Abbey Pharmacy on Trongate – one of the oldest streets in Glasgow – is home to the city's busiest drug needle exchange. As heroin, cocaine and steroid users stop by to collect fresh needles, office workers, shoppers and families walk up and down the busy street, largely oblivious.
John Campbell, the manager of Glasgow's needle exchanges, points out wrappers from freshly collected equipment discarded directly outside the pharmacy door, and an alleyway 20 seconds away that he says is a hotspot for injecting drugs. One block away is Argyle Street McDonald's – the first in Europe to introduce a key code on its toilet doors, following a spate of drug-related incidents, including one in which a man lay undiscovered for five hours in a cubicle after dying of an overdose.
"We provide probably the best range of injecting equipment anywhere in the world," says Campbell, as he shows me equipment including sterile needles, foils, water capsules and even a bank card-sized map of Glasgow's drug services designed in a smooth enough finish to provide a hygienic preparation surface.
"We've given out citric acid and then we've given out spoons, then filters, then water for injecting, then foil as an alternative," he continues – but adds that this has failed to stem the number of drug deaths in the city. "All this stuff is going out, but the problem's not going away."
My visit to Abbey Pharmacy took place before the publication of Tuesday's figures showing that last year 1,187 people died as a result of drugs in Scotland, up 27 percent from the previous year, and the highest ratio of drug deaths of any EU country. The largest death toll – 394 – was recorded in the Greater Glasgow and Clyde Health Board area.
"One day there won't be any deaths left to count because the current group of people injecting in the city centre – often with a long history of injecting – are dying in such great numbers," says Andrew McAuley, Senior Research Fellow at Glasgow Caledonian University. The biggest increase in fatalities is among those aged over 35.
Campbell estimates there are around 300 to 400 people injecting in the city centre each month, virtually all of whom are known to frontline services at some level. The population is characterised by poverty and deprivation, homelessness or unstable accommodation, and often mental health issues and related trauma.
But why are they so much more likely to die than other drug injectors, for example those in England and Wales? Campbell and McAuley say Glasgow's drug-taking behaviour is unique. While heroin has traditionally been the widest used drug in Glasgow, recent years have seen an increase in poly-drug use, particularly people injecting heroin and powder cocaine, taking powerful benzodiazepines and drinking strong alcohol. Poly drug use was implicated in 85 percent of last year's fatalities.
"Powder cocaine injecting is now as much a feature among the city centre population as heroin," says McAuley. Powder cocaine is not a drug typically associated with Glasgow's street heroin-using population – and unlike in the US, powder cocaine is not typically injected in Britain. McAuley says this new trend has changed the nature of drug use in Glasgow. "Heroin is a depressant but cocaine is a stimulant – you get a short, quick rush which dissipates quickly, and then you're looking for more," McAuley says. "People are injecting much more frequently and are therefore more at risk of injecting-related harms."
These harms can include blood-borne viruses such as HIV, and serious wounds and abscesses – injuries which can often be missed when certain areas are anaesthetised by cocaine itself. And in a booming market where people are more likely to pool money for drugs, the likelihood of batch preparation increases, bringing with it its own risks around unclean and shared equipment. An HIV outbreak in 2018 among people injecting drugs in Glasgow city centre sparked a renewed interest in harm reduction and allowed for the development of new services, such as a mobile outreach van.
"What we have is people consuming very high dose benzos, drinking a lot of alcohol, injecting good quality heroin, possibly prescribed methadone, and then injecting cocaine on top of that," Campbell tells me.
Using so many drugs makes it harder for harm reduction efforts and for people to access the necessary treatment, because their addiction is so complex. There is also a lack of support for people who have completed rehab, so many people lapse back into a cycle of addiction.
Jacqueline Rolland is Abbey Pharmacy's harm reduction nurse, and is responsible for dispensing such advice as well as dressing wounds, testing blood, providing condoms and sanitary products, and much more. For her, the idea that someone regularly injecting drugs might sit and converse about their health for 15 minutes is a pipe-dream.
The people she typically sees are already under the influence of drugs and alcohol, and struggle to retain information or to concentrate, on top of having highly scheduled lives structured around begging, buying and consuming drugs.
'It's about making brief interventions for people at times that suit them and in a way that's respectful to their already extensive knowledge of drugs," she explains. "A wee ten-second conversation can still reinforce some kind of change."
One element of Rolland's role is to distribute and provide training on naloxone kits, which reverse the effects of opioid overdose and were introduced nationally in 2011 and cited as best practice by the World Health Organisation. But while they undoubtedly save lives, convincing people to carry them can be a hard sell.
Rolland says some people don't like to have naloxone on them because they think it will get them in trouble with the police. Similarly, she says, people can be reluctant to seek emergency help because an ambulance callout also initiates a police response. Anecdotally, many of Glasgow's city centre injecting population report hostile and stigmatising interactions with the police and public services.
Glasgow's frontline services say a safer drug consumption facility – where people inject drugs in a supervised environment – is the single best answer to drug-related deaths. The idea is supported by the city's council, Scottish Government and all opposition parties except the Conservatives.
Such a service would allow people to inject with safe, clean equipment in the presence of professionals, reducing the risk of drug-related harm and increasing the chances of recovery by introducing people to services they weren't engaged with before. The success of these facilities has been proven in cities such as Vancouver, but the UK Home Office has blocked Glasgow from introducing such a service.
Mhairi McKean is HIV Street Support Manager at charity Waverley Care, a post that was introduced in the aftermath of the HIV outbreak. She says drug users are not being helped because they are seen as criminals.
Like all of Glasgow's frontline services, Waverly Care also build key relationships with the people they support and try to provide a joined-up service that meets people where they are. For McKean, a key part of the job is showing people that they matter and are cared for, and that their lives still have value amid an ever more divided society.
"People are always going to take drugs, but there's a real hierarchy of acceptability," says McKean. "Unfortunately, the more marginalised you are, the more likely you are to be in a situation where you're injecting in Glasgow city centre, rather than sitting in your house drinking two bottles of wine or snorting a line of cocaine."