Drugs and deprivation: How drug policy reform can help support Levelling Up

In February 2022, during his first incarnation as levelling up secretary, Michael Gove published the government’s flagship Levelling Up White Paper. Setting out how the state intends to “spread opportunity more equally” across UK regions, the paper has brought the question of geographic inequality to the forefront of British policy debate. Part of that vision for change is the role of drugs policy, and the recognition that it is in our most deprived areas that the health harms associated with drug use are felt most painfully.

The paper talks about the need for “combatting” drug use: breaking drug supply chains, closing ‘county lines’ distribution networks, and cutting drug-related violence. It also pledged investment in drug treatment and recovery programmes, helping to help break the cycle of problem drug use. While some of these measures are welcome, the whole package falls short of what is needed to properly address our drugs-deprivation problem.

Below, we provide evidence which shows that deprivation is strongly correlated with drug misuse. We also argue that if problem drug users were to no longer use drugs, or if places with high incidences of problematic drug use were to see drug use fall, then both people and places would see significant socioeconomic improvement. We propose that if the Government is to be successful in levelling up the UK, then better, bolder drugs policy must be on the table.

Drug use in the UK

Levels of drug use are high. In 2015, independent consultant and drugs expert Russell Webster showed that the UK has the highest rates of drug use in Europe, including the highest rate of heroin, cocaine, and ecstasy use. In 2021, the European Monitoring Centre for Drugs and Drug Addiction estimated it has the highest rate of problem drug use for opioids. Last year, the whole of the UK was also among countries with the most drug deaths in Europe, with Scotland having the highest.

The UK appears to have a drug problem. But why is consumption so high, and why are more people dying from drug overdoses in this country than in other, less wealthy European countries?

One explanation, as put forward by The Equality Trust, is its high levels of regional deprivation and socioeconomic inequality, with research showing that drug use is more common in unequal countries. As well as having one of the highest rates of drug use and drug deaths in Europe, the UK is also, according to the OECD, one of the most unequal.

The relationship between inequality and drugs is complicated. It would be rash to draw definitive conclusions from this association – countries such as Sweden and Norway have low inequality and high drug death rates, for example. But it is plausible to suggest that places with underlying socioeconomic disparities will be more likely to suffer from drug misuse.

Drugs and the people who use them are not inherently ‘bad’. Drug consumption does not always lead to harm, and some people take care to manage the risks of drug use. But some drugs are more dangerous than others and, in some cases, recreational drug use can lead to regular use and addiction. Problematic drug use can lead to a range of health and social problems, including disease, mental illness, unemployment, criminal activity, and death.

Unlike general drug use, drug addiction has been found to be concentrated among the country’s poorest communities. As the Advisory Council on the Misuse of Drugs (ACMD) has highlighted, deprivation is more closely associated with dangerous problematic drug use than with the casual – less harmful – use of drugs. The Council has said that “the highest concentration of drug-related problems is nearly always found in the poorest urban areas”, and that people living in disadvantaged areas are less likely to overcome drug problems, for example by having less access to employment and health treatment.

In 2020, an independent review of drugs for the Home Office by Dame Carole Black also discussed problem drug-use and its correlation with poverty. It noted that “the demand for opiates and crack/cocaine, and deaths from misuse of these substances, is closely associated with poverty and deprivation”, especially in more acutely deprived areas.

Drugs, deprivation, and place-based disparities

NHS data shows that the number of hospital admission episodes related to drug misuse is far greater in deprived areas. In England in 2019/20, the first decile of deprivation, as based on the government’s Indices of Multiple Deprivation (IMD) scores, has a rate of 470 admissions with a primary or secondary diagnosis of drug-related mental and behaviour disorders per every 100,000 people. In the last decile, representing the areas of the country that are least deprived, there are just 55 admissions for every 100,000.

In 2021, there were 4,859 deaths related to drug poisoning registered in England and Wales. Figure 2 shows the mortality rates for deaths relating to drug misuse – where the underlying cause is drug abuse or drug dependence – across countries and regions of England and Wales, with 3,060 deaths identified overall. Not only is there a pronounced north-south divide between those areas, but regions typically recognised as being ‘left behind’ and in need of levelling up – the North East, the North West, and Yorkshire – register many more overdose deaths, proportionally, than more affluent regions such as London, the East, and South East.

Among English and Welsh regions, the North East has the highest drug death rate, more than three times that of London. The weakness and deprivation of the North East economy is well documented, with, for example, research from the Bennett Institute showing that about two thirds of the region’s towns have levels of household deprivation higher than the British average. The North East has the worst, or among the worst, disposable income per capita, unemployment rate, child poverty rate, and life expectancy and health inequalities. It has also borne the brunt of austerity, seeing the largest reduction in local government service spending, a -24% change from 2009/10 to 2019/20. That is double the 12% reduction experienced by the South East.

Similarly, Blackpool is a town sometimes seen as being ‘left-behind’; a seaside resort overlooked by the modern economy. According to the English Indices of Deprivation, Blackpool is the most deprived local authority in the country, while neighbourhoods in Blackpool account for eight in ten of the most deprived neighbourhoods nationally. Internal migration data analysed by the Financial Times has showed that it is a net importer of poor health, unemployment, and precarious labour, while it is a net exporter of good health and skilled labour. Blackpool is the local authority with the highest drug misuse death rate in England and Wales.

Another example of the drugs ‘deprivation connection’ is Scotland, the ‘drug death capital of the world’. In 2021, there were 1,330 drug misuse deaths in Scotland. In 2020, its drug death rate was 3.7 times that for the UK as a whole, and higher than any other European country. People living in the most deprived parts of Scotland have been found to be 18 times more likely to die from a drug-related death than those living in the least deprived areas. Greater Glasgow and Clyde has the highest drug-related death rate, an area which also contains one of the highest shares of deprived areas in the country. According to the Scottish Index of Multiple Deprivation, council areas from the Greater Glasgow region occupy 18 of the top 30 most deprived communities in Scotland. The Scottish Drugs Forum says that poverty is the root cause of Scotland’s drug overdose crisis.

Putting drugs reform on the policy agenda

As the addiction and mental health expert Ian Hamilton has put it, not all is well in the UK. He argues that the extent of drug fatalities tells us an awful lot about our underlying structural problems, a clear indicator being the way that deaths are unequally distributed, with the risk of dying due to drugs significantly heightened in areas that are deprived.

Drug policy reform is a key policy lever that can be pulled to help address long-standing regional inequalities, protect vulnerable groups from harm, and ultimately save lives. The root-and-branch approach would be to completely overhaul UK drugs policy, moving towards a liberalised public health framework that prioritises support and treatment.

For example, in Portugal, decriminalisation has been successful in significantly reducing hard drug use, drug related HIV infections, and drug deaths, while increasing the number of people receiving drug addiction treatment. Wholesale reform like this would require significant primary legislative change, including the abolition of the Misuse of Drugs Act, the basis of our prohibitionist system of drug law enforcement since 1971.

A less radical approach would explore options for progressive reforms within the current legislative framework, or requiring minor changes to secondary legislation. This could include the expansion of drug policies such as safe drug consumption spaces, allowing users to take drugs under medical supervision; the targeted distribution of Naloxone, a medicine that rapidly reverses opioid overdoses; and the rollout of diversion schemes, whereby people caught with drugs are diverted towards treatment and education, rather than criminal punishment.

All of the above measures are already in use, to varying extents, across the country. For example, there are 13 police forces with diversion schemes for drug offences. But the current system leaves people who use drugs relying on a postcode lottery of provision, which is both unfair and less effective than standardised national practices.

Evidence-led measures are considered to be effective in mitigating the economic symptoms of drug misuse, as well as improving the health and wellbeing of users. However, they do little to address the  socioeconomic causes of drug misuse  directly. When it comes to social policy aimed at alleviating deprivation, there are a number of  important actions that can be used to target the underlying cause of the UK’s drugs-deprivation problem.

Indicators of poverty – unemployment, crime, problematic drug use, and inadequate housing – are often found in the same deprived urban area, community, or estate. One possible solution would be to develop local housing policies that specifically address the needs of people that use drugs and who have multiple and complex needs.

Another might relate to welfare to work programmes, supporting people who use drug services into employment and retraining workers at the local level. According to the Black review, “the majority of the costs associated with drug use are indirect costs related to lost outputs from the labour market”. In 2017-18, the cost of supporting unemployed drug users was estimated at £4 billion. Almost three-quarters (70%, or £2.8 billion) of that cost was associated with just 300,000 opioid and/or crack cocaine users, further evidence of the huge benefits that could be accrued by targeting support at problem users specifically.  By these figures, each of those users removed from unemployment would save the taxpayer more than £9,000.

A more obvious intervention would be to reverse cuts to local authority spending (37% down between 2009/10 and 2019/20) and the public health grant (24% lower in 2021/22 compared to 2015/16), allowing councils most affected by deprivation to invest in local services, while providing the funding needed to adequately address the ensuing drugs death emergency. Equally, the levelling up fund itself could do better to prioritise funding, making sure to deliver to the poorest areas of the country in order to correct regional imbalances.

Levelling down drug harms, levelling up equality

Better drug policies can help to support levelling up, but if we are to address long standing regional inequalities, improve wellbeing, and save lives, what is needed is something more ambitious than what the Government has offered so far.

There are several ways of looking at this. One is to simply think about how, through sensible, evidence-led intervention, drug policy could directly influence affected areas’ drug death count. For example, if the North East’s drug death rate (10.1 per 100,000 population) were reduced by 6.1, levelling up the region so that it matched that of the South East’s (4.0), 150 lives would have been saved last year alone.

The gains could be even greater under a more radical reform agenda. In Portugal, it has been reported that overdose deaths decreased by 80% after decriminalisation. If a similar approach – one that favours prevention and education; providing access to evidence-based, voluntary treatment programs; adopting harm reduction practices; and investing in the social reintegration of people with drug dependence – were to be applied to deprived UK areas, reducing deaths by 80%, then the tragic consequences of drug misuse could be avoided, benefiting families and communities across the country, not to mention the multitude of other potential societal benefits. To again use the North East as an example, an 80% reduction would result in around 200 fewer drug deaths a year. In Scotland, over 1,000 lives could be saved.

In reducing health inequalities, it is likely that economic inequality will also be diminished. For example, if a cohort of problem drug users were no longer using drugs due to the introduction of new policies, particularly social policies aimed at targeting deprivation directly, it is almost inevitable they will see improvements in their health, wellbeing, and decision-making. In turn, those people will have an increased likelihood of sustained employment.

The government is right to have recognised addressing drug harm as an important element of its levelling up project, but it needs to go further. The boldest way forward would be to completely overhaul UK drugs policy, root and branch, moving towards a liberalised public health framework that prioritises support and treatment. Even within the current paradigm, there are effective policies it could adopt to make a difference. Either way, a full and frank reassessment of our drugs policies is long overdue – and levelling up can’t happen without it.

Postscript: a note from James Kirkup, Director of the SMF

This is the second time the SMF has published this blog. The first time, the blog contained a significant error. We said that the Levelling Up White Paper doesn’t mention drugs. It does.

We published that error because of a mistake in the research done for the blog, and because of failings in the editing of the blog. As director of the SMF, I am ultimately responsible for both of those things, and I apologise for them.

After being made aware of that error, I took the decision to remove the blog from our site while corrections were made. This version of the blog, republished here, corrects that original error. The central argument of the piece remains unchanged.