(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.
'Trainspotting' turned a spotlight on Scotland's heroin problem. 25 years on, it's Europe's drug death capital
"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.
"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.
Poly-drug use is hugely dangerous, said Smith. "Maybe in the morning they've been using heroin, and then in the afternoon they've been using benzodiazepines, and it's the combined effects of those drugs that kills people," he said.
Over the past two decades, the illegal supply of drugs has also become bigger and more complex. Previously, people would steal or, as Smith puts it, "borrow" benzodiazepines from others who had been legitimately prescribed them. Now, he said there's a "mass importation of plastic tubs full of a pharmaceutical grade benzodiazepines ... and that's being pressed into palms locally by criminal gangs."
The common factor among Scottish people struggling with drug use is poverty, said Smith.
"They were brought up in poverty," he said. "They're not in poverty because they spent all their money on drugs -- they've never had money."
Traumas such as violence in the home, abuse and neglect are passed down through generations, said Smith. Indeed, Robertson said that these days he treats patients with the same drug issues he witnessed in their parents.
Such people have poorer engagement with health services, said Smith. And those who might suffer from sleep disorders and anxiety end up self-medicating with benzodiazepines.
"There's that stereotype, some of which is true, that the Scottish drink a lot," said Smith. "There's an appetite within Scottish culture for depressant drugs," he added.
Scotland has even been dubbed the "sick man of Europe," due to its higher mortality rates compared with other western European countries. Robertson said it's no secret that "Scotland is a poorer country, there's more people using drugs and alcohol, there always has been."
And that leads, in turn, to more deaths.
But last week's record-breaking figures are a fresh cause of shame for Scotland's First Minister, Nicola Sturgeon. The Scottish National Party leader was also health secretary from 2007 to 2012.
"The number of lives lost to drugs is unacceptable, each one a human tragedy," Sturgeon wrote on Twitter. The Scottish government "does not shirk the responsibility & we are determined to make changes that will save lives," she added.
The Scottish government last year appointed a dedicated Minister for Drug Policy, Angela Constance, to help tackle the problem, and earlier this year pledged £250 million ($348 million) in funding to address the health emergency posed by drug abuse.
But critics say the Scottish government has in the past heavily disinvested in drug, alcohol and mental health services. Others point the finger at the UK government in Westminster's opposition to safe drugs consumption rooms.
The answer is improving access and quality of treatment, said Smith. Scotland has around 60,000 problem drug users, and around 40% of these are in treatment at any one time, according to the Scottish Drugs Forum. That's compared to around 60% in treatment in England.
The last two decades have seen at least one positive change, said Smith: The way politicians talk about drug users. Previously, "politicians of all parties were cautious about standing up for such a marginalized, stigmatized group of people as injecting drug users," he said.
"Now the tone has been: 'This is all of our problem and in a way, all of our responsibility.'"