The HRB published the latest figures from the National Drug-Related Deaths Index (NDRDI) in December 2017.¹ The new bulletin presents an overview of trends due to poisoning (overdose) by alcohol and/or other drugs, and deaths among drug users (non-poisoning) in the period 2004–2015 (Figure 1).

In the context of rising drug-related deaths, and an increasingly vulnerable ageing cohort of people with drug problems,¹ what does the evidence tell us about keeping people safe?

This was the question posed for a rapid evidence review by NHS Scotland² to inform a conference held by the Scottish Government along with the Partnership for Action on Drugs in Scotland (PADS) in July 2017 entitled ‘Drug Policy through a Health Lens’.

Methodology

The report provided a combination of findings from the evidence based on the critical appraisal of systematic reviews and grey literature reports.

Findings

The evidence was divided into three categories listed as follows:

• Seek — engagement and access to services
• Keep — characteristics of treatment and support
• Treat — benefits of treatment

Recent research published by HIV Ireland examined national HIV knowledge and attitudes and the stigma associated with HIV.¹ HIV Ireland is a registered charity operating at local, national and European levels. The principal aim of the organisation is to contribute towards a significant reduction in the incidence and prevalence of HIV in Ireland and towards the realisation of an AIDS-free generation. The present study involved the development of two surveys. The first survey aimed to measure knowledge and attitudes among the general Irish population. The second survey measured stigma and the experiences of those living with HIV. Subjects were required to be 18 years of age or older and the surveys were completed by 1,013 and 168 respondents, respectively.

Ireland’s current drugs strategy emphasises a health-led response to drug use in Ireland.¹ Consistent with this focus, a pilot supervised injecting facility (SIF) will open in 2018 in Dublin city centre. As Ireland moves towards implementation of the country’s first SIF, information with regard to public injecting among drug users in Dublin’s inner city is important. A 2017 report from the Ana Liffey Drug Project (ALDP) examined street-based injecting in Dublin  city centre.²

Merchants Quay Ireland (MQI) is a national voluntary agency providing services for homeless people and drug users. There are 19 MQI locations in 12 counties in the Republic of Ireland. In September 2017, MQI published its annual review for 2016.¹ MQI aims to offer accessible, high-quality and effective services to people dealing with homelessness and addiction in order to meet their complex needs in a non-judgmental and compassionate way. This article highlights services provided by MQI to drug users in Ireland in 2016.

Open access services

Assertive Outreach Service (AOS)

In line with the MQI mission statement to reach out to the most vulnerable in society, this service aims to make contact with drug users not engaged with other services and to provide them with accessible support options. The geographical zone covered by the AOS is predominantly around each MQI location (Figure 1). Clients are assisted with clothing, food and drug treatment options. The service engaged with 116 individuals in specific casework, and with over 1,000 individuals on an informal support basis, throughout 2016.

The 15th annual report from National Self-Harm Registry Ireland was published in late 2017.¹ The report contains information relating to every recorded presentation of deliberate self-harm to acute hospital emergency departments in Ireland in 2016 and complete national coverage of cases treated. All individuals who were alive on admission to hospital following deliberate self-harm were included, along with the methods of deliberate self-harm that were used. Accidental overdoses of medication, street drugs or alcohol were not included.

There are currently in excess of 10,000 opioid-dependent patients receiving substitution therapy in Ireland,¹ with the majority of those attending detoxification receiving methadone. Given the weak evidence base with regard to the efficacy of detoxification, many clinicians opt to continue substitute-prescribing or may even dissuade opioid-dependent persons from detoxifying.

A small number of international studies have examined problem drug users in detoxification treatment. Follow-up studies have noted discernible reductions in heroin use as well as significant reductions in criminality, psychopathology, and injection-related health problems following treatment exposure.^2,3,4 Nevertheless, the majority of these studies are limited to two time points and fail to take into account longitudinal changes. Importantly, no studies to date have focused on aftercare post-detoxification.

A national cohort study published online in Heroin Addiction and Related Clinical Problems aimed to describe characteristics of methadone-related overdose deaths in Ireland and to compare deaths occurring among those registered for opioid agonist treatment (OAT) with deaths among those not registered.¹ OAT involves the use of drugs such as methadone or buprenorphine to reduce cravings and withdrawal symptoms among those addicted to opioids such as heroin.

It is well established that OAT, including methadone substitution therapy, can reduce deaths among problem opiate users. However, OAT is also associated with a risk of accidental overdose, as patients can experience lowered tolerance for opioids following a period of abstinence. Individuals completing detoxification, leaving prison, or exiting OAT may therefore be especially vulnerable to accidental death by overdose. Previous research in Ireland found that people treated with methadone were nearly four times more likely to die in periods off treatment than in periods on treatment.²