The Irish promotion of the survey was led by the Health Service Executive (HSE) website Drugs.ie and their affiliated social media channels. Sampling focused on populations accessible through online platforms. People who use drugs but who do not present to addiction services were of particular interest to the survey designers. This group includes a nightlife cohort that is underrepresented in official reports. The survey sought to engage with this population to ascertain if their drug use was continuing outside of the nightlife arena. A series of advertisements were issued with subcultural dance magazines to reach the target audience. Advertisements were place in these magazines and on Facebook and Instagram channels.²

The survey did not attempt to estimate prevalence or the extent of particular drug-using behaviours in Europe. Nevertheless, it provides a useful snapshot of patterns of drug use during Covid-19 restrictions in Ireland among a small cohort of people using drugs at that time and who chose to respond to the survey.

Study demographics

Almost three-quarters (71.2%) of participants were male; 27% were female; 1% identified as non-binary; and 0.9% selected ‘prefer not to say’. Age ranged from 18 to 67 years, with a median age of 26 years. Over one-half (54.1%) lived in a city, 30.9% in a town, and 15.1% in a village.

Drug usage

Respondents were asked about their frequency of drug use in the last year and in the last month for the following substances: cannabis, ecstasy, cocaine, amphetamines, heroin, LSD, synthetic cannabinoids, other synthetic stimulants
(e.g. cathinones), and other opioids without medical prescription (e.g. methadone, buprenorphine, fentanyl, or others) (see Table 1). Last-month use coincided with a period of Covid-19 restrictions. Cannabis was the most commonly used drug, with 85.2% and 64% reporting last-year and last-month use, respectively. While last-year use of both cocaine (71%) and ecstasy (62.6%) was high, last-month use of both substances was much lower (cocaine 29.2%, ecstasy 11.2%).

Impact of Covid-19 restrictions on drug use

Last-year users of each drug were asked if their use of that drug had changed since the introduction of Covid-19 restrictions. Eleven options were provided and respondents could select more than one option (see Table 2). Due to low numbers, the following options are not presented here: started using; used psychoactive medicines instead (e.g. benzodiazepines); used a new psychoactive substance instead; used a different form (e.g. pills, powder, capsule); used by a different route (e.g. changed from injecting to smoking or vice versa); and used other illicit drugs instead.

Table 1: Last-year and last-month drug use by drug type

* Data were only included for respondents who answered both last-month and last-year questions; respondents with contradictory responses, e.g. those reporting last-month use of a drug but reporting never use in the last year, were excluded.

Cannabis users were more likely than cocaine or ecstasy users to use more frequently (32.6%) and in greater quantities (12.5%) since the introduction of the Covid-19 restrictions. Those who used cannabis daily or almost daily were most likely to use more frequently (43.9%) compared with 16.9% of those who used cannabis less than monthly. Just 11.9% of cannabis users stopped using cannabis compared with 39.9% and 46% who reported stopping use of cocaine and ecstasy, respectively.

Changes in illicit drug use since introduction of Covid-19 restrictions

Respondents were asked ‘in general, would you say you have used more or less illicit drugs, since the start of the Covid-19 epidemic in your country?’ Of the 655 valid responses, 36.2% used less, 22.6% used more, 15.4% used the same amount, 23.5% had not used illicit drugs, and 2.3% did not know. The main reasons reported for using less illicit drugs were fewer opportunities to use drugs (65.4%) and reduced availability of drugs to buy (49%) (see Table 3).

Table 2: Changes in cannabis, ecstasy, and cocaine use since introduction of Covid-19 restrictions

* All last-year ecstasy users are presented together, as most respondents (82%) reported less than monthly use.

Table 3: Reasons for decreased and increased drug usage since Covid-19 outbreak

Note: Respondents could select more than one option.

Changes in how illicit drugs were obtained since Covid-19 outbreak

Less than two-thirds (63.2%) of respondents had obtained or attempted to obtain illicit drugs since the Covid-19 outbreak. Of these, 22.6% reported no difficulties accessing illicit drugs; 60.3% reported accessing drugs to be somewhat or moderately difficult; and 17.1% reported extreme difficulty. Those who had obtained illicit drugs reported a number of changes in the way in which they obtained illicit drugs (see Table 4). One-third (33.9%) of respondents who had obtained illicit drugs obtained larger quantities of drugs compared with pre-Covid times, while 28.4% used a different dealer. Of those who had obtained drugs since the Covid-19 outbreak, 22.3% reported that the purity of drugs was lower, while 5.6% reported higher purity; 3.3% reported that the cost of drugs was lower, while 39.9% reported higher costs.

Intention to access treatment and harm reduction professional supports

Regarding professional support, 6.6% reported an increase in their intention to seek professional support to reduce or abstain from illicit drugs since the Covid-19 restrictions, while 11.9% reported an increase in their use of online or remote professional support services to seek support for reducing drug-related risk behaviours and/or drug use.

Table 4: Changes in how illicit drugs were obtained during Covid-19 restrictions

Note:Respondents could select more than one option.

Conclusion

There have been changes in the patterns of illicit drug use since Covid-19 restrictions were implemented in Ireland. Cannabis users were least likely to change their pattern of use, although daily/almost daily users reported using cannabis more frequently. Those who used cocaine and ecstasy prior to the Covid-19 outbreak were more likely to stop using those drugs altogether. The main reason for reduced use of illicit drugs was fewer opportunities available to use drugs, while boredom was the main reason cited for increased use of illicit drugs.

Deirdre Mongan

2   The Health Research Board would like to acknowledge the role of Nicki Killeen (HSE Social Inclusion) in promoting this survey among the target group.

Sometimes the answer to a particular part of a complex problem is simple and obvious. The way to protect particularly vulnerable people, such as those without secure accommodation and at risk in a number of different ways, is to provide them with a place to live and the interventions they need to keep them safe. This was the route taken early in the pandemic. The cocoon metaphor described a particular instance of the Housing First approach, and conveyed a sense of care, protection, and attention at the heart of the response to the needs of people who were homeless and use drugs, particularly in urban areas.

This was an emergency and a literally life-saving intervention. A long-term response will involve a much greater integration of services, careful planning, and consideration of novel approaches. The recent Health Research Board evidence review on treatment services for people who are homeless and use drugs found that failure often stems from the service providers not recognising the breadth and complexity of individual needs. Success depends not only on selecting interventions that are supported by evidence, but also by ensuring that this support is given in a non-judgemental and compassionate way. The service user’s preferences and support from peers need to form part of how the service is delivered if positive outcomes are to be achieved. Sometimes we need scientific support to help us appreciate what we know intuitively to be good and valuable.

In every facet the pandemic is complex. The virus has proved resilient and dangerously mutable. But the response too is complex and adapts and changes as our knowledge of the virus and its transmissibility develops. Health systems design new preventive measures and discover effective treatments in the most trying environments. Patience, generosity, and vigilance have been the defining features of the public response. Social behaviours are not constant but change according to need. Throughout this period, we have learned the importance of careful analysis, the need to integrate insights from the medical and behavioural sciences, and to question easy answers. It may be a lesson we can apply in dealing with more intractable societal problems.

Background

Both reports are grounded in the context of Europe having per capita the highest levels of alcohol consumption, the highest prevalence of heavy episodic drinking, and the lowest rates of abstention from alcohol of any region in the world. In turn, it is estimated that more than one in every 10 deaths in Europe is caused by alcohol consumption.³ The reports reflect two of the 10 priority areas for action to address these harms, as identified in the WHO European Action Plan to reduce the harmful use of alcohol 2012–2020; and subsequently two of the four priority areas in the 2020 report on the consultation on strengthening the implementation of the WHO’s action plan to reduce the harmful use of alcohol.⁴ The pricing and marketing of alcohol are identified as policy areas for which there is ‘very strong evidence that such measures are effective’ in reducing alcohol-related harm
(p. 5).⁴

Alcohol pricing

Alcohol pricing in the WHO European Region¹ summarises the current evidence base for alcohol pricing policies and how this compares with the policies currently in place across the region. Based on the current evidence, the authors argue that increasing the prices that consumers pay for alcohol is one of the most effective tools available to policymakers looking to reduce alcohol consumption and associated harm. Pricing policies have also been found to be cost-effective, especially when the cost savings to healthcare and other public services are taken into account. There is a range of pricing policy options outlined in the report, some of which are found to be more effective in addressing alcohol-related harms and socioeconomic health inequalities than others. Specific taxation linked to inflation and minimum unit pricing (MUP) are the approaches found to be the most effective.

Taxation

Alcohol taxation is identified as the primary mechanism through which governments can influence alcohol prices. There are three ways in which taxation can be applied to alcohol: specific, unitary, and ad valorem (see Box 1). The evidence shows that the best approach from the perspective of improving public health and tackling health inequalities is through specific taxation, by which the tax payable on a product is directly proportional to its alcoholic content. It is argued that the different types of alcohol products (e.g. beer, wine, spirits) should have similar tax rates to avoid a scenario where heavy drinkers are encouraged to drink larger volumes of particular products because they are subject to a lower rate of tax and therefore cheaper. However, where products have low production costs relative to other types of alcohol, it can be justified to apply higher taxes to prevent these products being available to consumers at lower prices. To maximise the positive impact of this pricing strategy, alcohol taxes should also be linked to inflation to prevent the affordability of alcohol increasing over time.

Box 1: Three main approaches to alcohol taxation

Source: Alcohol pricing in the WHO European Region: update report on the evidence and recommended
policy actions, Box 2, p. 3

Minimum unit pricing

MUP attracted a lot of attention in Ireland in the course of passing the Public Health (Alcohol) Act 2018. MUP has a robust evidence base of being effective in reducing alcohol and consumption, especially among the heaviest drinkers. It introduces a floor price below which a fixed volume of alcohol (e.g. a unit or standard drink) cannot be sold to the public. While taxation affects the price of all products, MUP only increases the price of the cheapest alcohol. Since heavier drinkers typically favour cheaper drinks, MUP policies effectively target price increases at heavier drinkers without significantly affecting the prices of alcohol bought by moderate drinkers, who tend not to seek out the cheapest products. The report highlights the finding that MUP is particularly effective in addressing the health inequalities stemming from alcohol-related harm by targeting cheap, high-strength products.

Other pricing policies

Other pricing policies explored in the report are found to be relatively rarely implemented across the WHO European Region. These include applying restrictions or a ban on:

• The sale of alcohol at below the cost the retailer paid for it – ‘loss leaders’
• The sale of alcoholic products for less than the cost of the tax payable on the product
• The discounting of products by alcohol retailers
• Multibuy discounts.

Implementation

The report found that despite the clear evidence in favour of a specific tax system that is indexed to inflation, no country in the WHO European Region has fully implemented this. MUP is also not widely used across the region. The report maps out each country’s approach to pricing policies. Ireland’s basis of taxation (excluding VAT) is identified as specific for beer and spirits and unitary for wine, and that MUP is pending. Logistical and legal barriers are identified to implementing the preferred approach, as well as strong opposition from the alcohol industry. Even where they might wish to implement a fully specific system of alcohol taxation, member states of the European Union (EU) are prevented from doing so. There are EU directives that require wine and other products, including cider, to be taxed on a unitary basis. The report concludes that these restrictions mean that EU countries are unable to implement tax systems that are optimal from the perspective of public health. The report argues for the revision of these directives as a priority for public health.

Alcohol marketing

Alcohol marketing in the WHO European Region² finds that ‘research has shown a correlation between exposure to alcohol advertising and drinking habits – in particular, between youth exposure to alcohol marketing and initiation of alcohol use – and clear associations between exposure and subsequent binge or hazardous drinking’ (p. ii).² As a policy response to this correlation, the regulation of alcohol marketing has been found to be a cost-effective strategy to reduce alcohol-related harm and is recommended by WHO. The report explores the regulation of the marketing of alcohol products in the region.

Implementation of policies

The report finds that most European countries have implemented policies regulating alcohol advertising, especially that which reaches children and young people. These policies range from complete bans with penalties for legal offences to self-regulatory codes of conduct adopted by industry. Research is cited showing that the self-regulatory codes are limited in terms of their effectiveness in regulating the alcohol industry’s activities. While countries vary in their policies, Ireland is one of three countries identified in the report as having the protection of young people most explicitly and effectively taken into consideration through their policymaking.

Changing landscape for marketing

Central to the report² is the changing landscape of the media being used in the marketing of alcohol products and the challenges this presents to regulators. Consumers (including children and young people) are being targeted by marketing messages not just from the traditional channels of television and print media, but also through the internet (particularly through social media) via quickly evolving digital marketing methodologies. The report outlines the ways in which this is happening and draws on research into food brands and how they use digital media to target children and young people.

Digital media have changed the nature of alcohol marketing and the report outlines the complexities that this change presents. For example:

• Those marketing alcohol products not only create their own content but also tap into user-generated content to market their products, which means the boundaries between advertiser and consumer become blurred.
• Research has found that the sharing of content on social media communities that includes alcohol in some way increases the cultural acceptance of alcohol use among members of these communities.
• There are increased difficulties associated with monitoring the age of users and their exposure to alcohol-related content.

Recommended policy options

While the report makes a set of recommendations on how to develop a policy response in an environment characterised by the increasing use of digital marketing methodologies, this environment presents increasing challenges from a legislative and regulatory point of view. The five policy options (Box 4, p. 14)² identified are:

• WHO suggests that bans or comprehensive restrictions on alcohol advertising are one of the top three most effective and cost–effective interventions to address the harmful use of alcohol. Digital marketing should be included in such regulatory frameworks.
• If a complete ban is not feasible, partial statutory restrictions on the content of posts published online should be implemented. In this case, sufficient resources should be earmarked for active supervision and robust enforcement of policies. As thousands of posts are published on a multitude of platforms daily, this is an extensive, yet
  crucial task.
• There is an urgent need to develop a protocol to help distinguish between native advertising, user-generated content and other commercial messages that may be difficult to understand or interpret. The real senders of such material are likely to be invisible to consumers, especially young consumers and children.
• As many young people participate in social media milieus as a natural part of their everyday life, the very least a jurisdiction should do is to demand that alcohol brands properly enforce age verification (age-gating). Implementation of age limits on (for example) Facebook and Instagram pages is technically a small and straightforward matter. This is the least that should be expected to protect children and teenagers, and to ensure that underage users do not gain access to alcohol-related posts.
• Member states should take a consistent stance on the legal obligation of marketers to accurately tag media content and ensure that inappropriate content does not reach children.

Lucy Dillon

2   WHO Regional Office for Europe (2020) Alcohol marketing in the WHO European Region: update report on the evidence and recommended policy actions. Copenhagen: WHO Regional Office for Europe. https://www.drugsandalcohol.ie/32341/

3   World Health Organization (2018) Global status report on alcohol and health 2018. Geneva: World Health Organization. https://www.drugsandalcohol.ie/29701/

4   WHO Regional Office for Europe (2020) Final report on the regional consultation on the implementation of the WHO European Action Plan to reduce the harmful use of alcohol (2012–2020). Prague, Czech Republic, 30 September–1 October 2019. Copenhagen: WHO Regional Office for Europe. https://www.drugsandalcohol.ie/32587/

Drug education vs drug prevention

Drug education is defined by the author as ‘a systematic process of teaching and learning that involves imparting and acquiring knowledge about drugs to achieve understanding’ (p. 3).
He argues that drug education is often misunderstood or conflated with drug information and/or drug prevention.² This leads to drug education programmes being evaluated against inappropriate outcomes, thus making them appear ineffective. Drug education is best understood as a programme that includes knowledge activities with a clear learning aim. Therefore, its effectiveness is best measured by educational outcomes that capture, for example, the participants’ new understanding of particular drugs or increased knowledge of drug-related harms. Drug prevention, on the other hand, is about effecting changes in behaviour within a population and its effectiveness is therefore measured by exploring behaviour change.

Drug education and best practice standards

The author draws on guidance and evidence reviews that consider best practice for drug education and prevention programmes. He argues that the findings of these outputs are not always evident in practice and that those delivering drug education programmes would benefit from a more accessible synopsis of their findings. To meet this need, he draws key findings from these outputs to provide a toolkit for those working in drug education. Given the nature of the sources involved, these findings tend to be relevant to drug prevention activities more broadly as well as drug education as such.

A selection of key messages is outlined below, each of which is addressed in more detail in Darcy’s paper.

Ineffective approaches and practices to avoid

• Scare tactics that set out to scare participants by showing them graphic images or telling ‘horror stories’ (p. 4) that sensationalise the effects of drug use
• Testimonials or guest talks from people who have experienced drug use
• One-off talks and/or assemblies by experts such as police or medical professionals
• Information-only programmes
• Lecture-based (didactic) approaches that deal with the harmful effects of drugs or that focus on drug use as morally wrong
• Refusal programmes that focus on a ‘just say no’ message.

Effective approaches and practices to adopt

• Multicomponent programmes that take a holistic approach to drug education and include the development of personal and social skills to support participants in exploring how to safely navigate social situations in which drug use occurs
• Interactive programmes that use active learning and participatory teaching strategies
• Structured programmes that involve a series of structured sessions, boosted by follow-up sessions across time
• Programmes that are age, developmental level, and culturally appropriate – particularly important when working with children and young people
• Any focus on risk in relation to drug use that concentrates on short-term rather than long-term consequences
• Drug education that dispels misconceptions about drugs and their use.

Clancy also makes some general points about delivery, including:

• The need for appropriate training for those delivering programmes
• The role of an initial needs assessment before developing a programme
• The importance of the educator and organisation signing up to a programme/service agreement that outlines what will be delivered and how it will be evaluated
• The need for caution when using programmes or materials developed by others, or indeed enlisting the services of outside agencies or organisations to deliver drug education
• The need for participation to be voluntary and based on informed consent (in the case of young people, consent from both the young person and their adult)
• The need for ongoing evaluation and reflection throughout the programme delivery.

Conclusion

This paper focuses on the role of drug education as distinct from that of drug prevention. It is a useful starting point for those working in the sector to inform their practice and contribute to the delivery of more effective programmes. International guidance is referred to and the author signposts practitioners to existing resources that may be of interest, including the Best Practice Portal of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (see accompanying article for more information).

Lucy Dillon

2   The author has made this argument in previous papers. See C Darcy (2018) The precarious position of drug education workers in Ireland. Economic and Social Review, 49(3): 361–372. https://www.drugsandalcohol.ie/29721/. It was also covered in Drugnet Ireland, 68: 22.
https://www.drugsandalcohol.ie/30358/

1 Policy and practice briefings

The policy and practice briefings are designed as a one-stop-shop for anyone planning or delivering health and social responses to drug problems in Europe. They cover three topics:

• Types or patterns of substance use
• Needs of particular groups
• Responding in particular settings.

Each briefing consists of five sections:

• A summary of the main issues
• The main response options
• An overview of the European Union picture
• Key implications for policy and practice
• Links to further resources.

2 Implementation

This section of the portal provides four online inventories aimed at those planning or implementing interventions. These inventories are maintained by the EMCDDA.

• Xchange Prevention Registry
• Healthy Nightlife Toolbox
• European Prevention Curriculum (EUPC)
• Evaluation Instruments Bank (EIB).

3 Evidence database

The evidence database area of the portal gives access to the latest research and evidence on drug-related interventions. The information is based on systematic searches and is updated regularly.

4 Standards and guidelines

Standards and guidelines are popular instruments to promote quality and implement evidence-based recommendations. The translation of evidence-based recommendations into practice is the so-called ‘implementation’ process. In some cases, it is sufficient to adopt the guidelines at service level; in other cases, an adaptation to the local context is needed.

Figure 1: EMCDDA Best Practice Portal

Lucy Dillon

2   The Best Practice Portal is available at: https://www.emcdda.europa.eu/best-practice_en

Gap in debate

The authors acknowledge that some effort has been made by policymakers internationally to include the voices of PWUD in discussions on the development of drug policy. The Irish Government’s Working Group to Consider Alternative Approaches to the Possession of Drugs for Personal Use is identified as an example of where this has been attempted, albeit with limitations.² This view is set within the broader context of a global movement towards including those most affected by policies and practices in their planning, implementation, and evaluation (Nothing About Us Without Us) (p. 2).

Methods

Semi-structured interviews were carried out with eight people who had used drugs problematically. At the time of interview they all had at least one year of abstinence and had been criminalised for their drug use. Seven of the eight had served at least one custodial sentence. Six practitioners who work with PWUD were also interviewed. The interviews set out to explore the relationship between relative deprivation and problematic drug use; decriminalisation of drugs for personal use; depenalisation of cannabis; safe injecting facilities; and heroin-assisted treatment. The authors acknowledge the limitations of their study, including the small sample size and that all participants had undertaken therapy, and therefore acknowledge that they were not representative of the PWUD population more broadly.

Problematic drug use, economic deprivation, and criminalisation

A recurring theme throughout the paper is the link between problematic drug use and economic deprivation. The authors use a subterranean structuration framework to understand this link, which is a focus for study participants. This approach argues that a lack of meaningful employment opportunities for young people results in a situation where drug use and the surrounding activities (including buying and dealing) are perceived to offer an alternative and viable social and economic activity. It allows those living in economically deprived areas to find purpose and company, a sense of identity, excitement and adventure, while also dulling ‘the pains of existence and exclusion’ (p. 45).³

[Subterranean structuration draws attention to] the constraints placed on the choices made by people who have been most affected by the withdrawal of employment in deprived areas. These people are forced to make choices in situations which offer them little hope for pleasure, purpose or respect, no matter how hard they struggle. (p. 10)³

The experiences of those interviewed for this study illustrate the reality of this inextricable link between problematic drug use and economic deprivation.

Penalisation and criminalisation

Study participants argued that criminalising PWUD from economically deprived areas has little deterrent effect, rather it serves to exacerbate the problems that made drugs attractive in the first place. These findings are consistent with international literature. Some participants perceived arrest and incarceration as an ‘occupational hazard’ of problematic drug use. Unintended consequences were noted; for example, moving into heroin use while in prison; the impact on children and partners of their being in prison; and the negative impact of a criminal record on their employment opportunities.

Perceptions on alternative drug policies

Four alternative drug policies were explored: decriminalisation, depenalisation, supervised injecting facilities, and heroin-assisted treatment.

Decriminalisation and depenalisation: The authors used the Dutch and Portuguese models as examples of depenalisation and decriminalisation, respectively. Decriminalisation was defined to participants as ‘the removal of sanctions under the criminal law, with optional use of administrative sanctions (e.g. provision of civil fines or court ordered therapeutic responses)’. Depenalisation was defined as ‘the decision in practice not to criminally penalize offenders, such as non-prosecution or non-arrest’ (p. 999).⁴ Participants’ views were mixed about the Dutch model. While it was seen as a way to encourage safer cannabis use, some were concerned that it would lead to increased drug use. On the other hand, all of the participants were supportive of the Portuguese model. Much of this support revolved around drug treatment – Irish drug treatment services were perceived to be insufficient and ‘criminalisation without supports leads to a revolving door process for drug offenders’ (p. 20).¹ Overall, a model that combines decriminalisation with expansions in drug treatments and the welfare state was deemed to offer the greatest chance of success.

Supervised injecting facilities (SIF): There was overwhelming support for SIF among study participants. Among the benefits identified were a reduction in street litter (drug paraphernalia), safer injecting practices, and an opportunity to offer PWUD additional supports.

Heroin-assisted treatment (HAT): HAT is described as ‘a harm reduction measure for people who have used heroin long-term and have not responded well to other forms of treatment whereby pharmaceutical grade heroin is usually taken under medical supervision’ (p. 24). The aim is not abstinence but stabilisation. None of the PWUD in this study had heard of HAT and were described as surprised that it existed as a policy. While there was some tentative support for its inclusion as part of wider changes, concerns about it were also expressed. Overall, these stemmed from a concern that it might mean people would remain in long-term drug use for longer than necessary and that they might not be offered the opportunity to become abstinent. The possible benefits identified were a reduction in the harms associated with street heroin use – a safer product, a reduction in acquisitive crime, and a reduction in business for street dealers.

Conclusions

Leonard and Windle’s paper provides valuable insights on a variety of topics from the perspective of PWUD and those working with them. They illustrate the complexity of problematic drug use and the policy responses required. No single policy is perceived to offer a silver bullet to addressing the situation. Rather, participants returned to the need for wider structural reforms to address economic inequality and deprivation, alongside improvements in drug treatment services.

Lucy Dillon

2   Working Group to Consider Alternative Approaches to the Possession of Drugs for Personal Use (2019) Report of the Working Group to Consider Alternative Approaches to the Possession of Drugs for Personal Use. Dublin: Department of Health and Department of Justice and Equality.
https://www.drugsandalcohol.ie/30887/

3   Cited in Leonard and Windle: A Stevens (2011) Drugs, crime and public health: The political economy of drug policy. Abingdon: Routledge.

4   Cited in Leonard and Windle: CE Hughes and A Stevens (2010) What can we learn from the Portuguese decriminalization of illicit drugs? Brit J Criminol, 50: 999–1022.

Alcohol findings

The alcohol findings from the 2019 ESPAD in Ireland report regarding prevalence, perceived availability, and age of initiation of alcohol use are presented below. Associated factors, including gender, social class, and familial and peer variables, are also examined.

Alcohol consumption

Overall, 73% of respondents had consumed alcohol in their lifetime. Some 65% of students had consumed alcohol in the last 12 months and 41% had consumed alcohol in the last 30 days.

Heavy episodic (‘binge’) drinking

Eighteen per cent of respondents had engaged in binge drinking once or twice in the last 30 days and 14% had done so more than three times in the last 30 days.

Reports of being drunk

Thirty-six per cent of students had ever been drunk in their lifetime and 16% had been drunk in the last 30 days. More females (17%) than males (15%) reported being drunk in the last month.

Level of intoxication

Students were asked to indicate how drunk they were on the last day they drank alcohol, with male and female students being equally likely to report intoxication, including heavy intoxication.

Consumption of particular drinks

With regard to type of drinks consumed, the most popular alcoholic drinks among boys were beer (36%) and cider (32%), while among girls spirits (32%) and cider (25%) were the most popular.

Perceived access to alcohol

Students were asked how difficult they thought it would be to get particular alcoholic drinks. Results show that the majority of students believed it would be ‘fairly easy’ or ‘very easy’ to obtain all types of alcoholic drinks mentioned.

Age of first trying alcohol

As in previous surveys, age 15 years (52%) was the most common age at which students first drank alcohol, followed by age 14 (28%). Males were more likely to report early initiation at age 12 years or younger.

Age of first getting drunk

Most students (60%) had never been drunk, while the majority of students who said that they had ‘got drunk on alcohol’ had done so at age 15 years (21%).

Consequences of alcohol use

Asked about consequences of alcohol use, damaging or losing property was the most frequently reported (11%), followed by serious argument (7%), injury or accident (7%), involved in a fight (5%), and in trouble with the police (4%). Females were also more likely than males to be victims of an unwanted sexual advance while under the influence of alcohol.

Perceived risk

Students were asked how much they thought people risked harming themselves physically or in other ways if they consumed alcohol in varying amounts. The findings show that students were cognisant of the risks associated with alcohol consumption. Almost one-half of students perceived a moderate risk to drinking one or two drinks nearly every day. Over two-thirds of students said there was a great risk to drinking four to five drinks nearly every day, while 45% thought there was a great risk to having five drinks or more nearly every weekend.

Drinking motivation

The reasons given most frequently for using alcohol were to make social gatherings more fun (49%), to help respondents ‘to enjoy parties’ (48%), and ‘it’s fun’ (48%). The least popular motivations for drinking were ‘to be liked’ (13%) and ‘to get high’ (16%).

Factors related to alcohol consumption

Socioeconomic status

Socioeconomic status was measured by the educational attainment level of the student's father and mother. Results show that students whose father received primary education only were the most likely to have drunk alcohol 20 times or more in their lifetime (26%), while those whose fathers completed third-level education were the least likely (14%).

By contrast, students whose mothers had completed their education at or before the end of primary schooling were less likely to consume alcohol 20 times or more (10%) than students whose mothers had secondary (23%) or third-level (14%) education.

School

Absences: Skipping school and absence from school due to illness and other reasons were significantly associated with lifetime and current alcohol consumption. Some 67% of students who had not missed school due to illness had tried alcohol, with this number rising to 78% of students who had missed five to six days of school due to illness. Similarly, of students who had skipped school for seven or more days, 92% had tried alcohol in their lifetime. This number fell to 69% for students who had never skipped school. Some 81% of students who were absent from school for other reasons had tried alcohol in their lifetime compared with 69% of students who had not missed school for other reasons. Among students who had missed five to six days of school due to illness, about one-half had had alcohol in the last 30 days. Of students who had not missed school, a higher percentage (66%) were not current drinkers. Some 79% of students who skipped school on seven or more days were current drinkers.

School grade: Average grade in school was significantly associated with lifetime alcohol use. A lower percentage of students with A and B grades (67%) had tried alcohol in their lifetime compared with students who had E grade or lower (70%). However, D-grade students had the highest rate of lifetime alcohol consumption at 78%.

Parental monitoring: There was a significant association between parental monitoring of Saturday nights and alcohol consumption. Noticeably more students (96%) whose parents sometimes know where they are on Saturday nights have tried alcohol than those whose parents always know (64%). Similarly, 72% of students whose parents sometimes know where they are and 63% of students whose parents usually do not know where they are on Saturday nights were current drinkers compared with 31% whose parents always know where they are on Saturday nights.

Household type: 75% of students in one-parent households had tried alcohol, compared with 67% in ‘other’ households and 72% in households with two or more parents. Household type was not significantly associated with lifetime or current drinking.

Peer alcohol use: There was a significant association between lifetime and current drinking and peer drunkenness. Some 72% of students who answered that all their friends get drunk had tried alcohol in their lifetime, while 66% who said that none of their friends get drunk reported that they had tried alcohol. Similarly, one-half of students who said that all of their friends get drunk reported that they were current drinkers themselves, compared with 33% who said none of their friends get drunk.

Conclusion

Across Europe, there have been reductions in the use of alcohol and heavy episodic drinking. In Ireland, the reduction in drinking was at a substantial rate, with a 30% reduction in binge drinking and a 41% decrease in alcohol use since 1995. However, there has been an increase in the use of alcohol in the last four years. Since 2015, alcohol use has increased by 14% and heavy episodic drinking by 18%. These results call for continued targeted high-intensity campaigns and education initiatives, as well as policy and legislative change to protect adolescent health.

Anne Doyle

Alcohol-related harm to children

Research has shown that children growing up in a home with parental problem alcohol use are more likely to develop problems with substance use themselves and experience poor outcomes that persist into adulthood.³ Moreover, these children have been observed to adapt to their environment by developing a role within their dysfunctional family, which when carried into adulthood and into other relationships can have negative consequences.^4,5,6

The roles include the ‘family hero’, who in overachieving and trying to make the family look good often feels isolated, and the ‘mascot’, who jokes in order to turn the focus away from the painful truth of the situation yet is often fearful, embarrassed, and angry. The ‘scapegoat’, whose negative behaviour turns attention away from the alcohol-dependent person, gets into trouble at work or school and often turns to high-risk behaviours, while the ‘lost child’ withdraws from the situation, cares deeply but emotionally checks out to avoid trouble and drama. The ‘caretaker’, highly responsible, manages conflict and keeps the family going and yet enables the addict by taking on their problems and duties.⁵

Parental problem alcohol use and the school environment

Children may also worry about their parent’s wellbeing, which can affect their ability to concentrate and learn. Research shows that children of chronic alcohol users can exhibit learning difficulties, reading problems, poor concentration, and low performance in school.⁷ Research also shows that the unpredictable and frightening behaviour of parental substance use can cause symptoms in children similar to that of post-traumatic stress disorder (PTSD).^7,8

School can provide a safe haven for children experiencing parental problem alcohol use, but even away from home many children reported carrying the burden of their home lives with them. Often a sense of confusion exists, with the child unable to fully comprehend or articulate what is going on in their home and unable to understand that their situation is not normal. Another common theme is secrecy and loyalty
to their parents.

As they enter secondary school, children gain a greater awareness and understanding of their environment. The UCC study indicates that varying coping strategies were employed, from rebellion to apathy to industriousness – keeping busy externally to distract from inner turmoil.² With all strategies, the common goal is one of escapism and avoidance of a painful reality.

What can help?

Research highlights that factors that provide support, friendship, and opportunities for development build children’s resilience and protect them against some harmful impacts of ACEs.⁹ The UCC study includes direct quotations and accounts of experiences from ACOAs, explaining what helped them to cope better during their school years and what their recommendations for the future are, echoing those made in the academic literature.

The importance of a sensitive approach to the child was highlighted. The fact that it should not be the child’s responsibility to come forward for help is reflected in the recommendations noting the importance of the immediate availability of someone to talk to when needed. A good support network outside the home was key to becoming resilient, reinforcing the concept of ‘one good adult’.^{10, 11}

Respondents felt that children need a place where they can feel safe to talk about their problems. Increasing openness on the issue of parental problem alcohol use among school-aged children might help them to feel more comfortable in coming forward in this environment. Educational talks about alcohol and the availability of school psychologists were also suggested.

Participants also expressed the need for early intervention, greater awareness among professionals, access to talk therapies, and the provision of trauma-informed frontline services.¹² Overall, a wider societal awareness of alcohol-related harm is key to tackling the stigma and thus enabling parents to get treatment and children to get appropriate supports. Implementation of a public health campaign to address this was suggested.

Recommendations

For schools and teachers

Building on the feedback by ACOAs, the study sets out a number of recommendations:

• Educators are extremely well placed to identify children experiencing harm from parental problem alcohol use that impacts their development. Training provision in relation to trauma-informed approaches and ACEs should be implemented at teacher training level and at all levels of professional development – from teachers to principals to education welfare officers to special needs assistants and administrative staff.
• Guidance on the issues pertaining to children with ACEs in schools, including parental problem alcohol use, should be made available to all educators.
• Schools should seek to strengthen collaboration with Tusla and An Garda Síochána to support a child who might be at risk of hidden harm. The United Kingdom’s early intervention model, Operation Encompass,¹³ should be implemented in Ireland.

For wider public services

• Awareness of parental alcohol use during pregnancy should be strengthened across society so that women have the information and support they require to stop drinking during pregnancy, thus preventing fetal alcohol spectrum disorders.
• Awareness of parental problem alcohol use and its impact on young people and adult children should be raised through information campaigns and training that targets healthcare, social care, early years, child protection, family support, education, and mental health sectors, as well as families and communities.
• Investment should be made so that frontline services and counsellors are trauma informed in order to recognise and adequately deal with the issues that stem from adversity in childhood and from children and adult children affected by parental problem alcohol use. Innovative evidence-based programmes should be more widely available in communities nationwide.¹⁴

Impact of Covid-19 pandemic

This research predates Covid-19. AAI believes that the problem of young people experiencing issues in the home due to alcohol is likely to have increased significantly since early 2020 due to the pandemic. Data show that despite all licensed premises being closed during lockdown, alcohol sales experienced only a modest reduction, indicating that Ireland’s alcohol users substituted drinking in regulated licensed premises to consumption in the home.¹⁵ For young people, exposure to this increase in parental home drinking was accompanied by school closures, summer activities being curtailed, and lack of access to peer support.

Children and young people nowadays need their schools to be not just a place of learning but a place of refuge and support for other issues in their lives. Schools should become a place that recognises young people’s trauma, while teachers and schools should be supported to nurture trauma-informed environments.¹⁶

Anne Doyle

2   Keating L and Lambert S (2020) Understanding the experiences of adult children of alcoholics. Cork: All-Ireland Students Congress/UCC. Available online at: https://alcoholireland.ie/wpfb-file/annotated-fyp20final2028129-docx-pdf/2

3   Callingham M (2004) Survey for NACOA: Study to investigate the extent and nature of the problem of adults who grew up in a home with alcohol-dependent parents. London: National Association for Children of Addiction (NACOA).

4   Alvernia University (2021) Coping with addiction: 6 dysfunctional family roles. Reading, PA: Alvernia University. Available online at:
https://online.alvernia.edu/infographics/coping-with-addiction-6-dysfunctional-family-roles/

5   ASCERT (2013) Taking the lid off: a resource for families living with addiction and problematic substance abuse. Lisburn: ASCERT. Available online at: https://alcoholireland.ie/download/publications/alcohol_health/children_young_people/TakingTheLidOffBook.pdf

6   ASCERT (2008) Taking the lid off: a resource for families living with addiction and problematic substance abuse [workbook]. Lisburn: ASCERT. Available online at:
https://alcoholireland.ie/download/publications/alcohol_health/children_young_people/TakingTheLidOff_Adultworkbook.pdf

7   Cleaver H, Unell I and Aldgate J (2011) Children’s needs – parenting capacity: child abuse: parental mental illness, learning disability, substance misuse and domestic violence. London: The Stationery Office (TSO).

8   Holt S, Buckley H and Whelan S (2008) The impact of exposure to domestic violence on children and young people: a review of the literature. Child Abuse Negl 32(8): 797–810.

9   Bellis MA, Hughes K, Ford K, et al. (2018) Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance. BMC Public Health 18: 792. Available online at: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5699-8

10 Walsh B (2015) The science of resilience: why some children can thrive despite adversity. Cambridge, MA: Harvard Graduate School of Education. Available online at:
https://www.gse.harvard.edu/news/uk/15/03/science-resilience

11 Jigsaw (2020) What does one good adult mean? Dublin: Jigsaw. Available online at:
https://jigsawonline.ie/parents-and-guardians/what-does-one-good-adult-mean/

12 This mirrors recommendations made in a recently published UK report on alcohol harm. See Commission on Alcohol Harm (2020) ‘It’s everywhere’ – alcohol’s public face and private harm: the report of the Commission on Alcohol Harm. London: Commission on Alcohol Harm, pp. 15–22.

13 Operation Encompass directly connects the police with schools to ensure support for children living with domestic abuse in their homes, in light of a police-attended incident of domestic abuse the night before. Rapid provision of support within the school environment means children are better safeguarded against the short-term, medium-term, and long-term effects of domestic abuse. For further information, visit https://www.operationencompass.org/

14 Programmes specifically tackling parental alcohol misuse include: M-Pact
(https://www.actiononaddiction.org.uk/addiction-treatment/families-and-children/
m-pact); Parents Under Pressure
(http://www.pupprogram.net.au/); and Rory (https://www.roryresource.org.uk/).

15 For AAI’s statement on alcohol sales figures, visit:
https://alcoholireland.ie/provisional-revenue-receipts-demonstrate-durability-irish-alcohol-market-despite-covid-19-crisis/

16 For further information on the joint AAI/Mental Health Ireland paper calling for trauma-informed services and schools, visit:
https://alcoholireland.ie/download/publications/Trauma-informed-care-position-paper.pdf

Programme A

Overview

Launched in 2017, Programme A targets young people who are no longer suitable for or have refused to participate in the main GYDP.¹ The nature and frequency of crimes carried out by these young people, such as possession with intent to sell, assault causing harm, possession of a dangerous weapon, and dangerous driving, have led to a ‘serious level’ of contact with the criminal justice system. While the programme does not target crimes specifically, assessments suggest that 12 of 16 youths currently attending this programme may be involved in organised criminal networks.

The programme involves the young person moving through six stages:

1   Months 1–2: Determining suitability – building a relationship between the young person and the key worker.

2   Months 2–6: Building trust – continuing to build the relationship and develop an understanding of the programme purpose.

3   Months 6–24: Enabling engagement/personal growth – being willing to acknowledge issues and engage in new activities.

4   Months 18–30: Enabling contemplation – acknowledging the need to change; putting plans in place.

5   Months 30–42: Recognising lifestyle change – making more positive lifestyle changes.

6   Months 36–48: Sustaining change – taking full personal responsibility for actions and decisions.

Conclusions

Based on available data, participating in Programme A for 18 months of the four-year intervention has stopped or reversed the downward life trajectory in eight of these young people. Interviews with programme participants showed that they understand that their offending behaviour has resulted in their referral to the programme. While a ‘clear desire for change’ was expressed by the participants (p. 7), for most this has yet to be achieved, especially in relation to substance abuse and peer group/lifestyle.¹

Recommendations

The performance of Programme A thus far has met expectations and is deemed value for money with regard to its intensity and duration. Hence, the authors recommend that further funding is made available for a minimum of four years to enable the programme cycle to be completed and to allow for a full assessment and evaluation.

Programme B

Overview

Launched in 2015, Programme B provides ‘individually tailored support’ to young people that do not engage or benefit from the main GYDP.¹ Additionally, there is a risk that their offending/antisocial behaviour will increase. This model is based on an existing social care programme that focuses on young people with challenging behaviour or are viewed as a risk to themselves and those around them. Overall, Programme B has supported 43 participants. The programme duration on average is nine months but can range from three to 33 months. The main objectives of the programme are to:

1   Strengthen family relationships and support them to remain together.

2   Assist young people to develop problem-solving skills.

3   Assist young people to develop social and life skills, including positive peer interaction and positive community engagement.

4   Support young people to maximise their educational and vocational opportunities.

A final supplementary objective is to deliver intervention dosage at the optimal level.

Participants on this programme were court involved on referral or during engagement (47%); involved with the criminal justice system (53%); repeat offenders (42%); had charges for atypical youth offending; or diagnosed with mental illness (56%). Since the launch of the programme, 32 cases have been closed, 12 of which were positive (e.g. programme or probation order completion) and 20 were negative (e.g. lack of motivation, poor attendance, and poor engagement).

Conclusions

The authors note that it has not been possible to ‘thoroughly evaluate’ progress on the long-term objective achievement (p. 9).¹ However, in just over one-half of closed cases, the criminal risk has decreased or stabilised. In the urban area where the programme is based, stakeholders view it as a vital component of the youth justice infrastructure. Interviews with participants illustrated several positive outcomes from engaging with the programme:

• Not hanging around with the same people
• Going back to school/education
• Not getting into trouble with the Guards
• Not using drugs/alcohol
• Having better mental health
• Having more confidence
• Finding things they liked to do.

Recommendations

Several recommendations were made by the authors, including the importance of more funding for at least a year to allow the Programme B framework to be monitored and evaluated and to carry out data collection and prepare programme reports. In addition, it is important to identify the reasons for the high number of negative cases (n=20); programme participants need to be included in this process. Further funding has also been recommended to allow the programme to continue for three years in order to be evaluated properly. Pending a positive evaluation, it is recommended that Programme B should be extended to other areas.

Overarching conclusions and recommendations

The authors acknowledge that pilot programmes can provide important learning for policymakers who use new approaches to target societal issues.¹ However, to make full use of this learning it is vital that funders and grantees have a clear idea of how information should be reported and what kind of information is needed from the outset. With regard to the two programmes in this evaluation, this aspect has not been clear. The authors recommend that agreement should first be reached on these issues and that both programmes should be adequately skilled and resourced so that reporting requirements are met in order to steer the direction of Irish youth justice policy going forward.

Ciara H Guiney

2   Sandra Roe Research (2020) An evaluation of the Work to Learn Programme. Dublin: Department of Justice and Equality. https://www.drugsandalcohol.ie/33043/

3   Sandra Roe Research (2020) An evaluation of the QQI Co-Ordinator Programme. Dublin: Department of Justice and Equality. https://www.drugsandalcohol.ie/33043/

Small group discussions

Action Research Project

This session explored building transformative relationships with young people and drew on participants’ experience of what worked and what did not. Several themes emerged in this discussion, such as the role played by young people to bring about positive change; consistency of youth justice workers; benefits of informal engagement; positive reinforcement; importance of Garda training in youth justice methodologies; and the need for interagency cooperation. Barriers to successful engagement were identified, such as lack of funding, difficulties identifying young people for referral, and delays in the process.

Early Intervention Pilot Initiative

The aim of the Early Intervention Pilot Initiative discussion was to increase knowledge about the initiative, get input into its development, and consider its alignment with existing projects. The initiative focused on increasing the ability to engage at-risk children. Participants believed that antisocial and criminal behaviour was evident among those aged between 8 and 10 years. Children mainly of this age and younger are not catered for by GYDPs. The need for specialised training for GYDP employees working with this age group was highlighted along with appropriate policies and procedures for the referral process.

Family Support Pilot Initiative

The aim of the Family Support Pilot Initiative discussion was similarly to increase knowledge about the initiative, get input into its development, and consider its alignment with existing projects. The initiative targeted the home lives of young people participating in GYDPs with the aim of decreasing criminal behaviour. Participants believed that the initiative was unique as it provided support to families, particularly in rural areas who did not meet Tusla involvement criteria. Working with parents was viewed as critical in addressing inappropriate youth behaviour. However, it was acknowledged that youth justice workers did not have the capacity to provide this service. Several factors were identified that showed family support was required, such as family criminality and drug use, neglect, domestic violence, parental mental health issues, and intergenerational trauma. Effective parenting, developing coping skills, and a reduction in offending behaviour would be attainable if family support were made available across projects. However, it was acknowledged that some families would not accept this support even if offered.

Managing trauma

This session explored an understanding of trauma-informed practice, managing trauma, and youth suicide prevention within the GYDP context. Trauma was viewed as an emotional response to an event or events, with participants noting that an event considered a trauma by one person may not yield a similar response in others. Working with young people and families that have experienced trauma can also have an impact on youth justice workers. The main indicators of trauma that were identified included isolation, depression, hopelessness, aggression, underachievement, substance misuse, self-harm, issues with trust and attachment, and lashing out (p. 24). Participants believed that youth justice workers should be trained in trauma-informed practice. The importance of realising that trauma experiences can contribute to criminal/antisocial behaviour was noted; this should change the focus from ‘what’s wrong with you’ to ‘what happened to you?’ from the outset (p. 25). A multiagency approach was required where all services were in the one place. The YLS/SMI 2.0 youth assessment was considered inadequate to assess for the presence of trauma.

Regarding suicide prevention, the ASSIST (Applied Suicide Intervention Skills Training) programme was considered a ‘good starting point’ (p. 25), while experience of the STORM^® programme provided greater confidence to those working in suicide prevention. Identifying suitable out-of-hours services for at-risk youth was seen as challenging. A proposed solution was assigning qualified therapists to projects on a pilot basis to work with young people experiencing trauma.

Self-care

The aim of the self-care discussion was to provide participants with an opportunity to examine their own self-care, with an emphasis on their current or potential actions to increase their wellbeing. Self-care was viewed as something personal and hence approaches taken would depend on the individual. What self-care meant was explored by the delegates. External supervision was viewed as essential in self-care. Self-care practices included taking 10 minutes time-out from work, reflective diaries, exercise, an employment assistance programme, and informal peer support.

Specialist project evaluation

This session provided information on two pilot projects (Solas Rua in Dublin and Janus Justice in Limerick) that target harder-to-reach young people and examined how these projects fit with the GYDP network. The discussion explored reasons why some young people were harder to reach (p. 28), such as being involved in organised crime, limited parental engagement, unemployment at home, and parental mental illness. Participants noted the need to try and reach young people in their own community, even when numbers were small.

Supporting the role of An Garda Síochána

The Garda Síochána discussion explored the development and implementation of the Together Stronger Guidelines, put forward in 2017 and which aimed to strengthen the working relationships between juvenile liaison officers and youth justice workers. Participants identified what worked well and what areas they would like changed.

Work to Learn

The aim of this discussion was to increase knowledge about the Work to Learn initiative and consider how this approach could be applied in their own projects. The programme was developed in Kilkenny in 2015 and aimed to ‘expose’ young people on GYDPs to the ‘world of work’ and the skills necessary to function successfully in it (p. 31). It draws on a structured and supported process centred on preparation, placement, and reflection (p. 31). Participants noted that while the benefits of the programme were clear, it would pose challenges implementing it in rural areas. Difficulties also existed in preparing young people for work and how to keep them motivated.

Youth justice strategy

This session provided an opportunity to learn more about the new youth justice strategy. Participants focused on four issues – prevention and early intervention; diversion; procedural justice (detection, investigation, prosecution, court proceedings); and sanctions (including detention) and post-release and reintegration
(p. 32) – in relation to the three thematic areas of the strategy. These are:

• Supporting children and young people
• Criminal justice system processes for children and young people
• Oversight, governance, reporting, and development.

Training needs wall of ideas

Participants identified several areas where further training in their sector was needed. Suggestions and views on how to achieve this were placed on a training needs wall of ideas throughout the event.

Final guest presentation

The final presentation was delivered by Pat Divilly, author and high-performance coach. The focus of his presentation was personal development and self-care.

Conclusion

The conclusion section of the report brings together the main themes that emerged from the conference. These were interagency cooperation, innovation, reach, trauma-informed practice, and self-care.

Ciara H Guiney

Methods

A systematic review of randomised controlled trials of brief interventions in primary care settings aimed at BZRA reduction or cessation in adults with BZRA use of three months or more was carried out. The review was conducted across four databases: PubMed, EMBASE, PsycINFO, and CENTRAL. Findings were interpreted through TDF to identify the behavioural determinants targeted by interventions.

The review aimed to evaluate the evidence base for brief interventions targeting BZRA use in primary care settings. Interventions were defined as ‘an intervention comprising oral or written communication that involved discussion, negotiation or encouragement for reduction or discontinuation of long-term BZRA use, with or without additional support or follow-up‘ (p. 1620). ‘Long-term’ BZRA use was defined as three months or more. BZRA reduction was considered a reduction of 25% or more.

Key findings and discussion

The literature search identified eight studies comparing brief interventions with usual care. Some 2,071 patients aged 59–75 years, 71.2% of whom were female, were involved in the eight studies of the review. Interventions most commonly involved written letters suggesting BZRA reduction or discontinuation or short consultations containing recommendations for BZRA reduction or discontinuation. Others developed educational resources in the form of personalised booklets for patients. All interventions advocated a gradual dose reduction approach to BZRA reduction or discontinuation. Compared with control patients, intervention patients were more likely to have discontinued BZRA use at six months and 12 months post-intervention compared with usual care patients. This led the authors to conclude that brief interventions delivered in primary care settings are more effective than usual care at reducing and discontinuing BZRA use.

TDF analysis identified the behavioural determinants targeted by interventions to effect change. Constructs such as ‘knowledge’, ‘skills’, and ‘beliefs about consequences’ were coded frequently, with ‘beliefs about consequences’ existing across all interventions. Educating patients about the risks inherent in long-term BZRA use as well as providing them with the tools to practise gradual dose reduction may be effective areas for interventions to target. The absence of constructs related to emotions suggests to the authors that targeting emotions such as optimism may be effective at reducing BZRA consumption.

A gradual dose reduction approach must be specific to the individual to prevent rapid dose reduction, which has implications for withdrawal and can hinder patient success. Being flexible in reducing dosage and developing a personalised approach can prevent this. Involving other healthcare providers such as pharmacists is suggested to be a cost-effective way of delivering interventions.

Conclusion

More research is warranted to understand which interventions are most effective for reducing or discontinuing BZRA use.

Catherine Walshe

Addiction services

Health Promotion Unit

This unit provides drug users with information about the risks associated with drug use and the means to minimize such risks. MQI offers drug users a pathway into treatment and the possibility of living a life without drugs. The main focus is on reducing the harms associated with injecting drug use; fostering the motivation to become abstinent; and giving advice on HIV, hepatitis B virus, and hepatitis C virus infection prevention. In 2018, some 2,742 individuals used the service, an increase of 6% compared with 2017.

In 2018, there were 30,068 visits to the MQI needle exchange in Dublin, a 31% increase over the last five years. For those using the service, heroin continued to be the most commonly used drug. Of concern, MQI noted that 2018 saw a rise in individuals reporting crack cocaine as their primary drug.

Figure 1: MQI county locations in Ireland

Source: MQI annual review (2018)

(1) Dublin; (2) Co. Wicklow; (3) St Francis Farm, Co. Carlow; (4) Cork Prison; (5) Limerick Prison; (6) Co. Offaly; (7) Co. Westmeath; (8) Portlaoise, Co. Laois; (9) Co. Longford; (10) Castlerea Prison, Co. Roscommon; (11) Loughran House, Co. Cavan; (12) Leixlip, Co. Kildare.

Community Engagement Team

The Community Engagement Team works to cultivate and strengthen relationships between MQI and the local community. The team picks up and safely disposes of drug-related litter as well as offering some of the most vulnerable people (those rough sleeping or reluctant to engage with services) street-based advice and referral into the services they need. In 2018, the team, which operates in the area immediately around Merchants Quay in Dublin, conducted over 1,700 patrols.

Family Support Group

MQI offers one-to-one advice and support to family members on the realities of drug use and how they can best cope and provide optimum support to drug users. MQI also runs a Family Support Group (FSG), which meets every week and provides a forum where parents, as well as other close relatives and friends of drug users, are offered support and advice on a range of issues. Participants provide support for each other, and the group is continually open to new members. The weekly FSG is linked to the National Family Support Network, which offers an opportunity to raise issues at a national level. MQI’s FSG in Dublin worked with over 60 individuals throughout 2018.

Community Recovery and Integration Supports

In 2018, the launch occurred of the East Coast Community Recovery and Integration Supports (CRIS) service, provided by MQI and the East Coast Drug and Alcohol Task Force. The service was formally launched in November 2018 by the then Minister for Health Simon Harris TD. CRIS provides supports, including key working, case management, and links with external support, for people experiencing alcohol and/or drug addictions. Demand for this service was immediate after it commenced in September 2018, and by year end MQI had engaged with 44 clients.

Midlands services

Drug and Alcohol Treatment Supports Project

MQI’s Drug and Alcohol Treatment Supports (DATS) team provides a community-based drug and alcohol treatment support service for individuals over 18 years of age and their families in the Midlands area (Counties Longford, Westmeath, Laois, and Offaly). Each county has a dedicated drug and alcohol worker to coordinate the care of individuals and families experiencing problems due to drug and/or alcohol use.

In this region, MQI saw a total of 706 clients in 2018, a 53% increase on 2017. This increase was represented across all age groups, but was particularly evident among the younger cohort aged under 30, where there was a 47% increase. MQI also experienced a 47% increase in the number of women accessing Midlands services in 2018.

In terms of drug use in the Midlands, MQI noted that heroin was by far the most commonly consumed drug among clients accessing services, being used by 47% of clients. Within MQI’s Midlands needle exchange, the total number of sessions increased by 16% in 2018, with a 50% increase in clients who are homeless accessing the needle exchange service compared with 2017.

Rehab and detox treatment services

St Francis Farm Residential Rehab Programme and Detox Services

The St Francis Farm (SFF) Rehabilitation Service offers a 13-bed therapeutic facility with a 14-week rehabilitation programme set on a working farm in Co. Carlow. At SFF, MQI provides a safe environment where service users can explore the reasons for their drug use, adjust to life without drugs, learn effective coping mechanisms, and make positive choices about their future.

The 10-bed residential detoxification service at SFF delivers methadone and combined methadone/benzodiazepine detoxes for both men and women. The detox activity programme includes individual care planning, therapeutic group work, psychoeducational workshops, fitness training, and farm-work activities.

At High Park, Drumcondra, Dublin, MQI operates a 14-week residential programme in a 13-bed facility. The emphasis is on assisting clients to gain insight into the issues that underpin their problematic drug use and on developing practical measures to prevent relapse, remain drug-free, and sustain recovery.

In 2018, the total number of admissions across High Park and SFF was 169, with 110 completing treatment.

Prison-based services

Addiction Counselling Service and Mountjoy Drug Treatment Programme

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

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

A total of 2,149 unique clients were seen in 2018. Of particular concern, MQI observed a drop in residential admissions from prison to treatment, from 83 in 2017 to 53 in 2018, which is a reflection of the increasing difficulty in accessing treatment beds across the country.

Seán Millar

responses

Smyth BP, O’Farrell A and Cullen W (2020) European Journal of Public Health, Early online.
https://www.drugsandalcohol.ie/33275/

Government responded to public protests about head shops [selling new psychoactive substances (NPS)] by enacting legislation in May and August 2010 to end this trade. Many academics argued that such actions would prove futile. We sought to determine if changes in head shop activity coincided with changes in drug-related hospital admissions (DRHA).

Cessation of NPS sale by head shops coincided with a reversal in the upward trend of emergency hospital admissions related to drugs. Although correlation does not confirm causation, legislation which successfully curtails the commercial sale of NPS may result in reduced hospitalizations.

Connolly SP, Avramovic G, Cullen W, et al. (2020) Irish Journal of Medical Science, Early online.
https://www.drugsandalcohol.ie/32578/

This paper aims to summarize the methods and present the aggregate cascade of care figures for the Irish components of HepCare. ‘HepCare Ireland’ contained five integrated work packages: HepCheck, HepLink, HepFriend, HepEd and HepCost.

In HepCheck, HepLink, HepEd and HepFriend, we demonstrate a series of interventions to improve Irish HCV [hepatitis C virus] outcomes. Our findings highlight the benefits of multilevel interventions in HCV care.

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

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

© Health Research Board, 2021

Health Research Board
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67—72 Lower Mount Street
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T: 01 234 5168
E: drugnet@hrb.ie
W: www.hrb.ie

Mongan D, Millar S, OʼDwyer C, Long J and Galvin B (2020) BMJ Open, 10: e034520.
https://www.drugsandalcohol.ie/32429/

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

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

Lynn E, Doyle A, Keane M, Bennett K and Cousins G (2020) Journal of Studies on Alcohol and Drugs, 81(5): 543–555.
https://www.drugsandalcohol.ie/33222/

The objective of this study is to explore the extent, range, and nature of evidence in relation to drug poisoning deaths among women.

The majority of studies on drug poisoning deaths among women involved descriptive epidemiological data, primarily prevalence estimates, with limited in-depth analyses of factors explaining these trends. To inform policies and practices to prevent drug poisoning deaths among women, more evidence is required on risk factors specifically related to women.

Gargaritano KL, Murphy C, Auyeung AB and Doyle F (2020) Alcoholism: Clinical and Experimental Research, 44(12): 2386–2400.
https://www.drugsandalcohol.ie/33273/

We aimed to systematically review clinician-reported barriers in the provision of brief alcohol screening, brief advice and intervention specific to hospital inpatient and emergency department settings.

Clinicians cite a multitude of factors that impede their delivery of alcohol screening and brief interventions in the hospital inpatient and emergency department settings. These barriers were explored further under the framework of the COM-B model, which allows for intervention design. As such, changes can be made at the policy, managerial and educational level to address these barriers and help improve the self-efficacy and knowledge of clinicians who counsel patients on alcohol use.

McKey S, Quirke B, Fitzpatrick P, Kelleher CC and Malone KM (2020) Irish Journal of Psychological Medicine, Early online.
https://www.drugsandalcohol.ie/33216/

A rapid review of scientific publications related to mental health and suicide in Irish Travellers was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Searches of PubMed, PsycINFO and Google Scholar were performed. Eligibility criteria included: (i) Irish Travellers/Gypsy Travellers; (ii) information on mental health/suicide/self-harm; (iii) psychosocial anthropological perspectives of mental health; (iv) publications in English. Data on studies including design, methods, participants and key findings were extracted using a spreadsheet template.

This paper draws together strands from the disciplines of psycho/socio/anthropological perspectives to gain deeper insights into mental health and suicide in Irish Travellers. In a knowledge vacuum, it behoves the scientific community to explain the value of scientific research and rigour to both policymakers as well as Travellers, shifting the existing discourse towards new knowledge and understanding around mental health and suicide in Travellers.

Kinnunen JM, Rimpelä AH, Lindfors PL, et al. (2020) European Journal of Public Health, Early online.
https://www.drugsandalcohol.ie/33259/

We study studentsʼ e-cigarette and conventional cigarette ever-use, their social correlates and e-liquid use in seven EU countries.

Studentsʼ e-cigarette ever-use varies greatly between EU countries. E-cigarettes seem not to be a substitute for conventional cigarettes but more a complementary product. Tobacco control policies might also prevent e-cigarette use but specific regulations on e-cigarettes are needed to prevent nicotine addiction originating from them.

McCarten C, Byrne J, Campbell J, et al. (2020) Social Work Education, Early online.
https://www.drugsandalcohol.ie/33235/

Understanding the characteristics, motivations, and experiences of student social workers is important to inform their professional education and support needs. To date, there has been relatively little research about social work students in Ireland, both North and South. This study reports on an all-Ireland survey of students beginning their social work course in Autumn 2018 in the six universities delivering social work education. It describes the characteristics of the student cohort, examines the motivations behind choosing this career, and highlights some of the potentially relevant life experiences and beliefs which may have contributed to their ambition to join the social work profession. Implications for social work education, recommendations for curriculum development, workforce planning, and the provision of appropriate support for students are discussed.

Holton AE, Keeney C, Ryan B and Cousins G (2020) BMJ Open, 10 (8): e035212.
https://www.drugsandalcohol.ie/32918/

This study aims to estimate the prevalence of Potentially Serious Alcohol–Medication Interactions in Older Adults (POSAMINO) among community-dwelling older adults using drug dispensing data from the community pharmacy setting.

This study adds to the growing body of evidence, which suggests that older adults are vulnerable to potentially serious alcohol–medication interactions, particularly those involving cardiovascular and central nervous system agents, increasing their risk of orthostatic hypotension, gastrointestinal bleeds and increased sedation. Application of the POSAMINO criteria at the point of prescribing may facilitate the risk stratification of older adults and prioritise alcohol screening and brief alcohol interventions in those at greatest risk of harm.

Antoine J, Berndt N, Astudillo M, et al. (2020) Addiction, Early online.
https://www.drugsandalcohol.ie/32912/

This study aims to describe cocaine treatment demand in 10 western European countries and to examine the size, the direction and the temporality of recent trends in the proportion of cocaine users among all clients entering treatment.

Despite substantial country-specific variation regarding cocaine prevalence and treatment demand, there has been an overall significant increase since 2015 in the share of cocaine-related treatment demand in Western Europe.

Leonard J and Windle J (2020) International Journal of Drug Policy, 8: 102891.
https://www.drugsandalcohol.ie/32593/

People who use drugs problematically are consistently left out of consultations and deliberation on drug policy. This article explores how people who formerly used drugs problematically and service providers view Ireland’s current drug policy and if alternative policies could be successful in an Irish context.

Several participants were clear that none of the alternative policies discussed are silver bullets. Participates felt that, while they could reduce the harms caused by drugs and drug policies, the government’s longer-term objectives should be increased treatment provision and, reduced social exclusion and economic deprivation.

Kelly JR, Crockett MT, Alexander L, et al. (2020)
Irish Journal of Psychological Medicine, 1–6. doi:10.1017/ipm.2020.94
https://www.drugsandalcohol.ie/32853/

Preliminary evidence from the rapidly progressing field of psychedelic science shows that psilocybin therapy offers a promising transdiagnostic treatment strategy for a range of disorders with restricted and maladaptive habitual patterns of cognition and behaviour, notably depression, addiction and obsessive compulsive disorder.

While at a relatively early stage of clinical development, and notwithstanding the immense challenges of COVID-19, psilocybin therapy has the potential to play an important therapeutic role for various psychiatric disorders in post-COVID-19 clinical psychiatry.

Daly C, Griffin E, McMahon E, et al. (2020) International Journal of Environmental Research and Public Health, 17(17): 6159.
https://www.drugsandalcohol.ie/32865/

This study aimed to investigate repeat self-harm and method-switching following hospital-presenting intentional drug overdose (IDO) among young people.

Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk. Interventions targeting IDO among young people are needed that ensure that mental health assessments are undertaken and which address access to drugs.

Rosalim JP (2020) Journal of Correctional Health Care, 26(3): 258–266.
https://www.drugsandalcohol.ie/32751/

The exponential growth of the nurse-led clinic in the Republic of Ireland has proven to be effective in patients’ care in the Irish community (National Council for Professional Development of Nursing and Midwifery, 2005). This initiative has been replicated in the penal environment and assumed to add value to the prison health care system. To date, this concept has never been explored. The main goal of this study was to examine this concept in this setting. It was hoped that the outcome of this inquiry will provide a better insight into the service, which can be used in the development of an evidence-based policy in the future.

Quirke B, Heinen M, Fitzpatrick P, et al. (2020) Irish Journal of Psychological Medicine, Early online.
https://www.drugsandalcohol.ie/33022/

This study aims to identify factors associated with reported discrimination [of Travellers] and how this affects their experiences of accessing and quality of health services, including mental health.

Travellers experience high levels of discrimination which negatively affects their engagement with health services. Culturally competent services need to be developed.

Li S, Keogan S and Clancy L (2020) BMJ Open, 10(8): e032630.
https://www.drugsandalcohol.ie/32927/

This study aims to assess the role of tobacco control legislation (TCL) in youth smoking in Ireland. To examine the effects of smoke-free legislation in youth. To consider whether TCL contributed to the gender equalisation in prevalence in 16 years old seen between 2003 and 2015.

TC legislation helps to explain the out-of-trend reduction in youth smoking prevalence. The estimated differential effects of the workplace ban, point-of-sale displays, real price changes and graphical images on packs help to explain the sharper decline in girls than boys. These findings should remind policy-makers to give increased consideration to the possible effects on young people of any legislative changes aimed at adults in TCL.

Darcy C (2020) Irish Educational Studies, Early online.
https://www.drugsandalcohol.ie/33088/

This paper sets out to achieve four things: paint a picture of the Irish illicit drug landscape and of lay understandings of drugs and drug issues; highlight the emergent issue of people obtaining fake drug information on the Internet; explore drug education as a field of scholarship in Ireland; and reflect on 10 years of practitioner experience within the field.

Given the complexity of the drug landscape and the proliferation of questionable drug information available online, this paper argues that drug education is an appropriate and worthwhile response to precarious understandings of illicit drugs and drug issues. The paper suggests drug education warrants revival within the Irish context, particularly given the pace of change in both the drugs and online landscapes. To conclude, this practitioner urges other practitioners and scholars with an interest in drug education within the Irish context to revive and advance the field.

Impacts and drivers of drug markets

In the main, the effect of restriction measures on low-level violent crime has been positive. However, there has been an increase in drug-related violence in some areas, along with conflicts locally around drug distribution and territory. How drugs are trafficked has been impacted most by new border controls between EU members states. Because of Covid-19, drug traffickers have implemented new strategies to traffic, supply, and distribute products. Darknet markets have become more prominent, particularly in the distribution of small amounts of cannabis herb.

Focus on main drug types

Cannabis

Due to cannabis resin shortages and cannabis herb stockpiling, retail prices have increased in some EU member states. Covid-19 appears to have had no impact on domestic production.

Heroin

Heroin trafficking has persisted on established routes. However, due to quarantine rules and movement restrictions in some places, the availability of heroin has reduced, resulting in higher prices in several locations.

Cocaine

Cocaine trafficking via maritime shipping containers has remained at the same level or in some cases higher than in 2019. Significant seizures were reported in Europe and Columbia despite Covid-19 restrictions.

Amphetamine, MDMA, and methamphetamine

Synthetic drug production continued in the Netherlands and Belgium; however, demand for new psychoactive substances reduced, specifically MDMA, due to venue closures and festival cancellations. Several countries have reported a price increase for amphetamines and MDMA, except the Netherlands, where prices decreased in a bid to increase sales.

Criminal groups

The largest criminal market in Europe centres on drug trafficking. Organised crime groups (OCGs) regardless of size or ethnicity are actively involved in this type of offence. Collaboration and cooperation between different OCGs are mediated via brokers. The OCG/broker relationship tends to be unstable and short term. Brokers are also involved in money laundering and other criminal services. In the main, the frequency of violent incidents associated with drug trafficking has increased, with some member states reporting instances during the pandemic (e.g. Sweden and the Netherlands). Violent behaviours, such as physical harm, liquidations, and abductions, are mainly used by OCGs against competitors as part of debt recovery, payback, or to maintain control.

Law enforcement responses

To stop the spread of Covid-19, national governments across Europe have implemented border restrictions at land, sea, and air points of entry. The deployment of staff to these locations has resulted in several drug seizures. Notably, the alteration in operational focus has meant that less personnel are available to carry out investigative and intelligence work. Despite the challenges and reduction in shared information globally, EU member states in collaboration with Europol have continued to pursue high-risk OCGs along with their high-ranking members.

It is believed that as Covid-19 restrictions are lifted, it will emerge that those involved in the illicit drugs trade, from production through to distribution, will have adapted and overcome challenges by finding new ways of working, adding new routes, and carrying out more online business than in pre-pandemic times. While law enforcement agencies may find this challenging, it will also provide an opportunity to widen inquiries into serious and organised crime.

Outlook

The authors acknowledge that the data in this study, while limited, provide information that can inform preparations for comparable experiences likely to arise in the future. For example, restrictions and lockdowns reducing the movement of people have resulted in changes in how drug-related business is carried out. Across Europe restrictions are gradually being relaxed; however, changes that have occurred in the production, sale, and distribution of drugs are likely to endure particularly using online platforms. While travel restrictions have limited the movement of products between source and transit countries, large-scale drug importations have persisted via protected communication channels. Hence, it is likely that face-to-face meetings may decline. The modification of drug-related business by OCGs is likely to continue along with greater emphasis being placed on online drug distribution.

Ciara H Guiney