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The national drugs and alcohol strategy Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017‒2025¹ follows through on the commitment made by the Government in May 2016 to pursue a health-led rather than a criminal justice approach to drug use.² Seeing drug use as a health issue rather than a criminal one is an important step towards reducing the stigma experienced by people who use drugs. Activities that aim to raise awareness of the issue and set out to reduce the stigma are ongoing in Ireland.

UISCE and the Press Ombudsman

In October 2017, the Press Ombudsman of Ireland issued an advisory notice³ to all national and local newspaper editors.
The letter was sent following an approach made to the Ombudsman by the Union for Improved Services, Communication and Education (UISCE). In their submission, UISCE made a number of key points that are echoed in the report by the Global Commission on Drug Policy which is covered in the next article and explores the negative perceptions of drugs and the people who use them.⁴

Those cited in the Ombudsman’s advisory notice include:

• Stigma is a barrier to equality. The language and imagery used to describe addiction in the media contributes to the stigma experienced by people who use drugs.
• There is a ‘widely-held, generalising, and unscientific position’ that illicit drugs are ‘bad’ and this informs a perception that people who use drugs are bad too.
• Drug use is viewed as unacceptable and criminal and therefore people who use drugs are labelled as ‘deviant criminals’.
• Stigma leads to discrimination and they are ‘what drive the gross violations of the human rights of people who use drugs, and also result in these violations going for the most part unchallenged’.

UISCE provides a sample list of stigmatising language and offers alternatives that it advocates using.⁵

CityWide campaign

On behalf of CityWide Drugs Crisis Campaign, on 27 February 2018, the Minister of State for Health Promotion and the National Drugs Strategy, Catherine Byrne TD, launched a new campaign that focuses specifically on the issue of stigma called ‘Stop the Stigma: Addiction is a health issue not a crime’.⁶ Its overall aim is to challenge drug-related stigma. CityWide believes that stigma will have a negative impact on the effective implementation of many of the actions in the national drugs strategy. Stigma is identified by CityWide and its partners as presenting a barrier to people who want to address their problem drug use; it drives people into isolation, danger and back into addiction. They argue that it labels families and neighbourhoods. It destroys people’s prospects and their chance to contribute to society. CityWide see this as bad news for everyone; for people who have problems with addiction, for their families and their wider communities, and for people who work in addiction and related public services.

The first stage of the campaign is about increasing awareness of stigma and its impact, as well as building up alliances through a wide range of non-governmental organisations and civil society networks.

Lucy Dillon

2  Government of Ireland (2016) A programme for a partnership government. Dublin: Department of the Taoiseach.
http://www.drugsandalcohol.ie/25508/

3  See UISCE’s 2017 newsletter Brass Munkie, especially pages 8 and 9, which include the full advisory notice from the Press Ombudsman: http://www.drugsandalcohol.ie/28378/

4 Global Commission on Drug Policy (2018) The world drug perception problem: countering prejudices about people
who use drugs. Geneva: Global Commission on Drug Policy. https://www.drugsandalcohol.ie/28434/

5  The full list is available at: http://www.drugsandalcohol.ie/28473/ 

6  The campaign messages and materials can be accessed at: http://www.citywide.ie.

We were deeply saddened to learn of the death of Trutz Haase at Easter. Those involved with the preparation of the current drugs strategy will be familiar with Trutz’s work on the performance measurement framework for Drug and Alcohol Task Forces.

Trutz and co-author Jonathan Pratschke’s report represents very significant progress in the task of developing an effective appraisal system for both national and local responses to problem drug use and a more rational, fairer and sustainable approach to resource allocation. The framework is a further application of the Pobal HP Deprivation Index which has been used extensively to guide Irish health, education and social welfare policy over many years.

Trutz’s work on the index and his contribution to social and economic knowledge in Ireland was guided by a deep commitment to using science to build a more decent, democratic and equal society. He was always rigorous in the application of his deep knowledge but enormously generous, patient and good humoured in sharing his insights with others.

We wish to extend our deepest sympathies to Karena, his wife, and to all his family in Ireland and in Germany.

The impact of this change in emphasis, typical of policy development in the European Union in recent years, can be understood in a number of ways. First of all, we can see it as a consolidation of the generally humane view of those at most risk from harm due to their use of drugs and a recognition that a just society must commit to providing high-quality services and support to all, no matter where they are from or how their need has arisen. So the individually focused values of compassion and respect both support, and are supported by, the social values of equity and inclusion. While human rights are only specifically mentioned once in the strategy, a human rights approach is very evident in the sections dealing with supervised injecting facilities and alternatives to punishment.

The emphasis on increasing wellbeing rather than imposing sanctions is also pragmatic. There is a recognition that employing law enforcement as the State’s most effective response to drug use is counterproductive. It criminalises those whose drug use may be experimental or short-lived and may undermine the capacity or motivation of those in greatest need of professional help to access services. In this issue, we look at the recent Pompidou Group of the Council of Europe report on the unintended consequences of drug control policies, including the use of more hazardous substances, riskier use of drugs, physical danger as a result of involvement in illicit markets, and the stigma that results from using prohibited substances. The issue of stigma is considered in two further articles in this issue, and the mental and physical consequences associated with it exacerbate the already difficult situation faced by many people who use drugs.

Good policy depends on evidence, particularly reliable data, being available to make decisions, identify current harms and future risks, and plan responses. Administrative data are a very valuable research resource, but they have shortcomings when compared with data that are collected and analysed using a monitoring system created for that purpose. Criminological researchers, while adept at gathering and analysing behavioural information, often have to depend on administrative data that have not being collected with this type of analysis in mind. Criminal activity associated with or a consequence of drug use can be difficult to measure and monitor. Taking a public health perspective enables researchers of these activities to avail of well-established information systems that often contain highly relevant data. It also presents an opportunity to learn from a highly successful, well-established and scientific approach to information gathering.

Because of concerns about the negative impact that alcohol can have on individuals and communities, licensing statutes generally include a right for community members to object to the grant of a new licence or a renewal of a licence. The National Community Action on Alcohol Network, convened and supported by the Alcohol Forum, was formed in early 2017 to support community action on alcohol in Ireland and to facilitate collective working on issues of common concern. It approached the Public Interest Law Alliance (PILA) to develop a legal guide on the licensing process in Ireland, as it is recognised that there is a link between the licensing of alcohol and its consumption. The guide,¹ published in May 2017, was compiled amid growing concerns about the widespread availability of alcohol in communities. It is intended to be a practical guide to the when, where and how of objecting to a proposed grant or renewal of a licence.

Licence types

• An on-licence grants permission to sell intoxicating liquor for consumption either on or off the premises. Most current on-licences are full licences, that is, any type of alcohol may be sold during all permitted opening hours.
• An occasional licence permits an existing on-licence holder to sell alcohol during a special event, from a place other than that to which their existing on-licence is attached (e.g. a bar might have a drinks tent at a festival or Christmas market).
• An off-licence grants permission to sell intoxicating liquor for consumption off the premises. There are five types: spirit retailer’s off-licence; beer retailer’s off-licence; wine retailer’s off-licence; sweets retailer’s off-licence (sweets are products like mead); and the cider retailer’s off-licence.
• A public dancing licence grants permission to premises to hold a public dance or other entertainment, but it does not entitle the holder to sell alcohol.

There are a number of ‘exemptions’ that may be obtained in order to allow a licensed premises to open during otherwise prohibited hours. Bars that wish to gain such exemptions to stay open late will almost certainly require a public dance licence in order to be granted the exemption. Exemptions cannot be objected to as such. Therefore, if you wish to object to the operation of a nightclub, you must object to the public dance licence.

Objecting to a proposed grant or renewal of a licence

How can I know that an application is being made?

Applicants for a new licence must advertise their intention to make such an application in a newspaper circulating in the place in which the proposed premises are situated at least 21 days before the application is to be made. The superintendent of the Garda Síochána of the district in which the premises are situated also must be put on notice of any application for a new licence. An applicant intending to apply for an annual public dancing licence must publish notice of their intention to do this at least one month before the hearing. Existing licences must be renewed each year by Revenue. Most licences expire on 30 September each year, with the exception of wholesale dealer’s licences that are held in conjunction with other off-licences; in these cases, licences expire on 30 June.

What licences can be objected to?

Members of the public can object to any application for a new licence or any renewal of a licence in the civil parish in which they live or otherwise occupy or pay rates (e.g. as a business person). In relation to public dancing licences, any person who appears, to the judge, to be interested in the application may be heard in opposition. The superintendent of the Garda Síochána of the district in which the premises are situated is also a competent objector.

Where and when can I object?

Applications for new on-licences are made to the Circuit Court in the town nearest the premises and in the county in which the premises are situated. An objection in writing (which is not necessary) should be addressed to the county registrar of that circuit. Applications for new off-licences are made to the District Court in which the premises is situated. Objections in writing (which is not necessary) should be addressed to the District Court clerk for that district. Objections to renewals should be made to the relevant District Court for the premises. The very first application for a public dancing licence may be made at any sitting of the District Court in which the premises is situated. Subsequent applications must be made in September each year at the annual licensing court.

The main grounds of objection

The main grounds of objection are as follows:

• The character, misconduct or unfitness of the applicant: Character and misconduct are generally considered together and relate to an applicant’s public reputation; unfitness refers to the applicant’s fitness to run a licensed premises.
• Unfitness or inconvenience of the new premises: A premises will not be fit and convenient if it has previously been disqualified from ever being licensed; or a license in respect of the premises has previously been forfeited.
• Unsuitability for the needs of persons residing in the neighbourhood: To advance an objection on this ground, an objector would need to be clear on who are the persons that reside in the neighbourhood; what are their needs; and how the proposed new premises is unsuitable for those needs.
• The adequacy of the existing number of licensed premises of the same character in the neighbourhood: This relates to whether the existing number of licensed premises satisfies the existing level of demand for such premises. This will involve consideration of changes in volume of sales and changes in population.
• The number of previously licensed houses in the neighbourhood: This considers if the existing number of licensed premises in the area is sufficient to meet existing demand. The demand to be met must be existing demand; any projected increases in demand (e.g. due to development in the area) are not relevant.
• Manner in which a premises has been conducted in the previous year: Any evidence that the premises has been conducted in a disorderly manner would be relevant to this ground (e.g. convictions for ‘after hours’ trading, permitting drunkenness on the premises, serving to drunken or underage persons, etc.).

Further information on the licensing process and how to object to the grant or renewal of a licence may be found in the full report.

The Pompidou Group of the Council of Europe has published a new report, Costs and unintended consequences of drug control policies.¹ The overall aim of the report is to define and identify costs and unintended negative effects of drug control policies, borne by individuals and society (p. 9). The findings are based on a wider study carried out by the Pompidou Group in cooperation with the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).

In the previous issue of Drugnet Ireland,² the findings of two reports on drug-related public expenditure were discussed.^3,4 The first part of current report echoes many of the key findings reported in that article. It explores what drug-related public expenditure is, why it matters, and the methodological challenges faced in estimating its value. These are not repeated here; instead, this article focuses on the second part of the report — the unintended negative consequences of drug control policies.

Unintended negative consequences

The authors define unintended consequences as those ‘that are not deliberate or intentional; they are not the targeted effects of any given action’ (p. 9). These vary between countries: affected by, for example, the national drug legislation and its implementation, as well as the social and economic context, and the types of substances considered. The authors outline in detail the health and non-health (social and economic) consequences for both users and non-users of drugs (p. 10), as well as almost 40 ‘possible interventions’ to ameliorate these unintended (although not always unexpected) consequences. Below is a broad summary of the unintended consequences covered in this report.

Health-related consequences

Three broad categories of health-related consequences are identified:

• Effects from restricted availability of controlled medicines: One of ‘the most serious’ consequences of control policies for non-users of illegal drugs (p. 46) is the unmet pain relief and palliative care needs of patients due to the strict enforcement of the UN conventions. For opioid-dependent users (p. 46), the strict controls mean the denial of access in some countries to the ‘most effective treatment’ for them, i.e. opioid substitution treatment (OST). More broadly, restricted access to marijuana has made it more difficult to conduct research on its medical use.
• Effects due to enforcement of drug prohibition: Four unintended consequences are identified in this category. First, people may switch to using more hazardous substances because they are ‘legal’. The authors argue that the health risks associated with the new psychoactive substances are unknown and they are often ‘dangerous and potentially lethal substances’ (p. 27). Second, because of the elevated price that comes as a result of a drug being prohibited, people can use them in a more cost-effective but riskier way. For example, they move from smoking to injecting heroin. Third, the variation in purity of substances available on the black market means an increased risk of mortality and morbidity for people who use. Finally, use of a prohibited substance tends to be stigmatised. This can discourage people from seeking help and support, can have a negative impact on their self-esteem and mental wellbeing, and may lead to healthcare providers having negative attitudes towards people who use.
• Effects from enforcement actions: First, where there are periods of intensified police activity to enforce drug laws, this can have a negative impact on attendance at services. This can, for example, increase the risk of the spread of drug-related infectious diseases, and make it less likely for people to contact emergency services when someone has overdosed. Second, where there is contact between the police and ‘suspects of drug law offenders’ (p. 32), the authors argue that there is a risk of inappropriate use of force, violation of rights, and physical and mental harm. Third, there can be barriers to providing appropriate services to those who are in detention. This can increase the risk of the spread of drug-related infectious diseases.

Social and economic related consequences

Three broad categories of non-health-related effects are identified:

• Effects of high profit margins and price levels of illegal drugs: First, the high profit margins offered by the illegal drugs market attract and finance organised crime groups, including those involved with terrorism. It also encourages trafficking of people and other items through the same networks, as well as the associated corruption of officials. This all feeds into an environment characterised by ‘high levels of violence, criminal motivation and risk-taking’ (p. 36). Second, the high price levels associated with illegal drugs means that people commit acquisitive crime to finance their drug use.
• Effects of stigmatisation due to perceptions of people who use drugs as criminals: Feeling stigmatised can lead to low self-esteem and reduced motivation to engage in economic and social activity, and to access community life and services. The authors argue that it can exacerbate existing forms of discrimination and increase people’s readiness to get involved in illegal activities. The stigma associated with drug use can mean people who use drugs are at increased risk of arrest and pre-trial detention, when compared with people involved in some other criminal activities.
• Effects of criminal records and imprisonment for drug offences: First, having a criminal record limits a person’s future opportunities. As well as increasing the risk of stigmatisation and social exclusion, it can impact negatively on employment opportunities, access to housing, and access to education. Second, where people have been imprisoned for a period this can lead to ‘shattered ties with individual social support networks’ (p. 41), an increase in the risk of reoffending, and increased exposure to violence.

Concluding comment

The authors conclude that to evaluate and improve drug policy, stakeholders need to know how much these policies are costing, and take into account all possible effects of the associated interventions and actions, including the unintended negative consequences. They also argue that many of these consequences are predictable and appropriate interventions should therefore be put in place
to minimise their impact on people who use drugs and on wider society.

2  Dillon L (2018) Exploring drug-related public expenditure. Drugnet Ireland, 64: 15—16.

3  Bretteville-Jensen AL, Costa Storti C, Kattau T, Mikulic S, Trigueiros F, Papamalis F, et al. (EMCDDA) (2017) Public expenditure on supply reduction policies. Brussels: Council of Europe. http://www.drugsandalcohol.ie/27458

4  European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2017) Drug treatment expenditure: a methodological overview, EMCDDA Insights 24. Luxembourg: Publications Office of the European Union. http://www.drugsandalcohol.ie/28010/

The world drug perception problem: countering prejudices about people who use drugs¹ challenges common public perceptions of addiction, drugs, and the people who use them. It highlights the importance of language in creating and reducing stigma and discrimination. The report is by the Global Commission on Drug Policy (GCDP), which describes itself as made up of political leaders and leading thinkers from across the political spectrum. It sets out to ‘bring to the international level an informed, science-based discussion about humane and effective ways to reduce the harm caused by drugs to people and societies’.² Since its inception, the GCDP has published a series of reports that are ‘technical and political reports to ground evidence-based policy recommendations in human rights, health and development’.² The current report was published in January 2018.

Misconceptions

Based on earlier reports by the GCDP,^3—7 the authors start from the premise that ‘the potential harms of drugs for people and communities are exacerbated by repressive drug control policies at local, national and international levels’ (p. 7). At its core, the current report argues that drug policy development and reform should be based on evidence and factual discussions, instead of being frequently characterised by moral debates based on perceptions rather than facts. The main body of the report explores commonly held perceptions and fears about drugs and the people who use them. It then compares them with the evidence available and recommends changes that could be enacted to make more effective drug policies. In general, this involves a move away from a prohibitionist approach. A detailed summary of the report is beyond the scope of this article, but a few of the perceptions challenged are outlined below:

• Drugs are often perceived to be ‘unnatural contaminants, pushed into a society from the outside or by deviant forces’ (p. 7). However, using mind-altering substances is an almost universal activity across cultures. What varies is the cultural acceptability of specific substances; while alcohol use may be an acceptable part of social activity in some parts of the world, in others it is demonised and prohibited. The authors reiterate the finding that the ‘legal status of a drug does not systematically relate to its potential harm’ (p. 11). They argue that by making a drug illegal its potential harms are increased for the user.
• There is a widely held belief that if a person uses certain drugs, they will almost inevitably end up dependent on that drug. The authors highlight that while illegal drug use is relatively common, only an estimated 11.6% of those who use are considered to be problematic users or have an addiction: ‘The most common pattern of the use of psychoactive substances is episodic and non-problematic’ (p. 14).
• There is a common perception that people who use drugs engage in criminal activities. This is, of course,
  the case where the drugs and their use are illegal. The vast majority of people who use illegal drugs are not involved in any criminal activity, other than their purchase and use. The authors also argue that other linkages between drugs and crime are a result of the prohibition framework. For example, the cost of accessing a drug increases when it is made illegal, and this has been found to increase levels of criminal activity among people who use.

Language and stigma

The media is shown to have a strong influence on how the public perceives drugs, the people who use them, and related issues. The authors argue that media portrayals are overwhelmingly negative and focus on two narratives: the first links drugs with crime; the second that drug use will inevitably result in ‘devastating’ consequences for the user and their immediate environment (p. 26). Both of these, coupled with the extensive use of negative language when reporting on these issues, create an environment in which drugs and the people who use them are heavily stigmatised and discriminated against (see Figure 1). Indeed, the authors argue that no medical condition is more stigmatised than ‘addiction’ (p. 27). The language used dehumanises and alienates people who use drugs from the rest of society, thereby identifying them as ‘others’ for whom society does not have a responsibility to help. It reinforces the misconception that drug use stems from a problem with the individual rather than society as a whole. The impact of this is that the health needs of people who use drugs are not prioritised by society, resulting in a lack of appropriate services. Even where services do exist, people who experience stigma are less likely to identify themselves to services. They argue for a shift in the language used when reporting on drug-related issues (see Figure 2).

Recommendations

The authors make six recommendations structured around stakeholders, whom they believe have a strong influence on how drug policy is shaped. They argue that changing people’s perceptions of drugs and the people who use them will reduce stigma and discrimination and will contribute to an environment in which drug policy reform is driven by facts rather than moral beliefs.

The recommendations are:

1. Policymakers must aim to change current perceptions of drugs and the people who use them by providing reliable and consistent information. Their public policy decisions should be evidence based, and they should maintain their position even when it is not in line with public opinion that is grounded in a moral view rather than facts.
2. Opinion leaders, such as the media, religious leaders and celebrities, must be responsible in shaping public opinions and perceptions on drugs. They should promote the use of non-stigmatising and non-discriminatory language about drugs and their users.
3. Ordinary citizens need to act as advocates by taking part in the debate about drug policy reform; sustaining activism and advocacy; and keeping governments and other public representatives, as well as the media and health and social care professionals, accountable.
4. Agents of law enforcement (including the police and members of the judiciary) need to stop acts of harassment based on negative perceptions of people who use drugs. The incarceration of people who need medical and social support must be addressed.
5. The medical community and healthcare professionals need to be vocal in promoting evidence-based prevention, treatment, and harm reduction services so that health and safety are prioritised. They need to urgently address ‘perception-based stigma’ (p. 37) in healthcare settings.
6. The ministerial segment of the 2019 UN Commission on Narcotic Drugs provides an opportunity to review the use of language in international documents and negotiations. This needs to be acted upon.

2  For more information on the GCDP, visit: http://www.globalcommissionondrugs.org/

3  GCDP (2011) War on drugs. Geneva: GCDP. http://www.drugsandalcohol.ie/28476/

4  GCDP (2012) The war on drugs and HIV/AIDS: how the criminalization of drug use fuels the global pandemic.
Geneva: GCDP. http://www.drugsandalcohol.ie/28477/

5  GCDP (2013) The negative impact of the war on drugs on public health: the hidden hepatitis C epidemic. Geneva: GCDP. http://www.drugsandalcohol.ie/28474/

6  GCDP (2015) The negative impact of drug control on public health: the global crisis of avoidable pain. Geneva: GCDP. http://www.drugsandalcohol.ie/28475/

7  GCDP (2016) Advancing drug policy reform: a new approach to decriminalization. Geneva: GCDP. http://www.drugsandalcohol.ie/26410/

Activities of Irish psychiatric units and hospitals 2016,¹ the annual report published by the Mental Health Information Systems Unit of the Health Research Board, shows that the number of new admissions to inpatient care for alcohol disorders has stabilised.

In 2016, some 1,260 cases were admitted to psychiatric facilities with an alcohol disorder, of whom 445 were treated for the first time. Figure 1 presents the rates of first admission between 1996 and 2016 for cases with a diagnosis of an alcohol disorder. The admission rate in 2016 was similar to the previous year, while trends over time indicate an overall decline in first admissions. Just under one-third of cases hospitalised for an alcohol disorder in 2016 stayed just under one week, while 28% of cases were hospitalised for between one and three months, similar to previous years.

In 2016, some 943 cases were admitted to psychiatric facilities with a drug disorder. Of these cases, 415 were treated for the first time.

Figure 2 presents the rates of first admission between 1996 and 2016 of cases with a diagnosis of a drug disorder. Although the rate decreased slightly in 2016, there has been an overall increase in the rate of first admission with a drug disorder since 2011. It should be noted that the report does not present data on drug use and psychiatric comorbidity, so it is not possible to determine whether or not these admissions were appropriate.

Other notable statistics on admissions for a drug disorder in 2016 include the following:

• Just over one-half of cases hospitalised for a drug disorder stayed under one week (52.6%), while 99% were discharged within three months. It should be noted that admissions and discharges represent episodes or events and not persons.
• 14% of first-time admissions were involuntary.
• Similar to previous years, the rate of first-time admissions was higher for men (12.2 per 100,000) than for women (4.9 per 100,000).

Recent research conducted in 2014 by the National Advisory Committee on Drugs and Alcohol suggests that there are 18,988 opiate users in the Republic of Ireland (rate 6.18 per 1,000 population), indicating that Ireland has one of the highest estimated rates of problem opiate use across 17 countries in the European Union.¹ Opiate use disorder is an increasingly common condition in healthcare systems in Ireland, with over 200 opiate overdose deaths occurring annually.²

Naloxone is an antidote for opioid overdose that reverses the depressant effects of opiates such as heroin. Naloxone has been shown to reduce mortality among people who use opioids and its distribution to trained lay users is effective for reducing fatal overdose.³ The Naloxone Demonstration Project was initiated in the Republic of Ireland in 2015, and in that year 600 individuals were trained in how to use naloxone.⁴ To date, more than 400 drug users have been prescribed naloxone⁵ and there have been five recorded ‘overdose reversals’ that may have contributed to lives being saved.

Evidence suggests that there is support among general practitioners (GPs) in Ireland for wider naloxone availability.⁶ Nevertheless, medical students’ exposure to patients with substance use disorders is limited and usually only occurs during general practice and psychiatry placements. In addition, there is a lack of formal substance use education at undergraduate level in Ireland, along with information regarding effective treatments such as naloxone. A recent study examined final-year medical students’ learning experiences and attitudes towards opioid use disorder, overdose, and community naloxone provision as an emerging overdose treatment.

In this research,⁷ published in the journal Addictive Behaviors, an anonymous paper-based survey was administered to 243 undergraduate medical students undertaking their final professional completion module prior to graduation from University College Dublin. The results were compared with parallel surveys of GPs and GP trainees. A total of 197 medical students completed the survey (response rate: 81%), with just under one-half being male (45%), most being of Irish nationality (77%), and aged less than 25 years (63%).

Results

The respondents reported feeling reasonably prepared to recognise key markers of opioid use disorder but felt less prepared for other aspects of opioid use disorder management, consultation with a patient about their opioid use disorder, assessing addiction severity, formulating a treatment plan or managing an opioid overdose. Most had taken a history from a patient with an opioid use disorder (83%) and one-third had witnessed at least one opioid overdose. Nevertheless, only a small proportion (10%) had seen naloxone administered, and only three had themselves administered naloxone in overdose. In comparison, 35% of GPs and 63% of GP trainees in parallel surveys had administered naloxone.

Just over one-half (52%) of student respondents saw a need for wider naloxone availability. For those students who were in opposition to wider availability, concerns included potential use of naloxone, lack of evidence for the benefit of wider availability, and that it might encourage greater opioid use. A similar proportion of respondents (54%) supported wider naloxone availability among laypeople.

Conclusions

The study authors noted that while recognition of opioid use disorder was reasonably well reported, management competencies were, in general, less positive. Few had seen naloxone administered or administered it themselves. In addition, despite evidence of the effectiveness of lay administration of naloxone in preventing fatal overdose, 46% of respondents did not support wider naloxone distribution among laypeople. The authors suggest that these results may reflect students’ lack of exposure to patients with substance use disorder and overdose and to gaps in education in undergraduate levels.

2  Irish Medical Organisation (IMO) (2015) IMO position paper on addiction and dependency. Dublin: IMO. https://www.drugsandalcohol.ie/24092/

3  European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2015) Preventing fatal overdoses: a systematic review of the effectiveness of take-home naloxone. EMCDDA Papers. Luxembourg: Publications Office of the European Union. https://www.drugsandalcohol.ie/23289/

4  Merchants Quay Ireland (2016) Merchants Quay Ireland:
annual review 2015. Dublin: Merchants Quay Ireland. http://www.drugsandalcohol.ie/26106/

5  Merchants Quay Ireland (2017) Merchants Quay Ireland: annual review 2016. Dublin: Merchants Quay Ireland. http://www.drugsandalcohol.ie/27910/

6  Klimas J, Egan M, Tobin H, Coleman N and Bury G (2015) Development and process evaluation of an educational intervention for overdose prevention and naloxone distribution by general practice trainees. BMC Medical Education, 15: 206.

7  Tobin H, Klimas J, Barry T, Egan M, Bury G (2018) Opiate use disorders and overdose: medical students’ experiences, satisfaction with learning, and attitudes toward community naloxone provision. Addictive Behaviors. Early online. https://www.drugsandalcohol.ie/28290/

Evidence suggests that among men who have sex with men (MSM) and who use drugs, there is a preference for ‘sex drugs’, including alkyl nitrites (‘poppers’), crystal methamphetamine (‘crystal meth’), club drugs (including ketamine and ecstasy) and new psychoactive substances.¹ Drug use for or during sex (‘chemsex’) among MSM has caused concern because of the direct effects of the drugs themselves in addition to an increased risk of transmission of sexually transmitted infections (STIs).

Recent Irish research aimed to assess the prevalence of chemsex, associated behaviours and STIs among attendees at Ireland’s only MSM-specific sexual health clinic in Dublin, over a six-week period in 2016.² In this study, published in the International Journal of Drugs Policy, a questionnaire was used to collect demographic data, information on sexuality and sexual practice, self-reported history of treatment for STIs, and chemsex use. Key variables independently associated with treatment for STIs over the previous 12 months were identified using multivariable logistic regression. Ninety-four per cent of attendees who were asked to take part in the study completed the questionnaire.

Among the findings, the study authors highlighted the following:

• One in four (27%) reported engaging in chemsex within the previous 12 months.
• One-half had taken two drugs on their last chemsex occasion.
• One in five (23%) reported that they or their partners had lost consciousness as a result of chemsex.
• One in four (25%) reported that chemsex was impacting negatively on their lives and almost one-third (31%) reported that they would like help or advice about chemsex.

It was also found that those engaging in chemsex were more likely to have had more sexual partners (p<0.001), more partners for anal intercourse (p<0.001) and to have had anal intercourse without a condom (p=0.041). They were also more likely to report having been treated for gonorrhoea over the previous 12 months (adjusted OR: 2.03, 95% CI 1.19—3.46, p=0.009). Overall, 6% of participants reported that they had ever been diagnosed with HIV, though no significant difference was seen in the proportion of respondents who reported having been diagnosed with HIV according to whether they reported that they had (8%) or had not (5%) engaged in chemsex (p=0.097).

The authors concluded that the results from this survey of MSM clinic attendees in Dublin agree with international evidence suggesting a chemsex culture among a subset of MSM. They hope that these findings will be used to develop an effective response that addresses addiction and sexual ill-health among MSM who experience harm, and seek help as a consequence of engagement in chemsex.

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 and Behavior, 18(7): 1339—51.

2  Glynn RW, Byrne N, O’Dea S, Shanley A, Codd M, Keenan E, et al. (2018) Chemsex, risk behaviours and sexually transmitted infections among men who have sex with men in Dublin, Ireland. International Journal of Drug Policy, 52: 9—15. https://www.drugsandalcohol.ie/28327/

Alcohol misuse and alcohol consumption are significant risk factors for suicidal behaviour. Persons diagnosed with alcohol use disorder have been shown to be at increased risk of suicide in a meta-analysis of cohort studies,¹ and the lifetime risk of suicide among those with alcohol use disorder has been estimated at 7%.² In addition, subjects admitted with alcohol use disorder are more likely to present with self-harm during a 12-month follow-up period.³ However, although numerous studies have demonstrated an association between alcohol consumption and suicidal behaviour, very little attention has been paid to the factors associated with alcohol involvement in suicide and self-harm. A recent study conducted in Ireland sought to identify factors associated with alcohol consumption in cases of suicide and non-fatal self-harm presentations.⁴

Alcohol misuse and alcohol consumption are significant risk factors for suicidal behaviour. Persons diagnosed with alcohol use disorder have been shown to be at increased risk of suicide in a meta-analysis of cohort studies,¹ and the lifetime risk of suicide among those with alcohol use disorder has been estimated at 7%.² In addition, subjects admitted with alcohol use disorder are more likely to present with self-harm during a 12-month follow-up period.³ However, although numerous studies have demonstrated an association between alcohol consumption and suicidal behaviour, very little attention has been paid to the factors associated with alcohol involvement in suicide and self-harm. A recent study conducted in Ireland sought to identify factors associated with alcohol consumption in cases of suicide and non-fatal self-harm presentations.⁴

In this research, published in the journal Crisis, suicide cases in Cork, from September 2008 to June 2012, were identified through the Suicide Support and Information System. Emergency department presentations of self-harm for the years 2007—2013 were obtained from the National Self-Harm Registry Ireland. Logistic regression analysis was used to estimate independent variable associations with alcohol use prior to or during a suicide or self-harm act.

Key findings included the following:

• Alcohol consumption was detected in the toxicology of 44% of 307 suicide cases.
• Only younger age was significantly associated with having consumed alcohol among suicides.
• Alcohol consumption was noted in 21% of 8,145 self-harm presentations.
• Variables associated with having consumed alcohol in a self-harm presentation included male gender, older age, overdose as a method, not being admitted to a psychiatric ward, and presenting out-of-hours.

The study authors concluded that public health measures to restrict access to alcohol may be used to enhance suicide prevention, as population-based studies show reduced suicide rates following measures to restrict access to alcohol.⁵ In addition, as it was found that alcohol involvement was associated with different characteristics in self-harm presentations, but not in suicide cases, this may require a tailored clinical approach to minimise risk of further non-fatal or fatal self-harm.

2  Inskip HM, Harris EC and Barraclough B (1998) Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. British Journal of Psychiatry, 172: 35—37.

3  Singhal A, Ross J, Seminog O, Hawton K and Goldacre MJ (2014) Risk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage. Journal of the Royal Society of Medicine, 107(5): 194—204.

4  Larkin C, Griffin E, Corcoran P, McAuliffe C, Perry IJ and Arensman E (2017) Alcohol involvement in suicide and self-harm: findings from two innovative surveillance systems, Crisis, 38: 413—22. https://www.drugsandalcohol.ie/28375/ 

5  Värnik A, Kõlves K, Väli M, Tooding L and Wasserman D (2007)
Do alcohol restrictions reduce suicide mortality?, Addiction, 102(6): 251—56.

In October 2016, the Union for Improved Services, Communication and Education (UISCE) was invited to be part of the working group formed to discuss the proposed supervised injecting facility (SIF) that is planned to open in Dublin in 2018. UISCE provides an independent representative voice for people who use drugs and helps to ensure the sharing of accurate, up-to-date information. In order to identify the most important features of the proposed facility to the community of end-users, UISCE developed a short survey that included aspects identified by the working group as necessary to fully represent the opinions, thoughts and concerns of people who use drugs in public places.

In the survey, which was completed by 93 subjects (66% male), a set of questions focused on the person’s experience with regard to the specific drugs that they choose to inject, how long they have been injecting, and where on the body they normally inject. UISCE also sought clarification from each participant about the characteristics of the areas where they normally inject, what is important about these locations, and how they would like to see a SIF administered. Additional questions about safety and comfort, before and after using drugs, were also included.

Survey findings

Key findings included the following:

• 76% of respondents considered themselves homeless.
• 90% of the respondents affirmed they were currently injecting heroin.
• The average period of time that respondents reported injecting was 10 years, with a range of between 3 days and 30 years.
• In terms of the parts of the body that people who inject drugs use most frequently, the majority of the sample affirmed they use mostly the arms (52%), groin (31%) and legs (16%). Ten per cent stated that they inject all over the body (Figure 1).
• 49% of respondents said they inject between one and three times daily, with a majority stating that this was early in the morning (79%) and before they go to bed (73%) (Figure 2).
• 86% of the sample had injected while on the streets and 75% stated that they feel unsafe when they are on the streets.

In terms of specific injecting locations, the answers varied: despite some respondents stating they would inject ‘anywhere’ or ‘everywhere’, the majority chose ‘back lanes’ or ‘covered areas’ (‘parks’, ‘toilets’, etc.). Almost all participants pointed out the importance of privacy, the need for good lighting, and highlighted the fact that the location served as ‘shelter’. Furthermore, factors such as ‘having other people around’ (75%) and ‘being close to where they bought the drugs’ (74%) also stood out as having great importance when choosing a location. Regarding the sense of safety and comfort during and after injecting, over one-half of respondents affirmed that they are, or have been, comfortable injecting in front of other people, while 23% stated they would feel uncomfortable having other people around.

When respondents were asked about location and opening hours for a SIF, the answers varied extensively. While some people affirmed that they would travel ‘anywhere’ or ‘everywhere’, the majority said they would like it to be near the city centre or even close to a clinic. Regarding opening hours, the majority of respondents agreed it should be a service available 24/7 with a few exceptions. Finally, regarding the ideal set-up of the facility, it was agreed that some basic equipment, such as mirrors, tables and chairs, was essential. The answers highlighted the need to feel comfortable and of having access to medical professionals.

Conclusions

UISCE concluded that there is demonstrable support from the community of people who inject drugs in public places in Dublin for a SIF, which was indicated by the willingness of people to take part in the survey and share information to inform development. It was identified that a city centre location would be ideal. The percentage of people who identify as femoral injectors (31%) and the people who inject ‘all over their body’ (10%) highlight the need for space in the SIF to be designed with these people in mind. In addition, there is a need for education on safe injecting practices to be made available. In the recovery space, as demonstrated by the responses, there will need to be coffee and tea facilities as well as a smoking area. In addition, as there are high numbers of people who are homeless, coupled with high numbers of people who say that their preferred action after using drugs is to sleep, UISCE recommends support for people to access day services from the SIF.

In Europe, concerns about the potential risk for misuse of or dependence on the prescription drugs pregabalin and gabapentin have been raised for at least a decade. This article brings together a brief overview of some of the main international and national literature to date. In 2009, pregabalin and its potential involvement in drug-related deaths in Finland, Sweden and the United Kingdom (UK) was reported to the EMCDDA Early Warning System.¹ A retrospective analysis of German data showed that as early as 2008 cases of pregabalin misuse/dependence were reported in that country.² However, several years earlier in 2005, the United States (US) made pregabalin a controlled drug due to the recognition of the potential risk of misuse and/or dependence.³

What is pregabalin?

Pregabalin is a prescription-only drug, licensed to treat a number of serious conditions: epilepsy (antiseizure), neuropathic pain, e.g. caused by shingles (pain relief) and also for generalised anxiety disorder (antianxiety). A common brand name for pregabalin is Lyrica®. Pregabalin and gabapentin are frequently discussed together in the literature, usually under their group name ‘gabapentinoid’. This is because they are a similar type of drug, both cited as having a risk of misuse or dependency. A common brand name for gabapentin is Neurontin®. There has been a 23% increase in the number of GMS prescriptions for pregabalin in Ireland between 2008 and 2016 (unpublished data from the Primary Care Reimbursement Service).

What is gabapentin?

Gabapentin is a prescription-only drug, similar to pregabalin, and prescribed for epilepsy (anticonvulsant) and neuropathic pain (pain relief). Literature referring to pregabalin and gabapentin often refer to their ‘off label’ use. This means the drugs are being prescribed (or used) for a condition outside the terms of its original product authorisation (or in different doses or to patient groups not specified in the authorisation).⁴ Over the past decade there has been a massive increase in Europe in the number of prescriptions for pregabalin and gabapentin.^{5, 6} Analysis of UK data showed that there was a 24% increase in the number of gabapentinoid prescriptions between 2004 and 2015.⁶

Risk of misuse/dependence

The drugs are reported to give feelings of euphoria and relaxation.^5,7 Studies have shown that people do experience tolerance and subsequent withdrawal symptoms on stopping pregabalin and gabapentin; however, this is less common for those who use gabapentin. There are very few documented cases of dependence (rather than misuse) in Europe.⁵ Pregabalin appears to have a greater potential for misuse or dependency because of its more rapid absorption and potency.⁵

This is supported by the available evidence which suggests that dependence is more common for those who misuse pregabalin rather than gabapentin.^5,7

However, it is clear from the literature reviews that individuals who misuse pregabalin and gabapentin are taking (often much) higher than recommended doses and the vast majority have a history of misuse of or dependence on other drugs, in particular, opioids.^5,7 This is supported by studies that show prevalence of gabapentinoid misuse among opioid substitution treatment clients varied from 3% to 68%.⁷

The literature states that people who misuse opioids appear to use gabapentinoids, in particular pregabalin, to achieve a quicker euphoric high and reduce withdrawals.⁵ This close association with this high risk population is most likely to be influencing the increased prevalence of misuse/dependence and serious side-effects, including fatal overdose, rather than pregabalin or gabapentin solely as primary drugs of misuse or dependence.⁵ Some studies show higher prevalence of misuse among psychiatric patients and within prisons.⁷ It is not clear if this is directly related to drug misuse/dependence or a separate concern. In Ireland, the National Drug Treatment Centre (NDTC) tested 425 opioid substitution clients for pregabalin in 2014 following requests from health professionals concerned about misuse of this drug.⁸ In all, there were 498 samples across seven different clinics: 8.8% of samples tested positive, equivalent to 39 of 425 clients (9.2%) testing positive. Only 10 (10/39, 25.6%) clients were known to have been prescribed pregabalin.

Of those clients who tested positive for pregabalin, the average age was 38 years and the majority (59%) were female. Also published in 2014 was a case study of an individual with a history of drug misuse and dual diagnosis of mental illness who misused pregabalin.⁹

Risks associated with overdose

A known side-effect of pregabalin and gabapentin is central nervous system depression (ranging from sleepiness and drowsiness to difficulty breathing, coma and death). The literature suggests that potential risks of serious side-effects are greater for pregabalin than for gabapentin, although fatal overdose from either alone is thought to be very rare.^5,7 However, users prescribed the drugs are specifically advised not to take them with other drugs that may also negatively affect the central nervous system, such as opioids, benzodiazepines or alcohol. This is because they may interact together and have an additive effect, which in turn may increase the risk and severity of the serious side-effects, including death.

In Ireland, a recent study (see page 18) found that the annual number of intentional drug overdoses involving gabapentinoids, mainly pregabalin, increased year on year from 0.5% in 2007 to 5.5% in 2015.¹⁰ The majority were women (59.9%), with a median age of 37 years (74.6% were aged 24—54 years). Over one-half (52.4%) involved multiple drugs, while over one-third (37.2%) involved alcohol. However, history of drug misuse or dependence was unknown.

Fatal overdose

Fatal overdoses related to gabapentinoids, mostly pregabalin, have been reported from the US, Finland, Sweden, Germany and the UK in the literature.^5,6,7 These deaths appear to be almost always in combination with other drugs. The numbers of fatal overdoses reported have increased over the past decade. Of note, in the US where pregabalin has been controlled since 2005, gabapentin is more commonly implicated in fatal overdoses.⁵

The National Drug-Related Deaths Index is a census of all drug-related deaths in Ireland. Pregabalin has been implicated in fatal overdoses since 2009, although initially in small numbers (less than five per year).¹¹ The first significant increase was observed in 2013, with 14 deaths recorded where pregabalin was implicated. However, between 2014 and 2015, the number of deaths where pregabalin was implicated had increased by 69%, from 26 to 44. Of note, pregabalin has only been routinely screened for in postmortem toxicology in Ireland since 2013.

Summary

The evidence from Ireland, however limited, does mirror the available international literature on the risks of pregabalin and gabapentin. A factsheet¹² has been produced and there has been a call to consider making pregabalin a controlled drug.¹³

In 2014, the UK government issued advice for prescribers on the potential risk of misuse of both pregabalin and gabapentin.¹⁴ It advises caution in particular when considering prescribing a gabapentinoid to a person with a known history of drug misuse or dependence. However, this should not preclude them prescribing the medication if the benefit outweighs the risk. In Ireland, the patient factsheet on pregabalin, under warnings and precautions, urges patients to inform their doctor if they have a history of alcohol or drug dependence, or misuse of drugs before starting the medication.¹⁵ In 2017, the UK government commenced the process to make both pregabalin and gabapentin controlled drugs in response to concerns raised.^{16, 17}

2  Gahr M, Freudenmann RW, Hiemke C, Kölle MA and Schönfeldt-Lecuona C (2013) Pregabalin abuse and dependence in Germany: results from a database query. Eur J Clin Pharmacol, 69(6): 1335—42.

3  Federal Register (2005), Vol. 70, No. 144 / Thursday, July 28, 2005 / Rules and Regulations 43633. Washington DC: Office of the Federal Register. Available online at: https://www.gpo.gov/fdsys/pkg/FR-2005-07-28/pdf/05-15036.pdf

4    Irish Medicines Board (2003) Guidance note for healthcare professionals, June 2003. Dublin: Irish Medicines Board. Available online at: https://www.hpra.ie/docs/default-source/publications-forms/newsletters/drug-safety-newsletter-issue-no-17-june-2003-(guidance).pdf?Status=Master&sfvrsn=2

5  Bonnet U and Scherbaum N (2017) How addictive are gabapentin and pregabalin? A systematic review. Eur Neuropsychopharmacol, 27(12): 1185—215.

6  Lyndon A, Audrey S, Wells C, Burnell ES, Ingle S, Hill R, et al. (2017) Risk to heroin users of polydrug use of pregabalin or gabapentin. Addiction 112: 1580—589.

7  Evoy KE, Morrison MD and Saklad SR (2017) Abuse and misuse of pregabalin and gabapentin. Drugs, 77(4): 403—26.

8  McNamara S, Stokes S, Kilduff R and Shine A (2015) Pregabalin abuse amongst opioid substitution treatment patients. Ir Med J, 108(10): 309—10. https://www.drugsandalcohol.ie/24965/

9  Osman M and Casey P (2014) Pregabalin abuse for enhancing sexual performance: case discussion and literature review. Ir J Psychol Med, 31(4): 281—86. https://www.drugsandalcohol.ie/22563/

10  Daly C, Griffin E, Ashcroft DM, Webb RT, Perry IJ and Arensman E (2018) Intentional drug overdose involving pregabalin and gabapentin: findings from the National Self-Harm Registry Ireland, 2007—2015. Clin Drug Investig, 38(4): 373—80. https://www.drugsandalcohol.ie/28436/

11  Health Research Board (2017) National Drug-Related Deaths Index 2004 to 2015 data. Dublin: Health Research Board.
https://www.drugsandalcohol.ie/28086/

12  Ana Liffey Drug Project (2018) Pregabalin fact sheet. Dublin: Ana Liffey Drug Project. Available online at: http://www.drugs.ie/pregabalin

13  Corrigan D (2016) Concern increasing over the emergence of pregabalin as a drug of abuse. Irish Pharmacist, 18(3): 20.
https://www.drugsandalcohol.ie/26786/

14  Public Health England and NHS England (2014) Pregabalin and gabapentin: advice for prescribers on the risk of misuse. Available online at: https://www.gov.uk/government/publications/pregabalin-and-gabapentin-advice-for-prescribers-on-the-risk-of-misuse

15 Wockhardt UK (2017) Package leaflet: information for the user: pregabalin. Available online at: https://www.hpra.ie/img/uploaded/swedocuments/PIL-2192445-31082017145017-636397878185312500.pdf

16  Advisory Council on the Misuse of Drugs (2016) Letter to Minister for preventing abuse and exploitation re pregabalin and gabapentin advice. London: Advisory Council on the Misuse of Drugs. Available online at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/491854/ACMD_Advice_-_Pregabalin_and_gabapentin.pdf

17  UK Home Office (2017) Closed consultation: pregabalin and gabapentin: proposal to schedule under the Misuse of Drugs Regulations 2001. London: Home Office. Available online at: https://www.gov.uk/government/consultations/pregabalin-and-gabapentin-proposal-to-schedule-under-the-misuse-of-drugs-regulations-2001

Two-thirds of sales on darknet markets are drug related. These anonymous online markets enable transactions with neither buyer nor seller having to reveal anything about their identify. So-called ‘cryptomarkets’ are a relatively new phenomenon but the opportunity they present to undermine conventional law-enforcement approaches inevitably means that they will be a driver of significant growth in criminal activities over the next few years. A recent EMCDDA publication, Drugs and the darknet: perspectives for enforcement, research and policy¹ presents an analysis of drug-related activity on darknet markets, focusing on specific European countries and also looking at the phenomenon from the perspective of law enforcement agencies required to monitor and counter the operation of these markets.

In 2017, Europol identified the online trade in illicit goods and services as a key growth area for organised crime.² Darknet markets are websites that allow anonymous financial transactions. Access to these markets can be through ordinary, surface websites providing addresses for darknet sites; through surface mirror sites with links to hidden sites; or through invitation following reference from an existing user. The key technologies supporting these markets are anonymisation services, encrypted communication and cryptocurrencies, such as Bitcoin or Dogecoin. Users seeking to make illicit sales can use a search engine, Grams, specially designed for this purpose. Innovative use of instant messaging for communication and social media applications with GPS (global positioning systems) technologies presents particular difficulties for surveillance and regulatory work. In addition, many darknet markets offer their customers an escrow service with a multisignature function and the guarantee that the goods paid for will be delivered.

The first of these cryptomarkets was Silk Road, closed down by American law enforcement agents in 2013. Since then, an estimated 100 darknet markets have been created, many of which only operate for a short time (see Figure 2 overleaf). At the time of the EMCDDA report being written, there were an estimated 14 darknet markets operating. Despite the methodological and practical difficulties of researching darknet markets, a number of studies have provided useful data and at least highlight areas that will need further investigation and monitoring. Much of this work has focused on the behaviour and experience of those purchasing drugs online. Demographic characteristics were consistent across a number of studies with young, student or professional males with a history of drug use being the most common type of users in the limited samples observed. Personal safety and drug quality were the most frequently cited considerations when choosing to use online sources for drugs. While the purity of drugs purchased online does vary, a limited number of studies do show that what is ordered online will subsequently be delivered, and that those who purchase online usually find the suppliers are reliable. Websites use facilities such as marketplace feedback and rating polls to build confidence in their reliability and the quality of the products they supply. Researchers have used feedback data as a source of information in studying darknet activity.

The report looks at the findings of a 2015 study that sought to gain a better understanding of the extent of darknet drugs sales originating from Europe.³ Based on data gained from buyer feedback reports, the study estimated the volumes and value of drugs traded over a period of about three and a half years. The data suggest that the vast majority of sales originating from the EU during this period were from three countries: Germany (€26.6 of sales); the United Kingdom (UK) (€20.2m of sales); and the Netherlands (€17.9m of sales) (see Figure 1). The most common substances sold in the top four countries (including Belgium) were non-cocaine stimulants, principally MDMA and amphetamines. Cannabis and cocaine sales were also significant in the sales from these countries, while the UK-based sites were far more likely to sell dissociatives and new psychoactive substances. In terms of drug sales, EU countries represent roughly 46% of global revenue. A more detailed 2017 study of AlphaBay,² one of the most important darknet marketplaces and active for about two years, shows that the vast majority of drugs sales originated from the same three countries identified in the 2015 study.

Analysis of sales data shows that vendors tend to confine their activity to one market level: retail, middle or wholesale. In other words, very few vendors are involved in both bulk and small volume sales. While the majority of these vendors operate at the lower market level, it is estimated that just 1% of vendors are responsible for more than 50% of darknet sales. These sellers are connected to organised crime gangs and make considerable profits. Law enforcement authorities expect online markets to take an increasing share of the overall illicit drug market and may even replace the use of traditional distribution networks among some user demographics. The EMCDDA report describes darknet markets as ‘tailor-made polycriminal environments’, as they allow criminal groups to distribute a wide range of illicit commodities, with no restriction on the type of drugs they trade in online. The increasing professionalism of darknet markets suggests to law enforcement observers that criminals involved in distributing drugs via street dealers are increasingly using darknet market trading as an additional distribution channel and revenue stream. Law enforcement actions such as taking down major marketplaces have only a short-term effect, as both vendors and customers will move to alternative sites or new darknet markets will emerge.

In 2014, the European Court of Justice ruled that retention of data by internet service providers for law enforcement purposes was no longer legal, a ruling that has been interpreted and implemented differently in EU member states. Though its ultimate impact is uncertain, the ruling has reduced the ability to effectively prosecute online criminal activity. While international legislative instruments do exist, differences with domestic law often impede criminal investigations with an international dimension. An additional difficulty is the sometimes cumbersome nature of international cooperation, which often slows the investigative process, an important consideration in gathering electronic evidence. While a sustainable response to illegal online markets will require a significant increase in cybercrime expertise, a number of more traditional responses have been reasonably effective, including monitoring of postal and parcel deliveries.

Drug sales account for around two-thirds of all cryptomarket transactions reviewed. Effective responses to cybercrime require the same technological ability and innovative thinking as that displayed in criminal practice. This study provides the conceptual framework necessary to understand developments in this area. It includes an EU-focused analysis of darknet operations and of the challenges faced by law enforcement in responding to it. Market disruption needs to form part of an integrated set of measures, including identifying and targeting major vendors, dealing with key elements in the supply chain, and the development of responses that are technologically informed, coordinated and collaborative. Implementation of this response will require increased investment to support specialist investigation capacities. There needs to be pooling of resources at the European level to coordinate activities across jurisdictions, especially in light of recent judicial decisions. A framework for improving criminal justice in cyberspace is set out in the recent European Council conclusions.⁴

There are significant knowledge gaps around the darknet trade in drugs, especially regarding the actors and mechanisms not apparent through observation of online transactions. Currently, very little is known about the sources of drugs supplied on darknet markets or how the supply chain is organised (see Figure 3). It is also important to get a better understanding of what makes buying and selling online attractive and why online behaviour changes according to region. Potential further threats include development of decentralised software and new encryption technologies; changes in parcel delivery services; integration of local markets with online markets; and greater concentration on national online markets to avoid customs detection. Future software developments may allow websites to be hosted across several servers, countering current responses that involve targeting specific servers. This development, combined with innovative use of social media, instant messaging and GPS, may enable a highly efficient drug distribution network linked to local markets undermining existing markets and posing greater challenges to law enforcement. As yet, this remains a potential threat, but it underlines the importance of systematic monitoring of anonymous online activity.

1  European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol (2017) Drugs and the darknet: perspectives for enforcement, research and policy. Luxembourg: Publications Office of the European Union. https://www.drugsandalcohol.ie/28246

2  Europol (2017) European Union Serious and Organised Crime Threat Assessment (SOCTA): crime in the age of technology.
The Hague: Europol. Available at: https://www.europol.europa.eu/activities-services/main-reports/european-union-serious-and-organised-crime-threat-assessment-2017

3  Soska K and Christin N (2015) Measuring the longitudinal evolution of the online anonymous marketplace ecosystem. In Proceedings of the 24th USENIX Security Symposium, Washington DC, 12—14 August 2015, pp. 33—48. Available online at: https://www.usenix.org/system/files/conference/usenixsecurity15/sec15-paper-soska-updated.pdf

4. Council of the European Union (2016), Council conclusions on improving criminal justice in cyberspace of 9 June 2016, doc. 10007/16. Available online at: https://www.consilium.europa.eu/media/24300/cyberspace-en.pdf

A recent systematic review examining treatment for opioid use and outcomes among older adults was published in the journal, Drug and Alcohol Dependence.¹ The review aim was first to identify and distil key literature on ageing among people treated for opioid use, and secondly to investigate immediate treatment outcomes such as retention and abstinence.

The review consisted of targeted databases searches, supplemented by manual grey literature searches. Only articles explicitly involving individuals who received addiction treatment for opioid use were included in the study. The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and 76 papers were included in the review synthesis. The study lists a number of factors why large numbers of opioid users are living longer. These include:

(1) Demographic changes and increased life expectancy in the general population,

(2) ageing baby-boom and post-baby-boom cohorts (50 years-and-older age group) who experienced increasing levels of drug availability over time along with higher rates of illicit drug use during their youth, (3) developments in and improved access to healthcare, harm reduction and drug treatment services leading to increased longevity among drug users.

The authors found:

• The numbers of older drug users have been increasing internationally for the last 40 years, yet there is a dearth of literature addressing problematic drug use among older people.
• Evidence from epidemiological surveys and treatment admissions within developed countries show that people with opioid-use problems are ageing. This trend is likely to grow for the next two decades and place new demands on drug treatment services.
• There is no consensus in the literature on the definition of ‘old’, which ranges from 37—55, 40+, 45+, 50+, 60+, 65+, 49—61, 50—59, and 50—74 years of age.
• Issues relating to problem opioid use among older people have only recently been recognised and the literature calls for more attention to be given to this topic.
• Little is known about the characteristics of ageing among the opioid treatment population and there has been little discussion of appropriate treatment services for this group.
• Existing research on older adults is predominately from the United States and mainly involves alcohol and prescription medications, while existing larger-scale longitudinal studies tracking treatment and health outcomes have failed to include a significant sample of older people.
• Only a handful of studies have examined opioid treatment admissions among older adults. However, these studies are mainly small convenience samples that treat older adults as a homogenous group and/or compares them to their younger counterparts.
• Research lacks large quantitative studies explicitly examining the area, and existing treatment monitoring systems are not being utilised.
• Although opioid treatment numbers are decreasing, the average age of treatment admissions is increasing.
• Current literature points to the existence of two distinct types of older opioid substance users (early and late-onset subgroups), which have yet to be studied in depth.
• Although limited, there is some evidence that older treatment clients achieve better treatment outcomes than younger counterparts, and older women achieve better treatment outcomes than men.
• The ageing opioid-using population will present many challenges for policymakers and healthcare providers who are typically accustomed to working with younger drug users.

The authors note that important issues related to the care of older people with substance use problems (medical, psychiatric, multimorbidity, cognitive decline, social isolation, mediation drug interactions, burden of medications, etc.) have been excluded due to the narrow focus of the review. However, they note that outcome measures such as employment and involvement in criminality may be less appropriate for the older population, particularly in the case of the late-onset group who are at a later stage of life and financial security.

The article highlights that much work is required to effectively prepare for and respond to the needs of older people, including developing effective prevention and treatment responses (service availability, treatment models, workforce awareness and training), developing tools to measure substance use and abuse among older adults, and providing adequate data to measure emerging problems and predict future trends.

The study concludes that ageing populations who use opioids are a neglected topic within the literature, and highlights the importance of understanding their specific needs in order to prepare for and deliver appropriate care. Problematic drug use (of which opioids make up the largest proportion) had been incorrectly assumed to end as people age. The authors recommend further research using large samples to investigate subgroups in more detail.

This study looked at intentional drug overdoses (IDOs) involving pregabalin and gabapentin that were treated in emergency departments (ED) in Ireland, from 2007 to 2015, as recorded by the National Self-Harm Registry Ireland.¹ For more in-depth information on pregabalin and gabapentin (gabapentinoids), see the overview on page 11.

Results

The annual number of IDOs involving gabapentinoids increased year on year from 0.5% in 2007 to 5.5% in 2015. In 2015, there were 369 IDOs involving gabapentinoids, the highest number recorded in the study period. In total, there were 72,391 IDOs between 1 January 2007 and 31 December 2015. Of these, 2,115 (2.9%) were known to involve a gabapentinoid. Pregabalin was involved in 1,953 cases (2.7% of total IDOs; 92.3% of total known gabapentinoid IDO).

Of those IDOs involving gabapentinoids, the majority were women (59.9%), with a median age of 37 years (74.6% were aged 24—54 years). Over one-half (52.4%) involved multiple drugs, while over one-third (37.2%) involved alcohol.

Compared to those IDOs that did not involve gabapentinoids, the study group was older (median age 37 compared to 32 years); took significantly larger number of tablets (30 compared to 21); had less alcohol involvement (37.2% vs 42.8%); and were more likely to be admitted to hospital (general or psychiatric) (39.1% vs 34.0%).

Discussion

This large study showed the significant increase over a 10-year period in IDOs presenting to EDs involving gabapentinoids, typically involving more women and those in early/middle age. This increasing trend in the number of IDOs involving gabapentinoids reflects the international evidence. International evidence also shows that women are more likely to attempt an IDO and are more likely to take an antiepileptic (one indication for gabapentinoids) and are more likely to be prescribed an antiepileptic. This may explain why there were more women than men treated for IDOs involving gabapentinoids.

The authors note with concern the involvement of alcohol, even though it was slightly lower for IDOs involving gabapentinoids compared with other drug groups. Evidence shows that involvement of alcohol in an IDO is associated with repeat attempts, impacts on patient treatment and hospital resources. Mixing prescription drugs with alcohol also increases the risk of fatal overdose, particularly as both the gabapentinoids and alcohol are central nervous system depressants. The study also showed that this group was more likely to be admitted to hospital, again mirroring other research that shows that IDOs involving antiepileptics require more intensive medical and psychiatric treatment.

The large number of tablets consumed by this particular group is also worth mentioning. Often cases of larger numbers of tablets taken are associated with higher suicidal intent. However, choice of drug in IDO is mostly determined by availability, so it may be more reflective
of prescribing trends.

A number of limitations were highlighted by the authors. The study does not have information on intent, whether it was suicide or misuse. Another limitation is that the numbers of tablets taken were self-reported; however, where possible, the National Self-Harm Registry tries to corroborate information with other sources. It also does not report if any of the study group had a history of misuse of other drugs.

The authors state that this study shows the importance of responsible and vigilant prescribing for all psychotropic drugs, including gabapentinoids, in particular for those with a history of previous IDO and/or a history of drug misuse or dependence.

The dearth of literature examining the relationship between economic recessions and drug markets has indicated that economic recessions mainly result in higher drug consumption and drug dealing. A recent study carried out by James Windle at University College Cork examined this relationship from an Irish perspective.¹ Although the trends presented here have already been presented in the Irish national report on drug markets and crime (2016),² Windle extended the findings by putting forward explanations as to why these trends have occurred.

Methodology

Controlled drug offence data (2004—2015), recorded by An Garda Síochána (AGS) on their police using leading systems effectively (PULSE) system and published in annual reports by the Central Statistics Office (CSO), were analysed. This data acted as a proxy for consumption and drug dealing.

Results

As illustrated by the CSO data, possession of drugs for personal use and sale or supply reached a peak in 2008 and mainly declined thereafter (Figure 1). A similar trend was shown in Figure 2, where controlled drug offences peaked in 2008 and declined thereafter.

Figure 3 shows that trends for importation drug offences were similar to trends shown in Figures 1 and 2. However, trends for cultivation or manufacture initially showed a steady increase before the recession (2004—2008). But, during the recession it thrived; a ‘dramatic increase’ was shown between 2009 and 2011. Although a decline was evident thereafter, the number of incidents remained higher than levels shown before 2009.

In an attempt to explain the Irish drug market trends, Windle put forward two hypotheses.

Hypothesis 1: emigration

Windle argued that the trends evident in Ireland contrast with the international literature, which has suggested that during a recession drug consumption and drug dealing should increase. As this was not the case in Ireland, he proposed that emigration might be a more apt explanation for the Irish findings. Drawing on Irish data from the CSO, he stated that between 2006 and 2013, emigration increased from 36,000 to 89,000; a large number of these individuals were unemployed young people. This cohort is known to have higher levels of drug consumption.

Hypothesis 2: adaptation

The second hypothesis put forward focused on cannabis and postulated that Irish dealers and consumers adapted to having a reduced income by growing their own product, which contributed to a decline in the importation of drugs. Evidence to support this argument can be seen in Figure 4, where a major increase in cannabis plant seizures was evident between 2010 and 2012. Windle argued that the steady increase in cultivation illustrated before and during the recession could be construed as evidence that the recession resulted in adaption. However, he also noted that there is a number of other explanations for increased cannabis cultivation, which are not related to the recession. These include, for example, import substitution (i.e. growing the product closer to the consumer), being more cost effective, allowing control over quality and taste, and having no contract with criminals.

Limitations and future research

Throughout this paper, the author and others have acknowledged the extensive limitations of the data recorded by AGS.^3,4 That being said, it is recognised in academic research that there are advantages to using official data as it not only allows for trends over time to be examined but also acts as a primary source of information related to criminal activity in Ireland. The author made a number of suggestions for further research. For example, triangulating existing data with other types of quantitative and/or qualitative data; accounting for Irish citizens who emigrated during the recession and comparing them with those that stayed; and whether austerity measures, such as reduced Garda visibility, resulted in a reduction in recorded controlled drug offences. Finally, as the outcomes of the recession may not be fully known for 10 to 20 years, Windle identified the need for longitudinal research to follow children born in the recession until adulthood.

Conclusion

Windle concluded that changes in the drug market witnessed in Ireland may be due to young people leaving Ireland to seek work, which resulted in a reduction of potential consumers. Those that remained availed of advances in technology and communications to produce their own cannabis, which would have impacted further on the quantity of cannabis being imported into Ireland. The change evident in Ireland was consistent with those seen in other industrialised nations; however, the outcome was probably exacerbated by the recession. Windle argued that these changes illustrate Ireland’s global interconnectedness and emphasised the importance of recognising and understanding the influence of global and regional drug market trends on the local environment.

2  Health Research Board (2017) Focal Point Ireland: national report for 2016 — drug markets and crime. Dublin: Health Research Board. http://www.drugsandalcohol.ie/25286/

3  Central Statistics Office (2016) Review of the quality of crime statistics 2016. Cork: Central Statistics Office. http://www.drugsandalcohol.ie/26176/

4              Central Statistics Office (2015) Review of the quality of crime statistics. Dublin: Government of Ireland. http://www.drugsandalcohol.ie/24887/

 On 13 February 2017, Dr Sean Redmond, adjunct professor of youth justice at the School of Law in University of Limerick, launched the Lifting the lid on Greentown report, which examined the effect of a criminal network on the offending behaviour of children between 2010 and 2011 in a regional Garda sub-district outside Dublin referred to as Greentown.^1,2

Purpose and method

Work in this area is ongoing; a second study aimed to determine whether the results of the original study could be extended beyond Greentown.³ Similar to the first study, three research questions were addressed:

1. Is there evidence of children sharing the same general profile found in the original Greentown study in localities across Ireland?
2. Is there evidence of children’s involvement in criminal networks found in the original Greentown study in localities across Ireland?
3. If so, is there evidence of hierarchical difference in such networks that are determined by membership of dominant families?

Survey respondents

Garda juvenile liaison officers (JLOs) who were involved with the Garda Diversion Programme (GDP) across Ireland were invited to respond to a survey exploring their knowledge of the involvement of children in criminal behaviours. The response rate was high (90%) and indicated that all local Garda sub-districts were represented in this survey.

Findings

Responses from JLOs suggested that the profile and experiences that children had in other criminal areas across Ireland were in the main similar to those found in Greentown. For example:

• 86% of JLOs reported that children, in particular males (94%) aged 16 to 17 years (71%), took part in serious and persistent crime.
• JLOs believed that one in eight children involved in the GDP in rural and urban areas fit the same profile as those found in Greentown.
• Risk factors included a range of vulnerabilities; for example, being out late at night unsupervised, taking alcohol (97%) and taking drugs (88%). Welfare issues were also evident, for example, 77% of children were involved in welfare investigations.
• This lifestyle was deemed to appeal to young people as it provided access to drugs/alcohol (91%) and money (95%), on one level, and respect (89%), power (87%) and a sense of belonging (81%) on another.

Consistent with the Greentown study, evidence based on three indicators suggested that some children participated in criminal networks in these areas:

• Children referred to JLOs mainly lived in poorer areas (80%) with excessive antisocial behaviour (79%). Neighbourhoods were dominated by fear, intimidation and coercion. For example, residents were afraid of negative repercussions (80%) and believed those involved in crime would follow through on violent threats (84%). In consequence, crimes were not reported (72%) and no one would act as a witness (73%) to bring offenders to justice. A number of these children participated in criminal networks.
• Children participating in criminal networks learned practical skills, such as committing crime (86%), manipulating the justice system (91%) and manipulating authority (86%), from adults who had the most influence over them. Notably, these children were not likely to be loved or appreciated (43%).
• JLOs emphasised the challenges for children to disengage from crime. This was influenced by the level
  of trust (71%) and bond (71%) between the adult and
  the child. Moreover, having friends that were mainly involved in crime was viewed as a major barrier to disengagement (72%). Making children accountable for their criminal actions (65%), the desire to disengage (54%), and having an effective path away from crime (60%) were thought to be factors that would deter offending behaviour in children.

The Greentown study indicated that the criminal network revolved around one dominant criminal family. Children related to the family, referred to as family members, thereafter benefited from having a higher status than children that were not related, referred to thereafter as associates. In addition, family members were ‘relatively sheltered’ and did not have the same welfare issues. In this study, some of the findings of this part of the analysis were in contrast to the findings of the Greentown study. In the main, JLOs reported that family members were at higher risk and received less protection than associates. For example:

• The majority of family members participated in criminal activity before the age of 12 (92%), which was more than twice the proportion reported by associates (42%).
• In general, children involved with serious and persistent crime were viewed as vulnerable and as having complex needs. However, the results showed that family members were unlikely to experience protective factors.

As illustrated in Table 1, JLOs believed that associates were more likely to experience higher protective factors than family members.

Despite these findings, there was also evidence in support of the findings of the original study. Consistent with the Greentown study, for example, the majority of family members became involved in crime in order to live up to the family reputation (97%), to feel protected (77%), and because they believed that they had no choice (54%). Family members were also 50% less likely than associates to move to a new location to disengage from the network, from family members (34%) and from associates (60%).

Moreover, similarities were evident regarding the home life experienced by children. Parents of family members were more likely to be involved in crime (92%), convicted within the last six months, and were more likely to encourage criminal behaviour in their children (80%) than parents of associates, 37%, 17%, and 42%, respectively. However, in contrast to the Greentown study, parents of family members were more likely to have problems with alcohol and drugs (77%) and be argumentative with authority figures (95%).

JLOs identified how adults influenced family members and associates into criminality:

• Family members were influenced by adults who were male (87.5%), a family member (76%), and aged over 36 years (55%).
• The influence of this adult, more often a father, was higher if children were family members (89%). He instilled a sense of pride in the family’s reputation (86%), threatened violence (81%) and threatened aggression as a form of discipline (75%).
• However, associates were more likely groomed by adults, who were younger non-family members (‘recruiters’, p. 2) and by building a trusting relationship (79%).

Limitations

As acknowledged by the authors, a number of limitations was evident. Although the JLO response rate was high, the survey relied heavily on the perceptions of one profession. Hence, the results reported here may have been susceptible to respondent subjective bias. It utilised a cross-sectional design that only provided one ‘snapshot’ of what was happening at a specific point in time (p. 13). The authors highlighted the need to carry out longitudinal research and to avail of other sources for data collection, including other professionals, children and families involved. Further research also needs to examine hierarchical differences between those children categorised as family members and associates, as evidence in this study was contradictory.

Conclusion

In the main, the findings of this study have suggested that the JLO profile of children involved in serious and persistent crime was similar to the profile of children established in the Greentown study. Moreover, it is believed that these children were also involved with criminal networks. Evidence regarding the existence of hierarchies within networks outside Greentown was inconsistent.

Work by this research group continues. The Greentown study has been replicated in two other locations and they are in the process of analysing data collected from an expert panel group to inform the development of an intervention to reduce child engagement with criminal networks.

2 Guiney C (2017) Lifting the lid on Greentown. Drugnet Ireland, 61: 13—14. http://www.drugsandalcohol.ie/27205/

3  Naughton C and Redmond S (2017) National prevalence study: do the findings from the Greentown study of children’s involvement in criminal networks (2015) extend beyond Greentown? Interim report. Limerick: School of Law, University of Limerick. http://www.drugsandalcohol.ie/28326/

The Lifeskills survey is carried out by the Department of Education and Skills in primary and post-primary schools.¹ Data have been collected in 2009, 2012, 2015 and a fourth round is expected to be carried out in 2018.² The findings of the 2015 Lifeskills survey were published in July 2017.³

The survey

The Lifeskills survey focuses on skills being taught in schools that ‘are for life’ (p. 64), including physical activity and healthy eating; aspects of Social, Personal and Health Education (SPHE) and Relationships and Sexuality Education (RSE); anti-bullying; substance use; and road safety. In 2015, extra questions were added on: links between primary schools and early years’ settings; education for sustainable development; and, interaction with the entrepreneurial sector — both business and social. Survey questions focus on school policies, programme content and delivery. The findings are predominantly descriptive of outputs in the areas of interest (see Table 1). However, the survey attempts to deal with some more complex issues that may be beyond the scope of its design. For example, it asks ‘do students in your school know what to do, if bullied?’ with response options ‘yes/no’. While 99% of post-primary schools responded ‘yes’ to this question, it is unclear what this assessment is based on (p. 22).

Lifeskills is an online survey of schools and participation is voluntary. It is unclear from the report who completes the survey and whether or not this is consistent between schools. However, the survey is described by the authors as representing the ‘perspective of the school community’ (p. 54). In 2015, there was a response rate of 53% from the primary schools, down from 68% in 2012; and, 33% from post-primary schools, down from 52% in 2012. In relation to the post-primary school response rate, the authors noted the drop in participation as ‘very significant and a concern for the Department’ (p. 28).

Substance use

Substance use is one of the topics covered in the report. Schools were asked about whether a substance misuse policy was in place; whether parents contributed to its development; which topics were covered in related lessons; how challenging the school found it to teach in this area; and which outside agencies were involved in the delivery of work on this topic.

The findings for primary schools were:

• 88% of schools were either in the process of developing a policy or had one in place, while 12% had none. This is the same level as 2012. It is unclear from the report what proportion of the 88% of schools was only ‘in the process’ of developing a policy.
• Of those schools that had a substance misuse policy in place, 66% reported that parents were consulted on the development of the policy.
• 90% of schools reported that they address the topics of ‘awareness of and combating drug abuse’, ‘awareness of and combating alcohol abuse’ and ‘awareness of health risks of smoking’ with pupils. In addition, over 97% of schools reported that they addressed ‘resisting peer pressure’ and ‘making sound decisions’. These findings are all similar to 2012.
• 56% of schools described substance misuse as challenging or very challenging to teach, while 44% reported that it was not challenging to teach.
• 94% of schools used the Walk Tall⁴ programme to support teaching pupils about substance misuse. Twenty-two per cent used an external agency to help them to deliver their substance misuse programme. The main agencies used by primary schools were An Garda Síochána and the local drugs taskforce.

The findings for post-primary schools were:

•  
• 95% of schools either had a substance misuse policy or were in the process of developing one. As with the primary schools, it is unclear from the report what percentage actually had an active policy.
• 87% of schools had consulted parents in the development of their substance misuse policy, 13% had not.
• All of the schools reported that they address the topics of ‘awareness of and combating drug abuse’, ‘awareness of and combating alcohol abuse’ and ‘awareness of health risks of smoking’ with pupils.
• Three-quarters of schools reported using On My Own Two Feet⁴ to support them in their work in this area.
• 56% of schools found it a challenging topic to teach; 49% reported it as somewhat challenging, and 7% as very challenging. Forty-four per cent of schools reported that it was not challenging to teach.
• 48% of schools reported bringing in external agencies to support the delivery of their work in this area. The main agencies used were An Garda Síochána and the Health Service Executive.

Concluding comment

In its introduction, the report is described as providing ‘evidence of the very good work being undertaken by respondent schools/centres in helping their learners to develop the key skills and resilience necessary to cope with the many demands and pressures they face both within and outside their learning environment’ (p. 12). However, the methods used do not allow for any insights into the quality and effectiveness of, for example, the policies and what is being delivered to pupils. These are critical considerations when exploring schools’ delivery on addressing pupils’ needs in this area.

The authors identify a number of issues that need to be addressed to improve and support the delivery of lifeskills in the school environment. In relation to substance use, the focus is on providing staff with continued professional development to make the delivery of sessions ‘less challenging’. It is beyond the scope of the survey to reflect on the content and mode of delivery. However, some findings would suggest the need to explore further how the Department of Education and Skills can best facilitate schools in delivering programmes in line with the current evidence of best practice. For example, the finding that An Garda Síochána is involved in the delivery of classroom sessions on substance misuse in some schools is not in line with international best practice guidance.⁵

2 Department of Education and Skills (2014) Results of the Department of Education and Skills ‘Lifeskills’ survey, 2012. Dublin: Department of Education and Skills. http://www.drugsandalcohol.ie/21391/

3  Department of Education and Skills (2017) Lifeskills survey 2015. Report on survey findings. Dublin: Department of Education
and Skills. http://www.drugsandalcohol.ie/28560/

4  The Walk Tall and the On My Own Two Feet programmes are substance misuse prevention programmes, which have been integrated into the national SPHE curriculum for primary and post-primary schools, respectively.

5              As reported on in an earlier issue of Drugnet Ireland, the United Nations Office on Drugs and Crime (UNODC) has found that programmes that use police officers to deliver classroom sessions have no or negative prevention outcomes. See Dillon L (2017) ‘What works’ in drug education
and prevention? A review, Drugnet Ireland 61: 17—19. www.drugsandalcohol.ie/27211/1/Drugnet_61_final.pdf

The National Family Support Network (NFSN)¹ is an autonomous self-help organisation that provides support to families and respects the experiences of families affected by substance misuse in a welcoming non-judgemental atmosphere. On Thursday, 1 February 2018, the NFSN held its 19th Annual Service of Commemoration and Hope. This spiritual, multidenominational service is held in remembrance of loved ones lost to substance misuse and related causes and to publicly support and offer hope to families living with the devastation that substance misuse causes. Those in attendance included the Lord Mayor of Dublin, Mícheál Mac Donncha; Comdt Caroline Burke, aide-de-camp to An Taoiseach; Archbishop Diarmuid Martin; Archbishop Michael Jackson; Bishop Eamonn Walsh; and other religious representatives, as well as family members, friends, and many people involved in substance misuse work. Music was provided by the soprano Nickola Hendy and the High Hopes Choir.

In her address to the gathering, Sadie Grace, coordinator of the NFSN, spoke directly to family members, stressing that they are not alone. She highlighted the latest report from the National Drug-Related Deaths Index (NDRDI), which showed that 695 deaths occurred in 2015 directly or indirectly due to drug use. The NFSN advocated strongly for accurate figures on drug-related deaths and, as a result, the NDRDI was established in 2005. However, she stressed the importance of more detailed research on the impact that drug-related deaths have on families left behind. She mentioned important research carried out by Prof Sharon Lambert in this area, which highlights the stigma and shame felt by family members. Sadie emphasised the positive impact that support services provide in helping family members deal with all aspects of bereavement, and encouraged family members to contact the NFSN and avail of assistance from the bereavement support group programme.

Sadie spoke about the impact of drug-related intimidation and the need for real action and leadership to respond to the high level of intimidation in Dublin’s north inner city. In her closing statement, she spoke of the NFSN’s resilience to continue to advocate on behalf of families who have lost their children to drug-related deaths, and called on stakeholders to ensure actions, including those outlined in the new drugs strategy, are put into practice.

In her address, Minister of State Catherine Byrne TD emphasised the valuable work of the NFSN, including the importance of the NFSN being involved in the consultation process for the new National Drugs Strategy. She also mentioned the role of naloxone in helping to prevent deaths from opiate overdose and the importance of expanding the availability of naloxone nationwide. She stressed her commitment as Minister of State to continue to highlight the impact of drug-related deaths and welcomed the health-led approach and actions on family support included in the new strategy.

Hannah Rodriguez from UISCE, a forum for drug users in Dublin’s north inner city, highlighted the importance of UISCE being included in the consultation process for the latest National Drugs Strategy and welcomed the medical approach to supporting people who use drugs and the use of person-first terminology. She acknowledged the work of the NFSN in helping to dissolve the stigma attached to people who use drugs and their families.

In his address, Archbishop Diarmuid Martin spoke of the current horror, violence, brutality and intimidation in the drug scene. He stressed the debt of society to NFSN members for their support and understanding to others in grief.

For many families, this service was the first time that they could openly grieve for loved ones lost to drug use and related causes. The volume of family support groups was evident, with support groups from across the island of Ireland represented at this year’s service. Personal testimonies were given by members of family support groups, reflecting the vital support received through these groups. These included Terry Byrne, a member of North Star Family Support Project, who highlighted the vital importance of peer support groups, members of which support each other and provide a sense of belonging in a welcoming non-judgemental atmosphere with no stigma attached.

Finally, Marian Davitt gave a heartfelt speech about her experience of grief after the death of her son and the invaluable support she received through the bereavement support group. She encouraged people to look for support.

The NFSN runs a 10-week bereavement programme twice a year and family members can contact the NFSN and avail of assistance from this group.

The following abstracts are cited from published journal articles recently added to the repository of the HRB National Drugs Library at www.drugsandalcohol.ie

Moylett S and Hughes BM (2017)
Addictive Behaviors Reports, 6: 56–64.
http://www.drugsandalcohol.ie/28433/

The study presented one of the first examinations of the associations among personality, alcohol-related protective behavioural strategies (PBS), alcohol consumption, sexual intercourse and sex-related alcohol negative consequences in Irish, female college students (n=522).

The findings of this study posited that the use of PBS has a key role to play in the levels of sexual intercourse and alcohol consumption, age and openness, and the associated negative sexual consequences in Irish, female college students.

Barrett P, Griffin E, Corcoran P, O’Mahony M and Arensman E (2018) Journal of Affective Disorders, 229: 523–31.
http://www.drugsandalcohol.ie/28457/

The study aim was to estimate the incidence of self-harm among the homeless population and to assess factors associated with self-harm.

There is a disproportionate burden of self-harm among the homeless. Targeted preventive actions are warranted.

O’Rourke C, Linden MA, Lohan M and Bates-Gaston J (2016)
Brain Injury, 30(7): 839–54.
http://www.drugsandalcohol.ie/28446/

The aim of this review is to systematically explore the literature surrounding the rates of TBI and their co-occurrences in a prison population.

The high degree of variation in TBI rates may be attributed to the inconsistent way in which TBI was measured, with only seven studies using valid and reliable screening tools. Additionally, gaps in the literature surrounding personality outcomes in prisoners with TBI, female prisoners with TBI and qualitative outcomes were found.

Van Hout MC, Benschop A, Bujalski M, Dabrowska K,
Demetrovics Z, Felvinczi K, et al. (2018) International Journal
of Mental Health and Addiction, 16(2): 480–95.
http://www.drugsandalcohol.ie/28500/

This study describes health and social consequences of recent NPS use as reported in a survey of marginalised, nightlife and online NPS users in the Netherlands, Hungary, Portugal, Ireland, Germany and Poland (n=3023).

Marginalised users reported substantially more acute side effects, more mid- and long-term mental and physical problems, and more social problems. Development of country-specific NPS awareness raising initiatives, health and social service needs assessments, and targeted responses are warranted.

Daly C, Griffin E, Ashcroft DM, Webb RT, Perry IJ and Arensman E (2017) Clinical Drug Investigation, 38(4): 373–80.
http://www.drugsandalcohol.ie/28436/

This paper examines the trends in the prevalence of gabapentinoids taken in Intentional drug overdose (IDO), the profile of individuals taking them, and associated overdose characteristics.

It is important for clinicians to exercise vigilance while prescribing gabapentinoids, including being aware of other medications that their patients may have access to. Our findings support the need for routine monitoring for signs of misuse among those prescribed gabapentinoids.

McNamara PH, Coen R, Redmond J, Doherty CP and Bergin C (2017) Open Forum Infectious Diseases, 4(1): ofw242.
http://www.drugsandalcohol.ie/28177/

Human immunodeficiency virus (HIV)-associated neurocognitive disorders occur in 20%—50% of HIV-positive patients. We undertook this study to assess the prevalence of a positive screen for cognitive impairment in the clinic population at our institution and to demonstrate the feasibility of implementing a screening program in routine clinical encounters.

The study highlights the necessity for a structured, prospective, large-scale screening program for cognitive impairment across countries with limited resources and demonstrates the feasibility of easily implementing this with minimal training.

Different drinking motives, different adverse consequences? Evidence among adolescents from 10 European countries
Wicki M, Kuntsche E, Eichenberger Y, Aasvee K, Bendtsen P, Dankulincová Vselská Z, et al. (2017) Drug and Alcohol Review, 36(6): 731–41.
http://www.drugsandalcohol.ie/28172/

This study, which builds on previous research demonstrating that drinking motives are associated with adverse consequences, investigates the associations between drinking motives and non-alcohol-attributed adverse consequences and disentangles alcohol-related and direct effects.

While the actual mean level of drinking motives, alcohol use and adverse consequence varied across countries, the consistency of association patterns implies that drinking motive-inspired health promotion efforts are likely to be beneficial across Europe. This is particularly important for coping drinkers because they are especially prone to adverse consequences over and above their alcohol use.

Barsties LS, Walsh SD, Huijts T, Bendtsen P, Molcho M, Buijs T, et al. (2017) Drug and Alcohol Review, 36(6): 769–78.
http://www.drugsandalcohol.ie/28171/

This internationally comparative study examines differences in alcohol consumption between first- and second-generation immigrant and native adolescents. We also investigate to what extent origin and receiving country alcohol per capita consumption (APCC) rates and proportions of heavy episodic drinkers (HED) are associated with immigrant adolescents’ alcohol consumption.

Our results suggest differences in lifetime frequencies of alcohol use and drunkenness between natives and first- and second-generation immigrant adolescents. Origin country APCC and HED seem to affect immigrant adolescents' alcohol consumption differently than receiving country
APCC and HED.

Moriarty J, McVicar D and Higgins K (2016) Social Science & Medicine, 163: 37–44.
http://www.drugsandalcohol.ie/28397/

Peer effects in adolescent cannabis are difficult to estimate, due in part to the lack of appropriate data on behaviour
and social ties. This paper exploits survey data that have many desirable properties and have not previously been used for this purpose.

We conclude that cross-sectional data can be used to estimate plausible positive peer effects on cannabis use where network structure information is available and appropriately exploited.

Larkin C, Griffin E, Corcoran P, McAuliffe C, Perry IJ and Arensman E (2017)
Crisis, 38(6): 413–22.
http://www.drugsandalcohol.ie/28375/

This study sought to identify factors associated with alcohol consumption in cases of suicide and nonfatal self-harm presentations.

Alcohol consumption commonly precedes suicidal behavior, and several factors differentiated alcohol-related suicidal acts. Self-harm cases, in particular, differ in profile when alcohol is consumed and may require a tailored clinical approach to minimize risk of further nonfatal or fatal self-harm.

McMahon EM, Corcoran P, Keeley H, Cannon M, Carli V, Wasserman C, et al. (2017) BJPsych Open, 3(6): 291–99.
http://www.drugsandalcohol.ie/28369/

This study aims to examine the prevalence of emotional and behavioural difficulties, suicidal ideation and suicide attempts among migrant adolescents and their non-migrant peers.

Appropriate mental health services and school-based supports are required to meet the complex needs of migrant adolescents.

Dolphin L, Fitzgerald A and Dooley B (2017) Early Intervention in Psychiatry. Early online.
http://www.drugsandalcohol.ie/28353/

Risky sex behaviours among college students are a growing public health concern. However, few studies have profiled these behaviours using a large range of psychosocial correlates.

Suggestions are made for sexual education and intervention programs to specifically target subgroups of the student population.

Glynn RW, Byrne N, O’Dea S, Shanley A, Codd M, Keenan E, et al. (2017) International Journal of Drug Policy,
52: 9–15.
http://www.drugsandalcohol.ie/28327/

This study aimed to assess the prevalence of chemsex, associated behaviours and STIs among attendees at Ireland's only MSM-specific sexual health clinic in Dublin over a six week period in 2016.

These results support international evidence of a chemsex culture among a subset of MSM. They will be used to develop an effective response which simultaneously addresses addiction and sexual ill-health among MSM who experience harm/seek help as a consequence of engagement in chemsex.

Ryan M, McFadden R, Gilvarry E, Loane R, Whelan D and O’Neill D (2017)
Irish Medical Journal, 110(10).
http://www.drugsandalcohol.ie/28335/

Irrespective of national guidelines for medical fitness to drive, this study investigated the cumulative expert wisdom of clinicians regarding minimum periods of driving cessation required for patients suffering from conditions that can impair driver capability. Occupational Physicians (196) and Psychiatrists (103) completed an online questionnaire.

Chi-square test results indicated statistically significant differences in clinical opinion between Occupational Physicians and Psychiatrists regarding driving cessation times for drivers suffering from psychiatric and alcohol misuse conditions except for alcohol dependence. Further studies are warranted to investigate these issues in more depth.

Ní Cheallaigh C, Cullivan S, Sears J,
Lawlee AM, Browne J, Kieran J, et al. (2017) BMJ Open, 7(11): e016420.
http://www.drugsandalcohol.ie/28307/

We sought to compare the use of unscheduled emergency department (ED) and inpatient care between housed and homeless hospital patients in a high-income European setting in Dublin, Ireland.

Homeless patients represent a significant proportion of ED attendees and medical inpatients. In contrast to housed patients, the bulk of usage of unscheduled care by homeless people occurs in individuals aged 25—65 years.

Logan C, Asadi H, Kok HK, Looby ST, Brennan P, O’Hare A, et al. (2017) Journal of Medical Imaging and Radiation Oncology, 61(4): 435–40.
http://www.drugsandalcohol.ie/28292/

Alcohol is one of the most commonly abused substances worldwide. It results in a wide range of diseases and disorders affecting many organ systems. Alcohol-related nutritional deficiencies and electrolyte disturbance leave chronic abusers at risk of a range of demyelinating conditions to which the radiologist and clinician should always be alert.

We present an educational review of these entities in terms of their clinical features, neuropathology and imaging features along with a case example of each condition.

Columb D and O’Gara C (2017)
Irish Journal of Psychological Medicine. Early online.
http://www.drugsandalcohol.ie/28197/

The aim of this study is to look at an Irish population in relation to the online gambling activities people are engaging with, the reasons for gambling online, their attitudes to online gambling and the financial/mental health consequences of online gambling.

Online gamblers in Ireland share similar behavioural profiles to online gamblers in the United Kingdom and worldwide. The majority of participants in this research have been adversely affected from both a mental and financial perspective due to their gambling behaviours.

Nestor LJ, McCabe E, Jones J, Clancy L and Garavan H (2018) Brain Research, 1680: 54–61.
http://www.drugsandalcohol.ie/28368/

The present study set out to examine the neural correlates of operant response outcomes in current smokers, ex-smokers and matched controls using a monetary incentive delay task during functional MRI.

The results suggest a pattern of shared and divergent reactivity in current smokers and ex-smokers within corticolimbic regions that track both positive and negative operant response outcomes. Exaggerated adaptive processing in ex-smokers may promote long-term smoking cessation through amplified negative valence outcome monitoring.

Delimata A and Seymour M (2017)
Irish Probation Journal, 14: 92–111.
http://www.drugsandalcohol.ie/28165/

Extended custodial sentences (ECSs) for serious offenders were introduced under the Criminal Justice (Northern Ireland) Order 2008. These sentences combine custody with a subsequent period on supervised licence in the community during which offenders can be recalled to prison should their ‘risk of serious harm’ increase to an ‘unmanageable level’.

Using a documentary file analysis approach, the study investigates the outcomes for all ECS offenders released under supervised licence between 15 October 2010 and 31 December 2013
(n=57).

The paper offers tentative observations as to why some offenders remained under licence in the community and others were recalled to custody. Analysis points to the potential of enhancing pre-release working relationships between offenders and supervisors, strengthening through-care supports to reflect the complexity of offenders’ needs, and focusing on the integration of strengths-based approaches in risk management policy and practice.

Robinson E, Thornton L and Migone C (2017) Forum, 34(11): 46–48.
http://www.drugsandalcohol.ie/28341/

In Ireland there are between 20,100 and 42,000 people with HCV infection, 60% of whom are as yet undiagnosed.

New national clinical guidelines on hepatitis C screening was developed to make recommendations on who should be screened for HCV and how that screening should be done.

Carr N and Maguire N (2017)
Irish Probation Journal, 14: 52–71.
http://www.drugsandalcohol.ie/28303/

The research was commissioned by the Probation Service and was a small-scale, in-depth study exploring the role of PSRs (pre-sentence reports) in sentencing, with a particular emphasis on understanding the process of communication involved from the perspectives of Probation Officers who create the reports and judges who request and receive them.

This paper draws on the findings from the research to explore specific aspects of the use of PSRs. It begins by highlighting certain features of the Irish context and then provides a brief overview of the methodological approach before presenting a summary of selected findings, including those relating to the purpose of reports and variation in their use. We explore some of the key themes arising from the research, including consistency, temporality and contingency. We conclude by noting the potential positives of pausing a process, but highlight the need for greater consistency to ensure equitable access across the country.

Clarke N (2017) Irish Probation Journal, 14: 151–63.
http://www.drugsandalcohol.ie/28305/

The ‘Nothing Works’ and ‘What Works’ debates were central to discourse on recidivism in the 1970s and 1980s. When the outrage subsided and the research based on meta-analysis was reviewed, one simple message for practitioners emerged: some things work with some people some of the time. The challenge is to find the right intervention for the right person at the right time. As agents of change, no practitioner can afford to be a ‘one-trick pony’ but will draw from a toolkit of interventions to address the factors that contribute to offending behaviour.

Programme interventions, specifically CBT-based group work programmes, are recognised as providing an appropriate and structured environment in which to address pro-criminal thinking and attitudes in order to achieve reduced offending and ultimately desistance and reintegration into communities. The Probation Service Strategy 2011—2014 identified the introduction of a range of programmes to enhance and support effective practice as a key goal. The Choice and Challenge Group Programme was the Service’s first nationally approved offending behaviour programme. Developed in accordance with evidence-based principles, its central focus is to challenge negative beliefs and attitudes, promote prosocial behaviours and enhance individual capacity for problem-solving and personal growth and development. This is a narrative about its implementation.

Wall M, Lambert S and Horan A (2017) Journal of Psychoactive Drugs.
Early online.
http://www.drugsandalcohol.ie/28286/

The purpose of this study is to identify the issues highlighted in the data and consequently inform policy development, service delivery, future training, and pathways to support service users (SUs).

Findings indicate that, while practitioners had high levels of confidence in managing community-based detoxes, levels of knowledge of schedules, contraindications, access to support, and appropriate referral pathways were limited. Barriers to supporting detoxes emerged, emphasizing the importance of multidisciplinary and interagency care planning. Changing trends in drug use led participants to indicate a need for pharmacology training and development of specific local protocols.

Tobin H, Klimas J, Barry T, Egan M
and Bury G (2017) Addictive Behaviors. Early online.
http://www.drugsandalcohol.ie/28290/

We examined final-year medical students’ learning experiences and attitudes toward opioid use disorder, overdose and community naloxone provision as an emerging overdose treatment.

Our findings suggest an unmet learning need in undergraduate training on opioid use disorder, with potential consequences for patient care.

O’Farrell A, Kingsland M, Kenny S, Eldin N, Wiggers J, Wolfenden L, et al. (2018)
Drug and Alcohol Review, 37(1): 14–22.
http://www.drugsandalcohol.ie/28266/

The study aimed to test the effectiveness of an intervention to reduce alcohol misuse and related harms amongst amateur sports people in Ireland.

Intervention in community sports clubs may be effective in reducing the number of alcohol-related harms. Low levels of intervention participation and inadequate intervention dose are possible reasons for lack of a broader intervention effect.

Davies EL, Conroy D, Winstock AR
and Ferris J (2017) Addictive Behaviors,
75: 40–46.
http://www.drugsandalcohol.ie/28277/

The aim of the current paper was to explore the experiences that might lead people to reduce their alcohol consumption and to compare these findings between respondents from 21 different countries.

Understanding the different motivations that may lead individuals to change their drinking behaviours can be used to inform targeted brief interventions and targeted public health guidance.

Madureira-Lima J and Galea S (2018) Journal of Epidemiology & Community Health, 72(1): 54–60.
http://www.drugsandalcohol.ie/28342/

Alcohol control policy has a fundamental role in limiting negative health, economic and social harm caused by alcohol consumption. However, there is substantial international heterogeneity in country-level policy adoption, implementation and monitoring.

Comparative measures so far focused on Europe or the Organisation for Economic Co-operation and Development countries.

ACPI offers a measure of alcohol control policy across countries that makes use of a larger number of countries than its predecessors, as well as a wider range of methodologies for its calculation, both of which contribute to its validity. Furthermore, it shows that the statutory strictness of alcohol control policies is associated with lower levels of alcohol consumption.