Purpose: Scotland faces a crisis of drug-related deaths, disproportionately affecting people living in the most deprived areas. The purpose of this paper is to explore patient and service provider perceptions of engagement within shared care treatment systems, acknowledged as a critical factor in preventing drug-related harms and deaths.

Design/methodology/approach: A qualitative case study approach was adopted, focusing on two primary care practices in highly deprived urban areas. Thematic analysis was used to investigate the interplay of individual, organisational and structural factors acting as facilitators and barriers to service engagement. Data were collected through 34 semi-structured interviews with 6 people who use drugs, 4 family members, 20 health-care practitioners and 4 policymakers.

Findings: Engagement challenges were multifaceted, encompassing relational aspects (e.g. trust and stigma) and systemic issues, including poor collaboration across professional groups, fragmented services, inadequate communication and resource constraints. Participants emphasised the cumulative impact of socioeconomic deprivation and structural inequalities, which shaped the environments in which drug use occurred and constrained effective care delivery. Practitioners used various strategies, including harm reduction approaches and personalised support, to enhance engagement.

Originality/value: This paper provides new insights into the challenges faced by practitioners, people who use drugs and families in navigating the shared care system. The findings of this study highlight the need for policy action to strengthen service provision as well as reinforcing the importance of tackling cumulative health and social inequalities, seen as a key factor in drug-related deaths.