Yesterday, I saw a very interesting and important blog post from Dr. David McCartney, a key recovery advocate over the past two decades and a very good friend, on the Recovery Review website. David’s post is also thought provoking.
‘The future often arrives from the margins.’ Václav Havel
Throughout history, mutual aid societies have emerged to fill gaps left by formal institutions. From the Friendly Societies of the 19th century that pioneered worker welfare before the National Insurance Act of 1911, to the Temperance movements that established peer support for alcohol abstinence decades before NHS addiction services, civil society has repeatedly demonstrated its ability to identify and address problems faster than government can respond. Today, a similar pattern is unfolding in Scotland’s response to cocaine addiction.
The Service Mismatch
By the time I left my clinical role in residential rehabilitation, cocaine had become the commonest reason (after alcohol) for admission. Similarly, cocaine has become the dominant drug for new presentations in Scotland’s wider drug treatment landscape. According to Public Health Scotland (PHS), cocaine problems accounted for approximately 30% of all new treatment presentations for the last two years, for which figures are available, overtaking heroin. Cocaine-related deaths have risen from 6% of all drug deaths in 2008 to 41% in 2023.
However, Scotland’s drug services remain primarily configured for opioid dependency, with methadone and buprenorphine protocols dominating commissioning priorities. This structural misalignment leaves clinicians with few evidence-based options for stimulant addiction, despite an international scramble to come up with a pharmaceutical agent.
Unlike opioid dependence, which has established pharmacological treatments, cocaine use disorder currently has no approved medication. A 2024 review by the Drugs Research Network Scotland found insufficient evidence to support the use of pharmacological treatment, a finding that led Public Health Scotland in their 2025 publication on cocaine interventions to exclude pharmacological interventions from their scoping review.
Consequently, clinicians are left with a ‘therapeutic vacuum,’ relying on psychosocial interventions where, according to PHS, evidence is often mixed. Psychosocial interventions provided modest but reliable reductions, yet the review stressed a “critical need for higher-quality, longitudinal evaluations.” Interestingly, there was not much for PHS to say about mutual aid and lived experience approaches as pretty much nobody in Scotland has been looking at that.
In short, it looks bleak. Despite rising demand, the evidence base is weak, and statutory services lack proven tools to meet the need.
Cocaine Anonymous: A Grassroots Response
That doesn’t mean that nothing is happening. If we look outside the world of policy and treatment, something big is going on, albeit without fanfare or much scrutiny. Cocaine Anonymous (CA) is a mutual aid group which was introduced to Scotland around 25 years ago. While CA meetings are open to people with any substance problem, CA World Service surveys suggest around 80% of members have cocaine as their primary substance. The growth trajectory is striking. From just 3 weekly meetings in 2003, Scotland now hosts 212 meetings per week—an almost 8000% increase over 23 years.
Critically, the post-pandemic acceleration in the data suggests pent-up demand and continued reliance on mutual aid even as statutory services recovered. If official responses had caught up, perhaps we would not have expected this surge.
Scotland Punching Above Its Weight
The per-capita figures are compelling. By my reckoning, Scotland comprises approximately 7.5% of the UK and Ireland population but accounts for 20% of all CA meetings in the region.
Globally, Scotland’s 212 weekly meetings represent approximately 8% of the roughly 2,820 meetings reported worldwide by CA World Services. For a nation of about 5.5 million people, this is exceptional but also feels like a warning – a canary in the coalmine.
Why This Matters
Several factors may explain this phenomenon. First, the service mismatch creates demand for alternatives. Second, peer-led models are nimble and can scale rapidly without having to navigate commissioning procedures or clinical staffing requirements. Third, stigma around clinical settings may drive preference for anonymous peer support.
But the underlying driver appears to be unmet need. When statutory services cannot provide appropriate care, people organise themselves. This mirrors historical precedents where mutual aid preceded state action—from the Washingtonian Movement of the 1840s to Alcoholics Anonymous in the 1930s, both of which demonstrated that peer support was effective long before governments recognised it.
Something else
There is something curious about how such a remarkable growth is happening under the noses of government, commissioners, public health officials, treatment providers and researchers, yet it’s not on the radar. While assertive referral to mutual aid is embodied in policy, we have little evidence of how it is being enacted in practice. My observation is that the impact and importance of mutual aid is widely discounted. It we don’t rate it, why would we track and report on its reach and how effectively we connect individuals to it? It’s time to take the blinkers off.
Policy and Research Recommendations
These are my suggestions for change
1. Commission evaluation of CA effectiveness in Scotland (or mutual aid more widely) – longitudinal studies tracking outcomes for CA attendees versus statutory treatment or in both.
2. Map mutual aid in Scotland and how effectively we connect people to it – Geographic analysis of meeting locations against treatment presentation hotspots could identify underserved areas. Reach and connection are important to understand.
3. Establish referral pathways – Alcohol and Drug Partnerships should create effective connections between clinical services and mutual aid groups and train workers in assertive referral techniques.
4. Ensure mutual aid attendance is part of every induction programme – Have staff attend open meetings (of different types of mutual aid) on starting a new role and once a year as part of CPD.
5. Create meeting spaces for mutual aid groups in services – Offer rooms to groups and invite them in!
6. Have representatives from mutual aid groups at key policy, planning, development and delivery meetings.
Conclusion: Mutual Aid as Bellwether
The story of the growth of Cocaine Anonymous in Scotland illustrates a recurring historical pattern: grassroots responses often run ahead of official policy. Communities may identify problems and implement remedies before statutory services notice or adapt. But mutual aid is more than just a stopgap – it is both a solution and a bellwether. It signals where demand lies, what approaches resonate with affected communities, and where policy is falling short.
Scotland’s exceptional CA meeting density not only highlights community resilience and adaptability – it also almost certainly provides evidence of a structural gap that requires policy attention. The PHS review confirms that statutory services lack proven cocaine-specific interventions – meanwhile, peer-led models are scaling rapidly, organically, and effectively.
The question is not whether mutual aid should be integrated more effectively into statutory care pathways – it is about how quickly we can do so. History shows that civil society will continue to lead. The task for policymakers is to catch up, evaluate, and scale what works. In doing so, Scotland could set an example for the wider UK and beyond, demonstrating how mutual aid and statutory services can work together to address one of the most pressing public health challenges of our time.
(Thanks to CA World Services for providing data which informed this blog.)