Tackling the drug problem in the UK and Portugal – with Dame Carol Black and Dr João Castel-Branco Goulão Episode 17 of the Health Foundation podcast

Dr Jennifer Dixon: Like many other countries, we have a drugs problem and it's growing. In England, about 3 million people take drugs with 300,000 taking the hard stuff, heroin and crack cocaine. Drug deaths are the highest on record, nearly 3,000 a year. In the last decade, heroin related deaths have more than doubled and cocaine related deaths grew fivefold. Scotland is even worse, now also with the highest deaths on record and the drug death capital of Europe. Drug deaths are tragic enough, but there's a lot more. All the collateral damage, wasted lives, damaged families, theft, violence, gangs and on and on. It costs us an estimated £20bn pounds a year, but only a fraction – that’s £600m – is spent on prevention. Our approach here is that drugs is a criminal justice matter focused on punishment rather than a public health matter focused on support. But many countries are taking a different approach, most famously Portugal, which in 2000 decriminalised all drugs and concentrated instead on public health and harm reduction. The result? From one of the highest drug deaths in Europe to one of the lowest. How did they do it and what can we learn? Well with me today to explore some of this, I'm delighted to have two very expert guests close to the policy action: Dame Carol Black, who amongst many things led a two part review of the drugs problem in England and what to do about it published last year. And Dr João Goulão is a Portuguese physician and the main architect of Portugal's drug policy established in 2000. Since then, he's been what we would call the national drug czar in Portugal, serving at least eight successive governments. He's very active internationally in promoting more liberal supportive policies to combat drugs. Welcome both. So I thought it would be really useful to hear first about the extent of drug taking in the UK and Portugal and what sort of trends we've been seeing.

Dame Carol Black: I think first thing to say is, of course, we're four countries. So if you don't mind, I'll just draw some comments on that because Scotland of course has a massive drug death problem, and they are deeply concerned about that. And I think it's true to say they're top of a very unenviable league in Europe. They have more drug deaths than anyone else. Now, Wales is small enough, I think to have in a way more central direction and funding. And they've been really quite forward thinking and had a consistent approach to harm reduction. And I think they reported this year that their figures were getting better. I think Northern Ireland, coloured by the troubles, which [inaudible] drug supply that's led to more people being medicated for pain, depression, and anxiety. And then of course, England, by far the largest and with variation across the country. I think it would be fair to say that deprivation and drug use are generally much higher in the north. We've seen an increase in usage and death in England, which has not in any way plateaued or subsided. We have about 300,000 heroin and crack drug dependent people who are in the worst health and indeed contribute to crime in this country in their desperation for the drugs. So we are still experiencing the effect of heroin epidemics in the 80s and 90s, very poor health in these people. And then we have got the new psychoactive substances and there's a whole variety of them, of course, perhaps spice being the best known, cocaine and crack usage is growing. Cocaine, powder cocaine, particularly increasing in our young population, the 19 to 24 year olds. And as I said, drug deaths at their highest level ever, and more cocaine deaths.

Dr Jennifer Dixon: And also looking at the figures, I was struck by how many men are affected. So particularly the hard drugs, 75% of drug deaths are in men, aren't they, which is quite interesting, and a lot in prison too.

Dame Carol Black: Yes. And it has been easy for drugs to get into prison. There are very few prisons that are safe from that. There is a special prison, which has been one in the north of England where they have managed to exclude a very large number of drugs and where their treatment and recovery program is very good. It's called Holme House.

Dr Jennifer Dixon: And João, tell us about the picture in Portugal. Does it sound quite similar?

Dr João Castel-Branco Goulão: Yes, I would say it's quite similar. Our starting point and motivation for our new policies came from the 90s where the big problems were related to heroin use. Then we have been traveling through cycles. And some of them where party, where recreational environments took broader importance. We saw the increase of cocaine and substances like ecstasy for instance. And then with the successive crisis that we have been confronted with, heroin comes again into scene. And that's what we are watching today. Even if we are nowadays facing an increase in the number of substances available, the big problems in Portugal still remain related to the classic substances, such as heroin and cocaine. And nowadays during this pandemic, this is in fact what we notice. The old ladies are back and the big problems to which we try to address are present in our society. We have a huge population of heroin users. As you know, by the year 2000, we had around 1% of our population hooked on heroin. That means 100,000 people using heroin in a problematic way. We managed to keep them alive, but from time to time, when circumstances of the society turn more difficult, there are a lot of relapses and there's an ageing population of heroin users that poses major problems, major difficulties to deal with. And on top of that, we have more and more people using heroin, mostly crack cocaine. Of course, there's a lot of other substances which we are concerned about, but the big problems still arise from the classic substances.

Dr Jennifer Dixon: And are you finding as in the case in the UK that it's drug use is associated with poverty, with men, often in prison, and the younger population focus on the newer drugs and the more psychoactive substances.

Dr João Castel-Branco Goulão: Yes, it's similar. Younger people, more educated manage to deal with substances in a more informed way. There's a literacy around drugs that we have been trying to develop. So even if drug use has high levels, the fatalities, overdoses they are relatively low. So we at the starting point during the 90s, we had around one overdoses death a day, at least. That means 360 something. And nowadays we turn around 60 something a year, mostly still related to opioids.

Dr Jennifer Dixon: Clearly Portugal, with respect to drug use, was in a bad state in 2000 with some of the highest heroin use in Europe. Why was that? Why was Portugal particularly affected do you think at that point?

Dr João Castel-Branco Goulão: The spread of drug use in Portugal started much later than in other European countries. As you know, we lived for a long time under a dictatorship and drugs were not available and people didn't dare to use them. Of course, we had some people who used drugs, but was not a massive problem in our society. Suddenly we had a huge change in our sudden hopeness in our society and in my view is important to understand that was the end of our colonial wars that we were dealing with in our ancient colonies and Cape Verde and so on where drug use was tolerated or even incentivated a little bit like the Americans in Vietnam. Suddenly after the revolution, we had the decolonisation process, the return of the soldiers and settlers from the ancient colonies with their habits. And when they came back, they brought tonnes at least of cannabis that was easily available down there. They shared with their relatives, their friends, their families, and for us who were here, there was a kind of affinity to new things that came with freedom. So there was an explosion of drug use crosscutting all the society. And shortly after, some, let's call them some criminal organisations, brought and introduced in the market all the others, such as heroin, cocaine, LSD, you name it. As we were completely naive about drugs, it was easy to shift from one to another. And heroin became very, very popular, not only among marginalised populations in ghettos, but crosscutting all the society, medium class, upper classes, political class, everybody. It was difficult to find a Portuguese family that had no problems related to heroin.

Dr Jennifer Dixon: So there must have been huge pressure then to change and do something?

Dr João Castel-Branco Goulão: Yes. And in my view, this was also a factor in favour of the development of progressive policies. Because it's different, we have someone from mid class saying, ‘Oh my boy, my girl is not a criminal. He's someone in need of help, in need of support, in need of treatment.’ It's different from having people from the ghetto saying the same.

Dr Jennifer Dixon: And we'll get onto what was done because that was obviously a critical moment in 2000. Carol, just thinking about the pattern in Britain, it's an issue that is concentrating in poverty, isn't it? But how widespread is it in other parts of society?

Dame Carol Black: Well, let's take heroin and crack cocaine, Jennifer, first. I think that is very much concentrating in our deprived populations. Of course, when I did the reviews, I could never look at any data from those who were treated in private clinics, which would of course tend to be those who had more financial resources. And of course there will be some problems in middle class families and indeed among very rich, but I think it would be fair to say our heroin and crack drug dependent people are very much found in our deprived communities in the poorer areas of the country. Powder cocaine, it appeared from the review we did was really more the drug of choice of people who had more financial resources. So the idea of being taken in the city at the weekends, et cetera, and probably worryingly spreading it into our universities, whereas cannabis was considered and from all the work we did was taken a much more by people who had less financial resources. And indeed of course, a lot of cannabis has grown in the United Kingdom. And of course now the north of England has more drug dependency problems in the south.

Dr Jennifer Dixon: Yes. And there is an interesting thing. I can't remember whether it was in your report or the governments, I think it was your report, which talks about the new methods of distribution of drugs, which has evolved because of market saturation in London and declining heroin crack use in big cities. And actually these county lines, these new methods of distribution are actually now serving some of the more deprived coastal and market towns, which is an interesting phenomenon.

Dame Carol Black: I think probably what happened was the drugs market saturated the big cities, as you say, so they went on their roots to most of our coastal towns and they're so widespread around the country, but of course with that, they took with them children who'd been drawn into gangs, possibly already taking drugs, but if not, probably encouraged to take drugs. And these young children were taking the drugs out on trains, some buses to seaside towns, to towns outside of the big metropolitan centers. And this is really, as you know, associated with violence and with gangs fighting each other, territorial fighting. Where you are as a gang and the area you cover is extremely important. And often these young people get physically harmed as you know, and turn up in our A&E department. It's a very nasty trade.

Dr Jennifer Dixon: Yes. And João, are you seeing anything similar in Portugal, the use of children and gangs or changes in the trends of supply in this way?

Dr João Castel-Branco Goulão: Not exactly the same, even if what we notice is new trends for the distribution, what we call the Uberization of the distribution of substances. Mostly now during the pandemic, we have noticed that there are small dealers that provide drugs at home. People do not need to the classical areas for traffic, but in fact, there's not a big, big difference from what we had before. Drugs are relatively available in any areas. We are small country, as you know, but it's possible to find all over the country in specific places or via specific channels that are well known by the users.

Dr Jennifer Dixon: So let's move on then to government approaches now to tackling this issue. And perhaps I'll come to you João first. So here we are in 2000, there's a huge problem. 1% of the population affected, every family being touched by the scourge of drugs. You were a physician working in the Algarve weren't you in treatment centers to try to support individuals. And then there was a moment where something must be done. And tell us a little bit about this. And then what were the main elements were of the policy that you and others put in place?

Dr João Castel-Branco Goulão: Yes, since the beginning of the 90s, we were developing a set of responses in terms of treatment, a quite solid network of centres run by the state and complemented by NGOs, mostly offering their services in therapeutic communities and responses like that. So we had a quite important network for treatment. We started to develop the responses in terms of harm reduction, such as syringe and needles exchange and things like that. 97, 98, the government decided to invite a group of experts from several areas, from judges to psychiatrists, psychologists, and so on, group of nine people among whom I was included. And they invited us to propose a strategy, which we did with the elements in the supply side, but mostly on the demand side, prevention, treatment, harm reduction, reintegration. And we included in that proposal the proposal for decriminalisation of drug use, assuming that we were dealing mostly when talking about drug use, we were speaking about health and social issue rather than a criminal one. So we did it. We proposed it to the government, which adopted the strategy as a package, let's say, but the issue of decriminalisation was not in the powers of the government so we had to be discussed at the parliament. We took that here until the discussion in the parliament to promote a huge number of public discussions with the population. And what I take from that period was a huge social support from the common citizen to the idea of decriminalisation. When we came to the parliament, things were a little bit more complicated with the left wing parties supporting the idea, but the more conservative, the right wing parties opposing it, children will start using drugs in very early ages. Portugal will become a paradise for drug users from all over the world. We will have planes coming to Lisbon every day with people to use drugs freely. In 2000, the law was approved at the parliament and implemented. It's important to say that we decriminalized drug use, but drug use in Portugal is still prohibited and punished under the administrative law, something that we can compare to the use or not use of the safety belt when you drive. But there are still penalties, but we do not get if you using drugs or in possession of small amounts of drugs, you do not get a criminal record that stigmatise is you for life, and you never end up in prison for the mere use. So from 2001, we had the complete set of the new strategy put together and we developed and implemented it with the big investment in harm reduction measures. That's where we are standing now. We are developing new approaches, new responses every year to address the new problems that new trends in drug use poses to us.

Dr Jennifer Dixon: And can you tell us then what happened to the drug use, given that you were saying that 1% of the population were affected in 2000?

Dr João Castel-Branco Goulão: Yes. So talking only about heroin, we estimate that we had 100,000 problematic users. Nowadays, we estimate that problematic users of any drug around half of that number. That means 50,000 or less than that. And most of them are related to treatment centres, or at least related to harm reduction facilities. For instance, undergoing low threshold methadone programmes or other kind of connection with assist.

Dr Jennifer Dixon: And in terms of the effect on crime and other violence, what was the effect there?

Dr João Castel-Branco Goulão: There's a drop. We never have a big criminal activity, big violence related to drugs, but we had a huge number of petty crimes, acquisitive crimes related to drug use that dropped after the implementation of this strategy. So before that, there was a huge numbers of pick-pocketing, but what we saw was a decrease in that small criminality related directly to drug use. In terms of big activity of the police authorities related to drugs, we saw an increase in their efficiency if you measure it by the figures of the substances that are seized, because once they got rid of all the tasks related to mere use, when they find the user, they just refer to the health system so they could address their attention, their energy to other kind of criminal organizations, large scale trafficking. So the police authorities are one of the most enthusiastic nowadays with the system that we have implemented.

Dr Jennifer Dixon: Over the eight governments that you have been working with since 2000, clearly they will be of different political complexion and clearly the balance in approach between punishment and prevention is going to be changing with different governments. How have you managed to steer a steady course with different types of governments to get that balance right?

Dr João Castel-Branco Goulão: It was important to show to different governments the results that we were achieving. And nowadays there's a broad political consensus around the implementation of those policies. Even those parties who voted against the decriminalisation in 2000 are nowadays in favor, and they recognise that it was a good step. So the essential of our policies in fact did not suffer with those political changes. We had a continuous line. Of course, we had different speeds implementing some kind of responses, such as safe injecting sites, for instance, or to spread the use of Naloxone or to perform drug checking. There are different sensibilities, but we have dealt with those sensibilities I believe in a proper way. We could keep the essential of our policies.

Dr Jennifer Dixon: Yes. And the evidence speaks for itself. Thank you. So Carol, you've been really right at the center of this haven't you with your drugs review and then the government's 10 year drug strategy. Can you tell us a little bit about the main elements of the 10 year drugs pay and what your view of this balance between the punitive criminal justice side and the prevention side is.

Dame Carol Black: Just to say upfront Jennifer, I was not in the terms of reference in doing both part one and part two, I couldn't look at anything which required a change in the law. So I couldn't look at either decriminalisation or indeed at legalisation and that was made quite clear to me. So what I tried to do in my reports was to find a way in which we could reduce the harms that drugs were doing, and particularly bearing in mind the harms in terms of homicide and serious acquisitive crime and prison places without being allowed to think about the methods that had been used in Portugal. I think I should say up front that government, as far as I can see, has no plans to decriminalize drug possession. They feel it wouldn't eliminate the crime committed by the illicit trade, nor would it address the harms associated with drug dependency and the misery that this causes to families and communities, and that they would say there's a substantial body of scientific and medical evidence to show that controlled drugs are harmful, can damage people's mental and physical health and our wider communities, particularly worried about vulnerable people. So what I tried to do in part two of my report was to put together a whole system's plan that would allow us to really start to treat drug addiction as a medical, a public health problem, a chronic condition. And I didn't believe you needed to change the law to do that. This is the way we as a community, as a society, approach those very stigmatised individuals. We know from the evidence that high quality treatment and recovery will reduce drug taking, does reduce crime. We do not have any of that in place in the country at the moment. The austerity following the 2013 reforms and the lack of money to our local authorities who were then in charge of the local treatment and recovery services has meant that we are in a terrible place and we have a lot to do to catch up. And therefore in the courts, individuals who'd been committing petty crimes who would've benefited far more from a referral into a high quality treatment and recovery service were actually being sent to prison, useless, exposed to more drugs in prison, not there long enough to get any rehabilitation and then discharged. And it was a very vulnerable time, the time of discharge. They came out of prison, usually with no money, other than a few pounds, probably not an appointment with the benefit system, possibly not an appointment with the treatment services, nowhere to live, often, no family to support them. They overdosed a very vulnerable time for people to die. And you are seeing in my report, there is a big section on working very closely with the Ministry of Justice to do diversion from the criminal justice system into treatment and recovery, and to pick up people leaving prison who are at risk much earlier. So I suppose you could say I tried very hard to find a scheme that would allow us to try and do some of the very good work that has been done in Portugal, albeit with not using quite the same tools.

Dr Jennifer Dixon: Drug treatment is largely a local government issue in England, isn't it? And we do know that the local government budgets have been severely cut and actually the most cutbacks have been in the drug treatment services. Are you confident that the current 10 year plan then begins to right that?

Dame Carol Black: We have £780m in the spending review over the next three years. Of course, money was essential to start to reverse the terrible trends we've seen, but that money has to be ring fenced and will be ring fenced. It is going to go in the first trance to the most needy areas. It will need proper local accountability. It will need commissioning standards, which we've never had. It needs powerful local outcome frameworks, and it needs joined up working between the local authority, the health service, the police, the courts, social care, education, all of that, Jennifer, has been fragmented in the last eight years. I think it is possible, but it is a huge journey with so many bits of it needing repair. And we have a demoralised and reduced workforce. So I wouldn't like you to think that this isn't an almighty journey, but I do think we have now the possibility of doing this, I think it's a bit like turning around a tanker and we will need everyone to really work very hard to bring about an integrated service that integrates with housing, with DWP at the local level for the opportunities of work through the IPS service that's going to be offered individual placement support. A lot of things are there ready to be in place. There's a good central unit now as a result of my review six departments of state with their feet being held to the fire. I'm hopeful, but I'm very aware of the journey that needs to be travelled.

Dr Jennifer Dixon: Yes, I can't remember whether it was your report or the government's response, Carol, but there was some talk there about that there used to be a central unit, the National Treatment Agency, which was in place between 2001 and 2012. And then that was disbanded and almost central oversight sort of was dissipated and the responsibility down to local government. So this 10 year policy now begins to recreate the central oversight, is that right with the minister Kit Malthouse now having to lay and report parliament to monitor progress, for example.

Dame Carol Black: And there will be a national outcome framework, which of course will be at a higher level. But again, one of my worries, and I want to see it in place, very carefully put in place, is the connection between the central and the local, because of course services have to be delivered locally. But how do we have a real connection between the central unit with its departments of state, a minister, a responsible permanent secretary, and that is all in place at the moment. How do we ensure that the connections and the relationship between the central and then the local workings are good and we get the outcomes we want? And how do we make sure that for those local authorities who find it very difficult and for some of them, it is going to be very difficult, where is the improvement support? I don't think that's ever been there before. It's no use just hitting them on the head. It's how do you make sure they can have specialised commissioners, that they can do a joined up needs assessment? And I think that built into this plan, they have to be improvement support for people who are really finding this tough if we are going to see an improvement at a national level.

Dr Jennifer Dixon: And João, I know that you have a national role. And I wondered whether you had any thoughts to give us on the right balance you think between central control and grip of this policy versus the local autonomy.

Dr João Castel-Branco Goulão: We have a central agency. In fact, it's a general directorate, SICAD, where I work. It is within the Ministry of Health in charge of coordinating all the responses, public and private, all over the country. But the general director of SICAD, in this case myself, is also the national coordinator for drug addiction and harmful of alcohol. And I work closely in a very direct connection with the representatives of certain ministers, almost all the government. We have a body, the Inter-Ministry Commission, where we discuss all the plans, the strategic and action plans for the multi-annual planning we are doing so in this moment, preparing the new strategic cycle in line with the European strategy on drugs. And this body is produced at local level on each district. We have 18 districts in Portugal and on each one of them, the local center for integrated responses of the Ministry of Health is in charge of coordinating all the local authorities in this area. So we have a reproduction of the central body at a local level. And the responses that are developed on each district are assessed, result from the local diagnosis of the situation that is updated every two years, at least is what we wish to have and updated evaluation and assessment of the responses that are needed to respond to the local needs and this is quite agile.

Dr Jennifer Dixon: Yes, very agile. Carol, I don't know what your response to that is because that's quite a central standardisation in a sense, despite the local autonomy.

Dame Carol Black: I'm really interested to hear that because one of the major discussions at the moment for the various departments and for the Central Drug Unit is what should that local part and its relationship to the center look like? How should we ensure integration? I'm really interested in what just said and how it is replicated in each area. And I'm going to certainly take that back into the center because there's been a lot of discussion about will each local authority in England, what will be their response to that sort of approach? How do we make it that they own this thing and want to be reporting back and in what shape and form should we be having that reporting upwards? And of course we are doing a lot of thinking at the moment about exactly how do you evaluate the local service without being too burdensome? Because already, of course, DWP and justice and DLUHC, they'll all have their own systems for reporting from the local to the central. And here we are now putting in if you like a new service in an integrated form. So I would say that it's very much work in progress and I'm really interested in what I've just heard and how there are 18 districts, but definitely an integrated response and replication.

Dr Jennifer Dixon: João, I know you're particularly active on the international front and just if you can just chart for us what you are seeing internationally with the trends towards the approach to tackling drugs. Given this balance between the punitive approach, which is probably where we were all at the beginning, to now a much more public health supportive approach, are you seeing trends of that nature happening and with good results?

Dr João Castel-Branco Goulão: Well, there's a clear term clear change in the responsibilities in different states. For instance, around the responsibility and the... We can see the national coordinators on drugs all over Europe are turning more and more to the Ministry of Health instead of Ministry of Home Affairs or Justice as before. And I think in political terms, this is a clear sign of the centrality of the health and social side of the phenomenon instead of the punitive and the prosecution of it. If I may, Jennifer, I would like just to briefly explain a little bit more of how decriminalization work in our case. We have a threshold limit for the amounts of drugs that people can have on them without incurring in criminal procedures. If someone is intercepted on the street or in a public place using illicit substances or in possession of illicit substances, the police officers still takes the person into the police station, apprehends the substance or substances, weighs it, and if the person has more then the amount established by the table, the amounts that make the threshold. If the person has more than that, he undergoes criminal procedures as before. But if he has less, the police authority only refers the person to a commission under the Ministry of Health that is called the commission for this version of drug addiction, where the person must present in the next three days. There the person is interviewed, evaluated by a technical team of health professionals from his condition of addicted in need of treatment or of ease of her condition of occasional recreational user. And this is a kind of indicate prevention tool where people can assess what are the needs of this person. Okay, he's addicted, he's invited to join a treatment facility, not compulsory, but okay, well, have you ever thought of treating, searching for treatment? Oh yes, but it's so complicated. You think so I can find you an appointment for tomorrow, the next day. And usually most of the people, more than 80% of the people, accept to be referred and to have at least the first contact with the treatment center. I'm not saying that they are going to be all successful, but at least they have a face, they have a referral, they have someone, an entrance door that is open. But most of the people, the vast majority of the people who are referred to those commissions are not problematic users who are not addicted people in need of treatment. But even then, okay, I have no problems with drugs, I smoke a joint with my friends on weekends. But in the interview, you say, okay, my parents are divorcing or my father just got lost his job or myself, I am in balance with my gender choices or whatever, and a commission can, would you like to discuss it with a psychologist? Would you like to discuss the problems to seek the support of the social services and they refer and they open those gates. So this is how it works and why I think this system of this vision is really effective.

Dr Jennifer Dixon: Yes, it sounds very enlightened I must say. And I just wonder about the investment needed then in those services and how that compares in Portugal to how that compares in Britain, because it does sound like a lot of good integrated, coordinated responses are needed locally, which I'm not sure we have Carol, do we?

Dame Carol Black: No, as I say, we're in the foothills of really trying to put together a proper service for people at different levels of addiction. And I very much hope we're going to see us moving more towards the prevention, which João's just talked about so effectively of enabling people, not just to be referred to treatment, but their worries, their problems, because mental health underlies so much of our addiction problem. So we have a long way to go. We have a very decent amount of money now. We have six departments of state working together. We've never had any of that before. It's the biggest amount of money given to addiction. We just really have to make very good use of this money, start the journey and really make it so much better for the individuals who've had a very, very poor service in my opinion in this country.

Dr Jennifer Dixon: Thank you both for an absolutely fascinating discussion. I hope you've enjoyed it and also made some connections between you as you both do your fine work going forwards on this really critical issue. We must leave it there today. Thank you very much again, to Dame Carol Black and Dr. João Goulão for their insights, which we hope can help to steer us to a better place in future on this huge scourge of drugs across our populations, a topic I'm sure we'll return to in future. And thanks to you as always for listening. You can find more material on drugs policy in England, the UK and Portugal in the show notes with this podcast. So next month we'll be looking at the government's role in prevention and tackling risk factors and asking what might it take to get more action. Look forward to seeing you then.

• Independent review of drugs by Professor Dame Carol Black
• From harm to hope: A 10-year drugs plan to cut crime and save lives (December 2021)
• Ferreira, S. Portugal’s radical drugs policy is working. Why hasn’t the world copied it? (December 2017)
• National Records of Scotland, Drug-related deaths in Scotland in 2020 (July 2021)
• Nutt, D. UK drugs strategy promises to be tough on criminals, but evidence shows this doesn't work. BMJ 2021; 375 doi: https://doi.org/10.1136/bmj.n3066 
• The House of Commons Scottish Affairs Committee report on Problem drug use in Scotland (October 2019) includes an outline of some international case studies.