The 2019/20 NDAS followed best practice guidelines recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). The questionnaire, based on the European Model Questionnaire, was administered in face-to-face interviews with respondents aged 15 years and older. A sample comprising all households throughout the island of Ireland was randomly selected to participate; fieldwork began in February 2019 and was completed in March 2020. Of the household members contacted, 5,762 agreed to take part. The sample was weighted by gender, age, and region to ensure that it was representative of the general population. The main measures were lifetime use (ever used), last-year use (recent use), and last-month use (current use).

Use of any illegal drug

The proportion of respondents aged 15–64 years who reported using any illicit drug in their lifetime has increased from almost 19% in 2002/03 to 27.1% in 2019/20 (see Figure 1). However, lifetime use has stabilised since the last survey. Similarly, last-year and last-month prevalence of any illegal drug use has remained stable since 2014/15; from 8.9% to 9% and 4.7% to 4.9%, respectively. Any illegal drug refers to the use of cannabis, ecstasy, cocaine powder, magic mushrooms, amphetamines, poppers, LSD, new psychoactive substances (NPS), solvents, crack, and heroin.

Illicit drug use was more prevalent in males and also greater among young adults, with 9.8% of persons aged 15–34 years having reported illegal drug use within the previous month (compared to 8.5% in 2014/15). Results from the 2019/20 survey indicated that the most commonly used illicit substances in Ireland, based on last-year prevalence, were cannabis (5.9%), ecstasy (2.2%), and cocaine (1.9%).

Cannabis use

Findings revealed that 24.4% of the population (15–64 years) had used cannabis at some point in their lives; 7.1% reported use in the year prior to the survey and 3.4% in the preceding month (see Figure 2).

Similar to earlier surveys, rates of cannabis use were greater among men than women: for lifetime use (29.5% vs 19.3%); last-year use (9.9% vs 4.4%); and last-month use (5% vs 2%). Since 2002/03, lifetime, last-year and last-month rates of cannabis use among males have increased by 32.9%, 37.5%, and 47%, respectively. Lifetime and last-year use of cannabis among females has also increased. However, last-month prevalence in women has remained relatively stable over time.

The prevalence of cannabis use was noticeably higher among young adults. However, lifetime and last-month rates were lower than those recorded in 2014/15, while last-year prevalence was unchanged at 13.8%.

Source: NDAS, 2021
Note: Any illicit drug refers to the use of cannabis, ecstasy, cocaine powder, magic mushrooms, amphetamines, poppers, LSD, new psychoactive substances (NPS), solvents, crack, and heroin.
Figure 1: Lifetime, last-year, and last-month prevalence of any illicit drug use in Ireland,
2002/03, 2006/07, 2010/11, 2014/15, and 2019/20

Source: NDAS, 2021

Figure 2: Lifetime, last-year, and last-month prevalence of cannabis use in Ireland,
2002/03, 2006/07, 2010/11, 2014/15, and 2019/20

Cocaine use

Lifetime cocaine use has increased when compared with 2014/15 rates (see Figure 3). The percentage of respondents aged 15–64 years who reported using cocaine (including crack) at some point in their lives increased from 7.8% to 8.3%. As was observed in previous surveys, more men reported using cocaine in their lifetime compared with women (11.6% vs 5.1%).

Recent use of cocaine among 15–64-year-olds has increased from 1.1% in 2002/03 to 2.3% in 2019/20, although cocaine use remained stable between 2006/07 and 2014/15. Since the 2014/15 survey, recent cocaine use among males has increased from 2.6% to 3.5%, while use among females has increased from 0.5% to 1.2%. There were also noticeable increases in the use of recent and current use of cocaine among young adults; last-year prevalence has increased from 2.9% in 2014/15 to 4.8% in 2019/20, while current use increased from 0.9% in 2014/15 to 1.5% in 2019/20.

Ecstasy use

Ecstasy was found to be the second most commonly used illegal drug (after cannabis) in the year prior to the survey. With the exception of the 2010/11 survey, recent ecstasy use has increased at each survey; there was a significant decrease in 2010/11 (to 0.5%) but recent use increased to 2.1% in 2014/15 (see Figure 4).

Almost 14% of young adults (15–34 years) said they had tried ecstasy at least once in their lifetime, with 6.5% having used it within the last year (vs 4.4% in 2014/15) and 3.1% indicating current use (vs 2.1% in 2014/15).

New psychoactive substances use

Last-year prevalence of NPS use was included as a drug category for the first time in the 2010/11 drug prevalence survey. Findings from the 2014/15 survey demonstrated a reduction in the use of NPS in the Irish population among both genders.

Source: NDAS, 2021
Figure 3: Lifetime, last-year, and last-month prevalence of cocaine use (including crack) in Ireland, 2002/03, 2006/07, 2010/11, 2014/15, and 2019/20

Source: NDAS, 2021

Figure 4: Lifetime, last-year, and last-month prevalence of ecstasy use in Ireland,
2002/03, 2006/07, 2010/11, 2014/15, and 2019/20

Findings from the 2019/20 NDAS show that the prevalence of recent NPS use remains very low in Ireland, at 0.8% among 15–64-year-olds (compared with 3.5% in 2010/11). This perhaps highlights the continued impact of the Criminal Justice (Psychoactive Substances) Act 2010, which made the sale, import, export, or advertisement of unregulated psychoactive substances for human consumption illegal. The Act also gave appropriate powers to An Garda Síochána and the Courts to intervene quickly to prevent trade in a non-criminal procedure via the use of prohibition and closure orders.

Conclusion

Although results from the 2019/20 NDAS suggest that there has been no change in the prevalence of any recent (last-year) illegal drug use in Ireland since 2014/15, there have been changes regarding the types of drugs used. Importantly, while there has been a small decrease in the prevalence of cannabis use, the use of cocaine and ecstasy has increased.

It should be noted that although opioids were included as a drug category in the 2019/20 drug prevalence survey, the prevalence of heroin use was low, as the NDAS is a general population survey. Thus, persons who do not normally reside in private households have not been included. A national 3-source capture-recapture (CRC) study to provide statistically valid estimates of the prevalence of opiate drug use in the national population was commissioned by the National Advisory Committee on Drugs and Alcohol and undertaken in 2001³ and 2006.⁴ The three data sources used were the Central Treatment List (of clients on methadone), the Hospital In-Patient Enquiry (HIPE) scheme, and Garda PULSE data. A third study using the CRC method was published in 2017.⁵ In 2020, the HRB awarded a contract to the School of Public Health, University College Cork to conduct a fourth study on the prevalence of opioid use in Ireland for the years 2015–2019 and this research is due to be completed shortly.

Seán Millar

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

3   Kelly AW, Carvalho M and Teljeur C (2003) Prevalence of opiate use in Ireland 2000–2001: a 3-source capture recapture study. A report to the National Advisory Committee on Drugs Sub-Committee on Prevalence. Dublin: Stationery Office. http://www.drugsandalcohol.ie/5942/

4   Kelly A, Teljeur C and Carvalho M (2009) Prevalence of opiate use in Ireland 2006: A 3-source capture recapture study: a report to the National Advisory Committee on Drugs. Dublin: Stationery Office. http://www.drugsandalcohol.ie/12695/

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

The emergence of the phenomenon of new psychoactive substances (NPS) since the mid-2000s marks a new phase in our millennia-long relationship with mood or mind-altering substances. Until the 19th century, most psychoactive substances were consumed by eating or drinking crude plant material. Developments in organic chemistry in the 19th century allowed scientists and clinicians to develop more potent forms of the active ingredients extracted from plants and to deliver medicines more efficiently through technologies like the hypodermic needle. Eventually, thousands of new medicines with psychoactive properties were synthesised, only a fraction of which were used by clinicians. Inevitably, many of the new substances developed for research or experimental purposes came to be used in non-medical ways due to lax regulation and curiosity driven by sociocultural changes.

Synthesis was not confined to research settings and drugs with no medical application, such as LSD, ketamine, PCP, and MDMA, emerged through the work of hobbyists or criminal organisations. From the 1960s, these substances found their way onto the illegal drug market alongside medicines diverted from clinical use. However, in the mid-2000s, the quantity, type, and availability of these novel substances increased dramatically as the internet provided both the scientific information required to modify existing compounds and a means to facilitate distribution. Most novel substances serve as a short-term replacement for the more established drugs and are quickly replaced by newly synthesised products as their predecessors are controlled or fall out of favour. There is frequently a danger from very high potency and from the susceptibility of inexperienced users.

Legal classification of NPS is the first step in the policy response to the problem. From early on in their emergence on drug markets, international organisations have agreed to describe them as substances not controlled under the United Nations Drug Control Conventions, the basis on which most countries establish their drug control legislation. The volume of new drugs and the frequency of novel syntheses have made legislative responses difficult, with considerable variety in the approaches taken by national governments. The scientific response, in contrast, has been highly coordinated, at least in the European Union (EU). Monitoring bodies, laboratories, and health experts have created an integrated system of early warning systems across the EU, coordinating the work of national networks and building an efficient process of identification of substances likely to cause harm, adverse event reporting, and advice for both health services and regulatory authorities.

The rapid development of Covid-19 vaccines in 2020 was one of the most remarkable achievements in scientific history. The capacity and willingness of scientists to work together across national boundaries, a capacity often not displayed by governments, was essential to the rapid development and deployment of vaccines. The threat of new drugs to public health is, of course, far smaller than that of a pandemic. We still need to prepare for a rapidly changing situation in which a highly efficient and productive drug manufacture and distribution system can quickly supply new markets that may emerge over the coming years. While there is much work to be done in early warning, the knowledge infrastructure needed to respond to this danger to public health is in place. Europe’s early warning system is an outstanding example of scientific rigour, international cooperation, and refined communication, and provides valuable lessons to other spheres of public health.

Policy context

The goal of the National Strategy on Children and Youth People’s Participation in Decision-Making 2015–2020² was to ensure that children and young people have a voice in their individual and collective everyday lives across the five national outcome areas set out in Better outcomes, brighter futures: the national policy framework for children and young people, 2014–2020.³ These outcomes were for children to be active and healthy; to be achieving in all areas of learning and development; to be safe and protected from harm; to enjoy economic security and opportunity; and to be connected, respected, and contributing. One of the key fundamentals of the strategy was an acknowledgement that children and young people are not ‘beings in becoming’ but ‘citizens of today’ with the right to be respected and heard during childhood, their teenage years, and in their transition to adulthood (p. v).² The new framework is the latest in a series of developments to deliver on the strategy’s goal.

The strategy and framework are primarily aimed at children and young people under the age of 18, but also embrace the voice of young people in the transition to adulthood up to the age of 24. Both focus on the everyday lives of children and young people and the places and spaces in which they are entitled to have a voice in decisions that affect their lives. They are guided and influenced by the United Nations Convention on the Rights of the Child (UNCRC); the European Union (EU) Charter of Fundamental Rights (for the strategy); the UN Convention on the Rights of Persons with Disabilities (for the framework), and relevant national legislation (see Appendix 1 of the framework).^4,5,6,1

Identifying a need

Following the introduction of the strategy and the activities of organisations, such as Hub na nÓg and Comhairle na nÓg, an increasing number of statutory and non-statutory stakeholders sought support and guidance from DCEDIY on how best to meet their obligations in this area. They required support and training on how to effectively consult with children and young people and how to involve them in decision-making. The framework sets out to meet this need.

Framework vision

The vision of the framework is ‘participation with purpose’, which means involving both the purpose (or objective) of the organisation and the children and young people in the decision-making. At its core, participation with purpose ensures ‘that when children and young people are involved in decision-making, their views are listened to, taken seriously and given due weight, with the intention that these views will influence the outcome or initiate change’ (p. 6).¹

In addition to being a human right, the framework recognises that involving children and young people in decision-making results in more effective policies, services, programmes, facilities, learning approaches, clubs, cultural and sporting activities, and other initiatives.

Guidance

Children and young people’s participation in decision-making is defined by the UN Committee on the Rights of the Child as:

…ongoing processes, which include information-sharing and dialogue between children and adults based on mutual respect, and in which children can learn how their views and those of adults are taken into account and shape the outcome of such processes. (p. 3)⁴

In this context, the framework provides guidance for stakeholders on a wide range of topics in how best to carry out these processes. For example, guidance on involving children and young people in decision-making at different levels within organisations and descriptions of the various structures that can be used. It also deals with issues such as how to ensure the involvement of seldom-heard children and young people and how to follow up on their views and give them feedback. A large proportion of the report is taken up with examples of good practice in the field.

Checklists and feedback forms

The framework provides three checklists (planning, evaluation, and everyday spaces) and a series of feedback forms for children and young people. The authors argue that these provide a simple but structured way to guide decision-makers in their use of the rights-based model and good practice principles, which are at the core of the framework (see Lundy model in Figure 1). They are tools that organisations can use to effectively plan, conduct, and evaluate their child and youth participation processes and initiatives. They also give children and young people a voice in decision-making in everyday spaces or settings.

Enabling factors

Four enabling factors that underpin the effective implementation of the framework are identified. Stakeholders need to ensure:

• Organisational buy-in
• Training and capacity building for decision-makers
• Resources (financial, human, time)
• Monitoring and evaluation.

Source: Department of Children, Equality, Disability, Integration and Youth (2021), p. 15

Figure 1: Lundy rights-based model of participation

Next steps

The framework should be a valuable resource for those working in the sector. It is to be complemented by training and support from Hub na nÓg; a new National Participation Office; and ongoing Government commitment to Comhairle na nÓg, which works on the inclusion of young people in decision-making at local and national level.

1   Department of Children, Equality, Disability, Integration and Youth (2021) National framework for children and young people’s participation in decision-making. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/34379/

2   Department of Children and Youth Affairs (2015) National Strategy on Children and Young People’s Participation in Decision-making 2015–2020. Dublin: Government Publications.
https://www.drugsandalcohol.ie/24612/

3   Department of Children and Youth Affairs (2019) Better outcomes, brighter futures: the national policy framework for children and young people, 2014–2020. Dublin: Stationery Office.
https://www.drugsandalcohol.ie/31853/

4   UN Committee on the Rights of the Child (2009) General comment No. 12 (2009): The right of the child to be heard, 20 July 2009, CRC/C/GC/12. Geneva: United Nations. Available online at:
https://www2.ohchr.org/english/bodies/crc/docs/AdvanceVersions/CRC-C-GC-12.pdf

5   European Union (2000) Charter of Fundamental Rights of the European Union (2000/C 364/01). Brussels: European Union. Available online at: http://www.europarl.europa.eu/charter/pdf/text_en.pdf

6   UN Committee on the Rights of Persons with Disabilities (2018) General Comment No. 7 (2018) on the participation of persons with disabilities, including children with disabilities, through their representative organizations, in the implementation and monitoring of the Convention, CRPD/C/GC/7. Geneva: United Nations. Available online at:
https://www.ohchr.org/en/hrbodies/crpd/pages/gc.aspx

On 15 April 2021, Minister of State for Law Reform James Browne TD and Minister for Justice Helen McEntee TD launched a new Youth Justice Strategy 2021–2027.^1,2 It is centred on a developmental framework that aims to target ongoing and emerging challenges in youth justice.² A key strength of this strategy is that its development was informed by an expert steering group representing key stakeholders, such as the Department of Justice; Department of Health; Department of Children, Equality, Disability, Integration and Youth; the Probation Service; An Garda Síochána; Oberstown Children Detention Campus; Department of Education and Skills; Tusla; University College Cork (UCC); University of Limerick; Solas; Children’s Rights Alliance; and Foróige. The steering group was assisted by experts, Dr Louise Forde and Dr Katharina Swirak, from the UCC Centre for Children’s Rights and Family Law, who provided content and guidance from a valuable evidence base.¹

Focus of strategy

Guiding principles

The strategy is grounded on principles derived from international and national legal standards related to youth justice, such as the United Nations Convention on the Rights of the Child and the European Convention on Human Rights.^3,4 In a separate document, Forde (2020) provides an overview of these standards and outlines some of the main principles that emerge from them.⁵

Purpose, context, and scope

By using a developmental framework, it is hoped that the strategy will result in meaningful collaborative stakeholder engagement and allow for flexibility to address challenges and developments as they arise. Hence, the strategy is a living document subject to review, where progress reports will be published annually.

Youth Justice Strategy

Figure 1 shows the main themes that the strategy aims to address. The details of each will be presented separately in the article.

Theme 1: Governance, monitoring and support

The strategy aims to deliver governance, monitoring, and support for policy implementation. The development of practice and programmes will be based on evidence. As shown in Table 1, several objectives were identified.

Theme 2: Services for children and young people

The strategy aims to provide services to children and young people who come into contact with the criminal justice system or who are in situations that may result in offending behaviour in order to help them develop and stop offending behaviours. Table 2 outlines the main themes and objectives to be addressed.

Theme 3: Criminal justice system and processes

The strategy aims to implement criminal justice processes that help children and young people stay away from offending behaviour and adopt positive life choices, while at the same time ensuring that the rights of victims are upheld. Several objectives were identified, as outlined in Table 3.

Source: Youth Justice Strategy 2021–2027 (p. 10)1

Figure 1: Thematic objectives of the Youth Justice Strategy 2021–2027

Table 1: Governance, monitoring and support objectives

Source: Youth Justice Strategy 2021–2027.¹

Table 2: Services for children and young people objectives

Source: Youth Justice Strategy 2021–2027.¹

Table 3: Criminal justice system and processes objectives

Source: Youth Justice Strategy 2021–2027.¹

Conclusion

In launching the strategy, Minister Browne believes that it will address key ongoing challenges of youth crime as well as new and emerging issues in the youth justice area.

This strategy will respond collaboratively to the situation of vulnerable children and young people, with a strong focus on diverting them away from offending, prevention and early intervention. I can’t stress enough the importance of bringing all the relevant agencies and programmes together, and of supporting schools, to ensure that we provide a holistic, ‘wraparound’ response to the needs of children and young people at risk. (p. 2)²

The strategy was welcomed by Fíona Ní Chinnéide, executive director of the Irish Penal Reform Trust. She noted that the strategy is an opportunity to transform the lives and futures of disadvantaged children and young people in Ireland, with the emphasis on moving away from the formal justice system towards diversion as ‘of paramount importance’ (p. 1).⁸ She further acknowledged the importance of ensuring that the child-centred aims of the strategy are achieved with resources and wider social policy measures.

1   Department of Justice (2021) Youth justice strategy 2021–2027. Dublin: Department of Justice.
https://www.drugsandalcohol.ie/34061/

2   Department of Justice (2021) Minister Browne launches Youth Justice Strategy 2021–2027 [Press release]. 15 April 2021. Dublin: Department of Justice. Available online at:
http://www.justice.ie/en/JELR/Pages/PR21000079

3   United Nations (1989) Convention on the Rights of the Child. New York: United Nations. Available online at: https://www.ohchr.org/Documents/ProfessionalInterest/crc.pdf

4   Council of Europe (1950) European Convention for the Protection of Human Rights and Fundamental Freedoms [European Convention on Human Rights]. Rome: Council of Europe. Available online at:
https://www.echr.coe.int/documents/convention_eng.pdf

5   Forde L (2020) The international standards relating to youth justice: an overview. Cork: UCC Centre for Children’s Rights and Family Law. Available online at:
http://www.justice.ie/en/JELR/Justice_International_Standards.pdf/Files/Justice_International_Standards.pdf

6   Department of Public Expenditure and Reform (2019) Our Public Service 2020: first progress report. Dublin: Government of Ireland. Available online at:
https://www.gov.ie/en/policy-information/cc5b1f-our-public-service-2020/ 

7   Department of Children and Youth Affairs (2014) Better Outcomes, Brighter Futures: the national policy framework for children and young people 2014–2020. Dublin: Stationery Office.
https://www.drugsandalcohol.ie/21773/

8   Irish Penal Reform Trust (2021) Youth Justice Strategy marks an opportunity to transform the lives and futures of children facing multiple disadvantages [Press release]. 15 April 2021. Dublin: Irish Penal Reform Trust. Available online at:
https://www.iprt.ie/latest-news/youth-justice-strategy-marks-an-opportunity-to-transform-the-lives-and-futures-of-children-facing-multiple-disadvantages-iprt/

Introduction

The Public Health (Alcohol) Act 2018 in Ireland has been praised as a world-leading package of alcohol policy reforms. The path to alcohol policy change in Ireland was long and winding as well as politically perilous. Using policy feedback theory (PFT), a 2021 report investigated the political consequences of accumulating alcohol-related health and social harms for processes from the earlier phases of the policymaking process (prior to 2009).¹

Between 1987 and 2006, alcohol intake in Ireland increased from 9.8 to 13.4 litres of pure alcohol per capita, due in part to the Celtic Tiger period, where greater disposable income and relatively stable rates of alcohol taxation contributed to easier affordability of alcohol. Following the 2008–2009 financial crisis, alcohol consumption began to decrease in Ireland but by international standards alcohol intake has remained high.

The health and social burden of alcohol consumption has been the subject of numerous studies in Ireland. This body of research helped persuade the Government that a new policy approach to alcohol was required. In 2013, led by the Department of Health, a series of measures were proposed to reduce both consumption and alcohol-related harms.

Methods

The study traces the development of alcohol policy in Ireland over three decades, drawing on primary documents, secondary literature, and interviews with public health advocates, medical doctors, public health experts, and key decision-makers.

Results

The study documents the struggle to have alcohol recognised as a public health issue in Ireland due to insufficient institutional authority and the accumulative effects of policy failures. These factors elevated the visibility of alcohol-related harms for key stakeholders, helping spur greater demand for major policy change. The study identifies 2008/2009 as the key turning point. Table 1 provides a timeline of events, culminating in the enactment of the Public Health (Alcohol) Act in 2018.

Discussion and conclusions

The health and social impacts of the high consumption levels of alcohol in Ireland were largely overlooked by the Government for many years. In fact, many policy decisions resulted in increased alcohol consumption. Experts and subsequently civil society organisations and, to some extent, the general public could see evidence of alcohol-related harms on the rise. These forces placed significant pressure on the Government, leading first to the inclusion of alcohol under the NDS and eventually to the enactment of the Public Health (Alcohol) Act in 2018.

 Table 1: Key Irish policy developments, 1980s to 2010s 

Source: Adapted from Lesch and McCambridge (2021)¹

 
In conclusion, an understanding of innovations in alcohol policy decision-making requires an appreciation of the historical context, including earlier policy failures.

1   Lesch M and McCambridge J (2021) A long-brewing crisis: the historical antecedents of major alcohol policy change in Ireland. Drug Alcohol Rev, Early online. https://www.drugsandalcohol.ie/34383/

2   Department of Health (1984) The psychiatric services – planning for the future. Report of a Study Group on the Development of the Psychiatric Services. Dublin: Stationery Office. Available online at: https://www.lenus.ie/handle/10147/45556

3   Department of Health (1996) National alcohol policy: Ireland. Dublin: Stationery Office.
https://www.drugsandalcohol.ie/5263/

Background

Alcohol consumption has long been a source of major health and social problems in Ireland. A combination of factors undermined previous attempts to address alcohol as a public health issue, including the considerable political and economic power wielded by the alcohol industry and the failure of the Government to develop a fully integrated approach across its departments and agencies.

Methods

Using the multiple streams approach (MSA), a 2021 study focused on the period between 2008 and 2018 to explore how these barriers were overcome, how the Public Health (Alcohol) Bill made its way onto the Government agenda, and how the legislation was subsequently formulated.¹

Results

Policy context

The public health community and the alcohol industry formed two opposing coalitions and competed to influence the direction of alcohol policy. Public health actors have historically found it difficult to counter the alcohol industry’s influence within successive Irish Governments. Economic priorities have dominated public health issues in discussions over alcohol policy. However, since the mid-2000s, the public health community has steadily gained more influence, helping shift the debate over alcohol. Increased public attention to alcohol-related harms (problem stream), developments within the institutional location of policymaking (the policy stream), and the political pressure exerted by politicians and advocates (the political stream) combined to open a policy window.

The problem stream

Alcohol-related harms were highlighted by the Health Research Board (HRB) and provided the Government with data to validate the claims being made and enabled advocates to link alcohol-related harms to broader problems with the health system, thereby mainstreaming alcohol as a health policy issue. Concerns about the health service in Ireland had become a ‘hot political issue’¹ and the hospital trolley crisis of the late 2000s had generated a key opportunity for those advocating a public health approach to alcohol.

Pressure on the Government mounted following explicit links made between the HRB research and the fiscal pressures on the health system coupled with increasing public dissatisfaction.

The policy stream

When the Government decided to integrate alcohol and drugs into a combined National Substance Misuse Strategy (NSMS), it established a steering group with Dr Tony Holohan, the chief medical officer (CMO), as co-chair in 2008. Its task was to specify measures that could ‘tackle the harm caused to individuals and society by alcohol use and misuse’.²

The steering group report of 2012 recognised alcohol as a major societal problem and argued that the Government must take action and identified ‘price, availability and marketing’ as the key drivers of alcohol consumption.² The report included key international research, stressing that a reduction in overall drinking was needed for harms to be reduced across society because they were so closely related at a population level.

The steering group’s comprehensive review of the international and national evidence, its broad membership, and its concrete set of policy recommendations set it apart from earlier institutional processes. The CMO used his institutional position to ensure that the Minister for Health gave proper consideration to the report. Furthermore, research carried out by the HRB confirmed public support for the steering group’s key policy recommendations.

The political stream

Between the appointment of the steering group and the release of its recommendations in 2012, the political landscape had shifted profoundly with implications for the development of alcohol policy. Several Government ministers wanted to act on the recommendations of the steering group but there was pushback within the coalition parties (Fine Gael and the Labour Party), particularly around the proposed plan to ban the alcohol industry from any sports sponsorship. During 2013, conflicts between the health ministers and their colleagues prominently included Leo Varadkar TD, the Minister for Transport, Tourism and Sport. Key sporting organisations lobbied Varadkar, who had maintained that there was insufficient evidence that marketing or sponsorship restrictions would reduce under-age drinking. In autumn 2013, the Cabinet dropped the sports sponsorship ban from the proposed Bill. Industry lobbying and Varadkar’s opposition were identified as key influences on that decision.

In October 2013, the Government released its alcohol strategy proposals. The legislation would comprise four main pillars: (1) minimum unit pricing; (2) the structural separation of alcohol from other products in shops; (3) restrictions on alcohol advertising and marketing; and (4) health information on alcohol products and marketing. The plan represented the first time the Government addressed alcohol as a public health issue.

Despite the backing of the Government, the alcohol legislation was slow to progress. However, a major Cabinet shuffle in 2014 saw Varadkar installed as the new Minister for Health. Notwithstanding activities in his earlier ministerial brief, Varadkar enthusiastically took up the legislation and his attention to alcohol harms and the potential role of population-level measures in curbing these harms dramatically shifted in his new position. Advocates described the-then Minister for Health’s medical background as conducive for policy learning.

The opening of the policy window

In 2015, the Government published the Public Health (Alcohol) Bill. The general election in February 2016 saw Fine Gael retaining power and the new government announced in its Programme for Government a commitment to enact the Bill. Structural separation became a key target for industry lobbying. Retail trade associations claimed that the new regulations would burden small businesses. Fine Gael senators threatened to vote against the Bill if the Government failed to amend the structural separation provision.

The alcohol industry’s efforts to build a broader coalition of opponents to the structural separation was successful in slowing down the legislative process.

However, broader political shifts prevented the alcohol Bill from languishing in the upper house. In June 2017, Varadkar was appointed both leader of Fine Gael and Taoiseach and Simon Harris TD (Fine Gael) as Minister for Health, who was instructed to progress the Bill as soon as possible.

One former policy advisor explained:

Back in 2014 [Varadkar] could have stalled [the Bill], he could have put the brakes on it but … he did the opposite … When he [later] became the leader of the country … he made it one of his priorities … Once he did that, it was game, set and match.¹

Along with political leadership backing the Bill’s enactment, between 2016 and 2018, Alcohol Health Alliance Ireland waged a sophisticated campaign to advance the legislation. It was chaired by Prof Frank Murray, a highly respected liver specialist whose political astuteness and calm and effective communication skills commanded respect. This constellation of forces exerted enormous pressure in forming the wave that washed through the political system.

In October 2018, after nearly three years of debate and more than six years since the steering group’s report, the Irish parliament passed the Public Health (Alcohol) Bill.

Discussion

Previous observations have identified a lack of political leadership as a key impediment to legislative action. In this more recent period, advocates have been better organised and the Department of Health has benefited from a string of strong and highly capable ministers keen to develop the application of the public health approach to alcohol-related harms in Ireland. Across interviews and other key documents, Leo Varadkar, Tony Holohan, and Frank Murray emerged as the central players.

1   Lesch M and McCambridge J (2021) Waiting for the wave: political leadership, policy windows, and alcohol policy change in Ireland. Soc Sci Med, 282: 114116. https://www.drugsandalcohol.ie/34443/

2   Department of Health (2012) Steering group report on a National Substance Misuse Strategy. Dublin: Department of Health. https://www.drugsandalcohol.ie/16908

Key findings

Over the period, some 68,571 cases treated for problem drug use (excluding alcohol) were reported to the NDTRS.³ The number of treated cases recorded decreased from 9,890 in 2014 to 9,702 in 2020 (see Table 1). Between 2019 and 2020, the number of treated cases decreased by 9%, from 10,664 cases to 9,702 cases.

The overall drop in the number of cases entering drug treatment in 2020 is in part the result of temporary service closures and measures introduced to comply with Covid-19 restrictions and does not necessarily indicate a real decline in demand for treatment.^4,5

New cases (never previously treated) accounted for 38.2% of cases in 2014 and 39.1% in 2020. Previously treated cases accounted for 57.1% of cases in 2014 and 56.1% in 2020.

In 2020, the majority (70.2%) of cases were treated in outpatient facilities (as in previous years), while 12.3% of cases were treated in inpatient facilities, 9% in low-threshold services, 7.8% in prisons, and 0.8% by general practitioners (see Table 2).⁶

Between 2019 and 2020, the number of cases treated in residential settings decreased by 24.3%, from 1,571 cases to 1,190 cases. The reduction in residential case numbers can in part be attributed to temporary closures and measures introduced to comply with Covid-19 restrictions.

Main problem drug

Opioids (mainly heroin) remain the main problem drug reported over the period. As a proportion of all cases treated, opioids decreased year-on-year from 50% in 2014 to 36.7% in 2020 (see Table 3).

Cocaine was the second most common main problem drug reported in 2020. The proportion of cases treated for cocaine as a main problem increased from 8.6% in 2014 to 27% in 2020.

Cannabis was the third most common main problem drug reported in 2020. The proportion of cases treated for cannabis as a main problem decreased from 27.6% in 2014 to 21.9% in 2020.

In 2020, cocaine (35.8%) replaced cannabis as the most common main problem drug among new entrants to treatment (see Table 3). Cocaine was followed by cannabis (35.2%) and opioids (14.5%). Among new cases, cocaine increased from 11.3% in 2014 to 35.8% in 2020.

Polydrug use

Over the period, the majority of cases (58%) reported polydrug use (i.e. problem use of more than one substance). The proportion of cases that reported polydrug use decreased from 59.6% in 2014 to 53.4% in 2018, then increased to 58.6% in 2020 (see Table 4).

In 2020, cannabis (39.5%) was the most common additional substance reported by cases with polydrug use, followed by cocaine (36.8%), benzodiazepines (36.5%), and alcohol (34.9%).

Table 1: Number of cases treated for drugs as a main problem, by treatment status,
NDTRS 2014–2020

Table 2: Number of cases treated for drugs as a main problem, by type of service provider, NDTRS 2014–2020

* Includes any service where the client stays overnight, e.g. inpatient detoxification, therapeutic communities, respite, and step-down.

Table 3: Main problem drug (excluding alcohol) reported in 30 days prior to treatment,
NDTRS 2014–2020

Z-drugs are non-benzodiazepine hypnotic sedative drugs, e.g. zolpidem and zopiclone.

NPS: New psychoactive substances.

~ Cells with five cases or fewer.

Table 4: Polydrug use in cases treated for drugs as a main problem, NDTRS 2014–2020

Risk behaviour

The proportion of all cases that had ever injected decreased from 35.7% in 2014 to 23.3% in 2020. Among cases that had ever injected, the proportion currently injecting (i.e. in the 30 days prior to treatment) decreased from 37% in 2014 to 31.1% in 2020.

Sociodemographic characteristics

The following sociodemographic characteristics of the cases were noted:

• Three in every four cases reported over the period were male.
• The median age of cases when entering treatment increased from 29 years in 2014 to 31 years in 2018 and has remained stable ever since.
• Under 18s accounted for 6.9% of cases in 2020.
• Cases recorded as homeless increased in proportion from 8.5% in 2014 to 10.5% in 2020.
• The proportion of cases with an Irish Traveller ethnicity was 3% in both 2014 and 2020.
• A large proportion of cases (59%) were unemployed in 2020, as in previous years.
• The proportion of cases in paid employment increased from 8.3% in 2014 to 16.2% in 2020.

Sociodemographic characteristics
– cocaine as main problem

The following sociodemographic characteristics of cases with cocaine as a main problem were noted:

• Eight in 10 cases reported over the period were male.
• The proportion of female cases increased from 17.2% in 2014 to 20.8% in 2020.
• The median age of cases when entering treatment was the same in 2014 and 2020
  (30 years).
• Under 18s accounted for 2% of cocaine cases in 2014 and 1.7% in 2020.
• The proportion of cases in paid employment increased from 19.9% in 2014 to 30.2% in 2020.
• Cases with polydrug use decreased in proportion, from 70.2% in 2014 to 63.3% in 2020.
• In 2020, the most common additional substances were alcohol (53.9%), cannabis (49.8%), and benzodiazepines (31.7%).

1   The NDTRS is the national epidemiological surveillance system that reports on treated problem drug and alcohol use in Ireland. Established in 1990, the NDTRS is maintained by the National Health Information Systems (NHIS) of the Health Research Board (HRB) on behalf of the Department of Health.

2   Kelleher C, Carew AM and Lyons S (2021) National Drug Treatment Reporting System: 2014–2020 drug treatment data. HRB StatLink Series 6. Dublin: Health Research Board.
http://www.drugsandalcohol.ie/34162

3   The data reflect the number of entries into treatment in a calendar year, rather than the number of persons treated in that year.

4   The capacity and functionality of treatment services were impacted by Covid-19 restrictions. The NDTRS surveyed participating services to estimate the impact of the restrictions on treatment data for 2020 (the response rate was 80%). Around 40% of services surveyed expressed some impact on their ability to provide returns, while around 50% expected some impact on numbers (unpublished data).

5   To comply with European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) requirements and enable services to accurately reflect their activities in response to Covid-19 restrictions, the NDTRS added functionality to the LINK database to record treatment provided over the telephone or internet (teleworking).

6   Coverage of services was 71.1% for 2020. The number of services participating in the NDTRS varies annually, making small fluctuations in the numbers of cases difficult to interpret.

Introduction

Drug poisoning (overdose) deaths are a leading cause of avoidable death with rates increasing globally. According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the mortality rate due to drug poisoning in the European Union in 2019 is estimated at 14.8 deaths per million population aged 15–64 years, with over three-quarters (77%) of these deaths among men.¹ Consequently, as drug poisoning deaths are dominated by men, specific circumstances associated with drug poisoning deaths among women may be masked by combining trends for men and women. A 2021 publication examined differences by sex in the rates of overall drug poisoning deaths and deaths involving specific drugs implicated in drug poisoning deaths in Ireland between 2004 and 2017.²

Methods

Data for this study were extracted from the National Drug-Related Deaths Index (NDRDI) and the Health Service Executive’s Primary Care Reimbursement Service (PCRS). The NDRDI’s definition of a poisoning death is a death directly due to the toxic effect of one or more substances on the body. Joinpoint Regression Program was used to examine any changes in trends in age-standardised rates (ASR) from 2004 to 2017, expressed as annual percentage changes, with a summary of the overall trend expressed as an average annual percentage change (AAPC). The relationship between the ASR of drug poisoning deaths and prescription data for benzodiazepines and antidepressants was examined using linear regression. Analyses were stratified by sex.

Results

There has been an increase in the ASR of drug poisoning deaths in Ireland, from 6.86 per 100,000 in 2004 to 8.08 per 100,000 in 2017. This increase is mainly driven by deaths among men. For men, drug poisoning deaths involving cocaine (AAPC 7.7% [95% CI: 2.2–13.6]); benzodiazepines (AAPC 7.2% [95% CI: 2.9–11.6]); antidepressants (AAPC 6.1% [95% CI: 2.4–10.0]); and prescription opioids (AAPC 3.5% [95% CI: 1.6–5.5]) increased significantly between 2004 and 2017.

For women, drug poisoning deaths involving antidepressants (AAPC 4.2% [95% CI: 0.2–8.3]); benzodiazepines (AAPC 3.3% [95% CI: 0.1–6.5]); and prescription opioids (AAPC 3.0% [95% CI: 0.7–5.3]) increased significantly between 2004 and 2017, with a significant increase in drug poisoning deaths involving cocaine (albeit from a low baseline number of deaths), observed in the latter part (2011–2017) of the study period. While the ASR of drug poisoning deaths involving alcohol decreased among women (AAPC –4.0% [95% CI: –5.8 to –2.1]), there was no significant change observed among men.

A significant increase in two or more central nervous system (CNS) depressant drugs involved in drug poisoning deaths is reported among both men (AAPC 5.6% [95% CI: 2.4–8.8]) and women (AAPC 4.0% [95% CI: 1.1–6.9]).

Conclusions

The authors conclude that there was an increase in overall drug poisoning deaths in Ireland from 2004 to 2017. The increasing trend of two or more CNS depressant drugs implicated in drug poisoning deaths, especially the more recent significant increase among women, is of concern. The findings from this study highlight the need for an increased understanding among prescribers, people who use drugs, and policymakers of the physiological differences between men and women, how this affects drug activity in the body, and the associated risks with consumption of multiple CNS depressant drugs.

A significant decrease in drug poisoning deaths involving alcohol was reported for women. However, no significant change was reported for deaths involving alcohol among men. The authors highlight that alcohol is a CNS depressant and suggest that prescribers should assess for and advise on alcohol use when prescribing CNS depressant drugs.

Benzodiazepines were the most common drug group in deaths involving two or more CNS depressants. The decreasing rate of benzodiazepines dispensed through the PCRS appears to correspond with the introduction of stricter prescribing regulations. Given the increased availability of illicit benzodiazepines,³ this change in prescribing regulations may have partially resulted in an increased use of high-potent illicit benzodiazepines. The authors state that advocates for people who use drugs should be consulted on and contribute to policy decisions around drug use. In addition, increased focus on treatment provision for misuse of benzodiazepines should be considered. The authors suggest that harm reduction initiatives, along with treatment interventions, which include pharmaceutical combined with psychosocial assistance, need to focus on the range of problematic drugs. Furthermore, reducing stigma associated with drug use and drug poisoning deaths, aligned with actions to target economic deprivation, are required.

1   European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2021) European drug report 2021: trends and developments. Luxembourg: Publications Office of the European Union. Available online at: https://www.emcdda.europa.eu/edr2021_en

2   Lynn E, Cousins G, Lyons S and Bennett KE (2021) Trends in drug poisoning deaths, by sex, in Ireland: a repeated cross-sectional study from 2004 to 2017. BMJ Open, 11(9): e048000.
https://www.drugsandalcohol.ie/34812/

3   Duffin T, Keane M and Millar SR (2020) Street tablet use in Ireland: a Trendspotter study on use, markets, and harms. Dublin: Ana Liffey Drug Project. https://www.drugsandalcohol.ie/31872/

Background and methods

Individuals who use cannabis are more likely to use other illicit substances, with several epidemiological studies showing that the use of cannabis is significantly related to the use of ‘harder’ illegal drugs, including stimulants such as cocaine and ecstasy.¹ Increasingly, people entering addiction treatment are presenting with polysubstance use.² Consequently, further research on the relationships between cannabis and stimulant use is needed to guide future regulation systems, to inform both clinical and public health practice, and to assess drug policy. This is particularly relevant in Ireland in 2021, given the rise in treatment cases presenting for cannabis use disorder (CUD) and cocaine use, as well as increases in the use of ecstasy observed among the general population.³

A 2021 Irish study⁴ determined the relationships between patterns of cannabis use and recent stimulant use, drawing on data from two large nationally representative surveys. The study also explored how frequency of cannabis use relates to stimulant use and whether subjects with a CUD – defined as cannabis abuse or dependence – are more likely to be recent users of cocaine or ecstasy. In this research, published in the journal PLoS One, data were analysed from Ireland’s 2010/11 and 2014/15 National Drug Prevalence Surveys, which recruited 5,134 and 7,005 individuals, respectively, aged 15 years or more, living in private households. Multivariable logistic regression analysis was used to examine the associations between patterns of cannabis use and recent stimulant use.

Results

Among survey participants who had used cannabis in the last month, 17.9% reported recent cocaine use, while almost one-quarter (23.6%) reported recent ecstasy use. There was a significant linear relationship between patterns of cannabis use and recent use of cocaine, ecstasy, or any stimulants, with last-month cannabis users displaying greater odds (OR=12.03, 95% CI: 8.15–17.78) of having recent stimulant use compared with last year (OR=4.48, 95% CI: 2.91–6.91) and former (reference) cannabis users. Greater frequency of cannabis use in the last 30 days was also significantly related to the use of stimulants. In addition, results demonstrated an association between CUD and recent use of cocaine or ecstasy (OR=2.28, 95% CI: 1.55–3.35).

Conclusions

The authors noted that relationships between recent and current use of cannabis and the use of cocaine or ecstasy were noticeably strong. As the use of cannabis with stimulants may increase the risk of negative health consequences, they suggest that education in community and medical settings about polydrug use and its increased risks may be warranted.

1   Kandel DB, Yamaguchi K and Klein LC (2006) Testing the gateway hypothesis. Addiction, 101(4): 470–472.

2   Health Research Board (2018) Focal Point Ireland: national report for 2017 – treatment. Dublin: Health Research Board.
https://www.drugsandalcohol.ie/30589/

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

4   Millar SR, Mongan D, O’Dwyer C, Smyth BP, Perry IJ and Galvin B (2021) Relationships between patterns of cannabis use, abuse and dependence and recent                     stimulant use: evidence from two national surveys in Ireland. PLoS ONE, 16(8): e0255745.
     https://www.drugsandalcohol.ie/34684/

Background and methods

There is ongoing debate regarding the relationships between early onset substance use and later use of other drugs. The common liability model states that a combination of risk factors places some people at increased risk of both early initiation and of subsequent progression to more serious and sustained drug abuse.¹ Numerous studies have examined relationships between early onset drinking, tobacco, and cannabis use with later drug use. However, this research has tended to focus on a narrow 12–25-year-age range. In addition, fewer studies have explored factors associated with progression to ongoing, heavier, and problematic cannabis use among lifetime cannabis users. It is also unclear whether associations between younger age at substance use onset and cannabis use patterns are independent of other influential factors that may constitute an underlying vulnerability for heavier substance use and substance use disorders.

A 2021 Irish study² determined the relationships between age at first use of alcohol, tobacco, and cannabis and the patterns of cannabis use, frequency of use, and whether age of substance use onset is related to having a cannabis use disorder (CUD). In this research, published in the journal BMC Public Health, data were analysed from Ireland’s 2010/11 and 2014/15 National Drug Prevalence Surveys, which recruited 5,134 and 7,005 individuals, respectively, aged 15 years or more, living in private households. Multinomial, linear, and binary logistic regression analyses were used to determine the relationships between age of substance use onset and patterns of cannabis use, frequency of use, and having a CUD.

Results

When compared with former users, the odds of being a current cannabis user were found to be reduced by 11% (OR=0.89; 95% CI: 0.83–0.95) and 4% (OR=0.96; 95% CI: 0.92–1.00) for each year of delayed alcohol and cannabis use onset, respectively. Among current users, significant inverse linear relationships were noted, with increasing age of first use of tobacco (β=–0.547; p<0.001) and cannabis (β=–0.634; p<0.001) being associated with a decreased frequency of cannabis use within the last 30 days. The odds of having a CUD were found to be reduced by 14% (OR=0.86; 95% CI: 0.78–0.94) and 11% (OR=0.89; 95% CI: 0.82–0.98) for each year of delayed tobacco and cannabis use onset, respectively, in analyses which examined survey participants aged 15–34 years.

Conclusions

The authors discussed that planning models based on the needs of the population are important for the successful implementation of treatment services and to adequately plan these services requires an understanding of the population in need of treatment. Findings from this study suggest that, in Ireland, prevention initiatives should prioritise younger adult cannabis users with a pattern of very early onset tobacco or cannabis use.

1   Van Leeuwen AP, Verhulst FC, Reijneveld SA, Vollebergh WAM, Ormel J and Huizink AC (2011) Can the gateway hypothesis, the common liability model and/or, the route of administration model predict initiation of cannabis use during adolescence? A survival analysis – the TRAILS study. J Adolesc Health, 48(1): 73–78. https://www.drugsandalcohol.ie/34674/

2            Millar SR, Mongan D, Smyth BP, Perry IJ and Galvin B (2021) Relationships between age at first substance use and persistence of cannabis use and cannabis use disorder. BMC Public Health, 21: 997.
https://www.drugsandalcohol.ie/34249/

Until 2010, new psychoactive substances (NPS) could be bought legally in headshops in Ireland. However, recent finding from the Irish National Drug and Alcohol Survey 2019–20¹ show that the prevalence of recent NPS use remains very low, at 0.8% among 15–64-year-olds (compared with 3.5% in 2010/11). This perhaps highlights the continued impact of the Criminal Justice (Psychoactive Substances) Act 2010, which made the sale, import, export, or advertisement of unregulated psychoactive substances for human consumption illegal. The Act also gave appropriate powers to An Garda Síochána and the Courts to intervene quickly to prevent trade in a non-criminal procedure via the use of prohibition and closure orders. Nevertheless, research on NPS use is lacking in Ireland, in particular among opioid-dependent patients, who are likely to be at increased risk of consumption.

A 2021 study² investigated reasons for NPS use, administration, adverse effects, and consumption in the previous three months among patients attending an opium substitution clinic. In this research, published in the journal Heroin Addiction and Related Clinical Problems, data were collected on 213 subjects (69.5% male) by the National Drug Treatment Centre, Dublin through an interviewer-administrated survey.

It was found that a total of 133 (61.5%) participants had used NPS at least once and 14 (6.6%) had used NPS in the last three months. Being older at the time of interview and when first consuming illicit substances were found to be inversely associated with NPS consumption. Ninety-three participants (71.5%) bought NPS for the first time from a headshop, 20.8% from a friend, and 6.9% from a dealer. After the closure of headshops, dealers were the most common source of NPS. Cathinones were the most commonly consumed NPS class. One-third of participants injected NPS, while almost one-half of participants indicated having experienced no adverse effects, although paranoia did occur frequently.

The authors noted that only 11% of participants reported ongoing NPS use, implying that making the supply of NPS illegal reduced their consumption. They also suggest that as a high proportion of participants administered NPS intravenously, the closure of headshops is likely to have led to improved health outcomes among this group of patients.

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

2   McCarron P, Smyth BP, Carroll G, et al. (2021) Patterns of new psychoactive substance use among opioid-dependent patients attending for opioid substitution                       treatment. Heroin Addict Relat Clin Probl, Early online. https://www.drugsandalcohol.ie/34176/

In 2010, new psychoactive substances (NPS) were the subject of two pieces of legislation in Ireland.^1,2 The first (enacted in May 2010) expanded the list of substances controlled under the Misuse of Drugs Acts 1977−1984 to include over 100 NPS.¹ The second, the Criminal Justice (Psychoactive Substances) Act 2010 (enacted in August 2010), covered the sale of substances by virtue of their psychoactive properties. It was aimed at vendors of NPS and effectively made it an offence to sell a psychoactive substance.² A 2021 paper by Windle and Murphy reports on a systematic review of Irish media articles, entitled ‘How a moral panic influenced the world’s first blanket ban on new psychoactive substances’.³

Methods

Previous studies have found positive impacts of the legislation for public health.^4,5,6 Windle and Murphy’s study was not designed to evaluate the Acts or their impact on the NPS market, rather it set out to trace the ‘historical processes whereby attitudes towards heads shops shifted from one of toleration to the passing of this tough new law’ (p. 1). The authors carried out a qualitative and quantitative review of media coverage of headshops in Ireland published between 2000 and 2010 (n=338).

Findings

The authors argue that analysis of the media coverage of headshops over the period demonstrates that Ireland experienced a ‘moral panic’ about headshops, which at least in part led to the 2010 Act. Based on previous national and international research, they frame their findings around a moral panic theory. Four timeframes are identified:

• 2000–2007 (6 articles): Headshops first opened in Ireland in the early 2000s selling cannabis paraphernalia. They were only mentioned in the media sporadically and most of the articles published between 2004 and 2007 viewed them as harmless. However, once they started to sell NPS in 2007 a ‘trickle of condemnation began’ (p. 3).³

• 2008 (19 articles): Coverage of headshops was again sporadic in 2008 and tended to focus on the NPS benzylpiperazine (BZP) and its scheduling as a controlled substance in early 2009. Discussion of the negative impact of NPS on young people’s health and wellbeing also began to be discussed.

• 2009 (27 articles): Media interest increased in 2009 but continued to be at a relatively low level. The language used to describe headshops was ‘relatively timid’, although isolated incidents of them being described as a threat by stakeholders occurred. This is what the authors describe as a ‘core feature of moral panic language’ (p. 4).

• 2010 (286 articles): 2010 was when the authors argue the moral panic ensued. Articles on headshops and their supply of NPS were numerous and appeared regularly across local and national newspapers. They attracted high-level political attention as well as that from other stakeholders, including medical experts. The authors argue that the language used in the articles about NPS became gradually more stringent and sensationalist during the year and were characterised by methods such as ‘panic messages’ that fed into a moral panic. Articles linked NPS to violent crime and reported that headshops were selling to vulnerable people, especially young people. The narrative identified NPS and the headshops as the ‘folk devils’, where young people were depicted as victims. The year 2010 also saw peaceful and more violent protests organised by a variety of people, including drug dealers. All of this culminated in the State response of the Criminal Justice (Psychoactive Substances) Act 2010.

Conclusion

The authors are keen to note that while they make the case that analysis of media coverage provides evidence of a moral panic in Ireland over the headshops, they are not arguing that the State’s response was disproportionate. Indeed, they perceive the closure of the headshops as having been inevitable, given the nature of drug policy in Ireland. However, they consider that the moral panic may have resulted in more stringent legislation being passed more quickly than may otherwise have been the case.

1   Misuse of Drugs (Amendment) Regulations 2010 (SI No. 200/2010). Available online at:
http://www.irishstatutebook.ie/eli/2010/si/200/made/en/print

2   Criminal Justice (Psychoactive Substances) Act 2010. Available online at:
http://www.irishstatutebook.ie/eli/2010/act/22/enacted/en/html

3   Windle J and Murphy P (2021) How a moral panic influenced the world’s first blanket ban on new psychoactive substances. Drugs Educ Prev Pol, Early online. https://www.drugsandalcohol.ie/34014/

4   Previous articles in Drugnet Ireland have described the findings of studies which have shown how the legislation and consequent closure of the headshops were associated with a positive public health impact, for example: Dillon L (2017) Headshop legislation and changes in national addiction treatment data. Drugnet Ireland, 62 (Summer): 13–14. https://www.drugsandalcohol.ie/27740/

5   Smyth BP, Lyons S and Cullen W (2017) Decline in new psychoactive substance use disorders following legislation targeting headshops: evidence from national addiction treatment data. Drug Alcohol Rev, 36(5): 609–617. http://www.drugsandalcohol.ie/27172/

6   Smyth BP, Daly A, Elmusharaf K, McDonald C, Clarke M, Craig S, et al. (2020) Legislation targeting head shops selling new psychoactive substances and changes in drug-related psychiatric admissions: a national database study. Early Interv Psychiatry, 14(1): 53–60. https://www.drugsandalcohol.ie/30436/

Key findings

Over the period, some 51,205 cases treated for problem alcohol use were reported to the NDTRS. The number of treated cases recorded decreased from 7,760 in 2014 to 5,824 in 2020 (see Table 1). Between 2019 and 2020, the number of treated cases decreased by 22.8%, from 7,546 cases to 5,824 cases. The overall drop in the number of cases entering alcohol treatment in 2020 is in part the result of temporary service closures and measures introduced to comply with Covid-19 restrictions and does not necessarily indicate a real decline in demand for treatment.

New cases (those never previously treated) accounted for 48.6% of cases in 2014 and 42.8% in 2020. Previously treated cases accounted for 49.1% of cases in 2014 and 54.4% in 2020.

In 2020, three in every five (60.2%) cases were treated in outpatient facilities, while 28.8% of cases were treated in inpatient facilities, 8% in low-threshold services, and 3% in prisons (see Table 2).

Between 2019 and 2020, the number of cases treated in residential settings decreased by 40.1%, from 2,806 cases to 1,680 cases. The reduction in residential case numbers can in part be attributed to temporary closures and measures introduced to comply with Covid-19 restrictions.

Focus on gender

The median age of female cases that entered treatment was 43 years compared with 40 years for male cases. Among new female cases specifically, the median age entering treatment was 41 years. This compared with a median age of 38 years among new male cases that entered treatment. Among female cases, 32.6% were aged 50 years or over compared with 25.7% of male cases aged 50 years or over. Among those treated for alcohol, homelessness was more common for males (10.7%) than females (4.8%).

The proportion of female cases reporting problem use of other drugs in addition to alcohol was 17%. The most common additional drugs for females were cocaine and cannabis. Rates of benzodiazepines and opioid use were found to be more common among females than males. One in four male cases (26.9%) reported problem use of other drugs in addition to alcohol. The common additional drugs for male cases were cannabis and cocaine.

Polydrug use

In 2020, some 23.1% of cases treated for problem alcohol use reported problem use of more than one substance (polydrug use) (see Table 3).

In 2020, cannabis (54.9%) was the most common additional drug reported by cases with polydrug use, followed by cocaine (54.1%) and benzodiazepines (24.6%) (see Figure 1). The proportion of cases reporting cannabis use decreased from 63.2% in 2014 to 54.9% in 2020. Problem use of cocaine increased from 28.2% in 2014 to 54.1% in 2020. The proportion of cases treated for benzodiazepines decreased from 27.9% in 2014 to 21.8% in 2019, then increased to 24.6% in 2020.

Figure 1: Most common additional drugs in cases treated for problem alcohol use, NDTRS 2014–2020

Table 1: Number of cases treated for alcohol as a main problem, by treatment status, NDTRS 2014–2020

Table 2: Number of cases treated for alcohol as a main problem, by type of service provider, NDTRS 2014–2020

* Includes any service where the client stays overnight, e.g. inpatient detoxification, therapeutic communities, respite, and step-down.

Table 3: Polydrug use in cases treated for problem alcohol use, NDTRS 2014–2020

Level of problem alcohol use

In 2020, the median age at which cases commenced alcohol use was 16 years. Over the period, the majority (66.1%) were classified as alcohol dependent (by the healthcare professionals treating them). The proportion of new cases (those never previously treated for problem alcohol use) that were classified as alcohol dependent decreased from a peak of 66.8% in 2017 to 57.2% in 2020.

Sociodemographic characteristics

The following sociodemographic characteristics of the cases were noted:

• The median age at which cases entered treatment has remained stable since 2015, at 41 years.
• The proportion of cases aged 17 years or younger has decreased from 2.1% in 2014 to 1.7% in 2020.
• The majority of cases in 2020 were male (61.9%), similar to previous years.
• The proportion of cases recorded as homeless increased from 6.4% in 2014 to 8.5% in 2020.
• In 2020, some 2.1% of cases identified as Irish Traveller.²
• In 2020, some 21.2% of cases reported ceasing education (for the first time) before the age of 16 years.
• Just under one-half of reported cases were unemployed; this rate decreased over the reporting period from 56.4% in 2014 to 49.2% in 2020.
• In each year, rates of homelessness, ceasing education before age 16, and unemployment were higher among previously treated cases than among new cases.
• In 2020, some 17.4% (n=1015) of cases treated for alcohol were residing with children aged 17 years or younger. The majority were females (57.4%, n=583), while males accounted for 42.6% (n=432).
• A similar number of cases (17.6%, n=1027) treated for alcohol in 2020 had children aged 17 years or younger who were not residing with them. Almost three-quarters of these cases (72.4%, n=744) were males, while one-quarter were females (27.6%, n=283).

1   O’Neill D, Carew AM and Lyons S (2021) National Drug Treatment Reporting System 2014–2020 alcohol treatment data. HRB StatLink Series 7. Dublin: Health Research Board.
https://www.drugsandalcohol.ie/34164

2   Based on the 2016 Census, the proportion of Irish Travellers in the general population is 0.7%
(Central Statistics Office, 2019). Available online at:
https://www.cso.ie/en/releasesandpublications/ep/p-cp8iter/p8iter/p8e/

The first Health Behaviour in School-aged Children (HBSC) study was conducted in Ireland in 1998 and has been repeated every four years ever since. In 2018, Ireland participated for the sixth time in the HBSC study. The survey included 15,557 children drawn from third class in primary school through to fifth year in post-primary school; 255 primary and post-primary schools across Ireland participated. Data were collected on general health, smoking, use of alcohol and other substances, food and dietary behaviour, exercise and physical activity, self-care, injuries, bullying, and sexual health behaviours. The main results were published in 2021.¹ This article describes the results pertaining to the use of cannabis reported in the main report and makes comparisons with previous HBSC surveys.

Cannabis use in the last 12 months

Overall, 8.5% of 10–17-year-olds said they had used cannabis in the last 12 months. The prevalence of cannabis use increased with age and a higher percentage of boys reported using cannabis compared with girls, a difference consistent across each age category (see Table 1). Almost 22% of boys and 14% of girls aged 15–17 years of age reported having used cannabis in the last year.

Source: HBSC Ireland, 2021¹

Figure 1: Percentage of 10–17-year-olds who reported cannabis use in the last 12 months, overall and by gender from 1998 to 2018

Table 1: Percentage of 10–17-year-olds reporting cannabis use in the last year, by age group and gender, 2018

Source: HBSC Ireland, 2021¹

Trends in cannabis use among Irish school-aged children, 1998–2018

Although a higher percentage of 10–17-year-olds indicated having used cannabis in the 2018 HBSC survey compared with 2014 (see Figure 1), there has been a steady decrease in the lifetime use of cannabis among school-aged children since 1998, with a 35% reduction among boys and a 22% reduction among girls. Overall, trends in prevalence since 2010 suggest that the use of cannabis has stabilised among 10–17-year-olds in Ireland.

1   Gavin A, Költő A, Kelly C, Molcho M and Nic Gabhainn S (2021) Trends in health behaviours, health outcomes and contextual factors between 1998–2018: findings from the Irish Health Behaviour in School-aged Children Study. Dublin: Department
of Health and National University of Ireland Galway. https://www.drugsandalcohol.ie/33868/

The European Schools Project on Alcohol and Other Drugs (ESPAD) has conducted surveys of school-going children every four years since 1995 using a standardised method and a common questionnaire. The seventh survey was undertaken in 35 European countries during 2019 and collected information on alcohol, tobacco, and other substance use among 15–16-year-old students.

An important goal of the ESPAD survey is to monitor trends in alcohol consumption, tobacco, and other drug use among 15–16-year-olds and to compare trends between countries and groups of countries. It also provides an opportunity to observe changes in Irish trends over the six waves of the past 20 years. The rationale for the ESPAD surveys is that school students are easily accessible and at an age when the onset of substance use is likely to occur.

This article concentrates on findings from the survey conducted in Ireland in 2019, in which 3,565 questionnaires were completed by young people from 50 randomly selected post-primary schools.¹ Of these participants, 1,967 were born in 2003 and will be included in the international ESPAD dataset.

Alcohol use

Respondents were asked on how many occasions in their lifetime had they used alcohol. Over one-quarter (27.4%) answered that they had never consumed an alcoholic beverage in their lifetime. Overall, 72.6% of students had drunk alcohol in their lifetime, with 17.6% having tried alcohol once or twice. Seventeen per cent had drunk alcohol on more than 20 occasions. Although the percentage of students who indicated lifetime use of alcohol was similar according to gender (72.7% males vs 72.4% females), male students were more likely to have tried alcohol 40 times or more (11.7%) than females (7.1%).

Almost one-half (40.8%) of students had drunk alcohol in the last 30 days and were considered to be current drinkers. Almost one-quarter (23.4%) reported drinking alcohol once or twice in the past 30 days, while only a small proportion of respondents had used alcohol 10 times or more (3.7%). More male (42.1%) than female (39.5%) students indicated current alcohol use. Although the findings suggest an increase in current alcohol use among students since 2015, overall, current alcohol use among students in Ireland has declined (see Table 1), with a 44% reduction over the past 16 years.

Respondents were asked if they had been drunk in the last 30 days. Sixteen per cent of students reported being drunk, while 12.8% reported being drunk more than once or twice during the past month. More females (17.1%) than males (15.1%) reported being drunk in the last month.

Cider (28.5%), beer (27.3%), and spirits (27.1%) were the most common types of alcohol consumed in the month prior to the survey. The least popular drinks were wine (8.3%) and alcopops (14.2%). Respondents were asked how difficult they thought it would be to obtain specific alcoholic beverages, with response categories ranging from ‘impossible’ to ‘very easy’. A majority of students believed that it would be ‘very easy’ or ‘fairly easy’ to obtain all beverage types examined; 67.7% gave this answer for cider and 71.1% for beer. Only 8.5% believed it would be impossible to obtain spirits compared with 58.8% who said it would be ‘fairly easy’ or ‘very easy’ to access.

Table 1: Alcohol use in the last 30 days among 15–16-year-olds in Ireland, ESPAD surveys 2003–2019

Source: ESPAD Ireland, 2020

Table 2: Smoking in the last 30 days among 15–16-year-olds in Ireland, ESPAD surveys 2003–2019

Source: ESPAD Ireland, 2020

Smoking

Participants were asked on how many occasions had they smoked cigarettes during their lifetime. More than two-thirds (68.4%) of students reported that they had never smoked a cigarette and a further 11% had only smoked on one or two occasions. Just 7.2% of all students reported smoking on at least 40 occasions. Overall, almost one-third had ever smoked in their lifetime (31.6%).

When students were asked to consider how often they had smoked in the last 30 days, 85.6% reported that they had not smoked at all, while 14.4% had smoked at least once. Seven per cent of students reported smoking less than one cigarette per week and a further 1.9% smoked less than one cigarette per day. Only 11 students reported smoking more than 20 cigarettes a day. There were significant differences in current smoking between male and female students, as more male students had reported smoking in the last 30 days (16.2%) than had female students (12.8%).

Trends over time suggest that current smoking among school-aged children in Ireland has stabilised and is greatly reduced since 2003, representing a 58% reduction (see Table 2).

When students were asked how difficult they thought it would be to access cigarettes, over one-third (38.2%) responded that it would be ‘fairly easy’, while another 23.2% thought it would be ‘very easy’ to obtain a cigarette. Only 5.5% responded that it would be ‘impossible’. Most students believed that there is a moderate risk (34%) or a slight risk (27.4%) of smoking occasionally, while 22.7% answered that they perceived a great risk from smoking one or more packs of cigarettes per day.

Table 3: Lifetime use of drugs among 15–16-year-olds in Ireland, ESPAD surveys 2003–2019

Source: ESPAD Ireland, 2020

Other substance use

Students were asked how many times in their lifetime had they used cannabis. Male students (23.8%) were more likely than females (14.7%) to have ever tried cannabis. Overall, 19.1% of students had ever tried cannabis, of which most had tried it once or twice. There was also a sizeable minority of students who had smoked cannabis 20 times or more (4.1%).

Overall, 15.8% of students had used cannabis in the last 12 months. Again, more male (20%) than female respondents (11.8%) reported using cannabis in the past year. Almost 3.8% and 2.4% of male and female students, respectively, reported using cannabis at least 20 times or more in the last year. Six per cent of males and 3.9% of females had first used cannabis at 12 years or younger. Almost one-half (49.3%) of students first tried cannabis at 15 years of age and 11.4% first tried it at 13 years. When respondents were asked how easy they thought it would be to obtain cannabis, 46.3% perceived that it would be ‘impossible’, ‘very difficult’ or ‘fairly difficult’, while 42.4% perceived that it would be ‘fairly easy’ or ‘very easy’.

Regarding lifetime use of other substances, after tobacco, alcohol, and cannabis, inhalants were the most commonly used substance at 10%. The next most regularly used drugs were painkillers ‘to get high’ (5.4%), followed by cocaine, ecstasy, tranquilisers, magic mushrooms and LSD (3%) (see Table 3).

Trend analysis demonstrates that lifetime prevalence of cannabis use has remained relatively unchanged at approximately 20% since 2007 among 15–16-year-olds in Ireland (see Table 3). There has been a decrease in the use of illicit drugs other than cannabis by 29%, decreasing from 7% in 2015 to 5% in 2019. Overall, there has been a 69% reduction in the use of illicit drugs since 1995.

Conclusion

In summary, results from the ESPAD 2019 survey suggest a slight increase in the use of alcohol, while the use of cigarettes among school-aged children in the Republic of Ireland has stabilised. The use of cannabis, inhalants, and other illicit substances may also have stabilised. Nevertheless, it should be noted that early school-leavers, a group known to be vulnerable to alcohol and drug use, are not represented in this survey. Consequently, the results may not indicate the true extent of alcohol and other illicit substance use among all 15–16-year-old children in Ireland.

1   Sunday S, Keogan S, Hanafin J and Clancy L (2020) European Schools Project on Alcohol and Other Drugs: ESPAD 2019 Ireland. Dublin: TobaccoFree Research Institute Ireland and Department of Health. https://www.drugsandalcohol.ie/33347/

The Self-Harm Assessment and Data Analysis (SADA) Project was set up in Ireland in 2016 to provide robust information relating to the incidence and profile of self-harm within prison settings as well as individual-specific and context-specific risk factors relating to self-harm. In addition, it examines patterns of repeat self-harm (both non-fatal and fatal). The Health Service Executive’s National Office for Suicide Prevention and the National Suicide Research Foundation assist the Irish Prison Service with data management, data analysis, and reporting. This article highlights findings from a report presenting data in the analysis of all episodes of self-harm across the Irish prison estate during the year 2019.¹

Episodes of self-harm

Between 1 January and 31 December 2019, there were 203 episodes of self-harm recorded in Irish prisons, involving 109 individuals. The majority of prisoners who engaged in self-harm were male (78%), but taking into account the male prison population, the rate of self-harm among males was 2.4 per 100 prisoners. Twenty-four female prisoners engaged in self-harm in 2019, equating to a rate of 19.8 per 100 prisoners, which is 8.2 times higher than the rate among male prisoners.

Methods, severity, and intent

The most common method of self-harm recorded was self-cutting or scratching, which was present in 64.7% of all episodes. The other common method of self-harm was attempted hanging, which was involved in 21.1% of episodes. In 31% of self-harm episodes, no medical treatment was required, while almost one-half (49.8%) of all episodes required minimal intervention/minor dressings or local wound management. One in seven episodes required hospital treatment (15.3%). Over two-thirds (69%) of self-harm episodes were recorded as having no or low suicidal intent, with 22% recorded as having medium intent. Approximately one in 11 acts was rated as having high suicidal intent (8.9%).

Contributory factors

The most common contributory factors to self-harm are shown in Figure 1. The majority of contributory factors recorded related to mental health issues (44%). Substance misuse, including drug use and drug seeking, was the third most common factor recorded (19%).

Source: McTernan et al. (2021)

Figure 1: Most common contributory factors to self-harm in Irish prisons, 2019

Other findings

Other findings highlighted in the report include the following:

• Two-thirds (68%) of self-harm episodes involved prisoners in single cell accommodation. Considering the overall prison population, 51.9% of prisoners who self-harmed were accommodated in single cells in 2019.

• The rate of self-harm was higher among prisoners on remand or awaiting trial than among sentenced prisoners (5.7 vs 2.3 per 100 prisoners).

• In line with findings from previous reports, substance misuse continues to be one of the primary factors associated with self-harm among the prison population in Ireland.

1   McTernan N, Griffin E, Cully G, et al. (2021) Self-harm in Irish prisons 2019: third report from the Self-Harm Assessment and Data Analysis (SADA) Project. Longford: Irish Prison Service.
https://www.drugsandalcohol.ie/34047/

The Health Protection Surveillance Centre (HPSC) is Ireland’s specialist agency for the surveillance of communicable diseases. Part of the Health Service Executive (HSE), and originally known as the National Disease Surveillance Centre, the HPSC endeavours to protect and improve the health of the Irish population by collating, interpreting, and disseminating data to provide the best possible information on infectious diseases. The HPSC has recorded new cases among injecting drug users of HIV since 1982, HBV (hepatitis B virus) since 2004, and HCV (hepatitis C virus) since 2006. The figures and tables presented in this summary are based on data extracted from the Computerised Infectious Disease Reporting (CIDR) System in July 2021.¹ It should be noted that due to the Covid-19 pandemic and related lockdowns, HIV, HBV, and HCV notification data for 2020 are incomplete. Consequentially, these data have not yet been extensively validated and should be considered provisional.

Main drug-related infectious diseases among people who use drugs – HIV, HBV, and HCV

HIV notifications, 2020

According to data compiled by the HPSC, at the end of 2020, some 449 people were newly diagnosed with HIV in Ireland, a notification rate of 9.4 per 100,000 population. This marks a decrease of 16% compared with 2019 (n=535) (see Figure 1).

Of the HIV notifications in 2020:

• 106 were male and 42 were female.
• 85 were men who have sex with men.
• For 67% (301) of the HIV notifications in 2020, there was no reported risk factor, although this is likely to change as more data become available.

In 2020, some eight HIV notifications were of people who inject drugs (PWID), compared with 11 in 2019 (see Table 1). The figure for 2020 is the lowest number of PWID among HIV notifications since 2003 (see Figure 2).

Source: HSE and HPSC (2021)

Figure 1: Number of new HIV notifications reported in Ireland, by year of notification, 2010–2020

Table 1: New HIV notifications reported to the HPSC by risk factor status, 2020

Source: HSE and HPSC (2021)

Source: HSE and HPSC (2021)

Figure 2: Number and rolling average number of PWID among HIV notifications reported in Ireland, by year of notification, 2003–2020

Of the eight PWID among HIV notifications in 2020, four were male and four were female, with a median age of 36 years. No subjects were under 25 years of age (see Table 2). The increased number of PWID among HIV notifications in 2014/15 was due to an outbreak of HIV among homeless people in Dublin who use drugs. The outbreak was declared over in February 2016. Key control measures implemented included raising awareness among clinicians, addiction services, and PWID; intensive case finding and contact tracing; early treatment of HIV infection in those most at risk; greater promotion of needle exchange; increased access to methadone treatment; frontline worker training; and raising awareness about safe injecting and safe sex. Leaflets were distributed in hostels and settings in Dublin where patients/clients attended.

HBV notifications, 2020

There were 337 notifications of HBV in Ireland in 2020, a decrease of 36% on 2019, when there were 526 notifications. The notification rate for 2020 was 7.1 per 100,000 population. HBV notifications halved between 2008 (n=897; 21.2/100,000 population) and 2014 (n=442; 9.3/100,000 population). Although provisional data on HBV notifications in 2020 are considerably lower than those reported in 2019, it should be noted that recent trends have suggested that the number of cases diagnosed and notified is stabilising rather than continuing to decline (see Figure 3).

Seventy-nine per cent (n=266) of the 337 HBV notifications in 2020 contained information on acute/chronic status. Of these, 96.2% (n=256) were chronically infected (long-term infection), while 3.8% (n=10) were acutely infected (recent infection). Risk factor data were available for eight of the acute cases notified in 2020. Of these acute cases, none was a person who injects drugs (see Table 3).

Table 2: Characteristics of new HIV notifications who reported injecting drug use as a risk factor, 2020

Source: HSE and HPSC (2021)

Source: HSE and HPSC (2021)

Figure 3: Number of HBV notifications reported in Ireland, by year of notification, 2010–2020

Table 3: Acute and chronic new HBV cases reported to the HPSC, 2020

Source: HSE and HPSC (2021)

Data excluding proxy risk factor of born in endemic country/asylum seeker.

Table 4: New HCV cases reported to the HPSC, by risk factor status, 2020

Source: HSE and HPSC (2021)

Source: HSE and HPSC (2021)

Figure 4: Number of HCV notifications reported in Ireland, by year of notification, 2010–2020

Table 5: Characteristics of new HCV notifications who reported injecting drug use as a risk factor, 2020

Source: HSE and HPSC (2021)

HCV notifications, 2020

There were 326 HCV notifications in Ireland in 2020, a decrease of 31.2% on 2019, when there were 474 notifications. The notification rate for 2020 was 6.8 per 100,000 population. There has been a downward trend in HCV notifications since peak numbers (n=1538) were recorded in 2007. While provisional data on notifications from 2020 suggest a continued decline (see Figure 4), trends in notifications of HCV are difficult to interpret as acute and chronic infections are frequently asymptomatic, and most cases diagnosed and notified are identified as a result of screening in key risk groups. Therefore, notification patterns are highly influenced by testing practices, which may vary over time and may not reflect incidence very well.

Information on the most likely risk factor was available for 46.9% (n=153) of cases in 2020 (see Table 4). Eighty cases with risk factor data were PWID and six were infected through contaminated blood products. No risk factors were identified for 14 cases, for whom risk factor data were available despite public health follow-up.

The proportion of cases attributed to injecting drugs decreased from 88% in 2011 to 67% in 2019, but risk factor data were not available for a significant number of cases. Hence, this finding is difficult to interpret. The number of cases that were PWID among provisional HCV notification data for 2020 is also likely to be a significant underestimate. Data for 2020 will improve as further validation work is carried out.

Of the PWID among HCV notifications in 2020, 54 were male and 26 were female, with a median age of 40. Seven subjects were under 25 years of age. The majority (57.5%) resided in Dublin, Kildare or Wicklow (see Table 5).

1   For further information on the CIDR System, visit: https://www.hpsc.ie/cidr/

Alcohol Action Ireland (AAI), the national independent advocate for reducing alcohol harm, surveyed a number of alcohol treatment service providers to explore issues around the provision of treatment services for harmful and dependent drinkers in Ireland. Its report,¹ published in 2021, forms part of AAI’s programme of work on its strategic goal to advocate for services for those affected by alcohol harm, as outlined in Leading change: a society free from alcohol harm. Strategic Plan 2020–2024.²

Introduction

There are an estimated 250,000 people with alcohol dependency problems in Ireland,³ yet with a decrease in numbers accessing treatment.⁴ Using data from the National Drug Treatment Reporting System (NDTRS) of the Health Research Board (HRB), the report highlights there were approximately 7,500 cases of treatment reported in 2019⁴ and that the current national policy, Reducing Harm, Supporting Recovery,⁵ emphasises a health-led response to drug and alcohol use in Ireland, based on providing person-centred services that promote rehabilitation and recovery.

Methodology

Eleven residential rehabilitation services providing treatment interventions for harmful and dependent drinkers from a variety of locations were surveyed using a structured interview in early 2020. The service providers surveyed reported working with approximately 2,000 people in 2019 and encompassed a range of treatment models – including the Minnesota model, the recovery model, and/or psychotherapeutic interventions – and a number of providers were trauma-informed.

Demographics

According to Health Service Executive (HSE) data, current provision of all addiction residential treatment beds (alcohol, drugs, and gambling) stands at 793 residential beds. These comprise:

• 19 inpatient unit detoxification beds
• 127 community-based residential detoxification beds
• 4 adolescent residential detoxification beds
• 625 residential rehabilitation beds
• 18 adolescent residential beds.

Over one-half of the service providers surveyed were funded through the HSE and services were free to the public. The remainder were private fee-paying services, the majority of which have beds funded through the HSE. Many service providers noted a change in demographics in recent years, principally the increasing number of young people coming into treatment and an increase in cocaine use. A number of service providers noted an increase in people coming to treatment via their workplaces or while continuing to work.

Themes

A number of issues in relation to the challenges facing alcohol treatment providers emerged from analysis of the interview transcripts. These were grouped into four themes:

• Mental health and trauma
• Reducing the impact on children and families
• Gaps in services
• Barriers to treatment.

For each theme, the report includes extracts from the interview transcripts to support the theme followed by AAI discussion and key recommendations, as follows.

Theme 1: Mental health and trauma

All service providers surveyed spoke of the significant and serious concern of dual diagnosis, where both alcohol addiction and a mental health problem co-occur. Yet this cohort very often experiences problems getting treated for both issues in parallel. Service providers noted that those with a dual diagnosis require input from mental health professionals as part of their treatment and advocated for a shared approach to client’s mental health; however, additional funding for staff and/or training was required to do so.

Adverse childhood experiences (ACEs) such as abuse, neglect, loss, and other emotionally harmful traumatic experiences in childhood were acknowledged as an almost universal experience in the client population. Service providers held differing views on how best to address clients’ ACEs, with a number feeling that it is vital to understand their trauma in order to treat their addiction. However, others felt that unless there was a robust mechanism for dealing with that trauma, then ACEs should not be specifically raised.

Recommendations

• A national strategy with revised standards promoting best practice should be developed and implemented for residential services. Services should be person-centred and trauma-informed and monitored by the Health Information and Quality Authority (HIQA).

• Addiction services should have the skills and resources to respond to the mental health needs of their clients, suggesting a national training needs assessment, providing information on training already available through the HSE, and allowing staff time to take up training as required.

Theme 2: Reducing the impact on children and families

A number of service providers noted the intergenerational patterns which are frequently a feature of their clients, where members of the same family often experience similar substance misuse problems.

The effects of parental substance misuse have been largely hidden in Irish society; however, since 2019, a number of Irish studies, initiatives, and national policies have begun to recognise this hidden harm acknowledged as an ACE.^5,6,7,8

Treatment services play an important role in identifying parents (particularly mothers and pregnant women) and providing interventions or pathways to reduce the harmful impact of addiction on children and to break the cycle of intergenerational substance abuse that is so often a feature of addiction. Developing and adopting family and parenting programmes for high-risk families impacted by problematic substance use are emphasised in the national drug and alcohol strategy.⁵

Recommendations

• Access to residential services for women with children should be improved. A coordinated approach between addiction services, maternity services, and children’s health and social care services to respond to the needs of children affected by parental substance misuse is required.

• In recognition of the impact of parental substance misuse, services should place greater emphasis on working with family members as clients in their own right rather than as adjuncts to the client presenting with the addiction.

Theme 3: Gaps in services

Service providers cited what they viewed as gaps in how treatment services are delivered. These included:

• Lack of access to detoxification services and the impact it has regarding access to treatment.

• Lack of aftercare support. A key element of recovery, including treatment and aftercare, is the assurance that an integrated approach will be taken and that people can move from one service to another as required.

• Lack of staffing and resources. Service providers noted an issue around staffing levels and/or funding to provide the optimal service.

Recommendations

• Wider geographic access to addiction services should be provided, in accordance with the national drug and alcohol strategy, and diversifying the range of treatment options available to meet current and emerging needs should continue.

• There should be a national protocol on alcohol detoxification, streamlining the process of people moving straight from detoxification into residential treatment and aftercare services.

• A third-level course in specialist substance use should be developed and modules in substance misuse in counselling training courses should be included.

Theme 4: Barriers to treatment

As well as detoxification as a barrier to accessing treatment, other significant barriers quoted included the onerous admission criteria to residential care, the perceived stigma of going into treatment, and the financial costs limiting choice of treatment.

There was unanimity among service providers for greater recognition of the significant harm caused by alcohol. However, the funding, services, and policy interventions required are inadequate to deal with the scale of the problems presenting.

The prevalence of faith-based service providers was highlighted by a number of the participating service providers.

Recommendations

• The Government should acknowledge the harms caused by alcohol to individuals, their families, and to society and should fund services appropriately.

• An oversight body for all treatment service providers should be established, with comprehensive standards, regulation, and inspection to ensure that faith-based services meet the requirements of a modern human-rights-based service.

Conclusion

The high socioeconomic costs of alcohol harm in Ireland include costs to the healthcare system, criminal justice system, lost work, and loss of life. According to the World Health Organization, services ‘should be sufficiently strengthened and funded in a way that is commensurate with the magnitude of the public health problems caused by harmful use of alcohol’.⁹

It is important to understand the kinds of treatment services provided, the costs of services, and the outcomes and effectiveness of services in order to have a clear view of what is required to ensure modern and effective service provision. The current drug and alcohol strategy has adopted a health-led approach to addiction; however, alcohol treatment services do not fall under HIQA’s national guidance like other health services.

A national strategy for residential services and a HIQA inspection regime would ensure that Ireland’s treatment services are equipped to provide the best possible care to people in need.

1   Alcohol Action Ireland (2021) Alcohol treatment services: a snapshot survey 2021. Dublin: Alcohol Action Ireland. https://www.drugsandalcohol.ie/34359/

2   Alcohol Action Ireland (2019) Leading change: a society free from alcohol harm. Strategic Plan 2020–2024. Dublin: Alcohol Action Ireland. https://www.drugsandalcohol.ie/31321/

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.
https://www.drugsandalcohol.ie/34058/

4   Condron I, Carew AM and Lyons S (2020) National Drug Treatment Reporting System 2013–2019 alcohol data. Dublin: Health Research Board. https://www.drugsandalcohol.ie/32093/

5   Drugs Policy Unit (2019) Reducing Harm, Supporting Recovery progress 2018 and planned activity 2019. Dublin: Department of Health. https://www.drugsandalcohol.ie/30660/

6   Health Service Executive and Tusla (2019) Hidden Harm practice guide. Seeing through Hidden Harm to brighter futures. Dublin: Health Service Executive and Tusla – Child and Family Agency.
https://www.drugsandalcohol.ie/30190/

7   Department of Children and Youth Affairs (2019) Better Outcomes, Brighter Futures: the national policy framework for children and young people, 2014–2020. Dublin: Stationery Office.
https://www.drugsandalcohol.ie/31853/

8   Department of Children and Youth Affairs (2018) A whole-of-Government strategy for babies, young children and their families 2019–2028. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/29973/

9            World Health Organization (WHO) (2019) 10 areas governments could work with to reduce the harmful use of alcohol [Feature stories]. 10 July 2019. Available online at:
https://www.who.int/news-room/feature-stories/detail/10-areas-for-national-action-on-alcohol

Targeted Response with Youth (TRY) is a peer-mentoring project based in Dublin's south inner city, which targets young people involved in or at risk of becoming involved in the drug economy and antisocial behaviour (ASB). An evaluation of the programme was published in November 2020, entitled Relentless caring: trying something new.¹

Meeting a need

The project is based in and around St Teresa’s Gardens (STG), a local authority complex in Dublin’s south inner city. The area has high levels of early school leaving, unemployment, poor mental and physical health outcomes, crime, and drug use. Under the Pobal HP Deprivation Index, it was categorised as ‘very disadvantaged’, the lowest score on the scale.² Ongoing regeneration of the STG complex has meant that many tenants were moved elsewhere, leaving residences empty to facilitate new builds. The report argues that ‘as a consequence of detenanting STG, a small group of marginalised, hostile and “extremely threatening” young men with external addresses but family ties in STG made it their daily stomping ground for ASB and drug-related activity, negatively impacting the quality of life of residents’ (p. 16). Recourse to control tactics, such as prosecution and imprisonment or the threat of eviction for those living elsewhere, had failed to address the community’s needs. In addition, the young people causing the problems were considered hard to reach. A stakeholder described them as ‘extremely marginalised people who are not liked in the community and people do not want to work with them’ (p. 27). The lack of appropriate services to address the complex needs of these young people, and the consequences of their behaviour, led to the establishment of TRY.

Delivery model

Based on the experiences of national and international projects, TRY uses the intensive outreach and bridging (IOB) model.³ Youth workers contact the targeted young people at street level, build trust, and provide them with emotional and practical support. There is a focus on building their self-esteem and other positive traits to enable them to extend their social networks beyond those associated with the drugs economy. In addition, the project encourages and facilitates young people to engage with services, depending on their needs. Services accessed include those related to education or work pathways, physical or mental health services, housing, and childcare facilities. Engagement takes place on a one-to-one basis and through group work.

Target group

When it started in 2017, the project targeted a group of young men (aged 18–24 years) who were engaged in ASB, including drug-related activity, in and around STG. The project subsequently expanded to include young women and those under the age of 18. Between October 2019 and September 2020, TRY worked with 37 young people: 22 males (aged 18–24), 13 females (aged 18–24), and two under-18s (aged 14–17) (p. 41).

Method of evaluation

The evaluation involved a literature review, documentary analysis, and qualitative interviews with a variety of stakeholders (n=19). Participants were mainly those involved in the delivery and governance of the project. Only two local residents and two TRY participants were interviewed. Interviews were recorded and thematic analysis carried out on the data. No additional detail on the sampling, fieldwork or analytical approaches was provided in the report.

Findings

Childhood adversity

Young people participating in the project tended to have experienced one or more of a wide range of childhood adversities, including domestic, physical, and emotional abuse; familial drug addiction; parental incarceration; community violence; and family bereavements. It was identified as a ‘major problem’ (p. 28) that these traumas were often not discussed, which stakeholders described as leading to much anger among the young people. This was thought to have contributed to other service providers finding them challenging, hard to reach, and difficult to engage.

Central role of mentor relationship

Central to the success of the project is the relationship that mentors develop with the young people. A high level of trust must be built between the two, which takes time and persistence on the part of the mentor. The author argues that the mentor must be ‘authentic, believable, caring and kind’ (p. 24) with the relationship being built through intensive outreach. There also needs to be ‘exceptional levels of professionalism [on the part of the mentor] to appear to be involved in casual conversation but to actually have a careful professional agenda’ (p. 31), through which the young person’s needs are identified and bridging to appropriate services takes place. Staff also need a high degree of flexibility to deliver interventions at locations and times required by the young people. It was deemed critical that mentors have similar life experiences to participants and come from the same type of background.

Structured assessment

Mentors use various tools to add structure to how they work with young people. For example, they use a goals scale to highlight the gaps in a beneficiary’s life and to help them visualise and set achievable goals. They also use a logic model to determine what referrals need to be made and to support their bridging role.

Bridging

As the relationship between the mentor and young person develops, new needs frequently emerge. Additional needs often relate to mental health, parenting skills, anger management, and a desire to access addiction treatment services. Close collaboration between mentors and other service providers to meet the young people’s needs is critical. Mentors act as a bridge between the two and provide ongoing support to the young people to maintain attendance. This includes attending appointments with the young person.

Table 1: TRY project outcomes October 2019–September 2020 (Sláintecare Integration Fund interim report)

Source: Mulcahy (2020) p. 41

Outputs and outcomes

From October 2019 to September 2020, the total number of contacts made with individuals was 1,552 (p. 27), where the breakdown of referrals made to services in 2020 was: 22% to education/training; 24% drug intervention; 7% housing; 19% employment; 9% social welfare/money; and health services 19% (p. 36). The report includes examples of young people’s confidence building and of taking up opportunities to further their education, enter employment, and access other services to meet their health needs. Table 1 summarises the outcomes reported by the project for 2019/20.

Cost effectiveness

While no value-for-money analysis was carried out, the author does compare the costs of TRY (approximately €100,000 in 2019) with those of punitive criminal justice responses. The cost of detaining one young person in Oberstown Children Detention Campus is €383,574 and of imprisoning an adult is €75,349. She concludes that ‘in terms of criminal justice savings alone, the TRY project since its inception [2017] has been very good value indeed’ (p. 23).

Concluding comment

The findings echo those of an earlier more comprehensive piece of work published in 2019 by Bowden, notably The drug economy and youth interventions: an exploratory research project on working with young people involved in the illegal drugs trade.^4,5 While the TRY evaluation provides useful insights into the TRY project and the value of mentoring for this cohort of young people, it is also limited. A key limitation is that only two project participants took part. It is important that young people’s voices are heard in evaluations of programmes that affect them. Without this, there can only be a limited assessment of the strengths and weaknesses of a programme as regards for whom it works well and why. However, the key messages from Bowden’s report^4,5 remain relevant here:

• Engaging with people who are involved in drug distribution is not about excusing their behaviour, rather understanding it with the aim of prevention.

• Any engagement needs to be structured around a strong relationship with an advocate, characterised by trust and understanding.

• Young people involved in the drug economy or at risk of getting involved are reachable. If there were viable educational and employment pathways open to them, many would desist from the drug economy.

1   Mulcahy J (2020) Relentless caring: trying something new. An evaluation of the Targeted Response with Youth TRY project. Dublin: Donore Community Drug and Alcohol Team.
https://www.drugsandalcohol.ie/34556/

2   The Pobal HP Deprivation Index shows the degree of overall affluence and deprivation at the level of electoral division using data compiled from the Irish Census.

3   National and international IOB projects include the Easy Street project of Ballymun Regional Youth Resource (BRYR), Dublin and the Lugna Gatan (Easy Street) model in Sweden. For further information, visit: http://www.bryr.ie/ and https://www.bra.se/download/18.cba82f7130f475a2f1800026910/
1371914734658/2002_examination_of_lugna_gatan.pdf

4   Bowden M (2019) The drug economy and youth interventions: an exploratory research project on working with young people involved in the illegal drugs trade. Dublin: CityWide Drugs Crisis Campaign.
https://www.drugsandalcohol.ie/30487/

5   Dillon L (2019) The drug economy and youth interventions. Drugnet Ireland, 70 (Summer): 12–14. https://www.drugsandalcohol.ie/31007/

Lesch M and McCambridge J (2021) Drug and Alcohol Review, Early online.
https://www.drugsandalcohol.ie/34383/

Using policy feedback theory, this study specifically investigates the political consequences of accumulating alcohol-related health and social harms for processes of policy change prior to 2009.

Not acting on the population health harms caused by alcohol can produce significant societal costs, particularly when consumption is rising, and entail subsequent political consequences. Understanding of innovations in alcohol policy decision making requires an appreciation of the historical context, including earlier policy failures.

Lesch M and McCambridge J (2021) Social Science & Medicine, 282: 114116.
https://www.drugsandalcohol.ie/34443/

Ireland’s 2018 alcohol legislation adopts key evidence-based measures, introducing pricing, availability and marketing regulations that are world-leading in public health terms. Drawing primarily on the Multiple Streams Approach (MSA), this study investigates the adoption of the Public Health (Alcohol) Act 2018. We draw data from 20 semi-structured interviews with politicians, government advisors, public health experts, and advocates, as well as from relevant primary documents, newspaper articles, and other material in the public domain.

We find that increased public attention to alcohol-related harms in Ireland (problem stream), developments within the institutional location of policymaking (the policy stream), and the political pressure exerted by politicians and advocates (the political stream) all combined to open a policy window. Unlike previous alcohol policy reform efforts in Ireland, several personally committed and well-positioned leaders championed policy change. This study suggests that political leadership might be important in understanding why public health approaches to alcohol have been embraced in some contexts but not in others.

Perrett S, Plugge E, Conaglen P, O’Moore E and Sturup-Toft S (2020) Journal of Public Health,
42(4): e561-e572.
https://www.drugsandalcohol.ie/34235/

Prison populations experience an increased burden of physical, mental and social health needs compared to the community, further impacted by the prison environment. Surveillance systems to monitor health and well-being trends in prisons are lacking, presenting a challenge to services planners, and policy makers who often lack evidence to inform decisions.

The Five Nations Health and Justice Collaboration is proposing a new model for prison health surveillance, based on established guidelines for public health surveillance but with additional features that recognize the uniqueness of the prison environment and need for a whole prison approach, built on collaboration and sharing of data between health and justice sectors.

Birchall E, Perry IJ, Corcoran P, Daly C and Griffin E (2021) European Journal of Public Health, 31(4): 853–858.
https://www.drugsandalcohol.ie/34300/

The aim of this study was to examine the impact of this guidance [restricting the supply of over-the-counter (OTC) codeine-containing products] on the national rate of hospital-presenting self-harm involving codeine-related intentional drug overdose (IDO).

Our findings indicate that the rate of codeine-related IDOs was significantly lower in the period following the implementation of the guidance. There is a large body of evidence supporting the restriction of potentially harmful medication as an effective strategy in suicide prevention.

Peter K, Hegarty J, Dyer Kyle R and O’Donovan A (2021) Journal of Substance Abuse Treatment,
Early online, p. 108557.
https://www.drugsandalcohol.ie/34598/

This study was conducted across Irish community opiate prescribing services and drew on data from 12 in-depth qualitative interviews with frontline staff. This paper examines the narratives of staff about the factors which influence the dynamics and process of treatment services, particularly in relation to the implantation of change.

A range of interdependent factors which influence an ‘eco-system’ of service delivery were identified. Effective policy implementation in Ireland remains aspirational, but findings reported in this paper have important implications for future planning and design of services for people who use drugs, and provide a good basis for further investigation.

Fenton F, Stokes S and Eagleton M (2021) Irish Journal of Medical Science, Early online.
https://www.drugsandalcohol.ie/34581/

This study was conducted to determine seropositivity to the COVID-19 virus in patients attending the HSE National Drug Treatment Centre (NDTC), and to establish if patients tested had any clinical symptoms of this disease since March 2020.

Findings indicate (a) possible low level of exposure to COVID-19 among this patient cohort or (b) that those patients who have been exposed have not developed or maintained detectable antibody levels, nor developed symptoms of the disease. Public health measures could explain the low level of COVID-19 in this cohort. The findings are also consistent with the possibility of a protective effect of OAT [opiate agonist treatment] medications on development of the disease.

Gallagher B, Neiman A, Slattery M-C and McLoughlin DM (2021) Irish Journal of
Psychological Medicine, Early online, pp. 1-9.
https://www.drugsandalcohol.ie/34513/

Our objective was to examine how online news outlets have portrayed ketamine as an antidepressant by ascertaining the volume and content of relevant articles and trends over time.

Online news media articles have been generally positive about ketamine for treating depression but need to be interpreted with caution as many of them did not discuss negative aspects of ketamine and made unsubstantiated claims about ketamine.

Calnan S and Davoren MP (2021) Nordic Studies
on Alcohol and Drugs, Early online.
https://www.drugsandalcohol.ie/34130/

This qualitative study aimed to address this gap [limited research on students’ own perspectives on alcohol and related harms reduction interventions] by examining college students’ perspectives in the context of an alcohol prevention programme for college students in Ireland.

Viewing the findings through a social-ecological lens, students seemed to collectively acknowledge the different layers of influence on student drinking, acknowledging the complex nature of this issue. Providing a greater variety of leisure spaces, including alcohol-free environments, was viewed particularly favourably by the student participants in terms of solutions proposed.

O’Brien D, Long J, Quigley J, Lee C, McCarthy A and Kavanagh P (2021) BMC Public Health, 21(1): 954.
https://www.drugsandalcohol.ie/34317/

This systematic review of prospective longitudinal primary studies sought to determine whether electronic cigarette (e-cigarette) use by teenagers who had never smoked conventional tobacco cigarettes (tobacco cigarettes) at baseline was associated with subsequently commencing tobacco cigarette smoking.

The systematic review found that e-cigarette use was associated with commencement of tobacco cigarette smoking among teenagers in Europe and North America, identifying an important health-related harm. Given the availability and usage of e-cigarettes, this study provides added support for urgent response by policymakers to stop their use by teenagers to decrease direct harms in this susceptible population group, as well as to conserve achievements in diminishing tobacco cigarette initiation.

Johnson-Ferguson L and Di Forti M (2021) Irish Journal of Psychological Medicine, Early online, pp. 1-6.
https://www.drugsandalcohol.ie/34271/

In this editorial, we first present and critically discuss the evidence to date of the association between heavy cannabis use and psychosis. We argue that while the biological mechanisms underlying individual susceptibility to develop a psychotic disorder following heavy cannabis use are still unknown, heavy cannabis use remains the most modifiable risk factor for the onset of psychotic disorders and for its clinical and functional outcome. This demands a clear move towards both primary and secondary prevention intervention to reduce the impact of heavy cannabis use on the incidence and prevalence of psychotic disorders.

King L, Cullen SJ, O’Connor S, McGoldrick A, Pugh J, Warrington G, Woods G, Nevill AM and Losty C (2021) The Physician and Sportsmedicine, 49(2): 207–213.
https://www.drugsandalcohol.ie/34216/

The aim of the present study was to further explore the prevalence of CMDs [common mental disorders] among jockeys and to test for associations with potential risk factors.

The findings indicate that jockeys report CMD symptoms at comparable rates to athletes in other sports. The study was the first to highlight potential risk factors as predictors of CMDs among jockeys, including burnout, career satisfaction, and the current contemplation of retirement. Screening tools for the risk factors demonstrated may, therefore, provide useful in the early identification of CMDs among jockeys. The development of jockey-specific assessment tools, education programmes, and interventions may help better understand and support the mental health of jockeys.

Lambert S, O’Callaghan D and Frost N (2021)
Death Studies, Early online, pp. 1-11.
https://www.drugsandalcohol.ie/34409/

This paper explores the impact of complicated grief on the family system following the drug-related death of a family member. Drug-related deaths are rife with moral stigmas, and those left behind often carry an emotional burden laden with shame and guilt. Seventeen bereaved family members were interviewed using semi-structured interviews and transcripts were analyzed using reflexive thematic analysis. Three core themes were generated: Renegotiation of Relationships; Experiencing Complex Emotions; and Adjusting to
a New Reality.

The findings demonstrate that this population experiences great difficulty in processing their grief as they struggle with family breakdown, navigating supports and stigma.

Eogan M, Gleeson J, Ferguson W, Jackson V, Lawless M and Cleary B (2021) Irish Medical Journal, 114(5): 352.
https://www.drugsandalcohol.ie/34286/

The aim of this study was to review a decade of attendances at an addiction obstetrics clinic and compare with the general hospital population.

This limited retrospective review of women with addiction in pregnancy identifies a changing profile of attendances. It acknowledges the important role of the drug liaison midwife. It highlights increased risks for this population regarding prematurity and growth restriction, and it is important that these are reflected in care pathways and patient education. Further prospective multivariate analysis is advised to drive responsive service planning to optimise care of pregnant women with addiction.

McCarron P, Smyth BP, Carroll G, Glynn M, Barry J, Whiston L, Keenan E, Darker CD and Truszkowska E (2021) Heroin Addiction and Related Clinical Problems, Early online.
https://www.drugsandalcohol.ie/34176/

Among patients attending an opioid substitution clinic we sought to investigate reasons for NPS [new psychoactive substances] use, administration, adverse effects, and consumption in the previous three months.

In the current study the majority of those who had ever taken NPS did so before 2010 (when legislation forced the closure of headshops), and only 11% of participants reported ongoing NPS use, suggesting that making the supply of NPS illegal reduced their consumption. Furthermore, since a high proportion of participants administered NPS intravenously, the closure of headshops is likely to have led to improved health outcomes among this group of patients.

O’Carroll A and Wainwright D (2021) BJGP Open, 5(3): BJGPO.2021.0031.
https://www.drugsandalcohol.ie/34189/

This research sought to explore barriers to health service usage for people experiencing homelessness.

There are certain recurrent interactions between people experiencing homelessness and doctors that result in the exclusion of people experiencing homelessness from health services.

Villani J and Barry MM (2021) Health Promotion International, 36(5): 1450–1462.
https://www.drugsandalcohol.ie/33798/

This study explores Travellers’ perceptions of mental health and its determinants. It also identifies the most relevant factors for promoting positive mental health and wellbeing among this socially excluded group.

The findings suggest that Travellers’ mental health is multidimensional and requires a socio-ecological approach that addresses the wider determinants of health. Community mental health promotion initiatives should focus on reducing discrimination, enhancing social and emotional wellbeing and self-esteem, improvement of living conditions, reduced mental health stigma, and the promotion of Traveller culture and positive self-identity.

Kiernan S, Ní Cheallaigh C, Murphy N, Dowds J and Broderick J (2021) Scientific Reports, 11: 9911.
https://www.drugsandalcohol.ie/34166/

The objective of this study was to evaluate a broad range of physical functioning variables to enable better future planning of targeted health and accommodation services for this group [homeless adults].

This study revealed hospital in-patients registered as homeless displayed particularly poor physical functioning levels and mobility regardless of age. Health and housing services should address the unmet physical functioning needs of this vulnerable group.