JOHANNA REILLY – a primary care doctor working in an NHS practice for people who are homeless in Edinburgh – surveys the challenges of drug addiction and argues for a more progressive response.
Trainspotting stakes a claim as Edinburgh’s most iconic cinematic portrait. Walking down Princes Street, under the bridges to work, Ewan McGregor’s voice often loops in my head: “Choose Life. Choose a job. Choose a career. Choose a family. Choose a fucking big television, choose washing machines, cars, compact disc players and electrical tin openers. Choose good health, low cholesterol, and dental insurance. Choose fixed interest mortgage repayments. Choose a starter home. Choose your friends. Choose leisurewear and matching luggage.”
In the film, Renton starts by choosing heroin over this glossy checklist, but by the end, he claws his way to a different path. It was the ’90s – a rejection of materialism wrapped in counterculture grit, and it nailed it. Today, working with people who struggle to choose life – not just through drugs but every escape the 2020s offer – I feel that opening scene couldn’t be written now. Back then, culture pushed “choose life,” even if it rang hollow with consumerism. Now? We’re at the other extreme.
Choose death. Choose to dwell on past wounds, not heal them. Choose isolation over friends. Choose drugs with support to keep using, not to get clean. Choose a medically assisted exit. Choose solitude over relationships, childlessness over family. Choose unstable housing – starter homes and fixed-rate mortgages are a fantasy. Choose to shun your culture and identity. Choose death.
Scotland’s drug crisis ignited in the ’80s with rapid deindustrialization and a flood of cheap Afghan heroin. Injecting drug use spiralled, sparking an HIV epidemic in Edinburgh. Harm reduction – clean needles, opiate substitution like methadone – emerged as a lifeline, a pragmatic push to help people escape all-consuming addiction and choose life. It was a moral necessity when HIV ravaged the city. But today, despite expanded measures like drug injecting rooms, Scotland’s drug deaths top Europe at 277 per million (2023 data), 2.5 times England’s rate. Policy feels less about saving lives and more about managing decline – it’s a holding pattern, not a cure.
Harm reduction made sense once – cutting HIV transmission was urgent. Now, with deaths climbing, it’s morphed into something else. Many of my patients bear intractable scars – physical and mental – from years of addiction and chaos. Yet instead of hope or a path through their struggles, the horizon hints at a final fix: assisted dying. The war on drugs looks unwinnable, and jailing addicts gains little. But where’s the fight against the multibillion-pound drug trade? Policy barely connects the dots between dealers and deaths. Maybe it’s because the victims – mostly from poverty, often care-system survivors – lack a voice. They’re socially invisible, their losses shrugged off.
Assisted dying looms as Scotland debates it – a bill’s been kicking around since 2021 and if England’s bill is passed Scotland looks sure to follow. For some, it’s dignity; for others, it’s despair codified. My patients with ravaged health don’t need an exit – they need reasons to stay. Offering death as a solution feels like admitting we’ve failed to fix the roots: poverty, addiction, hopelessness. It’s Trainspotting in reverse – Renton walking off not to live, but to die, with the state holding the door.
Drug deaths aren’t just about drugs – they’re about what’s missing. The ’80s gutted Scotland’s industrial heart – shipyards, mines, factories – and left Muirhouse, Leith, and beyond as shells. A GP colleague once said it was easier to score heroin in Muirhouse than buy a sandwich. That’s not a punchline; it’s a policy failure. Government benefits catch some falls but don’t lift anyone up. Poverty’s stubborn – only jobs and meaning can break it. Scotland’s got wind farms and tech, yet deprived areas see none of it. Where’s the industrial strategy to rekindle purpose in these postcodes? A green jobs push – say, training for turbine plants – could be a “choose life” signal. Instead, we get net-zero slogans and no substance.
“Choose life” is tough. It demands more than methadone scripts or safe injection rooms – it needs recovery, reintegration, and dealers off the streets. It means social housing for Edinburgh locals, not years in grim hostels. It means an energy strategy that delivers jobs, not just headlines. It means seeing families as a strength, not a carbon footprint liability. It’s rejecting the nihilism seeping everywhere and betting that everyone’s worth something. Trainspotting ends with hope – Renton decides his life matters. I want that for Scotland too: a future where “choose life” isn’t a taunt, but a promise worth keeping.
