The new Government divides its commitments into a set of four and a further set of 24 actions, all of which are in line with the NDS.² The reason for having two separate sets is unclear; hence, they are dealt with together for the purpose of this article. Where relevant, the article puts them in the context of the existing strategic action plan for 2017–2020 embedded in the NDS.

Programme for Government commitments

When examined alongside the strategic action plan (2017–2020), most of the commitments in the new Programme for Government can be linked to existing actions and reflect progress made on their delivery since 2017. While one deals with a specific service (the re-establishment of the Galway city community-based alcohol treatment service), the others are broader in nature.

New actions

There are some actions that deal with new developments in Irish drug policy: a new topic, target group, or approach to addressing the needs of people who use drugs. This is not to suggest there has been no activity already in these areas in terms of delivery on the ground, rather they were not part of the 2017–2020 strategic action plan but reflect changes in the field.

There are seven new actions:

1. A representative of the National Oversight Committee for Reducing Harm, Supporting Recovery will be included in the implementation and monitoring arrangements for the new national mental health policy launched in June 2020, Sharing the Vision: a mental health policy for everyone.³
2. The Government will seek to retain the specific actions taken to support increased and improved access to opioid substitution services during Covid-19, so that pre-Covid waiting times in accessing these services are reduced.⁴
3. The regulations and legislation that apply to cannabis use for medical conditions and palliative care, having regard to the experience in Northern Ireland and Great Britain, will be examined. Cannabis use for medicinal purposes did not feature in the strategic action plan for 2017–2020. However, since the strategy was launched in 2017, it has been the subject of a scientific review and legislation. In 2017, Cannabis for medical use: a scientific review⁵ by the Health Products Regulatory Authority was published. On 26 June 2019, legislation was passed to allow for a Medical Cannabis Access Programme to operate in Ireland on a pilot basis for five years.
4. A citizens’ assembly to consider matters relating to drugs use will be convened. The development of the NDS involved extensive consultation with stakeholders and the public. In line with this, the Drugs Policy Unit of the Department of Health and the Health Research Board have collaborated on an annual drug forum to support evidence-informed practice and service delivery; promote participation of communities, service users, and their families in national structures; and strengthen the implementation and performance of the NDS.
5. The coercion and use of minors in the sale and supply of drugs will be legislated against. This is a new policy commitment for Government. A Private Members’ Bill on the topic lapsed in January 2020 with the dissolution of the last Government.⁶
6. A 24-hour helpline, based on the FRANK helpline in the United Kingdom, providing advice and assistance to people who use drugs and their family members, will be established. As part of Drugs.ie, the Health Service Executive currently runs a drug and alcohol helpline for anyone with a question or concern related to drug and alcohol use. The times are limited to office hours, Monday to Friday..
7. A ‘Good Neighbour’ policy for drug treatment centres to address any concerns held by local residents and businesses alike will be ensured.

A further four actions indicate a new focus or target group for existing actions:

8. The potential for an information campaign on the health impacts of steroid use, particularly on young men, will be examined. This is a new focus in relation to the existing action plan. While people who use steroids were mentioned in the existing action plan as a new service-user population at needle exchange programmes, steroids were not identified as a specific target for prevention and harm reduction activities.
9. That women can face barriers to accessing and sustaining addiction treatment, arising from an absence of childcare or the presence of domestic violence, will be recognised and targeted interventions aimed at responding to their needs will be developed. While domestic violence is noted as an issue facing women who use drugs in Reducing Harm, Supporting Recovery, it does not feature in its action plan. Childcare is recognised as a barrier needing to be addressed in one of the actions in the plan, but this new action recognises other barriers by specifically noting domestic violence.
10. Support for step-down accommodation to prevent high-risk single people and families from exiting treatment into homelessness will be significantly increased. This is a broadening out of an existing action to include high-risk single people.
11. Harm reduction and education campaigns aimed at increasing awareness of the risks of drug use and the contribution of drugs to criminality will continue to be resourced. This is a continuation of existing work but the focus on the contribution of drugs to criminality is new.

Commitments to a policy direction

Three of the actions indicate a move from exploring an issue in the strategic action plan to a commitment to a particular policy position:

12. To increase and support drug-quality testing services, particularly at festivals
13. To support the rollout of access to and training in opioid antidotes
14. To implement the recommendations of the Working Group to Consider Alternative Approaches to the Possession of Drugs for Personal Use and to review the alternative approach adopted after its first year of implementation in order to ensure that it is meeting its aims. However, the Health Diversion Approach launched by Government in August 2019 as the approach being adopted following the Working Group’s report is not referred to specifically in the document.

Support for existing actions

Ten of the actions are either the same, variations, or continuations of those in the strategic action plan:

15. Build on recent initiatives at Junior and Senior Cycle and support secondary schools in introducing drug and alcohol awareness programmes, particularly in relation to the hazards of casual drug use.
16. Examine approaches to identifying at-risk young people and vulnerable groups to interrupt their potential trajectory into problem drug and alcohol misuse.
17. Expand services for pregnant and postnatal women affected by substance use, and their children.
18. Create a path for people in rehabilitation from drug addiction to access education and training facilities in their local areas.
19. Progress the National Clinical Programme for Dual Diagnosis and work to develop joint protocols and referral pathways.
20. Support the Drug Related Intimidation Reporting Programme, developed by the National Family Support Network, in partnership with An Garda Síochána, to respond to the needs of drug users and families facing the threat of drug-related intimidation.
21. Develop health and social interventions, based on an inclusion-health approach to target people who are homeless and in addiction.
22. Ensure in-reach supports and pathways to access to treatment for homeless, Traveller, and new communities.
23. Increase the number of residential treatment beds for those stabilising, detoxing, and/or seeking drug-free services.
24. Reduce the number of lives lost through overdose by opening a pilot medically supervised injecting facility in Dublin city.

Drug and alcohol task forces

Finally, underpinning the NDS and its delivery, there is ongoing commitment to support the work of the drug and alcohol task forces in identifying local need in communities and supporting targeted initiatives.

Concluding comment

Overall, the new Programme for Government indicates an ongoing commitment to a health-led approach to meet the needs of people who use drugs, undertaking a similar set of actions to those within the NDS, and to be delivered under existing structures. The current strategic action plan expires at the end of 2020 but the new Programme for Government would indicate that any new version for 2021 and onwards will be closely aligned with its predecessor.

Lucy Dillon

__________________________

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

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

3    Department of Health (2020) Sharing the Vision: a mental health policy for everyone. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/32228/

4    See articles in this issue of Drugnet Ireland on Ireland’s response to Covid-19 for people who use drugs.

5    Health Products Regulatory Authority (2017) Cannabis for medical use: a scientific review. Dublin: Department of Health. http://www.drugsandalcohol.ie/26784/

6    Misuse of Drugs (Amendment) Bill 2019 sponsored by John Curran TD. Further information available at: https://www.oireachtas.ie/en/bills/bill/2019/97/

Fergus was a passionate, articulate and tireless champion for his own community in the North Inner City and he brought the same gifts to his work with Citywide Drugs Crisis Campaign, of which he was a founder member. Over the last 25 years Fergus travelled to communities all over Ireland to meet with people responding to the drugs crisis, he never said no to a meeting if it was possible for him to make it. Fergus understood what community development is about and he had a gift for it; no meeting was too small or too far away, he shared his knowledge, wisdom and experience with all of us, and he did it with grace, generosity and a lovely sense of humour …and of course always a comment on Spurs!

Fergus has represented the community sector on the National Drugs Strategy Committees since 1996 and continued as a member of the current National Oversight Committee until recently. Throughout the many years of his participation on these committees, Fergus was a brilliant advocate for our communities, strong, passionate and principled - that great phrase  “telling truth to power” could have been written for Fergus, because that is what he did, and in doing so, he won the respect of many of those people in power. He has been a leader, a mentor and an inspiration to me and to countless others involved with the community response to drugs. Above all else Fergus was a wonderful human being and our thoughts and sympathies are with Helena and the family on their profound loss, they have always been his light and inspiration.

What is the Bail Supervision Scheme?

Bail supervision has mainly been used to increase bail compliance in youth. It can result in reduced reoffending and in consequence a reduced demand for detaining youth during the remand period. In Ireland, DCYA established BSS to give courts another option for children at risk of being denied bail. In addition, in contrast to other jurisdictions, the view in Ireland is that the remand period is a time where behavioural change can occur. BSS applies the evidence-based multisystemic therapy (MST) model as part of routine court processes, such as supports provided by the Courts Service, Young Persons Probation (YPP), and An Garda Síochána (AGS) (p. 9).

Multisystemic therapy

MST is an intensive family-based intervention that aims to enable change by ensuring that young people remain at home, in education, training or working, and are not arrested for new charges (p. 12). The main objective is to help move the young person towards prosocial activities and peers. The MST model also enhances family functionality and support networks and enables caregivers to develop skills considered vital to allowing them to generalise learning and manage issues that may arise in the future. The intervention is implemented in the home and caregivers are given support 24/7 for a period of between three and five months (p. 12)

Eligibility requirements

To ensure that BSS targeted young people of highest risk, referrals initially were made by Oberstown Children Detention Campus and later on by Court 55 (Children’s Court). Eligible young people had to meet specific requirements:

• The scheme was mainly confined to the catchment area of within 20 miles of Children Court in Dublin.
• Those eligible were aged between 12 and 17 years (inclusive), with a minimum of three months prior to their 18th birthday.
• Those eligible must be living with an appropriate adult or caregiver for the duration of the scheme.

Offers to participate in the scheme occurred at the second court appearance when referred by Oberstown and at the first court appearance when referred by Court 55. Because MST occurred during pretrial court processes, the BSS team engaged with statutory agencies (AGS, Oberstown, Tusla, YPP, Courts Service) and non-statutory agencies (defence and prosecution legal teams, local agencies, e.g. educational establishments, youth services, community groups, drug counselling services, and local sports groups).

Evaluation methodology

The evaluation was centred on contribution analysis, which is a theory of change that involves a six-step rigorous and systematic process. This approach can produce credible evidence showing that behaviour outcomes can be attributed to an intervention. A quasi-experimental design was applied and allowed for comparisons to be made between BSS participants and a ‘naturally occurring’ control group, consisting of youth remanded to custody from areas outside the catchment area (p. 16).

Research questions

Three research questions were addressed:

1    Did the BSS work? More specifically, did the BSS contribute to changes in the young person’s behaviour including reduced reoffending and adherence to bail conditions?

2    How did the BSS work? More specifically, how many young people were referred to, enrolled on and completed the BSS during the evaluation period, and what were the factors that facilitated or acted as a barrier for referrals?

3    Why did the BSS work? More specifically, how did the BSS processes facilitate or act as a barrier to obtaining the observed outcomes? (p. 16).

Findings

The evaluation found that offending behaviours were reduced, young people had greater compliance with their bail conditions, and custodial sanctions were reduced. A summary of the key findings is presented in Table 1.

Source: Adapted from Naughton et al. (2020, p. 4)

Conclusion

Minister Zappone acknowledged the recognition that BSS had received within Ireland and internationally and thanked all agencies, statutory and non-statutory bodies, that were involved. Following the success of BSS in Dublin, in June 2020, the Minister provided funding to expand and extend the scheme to courts in Cork and Limerick.²

Ciara H Guiney

2  Department of Children, Equality, Disability, Integration and Youth (2020) Press release: Minister Zappone extends successful Bail Supervision Scheme. Available online at:
https://www.gov.ie/en/press-release/c0fb7-minister-zappone-extends-successful-bail-supervision-scheme/

Table 1: Key findings from BSS evaluation

Session 1

The topics addressed during session 1 covered a range of themes.

Theme 1: Role of the police

Delegates believed that the role of the police has evolved. Traditionally, policing has focused on detecting and prosecuting crime. However, more and more they respond to a wide range of social issues. For example, cases that centre on harm account for 80% of their workload. A possible explanation put forward is that An Garda Síochána is the only ‘first responder’ service available that can respond to a broad range of issues 24/7 (p. 7).

Theme 2: Public health and policing

Delegates acknowledged that public health and law enforcement overlapped. Many who experience problems with mental health, behaviour, or substance use may not receive or have access to suitable services. In consequence, these individuals may come into contact with the law or may be excluded, or may experience higher levels of adversity. It was noted that interventions can have negative and positive consequences. For example, there can be increased trauma for individuals instead of determining how challenges brought them into contact with the law in the first place. Principles that were viewed as important to community safety and first-response settings included using person-centred approaches, aimed at decreasing crime, stigmatisation, and traumatisation. These should be applied in the community, courts, and prison systems.

Theme 3: Need for meaningful partnerships

Meaningful partnerships that centred on ‘joint commitments, a shared vision and a shared understanding of goals’ (p. 8) were considered the most appropriate way to target community safety issues. The role carried out by police was acknowledged along with the challenges that arise in balancing interventions that provide support, while at the same time ensuring that individuals are accountable for their actions from the perspective of detecting and prosecuting crime. It was also acknowledged that establishing ‘a working multi-agency system takes time, commitment, flexibility, compromise, and good communication’ (p. 9).

Theme 4: Structural issues

The final theme that emerged centred on international and domestic structural issues that may act as a barrier to developing person-centred policy. One delegate noted that ‘drug policies in most countries of the world are not contributing to public health’ (p. 11). While the individual was deemed to be at the centre of any response, addressing drug use punitively via law enforcement has not been successful and often resulted in more harm to those that are disadvantaged. Despite this, drug policies globally have centred on a coercive approach. Moreover, the illicit drug market was identified as an area that created additional harms. Delegates noted that in order to focus on public health, the underlying assumptions that drug policies are centred on – namely, that ‘criminalisation is necessary, that (outside legitimate uses) a drug free world is possible or desirable’ (p. 11) – need to be critically examined and questioned. Other issues identified at a domestic level included structural challenges in service delivery; structural barriers that could restrict genuine partnership; and personality-led innovations. Attempts to overcome these issues depended on appropriate mandates being in place along with a commitment and shared understanding of how partnerships work.

Table 1: Relevant cross-cutting scenarios or issues for Ireland

Table 2: Questions addressed by working groups

Session 2

Session 2 consisted of plenary sessions and interactive workshops. The aim of this session was to provide delegates with an opportunity to investigate the difficulties of addressing issues of community safety by considering the challenges that communities are faced with. The session started with an overview of the Irish context and included participants reflecting on practical experience observations and government policy. Several areas were highlighted, including Ireland’s commitment to using a health-led and person-centred approach to drug use; ongoing development of policing services; and international attention for recent progressive policy developments. Table 1 illustrates the main issues identified.

With the aim of increasing understanding, motivations, roles, and potential intervention opportunities, four of the issues/scenarios identified in Table 1 were examined in more detail in breakout working groups (n=4). The main questions utilised to explore these issues are shown in Table 2.

Group 1: Organised crime

In the area of organised crime, more specifically the illicit drug market, delegates identified the key stakeholders involved. For example, the individual buying and taking drugs; local drug supplier; family of drug user; police; government; and community bodies. It was noted that while commonalities exist between stakeholders, for example community safety, there may also be competing objectives in terms of what should be prioritised.

Group 2: Mental health

The emphasis here was on dual diagnosis, where individuals presented with substance use disorder along with another mental health problem. The key stakeholders identified included the individual experiencing the dual diagnosis; their family or carers; health and social stakeholders involved in their care; and first responders to a crisis, which is often law enforcement officers. Delegates recognised that different roles occurred within these groups along with alternative beliefs regarding treatment. However, they believed that ultimately interventions should be centred on the needs and human rights of the individual. Challenges identified included inflexible current structures and ensuring consistent case management.

Group 3: Drug-related intimidation

Using a street-level intimidation scenario, delegates identified several stakeholders. For example, individuals with drug debt and their families; the dealer; other third parties, such as a middle person; and the police. It was mainly believed that stakeholders had diverging or overlapping motives. Delegates noted the complexity of drug-related intimidation and that roles are not always clear-cut. The main outcome desired was that all players – the person owing the debt, the dealer, and anyone else involved – leave the drug market. However, because of the illicit nature of the drug market, there is no legal remedy or way to resolve disputes that arise, which has resulted in intimidation being the only route to debt recovery. While this was not expected to change, delegates believed that interventions existed that could be helpful.

Group 4: Young offenders and life chances

The final group examined young offenders, specifically challenges in relation to repeat offending. The key stakeholders identified included the young person; their family or carer; their school; and broader community. Consistent with issues identified by delegates in other groups, it was noted that roles and motives differed within stakeholder groups. Issues were deemed complex; however, opportunities were also noted. For example, the importance of credible role models was discussed along with service orientation, where it was acknowledged that a ‘one size fits all’ (p. 16) approach was not likely to work. It was also noted that youth engagement was often centred on negative behaviour, ‘what the person wasn’t doing, or wasn’t doing right’ (p. 17). Focusing on relationships and building strong networks away from their education/social support system was deemed more effective.

While these four issues/scenarios were not the same, they did have themes in common: issues in community safety, public health, and law enforcement consistently emerged.

Conclusion

Concluding reflections reiterated and reinforced the themes that emerged throughout the day. In particular, it was noted that openness to partnership was necessary. It was acknowledged that an already recognised common goal for many agencies was working together. However, alongside State bodies and non-governmental organisations it is vital that the community participate in community safety. Interventions put forward need to be tailored to the needs of the individual using a human rights approach characterised by trust and commitment by stakeholders. For the system to work, it must be believed that improvements will occur in community safety and policing. For this to occur change is inevitable. The full implementation of recommendations by the Commission on the Future of Policing in Ireland are a vital step in initiating change along with stakeholder willingness to build meaningful partnerships.²

Ciara H Guiney

2  Commission on the Future of Policing in Ireland (2018) The future of policing in Ireland. Dublin: Commission on the Future of Policing in Ireland. Available online at: http://www.policereform.ie/en/POLREF/Pages/PB18000006

Substance use and mental health

Sharing the Vision recognises people who use drugs as a group for which tailored or additional work may be required to promote positive mental health and to build resilience. It is consistent with the national drugs strategy, Reducing Harm, Supporting Recovery, in recognising the ongoing challenges faced in addressing the needs of people with a dual diagnosis, that is, those who experience mental health problems alongside substance (drug and alcohol) misuse problems. Sharing the Vision removes the requirement in AVFC for mental health workers to establish that a mental health difficulty is ‘primary’ for an individual to access the support of a mental health team (p. 53).

However, the policy also acknowledges that being able to access ‘primary care addiction services and existing mental health supports when there is a co-existing mental health/addiction problem remains complicated’ (p. 53). It outlines and supports the approaches to meeting the needs of those with a dual diagnosis, as laid out in both the AVFC and Reducing Harm, Supporting Recovery. This includes the use of specialist multidisciplinary teams with clear pathways in and out of their service.

Unlike AVFC, Sharing the Vision includes an implementation roadmap with outcome indicators and allocates responsibility for delivery of the policy’s set of recommendations to relevant lead agencies. Improved delivery of services to meet the needs of those with a dual diagnosis are specifically addressed in this implementation map, where it is stated that ‘dedicated community-based Addiction Service Teams should be developed/enhanced with psychiatry input, as required, and improved access to mental health supports in the community should be provided to individuals with co-existing low-level mental health and addiction problems’ (p. 59). Those responsible for delivering on this action are primary care, the Health Service Executive, and the Department of Health via the local drug task forces (p. 99).

Lucy Dillon

2  Department of Health (2006) A Vision for Change: report of the Expert Group on Mental Health Policy. Dublin: Government of Ireland. https://www.drugsandalcohol.ie/6154/

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

Our understanding of the drug situation faces a different problem. The data systems that we depend on to provide detailed analysis of the nature of drug use and its consequences are, by necessity, slow to provide the information we need to observe trends, plan responses, and develop policy. In recent years, early warning systems, innovations such as wastewater analysis and open source media monitoring, and research developments like trendspotting have helped to make information more rapidly available.

The methodological advances complement rather than replace the information from prevalence studies and established treatment and harm-reduction information systems. In September 2020, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) published its annual European drug report, largely based on analysis of aggregated data from 29 countries in the European Union’s Reitox drug-monitoring network.¹ It also includes more recent information on the disruption caused by Covid-19 among support services to people who use drugs. There are discernible changes in patterns describing synthetic drug production and in the distribution routes used for the bulk supply of cocaine, heroin, and cannabis.

We have seen that Ireland and other countries responded quickly and were able to lessen the impact of Covid-19 on the most vulnerable populations. Important harm reductions lessons were learned. Security services also have faced new problems as restrictions forced those involved in drug distribution to develop new approaches to supply and create new markets as demand fell sharply, particularly in the night-time economy. The report identifies other important supply-related changes that predate the pandemic but may have accelerated over the last several months. It is clear from seizure figures that large quantities of cocaine are coming into Europe to meet an increasing demand. Also, analysis of drugs seized show that the purity of cocaine is rising, posing greater danger to public health. Cannabis too is increasing in potency and typically the levels of THC, the psychoactive part of cannabis, are double what they were 10 years ago.

The EMCDDA’s first report on aggregated estimates was the Annual report on the state of the drugs problem in the European Union 1995. So, this year marks 25 years of European-wide reporting on the drugs problem. As the agency’s scientific director explains, the evolution of the drugs problem during that time was accompanied by a dramatic increase in the quantity and quality of the information on this topic.² The European drug report presents an opportunity to compare the situation in Ireland with the rest of Europe.³ It also enables us to observe trends and patterns based on systematically collected and expertly analysed data. While each country has its idiosyncrasies, the cultural and demographic features determining drug-using behaviour are broadly similar. It is important that we keep this greater picture in mind when anticipating developments in our own context and planning responses to it.

1  European Monitoring Centre for Drugs and Drug Addiction (2020) European drug report 2020: trends and developments. Luxembourg: Publications Office of the European Union. https://www.drugsandalcohol.ie/33049/

2 Griffiths P (2020) Looking back on 25 years of annual reporting on the drugs problem in Europe. Lisbon: European Monitoring Centre for Drugs and Drug Addiction.https://www.emcdda.europa.eu/system/files/attachments/13265/Feature_article_EDR_25years_Final_web.pdf

3 Health Research Board (HRB) (2020) Health Research Board compares the Irish drug situation with the rest of Europe. Dublin: HRB.
https://www.hrb.ie/news/press-releases/

Methodology

The research used a qualitative study design, and data were collected through 22 semi-structured interviews and four focus groups during the period September 2018 to February 2019. Data collection consisted of individual semi-structured interviews with former and current users of crack cocaine, family support members, local community representatives, An Garda Síochána, and local treatment and rehabilitation service providers.

Findings

The main findings are discussed below.

Crack cocaine use and motivations for use

Among current crack users, 17 interviewees were polydrug users, and identified the use of heroin, alcohol, benzodiazepines and pregabalin along with their use of crack cocaine. The most widely used substance alongside crack cocaine was methadone. Thirteen (76.5%) of those interviewed were prescribed methadone and two (11.8%) had previously been prescribed methadone. Interviewees described several reasons for their use of crack cocaine. These reasons ranged from being introduced to it through their drug-using peer networks to a more deliberate decision-making process to help them forget about and escape other difficult life issues, and to enhance self-confidence.

Availability and accessibility

Research participants expressed their concerns in terms of the availability and visibility of both crack cocaine usage and dealing; the accessibility of crack through aggressive targeting and overt dealing; young people’s involvement in the crack cocaine market; and the role of environmental factors influencing the local crack cocaine market. In particular, the perceived increased availability of crack cocaine in the community was also identified by local service providers encountering and working with individuals who are using crack cocaine; by those engaged in broader community work; and by An Garda Síochána. The current availability of crack in the community was believed to have increased over the previous two years.

Physical and mental health

The two main physical health issues associated with crack cocaine use and experienced by interviewees were breathing problems and weight loss due to decreased appetite and desire to eat. Interviewees described the mental health consequences they experienced in connection with their crack cocaine use as being far greater than and more consequential than the physical health consequences experienced. Interviewees stated that they experienced confusion, depression, paranoia, and anxiety while using crack cocaine. They also discussed the self-harm and suicidal thoughts they experienced and which they directly attributed to their use of crack cocaine. Some interviewees described periods of time spent in mental health facilities as a direct consequence of the mental health issues they attributed to their use of crack cocaine.

Family and community impacts

Family members described being frightened in their homes as they experienced aggression and intimidation from their adult children. This aggression and intimidation were attributed to their adult children’s use of crack cocaine and their seeking of money for crack. The stigma associated with the use of cocaine was also experienced by family members of those using crack. Family members described their difficulty in accepting and acknowledging that a family member was using crack cocaine as they perceived this substance and its usage to be far worse than any other substance.

Community representatives and local service providers described the community’s concerns in relation to crack cocaine use. Participants described feeling frightened and intimidated by gangs, by the visible drug market, and by the evident crime and violence in the community. Overall, a sense of feeling unsafe within the community was expressed by many interviewees and research participants along with a heightened sense of risk to personal safety.

Responses and interventions

Service providers described the responses available within current service provision along with the prevailing challenges encountered in working with and providing a service to individuals who are using crack cocaine. Drop-in services, outreach – including street work and home visits – advocacy, one-to-one key working, and the distribution of food parcels were identified as core interventions and responses currently provided.

Crack pipe distribution was identified as a key intervention as both a tool for engagement and a harm reduction response. This intervention was implemented on foot of interagency discussions and the agreed need for an interagency approach to crack cocaine use in the community. Crack pipes are distributed on site in the Ballymun Youth Action Project and by the Health Service Executive (HSE) Addiction Service.

Conclusions

In light of the study findings, the report authors made a number of recommendations to support local crack cocaine policy and practice development. In particular, they recommend the establishment of a multiagency working group, including community representation, to develop and implement an action plan and that prioritisation be given to the following actions at both a local and national level:

• Accessible interventions: The lack of accessible crack-cocaine specific interventions emerged in the research. The need for early access to adequate crack cocaine services, including the provision of residential respite and stabilisation beds, is recommended.

• Mental health: Given the mental health consequences experienced by individuals using crack cocaine in this study and evidenced in previous studies, improved cooperation between drug services and mental health services is required. A local strategy responding to the dual diagnosis needs of individuals using crack cocaine is recommended.

• Outreach: Due to the chaotic nature of some crack cocaine use, the importance of outreach to individuals using crack cocaine is reinforced in this research. Building on existing local outreach services, the need for a more targeted and crack-cocaine specific outreach is recommended. This would include out-of-hours outreach and signposting to existing services.

• Basic needs: Given the personal adverse consequences experienced with crack cocaine use, the provision of services and interventions that respond to the physical and psychological wellbeing of individuals using crack cocaine, thus ensuring that basic needs such as food, light, heat, and primary healthcare are being met, is recommended. The potential role of contingency management should be considered further.

• Accommodation: Housing issues and hostile takeovers emerged as a key issue for individuals using crack cocaine. Building further on the existing interagency work that has taken place with regard to accommodation-related issues is recommended.

• Policing: Given the issues of fear, safety, and security which emerged in the research along with the increased availability of crack cocaine in the community, continued cross-agency and community engagement with An Garda Síochána is recommended.

1. O’Reilly L and Mac Cionnaith C (2019) Crack cocaine use in Ballymun: an evidence base for interventions. Dublin: Ballymun Youth Action Project.  https://www.drugsandalcohol.ie/31345/

European MSM internet survey

The European Men-Who-Have-Sex-With-Men Internet Survey-2017 (EMIS-2017) was part of ESTICOM (European Surveys and Training to Improve MSM Community Health) and funded by the European Commission Health Programme 2014–2020. The overall aim of EMIS-2017 was to generate data useful for the planning of HIV and sexually transmitted infection (STI) prevention and care programmes. EMIS-2017 was an online, behavioural surveillance survey designed to collect data from MSM living in 50 countries and included all 28 member states of the European Union. The EMIS-2017 study coordinators commissioned advertising on several dating platform apps that were used by MSM in each country. In Ireland, the EMIS-2017 survey was advertised on: PlanetRomeo, Grindr, Hornet, RECON, Scruff, Gaydar, Manhunt/Jack’d and GROWLr. Overall, 2,083 qualifying respondents were included in the Irish dataset and the results were recently published.³ The main findings regarding drug use among survey respondents are discussed below.

Results

Type of drug consumed

Participants were asked ‘When was the last time you consumed: cannabis (hashish, marijuana); synthetic cannabinoids; ecstasy; amphetamines; crystal meth; heroin or related drugs; mephedrone; synthetic stimulants other than mephedrone; ketamine; LSD; cocaine or crack cocaine?’ Overall, 41% of respondents used drugs in the last 12 months and 26% had used drugs in the last four weeks. The most commonly used drugs in the last 12 months were cannabis (34%), cocaine (20%), ecstasy pills (19%), and ecstasy powder (15%). In the last four weeks, cannabis and cocaine were used by 17% and 9% of respondents, respectively. Fewer than 1% of respondents indicated they had injected any drug to get high in the last 12 months and just over 1% of respondents had injected anabolic steroids in the last 12 months.

Injecting drugs

Of men who indicated they injected drugs to get high in the last 12 months (n=17), 59% had done so three times or less and three-quarters of men had done it five times or less. Crystal meth was used by 83% of men who injected drugs, followed by ketamine (18%). Among men who had injected to get high in the last 12 months (n=17), 29% had injected with a used needle or syringe.

Combining sex, drugs, and alcohol

Men who had sex with men in the last 12 months (n=1930) were asked ‘In the last 12 months, how much of the sex you’ve had with men has been under the influence of alcohol or any other drug?’ Over 45% indicated that they had some sex under the influence of alcohol or any other drug, while 12% said almost all or all sex was under the influence. Twenty per cent of all respondents had ever used stimulant drugs to make sex more intense or last longer and 14% had done so in the last 12 months. Stimulant drugs included in this definition were: ecstasy/MDMA, cocaine, amphetamine, crystal meth, mephedrone, and ketamine. Overall, 75% of men who had used stimulant drugs during sex in the last 12 months had experience of doing so with more than one partner at once, with 61% doing so in the last 12 months.

Conclusions

The authors noted that the prevalence of stimulant drug use among MSM during or before sex (ever) was higher in Ireland compared with the overall European prevalence (15%). Additionally, 72% of men who used stimulant drugs to make sex more intense or last longer had done so with more than one partner and this was also higher than the overall European proportion (66%). As chemsex has been associated with increased HIV and STI transmission, additional work is required to better understand chemsex and how best to mitigate the negative outcomes associated with it.

1  McCarty-Caplan D, Jantz I and Swartz J (2014) MSM and drug use: a latent class analysis of drug use and related sexual risk behaviors. AIDS Behav, 18(7): 1339–1351.

2  Tomkins A, Ahmad S, Cannon L, Higgins S, Kliner M, Kolyva A, et al. (2018) Prevalence of recreational drug use reported by men who have sex with men attending sexual health clinics in Manchester, UK. Int J STD AIDS, 29(4): 350–356.

3  Casey C, O’Donnell K, Brady M and Igoe D (2019) EMIS-2017 Ireland: findings from the European Men Who Have Sex With Men Internet Survey      (Ireland). Dublin: Health Protection Surveillance Centre. https://www.drugsandalcohol.ie/31180/

Key service user statistics

The SATU annual report collects key demographics on service users and service provision. Some 943 people attended these services in 2019. An additional two service users attended SATU in 2019 compared with 2018, representing a 1% increase of SATU attendance. This is the fifth consecutive year SATU attendance figures have increased. In 2019, some 93% of service users were female and the mean age of service users was 26 years.

Of the 943 reported incidents, 67% occurred indoors, with 21% in the assailant’s home and 21% in the victim’s home. Some 675 (62%) of 1,084 perpetrators were described as ‘stranger’ or ‘recent acquaintance’; 177 (17%) as ‘friend’ or ‘family member’; while 94 (9%) were described as an intimate (or ex-intimate) partner. Sixty-three per cent were referred to SATU by a member of An Garda Síochána and 16% were self-referrals.

Drug and alcohol use

The current report gathered statistics on service users’ drug and alcohol consumption. According to the findings, 422 (45%) had consumed more than six standard drinks, while 194 (21%) had consumed less than six standard drinks.² Some 242 (26%) had consumed no alcohol in the 24 hours prior to the incident. In relation to drug consumption, 684 (73%) had not taken any drugs, 143 (15%) had taken recreational drugs, and 22 (2%) had taken both recreational and prescription drugs in the 24 hours prior to the incident. Some 153 (16%) expressed concern that drugs (including alcohol) had been used to facilitate the sexual assault. According to data collected by the Rotunda Hospital SATU in Dublin, concern about drug-facilitated sexual assault has increased over the years, with 9% of service users expressing concern in 2017, 13% in 2018, and 20% in 2019.

Harm reduction and service improvement

To reduce the physical impact of sexual violence, all SATUs provide Chlamydia prophylaxis, hepatitis B vaccination, and risk assessment for HIV postexposure prophylaxis. In 2019, some 64% of service users received Chlamydia prophylaxis, 61% commenced a hepatitis B immunisation programme, and 10% began postexposure prophylaxis for HIV. SATUs offer sexually transmitted infection screening at the initial appointment or at a follow-up appointment. This offer was availed of by 75% (n=709) service users in 2019. SATUs cater for the psychological wellbeing of service users through the provision of psychological support workers. A total of 920 service users engaged with a psychological support worker during their initial SATU visit.

The SATU dedication to service development and improvement is illustrated in the launch, publication, and implementation of the Department of Health’s SATU Policy Review³ to improve SATU services across the country. This includes upgrades to SATU environments. Continued education and upskilling of staff ensures the highest standard of service delivery. SATUs are striving to provide a more holistic service to attendees by encouraging attendance at follow-up, using a text reminder service and by providing referrals to other services. This interagency collaboration has also seen SATUs receive increased referrals from other services. Requests for education of schools and universities reflect a growing interest in reducing the impact of sexual violence in society. Representatives from SATUs deliver this education, which includes debunking rape myths and tackling issues of consent.

The Central Statistics Office (CSO) is currently undertaking a nationwide prevalence survey on sexual violence in Ireland.⁴ This survey intends to reflect changes in prevalence rates since the last survey was conducted on sexual violence in 2002⁵ and to inform policy on sexual violence.

1  Eogan M (2020) National Sexual Assault Treatment Unit (SATU) annual report 2019. Dublin: National Sexual Assault Treatment Unit. https://www.drugsandalcohol.ie/32338/

2  One standard drink is a half-pint of beer, lager or stout (284 ml), a small glass of wine (100 ml) or a pub measure of spirits (35.5 ml).

3  Department of Health (2019) Department of Health policy review: Sexual Assault Treatment Units (SATUs). Dublin: Department of Health. Available online at: https://www.gov.ie/en/publication/e9ee89-department-of-health-policy-review-of-the-national-sexual-assault-tr/

4  Central Statistics Office (CSO) (2019) Press release: CSO to oversee new national survey on the prevalence of sexual violence in Ireland. Cork: CSO. Available online at: https://www.cso.ie/en/csolatestnewspressreleases/2019pressreleases/csotooverseenewnationalsurveyontheprevalence
ofsexualviolenceinireland/

5. McGee H, Garavan R, de Barra M, Byrne J and Conroy R (2002) The SAVI report: sexual abuse and violence in Ireland – a national study of Irish experiences, beliefs and attitudes concerning sexual violence. Dublin: Liffey Press.
https://www.drugsandalcohol.ie/3793/

Background and methods

The World Health Organization has set a goal to eliminate hepatitis C virus (HCV) as a global public health threat by 2030. Targets include reducing new HCV infections by 80%, the number of HCV deaths by 65%, and increasing HCV diagnoses from 20 to 90% and eligible people receiving HCV treatment from <5 to 80%.¹ Unsafe injecting drug use is the main route of HCV transmission in developed countries.² Consequently, people who inject drugs (PWID) in the general and prison population represent a priority population for HCV elimination, given the high prevalence and incidence in this group. However, the prevalence of HCV infection among PWID in Ireland remains poorly understood. A recent study aimed to map key previous findings and identify gaps in the literature (published and unpublished) on HCV infection in Irish PWID and prisoners.³

In this research, published in the BMC journal Infectious Diseases, a scoping review was carried out, guided by the methodological framework set out by Levac and colleagues (based on previous work by Arksey and O’Malley).^4,5

Results

Two 2014 studies identified from the grey literature reported on HCV infection in PWID attending methadone maintenance therapy (MMT) in drug clinics outside of Dublin and reported an anti-HCV prevalence of 24% (Horan A (2014): Chart audit of HCV screening measuring the effect of chart labelling, unpublished).⁶ A published 2017 study reported an anti-HCV prevalence of 63.6% among PWID attending MMT at a north Dublin inner-city treatment centre.⁷

Two large HCV screening audits in 2016 reported an anti-HCV prevalence of almost 80% and a chronic HCV prevalence of 65% among PWID attending MMT at 23 drug treatment clinics in Dublin (Burke M (2016): Audit of HCV screening using retrospective patient records, unpublished). The most recent prevalence study in PWID attending opioid substitution therapy in general practice in Ireland reported an anti-HCV prevalence of 77.2%.⁸

With regard to the prison population, a 2014 study conducted in 13 of the 15 prisons in the Republic of Ireland reported an anti-HCV prevalence of 13% (95% CI: 10.9–15.2%) among the general prison population, increasing to 41.5% in prisoners with a history of injecting drug use and 54% in those with a history of injecting heroin.⁹ Another prison study from 2014 (single site) reported an HCV prevalence of 37% among prisoners on MMT.¹⁰

Conclusions

The authors noted that only two studies reported on HCV prevalence in PWID outside of Dublin and both were from secondary urban centres. In addition, the majority of the prevalence studies were over a decade old and only reported on anti-HCV prevalence and not on HCV RNA prevalence, which limits their usefulness at estimating the levels of chronic untreated infection and reinfection. Finally, the most recent epidemiological studies included in the review were mostly chart review audits, which limit their usefulness in informing policy and strategy.

1  World Health Organization (WHO) (2017) Global hepatitis report 2017. Geneva: WHO. https://www.drugsandalcohol.ie/27177/

2  Nelson P, Mathers B, Cowie B, Hagan H, Des Jarlais D, Horyniak D, et al. (2011) Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet, 378(9791): 571–83. https://www.drugsandalcohol.ie/15845/

3  Crowley D, Murtagh R, Cullen W, Lambert JS, McHugh T and Van Hout MC (2019) Hepatitis C virus infection in Irish drug users and prisoners – a scoping review. BMC Infect Dis, 19(1): 702. https://www.drugsandalcohol.ie/31395/

4  Levac D, Colquhoun H and O’Brien KK (2010) Scoping studies: advancing the methodology. Implement Sci, 5: 69.

5  Arksey H and O’Malley L (2005) Scoping studies: towards a methodological framework. Int J Soc Res Methodol, 8: 19–32.

6  Ryan H and Ryan S (2014) Increasing incidence of hepatitis C among intravenous drug users in HSE Mid-West. NIHS Res Bull, 7(1): 32. https://www.drugsandalcohol.ie/22639/

7  Keegan D, Crowley D, Laird E and Van Hout MC (2017) Prevalence and risk factors for hepatitis C viral infection amongst a cohort of Irish drug users attending a drug treatment centre for agonist opioid treatment (AOT). Heroin Addict Relat Clin Probl, 19(1): 45–54. http://www.drugsandalcohol.ie/25815/

8  Murtagh R, Swan D, O’Connor E, McCombe G, Lambert JS, Avramovic G, et al. (2018) Hepatitis C prevalence and management among patients receiving opioid substitution treatment in general practice in Ireland: baseline data from a feasibility study. Interact J Med Res, 7(2): e10313. https://www.drugsandalcohol.ie/30874/

9  Drummond A, Codd M, Donnelly N, McCausland D, Mehegan J, Daly L, et al. (2014) Study on the prevalence of drug use, including intravenous drug use, and blood-borne viruses among the Irish prisoner population. Dublin: National Advisory Committee on Drugs and Alcohol. https://www.drugsandalcohol.ie/21750/

10 Galander T, Rosalim J, Betts-Symonds G and Scully M (2014) A survey of patients on methadone programmes in Wheatfield Prison, Dublin, Ireland. Heroin Addict Relat Clin Probl, 16(2): 17–22. https://www.drugsandalcohol.ie/23736/

Background and methods

Unsafe injecting drug use is the main route of hepatitis C virus (HCV) transmission in developed countries,¹ and it is generally acknowledged that people who inject drugs (PWID) and HCV infection are typically over-represented in prison populations across Europe.² A 2016 meta-analysis reported a prison HCV prevalence in Western Europe of 15.5%, with this prevalence increasing to over 40% among those prisoners with a history of injecting drug use (IDU).³ However, the prevalence of HCV infection among prisoners in Ireland remains poorly understood. In addition, most epidemiological studies among PWID and prisoners report on HCV antibody prevalence (exposure) and not the presence of HCV RNA. Thus, they do not differentiate between treated chronic infection with sustained viral response (SVR) and the 20–30% of HCV-infected people who spontaneously clear HCV without treatment. A recent study aimed to estimate the seroprevalence of untreated chronic HCV infection and to identify associated risk factors in an Irish male prison population.⁴

In this research, published in the journal Eurosurveillance, the authors conducted a cross-sectional study in Mountjoy Prison, Dublin involving a researcher-administered questionnaire, review of medical records, and HCV serology. All prisoners were offered screening for blood-borne viruses, including reflex RNA testing and genotyping.

Results

Of the 422 prisoners (78% of the study population) who participated in the study, 298 (70.6%) completed the questionnaire and 403 (95.5%) were tested for HCV antibodies. Of those tested, 92 (22.8%) were HCV antibody-positive. Of those antibody-positive, 53 (57.6%) were HCV RNA-positive; 23 (25%) had spontaneous clearance; 16 (17.4%) had a SVR; 10 (11%) were co-infected with HIV and 6 (6%) with hepatitis B virus. The untreated chronic HCV seroprevalence estimate was 13.1% and the seroprevalence of HCV among prisoners with a history of IDU was 79.7%.

Risk factors significantly associated with past HCV infection were IDU (p<0.0001); having received a prison tattoo (p<0.0001) or a non-sterile community tattoo (p<0.0001); and sharing needles and other drug-taking paraphernalia (p<0.0001). On multivariable analysis, history of receiving a non-sterile community tattoo was the only significant risk factor associated with HCV acquisition (after IDU was removed from the model) (p=0.005).

Conclusions

The authors concluded that the level of untreated chronic HCV infection in Irish prisons is high, with IDU being the main associated risk. The reporting of HCV infection in prisoners in this way is unique in both the Irish and international literature and allows for the estimation of the true levels of active HCV infection, the monitoring of treatment outcomes, and rates of reinfection. Identifying risk factors for HCV infection may allow for targeted prevention, screening, and treatment strategies. Combined, these may help to inform planning and implementation of national and international HCV strategies.

1  Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, et al. (2011) Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet, 378(9791): 571–583. https://www.drugsandalcohol.ie/15845/

2  Larney S, Kopinski H, Beckwith CG, Zaller ND, Jarlais DD, Hagan H, et al. (2013) Incidence and prevalence of hepatitis C in prisons and other closed settings: results of a systematic review and meta-analysis. Hepatology, 58(4): 1215–1224.

3  Dolan K, Wirtz AL, Moazen B, Ndeffo-Mbah M, Galvani A, Kinner SA, et al. (2016) Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees. Lancet, 388(10049): 1089–1102. https://www.drugsandalcohol.ie/25800/

4  Crowley D, Lambert JS, Betts-Symonds G, et al. (2019) The seroprevalence of untreated chronic hepatitis C virus (HCV) infection and associated risk factors in male Irish prisoners: a cross-sectional study, 2017. Euro Surveill, 24(14): 1800369. https://www.drugsandalcohol.ie/31182/

5  Cloverhill Visiting Committee (2020) Annual report 2018 from Cloverhill Visiting Committee to the Minister for Justice and Equality Charles Flanagan TD. Dublin: Department of Justice and Equality. https://www.drugsandalcohol.ie/32084/

6  Arbour Hill Visiting Committee (2020) Arbour Hill Prison Visiting Committee annual report 2018. Dublin: Department of Justice and Equality. https://www.drugsandalcohol.ie/32084/

7  Shelton Abbey Visiting Committee (2020) Visiting Committee annual report 2018: Shelton Abbey. Dublin: Department of Justice and Equality. https://www.drugsandalcohol.ie/32084/

Backgrounds and methods
 Unsafe injecting drug use is the main route of hepatitis C virus (HCV) transmission in developed countries.1 Consequently, people who inject drugs (PWID) in the general and prison population represent a priority population for HCV elimination, given the high prevalence and incidence in this group. The current national drugs strategy2 aims to reduce harms arising from substance misuse and to reduce the prevalence of blood-borne viruses among PWID through the expansion of needle exchange. In Ireland, this service is delivered in a number of ways, including fixed-site locations such as clinics or community pharmacies and novel interventions such as Backpacking Outreach programmes. However, in 2020, there is no needle exchange provision in Irish prisons. A recent study examined the views of six senior managers, employed as prison health staff and security management, in order to discover attitudes towards needle exchange provision within Irish prisons, as an element of prisoner health service provision in the context of wider service provision for drug users within the prison system.3

In this research, published in the Journal of Correctional Health Care, data were collected in Dublin, using face-to-face, non-standardised, semi-structured interviews in May 2014. They were thematically analysed using subjective narratives that were recorded and transcribed.

Results

Impact of changing dynamics of prison drug use
A majority of the participants agreed that in Ireland, as in other jurisdictions, drug use occurs in prisons. However, research participants claimed that at present there was minimal injecting drug use and needle sharing in Irish prisons and that needles were generally not found in searches. They also reported that there were no verbal reports or physical evidence of injecting drug use and that no significant incidents of needle sharing are emerging or recorded in the prison medical record system. It was asserted that drug culture in prison had shifted compared with 15 years ago. Research participants argued that the catalyst for this change away from an injecting drug use culture in Irish prisons was the availability and remarkable success of methadone maintenance as a treatment option for opiatedependent prisoners.

Operational and logistic issues and challenges
The expressed opposition to the introduction of needle exchange to the Irish prison system was not, however, solely attributable to new evidence that injecting drug use has declined significantly among the prison population. It was also linked to strong ideological conflict expressed by the participants. In particular, it was suggested that the introduction of needle exchange generally implies condoning prison drug use. Also, participants expressed the view that there was a high level of concern from prison staff members in relation to ‘perceived threat to own safety’ should needle exchange provision be introduced. The risks in question refer to assaults by prisoners on staff involving needles, similar conflict between prisoners, and accidental sharps injury from unsafe disposal of drug paraphernalia. All participants felt that the introduction of needle exchange provision would pose serious logistical and operational challenges. Furthermore, it was contended that prisoners who were likely to avail of needle exchange were those who were generally more ‘chaotic in their lives’. The majority of participants conceded that prisoners, like other citizens, have individual civil rights. However, it was argued that these rights were of necessity curtailed in the prison environment. Thus, it was assumed that if a prisoner was convicted, they were entitled to minimal consideration.

Needle exchange as a policy development
Although participants felt that the evidence supporting needle exchange provision has been quite convincing in prisons in other jurisdictions, it was suggested that injecting drug culture was more prevalent in the prison systems of these other countries and that such a harm reduction scheme was unnecessary in Ireland. In addition, it would be difficult to introduce needle exchange due to role conflict between the professional duties to the care of prisoners while in custody and implied obligations to prison administration. Furthermore, the introduction of needle exchange provision in Irish prisons would entail changes in legislation and institutional prison policy regulations. Participants also expressed doubt that the general public would accept the concept of needle exchange in Irish prisons, as drugs are not meant to be used there in the first place.

Conclusions
The authors noted that research participants were generally opposed to the introduction of prison needle exchange in Ireland, suggesting that injecting drug use within Irish prisons has declined and that making needles freely available to prisoners would make prisons riskier since these needles might be used as weapons against prison staff or other prisoners. However, the study authors also observed that opposition to prison needle exchange provision had a strong symbolic component. This was in the sense that to introduce this form of harm reduction to Irish prisons might be seen as condoning illicit drug use and sending out the ‘wrong message’ in relation to the criminal justice system’s approach to this matter

1 Nelson PK, Mathers BM, Cowie B, Hagan H, Jarlais DD, Horyniak D, et al. (2011) Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet, 378(9791): 571–583. https://www.drugsandalcohol.ie/15845/ 2 Department of Health (2017) Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017–2025. Department of Health, Dublin.  https://www.drugsandalcohol.ie/27603/ 3 Rosalim JP (2020) A senior management perspective on the policy debate of needle and syringe exchange program provision in Irish prisons. J Correct Health Care, 26(1): 27–35.  https://www.drugsandalcohol.ie/31593/

Mountjoy Prison, Dublin
In its report, the Mountjoy Visiting Committee2 noted that substance abuse and related activity is contributing to risk to both prisoners and staff, with a reported increase in intimidation, violence, and injury to physical and mental health. Practices and endeavours to disrupt the inflow of drugs need continued attention in the interests of both prisoners and staff. The committee also observed that a number of male prisoners enter the prison from conditions where physical, mental, and dental health may have been chronically neglected due to substance abuse and other circumstances. Consequently, it is likely that the most vulnerable individuals are falling through the gaps in community-based mental health services and are sentenced to imprisonment where mental health problems and the risk of self-harm may be intensified.

The lack of permanent posts in the treatment teams and the significant shortage of beds in a secure mental-health inpatient treatment unit were also noted as a cause of serious concern. The committee heard that prisoners regularly highlight their wish for drug addiction counselling and furthermore for a drugfree section in the prison following effective treatment. The committee stated that it is regrettable that some prisoners who successfully complete drug treatment regress while awaiting supportive accommodation in transition, or when they return to inadequate services in the community.

Dóchas Centre, Dublin
The Dóchas Visiting Committee noted in its report3 that they had received complaints about the presence of illicit drugs within Dóchas. Many women had told the committee that they are afraid to leave their rooms for fear of aggressive behaviour from prisoners under the influence of illicit drugs. The committee observed that this problem appeared to be growing and urged that all the necessary resources be used to tackle this serious development.

Wheatfield Prison, Dublin
The Wheatfield Place of Detention Visiting Committee’s report4 observed that the Wheatfield yards are large spaces. Although the yards are covered with netting in order to prevent drugs and objects being thrown over the perimeter wall, this continues to be a considerable difficulty for the authorities in Wheatfield Prison. The committee recommended that more netting and a solution to the security of the perimeter wall are essential to prevent illicit contraband entering the prison. The committee also noted that illicit drugs continue to be a serious and ongoing difficulty both for the prison authorities and also for prisoners and their families. Despite the best efforts of the authorities in Wheatfield Prison, scanners, sniffer dogs, X-ray and bags searches, and the perimeter wall being monitored daily, drugs continue to enter the prison.

Cloverhill Prison, Dublin
In its report, the Cloverhill Visiting Committee5 noted that the issue of drugs and security measures at Cloverhill remain a deep concern. In particular, drugs coming over the wall from boundaries outside the prison confines and over the netting continue to be a huge problem, given the increase in drugs from this source. The committee was informed that when prisoners retrieve some of these drugs, by climbing walls, it can lead to serious injury, with one hospitalisation in 2018. The committee was told that the problem is being addressed by prison authorities, with extensive building work being carried out to secure netting and any areas of the perimeter that allow access to prisoners.

Arbour Hill Prison, Dublin
The Arbour Hill Visiting Committee’s report6 noted that incidents relating to drugs within the prison remained exceptionally low in 2018, and complimented the prison management and staff on this matter. Arbour Hill remains fully committed to ensuring that the prison remains drug-free. All prisoners are fully aware that they are expected to be 100% drug-free and access to the prison’s facilities and services depend on this. Random drug testing is part of the day-to-day routine at the prison.

 Shelton Abbey Prison, Co. Wicklow
The Shelton Abbey Visiting Committee’s report7 noted that a full-time addiction counsellor was appointed in 2017, who is respected by offenders and noted as a trusted listener. A number of addiction-related programmes took place at Shelton Abbey during 2018.

1 Department of Justice and Equality (2020) Prison visiting committee annual reports 2018. Dublin: Department of Justice and Equality. Available online at:  http://www.justice.ie/en/JELR/Pages/Prison_Visiting_Committee_Annual_Reports_2018 2 Mountjoy Visiting Committee (2020) Annual report for 2018 to Minister for Justice and Equality Charles Flanagan TD from Mountjoy Visiting Committee. Dublin: Department of Justice and Equality. https://www.drugsandalcohol.ie/32084/ 3 Dóchas Visiting Committee (2020) 2018 Annual report Dóchas Visiting Committee. Dublin: Department of Justice and Equality. https://www.drugsandalcohol.ie/32084/ 4 Wheatfield Place of Detention Visiting Committee (2020) Visiting Committee 2018 annual report for Wheatfield Prison. Dublin: Department of Justice and Equality.  https://www.drugsandalcohol.ie/32084/

The services offered in Dublin are:

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

Nursing services

In Dublin, nursing services are provided on a drop-in basis. Services offered include blood-borne virus testing, wound care, and compression bandaging. ALDP also provides an in-reach nursing service to the residents of Crosscare Cedar House every Tuesday from 3.00 pm to 4.30 pm. In addition to providing nursing services on a daily basis, ALDP works in partnership with Safetynet Primary Care to provide a GP clinic every Friday between 11.30 am and 1.30 pm.

Mid-West region

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

Annual report

The ALDP annual report was published in 2019.¹ It noted that Dublin open access services provided help to 982 individuals in 2018, the majority of whom were homeless and many were polydrug users with mental and physical health problems; 151 individuals received key working and case management; 437 people attended treatment groups; and 538 individuals used the needle and syringe programme. ALDP also provided in-reach services to Mountjoy Prison, where 54 individuals attended groups run in this setting.

In the Mid-West, ALDP served a similar cohort of people: 281 people were registered with the service in 2018. Of these, 75 individuals accessed case management services and 129 people accessed the ALDP needle and syringe programme.

September 2018 saw the winding down of the Online and Digital Services team at ALDP. The team managed the Drugs.ie website, which had 1,754,779 visits from its inception to September 2018. During this period, the team also received 809 calls through the Live Helper chat service.

1. Ana Liffey Drug Project (2019) Ana Liffey Drug Project annual report 2018. Dublin: Ana Liffey Drug Project.
   https://www.drugsandalcohol.ie/31432/

Referrals

In 2019, AAS worked with 49 young people and their families, with a mean age of 15.3 years (range: 13–18 years). This figure includes new referrals, re-referrals, and continuances. The majority (90%) were male and 12% were non-Irish nationals. In terms of referral areas, the greatest numbers of referrals were from Clondalkin followed by Lucan, Ballyfermot, Palmerstown, and Inchicore.

Drug and alcohol use

Cannabis (weed) continued to be the main substance used by clients at 96%, while alcohol use was at 67% (see Figure 1). Other substances of use included cocaine (29%), benzodiazepines (28%), amphetamines (22%), and opiates (2%). Solvents and head-shop-type products did not feature among young people’s substance use in 2019. The report noted that the biggest change concerning secondary drug use related to increases in benzodiazepine use by 16% as well as the introduction of ‘eatables’, i.e. edibles. There were decreases in amphetamine use by 8% and cocaine by 7% compared with 2018.

Figure 1: Main substances used by AAS clients, 2019

Source: HSE AAS (2020)

Other issues

Other issues that presented related to absconding, indebtedness, and holding, distributing or dealing drugs. The service submitted child protection notifications and also held interagency meetings in relation to 10 young people. Of those who exited treatment, 62% had a planned discharge, 33% declined further treatment, and 5% moved out of the community or returned to the community of origin. The majority of young people (94%) were seen by a family therapist only, with 6% having a psychiatric assessment and 4% prescribed medication.

Conclusions

The report authors noted that, as in previous years, most young people had established patterns of substance use prior to referral and, as a consequence, some struggle to maintain a drug-free status. Nevertheless, most achieve stability and several remain abstinent. They concluded that there is a need for parents and non-parental adults to identify young people within risk groups at an early stage and to elevate concern for them.

1. Adolescent Addiction Service (2020) Adolescent Addiction Service report 2020. Dublin: Health Service Executive.
   https://www.drugsandalcohol.ie/31890/

National policing

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

National Criminal Intelligence Unit

The National Criminal Intelligence Unit (NCIU) works with national and local investigation units with the aim of finding, stopping, and dismantling organised crime groups. The main point of contact within NCIU is the National Criminal Intelligence Officer (NCIO). Its role is to provide other CIOs within AGS with information and intelligence on incidents as they arise.

Garda National Drugs and Organised Crime Bureau

Table 1 provides a breakdown of seizures relating to operations carried out by the Garda National Drugs and Organised Crime Bureau (GNDOCB) in 2018.

Operation Thor

Operation Thor, AGS’s national anti-burglary operation, commenced in November 2015. Between November 2015 and 31 December 2018, there were 9,200 arrests and 177,460 checkpoints. The incidence of burglary in residential (n=41,588) and non-residential (n=15,481) settings decreased by 35% and 23%, respectively.

Garda National Protective Services Bureau

The Garda National Protective Services Bureau (GNPSB) targets suspects involved in online child exploitation, child sexual abuse, and human trafficking. Operation Ketch, managed by the Online Child Exploitation Unit (OnCE), targeted suspects who possess, import, and supply child abuse material online. Overall, OnCE identified 137 targets in 137 searches under warrant. In 2018, some 56 children that were being exploited online were identified by the Victims Identification Unit. Human trafficking increased by 25% between 2017 (n=51) and 2018 (n=64).

GNPSB also works with agencies in the United Kingdom (UK) (e.g. National Crime Agency and North Wales Police) to identify bodies of individuals found on the west coast of the UK who may have been reported missing in Ireland. From its inception in January 2017 to 2018, comparative analysis utilising familial DNA resulted in 10 individuals being identified.

Garda National Cyber Crime Bureau

The Garda National Cyber Crime Bureau (GNCCB) assisted in several enquiries: child pornography (248 cases); theft and fraud (83 cases); child exploitation/grooming (31 cases); data retrieval (30 cases); and sexual assault/rape (19 cases). It provided technical support on several operations. For example, in Operation Myriad, which targeted organised crime groups involved in fraud, money laundering, and forgery, 50 exhibits were examined. Similarly, serious crime investigations were supported in forensic examination of exhibits related to murder, organised criminal gangs, missing persons, and terrorism.

Criminal Assets Bureau

In 2018, the Criminal Assets Bureau (CAB) targeted ‘lower level’ associates of major organised crime gangs with the aim of ‘disrupting’ their advancement within these organisations. The main crime categories focused on included:

• Robberies
• Stolen vehicles
• Sale and supply of controlled drugs
• Sale of encrypted devices
• International mail fraud scams
• Fuel and tobacco smuggling.

Table 1: Summary of seizures by GNDOCB

Source: AGS annual report, 2018, p. 7

* 59 relates to threat-to-life operations carried out since the murder of David Byrne at the Regency Hotel, Dublin on 5 February 2016. Included in the threat-to-life operations figure are Special Crime Task Force arrests as well as drug seizures and arrests from controlled delivery operations carried out in conjunction with Customs and Revenue Service.

Table 2: Actions taken by the security and intelligence section to keep Ireland safe

Source: AGS annual report, 2018, pp. 15–17

Operational support services

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

• GASU: In March 2018, GASU provided support to local fire services at a hotel fire in Ballymun, Dublin by providing live aerial pictures to personnel, enabling the identification of hotspots, secondary fires, and people who may be trapped.

• Garda Dog Unit: The unit carried out 1,648 searches in 2018 to find missing persons, drugs, firearms, explosive substances, and stolen property.

• Garda Mounted Unit: The aim of this unit is mainly crime prevention. It has provided high-visibility patrols as part of Operation Thor and covers public events, crowd control, and VIP protection.

• Garda Water Unit: In 2018, this unit recovered 10 bodies as part of humanitarian missing person searches.

National security and intelligence

Security and intelligence

The national security and intelligence section provides intelligence to units working to detect and examine threats to Ireland from terrorists and organised crime gangs. The threat level in 2018 was ‘moderate’, indicating that ‘an attack is possible but unlikely’ (p. 14). Table 2 provides an overview of some of the work carried out by this section.

Liaison and protection

Within AGS, the Garda Síochána Analysis Service evaluated national initiatives, such as Sex Offender Risk Assessment and Management (SORAM), and contributed to national strategies. In addition, AGS continued to work closely with agencies outside Ireland. Its activities included:

• Multiagency terrorism exercise: AGS tested response capabilities in the event of terrorist attacks in Operation Barracuda.
• Fixed Interpol Network Database (FIND): AGS can query information on stolen/lost travel paperwork 24/7. Between November 2016 and February 2019, some 23,976,128 checks were carried out on passengers arriving in Ireland by air and sea.
• Interpol European Regional Conference: This conference was hosted by AGS in Dublin; 229 delegates and observers attended.
• Europol: AGS supported several European Joint Action Days, such as cyberattacks, human trafficking, and cocaine trafficking. In addition, they contributed to Europol’s Organised Crime Threat Assessment, the Internet Organised Crime Threat Assessment, and reports on terrorism in the European Union.
• International Coordination Unit (ICU): AGS continued to manage the National Internal Security Fund Project, focusing on projects that prioritised policing and security.

Community safety

Community engagement is at the heart of the work of AGS. Several activities were carried out in 2018, such as crime prevention campaigns (e.g. burglary prevention, public assaults, online safety), Crimecall, Campus Watch, and the Joint Agency Response to Crime Conference.

Statistics

Incidents of sale and supply of drugs marked as detected

Figure 1 shows the number of sale and supply incidents detected between 2013 and 2018. Between 2013 and 2015, there was on average 311 incidents per month. Between 2016 and 2018, there was on average 285 incidents per month. The report states that the detection figures should be interpreted with caution as the PULSE system used to record detections was upgraded in February 2018. Hence, detections before and after the upgrade cannot be compared.

Garda-only drug seizures, 2018

Drug seizures are submitted to Forensic Science Ireland (FSI) for analysis. Overall, it was estimated that the value of drugs seized by Gardaí in 2018 was €30,696,694. As illustrated in Table 3, the most prominent drugs seized in Ireland with values greater than €1 million were cannabis herb, cocaine, cannabis plants, diamorphine, phenethylamines, benzodiazepines, and cannabis resin. While cannabis plants are ranked third, it is likely that this figure is higher, as not all plants are sent to FSI for analysis.

Conclusion

Garda Commissioner Drew Harris acknowledged the ‘dedication and determination of Garda members, staff and reserves to keeping people safe’ (p. 2). Evidence of this work is seen throughout the report, from significant drug seizures, reductions in burglaries, education initiatives on shielding themselves from crime to positive engagements with communities across Ireland (p. 3).

Commissioner Harris stated that the main goal of AGS is the keep people safe. This can be achieved by delivering an ‘efficient, effective and ethical police and security service’ (p. 3). He acknowledged that significant advances were made to achieve this goal in 2018 and is confident that the provision of services to the public and the State by AGS will progress further in 2019 (p. 3).

Figure 1: Detected incidents of sale and supply of drugs

Source: Operational PULSE data ICCS types: 1011, 1012, 1021, AGS annual report, 2018, p. 45

Table 3: Garda drug seizures, 2018

Source: AGS annual report, 2018, p. 49

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

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

1  An Garda Síochána (2019) An Garda Síochána: annual report 2018. Dublin: An Garda Síochána. https://www.drugsandalcohol.ie/32192/

2  An Garda Síochána Strategic Planning Unit (2018) An Garda Síochána annual policing plan, 2018. Dublin: An Garda Síochána. https://www.drugsandalcohol.ie/29169/

3  Guiney CH (2018) An Garda Síochána policing plan 2018. Drugnet Ireland, 67 (Autumn): 20–21. https://www.drugsandalcohol.ie/29934/

Recent publications

Mongan D, Millar SR, O’Dwyer C, Long J and Galvin B (2020) BMJ Open, 10(7): e034520.
https://www.drugsandalcohol.ie/32429/

The aim of this study was to determine awareness of drinking pattern in an Irish population using a representative random sample and to identify characteristics associated with self-awareness of hazardous or harmful drinking.

The results of this study suggest that patterns of alcohol use in Ireland are problematic. Older respondents and those with lower educational attainment are less likely to be aware of their hazardous or harmful drinking pattern. There is also a population of younger, more-educated drinkers who engage in potentially risk-taking behaviours and these subjects are aware of their harmful drinking pattern. Initiatives to reduce overall alcohol consumption and raise awareness around drinking patterns are required.

Crowley D and Delargy I (2020) Harm Reduction Journal, 17: 49.
https://www.drugsandalcohol.ie/32420/

In response to Covid-19, healthcare is increasingly being delivered by telephone and video consultation, and this report describes the development of a national model of remote care to eliminate waiting lists and increase access to OAT [opioid agonist treatment] in Ireland.

The development of a remote model of healthcare delivery allows for the reduction in transmission risks associated with Covid-19, increases access to OAT, reduces waiting times and minimises barriers to services. An evaluation of this model is ongoing and will be reported once completed. Fast adaptation of OAT delivery is critical to ensure access to and continuity of service delivery and minimise risk to our staff, patients and community. Innovative models of remote healthcare delivery adapted during the Covid-19 crisis may inform and have important benefits to our health system into the future.

O’Connor AM, Cousins G, Durand L, Barry J and Boland F (2020) PLoS ONE, 15(5): e0232086.
https://www.drugsandalcohol.ie/32009/

This systematic review aims to identify both protective factors supporting retention in OST [opioid substitution treatment], and risk factors for treatment dropout.

Younger age, substance use, particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT [methadone maintenance treatment] appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.

Cully G, Leahy D, Shiely F and Arensman E (2020) Archives of Suicide Research, Early online.
https://www.drugsandalcohol.ie/32267/

This study addressed the experiences of engaging with healthcare services following a self-harm presentation to hospital of high lethality or high suicidal intent by documenting patients' experiences.

Our findings show that satisfaction with services, help-seeking and treatment adherence may be improved by ensuring the consistent provision of timely, comprehensive and supportive aftercare following a HRSH [high-risk self-harm] presentation. Absence of these aspects of care may contribute to ongoing distress and further suicidal behavior.

Vaughan E, Power M and Sixsmith J (2020) AIDS Care, 32(9): 1162–1167.
https://www.drugsandalcohol.ie/32237/

This study examined the stigma experiences in healthcare settings of people living with HIV (PLHIV) in Ireland.

The findings indicate experiences of enacted, anticipated and internalised stigma were common. A further finding of spatial stigma was also uncovered. Analysis showed these experiences impacted participants' engagement with care and affected health-seeking behaviours and treatment adherence. The results suggest stigma experienced in healthcare settings may impact negatively on health outcomes.

Crowley D and Cullen W (2020) Heroin Addiction and Related Clinical Problems, Early online.
https://www.drugsandalcohol.ie/32214/

This study aims to describe and discuss the associated evidence for the measures implemented to reduce the risks associated with COVID-19 to Irish OAT [opioid agonist treatment] services.

Irish OAT services have implemented the following measures: reduced supervision requirements, increased the use of virtual patient care, streamlined assessment and induction processes to remove barriers to OAT access, provided home delivery of medications, increased access to naloxone and overdose programmes, targeted health and social interventions for the homeless and reduced our prison population. For now, non-essential services including drug and blood-borne virus screening and hepatitis C treatment have been postponed. Planning and review of Irish OAT services is ongoing so that further adaptations can be implemented as challenges emerge.

Clarke M, Devlin J, Conroy E, Kelly E and Sturup-Toft S (2020) Journal of Public Health, 42(3): 519–524.
https://www.drugsandalcohol.ie/32262/

This paper describes the approach to contact tracing taken by the Irish Prison Service (IPS).

A partnership approach with development of prison-led CTTs [contact tracing teams] can provide an effective mechanism for contact tracing of COVID-19 cases within the prison setting.

Hayden JC and Parkin R (2020) Irish Journal of Psychological Medicine, 37(3): 198–203.
https://www.drugsandalcohol.ie/32165/

This article reviews the pandemic-related challenges and responses by pharmacists, as well as forming recommendation for areas of professional support and role expansion, particularly in the case of mental health.

D’Sa S, Foley D, Hannon J, Strashun S, Murphy A-M and O’Gorman C (2020) Irish Journal of Medical Science, Early online.
https://www.drugsandalcohol.ie/32150/

Our aim was to evaluate current knowledge on the psychological impact of homelessness in children. Using the PRISMA model, we performed a review of the currently available literature on the psychological impact of homelessness on children.

Our study highlights violence, aggression and poor academic learning outcomes to be just some of the key findings in our review of homelessness in childhood, worldwide. Unfortunately, there has been minimum research to date on paediatric homelessness within the context of the Irish population. We anticipate this review to be the first chapter in a multipart series investigation to evaluate the psychological morbidity of paediatric homelessness within the Irish society.

Griffin E, Kavalivdou K, Bonner B, O’Hagan D and Corcoran P (2020) EClinicalMedicine, 23: 100378.
https://www.drugsandalcohol.ie/32147/

The aim of this study was to establish the risk of repeat presentation to hospital following suicidal ideation and to identify factors which were associated with further ideation or subsequent self-harm.

During the period April 2014 to March 2019, a total of 14,695 presentations to hospital due to suicidal ideation were made in Northern Ireland. The cumulative incidence of repeat presentation to hospital was 40.5% within five years, with an 18.3% risk of subsequent self-harm. Previous ideation had the strongest association with repeat presentation. There was evidence of recidivism considering further ideation, with an increased risk according to number of previous presentations. In contrast, risk of subsequent self-harm was highest after the first or second presentation. Male gender and alcohol were associated with further ideation, while females and young people were more likely to re-present with self-harm.

Leão T, Perelman J, Clancy L, Mlinarić M, Kinnunen JM, Nuyts PAW, et al. (2020) Nicotine & Tobacco Research, 22(7): 1202–1209.
https://www.drugsandalcohol.ie/32240/

We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal.

All five policies were highly cost-effective in all countries according to the World Health Organization thresholds for public health interventions. Cost-effectiveness was preserved even when using the highest costs and most conservative effectiveness estimates.

O’Sullivan B, Scully P, Curtin RJ and Plant BJ (2020) QJM: An International Journal of Medicine, Early online.
https://www.drugsandalcohol.ie/32239/

We aimed to ascertain the prevalence of tobacco consumption in a sporting population. We also endeavoured to quantify the use of e-cigarettes and assess exposure to passive smoking.

The prevalence of smoking in our study population was higher than other literature reports. Further studies are essential to evaluate the potential negative effects this may be having on sporting performance, career progression and indeed injury occurrence/rehabilitation. It is imperative to address the matter of smoking in athletes, not only for public health concerns but also considering they are important role models in our society.

Vallance K, Vincent A, Schoueri-Mychasiw N, Stockwell T, Hammond D, Greenfield TK, et al. (2020) Journal of Studies on Alcohol and Drugs, 81(2): 273–283.
https://www.drugsandalcohol.ie/32152/

The purpose of this study was to examine the framing of news coverage of alcohol warning label (AWL) initiatives that included a cancer message on alcohol containers in two different countries. Policy contexts and industry perspectives were also evaluated.

News coverage of AWLs with a cancer message was more supportive in Canada than Ireland, where alcohol industry perspectives were consistently foregrounded. Industry arguments opposing the cancer label bore similarities across contexts, often distorting or denying the evidence. Increasing awareness of industry messaging strategies may generate more critical coverage of industry lobbying activities and increase public support for alcohol policies.

Columb D, Hussain R and O’Gara C (2020) Irish Journal of Psychological Medicine, 37(3): 164–168.
https://www.drugsandalcohol.ie/32062/

The COVID-19 pandemic has undoubtably had a major impact on the provision of physical healthcare in Ireland and worldwide. The mental health impact of this pandemic cannot be underestimated, particularly relating to patients suffering with addiction. Heightened public stress and anxiety levels, increasing isolation and the physical consequences of addiction play a large role in the proliferation and ongoing relapse of substance misuse and behavioural addiction. Service provision is an ongoing challenge due to the increasing need for services given the increased mental health burden of COVID-19 but also the restrictions in place in clinical areas to achieve social distancing. The necessary adaptations to service provision provide opportunities for the analysis of current processes used in our addiction unit and the introduction of new processes to our service. The current crisis tests the sustainability of the service to provide the high standard of care required for these patients.

Mitchell JM, Jeffri FJ, Maher GM, Khashan AS and McCarthy FP (2020) Journal of Affective Disorders, 269: 94–100.
https://www.drugsandalcohol.ie/32011/

The aim of the study was to investigate the relationship between prenatal maternal alcohol consumption and the risk of attention deficit hyperactivity disorder (ADHD), the strengths and difficulties questionnaire (SDQ) score and abnormal hyperactivity score in seven-year-old children.

Light, moderate or heavy antenatal alcohol consumption was not associated with an increased susceptibility to ADHD or behavioural outcomes in this study. However, due to the limited number of cases we cannot rule out an increased risk of ADHD in relation to heavy alcohol consumption.

Keogh B, Brady AM, Downes C, Doyle L, Higgins A and McCann T (2020) Issues in Mental Health Nursing, 41(9): 799–806.
https://www.drugsandalcohol.ie/32010/

A Traveller Mental Health Liaison Nurse (TMHLN) was introduced in one health care region in Ireland to provide support for Travellers and increase their access to mental health services. The aim of this paper is to present the findings from an evaluation which explored Travellers' access to and reasons for accessing the TMHLN, the interventions provided and their experiences of and perceptions of the role of the TMHLN.

The findings highlight how the interpersonal skills associated with mental health nursing set against recovery orientated and culturally congruent practices are suitable approaches when working with Travellers.

Founta O, Adamzik K, Tobin A-M, Kirby B and Hevey D (2019) Journal of Clinical Psychology in Medical Settings, 26(2): 200–219.
https://www.drugsandalcohol.ie/31944/

This study investigates (a) the prevalence of psychological distress, alexithymia and alcohol misuse in psoriasis patients; and (b) the relationship between psoriasis severity, alexithymia, alcohol and psychological distress in patients with psoriasis.

Alexithymia was associated with anxiety, depression and worry; subjective psoriasis severity was associated with worry. Alcohol misuse was related to anxiety and worry, but not to depression. Appropriate identification and treatment of alcohol difficulties and psychological distress of patients with psoriasis is needed.

Columb D, Wong MC, O’Mahony V, Harrington C, Griffiths MD and O’Gara C (2020) Irish Journal of Psychological Medicine, Early online.
https://www.drugsandalcohol.ie/32390/

The aim of the present study was to analyze gambling advertisements shown during live sporting events broadcast in Ireland and to assess these advertisements for responsible gambling (RG) practices.

Gambling advertisements are commonly shown during live televised sporting broadcasts in Ireland, especially during live football matches and typically before the adult television watershed. Gambling legislation is required to minimize harm to vulnerable groups including children

Leahy D, Larkin C, Leahy D, et al. (2020) Social Psychiatry and Psychiatric Epidemiology, 55: 1525–1533.
https://www.drugsandalcohol.ie/32384/

There is limited research on the associations between factors relating to mental and physical health in people who died by suicide.

Different factors associated with suicide were identified among people with mental and physical illness and those with and without a diagnosis, and need to be taken into account in suicide prevention. The identified factors highlight the importance of integrated care for dual-diagnosis presentations, restricting access to means, and early recognition and intervention for people with high-risk self-harm.

Hayden JC, Kelly L and McNicholas F (2020) Acta Paediatrica, 109(11): 2237–2242.
https://www.drugsandalcohol.ie/32236/

Deliberate self-poisoning or overdose is a common presentation to the paediatric emergency departments (ED) due to a lack of emergency access to child and adolescent mental health services. We overview medical and psychiatric assessment of overdoses in youth with the most commonly implicated drug, paracetamol, as a case study.

Given the importance of timely assessment and treatment, paediatric emergency staff need to be familiar with the protocol for care. Attention needs to be focused on both the medical and psychological risk, and staff need to consider the reasons behind the overdose, and following a biopsychosocial assessment, ensure that the young person and family are adequately signposted for future mental health care if needed.

Costa C, Ismail M, Stevenson D, Gibson B, Webb R and Bailey M (2020) Journal of Analytical Toxicology, 44(3): 218–225.
https://www.drugsandalcohol.ie/31930/

Fingerprints have been proposed as a promising new matrix for drug testing. In previous work it has been shown that a fingerprint can be used to distinguish between drug users and nonusers. Herein, we look at the possibility of using a fingerprint to distinguish between dermal contact and administration of heroin.

This research highlights the importance of washing hands prior to donating a fingerprint sample to distinguish recent contact with heroin from heroin use.

Melia R, Francis K, Hickey E, et al. (2020) JMIR mHealth and uHealth, 8(1): e12516.
https://www.drugsandalcohol.ie/32322/

This review aimed to examine the effectiveness of currently available mobile health (mHealth) technology tools in reducing suicide-specific outcomes.

The small number of studies reported in this review tentatively indicate that such tools may have a positive impact on suicide-specific outcomes. Future mHealth intervention evaluations would benefit from addressing the following 3 main methodological limitations: (1) heterogeneity of outcomes: a lack of standardized measurement of suicide outcomes across studies; (2) ecological validity: the tendency to exclude potential participants because of the elevated suicide risk may reduce generalizability within clinical settings; and (3) app regulation and definition: the lack of a standardized classification system for mHealth intervention type points to the need for better definition of the scope of such technologies to promote safe practice.

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

Managing editor:    Brian Galvin
Copy-editing:          O’Hanlon Media

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Housing response

People experiencing homelessness were identified as a vulnerable group when the Covid-19 pandemic reached Dublin. Protocols for identification and immediate testing for people in this group were developed and implemented. Accommodation was provided to allow suspected and positive cases to isolate, as well as those deemed vulnerable due to age or medical condition. The report argues that this resulted in much lower than expected Covid-19 infection and mortality rates. Seven hundred and fifty clients were tested, of whom 63 tested positive. One person died. Dr Austin Carroll is one author of the report and the Covid-19 clinical lead for homelessness in Dublin. His team carried out projections on the number of expected fatalities using a data projection programme developed in the United Kingdom and adjusted for Ireland.² It indicates that the policy response, combined with the quick and dedicated response of services and their staff, contributed to a much lower than expected mortality figure (see Figure 1).

Drug policy changes

In addition to meeting the testing and housing needs of this group, policy changes were made that improved access to three harm reduction interventions for those who were using drugs. These were opiate substitution therapy (OST); naloxone; and benzodiazepine (BZD) maintenance, which are outlined below.

Opiate substitution therapy: There were two key changes in the area of OST – one related to accessing a programme, the other to the dispensing of methadone. National contingency guidelines were issued, allowing for reduced waiting times and removal of caps on recruitment to OST at the two clinics that provide treatment for this group (National Drug Treatment Centre and GMQ Medical).³ These new guidelines resulted in the waiting times for treatment at one service provider (GMQ Medical) being reduced from 12–14 weeks to 2–3 days. Access was further improved by other treatment clinics agreeing to take on homeless patients who were resident in their catchment areas. Supervision guidelines were also amended. Staff at relevant agencies were allowed to collect clients’ OST medications and deliver them to the client’s accommodation. This supported clients who were self-isolating.

Naloxone: Access pathways to the opioid antagonist naloxone were relaxed in response to the Covid-19 crisis through the national contingency guidelines.³ The new guidelines recommend that everyone in receipt of OST should be offered and encouraged to take a supply of naloxone. It was to be administered by a person trained in its use and the injectable product used instead of the intranasal product. Access was then extended to those most at risk of overdose in the evolving situation, and packs were distributed to those using a needle and syringe programme by Ana Liffey Drug Project. The requirement for a prescription to be issued by a general practitioner to the client by name could be met retrospectively.

Figure 1: Mortality from Covid-19 homeless sector

Source: Carroll et al. (2020), p. 4

Benzodiazepine maintenance: In Ireland, the focus of national guidelines for the treatment of BZD use is detoxification, not maintenance.⁴ However, in response to the pandemic, national contingency guidelines were published, which recommended that isolating clients of treatment services could be offered up to 30 mg daily to prevent withdrawals for the period of isolation. O’Carroll et al. note that this was extended by those working in the homeless sector to those who were shielding (p. 7) and to all those on OST with established BZD dependency in one service (GMQ Medical). As with OST medications, service providers were able to deliver medications to clients in their accommodation.

Call to sustain the changes

In their conclusion, the authors note that the key element of the first two of these policy changes (the removal of barriers to rapid access to OST and naloxone) resulted in the implementation of existing national policy, which they argue raises the question as to why barriers existed prior to the pandemic. They also argue that prior to and independent of Covid-19 there was a ‘strong public health argument for having no waiting lists for OST and improved naloxone distribution to PWUD [people who use drugs]’ (p. 9).

The authors describe the pandemic as having ‘acted as a catalyst for changes in the delivery of harm reduction measures to homeless PWUD’ (p. 10). They recommend that ‘practices continue to deliver on OST and naloxone policy objectives and that policy makers review the evidence on BZD maintenance treatment’ (p. 10). In conclusion, they view the Covid-19 experience as a ‘potentially important milestone in the development of national drug policies’ (p. 10).

Conclusion

As mentioned, the report’s authors recommend that the policy changes made in response to Covid-19 be maintained in the post-Covid era. While there is no reference to BZD use, the June 2020 Programme for Government: our shared future⁵ offers a commitment to elements of the other two policy changes:

• To retain the specific actions taken to support increased and improved access to opioid substitution services during Covid-19,
  so that pre Covid waiting times in accessing these services are reduced.
• To support the rollout of access to and training in opioid antidotes.

1  O’Carroll A, Duffin T and Collins J (2020) Saving lives in the time of COVID-19: case study of harm reduction, homelessness and drug use in Dublin, Ireland. London: London School of Economics and Political Science. https://www.drugsandalcohol.ie/32291/

2  The data projection programme was devised for the homeless population in London by Prof Al Story and Prof Andrew Hayward of University College London.

3  Health Service Executive (HSE) National Social Inclusion Office (2020) Guidance on contingency planning for people who use drugs and COVID-19. Dublin: HSE.
https://www.drugsandalcohol.ie/31804/

4  Health Service Executive (2016) Clinical guidelines for opioid substitution therapy. Dublin: HSE.
https://www.drugsandalcohol.ie/26573/

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

Introduction

In response to the Covid-19 pandemic, the Irish Government implemented unprecedented measures restricting the movements, activities, and social contacts of the population. These restrictions, which came into effect on 12 March 2020, have greatly disrupted people’s lives, with many unable to pursue their usual occupational, educational, social, and recreational goals, or to access healthcare as before. Health professionals have raised concerns about the possible public health impacts, including changes in levels and patterns of alcohol use associated with increased stress and anxiety, as well as social isolation, loneliness, and boredom.^1,2,3 These predictions are supported by data from a recent Central Statistics Office (CSO) survey, in which 22.2% of respondents reported increasing their alcohol consumption since the introduction of restrictions.⁴

Alcohol-dependent persons and those who may develop harmful patterns of alcohol use are at risk under the restrictive conditions.^1,3 Persons already in treatment or recovery risk relapse as a result of increased stress and decreased access to the usual supports, such as Alcoholics Anonymous.^2,3 With physical distancing restrictions and pressures on health services due to Covid-19, people may experience a delay in accessing care or may delay contact with services due to fear, with potential longer-term health impacts and increased pressure on services.

While some persons with alcohol dependency will require inpatient or other residential detoxification, others can safely detoxify at home with appropriate supervision and support.^5,6 The Health Service Executive (HSE), in line with 2011 National Institute for Health and Clinical Excellence (NICE) principles, issued guidelines recommending community-based assisted withdrawal where possible for persons presenting with alcohol withdrawal symptoms during the crisis.^7,8 Community alcohol detoxification (CAD) programmes aim to provide safe and controlled withdrawal in the community for persons who are alcohol dependent.^9,10 For persons with mild-to-moderate alcohol dependency, the community is considered a safe, successful, and cost-effective setting in which to reduce alcohol use and associated harms.^5,6

Covid-19 has challenged treatment providers to ensure continuity of services in an environment that is safe for service users and the staff who support them. Doing so has required timely adaptation and innovation on behalf of providers. The impact of Covid-19 on a CAD programme in the northeast of Ireland is described below.

Turas CAD programme

Based in Dundalk, Turas (meaning journey) has been providing a CAD programme since 2011. The CAD process includes motivational support, medical detoxification, relapse prevention, and counselling, followed by SMART Recovery for those who wish to avail of it. A key feature of CAD is the provision of individually tailored programmes with wraparound supports, which are provided while enabling the individual to maintain education, work, and family responsibilities. Another key feature is that CAD requires a support person, usually a family member or friend, whose role is to support the detoxification client through withdrawal at home. Access to the programme starts with a general practitioner referral and acceptance is based on medical assessment. Turas CAD is provided by two project workers; a clinical manager; a counsellor; and a specialist detoxification nurse, who manages the programme with general practitioner oversight. Approximately 40 persons complete the CAD programme with medical detoxification annually.

Impact of Covid-19 on service provision

Like other frontline providers, Turas has had to reconfigure itself in order to continue delivering its services, including CAD, throughout the crisis. Manager Nicki Jordan explained that following the closure of the offices on 12 March, the aim was to provide an effective and successful programme remotely, with staff and client safety to the fore. Face-to-face sessions were replaced with telephone, video, ‘walk-and-talk’, and ‘car-to-car’ meetings, where possible. Physical distancing meant group-based interventions could not be continued; instead, meetings were held using video conferencing. With distancing, it was not possible for CAD nurse Patricia Kelly to carry out baseline observations, breathalyser checks, haematology screening, and BMI checks as before. Instead, additional assessment tools were incorporated and carried out by telephone where relevant, with greater reliance on the client’s own general practitioner to ascertain the client’s physical health needs.

With reduced access to the usual social outlets and distractions, loneliness and boredom have increased among clients. In some cases, mental health issues have emerged or intensified. In response, the programme is focusing more intensely on the client’s self-care and on structuring, planning, and relaxation. Daily online meditation has been added to the programme, and resources have been updated to include distraction exercises and videos on topics such as relapse prevention and anxiety management. Where possible, clients are linked to online peer-to-peer support meetings. Kelly explained that some clients have little or no social contact outside of CAD staff and that these clients expressed genuine relief that the service remained open, albeit remotely. Staff have been proactive in contacting past clients at risk of relapse and placed a notice in the newspaper to communicate that services are available. A significant challenge, however, has been the reduced access to other treatment and aftercare services, mental health services, and beds in residential services. Also, in some instances, clients have refused to attend for emergency medical treatment due to fear of Covid-19.

Over the period, the number of clients remained stable or increased across Turas programmes. From a staff perspective, working in a more diverse and flexible way has been key to maintaining the service and client engagement. For staff, Covid-19 protocols, extended operational hours, and more frequent team meetings have meant that self-care has been more important than ever.

There is a lack of published research to inform CAD via remote delivery. Staff plan to undertake an evaluation to determine which adaptations and processes have been effective and for whom. While teleworking has worked well with some clients, it is less suitable for others, such as those without the necessary technologies and some clients for whom English is not a first language. Going forward, Turas is likely to provide a blended approach for clients to complement existing services. Although this will not suit everyone, it will work effectively for some, including clients who do not need face-to-face contact or who experience transport barriers in accessing the service.

Conclusion

Measures to control Covid-19 have implications for public health, the provision of services, and targeting of support within public health guidelines. SARS-CoV-2 continues to circulate, while the full impact on alcohol use, alcohol-related harm, and service delivery is not yet known. Research is needed to address the impact of Covid-19 on those at risk of harmful drinking and those already dependent. It should also aim to identify best practice in service delivery through remote and blended approaches.

1  Clay JM and Parker MO (2020) Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis? Lancet Public Health, 5(5): e259.

2  Columb D, Hussain R and O’Gara C (2020) Addiction psychiatry and COVID-19: impact on patients and service provision. Ir J Psychol Med, 37(3): 164–168.https://www.drugsandalcohol.ie/32062/

3  Drinking alone: COVID-19, lockdown, and alcohol-related harm [editorial] (2020) Lancet Gastroenterol Hepatol, 5(7): 625.

4  Central Statistics Office (CSO) (2020) Social impact of COVID-19 survey April 2020. Cork: CSO. https://www.drugsandalcohol.ie/31956/

5  Davis C (2018) Home detox – supporting patients to overcome alcohol addiction. Aust Prescr, 41(6): 180–182.

6  Nadkarni A, Endsley P, Bhatia U, et al. (2017) Community detoxification for alcohol dependence: a systematic review.
Drug Alcohol Rev, 36(3): 389–399.

7  Health Service Executive (2020) Guidance on contingency planning for people who use drugs and COVID-19. Dublin: Health Service Executive. https://www.drugsandalcohol.ie/31804/

8  National Institute for Health and Clinical Excellence (NICE) (2011) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. National Clinical Practice Guideline 115. London: NICE. https://www.drugsandalcohol.ie/14743/

9  Mannix M (2006) Drug and alcohol detoxification services: a needs assessment for Cork and Kerry 2015. Cork: Department of Public Health and HSE South (Cork and Kerry). https://www.drugsandalcohol.ie/6047/

10 Substance Abuse and Mental Health Services Administration (SAMHSA) (2006) Detoxification and substance abuse treatment. A Treatment Improvement Protocol (TIP) Series, No. 45. Rockville, MD: Substance Abuse and Mental Health Services Administration. https://www.drugsandalcohol.ie/14171/

Changes to OAT services

Many Irish OAT services have adapted treatment delivery to reduce the emerging Covid-19 risks. These changes include:

• Restructuring OAT assessment and induction procedures to allow easy access to treatment and to avoid waiting lists
• Fast-tracking of patients requiring isolation to OAT
• Home delivery of OAT and other medications
• Reducing OAT supervision requirements
• Adapting virtual patient care and telemedicine
• Reducing/postponing non-essential services, including drug and blood-borne virus (BBV) screening and hepatitis
  C treatment
• Providing remote counselling support
• Providing virtual multidisciplinary team meetings
• Increasing access to overdose prevention training and naloxone
• Providing targeted interventions for homeless and more vulnerable patients, including increased access to more suitable accommodation and supports
• Reducing the prison population.

In common with all health services, reducing the need for face-to-face interactions is advised. By reducing this requirement, the potential risk of transmission is minimised, thus protecting staff and patients.

Risk of drug overdose

Reduced supervision may increase street diversion and drug overdose; therefore, risk assessment and individualisation of care are critical. Providing information on OAT-related dangers and safe storage may reduce these risks. Irish overdose prevention and naloxone programmes have also been expanded to lessen the risks. Overdose education and naloxone programmes have been shown to reduce fatal opioid-related overdose.³ Overdose prevention programmes have conventionally recommended the use of cardiopulmonary resuscitation (CPR) and the administration of intranasal or intramuscular naloxone. Given the increased risks associated with Covid-19, training programmes have now been revised and delivered remotely, removing the endorsement of CPR and use of intranasal naloxone.

Drug screening

Reducing OAT supervision requirements provides services with an opportunity to evaluate the practicality of drug screening and to adopt a more evidence-based approach in the post-Covid future. Currently, there is little published evidence on the efficacy of routine drug screening. Indeed, screening schedules tend to be philosophical and historical within services.⁴

Telemedicine and opioid substitution therapy

Irish OAT services have adopted telemedicine to conduct risk triaging, assessment, reviews, counselling, and psychosocial support. Using telemedicine, OAT services have been able to offer patients quicker access to opioid substitution therapy (OST) and reduce waiting lists. OST induction is acknowledged as a high-risk period for overdose and caution should therefore be exercised. Establishing dependence and assessing tolerance are critical, as is dosing over the first four days.⁵

Self-isolation

Given the risk profile of PWUO, many patients attending OAT services will be required or recommended to self-isolate. This presents difficulties for both service providers and patients. Irish OAT services have established a home delivery network informed by local resources, geography, and need. Staff redeployed from statutory and non-statutory services and An Garda Síochána have been engaged in providing risks assessments and supports, where necessary.

BBV screening and treatment

OAT services have suspended routine BBV screening, vaccinations, and new hepatitis C treatment. In the short term this may have little impact but there may be medium-term to long-term costs for patients. Central to the work of OAT services has been the identification and management of BBVs. Prior to Covid-19 restrictions, OAT services had been engaged in increasing hepatitis C screening and treatment, with elimination of hepatitis C infection as their goal. Lack of testing and treatment, along with reduced supports and access to harm reduction services, may increase rates of reinfection and may impact negatively on ‘treatment as prevention’ initiatives.⁶ Irish OAT services have effectively used telemedicine for hepatitis C treatment, provision of psychological support, and other supports.^7,8,9

Wider usage of telemedicine

The wider usage of telemedicine has brought about a fundamental change in care delivery and work practices. While patients have adapted well to these changes, it has highlighted the need to have up-to-date phone contact details. Provision of phones to those without them is vital to capitalise on the benefits of these changes. Telephone consultations are adequate for most patients; however, video consultations may be more appropriate for patients with greater health and psychosocial needs.¹⁰

It is worth noting at time of writing that the HSE has not yet agreed a common platform for use in telemedicine. However, it does not recommend the use of video-conferencing services for clinical purposes.

Remote counselling services and supports

From the onset of Covid restrictions, residential drug treatment and aftercare services closed. This afforded the opportunity to redeploy staff to provide remote counselling services and other supports. At first, patients struggled to adapt to the situation but are now increasingly reporting satisfaction with this approach.

New models of care

The authors note while it is important to focus on emergency efforts to manage, treat, and develop a vaccine to control this pandemic, it is also important that new models of delivering medical and social care are fully evaluated.¹¹ Models developed during this time of crisis may have real benefits for patients and the healthcare systems in the future. It is also imperative to evaluate any potential negative impacts of these new models and work to decrease them.¹¹

Adequate resources for such evaluations should be factored into health budgets, as many of these new measures could have significant health benefits and cost savings in a post-Covid future.

Conclusion

In conclusion, PWUO have greater health and social risks that make them more vulnerable during the current Covid-19 pandemic. OAT services can and have adapted to reduce the risks faced by this marginalised population. Measures adopted have both immediate and future benefits to this group. Ongoing evaluation of such measures is critical, as it can inform how health and social care are delivered across the health services. Many of these measures will also impact health and social care outcomes and potential cost savings in a post-Covid future.

The report authors hope that these positive changes and learnings can address some of the social and health inequalities experienced by so many.

1  Crowley D and Cullen W (2020) Caring for opioid drug users during the COVID-19 pandemic: a commentary on the Irish experience. Heroin Addiction and Related Clinical Problems, Early online. https://www.drugsandalcohol.ie/32214/

2  Health Service Executive (2020) Guidance on contingency planning for people who use drugs and COVID-19. Dublin: Health Service Executive. https://www.drugsandalcohol.ie/31804/

3  Walley AY, Xuan Z, Hackman HH, et al. (2013) Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ, 346(7894): f174.

4  McEachern J, Adye-White L, Priest KC, et al. (2019) Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy. Int J Drug Policy, 64: 30–33.

5  Sordo L, Barrio G, Bravo MJ, et al. (2017) Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ, 357: j1550.

6  Grebely J, Bruneau J, Bruggmann P, et al. (2017) Elimination of hepatitis C virus infection among PWID: the beginning of a new era of interferon-free DAA therapy. Int J Drug Policy, 47: 26–33.

7  Eibl JK, Gauthier G, Pellegrini D, et al. (2017) The effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. Drug Alcohol Depend, 176: 133-138.

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

9  Marciano S, Haddad L, Plazzotta F, et al. (2017) Implementation of the ECHO^® telementoring model for the treatment of patients with hepatitis C. J Med Virol, 89(4): 660–664.

10 Greenhalgh T, Koh GCH and Car J (2020) Covid-19: a remote assessment in primary care. BMJ, 368: m1182.

11  Brooner RK, King VL, Kidorf M, Schmidt CW Jr and Bigelow GE (1997) Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry, 54(1): 71–80.

Background and concerns

The current national drugs strategy¹ aims to reduce harms arising from substance misuse and to reduce the prevalence of blood-borne viruses among people who inject drugs (PWID) through the expansion of needle exchange. In Ireland, this service is delivered in a number of ways, including fixed-site locations, such as clinics or community pharmacies, and novel interventions, such as Backpacking Outreach programmes.

In Ireland, the Health Service Executive (HSE) has noted that just as the sharing of injecting material increases the risk of infection with blood-borne viruses, such as HIV and viral hepatitis B and C, the sharing of injecting equipment contaminated with Covid-19 may also increase the risk of infection and play a role in the spread of the virus. In addition, the Covid-19 outbreak may present additional risks currently not widely recognised. These may include the sharing of cannabis joints, cigarettes, vaping or inhalation devices, or
drug paraphernalia.

With regard to needle exchange provision in Ireland, the HSE notes that disruption to the supply of, and access to, equipment is likely to occur for a number of reasons. These may include staff shortages, service disruption and closure, self-isolation, and restrictions placed on free movement.

Recommendations and processes

With these concerns in mind, the HSE has made a number of recommendations.² These include:

A broader harm reduction approach in the current Covid-19 pandemic should be considered by services when they deliver interventions.

• Harm reduction advice should include information on the risk of Covid-19 transmission through all forms of intake, including sharing of cannabis joints, cigarettes, vaping, and injecting equipment.

• Contingency plans should be developed to ensure continuity of provision of drug use paraphernalia. Scaling up the level of equipment provision for individuals in self-isolation is likely to be necessary.

• The utilisation and training of additional staff from Section 39 agencies involved in the provision of care for PWID should be considered to deal with staff shortages in community healthcare organisation areas. The phone number of the harm reduction service should be available and circulated widely among the community targeted for injecting equipment.

• If an individual is in self-isolation and requires needle exchange, requests for equipment should be made by phone and amounts and equipment should be prepacked and then delivered to the specific location.

• Staff members should ensure that the intended target is in receipt of the package and that the package is not left unattended.

• At fixed-site location services, requests should be made by phone and equipment should be prepacked and handed out at the front door.

• All HSE staff and allied professionals delivering harm reduction services and injecting equipment should be provided with clear guidelines in relation to minimising contact with individuals, dealing with issues over the phone, and maintaining personal safety.

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

2  Health Service Executive (2020) Needle exchange provision in COVID-19 pandemic. Dublin: Health Service Executive.
    https://www.drugsandalcohol.ie/32048