Unusually for books on the topic, Drug Policy includes a chapter on the democratic process and the role played by the public in drug policy formation.1 Author Alison Ritter explores how the public might participate in the decision-making process and identifies several obstacles to participation in contemporary liberal democracies. Justifications for government decisions are based on the strength of the arguments supporting them and on the consent which the electorate gives through the electoral process. Because of the complexity of governing, the technical tasks of policy are left to experts, with input from the bulk of the population largely limited to infrequent elections.

The neologism ‘technocratic’ is used to describe this concentration of decision-making and implies a separation between public consent and policy formation. Delegation to experts results in a distance from the political process and a susceptibility to arguments that promote a simpler, more responsive form of government that expresses the will of the people. Populism can be persuasive, but it relies on emotion and the identification of impediments to the popular will. This reduces the capacity to deal with nuance and complexity in policy areas around which there is no clear consensus and further erodes the capacity of the democratic system to respond to its electorate.

Ritter describes the opportunities provided by deliberative forms of public engagement that enable an informed and considered exchange of opinion. This allows a deeper understanding of the policy issue being considered to emerge, a respect for opposing positions, and a genuine effort to find workable and just solutions to problems.

The opportunities for deliberative input into policymaking are limited, but deliberative democracy can add a further level of legitimacy for policy decisions in that public justification for a position is built through reasoning among equals. Accounts of the origins and development of deliberative democracy emphasise its equally important epistemic and normative aspects: reasons are weighed and their strength is determined through a political process that supports equal participation and produces a collective judgement on the matter being considered.

The deliberative process faces obvious challenges, such as the extent to which voices other than those of the expert can be heard. Public reasoning must give space for ethical positions, values, and philosophical outlooks, which all play just as important a part as science in opinion-forming. It is difficult to integrate input based on scientific knowledge with emotive insight, lived experience, and anecdotal accounts. A process based on the principles of deliberative democracy supports this type of inclusion and ensures that all these perspectives are heard.

Citizens’ assemblies, citizen juries, mini-publics, or other mechanisms for deliberative democracy, invariably focus on topics where there are sharp differences of opinion. The topic of controlled drugs, and how best governments should respond to problems that arise from their use, presents very particular challenges to the deliberative process. There are legitimate ethical, security, and economic considerations while trying to work out the most appropriate path to ensuring the wellbeing of those who use or have used drugs, their families, communities, and society.

Policy formation can be opaque, contingent on economic circumstances, shifts in public opinion or political commitment. While citizens’ assemblies are exciting experiments in participation, no single event will determine policy. What they can do is frame policy problems in new ways and provide a different perspective that empowers decision-makers to consider more ambitious solutions than they might otherwise have done. The Citizens’ Assembly in Ireland in 2023 is the first time the topic of illegal drug use has been considered by this kind of forum. Its findings may well be of international significance.

1. Ritter A (2022) Drug policy. 1st edn. Abingdon: Routledge.

The Programme for Government, which was launched in June 2020, committed to holding a Citizens’ Assembly on Drugs Use.1 In February 2023, the Government gave its approval for the assembly to be established. The assembly’s work will run from April to December 2023. The establishment of the assembly has been overwhelmingly welcomed by stakeholders across the sector and the political spectrum.

What is a Citizens’ Assembly?

A Citizens’ Assembly is a democratic structure in which people living in Ireland are brought together to discuss and consider important and often complex legal and policy issues, independent of the Government and Oireachtas. Based on submissions from stakeholders and discussions, the assembly makes recommendations on the topic at hand and reports to the Oireachtas. Previous assemblies have covered diverse topics such as a directly elected mayor for Dublin and local government structures for Dublin; biodiversity loss; gender equality; the Eighth Amendment of the Irish Constitution (abortion); the needs of an ageing population; fixed-term parliaments; the system for referenda; and climate change.2

How will the Citizens’ Assembly on Drugs Use run?

The running of the Citizens’ Assembly on Drugs Use follows the structure of previous assemblies. Membership is made up of a selection of 99 Irish residents over the age of 18 and an appointed independent chair. Members do not have to be Irish citizens or on the electoral register. Based on a random selection, a pool of 20,000 households are invited to take part; of those who agree to be considered for membership a selection is made that reflects the age, gender, social class, and regional spread of Irish society. The chair of this assembly is Paul Reid, former head of the Health Service Executive (HSE).

The assembly sets its own rules and procedures, within the confines of six key principles (see Box 1). In her presentation of the motion to establish the assembly, the Minister of State with responsibility for Public Health, Wellbeing and the National Drugs Strategy, Hildegarde Naughton TD, emphasised the importance of this feature:

The terms of reference for the assembly have been designed so that they are  sufficiently well defined to provide a clear focus for the assembly. At the same time, they are not so prescriptive as to inhibit the scope of the assembly to define its work programme as it deems appropriate. We have learnt from the experience of previous assemblies that the terms of reference should not be expressed in an overly precise way. Every citizens’ assembly needs discretion and flexibility to define and organise its work programme as it deems appropriate.3

Key principles of the Citizens’ Assembly

Openness: The Citizens’ Assembly will operate with complete transparency with all plenary meetings being broadcast live at www.citizensassembly.ie and all documentation freely available. The assembly should be open to hearing from all sections of society on any issue, including our diaspora and young people under 18 years of age, who are not directly represented in the assembly membership.

Fairness: It is important that we allow the full spectrum of views to be heard on every issue and that our briefing material for assembly members is of the highest quality.
Equality of voice: Amongst all assembly members. Each member will be given an opportunity to voice their opinions, should they so wish.

Efficiency: The assembly will make best use of our limited time together and ensure that all documentation is circulated in advance so members can properly prepare for meetings.

Respect: It is important that members can freely and confidently make contributions and express their views without fear of personal attacks or criticism.

Collegiality: We will work together in a spirit of friendship as together we embark on this task.

Source: The Citizens’ Assembly, 2018

https://2016-2018.citizensassembly.ie/en/About-the-Citizens-Assembly/Background/Key-Principles-for-the-Assembly/

What are the terms of reference for this assembly?

The Citizens’ Assembly on Drugs Use will consider the legislative, policy, and operational changes the State could make to significantly reduce the harmful impacts of illicit drugs on individuals, families, communities, and wider society. In bringing the motion on the terms of reference of the assembly before the Dáil, the Minister presented that the assembly shall consider, among others:

• The drivers, prevalence, attitudes, and trends in relation to drugs use in Irish society
• The harmful impacts of drugs use on individuals, families, communities, and wider society
• Best practice in promoting and supporting rehabilitation and recovery from drug addiction
• The lived experience of young people and adults affected by drugs use, as well as their families and communities
• International, European Union (EU), national, and local perspectives on drugs use
• The efficacy of current strategic, policy, and operational responses to drugs use
• International best practice and practical case studies in relation to reducing supply, demand and harm, and increasing resilience, health, and wellbeing
• The opportunities and challenges, in an Irish context, of reforming legislation, strategy, policy, and operational responses to drugs use, taking into consideration the implications for the health, criminal justice, and education systems.3

What sources of information will the assembly use?

To inform its deliberations, the assembly will engage with experts in the field, including members of an Expert Advisory Group.4 It will also engage with stakeholders and the general public, including through a public consultation process, and by inviting selected speakers to participate in meetings of the assembly.4 It is expected that the assembly will avail of international evidence sources through the work of the European Monitoring Centre for Drugs and Drug Addiction, other EU member states, and the British–Irish Council work sector on drugs, which is chaired by Ireland. Given that members of the assembly must be over 18 years of age and that the issue of drugs also affects people below this age, the Minister of State initiated a consultation with young people ‘through Comhairle na nÓg and youth drug projects in disadvantaged areas, which will be presented to the Citizens’ Assembly for its consideration’.5

How will the assembly report its findings?

The assembly will draft a set of recommendations that will be voted on by its members. Those that pass the vote will be included in a report to the Oireachtas. This report will be referred to a committee comprising members of the Oireachtas and Seanad for consideration, with the committee bringing its conclusions to the Houses of the Oireachtas for debate. The Government is obliged to respond to each recommendation of the report in the Oireachtas. For recommendations that it accepts, it is obliged to set out a timeframe for their implementation.

1. Fianna Fáil, Fine Gael, and the Green Party (2020) Programme for Government: our shared future. Dublin: Department of the Taoiseach. Available from: https://www.drugsandalcohol.ie/32212/
2. For more information on the Citizens’ Assembly, visit: https://www.citizensassembly.ie/en/
3. Naughton H (2023) Parliamentary Debates Dáil Éireann. 21 February 2023. Vol. 1033, No. 6. Available from: 
   https://www.drugsandalcohol.ie/38235/
4. Members of the Expert Advisory Group are: Jo-Hanna Ivers, associate professor in addiction, School of Medicine, Trinity College Dublin (TCD) and associate dean of civic engagement and social innovation at TCD; Philly McMahon, advocate for people affected by drugs use; Mary Cannon, professor of psychiatric epidemiology and youth mental health, RCSI University of Medicine and Health Sciences, and consultant psychiatrist at Beaumont Hospital, Dublin; Joe O’Neill, chair of the Western Region Drugs and Alcohol Task Force; Ann Ryan, retired judge of the District Court; Brian Galvin, programme manager for drug and alcohol research, Health Research Board; John Garry, professor of political behaviour, Queen’s University Belfast (QUB) who leads the Democracy Unit at QUB. Available from: 
   https://citizensassembly.ie/advisory-support-group-announced/
5. Irish Government News Service (2023) Government agrees to establish a Citizens’ Assembly on Drugs Use [Press release]. 14 February 2023. Available from:  https://merrionstreet.ie/en/newsroom/news/government_agrees_to_establish_a_citizens_assembly_on_drugs_use.175694.shortcut.html

In December 2022, the Joint Committee on Justice published Report on an examination of the present approach to sanctions for possession of certain amounts of drugs for personal use.1 The report makes a set of wide-reaching recommendations on how the committee thinks Ireland’s approach to people who use drugs should change. It includes a recommendation for the decriminalisation of the possession of drugs for personal use.

Joint Committee on Justice

The Joint Committee on Justice is described as shadowing the Department of Justice and considers policy ‘in the fields of justice, security and the rule of law to ensure that Irish society is safe, secure, just, open-minded and impartial’.2 The committee comprises Dáil Deputies and Senators of the Oireachtas from across all political parties and independents. It is chaired by James Lawless TD of Fianna Fáil and its members include Labour Party TD Aodhán Ó Ríordáin and Independent Senator Lynn Ruane, both of whom are long-standing contributors to the national discussion on drug issues. The aim of the committee is to have meaningful input into key legislation and policy areas. It should be noted that the committee’s findings and recommendations do not necessarily reflect those of the Minister for Justice or the Department of Justice.

Committee’s focus on drug issues

The committee chose to address the issue of drug use given that this policy area has seen significant developments since the late-2010s. These include the move to a more health-led approach in the national drugs strategy, the introduction of the first on-site drug testing facility at a music festival in 2022, and the proposal to establish a Citizens’ Assembly on Drugs Use, which in fact convened in April 2023. To inform its work, the committee carried out a public engagement that involved face-to-face meetings with stakeholders and inviting them to make written submissions. These focused on four broad questions:

1. Did they believe the criminal justice system is the most appropriate avenue for dealing with possession of small quantities of drugs for personal use?
2. Is the current approach towards drugs, which can result in a criminal record, counterproductive in terms of dissuading people from drug use and encouraging engagement in rehabilitative programmes?
3. Would an administrative sanction be an appropriate (and more cost-effective) alternative to a criminal sanction?
4. Are there particular jurisdictions with alternative drug policies from which Ireland could learn?

Stakeholder responses

Submissions were made based on stakeholder experiences in the field and their views on how Irish drug policy should progress, with some making reference to existing research and other evidence sources.

Stakeholder submissions reflected a range of positions in response to the questions posed by the committee. Among the alternative approaches suggested for consideration were the potential decriminalisation of the possession of drugs for personal use and the potential to introduce a regulatory model around the use of drugs. While there was broad (but not unanimous) consensus on the benefits of the first of these approaches, the second attracted more debate. Among the arguments in favour of decriminalisation were that the use of the criminal justice system for possession for personal use is disproportionate, that there is stigma attached to a criminal conviction, and that criminalisation may have a negative impact on the introduction of better harm reduction and treatment interventions for people who use drugs. While some argued that there was a lack of evidence that criminalisation deters drug use, one group argued that there was evidence that the threat of criminal sanctions deters some young people from using.

Recommendations of Justice Committee

The committee made 22 recommendations based on its findings. Underpinning these is its position that a criminal justice-led approach to drug use causes harm and that a health-led approach should be prioritised in drug-related policy and practice in Ireland.
The Committee acknowledges the harms associated with pursuing a criminal justice led approach to drug use and misuse and recommends that a health led approach is prioritised in both policy and practice.1 (p. 6)

Service-related recommendations

Many of the recommendations focus on the provision of services for people who use drugs. The committee recognises the role of poverty, inequality, and trauma in drug use and advocates for a poverty and trauma-informed approach to be taken in the development and delivery of addiction services. The existing services that it recommends be expanded or developed further in Ireland are: dual diagnosis services; drug testing at festivals; naloxone training and provision; opioid substitution treatment; and an expanded Medical Cannabis Access Programme. Other services that it recommends introducing in Ireland are: heroin-assisted treatment; fixed/mobile medically supervised injecting facilities; and mobile overdose prevention clinics. It also recommends the introduction of a ‘fact-based, educational campaign on drug use and harm reduction’ (p. 6).1

Recommendations on decriminalisation and regulation

The committee explicitly recommended decriminalising the possession of drugs for personal consumption. It does not make a distinction between different types of drugs for this recommendation. It also recommends that steps are taken to introduce ‘a regulatory model for certain drugs’ (p. 7), although these drugs are not named explicitly. Among the activities that it recommends ‘be examined’ is the practice of cultivating illicit substances at a non-profit level. This is linked to another recommendation to carry out research on the benefits and drawbacks of mechanisms, such as community collectives or social clubs, through which people can grow personal supplies of cannabis or other drugs.

The Committee recommends that a policy of decriminalisation is pursued, in line with emerging international best-practice, in respect of the possession of drugs for personal consumption, through appropriate legislation reform, in favour of a health-led approach to problem drug use.1 (p. 7)

Concluding comment

The Citizens’ Assembly on Drugs Use convened for the first time in April 2023. The committee has recommended that the assembly facilitates a discussion on Ireland’s approach to drug possession and use. Based on the current report, the committee would support the selection of decriminalisation and regulation of the drug market as topics to be covered.

1    Joint Committee on Justice (2022) Report on an examination of the present approach to sanctions for possession of certain amounts of drugs for personal use. Dublin: House of the Oireachtas. Available from: 
https://www.drugsandalcohol.ie/37755/
2    For further information on the Joint Committee on Justice, visit: https://www.oireachtas.ie/en/committees/33/justice/

Alcohol use is a leading risk factor for death and disability and there is a need for evidence-based policy measures to tackle excess alcohol consumption and related harms. A 2023 study, led by University College Cork (UCC), examined attitudes towards alcohol control measures among the general public in Ireland in the context of significant reforms undertaken in the Irish alcohol policymaking landscape.1

In this research, conducted by Dr Susan Calnan and Dr Seán Millar of the UCC School of Public Health and Dr Deirdre Mongan of the Health Research Board, a representative household survey was undertaken in three regions of Cork and Kerry. A total of 1,069 participants took part. Descriptive and univariate analyses were used to examine factors associated with support for alcohol control policy measures.

Notable findings from the study, published in the European Journal of Public Health, include the following:

• The survey suggests that there is broad public support for evidence-based alcohol policies legislated under Ireland’s Public Health (Alcohol) Act 2018. Support was strongest for a ban on alcohol advertising near schools and creches (85.1%) and for warning labels on alcohol products (81.9%). A ban on price promotions and support for minimum unit pricing generated the lowest levels of support overall, although over 50% of respondents still indicated their support for these measures.
• Differences were found in levels of support according to sociodemographic characteristics, alcohol consumption patterns, knowledge of health risks, and harms experienced. For example, women were more likely than men to support alcohol control policy measures, while participants with harmful alcohol use patterns were significantly less likely to support these measures. Respondents with a greater awareness of the health risks of alcohol also showed higher levels 
  of support.
• Surprisingly, participants who had experienced harms due to other people’s drinking showed lower support compared with those who had not experienced such harms. However, this may be partly explained by the fact that these subjects were also more likely to have engaged in harmful alcohol use patterns themselves.

The authors suggest that additional research could help shed further light on reasons for such differences and to help inform strategies aimed at increasing public support for, and understanding of, public health policies related to alcohol use.

1. Calnan S, Millar SR and Mongan D (2023) Support for evidence-based alcohol policy in Ireland: results from a representative household survey. Eur J Public Health, 33(2): 323–330. Available from: https://www.drugsandalcohol.ie/38321/

A 2023 report grounded in women’s lived experiences of substance use in Ireland was launched by the then Minister for Justice Simon Harris TD on 30 March entitled, ‘You can’t fix this in six months’: Understanding the intersectionality of women’s substance use in the Irish context.1 The report highlights the complex nature of women’s substance use and the issues they face. It argues for female-only services that support motherhood and recognise the exploitation, trauma, and abuse many women who use substances experience (p. 19).1 The research, funded by the Irish Research Council New Foundations scheme, was carried out by a team from University College Dublin led by Dr Sarah Morton in partnership with Merchants Quay Ireland.

Context and study aim

The report argues that Irish drug policy and practice have often overlooked the gendered needs of women who use drugs. However, the authors recognise the gender dimension in Ireland’s national drugs strategy and the introduction of some gender-specific initiatives and services on the Irish service landscape.2,3 They explore the existing literature to illustrate how women have different substance-using patterns and trajectories when compared with men, and how the health-related and social consequences they experience may also differ, particularly in relation to physiological factors, experiences of trauma, mental health, and cultural considerations.

The authors argue that there continues to be a gap in our understanding of how women’s substance use intersects with other issues. They define intersectionality as ‘how one’s life experiences are constituted by reinforcing occurrences relative to different aspects of one’s identity, including gender and class’ (p. 3). Women’s substance use may intersect with issues such as poverty, migration status, trauma, domestic violence, sexual violence, prostitution, homelessness, motherhood, and involvement with the criminal justice system. The study aimed to explore the lived experience of women who were subject to such intersectionality to inform policy innovation and the treatment needs of women.

Methods

Qualitative interviews were carried out with 14 women aged between 25 and 60 years and with lived experience of substance use and other complex issues. Eleven were mothers, four were actively using substances, and 10 described themselves as abstinent. Transcripts of the interviews were analysed thematically and patterns and themes within the data were explored and reported on in the publication.

Findings

The women’s narratives illustrate the complex nature of their substance use and how it is interlinked with a wide range of issues, such as lifetime trauma and abuse, gender-based and domestic violence, transactional sex, homelessness, involvement in the criminal justice system, and motherhood. The authors identified five overarching themes in their analysis.

1. Substance use patterns and prevalence: Substances used by women in the study included alcohol, prescription medicines, and illicit substances. Two patterns were identified in relation to initiation of use. First were those who started when they were teenagers and were often ‘initiated or groomed into substance use and an intimate relationship by an older male’ (p. 18). These women often linked their use to difficulties, tensions or abuse in their home settings, with some reporting use among other family members. Second were those women whose use had started subsequent to an experience of violence or abuse within a relationship. Medication misuse was a common feature of these women’s initiation. Benzodiazepines and pregabalin were the two medications women reported as causing the most harm.
2. Relationships and family: While some women described having supportive parents or families, more often family relationships were characterised by abuse, neglect, and drug use. These experiences were perceived by the women to have left them vulnerable to grooming, exploitation, or an abusive relationship in their early teenage years. Across their relationship histories, domestic violence was a feature of every woman’s experience. Furthermore, coercive control, sexual violence, physical violence, and stalking also featured for some. For the majority of women, there was a deep interface between women’s substance use and their experiences of abuse and control.
3. Stigma and shame: Women spoke about stigma and shame, both in relation to their substance use and being a mother. This impacted on how they engaged with services. For example, some were reluctant to raise issues, such as experiences of domestic violence, with drug treatment services. They were concerned about how service providers would respond to these issues and whether it would raise child protection and welfare issues.
4. Implications and intersectionality: As mentioned above, domestic, sexual, and gender-based violence featured heavily in the women’s experiences. The authors found five subthemes that cut across their experiences to varying degrees: mothering; housing and homelessness; transactional sex and prostitution; criminal and civil justice involvement; and mental health and trauma. Each of these themes interacted with women’s substance in complex ways. For example, being a mother had been a source of great trauma for women due to the grief and devastation experienced from children’s deaths, miscarriages, and loss of contact with children. However, being a mother had also been a motivator for positive change among some women, as they were driven by a desire to meet their children’s needs. Another example is homelessness and a lack of security around housing, which was described as ‘normative’. Addressing substance use issues while experiencing homelessness and living in a hostel with other women who use, for example, was problematic.
5. Engagement with support and interventions: Three subthemes were identified in relation to this theme: turning points and initial contact with services; pathways through services; and policy and practice change. Involvement in the criminal justice system, the needs of children, and personal health issues were the three circumstances that led women to seek help. Factors impacting on women accessing services included the mixed-gender nature of most services, geographical location, childcare availability, and the treatment or intervention approach.

Policy and intervention implications

The report highlights the need for female-only services that recognise the specific needs of women as mothers as well as providing the support needed to address their experiences of exploitation, trauma, and abuse, among other issues. Given the prevalence of gender-based violence in these women’s narratives, the authors argue that ‘an effective response requires an integration of expertise and ongoing support to develop and maintain realistic and appropriate coping strategies’ (p. 19). They also highlight the need for women to be safe when seeking and accessing support: ‘This may include female-specific services and interventions, as well as safety planning, risk assessment, exploration with women about the current risks in their lives and clear policy and operational guidelines for mixed-gender interventions’ (p. 19). The authors call for attention to be paid to the prescribing and misuse of medications, highlighting in particular benzodiazepines and pregabalin and their associated risk of dependency and overdose. They also flag an initial interaction with the criminal justice system, or child protection, and welfare involvement as important opportunities to engage women in services.

1. Morton S, Gallagher B and McLoughlin E (2023) ‘You can’t fix this in six months’: Understanding the intersectionality of women’s substance use in the Irish context. Dublin: University College Dublin and Merchants Quay Ireland. Available from: 
   https://www.drugsandalcohol.ie/38492/
2. Department of Health (2017) Reducing Harm, Supporting Recovery: a health-led response to drug and alcohol use in Ireland 2017–2025. Dublin: Department of Health. Available from: 
   https://www.drugsandalcohol.ie/27603/
3. In particular, gender-specific initiatives and services such as Ashleigh House in Coolmine and Jane’s Place in Merchant’s Quay Ireland.

Background

Breast cancer is the most common cancer among women in Ireland and alcohol use is estimated to be attributable to approximately 7% of breast cancer cases.1,2 Almost one-half of women in Ireland drink alcohol on a weekly basis (48%) and approximately one in five women report binge drinking on a typical drinking occasion (19%). However, despite alcohol being classified as a Group 1 carcinogen (cancer-causing) since 1988, many people appear unaware of this fact.3,4

Methods

The annual Healthy Ireland Survey, representative of the adult population of Ireland, examines various health behaviours, including smoking, alcohol use, weight, dental health, menstrual health, mental health, as well as information about the use of health services. The survey has included baseline questions about alcohol use every year since its inception in 2015 and occasionally has additional questions about alcohol. In Wave 2 of the Healthy Ireland Survey, 2016, respondents were asked to identify which of the five alcohol-related health conditions (liver disease, pancreatitis, high blood pressure, breast cancer, bowel cancer) they thought people were at an increased risk of developing if they regularly drank more than the low-risk limits recommended in Ireland (currently no more than 11 standard drinks per week for women or 17 standard drinks for men).4

Of the health conditions, awareness of the link between alcohol use and breast cancer was the lowest. A 2023 study therefore sought to examine their characteristics so that recommendations could be made to target specific groups.5

Results

Just one in five respondents correctly identified that alcohol use was associated with increased risk of breast cancer (21%). Women (27%) showed greater awareness than men (15%), as did those aged 45–54 years (27%), especially when compared with those aged 15–24 years (13%). When considering educational attainment, those educated to degree level or higher were almost twice as likely than those with no qualifications to know of the risk (29% vs 16%). Greater awareness was evident among those engaged in home duties (26%), those in employment (24%), those married or in a civil partnership (24%), and those in the least deprived deprivation category (23%).

Drinking patterns, such as how often and how much alcohol respondents drink, did not influence level of knowledge, with hazardous drinkers (20%), low-risk drinkers (23%), and non-drinkers (21%) showing an almost equally low level of awareness. Similarly, area of residence did not impact knowledge.

Discussion

The low level of awareness of the carcinogenic effect of alcohol is a cause for concern, especially given the drinking patterns of many women in the country. In Ireland, the Public Health (Alcohol) Act 2018 aims to reduce population-level alcohol use and related harm. The legislation includes components such as structural separation (alcohol products in mixed-retail outlets must be kept separate from other products), minimum unit pricing, restrictions on alcohol advertising and sports sponsorship, and restrictions on the sale and supply of alcohol. The Act has also legislated for health warning labels on alcohol products, although to date, these have not yet commenced due to an ongoing European Union consultation process.

These labels are intended to advise the public of the link between alcohol use and cancer, provide information about the number of standard drinks in the product, the calorie content of the product, the danger of alcohol use during pregnancy, and a website that provides impartial information about alcohol use and its harm. Such labelling on alcohol products has been found to be effective in providing information and in changing health behaviours in other jurisdictions where introduced. They are also recommended by the World Health Organization (WHO).

It is important that efforts be increased to raise awareness of the breast cancer risk associated with alcohol use. This can be achieved through social media campaigns, health practitioner advice, and education programmes in communities and schools, with strategic targeting of those identified as having particularly low levels of knowledge. As the risk is specific to female breast cancer, it is crucial that women are made aware, but also men, so that they can provide support to female family members, friends, and colleagues. To inform effective public health messaging to reinforce this message, a greater understanding of drinking motivations among women who drink and yet know of the risks involved is required. In highlighting this risk, it may contribute to a decrease in hazardous drinking as well as reducing breast cancer incidence.

The authors recommend that the low-risk drinking guidelines in Ireland be revised in view of WHO recommendations that there is no safe level of alcohol use. Finally, the findings from this study support the need for health warning labels on alcohol products, as set out in the Public Health (Alcohol) Act 2018.

1. Irish Cancer Society (2022) Cancer statistics. Dublin: Irish Cancer Society. Available from: https://www.cancer.ie/cancer-information-and-support/cancer-information/about-cancer/cancer-statistics
2. Health Service Executive (HSE) (2022) Alcohol 
   and cancer. Dublin: HSE. Available from: 
   https://www2.hse.ie/wellbeing/alcohol/physical-health/alcohol-and-cancer.html
3. Ipsos MRBI (2018) Healthy Ireland survey 2018: summary of findings. Dublin: Government Publications. Available from: 
   https://www.drugsandalcohol.ie/29851/
4. Department of Health (2016) Healthy Ireland survey 2016: summary of findings. Dublin: Stationery Office. Available from: 
   https://www.drugsandalcohol.ie/26278/
5. Doyle A, O’Dwyer C, Mongan D, et al. (2023) Factors associated with public awareness of the relationship between alcohol use and breast cancer risk. BMC Public Health, 23: 577. Available from: https://www.drugsandalcohol.ie/37780/

Background

Minimum unit pricing (MUP) of £0.50 sterling per unit (10 ml or 8 g) was introduced in Scotland in 2018 in response to health harms from alcohol being disproportionately higher in Scotland compared with the rest of the United Kingdom, especially so in areas of deprivation. MUP is a measure recommended by the World Health Organization as a ‘best buy’ to reduce alcohol-related harms. As it targets those who buy the cheapest alcohol who are typically the heaviest drinkers, it has the potential to reduce inequalities of alcohol-related harms.1,2 Three years after implementation, MUP resulted in a 3% reduction in alcohol sales in Scotland, most evident in households that before MUP had purchased the most alcohol.1 A 2023 study to examine the impact of MUP on alcohol-related deaths and hospitalisations wholly attributable to alcohol use compared time periods before and after the introduction of MUP.3

Methods

The study involved a controlled interrupted time series design to estimate the impact of MUP in Scotland, while England (where MUP is not in place) was used as a control group. Routinely collected data on deaths and hospitalisations for causes wholly attributable to alcohol, along with the socioeconomic deprivation group, were examined.

Results

Alcohol-attributable deaths

Following the implementation of MUP in Scotland, there was a 13.4% decrease in the rate of alcohol-attributable deaths, equating to approximately 156 deaths wholly attributable to alcohol use prevented. Significant decreases in alcohol-attributable deaths were observed in chronic conditions (14.9% decrease), alcoholic liver disease (11.7% decrease), and alcohol dependence syndrome (23% decrease).

The study revealed that MUP resulted in significant reductions in wholly alcohol-attributable deaths among both males and females, those aged 35–64 years, those aged 65 years and older, and in the four most socioeconomically deprived decile groups.

Alcohol-attributable hospitalisations

As well as a reduction in alcohol-attributable deaths, a 4.1% decrease in wholly alcohol-attributable hospitalisations was also observed during the study period. Although chronic conditions decreased by 7.3%, acute conditions increased by 9.9%, offsetting the significant reduction observed. Hospitalisations for alcoholic liver disease decreased by 9.8%, alcohol psychoses decreased by 7.2%, although alcohol dependence syndrome hospitalisations increased by 7.2%.

MUP led to insignificant reductions in wholly alcohol-attributable hospitalisations among males, those aged 35–64 years, and as with wholly alcohol-attributable deaths, those in the four most socioeconomically deprived decile groups.

Discussion

This study adds to the evidence that MUP is effective in reducing alcohol-related harms, demonstrating a 13% reduction in wholly alcohol-attributable deaths in the study period. A 4% reduction in wholly alcohol-attributable hospitalisations was also estimated, the equivalent of 411 hospitalisations per year on average.

The study confirmed that MUP had a positive impact in tackling deprivation-based health inequalities in alcohol-related harms, as declines in hospitalisations and deaths were more evident among those in the lower socioeconomic areas. Alcohol-attributable deaths were evident among males and females and those aged 35 years and over, but reductions were not observed among those aged 16–34 years.

The implementation of MUP resulted in a worsening of acute outcomes for deaths and hospitalisations wholly attributable to alcohol. The authors suggest a potential explanation is that certain subgroups may have reduced their expenditure on food or reduced their food intake to compensate for the price increase for alcohol products, resulting in faster intoxication or poisoning. It has been reported elsewhere that MUP may have resulted in switching to higher alcohol-by-volume products (e.g. cider to spirits) leading to quicker intoxication.4

Despite the increase in acute effects, overall this study supports the theory of change which was the basis for the policy being implemented. This is that an overall reduction in alcohol sales (3% in the 3 years following MUP being introduced) would result in a reduction in alcohol-related deaths and hospitalisations and, importantly, tackle alcohol-related health inequalities.

1. Giles L, Mackay D, Richardson E, et al. (2022) Evaluating the impact of minimum unit pricing (MUP) on sales-based alcohol consumption in Scotland at three years post-implementation. Edinburgh: Public Health Scotland. Available from: https://www.drugsandalcohol.ie/37516/
2. World Health Organization (2017) Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization. Available from: 
   https://www.drugsandalcohol.ie/37100/
3. Wyper GMA, Mackay D, Fraser C, et al. (2023) Evaluating the impact of alcohol minimum unit pricing (MUP) on alcohol-attributable deaths and hospital admissions in Scotland. Edinburgh: Public Health Scotland. Available from: 
   https://www.drugsandalcohol.ie/38412/
4. Holmes J, Angus C, Boyd J, et al. (2022) Evaluating the impact of minimum unit pricing in Scotland on people who are drinking at harmful levels. Edinburgh: Public Health Scotland. Available from: https://www.drugsandalcohol.ie/36398/

Background

A systematic review of the literature was undertaken to examine the impact of minimum unit pricing (MUP) on alcohol-related hospitalisations.1 The review also sought to determine if MUP had an effect on length of hospital stay for alcohol-related conditions, on hospital mortality, and for alcohol-related liver disease. Given that the costs of alcohol-related hospitalisations on the Irish healthcare system are estimated at €1.5 billion (in 2012) and the high levels of alcohol use in Ireland, legislation to reduce alcohol use and related harms were introduced in 2018.2–4 A component of this legislation, the Public Health (Alcohol) Act 2018, is MUP, set at €1.00 per standard drink or per 10 g of alcohol. Ireland is one of the few countries globally to introduce such a measure, as well as certain provinces in Canada; Northern Territory, Australia; Scotland; Wales; Jersey; Armenia; Belarus; Kyrgyzstan; Moldova; Russia; Ukraine; and Uzbekistan.5

Methods

A systematic search of MEDLINE, Embase, Scopus, APA PsycInfo, CINAHL Plus, and Cochrane Reviews as well as a search of grey literature was carried out between 1 January and 11 November 2022. Inclusion criteria were studies evaluating the impact of MUP with no restriction on country of origin.

Results

Along with 20 studies retrieved from grey literature, 591 articles were identified from the search, with the final number meeting the inclusion criteria at 22: five from Canada, six from England, three from Scotland, two from Wales, one from Northern Ireland, one from Ireland, three from Australia, and one from South Africa. Almost three-quarters of the studies used modelling studies (n=16), most commonly the Sheffield Alcohol Policy Model.6 There were six natural experiments studies: two originated from Canada, one from Scotland, and three from Australia.

Modelling studies

The results from the modelling studies are displayed in Table 1.

Table 1: Findings from modelling studies, by country

MUP: minimum unit pricing; ALD: alcoholic liver disease; UK: United Kingdom.

Table 2 presents summarised findings from the natural experiments.

MUP: minimum unit pricing; ALD: alcoholic liver disease; ICU: intensive care unit.

Discussion

The findings from this systematic review support policies that include MUP to reduce alcohol-related hospitalisations. Furthermore, such policy implementation impact is most effective in tackling health inequalities. The review included studies that compared the effectiveness of MUP with general alcohol taxation, bans on below-cost sales, and restrictions on price promotions. The authors note that MUP cannot be considered a ‘panacea to all alcohol-related issues’ (p. 9) and is most effective when combined with other alcohol control measures.1

1. Maharaj T, Angus C, Fitzgerald N, et al. (2023) Impact of minimum unit pricing on alcohol-related hospital outcomes: systematic review. BMJ Open, 13: e065220. Available from: https://www.drugsandalcohol.ie/38116/
2. Mongan D and Long J (2016) Alcohol in Ireland: consumption, harm, cost and policy response. HRB Overview Series 10. Dublin: Health Research Board. Available from: https://www.drugsandalcohol.ie/25697/
3. Mongan D, Millar SR and Galvin B (2021) The 2019–20 Irish National Drug and Alcohol Survey: main findings. Dublin: Health Research Board. Available from: https://www.drugsandalcohol.ie/34287/
4. Office of the Attorney General (2018) Public ¬Health (Alcohol) Act 2018. Dublin: Irish Statute Book. Available from: 
   https://www.drugsandalcohol.ie/33698/
5. Neufeld M, Bobrova A, Davletov K, et al. (2021) Alcohol control policies in Former Soviet Union countries: a narrative review of three decades of policy changes and their apparent effects. Drug Alcohol Rev, 40: 350–367.
6. Angus C, Gillespie D, Ally A, et al. (2015) Modelling the impact of minimum unit price and identification and brief advice policies using the Sheffield Alcohol Policy Model version 3. Sheffield: University of Sheffield.

Background

Methadone maintenance treatment (MMT) is considered a common treatment for opiate- dependent people across Europe and especially in Ireland. As MMT services cater for vulnerable populations, a human-rights-focused approach can assist in shaping and framing processes to provide more equality and access to services. A 2022 qualitative study1 looked at how to better understand the human-rights perspective in relation to people accessing MMT services in Ireland.

Method

In-depth qualitative interviews about the experiences of MMT were conducted with 40 current and recent service users. The majority of participants were from Dublin and included 17 women and 23 men. Data were collected between January and December 2019 and analysed using a narrative inquiry design.

Results

The authors found five interrelated themes from the narratives of the participants.

1. Giving away control and eroding personal autonomy
2. Coercive, restrictive, and disrespectful practice
3. A system predicated on reward and punishment
4. Disregarding best practice
5. Consequences of system failure.

Narrative 1: Giving away control and eroding personal autonomy

This is characterised by power imbalances; restriction of personal agency; and fear of perceived authority. The narratives suggested an unequal power relationship between the participant and their service provider. One example was signing a consent form at the start of treatment, with many not understanding or recalling the content of these forms or the consequences of what they were signing.

I wouldn’t have a clue what they said [staff], but you’re hardly not going to sign them ... if that what it takes to get help. You’ve got to remember you’re usually in a heap [highly distressed] signing those forms. John (p. 3)

Some participants felt their privacy had been violated, especially when they became aware that the signing of these forms permitted their service provider to share personal information, manifesting the power of the service provider.

Many expressed living in fear or being ‘controlled’ or ‘chained’ and feeling like a ‘puppet’ due to the practices of some service providers. They reported that they felt doctors had powers that often impinged on their private lives, such as around childcare, and brought unnecessary difficulty to their lives.

I do feel under threat by the doctor. She’s never come straight out and said it but there are things she could do that would make my life more awkward. She could put me back on ‘dailys’ [daily supervision of consuming methadone] … and she uses this to control me. Joseph (p. 5)

As for dignity and respect, me bollix. One dirty urine, the takeaway is gone, even if you have months of clean urines. Really, with the amount of urines, clean urines that I’ve given, I should be on weekly takeaways. If I had these, maybe then I could get a job. Jason

Participants who were parents also expressed fear of social workers and considered them a threat to their role as parents.

Narrative 2: Coercive, restrictive, and disrespectful practice

This is characterised by unmet expectations of treatment; social opprobrium; and shame and hopelessness. Many service users spoke of becoming disillusioned with their expectations of MMT, which they had hoped would improve their lives, enable them to rehabilitate, to return to work, and to repair relationships, for example. Moreover, most participants felt they had received unequal treatment when compared with other health service users and sometimes felt treated like second-class citizens.

[At the GP practice] I mean you could have an appointment … but they just put people ahead of you [in order of arrival], looking down at you [staff]. It’s hard to explain but you feel like a second-class citizen. Aido (p. 5)

Some participants also felt ‘subhuman’ at the hands of MMT service providers, in particular in relation to the imposition of sanctions. Others provided examples of where their service provider expressed a lack of confidence in the ability of the service user to achieve positive outcomes. In addition, service-user narratives described a sense of hopelessness sometimes combined with feeling ‘belittled’ and having no ‘self-respect’ or ‘self-worth’, to the point where they felt they had no right to an acceptable standard of treatment.

…I can’t complain, anything I done was my own fault, dirty urines so I had to be punished. Anything I got punished for was my own fault. Emma (p. 5)

Narrative 3: A system predicated on reward and punishment

This is characterised by pejorative binaries and the lack of a robust complaints facility. Participant narratives often referred to being ‘dirty/clean’ (in relation to urine samples) and how this was internalised.

We’re calling ourselves clean and dirty, we shouldn’t be labelling ourselves like this, but it’s the clinics, they put that into [you], your urine is either clean or dirty, and that’s how you’re treated. Jenna (p. 6)

Some participants spoke of their reluctance to make a complaint about certain service providers because of the fear of any ensuing consequences.

I can’t complain about him [doctor/service provider], even it was anonymous, he would find out it was me .... I would be reluctant to make a complaint because I think he would make my life a living hell. Jason (p. 6)

Narrative 4: Disregarding best practice

This is characterised by an observed lack of staff knowledge and experience and lack of choice. Narratives suggested some participants felt doctors in MMT services did not have enough experience and this hampered their recovery.

I don’t feel my doctor knows enough about addiction to be running my life. They don’t do much training, but we are expected to do all the work to get on methadone and stay on methadone .... They don’t realise there is more to it than the drug. Lisa (p. 6)

We get them stand-in doctors, they’re training. One would give you a sleeper [sleeping tablet], the other would take it off you. Louise (p. 6)

Some participants also felt that some doctors often overlooked their other medical problems, such as stress, anxiety, and pain.

I’ve always had anxiety and insomnia but as an addict, they won’t give me anything .... It’s like, ‘she’s a junkie, she’s only looking for tablets’. This really annoys me. Sinead (p. 6)

Several participants discussed that one of the consequences of the perceived power imbalance with MMT services and lack of choice was that they had no choice but to try to self-detox without medical supervision, despite knowing the dangers of doing so.

I feel like just a cheque to my doctor, a number; me and the fella, we had to detox ourselves because the doctor would have left us where we were. Emma (p. 6)

When I wanted to detox, I had to do it behind the doctor’s back. I was never even asked about detox, I think they had me down as someone who would be on methadone for life. They said I couldn’t do it when I asked, wouldn’t let me. So, I had to do it myself, without them knowing and that’s how I got off methadone. Unfortunately, I think this puts a lot of people off and keeps them on methadone. Louise (p. 6)

Narrative 5: Consequences of system failure

This is characterised by geographical restrictions; the stigma of MMT precluding social reintegration; being ‘back in the circle’; and a lack of follow-up care. Many participants, especially those from more rural areas, discussed the consequences of long waiting times – ranging from 2 months to 2 years – to access MMT services.

I went through the usual three urines and visits to counsellors and was waiting two months to get back on … I had relapsed .... I was living on the streets … it’s a long time to be waiting to get back on methadone, especially when you are living rough and tapping [begging] …. No other illness is treated like this. Aoife (p. 6)

Narratives frequently indicated that the set-up of MMT services hindered the attempts of many service users to get employment, which for some put them at risk of returning to criminal activities in order to alleviate financial pressures. The participants spoke of other external risks associated with MMT, for example, exposure to drug dealing in the environs of the clinics.

Going back into the clinics every day makes it impossible to stay clean, especially when you’re from the inner city. Zimovane, Valium, there would be everything, never mind heroin. And I’d be stable. I think that once you get stable there is no need for you to be going in there every day or even every few days .... I could get lay on [drugs first, money later], the lot, I wouldn’t even need money. Robbie (p. 7)

Other issues highlighted were the lack of support services when a person finishes MMT and then the subsequent problem of accessing services if they need to return to treatment. These factors encouraged participants to stay in MMT rather than to move on.

That’s one of the reasons why I don’t want to leave the methadone services, there’s nothing afterwards. It scares me that when I finish with the doctor there is nothing there for me afterwards …. It’s so hard to get back on the services that I don’t want to leave or come off them. Linda (p. 7)

Discussion and conclusion

The authors conclude that their study presents an over-arching narrative which does not support the position that Irish MMT services are ‘compliant with a human rights-based approach that incorporates principles such as fairness, respect, equality, dignity and autonomy’ (p. 7). As such, they point to possible ‘system failures’ in Irish MMT services. The response needs to be multidimensional and include adequate resources to move towards a more human-rights approach within the system.

1. Healy R, Goodwin J and Kelly P (2022) ‘As for dignity and respect…. me bollix’: A human rights-based exploration of service user narratives in Irish methadone maintenance treatment. Int J Drug Policy, 110: 103901. Available from: 
   https://www.drugsandalcohol.ie/37442/

The Adolescent Addiction Service (AAS) of the Health Service Executive (HSE) provides support and treatment in relation to alcohol and drug use for young people and families from the Dublin suburbs of Ballyfermot, Clondalkin, Palmerstown, Lucan, and Inchicore. Services provided include advice, assessment, counselling, family therapy, professional consultations, and medications if required. In 2023, AAS published a report detailing referrals for 2022.1

Referrals

In 2022, AAS worked with 53 young people and their families, with a mean age of 15 years (range: 13–18 years). This figure includes new referrals, re-referrals, and continuances. The majority of young people were male (76%), while 7% were non-Irish nationals. In terms of referral areas, the greatest numbers of referrals were from Clondalkin, followed by Lucan and Ballyfermot. In comparison with 2021, referrals were up by 10%. However, 12% were from outside the catchment area and, as a result, 10% were referred to services within their own area.

Drug and alcohol use

Cannabis (weed) continued to be the main substance used by clients, with an overall use rate at 98%, while alcohol use was at 35% (see Figure 1). Other substances of use included cocaine (9%), reflecting a 43% reduction compared with 2021; benzodiazepines (4%), reflecting a reduction of 75% on 2021; ketamine (8%); and amphetamines (6%). Solvents and head-shop-type products did not feature among young people’s substance use in 2022. However, 22% admitted to taking nitrous oxide on occasion, reflecting an increase of 175% compared with 2021.

 
Source: HSE AAS, 2023

Figure 1: Main substances used by AAS clients, 2022

Other issues

As in previous years, most young people had established patterns of substance use prior to referral, with an average of 17 months (range: 1–60 months); the extent to which substance use featured within families was 65%. A majority of young people (95%) were seen by a family therapist only, with 5% having a psychiatric assessment.

Conclusions

The report concluded that there is a need for parents and non-parental adults to identify young people within risk groups at an early stage and to elevate concern for them. However, it was also noted that given the level of tolerance for substance use within certain communities, and petitions for the decriminalisation and legalisation of all drugs, young people are being given mixed messages. Indeed, some adults do not fully appreciate the consequences of substance use for young people.

1. Adolescent Addiction Service (AAS) (2023) Adolescent Addiction Service report 2023 [2022]. 
   Dublin: Health Service Executive. Available from: https://www.drugsandalcohol.ie/38451/

The annual report published by the Mental Health Information Systems Unit of the Health Research Board, Activities of Irish psychiatric units and hospitals 2021,1 shows that the rate of new admissions to inpatient care for alcohol disorders has decreased.

In 2021, some 758 cases were admitted to psychiatric facilities with an alcohol disorder, of whom 311 were treated for the first time. Figure 1 presents the rates of first admission between 2001 and 2021 for cases with a diagnosis of an alcohol disorder. The admission rate in 2021 was lower than the previous year and trends over time indicate an overall decline in first admissions. Just over one-third (35.2%) of cases hospitalised for an alcohol disorder in 2021 stayed under 1 week, while 29.8% of cases were hospitalised for between 1 and 3 months, similar to previous years.

In 2021, some 976 cases were also admitted to psychiatric facilities with a drug disorder. Of these cases, 410 were treated for the first time. Figure 2 presents the rates of first admission between 2001 and 2021 of cases with a diagnosis of a drug disorder. The admission rate in 2021 was lower than the previous year, although trends over time indicate an overall increase in the rate of first admission with a drug disorder since 2011. It should be noted that the report does not present data on drug use and psychiatric comorbidity; it is therefore not possible to determine whether or not these admissions were appropriate.

 
Source: Daly and Craig, 2022
Figure 1: Rates of psychiatric first admission of cases with a diagnosis of an alcohol disorder per 100,000 population in Ireland, 2001—2021

Source: Daly and Craig, 2022

Figure 2: Rates of psychiatric first admission of cases with a diagnosis of a drug disorder per 100,000 population in Ireland, 2001—2021

Other notable statistics on admissions for a drug disorder in 2021 include the following:

• Just under one-half of cases hospitalised for a drug disorder stayed under 1 week (47.2%), while 99.2% were discharged within 3 months. It should be noted that admissions and discharges represent episodes or events and not persons.
• 18.8% of first-time admissions were involuntary.
• Similar to previous years, the rate of first-time admissions was higher for men (13.5 per 100,000 population) than for women (3.8 per 100,000 population).

1. Daly A and Craig S (2022) Annual report on the activities of Irish psychiatric units and hospitals 2021. HRB StatLink Series 10. Dublin: Health Research Board. Available from: https://www.drugsandalcohol.ie/37218/

Strategy Statement 2022–2024

An Garda Síochána Strategy Statement 2022–2024 was published on 9 June 2022.1 The mission of An Garda Síochána (AGS) for the duration of the strategy is simply ‘Keeping people safe’ (p. 6). While the strategy is set against the backdrop of living in a post-pandemic world, with global political and economic uncertainty, AGS is committed to evolving and meeting policing demands that are continually changing. The five pillars that the strategy focuses on are:

• Community
• Tackling crime and preventative policing
• Victims and the vulnerable
• Protecting the security of the Irish State
• Sustainable change and innovation.

Policing Plan 2022

The AGS Annual Report Policing Plan 2022,2 proposed by Garda Commissioner Drew Harris, represents the first of three annual plans to give effect to the AGS Strategy Statement 2022–2024.1 The focus of the Policing Plan 2022 is on community policing and preventing and detecting crime. While drug trafficking is only mentioned in the community pillar, it is implied throughout the plan that drugs will be targeted.

Strategic pillars

Initiatives related to the five pillars in the policing plan are highlighted below.

Community
AGS aims to continue to strengthen connections with communities and to work in partnership to keep people safe. It will achieve this by using a proactive problem-solving approach, by continuing to implement the Community Policing Framework, and by increasing engagement with vulnerable and minority groups in order to strengthen understanding of their needs. Tackling drug trafficking and the harm caused by drug dealing will also be continued.2

Tackling crime and preventative policing
The priority is to deal with current and emerging trends in crime by targeting organised crime, implementing approaches that will increase the ability of AGS to identify and disrupt new and emerging criminal activities in private, rural, and urban settings. In addition, the aim is to increase collaboration with internal, national, and international stakeholders. It is hoped that this will be achieved by an intelligence-led response to crime, by targeting increases in fraud and cyber-enabled crimes, by completing and reviewing the National Criminal Intelligence Framework and the Serious Organised Crime Threat Assessment, and by disrupting organised and serious crime.2

Victims and the vulnerable
The aim here is to reduce harm by promoting and protecting the dignity and human rights of victims and all vulnerable individuals engaging with AGS. This will be achieved by enhancing capability to support victims of domestic violence, including coercive control, and by ensuring that supports are available for victims and those that are vulnerable.2

Protecting the security of the Irish State
AGS aims to protect Ireland and its people from terrorism and threats. This will be achieved by increasing security and intelligence capability via the continued implementation of the Security and Intelligence Operating Model, participating in Major Emergency Management interagency structures and carrying out intelligence-led operations nationally and internationally.2

Sustainable change and innovation
In order to inspire and sustain continuous improvement, a culture of innovation needs to be adopted. To achieve this, the AGS change management capacity building plan needs to be implemented. This will enhance innovation and responsiveness to change.2

Strategic enablers

Five enablers are essential to the successful implementation of the policing plan. These are people and purpose; partnerships; engagement; empowerment and trust; and information-led policing.

People and purpose
AGS aims to be a people-focused organisation where workplace culture is encapsulated by valuing and supporting employees. Priorities between 2022 and 2024 include personnel recruitment that fosters and embraces diversity, supporting and adapting to changes in how AGS works, enhanced learning, development, and information sharing, and the implementation of ‘health and wellbeing strategy initiatives’ (p. 13).2

Partnerships
Engagement in collaborative partnerships with specialists, thought leaders, universities, and research hubs are viewed as a way to increase knowledge, service, and effectiveness nationally and internationally.

Engagement

Two-way communication needs to be strengthened, allowing engagement via new and existing channels. The Public Attitudes Survey and Cultural Audits within AGS will increase understanding and allow appropriate responses to be developed.

Empowerment and trust
A culture of empowerment and trust needs to be nurtured and rooted in integrity and the protection of human rights. AGS hopes to achieve this by increasing professionalism among AGS employees by establishing processes that are effective and efficient and by ensuring that decision-making is centred on ethics and human rights.

Information-led policing
Finally, an information-led service centred on using data and technology to inform decisions can be achieved by implementing the 2022 Information and Communications Technology (ICT) Roadmap, by incorporating data quality processes to improve consistency, and by increasing the abilities of AGS mobility devices and widening their usage.2

Conclusion

Commissioner Harris acknowledged that 2021 was overshadowed by the Covid-19 pandemic but that AGS remains focused on organisational objectives and goals to keep people safe. He stated that ‘the trust built between the community and An Garda Síochána is at the heart of the service [provided and] … whilst there is a degree of uncertainty in the immediate future, I am confident that we are well placed to deliver on our goal of keeping people safe in 2022’ (p. 4).2

1. An Garda Síochána (2022) An Garda Síochána strategy statement 2022–2024. Dublin: An Garda Síochána. Available from: https://www.drugsandalcohol.ie/36428/
2. An Garda Síochána (2022) An Garda Síochána policing plan 2022. Dublin: An Garda Síochána. Available from: 
   https://www.drugsandalcohol.ie/36429/

The 2021 annual report of the Courts Service was published on 28 July 2022. While the report presented data for all criminal cases arising within the Irish justice system between January and December 2021, this article only discusses the statistics of prosecutions for drug offences.1 The data provided are for overall drug law offences. The Courts Service in Ireland does not distinguish between the different supply offences and possession/use offences (Courts Service, personal communication, 2017).

District Court

In most cases, prosecutions for drug offences are carried out in the District Court, which is the lowest court in the Irish legal system. The District Court, exercising its criminal jurisdiction, deals with four types of offences: summary offences, indictable offences tried summarily, some indictable offences, and indictable offences not tried summarily. When the District Court hears a criminal case, the judge sits without a jury. The District Court judge decides the issues of fact and whether to convict. They also determine the sentence. In the case of most indictable offences that must be tried by a judge sitting with a jury, the District Court may impose a sentence where the accused pleads guilty, provided that the Director of Public Prosecutions consents, and the judge accepts the guilty plea. Otherwise, the accused is sent forward to the Circuit Court on their signed guilty plea for sentencing. The District Court has a limit on the sentence it may impose in respect of a single criminal charge, which is 12 months’ imprisonment.2 Overall, 25,727 orders were made in relation to drug offences in 2021 (summary: n=3231; indictable: n=22496) – involving 19,909 defendants, which represents a 56% increase since 2020 (n=16456) (see Tables 1 and 2).1

Table 1: Number of sentences for drug offences in the District Court, 2021

 
* There may be more than one offence brought against a defendant.
Source: Courts Service, 2022, p. 90

Table 2: Number of summary and indictable offences: outcomes in the District Court, 2021

 
Dis: dismiss; S/O: strike out; TIC: taken into consideration; Disq: disqualified; C/S: community service; 
Prob: probation; Imp/Det: imprisonment or detention; Susp: suspended sentence.
Source: Courts Service, 2022, pp. 90–91

Juvenile crime

The age of criminal responsibility in Ireland is 12 years (Section 52 of the Children Act 2001, as amended by Section 129 of the Criminal Justice Act 2006).3 Generally, children who come before the courts are aged between 15 and 17 years. The total number of orders that were made in respect of drug offences in the Children Court in 2021 was 488 (see Table 3),1 which represented an 118% decrease, approximately, since 2020 (n=224). In 2021, some 124 young offenders were imprisoned or detained, of which two were sentenced to community service (n=2), while the rest were sentenced to probation (n=122). The number of young people placed on probation in 2021 (n=122) was nearly three times higher than the 2020 figure (n=38).

Table 3: Number of juvenile crime outcomes, 2021

 
Dis: dismiss; S/O: strike out; TIC: taken into consideration; Disq: disqualified; C/S: community service; 
Prob: probation; Imp/Det: imprisonment or detention; Susp: suspended sentence.
Source: Courts Service, 2022, p. 92

Circuit Court

The Circuit Court heard cases for 892 defendants that involved 3,310 drug offences in 2021. There were 2,181 guilty pleas, which represented a 24% increase from 2020 (n=1758). Of the cases that went to trial, 23 resulted in convictions and 19 resulted in acquittals (see Table 4). Trials resulted in 349 imprisonments/detentions and 378 suspended sentences (see Table 5).1

Table 4: Number of sentences for drug offences in the Circuit Court, 2021

 
Guilty: guilty pleas; NP: nolle prosequi; TIC: taken into consideration; Quash: quash a return for trial; 
Dec: accused deceased.* There may be more than one offence brought against a defendant.
Source: Courts Service, 2022, p. 93

Table 5: Number of offence outcomes following conviction in the Circuit Court, 2021

 
TIC: taken into consideration; Disq: disqualified; C/S: community service; Prob: probation; Imp/Det: imprisonment or detention; Susp: suspended sentence.
Source: Courts Service, 2022, p. 94

Appeals (from the District Court)

In 2020, some 574 appeals from the District Court, representing 1,075 offences, were dealt with in the Circuit Court.1 Appeals and offences were 48% and 41% higher than in 2019, respectively (appeals: n=387; offences: n=764). Table 6 shows a breakdown of resolved offences.

Table 6: Number of appeals from the District Court, 2021

 
S/O: struck out; S/O N/A: struck out no appearance.
Source: Courts Service, 2022, p. 94

Court of Appeal

Overall, the number of appeals that were lodged from the Circuit Criminal Court for drug/misuse of drugs offences were over three times higher in 2021 (n=113) when compared with 2020 (n=36). All the appeals that originated in the Circuit Criminal Court were resolved in 2021.1 Table 7 indicates that most appeals resolved were for sentence severity (n=29), followed by conviction and sentence (n=7), conviction (n=3), and sentence leniency (n=1).

Table 7: Summary of number of resolved appeals, 2021
 

DPP: Director of Public Prosecutions.
Source: Courts Service, 2022, p. 104

Conclusion

The report was commended by the Chief Justice and chairperson of the board, Mr Justice Donal O’Donnell. He described efforts by the Courts Service in 2021 as one of ‘adaptation and innovation’ as they dealt with the consequences of the Covid-19 pandemic and how it affected access to and the administration of the service (p. 5).1

1. Courts Service (2022) Courts Service annual report 2021. Dublin: Courts Service. Available from: https://www.drugsandalcohol.ie/36984/
2.  Courts Service (2013) Courts Service annual report 2012. Dublin: Courts Service. Available from: https://www.drugsandalcohol.ie/20180/
3. Office of the Attorney General (2006) Criminal Justice Act 2006. Available at: 
   https://www.irishstatutebook.ie/eli/2006/act/26/section/129/enacted/en/html

The 2021 annual report of the Department of Justice was published on 18 January 2023.1 The report outlines the progress made by the Department to fulfil goals and objectives identified in its Statement of Strategy 2021–2023.2

2021 in review

A broad range of actions were taken by the Department in 2021.

Table 1 provides a summary of these actions.

The Minister for Justice Helen McEntee TD took maternity leave from 30 April to 1 November 2021. In the interim, Heather Humphreys TD was Minister for Justice. Minister McEntee was the first serving Minister for Justice in the history of the State to take maternity leave. 
Source: Department of Justice, 2023, pp. 21–34

Legislation

Several criminal legislation Bills were enacted in 2021. These include the following:

Children (Amendment) Act 2021: It provides for deceased children who were the victims of crime to be named publicly.

Counterfeiting Act 2021: It provides for updates to Irish law in relation to four pieces of EU legislation.

Criminal Justice (Amendment) Act 2021: It provides for the removal of mandatory minimum sentences for second or subsequent offences.

Criminal Justice (Money Laundering and Terrorist Financing) (Amendment) Act 2021: It transposes sections of the 5th EU Anti-Money Laundering Directive, which helps the EU prevent money laundering and terrorist financing via financial systems.

Criminal Justice (Perjury and Related Offences) Act 2021: It provides for statutory offences related to perjury, subornation of perjury, and the making of specific false statements.

Criminal Justice (Smuggling of Persons) Act 2021: It provides for three international instruments against people-smuggling. It replaced most of the Illegal Immigrants (Trafficking) Act 2000. The new Act covers a wider range of offences, including intentionally assisting entry, transit or presence, where it is known there is a breach of specific provisions of immigration law. It also covers smuggling into other EU member states and parties under the United Nations Protocol.

Criminal Justice (Theft and Fraud Offences) (Amendment) Act 2021: It provides for the transposition of EU Directive 2017/1371, which targets fraud.

Criminal Procedure Act 2021: It provides for the use of preliminary trial hearings in Ireland. This move is expected to improve the criminal justice system, making it more efficient.

In addition, criminal legislation Bills and a general scheme were published in 2021. These include the following:

• Criminal Justice (Mutual Recognition of Custodial Sentences) Bill 2021
• Garda Síochána (Compensation) Bill 2021
• Garda Síochána (Functions and Operational Areas) Bill 2021
• Sex Offenders (Amendment) Bill 2021
• Criminal Justice (Hate Crime) Bill (General Scheme)

Civil legislation Bills enacted in 2021 provided for amendments to Acts focusing on personal insolvency, civil law, private security services, and land and conveyancing law reform Acts. Two Civil Legislation General Schemes were published in 2021: the Courts and Civil Law (Miscellaneous Provisions) Bill 2021 and the Gambling Regulation Bill 2021.

Progress under Justice Plan 2021

The Justice Plan 20213 was the first action plan that aimed to meet the objectives identified in the Department’s Statement of Strategy 2021–2023.2 The annual report provides progress on actions made to achieve objectives in five areas. What follows is an outline of some of these achievements.

1. Tackle crime, enhance national security and transform policing
For example, the Department of Justice supported ongoing recruitment of Garda members and staff; monitored progress of use of video link technology in criminal cases; in collaboration with other agencies started to implement plans targeting economic crime and corruption; carried out anti-money laundering inspections; worked closely with the Garda National Cybercrime Bureau and supported its expansion to regional hubs; and ensured An Garda Síochána’s connection to SIS II (Schengen Information System), enabling information exchange on criminality.

2. Improve access to justice and modernise the courts system
For example, the Department provided management of the Criminal Legal Aid Scheme, including timely delivery of sanctions for reports provided by expert witnesses, and commissioned research to inform review of judicial numbers and skills, which included drawing on experiences and practices from other jurisdictions.

3. Strengthen community safety, reduce reoffending, support victims and combat domestic, sexual and gender-based violence
For example, the Department published a policy paper on community safety; continued to drive implementation of the Second National Strategy for Combatting Domestic, Sexual and Gender-based Violence; completed an audit of responsibility for domestic, sexual, and gender services; kept implementation of the Victims’ Charter under review; and published results of a research study on familicide; and had an input into and monitored development of specialist training programmes for criminal justice personnel involved in sexual offence investigations and trials.

4. Deliver a fair immigration system for a digital age

For example, the Department published a roadmap of the move to online application processes for immigration services; to increase service efficiency introduced online vetting and an online appointment scheduling system for applicants; completed a process review of the International Protection Process; and developed and implemented a scheme to regulate undocumented migrants.

5. Accelerate innovation, digital transformation and climate action across the justice sector

For example, the Department supported the Court Services in the delivery of their modernisation programme; developed a three-year plan to expand the Criminal Justice Operational Hub, enabling automatic information exchange between criminal justice agencies. This work is ongoing. Of the 321 actions identified in the Justice Plan, 202 were achieved (69%) and 101 (31%) required additional work for completion, as of 31 December 2021.

Conclusion

The Minister for Justice, Helen McEntee TD, acknowledged that this report has brought great pride and reflects the continued collaboration between agencies, offices, and bodies together with the dedication of frontline teams who ensured that services continued during the pandemic. Despite considerable constraints as a result of Covid-19, the Department continued to make advances in policy objectives identified in its Statement of Strategy. This work is ongoing. Minister McEntee, on behalf of herself and Minister of State James Browne thanked all involved for their ‘continued exemplary work and their deep commitment to public service’ (p. 5).1 The Secretary General, Oonagh McPhillips, similarly expressed her gratitude at the efforts and support colleagues have provided across the Department and criminal justice agencies.1

1. Department of Justice (2023) Annual report 2021. Dublin: Department of Justice. Available from: https://www.drugsandalcohol.ie/37948/
2. Department of Justice (2021) A safe, fair and inclusive Ireland: Statement of strategy 2021–2023. Dublin: Department of Justice. Available from: https://www.drugsandalcohol.ie/33820/
3. Department of Justice (2021) Justice plan 2021. Dublin: Department of Justice. Available from: https://www.drugsandalcohol.ie/34725/

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

The services offered in Dublin include:

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

Midwest region

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

Annual report

The ALDP annual report was published in December 2022.1 The report noted that, in 2021, the Dublin Services team worked with a total of 1,301 individuals across multiple projects. These included private emergency accommodation in-reach; Granby Clinic in-reach; outreach overdose prevention; low-threshold stabilisation; and dual diagnosis support work. In addition, the Ana Liffey management team continued to provide specialist Covid-19 support to the homeless sector across Dublin city and county. The Assertive Case Management team based in Dublin city, comprising five team members, worked intensively with 127 individuals in 2021. Of these, 64 people availed of key working or case management supports, while 63 availed of harm reduction interventions.

In the Midwest region, 352 people received key working, case management and harm reduction interventions from ALDP in 2021. The ALDP team also provided 2,908 needle and syringe programme interventions, which include overdose prevention interventions, the provision of sterile crack pipes, and the delivery of naloxone training and product.

1. Ana Liffey Drug Project (2022) Ana Liffey Drug Project annual report 2021. Dublin: Ana Liffey 
   Drug Project. Available from: https://www.drugsandalcohol.ie/37822/

The Danger of Viral Exposure (DOVE) Service in the Rotunda Hospital, Dublin was established to meet the specific needs of pregnant women who have or are at risk of blood-borne or sexually transmitted bacterial or viral infections in pregnancy. Exposure may also occur through substance use. Figures from the service for 2021 were published in the hospital’s annual report in 2022.1

Clinical activity

Figure 1 shows the number of women who booked into the DOVE Service for antenatal care each year during the period 2011–2021. It also shows the diagnosis of viral disease for these women. During 2021, some 166 women booked into the DOVE Service for antenatal care. 

Of these:

• 19 (18%) women were positive for HIV infection.
• 35 (33%) women were positive for hepatitis B (HBV) surface antigen.
• 33 (30%) women were positive for hepatitis C (HCV) antibody.
• 16 (15%) women had positive treponemal serology (syphilis).

Source: The Rotunda Hospital, 2022

Figure 1: DOVE Service bookings by year, 2011–2021

Table 1: Deliveries to mothers attending the DOVE Service who were positive for HIV, HBV, HCV or syphilis, or who were attending the drug liaison midwife, 2021

 
* One set of twins.
** Final serology test not yet available for all infants.
DLM: drug liaison midwife.

Source: The Rotunda Hospital, 2021

In addition to the figures presented above, a number of women attended the service for diagnosis and treatment of human papillomavirus (HPV), herpes simplex virus, chlamydia, and gonorrhoea. It should be noted that these numbers refer to patients who booked for care during 2021. Table 1 summarises the outcome of patients who actually delivered during 2021. Of these patients, 15 were HIV-positive, 40 were HBV-positive, 35 were HCV-positive, and 14 had syphilis. During 2021, some 103 women were referred to the drug liaison midwife (DLM) service, including 39 women who had a history of opioid addiction and were engaged in a methadone maintenance programme. There was a total of 60 deliveries to mothers under the DLM service in 2021, of which 35 were on prescribed methadone programmes.

1. 
   The Rotunda Hospital (2022) The Rotunda Hospital Dublin annual report 2021. Dublin: 
   The Rotunda Hospital. Available from: https://www.drugsandalcohol.ie/37340/

Prevalence and current situation

Denormalising alcohol industry activities in schools
van Schalkwyk MCI, Petticrew M, Maani N and Hawkins BR (2023) Lancet, 8(2): e90–e91.
https://www.drugsandalcohol.ie/38019/ 

‘The area I’m from is very rough’: drug users’ views on the role of social and economic factors in their experiences of drug-related harm
O’Mahony S (2023) Journal of Ethnicity in Substance Abuse, Early online. https://www.drugsandalcohol.ie/38331/ 

Illicit drug use in university students in the UK and Ireland: a PRISMA-guided scoping review
Boden M and Day E (2023) Substance Abuse Treatment, Prevention, and Policy, 18: 18.
https://www.drugsandalcohol.ie/38384/ 

Support for evidence-based alcohol policy in Ireland: results from a representative household survey
Calnan S, Millar SR and Mongan D (2023) European Journal of Public Health, 33(2): 323–330.
https://www.drugsandalcohol.ie/38321/ 

Alcohol branding during rugby union matches in Ireland after commencement of Sect. 15 from the Public Health (Alcohol) Act: a frequency analysis of highlights from the European Rugby Champions Cup and Six Nations Championship
Critchlow N and Purves RI (2023) Irish Journal of Medical Science, Early online. https://www.drugsandalcohol.ie/38429/ 

A mixed methods study of attendance and treatment rates among patients with hepatitis C
Nic an Ríogh E, McCombe G, Connolly SP, et al. (2023) Irish Medical Journal, 116(3): 742.
https://www.drugsandalcohol.ie/38469/ 

Exploring barriers and enablers to the delivery of Making Every Contact Count brief behavioural interventions in Ireland: a cross-sectional survey study
Meade O, O’Brien M, Noone C, et al. (2023) British Journal of Health Psychology, Early online.
https://www.drugsandalcohol.ie/38319/ 

Physical and mental illness comorbidity among individuals with frequent self-harm episodes: a mixed-methods study
Sadath A, Troya MI, Nicholson S, et al. (2023) Frontiers in Psychiatry, 14: e1121313. https://www.drugsandalcohol.ie/38368/ 

How to be Irish in an epidemic: a dossier article on HIV and AIDS in Ireland, then and now
Foley B, Nugent E, Donnellan N, et al. (2023) Journal of Medical Humanities, 44: 7–26..
https://www.drugsandalcohol.ie/38320/ 

The impact of the COVID-19 pandemic on presentations of self-harm over an 18-month period to a tertiary hospital
O’Malley A, McIntyre A, McGilloway A, Doherty A and Hallahan B (2023) Irish Journal of Psychological Medicine, Early online. https://www.drugsandalcohol.ie/38223/ 

Deterrence effect of penalties upon adolescent cannabis use
Smyth BP, Davey A and Keenan E (2023) Irish Journal of Psychological Medicine, Early online.
https://www.drugsandalcohol.ie/38222/ 

A comparison of daytime and out of hour mental health presentations to Beaumont Hospital Emergency Department between 2018 and 2020
Subramanian Y, Barrett J, Kim S, Carey C, Barry H and MacHale S (2023) Irish Journal of Medical Science, Early online. https://www.drugsandalcohol.ie/37862/ 

Explaining the association between fetal growth and childhood ADHD symptoms: cross-cohort replication
Dooley N, Healy C, Brannigan R, et al. (2023) Research on Child and Adolescent Psychopathology, 51(2): 247–259. https://www.drugsandalcohol.ie/38057/

The impact of the Celtic Tiger and Great Recession on drug consumption
Windle J, Cambridge G, Leonard J and Lynch O (2023) Drugs, Habits and Social Policy, 24(1): 26–38.
https://www.drugsandalcohol.ie/37867/ 

Predictors of adverse gambling behaviours amongst elite athletes
Turk MA, Murphy C, McCaffrey J and Murray K (2023) Scientific Reports, 13: 823. 
https://www.drugsandalcohol.ie/37982/

Drug use in pregnancy in Ireland’s capital city: a decade of trends and outcomes
Corbett GA, Carmody D, Rochford M, et al. (2023) European Journal of Obstetrics & Gynecology and Reproductive Biology, 282: 24–30. https://www.drugsandalcohol.ie/37901/

Five areas which make the Irish organized crime milieu distinctive
Windle J (2023) Journal of Contemporary Criminal Justice, 39(1): 133–152. https://www.drugsandalcohol.ie/38002/

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

Responses

Exploring key informants’ perceptions of Covid-19 vaccine hesitancy in a disadvantaged urban community in Ireland: emergence of a ‘4Cs’ model
Ingram C, Roe M, Downey V, Phipps L and Perrotta C (2023) Vaccine, 41(2): 519–531.
https://www.drugsandalcohol.ie/37900/

The development of the Irish youth justice system: toward a children’s rights model of youth justice?
Forde L and Swirak K (2023) Journal of Contemporary Criminal Justice, 39(1): 114–132.
https://www.drugsandalcohol.ie/38013/

Policy

The implementation of a public health alcohol policy in Ireland
Barry J and Lyne J (2023) Irish Journal of Psychological Medicine, 40(1): 103–106.
https://www.drugsandalcohol.ie/38127/

Distilling the message: Irish plans for alcohol warning labels
Editorial (2023) Lancet Gastroenterology & Hepatology, 8(3): 199. https://www.drugsandalcohol.ie/38147/ 

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
Copyediting: O’Hanlon Media

© Health Research Board, 2023
 
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