.34
9 Gera E. Nagelhout et al., “How Economic Recessions and Unemployment Affect Illegal Drug Use: A Systematic
Realist Literature Review,” International Journal of Drug Policy (April 25, 2017),
https://www.sciencedirect.com/science/article/pii/S0955395917300877.
2decade of austerity in the United Kingdom has done nothing but exacerbate the problem.11 With
unemployment and stress rising due to COVID-19, more Scottish citizens are turning to
substances to cope.12 Since the commencement of the lockdown, overdose deaths have risen by
one-third.13
Canada is currently experiencing the world’s worst opioid crisis. Comparatively, in 2016, the
Canadian national rate of opioid-related deaths was .79 per 1,000 people.14 Without immediate
intervention, calculations reveal a grim path for Scotland. If fatalities continue to rise at the
current rate of 27% per year, we can expect Scotland to close the gap between itself and Canada
within two years.15 In contrast to the Canadian experience, Scotland has little support from the
conservative British Parliament in the Westminster Home Office.16 Harm reduction interventions
have proven successful in reducing overdose fatalities in Canada. Interventions can perform
similarly in Scotland, but not without the support of British policymakers.
Policy Alternatives
Three harm reduction policies could reduce overdose deaths in Scotland: (1) government-
subsidized Take-Home Naloxone (THN) kits, (2) expanding the Assertive Outreach Programme,
and (3) the establishment of a Supervised Drug Consumption Site (SDCS) in Glasgow.
Take-Home Naloxone
According to 2019 Human Medicines Regulations, Naloxone is prescription-only and available
only through accredited drug treatment services.17 Fear of arrest or disinterest in treatment
10 Geert Dom et al., “The Impact of the 2008 Economic Crisis on Substance Use Patterns in the Countries of the
European Union,” International journal of environmental research and public health (MDPI, January 13, 2016),
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730513/.
11 Polly Toynbee and David Walker, “The Lost Decade: the Hidden Story of How Austerity Broke Britain,” The
Guardian (March 3, 2020), https://www.theguardian.com/society/2020/mar/03/lost-decade-hidden-story-how-
austerity-broke-britain.
12 Mark McLaughlin, “Coronavirus in Scotland: Substance Abuse Fatalities up by a Third in Lockdown,” The
Times (September 1, 2020), https://www.thetimes.co.uk/article/coronavirus-in-scotland-substance-abuse-fatalities-
up-by-a-third-in-lockdown-t6k8g97l3.
13 Ibid.
14 Lisa Belzak and Jessica Halverson, “The Opioid Crisis in Canada: a National Perspective,” (Public Health
Agency of Canada (June 2018), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034966/.
15 (Canadian rate - Scottish rate)/rate of increase in Scotland = (0.79-0.30)/0.27 = 1.8 years
16 Drug legislation is an area of policymaking that is still reserved for the United Kingdom. Stigma, lack of
sympathy, and a law-and-order approach to controlling addiction and its consequences has left little political reform
motivation.; Mattha Busby, “Drugs expert barred from policy panel after criticising Home Office,” The Guardian
(June 11, 2019), https://www.theguardian.com/politics/2019/jun/11/drugs-expert-barred-from-policy-panel-after-
criticising-home-office.
17 “Widening the Availability of Naloxone,” GOV.UK (2019).
https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-
naloxone.
3programs impedes addicts' acquisition of Naloxone.18 Consequently, it is not available to those
who need it when they need it.19
This solution suggests government provision of cost-free, Take-Home Naloxone kits to at-risk
opioid users and persons likely to witness or respond to overdoses20 through neighborhood
pharmacies and NHS clinics.
Financially, this intervention is feasible at a maximum cost of £8,570,278.71 annually—a small
cost to the government compared to the benefit of saving 934 Scottish overdose victims.21
Politically, the United Kingdom (UK) has already begun work in widening the availability of
Naloxone.22 Without any legal limitations to expansion, continuation down this path is highly
likely.
Canada already implemented a version of this policy with great success.23
Expansion of the Assertive Outreach Programme
In 2014, in partnership with the NHS Glasgow, Scotland established an Assertive Outreach street
team to provide overdose prevention and training in Glasgow city center.24 The team's presence
has prevented overdose in a few cases25; however, the NHS has identified scope for improvement
in presence and Naloxone training. This solution suggests increasing hours and membership to
24, with 12 volunteers and eight trained addictions nurses sourced from the NHS.26 Greater street
presence will increase the likelihood of encountering a public overdose while improved
Naloxone training will ensure effective resuscitation when one is encountered.
Financially, this option is the most feasible at £334,000.27
Politically, this option is highly feasible, considering the low relative cost of expansion and a
program's current existence.28
18 EJ Tweed, S. Priyadarshi, and M. Rogers, “‘Taking Away the Chaos’: a Health Needs Assessment for People
Who Inject Drugs in Public Places in Glasgow, Scotland,” NHS Greater Glasgow and Clyde (July 4, 2018),
https://pubmed.ncbi.nlm.nih.gov/29973179/.
19 Ibid.
20 Provision of THN kits to citizens 15 years of age and older (the age of the youngest recorded opioid user in
Scotland).
21 See Appendices 2 and 3.
22 “Widening the Availability of Naloxone.”; see Appendix 2.
23 See Appendix 2.
24 The team consists of four support workers present in the city center during afternoons and evenings; Tweed,
Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
25 See Appendix 2; Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
26 See Appendix 2.
27 See Appendices 2 and 4.
28 See Appendix 2.
4A significant limitation to success is the ability of the team to be present for every overdose.
Addicts in Glasgow commonly inject in private, and when not possible, in very secluded and,
often, inaccessible areas.29 Although expanding the team would reduce overdose deaths, it is not
as effective as other options.
Supervised Drug Consumption Site
An extensive body of international research has amassed to support SDCS’s30 effectiveness in
reducing the health and social harms associated with drug use. In 2003, a pioneer SCDS was
established in Vancouver to combat Canada's overdose crisis.31 This solution suggests the
establishment of a similar facility in Glasgow.
Based on Canada's data, this solution will avert 1.08 deaths annually—a significantly lower
impact than alternatives.32
Financially, this is the second most expensive option. Based on Canada's cost calculations, a
single SCDS will cost approximately £661,830 to establish and operate for one year.33
Politically, this solution is not feasible whatsoever. SDCSs are currently banned under the
Misuse of Drugs Act 1971.34 In 2018, the Home Office turned down a proposal to amend the
Act.35
****************
29 Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
30 A SDCS offers a safe environment to consume opioids under supervision.
31 Amos Irwin et al., "A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco,
California, USA." Journal of Drug Issues 47 (2016): 4-5.
32 Given the political, ideological, and situational similarities between Canada and Scotland, there is no reason to
believe that Scotland would have differing success; ibid.
33 See Appendix 2; this is an estimate of the annual cost of establishing a new SCDS and combines both upfront and
operating costs; Irwin et al., "A Cost-Benefit Analysis.”; “Cost of living in Scotland,” Scottish Development
International (2020), https://www.sdi.co.uk/business-in-scotland/cost-of-living-in-scotland.
34 The Newsroom, “‘Safe Injection' Rooms for Addicts Plan to Be Refused by Home Office,” The Scotsman (June 4,
2018), https://www.scotsman.com/news/safe-injection-rooms-foraddicts-plan-to-be-refused-by-home-office-1-
4749465.
35 Ibid.
5Evaluation Criteria
In ascertaining the viability of each policy alternative, three criteria are considered:
1. Financial feasibility - evaluated using a simple calculation of cost36
2. Political feasibility - identifies which policy has the greatest chance of adoption given
political and ideological obstacles, yet still achieves overdose reduction aims
3. Estimated impact on reducing overdose deaths - extrapolated from the reduction of
overdose deaths post-implementation from existing interventionist policies or similar in
Canada37
(Table from Appendix)
Policy
Solution
Policy
Specifics
Financial
Feasibility
Political
Feasibility
Reduction of
Overdose Deaths
Take-
Home
Naloxone
Offer no-cost
Naloxone to
all Scottish
citizens over
15 years
Medium.
Estimated
maximum upfront
cost of
£8,570,278.71.38
High. The Home
Office already
widened the
availability of
Naloxone.39
Seemingly no
limitations to
further expansion.
High. Canadian
THN program has
distributed 110,913
kits, and 69,136
overdoses were
reported to be
reversed using
distributed kits.40
Expansion
of
Assertive
Outreach
Expand size,
shifts, and
experience of
existing
Assertive
Outreach team
in Glasgow
High. Estimated
programme
expansion cost of
£334,000.41
High. Program
already in place.
No legal
limitations to
expansion. Only
funding, no Home
Office oversight
necessary—
overseen by
Glasgow City
Council Alcohol
and Drug
Low. Existing team
averted ~4 overdose
deaths in 2019.42
36 Estimates rely on costs from similar, international interventions.
37 Given the political, institutional, and demographic similarities between Scotland and Canada, we can expect the
results of strategies implemented in either location to be translatable.
38 See Appendix 3.
39 “Widening the Availability of Naloxone.”
40 “THN in BC Infograph,” Toward the Heart (2020), https://towardtheheart.com/thn-in-bc-infograph.
41 See Appendix 4.
42 Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
6Partnership.43
Supervised
Drug
Consumpti
on Sites
Establish one
Supervised
Drug
Consumption
Site in
Glasgow
Low. Estimated
establishment
cost ~£661,830
(based upon
estimates from
the establishment
of Insite in
Vancouver).44
Low.
SDCSs are banned
under the Misuse
of Drugs Act
1971.45 In 2018,
the Home Office
turned down a
proposal to amend
the Act.46
Low. Vancouver
SDCS averts ~1
death in a
neighborhood with
20-30 overdose
deaths per year.47
*************
Stakeholder Analysis48
43 Ibid.
44 Estimation assumes the same staffing levels, equipment needs, and other operating cost inputs as Vancouver
establishment. Operating costs calculated by multiplying the US$1.5 million (£870,832.87) estimated establishment
costs by a -34% cost of living adjustment between Vancouver and Glasgow; Irwin et al., "A Cost-Benefit Analysis.”
45 The Newsroom, “‘Safe Injection' Rooms.”
46 Ibid.
47 Irwin et al., "A Cost-Benefit Analysis.”
48 This is an abridged list of stakeholders. For a complete list, see Appendices 5 and 6.
7The harm intervention policy debate in the UK has two factions, divided along party lines: the
progressive Scottish government and fellow supporters of harm reduction interventions and the
conservative UK government, captive to anti-addict stigma and finance.49
Indeed, the most directly impacted groups are addicts and their families. Stigmatized, these
groups have little influence; however, their opinions on policy effectiveness are an important
gauge of success and should be considered by policymakers.
The NHS has been integral in expanding the availability of Naloxone.50 In that way, their role is
large, but their influence is relatively low.51 However, their interest is great—both as advocates
for existing interventions and as a result of internalizing the cost of rising overdose
hospitalizations. Given the COVID-19 pandemic, keeping the NHS unburdened by avoidable
hospitalizations a publicized political priority—one which remains unachieved so long as the
overdose crisis rages on unaddressed by the Home Office.52
The Scottish Government has power limited to insight and leveraging stakeholders to support
interventions. Politically, its hands are tied. Scotland recommended numerous harm-reduction
policy proposals in recent years, all of which have been rejected by the Home Office.53 Despite
this, Scotland expresses confidence that there are solutions where cooperation is possible.54
Prime Minister Boris Johnson is the most influential Parliamentarian.55 He is strongly aligned
with the national anti-addict stigma and has no interest in legalization or deregulation.56 Minister
of State Kit Malthouse is his advisor on drug policy. Minister Malthouse replaced an ultra-
conservative predecessor, creating a genuine opportunity for an evidence-based approach to
considering a cost-sensitive policy to address this crisis.57 Both Conservative Ministers'
incentives are strongly tied to economic impact and reelection58, especially considering the Prime
Minister's approval rating is 34% and dropping.59
49 The Newsroom, “‘Safe Injection' Rooms.”
50 “Widening the Availability of Naloxone.”
51 The NHS is a government service provider and is, therefore, captive to the whims of the Home Office.
52 Anna Charles and Leo Eubank, “The Road to Renewal: Five Priorities for Health and Care,” The King's Fund,
(July 16, 2020), https://www.kingsfund.org.uk/publications/covid-19-road-renewal-health-and-
care?utm_source=social.
53 The Newsroom, “‘Safe Injection' Rooms.”; “Rights, Respect and Recovery.”
54 “Rights, Respect and Recovery.”
55 “Prime Minister,” GOV.UK, https://www.gov.uk/government/ministers/prime-minister.
56 Marisa Bellack and Oliver Laurent, “Who is Boris Johnson?,” The Washington Post (December 9, 2019),
https://www.washingtonpost.com/graphics/2019/world/amp-stories/who-is-boris-johnson/.
57 Mattha Busby, “Britain's Minister Responsible for Drug Policy Replaced,” The Guardian (October 7, 2019),
https://www.theguardian.com/politics/2019/oct/07/britains-minister-responsible-for-drug-policy-replaced-victoria-
atkins.
58 Holly Ellyat, “UK needs ‘Rooseveltian’ approach to the economy, Boris Johnson says,” CNBC (June 29, 2020),
https://www.cnbc.com/2020/06/29/uk-needs-rooseveltian-approach-to-the-economy-boris-johnson-says.html.
59 “Boris Johnson Approval Rating,” YouGov (October 26, 2020),
https://yougov.co.uk/topics/politics/trackers/boris-johnson-approval-rating.
8Stakeholder Engagement Strategy
Other stakeholders are supportive and already engaged in ad-hoc harm reduction programs. Yet,
the most effective programming requires the support and funding of the British government. The
key to ensuring THN program implementation is gaining support from Minister Malthouse to
encourage the Prime Minister to take action despite hesitations. Any plan to bring the Ministers
onside requires sharing the economic and political evidence of the adverse impacts of avoiding
implementation.
The cost of the Scottish opioid crisis is draining the NHS budget, which is set aside to address
the healthcare needs of 66.8m60 citizens. Not only would adopting the THN programming reduce
healthcare costs associated with overdose, but it would also earn Ministers the respect and
reelection votes of millions of citizens who value keeping taxes low and the NHS fully
functional, especially amidst the COVID-19 pandemic.61
The Home Office, the NHS, and Scottish citizens cannot afford the costs associated with
ignorance. The THN program will reduce overdoses and costs, thereby avoiding a greater deficit
for the UK62 and the Prime Minister's defeat in the next election.
Policy Recommendation
Despite Assertive Outreach expansion being the least expensive solution, Take-Home Naloxone
is politically feasible, and the most effective option to reduce overdose deaths in Scotland. Based
on estimates from the Canadian THN program, this solution would directly reduce the overdose
death rate while only increasing total government expenditure by £8m upfront. The relatively
low cost could reasonably be absorbed into the NHS's £140.4b annual operating budget and is
dwarfed by the costs of ignorance.63
60 “Population Estimates,” Office for National Statistics (2019),
https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates.
61 Andrew Woodcock, “People Who Voted for Boris Johnson Want Government to Raise Taxes on the Rich,
Survey Finds,” The Independent (March 6, 2020), https://www.independent.co.uk/news/uk/politics/tax-rich-boris-
johnson-budget-government-conservative-a9383966.html.
62 The UK is currently in its second decade of austerity.; Toynbee and Walker, “The Lost Decade.”
63 “The NHS Budget and How It Has Changed,” The King's Fund (March 13, 2020),
https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget.
9Source: Drug-Related Hospital Statistics Scotland 2016/17
Appendix 1: Drug-related general acute patient rates, by age group (Scotland; 1996/97 to 2016/17)
10
Policy
Solution
Policy
Specifics
Financial
Feasibility
Political
Feasibility
Reduction of
Overdose Deaths
Take-
Home
Naloxone
Offer no-cost
Naloxone to
all Scottish
citizens over
15 years
Medium.
Estimated
maximum upfront
cost of
£8,570,278.71.64
High. The Home
Office already
widened the
availability of
Naloxone.65
Seemingly no
limitations to
further expansion.
High. Canadian
THN program has
distributed 110,913
kits, and 69,136
overdoses were
reported to be
reversed using
distributed kits.66
Expansion
of
Assertive
Outreach
Expand size,
shifts, and
experience of
existing
Assertive
Outreach team
in Glasgow
High. Estimated
programme
expansion cost of
£334,000.67
High. Program
already in place.
No legal
limitations to
expansion. Only
funding, no Home
Office oversight
necessary—
overseen by
Glasgow City
Council Alcohol
and Drug
Partnership.68
Low. Existing team
averted ~4 overdose
deaths in 2019.69
Supervised
Drug
Consumpti
on Sites
Establish one
Supervised
Drug
Consumption
Site in
Glasgow
Low. Estimated
establishment
cost ~£661,830
(based upon
estimates from
the establishment
of Insite in
Vancouver).70
Low.
SDCSs are banned
under the Misuse
of Drugs Act
1971.71 In 2018,
the Home Office
turned down a
proposal to amend
the Act.72
Low. Vancouver
SDCS averts ~1
death in a
neighborhood with
20-30 overdose
deaths per year.73
64 See Appendix 3.
65 “Widening the Availability of Naloxone.”
66 “THN in BC Infograph,” Toward the Heart (2020), https://towardtheheart.com/thn-in-bc-infograph.
67 See Appendix 4.
68 Ibid.
69 Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
70 Estimation assumes the same staffing levels, equipment needs, and other operating cost inputs as Vancouver
establishment. Operating costs calculated by multiplying the US$1.5 million (£870,832.87) estimated establishment
costs by a -34% cost of living adjustment between Vancouver and Glasgow; Irwin et al., "A Cost-Benefit Analysis.”
71 The Newsroom, “‘Safe Injection' Rooms.”
72 Ibid.
73 Irwin et al., "A Cost-Benefit Analysis.”
Appendix 2: Summary of Policy Solutions and Evaluation Criteria
11
Per unit cost of Naloxone to NHS, if bought in bulk (based
upon 2018 average drug cost data from Italy)74
£1.89
*
Number of citizens of Scotland (approximate based upon
mid-2019 population estimates)75
5,463,300
* Percentage of population over 15 years old76 .83
= Total cost to government £8,570,278.7177
74 Susanna Ronconi, “Italy's 20-Year Head Start on Stopping Overdose,” Open Society Foundations (March 30,
2017), https://www.opensocietyfoundations.org/voices/learning-italy-s-lead-naloxone.
75 National Records of Scotland Web Team, “National Records of Scotland,” National Records of Scotland (May 31,
2013), https://www.nrscotland.gov.uk/statistics-and-data/statistics/scotlands-facts/population-of-scotland.
76 Only equipping citizens 15 years and older (the age of the youngest registered drug used in Scotland).
77 Note this is the maximum program cost. The realized cost will likely be significantly lower, as fewer than 83% of
the Scottish population will request THN kits.
Appendix 3: Cost to offer no-cost, Take-Home Naloxone kits
12
Salary of a volunteer £0
* Number of volunteers needed 12
+ Salary of an NHS addictions nurse78 £41,750
* Number of NHS addictions nurses needed 8
= Total annual expansion cost to government £334,000
78 Average salary for a Band 7 NHS employee (nurses, paramedics, etc.); “Agenda for Change - Pay Rates (April
2020),” NHS, https://www.healthcareers.nhs.uk/working-health/working-nhs/nhs-pay-and-benefits/agenda-change-
pay-rates.
Appendix 4: Cost to expand Assertive Outreach Programme
13
Appendix 5: Stakeholder Interest and Influence
14
Appendix 6: Stakeholder Support or Opposition
学霸联盟
To: Nicola Sturgeon, First Minister, The Scottish Government
From: (Do not Write your name in assignments)
Subject: Addressing Scotland's Opioid Overdose Crisis
Date: October 13, 2020
Scotland is in the midst of a public health crisis. Nearly 61,500 citizens use opioids.1
Approximately 0.30 per 1,000 Scottish citizens die of overdose annually.2 In 2017, a record of
934 people died from overdose, which is more than double the number from 2007. Last year,
Scotland experienced the greatest annual increase in overdose deaths—27% from 2018.3
Glasgow is the city with the highest number of overdose deaths.
In 2017, 20,700 emergency hospital visits resulted from drug overdoses, costing an estimated
£88.8m.4 Since then, data continues to show growth in drug-related hospital admissions, driving
the already-underfunded and overextended National Health Service's (NHS) expenditure through
the roof.5 Sum the non-health outcomes created by drug abuse and the cost is even greater.
Canada estimated the total cost for health and non-health outcomes created by drug abuse to be
$110b6 in 1995.7 Factoring in inflation, at current addiction and overdose rates, the Scottish crisis
costs roughly £125b per year.8
Long-term unemployment, financial instability, and psychological distress are major risk factors
for addiction.9 The 2008 economic crisis led to an alarming increase in substance abuse.10 A
1 “Rights, Respect and Recovery: Scotland’s Strategy to Improve Health by Preventing and Reducing Alcohol and
Drug Use, Harm and Related Deaths,” The Scottish Government (2018), pp. 1-65.
2 Ed Lowther and Steven Brocklehurst, “Scotland's Drug Death Crisis in Six Charts,” BBC News (February 26,
2020), https://www.bbc.com/news/uk-scotland-48853004.
3 Simon Jenkins, “Scotland Has a Drugs Problem – and It's Called Westminster,” The Guardian (July 19, 2019),
https://www.theguardian.com/commentisfree/2019/jul/19/scotland-drugs-problem-westminster-policy.
4 Notation “m” refers to “million”; Reevel Alderson, “Older Addicts Cost £51m in Hospital Stays, Report Says,”
BBC News (June 22, 2017), https://www.bbc.com/news/uk-scotland-scotland-politics-40370051.
5 See Appendix 1; “Rights, Respect and Recovery”; Nick Triggle, “10 charts that show why the NHS is in trouble,”
BBC News (May 24, 2018), https://www.bbc.com/news/health-42572110.
6 Notation “b” refers to “billion.”
7 Canada’s overdose rates in 1995 were similar to Scotland’s rates at present (see following citation); given the
political, institutional, and demographic similarities between Scotland and Canada, we can expect costs to be
translatable; D. Fisk, E. McCormack, and J. Rakfeldt, “Assertive Outreach: An Effective Strategy for Engaging
Homeless Persons With Substance Use Disorders Into Treatment,” The Homeless Hub (2006),
https://www.homelesshub.ca/resource/assertive-outreach-effective-strategy-engaging-homeless-persons-substance-
use-disorders.
8 In 1995, $110b CAD = £64,395,100.00 * inflation of GBP from 1995-2019 (sourced from Bank of England
Inflation Calculator) = £124,728,557.34
9 Gera E. Nagelhout et al., “How Economic Recessions and Unemployment Affect Illegal Drug Use: A Systematic
Realist Literature Review,” International Journal of Drug Policy (April 25, 2017),
https://www.sciencedirect.com/science/article/pii/S0955395917300877.
2decade of austerity in the United Kingdom has done nothing but exacerbate the problem.11 With
unemployment and stress rising due to COVID-19, more Scottish citizens are turning to
substances to cope.12 Since the commencement of the lockdown, overdose deaths have risen by
one-third.13
Canada is currently experiencing the world’s worst opioid crisis. Comparatively, in 2016, the
Canadian national rate of opioid-related deaths was .79 per 1,000 people.14 Without immediate
intervention, calculations reveal a grim path for Scotland. If fatalities continue to rise at the
current rate of 27% per year, we can expect Scotland to close the gap between itself and Canada
within two years.15 In contrast to the Canadian experience, Scotland has little support from the
conservative British Parliament in the Westminster Home Office.16 Harm reduction interventions
have proven successful in reducing overdose fatalities in Canada. Interventions can perform
similarly in Scotland, but not without the support of British policymakers.
Policy Alternatives
Three harm reduction policies could reduce overdose deaths in Scotland: (1) government-
subsidized Take-Home Naloxone (THN) kits, (2) expanding the Assertive Outreach Programme,
and (3) the establishment of a Supervised Drug Consumption Site (SDCS) in Glasgow.
Take-Home Naloxone
According to 2019 Human Medicines Regulations, Naloxone is prescription-only and available
only through accredited drug treatment services.17 Fear of arrest or disinterest in treatment
10 Geert Dom et al., “The Impact of the 2008 Economic Crisis on Substance Use Patterns in the Countries of the
European Union,” International journal of environmental research and public health (MDPI, January 13, 2016),
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730513/.
11 Polly Toynbee and David Walker, “The Lost Decade: the Hidden Story of How Austerity Broke Britain,” The
Guardian (March 3, 2020), https://www.theguardian.com/society/2020/mar/03/lost-decade-hidden-story-how-
austerity-broke-britain.
12 Mark McLaughlin, “Coronavirus in Scotland: Substance Abuse Fatalities up by a Third in Lockdown,” The
Times (September 1, 2020), https://www.thetimes.co.uk/article/coronavirus-in-scotland-substance-abuse-fatalities-
up-by-a-third-in-lockdown-t6k8g97l3.
13 Ibid.
14 Lisa Belzak and Jessica Halverson, “The Opioid Crisis in Canada: a National Perspective,” (Public Health
Agency of Canada (June 2018), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034966/.
15 (Canadian rate - Scottish rate)/rate of increase in Scotland = (0.79-0.30)/0.27 = 1.8 years
16 Drug legislation is an area of policymaking that is still reserved for the United Kingdom. Stigma, lack of
sympathy, and a law-and-order approach to controlling addiction and its consequences has left little political reform
motivation.; Mattha Busby, “Drugs expert barred from policy panel after criticising Home Office,” The Guardian
(June 11, 2019), https://www.theguardian.com/politics/2019/jun/11/drugs-expert-barred-from-policy-panel-after-
criticising-home-office.
17 “Widening the Availability of Naloxone,” GOV.UK (2019).
https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-
naloxone.
3programs impedes addicts' acquisition of Naloxone.18 Consequently, it is not available to those
who need it when they need it.19
This solution suggests government provision of cost-free, Take-Home Naloxone kits to at-risk
opioid users and persons likely to witness or respond to overdoses20 through neighborhood
pharmacies and NHS clinics.
Financially, this intervention is feasible at a maximum cost of £8,570,278.71 annually—a small
cost to the government compared to the benefit of saving 934 Scottish overdose victims.21
Politically, the United Kingdom (UK) has already begun work in widening the availability of
Naloxone.22 Without any legal limitations to expansion, continuation down this path is highly
likely.
Canada already implemented a version of this policy with great success.23
Expansion of the Assertive Outreach Programme
In 2014, in partnership with the NHS Glasgow, Scotland established an Assertive Outreach street
team to provide overdose prevention and training in Glasgow city center.24 The team's presence
has prevented overdose in a few cases25; however, the NHS has identified scope for improvement
in presence and Naloxone training. This solution suggests increasing hours and membership to
24, with 12 volunteers and eight trained addictions nurses sourced from the NHS.26 Greater street
presence will increase the likelihood of encountering a public overdose while improved
Naloxone training will ensure effective resuscitation when one is encountered.
Financially, this option is the most feasible at £334,000.27
Politically, this option is highly feasible, considering the low relative cost of expansion and a
program's current existence.28
18 EJ Tweed, S. Priyadarshi, and M. Rogers, “‘Taking Away the Chaos’: a Health Needs Assessment for People
Who Inject Drugs in Public Places in Glasgow, Scotland,” NHS Greater Glasgow and Clyde (July 4, 2018),
https://pubmed.ncbi.nlm.nih.gov/29973179/.
19 Ibid.
20 Provision of THN kits to citizens 15 years of age and older (the age of the youngest recorded opioid user in
Scotland).
21 See Appendices 2 and 3.
22 “Widening the Availability of Naloxone.”; see Appendix 2.
23 See Appendix 2.
24 The team consists of four support workers present in the city center during afternoons and evenings; Tweed,
Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
25 See Appendix 2; Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
26 See Appendix 2.
27 See Appendices 2 and 4.
28 See Appendix 2.
4A significant limitation to success is the ability of the team to be present for every overdose.
Addicts in Glasgow commonly inject in private, and when not possible, in very secluded and,
often, inaccessible areas.29 Although expanding the team would reduce overdose deaths, it is not
as effective as other options.
Supervised Drug Consumption Site
An extensive body of international research has amassed to support SDCS’s30 effectiveness in
reducing the health and social harms associated with drug use. In 2003, a pioneer SCDS was
established in Vancouver to combat Canada's overdose crisis.31 This solution suggests the
establishment of a similar facility in Glasgow.
Based on Canada's data, this solution will avert 1.08 deaths annually—a significantly lower
impact than alternatives.32
Financially, this is the second most expensive option. Based on Canada's cost calculations, a
single SCDS will cost approximately £661,830 to establish and operate for one year.33
Politically, this solution is not feasible whatsoever. SDCSs are currently banned under the
Misuse of Drugs Act 1971.34 In 2018, the Home Office turned down a proposal to amend the
Act.35
****************
29 Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
30 A SDCS offers a safe environment to consume opioids under supervision.
31 Amos Irwin et al., "A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco,
California, USA." Journal of Drug Issues 47 (2016): 4-5.
32 Given the political, ideological, and situational similarities between Canada and Scotland, there is no reason to
believe that Scotland would have differing success; ibid.
33 See Appendix 2; this is an estimate of the annual cost of establishing a new SCDS and combines both upfront and
operating costs; Irwin et al., "A Cost-Benefit Analysis.”; “Cost of living in Scotland,” Scottish Development
International (2020), https://www.sdi.co.uk/business-in-scotland/cost-of-living-in-scotland.
34 The Newsroom, “‘Safe Injection' Rooms for Addicts Plan to Be Refused by Home Office,” The Scotsman (June 4,
2018), https://www.scotsman.com/news/safe-injection-rooms-foraddicts-plan-to-be-refused-by-home-office-1-
4749465.
35 Ibid.
5Evaluation Criteria
In ascertaining the viability of each policy alternative, three criteria are considered:
1. Financial feasibility - evaluated using a simple calculation of cost36
2. Political feasibility - identifies which policy has the greatest chance of adoption given
political and ideological obstacles, yet still achieves overdose reduction aims
3. Estimated impact on reducing overdose deaths - extrapolated from the reduction of
overdose deaths post-implementation from existing interventionist policies or similar in
Canada37
(Table from Appendix)
Policy
Solution
Policy
Specifics
Financial
Feasibility
Political
Feasibility
Reduction of
Overdose Deaths
Take-
Home
Naloxone
Offer no-cost
Naloxone to
all Scottish
citizens over
15 years
Medium.
Estimated
maximum upfront
cost of
£8,570,278.71.38
High. The Home
Office already
widened the
availability of
Naloxone.39
Seemingly no
limitations to
further expansion.
High. Canadian
THN program has
distributed 110,913
kits, and 69,136
overdoses were
reported to be
reversed using
distributed kits.40
Expansion
of
Assertive
Outreach
Expand size,
shifts, and
experience of
existing
Assertive
Outreach team
in Glasgow
High. Estimated
programme
expansion cost of
£334,000.41
High. Program
already in place.
No legal
limitations to
expansion. Only
funding, no Home
Office oversight
necessary—
overseen by
Glasgow City
Council Alcohol
and Drug
Low. Existing team
averted ~4 overdose
deaths in 2019.42
36 Estimates rely on costs from similar, international interventions.
37 Given the political, institutional, and demographic similarities between Scotland and Canada, we can expect the
results of strategies implemented in either location to be translatable.
38 See Appendix 3.
39 “Widening the Availability of Naloxone.”
40 “THN in BC Infograph,” Toward the Heart (2020), https://towardtheheart.com/thn-in-bc-infograph.
41 See Appendix 4.
42 Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
6Partnership.43
Supervised
Drug
Consumpti
on Sites
Establish one
Supervised
Drug
Consumption
Site in
Glasgow
Low. Estimated
establishment
cost ~£661,830
(based upon
estimates from
the establishment
of Insite in
Vancouver).44
Low.
SDCSs are banned
under the Misuse
of Drugs Act
1971.45 In 2018,
the Home Office
turned down a
proposal to amend
the Act.46
Low. Vancouver
SDCS averts ~1
death in a
neighborhood with
20-30 overdose
deaths per year.47
*************
Stakeholder Analysis48
43 Ibid.
44 Estimation assumes the same staffing levels, equipment needs, and other operating cost inputs as Vancouver
establishment. Operating costs calculated by multiplying the US$1.5 million (£870,832.87) estimated establishment
costs by a -34% cost of living adjustment between Vancouver and Glasgow; Irwin et al., "A Cost-Benefit Analysis.”
45 The Newsroom, “‘Safe Injection' Rooms.”
46 Ibid.
47 Irwin et al., "A Cost-Benefit Analysis.”
48 This is an abridged list of stakeholders. For a complete list, see Appendices 5 and 6.
7The harm intervention policy debate in the UK has two factions, divided along party lines: the
progressive Scottish government and fellow supporters of harm reduction interventions and the
conservative UK government, captive to anti-addict stigma and finance.49
Indeed, the most directly impacted groups are addicts and their families. Stigmatized, these
groups have little influence; however, their opinions on policy effectiveness are an important
gauge of success and should be considered by policymakers.
The NHS has been integral in expanding the availability of Naloxone.50 In that way, their role is
large, but their influence is relatively low.51 However, their interest is great—both as advocates
for existing interventions and as a result of internalizing the cost of rising overdose
hospitalizations. Given the COVID-19 pandemic, keeping the NHS unburdened by avoidable
hospitalizations a publicized political priority—one which remains unachieved so long as the
overdose crisis rages on unaddressed by the Home Office.52
The Scottish Government has power limited to insight and leveraging stakeholders to support
interventions. Politically, its hands are tied. Scotland recommended numerous harm-reduction
policy proposals in recent years, all of which have been rejected by the Home Office.53 Despite
this, Scotland expresses confidence that there are solutions where cooperation is possible.54
Prime Minister Boris Johnson is the most influential Parliamentarian.55 He is strongly aligned
with the national anti-addict stigma and has no interest in legalization or deregulation.56 Minister
of State Kit Malthouse is his advisor on drug policy. Minister Malthouse replaced an ultra-
conservative predecessor, creating a genuine opportunity for an evidence-based approach to
considering a cost-sensitive policy to address this crisis.57 Both Conservative Ministers'
incentives are strongly tied to economic impact and reelection58, especially considering the Prime
Minister's approval rating is 34% and dropping.59
49 The Newsroom, “‘Safe Injection' Rooms.”
50 “Widening the Availability of Naloxone.”
51 The NHS is a government service provider and is, therefore, captive to the whims of the Home Office.
52 Anna Charles and Leo Eubank, “The Road to Renewal: Five Priorities for Health and Care,” The King's Fund,
(July 16, 2020), https://www.kingsfund.org.uk/publications/covid-19-road-renewal-health-and-
care?utm_source=social.
53 The Newsroom, “‘Safe Injection' Rooms.”; “Rights, Respect and Recovery.”
54 “Rights, Respect and Recovery.”
55 “Prime Minister,” GOV.UK, https://www.gov.uk/government/ministers/prime-minister.
56 Marisa Bellack and Oliver Laurent, “Who is Boris Johnson?,” The Washington Post (December 9, 2019),
https://www.washingtonpost.com/graphics/2019/world/amp-stories/who-is-boris-johnson/.
57 Mattha Busby, “Britain's Minister Responsible for Drug Policy Replaced,” The Guardian (October 7, 2019),
https://www.theguardian.com/politics/2019/oct/07/britains-minister-responsible-for-drug-policy-replaced-victoria-
atkins.
58 Holly Ellyat, “UK needs ‘Rooseveltian’ approach to the economy, Boris Johnson says,” CNBC (June 29, 2020),
https://www.cnbc.com/2020/06/29/uk-needs-rooseveltian-approach-to-the-economy-boris-johnson-says.html.
59 “Boris Johnson Approval Rating,” YouGov (October 26, 2020),
https://yougov.co.uk/topics/politics/trackers/boris-johnson-approval-rating.
8Stakeholder Engagement Strategy
Other stakeholders are supportive and already engaged in ad-hoc harm reduction programs. Yet,
the most effective programming requires the support and funding of the British government. The
key to ensuring THN program implementation is gaining support from Minister Malthouse to
encourage the Prime Minister to take action despite hesitations. Any plan to bring the Ministers
onside requires sharing the economic and political evidence of the adverse impacts of avoiding
implementation.
The cost of the Scottish opioid crisis is draining the NHS budget, which is set aside to address
the healthcare needs of 66.8m60 citizens. Not only would adopting the THN programming reduce
healthcare costs associated with overdose, but it would also earn Ministers the respect and
reelection votes of millions of citizens who value keeping taxes low and the NHS fully
functional, especially amidst the COVID-19 pandemic.61
The Home Office, the NHS, and Scottish citizens cannot afford the costs associated with
ignorance. The THN program will reduce overdoses and costs, thereby avoiding a greater deficit
for the UK62 and the Prime Minister's defeat in the next election.
Policy Recommendation
Despite Assertive Outreach expansion being the least expensive solution, Take-Home Naloxone
is politically feasible, and the most effective option to reduce overdose deaths in Scotland. Based
on estimates from the Canadian THN program, this solution would directly reduce the overdose
death rate while only increasing total government expenditure by £8m upfront. The relatively
low cost could reasonably be absorbed into the NHS's £140.4b annual operating budget and is
dwarfed by the costs of ignorance.63
60 “Population Estimates,” Office for National Statistics (2019),
https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates.
61 Andrew Woodcock, “People Who Voted for Boris Johnson Want Government to Raise Taxes on the Rich,
Survey Finds,” The Independent (March 6, 2020), https://www.independent.co.uk/news/uk/politics/tax-rich-boris-
johnson-budget-government-conservative-a9383966.html.
62 The UK is currently in its second decade of austerity.; Toynbee and Walker, “The Lost Decade.”
63 “The NHS Budget and How It Has Changed,” The King's Fund (March 13, 2020),
https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget.
9Source: Drug-Related Hospital Statistics Scotland 2016/17
Appendix 1: Drug-related general acute patient rates, by age group (Scotland; 1996/97 to 2016/17)
10
Policy
Solution
Policy
Specifics
Financial
Feasibility
Political
Feasibility
Reduction of
Overdose Deaths
Take-
Home
Naloxone
Offer no-cost
Naloxone to
all Scottish
citizens over
15 years
Medium.
Estimated
maximum upfront
cost of
£8,570,278.71.64
High. The Home
Office already
widened the
availability of
Naloxone.65
Seemingly no
limitations to
further expansion.
High. Canadian
THN program has
distributed 110,913
kits, and 69,136
overdoses were
reported to be
reversed using
distributed kits.66
Expansion
of
Assertive
Outreach
Expand size,
shifts, and
experience of
existing
Assertive
Outreach team
in Glasgow
High. Estimated
programme
expansion cost of
£334,000.67
High. Program
already in place.
No legal
limitations to
expansion. Only
funding, no Home
Office oversight
necessary—
overseen by
Glasgow City
Council Alcohol
and Drug
Partnership.68
Low. Existing team
averted ~4 overdose
deaths in 2019.69
Supervised
Drug
Consumpti
on Sites
Establish one
Supervised
Drug
Consumption
Site in
Glasgow
Low. Estimated
establishment
cost ~£661,830
(based upon
estimates from
the establishment
of Insite in
Vancouver).70
Low.
SDCSs are banned
under the Misuse
of Drugs Act
1971.71 In 2018,
the Home Office
turned down a
proposal to amend
the Act.72
Low. Vancouver
SDCS averts ~1
death in a
neighborhood with
20-30 overdose
deaths per year.73
64 See Appendix 3.
65 “Widening the Availability of Naloxone.”
66 “THN in BC Infograph,” Toward the Heart (2020), https://towardtheheart.com/thn-in-bc-infograph.
67 See Appendix 4.
68 Ibid.
69 Tweed, Priyadarshi, and Rogers, “‘Taking Away the Chaos’.”
70 Estimation assumes the same staffing levels, equipment needs, and other operating cost inputs as Vancouver
establishment. Operating costs calculated by multiplying the US$1.5 million (£870,832.87) estimated establishment
costs by a -34% cost of living adjustment between Vancouver and Glasgow; Irwin et al., "A Cost-Benefit Analysis.”
71 The Newsroom, “‘Safe Injection' Rooms.”
72 Ibid.
73 Irwin et al., "A Cost-Benefit Analysis.”
Appendix 2: Summary of Policy Solutions and Evaluation Criteria
11
Per unit cost of Naloxone to NHS, if bought in bulk (based
upon 2018 average drug cost data from Italy)74
£1.89
*
Number of citizens of Scotland (approximate based upon
mid-2019 population estimates)75
5,463,300
* Percentage of population over 15 years old76 .83
= Total cost to government £8,570,278.7177
74 Susanna Ronconi, “Italy's 20-Year Head Start on Stopping Overdose,” Open Society Foundations (March 30,
2017), https://www.opensocietyfoundations.org/voices/learning-italy-s-lead-naloxone.
75 National Records of Scotland Web Team, “National Records of Scotland,” National Records of Scotland (May 31,
2013), https://www.nrscotland.gov.uk/statistics-and-data/statistics/scotlands-facts/population-of-scotland.
76 Only equipping citizens 15 years and older (the age of the youngest registered drug used in Scotland).
77 Note this is the maximum program cost. The realized cost will likely be significantly lower, as fewer than 83% of
the Scottish population will request THN kits.
Appendix 3: Cost to offer no-cost, Take-Home Naloxone kits
12
Salary of a volunteer £0
* Number of volunteers needed 12
+ Salary of an NHS addictions nurse78 £41,750
* Number of NHS addictions nurses needed 8
= Total annual expansion cost to government £334,000
78 Average salary for a Band 7 NHS employee (nurses, paramedics, etc.); “Agenda for Change - Pay Rates (April
2020),” NHS, https://www.healthcareers.nhs.uk/working-health/working-nhs/nhs-pay-and-benefits/agenda-change-
pay-rates.
Appendix 4: Cost to expand Assertive Outreach Programme
13
Appendix 5: Stakeholder Interest and Influence
14
Appendix 6: Stakeholder Support or Opposition
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