In December 2022, Hildegarde Naughton TD was appointed as the new Minister of State with responsibility for Public Health, Wellbeing and the National Drugs Strategy, as well as Government Chief Whip. Minister Naughton has been a Fine Gael TD for Galway West since 2016. Her ministerial role focuses on the promotion of healthier lifestyles and policies to improve the health of people in Ireland, including overseeing the delivery of Ireland’s national drugs strategy, Reducing Harm, Supporting Recovery 2017-2025.¹

Among the most pressing issues facing the new Minister will be the establishment of the Citizens’ Assembly on drugs, committed to by the Government in its Programme for Government.² Speaking to the Seanad on behalf of the Minister for Health, Stephen Donnelly TD, in November 2022, she said:

There are two issues in particular that the Citizens’ Assembly on drug use could consider. The first is how to better meet the diverse health needs of people who use drugs, while the second is how to prevent the harmful impact of drugs on children, families and communities.³

1    Department of Health (2017) Reducing Harm, Supporting Recovery: a health-led response to drug and alcohol use in Ireland 2017–2025. Dublin: Department of Health. https://www.drugsandalcohol.ie/27603/

2    Fianna Fáil, Fine Gael, the Green Party (2020) Programme for Government: our shared future. Dublin: Department of the Taoiseach. https://www.drugsandalcohol.ie/32212/

3    Naughton H (2022) Seanad Debates. 29 November 2022. Vol. 290, No. 6. Available from: https://www.oireachtas.ie/en/debates/debate/seanad/2022-11-29/3/

Problematic opioid use is a significant problem in Ireland and across the world. However, measuring the prevalence of opioid use is challenging. Given the nature of this population, a simple head count is not feasible and general population surveys are known to be ineffective at capturing this ‘hidden’ population. Because people who use drugs fear stigmatisation and are often marginalised in society, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) recommends the use of indirect approaches, such as the capture–recapture (CRC) method, to estimate the prevalence of problematic (high-risk) drug users.

A national three-source CRC study to provide statistically valid estimates of the prevalence of opioid drug use in the national population was commissioned by the National Advisory Committee on Drugs and Alcohol and undertaken in 2001¹ and again in 2006.² The three data sources used were the Central Treatment List (of clients on methadone), the Hospital In-Patient Enquiry (HIPE) scheme, and An Garda Síochána PULSE (Police Using. Leading Systems Effectively) data. A third study using the CRC method was published in 2017.³

In 2020, the Health Research Board (HRB) awarded a contract to the School of Public Health at University College Cork to conduct a fourth study on the prevalence of opioid use in the Republic of Ireland for the years 2015–2019. The methodology and main findings from this study are discussed below.⁴

Methods

Data on opioid use for the years 2015–2019 were collected from four sources: treatment clinics, general practitioners (GPs), the Irish Prison Service, and the Probation Service. Employing the CRC method, Poisson log-linear models were applied to the overlap data to find the model with the best fit to estimate the hidden population not identified by any of the data sources. Source-by-source interaction terms were tested by adding them to the base model in all possible combinations. The best model for estimating the size of the hidden population was determined by comparing the deviance to the chi-squared distribution and the Akaike information criterion (AIC) value. The simplest model with the lowest AIC value that provided a credible estimate was used.

Results

Table 1 summarises the main results of the study, stratified by Co. Dublin/rest of Ireland as well as by age group and sex. In total, there were an estimated 19,875 problematic opioid users in Ireland in 2019 (95% confidence interval [CI]: 19 522–21 608), which equates to a prevalence rate of 6.68 per 1,000 population (95% CI: 6.57–7.27). The majority of problematic opioid users were male (72.3%) and more than two-thirds (72.93%) of problematic opioid users were in the older 35–64-years age group. There were an estimated 11,729 problematic opioid users (95% CI: 11 298–12 944) in Co. Dublin in 2019, with a rate over three times higher there than in the rest of Ireland (12.72 per 1,000 population) (95% CI: 12.25–14.03) versus 3.97 per 1,000 population (95% CI: 3.84–4.47).

Data for the prevalence of problematic opioid use for the years 2015, 2016, 2017 and 2018 are additionally presented to provide information on changes in trends over time (see Table 2). While there was a slight decrease in the overall number of opioid users between 2015 and 2019, this decrease was not statistically significant. The prevalence of problematic opioid use among younger age groups (15–24-year-olds and 25–34-year-olds) (see Tables 3 and 4) also appears to be in decline, while the number of problematic opioid users in the older age group (35–64 years) has increased (see Table 5).

Table 1: Summary of prevalence estimates of problematic opioid use (2019)

Source: Hanrahan et al., 2022

Table 2: Comparison of the number of problematic opioid users and rates per 1,000 population aged 15 to 64 years (2015–2019)

Source: Hanrahan et al., 2022

Table 3: Comparison of the number of problematic opioid users and rates per 1,000 population aged 15 to 24 years (2015–2019)

Source: Hanrahan et al., 2022

Table 4: Comparison of the number of problematic opioid users and rates per 1,000 population aged 25 to 34 years (2015–2019)

Source: Hanrahan et al., 2022

Table 5: Comparison of the number of problematic opioid users and rates per 1,000 population aged 35 to 64 years (2015–2019)

Source: Hanrahan et al., 2022

Conclusions

Commenting on the study’s findings, Dr Michael Hanrahan, who led the data collection and analyses, said:

The decline in opioid use among young people is a positive development and could be attributed to the negative image of heroin among young people or the provision of prompt treatment that can break a cycle whereby opioid users introduce the drug to others, or a combination of these factors. This finding should also be viewed in light of recent data from the HRB’s National Drug and Alcohol Survey,⁵ which found that the use of stimulant-type drugs such as cocaine and ecstasy has increased among younger age groups since 2014.⁶

1    Kelly A, Carvalho M and Teljeur C (2003) Prevalence of opiate use in Ireland 2000–2001: a 3-source capture recapture study. Dublin: Stationery Office. https://www.drugsandalcohol.ie/5942/

2    Kelly A, Teljeur C and Carvalho M (2009) Prevalence of opiate use in Ireland 2006: a 3-source capture recapture study. Dublin: Stationery Office. https://www.drugsandalcohol.ie/12695/

3    Hay G, Jaddoa A, Oyston J, Webster J, Van Hout MC and Rael dos Santos A (2017) Estimating the prevalence of problematic opiate use in Ireland using indirect statistical methods. Dublin: National Advisory Committee on Drugs and Alcohol. https://www.drugsandalcohol.ie/27233/

4    Hanrahan MT, Millar SR, Phillips KP, Reed TE, Mongan D and Perry IJ (2022) Problematic opioid use in Ireland, 2015–2019. Dublin: Health Research Board. https://www.drugsandalcohol.ie/35856/

5    Mongan D, Millar SR and Galvin B (2021) The 2019–20 Irish National Drug and Alcohol Survey: main findings. Dublin: Health Research Board. https://www.drugsandalcohol.ie/34287/

6    Health Research Board (2022) HRB report shows a decline in problem opioid use among younger age groups [Press release]. Dublin: Health Research Board. Available from: https://www.hrb.ie/news/press-releases/single-press-release/article/hrb-report-shows-a-decline-in-problem-opioid-use-among-younger-age-groups/

In December 2022, Taoiseach Micheál Martin TD launched the Dublin North East Inner City (NEIC) initiative’s 2022 progress report.¹ Since its establishment in 2017, the NEIC’s vision is of ‘making the North East Inner City a safe, attractive, and vibrant living and working environment for the community and its families with opportunities for all to lead full lives’ (p. 6).¹ This most recent progress report describes the activities undertaken in 2022 to meet this aim.

Background

In June 2016, a ministerial taskforce chaired by the then Taoiseach, Enda Kenny TD, was established to support the long-term economic and social regeneration of Dublin’s NEIC. A report on the area and the challenges it faced was subsequently published, known as the Mulvey Report, which outlined a plan for the area’s regeneration, grounded in a combination of place-based and people-based approaches to inform regeneration in the NEIC.² The report led to the establishment in 2017 of the NEIC Programme Implementation Board (PIB). Six subgroups were set up based on the priority areas of work identified in the report and the subsequent NEIC Strategic Plan 2020–2022.^2,3,4 These priorities were enhancing policing; maximising educational, training and employment opportunities; family wellbeing; enhancing community wellbeing and the physical environment; substance use, misuse and inclusion health; and alignment of services.

The NEIC PIB had been working to a three-year strategic plan for 2020–2022, which given the impact of the Covid-19 pandemic was extended to 2023.

2022 progress report and substance use

The 2022 progress report outlines the wide range of projects and programmes delivered in the NEIC over the year. Activities reflect the broad range of priorities across the six subgroups listed above. Many of the activities relate directly or indirectly to drug use and initiatives that may help reduce the harms it causes at a community and individual level. Among the many initiatives outlined in the report are:

• The Community Dialogue Initiative, which aims to improve relationships between young people and members of An Garda Síochána in the NEIC. The initiative adopts a restorative model of working.
• The Law Enforcement Assisted Recovery (LEAR) Project, developed by Ana Liffey Drug Project, which established a specific team to work in the NEIC in 2022. The LEAR Project aims ‘to support people who have complex and multiple needs such as addiction, criminality, homelessness and mental health to engage effectively with support services, often for the first time, and to identify and achieve their goals’ (p. 16).¹ It supports people to move away from criminality and antisocial behaviour and towards their personal recovery.

Substance use subgroup

The subgroup on substance use, misuse and inclusion health is chaired by Mr Jim Walsh of the Department of Health. It focuses on improving health outcomes for people who use and misuse drugs and alcohol and on promoting inclusion health for socially excluded groups experiencing severe health inequalities. Activities in 2022 included:

• Healthcare Navigation Service (HNS): The HNS is a pilot community aftercare programme aimed at supporting people leaving prison and returning to live in the NEIC. It sets out to support these people navigate and engage with health services. An individualised care plan is developed prior to release with the aim of bridging the gap between custody and community living, which in turn can help improve the physical and mental health outcomes of vulnerable adults.
• Prevention and treatment of non-fatal drug overdose: The subgroup identified the need to develop a targeted drug-related death prevention initiative among high-risk groups. A team at Trinity College Dublin was commissioned by the NEIC to conduct an exploratory study of non-fatal overdose in the community. It will develop recommendations on the prevention and treatment of non-fatal overdose. The study is expected to be completed in Q3 of 2023.
• Community Addiction Assessment Hub (CAAH): Initially funded by the NEIC, the CAAH is a Health Service Executive led service established in 2022. CAAH works with individuals or family members who have concerns regarding drug use, gambling, and other behavioural addictions. It has a multidisciplinary team including an addiction specialist nurse, doctor, and counsellor. It also has access to residential stabilisation and detoxification, addiction psychiatry, and case management.
• Dual diagnosis: A community development worker has been employed to support the building of capacity among stakeholders in the community to meet the needs of those experiencing dual diagnosis.
• Anti-stigma training linked to drug use and addiction: A programme of training has been delivered to address drug-related stigma in NEIC services. It has worked to educate professionals in the community with the aim of ensuring that people who use drugs can access and avail of services in the NEIC ‘in a fair and equal manner’ (p. 52).¹

Ambitions for 2023

In 2023, the subgroup on substance use, misuse and inclusion health aims to further build on its work. It intends to specifically develop a community response to domestic, sexual, and gender-based violence and thus support the local implementation of the national domestic, sexual and gender-based strategy.⁵ In addition, it seeks to develop an interagency response to drug-related intimidation and violence using the Drug-Related Intimidation and Violence Engagement (DRIVE) model, in association with the Local Community Safety Partnership.

Conclusion

The PIB progress report for 2022 illustrates the ongoing challenges facing those living in the NEIC, as reflected in the profile of projects and programmes receiving funding. A key objective of the PIB is ‘to develop services that are evidence-based and sustainable in the long-term’ (p. 53). The report identifies some initiatives initially funded by the PIB that are now receiving core funding through the Department of Health.

1    North East Inner City Programme Office (2022) Dublin North East Inner City progress report 2022. Dublin: Dublin City Council. https://www.drugsandalcohol.ie/37662/

2    Mulvey K (2017) ‘Creating a brighter future’: an outline plan for the social and economic regeneration of Dublin’s North East Inner City. Dublin: Government Publications. http://www.drugsandalcohol.ie/26859/

3    North East Inner City Programme Office (2019) The social and economic regeneration of Dublin’s North East Inner City (NEIC): 2020–2022 strategic plan. Dublin: Dublin City Council. https://www.drugsandalcohol.ie/33752/

4    North East Inner City Programme Office (2020) Dublin North East Inner City progress report 2020. Dublin: Dublin City Council. https://www.drugsandalcohol.ie/33577/

5    Department of Justice (2022) Zero tolerance: third national strategy on domestic, sexual & gender-based violence 2022–2026. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/36540/

Background

Safe, effective, efficient, and sustainable health and social care systems are dependent on high-quality data and information. Within the context of alcohol and drug use in Ireland, relevant health information may be used to answer key questions related to the epidemiology of substance use and addiction, inform the development of harm reduction strategies, identify areas of need, and direct resource allocation. There are many organisations responsible for collecting and storing health and social care information in Ireland, with more than 85 national data collections. Consequently, there is poor integration of systems and a lack of standardisation of the type of data being collected nationally. Change is needed to improve access to health and social care information for both patients and professionals in Ireland, to promote better use of resources through use and reuse of data, and to increase transparency and choice about how this information is used for primary and secondary purposes.

Source: Health Information and Quality Authority, 2022, p. 9.

Figure 1: Key policy areas for the collection, use, and sharing of health and social care information in Ireland

Key findings

The report was informed by a national public consultation project and public feedback, engagement with key stakeholders, and a review of international evidence. Four key areas of potential transformation were identified: effective engagement; legislative framework; governance structures; and technical and operational requirements (see Figure 1). These four key policy areas are interdependent, meaning that lack of progress in one area will hinder progress in the other three.

1. Effective engagement

People should be involved in decisions about their health information, with a rights-based approach to health information and its use. Eighty-six per cent of the public would like access to their medical records online and 94% want to be informed about possible future uses of their health information. HIQA recommends that effective engagement be undertaken with members of the public and professionals to guide changes that meet their needs. This will involve the development of a national health information strategy and action plan to outline how, where, and when engagement should take place. As new technologies, such as electronic health records (EHRs), are implemented, it is important to engage with stakeholders on an ongoing basis. Hence, these technologies and the information contained within are managed and delivered in a way that is acceptable to healthcare professionals and the public.

2. Legislative framework

The current legislative landscape in Ireland for health information is complex. Existing legislation includes the General Data Protection Regulation (GDPR) 2018 and the Health Research Regulations 2018. The European Commission intends to enact additional legislation that will impact the reuse and sharing of public data. Accordingly, in 2022, the Department of Health announced plans to develop the General Scheme of a Health Information Bill. HIQA recommends a review of existing and forthcoming legislative requirements for health data as well as a review of the legal bases for data processing to address inconsistency and concerns around application of GDPR principles. Planned legislation will also support a centralised approach to the development of national registries. For some registries in Ireland, data are processed on the legal basis of a public task (e.g. the National Drug Treatment Reporting System), while others operate under the legal basis of consent. New legislation will provide for the structured collection of health information in line with international best practice and underpinned by a rights-based approach.

3. Governance structures

There is a need for improved governance structures that support the secure and effective use of health information in Ireland. HIQA recommends that a national organisation with responsibility for health information be established. This organisation should have strong legislative powers and take a strategic role in advancing health information in Ireland. It will have responsibility for development of a national data governance framework and data standards, monitor information-sharing practices in health and social care, coordinate and standardise national datasets, and coordinate a national, secure, linkage and de-identification service for health information. To date, eHealth Ireland, the organisation with ongoing responsibility for delivering Ireland’s eHealth strategy,² has not been formally established as separate entity to the Health Service Executive (HSE), a critical shortcoming identified by participants during the public consultation process.

4. Technical and operational requirements

Improvements in technical and operational requirements include further implementation of EHRs and a citizen health portal, which allows patients have access to their own health data using an app or website. Currently, Ireland is one of only two countries in the European Union that does not provide citizens with access to electronic records, and consequently disempowers them in managing their own online information and care resources. To implement EHRs and a citizen health portal, adequate investment, effective leadership, appropriate infrastructure, and sufficient and expert operational resources are essential throughout. Furthermore, technical advances in health and social care will only be successful if supported by improvements in relation to data quality, data interoperability, and data security.

Conclusions

Sharing and processing personal information is an integral part of healthcare provision. The Covid-19 pandemic and the HSE cybersecurity breach in 2021 have emphasised the need to improve Ireland’s health information systems and information-sharing processes. This is an opportune time to engage meaningfully with the public and professionals in advance of the forthcoming legislation on health information and to drive transformational change in relation to the collection, use, and sharing of health and social care information in Ireland.

1.   Health Information and Quality Authority (HIQA) (2022) Key considerations to inform policy for the collection, use and sharing of health and social care information in Ireland. Dublin: HIQA. Available from:
https://www.hiqa.ie/sites/default/files/2022-08/Key-policy-considerations-for-health-information.pdf

2.   Department of Health (2013) eHealth strategy for Ireland. Dublin: Health Service Executive. Available from:
https://www.drugsandalcohol.ie/32061/

MUP on alcohol was introduced in Scotland in May 2018, the first nation in the world to do so. It sets a minimum floor price of 50 pence per unit of alcohol (one unit is the equivalent of 8 g of pure alcohol or ethanol). Ireland followed suit in October 2018 as part of the Public Health (Alcohol) Act 2018. MUP came into effect in January 2022 at 10 cent per gram of ethanol or €1 per standard drink (10 g of pure alcohol).² MUP is also in operation in some Canadian provinces; Belarus; Kyrgyzstan; the Republic of Moldova; the Russian Federation; Ukraine; the Northern Territory in Australia; Wales; and Jersey. As MUP was only introduced in Ireland in 2022, it is too early to tell yet what effect it has in reducing alcohol-related harms. However, as MUP has been in place in Scotland for over four years, there is much interest in Ireland in the potential impact it has had there. Two publications in late 2022 examined the impact of MUP in Scotland: one examining the experiences of stakeholders who work directly with people experiencing homelessness,³ while the other looked at the impact on road traffic collisions and drink-driving incidents.⁴

1. Stakeholders’ perspectives and experiences of MUP and people experiencing homelessness

This study examined the impact of MUP on marginalised groups by interviewing stakeholders from statutory and third-sector organisations across Scotland who work with people experiencing homelessness and those who are street drinkers. Alcohol use disorder is higher among this group compared with the general population and their drinking patterns differ due to the types and amount they drink, making them particularly susceptible to alcohol-related harms.

Methods

Using qualitative semi-structured interviews with 41 stakeholders, the study sought to determine the stakeholders’ views on MUP, their perception of the consequences of the commencement of MUP, its impact on service provision, and the implications for policy among people experiencing homelessness and street drinkers. The data from interview transcripts were analysed using thematic analysis.

Results

Findings from the study indicated that despite initial concerns about the potential impact MUP could have on this vulnerable group, there was no significant negative effect on people experiencing homelessness and service providers supporting them. There was support for MUP and acknowledgement of the need for such a policy. However, participants acknowledged that they felt poorly informed about MUP before its commencement and that due to the complex needs of their clients (along with alcohol use) had anticipated some of the outcomes, but there were some groups adversely affected. For example, one stakeholder reported an increase in hospital admissions for alcohol withdrawal symptoms, while a small minority reported an increase in accessing food banks, which may have been as a result of prioritising alcohol over food, although it was acknowledged that this may have been more likely due to the ongoing Covid-19 pandemic at the time of the study. Furthermore, there were reports of clients swapping formerly cheap cider for spirits and concern was raised that if they drank at the same levels they had previously, this would increase their risk of injury from falls, head injuries, and gastric bleeds. A number of participants raised concerns about a move to illicit drug use (commonly street ‘benzos’ and Valium) in response to the increase in costs of alcohol. However, this was reported in addition to alcohol use rather than a replacement for alcohol. A number of participants said that they heard anecdotal reports of clients drinking hand sanitiser or buying ‘contraband’ alcohol or buying alcohol at pre-MUP prices in small independent shops following the introduction of MUP, although such reports appeared confined to those with limited access to benefits.

Participants raised an important issue about how MUP does not address the underlying reasons for alcohol use among this population. They emphasised how services need to work together to provide trauma-informed care to their clients and not be restricted to entry criteria, such as alcohol or drugs or mental health issues. Also criticised were long waiting lists for detoxification programmes.

Yet the majority of feedback from stakeholders was that MUP provided them with an opportunity to discuss the client’s alcohol use with them, to encourage accessing treatment, and that the price increase reduced their alcohol use. Initial concerns about an increase in crime to fund alcohol use were unfounded.

Participants noted that to be better prepared for the needs of their clients, any future discussions regarding MUP should consider their views in order to best anticipate service changes to accommodate their clients.

Conclusion

MUP is intended to reduce alcohol use at a population level, but for those experiencing homelessness, it is essential that services and supports are in place to support them directly due to their complex needs, in particular those without or with limited benefits. The study found that although the participants expected adverse effects among their clients as a result of the introduction of MUP, these did not materialise to the degree anticipated.

2. Alcohol price floors and externalities: the case of fatal road crashes

Building on the evidence of the impact of MUP in Scotland, another study examined the impact MUP had on fatal road traffic collisions (RTCs) and accidents involving drink drivers.⁴ This is an important indicator of alcohol-related harm. The study highlighted the proportion of fatal RTCs attributed to alcohol in a selection of countries and it is worth noting that Ireland is ranked highest.⁵

Methods

The study involved the use of administrative data on RTCs and a range of quasi-experimental modelling approaches. Road Accidents Data (RAD) in Britain were used to examine all fatal RTCs between 2009 and 2019 and all accidents where a positive breath test specimen for alcohol was recorded.

Results

In examining the fatal RTCs and the accidents where drink driving was involved in the months before and after the introduction of MUP, the results indicated that there was no change in the number of incidents in Scotland compared with the rest of Britain (where MUP is not in place), implying that the policy did not affect such accidents.

Conclusion

The study suggests that MUP resulted in a reduction in alcohol use and consequently had a significant impact on alcohol-related RTCs, although the authors note that the majority of RTCs involving alcohol are caused by on-trade consumption that is not impacted by MUP. The findings from this study are valuable to countries such as Ireland who have recently introduced MUP.

Overall conclusion

Both studies from Scotland provide important evidence to contribute to the MUP impact portfolio. This evidence is especially useful to Ireland as MUP was introduced in early 2022 with some scepticism and criticism. Although the two studies differ methodologically, they both confirm that the concerns regarding the commencement of MUP did not materialise. MUP is an important element of a suite of recommendations that complement each other to reduce alcohol-related harms, and the Public Health (Alcohol) Act 2018 places Ireland at the forefront of those countries taking legislative action to address these issues.

1    World Health Organization (WHO) Regional Office for Europe (2020) Alcohol pricing in the WHO European Region: update report on the evidence and recommended policy actions. Copenhagen: WHO Regional Office for Europe.
https://www.drugsandalcohol.ie/32286/

2    Office of the Attorney General (2018) Public Health (Alcohol) Act 2018. Dublin: Irish Statute Book. https://www.drugsandalcohol.ie/33698/

3    Dimova ED, Strachan H, Johnsen S, et al. (2023) Alcohol minimum unit pricing and people experiencing homelessness: a qualitative study of stakeholders’ perspectives and experiences. Drug Alcohol Rev, 42(1): 81–93.
https://www.drugsandalcohol.ie/37215/

4    Francesconi M and James J (2022) Alcohol price floors and externalities: the case of fatal road crashes. J Policy Anal Manage, 41(4): 1118–1156. https://www.drugsandalcohol.ie/37307/

5    World Health Organization (2021) Global Health Observatory data repository, 2020. https://www.drugsandalcohol.ie/29703/

The Irish context

Professor Ivers introduced the event and provided the Irish context in relation to recovery. She argued that Reducing Harm, Supporting Recovery (2017–2025), the current national drugs strategy, is vague in relation to recovery and how it is to be supported through the existing action plan.² She called for more support in Ireland for approaches that build recovery capital across all areas, including health, housing, education, training, social services, and justice.

Key messages

Speakers argued for recovery to become more of a central tenet of drug policy and the profile of services and supports available to people who use drugs. To do so, they emphasised the importance of building support among policymakers and other stakeholders for recovery and the mechanisms required for recovery capital.

Underpinning the presentations was the speakers’ understanding that people who withdraw from drug use face ongoing challenges, for example, in experiencing an impaired ability to regulate for stress in the years post-withdrawal. Generally speaking, they argued that while treatment services are broadly effective in supporting people through withdrawal (e.g. through 12-week programmes), the service landscape was less well-equipped to support recovery in the longer term. They made the case for increasing support for services and supports for long-term recovery and building recovery capital. There was recurring evidence throughout the presentations that being part of a positive social network and engaging in meaningful activities (that support physical and psychological wellbeing) are key to developing and maintaining recovery. Peer support was placed at the centre of recovery.

Some speakers presented on the experience of providing recovery support for students in third-level institutions. The term ‘collegiate recovery settings’ originated in the United States and they provide supports, such as accommodation, especially for those in recovery; peer support networks; and on-site counselling. They also work to reduce the stigma that presenters argued exists in the third-level environment, by students who do not engage in the use of alcohol and other drugs.

Resources

Resources identified for those interested in recovery and its evidence base were the Recovery Research Institute in Massachusetts³ and a repository of papers by addiction and recovery expert William White.⁴ 

1    The speakers were Professor Jo-Hanna Ivers, Trinity College Dublin; Professor John Kelly, Harvard University; Professor David Best, Leeds Trinity University; Dr Ed Day, University of Birmingham; Professor Emily Hennessy, Harvard University; Professor Keith Humphreys, Stanford University.

2    Department of Health (2017) Reducing Harm, Supporting Recovery: a health-led response to drug and alcohol use in Ireland 2017–2025. Dublin: Department of Health. https://www.drugsandalcohol.ie/27603/

3    For further details on the Recovery Research Institute, visit: https://www.recoveryanswers.org/

4    For further details on the William White papers, visit: https://www.chestnut.org/william-white-papers/

Background

Parental problem alcohol use (PPAU) refers to where a parent’s alcohol use impacts the welfare of the child or results in their maltreatment. It is not necessarily the quantity of alcohol consumed by the parent that can result in adversity, rather the pattern of use, the motivation for use, and its consequences. PPAU has been identified as one of the ‘toxic trio’ or the ‘trigger trio’ (along with parental mental health issues and/or learning disability, and domestic violence) that has a significant impact on child wellbeing.

Prevalence and impact of parental problem alcohol use

PPAU is estimated to impact 12.4% of the population of Ireland, both children and adults. In excess of 250,000 children currently live with adults who drink in a hazardous manner. Such alcohol use can have detrimental impacts on the children in those households and, as such, PPAU has been classified as an adverse childhood experience (ACE). Exposure to ACEs during childhood can affect health and development and can have a long-lasting negative impact. Living with PPAU can increase the risk for other ACEs, including neglect (both physical and emotional), abuse (emotional, physical, and/or sexual), parental mental health issues, and parental separation or divorce.

Children living with PPAU, or adult children of alcoholics, have described feeling embarrassed by their parents’ drinking behaviour, as well as feelings of guilt, frustration, and anger. They are also more likely to experience violence; adopt avoidant coping strategies; experience poor mental health, including being more likely to attempt suicide, in particular if maternal problem drinking is present in their lives; and living with PPAU can impact their relationships with others through to adulthood. Experience of PPAU has also been associated with earlier alcohol initiation, steeper escalation of alcohol use (compared with their peers without PPAU), and problem substance use in the child. However, as PPAU often co-occurs with other ACEs in the individual’s life, it is difficult to identify PPAU as the sole cause of such adverse outcomes.

‘Parentification’, where the child takes on parenting roles and responsibilities, has been described as a consequence for many children living with PPAU. It often results from the child’s need to regulate their own needs for attention, comfort and guidance, to provide a sense of control, to manage the stressors in their lives, but also to provide for their parents’ emotional needs. Such role-reversal has been found to have a significant impact on the mental health of the child, through to adulthood. Children exposed to PPAU have also been found to develop behaviours as a form of escapism from their situation; for example, participating in multiple extracurricular activities to avoid being at home.

Supports in Ireland

Despite PPAU being recognised as an ACE, there are no specific supports in Ireland equipped to deal with the complexities of children affected by PPAU. Many barriers exist to accessing available supports such as stigma, denial, secrecy, a lack of confidence, fear, and embarrassment, and often the focus is on treating the parent’s alcohol use but with little emphasis on the child’s needs. Also noted in the literature is the earlier intervention for children affected by problem drug use (illegal substances) compared with PPAU, resulting in the latter being exposed to adversity for longer. The Silent Voices initiative from Alcohol Action Ireland has urged the Government to fund services for those affected by PPAU and work to raise awareness of the issue among parents, educators, health professionals, the media, policymakers, and others who interact with children.² Silent Voices is advocating for an initiative like that of Operation Encompass³ in the United Kingdom to be implemented in Ireland. Operation Encompass guarantees that where children are present at a police-attended domestic violence incident, the children’s school is notified, thus ensuring that services and supports are made available to the child.

Methods

In the survey, the responses of 132 mental health professionals were examined to determine their experience of working with clients who have experienced PPAU. The survey looked at their awareness, attitudes, knowledge, any training they received, and included open-ended questions which were analysed using thematic analysis.

Results

The majority of respondents were female (74%) and worked across the private and public sector, hospitals, charities, universities, and addiction clinics. Their experience in their role varied from less than 1 year to more than 25 years. Most had not received PPAU-specific training (70%), illustrating how mental health professionals have inadequate resources to meet the needs of their service users. Most respondents indicated that they would be in favour of training to enable them to identify children who have experienced PPAU (92%) and 97% supported anonymous data collection of PPAU prevalence through reporting to a central database, such as the Health Research Board (97%).

Less than one-quarter of mental health professionals who responded to the survey reported that they routinely ask their clients about PPAU (24%), with addiction counsellors and cognitive behavioural therapists most likely to ask (64% and 63%, respectively). Those who responded that they do not always ask their clients about PPAU were further prompted to expand on the scenarios when they would ask about PPAU. Four themes emerged:

1   A selective approach to enquiry (e.g. childhood difficulties, mental health difficulties, and financial and/or relationship difficulties)

2   Intergenerational problem substance use

3   Universal screening for PPAU

4   The exploration of PPAU only when disclosed.

Mental health professionals highlighted that their adult clients often reported how experiencing PPAU in childhood impacted their own parenting style and how they consciously strive to avoid repeating their parents’ behaviours. The most common protective factor identified was that of ‘one good adult’, a positive relationship with someone who shields the child from the potential distress of their PPAU experience. Certain traits and skills were also identified that act as protective factors, including extraversion, creativity, and intelligence along with education, extracurricular activities, having an awareness that their situation is not/was not within their control, and the value of talking to a mental health professional about their experiences.

Discussion

The study confirmed that many mental health professionals have not received adequate training to identify or deal with clients who have experienced PPAU but are amenable to such. The authors suggest conducting further research to identify why this lack of training exists and to identify potential barriers to accessing training. The risk and protective factors identified in the study correlated with those found in the literature and how co-occurring ACEs are prevalent among this population. The study also highlighted areas where interventions and programmes are most needed to reduce the impact of PPAU, specifically how supports outside the family home should be accessible and available to children.

1    Feeney M and Lambert S (2022) Understanding the views of professionals of the impact of parental problem alcohol use on clients. Dublin: Alcohol Action Ireland.
https://www.drugsandalcohol.ie/37305/

2    For further information on the Silent Voices initiative, visit:
http://alcoholireland.ie/campaigns/silent-voices/

3    For further information on Operation Encompass, visit: https://www.operationencompass.org/

Background

The latest edition of Alcohol: No Ordinary Commodity^1,2 was published in November 2022 following on from the success of the previous two editions. The third edition provides an updated examination of alcohol-related harms globally, while also updating and critically reviewing the scientific evidence of global alcohol control policies.

Key findings

Five major issues are outlined in the book.

1. Alcohol as a leading contributor to death and disease worldwide

Alcohol continues to be a leading contributor to death and disease worldwide, linked to many health conditions and social problems, including cancer, heart disease, liver disease, self-harm, and domestic violence. Alcohol use not only impacts the person who drinks but those around them. Hence, the book outlines the substantial harm to the health burden of others, including road traffic deaths, homicides, child maltreatment deaths, and interpersonal violence. The book also outlines the growing alcohol use and related harms in low-income and middle-income countries and how policies to reduce per capita consumption have been opposed by the alcohol industry.

2. The alcohol industry: a nexus of considerable influence

The shift from multiple regional producers of alcohol products to a small number of transnational corporations has resulted in dominant corporate power of the major alcohol producers and trade associations that are hugely profitable and influence the political decisions that affect consumption and harm. This nexus of actors actively markets alcohol products to recruit more people who drink, build brand loyalty, normalise alcohol, and validate the industry’s role in the policy arena. This globalisation is facilitated by trade and investments agreements.

3. Strategies and interventions to reduce alcohol-related harm

The book rates 69 policy options as (1) best practices – those considered to be highly effective, supported in numerous studies, capable of reaching their target group, and relatively low in cost; (2) good practices – policies, strategies, and interventions considered a good investment but are less supported in the research and less effective than best practices; and (3) ineffective or potentially harmful policies and practices.

Pricing and taxation policies: The policy areas classified as best practices in the book were alcohol taxes that decrease affordability, noting that with price increases come less drinking and consequently less harms and problems. Tax increases reduce population-wide alcohol use, including among the heaviest drinkers and young people as well as providing governments with tax revenues, which in turn can be used to offset the costs of treatment, prevention, and enforcement. However, the authors note that alcohol taxes need to be substantial to be effective. One study included in the book highlights the case study of Lithuania, where substantial alcohol tax increases resulted in preventing over 1,000 deaths in 1 year alone along with economic gains. Minimum unit pricing (MUP), product-specific pricing, and special taxes targeting drinks favoured by children and young people were found to be good practices. Unsurprisingly, policies that increase the affordability are considered harmful and ineffective at reducing alcohol use and related harms.

Regulating physical availability: Limiting the hours and places of alcohol sales, alcohol monopolies that are welfare-orientated, and age restrictions to purchase alcohol are considered best practices. Less effective but rated as good practices are restricting outlet density; promoting lower-strength alcohol products; preventing alcohol use and sale at an individual level, such as a court order; and prohibiting alcohol, where supported by religious or social norms. Ineffective practices were identified as those that increase outlet density. Evidence to support the best practice of reducing hours of sale was highlighted by the example of significant homicide reductions in a Brazilian city following earlier closing times.

Restrictions on alcohol marketing: Children and young people exposed to alcohol marketing are more likely to drink and to drink early. Those with alcohol dependence are more likely to relapse and experience cravings for alcohol when exposed to such marketing. Thus, predictably, total bans on alcohol marketing (best practice) and partial bans (good practice) are favoured over industry voluntary self-regulation of marketing (ineffective and harmful).

Drink-driving countermeasures: Dissuading drink-driving through monitoring and detection measures (e.g. checkpoints, breathalysing) were noted as the most effective policies. Good practices include low blood alcohol concentration levels, graduated licensing for young or new drivers, drink-driving courts, and interlock devices. Ineffective policies include severe punishment, designated driver programmes, safe ride services, education programmes, and victim impact statements.

Other good practices addressing alcohol use and harms: Several other approaches are acknowledged in the book as being good practices but with limited evidence of their effectiveness in reducing alcohol use and related harms. These include (1) education and persuasion strategies, such as public health campaigns promoting abstaining from alcohol, low-risk drinking guidelines, health warning labels, and school-based programmes; (2) modifying the drinking environment, for example, training and licensing of security personnel and bar staff, and policing approaches; (3) treatment in the form of therapeutic approaches, some pharmacotherapies, Alcoholics Anonymous (AA); and (4) early intervention to screen and provide brief interventions for hazardous and harmful drinkers, which is a cost-effective approach compared with most treatment services.

4. The policy process: multiple stakeholders, multiple agendas
The major stakeholders involved in alcohol policy often have competing values, interests, and ideologies. There are no international-level agreements to limit alcohol-related harms, unlike other psychoactive substances. For alcohol policy to use science in the public interest, there is a need for multinational processes to address the consequences of increasing globalisation of alcohol production, trade, and marketing.

5. Alcohol policies: a consumer’s guide

According to the latest alcohol policy research, best practices and good practices are more numerous and more effective than ever. No one single approach addresses alcohol-related harms, but along with the most effective best practices (e.g. price, availability, marketing controls), there are numerous other good practices that can contribute to reducing alcohol use and related harms.

Conclusion

The welcome publication of the third edition, a hugely valuable resource book for those working or interested in the public health approach to alcohol, like its two previous editions, contributes to an extraordinary advancement in the evidence base on alcohol policy issues.

Alcohol is no ordinary commodity. It is a carcinogen causing millions of deaths globally every year and yet it continues to be sold in the marketplace like many other products. This book seeks to stop the normalisation of drinking and to publicise the dangers of its use and highlight how poorly regulated it is. Not only does the third edition do this, but it also suggests effective and cost-effective solutions to reduce alcohol use and related harms.

Book launch and lead author visit to Dublin

The book was launched in the World Health Organization Regional Office for Europe in Copenhagen on 6 December 2022, with two of the main authors presenting the findings, Professor Thomas Babor and Dr Jürgen Rehm. Two days later, on 8 December, Professor Babor visited Dublin to again present a number of key findings from the book and participate in a discussion on alcohol policy.

1    Babor TF, Casswell S, Graham K, et al. (2022) Alcohol: no ordinary commodity – research and public policy. 3rd edn. Oxford: Oxford University Press. Available as a free e-book from:
https://www.drugsandalcohol.ie/37638/

2    Babor TF, Casswell S, Graham K, et al. (2022) Alcohol: no ordinary commodity – a summary of the third edition. Addiction, 117: 3024–3036. Available from:
https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.16003?af=R

Background

Across most high-income countries, youth drinking is in decline and researchers are increasingly focusing on the nature and underlying reasons for this decline. To explore this phenomenon, the Kettil Bruun Society for Social and Epidemiological Research on Alcohol¹ held a thematic meeting in Stockholm, Sweden, titled ‘Youth Drinking in Decline’. This three-day event held at Systembolaget conference facility on the island of Skarpö outside Stockholm brought together experts from around the world to discuss four overarching themes:

1   What are the key findings from the research on the nature and causes of the decline?

2   Which theories or explanations for the decline have been rejected and why?

3   What are the key unanswered questions or which theories, explanations or research areas have been neglected?

4   What are the research priorities going forward, including questions, infrastructure or data needs, dissemination or advocacy?

Presentations with perspectives from Germany, Sweden, Finland, United Kingdom, Australia, New Zealand, and Ireland were delivered to build greater understanding of the causes for the decline, the potential consequences, to where attention needs to be turned next, and how research can inform policymaking. All participants prepared and presented a paper on the topic of the conference theme.

Presentation themes

Historical origins of youth drinking in decline

The decline in youth drinking was first noted in the United States in the late 1990s and slowly spread to Nordic countries and by mid-2000 was observed in Australia, New Zealand, and Western Europe, including Ireland. Researchers have attempted to explain why more and more young people choose not to consume alcohol and the first theme of the event was to examine these possible explanations.

Theme 1: Key findings on the nature and causes of the decline

From the outset it was clear that there is no single reason for the decline, rather numerous influencing factors were discussed. A key point of discussion was how social media, online gaming, and technology use coincided with the timing of the decline and how it certainly is a contributing factor, as socialising face-to-face has decreased, but social media and technology use and gaming cannot be viewed as the causal explanation.

Neoliberalism discourses were at the heart of the event, whereby young people are expected to consider their older selves.² In a contemporary neoliberal society, this involves maintaining individual responsibility, exercising self-control, continually working for self-improvement, and where excessive alcohol use represents irresponsible and risky behaviour that reflects badly on the individual. As such, young people strive to meet higher educational expectations and are motivated to lead healthier lives. Being healthy, it seems, has become the new ‘cool’, but healthism is important too to young people and extends beyond alcohol use to include veganism, meditation, and mindfulness, symbolic of a fear of being unhealthy.

Attendees discussed how there has been a wider shift in adolescent behaviours. In focusing on the ‘self’, young people now view drinking less as more authentic, and peer pressure, which was a key driver of alcohol use in the 1990s, has decreased. However, the enthusiasm for the decline in youth drinking is marred by the disquieting evidence of the decline occurring in parallel with an increase in anxiety among young people. With the many competing activities in their lives, there is no ‘down time’. Is this why they are not as happy as previous generations?

Theme 2: Theories and explanations that we can reject and why

Despite an increase in other drug use noted in some of the countries examined, the theory that young people are substituting alcohol with cannabis and/or other drugs was dismissed. Furthermore, the immigration effect was rejected. The decline cannot be apportioned to the increase in immigrants from non-drinking communities within the countries where a decline has been noted. Also rebuffed was the notion that younger generations are rebelling against their binge-drinking parents, choosing not to emulate their behaviour. Parents do play a role in the decline, however. The increase in parental expectations for their adolescents has resulted in the younger generation seeking perfectionism, both academically and in other areas of their lives. Yet parenting has changed; it has become less authoritarian, rules are not dictated, and adolescents and parents alike agree rules and boundaries. Perhaps this interpersonal approach to communication between parents and their adolescent children has had this beneficial outcome.

The concept of ‘hardening’ was discussed, whereby the remaining young people who drink are described as a deviant or ‘riskier’ group, less susceptible to intervention, and at a higher risk of harm, similar to that witnessed in high-income countries that have experienced declines in smoking.³ However, as the decline is seen across all social groups and sexes, the consensus is that it has not resulted in hardening among those who do drink.

Theme 3: Unanswered questions and neglected theories

The group also discussed what areas may have been overlooked in the research on declining youth drinking that may contribute to a greater understanding. Research to date has not explored why the decline has plateaued; why the decline spread geographically as it did; why youth drinking increased so rapidly in the late 1980s to early 1990s; why the decline is more pronounced among boys in most countries examined; and have the media or indeed the alcohol industry played a role? Are there different drivers in different countries? To date, research has looked for common themes to explain the decline but perhaps it varies by country. There is no clear evidence available to explain or link the rise in poor mental health and its potential impact on alcohol use. All that is known is both have happened concurrently. These are but a sample of the many questions raised over the course of the event.

Theme 4: Research priorities going forward

With a room full of researchers, the conversation inevitably led to what future research priorities would be. The decline in youth drinking potentially has profound implications for what the population of the featured countries will look like in 20–30 years’ time. The consequences of the decline should now begin to be apparent. Suggestions were made on data sources that may now reflect the impact of the decline in drinking and the resulting implications for later initiation. A final word of caution was expressed as the group considered whether the impact of the Covid-19 pandemic could buck the trend.

Conclusion

Ultimately, there was a common goal of ensuring that they, as researchers, continue to explore why many young people shun alcohol, thus ensuring that policymakers are not allowed to become complacent in introducing policies to prevent alcohol-related harms.

1    For further information on the Kettil Bruun Society, visit: https://www.kettilbruun.org/

2    Törrönen J, Samuelsson E, Roumeliotis F andMånsson J (2021) Negotiating emerging adulthood with master and counter narratives: alcohol-related identity trajectories among emerging adults in performance-oriented neoliberal society. J Adolesc Res, Early online.

3    Livingston M, Raninen J, Pennay A and Callinan S (2023) The relationship between age at first drink and later risk behaviours during a period of youth drinking decline. Addiction 118(2): 256–264. https://www.drugsandalcohol.ie/36994/

Control status of nitrous oxide

Nitrous oxide is not currently a controlled substance under Ireland’s Misuse of Drugs Act 1977 and can be legally sold for catering and industrial purposes. The Criminal Justice (Psychoactive Substances) Act 2010 prohibits the sale, importation, or exportation of psychoactive substances and under this legislation it is illegal to sell nitrous oxide for its psychoactive properties.

Prevalence of nitrous oxide use

As prevalence of nitrous oxide use is not routinely collected in Ireland’s National Drug and Alcohol Survey, it is not possible to provide population prevalence estimates. The only source of data on adult nitrous oxide use is the Irish results of the 2021 European Web Survey on Drugs (EWSD),² which surveyed adults aged 18 years and over who had used illicit drugs in the last year. Of the 4,398 EWSD respondents who answered the question on nitrous oxide use, 1.1% reported last-month use and a further 3.7% had used nitrous oxide in the last year. In total, 23.3% had ever used nitrous oxide. Respondents aged 18–24 years were most likely to have used nitrous oxide in the last year (see Table 1).

Of those who reported last-year use of nitrous oxide, 89% reported infrequent use (1–11 days) and 11% reported occasional use (12–51 days); there were no sex or age group differences. On a typical day that nitrous oxide was used, 21.1% used no more than one canister, while 26.3% used at least 10 (see Table 2).

Table 1: Most recent use of nitrous oxide among Irish respondents in the European Web Survey on Drugs, by sex and age group

Table 2: Number of canisters typically used on a day that nitrous oxide is used, by sex and age group

Nitrous oxide use among young people

The Planet Youth Survey conducted among post Junior Certificate students in schools in North County Dublin in 2021 collected data on nitrous use among young people (<18 years).³ The questions on nitrous oxide were answered by 2,384 respondents. The main results were:

• 6.2% of young males and 5.3% of young females had ever used nitrous oxide.
• There were no significant differences in use by sex in the overall sample.
• Males attending 5th year had a significantly greater lifetime prevalence of use (11.9%).
• Heavy use (more than 40 lifetime uses) was low, at 1% for males and 0% for females.

Nitrous oxide use in festival settings

A 2019 online survey of 1,193 Irish festival attendees aged 18 years and over found that 28% had used nitrous oxide while attending music festivals in Ireland in the last year. Of those who had attended music festivals abroad (n=619), 38% had used nitrous oxide. Respondents to this survey typically used stimulant ‘club drugs’ mainly as part of a polydrug use pattern.⁴

Availability of nitrous oxide

To assist with the EMCDDA report, Merchants Quay Ireland undertook a short survey of 15 member organisations of the National Voluntary Drug and Alcohol Sector (NVDAS). None of the respondents had robust data concerning prevalence. However, 12 respondents stated that nitrous oxide was available in their area: eight believed it had increased in popularity in the last year, with four believing its popularity had remained the same. The sporadic nature of its popularity was also highlighted – respondents reported that it can be very prevalent for a number of months at a time and that it is particularly prevalent on weekends, midterm breaks, and bank holidays.

Regarding availability, one Dublin respondent noted that it is available in large blue bottles for €100 per bottle and also in smaller capsules that cost €50 per box. Young people arrange to buy it from a local nitrous oxide dealer as most shops will not sell it to them, despite being available in some discount shops.

Another respondent reported a difference in cost between online purchases, where it costs 30 cent per canister, and street purchases, where it can cost €2–€5 per canister. Respondents viewed nitrous oxide as a drug primarily used by younger people who also use other drugs. Two respondents identified a couple of distinct groups and contexts: early teens who use nitrous oxide in parks and wastelands and older teens who use it at house parties. It was noted that there is a growing trend for people in their early twenties to use it at parties or ‘preloading’ before going out.

Harms associated with nitrous oxide

Requests for information were submitted to a number of sources in order to assess the extent of nitrous oxide-related harm in Ireland. These were the National Drug Treatment Reporting System (NDTRS), the National Drug-Related Deaths Index (NDRDI), the Hospital In-Patient Enquiry (HIPE) scheme, and emergency departments.

In mid-2020, in response to anecdotal reports of increased use, the NDTRS added nitrous oxide to its system. In 2020, less than five episodes of treatment were reported. Preliminary data from 2021 indicate that 10 episodes of treatment were reported. The majority of these cases were male and the mean age was 16 years. All were new cases that had never received treatment before and most were polydrug users who also reported problem use of cannabis. The NDRDI recorded no drug poisoning deaths due to nitrous oxide for the period 2004–2017 inclusive. Data for 2018 onwards are not yet available.

In the HIPE scheme, poisoning by nitrous oxide falls under the ICD-10-AM code T41.0 – poisoning by inhaled anaesthetics.As this code is used for poisoning by any inhaled anaesthetic, it is not specific to nitrous oxide. However, analysis of discharges from 2018 to 2020 indicates that in this three-year period there were less than five discharges with a T41.0 diagnosis. A case report was published in 2022 describing the presentation of two young males to the emergency department of a large urban university hospital in Dublin with progressive neurological dysfunction related to nitrous oxide use.⁵ A case with subacute combined degeneration of the cord secondary to nitrous oxide use has also been reported by a hospital in Dublin.

Conclusion

While the information presented here would indicate that the prevalence of nitrous oxide use in Ireland is relatively low and that, to date, low levels of nitrous oxide-related harm have been reported, the recreational use of nitrous oxide is a growing public health concern. It will be important to continue to monitor trends in nitrous oxide into the future and therefore respond to changes in its use.

1    European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2022) Recreational use of nitrous oxide: a growing concern for Europe. Luxembourg: Publications Office of the European Union. https://www.drugsandalcohol.ie/37506

2    Mongan D, Killeen N, Evans D, Millar SR, Keenan E and Galvin B (2022) European Web Survey on Drugs 2021: Irish results. Dublin: Health Research Board. https://www.drugsandalcohol.ie/36571/

3    North Dublin Regional Drug and Alcohol Task Force (NDRDATF) (2022) ‘Improving health outcomes by understanding the lived experiences of young people in North Dublin’. Planet Youth Report 1. Dublin: Merlin Press.
https://www.drugsandalcohol.ie/36972/

4    Ivers J-H, Killeen N and Keenan E (2022) Drug use, harm-reduction practices and attitudes toward the utilisation of drug safety testing services in an Irish cohort of festival-goers. Ir J Med Sci, 191: 1701–1710. https://www.drugsandalcohol.ie/34860/

5    McCormick JP, Sharpe S, Crowley K, et al. (2023) Nitrous oxide-induced myeloneuropathy: an emerging public health issue. Ir J Med Sci, 192: 383–388. https://www.drugsandalcohol.ie/35688/

The most recent report presents the findings of 5,190 interviews of the 20-year-olds, which were conducted in 2018 and 2019.¹ Key findings regarding drug use are discussed below.

Any drug use

Figure 1 shows the prevalence of illicit drug use among 20-year-olds in the GUI study. Cannabis was the most prevalent drug, with 59% stating that they had ever tried it. More than one-quarter (28%) of all 20-year-olds said they had ever tried other non-prescribed drugs, with the most commonly reported drugs being cocaine (22% of all 20-year-olds had tried it at least once), ecstasy (17%), and ketamine (12%).

Cannabis use

It was found that almost one-quarter of 20-year-olds used cannabis at least occasionally (Figure 2), with 6% stating that they used cannabis once per week. Differences in the percentage of young adults taking cannabis occasionally or more often were observed in terms of both sex and parental education: a greater proportion of males took cannabis regularly (29% vs 18% females), as did a greater proportion of 20-year-olds whose parents had higher levels of education (degree or more, 28%, vs lower second level or less, 19%).

Prior experience with drugs was also found to be related to current cannabis use (see Figure 3). Young adults who had already tried cannabis by age 17/18 were more likely to be current cannabis users at age 20. In addition, they were more than twice as likely to be occasional users (34% vs 12%) and were also more likely to use more than once a week (16% vs 1%).

Figure 1: Illicit drug use (at least once) among 20-year-olds in Ireland, 2018–2019 

Source: GUI Ireland, 2021

Figure 2: Percentage of 20-year-olds who took cannabis occasionally or more than once per week, according to key background characteristics, 2018–2019

Source: GUI Ireland, 2021

Figure 3: Status regarding cannabis use at age 20, based on cannabis use at age 17/18, 2018–2019

1    O’Mahony D, McNamara E, McClintock R, Murray A, Smyth E and Watson D (2021) Growing Up in Ireland: The lives of 20-year-olds: making the transition to adulthood. Cohort ‘98. Report 9. Dublin: ESRI; Trinity College Dublin; Department of Children, Equality, Disability, Integration and Youth. https://www.drugsandalcohol.ie/35334/

Background

The eight wave of the Healthy Ireland Survey, carried out by Ipsos and commissioned by the Department of Health, involves a representative sample from the general population aged 15 years and over to increase knowledge of the population’s health and health behaviours.¹ The survey is central to the Healthy Ireland Framework and subsequent Healthy Ireland Strategic Action Plan as it enables research and is a mechanism to monitor and evaluate the impact of policy initiatives under the framework.^2,3

Telephone interviews took place with 7,455 respondents between November 2021 and July 2022. Along with questions about alcohol use, the survey examined general health, tobacco use, weight management, use of health services, dental and oral health, skin protection, menstrual health and period poverty, suicide awareness, and health behaviours during the Covid-19 pandemic.

Main findings on alcohol

Alcohol use

Two-thirds (67%) of the population aged 15 years and over reported consuming alcohol in the 6 months prior to the survey. Those aged 15–24 years (71%) and those aged 25–34 years (68%) were more likely to report consuming alcohol in the previous 6 months. Males (69%) were more likely than females (65%) to have consumed alcohol, although more young females aged 15–24 years (74%) reported alcohol use compared with males in the same age group (68%) (see Figure 1). In addition to more young females reporting alcohol use in the last 6 months compared to young males, there was a notable increase since the 2021 survey of females aged 15–24 years reporting alcohol use, from 67% in 2021 to 74% in 2022.

Figure 1: Percentage of respondents who consumed alcohol in the previous 6 months, by sex and age

Over one-half of drinkers reported drinking typically once per week (52%), while 32% reported drinking more than once per week. Males were more likely than females to report drinking multiple times per week (36% males vs 27% females).

Drinking behaviour changes since Covid-19

The percentage of respondents (13%) who reported drinking more since the start of the Covid-19 pandemic remained unchanged since the 2021 survey. However, in 2021, 42% of respondents reported that they were drinking less since the beginning of the pandemic, but this had decreased to 33% in 2022.

Binge drinking

Almost one-third (32%) of those who reported drinking in the previous 6 months reported binge drinking – defined as consuming six standard drinks or more in one sitting – higher than that reported in 2021 (22%). Males (48%) are more likely to report binge drinking compared with females (16%) and this applies to all age groups (see Figure 2).

Over one-quarter (27%) of parents who reported binge drinking on a typical drinking occasion indicated that children aged less than 16 years are present some of the time; this was slightly more commonly reported among fathers (29%) than mothers (24%).

Figure 2: Percentage of respondents who reported binge drinking in the previous 6 months, by sex and age

Drinking and social environments

More respondents who consumed alcohol (45%) reported drinking with one other person the last time they drank, 43% reported drinking with a group of people, and 11% drank alone. The latter was more common among male drinkers (16%) than female drinkers (7%) and among those who were unemployed (21%) and retired (17%).

Drinking at home was the most common location reported among drinkers (44%), with 30% drinking in a pub (more common among younger drinkers at 42%), 13% in a restaurant, hotel or café, and 10% drinking in someone else’s home on the last occasion they drank.

Conclusion

The Covid-19 pandemic has had an impact on drinking patterns, with more females in all age groups, except for those aged 25–34 years and those aged 75 years or more, reporting drinking in the last 6 months compared with the 2021 survey findings. The percentage of older males (75 years or over) reporting drinking in the last 6 months increased from 52% in 2021 to 62% in 2022. And although binge drinking has not returned to 2018 levels (28% of the population), it is higher in 2022 (22%) compared with the 2021 survey (20%), indicating that binge drinking has almost returned to pre-pandemic levels, particularly among males.

1    Ipsos (2022) Healthy Ireland Survey 2022: summary report. Dublin: Government Publications.
https://www.drugsandalcohol.ie/37636/

2    Department of Health (2013) Healthy Ireland: a framework for improved health and wellbeing 2013–2025. Dublin: Department of Health. https://www.drugsandalcohol.ie/19628/

3    Department of Health (2021)Healthy Ireland strategic action plan 2021–2025. Dublin: Government of Ireland.
https://www.drugsandalcohol.ie/34172/

The reports present an overview of baseline data on health and wellbeing indicators as well as associated risk and protective factors.

Planet Youth

As outlined previously in Drugnet Ireland, Planet Youth aims to prevent drug use among young people.⁴ It takes a universal approach to prevention and targets the whole population of young people in a community, rather than as individuals or groups. Developed in Iceland, Planet Youth is grounded in evidence-based practice; a community-based approach; and creating and maintaining a dialogue among research, policy, and practice.⁵ There are three key components to the programme: data collection and analysis that map out the nature of the risk and protective factors facing young people; implementing prevention activities through a wide range of stakeholders to increase protective factors and reduce the risk factors; and reflection and learning. The reports published in 2022 deal with the first component.

Coverage

The surveys in Fingal, Cavan, and Monaghan were carried out in Q4 of 2021. In Fingal, 2,677 young people completed the survey, while 882 did so in Cavan, and 845 in Monaghan. The young people were situated in secondary schools and alternative education settings (Youthreach) and were aged 15/16 years. Data were collected through the standard Planet Youth questionnaire, which includes 78 primary questions on health and wellbeing indicators. The findings from the surveys will be used to plan interventions to improve outcomes for young people living in these regions.

Reports

The published reports provide an overview of key findings and represent the first step in the development of a wider programme of prevention in the regions. As outlined in the Fingal report, the intention is that the North Dublin Regional Drug and Alcohol Task Force and other stakeholders will examine the dataset in more detail, using the findings to gain a better understanding of the challenges facing young people in the region.¹ They will then collaborate to develop appropriate responses.

Each report presents a set of key findings for the relevant region. While the reports from Cavan and Monaghan present the same analysis of a core set of indicators, Fingal chose to analyse different responses for its report. Examples of findings include:

• Across the three regions, young people tended to have positive attitudes towards their relationships with their parents and teachers, which was seen as an encouraging protective factor. In the Fingal report, authors identify parents and teachers as ‘important community allies to support improved outcomes’ (p. 7).¹
• Parents and carers feature heavily as the source of alcohol for young people across all regions. All of the reports recommend that parents and carers do not provide their young people with alcohol.
• In Cavan and Monaghan, it was found that teenagers that report high levels of unsupervised leisure time regularly are six times more likely to use cannabis.
• In Fingal, vaping was identified as a specific risk behaviour – 32% had a lifetime use, while 18% used in the last 30 days. Lifetime use of nitrous oxide was also identified (6%), although it was associated with specific social events rather than regular usage.
• In Fingal, it appeared that attitudes and perceptions of risk impact on levels of substance use. Where there was a lower perception of risk or harm, there appeared to be a correlating increase in consumption levels. It was recommended that existing partners and initiatives, who were well-placed, should strengthen health promotion initiatives that target parental, youth, and community perceptions of harm in the region.

Finally, across the three regions, it was recognised that further analysis of the data will be warranted to inform responses that meet the needs of young people and reduce their drug use.

The Fingal report summarised its key findings on substance use in the following infographic (p. 18).¹

1    North Dublin Regional Drug and Alcohol Task Force (2022) ‘Improving health outcomes by understanding the lived experiences of young people in North Dublin’: North Dublin risk and protective factors Planet Youth report 1. [Fingal report]. Dublin: Merlin Press. https://www.drugsandalcohol.ie/36972/

2    Planet Youth (2022) Growing up in Monaghan. Monaghan: Planet Youth. https://www.drugsandalcohol.ie/36707/

3    Planet Youth (2022) Growing up in Cavan. Monaghan: Planet Youth. https://www.drugsandalcohol.ie/36706/

4    Dillon L (2020) Strategy and intervention framework for Planet Youth. Drugnet Ireland, 74 (Summer): 21–23.
https://www.drugsandalcohol.ie/32737/

5    Sigfúsdóttir ID, Thorlindsson T, Kristjánsson AL, Roe KM and Allegrante JP (2009) Substance use prevention for adolescents: the Icelandic Model. Health Promot Int, 24(1): 16–25. http://www.drugsandalcohol.ie/28656/

Rates of self-harm

There were an estimated 12,553 recorded presentations of deliberate self-harm in 2020, involving 9,550 individuals. Taking the population into account, the age-standardised rate of individuals presenting to hospital in the Republic of Ireland following self-harm was 200 per 100,000 population (see Figure 1). This was a decrease of 3% compared with the rate recorded in 2019 (206 per 100,000) and 10% lower than the peak rate recorded by the registry in 2010 (223 per 100,000).

In 2020, the national male rate of self-harm was 176 per 100,000 population, 6% lower than in 2019. The female rate was 224 per 100,000 population, which was 1% lower than in 2019. With regard to age, the peak rate for males was in the 25–29-age group, at 430 per 100,000 population. The peak rate for females was among 15–19-year-olds, at 779 per 100,000 population.

Source: National Suicide Research Foundation, 2022

‘All’ in the legend refers to the rate for both males and females per 100,000 population.

Figure 1: Person-based rate of deliberate self-harm, 2010–2020, by sex

Self-harm and drug and alcohol use

Intentional drug overdose (IDO) was the most common form of deliberate self-harm reported in 2020, occurring in 7,426 (62.2%) of episodes. As observed in 2019, overdose rates were higher among women (65%) than among men (58.6%). Minor tranquillisers and major tranquillisers were involved in 33% and 10% of drug overdose acts, respectively. In total, 33% of male and 48% of female overdose cases involved analgesic drugs, most commonly paracetamol, which was involved in 31% of all drug overdose acts. In 66% of cases, the total number of tablets taken was known, with an average of 28 tablets taken in episodes of self-harm that involved a drug overdose.

Although the proportion of self-harm presentations to hospital involving IDO in 2020 was similar to that recorded in 2019 (62%), there was an increase in self-harm presentations involving street/illegal drugs. Since 2007, the rate per 100,000 population of IDO involving illegal drugs has increased by 100% (from 9.9 to 19.6 per 100,000). The male rate has increased by 91% (from 14.6 to 27.9 per 100,000), while the female rate has increased by 111% (from 5.3 to 11.2 per 100,000) (see Figure 2).

Cocaine and cannabis were the most common street drugs recorded by the registry in 2020, present in 8% and 4% of overdose acts, respectively. Cocaine was more common among men than women and was involved in 23% of overdose acts by 25–34-year-olds. Cannabis was most common among men aged 15–24 years and was present in 11% of overdose acts. Alcohol was involved in 33% of presentations and was more often involved in male episodes of self-harm than female episodes (38% vs 28%, respectively).

Source: National Suicide Research Foundation, 2022

Figure 2: Trends in rate of intentional drug overdose involving illegal drugs, 2007–2020, by sex

Recommendations

In 2020, there was a further increase in the proportion of presentations by persons experiencing homelessness. The report authors noted that this group of individuals represents a particularly vulnerable population – at high risk of repetition and mortality from all causes – and that further work to examine the specific risk and protective factors associated with self-harm among persons experiencing homelessness is required.

1. Joyce M, Chakraborty S, O’Sullivan G, et al. (2022) National Self-Harm Registry Ireland annual report 2020. Cork: National Research Foundation. https://www.drugsandalcohol.ie/37441/

Number of units provided and outcomes

From 2018 to 2020, there were 8,881 units of naloxone supplied by the HSE National Social Inclusion Office to service providers (see Table 1). Overall, 59% of units were intramuscular, with 41% intranasal. The majority of naloxone was administered by service provider staff (94%), with 3% administered by peers, 2% by an unspecified individual, and 1% by a general practitioner or a nurse. Between 2018 and 2020, it was reported that naloxone was administered to 569 people. Of these, 98% survived the overdose, with 9 deaths. The number of people receiving naloxone has fluctuated, with a 13% increase experienced in 2020 compared with 2018 (see Table 2).

Table 1: Number of naloxone units supplied to service providers, 2018–2020

Table 2: Naloxone administration by outcome, 2018–2020

Profile of those receiving naloxone

Age and sex information was supplied for 79% and 91% of those receiving naloxone, respectively. Between 2018 and 2020, 61% of those receiving naloxone were male, with this proportion significantly increasing from 51% in 2018 to 75% in 2020. Seventy-one per cent were aged between 25 and 44 years, with an average age of 37.6 years.

Other findings

Other notable findings from the report include the following:

• Four areas of Dublin City (Dublin 7, Dublin 1, Dublin 8, and Dublin 2) accounted for over two-thirds (67%) of overdoses where naloxone was administered.
• Some 51% of those that had received naloxone were reported to have taken more than one substance, with 35% taking two substances.
• Some 62% of people were reported to have overdosed by injection. Over two-thirds (68%) of those that had taken heroin had injected.
• It is estimated that the naloxone programme has saved the lives of at least 22 people between 2018 and 2020.

Seán Millar

1. Evans D, Bingham T, Hamza S and Keenan E (2022) Naloxone administration by addiction and homeless service providers in Ireland: 2018–2020. Drug Insights Report 2. Dublin: HSE National Social Inclusion Office.
   https://www.drugsandalcohol.ie/36455/

Period of growth and increasing need

The speakers at the launch of the annual report were Alan Connolly, chairman of the board of directors at Coolmine; Pauline McKeown, chief executive of Coolmine; Rachel Galvin, graduate of Coolmine Ashleigh House, and Matt Cooper, journalist and broadcaster. Speakers emphasised the ongoing commitment to Coolmine’s vision in which it ‘believes that everyone should have the opportunity to overcome addiction and lead a fulfilled and productive life’.

Alan Connolly spoke of the organisation going through a period of growth, with its expansion in the Mid-West and South West regions during 2021. In managing this growth, the organisation remains committed to providing high-quality services that produce enduring outcomes of quality for the people who use them.

Pauline McKeown emphasised the increased demand on their services and the impact of the Covid-19 pandemic on the experiences of people seeking help. The pandemic brought about a period in which people struggled to sustain their social and recovery capital, which in turn negatively impacted on people’s recovery. The year 2021 was a period of expansion for Coolmine, with a strong emphasis in 2022 of ensuring the appropriate governance was in place to manage a growing organisation.

Rachel Galvin spoke powerfully of her recovery journey and the support she received from Coolmine. She described the ‘sense of home’ she found during her time in Ashleigh House.

Two issues of concern raised by speakers and reiterated by the final speaker Matt Cooper were:

• The ongoing inequity in the salaries of Coolmine’s service providers when compared with their equivalents in State-run services.
• A need for funding to be able to reinstate the delivery of a community-based Parents Under Pressure (PuP) programme, which had been delivered in 2021 with the support of a grant from Rethink Ireland.

Highlights of report

Among the highlights of the report on Coolmine’s activities for 2021 were:

• 1,885 individuals accessed support from Coolmine’s services.
• There was an 85% retention rate in the Ashleigh House service – 63 women were supported through the service, including 18 mother-and-child residential placements, and 30 children provided with a full-time early years and preschool service.
• There was a 76% retention rate in Coolmine Lodge, which provides a residential service for men. Some 90 men were supported, 27% of whom were from the probation/prison services.
• 57 people from the Traveller community were supported by the services.
• 118 individuals were worked with in Coolmine Mid-West, which achieved a 100% retention rate for its Reduce the Use and PuP programmes.

Lucy Dillon

1    Coolmine (2022) Coolmine annual report 2021. Dublin: Coolmine. https://www.drugsandalcohol.ie/37483/

Doyle A, O’Dwyer C, Mongan D, et al. (2022) BMC Public Health, Early online.
https://www.drugsandalcohol.ie/37780/

This study examined factors related to awareness of the association between alcohol use and breast cancer risk.

As breast cancer is a prevalent disease among women in Ireland, it is essential that the public, in particular women who drink, are made aware of this association. Public health messages that highlight the health risks associated with alcohol use, and which target individuals with lower educational levels, are warranted.

Duggan B and Mohan G (2022) Journal of Gambling Studies, Early online.
https://www.drugsandalcohol.ie/37798/

This paper develops and expands upon social identity theory as an explanation for gambling among youth engaged in team sport.

Analysing longitudinal data for over 4,500 20-year-olds from the Growing Up in Ireland study reveals that online gambling increased from 2.6 to 9.3% between 17 and 20 years in the cohort, with the increase driven by males.

Foley M, Reidy M and Wells JSG (2022) Journal of Substance Use, 27(3): 283–288.
https://www.drugsandalcohol.ie/37216/

Stakeholder’s views on the role of recovery capital, including issues and barriers, that might address service provision for individuals with alcohol- and drug-related problems are important for improving outcomes.

This research highlights the need for greater integration between policy and practice. Providing an assessment of evidence-based recovery-orientated interventions is likely to improve the system.

Sheedy O’Sullivan E, McCarthy KM, O’Neill C, et al. (2022) International Journal of Environmental Research and Public Health, 19(23): 16096. https://www.drugsandalcohol.ie/37749/

The current study sought to investigate these impacts [of COVID-19 on university students’ health and lifestyle parameters] within an Irish university setting. A cross-sectional design was employed, with a 68-item questionnaire instrument disseminated to all Year 2 undergraduate students in the host institution (N=2752), yielding a 9.7% response rate (n=266). This questionnaire elicited students’ self-reported changes to health-related behaviours, mental well-being and academic engagement across 4 defined time-points: (T0: prior to COVID-19, T1: initial onset of COVID-19, T2: during COVID-19, and T3: time of data collection). Many items were adapted from previous Irish research and additional validated scales included the Alcohol Use Disorders Identification Test (AUDIT-C) and the World Health Organisation’s Well-being scale (WHO-5).

Worryingly, AUDIT-C scale data revealed hazardous drinking habits were evident in both males and females.

Critchlow N, Moodie C, Mackintosh AM, Gallopel-Morvan K, et al. (2022) Journal of Studies on Alcohol and Drugs, Early online.
https://www.drugsandalcohol.ie/37702/

This study examined (1) changes in awareness [of alcohol advertising] two years post-restrictions, when COVID-19 mitigation measures had eased; and (2) how changes in Ireland compare to Northern Ireland, where the restrictions do not apply.

Ireland’s restrictions have reduced past-month awareness of alcohol advertising at the cinema and on public transport, but not outdoors. Continued monitoring is required.

Reddon H and Ivers J-H (2023) Addiction Research & Theory, 31(2): 148–154.
https://www.drugsandalcohol.ie/37292/

The present study was conducted to estimate the association between measures of hope for the future and time to substance use relapse among people living with opioid dependence following their discharge from opioid detoxification programs.

In the present study, increased mean levels of hope were associated with slower rates of relapse among people living with opioid dependence following discharge from detoxification programs. These findings suggest that empowering people in recovery and providing additional support following services such as detoxification may be valuable strategies to reduce relapse rates among people living with opioid dependence.

Healy R, Goodwin J and Kelly P (2022)International Journal of Drug Policy, 110: 103901.
https://www.drugsandalcohol.ie/37442/

This paper explores the narratives of service users of contemporary methadone maintenance treatment services (MMT) in the Republic of Ireland to obtain their perspectives in the context of them negotiating their right to health.

The treatment of service users, based on human rights principles such as equality, respect, autonomy, empowerment and personal choice, remains aspirational and is unlikely to be fulfilled without addressing more systemic challenges such as funding, training of staff, service culture, governance and independent oversight of MMT services.

Mac Dhonnagáin N, O’Reilly A, Shevlin M, et al. (2022) Child Psychiatry & Human Development, Early online.
https://www.drugsandalcohol.ie/37279/

This study aimed to identify risk factors among youth attending Jigsaw, a youth mental health service in Ireland.

The findings provide insight into associations between young people’s identified presenting issues and self-identified distress. Implications include applying appropriate therapeutic modalities to focus on risk factors and informing routine outcome measurement in integrated youth mental health services.

Kelly P, Hegarty J, Dyer KR and O’Donovan A (2022) Drugs: Education, Prevention and Policy, Early online.
https://www.drugsandalcohol.ie/37350/

The objective of this multi-site cross-sectional study was to identify and understand how client characteristics and staff perceptions of organizational functioning related to client engagement in community-based opiate substitution therapy services in Ireland.

This paper provides valuable information for policymakers and provides an ample basis for further exploration of how treatment organizations work, and not just that they work.

Drugnet Ireland is the quarterly newsletter of Ireland’s focal point for the EMCDDA and is produced in collaboration with the HRB National Drugs Library. Drugnet Ireland is published by the Health Research Board.

Managing editor:     Brian Galvin
Copyediting:            O’Hanlon Media

© Health Research Board, 2023
 

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A key part of this reform is a radical shift in the allocation of resources to support an integrated model of care in place of the current heavy reliance on acute hospitals. This shift must also be matched by greater equality in the geographical distribution of resources. Historically, health resources in Ireland are allocated based on existing level of service patterns, which makes it difficult to match the quality of care provided with those countries that apply more robust mechanisms of resource allocation. The Irish health reform programme has driven considerable academic and research interest in identifying the most appropriate mechanisms of resource allocation to create a more equitable health system. This article looks at some Irish research and commentary in this area.

Regionalisation and resource allocation

As part of Ireland’s development of a universal healthcare system, health policymakers are considering the approach to population-based resource allocation (PBRA) based on the six regional health areas (RHA) established under the Sláintecare health reform programme in 2017. RHAs will be regional divisions within the Health Service Executive (HSE) with the objective of aligning hospital and community care services and promoting innovation, integrated care, efficiency, clinical and corporate governance, and accountability. PBRA policies can facilitate the decentralisation process by allocating healthcare resources in a way that is sensitive to local population profiles and regional variation. Implementing a population-based health funding model would link expenditure to population characteristics to estimate future need for healthcare and could improve transparency and predictability in the allocation of funding. This could allow for greater ability to forecast required healthcare expenditure over the medium and longer term.

Resourcing non-acute hospital health services in Ireland

Implementing an effective system of resource allocation needs careful consideration of current resourcing of health services, particularly in the non-acute area. A 2019 report by Smith et al. on the supply of, and the need for, non-acute care in Ireland found that there were significant inequalities in the supply of primary, community, and long-term care services across Irish counties.³ The authors state that this inequality can partially be explained by the absence of any formal resource allocation system and the persistence of historical budgeting for community-based care. The report was commissioned to inform policymakers planning non-acute services and building capacity in the context of the Sláintecare reforms. When judging whether there was an inequitable supply of care across regions, the report took into account demographic differences, such as age, disability, and chronic illness rates, as these have a significant bearing on healthcare need. The supply per capita, based on identifying services in a particular area, is adjusted based on healthcare need indicators in that area. Inequity can be established by the extent to which supply did not meet need in some areas, or exceeded it in others. The results of the report’s analysis consistently show that needs adjustment does not remove inequities in supply. Some regions are significantly under-resourced in terms of supply of non-acute healthcare services.

Availability of information and health service reform

Smith et al. collated and combined available data to provide a detailed profile of the supply of non-acute health services across regions. This represents the most comprehensive account of non-acute care supply in Ireland that has been prepared to date. While this is a valuable new information resource, reform of allocation mechanisms will be impeded if there are not improvements in the accuracy and timeliness of data on both the demand for and the current supply of health services. Greater integration in the Irish health and social care system faces the challenges of insufficient evidence on the capacity of the non-acute sector to meet current and future demand. The report identifies a historic failure to invest in surveillance and survey-level data. Developments such as the Growing Up in Ireland survey, The Irish Longitudinal Study on Ageing (TILDA), and the Healthy Ireland Survey have aided health policy decision-making, but significant gaps remain.

Resource allocation models

Despite a lack of consensus on the approach to modelling, many health systems favour PBRA models as they are seen to promote equity in outcomes, support reform, and encourage stakeholder involvement and support. Two reviews published in 2021 looked at the impact and implementation of PBRA models in a number of countries. In the models studied in these reviews, resource allocation is determined largely by the profile of local populations, based on the entire range of determinants of health and wellbeing, and on the measurement of the population’s health needs.

Review of international PBRA models

The first review by Johnston et al. summarised recent evidence and found that all the models studied used population size as a starting point for determining resource allocation requirements, adjusting in different ways for direct and indirect factors such as age, gender, morbidity or, less commonly, ethnicity and rurality.⁴ These models used different variables to account for population need. However, they shared several guiding principles with regard to the nature of the variables selected. The review found that PBRA models promote technical efficiency and equity in terms of health outcomes and access, but care must be taken to ensure that funding aligns with policy objectives especially when undergoing a regionalisation or decentralisation process. PBRA is viewed as a valuable policy lever to promote equity in health outcomes and access to services. It is essential that the selection of the model be based on clearly defined objectives, whether it is equity in outcomes, matching needs or regional equality. Important contextual considerations for the implementation of a PBRA model in Ireland include the proportion of funding covered by the model, the range of services covered, compensation for regional differences, and determinants of costs.

Reliable data on the factors relevant to modelling health needs and robust information on cost are essential for describing this context accurately. The collection, management, and analysis of these data in turn require expertise in several disciplines and well-supported analytical capacity. Successful implementation of a PBRA model will require decisions to be made regarding regional delegation, including workforce planning and recruitment and support in using funding effectively.

Department of Health spending review

Building on the Johnston et al. review, a Department of Health spending review considered what is the most appropriate PBRA model to be implemented as part of the Sláintecare reform programme.⁵ The Department of Health report investigated reviewing policy and technical documents related to PBRA in a sample of formulae from six countries, selected partly on the basis that they use a similar funding for their health systems as Ireland is hoping to implement under Sláintecare.

One of the study’s considerations is how the different systems established the relationship between need indicators and healthcare costs, which can then be used to account for differences in geographical areas and estimate expenditure. Population size, age and sex, socioeconomic status or deprivation, ethnicity, and standardised mortality ratio (SMR) or mortality were indicators common to all the formulae studied. Less common were geographical area/place of residence (geographical) (rural versus urban), ethnicity, and cross-boundary flows.

Selecting indicators is a complex and potentially contentious process. It is also contingent on the extent and quality of data available, for instance on morbidity, which is an indicator closely related to healthcare needs, and the availability of relevant and recent research on needs factors. The linkage between needs factors is often difficult to determine and there are usually historical political and administrative practices that should be considered. Age, with the higher need for healthcare in early and later stages in life, and sex, because of the different healthcare needs of men and women, are demographic indicators common to all the PBRA formulae examined. Methods of disaggregation of ages vary between countries. Various measures of socioeconomic status or deprivation are included in all of the models examined, with ethnicity used in countries with large indigenous populations such as Canada and New Zealand, and unmet needs sometimes used as an indicator to divert resources to population centres that have a high level of poor health outcomes. Geographical impacts on the cost of delivering health services and rurality or remoteness are common indicators.

Role of data in designing PBRA models

Data availability on healthcare costs, the distribution of needs, and healthcare supply is the factor that most limits the choice of resource allocation model. Some countries support comprehensive data systems that record individual healthcare costs which can be linked to other databases providing information on other indicators. However, most countries rely on non-administrative sources of information such as health surveys. The lack of a unique health identifier means that Ireland is not yet in a position to pursue the type of approach taken in countries that can match utilisation and costs with other indicators such as socioeconomic status.

Linberg et al.’s investigation of a sample of PBRA formulae from the countries reviewed helped to inform the selection of Irish data sources to support a potential PBRA model.⁵ The Central Statistics Office (CSO) Census of Population and the Department of Health’s Healthy Ireland Surveys were found to be the most useful and reliable data sources for the purposes of designing a PBRA model. Census data provide valuable demographic information and support the examination of regions by socioeconomic, ethnicity, health status, and rurality/urbanity variables. There are limitations to using Census data for this purpose but initiatives like the HP Deprivation Index, a combination of 10 key indicators, serves as a proxy for deprivation across regions. The Department of Health’s Healthy Ireland Survey of health and health behaviours is conducted annually and provides data for several of the indicators typically used by PBRA models. The review presents comparable data under a number of variables as a demonstration of the potential of both of these information sources to support the development of a PBRA in Ireland.

Conclusion

In this supplement to the 2023 Winter issue of Drugnet Ireland, geographical analyses of indicators of drug use are presented in various articles. Treatment demand mapped to Small Areas (SA)⁶ and population prevalence to Electoral Divisions (ED) demonstrates the geographical distribution of these indicators and current need for responses in these areas. In addition, by mapping treatment data to the levels of deprivation in Small Areas, which is calculated using the HP Deprivation Index, the socioeconomic determinates of drug use are clearly demonstrated. Treatment demand is a response to problematic drug use, but also serves as a reliable proxy indicator of prevalence. It will be possible to extend the range of these indicators to include data on consequences of substance use, such as drug-related deaths, and on problematic drug use to develop more detailed population-based pictures of the drug situation.

The reviews referred to above emphasise the difficulties presented by the lack of availability of the data required to build a regional profile of healthcare needs, an essential part of an effective resource allocation model. Ireland has a well-resourced and highly efficient system for monitoring substance use and a supply of timely, comparable, and detailed data in this area. By integrating data from this system with the kind of detailed population-based information and analysis provided by the deprivation model, it is possible to more accurately devise a measurement of needs for interventions designed to prevent, treat or reduce the harms associated with drug use.

1    Houses of the Oireachtas Committee on the Future of Healthcare (2017) Houses of the Oireachtas
Committee on the Future of Healthcare: Sláintecare report. Dublin: Houses of the Oireachtas.
https://www.drugsandalcohol.ie/27369

2    Department of Health (2018) Sláintecare implementation strategy and next steps. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/29415

3    Smith S, Walsh B, Wren M-A, Barron S, Morgenroth E, Eighan J, et al. (2019) Geographic profile of healthcare needs and non-acute healthcare supply in Ireland. Research Series No. 90. Dublin: Economic and Social Research Institute. https://www.drugsandalcohol.ie/30828

4    Johnston BM, Burke S, Kavanagh PM, O’Sullivan C, Thomas S and Parker S (2021) Moving beyond formulae: a review of international population-based resource allocation policy and implications for Ireland in an era of healthcare reform.HRB Open Res, 4: 121. Available from: https://hrbopenresearch.org/articles/4-121

5    Linberg C, McCarthy T and Department of Health (2021) Spending review 2021: impact of demographic change on health expenditure 2022–2025.Dublin: Government of Ireland. https://www.drugsandalcohol.ie/34728

6    Small Areas are areas of population comprising between 80 and 120 dwellings created by the National
Institute for Regional and Spatial Analysis (NIRSA) on behalf of Ordnance Survey Ireland (OSi) in consultation with the CSO. Small Areas were designed as the lowest level of geography for the compilation of statistics in line with data protection and generally comprise either complete or part townlands or neighbourhoods. There is a constraint on Small Areas that they must nest within Electoral Division boundaries. Small Areas were used as the basis for the enumeration in Census 2016. Available from: https://www.cso.ie/en/census/census2016reports/census2016boundaryfiles/

Introduction

SAs sit within Electoral Division boundaries and are the lowest level of geographic boundary in Ireland. They correspond to between 80 and 120 dwellings, relating to townlands or neighbourhoods. They were created by the National Institute for Regional and Spatial Analysis on behalf of Ordnance Survey Ireland in consultation with the Central Statistics Office (CSO).³

The National Drug Treatment Reporting System (NDTRS) is an epidemiological database of drug and alcohol use treatment in Ireland maintained by the Health Research Board (HRB) on behalf of the Department of Health. The national drug and alcohol strategy, Reducing Harm, Supporting Recovery: a health-led response to drug and alcohol use in Ireland 2017–2025, requires all publicly funded drug and alcohol services to complete the NDTRS for all people who use services (Action 5.1.47).⁴ The NDTRS includes cases (or episodes) treated in all types of services: outpatient, inpatient, low threshold, general practitioners, and those treated in prison.

The concept for a project to analyse the relationship between addiction treatment data and geographic deprivation in Ireland, arose from discussions between Pobal and the HRB. Both organisations were looking to maximise the use and impact of their data in such a way that better leverages decisions from a policy and operational planning perspective.

Research aims and methodology

The aim of this small-scale research project was to demonstrate the potential for geographic analysis of the HRB addiction (alcohol and other drugs) treatment data when mapped onto area-based disadvantage using the Pobal HP Deprivation Index.¹ This research can be viewed as complementary to the 2017 work of Haase and Pratschke² in that it seeks to further demonstrate the empirical relationship between deprivation and addiction treatment and/or prevalence. It should be noted that the metric of addiction treatment represents a response to drug use, but can be used as a proxy indicator for prevalence, which is the estimation of drug use within a population.

Using anonymised addiction treatment data, this paper presents findings on the relationship between addiction treatment and geographic deprivation, as categorised by the Pobal HP Deprivation Index.

Datasets used in analysis

As mentioned previously, the analysis used two datasets:

• NDTRS: Three years of anonymised NDTRS data on alcohol and drug treatment episodes (2019, 2020, and 2021) were included in the analysis.
• Pobal HP Deprivation Index: The Deprivation Index used a series of data points from the Census to ascertain levels of disadvantage under the three domains of demographic profile, social class composition, and labour market situation at the level of Small Area. The data underpinning the Deprivation Index used in the analysis is drawn from the 2016 Census. The Deprivation Index bands are based on a normal distribution curve, where the majority of individuals in the State live in areas that are marginally above average and marginally below average. Only around 15% of individuals live in deprived (or very/extremely deprived) areas, with a similar percentage living in affluent (or very/extremely affluent) areas.

Preliminary analysis of data

The aim of the project was also to undertake a preliminary analysis of the data, using a relatively straightforward methodology of first-order descriptive analytics. An anonymised dataset was provided by the HRB to Pobal for geospatial analysis. This dataset included the SA identity (ID) related to where the case resided 30 days prior to treatment. Other variables provided included the unique centre code; gender; problem (alcohol, opioids, cocaine, cannabis, and other drugs); year treated; treatment status (never or previously treated); and number of times treated in that centre in that calendar year. Pobal joined the SA ID with the Pobal HP Deprivation Index, as well as mapping the data spatially using ArcGIS software.

Following an initial analysis of the treatment data with Deprivation Index scores, it was decided that the national analysis required a reconceptualisation and reorientation of the data. This needed to be undertaken in such a way that also facilitated an assessment of SAs where there were no treatment records, so that these could be compared and analysed against areas that did include treatment episodes. This led to the creation of a dataset beginning with a list of all SAs, to which the sum total of drug treatment episodes, by episode type, was added. This allowed for a more comprehensive analysis of disadvantage characteristics associated with drug treatment episodes.

Coverage of Small Areas in NDTRS treatment data

In 2016, the NDTRS moved to a new online data entry portal. Since then, treatment records have included the SA associated with the residence of the treated case as part of routine data collection, through an arrangement with the Health Service Executive’s Health Atlas Ireland. The changeover of services from a paper-based system to the new online system took some time, so only data from 2019 onwards was included in the analysis to ensure that the best coverage of SA in the treatment data was included. In total, 70% of relevant addiction services participate in the NDTRS.

For the period 2019–2021, 91.5% of NDTRS treatment episodes had an associated SA. Missing SAs were due to a number of issues, but often because the address was unknown or unavailable, mostly in relation to homelessness.

Results

In total, 48,638 drug and alcohol treatment episodes with a SA code for the years 2019–2021 were provided for analysis, of which 46,004 (95%) could be associated with the necessary geographic information needed for categorisation under the Pobal HP Deprivation Index. Table 1 provides the number of drug and alcohol treatment episodes by deprivation category.

If there were no relationship between deprivation and drug and alcohol treatment, it would be expected that the number of episodes in very disadvantaged areas (n=3943) should be similar to the number in very affluent areas (n=555). However, there are substantially more treatment episodes recorded in disadvantaged areas than in affluent ones.

Table 2 presents the percentage of drug and alcohol treatment episodes by deprivation band compared with the percentage breakdown of the Pobal HP Deprivation Index in the overall population. For example, while 2.8% of the population live in SAs classified as ‘very disadvantaged’, 8.6% of all drug and alcohol treatment episodes are reported from these areas. This is even more pronounced when looking at drugs. Some 11.03% of all opioid treatment episodes are reported from very disadvantaged areas, but only 2.8% of the population live in these areas.

Putting drug and alcohol treatment data alongside the distribution of deprivation for the general population allows for the comparison and identification of which areas are under-represented and over-represented in terms of the number of treatment episodes. The proportion chart in Figure 1 shows a more visual representation of the distribution of opioid treatment by deprivation band in the population, as outlined in Table 2.

Table 2 also highlights that while the number of drug and alcohol treatment episodes reported from very affluent areas are low, they comprise a greater share of opioid drug treatments than for any other drug type. This may be attributable to codeine products rather than heroin or methadone or variations in reporting to the NDTRS, but it needs to be investigated further.

Figure 1 clearly demonstrates the relationship between deprivation and opioid treatment. While 14% of the population are from all areas of disadvantage, 42% of all opioid treatments are reported from these areas. While it is correct that there appears to be a relationship between area-based disadvantage and treatment uptake, it is not correct to say that drug and alcohol treatment is provided only to those from disadvantaged areas. Indeed, almost one-third of all treatment episodes are reported from areas of above average affluence, although this figure varies greatly by drug type.

For the purpose of this analysis, the metric of treatment episodes per 10,000 population was calculated for each Deprivation Index band for the three-year period of 2019–2021. The number of treatment episodes per 10,000 population in the bands ‘very and extremely disadvantaged’, as well as in ‘disadvantaged’, is considerably higher than for average and affluent areas (see Table 3). Of note, the data suggest that the difference between the three bands, ‘marginally above average’, ‘affluent’, and ‘very and extremely affluent’, is minimal. This requires further investigation. The slightly higher rate, 66 per 10,000 population, in the ‘very and extremely affluent’ band appears to be attributable to the higher number of treatments for alcohol, especially in rural areas of high affluence.

The same data in Table 3 are also presented in Figure 2, which visually demonstrates the relationship between Deprivation Index score and the rate of treatment episodes per 10,000 population.

A further analysis was completed by drug type using the CSO’s urban and rural classification, per 10,000 population (see Figure 3). Within urban areas, the linear trend of higher-reported drug and alcohol treatment episodes in disadvantaged areas can be observed across all drug types. However, in rural areas the rate of drug and alcohol treatment episodes for all drug types, apart from alcohol, is quite low across all deprivation bands.

Table 1: Number of NDTRS treatment episodes, by drug type and Pobal HP Deprivation Index band, 2019–2021

~ Cells with five cases or fewer

Table 2: NDTRS treatment episodes, by percentage drug type and general population, and Pobal HP Deprivation Index band, 2019–2021

Table 3: NDTRS treatment episodes per 10,000 population, by Pobal HP Deprivation Index band, 2019–2021

Figure 2: NDTRS treatment episodes per 10,000 population, by Pobal HP Deprivation Index, 2019–2021

Figure 3: NDTRS treatment episodes per 10,000 population, by Pobal HP Deprivation Index band, urban/rural classification, and drug type, 2019–2021

Conclusion

Health policy is increasingly framed in terms of furthering healthy outcomes and positive wellbeing.  The Sláintecare programme envisages a radical shift from acute hospital settings to community health supports with greater emphasis on self-care and prevention.^5,6 This will entail a more targeted distribution of resources to ensure services are provided where they are most needed. Substance use is an area where the social determinants of certain behaviours and outcomes is very apparent. This project demonstrates that it is possible and useful to map drug and alcohol treatment to the Pobal HP Deprivation Index. It demonstrates a relationship between area-based disadvantage and the prevalence of drug and alcohol treatment episodes. The analysis found, for example, that while just 14% of the national population come from the areas classified as disadvantaged on the Pobal HP Deprivation Index, 42% of drug treatment episodes, where opioids were the primary drug type, were reported from these areas.

When calculated as a measure of treatment episodes per 10,000 population, the relationship between disadvantage and drug and alcohol treatment is evident, with 293 treatments per 10,000 in very and extremely disadvantaged areas, while the rate ranged from 61 to 66 in all areas of above average affluence.

Treatment episodes for all drugs had a relatively linear relationship with deprivation, that is, higher in more deprived areas. However, this appears largely driven by urban areas. In rural communities, the overall rate of drug treatment episodes is lower for all drug types, apart from alcohol, and the relationships with area-based deprivation are less pronounced. This type of analysis may provide an opportunity to identify the communities where the need for prevention, treatment, harm reduction and rehabilitation services are most likely to be greater. 

The analysis shows that there is the potential to use Deprivation Index data as a means of objectively understanding or predicting levels of drug and alcohol treatment demand (i.e. drug prevalence). However, other factors, such as age profile and drug use patterns, and in particular the availability of treatment places and options, may also influence this relationship and should be considered alongside the data points presented above for any future analysis.

The analysis has raised a number of questions for further consideration. For example, the greater share of opioid drug treatments than any other drug type is reported from very affluent areas. Further analysis, along with the introduction of other factors, is likely to provide important perspectives on the demand for and allocation of drug and alcohol treatment services.

An impact analysis of the missing SA values in the NDTRS was not undertaken to ascertain if this could in any way introduce bias in the data analysis. If further more in-depth analysis is required, particularly at a more local level, then the impact of the missing values would need to be considered, especially in relation to non-participation in the NDTRS.

There is also the potential to expand the project to include other relevant data sources, for example, the National Drug and Alcohol Survey and the National Drug-Related Deaths Index. Some consideration could be given to the development of interactive maps of results and provide them to relevant stakeholders. In the meantime, the HRB will continue to work to improve the coverage of SAs in the NDTRS.

Next steps

The project will require additional input from a broader range of partners to progress this work of conducting further and more in-depth analyses of the relationship between addiction treatment and deprivation. This could be facilitated by an initial stakeholder workshop to consider findings and to identify areas for further investigation.

1    Haase T (2016) The 2016 Pobal HP Deprivation Index (SA). Dublin: Trutz Haase Social and Economic Consultants. Available from: http://trutzhaase.eu/deprivation-index/the-2016-pobal-hp-deprivation-index-for-small-areas/

2    Haase T and Pratschke J (2017) A performance measurement framework for drug and alcohol task forces. Dublin: Trutz Haase Social and Economic Consultants. https://www.drugsandalcohol.ie/27488/

3    Central Statistics Office (CSO) (2016) Census 2016 Boundary Files. Dublin: CSO. Available from:
https://www.cso.ie/en/census/census2016reports/census2016boundaryfiles/

4    Department of Health (2017) Reducing Harm, Supporting Recovery: a health-led response to drug and alcohol use in Ireland 2017–2025. Dublin: Department of Health. https://www.drugsandalcohol.ie/27603/

5    For further information on Sláintecare, visit:
https://www.gov.ie/en/campaigns/slaintecare-implementation-strategy/

6    Department of Health (2021) Sláintecare implementation strategy & action plan 2021–2023. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/34321/

1. Alcohol and drug treatment by regional health area

Background

Sláintecare is the Irish Government’s 10-year programme for transforming how healthcare is delivered in Ireland.¹ It aims to give equal access to services, with a vision of a universal health service, under the banner of Right Care, Right Place, Right Time. Part of this process is the creation of new healthcare areas that are based on population data, including on how people currently access services, in addition to being informed by a public consultation. In total, there are now six regional health areas (RHA) (see Box 1), encompassing 96 Community Health Networks (CHN).

Box 1: Regional health areas

Area A:         North Dublin, Meath, Louth, Cavan, Monaghan

Area B:         Longford, Westmeath, Offaly, Laois, Kildare, parts of Dublin and Wicklow

Area C:         Tipperary South, Waterford, Kilkenny, Carlow, Wexford, Wicklow, part of South Dublin

Area D:        Kerry and Cork

Area E:         Limerick, Tipperary North, Clare

Area F:         Donegal, Sligo, Leitrim, Roscommon, Mayo, Galway

Ensuring that the National Drug Treatment Reporting System (NDTRS) can provide data for the new Sláintecare areas will support the current Sláintecare reform programmes.²

• Programme 1: Improving Safe, Timely Access to Care and Promoting Health and Wellbeing is focused on integration, safety, prevention, shift of care to the right location, productivity, extra capacity, and achieving Sláintecare waiting time targets. 

• Programme 2: Addressing Health Inequalities is focused on a journey towards universal healthcare.

Methods

The NDTRS is the national epidemiological surveillance database that records and reports on treated problem drug and alcohol use in Ireland. Established in 1990, the NDTRS is maintained by the National Health Information Systems (NHIS) of the Health Research Board (HRB) on behalf of the Department of Health. Treatment for problem alcohol and drug use in Ireland is provided by statutory and non-statutory services, including residential centres, community-based addiction services, general practices, and prison services. The NDTRS records cases of treatment, as there is currently no national system-wide unique identifier in the Irish health system. In any given year, individuals may appear more than once if treated in different centres or if they return to treatment in the same centre.

NDTRS data are recorded on LINK, an online reporting tool. LINK utilises Health Atlas Ireland to record geographical markers automatically as cases are entered. Through Health Atlas, the NDTRS currently records small area (SA), community healthcare organisation (CHO), local health office (LHO), electoral division (ED), county, and task force area (TFA). Using a mapping guide provided by the Central Statistics Office (CSO), and existing geographical markers in LINK, it was possible to derive RHA and CHN from the current and historical NDTRS data. NDTRS data were then analysed using RHA to describe the national treatment data based on where the client resided in the 30 days prior to treatment.

The population for each RHA varies, ranging from 390,000 (Area E) to 1,080,000 (Area A) (see Box 2). Rates of treatment cases per 100,000 population for both alcohol (see Table 4) and drugs (excluding alcohol) (see Table 5) as main problems were analysed using Census 2016 population data for each RHA.

Box 2: Regional health area population*

Area A:     1,080,000

Area B:      1,000,000

Area C:      900,000

Area D:     690,000

Area E:      390,000

Area F:      710,000

* Census 2016 figure rounded

Results

Between 2016 and 2021, Area A (North Dublin, Meath, Louth, Cavan, Monaghan) accounted for the highest proportion (24.9%) of treatment episodes (drugs and alcohol) nationally (see Table 1). The lowest proportion of episodes (7.8%), where RHA is known, occurred in Area E (Limerick, Tipperary North, Clare) (see Table 1). A small proportion of episodes (3.3%) could not be attributed to an RHA, either because the client address was not known (3.0%) or the client resided outside of Ireland (0.3%).

Over the period 2016–2021, Area C (Tipperary South, Waterford, Kilkenny, Carlow, Wexford, Wicklow, part of South Dublin) accounted for the highest proportion (21.6%) of cases reporting alcohol as a main problem nationally, followed by Area A (19.3%) (see Table 2). Area E had the lowest proportion of such cases (7.0%).

Over the period, Area A accounted for the highest proportion (28.8%) of cases of drug treatment (excluding alcohol), followed by Area B (Longford, Westmeath, Offaly, Laois, Kildare, parts of Dublin and Wicklow) (24.5%). Area F (Donegal, Sligo, Leitrim, Roscommon, Mayo, Galway) had the lowest proportion (6.7%) of drug treatment cases (see Table 3).

In 2021, the number of alcohol treatment cases per 100,000 population at RHA-level ranged from 123.8 (Area E) to 163.8 (Area C) (see Table 4). All areas experienced a substantial drop in treatment figures in 2020, due to the Covid-19 pandemic. In 2021, many of the areas had not yet returned to pre-pandemic numbers accessing treatment.

In 2021, the number of drug treatment (excluding alcohol) episodes per 100,000 population at RHA-level ranged from 94.4 (Area F) to 325.6 (Area A) (see Table 5). Treatment figures for 2020 were impacted by the Covid-19 pandemic in almost all areas. However, most areas had returned to pre-pandemic levels in 2021.

Table 1: Number of cases treated for drugs or alcohol as a main problem, by RHA and year, NDTRS 2016-2021

* Treatment figures impacted by the Covid-19 pandemic.

Table 2: Number of cases treated for alcohol as a main problem, by RHA and year, NDTRS 2016–2021

*Treatment figures impacted by the Covid-19 pandemic.

Table 3: Number of cases treated for drugs (excluding alcohol) as a main problem, by RHA and year, NDTRS 2016–2021

*Treatment figures impacted by the Covid-19 pandemic.

Table 4: Number of cases treated for alcohol as a main problem per 100,000 of RHA population, by RHA and year, NDTRS 2016–2021

*Treatment figures impacted by the Covid-19 pandemic.

Table 5: Number of cases treated for drugs as a main problem per 100,000 of RHA population, by RHA and year, NDTRS 2016–2021

*Treatment figures impacted by the Covid-19 pandemic.

Discussion

NDTRS episode-based addiction treatment data for RHAs and CHNs can assist with developing a population-health approach for service planning and funding in addiction services, monitor access to addiction services by socially excluded groups, and inform any population-based resource allocation funding model.

The NDTRS has a coverage of over 70% of all applicable services, but this analysis did not take into account the impact of those services that do not participate in the NDTRS. At the higher RHA level, the impact is likely to be minimal, but at a CHN level the variation in participation could hinder efforts to understand addiction treatment service needs and potential inequalities in access. Greater cross-organisation communication between the HRB, funders and stakeholders, and services would assist in addressing this gap.³

2. Analysis of 2019–20 National Drug and Alcohol Survey by regional health area

Introduction

In 2018, the HRB commissioned IPSOS MRBI to conduct the fifth Irish National Drug and Alcohol Survey (NDAS). The 2019–20 NDAS followed best practice guidelines recommended by the European Monitoring Centre for Drugs and Drug Addiction. The questionnaire, based on the European Model Questionnaire, was administered in face-to-face interviews with respondents aged 15 years and older. A sample comprising all households throughout Ireland was randomly selected to participate. To facilitate comparisons between the 10 regional drug and alcohol task force (RDATF) areas, sampling was undertaken by RDATF area to enable the estimation of drug use prevalence in each area and to allow for monitoring of drug prevalence trends over time. Fieldwork began in February 2019 and was completed in March 2020. Of the household members contacted, 5,762 agreed to take part. The sample was weighted by sex, age, and region to ensure that it was representative of the general population. A more comprehensive description of the NDAS methodology is provided in the survey’s technical report.⁴

Alcohol use

Almost three-quarters (74.2%) of respondents were current drinkers (defined as those who had used alcohol in the last year). This ranged from 68.1% in Area E to 77.3% in Area B (see Table 6). Hazardous drinking was measured using the World Health Organization’s Alcohol Use Disorders Identification Test–Concise (AUDIT-C) screening tool. Among the whole sample, 37.9% met the criteria for hazardous drinking, which ranged from 32.3% in Area E to 41.1% in Area C. Alcohol use disorder (AUD) was measured using the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). There was considerable variation in the prevalence of AUD, from 8.2% in Area D (Kerry and Cork) to 17.5% in Area A. The overall prevalence of AUD in Ireland was 14.8%.

Table 6: Prevalence of current drinking, hazardous drinking, and alcohol use disorder, by RHA

Illegal drug use

In Ireland, 7.4% of adults reported use of any illegal drug in the previous year (see Table 7). Last-year prevalence of any illegal drug was lowest in Area E (6.1%) and highest in Area B (8.7%). There were differences in the types of drug use across RHA. In Area F, last-year prevalence of cannabis was relatively low (4.7% vs 5.9% nationally) and it also had the lowest prevalence of cocaine use (0.9% vs 1.9% nationally). However, it had the highest prevalence of ecstasy use (4.0% vs 2.2% nationally) and LSD use (2.8% vs 0.9% nationally).

Table 7: Prevalence of last-year drug use, by drug type and RHA

Table 8: Prevalence of last-year cannabis use disorder, by RHA

Last-year prevalence of cannabis use was 5.9% in Ireland, ranging from 2.1% in Area E to 7.4% in Area B. The prevalence of ecstasy use ranged from 1.0% in Area A to 4.0% in Area F. There was less variation in the prevalence of cocaine use; last-year prevalence was low in Area D and Area F (1.0% and 0.9%, respectively) and ranged from 1.9% to 2.2% in the four other RHA areas.

Cannabis use disorder (CUD) was defined as any cannabis abuse or dependence in the 12 months prior to the survey and was measured using an instrument called the Munich-Composite International Diagnostic Interview (M-CIDI). The last-year prevalence of CUD was 1.2% in Ireland and ranged from 0.7% in Area E to 1.8% in Area A (see Table 8).

Use of prescribable drugs

Last-year prevalence of opioid pain relievers was 32.2% in Ireland, ranging from 17.3% in Area D to 37.6% in Area A. There was less variation in the prevalence of sedatives or tranquillisers; last-year prevalence nationally was 5.5%, ranging from 4.2% in Area D to 6.8% in Area C (see Table 9).

Table 9: Prevalence of last-year use of prescribable drugs, by drug type and RHA

Impact of drug use on local communities

Questions about the impact of drug use on local communities and drug-related intimidation were included in the 2019–20 NDAS for the first time. Three in 10 (30.5%) of respondents reported that there was a very big or fairly big problem with people using or dealing drugs in their local area (see Figure 1). People living in Area B were most likely to state that this was a big or fairly big problem (40.7%).

One in 10 respondents (9.9%) had either personal experience of drug-related intimidation or knew somebody who had been intimidated. People living in Area A (13.0%) and Area B (13.8%) were most likely to report an experience of drug-related intimidation (see Figure 2).

Figure 1: Proportion of respondents reporting that people using or dealing drugs was a very big or fairly big problem in their local area, by RHA

Figure 2: Proportion of respondents reporting experience of drug-related intimidation, by RHA

3. Estimates of problematic opioid use, 2019, by regional health area

Data on opioid use for the years 2015–2019 were collected from four sources: treatment clinics, general practitioners (GPs), the Irish Prison Service, and the Probation Service5. Employing the capture–recapture (CRC) method, Poisson log-linear models were applied to the overlap data to find the model with the best fit in order to estimate the hidden population not identified by any of the data sources. Source-by-source interaction terms were tested by adding them to the base model in all possible combinations. The best model for estimating the size of the hidden population was determined by comparing the deviance to the chi-squared distribution and the Akaike information criterion (AIC) value. The simplest model with the lowest AIC value that provided a credible estimate was used (see Table 10).

Table 10: Estimates of the number of problematic opioid users, by RHA and rates per 1,000 population aged 15–64 years, 2019

1    For further information on Sláintecare, visit:
https://www.gov.ie/en/campaigns/slaintecare-implementation-strategy/

2    Department of Health (2021) Sláintecare implementation strategy & action plan 2021–2023. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/34321/

3    LINK, the NDTRS online data entry portal, will be updated by mid-2023 to automatically include these RHA and CHN, along with the existing geocodes. In the meantime, specific analysis requests can be provided on request by the NDTRS team at ndtrs@hrb.ie.

4    Ipsos MRBI (2022) The 2019–20 Irish National Drug and Alcohol Survey: technical report. Dublin: Health Research Board. https://www.drugsandalcohol.ie/36492/

5    Hanrahan MT, Millar SR, Phillips KP, Reed TE, Mongan D and Perry IJ (2022) Problematic opioid use in Ireland, 2015–2019. Dublin: Health Research Board. https://www.drugsandalcohol.ie/35856/

The Health Research Board (HRB) National Drugs Library has a new online resource that provides regional data on alcohol and other drugs.¹ There are nine Community Healthcare Organisations (CHOs) in Ireland whose services are delivered through the Health Service Executive (HSE) and its funded agencies (see Figure 1). Each CHO operates through an average of 10 primary care networks, which serve a population of approximately 50,000.

A data factsheet has been created for each CHO area with information on drug use and treatment. Prevalence data are from the National Drug and Alcohol Survey (NDAS) and the Problematic Opioid Use in Ireland, 2015–2019 study. Treatment data are from two HRB information sources: the National Drug Treatment Reporting System (NDTRS) and the National Psychiatric In-patient Reporting System (NPIRS).

For easy comparison across areas, an overview factsheet with all CHO data is provided.²

Figure 1: Map of Community Healthcare Organisation areas in Ireland

1    To access the HSE CHO area data, visit: https://www.drugsandalcohol.ie/hse_cho_area_data

2    HRB National Drugs Library (2022) Drugs data factsheet: all CHO areas. Dublin: Health Research Board. https://www.drugsandalcohol.ie/37510/