'Trainspotting' turned a spotlight on Scotland's heroin problem. 25 years on, it's Europe's drug death capital

A drug user prepares heroin before injecting, inside a Safe Consumption van in September 2020, in Glasgow, Scotland.

(CNN)It's one of the most famous monologues in cinematic history: "Choose life," says Ewan McGregor in the 1996 film adaptation of "Trainspotting," Irvine Welsh's gritty novel about a group of drug addict friends living in Edinburgh.

"But why would I want to do a thing like that?" continues McGregor's character Mark Renton. "I chose not to choose life. I chose somethin' else. And the reasons? There are no reasons. Who needs reasons when you've got heroin?"
The dark comedy-drama with a blistering Britpop soundtrack was an international success that shone a light on Scotland's drug scene.
    "Irvine Welsh did us a favor," said Roy Robertson, professor of Addiction Medicine at the University of Edinburgh who has worked as a doctor in the city for more than 40 years.
      The book's original publication in 1993 was "a landmark moment," said Robertson. "For those of us who worked in, and lived in that sector at that time, it really was a very accurate portrayal of the problem. That very young, very dynamic, very aggressive marketing of very pure heroin -- and all the consequences of that."
      But 25 years after the movie's release, Scotland's drug problem is, by some measures, worse than ever.
      The country's drug-related death rate is the highest in Europe, according to a recent report by the national statistics agency. Scotland's death rate far outstrips the closest countries -- Sweden and Norway -- and is more than three-and-a-half times the rate in the United Kingdom as a whole, the report found.
        Many of these deaths are of older drug users who were in their teens or 20s when Welsh's novel-turned-film was released -- part of what has been dubbed the "Trainspotting Generation." After a lifetime of drug abuse, their physical health isn't what it used to be.
        But experts say there's also a more complicated back story to Scotland's drug problem, involving generations of deprivation, government underinvestment and shifting supply chains.
        Last year there were 1,339 drug-related deaths registered in Scotland, according to the annual report. That's the equivalent of more than three deaths a day, in a country with a population of just 5.4 million.
        Scotland's drug-related deaths are now at the highest level since these records began in 1996, the report states.
        Meanwhile Slovakia, which has a similar population to Scotland, recorded 34 overdose deaths in 2019 -- though Robertson points out the "huge underestimate of deaths in many European countries" where statistics gathering on drug issues may not be as robust as it is in Scotland.
        Scotland has the highest drug-death rate per capita in Europe. Its death rate was 318 per million of the population (aged 15-64), in 2019. The next highest countries, Sweden and Norway, both had 77 deaths per million, the national statistics agency report said.
        Over the past two decades, the average age of Scottish drug deaths has steadily increased from 32 to 43. According to the report, almost two-thirds of all drug-related deaths were of people aged between 35 and 54.
        What the report doesn't examine is additional deaths from drug-related causes such as violence, suicide, HIV infection, Hepatitis C and lung cancer -- which could number 1,000 a year, said Robertson.
        And then there's those drug users who have been in and out of treatment and come through the other side, said Austin Smith, spokesperson for the Scottish Drugs Forum. "It's a credit to their massive resilience and to the health services that they have survived," he said.

        Topping up

        "Trainspotting" was set in 1980s Edinburgh, and draws on Welsh's first-hand experience of the drug scene in his hometown. It was a momentous time in Scottish, and European, drug culture.
        In the early 1980s there was a "wave of Afghan and Iranian heroin that came into western Europe, which was very pure by anybody's standards," said Robertson. Even today, older drug users "still wax eloquent about how lovely it was, that heroin that was 50% purity. It didn't need to be mixed with anything else."
        These days, heroin users are more likely to top up their hit with other drugs, in an attempt to "supplement the euphoric effect of the drug," said Robertson. Indeed, last week's report found that in 93% of all drug-related deaths, tests revealed that more than one drug was present in the body of the deceased.
        Opiates such as heroin and methadone, and benzodiazepines -- a type of sedative -- were the most commonly found drugs.