Roy Robertson
Biography
Prof Roy Robertson is a Professor of Addiction Medicine at the University of Edinburgh.
Details
- Date of interview: April 2025
- Archive reference: OBJ/ORA/10/1
- Interviewer: Allan Beveridge
Transcription
Roy Robertson:
I was a junior doctor in Edinburgh. I trained in Edinburgh and did junior house jobs, hospital jobs, and went into general practice as a sort of preferred option. And the last year before I started in practice, I did encounter a few people who had drug problems in hospital. And that was interesting because it wasn't something I'd been taught about as a student and it wasn't something, you know, that that was in the common experience in hospital wards. But I remember a young woman in the Northern General Hospital who was clearly addicted to heroin and she had pneumonia. So, she was in and she wasn't terribly unwell. She got better pretty quickly. But then she asked me if I could give her some heroin. And I'd never thought about that before. And I'd never really thought and I said to my consultant, "What should we do with this lady?" I was felt sorry for her because she was clearly distressed and he said, "Give her some heroin and send her home." And that was what we did. And it was I mean, I don't know if it was legal or not, but it wasn't sort of recommended.
Interviewer:
[unclear]
Roy Robertson:
Yeah, it wasn't standard practice. But shortly after that, it went into general practice in Muirhouse and there were a lot of people with drug problems, young people. Very young, seventeen, eighteen, recently left school. So, there was a sort of cohort of new drug users, and at that time there was a big influx of heroin into the city and problems arose from then.
Interviewer:
Maybe say a bit more about your professional career in terms of the addiction and what was happening?
Roy Robertson:
As I was a trainee in that practice for a year and then a partner in the practice, it became obvious that we had a clinical problem, quite a big problem of young people and without any guidelines, without any clear sort of direction of travel. And the partners in the practice were reluctant to take on people with drug problems. It was always felt it was somebody else's problem, and the logical place was to refer people to psychiatry, which held the responsibility. The regional drug dependency unit at the Royal Edinburgh Hospital was the regional place with the responsibility for managing drug problems. But, again, things had been changing over the preceding few years. The previous cohort of drug users came from the 1960s and 1970s and were a sort of aging cohort of alternative lifestyle people, some medical people, doctors and nurses who'd had addiction problems throughout that period. And the organization was set up to deal with that that group. The standard treatment of methadone substitute, opiate substitute treatment had been in a way discredited nationally. Guidelines had veered away from that, towards rehabilitation, towards nonpharmacological treatments and addressing people's social problems addressing people's psychological problems. So, the whole system was in a period of flux and change and was totally unprepared for this new cohort of very young drug users with a serious addiction problem.
The national guidelines, issued from the home office in London, were all about rehabilitation, were all about detoxification units in Edinburgh, but also around the country where people could be referred for rehabilitation were largely drug-free. The treatment was to wean people off drugs very quickly and more or less discharge them. And, I mean, these treatments hadn't been yet shown to be a complete failure, but they were a complete failure. They didn't acknowledge, they didn't recognize the long-term problem of drug dependency and how it was something that didn't often, in many cases, respond to these short-term interventions.
So, over the next year or two, the next few years we did some basic research, I mean this was sort of observational research. It wasn't terribly sophisticated, but it was gathering data gathering information from our patient case load and demonstrating that, you know, that we needed to manage the problem in a different way. And looking around for support and for help from other agencies, there wasn't an awful lot at the time. I mean, there were people who were interested, and of course public health became interested because of the associated hepatitis B epidemic, which went along with it in the early 1980s. So, there was a gathering of public health interest and looking further afield at people in other parts of the UK. Liverpool, London, Manchester were experiencing similar problems with epidemic heroin use. Things built up and the response was, I suppose, slow but eventually we adopted this policy of prescribing and of substitute methadone and became engaged a bit with that and things moved on from there.
Interviewer:
Thank you. That brings us to the next question. Do you think there's anything distinctive about the addiction field in Scotland? And if so, what would that be?
Roy Robertson:
The story about Scotland is distinctive in a way. It was slightly different from different parts of the UK. The availability of heroin was what caused the sort of epidemic and the subsequent problems, but we tended to have more injecting heroin in, certainly in Edinburgh and Glasgow and Dundee. When I visited other parts of the country, Liverpool, Manchester, they were quite surprised at the level of injecting in Scotland. And they did have injecting, of course, in these places and there was a history, of course, in the big centres in London of injecting drug use, but this new wave of heroin use was largely injecting in Scotland and almost exclusively injecting. It was really quite interesting how it unfolded and that was different.
And in Europe it was it was slightly different. In Europe there were centres in Milan, in Amsterdam obviously and centres in Spain that had epidemic drug use, injecting drug use in young people with similar problems. But Scotland was a little bit of an outlier in the UK. It was partly that, it was partly just the number of people using heroin. There was a large cohort suddenly emerged, first in Glasgow, which was less injecting, in Edinburgh this explosion of injecting drug use and the large number of people and we retain a higher percentage of the population using drugs in Scotland than in other parts of the UK.
And I'm not quite sure why that is. I mean, people say it's a post-industrial problem. It's large parts of the West of Scotland particularly are relatively impoverished and have a number of health care problems, a history of alcohol problems, of course. And so that association with deprivation, poverty, unemployment, homelessness is definitely there and that tends to be the hotspots in Scotland, Glasgow, North Lanarkshire, parts of Edinburgh, parts of Dundee. Which isn't of course completely different from other parts of the UK, but we do seem to have a problem of drug use that’s slightly different from other parts.
Interviewer:
Thank you. And the next topic is decriminalization. What are your views on that?
Roy Robertson:
Gosh, decriminalization is tricky. I'm not even sure I have a fixed view on that, because the difficulty is that you can see both sides of the argument, especially coming from a medical perspective, and the last thing you want to do is encourage more people to use drugs. Decriminalization inevitably would lead to more people using drugs, but the argument, of course, in favour of it is that they would use more safely and they wouldn't be getting the problems that go along with the criminalization of drugs and all that. So, I can completely see that, and I think decriminalization is different from legalization. Some countries have gone from legalizing drugs, and cannabis is the front runner in places like Canada and North America and which again the evidence is that there are problems. I mean, there are problems of young people using excessive amounts.
There's a similar sort of story to alcohol. Alcohol is legalized in most western countries, but it causes problems, it causes immense amount of poverty suffering dementia, everything, you name it, multi-system diseases with alcohol. But we tolerate that and we like it and we want to continue with alcohol. So, it's all about some sort of control. And there are many areas of alcohol, many areas of legislation that control alcohol use, of course, in young people in quantities that it can be made, how it's made, how it's marketed, so there's lots of controls. If you're going to legalize a drug like cannabis or other drugs, heroin, cocaine, then you need to think about what legal protections would be in place to protect young people, to protect vulnerable people, to avoid over marketing, avoid this sort of marketization that actually is currently happening in North America and Canada. Cannabis has become a market product and has been heavily marketed towards people, all sorts of people.
But, I think, in favour of decriminalization, I think, it's clear that the war on drugs approach has been damaging and difficult and hasn't helped, and in fact has caused a lot of harms. So, we need to find some way forward and decriminalizing the penalties for drug um possession, of course, is an easy target, but penalties for drug possession can be hugely punitive and sentencing people to prison sentences for possession of cannabis or for selling small amounts of cannabis seems absurd now. So, there has been a level of decriminalization, even if it's not enshrined in law, it's been adopted in policy and it's been tolerated. The police have adopted a policy in most parts of the UK of taking less reaction to possession of cannabis, for example. That's been a good thing, I think reducing penalties is a good thing. But decriminalizing, well it's a process rather than the I don't think anybody's going to do it in a sudden Act of Parliament to say “we're going to decriminalize these drugs”, and which drugs we're going to reduce penalties for is a matter of debate. But I think it's good that it's part of an ongoing process of discussion and, I think, definitely we’re moving in a direction of penalizing people less. But I find myself, you know, confused and conflicted because I do think a lot of the problems with drugs aren't just about the illegal status. A lot of them are about inequalities and poverty and homelessness and desperation and things like that.
Well, addiction problems are everywhere really, aren't they? And it's a sweeping sort of question about, you know, what do we do about addictions? Because addictions, it takes in alcohol, takes in the less damaging drugs like cannabis or superficially less damaging, or it's got its problems. And, of course, the tough problems of heroin and injecting drug use and the Scottish focus on drugs recently has been quite interesting, because it's shown up the breadth of the problem and how it's and all system approach.
You really have to look at the criminal justice approach. You have to look at, you know, the sentencing approach. You have to look at how people are managed in custody, how people are managed in the health service. And, you know, so it's there are huge areas of addictions that we're constantly needing change. I mean there are some very good examples, I think, of how Scotland has been innovative. We have an assisted treatment clinic in Glasgow which has been running for a few years now, and recently this year we opened a safer injecting consumption room, which I think is a great innovation. I mean there are several hundred in Europe and we've been a bit behind the times, and there's none in England and Wales, so Scotland have been innovative there and already, I think, it's shown an interesting sort of pattern of behaviour. It’s given us an insight into what people do and what people take and it gives us a way of understanding the problem better, and it also draws people into contact with services so that their homelessness problems, their financial problems, their emotional, psychiatric problems can be addressed as well. So, I think all these things are ways of engaging with people with drug problems, of trying to understand drug problems better, and I think we've been reasonably good at that, although it tends to come in waves of enthusiasm from the politicians, and the politicians, when a problem arises.
And a current problem that's the headline really in Scotland, still, is the drug related deaths where we have more per head of population than most parts of Europe, so that's concentrated in the minds of the politicians and the policy makers, which has been a good thing. But as soon as that begins to plateau, begins to come down, you know, you can predict that the interest will go, and I think it's still an area that's hugely underfunded. Compared to other areas of health or social policy or public health, it really is hugely underfunded. And in my own area of general practice, I think things have not been going in the right direction. We had a period maybe ten, twenty years ago, when GPs became much more interested and engaged with people with drug problems or addiction problems and that seems to be going away again. I think that's a great pity.
Everybody again has gone back to this sort of desperate area of just trying to pass the responsibility to somebody else. I mean whose responsibility is it? Is it psychiatry? And psychiatry says quite rightly they deal with psychiatric problems. They deal with you the tough psychiatric problems and the difficult, enduring, very hard to treat sometimes, psychiatric problems. And addictions, I mean, is it their responsibility or do they have the resources to do it? And I'm sure they don't. I'm sure they don't have the responsibilities to do that sort of level of community work and outreach work and liaison with GPs and with third sector agencies, social work. So, it's difficult to know who's whose responsibility it is.
I mean, personally, I think it's everybody's responsibility, but I think GPs should be taking a lead role, or primary care, the wider concept of primary care not just the GP doctors but nurse practitioners and the whole primary care team. I think they have to work with social work and they have to work with so- I think we had a very good model in the practice I worked in for many years of working in close association with our social work colleagues, with our third sector colleagues, with our pharmacy colleagues who were, you know, increasingly engaged with the prescribing areas of it. And to a certain extent with the research and laboratory people and criminal justice sector. And I think that was, I thought that was very good and very exciting and I thought it did work to the benefit of the patients. But it was difficult to sustain because of the pressures. I mean everybody knows the pressures on all parts of the health care system just now and primary care is always quite a focus of people getting not being able to get appointments having to wait long times. Referral patterns have been difficult. Secondary care is struggling. So, we're in a period when people are looking to cut back, rather than expand their responsibilities. And health boards in Scotland are struggling financially and cutting back to the sort of statutory services that they have to provide, rather than what might be seen as additional sort of outreach work. And I think funds are being withdrawn rather than expanded.
Predicting the future is difficult. I wish I'd been able to predict the future earlier on my career because I could have, I think we could have done more useful things. So, I mean it is very difficult, I mean, every day there's something to do with addictions in the media or the press or something. Last night, on Newsnight, there was a thing about ketamine in Liverpool, an alleged ketamine epidemic amongst young people causing physical problems and they concentrated on the physical problems which is what medics do. I mean, they were interviewing a lot of medical people, and I think that's where I come from, the medical problems, and so you tend to look at what are you know, what are the consequences of drug use.
And, you know, you get drawn into, research and treatment and policy and I don't mind that but, our job is largely treating the symptoms of drug use and treating the, you know, the outcomes of people taking too much of one drug or another. And you can see new problems emerging, and we have had various problems over the years which have come totally unexpected, taken us by surprise completely. The HIV epidemic is the good example, but also hepatitis C. All of a sudden, we discovered we had this huge cohort of historically infected people with hepatitis C. So, these sorts of things turn up that you don't expect, and, in the future, that'll happen, and that’ll continue to happen.
I do think we'll continue down this pathway of slightly reducing pressure on ourselves by decriminalizing or reducing penalties, which is a good thing. I mean, I think research is revealing more interesting outcomes for the benefits of treatment. And I mean, I think it's easier now to get involved with treatment and people are getting better treatment now than they used to, I think. And I hope that'll continue. I mean, I hope these, I suppose they're experimental, but they're only experimental in the UK. They've been well trialled elsewhere, treatment rooms and heroin assisted treatment. I hope that'll continue, but I do worry for their safety, you know, politically and economically because they're very expensive and they could quite easily be seen as an easy target for cutbacks in the future. And I think we have to work hard to protect that. Because compared to running, you know, other parts of the healthcare system, they aren't expensive, but they're seen, as in some ways, additional to or not essential parts of healthcare. So, I think we're I think the worry is that, you know, we're facing economic hard times and there like to be more cutbacks.
But I do hope that we can develop a, I mean, I think we're in a more compassionate area now when we're managing drug use problems, but I think there still a lot of education needs to be and a lot of research needs to be done. And the area that I'm currently working in, in research, is really about, you know, how we can expand treatment, how we can be better at treating people with new problems as they come along. There's less heroin around just now, a lot more cocaine. And cocaine in the assisted treatment room was the dominant drug of injection, which was quite interesting. And that was an interesting finding, in the first two months, it was mostly cocaine injecting that was causing the problem. So, you know, new things that are new emerging drugs, ketamine, you know, there are always new stronger opiates.
We might well get fentanyl. Fentanyl has been the problem of course in Canada and North America. Methamphetamine is the major problem in southern in Australia and New Zealand. So, the problems are different in different parts of the world, different countries and that depends on, I suppose, the illegal supply chain and how that works. I don't know and, I think many people don't know that. A fentanyl problem would be a real disaster; it really would be another major problem. And the drug related deaths in Canada particularly, but also North America caused by fentanyl are huge, so that could easily be a problem. This new group of drugs [unclear], are strong super strength opiates which have been shown up in various parts of the UK. I mean if that becomes a problem then, you know, we're, drug related deaths might well increase again.
So, I think there are spectres on the horizon that we could worry about. But we need to be in a position to have a robust enough service to cope with it and I think that's the only way you can manage things. I mean, the COVID epidemic showed up the health service’s weak points and, but it also showed up some strong points. I mean the health service, you know, had systems in place. I mean, they had intensive care units, and it tested the strength of the system, but the system was there. And I'm not sure we have that, I mean, I think we need that in the addictions field. We need some capacity for, you know, for any new wave of whatever it happens. So, we need more hospital beds undoubtedly for treating addiction problems, and we need more capacity in the community. We need more, you know, a broader view of how we manage drug problems in the community and at the moment, I think if we tested the system, it wouldn't do terribly well.