The ninth wave of the Healthy Ireland Survey, commissioned by the Department of Health and carried out by Ipsos B&A, 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 in accordance with Ireland’s Well-being Framework 2023, which seeks to measure the current status of Ireland’s performance as a nation based on a set of indicators. These focus collectively not only on economic standing but also equality issues and sustainability.² A number of these indicators are incorporated into the survey.

Methodology

Telephone interviews took place between October 2022 and April 2023 with approximately 7,500 respondents. Along with questions about alcohol use, the survey examined general health, tobacco use, illicit drug use, mental health, use of general practitioners (GPs) and other health services, suicide awareness, antibiotic usage, quality of life, and social connectedness. Questions about alcohol use are routinely asked in each wave of the survey, but in the 2023 survey, additional alcohol questions were included to better understand the public’s observation of labels on alcohol products. Section 12 of the Public Health (Alcohol) Act 2018 was signed into law in May 2023, which provides for more comprehensive health labelling of alcohol products. However, to allow businesses/producers sufficient time to prepare, it will not be mandatory until 2026.³ Therefore, it is important that baseline information be available to gauge how much the general public notice these labels in their current limited state and the extent to which they interact with the labels, so that comparisons can be made following the commencement of Section 12 in 2026.

Figure 1: Percentage of respondents who consumed alcohol in the previous 12 months, by sex and age

Main findings on alcohol

Alcohol use

Seventy per cent of the population aged 15 years and over reported consuming alcohol during the past 12 months, 73% of males and 67% of females. This was a decline since the 2018 Healthy Ireland Survey (the last time alcohol use was measured by the past 12 months), which was 75% overall (78% males vs 72% females).⁴ In 2023, those aged 15–24 years (75%) were more likely to report consuming alcohol in the previous 12 months, particularly males (see Figure 1).

Drinking at least once a week was reported by 38% of respondents, a decrease since 2018 (41%). In 2023, drinking at least once a week was more common among those aged 55–64 years (48%), particularly males in this age group (52% vs 43% females). Males aged 65–74 years were also likely to report drinking at least once a week (53%), considerably higher than females in the same age group (34%).

Binge drinking

Almost one-quarter (24%) of the population reported binge drinking on a typical drinking occasion – defined as drinking six standard drinks or more in one sitting – lower than that reported in 2018 (27%). Males (43%) were more likely to report binge drinking compared with females (34%), which applied to all age groups (see Figure 2).

Almost one-quarter (24%) of parents of children aged less than 18 years binge drink on a typical drinking occasion; this was more commonly reported among fathers (39%) than mothers (11%).

Alcohol packaging and advertising awareness

Over one in every 10 respondents reported often or always seeing health messages when looking at alcohol packaging, while 59% never see health messages. Just 6% of respondents reported that they often or always read or look closely at health warning messages on alcohol products. The most common warnings noticed were about alcohol content (28%), drinking during pregnancy (14%), and consumption warnings (13%).

Often or always seeing or hearing health messages for alcohol advertising was reported by 16% of respondents, although 47% of respondents reported that they never hear or see such messages for alcohol advertising. Of those who reported seeing or hearing health warning messages on alcohol advertising, 8% reported paying close attention to the information. Just 6% of respondents sought out information on the effects of drinking alcohol in the previous 12 months.

Figure 2: Percentage of respondents who reported binge drinking on a typical drinking occasion, by sex and age

Conclusion

Alcohol use remains high among the Irish population; however, it has decreased since 2018 when alcohol use was measured as last-year use. (Surveys in between these time periods asked about alcohol use in the last 6 months and are therefore not comparable.)

This is the first time that the Healthy Ireland Survey has asked about health warnings on alcohol products or in alcohol advertising. This information provides a valuable baseline for which to compare future data, as health warning labels will become mandatory in 2026.⁵

1    Ipsos B&A (2023) Healthy Ireland Survey 2023: summary report. Dublin: Government Publications. Available from: https://www.drugsandalcohol.ie/39977/ 

2    Department of the Taoiseach (2023) Understanding life in Ireland: the Well-being Framework 2023. Dublin: Government of Ireland. Available from: https://www.drugsandalcohol.ie/38968/ 

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

4    Ipsos MRBI (2018) Healthy Ireland Survey 2018: summary of findings. Dublin: Government Publications. Available from: https://www.drugsandalcohol.ie/29851/

5    Doyle A (2023) Public Health (Alcohol) (Labelling) Regulations 2023 signed into law. Drugnet Ireland, 86 (Summer): 11–12. Available from: https://www.drugsandalcohol.ie/39492/

A special supplement of this issue of Drugnet Ireland presents an overview of the Citizens’ Assembly on Drugs Use, which completed its work in late 2023 and published a final report in January 2024. Ireland’s experience with citizens’ assemblies is recognised internationally as a bold experiment in deliberative democracy and an example of pluralism and inclusion in the policy decision-making process. Unlike some of the previous assemblies, the members of the Citizens’ Assembly on Drugs Use were not offered a binary choice and they completed their work with a detailed and nuanced series of recommendations on all aspects of the topic that had been discussed. The members demonstrated exemplary commitment and a remarkable capacity to learn and absorb great detail on the topic. The citizens’ assemblies are evidence of a robust democratic process, an engaged citizenry, and a political environment that allows expression of opposing views and political opinion.

While Ireland faces political, economic, and social challenges, and we need vigilance and care to ensure our democratic institutions remain strong, other countries face far more formidable threats to the democratic process. In 2024, nearly one-half of the world’s population are in countries that will engage in elections to elect a national legislative assembly or select a head of state. This should be a cause for celebration, but much of the political commentary has focused on the difficulties posed by both the perfunctory nature of many of these elections and the growing strength of illiberal political movements in healthy, long-established democracies.

The impact of globalisation on those with limited economic resources, climate emergency and related problems, in particular migration, and increasing international tensions have combined to create an environment not conducive to the spreading of liberal democratic values. The illegal drugs market compounds these factors and presents a separate and very formidable problem for both national governments and international institutions across the globe. Ecuador, a country that had avoided the type of prolonged civil conflict endured by many neighbouring countries, is currently dealing with a profound threat to its stability from organised crime groups determined to counter any interference with their operations. Much of the drug-related criminal activity in Ecuador is connected to the European cocaine market. Describing Wa State, a breakaway region of Myanmar, as a ‘narco state’ is not hyperbolic. Its entire economy depends on supplying the methamphetamine market of South East Asia and growing opium for heroin.

The Netherlands is also dealing with serious threats from organised crime. While these are nowhere near the depths of the problems faced by countries in the Global South, the speed with which they have emerged, the diversity of the problem, and its capacity to impact on so many parts of Dutch society are potentially very destabilising. Much of Europe’s supply of cocaine is routed through the port of Rotterdam, part of an illegal economy marked by both corruption and violence, and much of the profits from this trade are laundered in Amsterdam’s financial centre. Dutch-based laboratories supply much of Europe’s demand for synthetic drugs, such as MDMA, presenting further opportunities for organised crime and serious environmental problems from discarded waste.

The European Commission has identified the illegal drugs market as Europe’s primary internal security concern and recognises its potential to cause considerable political and economic disruption. Ireland has given a lot of attention to the issues of drugs use, and provided the Government with a clear-sighted, empathetic, representative, and radical guide for drug policy. Drugs are an international concern and the response requires cooperation and agreement in organisations like the European Union. Resources, technological advances, and political leadership will be needed for this response to be effective. Much can be learned from Ireland’s experience, and by using the mechanisms of deliberative democracy it may be possible to develop solutions not just effective but which reflect the values and philosophy of European citizenry.

Since the early 2000s, the evaluation of drug policies and strategies has increasingly featured as part of the drugs landscape at European Union (EU) and member state levels. Evaluation is a critical part of the policymaking process. It supports effective policymaking by helping it adapt to changes over time, ensure lessons are learnt from previous successes and failures, and therefore strengthens value for money in the approach taken by the EU and member states to dealing with the drugs issue.

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) considers policy evaluation a priority (see Box 1). In December 2023, it updated its online content for the topic overview on drug policy evaluation in Europe.¹ Stakeholders can find links to sources to support policy evaluation, as well as examples of EU and member state outputs on the topic. The overview presents the state of play at the end of 2023 on the focus of national drug strategies and their evaluations.

Focus of national drug strategies

At the end of 2023, all 29 reporting countries (EU-27, plus Türkiye and Norway) had an active drug strategy. This compares to the mid-1990s when only one-third of the countries reporting to the EMCDDA had one, increasing to two-thirds in 2000. While some member states have a strategy that focuses specifically on illicit drug use, others (like Ireland) have a broader focus that covers other substances (e.g. alcohol, tobacco, and medicines) or addictive behaviours (e.g. gambling). Based on data collected through the 2023 national reports to the EMCDDA, Figure 1 illustrates the situation at the end of 2023 in terms of focus.

Source: EMCDDA (2023)¹

Figure 1: Focus of national drug strategy documents reported by end 2023

Source: EMCDDA (2023)¹

Figure 2: National evaluations reported to the EMCDDA by end 2023

Evaluations of national drug strategies

Since 2010, the evaluation of national drug strategy documents is described by the EMCDDA as having become ‘standard practice’. Evaluations take many different forms depending on the focus, needs, and resources of national stakeholders, among other factors. To monitor evaluation practices across the member states, the EMCDDA has developed a typology that incorporates both whole-strategy and targeted evaluation, alongside ongoing monitoring and research aimed at supporting evaluation. These are:

• Implementation progress review: A review of the actions taken and/or the strategy’s context at its midpoint or end point.
• Multi-criterion evaluation: An evaluation of a strategy and/or action plan at its midpoint or end point.
• Targeted evaluation: An evaluation or audit of a specific policy or strategy aspect or area.
• Other approaches: Assessment by means of ongoing indicator monitoring, research projects, or regional or local strategy evaluation.

Box 1: Guide for commissioners and managers of policy evaluations

The EMCDDA’s seven-step guide to support the commissioning and managing of drug policy evaluations, published in 2017, continues to be a valuable resource. It offers an introduction to the topic and is designed to support those in the relevant roles in choosing the best approach to meet their needs, fit with their circumstances, and maximise the value of the evaluation. Four key messages were identified in the guide:

1   There is no one ‘correct’ way to perform an evaluation of drug policy. What is best will depend on what you want to know, what data you have available or can obtain, and the resources and time available to you.

2   Evaluation should not be seen as a one-off event but will be most useful if viewed as an ongoing process intertwined with policy or strategy development and implementation.

3   Evaluation needs to be accompanied by a commitment to taking action on the findings, and the opportunity to do so. The timing and choice of evaluation design need to be realistic and take this into account; producing a detailed evaluation of a previous strategy only after a new strategy has been developed and implementation begun will limit its usefulness.

4   Developing the expertise and data sources for drug policy evaluation over time will increase the ability to conduct evaluations in support of drug policy development and enhance action to address drug problems.

Source: EMCDDA (2017),² p. 5

1    European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2023) Drug policy evaluation in Europe – topic overview. Lisbon: EMCDDA. Available from: https://www.emcdda.europa.eu/publications/topic-overviews/policy-evaluation_en 

2    European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2017) Evaluating drug policy: a seven-step guide to support the commissioning and managing of evaluations. Luxembourg: Publications Office        of the European Union. Available from: https://www.drugsandalcohol.ie/27536/

Background

The first Health Research Board (HRB) conference solely dedicated to alcohol research was held on 14 September 2023 in partnership with the Department of Health. The event was opened by the HRB CEO, Dr Mairéad O’Driscoll, who welcomed the support of the Department of Health, which, along with the HRB, recognises the importance of and is committed to progressing alcohol-related research.

One of the objectives of the HRB Strategy 2021–2025 is to collect and report alcohol-related data for policy and service planning purposes, and the event included speakers from across the organisation presenting the work of the HRB.¹ The strategy (key action 3.4) also promotes primary research and secondary data analysis to support drug and alcohol strategies at a national and European level. The HRB also has a responsibility to ‘assist the Department of Health to monitor the Public Health Alcohol Act through data collection, validation, analysis and dissemination’ (implementation action 3.4.4). This important obligation is achieved through the work of the team in the HRB Evidence Centre and through the alcohol overviews published periodically. Dr O’Driscoll acknowledged the work of the HRB, particularly that of the evidence team and the drugs and alcohol policy team, whose work has been instrumental in providing evidence to influence policy. An important example given was of collating key evidence of alcohol-related harm directly influential in the eventual passing of the Public Health (Alcohol) Act in 2018.²

Why hold an alcohol-themed conference?

Alcohol continues to pose a significant public health problem, and throughout the course of the day, accounts were given of the profound impact of alcohol on individuals, families, and the wider community. This was the primary motivation for organising the conference, along with the concern that many of the key public health advocates who played a crucial role in the passage of the 2018 legislation have since retired, changed roles, or moved on for various reasons. In light of this, fear exists that the momentum may be lost in this transition period and that the implementation of the Public Health (Alcohol) Act 2018 may lead to the perception that alcohol-related harm has been effectively addressed, potentially hindering further action.

As such, alcohol as a public health issue runs the risk of falling down the Government’s agenda as other public health issues take precedence, such as illicit drugs, vaping and smoking, obesity, mental health, and social deprivation, all of which are interrelated with alcohol but tend to be treated in silos. There are also conflicting priorities and pressure on the Government, particularly concerning the economic and cultural consequences of intervention, a concern that has intensified since the Covid-19 pandemic in terms of the night-time economy and the closure of pubs. These factors make it increasingly challenging for those advocating for public health to attract Government attention, with the danger that those with a vested interest in alcohol profits may exert more influence using arguments that further action or legislation is no longer required or is actively harming economic and cultural assets.

However, we know that there is public support for the legislation and that alcohol-related harm is not going away. Hospitalisations for alcohol-related liver disease reached the highest rates ever recorded in 2021; the numbers receiving treatment for alcohol use have increased; and at least three people die every day due to alcohol use.^3,4 Hence, the purpose of the conference was to showcase the ongoing work of those involved in this space; to demonstrate that there are many working hard to continue the groundbreaking efforts of our predecessors; to encourage more alcohol-related research; and to hear about and learn from the experiences of those who work in the community, who are the voice of the people experiencing alcohol-related harm.

Presentations at the conference

Chair of the Alcohol Health Alliance, Professor Frank Murray, presented and chaired the first part of the day and reinforced the importance of evidence-informed alcohol policy and how this evidence led to the eventual implementation of the Public Health (Alcohol) Act 2018. Dr Helen McAvoy, director of policy with the Institute of Public Health in Ireland, outlined the existing and proposed legislation governing alcohol use and raised concerns about the proposed Sale of Alcohol Bill 2022, which seeks to increase the availability of alcohol in our communities.⁵ Dr Frank Houghton, director of Social Sciences ConneXions at the Technological University of the Shannon, discussed the importance of research integrity and how to ensure impartial and trusted research when faced with an industry that acts as commercial determinants of health and who will often go to great lengths to prevent or dilute alcohol policies.

Chaired by Dr Nathan Critchlow, an academic fellow for the Society for the Study of Addiction based at the Institute for Social Marketing and Health, University of Stirling, the day continued with Dr Zubair Kabir, senior lecturer in public health at University College Cork, presenting evidence of alcohol-related harm in Ireland using data from the Global Burden of Disease (GBD) data source.⁶ As the HRB is home to the National Drugs Library, to give an overview of the wealth of information that can be accessed there, chartered information specialist Mary Dunne and chartered information officer Mairea Nelson talked the audience through how to stay up-to-date with the latest national and international alcohol-related research.

The afternoon session was chaired by Alcohol Forum Ireland CEO Paula Leonard and began with Dr Catherine Gill, HRB programme manager, advising on the various schemes provided by the HRB to potentially fund alcohol-related research. This was followed by Anne Doyle, HRB research officer, who provided a snapshot of the sources of alcohol-related data to encourage further alcohol-related research.

Ireland often looks to other jurisdictions to understand best practices for monitoring policy effectively. Hence, to give the Scottish experience, Professor Niamh Fitzgerald, professor of alcohol policy and director of the Institute for Social Marketing and Health at University of Stirling, spoke of her experience there in prioritising alcohol as a public health issue. Finally, Dr Susan Calnan, a postdoctoral researcher in the School of Public Health at University College Cork, reflected on how alcohol use can impact not only the individual but the entire family and wider community.

Poster presentations

• Poster presentations provided a synopsis of the array of studies carried out, including:
• Alcohol use of women between 50 and 62 years, associated biopsychosocial factors, and primary care utilisation
• Rural hospitals’ inpatient data on substance use
• Effective interventions and approaches in the delivery of integrated alcohol services in community settings
• Association of alcohol per capita with national, regional, and global prevalence of alcohol use during pregnancy and foetal alcohol syndrome
• A survey of Irish healthcare, social care, and education professionals’ knowledge, attitudes, and experience of foetal alcohol spectrum disorders (FASD)
• Prenatal alcohol exposure
• Association between parental factors and adolescent alcohol consumption
• Risk factors for heavy episodic drinking in adolescents
• Evaluation of the school-based substance use prevention programme – Know the Score.

Conclusion

Ireland took the lead on a global scale with the introduction of the Public Health (Alcohol) Act 2018, and many countries worldwide are watching with great interest to see how we perform. It is crucial therefore that those involved in public health work together to ensure its success and be proud of what has collectively been achieved.

1    Health Research Board (2021) Strategy 2021–2025: Health research – making an impact. Dublin: Health Research Board. Available from: https://www.hrb.ie/about/strategy-2025/

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

3    O’Dwyer C, Mongan D, Doyle A and Galvin B (2021) Alcohol consumption, alcohol-related harm and alcohol policy in Ireland. HRB Overview Series 11. Dublin: Health Research Board. Available from:  https://www.drugsandalcohol.ie/33909/

4    Calnan S, Millar SR and Mongan D (2023) Support for evidence-based alcohol policy in Ireland: results from a representative household survey. Eur J Public Health, 33: 323–330. Available from: https://www.drugsandalcohol.ie/38321/

5    Department of Justice (2022) General Scheme: Sale of Alcohol Bill 2022. Dublin: Government of Ireland. Available from: https://www.drugsandalcohol.ie/37347/ 

6    Institute for Health Metrics and Evaluation (2020) Global Burden of Disease (GBD). Seattle, WA: University of Washington. Available from:https://www.healthdata.org/gbd

The Medical Cannabis Access Programme in Ireland¹ currently provides access to cannabis to patients with one of three conditions when other treatments have been unsuccessful. The three conditions are spasticity (stiff and/or rigid muscles) associated with multiple sclerosis, nausea and vomiting associated with chemotherapy, and severe epilepsy.

An evidence review was conducted by the Health Research Board (HRB) to inform a Department of Health review of the current Medicinal Cannabis Access Programme on the suitability of cannabis-based products for medical conditions.

Findings

The HRB found evidence to support the use of prescribed medicinal cannabis for certain conditions for which it is currently approved in Ireland. These are nausea and vomiting in cancer and spasticity in multiple sclerosis. There was also evidence of a significant benefit for neuropathic or nerve pain, which can occur with conditions such as multiple sclerosis, diabetes, or spinal cord injury.

For most other conditions, including anxiety and pain in conditions such as cancer, rheumatic diseases, and fibromyalgia, there was no conclusive evidence to confirm the efficacy of prescribed medicinal cannabis.

Regarding the safety of prescribed medicinal cannabis, the review found that although serious adverse events do not appear to be common, there is some evidence that some side-effects such as dizziness, dry mouth, sedation, and headache can occur. Mixed evidence was found, however, on the likelihood of other adverse events such as drowsiness, nausea, and any psychiatric disorder adverse events. The HRB findings are similar to those reported by other overviews.

Methodology

The HRB review was an overview of reviews. While traditional systematic reviews gather evidence from existing original research studies (primary studies), an overview of reviews gathers evidence from existing systematic reviews. We focused on systematic reviews of studies of adults who received prescribed medicinal cannabis containing natural or synthetic cannabidiol (CBD) or tetrahydrocannabinol (THC) or their derivatives, and excluded evidence on cannabis for recreational use or for medicinal use without prescription/medical supervision.

The 47 reviews included systematic reviews covering research from the last 30+ years on a wide range of medical conditions. These included cancer, multiple sclerosis, rheumatic diseases, chronic pain, and mental health and neuropsychological conditions.

Conclusion

The evidence review revealed a fragmented body of research. Many types of medicinal cannabis exist, making it difficult to gather a strong body of evidence for one particular formulation for a given condition or complaint. Further high-quality research is needed based on randomised controlled trials. In the meantime, this review will help inform decision-making in relation to future policy on the use of prescribed medicinal cannabis along with input from patient groups, clinicians, and service planners.

The full text of the review is available for download on the HRB website.²

1    Department of Health (2020) Medical Cannabis Access Programme. Dublin: Department of Health. Available from: https://www.drugsandalcohol.ie/31653/

2    For further information, visit: https://www.hrb.ie/publications/

Background

In January 2022, Ireland introduced minimum unit pricing (MUP) at EUR 1.00 per 10 grams of alcohol as per Section 11 of the Public Health (Alcohol) Act 2018.¹ The Act was introduced in response to the high level of alcohol use and related harms in Ireland. Alcohol-related hospital discharges are collected through the Hospital In-Patient Enquiry (HIPE) Scheme; however, the burden of alcohol-related harm in emergency departments (ED) in Ireland is largely unknown, as this information is not routinely collected.² One study in 2018 estimated that 6% of ED presentations are alcohol related.³ A study by Maharaj et al. in 2024 sought to determine the impact of alcohol on ED presentations and hospital admissions and to investigate if the introduction of MUP impacted such presentations or admissions.⁴

Methods

The study author was stationed in the ED of Beaumont Hospital, Dublin for two periods: one before the commencement of MUP (November–December 2021) and again following the commencement of MUP (February, March, and April 2022). Interviews with those who presented to ED were carried out and included a brief clinical history and type of alcohol usually consumed, and the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) was administrated to determine drinking patterns of patients.⁵

Results

In period 1, some 364 patients were interviewed, while 361 patients were interviewed in period 2. Alcohol-related presentations accounted for 19.4% of all ED presentations. Males accounted for 63.1% of alcohol-related presentations compared with 36.9% of females; those aged 40–50 years were more associated with alcohol-related ED presentations compared with other age groups.

The median AUDIT-C score for alcohol-related presentations was 9 (3 for overall sample). Wholly alcohol-attributable presentations were more common on Thursdays and Saturdays and the most common purpose of the ED visit was for acute injuries (32.6%), chest complaints (19.1%), and mental health queries (16.3%). Beer was the beverage preferred by 40.5% of the sample and wine by 24.0%.

In period 1, some 22.8% of ED presentations were alcohol related, while in period 2, it had reduced to 16.1%. However, acute wholly alcohol-related presentations increased by 19.8% between periods 1 and 2. Of all admissions to hospital, 17.3% were alcohol related (3.1% wholly alcohol-attributable); the number decreased between period 1 (19.7%) and period 2 (14.0%), although this decrease was not statistically significant.

Discussion

This study demonstrates the extent of the burden that alcohol places on Beaumont Hospital. Although the study found a significant reduction in alcohol-related ED presentations following the commencement of MUP, alcohol-related hospital admissions did not decrease. The authors recommend the instruction of cost-effective alcohol care teams (ACTs) in Irish hospitals to reduce alcohol-related ED presentations, hospital admissions, and mortality.

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

2    Healthcare Pricing Office (2004) Hospital In-Patient Enquiry (HIPE) Scheme. Dublin: Health Service Executive. Available from: https://www.hpo.ie/

3    McNicholl B, Goggin D and O’Donovan D (2018) Alcohol-related presentations to emergency departments in Ireland: a descriptive prevalence study. BMJ Open, 8: e021932. Available from: https://www.drugsandalcohol.ie/29070/

4    Maharaj T, Fitzgerald N, Gilligan E, Quirke M, MacHale S and Ryan JD (2024) Alcohol-related emergency department presentations and hospital admissions around the time of minimum unit pricing in Ireland. Public Health, 227: 38–41. Available from: https://www.drugsandalcohol.ie/40186/

5    Babor TF, Higgins-Biddle JC, Saunders JB and Monteiro MG (2001) AUDIT: The Alcohol Use Disorders Identification Test – guidelines for use in primary care. 2nd edn. Geneva: Department of Mental Health and Substance Abuse, World Health Organization. Available from: https://www.drugsandalcohol.ie/14104/

Suicide is a complex, major public health issue globally. While people who use drugs (PWUD) are known to be at increased risk of suicide, there is limited information on the specific candidate risk factors for this group, which could help to inform targeted interventions to reduce their risk. To this end, a scoping review was conducted with three aims: (1) to map the extent, range, and nature of available evidence on factors associated with death by suicide among PWUD; (2) to identify knowledge gaps and limitations in this body of evidence; and (3) to inform suicide prevention policy and best practice guidelines for working with PWUD, where appropriate.¹

Methods

The aim of scoping reviews is to systematically search for and then map all the evidence in relation to the research question. Scoping reviews encompass all available literature, both published and grey, with stakeholder consultation an important component. Unlike systematic reviews, this method in general does not include a quality appraisal of the literature.

Results

In total, 12,395 items published between 2000 and 2021 were identified, but following a screening process (e.g. removing duplicates; non-English language; insufficient data) only 53 items were included in the review. Most of the eligible studies were based on primary research (mainly uncontrolled retrospective studies), while the secondary research included literature reviews, reports, and editorials.

Eleven potential candidate risk factors for death by suicide among PWUD were found: sex; mental health conditions; periods of heightened vulnerability; age profile; use of stimulants, cannabis, or new psychoactive substances; specific medical conditions; lack of dual diagnosis service provision; homelessness; incarceration; intravenous drug use; and race or ethnicity. Some of the literature associated with each of the candidate risk factors is highlighted below; however, as this was a scoping review and not a systematic review, the findings must be interpreted as such.

Sex

Male sex as a risk factor featured in over one-half of the studies. However, some of the studies did find an increased risk among women who used drugs compared with men, for example, in relation to potential years of life lost. In the studies that only included women who used drugs, the risk of death by suicide was linked to high levels of mental health issues.

Mental health conditions

Two-fifths of the included publications cited mental health conditions as a candidate factor, with depressive disorders most frequently mentioned. Two studies among people who used opioids found high rates of depressive disorders or history of suicide attempts (between 65% and 89%), but the overall number of suicide deaths was low.

Periods of heightened vulnerability

The literature pointed to vulnerable periods where the risk of suicide was heightened. This included commencing or stopping opioid agonist treatment (OAT), disengaging/leaving health services, and (for women) the first months of imprisonment.

Age profile

Of the seven publications that included an age profile, most indicated that younger PWUD were at risk of death by suicide, although the definition of ‘younger age’ varied (from teens to those in their forties) across the publications. Of the studies that focused on opioid use, one found that being older when starting treatment conferred a higher risk of suicide.

Use of stimulants, cannabis, or new psychoactive substances

Stimulants (including cocaine), cannabis, or new psychoactive substances (NPS) were the focus of some studies. Six studies found that the use of these substances were potential candidate risk factors for violent non-poisoning suicide deaths, for example, by hanging. This suggests that these drugs may increase impulsivity and risk-taking, leading to a more violent manner of death.

Specific medical conditions

Blood-borne viruses were the most common conditions cited in the studies, with HIV infection in particular linked as a candidate risk factor for people who used opioids. However, history of cancer and chronic pain were also found as risk factors among people who used opioids.

Lack of dual diagnosis service provision

Some of the issues found were in relation to non-integrated addiction services and mental health services as well as poor levels of diagnosis or treatment of dual diagnosis. However, all highlighted the complex medical and psychological needs of this group.

Homelessness

While there is a higher rate of homelessness among PWUD compared with the general population, three studies did show that being homeless increased the risk of death by suicide in both men and women who use drugs.

Incarceration

Two of the three studies that identified incarceration as a candidate factor showed a clear link between lack of OAT in prison and increased risk of death by suicide.

Intravenous drug use

Three studies identified a history of intravenous drug use as a potential candidate risk factor, in particular poly-intravenous drug use. One study identified a higher risk for men compared with women.

Race or ethnicity

While only two studies found race or ethnicity as a risk factor, both were cohort studies (despite relatively dated data). An Italian study found a higher risk of suicide for people who used heroin and who were born outside Italy. An American study found that cocaine use was associated with a higher risk of suicide among African Americans compared with White Americans.

Issues for consideration

A significant number of the studies related to people who used opioids, perhaps because of existence of well-established OAT registers, where data on this population are readily available. The impact of drugs other than opioids also needs to be considered, such as cannabis as the most commonly used substance globally.

Strengths and limitations

This is the first scoping review on factors associated with death by suicide in PWUD. While the strength of the review is that it includes all types of literature, it does not include any in-depth assessment of the quality of the evidence.

Other limitations were an over-representation of articles from Europe and Australia. As many of the American articles overlapped with military veteran research, they did not meet the strict criteria of this scoping review. There was also over-representation of people with HIV in relation to studies on intravenous drug use and blood-borne viruses, meaning that this may be a potential confounder.

Therefore, these specific candidate risk factors for PWUD should be considered when developing suicide prevention policies. Additionally, there is a need for better-quality robust, prospective primary research among PWUD to gain a greater understanding of the risk factors associated with suicide in this group.

1    Devin J, Lyons S, Murphy L, O’Sullivan M and Lynn E (2023) Factors associated with suicide in people who use drugs: a scoping review. BMC Psychiatry, 23: 655. Available from: https://www.drugsandalcohol.ie/39507/

Globally, there are an estimated 15.6 million people who inject drugs (PWID).¹ Among PWID, the risk of acquiring HIV is more than 30 times higher than the rest of the population.² However, HIV incidence has declined among PWID in Western Europe over the last two decades. In light of this improved situation, a 2023 study investigated changes in HIV incidence in Ireland among PWID from 2000 to 2018.²

In this study, published in the journal Addiction, data on new diagnoses of HIV among PWID, as reported by the Health Protection Surveillance Centre, were examined. New HIV cases in two time periods (2000–2009 and 2010–2018) were compared by sex, age group, area of residence, and country of birth.

HIV incidence

A total of 753 cases were reported in PWID in Ireland between 2000 and 2018. During this time period, HIV incidence among 15–29-year-old PWID in Ireland declined from 5.69 to 0.11 cases per 100,000 persons, equivalent to 0.22 cases per 100,000 annually. Among PWID aged 30–64 years, HIV incidence declined annually by 0.06 cases per 100,000.

Table 1: Comparison of new diagnoses of HIV in Ireland between 2000–2009 and 2010–2018

Comparisons of new diagnoses

Table 1 shows the comparisons of new diagnoses of HIV among PWID during the first half of the study period (2000–2009) and the second half (2010–2018). Although there was a small increase in the number of males diagnosed with HIV, this finding was not statistically significant. There was a relative increase in HIV cases among older adults, while those born outside of Ireland accounted for a growing minority of cases (14.7% to 28.0%).

Conclusions

The authors observed that since 2000, Ireland has achieved an ongoing reduction in HIV among PWID and that this reduction has occurred in the context of a reasonably comprehensive health-led and harm-reduction-orientated drugs strategy. Nevertheless, HIV outbreaks among PWID that were observed in 2014/2015 in Ireland highlight the ongoing challenges faced by surveillance, treatment, and harm-reduction services.

1    Degenhardt L, Peacock A, Colledge S, et al. (2017) Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health, 5(12): e1192–e1207.

2    McCarron P and Smyth BP (2023) Changes in HIV incidence in people who inject drugs in Ireland from 2000 to 2018: longitudinal observational study. Addiction, 118(6): 1177–1181. Available from: https://www.drugsandalcohol.ie/38061/

Drug use during pregnancy is a worldwide problem and the consequences of continued drug misuse in pregnancy can be significant.¹ Pregnancy may provide opportunities to engage vulnerable women in essential healthcare. However, women with an addiction may have poor adherence with prenatal appointments, presenting late in pregnancy or not until labour. Hence, drug liaison midwives (DLMs) were appointed to the three Dublin maternity hospitals in 1999.

A 2023 retrospective observational cohort study was conducted at an Irish tertiary maternity unit.² In this study, published in the European Journal of Obstetrics & Gynecology and Reproductive Biology, all women with opioid use disorder (OUD) or substance use in pregnancy delivered under this service between 2010 and 2019 were included. Data were collected by combining electronic and hand-held patient records, and trends and outcomes were analysed by year of delivery.

Findings

The main findings from the review included the following:

• Of the 82,669 women delivered, 525 had OUD or substance use in pregnancy (1 in every 160 women booking into the service). Some 11.6% were homeless, 20% were in full-time employment, and 91% smoked tobacco in pregnancy. Some 66.3% had a history of psychiatric disorders.
• Over the 10 years, there was a significant reduction in women delivered with OUD or substance use in pregnancy (0.8–0.4%, RR=0.55, 95% CI: 0.36–0.85) and a significant reduction in the proportion of women on opioid substitute treatment (RR=0.66, 95% CI: 0.51–0.87).
• Rates of cocaine and cannabis consumption increased (20.6%, RR=3.8, 95% CI: 1.57–9.44; 24%, RR=3.7, 95% CI: 1.58–8.86, respectively).

Conclusions

The authors noted that the study shows a change in the profile of the women with substance use in pregnancy, with significant increases seen in the numbers of women using cocaine and cannabis in pregnancy. They suggest that specialist antenatal addiction services, coordinated by the DLM, are critical in adapting care to respond to this dynamic and vulnerable patient cohort.

1    Covington CY, Nordstrom-Klee B, Ager J, Sokol R and Delaney-Black V (2002) Birth to age 7 growth of children prenatally exposed to drugs: a prospective cohort study. Neurotoxicol Teratol, 24(4): 489–496.

2    Corbett GA, Carmody D, Rochford M, Cunningham O, Lindow SW and O’Connell MP (2023) Drug use in pregnancy in Ireland’s capital city: a decade of trends and outcomes. Eur J Obstet Gynecol Reprod Biol, 282: 24–30. Available from: https://www.drugsandalcohol.ie/37901/

The annual report published by the Mental Health Information Systems Unit of the Health Research Board, National Psychiatric Inpatient Reporting System (NPIRS) annual report on the activities of Irish psychiatric units and hospitals, 2022,¹ shows that the rate of new admissions to inpatient care for alcohol disorders has decreased.

In 2022, some 806 cases were admitted to psychiatric facilities with an alcohol disorder, of whom 263 were treated for the first time. Figure 1 presents the rates of first admission between 2002 and 2022 for cases with a diagnosis of an alcohol disorder. Trends over time indicate an overall decline in first admissions. Just over one-third (35.3%) of cases hospitalised for an alcohol disorder in 2022 stayed just under 1 week, while 26.5% of cases were hospitalised for between 1 and 3 months, similar to previous years.

In 2022, some 813 cases were admitted to psychiatric facilities with a drug disorder. Of these cases, 318 were treated for the first time. Figure 2 presents the rates of first admission between 2002 and 2022 for cases with a diagnosis of a drug disorder. The admission rate in 2022 was lower than the previous year and is the lowest rate recorded since 2008. It should be noted that the report does not present data on drug use and psychiatric comorbidity; it is therefore not possible to determine whether or not these admissions were appropriate.

Source: Daly and Lynn (2023)

Figure 1: Rates of psychiatric first admission of cases with a diagnosis of an alcohol disorder per 100,000 of population in Ireland, 2002–2022

Source: Daly and Lynn (2023)

Figure 2: Rates of psychiatric first admission of cases with a diagnosis of a drug disorder per 100,000 of population in Ireland, 2002–2022

Other notable statistics on admissions for a drug disorder in 2022 include the following:

• Just under one-half of cases hospitalised for a drug disorder stayed under 1 week (44.7%), while 99.4% were discharged within 3 months. It should be noted that admissions and discharges represent episodes or events and not persons.
• 23.0% of first-time admissions were involuntary.
• Similar to previous years, the rate of first-time admissions was higher for men (10.7 per 100,000 population) than for women (2.7 per 100,000 population).

1    Daly A and Lynn E (2023) National Psychiatric Inpatient Reporting System (NPIRS) annual report on the activities of Irish psychiatric units and hospitals, 2022. HRB StatLink Series 13. Dublin: Health Research Board. Available from:  https://www.drugsandalcohol.ie/39109/

The inaugural More Than That Festival to mark recovery month was held in Naas, Co. Kildare, on 30 September 2023. It was organised by the South Western Regional Drugs and Alcohol Task Force (SWRDATF) area to celebrate recovery from addiction.¹ A series of activities and events were held throughout the day, beginning with the Recovery Champions 5K Run, which featured famous Kildare faces such as former Gaelic footballer Anthony Rainbow, leading out a run/walk in support of addiction recovery.

The festival continued with music and conversation with musician and mental health advocate Bressie (Niall Breslin) at Naas Farmers Market followed by Lunchtime Songs and [Funny] Stories, culminating in the ‘Leave a Light On’ Fireside event hosted by former 2FM DJ Keith Walsh. A lively and often emotional evening of music and heartfelt stories of addiction and recovery experiences could not but move the audience.

Former Ireland international footballer Niall Quinn regaled the audience with tales from his time with Arsenal Football Club in the 1980s and 1990s, but it wasn’t all glitz and glamour! Niall recalled a team sheet his mother had kept dating back to one of his early days at Arsenal. He went on to list the (many) names of players who had developed addiction issues and how alcohol, drugs, and gambling had been such a core part of many of their lives.

Aubrey McCarthy, chairperson of SWRDATF, presented the Christy Dignam Recovery Champion award to Mary Hulgraine, the Kildare GAA All-Star ladies footballer and mental health advocate in acknowledgement of her work educating others about addiction recovery. Mary’s own recovery story began with her winning a prestigious college basketball scholarship in the United States. However, prescribed OxyContin after surgery for a leg injury led to dependency on the drug and later alcohol too. Back in Ireland, her mental health problems and addiction continued, but having hit rock bottom, a chance meeting with a stranger while out walking her dog on the Curragh ignited some hope. Mary now shares her experience openly to highlight how recovery is possible.

The night ended with the audience on their feet, singing along to a rousing rendition of ‘Crazy World’ led by Kiera Dignam, daughter of the late Christy Dignam, and words from Steven Joyce, community harm prevention coordinator, declaring that ‘the light is on and we’re going to bring them home’.

1    For further information on the More Than That Festival, visit: http://swrdatf.ie/more-than-that-festival-30th-september-2023/

Background

The Alcohol Programme in the Health Service Executive (HSE) was established in 2016 to address the impact of alcohol-related harm on individuals, families, and children. The programme aims to decrease per capita alcohol use to 9.1% (10.2 litres in 2022), in accordance with the Healthy Ireland Framework 2013–2025.^1,2 The work of the HSE Alcohol Programme involves collaborating with the Department of Health, Alcohol Health Alliance Ireland, and other stakeholders to actively support the Public Health (Alcohol) Act 2018. This involves identifying national priority areas, supporting effective policies, and advocating for evidence-based interventions and community action as well as informing and supporting the public in reducing alcohol use and signposting to support services through the AskAboutAlcohol campaign and website.³

AskAboutAlcohol website

The HSE AskAboutAlcohol website is a resource available to the public to seek impartial advice about alcohol use and alcohol-related harms. Users of the website can access a drinks calculator to determine how much alcohol they are drinking and how much money they are spending on alcohol per week. By entering this information, users receive feedback on whether they are exceeding the HSE low-risk alcohol guidelines or not, as well as advice about the harms associated with alcohol and a link to further advice on how to reduce alcohol use and the benefits of doing so.⁴

Information is provided on alcohol use and pregnancy, alcohol dependency, information for parents, advice for reducing alcohol use, and a list of services that can support individuals and their families who are impacted by alcohol. The website also contains a self-assessment tool, where visitors can complete an effective, brief screening test to identify potential problem drinking.

AskAboutAlcohol self-assessment tool

At total of 24,205 people filled out the AskAboutAlcohol.ie online self-assessment tool between 1 December 2022 and 30 November 2023 inclusive. The self-assessment tool is based on the World Health Organization (WHO) Alcohol Use Disorders Identification Test (AUDIT), a 10-item tool used to screen for alcohol problems.⁵ AUDIT scores can range from 0 to 40, where a score of 0–7 represents low-risk drinking; 8–15 increasing risk drinking; 16–19 high-risk drinking; and a score of 20 or greater indicates possible dependence.

Methods

Data were screened for anomalies and outliers. Ten respondents were removed as they reported an age of 100 years or greater. The age range of remaining respondents was 18–98 years. One respondent who reported drinking 477 standard drinks in the last week was identified as an outlier and also removed from the analyses, while 99 cases were removed as they did not enter a number of drinks despite stating that they drink alcohol regularly. Following the removal of these 110 cases, a total of 24,095 cases were included in the analyses.

Respondents were grouped into the following six age brackets: 15–24 years; 25–34 years; 35–44 years; 45–54 years; 55–64 years; 65 years and older. Statistical analyses were carried out using SPSS Version 29. Chi-squared tests were carried out to test for statistical significance between AUDIT scores and demographic variables of age, gender, and region. An alpha level of p <0.05 indicated statistical significance.

Findings

Profile of respondents using the online assessment tool

Table 1 provides a breakdown of the demographics of those who completed the online assessment tool. More females (53.7%) than males (46.3%) completed the self-assessment tool. Those aged between 35 and 54 years represented 44.8% of all respondents. Demographic data collected by the site identified users from all 26 counties in the Republic of Ireland, with the highest number of responses coming from the most populated counties, Dublin (13.9%) and Cork (9.8%).

Drinking classification of respondents

The mean score of respondents (n=24,095) on AUDIT was 13.9 (SD=8.8). Such a score indicates hazardous alcohol use or ‘increasing risk’ alcohol use. Table 1 indicates that 31.2% of drinkers were classified as low risk according to AUDIT; 29.5% were classified as hazardous or increasing risk drinkers; 13.0% as high-risk or harmful drinkers; and over one-quarter of those who completed the online assessment tool were classified as having probable alcohol dependence (26.3%).

There were significantly more males than females in the harmful drinking and probable dependence groups. Of males who completed the self-assessment tool, one-third (33.7%) were classified as having probable alcohol dependence, with one-fifth of women (20.0%) meeting these criteria.

Those in the 15–24 years age group (35.4%) and the 25–34 years age group (35.6%) were the most likely to score as probable dependence category. There was no statistically significant difference in scores across the five regions.

Table 1: Demographic profile of respondents, by drinker type

^a Gender missing for 258 respondents. ^b Age missing for 755 respondents.

^c Province missing for 1638 respondents. ^d Excluding Dublin.

Conclusion

The analyses indicate that almost two-fifths of the users of the AskAboutAlcohol.ie online self-assessment tool met the AUDIT criteria for harmful drinking or probable dependence (scoring 16 or greater), with rates highest among males and young people. Upon completion of the self-assessment tool, users are informed if their drinking is within low-risk limits or if their drinking is considered to be placing them at risk of harm and the potential impact of such drinking patterns. Further information is available on how to seek support for themselves or family members.

It is important to note that these results are not representative of the Irish population, as those who are conscious about their health are more inclined to seek out health-related information.⁶ Or the high number of hazardous and possible dependent drinkers may be due to higher numbers of people who are already concerned about their drinking completing the test. The online format may restrict certain groups such as older people and may have been completed by the same individual multiple times or have been completed on someone else’s behalf by a concerned friend or relative.

Finally, it is important to note that AUDIT is intended as a screening tool for harmful or hazardous patterns of drinking, not as a diagnostic tool for alcohol dependence. Those meeting the criteria for possible dependence should therefore not be taken as having the equivalent diagnosis of alcohol dependence, but rather an indication of a potentially harmful or dependent pattern of drinking. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is considered more accurate in measuring for an alcohol use disorder (AUD).⁷ DSM-5 was used in the National Drug and Alcohol Survey, which is based on a representative sample of the Irish population, and found that 14.8% of the general population in Ireland aged 15 years and older had an AUD, from mild (11.6%), moderate (5.4%) to severe AUD (3.1%).⁸

1    Revenue, Irish Tax and Customs (2022) Revenue quarterly excise receipts and volumes. Dublin: Revenue, Irish Tax and Customs.

      Available from: https://www.revenue.ie/en/corporate/information-about-revenue/statistics/excise/receipts-volume-and-price/quarterly-update.aspx

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

3    Health Service Executive (HSE) (2021) AskAboutAlcohol. HSE our health service. Dublin: HSE. Available from:  https://www2.hse.ie/alcohol/ 

4    Health Service Executive (2022) HSE weekly low-risk alcohol guidelines. Dublin: HSE. Available from: https://www2.hse.ie/wellbeing/alcohol/improve-your-health/weekly-low-risk-alcohol-guidelines.html

5    Babor TF, Higgins-Biddle JC, Saunders JB and Monteiro MG (2001) AUDIT: The Alcohol Use Disorders Identification Test – guidelines for use in primary care. 2nd edn. Geneva: Department of Mental Health and Substance Abuse, World Health Organization. Available from: https://www.drugsandalcohol.ie/14104/

6    Dutta-Bergman MJ (2004) Primary sources of health information: comparisons in the domain of health attitudes, health cognitions, and health behaviors. Health Commun, 16(3): 273–288.

7    American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM–5). 5th edn. Arlington, VA: American Psychiatric Association.

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

Purpose of scenario development in drug policy

All foresight work involves developing a capacity to identify weak signals, considering how they may react within a specified environment, and determining the level of attention they deserve. Epidemiologists and drug policy experts anticipate greater diversity in patterns of drug use as the plant-based drugs that have dominated the picture in recent decades are partially replaced by synthetic drugs and polydrug use becomes increasingly common. Geopolitical changes, the emergence of new trafficking routes, and other supply-related factors add further complexity. As with any complex system, it is problematic to assign significance to a particular variable in the drugs field, especially if it is difficult to discern. We can easily overlook signals or fail to recognise their potential significance or predict what signals will become trends. There are cognitive as well as imaginative factors that can impede a thoughtful consideration of possible future events, but foresight helps us to identify what these barriers are and allows us to be more playful and open in considering signals. It is a valuable tool for developing anticipatory capacity and considering the range of possible outcomes from currently observable trends.

Scenario planning

Scenario planning presents a particular challenge. An approach that is often adopted in business and policy fields is to make our assumptions about the future explicit and then challenge them by imagining very different outcomes.¹ By articulating or illustrating concepts of the future, they become part of the discourse, and our capacity to prepare for them helps us to make an impact in the present. This is the anticipation which is the goal of all foresight work. It aims to alert actors to possible developments before it is too late or while they still have some power to influence the course of events and, otherwise, to confront successfully the challenges that were hopefully anticipated. Ideally, this is developed in an environment where experts are encouraged to be creative, respectful of the expertise of other perspectives, and have access to quantitative evidence to support conclusions. But also to have access to qualitative data relative to the so-called ‘soft variables’, which may be difficult to discern but often play a determining role in shaping the future of a given topic, country or organisation; hence their importance in the analysis.²

Scenarios are internally consistent hypothetical yet plausible events, or series of events, constructed to enable us to see the processes that might lead to this event and inform the actions we can take to either bring it about or prevent it. Scenario planning identifies trends and key uncertainties which can then be combined to create a picture of the future. There are several techniques of scenario planning, but all begin with a definition of scope: what is the broad question we want to answer? Several trends are identified and from these key drivers for a scenario workshop are selected. Two extremes describe the ends of the spectrum of possible outcomes from these drivers. These outcomes are the key uncertainties, and two of these uncertainties can be combined to create the scenario matrix.³

Merchants Quay Ireland (MQI) is a national voluntary agency providing services for homeless people and those that use drugs. There are 22 MQI locations in 13 counties in the Republic of Ireland (see Figure 1). MQI aims to offer accessible, high-quality, and effective services to people dealing with homelessness and addiction in order to meet their complex needs in a non-judgemental and compassionate way. This article highlights services provided by MQI to people who use drugs in Ireland in 2021.¹

Source: Merchants Quay Ireland annual review 2021, p. 36

The 13 counties are Dublin, Wicklow, Carlow, Cork, Limerick, Offaly, Westmeath, Laois, Longford, Roscommon, Cavan, Monaghan, Kildare.

Figure 1: MQI locations in the Republic of Ireland

Harm reduction services

The aim of harm reduction is to minimise the risks stemming from sharing drug-use paraphernalia. In 2021, MQI facilitated 49,448 interventions in its needle exchange and harm reduction services; 4,777 of these clients were unique. When compared with 2020, MQI saw an increase of 27% in the numbers of clients engaging in the needle exchange service.

Substance use case workers

MQI substance use case workers support people addressing their substance use, including exploring treatment options for detox and rehabilitation. This support is carried out by phone and on a one-to-one basis. In 2021, some 145 clients were supported. Of these 145 clients, 34% were young people aged 18–24 years.

Community Detox and opioid substitution therapy

In 2021, some 80 unique clients accessed the Community Detox service in Riverbank, Dublin, with 65 clients accessing benzodiazepine detox and 15 clients alcohol detox; 185 clients accessed opioid substitution therapy (OST). In 2020, MQI had witnessed a steady increase in clients availing of OST compared with 2019. The number of people receiving OST in 2020 was 483 unique clients and access to this treatment was believed to be significantly increased due to the reduced waiting times as a result of the Covid-19 pandemic.

Harm Reduction Outreach Team

MQI has a Harm Reduction Outreach Team that provides harm reduction interventions. Services provided include needle exchange, safer injecting information, and naloxone training. The team also supports clients by referring them to other services such as medical, housing, and mental health. In addition, the team aims to build relationships with clients who are service-resistant and to support them overcome the barriers they face in order to engage with mainstream services. In 2021, this team supported 1,092 unique individuals through 6,642 interventions.

Hepatitis C treatment

The hepatitis C worker is the member of the MQI team who liaises with the primary healthcare team to ensure clients who use drugs intravenously are screened for blood-borne viruses. This worker advocates for testing; if a client is positive, a general practitioner refers the client to a specialist nurse. The hepatitis C worker continues to regularly check in with clients in these situations, ensuring that they are attending appointments and receiving care where required. In 2021, some 59 unique clients engaged with the worker, with 383 visits in total.

East Coast services

A community-based drug and alcohol treatment support service is provided for the East Coast region and South Dublin. In 2021, some 209 unique individuals accessed the service and 2,973 interventions were provided. In addition to the client interventions, the team provided 1,402 phone calls to support people enquiring about the service.

Midlands services

Drug and Alcohol Treatment Supports project

MQI’s Drug and Alcohol Treatment Supports (DATS) team provides a community-based drug and alcohol treatment support service for individuals over 18 years of age and their families in the Midlands area (Counties Longford, Westmeath, Laois, and Offaly). Services provided include an outreach-based crisis support service, mobile harm reduction, needle and syringe exchange, rehabilitation and aftercare supports, and support for families affected by substance use. In 2021, some 702 unique individuals were supported through 11,538 interventions.

Recovery services

St Francis Farm and High Park

The St Francis Farm (SFF) Rehabilitation Service offers a 13-bed therapeutic facility with a 14-week rehabilitation programme set on a working farm in Tullow, Co. Carlow. At SFF, MQI provides a safe environment where service users can explore the reasons for their drug use, adjust to life without drugs, learn effective coping mechanisms, make positive choices about their future, and gain hands-on experience in animal care and vegetable production. In 2021, there were 167 referrals, 90 assessments, 47 admissions, and 39 completions. The 10-bed residential detoxification service at SFF delivers methadone and combined methadone/benzodiazepine detoxes for both men and women. In 2021, there were 302 people referred to SFF detox. Of the 157 people who completed assessments, 42 were admitted, and 40 individuals completed the programme.

At High Park in Drumcondra, Dublin, MQI operates a 14-week residential programme in a 13-bed facility. The emphasis is on assisting clients to gain insight into the issues that underpin their problematic drug use and on developing practical measures to prevent relapse, remain drug-free, and sustain recovery. In 2021, the service received 304 referrals. Of this number, 250 people completed assessments, 52 were admitted, and 37 individuals completed treatment.

Prison-based services

Addiction Counselling Service and Mountjoy Drug Treatment Programme

MQI, in partnership with the Irish Prison Service, delivers a national prison-based Addiction Counselling Service (ACS) aimed at prisoners with drug and alcohol problems in 11 Irish prisons. This service provides structured assessments, one-to-one counselling, therapeutic group work, and multidisciplinary care, in addition to release-planning interventions with clearly defined treatment plans and goals. Services offered include:

• Brief interventions
• Motivational interviewing and motivational enhancement therapy
• A 12-step facilitation programme
• Relapse prevention and overdose reduction
• Cognitive behavioural therapy
• Harm reduction approaches
• Individual care planning and release planning.

In 2021, MQI counselling staff saw a total of 1,930 unique clients. In addition, MQI continued to operate a national phoneline where prisoners could access phone support, averaging 33 calls per day.

1    Merchants Quay Ireland (2022) Merchants Quay Ireland annual review 2021. Dublin: Merchants Quay Ireland. Available from: https://www.drugsandalcohol.ie/37321/

A visiting committee is appointed to each Irish prison under the Prisons (Visiting Committees) Act 1925 and the Prisons (Visiting Committees) Order 1925. Members of the 12 visiting committees are appointed by the Minister for Justice for a term not exceeding three years. The function of prison visiting committees is to visit, at frequent intervals, the prison to which they are appointed and hear any complaints that may be made to them by any prisoner. They report to the Minister for Justice regarding any abuses observed or found, and any repairs which they think are urgently needed. Prison visiting committee members have free access, either collectively or individually, to every part of the prison to which their committee is appointed. Information from prison visiting committee reports relating to drug use in prisons for 2021 (n=8) is summarised below.¹

Mountjoy Prison, Dublin

In its report, the Mountjoy Visiting Committee noted that prisoners expressed a mood of frustration, hopelessness, and at times anger about conditions of their custody, including the prevalence of drug abuse, intimidation, and absence of adequate drug treatment services. The entry of substances into the prison, despite the efforts of staff, is an ongoing feature for the lives of detained prisoners. In addition, there were reports in 2021 of intimidation of family members in the community and a mirroring in the prison of coercion in the context of drug use and debts. The committee has consistently highlighted in past annual reports the availability of illicit drugs in the prison and recommended the continued high priority to reducing supply into the prison.

Dóchas Centre, Dublin

The Dóchas Visiting Committee observed that, as in 2020, there has been a noticeable decrease in the presence of drugs and problems associated with drugs in the prison in 2021, which is a positive development. This is likely in part because of the Covid-19 restrictions and the more structured regime within the prison.

Wheatfield Prison, Dublin

The Wheatfield Place of Detention Visiting Committee’s report observed that drugs thrown over the perimeter wall are a daily scourge for the Prison Service and prisoners who are compelled to pick up these drugs in the yard. Although the Wheatfield yards are large spaces covered with netting, there is a continued struggle to prevent drugs and objects being thrown over the perimeter wall. The committee also felt that the continual drug-throws undermine the prison methadone programme. The report suggested that a more permanent solution with regard to the numerous State-owned lands at the back of the prison could assist in drastically reducing drug-throws.

Cloverhill Prison, Dublin

In its report, the Cloverhill Visiting Committee noted that while the continued commitment of prison authorities to intercept the supply of drugs, particularly in the exercise yard, is commendable, the culture of drugs within the prison remains a reality. The committee recommended that additional support be provided to the Addiction Counselling Service for this purpose. Moreover, it again recommended the provision of a drug-free area.

Arbour Hill Prison, Dublin

The Arbour Hill Visiting Committee’s report noted that Arbour Hill remains fully committed to ensuring that the prison remains drug-free. All prisoners are fully aware that they are expected to be 100% drug-free and access to the prison’s facilities and services depend on this. Random drug testing is part of the day-to-day routine at the prison.

Loughan House, Co. Cavan

The Loughan House Visiting Committee heard that face-to-face addiction and counselling sessions were suspended due to Covid-19 restrictions in 2021. However, counselling staff made themselves available via a telephone-based service. This was coupled with the fact that prisoners in Loughan House are permitted their own mobile phone, meaning that Merchants Quay Ireland addiction team specialists remained fully accessible throughout the year.

Shelton Abbey Prison, Co. Wicklow

The Shelton Abbey Visiting Committee’s report noted that a full-time addiction counsellor is on-site, since being appointed in 2017. All prisoners are seen on entry, regardless of charge, and are assessed for current or previous addiction issues. They are offered one-to-one addiction counselling if required or, in the absence of a psychology service, are offered general counselling for issues other than addiction.

Midlands Prison, Co. Laois

The Midlands Prison Visiting Committee was informed that a general practitioner (GP) addiction specialist holds weekly sessions as part of the drug treatment service within the prison. In addition, the Addiction Counselling Service in the prison is supported by Merchants Quay Ireland and includes one-to-one counselling and assessments.

1    Department of Justice (2023) Prison Visiting Committee annual reports 2021 [Arbour Hill Prison, Castlerea Prison, Cloverhill Prison, Cork Prison, Dóchas Centre, Limerick Prison, Loughan House, Midlands Prison, Mountjoy Prison, Portlaoise Prison, Shelton Abbey Prison, Wheatfield Prison]. Dublin: Department of Justice. Available from: https://www.drugsandalcohol.ie/39024/

The Ana Liffey Drug Project (ALDP) is a ‘low-threshold, harm reduction’ project working with people who are actively using drugs and experiencing associated problems. ALDP has been offering harm reduction services to people in the north inner city area of Dublin since 1982, from premises at Middle Abbey Street. ALDP offers a wide variety of low-threshold, harm reduction services that provide pathways for people who use drugs out of their current circumstance, including addiction and homelessness.

The services offered in Dublin include:

• Open access
• Assertive outreach
• Needle and syringe programme
• Medical services
• Stabilisation group
• Detox group
• Harm reduction group
• Treatment options group
• Assessment for residential treatment
• Key working and case management
• Prison in-reach.

Midwest region

The ALDP Midwest region provides harm reduction services in Limerick city and three counties to people affected by problematic substance use, their families, and the wider community. The counties served are Limerick, Clare, and North Tipperary. The ALDP Online and Digital Services team also offers support and information to the general public and to people who use drugs, as well as to other agencies that work with people with problematic drug use.

Annual report

The 2022 ALDP annual report was published in 2023.¹ The report noted that in 2022 the Law Engagement and Assisted Recovery (LEAR) programme, which had been running for 8 years, came of age with increased cooperation from An Garda Síochána, who committed more time and effort to it than ever before. The aim of LEAR is to support people who have complex and multiple needs, such as addiction, criminality, homelessness, and mental health, to engage effectively with support services and to identify and achieve their goals. A key focus of the project is supporting people to move away from criminality and antisocial behaviour and towards their personal recovery. In April 2022, ALDP expanded LEAR into Dublin’s northeast inner city with four additional staff and two more Garda Stations in Mountjoy and Fitzgibbon Street coming on board. The report noted that prior to the Covid-19 pandemic, ALDP was renowned for its open access drop-in service, whereas the emphasis is now on working with service users in community settings.

In 2022, ALDP also facilitated training on overdose prevention and naloxone use for hundreds of staff working in private emergency accommodation and for people who use drugs.

1    Ana Liffey Drug Project (2023) Ana Liffey Drug Project 2022 annual report. Dublin: Ana Liffey Drug Project. Available from: https://www.drugsandalcohol.ie/39563/

In October 2023, An Garda Síochána (AGS) published its annual report for 2022.¹ This article first reports on activities related to national policing, followed by national security and intelligence, community safety, and finally statistics for detections of incidents related to the sale and supply of drugs and Garda drug seizures for 2022.

National policing

Gardaí work in various units to fight crime across Ireland. What follows is a brief outline of a selection of the work undertaken by some of these units.

Garda National Drugs and Organised Crime Bureau

Table 1 provides a breakdown of seizures relating to operations carried out by the Garda National Drugs and Organised Crime Bureau (GNDOCB) in 2022.

Table 1: Summary of seizures by GNDOCB, March 2015–December 2022

Source: AGS (2023, p. 14)¹

* This is the amount of cash forfeited to the State after relevant Court proceedings.

** 80 threat-to-life operations since 5 February 2016.

Note: These statistics relate to operations involving the GNDOCB and do not include seizures made by local Garda units.

Operation Thor

Operation Thor, AGS’s national anti-burglary operation, commenced in November 2015. Since then, there have been 18,189 arrests and 534,076 checkpoints. Burglary incidents in residential and non-residential settings have decreased by 48% and 44%, respectively.

Garda National Protective Services Bureau

The Garda National Protective Services Bureau (GNPSB) targets suspects involved in sexual crime, online child exploitation, child protection, domestic abuse, and human trafficking:

• The dedicated Child Sexual Abuse Reporting phoneline provided by AGS received 221 calls in 2022.¹
• In 2022, some 42 victims (15 females and 27 males) of human trafficking were identified by AGS.
• In 2022, the Missing Persons Unit (MPU) recorded 10,510 missing person incidents, with 4,268 persons reported missing one or more times. At the end of 2022, there were 58 missing persons. The MPU also supported the United Kingdom’s (UK’s) National Crime Agency and police on a historical missing person case since 1982.
• Coercive control legislation has resulted in an increase in recorded coercive incidents in 2022. The Domestic Abuse Intervention and Policy Unit (DAIPU) continued to collaborate with GNPSB on campaigns to increase public awareness and support victims during Garda investigations. A presentation developed by DAIPU is now part of training implemented by the Divisional Protective Services Unit.
• In September 2022, AGS published a report on domestic, sexual, and gender-based violence, outlining current trends and Garda operational responses. This report has further increased public awareness, engagement, and enhanced victim support as well as commitment to the investigation and prosecution of offenders.

Garda National Economic Crime Bureau

The Garda National Economic Crime Bureau (GNECB) was involved in several operations in 2022:

• Operation Omena investigated the use of Irish bank accounts to launder money by an organised crime gang (OCG). While 12 foreign nationals were placed under arrest and prosecuted, the investigations are ongoing, and it is hoped that more suspects will be extradited to Ireland to face charges.
• Operation Skein investigated an OCG suspected of worldwide fraud using business emails, with proceeds being laundered from Irish bank accounts to other jurisdictions. An extensive OCG network has been identified involving 800 suspects who are mainly money mules. Investigations have shown that over EUR 40 million has been stolen and laundered through bank accounts in Ireland. So far more than 200 suspects have been arrested.¹
• Operation Elaborate is an ongoing investigation led by Europol into smishing/phishing frauds. Using the iSpoof server, criminals contacted victims to pretend that they were banks or service providers. The server was removed by police in the UK and the Netherlands. Searches carried out in Ireland in November 2022 resulted in the identification of 17 suspects, the seizure of 100 devices, and EUR 100,000 in cryptocurrency frozen. Gardaí continued to examine the devices and another 300 suspects are thought to be identifiable.

Garda National Cyber Crime Bureau

The Garda National Cyber Crime Bureau (GNCCB) assisted in several enquiries. In 2022, some 488 new cases were opened and 692 were closed. Case types included:

• Cyber forensics (n=468): Nine children who had been sexually abused and exploited were identified. The GNCCB collaborated with GNPSB to implement child protection interventions.
• Cyber investigations (n=19): GNCCB participated in Operation Elaborate to shut down the iSpoof computer server. As part of Operation Vaccination, it helped shut down the FluBot android malware server. The examination of multiple ransomware attacks on educational and corporate systems is ongoing.
• Cyber intelligence (n=1): Intelligence on existing threats, risks, and suspects collated from stakeholder partners were shared via internal bulletins and publicly via cyber safety releases.

Criminal Assets Bureau

In 2022, the Criminal Assets Bureau (CAB) continued to target ‘high-ranking’ criminals along with mid and lower-level tiers involved in OCGs, with the aim of depriving them of the proceeds of crime. It continued to engage with international agencies and participated in asset forfeiture and confiscation conferences. In 2022, training continued and resulted in an increase in the network of Divisional Assets Profilers.¹

Operational support services

AGS has several operational support units to reinforce its work: the Garda Air Support Unit (GASU), Garda Dog Unit (GDU), Garda Mounted Unit (GMU), and Garda Water Unit (GWU).

• GASU: In 2022, GASU carried out 1,177 flights, resulting in 1,068 hours flown. Overall, 1,624 incidents were attended, 128 suspects detained, 17 missing persons located, and 40 vehicles located.
• GDU: The unit has 29 dogs and carried out 368 searches in 2022 to find drugs, firearms, and cash. To ensure security at major events, 151 searches were carried out by GDU detection dogs.
• GMU: In 2022, this unit carried out missing person searches; assisted in the VIP visit of the then Prince Charles to Ireland; provided high visibility mounted patrols at the Galway Races, Rose of Tralee, and Electric Picnic; assisted policing operations; and worked with and assisted charities.
• GWU: In 2022, this unit carried out a range of searches and activities, such as person-related searches, recovering nine human remains; firearm searches, also providing underwater video and still photography to investigators; security searches, also providing berth clearing and ship’s hull searches on visiting ships that posed a security threat.

National security and intelligence

Security and intelligence

The Garda National Crime and Security and Intelligence Service collates, analyses, and disseminates intelligence related to national security. Table 2 highlights some of the work carried out by this service in 2022.

Table 2: Actions taken by the Security and Intelligence section to keep Ireland safe

Source: AGS (2023, pp. 28–30).¹

Total national figures are based on a computation of regional data provided in AGS report (AGS 2022, p. 27).

Liaison and protection

In terms of liaison and protection,, AGS continued to work closely with agencies outside Ireland. Its activities included:

• Interpol: Interpol Dublin contributed to Interpol databases to help in the prevention, disruption, and detection of transnational crime. Members of AGS participated in several Interpol-led projects that targeted cybercrime, financial crime, organised crime, environmental crime, and crimes related to the Covid-19 pandemic.
• Europol: AGS in collaboration with Europol conducted several cross-border operations involving serious and organised crime. Garda personnel attached to specialist units completed online training, attended virtual conferences, and were involved in joint action days as part of Europol’s drive to upskill law enforcement to essential standards.
• Schengen Information System (SIS II) and Supplementary Information Request at the National Entries (SIRENE) Bureau: In March 2021, AGS was connected to SISII. The SIRENE Bureau was established by AGS to implement SISII. In relation to Ireland, overall in 2022, there were 1,424 hits on other member states and 809 hits on Irish alerts.
• International Coordination Unit (ICU): The ICU participated in the European Commission Internal Security Fund (ISF) (police) National Programme 2021–2027. The ISF was established by the European Commission to maintain high security levels in the EU.
• National Major Emergency Management (MEM) office: In 2022, MEM continued to be part of the Cross Border Emergency Management Exercise Group, which created Exercise Enya. The aim of this exercise was to:

-             Assess the cross-border activation protocol for anticipated or confirmed major emergency incidents between the borders of Northern Ireland and the Republic of Ireland

-             Establish coordination structures, and

-             Manage multiagency communications on a cross-border basis.

This unit also represented AGS on the:

-             Government Task Force on Emergency Planning

-             National MEM Steering and Working Groups, and

-             Cross Border Emergency Management Group.

Community safety

Community engagement is at the heart of the work of AGS. Several activities were carried out in 2022, such as crime prevention campaigns via traditional, social, and online media (e.g. burglary prevention, online safety, public safety and harm reduction, rural safety, and bogus callers/fraud). For example:

• Halloween Safety Schools Campaign was delivered in primary schools to keep children safe at Halloween.
• Operation Twin Tracks targeted antisocial behaviour on the DART, Luas, and intercity rail routes.
• The Garda National Community Policing Unit (GNCPU) in collaboration with Crimecall implemented an online safety campaign to support Safer Internet Day in February.
• The Rural Safety Plan 2022–2024 was launched in September, written by the GNCPU and the Garda National Crime Prevention Unit. The main priorities identified were community safety, burglary and theft, roads policing, animal crime, and heritage crime.

Source: Operational PULSE data ICCS types: 1011, 1012, 1021 (AGS 2023, p. 71)¹

Figure 1: Detected sale and supply of drugs, 2017–2022

Statistics

Incidents of sale and supply of drugs marked as detected

Figure 1 shows the number of sale and supply incidents detected between 2017 and 2022. Between 2019 and 2021, there were on average 369 incidents per month. The average for 2022 was 355 per month. Between 2021 and 2022, the average per month decreased by 10.1%. The PULSE system used to record detections was upgraded to PULSE 7.3 in February 2018. Hence, detections before and after the upgrade cannot be compared.

Garda-only drug seizures 2022

Drug seizures are submitted to Forensic Science Ireland (FSI) for analysis. Overall, it was estimated that the value of drugs seized by Gardaí in 2022 was EUR 63,226,886. As illustrated in Table 3, the most prominent drugs seized in Ireland with values greater than EUR 1 million were cannabis herb, cocaine, diamorphine, cannabis plants, phenethylamine, and hallucinogens. While cannabis plants were ranked fourth, it is likely that this figure is much higher, as not all plants are sent to FSI for analysis.

Table 3: Garda drug seizures, 2022

Source: Adapted from AGS annual report 2022 (AGS, 2023, p. 83).¹

* Cannabis plants are calculated based on figures recorded on PULSE, as not all plants seized are routinely sent to FSI.

** Phenethylamines include ecstasy (MDMA) and other similar related drugs.

*** This total figure is based on Garda-only seizures as recorded by FSI and PULSE. The GNDOCB figure may differ for a number of reasons, such as the inclusion of seizures outside the remit of FSI and PULSE; GNDOCB report based on seizure data; FSI based on analysis date; weights/quantities may differ once confirmed by FSI. All figures are provisional, operational, and subject to change as of 1 March 2023.

Conclusion

The year 2022 marked 100 years since AGS was established in Ireland. Garda Commissioner Drew Harris recognised that ‘it was a year of reflection and thanks for the organisation’ (p. 4).¹ He reflected on the contributions made by AGS and the bond developed with communities where AGS is viewed as ‘one of the most trusted police services in the world’ (p. 4). Due to their commitment and professionalism, AGS personnel have worked effectively and efficiently to prevent and detect crime, maintain peace, and provide national security. However, as an organisation, more work is needed to support personnel. AGS continues to progress its implementation of the Government’s reform programme, A Policing Service for the Future,² so that AGS can continue to work closely with communities and keep them safe as they have done since 1922.¹

1    An Garda Síochána (AGS) (2023) Annual report An Garda Síochána 2022. Dublin: An Garda Síochána. Available from: https://www.drugsandalcohol.ie/39853/

2    Government of Ireland (2019) A policing service for the future: implementing the Report of the Commission on the Future of Policing in Ireland. Dublin: Government of Ireland.

      Available from: https://www.drugsandalcohol.ie/33265/ 

3    An Garda Síochána (2022) Domestic, sexual and gender-based violence: a report on crime levels and Garda operational responses. Dublin: An Garda Síochána.

      Available from: https://www.drugsandalcohol.ie/37126/

The European Working Group on Drugs Orientated Research (EWODOR) Conference took place on 23–24 October 2023 in Trinity College Dublin, in partnership with Coolmine Therapeutic Community. EWODOR was established in 1983 as a forum for researchers in the drug and alcohol field to share their work and learnings, with a particular focus on drug-free therapeutic communities. It is the oldest European network of researchers working in the sector. Its work has expanded with practitioners becoming members of the group; while maintaining a focus on recovery pathways, EWODOR also explores drug treatment more broadly.

Recovery capital

The conference in October had as its theme the role of support, connectedness, and communities in promoting addiction recovery. Cutting across most of the presentations was the concept of ‘recovery capital’. Recovery capital is concerned with the internal and external resources that a person can access to support their recovery process. It is an asset-based concept that focuses on strengths that tend to fall under three categories: personal, social, and community.

In their introduction to the conference programme, the event’s coordinators¹ explained that ‘recovery capital entails the personal, social and community resources and assets that help individuals to initiate and maintain addiction recovery’. Rather than just being focused on the individual, they argued for the importance of ‘recovery ready communities’ which promote relational recovery and lived experience expertise. These in turn stimulate innovation in the development of new services, approaches, and policies that support sustainable recovery journeys and communities.

Conference presentations

The programme comprised 40 presentations from national and international speakers with a wide range of experience in the field. They ranged from a focus on theoretical understandings of recovery and the barriers and facilitators that impact on it to illustrations of comprehensive services and programmes that support people in building their recovery capital. Below are some short examples of the presentations.

• Jim Walsh of the Department of Health noted that recovery is one of the pillars of the current national drugs strategy in Ireland. However, he acknowledged that the strategy needs to ’up its game‘ in delivering on recovery, but argued that it is currently a focus of Irish policy, which provides ‘fertile ground’ in Ireland for building recovery communities.
• Professor David Best of Leeds Trinity University argued that treatment and recovery are too often conflated in policy and practice and that they are fundamentally different in terms of their principle, policy, and practice. Treatment involves a professional or ‘expert’ and patient relationship, whereas recovery involves the provider ‘walking alongside’ the person working towards recovery – a role often best fulfilled by peers. He argued that recovery is a fundamental process of change that focuses on strengths and which can best happen within families and communities. Based on his work, compared to people who are struggling with recovery, those who do well tend to spend more time with other people in recovery and engage in meaningful activities on a daily basis. Recovery capital (personal, social, and collective) underpins it all.
• Professor Edward Day of the University of Birmingham made a presentation entitled Toward Better Treatment and Recovery Systems: The Case of Lived Experience Recovery Organisations (LEROs). LEROs are defined as follows:

A LERO is an independent organisation led by people with lived experience of drug and alcohol recovery. LEROs deliver a range of harm reduction interventions, peer support and recovery support, and help people to access and engage in treatment and other support services.²

• He spoke about addiction being the opposite of connectedness and that LEROs support building connectedness and therefore build recovery capital. This was illustrated by, for example, recovery housing schemes and recovery community centres. LEROs can be particularly effective when linked with treatment services, building a system containing all the elements needed to support recovery.
• There were presentations that specifically looked at the experiences of women who use drugs and their needs. A presentation by Dr Polly Radcliffe of King’s College London highlighted how women continue to be seen under the lens of ‘mother’ and that services are often focused on child welfare rather than the needs of the mother. Fear of child removal is central to the experience of pregnant women who use drugs.

1    The coordinators were Professor Jo-Hanna Ivers, Trinity College Dublin; Professor Wouter Vanderplasschen, Ghent University and EWODOR chair; and Pauline McKeown, chief executive officer of Coolmine.

2    Office for Health Improvement and Disparities (2023) Recovery support services and lived experience initiatives. Part 4: glossary and resources. London: Office for Health Improvement and Disparities. Available            from: https://www.drugsandalcohol.ie/39814/

The Courts Service annual report 2022was published on 27 September 2023.¹ While the report presented data for all criminal cases arising within the Irish justice system between January and December 2022, this article only reports on statistics of prosecutions for drug offences.¹ The data provided are for overall drug law offences. The Courts Service in Ireland does not distinguish between the different supply offences and possession/use offences (Courts Service, personal communication, 2017).

District Court

In most cases, prosecutions for drug offences are carried out in the District Court, which is the lowest court in the Irish legal system. The District Court, exercising its criminal jurisdiction, deals with four types of offences: summary offences, indictable offences tried summarily, some indictable offences, and indictable offences not tried summarily. When the District Court hears a criminal case, the judge sits without a jury. The District Court judge decides the issues of fact and whether to convict. They also determine the sentence. In the case of most indictable offences that must be tried by a judge sitting with a jury, the District Court may impose a sentence where the accused pleads guilty, provided that the Director of Public Prosecutions consents and the judge accepts the guilty plea. Otherwise, the accused is sent forward to the Circuit Court on their signed guilty plea for sentencing. The District Court has a limit on the sentence it may impose in respect of a single criminal charge, which is 12 months’ imprisonment.² Overall, 21,393 orders were made in relation to drug offences in 2022 – involving 17,073 defendants – which represents a 14% decrease since 2021 (n=19909) (see Tables 1 and 2).¹

Juvenile crime

The age of criminal responsibility in Ireland is 12 years in line with Section 52 of the Children Act 2001, as amended by Section 129 of the Criminal Justice Act 2006.³ Generally, children who come before the courts are aged between 15 and 17 years. The total number of orders that were made in respect of drug offences in the Children Court in 2022 was 462 (see Table 3), which represented a 5% decrease, approximately, since 2021 (n=488).¹ In 2022, young offenders received a range of punishments: imprisoned or detained (n=8), community service (n=5) or sentenced to probation (n=114). The number of young people placed on probation in 2022 (n=114) was nearly 7% lower than the 2021 figure (n=122).¹

Table 1: Number of sentences for drug offences in the District Court, 2022

Source: Courts Service (2023)¹

* There may be more than one offence brought against a defendant.

Table 2: Number of summary and indictable offences: outcomes in the District Court, 2022

Source: Courts Service (2023)¹

Dis. = dismiss; S/O = strike out; TIC = taken into consideration; Disq. = disqualified; C/S = community service; Prob. = probation; Imp/Det. = imprisonment or detention; Susp. = suspended sentence.

Table 3: Number of juvenile crime outcomes, 2022

Source: Courts Service (2023)¹

Dis. = dismiss; S/O = strike out; TIC = taken into consideration; Disq. = disqualified; C/S = community service; Prob. = probation; Imp/Det. = imprisonment or detention; Susp. = suspended sentence.

Table 4: Number of sentences for drug offences in the Circuit Court, 2022

Source: Courts Service (2023)¹

* There may be more than one offence brought against a defendant.

Guilty = guilty pleas; NP = nolle prosequi; TIC = taken into consideration; Quash = quash return for trial; Dec. = accused deceased.

Table 5: Number of offence outcomes following conviction in the Circuit Court, 2022

Source: Courts Service (2023)¹

TIC = taken into consideration; Disq. = disqualified; C/S = community service; Prob. = probation; Imp/Det. = imprisonment or detention; Susp. = suspended sentence.

Table 6: Number of appeals from the District Court, 2022

Source: Courts Service (2023)¹

Off. = offences; Def. = defendants; Aff. = affirmed; Rev. = reversed; S/O = struck out; S/O N/A = struck out no appearance.

Table 7: Summary of number of resolved appeals, 2022

Source: Courts Service (2023)¹

DPP = Director of Public Prosecutions.

Circuit Court

The Circuit Court heard cases for 813 defendants that involved 3,151 drug offences in 2022. There were 2,551 guilty pleas, which represented nearly a 17% increase from 2021 (n=2181). Of the cases that went to trial, 25 resulted in convictions and 18 resulted in acquittals (see Table 4). Trials resulted in 362 imprisonments/detentions and 446 suspended sentences (see Table 5).¹

Appeals from the District Court

In 2022, some 489 appeals from the District Court, representing 977 offences, were dealt with in the Circuit Court.¹ Appeals and offences in 2022 were approximately 15% and 9%, respectively, lower than that reported in 2021 (appeals n=574; offences n=1075). Table 6 shows a breakdown of resolved offences.

Court of Appeal

Overall, the number of appeals that were lodged from the Circuit Criminal Court for drug/misuse of drugs offences was more than 27% higher in 2022 (n=144) when compared with 2021 (n=113). Overall, 122 appeals that originated in the Circuit Criminal Court were resolved in 2022.¹ Table 7 indicates that most appeals resolved were for sentence severity (n=89), followed by sentence leniency (n=23), conviction and sentence (n=5), and conviction (n=5).

Conclusion

The report was commended by the Chief Justice and chairperson of the Courts Service Board, Mr Justice Donal O’Donnell. He described efforts by the Courts Service in 2022 as one of ‘innovation, diligence and continued efforts’ as they worked towards making the modernisation of the Courts a reality (p. 5).¹

1    Courts Service (2023) Courts Service annual report 2022. Dublin: Courts Service. Available from: https://www.drugsandalcohol.ie/39636/

2    Courts Service (2013) Courts Service annual report 2012. Dublin: Courts Service. Available from: https://www.drugsandalcohol.ie/20180/

3    Office of the Attorney General (2006) Criminal Justice Act 2006. Dublin: Irish Statute Book. Available from: https://www.irishstatutebook.ie/eli/2006/act/26/section/129/enacted/en/html

Coolmine Therapeutic Community is a drug and alcohol treatment centre providing community, day, and residential services to men and women with problematic substance use and to their families in Ireland. Established in 1973, Coolmine was founded on the philosophies of the therapeutic community approach to addiction treatment. This is primarily a self-help approach in which residents are responsible for their own recovery, with peers and staff acting as facilitators of change. Participants are expected to contribute to the general running of the community and to their own recovery by actively participating in educational activities and in group and individual therapy. This article highlights services provided by Coolmine in 2021.¹

Coolmine House

Located in Dublin City centre, services provided at Coolmine House include one-to-one counselling, assessment, and information to support and assist clients to make the right choice to get help. The Drug-Free Day Programme (DFDP) provides a supportive setting for clients to build self-confidence and the skills to maintain a drug-free life. The programme lasts a minimum of 10 months: 5 months of primary treatment and 5 months of aftercare. Clients engage in open therapy groups, self-development workshops, one-to-one key working sessions, relapse prevention groups, and various other therapeutic/educational programmes. In 2021, some 802 individuals were supported in Coolmine House, with a 59% retention rate in the DFDP.

Source: Coolmine (2022, p. 14)

Community and day services (green marker): Coolmine House, Dublin 2; D15 Community Addiction Team, Dublin 15; Coolmine Midwest, Mahon House, Limerick City; Coolmine Cork City North Hub, The Glen; Coolmine Cork City South Hub, Mary Street; Coolmine East Cork Hub, Midleton; Coolmine West Cork Hub, Ahiohill; Coolmine North Cork Hub, Spa Glen, Mallow; Coolmine Kerry Hub, Dóchas House, Tralee. Women and children’s residential services (pink marker): Ashleigh House, Dublin 15; Westbourne House, Limerick. Men’s residential services (blue marker): Coolmine Lodge, Dublin 15. Administrative office (brown marker): 7 Ringwood Centre, Damastown, Dublin 15.

Figure 1: Coolmine services and locations, 2021

Community Addiction Team Dublin 15

The Community Addiction Team Dublin 15 (D15 CAT) service provides focused care pathways specifically to the local community in Dublin 15 impacted by problem substance use. It includes treatment and rehabilitation support for adult men and women with problem substance use; contact and interventions to young people and adolescents at risk of experiencing problematic substance use; tailored support to members of ethnic and new communities impacted by problematic substance use; and integrated family work to deliver whole-family outcomes. Services include:

• Information and support
• Specific support for young people
• Cannabis programme
• Family support
• Alcohol programme
• Support for new community members
• Mindfulness-based stress reduction programme
• Support for all problematic substance use.
• In 2021, some 344 individuals were supported by the D15 CAT team.
•  

Coolmine residential services

Coolmine Lodge – men’s residential

Coolmine Lodge in Dublin 15 is a therapeutic community that hosts a five-month residential treatment programme for men who are working towards an independent life, free from addiction. It provides a supportive, peer-led environment where clients can build confidence, strength, resilience, and hope for a positive future. The service can admit men who may be prescribed medication, or those detoxifying from methadone, following assessment. In 2021, some 90 men were supported in residential treatment at Coolmine Lodge, with a 76% retention rate. Twenty-seven per cent of admissions to Coolmine Lodge in 2021 were referrals from the Probation Service or Irish Prison Service.

Ashleigh House – women and children’s residential

Ashleigh House in Dublin 15 is a residential therapeutic community for women, expectant mothers, and mothers with young children. The service can admit women who may be prescribed medication, or those detoxifying from methadone, following assessment. Ashleigh House is designed to help women in recovery develop the skills they need to live a drug-free, independent life. In 2021, some 63 women were supported in residential treatment at Ashleigh House.

New services

In 2021, Coolmine established community-based facilities in the Midwest and Southwest of Ireland. All Coolmine community and day services provide assertive outreach strategies, pre-entry supports, stabilisation, and day programmes. At year-end, there were 13 facilities operating nationally (see Figure 1), with 241 new referrals to Coolmine Midwest, while 345 individuals were worked with in Coolmine Southwest.

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

The Danger of Viral Exposure (DOVE) Service in the Rotunda Hospital, Dublin was established to meet the specific needs of pregnant women who have or are at risk of blood-borne or sexually transmitted bacterial or viral infections in pregnancy. Exposure may also occur through illicit substance use. Figures from the service for 2022 were published in the hospital’s annual report in 2023.¹

Clinical activity

Figure 1 shows the number of women who booked into the DOVE Service for antenatal care each year during the period 2012–2022. It also shows the diagnosis of viral disease for these women. During 2022, some 157 women booked into the DOVE Service for antenatal care. Of those attending the service, 99 were serology-positive. Of these:

• 14 women were positive for HIV infection.
• 41 women were positive for hepatitis B (HBV) surface antigen.
• 20 women were positive for hepatitis C (HCV) antibody.
• 24 women had positive treponemal serology (syphilis).

Source: The Rotunda Hospital (2023)

Figure 1: DOVE Service bookings by year, 2012–2022

Table 1: Deliveries to mothers attending the DOVE Service who were positive for HIV, HBV, HCV or syphilis, or who were attending the DLM service, 2022

Source: The Rotunda Hospital (2023)

* One set of twins.

** Final serology test not yet available for all infants.

DLM = drug liaison midwife.

In addition to the figures presented above, a number of women attended the service for diagnosis and treatment of human papillomavirus (HPV), herpes simplex virus, chlamydia, and gonorrhoea.

It should be noted that these numbers refer to patients who booked for care during 2022. Table 1 summarises the outcome of patients who actually delivered during 2022. Of these patients, 17 were HIV-positive, 37 were HBV-positive, 31 were HCV-positive, and 18 had syphilis. During 2022, some 117 women were referred to the drug liaison midwife (DLM) service, including 36 women who had a history of opioid addiction and were engaged in a methadone maintenance programme. There was a total of 62 deliveries to mothers under the DLM service in 2022, of which 32 were on prescribed methadone programmes.

1    The Rotunda Hospital (2023) The Rotunda Hospital Dublin annual report 2022. Dublin: The Rotunda Hospital. Available from: https://www.drugsandalcohol.ie/39464/

The Tabor Group is a provider of residential addiction treatment services in Ireland. It aims to offer hope, healing, and recovery to clients suffering from addictions through integrated and caring services. In addition to two residential facilities, the organisation provides a Continuing Care Programme to clients who have completed treatment to assist with their recovery as well as a community-based programme. Its Family Support Programme offers counselling to families whose loved ones are struggling with an addiction. In 2023, the Tabor Group published its annual report for 2022.¹ This article highlights services provided by the Tabor Group to individuals with a substance use addiction in 2022.

Tabor Lodge: residential addiction treatment centre

Tabor Lodge is a residential addiction treatment centre for people addicted to alcohol, drugs, gambling, and food. It is situated 15 miles south of Cork City. Tabor Lodge is guided by the Minnesota Model of addiction treatment in delivering its treatment programme. This model is characterised by the understanding that addiction is primarily a substance use disorder. The main focus of the treatment programme is to educate clients on the dynamics of this disorder as they manifest in the life of the individual. Another important focus of the treatment programme is to assist clients develop the skills necessary to manage their disorder while going forward in their lives.

A total of 148 clients were admitted to Tabor Lodge for residential treatment of addiction in 2022. The standard length of stay for clients in 2022 was 28 days, although this varied depending on the needs of the person. Some 141 clients completed the programme and were discharged into the Continuing Care Programme. All residential treatment programmes at Tabor Group were delivered by accredited addiction counsellors and psychotherapists; there are four counsellors working with the 14 clients resident in Tabor Lodge at any one time.

Tabor Fellowship: integrated recovery programme

Tabor Fellowship is located at Spur Hill in Doughcloyne on the outskirts of Cork City. The integrated recovery programme is based on the Hazelden Minnesota Model and promotes total abstinence. The aim is to build on and consolidate the work of recovery already begun in primary treatment – even if that treatment was not in the recent past and the client is struggling to maintain sobriety.

In 2022, some 79 clients were admitted to Tabor Fellowship for extended treatment. The report observed that the standard length of stay for this programme was 12 weeks and that 44 of these clients transitioned to Recovery Living houses in Cork City for a further 12 weeks.

1    Tabor Group (2023) Tabor Group annual report 2022. Cork: Tabor Group. Available from: https://www.drugsandalcohol.ie/39057/

Ireland’s Citizens’ Assembly on Drugs Use ran from April to October 2023 and provided the opportunity for an unprecedented in-depth discussion on the drugs situation in Ireland, reflecting all its complexities. Following consideration of the extensive body of evidence presented to them, the assembly members made 36 recommendations to Government. These address legislative, policy, and operational changes that the State should make to reduce the harmful impacts of illicit drugs.

The assembly’s final report was published in two volumes in January 2024.¹ It presents a comprehensive record of the assembly’s six meetings and their recommendations. The report is an invaluable resource for those interested in understanding the drugs situation in Ireland.

According to Paul Reid, chairperson of the Citizens’ Assembly on Drugs Use:

Drug use in Irish society is a wide-ranging, complex and multi-faceted issue. Unfortunately, political debate and media coverage far too often tends towards one-dimensional analysis and over-simplification of the issues. In contrast, the Citizens’ Assembly has given extensive time to delving into the complexities and nuances of drug use, examining the evidence and hearing different perspectives. (vol 1, p. 3)¹

Background

The Government committed to the Citizens’ Assembly on Drugs Use in its 2020 Programme for Government,² and in February 2023 gave its approval for the assembly to be established. In Ireland, a Citizens’ Assembly is a democratic structure in which people living in the country are brought together to discuss and consider important and often complex legal and policy issues, independent of the Government and Oireachtas.³

The Citizens’ Assembly on Drugs Use met over six weekends. Membership of the assembly was made up of a selection of 99 Irish residents over the age of 18 years and an appointed independent chair, Paul Reid, former chief executive of the Health Service Executive (HSE). Members did not have to be Irish citizens or on the electoral register. Based on a random selection, a pool of 20,000 households were invited to take part. Of those who agreed to be considered for membership, a selection was made that reflected the age, gender, social class, and regional spread of Irish society. The group was also found to have ‘a diverse range of perspectives and levels of experience in relation to the issue of drug use’ (vol 1, p. 7).¹ The assembly set its own rules and procedures, within the confines of nine key principles: openness, balance, transparency, equality of voice, respect, privacy and confidentiality, inclusivity, collegiality, and professionalism (vol 2, p. 205).¹ It was supported by a Steering Group, Advisory Support Group, and Lived Experience Group, as well as research support by the Health Research Board and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).

Terms of reference

The remit of the Citizens’ Assembly on Drugs Use was to consider the legislative, policy, and operational changes the State could make to significantly reduce the harmful impacts of illicit drugs on individuals, families, communities, and wider society. It was to consider, among others:

• The drivers, prevalence, attitudes, and trends in relation to drugs use in Irish society
• The harmful impacts of drugs use on individuals, families, communities, and wider society
• Best practice in promoting and supporting rehabilitation and recovery from drug addiction
• The lived experience of young people and adults affected by drugs use, as well as their families and communities
• International, European Union (EU), national, and local perspectives on drugs use
• The efficacy of current strategic, policy, and operational responses to drugs use
• International best practice and practical case studies in relation to reducing supply, demand and harm, and increasing resilience, health and well-being, and
• The opportunities and challenges, in an Irish context, of reforming legislation, strategy, policy, and operational responses to drugs use, taking into consideration the implications for the health, criminal justice, and education systems.⁴

Building the assembly’s knowledge

Over the course of the six weekends, presentations were made by approximately 130 national and international contributors, including those with lived experience of drug use, policy and research experts, practitioners in the field, service providers, service users, and representatives of lobby groups, among others. Members’ deliberations were further informed by site visits to services for people who use drugs, almost 800 oral or written submissions from the public, and research on young people’s views on the topic.⁵

The members of the assembly agreed a work programme through which a broad theme would be covered over each of the six weekends, ensuring that they had the information required to meet their terms of reference. Other than when site visits were being made to drug services, the meetings followed a structured format. A set of presentations would be made by contributors or a panel discussion held on a particular topic or theme, then in a roundtable discussion members would discuss what they had heard, followed by a question-and-answer session. The final report provides an account of each of the six meetings. It includes summaries or full transcripts of each of the presentations, an account of themes emerging from the roundtable discussions, as well as the question-and-answer sessions. This makes for valuable reading and captures the depth and complexity of the topics covered in the meetings. Full video recordings of each session are also available to watch online.⁶

Overview of the six meetings

1. Setting the scene: The first meeting provided an overview of deliberative democracy and tools such as citizens’ assemblies and how they can inform policymaking. This was followed by presentations on drug policy, trends, and patterns of use at the national, international, and European levels.
2. Lived experiences: The second meeting involved site visits to drug services followed by panel discussions and presentations that explored the lived experiences of people who use drugs, their families, communities, and service providers.
3. Health and community-based perspectives: The third meeting focused on the role of policy and service delivery providers in the health, community, and voluntary sectors. This included consideration of health-led approaches to drug use, including those implemented in Austria and Portugal. Presentations were also made by national contributors who described the landscape of harm reduction, treatment, and recovery services available for people who use drugs, illustrating good practice and innovative ways of working.
4. Criminal justice and Ireland’s legislative framework: The fourth meeting provided an overview of supply-side issues at a national and international level. Members heard about the experiences of those involved in the courts and prisons and the various options available in those settings for people who use drugs. Contributors also reflected on alternative options to dealing with people who come into contact with the criminal justice system because of their drug use. This meeting addressed a core element of the work of the assembly: the exploration of possible alternatives to the current legislative framework in Ireland in relation to drugs use. Models explored ranged from maintaining the status quo to legalisation with regulation (see the section on recommended legislative changes below).
5. Prevention strategies and practice: The fifth meeting focused on prevention strategies and practice across a range of settings. It also included presentations on health-led recovery as well as governance and funding options.
6. Conclusions and recommendations: In the sixth and final meeting members of the assembly voted through a secret ballot to decide on the recommendations of the assembly to Government. Prior to the meeting, draft ballot statements on the issues that had emerged as priorities for assembly members were circulated to them for comment. Through an iterative, democratic process these were amended and then voted on by the assembly. The outcome of this process is discussed in the next section.

Recommendations of the Citizens’ Assembly

The recommendations of the Citizens’ Assembly form the core outcome of the process. As with previous assemblies, technically the recommendations are only advisory in nature and the Oireachtas, Government, and judiciary are not obliged to act on them. The report of the assembly is referred to a committee comprising members of the Oireachtas and Seanad for consideration, with the committee bringing its conclusions to the Houses of the Oireachtas for debate. The Government is obliged to respond to each recommendation of the report in the Oireachtas. For recommendations that it accepts, it is obliged to set out a time-frame for their implementation.

The process of drafting and selecting the recommendations illustrated the democratic and iterative nature of the assembly. Having been presented with a wide range of evidence by contributors, the assembly identified the issues they considered to be the most important. As mentioned above, related ballot statements were drafted, revised, and finalised to reflect feedback from members. Secret ballots were held involving 41 statements in which members voted for those that would form their recommendations.

In line with the assembly’s terms of reference, the recommendations reflect the legislative, policy, and operational changes that it considers the State should make to significantly reduce the harmful impacts of illicit drugs on individuals, families, communities, and wider society. Box 1 lists the 36 recommendations made by the assembly. In the report, each of them is accompanied by an explanatory narrative which, to varying degrees, provides greater detail and specification to the recommendation. It is beyond the scope of this article to provide a detailed account of each of them, and readers are encouraged to examine the relevant section of the report in full (vol 1, pp. 9–18).¹ There are some themes that however cut across the recommendations and illustrate the broad consensus among members on many issues. While not an exhaustive list, these include:

1. Drug use is a ‘serious, urgent, complex, escalating and evolving public health issue that causes widespread and significant harm’ (vol 1, p. 9).¹
2. Not enough is being done in Ireland to address the drug situation and to meet the needs of those affected – people who use drugs, their families, communities, and wider society. The situation ‘demands a more effective, urgent and ambitious response from the State’ (vol 1, p. 9).¹ This includes giving much greater political prominence and priority to drug policy.
3. Given the complex and cross-cutting nature of the issues involved, the assembly’s recommendations argue for a response that invokes effective involvement from all stakeholders, with high-level leadership. Stakeholders include Government Departments, policymakers, State bodies, service providers, service users, the community and voluntary sectors, civic society, and the general public.
4. Significant additional funding resources need to be allocated to implement the wide range of responses identified in the recommendations, for example, in supply reduction, community safety, prevention, treatment, and harm reduction.
5. The assembly would like those with responsibility for addressing drugs issues to be held to account, for example, when implementing the Citizens’ Assembly’s recommendations and the National Drugs Strategy. It advocates for rigorous monitoring of progress and spend across all areas.
6. The assembly considered drugs use to be predominantly a health issue. For example, it would like health-led options to be formally adopted and resourced as an alternative for people experiencing drug addiction who are in contact with the criminal justice system. None of the changes recommended involve stricter penalties on people who use drugs, in fact, the contrary.
7. The assembly recognised the value of rigorous evidence. For example, it is essential to inform best practice and remove barriers when evidence-based approaches are identified.
8. More treatment and other service places are needed across the settings where people who use drugs present for support.
9. The skills and knowledge of those working in a role that involves addressing the drugs issue at any level need to be supported and developed.

The explanatory narrative of Recommendation 1, for example, states:

While there are good examples of effective evidence-based operational and policy responses to drugs issues, there is clear evidence that the State’s response continues to be hindered by delays, inaction, lack of policy innovation, under-investment, policy incoherence and the need for more effective leadership at all levels. (vol 1, p. 9)¹

Box 1: Recommendations of the Citizens’ Assembly on Drugs Use

1. The State should take urgent, decisive and ambitious action to improve its response to the harmful impacts of drugs use, including implementing necessary legislative changes.
2. Government should prioritise drugs misuse as a policy priority, as part of an overall socio-economic strategy.
3. Government should give greater political priority and prominence to drugs policy and related issues. A dedicated Cabinet Committee chaired by the Taoiseach, supported by a Senior Officials Group, should consider and publish a detailed annual report on drug trends and emerging risks. The Department of Health must be supported in providing effective leadership and coordination of the work of the National Oversight Committee for the National Drugs Strategy.
4. Government should recognise that an effective national response to drugs-related issues requires whole of government policy coherence, operational cohesion and effective leadership.
5. The Government must assign accountability, at the highest level, for the State’s response to problematic drug use, including for the implementation and tracking of the progress of the Citizens’ Assembly recommendations.
6. The Government should introduce a ‘Health in all Policies’ approach to policy development.
7. Government should publish a new iteration of the National Drugs Strategy as a matter of urgency. A first draft should be published by June 2024 for consultation, with the recommendations of the Citizens’ Assembly as a key input. The [next] Strategy should contain annual action plans with measurable targets and objectives, clear designation of responsibilities, and regular reporting on implementation and expenditure.
8. Government should ensure effective stakeholder involvement in implementing the [next iteration of the] National Drugs Strategy.
9. Government should work with key stakeholders to build an effective whole of society response to drugs-related issues.
10. Drugs policy design and implementation should be informed by service users and people who use drugs as well as family members of people affected by drugs, with provision of appropriate supports to enable this involvement.
11. The State should formalise, adopt and resource alternative, health-led options for people with a drug addiction within the criminal justice system.
12. The Government should allocate additional resources to fund community-based and residential treatment and recovery services as an alternative to custodial sentences for people with problematic drugs use.
13. The Department of Justice and the Irish Prison Service should develop and fund enhanced prison-based addiction treatment services.
14. The Government should develop and expand the use of alternative pathways for young people engaged in low-level sale and distribution of drugs. The Assembly recommends that the criminal justice system adopts the widespread use of restorative justice and diversion initiatives in these cases, with enhanced investment in community-based youth work and community development projects and initiatives.
15. Drugs policy should prioritise the needs of vulnerable and marginalised groups and disadvantaged communities.
16. The National Drugs Strategy should seek to optimise services to ensure continuity of care and joined-up care for all service users, including people with complex and/or specific needs.
17. The State should introduce a comprehensive health-led response to possession of drugs for personal use.
18. Government should allocate significant additional funding on a multi-annual basis to drugs services across the statutory, community and voluntary sectors, to address existing service gaps, including in the provision of community-based and residential treatment services, to support the implementation of the recommendations of the Citizens’ Assembly. This funding should ensure geographic equitability in terms of access to statutory services, as well as providing for accountability, transparency and traceability of allocations.
19. The Government should examine the potential of novel funding sources to support increased drug services within the health and criminal justice systems, and in the community and voluntary sectors. Any novel funding should be secured, tracked and ringfenced for drug services expenditure.
20. Key stakeholders should publish a joint report on an annual basis detailing total and disaggregated expenditure and channels of funding provided for drug-related services in Ireland, audited by the Comptroller and Auditor General.
21. The Government should recognise, value and adequately resource the role of family members and extended support network in supporting people affected by drugs use, and their children. Kinship carers and children should have the same rights as foster carers and foster children, and this should include legal rights and monetary rights on a non means-tested basis.
22. The [next iteration of the] National Drugs Strategy should include a strategic workforce development plan.
23.  A minimum, mandatory basic training should be implemented for personnel across education, health, criminal justice, prison and social care services on trauma-informed and problem-solving responses to addiction, and health-led response options for those presenting with problematic drug use or addiction.
24. The National Drugs Strategy should continue to prioritise the objective of reducing illicit drugs supply and associated structures, at international, national and local level within communities.
25. The National Drugs Strategy should focus on building resilient, sustainable communities though local partnerships in both urban and rural settings, and stronger community policing.
26. The National Drugs Strategy [should] continue to prioritise the objective of tackling the source and impact of drugs-related intimidation and violence, and take a zero-tolerance approach.
27. The National Drugs Strategy should include a detailed action plan to enhance Ireland’s approach to prevention of drugs use.
28. The Departments of Health and Education, in conjunction with the HSE, should design and implement a comprehensive, age-appropriate school-based drug prevention strategy for primary school children, junior and senior cycle secondary students, and wider community settings, as well as their parents/guardians and teachers. Prevention programmes should utilise external experts to deliver to classrooms, supporting teachers, with regular updating by the experts to the schools.
29. The Department of Health should roll out regular national public health information campaigns, focusing on reducing shame and stigmatisation of people who use drugs, prevention, risk mitigation and advertising services.
30. The National Drugs Strategy should prioritise a systemic approach to recovery.
31. The Department of Health should develop a strategy to enhance resilience, mental health, well-being and prevention capital across the population, including a focus on providing therapeutic supports for children and young people, and for people dealing with trauma and adverse childhood experiences and dual diagnosis.
32. The [next] National Drugs Strategy should incentivise and promote evidence-based innovations in service design and delivery, prioritise the evaluation of pilot projects and emphasise the timely mainstreaming of best practice nationally and internationally.
33. The National Drugs Strategy should include a plan to strengthen the national research and data collection systems for drugs to inform evidence-based decision-making.
34. Referral of submissions received by the Citizens’ Assembly from the general public and stakeholders on drugs use to inform the development and implementation of the National Drugs Strategy.
35. Referral of certain submissions received by the Citizens’ Assembly on Drugs Use, in relation to the potential therapeutic benefits of certain substances, to the appropriate authorities for consideration.
36. The National Drugs Strategy should use evidence-based approaches to harm reduction, and take measures to reduce the barriers to implementing harm-reduction approaches without undue delay. See vol 1, pp. 9–18.

Recommended legislative change

The assembly was asked to consider legislative changes that the State could make to reduce the harms of illicit drugs use. This issue attracted a lot of debate within the assembly and illustrated how divided opinion is on the topic. It is worth exploring this recommendation in more detail.

Preparing for the ballot

Choosing a legislative approach is a technically complex issue for which the Secretariat prepared a background paper to support the members in their deliberations ahead of their fourth meeting.⁷ Among the topics covered were key terms and concepts such as decriminalisation, diversion, legalisation, etc.; the current legislative framework at national, EU, and international levels (including that related to human rights); the interplay between legislation, policy, and practice; and an overview of the harms caused by drug use in Ireland.

The paper also introduced five examples of different legislative models to illustrate plausible alternative approaches that the assembly may consider recommending for the Irish legislature to adopt to deal with possession for personal use. The fourth assembly meeting was structured as a workshop that explored the models. It facilitated an extensive opportunity for members to draw on the knowledge of an expert panel, have additional time for roundtable discussions, and to report their comments back to the Secretariat. Participants were asked to reflect on the different models and what effects they may have on stakeholders; how effective the model would be in reducing the various harms of drug use; and the advantages and disadvantages of each model and possible improvements. They were also invited to suggest any alternative models they would like considered. The main objective of the workshop was for members to develop a methodology that they could use for the remainder of their deliberations to assess the pros and cons of alternative systems that might be considered in relation to dealing with illicit drugs in Ireland.

Ballot options

Five models were on the ballot, including the text of the recommendation (initalics below). Some of the key elements of the accompanying explanatory narrative are also outlined; the full text for each model can be found in Appendix H of volume 2 of the report (pp. 216–218).¹

A   The status quo/options within the current legal framework: To retain the current legislative approach to possession of drugs for personal use, including offences specified under S3 of the 1977 Misuse of Drugs Act, and sentencing as specified under S28 of the Act. Under this approach, possession for personal use can result in a criminal conviction and a prison sentence. There is also no legal basis for direct referrals by Gardaí to health-led services.

B   Limited health diversion: The Government should introduce the planned Health Diversion legislation as an urgent legislative priority. Under this approach, the offence of possession of drugs for personal use and the related sentences would be retained as per the status quo model. However, new legislation would provide for leniency in the treatment of people found in possession of drugs for personal use for the first time. First-time offenders would be referred for a brief intervention. They would avoid an appearance in court, with the prospect of a criminal conviction, fine, and possible prison sentence.

C   Comprehensive health-led approach: The State should introduce a comprehensive health-led approach to possession of drugs for personal use. Under this approach, the State would respond to drug use primarily as a health rather than a criminal justice issue. While possession of drugs would remain illegal, those found in possession would be afforded extensive opportunities to engage voluntarily with health-led services. This would minimise or potentially completely remove the possibility of criminal conviction and prison sentences for simple possession. At its core, this model combines diversion, decriminalisation, and dissuasion (see Box 2 for definitions of the first two of these).

D   Tolerance of possession of drugs for personal use: The State should take a more tolerant approach to people found in possession of drugs for personal use. Under this approach, possession of drugs for personal use would remain illegal but an approach combining decriminalisation and depenalisation would be adopted (see Box 2 for definitions). People found in possession would have their drugs confiscated with no further consequences or charges to follow, and no required referral to health or other support services.

E   Legalisation and regulation of drugs: Drugs should be legalised and made available to adults on a regulated basis. This is a significantly different proposal to the previous approaches and would have implications for the production, sale, and distribution of drugs, as well as possession for personal use. People who use drugs would be able to purchase and consume drugs without fear of prosecution, among other potential benefits. The Exchequer would also be impacted with a new revenue stream from taxation of drugs sales.

Box 2: Decriminalisation and diversion

The comprehensive health-led approach recommended by the Citizens’ Assembly is structured around a combination of decriminalisation, diversion, and dissuasion. There is sometimes a lack of clarity about the meaning of the first two of these terms. Definitions that are provided in the report are consistent with those of the EMCDDA.

Decriminalisation refers to the removal of criminal status from a certain behaviour or action. However, it does not mean that the behaviour becomes legal, nor does it mean the elimination of sanctions or penalties for the commission of an offence. It generally means that the nature of penalties and sanctions change from criminal to non-criminal. Therefore, the likelihood of an offender receiving a criminal record and custodial sentence can be significantly reduced, or indeed entirely eliminated following decriminalisation. However, other sanctions and penalties can still be applied. For example, drugs can be confiscated and non-criminal penalties such as fines may still be applied. In debates about drugs policy, ‘decriminalisation’ is usually used to describe laws related to personal possession or use (typically of small amounts without any intent or attempt to supply) rather than drug supply.

When talking about decriminalisation for possession for personal use, the terms ‘de jure’ and ‘de facto’ are often used. The distinction is explored in-depth in the report of the Citizens’ Assembly (vol 2, pp. 139–140). In its simplest terms, de jure decriminalisation occurs when legislation is changed to explicitly remove a criminal offence from the statute books, as was done in Portugal in 2000 in relation to the possession of drugs for personal use. In contrast, other jurisdictions may pursue the objective of decriminalising, while retaining the criminal status of an act. This approach, which could be described as de facto decriminalisation, can be achieved by introducing such additional diversion and depenalisation measures as to render the act effectively, or to all intents and purposes, decriminalised.

Diversion refers to any mechanism that moves an offender away from the path of punishment by the criminal justice system and towards a health-oriented response such as counselling, treatment or social reintegration.

Based on extracts from vol 2, p. 120 and p. 139.

Results of the ballot

A universal comprehensive health-led approach is the model recommended by the assembly. This was the most divisive of the recommendations within the assembly. While appearing as number 17 in the list of recommendations, it was the first to the ballot. Six ballots were taken to come to the recommendation of adopting a comprehensive health-led approach for all drugs. Initially members were asked to choose whether they would recommend a universal or a hybrid approach to any legislative model, that is, would the same or a different approach be recommended for different types of drugs. It was agreed by the assembly to take separate ballots for (1) cannabis; (2) DMT, psilocybin/mushrooms, ayahuasca, ibogaine, etc.; (3) cocaine; and (4) all other drugs. Despite the decision to consider a hybrid approach, the comprehensive health-led approach was chosen in each of the ballots, essentially resulting in the recommendation of a universal approach. However, there was variation in the numbers between drugs, with the cannabis vote proving especially divisive. The comprehensive health-led model received only one more vote than the legalisation and regulation model (39 vs 38 votes). In contrast in the cocaine vote, the comprehensive health-led model received 56 votes in the final count, with the status quo being the next most popular model with 22 votes. The ballot results are presented in detail in the final report (vol 2, pp. 180–202).¹

Concluding comment

The final report of the Citizens’ Assembly is an invaluable record of the drugs situation in Ireland in 2023 and its complexities. Drug use is often an emotive and divisive topic and both members and contributors sometimes held conflicting views on the best approach to take to address the harms drugs can cause. However, the nature of the process provided an opportunity for all perspectives to be heard, and a comprehensive overview of the evidence base underpinning work in the field to be presented and reflected upon. Furthermore, the comprehensive set of recommendations included in the report indicates an understanding of the complex nature of drugs use and a commitment to reduce the harms caused, through a compassionate, humane, and health-led approach.

If the assembly is to have an impact on policy and bring about legislative change on a par with other citizens’ assemblies, there will need to be a firm commitment from Government and an increase in the resources provided. Furthermore, there will need to be a new sense of urgency at the highest levels, especially where legislative changes are to be made. Developing the new National Drugs Strategy provides an opportunity to harness the learning from the assembly and state a commitment to what is needed to reduce the harms caused. There is an opportunity to build on the innovation, expertise, and commitment of those working across the sector so evident over the course of the assembly.

1    The Citizens’ Assembly (2024) Report of the Citizens’ Assembly on Drugs Use. vols 1 and 2. Dublin: The Citizens’ Assembly. Available from: https://www.drugsandalcohol.ie/40393/

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

3    For more information on the Citizens’ Assembly, visit: https://www.citizensassembly.ie/en/

4    Naughton H (2023) Parliamentary Debates Dáil Éireann. 21 February 2023. Vol. 1033, No. 6. Available from: https://www.drugsandalcohol.ie/38235/

5    Dillon L (2023) Young people’s consultation for the Citizens’ Assembly on Drugs Use. Drugnet Ireland, 86 (Summer): 13–15. Available from: https://www.drugsandalcohol.ie/39493/

6    A full record of presentations, panel events, and question-and-answer sessions can be viewed on the Citizens’ Assembly website: https://citizensassembly.ie/assembly-on-drugs-use/meetings/

7    Citizens’ Assembly (2023) Workshop on options for legal frameworks in relation to illicit drugs. Dublin: Citizens’ Assembly. Available from: https://www.drugsandalcohol.ie/40395/

Ireland’s Citizens’ Assembly on Drugs Use, which published its report in January 2024, is the first time that the topic of illegal drugs use has been considered by a deliberative forum of this type in any country. This article is a brief introduction to the concept of deliberative democracy and the ideas from which it developed.

Deliberative and aggregative democracy

Deliberative democracy is a political exercise in which deliberation is the defining feature, and so differs from aggregative democracy, which primarily involves the counting of votes. Citizens’ assemblies, citizen juries, mini-publics, or other mechanisms for deliberative democracy invariably focus on topics where there are sharp differences of opinion. Deliberative democracy does not seek to replace aggregative systems or become the only or even the main form of public policy formation. Accounts of the origins and development of deliberative democracy emphasise its equally important epistemic and normative aspects; reasons are weighed and their strength is determined through a political process that supports equal participation and produces a collective judgement on the matter being considered. The opportunities for deliberative input into policymaking are limited, but deliberative democracy can add a further level of legitimacy for policy decisions in that public justification for a position is built through reasoning among equals.

Settings for deliberative democracy

It is possible to see attempts at deliberation in formal political settings, such as parliament or in selective forums in civil society, where non-governmental actors bring the techniques and standards of deliberative democracy to resolve conflicts in a public setting. While public adherence to deliberative principles may improve the quality of debates, probably the only settings in which they can be consistently applied are those that are created specifically for the purpose of deliberation, such as citizens’ assemblies, citizen juries, or mini-publics.

Ideally, these forums comprise citizens who are randomly selected, not because of their interest in a topic or prior position in a policy debate. Mini-publics, citizen juries, or consensus conferences involve 15 to 20 people debating a particular policy issue. Citizens’ assemblies involve 100 to 150 people, and so have a greater claim to population representation. While their role in relation to the workings of the more established structures of power remains advisory, policymakers may give greater consideration to results of these forums than the submissions of interest groups or professional politicians.

Development of deliberative theory

The deliberative paradigm emerged as a response to concepts of democracy based on rational choice theory and the aggregation of interests. One of the key points of separation is the importance placed on the link between epistemic outcomes and the principle of inclusivity. The act of deliberation is a collective exercise in learning, weighing evidence, and considering the positions of other participants in a problem-solving process. This process is supported by scientific evidence, expert argument, and facilitated discussion. The democratic legitimacy and the epistemic value of the process depend on both equal participation and demonstrable reason-giving.

Several different strands of political philosophy merged in the first generation of scholars in the 1960s and 1970s to shape the concept. The emphasis was on creating the opportunity for public rational debate, respect for the opinions of others, and the goal of a consensus position firmly grounded in an agreed notion of the common good. The second generation of thinkers, beginning in the 1990s, are less fixed on reason-giving in argument and say that emotions and values have just as important a place in debate and that there should also be plurality in the styles of communication.¹ This is not simply to ensure that expression is not suppressed based on assessment of the quality of reason it attains. Reason and emotion are not two immutable opposites. Emotions are learned responses to stimuli and allow for subtlety and calibration and an understanding of context when reason is being applied. Empathy and compassion also help to facilitate deliberation and widen the opportunities for stories, accounts of lived experience, and other less rigorous forms for evidence.²

Managing obstacles to deliberation

Plurality, political equality, and democratic inclusion are the overarching objectives of deliberation, with mutual respect being the standard to which all instances of deliberation must meet. For the ideal of mutual respect to be realised, coercive power in deliberation must be removed, clearly a challenge when the different experiences and expectations of class, gender, or ethnicity in any randomly selected group of citizens are considered. Polarisation within groups is inimical to gaining empirical knowledge but is far less likely when discussion is facilitated. Neither is class nor disparity in education nor income a barrier to engagement nor a drag on the quality of deliberation. Attention to evidentiary pluralism, such as allowing stories to complement reasoning based on observation or science, enables participants who may be less confident in their communication skills at the beginning to present their positions through logical argument.³ Empirical evidence demonstrates that in several deliberative assemblies, members gained an impressive body of knowledge on the topic, demonstrating that engagement with arguments in the right conditions was more likely to change opinions than motivated reasoning.

Philosophical origins

The emergence of deliberative democracy as a distinct concept in political theory began in the 1960s and while it challenges the dominant paradigms prevailing in liberal democracy, it is established on the same philosophical foundations. Some reinterpretations of Aristotle’s commentary on Athenian democracy draw attention to his recognition of the value of occasionally consulting the multitude.² While wisdom and virtue might be qualities confined to a tiny number of citizens, given the right conditions, Aristotle does concede a more inclusive democratic process is capable of arriving at decisions that benefit the polity. Rousseau’s concept of the general will might appear to be an unlikely source of inspiration for deliberative theorists, given that it envisages a direct form of democracy that eschews the type of deep consideration required by the deliberative process. At the same time, the idea of the common good is a powerful inspiration for those genuinely seeking solutions to policy differences.

From this perspective, Rousseau is not opposed in principle to deliberation, but is concerned at its potential to encourage factionalism and distract from clear articulation of the people’s will. It is the Enlightenment’s emphasis on political equality, rather than the mode through which the general will is expressed, that is of most interest to contemporary theorists of deliberative democracy such as Cohen.^4,5 The Kantian principle that all human beings are deserving of respect is inherent in the egalitarian basis of deliberative democracy. While Kant was not a democrat, he did argue that the legitimacy of laws needed to be established on reason, and this test could theoretically be done through public argument and reasoning and persuasion.

Contemporary political theory

John Rawls and Jürgen Habermas presented radical, separate challenges to the liberal notion of political justification being underpinned by a social contract and the state’s winning the consent of the governed.⁶ In common with the pragmatist tradition, Rawls and Habermas see the shortcomings in a liberal tradition rooted in metaphysical concepts like natural law theory. Political justification is established through reasoning in public and in conditions of pluralism and equality. Through our laws, it is argued, that we hand coercive authority to the state and the legitimisation of this control cannot depend on something as flimsy as personal belief. Rawls introduced the concept of public reason to democratic political theory as an attempt to move beyond subjective or personal beliefs and values and ground collective decisions on principles that derive their strength from rational appraisal and agreement. It might be asked how realistic it is to expect people to set aside deeply held beliefs and enter a process of reason-giving, unsullied by world views established over a lifetime. Other thinkers  accepted this challenge and offer a less rarefied and possibly more viable concept of reason-giving.¹

For Habermas, the creation of a new sphere of political debate, as the early shoots of democracy emerged in Europe, allowed for the development of a new form of political communication. Public opinion became a recognisable feature of states moving into greater openness in expression of opinion and paying greater attention to the discussions taking place in newspapers and public settings outside the formal political gatherings. Habermas talks about ‘the ideal speech situation’, a key part of his linguistic theory of argumentation that describes the setting in which reason-giving can lead to a position that all participants in the discussion can agree to. While there may be similarities with Rawls’ notion of the outcome of reason-giving as the condition for acceptance of state coercion, Habermas is careful to stress that the ideal speech situation is a linguistic conception and sets out the rules of argumentation that must be adhered to if an argument is to be justified. It is quite formal and the rules are based on logic, rather than social or political requirements or the content of public reason. The distinction appears subtle. The rules of argumentation appear similar to the requirements of equality, respect, and pluralism that underpin public reason. Yet, each of us has an intuitive understanding of what these rules of argumentation are and are aware of transgressions in everyday interactions.

Proponents of deliberative democracy have made extensive use of Habermas’s understanding of reason as the outcome of communication that must meet exacting conditions of inclusivity, equal opportunity to speak, and the absence of deception or manipulation and coercion. The ideal speech situation can be given concrete expression in conditions of equality and respect. Reason in this context has a definite normative aspect; it is both the guarantor of the freedom and equal status of the participants in a discussion and the outcome of the deliberation that meets these standards. We must be careful when applying these standards in a political context; however, they do provide a guide to how the public sphere can be developed so the state is held to account and shortcomings regarding reason can be corrected. Habermas speaks of ‘the unforced force of the better argument’, which can at least point to a direction of travel towards reason-giving in deliberative contexts, even if we are cautious about applying the concepts implicit in the ideal situation to debate in recognisable public arenas.

Habermas’s unforced force of the better argument is a contemporary variation of philosophy’s championing of the epistemic value of deliberation. The practical work of deliberation sifts the jumble of arguments and bits of information, presents opportunities to look at information from a different perspective, and introduces new ideas and ways of seeing the world to those participating. Deliberation also helps to offset what might be considered impediments to reason due to personal histories, socioeconomic background, or even prejudice. In fact, it is the cognitive diversity of the participants rather than the pooling of expertise that gives deliberation the edge. Democratic deliberation, involving a public and equal exchange among a representative group, adds a further dimension in that it assures cognitive diversity and the confidence that, whatever the outcome, it will be accepted as legitimate.

1    Floridia A (2018) The origins of the deliberative turn. In Bächtiger A, Dryzek JS, Mansbridge J and Warren ME (eds) The Oxford handbook of deliberative democracy. Oxford: Oxford University Press.

2    Dryzek JS (2002) Deliberative democracy and beyond: liberals, critics, contestations. Oxford: Oxford University Press.

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