The use of illicit drugs is a public health issue worldwide with the annual prevalence of drug use increasing over the past decade.^1–4 International research from Ireland, the United Kingdom, and the United States suggests that approximately one-quarter of students in higher education institutes (HEIs) report using illicit drugs within the last 12 months.^5–10 However, there is a lack of recent comprehensive data on drug use among students in higher education in the Republic of Ireland.

In September 2019, the then Minister of State for Higher Education, Mary Mitchell O’Connor TD, established a rapid response group to address the issue of drug use in higher education in Ireland. Minister O’Connor tasked the group with recommending a suite of specific actions appropriate to the higher education setting and in line with the Government’s national drugs strategy, Reducing Harm, Supporting Recovery: a health-led response to drug and alcohol use in Ireland 2017–2025,¹¹ with the overall aim being to reduce harms experienced by students through the use of drugs. The My Understanding of Substance-use Experiences (MyUSE) research team in University College Cork (UCC), led by Dr Michael Byrne, was selected to develop the Drug Use in Higher Education in Ireland (DUHEI) Survey.¹² The survey population included undergraduate and postgraduate students aged 18 years and over in publicly funded HEIs. The sampling strategy that was used ensured that a random representative sample of the student population was invited to participate in the survey.

At the lunch of the DUHEI report were (L to R): Ahsa Woodhouse, president of the UCC Students' Union; DR Michael Byrne, DUHEI principal investigator and head of UCC Student Health Department; Sam Dick, DUHEI project manager, UCC School of Public Health; and Lisa Ryan, DUHEI research assistant.

Source: DUHEI, 2022

Figure 1: Type of drugs used by DUHEI survey participants who reported ever using an illegal drug

Twenty-one publicly funded HEIs in the Republic of Ireland participated in DUHEI. Data collection was completed in early 2021 via a secure online survey platform. Over 11,500 participant responses were included for analysis, of which 60% were female. The median age was 21 years; 81% were undergraduates and 90% were European Union students. The main findings from the DUHEI survey are discussed below.

Student drug use

Results from the DUHEI survey revealed that over one-half of participating students reported ever using an illicit drug, with over one-third reporting drug use in the last year (recent use) and one-fifth reporting using drugs in the last month (current use). Among students reporting ever using an illegal drug (see Figure 1), the most commonly used drugs were cannabis (52%), cocaine (25%), ecstasy (23%), ketamine (16%), mushrooms (12%), amphetamines (9%), and new psychoactive substances (NPS) (8%). This order of prevalence of drugs/drug types was maintained across all three user groups.

Current users of cannabis reported doing so approximately twice weekly, while current users reporting cocaine or ketamine use did so approximately once monthly. One in four males and one in six females indicated current drug use; four out of 10 current users reported using two or more drugs on the same occasion. For the majority of drug types, the age of first use was between 19 and 21 years, whereas for cannabis it was between 16 and 18 years. One in four current users reported using cannabis when they were less than 16 years of age.

Harms and effects

Although a majority of recent and current users felt that their drug use had neither negative nor positive effects on many aspects of their lives, the survey found that based on Drug Abuse Screening Test (DAST-10) scores, one in three recent users and over one in two current users were at moderate or substantial risk of harms arising from their drug use. Just under one in two recent or current users reported having unprotected or unintended sex, or getting into fights, on at least one occasion in the preceding year. Six out of 10 current users reported engaging in sexual activity while under the influence of drugs and one in three of these reported that the drug used was cocaine. In addition, one in three current users believed that drugs have a negative effect on student life.

Changing drug use behaviours

One in three users reported that they had tried to reduce their drug use. The most commonly reported means of changing drug use were avoiding environments where drugs are used and avoiding friends and peers who use drugs. For all participants, face-to-face interventions were perceived as being more effective than online interventions to reduce drug-related harms. Education was perceived as being the least effective intervention to reduce harm, while counselling was perceived as being the most effective intervention to reduce harms from drug use.

Other findings

Other findings from the DUHEI survey include the following:

• Less than one in 20 participants reported using smart drugs (i.e. study drugs/nootropics/cognitive enhancers), while one in 10 current users reported using smart drugs to enhance their academic performance.
• Over one in 20 participants reported that they previously had a drug or alcohol problem; for one-half of these, it had resolved within the previous two years.
• One in four of those with a previous drug or alcohol problem identified themselves as currently in active recovery.
• Of those who had used drugs during the Covid-19 pandemic, one in three had decreased their use, while just less than one in four had increased their use over this period.
• One in 10 participants reported using drugs for the first time since the Covid-19 pandemic began.

Conclusions

The study authors noted that over one-half of those who currently use drugs identified in the DUHEI survey were at moderate or substantial risk of harm from drug use based on their DAST-10 score. They suggest that interventions targeted at the level of the individual are clearly required in Irish HEIs. In addition, interventions at an institution and sector level are also required to support those who do not use drugs and to aid the recovery and reduce the harms experienced by those who do. They also recommend that the DUHEI survey should be repeated at five-yearly intervals to monitor trends in drug use prevalence, attitudes, and behaviours among students in Ireland.

1  European Monitoring Centre for Drugs and Drug Addiction (2012) The state of the drugs problem in Europe: annual report 2012. Luxembourg: Publications Office of the European Union.
https://www.drugsandalcohol.ie/18783/

2  World Health Organization (2016) The health and social effects of nonmedical cannabis use. Geneva: World Health Organization. https://www.drugsandalcohol.ie/25267/

3  United Nations Office on Drugs and Crime (2018) World drug report 2018. Vienna: United Nations.
https://www.drugsandalcohol.ie/29252/

4  Substance Abuse and Mental Health Services Administration (2017) Key substance use and mental health indicators in the United States: results from the 2016 national survey on drug use and health. Rockville, MD: Center for Behavioral Health Statistics and Quality. pp. 17–44. Available online at: https://store.samhsa.gov/

5  Bennett TH and Holloway KR (2014) Drug misuse among university students in the UK: implications for prevention. Subst Use Misuse, 49(4): 448–455.

6  Cahill E and Byrne M (2010) Alcohol and drug use in students attending a student health centre. Ir Med J, 103(8): 230–233.

7  Hope A, Dring C and Dring J (2005) College Lifestyle and Attitudinal National (CLAN) Survey. Dublin: Health Promotion Unit, Dept of Health and Children. https://www.drugsandalcohol.ie/4327/

8  Dooley B, O’Connor C, Fitzgerald A and O’Reilly A (2019) My World Survey 2: The National Study of Youth Mental Health in Ireland. Dublin: University College Dublin/Jigsaw National Centre for Youth Mental Health. https://www.drugsandalcohol.ie/31343/

9  Davoren MP, Shiely F, Byrne M and Perry IJ (2015) Hazardous alcohol consumption among university students in Ireland: a cross-sectional study. BMJ Open, 5(1): e006045.

10 Skidmore CR, Kaufman EA and Crowell SE (2016) Substance use among college students. Child Adolesc Psychiatr Clin N Am, 25(4): 735–753.

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

12 Byrne M, Dick S, Ryan L, Dockray S, Davoren M, Heavin C, et al. (2022) The Drug Use in Higher Education in Ireland (DUHEI) Survey 2021: main findings. Cork: University College Cork.
https://www.drugsandalcohol.ie/35515/

Background

In 2021, a national survey was carried out among 7,901 students and 3,516 staff to monitor the experiences of students and staff in relation to sexual violence and harassment in higher education institutions (HEIs) in Ireland and their awareness and confidence in HEI policies, processes, and initiatives in the area.^1,2

Overall, the survey found that students and staff felt safe from sexual harassment at their HEI. A majority of students were aware and had seen awareness-raising campaigns on consent, sexual violence, or harassment on social media or Students’  Union campaigns and posters.

This comprehensive survey included extensive and detailed findings from both the student and staff surveys. However, for the purposes of this article, sexual violence pertaining to alcohol and/or drug use mentioned by students is summarised. This includes where sexual violence was reported and the student taken advantage of when too drunk or ‘out of it’ to stop what was happening, and the reporting of drug and/or alcohol use prior to the incident by the perpetrator and by the student who experienced the sexual violence.

Sexual violence when student was drunk or incapacitated

One part of the student survey looked at sexual violence where the student was too drunk or out of it to stop what was happening. It contained questions about the experience of sexual violence, which included non-consensual sexual touching, oral sex, vaginal penetration, anal penetration, being made to perform anal or vaginal sex, as well as attempted oral, anal, or vaginal sex. Students were provided with a statement at the beginning of each section and asked if the statement applied to them. Those that completed this section of the survey were then asked to complete further follow-up questions relating to the sexual violence experienced.

Non-consensual sexual touching

The experience of non-consensual sexual touching when the student was too drunk or out of it to stop what was happening was reported by 31.3% of students. It was more commonly reported by female students (36.2%) and non-binary students (30.6%) compared with 12.9% of males and 19.2% of those who preferred not to disclose their gender.

Non-consensual oral sex

Overall, 13.5% of students reported experiencing non-consensual oral sex by being taken advantage of when they were too drunk or out of it to stop what was happening. This was more common among female students (15.3%) and non-binary students (13.4%).

Non-consensual vaginal penetration

Over one-quarter of female students (28.2%) and 24.1% of non-binary students reported that they experienced non-consensual vaginal penetration when they were too drunk or out of it to stop what was happening. When examining such experiences by sexual orientation, 33.8% of bisexual women and 27.2% of heterosexual women said they had such an experience.

Non-consensual anal penetration

Non-binary students were more likely to report experiencing non-consensual anal penetration when they were too drunk or out of it to stop what was happening (6%), followed by 5.9% of female students. When broken down by sexual orientation, gay, lesbian, queer and other students were more likely to report this experience (8%), followed by bisexual students.

Being made to perform vaginal or anal sex

The experience of being made to perform anal and/or vaginal sex when they were too drunk or out of it to stop what was happening was reported by 6.6% of male students and 14.3% of non-binary students. When analysed by sexual orientation, 7.1% of bisexual, 7.1% of gay, lesbian, queer or other students, and 6.6% of heterosexual students reported being made to perform vaginal or anal sex while too drunk or out of it to stop what was happening.

Attempted oral, anal, or vaginal sex

Compared with male students (6.3%), female (21.8%), non-binary (18.7%) and students who preferred not to disclose their gender (19.2%) experienced a higher rate of attempted oral, anal, or vaginal penetration while too drunk or out of it to stop what was happening. Bisexual (24.4%) and gay, lesbian, queer and other (18.9%) students were more likely to report this experience than heterosexual students (17.4%).

­

Table 1: Percentage of students who said the other person had been using alcohol or drugs prior to the sexual violence incident, by gender and for the total sample

Table 2: Percentage of students who said that the other person had been using alcohol or drugs prior to the sexual violence incident, by sexual orientation

Table 3: Percentage of students who had been using alcohol or drugs prior to the sexual violence incident, by gender and for the total sample

Sexual violence follow-up questions

The students who reported experiencing sexual violence were asked if they would like to complete a further set of questions about the sexual violence. Of those who answered the items on sexual violence, 42.8% of the students agreed to answer follow-up questions.

Perpetrator use of alcohol and/or drugs prior to incident

One of the follow-up questions asked whether alcohol or drugs were being used by the other person prior to the incident. Alcohol was the most commonly reported substance used by the person responsible for the violence, reported by 52% of the students who responded (see Table 1). Heterosexual students (55.3%) were most likely to indicate that the person who was responsible for the violence had been using alcohol prior to the incident, followed by bisexual students (47.9%) (see Table 2).

Student use of alcohol and/or drugs prior to incident

Students were also asked if they had been using drugs and/or alcohol prior to the sexual violence experience. The majority of students who experienced sexual violence reported consuming alcohol before the incident occurred (68.5%) and over one-quarter stated they had not been using drugs or alcohol before the incident (25.9%) (see Table 3).

Heterosexual students were most likely to report the consumption of alcohol prior to the incident (72%), followed by bisexual students (64.4%). Less likely to report having consumed alcohol before the incident were those who preferred not to disclose their sexual orientation (54.8%) and gay, lesbian, queer and other students (54.9%).

Conclusion

This short summary of just one section of the report on student experiences of sexual violence in HEIs raises important concerns regarding students experiencing sexual violence when too drunk or out of it to stop what was happening or to give consent to what was happening. It also highlights the extent of alcohol and other drug use among perpetrators prior to the incident. The Department of Further and Higher Education, Research, Innovation and Science intend to use the results of the survey, as well as the staff survey results, to inform policy and funding decisions to tackle sexual violence and harassment in HEIs.

1  MacNeela P, Dawson K, O’Rourke T, Healy-Cullen S, Burke L and Flack WF (2022) Report on the National Survey of Student Experiences of Sexual Violence and Harassment in Irish Higher Education Institutions. Dublin: Higher Education Authority.
https://www.drugsandalcohol.ie/35563/

2  MacNeela P, Dawson K, O’Rourke T, Healy-Cullen S, Burke L and Flack WF (2022) ) Report on the National Survey of Staff Experiences of Sexual Violence and Harassment in Irish HEIs. Dublin: Higher Education Authority.
https://www.drugsandalcohol.ie/35563/

In Ireland, the Joint Committee on Health scrutinises the work of the Department of Health and its agencies. It is responsible for examining health policy, the future planning of health services, and proposed changes to the way in which healthcare is delivered.¹ Membership includes representation from the Dáil and the Seanad.²

On 19 January 2022, the Minister of State for Public Health, Wellbeing and the National Drugs Strategy, Frank Feighan TD, came before the committee to provide an update on the national drugs strategy. He was supported by Dr Eamon Keenan, the national clinical lead for the Health Services Executive’s (HSE) addiction services, and Jim Walsh, principal officer at the Drugs Policy and Social Inclusion Unit at the Department of Health.

Minister’s opening statement

The minister identified three key messages in his opening statement to the committee. First, that drugs continue to be a major policy challenge for Irish society. Second, that the Government is committed to a health-led approach to dealing with drug use as reflected in the national drugs strategy. Specifically, he said that ‘a war on drugs is not an effective response to drug use’ (p. 2).³ Third, he commented on the effectiveness of the national drugs strategy to date, in which he referred to the midterm review and the progress made on its 50 actions. The six strategic priorities for the remainder of the strategy from 2021 to 2025 were outlined.⁴

Themes discussed

In response to the minister’s statement, members of the committee raised a wide variety of issues and concerns. These reflect the heterogeneity within the committee in terms of the positions held on the best approach to address the drugs issue. A selection of the recurring themes discussed are outlined here, including cocaine and crack cocaine use; a citizens’ assembly on drugs; task force funding; cross-departmental working; decriminalisation of drug use; and new structures for the national drugs strategy. More detail is available in the transcript of the committee meeting.⁵

Cocaine and crack cocaine

Concern was raised over the increase in the sale and use of cocaine and crack cocaine in Ireland. A particular focus was given to the needs of communities affected by growing crack cocaine use. A new funding stream of €850,000 to address cocaine and crack cocaine use is being allocated, according to the minister. Projects are expected to be functioning in Q2 of 2022. There was concern among committee members that the funding was inadequate to meet the growing need in this area.

Citizens’ assembly

The minister reiterated the commitment in the current Programme for Government to hold a citizens’ assembly on drugs in the lifetime of the Government. However, some committee members voiced a strong opinion that it should be held as a matter of urgency and encouraged the minister to hold it in 2022.

Task force funding

Concerns were raised about the funding of the drug and alcohol task forces. There were calls for increased funding so that task forces could meet the increasing need in their communities. The system through which funding is allocated to task forces was also criticised. It was suggested that it lacks transparency and resulted in an unfair distribution of funds. Mr Walsh agreed that ‘it is not fairly distributed’ and that enhancement funding was being allocated through a ‘population-based resource allocation model’ in an attempt to address this inequity.⁵ In a separate issue, concern was raised by a few committee members about funding for the operational costs in the North Inner City Drugs and Alcohol Task Force.

Cross-departmental working

The minister emphasised the importance of cross-departmental working in the delivery of the national drugs strategy. Some committee members noted that experience to date on national and local bodies responsible for the delivery of the strategy (including task forces) would suggest that some departments and State bodies are not fully engaged or committed to the process. The Department of Education was singled out as being particularly difficult to engage.

Decriminalisation

Decriminalisation of drug use was raised by some committee members and was suggested as a topic for the citizens’ assembly. It was argued that a truly health-led approach to drug use and a move away from the war-on-drugs rhetoric would require decriminalisation. There was division within the committee on this topic, with some suggestion that there remains a lack of clarity among stakeholders about the distinction between decriminalisation and legalisation. Decriminalisation was being advocated by the relevant members, not legalisation.⁶

New structures for the national drugs strategy

The revised membership of the National Oversight Committee was noted, while the absence of addiction nursing representation and reduced civic society representation were heavily criticised.

Other topics discussed

Among the other issues discussed were care plans for those in treatment; the impact of Covid-19 on services; the link between drug use, poverty, and marginalisation; drug-related deaths; dual diagnosis; prevention activities in education (including Know the Score); helpline services; supervised injecting rooms; and services for pregnant women who use drugs.

Final comment

The Joint Committee on Health debate highlighted the ongoing heterogeneity among representatives of the Dáil and the Seanad in how best to address the challenges raised by drug use. While members advocated strongly for the health-led approach represented in the national drugs strategy, there were still those who were grounded in war-on-drugs rhetoric, with an emphasis on abstinence. It should also be noted that while the strategy is a joint drug and alcohol strategy, there was minimal discussion of the problems presented by alcohol use and the Government’s response to these.

1  For more information on the Joint Committee on Health, visit: https://www.oireachtas.ie/en/committees/33/health/

2  For a full list of the committee’s membership, visit:
https://www.oireachtas.ie/en/committees/33/health/membership/

3  Joint Committee on Health (2022) Minister Frank Feighan: opening statement on implementation of the national drugs strategy 2021–2025 [Debate]. 19 Jan 2022. Dublin: Houses of the Oireachtas. https://www.drugsandalcohol.ie/35542/

4  Drugs Policy and Social Inclusion Unit (2021) Mid-term review of the national drugs strategy, Reducing Harm, Supporting Recovery and strategic priorities 2021–2025. Dublin: Department of Health. https://www.drugsandalcohol.ie/35183/

5  Joint Committee on Health (2022) Minutes of Joint Committee on Health debate, Wednesday, 19 Jan 2022. Dublin: Houses of the Oireachtas. Available online at:
https://www.oireachtas.ie/en/debates/debate/joint_committee_on_health/2022-01-19/

6  For a clear definition of decriminalisation, visit:
https://www.emcdda.europa.eu/media-library/motion-graphic-what-decriminalisation-drugs_en

Background

Evidence of the harms caused by alcohol consumption globally, including the three million annual deaths worldwide,¹ has encouraged national governments to commit to strategies to reduce alcohol-related harms. These include those set out in the World Health Organization (WHO) 2010 Global strategy to reduce the harmful use of alcohol² and the 2030 Sustainable Development Goals as well as through the development of the WHO Global alcohol action plan.³ It is well-recognised that policies to control the harms associated with alcohol consumption need to be instituted at national level to be effective; however, national governments face resistance and opposition from the alcohol industry when attempting to implement such policies. Common arguments by the alcohol industry when lobbying against such policies are that they are not required and are expensive to implement. Instead, it proposes alternatives, including information campaigns and a focus on subpopulations only, such as those pregnant, young people, or drink drivers. In its efforts to influence decision-making, the alcohol industry often questions the legality and effectiveness of proposed interventions and the extent of alcohol-related harms, citing the benefits of moderate consumption.

A 2022 study aimed to identify whether the alcohol industry sought to influence alcohol policy through arguments made by national government representatives in the Technical Barriers to Trade (TBT) Committee of the World Trade Organization (WTO) when discussing health warning labels on alcohol products.⁴

Methods

The analysis involved examining the minutes and referenced documents related to discussions on alcohol health warning labelling policies that occurred at the WTO’s TBT Committee meetings between January 1995 and December 2019.

From these discussion notes, the authors identified all occasions where WTO members specifically acknowledged that their statements reflected comments raised by the alcohol industry. The authors then categorised all further WTO member statements to identify whether they featured common arguments used by the alcohol industry in domestic policy forums to stall alcohol policy. These were classified as either policy positions (alcohol industry arguments regarding policies and how they should be developed and enforced) or discursive strategies (relating to how the policy issue, its causes, and consequences were described, as well as other statements concerning the appropriateness of the policy or need for reform).

Findings

Some 212 statements in 83 documents were identified from TBT Committee minutes, notifications to the WTO of the policy proposal, and written comments by WTO members referring to alcohol health warning labelling policies proposed by Thailand, Kenya, the Dominican Republic, Israel, Turkey, Mexico, India, South Africa, Ireland, and South Korea. Just seven of the 212 statements (3.3%) were attributed to the alcohol industry and 117 statements (55.2%) featured alcohol industry arguments. Evidence of instances in which WTO members’ arguments resembled the alcohol industry’s common position in domestic contexts included the following:

• 39 statements claimed the measures were unnecessarily restrictive.
• 46 statements questioned the evidence behind the policy decision, downplaying the need for policy intervention.
• 57 statements highlighted the negative unintended consequences for manufacturers and the economy.
• 15 statements proposed alternative policies (e.g. information and education campaigns).

Arguments against alcohol labelling focused on reframing alcohol-related harms, by minimising the problem and suggesting that the harms were restricted to a particular cohort and therefore population-wide interventions were not required. Industry partnerships were also proposed in developing policies relating to labelling.

Discussion

This study suggests that the alcohol industry may have influenced WTO members to promote their own interests and influence alcohol policy internationally. WTO members rarely explicitly referenced alcohol industry demands but evidence of alcohol-industry rhetoric was evident from many of the proposed arguments. The study highlights the need for increased vigilance and transparency about vested interests in order to effectively implement national alcohol policies.

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

2  World Health Organization (2010) Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization. https://www.drugsandalcohol.ie/14845/

3  World Health Organization (2021) Global alcohol action plan 2022–2030 to strengthen implementation of the Global Strategy to Reduce the Harmful Use of Alcohol. 2nd draft, unedited. Geneva: World Health Organization. Available online at:
https://www.who.int/publications/m/item/global-alcohol-action-plan-second-draft-unedited

4  Barlow P, Gleeson D, O’Brien P and Labonté R (2022) Industry influence over global alcohol policies via the World Trade Organization: a qualitative analysis of discussions on alcohol health warning labelling, 2010–19. Lancet Global Health, 10(3): e429–e437. https://www.drugsandalcohol.ie/35608/

Like many contentious social issues, positions on drug policy are often aligned with political outlooks. While what are described as cultural issues have blurred the traditional dividing line between left and right, we can still speak about coherent political philosophies. Politics, at least in the developed world, can be understood as competition between liberal and conversative world outlooks. Liberals comprise two camps: one libertarian, which is liberal on economic issues and protective of individual liberty; and one which is social democratic, also keen to guard personal freedoms but in favour of an interventionist state to offset the consequences of market failures. Conservatives emphasise the value of stability and see government’s role as supporting societal anchors such as the family, personal responsibility, self-reliance, and respect for tradition. Personal freedom is an essential aspect of conservative philosophy, but the state has the right to intervene to prevent behaviour deemed harmful to the individual or the community.

Over the past several decades we’ve seen how these, admittedly loosely defined, political outlooks are reflected in stances taken on the legal status of drugs and the sanctions used to control their use, the response to problematic use, and the attention given to the adverse consequences of using illegal substances. Liberals argue that an individual’s behaviour is their own concern and the state has no business interfering if no harm is being done to others. Further, criminalisation is a cruel reaction to personal preferences and merely enriches those who operate outside the law. While libertarians might have no truck with state support for treatment and harm reduction interventions, like social democrats they acknowledge that drug use is a feature of contemporary life and its suppression is both counterproductive and unethical.

Liberals tend to take a common position on a famous historical experiment that attempted to alter a population’s substance use behaviour. Prohibition in America (1920–1933) is often seen as a historical catastrophe, a blunt policy instrument and a futile attempt by an overreaching state heavily influenced by a political movement that was puritanical, intolerant of alternative world views, and imbued with evangelical zealotry.

A recent comparative history of prohibition and temperance movements in different parts of the world challenges this consensus.¹ It puts the American prohibition period in the context of a diverse international response to alcohol-related harm. Temperance in the 19th and early 20th centuries was aligned with abolitionism, anticolonialism, and organised labour, and was a humane and often politically radical response to a major social problem. Major pro-temperance and prohibition figures such as Frederick Douglass, Hjalmar Branting, founder of the Swedish Social Democratic Party, and Emile Vandervelde, founder of the Belgian Labour Party, would be highly regarded by today’s champions of progressive causes.

All facets need to be considered in discussions around regulation of both legal substances and those that are currently controlled. Commercial interest in one or other side of the debate adds a further layer of complexity. It is often difficult to determine how personal freedoms are best served, but we have to make sure that contributions are based on rigour and respect for facts. When protagonists on one or other side of a debate refer to historical events, they should treat them with the same respect as epidemiological or other evidence. Assertions need to be challenged, even if they refer to the distant past. While we should also avoid anachronistic comparisons, it if fair to say that today’s defenders of human rights would be in good company with the leaders of prohibition and temperance movements of the past. They may have used different language, but they too were committed to the rights of the individual, building a collective approach to health and wellbeing and bravely challenging powerful interests to create a better society.

1                Schrad ML (2021) Smashing the liquor machine: a global history of prohibition. New York: Oxford University Press.

Background

Drug-related deaths (DRDs) are a growing burden,¹ with limited international evidence of the impact of grief and the lived experience of an affected family. DRDs are associated with moral stigmas, emotional burden, shame, guilt, and complicated grief from ‘a loss that cannot be socially sanctioned, openly acknowledged or publicly mourned’.² Evidence suggests there is a need for targeted interventions in this population to explore the complex grief experienced. A 2021 study investigated the impact of complicated grief on the family system following the DRD of a family member from an Irish context.³

Method

Seven families affected by DRDs, comprising 17 family members, mainly parents, were recruited through the National Family Support Network in Ireland. Their ages ranged from 19 to 46 years (median 32 years) and the time since death of their loved one ranged from 1 to 21 years (median 9 years). Participants were interviewed using semi-structured interviews, consisting of six focus groups and one in-depth interview with a single mother. Interviews took place in the south, southeast, and east of Ireland. General qualitative interview practices were used, allowing for unprompted discussion. Interviews were conducted in the homes of the participants between August and December 2019.

Data analysis

Transcribed data were analysed using inductive reflexive thematic analysis as per Braun and Clarke’s six-step process.⁴ This approach uses a repetitive sequential process, moving between familiarisation with the data, coding, generating initial themes, reviewing themes, defining and naming themes, and writing up. The authors used NVivo qualitative data analysis software in the process. Careful consideration of the data by all authors resulted in the scope and naming of themes being agreed. Dodgson’s (2019) recommendations⁵ for quality control in qualitative research were maintained throughout the research process to avoid author influence of data interpretation.

Results

Three core themes were generated from the analysis, each with associated subthemes: (i) renegotiation of relationships; (ii) experiencing complex emotions; and (iii) adjusting to a new reality.

Renegotiation of relationships

‘Family dynamics’ and a ‘fractured sense of community’ were identified as subthemes. The trauma of a DRD on already strained family relationships can lead to a family unit breaking down or co-existing in silence following the loss. Family dynamics transition from the chaos of living with an active drug user and fractured relationships to withdrawal and an inability to remain connected to surviving members. One mother recalled:

I had three grandchildren when [son] died … but I find now that instead of helping them [pause] I kinda neglected ’em.

Another family member discussed the loss of connection:

Now his children, unfortunately, haven’t spoken to us since and we would love to have them back into our lives, you know; we tried to reclaim the family but it’s not to be because the mother has blocked it.

A fractured sense of community was described by family members from the associated stigmas and expressed feelings of loss of community.

And all the people from the area judged his parents because their son [was in addiction]. Sometimes I feel like I deserve to be punished but it’s very hard to come out the other end...

Experiencing complex emotions

Other subthemes identified were ‘lack of help during life intensifies complicated grief’, ‘the right to grieve’ and ‘relief’. The subtheme ‘lack of help during life intensifies complicated grief’ heightened the complicated grief process for the family members, leading to anger, isolation, and frustration:

I rang Dr [name] and I spoke to her …. [Doctor] asked ‘Is he coming off drugs?’ and I said ‘he’s off heroin three weeks, that’s not the problem, he’s suicidal’. [Imitates doctor] ‘Oh we don’t deal with drug cases’ … A couple of days after, I rang and I said, ‘I rang you the other day about my brother’. She said, ‘oh how’s he getting on?’ and I said ‘he’s fucking dead’ and I just hung up the phone, that was the end of it then, but I was very, very angry at her, really angry.

The preventable nature of DRDs left family members with feelings of self-blame, questioning whether they had done enough to support their loved ones. Lack of compassion from professional services left families with feelings of isolation, abandonment, and anger, giving rise to self-blame and frustration, and delegitimised their grief, as the perceived ‘bad’ death was undeserving of support.

There was nobody for me to talk to now the first time … the shame that is forced on ya because your son, you know. You didn’t deserve any of your feelings, you know, you didn’t deserve to talk about him, you didn’t deserve anything because he was a heroin addict or a junky.

Relief was a common subtheme expressed by family members at the loss of their loved ones with associated guilt:

Now when [my son] died it did break me heart but thanks be to God I knew where he was gone and maybe taken before he’s worse. I knew where he went, I was very happy. I didn’t like him to be gone but I knew where he had went.

Adjusting to a new reality

The following subthemes were identified: ‘the missing piece’, ‘illness’, and ‘new purpose in life’. The commonality of difficulty experienced coming to terms with the loss prevailed, with the feeling of a void left following a DRD:

There’s always been something missing at Christmas time... if I am ever going to get married [my only brother] is going to be missing … a part of you is gone and you are never going to regain that back.

The trauma and heavy emotional burden of a DRD can take its toll on health, as one mother recalled:

I had a brain haemorrhage after [my son] dying; they said it was the stress that caused it.

Family members also experienced new positive realities following a DRD and healing through activism was found to be helpful. Engaging with peers gave families hope, with the potential to influence change ultimately facilitating the healing process.

Discussion

This study was the first of its kind in Ireland. DRDs in Ireland are above the European average; therefore, it is important to understand their widespread impact. The study used a purposive sampling strategy that may have benefitted from a more nationwide approach, however. Time since death was listed as a limitation as recruited families were at different stages of grief and in turn levels of grief expressed. The findings demonstrate that this population experiences great difficulty in processing their grief as they struggle with family breakdown, navigate supports and stigma, and it highlights the need for a robust policy shift and direct family unit support.

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

2  Doka KJ (2002) Disenfranchised grief: new directions, challenges, and strategies for practice. Champaign, IL: Research Press, p. 4.

3  Lambert S, O’Callaghan D and Frost N (2021) ‘Special death’: living with bereavement by drug-related death in Ireland. Death Studies, Early online. https://www.drugsandalcohol.ie/34409/

4  Braun V and Clarke V (2019) Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health, 11(4): 589–597.

5  Dodgson JE (2019) Reflexivity in qualitative research. J Hum Lact, 35(2): 220–222.

Background

Patients prescribed opioid agonist therapy (OAT) for opioid dependence are known to have increased risk of multiple substance addiction, including alcohol.¹ Benzodiazepines are commonly used to treat alcohol withdrawal syndrome (AWS); however, given their sedative effects, increased risk of misuse, and accidental overdose, an alternative therapy is warranted for OAT patients undergoing alcohol detoxification. Baclofen is an emerging treatment for alcohol detoxification as it can reduce the craving to drink and can suppress AWS symptoms. Currently, there is a lack of evidence for its effectiveness in OAT patients. A 2021 study therefore investigated baclofen’s effectiveness and patient acceptability in treating AWS in OAT patients.²

Methods

In total, 23 alcohol-dependent patients attending Dublin OAT addiction clinics were invited to take part in this proof-of-concept study. The study was non-blinded (i.e. the participants knew what drug they were taking), with no control group as the sample size was limited, with the key aim to determine baclofen’s acceptability. Patients were assessed for alcohol intake and had a physical assessment, including liver and cardiac function. The Clinical Institute Withdrawal Assessment for Alcohol Scale Revised (CIWA-Ar) was used to monitor alcohol withdrawal symptoms during detoxification. The Treatment Satisfaction Questionnaire for Medication version 1.4 (TSQM 1.4) was undertaken once the detoxification period was completed to assess the participants’ satisfaction with baclofen. Data were gathered on side-effects, effectiveness, convenience, and global satisfaction with the treatment. A baclofen treatment regime was administered while the patients attended a daily clinic during the 11-day detoxification period.²

Data analysis

An intention-to-treat analysis was carried out to compare alcohol intake and withdrawal symptoms before and after the detoxification using baclofen. An intention-to-treat analysis includes all available data from participants, with data from those who dropped out also included in the analysis.³ Appropriate statistical tests were applied to compare results among participants who completed the study and those who dropped out.

Results

Of the 23 participants invited to take part, three dropped out before the trial commenced, reducing the study to 14 males and six females. A further three participants had dropped out by Day 4 of the trial. Approximately, one-half of the participants were homeless and alcohol intake was deemed very high. As this was an intention-to-treat study, any available data from the participants who dropped out were included in the analysis. The mean age was 37.6 years (males 38.7 yrs vs females 35.1 yrs). All participants had positive urinalysis for benzodiazepines, most (n=16/20) had abnormal liver findings, and one-half tested positive for hepatitis C. Following detoxification with baclofen, a statistically significant difference in median alcohol intake (interquartile range (IQR)) per day was observed, falling from 26.5 units (20.8–37.3) to 6.0 units (3.9–8.0), with a median reduction of 21.0 units (13.8–27.0). There was no difference observed between genders. Substantial reductions were also seen in AWS as measured by the CIWA-Ar, as median CIWA-Ar were also observed. Female participants were more likely to experience moderate withdrawal symptoms than males at the beginning of the study. Patient satisfaction with baclofen therapy was excellent across the four domains (side-effects, effectiveness, convenience, and global satisfaction) on the TSQM. Female participants scored slightly higher than males across the four scales, yet males still scored very high in relation to global satisfaction.

Discussion

The baclofen therapy for AWS saw a large decline in alcohol units consumed per day over a detoxification period of 11 days in both male and female opioid-dependent participants on OAT recruited in this proof-of-concept study. Combined with the CIWA-Ar results, baclofen appeared to effectively suppress withdrawal effects. Participants considered baclofen to be effective, convenient to take with few side-effects, and gave very high satisfaction scores, suggesting acceptability. The authors state that this study is the first of its kind to show that a non-addictive drug (baclofen) may work in the opioid-dependent population requiring alcohol detoxification.

However, the major weakness of the study was the positive benzodiazepine urinalysis observed in all patients, as no participant was known to have been prescribed benzodiazepines. This indicates illicit use, with the type and dose of benzodiazepines not known or regulated. Therefore, the reduction in withdrawal effects could be attributed to benzodiazepines rather than baclofen.

Another weakness was the small study numbers, which meant that a blinded controlled study could not be conducted. With no control group, a direct link to baclofen as an effective treatment of AWS in OAT patients undergoing alcohol detoxification is not possible. The authors noted that the mean alcohol consumption did not reach zero units by the end of the study. However, baclofen may be a suitable therapy for AWS in high-risk groups of relapses or developing benzodiazepine addiction, and further study is warranted.

1  Soyka M (2015) Alcohol use disorders in opioid maintenance therapy: prevalence, clinical correlates and treatment. Eur Addict Res, 21(2): 78–87.

2  Gibbons Z, McCarron P, Santlal K, McCarthy R and Keenan E (2021) Baclofen in the treatment of alcohol withdrawal syndrome in opioid-dependent patients. Heroin Addict Relat Clin Probl, Early online. https://www.drugsandalcohol.ie/35053/

3  Elkins MR and Moseley AM (2015) Intention-to-treat analysis. J Physiother, 61(3): 165–167.

Background

The prevalence of alcohol use disorder among the general population in Ireland is estimated at 14.8%.¹ In an attempt to reduce alcohol consumption in Ireland and consequently the rate of alcohol-related harms, the Public Health (Alcohol) Act was enacted in 2018.² Several components of the Act have been commenced but a number remain outstanding, such as Section 13. Section 13 of the Act will restrict the content of alcohol advertisements, requiring the marketing of alcohol products to contain facts about the dangers associated with alcohol consumption; how its use is linked to a number of cancers; how unsafe it is to consume during pregnancy; and will include a link to an independent website containing public health information about alcohol.

Pending commencement of Section 13, alcohol advertising is currently controlled through self-regulation by the alcohol industry and other media bodies and through a non-statutory code of conduct administered by the Advertising Standards Authority for Ireland. The latter stipulates that alcohol products should include responsible messaging (‘responsible drinking’) but explicit health warnings are not mandatory.

A 2022 study³ sought to examine the presence of consumer protection messaging in alcohol advertising on the social media platform Twitter in Ireland. It specifically aimed to observe the presence of voluntary and self-regulated messages and also to examine if the Twitter posts or their related accounts provide the consumer with warnings about alcohol use and/or signposts to public health information about alcohol.

Methods

Content analysis of 554 tweets from 13 alcohol companies based in Ireland, or where their marketing was directed at consumers in Ireland, was carried out. Analysis included coding the content of the Twitter posts according to the presence of warnings related to alcohol consumption (including warnings related to drinking during pregnancy and the link between alcohol use and cancers); the presence of voluntary and self-regulated consumer protection messages; and whether there was information available that referenced websites with public health information about alcohol.

Results

Warnings relating to alcohol consumption, drinking during pregnancy, and fatal cancers

The analysis indicated that none (0%) of the 554 tweets or their associated Twitter accounts provided information about the link between alcohol consumption and fatal cancers. Just three tweets (0.5%) provided a warning relating to drinking during pregnancy (via a logo) but none of the related Twitter accounts had pregnancy warnings.

Voluntary and self-regulated consumer protection messages

Voluntary and self-regulated consumer protection messages were observed in 36.3% of the tweets. The most common messages were ‘Get the facts. Be DRINKAWARE’ (20%) or ‘drink responsibly’ (10.3%).

Websites with public health information about alcohol

The majority of tweets (72.9%) had no link to a public health website, while 20.6% provided a link to Drinkaware.ie (an alcohol-industry-funded site).

Discussion

The findings from this study highlight the shortcomings of the current self-regulatory approach to consumer protection messaging in Ireland. This was evident through the lack of consumer warning messaging as stipulated by the Advertising Standards Authority for Ireland. It, as the authors note, is ‘an opportunity missed by alcohol companies to demonstrate adherence to simple, self-imposed rules’ (p. 5). Where such messaging was present, it indirectly encouraged consumption (e.g. ‘drink responsibly’) but independent health information was not present.

The findings also indicate a near complete absence of health warning messages, specifically referring to the dangers associated with alcohol use, the links between alcohol use and fatal cancers, or the dangers of drinking during pregnancy. However, a small number of tweets inadvertently showed brief symbols of packaging that warned that alcohol should not be consumed during pregnancy.

Conclusion

Commencement of Section 13 of the Public Health (Alcohol) Act 2018 will require that alcohol-industry marketing must inform consumers about alcohol and alcohol-related harms with impartial information on Twitter.

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

2  Office of the Attorney General Ireland (2018) Public Health (Alcohol) Act 2018. Dublin: Irish Statute Book.
https://www.drugsandalcohol.ie/33698/

3  Critchlow N and Moodie C (2022) Consumer protection messages in alcohol marketing on Twitter in Ireland: a content analysis. Drugs: Educ Prev Policy, Early online.
https://www.drugsandalcohol.ie/35588/

Introduction

Suicide is a significant public health concern with over 700,000 people worldwide dying by suicide each year. Accurate data on suicide deaths, including the characteristics of those who die by suicide and factors associated with these deaths, are essential to inform effective suicide prevention strategies.² In Europe, drug poisonings are estimated to account for 9.1% of suicides among young men and 23% of suicides among young women.³ Suicide by drug poisoning is potentially preventable; however, evidence on associated risk factors by sex is limited.

The aim of this study is to determine the extent to which individual and social contextual factors and specific drugs/drug groups are associated with suicide compared with NSDPD, and to determine whether there are differences between men and women in a national Irish study of drug poisoning deaths between 2015 and 2017.

Methods

Data for this study were extracted from the National Drug-Related Deaths Index (NDRDI). The NDRDI’s definition of a poisoning death is a death directly due to the toxic effect of one or more substances on the body. The suicide drug poisoning deaths (SDPD) group includes all drug poisoning deaths that met both the narrow (‘beyond reasonable doubt’) as recorded by the coroner and broad (‘based on the balance of probabilities’) definitions of suicide. Suicide based on the balance of probabilities was identified using the Rosenberg criteria for determination of suicide.⁴ To be included ‘based on the balance of probabilities’, the death had to be self-inflicted with evidence of intent to die in addition to risk factors for suicide. Analysis included univariable and multivariable logistic regression to estimate unadjusted and adjusted odds ratios (AOR) and 95% confidence intervals (CI) for factors associated with SDPD (primary outcome) compared with NSDPD and stratified by sex.

Results

SDPD accounted for 240 (22%) of 1,114 poisoning deaths reported during the period 2015–2017 inclusive, the majority among men (n=147, 61%). Increasing age, especially over 54 years of age (AOR 3.01 [95% CI: 1.68–5.38]), mental ill-health (AOR 7.85 [95% CI: 5.46–11.28]), chronic pain (AOR 5.57 [95% CI: 3.28–9.46]), and history of previous overdose (AOR 5.06 [95% CI: 3.39–7.56]) were associated with increased odds of SDPD, with similar results for both sexes. The main drugs associated with SDPD were non-opioid analgesics (OR 4.06 [95% CI: 2.66–6.18]), antipsychotics (OR 2.42 [95% CI: 1.63–3.60]), and antidepressants (OR 2.18 [95% CI: 1.59–2.97]). Pregabalin was associated with SDPD among women only.

Conclusions

The authors conclude that factors associated with SDPD included being male, older age, mental illness, chronic pain, and history of a previous overdose. The main drugs found to be associated with SDPD included non-opioid analgesics, antidepressants (specifically tricyclic antidepressants), and antipsychotics. Similar effects were observed among men and women in the sex-specific analyses, with small variations in magnitude of effects.

Ongoing monitoring for signs of suicidal intent in individuals with mental illness, chronic pain, overdose, and/or prescribed mental health medications may identify individuals in need of additional intervention. Adequate specialised pain management clinics, with non-pharmaceutical therapy used to complement pharmaceutical therapy, should be resourced. 

1  Lynn E, Cousins G, Lyons S and Bennett KE (2022) Comparing characteristics of suicide to non-suicide drug poisoning deaths, by sex, in Ireland. J Affect Disord, 306: 80–89.
https://www.drugsandalcohol.ie/35890/

2  World Health Organization (2014) Preventing suicide: a global imperative. Geneva: World Health Organization.
https://www.drugsandalcohol.ie/22594/

3  Värnik A, Kõlves K, van der Feltz-Cornelis CM, Marusic A, Oskarsson H, Palmer A, et al. (2008) Suicide methods in Europe: a gender-specific analysis of countries participating in the ‘European Alliance Against Depression’. J Epidemiol Community Health, 62(6): 545–551.

4  Rosenberg ML, Davidson LE, Smith JC, Berman AL, Buzbee H, Gantner G, et al. (1988) Operational criteria for the determination of suicide. J Forensic Sci, 33(6): 1445–1456.

Published by the Mental Health Information Systems Unit of the Health Research Board, the Annual report on the activities of Irish psychiatric units and hospitals 2020¹ shows that the rate of new admissions to inpatient care for alcohol disorders has increased.

In 2020, some 958 cases were admitted to psychiatric facilities with an alcohol disorder, of whom 382 were treated for the first time. Figure 1 presents the rates of first admission between 2000 and 2020 for cases with a diagnosis of an alcohol disorder. The admission rate in 2020 was higher than the previous year, although trends over time indicate an overall decline in first admissions. Approximately one-third (33.3%) of cases hospitalised for an alcohol disorder in 2020 stayed just under 1 week, while 32.7% of cases were hospitalised for between 1 and 3 months, similar to previous years.

In 2020, some 973 cases were also admitted to psychiatric facilities with a drug disorder. Of these cases, 434 were treated for the first time. Figure 2 presents the rates of first admission between 2000 and 2020 of cases with a diagnosis of a drug disorder. The admission rate in 2020 was similar to 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.

• Other notable statistics on admissions for a drug disorder in 2020 include the following:
• Over one-half of cases hospitalised for a drug disorder stayed under 1 week (52.3%), while 99% were discharged within 3 months. It should be noted that admissions and discharges represent episodes or events and not persons.
• 16.4% 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 (4.8 per 100,000 population).

Source: Daly and Craig (2021)

Figure 1: Rates of psychiatric first admission of cases with a diagnosis of an alcohol disorder per 100,000 of population in Ireland, 2000-2020

Source: Daly and Craig (2021)

Figure 2: Rates of psychiatric first admission of cases with a diagnosis of a drug disorder per 100,000 of population in Ireland, 2000-2020

1                Daly A and Craig S (2021) Annual report on the activities of Irish psychiatric units and hospitals 2020. HRB StatLink Series 5. Dublin: Health Research Board. https://www.drugsandalcohol.ie/34575/

Background

The Covid-19 pandemic impeded the delivery of addiction support services to this high-risk group as existing healthcare models were dramatically altered or abolished. The impact of the pandemic negatively affected addiction recovery, with adverse health outcomes and drug-related mortality seen to increase, in turn impacting the wellbeing of practitioners already under pressure.¹ A 2022 study explored the impact that the pandemic had on the wellbeing of Irish healthcare professionals supporting clients with addiction.²

Method

In total, 15 professionals working in homelessness, addiction, public health, and emergency medicine who worked with people who actively take drugs were recruited to take part in the qualitative study using semi-structured interviews. To be included in the study, participants must also have experienced a drug-related death of a client (excluding bereavements within 3 months of the survey) and be in an active healthcare role. Participants were recruited nationwide.

Data analysis

Transcribed data were analysed using Braun and Clarke’s updated six-step process, where data are analysed using reflexive thematic analysis.³ This technique uses a repetitive sequential process of data familiarisation, coding, initial themes generation, reviewing themes, defining and naming themes, and writing up. Qualitative analysis software NVivo was used in the process. From a quality control perspective, Dodgson’s recommendations⁴ to avoid author influence of data interpretation were maintained throughout the qualitative research process.

Results

Four core themes were generated from the analysis: shift in priority; being left behind; managing a death; and anxious environment. Associated subthemes provided further information and context.

Shift in priority

Priorities that were typically client-centric shifted towards Covid-19 safeguarding and infection controls. Participants expressed feeling unprepared, confused, anxious, occupationally stressed, and internally conflicted as the new priorities challenged their existing professional values:

In addiction you’ve got to be flexible. Especially with Covid, it can’t just be about the client now. I have to consider all the people in the building, my colleagues, my staff, myself, even my own family.

While the importance of safeguarding was understood, the participants feared for the lack of services for their clients:

...in the last six months, I don’t know if I’ve had one patient who was treated…

The subtheme ‘high threshold’ was identified as the ease of accessing services was reduced, creating a barrier for clients:

The ideal is to have specialist low threshold services, no appointments, the least amount of administrative barriers. And all of that is the total opposite of what we’re told to do as a service provider to keep the service safe now [during the Covid-19 pandemic].

Covid-19 protocols undermined the foundation of addiction services and reduced the number of services remaining in operation because of closures. Participants reported stress and associated emotions with the loss of control over client care.

Being left behind

Three subthemes were identified: ‘lost in transition’, ‘digital divide’, and ‘new relationship dynamics’. Addiction continued as a major public health concern during the pandemic with those experiencing addiction becoming more vulnerable than before:

Addiction doesn’t go away, and the lockdown has pushed more people to risky behaviours ... I feel [the pandemic] is going to leave more people behind than were being left behind before.

Participants were left feeling uncertain, experiencing loss of control and feelings of helplessness to provide services required by their clients:

That is my biggest fear right now ... I don’t feel I can do anything for them right now, even as somebody with a lot of experience. I feel a little bit helpless in this situation.

Clients’ recovery noticeably worsened with increasing wait times leading to ‘slips’, dropping out of contact, and getting ‘lost in transition’ during their recovery period. It left the participants feeling demoralised or with low morale:

If you’re in recovery and you were struggling beforehand, you know it’s too much to handle for people on their own.

One participant declared:

I can’t do that for six months ... It’s really disheartening as a worker to know that a service might not be available for someone when you know they’re ready now.

The introduction of virtual communication with clients resulted in many barriers from lack of infrastructure, knowledge, access, and tools, and abolished the sense of security and safety that in-person private sessions provided. One participant recalled:

The front doors of services were shut, and not all my patients and clients have smartphones and can’t do video counselling. There is a digital divide.

Another pointed out:

…some don’t like speaking over the phone, because they might have a mental health fixation on the fact that someone is going to hear something about their business. On the phone, how are you supposed to make someone feel safe?

The pandemic changed relationship dynamics between the participants and their clients, with connections becoming strained, leaving clients feeling abandoned when staff were redeployed due to the pandemic:

It has a huge impact on staff wellbeing … We have such an amazing relationship with the participants … and they’ve built such trusting professional relationships … But all our clients may not understand the fact that I’ve been redeployed and I’m unavailable...

Managing a death

In the event of a client’s death, participants reported feelings of guilt, blame, personal responsibility, and self-questioning for these ‘preventable deaths’.

There’s an unbelievable guilt. I always feel it’s my fault if one of my patients dies.

Participants’ strong emotional investment accompanied with Covid-19 protocols and administrational demands following the death of a client left little time to process the death:

...and they’re left with nowhere to process that emotion, or that grief. They can’t attend the funeral ... If I don’t go to funerals, I always expect them [the client] to come back. It’s me closing that relationship with them…

Certain guidelines were loosened due to Covid-19 protocols to cater for the needs of clients, leaving participants feeling exposed and anxious about legal outcomes should a death occur:

You might give them a little bit more takeaways so that they don’t have to go to the chemist every day to get their methadone. Those sort of loosening of the guidelines means that everyone is a little bit more exposed.

Anxious environment

Anxiety was highly prevalent throughout the interviews, suggesting Covid-19 created an anxious environment for the participants to work in. Between self-monitoring for Covid-19, questioning their own mental health and fitness to work, and the occupational stress the pandemic created, all corners of their lives were affected. One participant recalled:

It is so impactful at all levels ... Never, ever, ever have I found it so difficult to separate work from home.

Discussion

Areas of concern for future service delivery and opportunities to future-proof services as society moves towards hybrid models of working were highlighted. The rigid protocols around service provision and the digital divide created due to public health measures pushed this high-risk group further away, significantly impacting practitioners’ occupational wellbeing. Feelings of anxiety, helplessness, and concern for mortality of their clients prevailed. Nonetheless, the participants continued to support this group in the most difficult of circumstances.

1  Nikmanesh Z, Baluchi MH and Pirasteh Motlagh AA (2017) The role of self-efficacy beliefs and social support on prediction of addiction relapse. Int J High Risk Behav Addict, 6(1): e21209.

2  O’Callaghan D and Lambert S (2022) The impact of COVID-19 on health care professionals who are exposed to drug-related deaths while supporting clients experiencing addiction. J Subst Abuse Treat, Early online. https://www.drugsandalcohol.ie/35544/

3  Braun V and Clarke V (2019) Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health, 11(4): 589–597.

4  Dodgson JE (2019) Reflexivity in qualitative research. J Hum Lact, 35(2): 220–222.

Background

In 2017, the per capita alcohol consumption in Ireland equated to every Irish adult (aged 15 years and over) drinking 13.9 litres of alcohol, considerably higher than the 6.5 litres globally.¹ Alcohol-related harms are associated with this level of alcohol consumption, with the period from 1995 to 2013 seeing an 82% increase in alcohol-related hospital admissions in Ireland.^2,3 Alcoholic liver disease (ALD) is caused by damage to the liver from excessive drinking over a prolonged period, and treatment involves alcohol abstinence, managing complications of liver failure, and/or liver transplantation. ALD is a major cause of both liver cirrhosis and hepatocellular carcinoma (HCC), a type of primary liver cancer.

Methods

Using Hospital In-Patient Enquiry (HIPE) scheme data, a 2022 study⁴ examined the prevalence of ALD discharges, including HCC, from Irish hospitals during the period 2007–2016. The study examined the demographics of those discharged with a diagnosis of ALD and the ALD mortality rate as well as complications associated with ALD.

Results

According to HIPE data, during the period 2007–2016, there were 33,794 discharges with a diagnosis of ALD, increasing by 38% from 2,563 discharges in 2007 to 3,532 discharges in 2016. When examined by rates per 100,000 of the population, ALD discharges increased by 23% in the study period: from 59 per 100,000 in 2007 (based on the entire population of 4.376 million) to 73 per 100,000 in 2016 (based on the entire population of 4.76 million). Of the ALD discharges, 57% were coded as alcoholic cirrhosis of the liver, 3% as hepatorenal syndrome, 10% as acute kidney injury, and 24% as ascites. In 2016, there were 289 oesophageal variceal bleed discharges and 129 HCC discharges (a 300% increase from the 37 discharges in 2006).

The data indicated that the majority of ALD discharges during the period 2007–2016 were male (70%) and the mean age of admissions increased from 51 years in 2006 to 54 years in 2016. Patients with ALD remained in hospital for an average of 13 days; the data indicated that an average of 120 hospital beds per day were occupied due to ALD, equating to a cost of €34 million annually.

Over one-half of ALD-discharged patients were under the care of general medicine or medicinal specialities (53%), while 31% were under a gastroenterologist or hepatologist.

The overall mortality rate among those discharged with ALD was 9.8% but it varied between diagnoses. There was a 16% mortality rate for patients diagnosed with variceal bleeding; 15% for those with ascites, 42% for acute kidney injury, and 43% for hepatorenal syndrome. Overall, there was a 29% increase in hospital deaths due to ALD from 2006 (n=233) to 2016 (n=300).

Conclusion

The HIPE data analysed for this study indicated an increase in ALD discharges in Ireland during the period of investigation. Comparable data in the United Kingdom, Australia, and Brazil also reported increases in rates of ALD. The study authors acknowledged the evidence indicating that reductions in per capita alcohol consumption are associated with a reduction in alcohol-related harm³ and noted that per capita alcohol consumption in Ireland remains high.⁵

ALD hospitalisations highlight the considerable burden on the Irish health system and the substantial loss of life for what is a preventable condition. The authors note that the financial cost is likely to be significantly higher due to the complexity of care required for these patients and the underreporting of alcohol-attributable conditions. The authors advocate for the creation of alcohol care teams in Irish hospitals and are confident that measures commenced as part of the Public Health (Alcohol) Act 2018 will result in fewer hospital discharges due to ALD.

1  Manthey J, Shield KD, Rylett M, Hasan OSM, Probst C and Rehm J (2019) Global alcohol exposure between 1990 and 2017 and forecasts until 2030: a modelling study. Lancet, 393(10190): 2493–2502. https://www.drugsandalcohol.ie/30508/

2  Norström T and Ramstedt M (2018) The link between per capita alcohol consumption and alcohol-related harm in Sweden, 1987–2015. J Stud Alcohol Drugs, 79(4): 578–584.

3  Long J and Mongan D (2014) Alcohol consumption in Ireland 2013: analysis of a national alcohol diary survey. Dublin: Health Research Board. https://www.drugsandalcohol.ie/22138/

4  Armstrong PR, Ring E and MacNicholas R (2022) A decade of rising alcoholic liver disease hospital admissions and deaths in Irish hospitals, 2007–2016: a retrospective cross-sectional analysis.
Eur J Gastroenterol Hepatol, Early online.
https://www.drugsandalcohol.ie/35445/

5  O’Dwyer C, Mongan D, Doyle A and Galvin B (2021) Alcohol consumption, alcohol-related harm and alcohol policy in Ireland. HRB Overview Series 11. Dublin: Health Research Board.
https://www.drugsandalcohol.ie/33909/

Background

Internationally, case management (CM) was first adapted in the 1980s to work with people who use drugs; however, the concept had emerged first in the 1920s.¹ In 2010, the Health Service Executive (HSE) published the National Drugs Rehabilitation Framework Document,² in which CM was outlined as a key component. This framework was in response to the earlier policy document, Report of the Working Group on Drugs Rehabilitation,³ which recommended ‘a framework through which service providers will ensure that individuals affected by drug misuse are offered a range of integrated options tailored to meet their needs and create for them an individual rehabilitation pathway’ (p. 7).²

The framework document also supplied definitions of ‘case management’ and ‘case manager’ (p. 29):²

Case management is the process of coordinating the care of a service user through a shared care plan and resolving any gaps and blocks that arise.

Case manager is the named person who has the formal lead role in the management of interagency communication and the provision of coordinated care for the service user in question.

Models of case management

Six basic models of CM have been identified by Vanderplasschen et al. and as outlined by Nic Gabhainn et al.  (p. 7):^1,4

• The brokerage model: Case managers act as ‘brokers’, assisting clients to identify their needs and gain access to other services or supports; generally, it involves a brief engagement with clients with only one or two meetings.
• Generalist models: Case managers work with clients to identify needs and negotiate access to required services and supports; a longer-term and closer relationship with clients is developed over time.
• Assertive community treatment (ACT): Case managers work in teams to help identify client needs and provide services directly to clients through assertive outreach.
• Intensive case management (ICM): Case managers work on a more intensive, individual basis with clients and usually have a lower caseload; they identify needs, provide services directly and link clients with relevant services.
• The strengths perspective: Case managers seek to empower the client to identify their own strengths to build on, rather than primarily focusing on correcting their deficits; this approach encourages the use of informal sources of support and help.
• Clinical case management: Case managers provide direct clinical input to clients and combine that with assistance in accessing other resources, particularly from the health and social care sector.

Review of evidence

In 2016, the Health Research Board (HRB) published a scoping review of the evidence from peer-reviewed non-experimental research on CM (2003–2013).⁴ The review sought to answer three questions, which are briefly summarised below.

1 What additional knowledge regarding the nature of case management can we gain from a review of recent non-experimental research on the topic?

The literature showed that there was an expectation that CM would achieve multiple objectives, many directly related to the client, such as reducing substance use and improving social and psychological issues to broader operational issues (e.g. improving service coordination). The review found that there were some key elements of CM that improved outcomes, including duration and intensity of the intervention and team-based CM, with the engagement of case managers identified as important in successful outcomes.

2 What outcomes have been evaluated in the non-experimental research literature?

Almost all of the studies included (17/20) found evidence that CM improved outcomes for clients in at least one area. However, it was not definitive if the improved outcomes reported were directly related to CM or other factors which were outside the scope of the studies reported.

3 What are the gaps in the non-experimental literature?

One of the major gaps of the literature reviewed was in the identification of the specific aspects of CM that lead to improved outcomes. The number of types of outcomes evaluated in studies should be expanded to include quality-of-life perspectives from clients. To have a better understanding, CM would benefit from studies that examine different aspects of CM in different areas and for different client groups, with more rigorous or appropriate evaluation methods.

Evaluation

An external review of the shared framework of CM in the Cork/Kerry region was conducted in 2017.⁵ This found that the model used in the region was a blend of several models which had evolved over a number of years. In general, participants were positive about CM, in particular in relation to consistency of care, reduction of work duplication, improved clarity, and standardisation of roles and paperwork. While optimal interagency working was identified as key to success, participants reported that it could be difficult to engage all relevant agencies, with ‘missing partners’ a theme that emerged throughout the study. Participants were divided on the benefits of the CM supervisor role that worked across all sectors, which was part of the project in the region. Other weaknesses reported were hierarchy, loss of professional identify, and burden of administration. While the participants reported that one of the benefits of CM was that it was client-centred, one of the limitations of the study was the limited involvement of service users in the evaluation.

1  Vanderplasschen W, Wolf J, Rapp RC and Broekaert E (2007) Effectiveness of different models of case management for substance-abusing populations. J Psychoactive Drugs, 39(1): 81–95.

2  Doyle J and Ivanovic J (2010) National Drugs Rehabilitation Framework Document. Dublin: Health Service Executive.
https://www.drugsandalcohol.ie/13502

3  Working Group on Drugs Rehabilitation (2007) National drugs strategy 2001-2008: rehabilitation. Report of the Working Group on Drugs Rehabilitation. Dublin: Department of Community, Rural and Gaeltacht Affairs. https://www.drugsandalcohol.ie/6267/

4  Nic Gabhainn S, D’Eath M, Keane M and Sixsmith JA (2016) Scoping review of case management in the treatment of drug and alcohol misuse, 2003–2013. HRB Drug and Alcohol Evidence Review 3. Dublin: Health Research Board.
https://www.drugsandalcohol.ie/26681/

5  Ivers J-H and Barry J (2017) An evaluation of a framework for case-management in the Cork/Kerry region. Dublin: Trinity College Dublin. https://www.drugsandalcohol.ie/29012/

Chrysalis is a community drug and alcohol service which has been operating for almost 25 years in Dublin’s north inner city.^1,2 The service has grown significantly since then, especially in more recent years; having started as a counselling service it has moved on to provide a range of other services. Its vision is that ‘everyone living with problem substance use should be empowered to fulfil their full potential and have access to the same opportunities and rights as others’.³

Chrysalis has been incorporating case management (CM) into its work since 2007. Based as it is in Dublin city, many of the Chrysalis service users present with complex needs, addiction, mental health problems, homelessness, legal or family issues, for whom CM can be most effective. In 2019, Chrysalis extended this service to the service users of the newly set up Inclusion Health Hubs. Since then, it has extended the service to other agencies. It now also provides training on CM and the comprehensive needs assessment tool to other addiction services.

The experience of Chrysalis working with CM may be useful for other services, as it has embraced and successfully embedded the model into its work and expanded the service in recent years.

For more information on CM, see the article ‘Overview of case management related to work with people who use drugs’ on page 18.

The Chrysalis experience

Suitability of service users

Chrysalis strives to ensure the service user is always at the centre of the process; however, its ethos is that participation must always be the choice of the service user. While CM can be most effective for service users with complex needs (addiction/legal/dual diagnosis/housing, etc.), not all service users will benefit from it, as they require a level of motivation to make some changes in their life, to engage, and commit to the process. For example, they have to be active in all the associated processes, such as care planning and attending their appointments. For some service users, CM will not be appropriate at that point in time, but they are reassessed periodically for suitability, as their situation or motivation changes. However, when implemented properly, CM can often provide a service user with clarity and define a pathway for them to navigate the services they need in order to meet the objectives of their care plan.

Role of case manager

In the experience of Chrysalis, the case manager requires a high level of skill to ensure that the CM process is successful for both the service user and all the agencies involved. As CM is used to coordinate the service user’s care plan across many services, the case manager needs to be able to coordinate, organise, advocate, build networks, and negotiate on behalf of their service users in order to progress their care plans. In this regard, the case manager must have the authority to build strong working relationships across all agencies, not just in health but also social services and justice. The term ‘broker’ is sometimes used in this context and does convey the need to ‘put the pieces together’. The Chrysalis team acknowledges that to be an effective case manager involves much administration, IT skills, and time management. This combined workload can be considerable and, according to Chrysalis, the job functions better as a standalone post. This also ensures that the role of case manager is clearly delineated for other staff and service users.

CM in other settings

When providing CM in other settings, the Chrysalis team tries to get an understanding of the unique culture of the service, while the service user also needs to adapt to this new approach. Therefore, it can take a considerable amount of time to build up a relationship of trust with service users so they come to understand the role of the Chrysalis team, CM, and how the process could help them to progress. For Chrysalis, its work over time can help to improve the relationships between the service users and the staff in the clinic.

Even though CM has been operationalised in addiction services for a number of years, the team still finds that some services are not always clear on what CM entails, and/or the extent of the process, and/or is implemented slightly differently in different services. There can be uncertainty about the scope of the role of the case manager and how CM differs from key working, for example.

During the public health crisis of the Covid-19 pandemic, CM was impacted because of the public health restrictions on addiction services, which limited referral options for service users.

Challenges and streamlining

If all services could share the same assessment tool, which would be securely available to all relevant staff, it would help to streamline the CM process for everyone. It would also be useful if the salary and scale of the case manager could be reviewed, given the high level of skill required. In addition, a formal certified and accredited training for CM for addiction services would allow project workers to upskill and also to ensure a standard level of competency of case managers across all addiction services.

Final thoughts from Chrysalis team

The Chrysalis team feels that CM has been successful for them as an organisation. It is an easy framework to follow: from assessment where the needs are identified to care planning where the responses required are identified, along with regular care planning review.⁴

One of the key values for Chrysalis as an organisation is to be person-centred; therefore, CM fits in with its ethos as person-centred, client-led, and always driven by the client’s needs. The voice of the service user is central to the care plan and CM is about empowerment and self-efficacy. CM is also about coordinating resources; when successful it is an example of interagency practice at its best. It concerns linkage and brokerage and tapping into local and nationwide resources in response to the identified needs of the service user. A multidisciplinary team all working together in unison on an integrated care plan will have positive outcomes for the service user.

1  Chrysalis Community Drug and Alcohol Team (2018) Strategic plan 2019–21: treatment in partnership. Dublin: Chrysalis Community Drug and Alcohol Team. Available online at:
https://chrysalisproject.ie/wp-content/uploads/2019/09/Strategic-Plan-Brochure-2018.pdf

2  This article was based on discussions with Chrysalis CEO Passerose Mantoy and team leader Sarah McGillivary, with a contribution from Yvonne Byrne. For further information on Chrysalis, contact passerose@chrysalisdrugproject.org

3  For further information on the Chrysalis vision, visit:
https://chrysalisproject.ie

4  For an example of an initial and comprehensive assessment protocol, see Cork and Kerry Drug and Alcohol Services (2017) Case management manual 2015. Cork: Cork and Kerry Drug and Alcohol Services. https://www.drugsandalcohol.ie/26727/

In September 2021, Merchants Quay Ireland (MQI) launched a briefing paper calling for governmental support to provide gender-specific services for women experiencing homelessness and addiction, entitled A space of her own: the need for gender specific services for women in homelessness and addiction.¹ The briefing paper draws on the findings of a number of studies, in particular Responding to women with complex needs who use substances, which was published in 2020.²

Policy context

The needs of women who use drugs are included in Ireland’s national drugs strategy under its second goal to ‘minimise the harms caused by the use and misuse of substances and promote rehabilitation and recovery’ (p. 33).³ These were addressed specifically as part of the objective ‘to attain better health and social outcomes for people who experience harm from substance misuse and meet their recovery and rehabilitation needs’ (p. 33).³ Furthermore, the Programme for Government launched in June 2020 reiterated the Government’s commitment to address the needs of women who face barriers to accessing and sustaining addiction treatment, arising from an absence of childcare or the presence of domestic violence.⁴ Within this national policy context, MQI argues that to achieve better outcomes for women, services need policies that allow them to adapt their services to support female clients. Overall, there is a need to understand and invest in services that work for women.

Complex needs

Evidence cited in both publications illustrates the complex nature of the needs of women who experience homelessness and addiction. Among those issues identified in the reports are higher rates of mortality, sexual and intimate partner violence, HIV infection, trauma, and abuse than in the general female population. The impact of the Covid-19 pandemic has resulted in the further marginalisation of these women. Stigma, shame, and fear are among the many issues women in addiction and homelessness face, which also act as barriers to women’s engagement and ongoing contact with practitioners and services. However, international evidence has found that gender-specific services can help women overcome these barriers.

Gender-specific services

The MQI briefing paper argues that there is a lack of specific services for women experiencing addiction and homelessness in Ireland. Moreover, there is a lack of gender sensitivity in the services that are available. The presence of men at these services can create an intimidating atmosphere for women who have experienced trauma. MQI argues that it is imperative that gender-responsive and trauma-informed services are provided for these vulnerable women. They need to reflect the complexities of these women’s needs and provide flexible pathways into the services, with speedy access, integration of services, and inclusivity (p. 3).¹

MQI vision

The briefing paper identifies five elements to MQI’s vision for progress in this area.

• That there would be services that recognise and respond to the unique and complex challenges faced by women in Ireland today. They would be delivered in a safe, supportive, and non-judgemental environment.
• That services would be trauma-informed to allow women to address their complex needs. The services would be promoted in a female-friendly way to encourage more women to engage with the services earlier.
• That there would be a low-threshold female-only wellbeing centre in Dublin. The centre would be holistic in its approach and would link in with other relevant services to support vulnerable women.
• That staff would be trained and upskilled to work with and support vulnerable women who experience trauma, violence, and abuse.
• That further research would be carried out to explore the intersectionality of women’s problematic substance use within an Irish context.

1  Merchants Quay Ireland (2021) A space of her own: the need for gender specific services for women experiencing homelessness and addiction. Dublin: Merchants Quay Ireland.
https://www.drugsandalcohol.ie/34831/

2  Morton S, Macdonald S and Christophers L (2020) Responding to women with complex needs who use substances. Dublin: University College Dublin. https://www.drugsandalcohol.ie/33443/

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

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

People who use drugs (PWUD) and are aged 40 years or over experience particular challenges as a cohort. These include social isolation and exclusion as well as poorer physical and mental health outcomes.¹ The Ballyfermot Local Drug and Alcohol Task Force (BLDATF) commissioned a study on the needs of this cohort in their area of Dublin. Entitled It’s like we’re the forgotten...: an exploration of the issues affecting older people in Ballyfermot who are experiencing problematic drug and alcohol use, it was published in March 2021.¹

Study context and aims

Both Ireland’s national drugs strategy and that of the European Union (EU) recognise the necessity of improving the response to the needs of older PWUD.^2,3 The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) notes that while this cohort is not a homogenous one, many of them began using heroin in the 1980s and 1990s and are now at high risk of a variety of serious conditions and will need health and social care interventions in the future.⁴ With this in mind and recognising a need in the local area, BLDATF agreed three aims for their research:

• To help build a supportive environment for older drug and alcohol users in the Ballyfermot community in partnership with key stakeholders
• To research the needs of older drug and alcohol users in the community
• To make recommendations on the development and strengthening of appropriate supports in partnership with other stakeholders.

Methodology

The research took a mixed methods approach. Interviews and focus groups were carried out with service providers and PWUD in this older age cohort. A limited literature review was carried out and data analysed from the Health Research Board’s (HRB) National Drug Treatment Reporting System (NDTRS) and the Health Service Executive’s (HSE) Central Treatment List for methadone maintenance. Most of this work was carried out before the onset of the Covid-19 pandemic, but a survey of community and statutory service providers was added to the research brief to explore the impact of the pandemic and Government restrictions on the services and service users.

Findings

Barriers to accessing services

The study identified barriers that PWUD faced when accessing services. Some related to service users’ having ‘entrenched behaviours resulting from lifelong experience of serious disadvantage to a variety of structural issues which made it more difficult for this group to access services easily and receive effective care in the setting best suited to their needs’ (p. 22).¹ These barriers included:

• Service users often did not trust or had a poor relationship with service providers. This translated into a reluctance to engage with services and poor attendance at appointments.
• Service users would prefer to be more discreet in their attendance at the methadone treatment clinic. The entrance to the Ballyfermot treatment clinic was described as being in a ‘highly visible location’, prohibiting discreet attendance at the service. Users did not like other members of their community being able to see them queuing for or entering the service. This was perceived to be stigmatising.
• Linked to the previous finding, people on methadone maintenance felt particularly stigmatised by the wider community. This stigma impacts on their lives by ‘perpetuating shame and isolation’ (p. 23).¹
• Service providers and users reported an unconscious bias on the part of some health and social care professionals, which impacted the way in which they interact with clients. They have a negative bias towards older PWUD, in particular those on methadone maintenance, which affects their ability to be non-judgemental and deliver a quality service.
• A recurring theme among community and statutory service providers was a lack of accurate information and knowledge among providers and users about the services available to older PWUD. There were also gaps in service providers’ knowledge of the roles of various professionals in the system and how referral systems worked. This prevented PWUD from accessing the right services and experiencing continuity of care, for example.
• There was agreement across both statutory and community service providers that there was a lack of joined-up working in Ballyfermot drug and alcohol services. It was perceived that there were ‘too many different voices working in the sector and that this caused confusion and inefficiencies’ (p. 26).¹ This was linked to a perception that given the confusion among services, users sometimes attended multiple projects at the same time. This resulted in duplication of resources and clients lacking a clear progression pathway.

Additional services

Service users and providers identified services that they would like to see in Ballyfermot, including:

• A multipurpose day centre where PWUD can interact socially, access services, and be signposted to other interventions was top of the list. The space would provide a ‘hub in which people could access health and social care services in, including preventative health care and screening services’ (p. 31).¹
• A space in which people who were on methadone maintenance could stabilise and reduce their ‘double dosing’ (p. 32)¹ where they took their methadone dose and additional drugs.
• Improved access to HSE services for those experiencing dual diagnosis. PWUD wanted access to addiction and mental health services at the same time rather than ‘falling between the gaps’ (p. 32).¹
• Peer mentoring in the community-based services.
• Extended hours for those services that are already established in Ballyfermot.
• A bus service to provide lifts back to the city centre for those who are accessing services in the Ballyfermot area but have hostel accommodation in the city centre. While the ideal solution would be that they could be housed in Ballyfermot, in the meantime the bus service would reduce their vulnerability and support their access to services.

Concluding comment

The report provides BLDATF with a set of recommendations covering a range of themes, including the barriers to accessing supports; how programmes in the area could better meet the needs of older PWUD; how interagency and joint working practices could be improved; and what resources are required to improve the physical and mental health for this age cohort. While these findings are targeted at BLDATF, they are likely to be of interest to those working in other task force areas.

1  Deane A (2021) It’s like we’re the forgotten...: an exploration of the issues affecting older people in Ballyfermot who are experiencing problematic drug and alcohol use. Dublin: Ballyfermot Local Drug and Alcohol Task Force. https://www.drugsandalcohol.ie/35208/

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

3  Council of the European Union (2020) EU drugs strategy 2021–2025. Brussels: Council of the European Union.
https://www.drugsandalcohol.ie/33750/

4  European Monitoring Centre for Drugs and Drug Addiction (2017) Health and social responses to drug problems: a European guide. Luxembourg: Publications Office of the European Union.
https://www.drugsandalcohol.ie/28040/

Harm reduction services

Harm Reduction Service, Riverbank Centre, Dublin

In 2020, some 36,180 clients visited MQI needle exchange and harm reduction services in the Riverbank Centre in Dublin; 3,369 of these clients were unique. When compared with 2019, MQI saw an increase of over 10% in the numbers of clients engaging in the needle exchange service.

Substance use case workers

MQI substance use case workers support people addressing their substance use, including exploring treatment options for detox and rehabilitation. This support is carried out by phone and on a one-to-one basis. In 2020, some 129 clients were supported. Of these 129 clients, 38% were young people aged 18–24 years.

Source: MQI annual review, 2017

(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.

Figure 1: MQI locations in the Republic of Ireland

Opioid substitution therapy

In 2020, MQI witnessed a steady increase in clients availing of opioid substitution therapy (OST) compared with 2019. The number of people receiving OST in 2020 was 483 unique clients and access to this treatment was believed to be significantly increased due to the reduced waiting times as a result of the Covid-19 pandemic.

Opioid drug reversal with naloxone

Along with partners in the Health Service Executive, the National Family Support Network, and the Ana Liffey Drug Project, MQI was front and centre in the national rollout of the Naloxone Demonstration Project in 2015. Naloxone is an antidote for opioid overdose that reverses the depressant effects of opioids such as heroin. Throughout 2020, some 263 unique clients were prescribed naloxone, with 318 kits provided. In 2020, some 281 clients also completed training, with 353 sessions provided by staff. In addition, 488 safer injecting interventions were undertaken.

Community detox

In 2020, some 18 unique clients accessed the MQI Community Detox in the Riverbank Centre, with 14 people accessing benzodiazepine services and four people receiving alcohol detox. People accessing this treatment were supported by a substance use case worker.

Harm Reduction Outreach Team

MQI has a Harm Reduction Outreach Team that provides harm reduction interventions. Services provided include needle exchange, safer injecting information, and naloxone training. The team also supports clients by referring them to other services such as medical, housing, and mental health. In addition, the team aims to build relationships with clients who are service-resistant and to support them overcome the barriers they face in order to engage with mainstream services. In 2020, this team supported 714 unique clients through 2,744 interventions.

North East Drug and Alcohol Service

This service provides harm reduction supports to active substance users in the North East region in partnership with a wide range of local agencies. In 2020, one MQI staff member worked three days a week in this service and provided needle exchange, safer injecting advice, signposting, and advocacy interventions to individuals in active addiction. Between January and August 2020, some 24 clients were supported.

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). Services provided include an outreach-based crisis support service, mobile harm reduction, needle and syringe exchange, rehabilitation, a community employment scheme, aftercare supports, and support for families affected by substance use. In 2020, some 1,298 unique clients were supported through 36,181 interventions. Of these individuals, family support was provided to 119 people, with 1,153 interventions.

Recovery services

St Francis Farm and High Park

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 Tullow, 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.

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.

There was a total of 891 referrals to MQI recovery services in 2020. All 891 people referred to the services received ongoing contact and support through phone or video. There were 517 assessments carried out, with 137 admissions and 115 completions during 2020. Covid-19 risk reduction measures resulted in residential capacity being reduced. Groups were brought in together where possible and tested for Covid-19 prior to admission.

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.

In 2020, MQI counselling staff saw a total of 1,948 unique clients, with on average 1,187 monthly interventions.

1. Merchants Quay Ireland (2021) Merchants Quay Ireland annual review 2020. Dublin: Merchants Quay Ireland.
   https://www.drugsandalcohol.ie/34984/

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 for 2020 was published in 2021.¹ The report noted that, in 2020, some 1,921 people accessing Dublin services received Covid-19-specific interventions. These included being provided with Covid-19 information, education, supplies, and transport to testing and isolation accommodation. Some 328 people living in private emergency accommodation received assessments and brief interventions, while 32 people residing in accommodation provided by non-governmental organisations (NGOs) received assessments and brief interventions. A further 198 people received case management, while 81 subjects accessed the ALDP needle and syringe programme.

In the Midwest region, 280 people received key working and psychosocial supports from ALDP in 2020. In addition, supported by the Health Service Executive and the Mid-Western Regional Drug and Alcohol Task Force, ALDP became the only provider of a needle-exchange programme in Limerick and much of the Midwest in 2020. Working throughout the year, during the three waves of Covid-19, ALDP met clients face-to-face, with 340 people accessing Midwest region needle-exchange services in 2020.

1. Ana Liffey Drug Project (2021) Ana Liffey Drug Project annual report 2020. Dublin: Ana Liffey Drug Project.
   https://www.drugsandalcohol.ie/35046/

O’Callaghan D and Lambert S (2022) Journal of Substance Abuse Treatment, Early online.
https://www.drugsandalcohol.ie/35544/

This paper explores the impact of the COVID-19 pandemic on health care professionals who support clients experiencing addiction.

This paper highlights some areas of concern to address for future service delivery and presents opportunities to future-proof services as the world moves toward hybrid models of working. The inflexibility of service provision during the pandemic and the digital divide due to public health measures pushed marginalized groups further into the margins, with significant implications for practitioner occupational well-being due to feelings of anxiety, powerlessness, and concern for mortality of clients. This study collects a broad scope of experiences across disciplines in health care and demonstrates how professionals navigated unprecedented circumstances.

Giulini F, Keenan E, Killeen N and Ivers J-H (2022) Journal of Psychoactive Drugs, Early online.
https://www.drugsandalcohol.ie/35539/

A systematized review of the literature regarding drug checking (DC) methods and testing locations, advantages and disadvantages, and legal frameworks with an emphasis on HR [harm reduction] was conducted referencing PRISMA guidelines.

The results suggest using multiple drug checking methods to be most beneficial. Further, DCS [drug-checking services] and the personalized interventions they provide can positively influence behavior change, minimize harm, and reduce mortality. DCS are a viable public health intervention that requires cross-sector support beyond the legal frameworks and testing methods. Services will need to be tailored to meet the needs of their chosen setting, local drug market, and target audience.

Doody E, Malone A, Gallagher B, Hopkins K, Weir D, Nolan M, Kowalska-Beda P and Naughton M (2022) Irish Medical Journal, 115(1): 516–524.
https://www.drugsandalcohol.ie/35530/

We describe a clinical audit on alcohol detoxification using NICE clinical guidelines as a comparable standard.

The results of this audit indicate that adherence to defined clinical standards within this mental health service exceeds that of the benchmark POMH-UK [Prescribing Observatory for Mental Health-UK] data. The effectiveness of electronic patient records in improving adherence to set clinical standards, specifically in relation to documentation of clinical parameters is evident. The report also confirms continued improved results with each audit cycle within the service.

Moriarty F, Bennett K and Fahey T (2022) Pharmacology Research & Perspectives, 10(1): e00899.
https://www.drugsandalcohol.ie/35446/

This study aims to characterize changes in opioid and other analgesic prescribing in Ireland over a 15-year period (2000-2015). This is a repeated cross-sectional study of administrative pharmacy claims data in 2000 and 2015. Individuals of all ages in Ireland’s Eastern Health Board region who were eligible for the General Medical Services (GMS) scheme were included. This scheme covers 40% of the population, mostly those on lower incomes and older people.

The primary outcome was dispensing of opioids, both prevalence of any use and rate per 1000 GMS eligible population (standardized to the 2015 population). Increased prescribing of opioids, particularly strong opioids, between 2000 and 2015 is evident in Ireland. This is concerning due to the potential for misuse, and opioid-related morbidity/mortality.

Armstrong PR, Ring E and MacNicholas R (2022) European Journal of Gastroenterology & Hepatology, Early online.
https://www.drugsandalcohol.ie/35445/

The aim of the study was to identify the epidemiological profile, temporal trends, development of complications and mortality arising from inpatient care episodes linked to ALD in Ireland from 2007 to 2016.

Ireland is seeing a rise in ALD-related hospital admissions and deaths, including HCC [hepatocellular carcinoma] which increased three-fold. ALD is a preventable disease, and public health interventions are of proven benefit and required to reverse this trend.

Richards GC, Aronson JK, MacKenna B, Goldacre B, Hobbs FDR and Heneghan C (2022) Drug Safety, 45: 237–247.
https://www.drugsandalcohol.ie/35572/

This study aimed to assess national sales and expenditure trends of over-the-counter codeine-containing products purchased in countries with available data over 6 years.

In many parts of the world, substantial numbers of people may be purchasing and consuming codeine in over-the-counter products. Clinicians should ask patients about their use of over-the-counter products, and public health measures are required to improve the collection of sales data and the safety of such products.

Mahon C, Fitzgerald A, O’Reilly A and Dooley B (2022) Irish Journal of Psychological Medicine, Early online.
https://www.drugsandalcohol.ie/35502/

This study aimed to identify risk and protective factors for mental health across student cohorts to guide mental health provision.

In this sample of students, undergraduates, especially those attending Institutes of Technology, were at increased risk of mental health difficulties. Findings suggest the need to tailor interventions to meet cohort needs, and consider the differing vulnerabilities and strengths across student cohorts. Due to limitations of this study, such as selection bias, further research is warranted.

Lynn E, Cousins G, Lyons S and Bennett KE (2022) Journal of Affective Disorders, 306: 80–89.
https://www.drugsandalcohol.ie/35890/

This study aims to assist in understanding how individual and social contextual factors, and specific drugs, influence risk of suicide compared to non-suicide drug poisoning deaths, and how this differs by sex.

Ongoing monitoring for signs of suicidal intent in individuals with mental illness, chronic pain, overdose, and/or prescribed mental health medications may identify individuals in need of additional intervention.

Corey J, Lyons J, O’Carroll A, Stafford R and Ivers J-H (2022) International Journal of Environmental Research and Public Health, 19(6): 3219.
https://www.drugsandalcohol.ie/35804/

This scoping review aimed to explore the impacts of the COVID-19 pandemic on the health and well-being of persons experiencing homelessness (PEH) in North America and Europe.

Numerous health impacts of the pandemic on PEH were identified, including SARS-CoV-2 infection, morbidity, mortality, and hospitalisation, fear of infection, access to housing, hygiene, PPE [personal protective equipment], food, as well as mental health, substance use, other health-related outcomes and treatment services. Gaps in the literature relating to persons using alcohol, access to mental health support, and violence were also identified. Implications for future research are discussed.

Dockray S, Whelan E, Dick S, Davoren M, Heavin C, Linehan C and Byrne M (2022) Irish Journal of Psychological Medicine, Early online.
https://www.drugsandalcohol.ie/35772/

The aim of this scoping review was to determine factors that contribute to student motivations to reduce or stop their use of illicit substances, and to elaborate on factors that may be pertinent for student-focused behaviour change interventions for substance use.

Few studies have examined motivations of third-level education students to decrease or cease substance use. Promising avenues for research on motivations to change substance use behaviour include the social contextual factors, perceived effects on social relationships, and actions of friends and family to prompt contemplations of change.

Carbia C, García-Cabrerizo R, Cryan JF and Dinan TG (2022) Alcohol and Alcoholism, 57(2): 211–218.
https://www.drugsandalcohol.ie/35897/

The objective of this study was to characterize changes in alcohol use during lockdown in Ireland and associations with drinking motives and psychopathological symptoms.

Older adults who drink to cope – mainly with depression symptomatology – are an important at-risk population, in line with predictions from alcohol self-medication frameworks. Future research is needed to incorporate strategies into the public mental health ecosystem.

Coll S, Walsh ME, Fahey T and Moriarty F (2022) Research in Social & Administrative Pharmacy, 18(4): 2670–2674.
https://www.drugsandalcohol.ie/35931/

This study aims to examine factors associated with continuation of hospital-initiated benzodiazepine receptor agonists (BZRAs) among adults aged ≥65 years, specifically instructions on hospital discharge summaries.

Improved communication to GPs after hospital discharge may be important in avoiding long-term BZRA use.

O’Brien N, Quinn N, Joyce B, Bedford H and Crushell E (2022) BMJ Paediatrics Open, 6(1): e001368.
https://www.drugsandalcohol.ie/35896/

A retrospective review was performed of homeless children attending a paediatric emergency department in Dublin, Ireland, from 1 January 2017 to 31 December 2020. Despite increasing prevalence, European family homelessness remains under-researched.

Infants, Irish Travellers, Roma and black ethnicities were over-represented in homeless presentations. Homeless children had increased reliance on emergency services for primary healthcare needs.

Hartnett Y, Alshurafa K, McAndrew J, et al. (2022) Irish Journal of Psychological Medicine, Early online.
https://www.drugsandalcohol.ie/35915/

This study aims to examine the impact of the first full year of the COVID-19 pandemic and its associated restrictions on the volume and nature of psychiatric presentations to an emergency department (ED) in a large academic hospital.

Psychiatric presentations to the ED have increased during the first year of the COVID-19 pandemic in contrast to a decrease in presentations for other medical specialties, with this increase being driven by out-of-hours presentations. The fourfold increase in presentations of young people below the age of 18 years to the ED with mental health difficulties is an important finding and suggests a disproportionate burden of psychological strain placed on this group during the pandemic.

Tanner B and Doherty AM (2022) Crisis, 43(2): 149–156.
https://www.drugsandalcohol.ie/35774/

This study aimed to establish the prevalence and correlates of suicidal ideation (SI) and self-harm (SH) among Irish Travellers.

Travellers were more commonly diagnosed with depression or substance abuse, referred from critical care, and transferred for inpatient psychiatric treatment. Limitations include the use of retrospective data from a service activity database rather than clinical information collected prospectively. There are significant differences in patterns of suicidal behaviors between Irish Travellers and the general population. Further research is required to understand and address the high rates of suicidal behaviors in this population.

Kavalidou K, Daly C, McTernan N and Corcoran P (2022) Research Square, Early online.
https://www.drugsandalcohol.ie/35870/

The aim of the current study was to compare the incidence of hospital-presenting self-harm and suicide-related ideation of Travellers to non-Traveller patients and describe any ethnic disparities in the aftercare of their presentation.

Given that Irish Travellers are at higher risk of suicide-related hospital presentations, compared to other ethnic groups in Ireland, EDs [emergency departments] should be viewed as an important suicide intervention point.

Hamilton C (2022) European Journal of Criminology, Early online.https://www.drugsandalcohol.ie/35769/

This country survey examines: the core Irish criminal justice institutions; basic trends in crime and punishment over the last 50 years; and critical junctures in the debate over law and order in recent decades. Using an earlier country survey by O’Donnell (2005a) as a baseline, it charts the significant growth of the discipline of criminology within Ireland.

The article argues that Irish criminal justice retains a distinctively local flavour and highlights the promise of Irish criminology in many key areas of contemporary interest.

Hayes CB, Patterson J, Castello S, Burke E, O’Connell N, Darker CD, et al. (2022) Nicotine & Tobacco Research, 24(4): 564–573.
https://www.drugsandalcohol.ie/35773/

We Can Quit (WCQ) is a community-based stop-smoking program delivered by trained community facilitators, based on the socio-ecological framework and developed using a Community-based Participatory Research approach, targeting women living in socioeconomically disadvantaged (SED) areas of Ireland. The We Can Quit2 (WCQ2) pilot trial assessed the feasibility of WCQ.

This pilot trial showed that a stop-smoking intervention tailored to a group of women smokers living in SED areas which was delivered by trained local women within their local communities was feasible. Furthermore, although not formally compared, more WCQ women were abstinent from smoking at the end of treatment. The results are relevant to enhance the design of a fully powered effectiveness trial, and provide important evidence on the barriers to deliver a tailored smoking cessation service to SED women smokers in Ireland.

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, 2022

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