Welcome
Twenty years of the Methadone Treatment Protocol
by Suzi Lyons
 

In recognition of the 20-year anniversary of the Methadone Treatment Protocol in 2018, the Irish College of General Practitioners (ICGP) has brought together a series of reflections of their Substance Misuse Programme.1 This comprises articles and extracts from Forum, the journal of ICGP, summaries of ICGP publications, pictures, and personal reflections from doctors and patients.


In recognition of the 20-year anniversary of the Methadone Treatment Protocol in 2018, the Irish College of General Practitioners (ICGP) has brought together a series of reflections of their Substance Misuse Programme.1 This comprises articles and extracts from Forum, the journal of ICGP, summaries of ICGP publications, pictures, and personal reflections from doctors and patients.

 

Context to the Methadone Treatment Protocol in Ireland

Fifty years ago, the first Working Party on Drug Abuse was established in Ireland, after which came a series of committees leading to the introduction of the Misuse of Drugs Act, 1972. By 1983, an escalation of problem opiate use was apparent, particularly in relation to injecting drug use and the risk of HIV, prompting a response from health professionals and authorities. In 1989, Professor Gerard Bury wrote that:

General practice has much to offer in the care of drug misusers. The unique relationship between many GPs and their patients is an important resource in educating and motivating misusers to change their pattern of use. This is particularly important with respect to high-risk practices for the transmission of HIV. (p. 5)2

 

From L to R: Fintan Foy, Dr John O’Brien, Minister Catherine Byrne TD, Dr Íde Delargy, Senator Lynn Ruane and Professor Sir John Strang at an event in the Royal Irish Academy marking the 20-year anniversary of the Methadone Treatment Protocol

By 1991, the role of general practitioners (GPs) in providing methadone treatment was cemented in the Government strategy to prevent drug misuse, which highlighted the role of GPs in the community for caring for problem drug users.3

 

ICGP substance misuse programme: the first two decades

When the Methadone Treatment Protocol was introduced in 1998, it brought about a change in practice; for example, methadone replaced Physeptone as the choice of opiate substitute. There was a significant amount of cooperation and work needed between all partners to get the programme started, which was initially limited to the Greater Dublin Area. Since then, the number of clients receiving methadone both in clinics and with GPs has expanded greatly.

 

Dr John Latham, writing for Forum in March 2018, said of the methadone protocol:

 

Twenty years on, the Opioid Protocol remains a remarkable system of life-saving, health-enhancing, public health positive care in the community. The protocol has ensured that this care is now available to about 10,000 patients nationwide. Practice has changed with regard to frequency and observation of urine sampling and I hope in future there will be more emphasis on encouragement and safe care for those wishing to detox and become drug-free. (p. 15)

 

The ‘Education and innovations through the years’ section showcases the education and training developments over the past 20 years in the ICGP related to substance misuse. ‘Reflections on 20 years of the Methadone Treatment Protocol in Ireland’ is a collection from professionals and clients on the overall success of the programme, two of which are reproduced below:

 

It’s been extraordinarily helpful. I don’t want to be on it forever but certainly as I become more and more stable and I am able to benefit from the support structures I have as a result of that stability.

Anonymous client (p. 28)

 

The implementation of the Methadone Treatment Protocol in 1998 represented the most radical abandonment of such negative ideas about the possibility of normalizing addiction treatment, … building in a variety of safeguards for doctors, their patients and the community at large in a clever piece of legislative action in an unusually complex policy arena. Credit for the Methadone Protocol, it seems to me, should be shared amongst several stakeholder groups: from the early-1990s onwards, Dublin GPs who had worked responsibly (and without much thanks) with drug users were joined by a new cohort of GPs who had experience of this kind in the UK; the voluntary harm reduction agencies (chiefly the Ana Liffey Project and Merchants Quay Ireland) played a helpful role; and, as already indicated, some Department of Health officials were crucial to this process.

Dr Shane Butler, Emeritus Fellow, Trinity College Dublin (p. 30)

 

Professor Sir John Strang (left) and Dr Eamon Keenan at the Methadone Treatment Protocol event in the Royal Irish Academy

 

Proven successful model of managing chronic disease – where to from here?

The editors of the publication point to the key role that GPs will continue to have in identifying and caring for patients with addiction problems, highlighting the ongoing problems of alcohol, benzodiazepine and over-the-counter codeine misuse in addition to opiate problems. In primary care, there is the opportunity to normalise addiction treatment and reduce the stigma of opiate substitution treatment, particularly as a long-term treatment. Although much has been achieved over the past two decades, there remain significant challenges; for example, waiting times in parts of the country, lack of choice of opiate substitution medication for patients, and poor patient experiences in relation to service provision. The editors recommend the full implementation of the recommendations of the external review of the protocol, conducted by Professor Michael Farrell and Professor Joe Barry in 2010.4

1   Delargy I, Doran G and Patton P (eds) (2018) 20 years of the Methadone Treatment Protocol in Ireland. Dublin: Irish College of General Practitioners. https://www.drugsandalcohol.ie/29872/

2   Bury G (1989) Drug problems in Dublin. The Practitioner, 233: 1486–89. https://www.drugsandalcohol.ie/6704/

3   National Co-ordinating Committee on Drug Abuse (1991) Government strategy to prevent drug misuse. Dublin: Department of Health. https://www.drugsandalcohol.ie/5108/

4   Farrell Ml and Barry J (2010) The introduction of the opioid treatment protocol. Dublin: Health Service Executive.

https://www.drugsandalcohol.ie/14458/

In brief

The Report of the rapid expert review of the National Drugs Strategy 2009−2016 noted that one of the key features of that strategy was the strong role of community organisations in both strategy development and delivery. This role is maintained in the current strategy, and community and voluntary services are partners with the statutory section in delivering the interventions that drive the strategy.

 

The rapid expert review also observed that coordination between local, regional and national levels became less effective over time. While the review team frequently observed good practice at the local level, blurred communication impeded the task of making this good practice systemic and also made roles and responsibilities less clear. There are several practical reasons for supporting the role of community-based organisations (CBO), defined in the literature as not-for-profit civil society organisations with particular governance structures and whose strategic objectives are developed in consultation with community stakeholders. CBOs providing, or coordinating, services to socially excluded groups play an important role in the delivery of health programmes. United Nations/World Health Organization documents and strategies frequently emphasise the role of CBOs in health activities and the need to strengthen intersectoral collaboration and increase participation in decision-making around health strategies. 

 

The recent National Drugs Forum provided an opportunity for CBOs and other organisations to highlight the work that they are doing and to share knowledge with others. While these kinds of learning opportunities are important, ensuring that evidence is used effectively and that interventions are monitored will need a structured approach with a sound theoretical basis. Supporting the CBO’s use of evidence is an effective way to link research to action in health programmes. One approach to this work is to develop a strategy of community-based knowledge transfer and exchange (KTE). KTE is used as a broad umbrella term for activities which facilitate the use of research evidence in service planning and delivery. Research on this topic identifies four main barriers to the use of research in CBO work: several other factors are involved in decision-making; research evidence is not valued; a lack of available relevant evidence; and the difficulty in using research evidence. Approaches to overcoming these barriers include fostering a culture favourable to the use of evidence; providing evidence that is directly relevant to the work of these organisations; and providing support to them to evaluate the impact of strategies designed to link research to action. Reports on each of the workshops held during the National Drugs Forum are presented in this issue. These reports are a useful reminder of the quality and impact of the work that is being done and also of the particular challenges faced by non-statutory organisations in delivering services.

Policy
National Drugs Forum 2018: reports on workshops
 
From L to R: Dr Brigitte Manteuffel of the Georgia Health Policy Center; Minister Catherine Byrne TD; Dr Darrin Morrisey, chief executive of the Health Research Board; and Dr Karen Minyard, director of the Georgia Health Policy Center, at the National Drugs Forum
From L to R: Dr Brigitte Manteuffel of the Georgia Health Policy Center; Minister Catherine Byrne TD; Dr Darrin Morrisey, chief executive of the Health Research Board; and Dr Karen Minyard, director of the Georgia Health Policy Center, at the National Drugs Forum

One of the aims of the first National Drugs Forum was to provide an opportunity for community-based services to inform colleagues about their work, to exchange knowledge around what works, and to identify information gaps. The workshops were a recognition the dynamism and commitment of these services.

 

They were designed to enable shared learning and encourage discussion among practitioners, activists and administrators who face similar challenges. The forum appointed a rapporteur to each workshop and a brief report on each workshop was presented at the final plenary session. The rapporteurs’ final reports are presented below.


One of the aims of the first National Drugs Forum was to provide an opportunity for community-based services to inform colleagues about their work, to exchange knowledge around what works, and to identify information gaps. The workshops were a recognition the dynamism and commitment of these services.

 

They were designed to enable shared learning and encourage discussion among practitioners, activists and administrators who face similar challenges. The forum appointed a rapporteur to each workshop and a brief report on each workshop was presented at the final plenary session. The rapporteurs’ final reports are presented below.

 

Each report presents an overview of each presentation, including some key issues raised in the discussion after each presentation.

 

More details on the content of the presentations are available through the slide packs available at: https://www.drugsandalcohol.ie/php/ndfabstracts.php

 

WORKSHOP 1: Supporting prevention work in the community

 

Planet Youth

Michéal Durcan, Western Region Drug and Alcohol Task Force (WRDATF)

 

Planet Youth is an evidence-based approach to preventing children and adolescents from initiating drug use. The model originated in Iceland and has been rolled out in communities in 18 countries to date. A dramatic decrease in substance use among Icelandic adolescents since 1997 has been attributed to this model. In the 1990s, a group of Icelandic social scientists, policymakers and practitioners began collaborating in an effort to address the increasing levels of drug and alcohol use among Icelandic young people. The prevention model that emerged involves the regular collection of data from young people through a school-based questionnaire on background factors, substance use, social circumstances, and potential risk and protective factors associated with substance use. The findings are used by local stakeholders to plan and deliver a set of prevention responses. There was a broad range of prevention interventions introduced in Iceland, which involved significant public expenditure, for example, structured high-quality recreational activities for young people and support for families to spend more time together. The impact of the interventions is then measured through regular data collection, interventions amended in response to the findings, and any new issues identified. The outcomes found in Iceland have gone beyond drug and alcohol use and include: lower suicide rates; lower obesity rates; less alcohol use at university age; improved general mental health and wellbeing; improved youth facilities and services; less early school leaving; and, less crime and imprisonment.

 

In association with local partners, WRDATF has committed to supporting the introduction of Planet Youth in parts of the region: the task force has committed to taking the lead on managing the survey and its analysis. Because of the resources required, in collaboration with WRDATF, other agencies (e.g. Tusla and the Health Service Executive) will have to take responsibility for developing the interventions. Data have been collected using the standardised Planet Youth tool with students in transition year in secondary schools across Galway, Mayo and Roscommon. Data collection was successful with 4,600 forms returned from across 83 schools. These are currently being analysed by the team in Iceland and the findings of this baseline survey will be reported on at the end of February 2019.

 

Key points made in the discussion:

  • There is a need to ensure that interventions from the Planet Youth model are adapted so that they are culturally appropriate. For example, the curfews imposed in Iceland would not be appropriate in the Irish context.
  • The funding structure in Iceland allows for taxes collected locally to be spent locally. An innovative and clever approach to resourcing the project in the western region will be required.
  • There are good relationships with sporting clubs and facilities in the western region that could be supported to develop innovative interventions.
  • Innovative approaches will be needed to engage with parents. Parents who attend regularly can help build capacity within the community.
  • There needs to be a long-term commitment to this programme: change will take at least a couple of years to bring about.
  • The programme would benefit from establishing a formal mechanism through which young people could contribute to the development of initiatives and the programme as a whole.

From L to R: Dr Brigitte Manteuffel of the Georgia Health Policy Center; Minister Catherine Byrne TD; Dr Darrin Morrisey, chief executive of the Health Research Board; and Dr Karen Minyard, director of the Georgia Health Policy Center, at the National Drugs Forum

 

Drug-Related Intimidation Reporting Programme: interagency working and supporting families

Aoife Frances, National Family Support Network, and Brian Woods, Garda National Drugs and Organised Crime Bureau

 

The National Family Support Network (NFSN) is a self-help organisation supporting the development of family support groups and networks throughout Ireland. Through its work it raises awareness of the difficulties faced by families in coping with substance misuse, while recognising the important role that families play in supporting the recovery of the person using drugs. NFSN identified the need for a programme to support those experiencing drug-related intimidation and debt. Approximately one-third of the calls for support they were receiving related to these issues.

 

Most calls come from mothers of people who use drugs and who were in debt. In response to this, NFSN worked with the Garda National Drugs Unit (now part of the Garda National Drugs and Organised Crime Bureau) to establish the Drug-Related Intimidation Reporting Programme (DRIRP) in 2013.

 

The purpose of the programme is to respond to the needs of drug users and family members who are experiencing drug-related intimidation. It is a challenging programme and the speakers noted that drug-related intimidation is not an issue that receives much discussion in other European countries. Therefore, there is a lack of knowledge and evidence about how best to set up and run such a programme. Both organisations are undertaking a review of the programme.

 

Key points presented in the workshop:

  • Good positive collaboration between the delivery partners is essential for the success of the programme.
  • Family members are hesitant about approaching the Gardaí in the traditional way for a number of reasons, including fear of reprisal from dealers and that their family member would be arrested given that possession is criminalised.
  • Gardaí are trained through the programme to support the families. An important feature is that people can meet with the nominated Garda Inspector but there is no obligation on the family to make a formal complaint. They can just get support and advice.
  • Staff and client safety are of major concern.
  • The consistency in language that has come from the programme to name ‘intimidation’ is helpful – this has been seen as positive for families and communities.
  • Dealing with drug-related intimidation is a priority in the current policing plan. To back this up, there are new strands of training on drug-related issues under development for Gardaí.
  • The NFSN is planning to deliver a train-the-trainer programme for organisations around the country so that they can work with their local Gardaí on the topic. Additional resources are needed.

 

Key points made in the discussion:

  • While there is a need nationally for services that support those experiencing intimidation, projects do not want to be identified as an ‘intimidation project’ as such. It presents too many risks for staff and clients/participants.
  • Ongoing cuts in funding for community projects put communities at increased risk.
  • Initiatives such as DRIRP need careful evaluation; there is a need to look at how they coordinate with communities in particular.
  • Resources need to be made available to provide the services and make the necessary changes in response to the findings of any evaluation/research.
  • The requirement of any community programme, such as the Social Inclusion and Community Activation Programme (SICAP), to ask for participants’ names and supporting information was described as a ‘disaster’. It prevents people who are experiencing intimidation from accessing services.

Professor Harry Sumnall of Liverpool John Moores University speaking at the National Drugs Forum

 

 

The Let’s Learn About Drugs and Alcohol Together (LLADAT) programme

Sancha Power, Health Service Executive

 

Let’s Learn About Drugs and Alcohol Together (LLADAT) is an alcohol awareness and drug education programme aimed at second-year senior cycle students and their parents in the Mid-West. It is designed to support the existing work being carried out in schools through Social, Personal and Health Education (SPHE) and the new Wellbeing programme. It sets out to engage parents in shared dialogue around substance use through two workshop sessions that are held during out-of-school hours. The first workshop is just for parents; the second for parents and pupils. The presenter noted that it is ‘hard to evidence education and prevention initiatives’; therefore, to illustrate the success of the programme she reported on, for example, positive relationships with participants and the ongoing interest of schools in the programme. Among the strengths of the programme identified were that it takes a multimodal approach, it encompasses the family, and supports what is already being delivered in schools.

 

Key points made in the discussion:

  • The programme is not available to be delivered elsewhere at the moment.
  • There were some concerns about the programme covering solvent use – that this may encourage its use in a context where they were no longer widely used. However, the presenter noted that their use was evident in the area of delivery.

 

Design and implementation of a pilot programme to reduce student drinking: Responding to Excessive Alcohol Consumption in Third-level (REACT)

Susan Calnan, University College Cork

 

High levels of alcohol use have been found among third-level students in Ireland. In 2014, the Health Service Executive (HSE) commissioned a research team to develop a public health intervention to address alcohol use among third-level students. Responding to Excessive Alcohol Consumption in Third-level (REACT) was developed in collaboration with the Health Matters team at University College Cork, the Irish Student Health Association, and the Union of Students in Ireland (USI). Its development followed a three-step process: systematic review, knowledge exchange forum, and expert consultation. The programme is an environmental rather than an educational initiative; as such it takes a settings approach rather than focusing on the individual. Therefore, it is focused on bringing about change in the culture, processes and policies of the university in relation to alcohol use. For example, the presenter mentioned interventions such as offering alcohol-free student accommodation and social spaces. REACT is currently being implemented in 15 higher education institutions across Ireland.

 

While the programme’s evaluation has not yet been completed, the presentation covered a range of preliminary findings from the process element of the evaluation and the work with students.

 

Key points presented in the workshop:

  • The majority of students who were engaging in hazardous drinking defined their own drinking as low risk – indicating low levels of awareness of own drinking among students.
  • In terms of concerns about their own drinking, ‘spending too much money on alcohol’ emerged as the biggest concern for students and ‘negative impact on physical health’ as the second biggest.
  • A ‘considerable proportion’ of the students saw the control of alcohol consumption as their personal responsibility rather than that of the third-level institution they are attending.

 

Key points made in the discussion:

  • The need to have someone championing a programme such as REACT was highlighted; programmes need someone to take ownership for it to move forward.
  • A settings approach to prevention such as that demonstrated by REACT was welcomed. It was suggested elsewhere that communities have a key role in delivering on prevention in their areas.
  • It was suggested that it was not a matter of personal responsibility versus institutional responsibility when addressing hazardous drinking, rather it should be a combination of both.

     

WORKSHOP 2: Dual diagnosis: using partnership and peer support as resources in treatment

 

Dual Diagnosis: a community-led response

Jennifer Clancy, Clondalkin Drug and Alcohol Task Force

 

The Drug and Alcohol Task Force Treatment and Rehabilitation subgroup had become aware of a higher number of more complex dual diagnosis cases, with little or no interagency casework. Initial meetings with the Community Mental Health Team took place in August 2014.

 

A social worker and clinical nurse manager joined the subgroup, and as part of the implementation of the National Drug Rehabilitation Framework, training on substance misuse issues and responses was delivered to mental health staff, and training on mental health issues and responses was delivered to substance misuse staff. This led to the establishment of an interagency Dual Diagnosis working group.

 

The working group gathered baseline data; identified barriers to developing care pathways; training needs; gaps in services; and formalised relationships between services. Documents to formalise shared care were developed and a case management approach agreed.

 

The outcomes of this approach were that there was a reduction in the duplication of services; integrated care pathways were developed; better understanding of different services’ roles; reduction in hospital stays; utilisation of standardised assessment tools; and the provision of Wellness Recovery Action Plan (WRAP) as part of general substance misuse service provision.

 

 

Miriam Coffey of the North Inner City Drugs and Alcohol Task Force, who attended the National Drugs Forum in November 2018

 

 

The establishment of a ‘seeking safety’ group in the National Drug Treatment Centre for supporting patients’ substance dependence and a history of trauma

Siobhan Rooney and Ruth Anne Buckley, Health Service Executive

 

‘Seeking safety’ is a manualised, evidenced-based treatment for post-traumatic stress disorder/trauma and substance misuse, utilising cognitive behavioural therapy and psychoeducational approaches that are problem–solution oriented and can be applied in groups or in one-to-one sessions. The process commenced with staff training in the approach, with an advertisement for the planned group placed on the notice board in the National Drug Treatment Centre.

 

Sessions commenced by checking in with each participant, and continued with a quotation and handout from the manual. The objective is to engage with the client emotionally, provide a point of inspiration, and to relate the handout subject matter to the clients’ lives, with rehearsals of coping skills, role play, and discussions. Participants’ feedback was positive, with improvements in self-esteem, confidence, assertiveness, and with the course described by participants as practical and straightforward.

 

Elements considered important were peer support, the social aspect, lack of exclusion criteria, the ability to miss sessions and rejoin without requiring a catch-up, and peer learning.

 

 

Minister of State with responsibility for Health Promotion and the National Drugs Strategy, Catherine Byrne TD, giving the closing address at the National Drugs Forum

 

 

Addressing dual diagnosis within a residential treatment programme serving women with complex needs

Anita Harris, Coolmine Therapeutic Community

 

The women’s residential service in Coolmine had identified a need for dual diagnosis supports, given that dual diagnosis was associated with higher dropout rates, lower psychological health, and high rates of prescribed medication to deal with the management of emotions.

 

The intervention was a mental healthcare plan, devised and coordinated by a visiting consultant psychiatrist, and delivered by both substance misuse and mental health staff, alongside the existing addiction treatment of the therapeutic community. The approach involved was psychoeducational, with a resistance to prescribing psychotropic medication for the first six weeks.

 

Features included reduced barriers to appropriate care, faster access to mental health services, an interagency approach, and integrated care planning. Outcomes included reduced medication, improved retention rates, improved family dynamics, reduced hospital emergency attendances, and improved mental health.

 

Dual diagnosis: emotional regulation skills training in Keltoi

Peter Sherry and Ruth Anne Buckley, Health Service Executive

 

The development of an emotional regulation skills approach to substance misuse is based on the viewpoint that substance misuse is viewed as self-soothing behaviour. This is further complicated by the relationship between trauma and substance misuse. Various examples were presented from the literature to evidence this.

 

Emotional regulation incorporates individuals’ attempts to manage emotionally charged states, including anxiety, low mood, depression, stress and post-traumatic stress disorder. Keltoi staff observed hyper (hypervigilance, impulsivity and anger) and hypo (depression and disassociation) arousal states in clients, and conducted qualitative research in relation to the use of emotional regulation.

 

The emotional regulation skills training included use of the ‘Window of Tolerance’ approach, mindfulness, cognitive behavioural therapy, and coping strategies. The evaluation indicated that participants developed an ability to identify and discuss their emotions, increased their self-esteem, self-regulation, normalised their emotions, and increased their quality of life.

 

Key aspects were considered to include the ability to deliver the intervention in groups or as one-to-one; the ability to deliver the intervention to clients at various stages of their recovery; peer support; free staff training; dual use as a staff self-care tool.

 

Commonalities:

  • Data: The four interventions/initiatives were able to identify the negative impact of not responding effectively to dual diagnosis, which bolstered their arguments for commencing their initiatives.
  • Vision: Each had a model or intervention approach that they were able to describe clearly to their potential partners.
  • First steps: Each were clear on what they were able to start with, were able to then learn from their experiences, and develop further positive working relationships with partners from those initial experiences.

 

WORKSHOP 3: The role of social reintegration in recovery

 

Social enterprise and co-production: a synergy-promoting social reintegration

Paul Delaney, The Cornmarket Project, Wexford

 

The Cornmarket Project is an interagency community-based treatment and rehabilitation project under the auspices of Wexford Local Development. The project works with clients in recovery from substance addiction to promote a stable and productive lifestyle. The social enterprise and co-production initiative is a major plank of the portfolio of services provided by the Cornmarket Project. The social enterprise and co-production initiative works with clients in recovery from substance addiction to improve their chances of moving to employment. The initiative grew from the Community Employment Drugs Rehabilitation scheme, which was a national initiative to promote vocational training and employment for clients in recovery. The social enterprise initiative designs t-shirts and bags and a wide range of paraphernalia that are used at conferences and other social events. The initiative has been recognised as an example of good practice and was awarded a place on the Social Innovation Fund’s social enterprise development accelerator programme 2018. An innovative feature of the social enterprise initiative is that participants receive a job reference to enable them to improve their chances of securing other employment opportunities.

 

Clients working with the social enterprise initiative can also avail of working with the Change Outcome and Impact Measurement (COAIM) system, which forms a major part of the work in the Cornmarket Project overall. The COAIM system is focused on client assessment and progression and works with clients to improve their quality of life in 10 domains, including offending behaviour; accommodation; pro-social activities; anger and emotion management; attitudes and cognitive style; drug and alcohol misuse; lifestyle and associates; relationships and family issues; training and employability; and financial issues and debt. Data presented at the workshop suggest that clients achieved positive change in nine of the 10 domains; positive changes to accommodation status were less pronounced for clients, which are likely to be influenced by the shortage in accommodation options on a national basis.

 

Key points presented in the workshop:

  • Co-production is not just a word, not just a concept, it is a meeting of minds coming together to find a shared solution. In practice, it involves people who use services being consulted, included, and working together from the start to the end of any project that affects them.
  • Projects are strengthened when the focus is on measuring outcomes for clients rather than outputs for services.
  • Projects need to recognise and understand the lived experience of people in recovery and offer them a holistic and integrated suite of services to meet their needs as they present.
  • The quality of life indicators included in the COAIM system could be used by other services to assess progression and positive change in outcomes for clients.

 

Parents Under Pressure programme working with high-risk families in recovery from substance addiction

Emma Timmins, Parents Under Pressure programme

 

The Parents Under Pressure (PUP) programme is primarily delivered in the residential setting of Ashleigh House, which is run by the Coolmine Therapeutic Community as part of the suite of services provided to clients in recovery from substance addiction. Ashleigh House is a residential therapeutic community for women, expectant women, and mothers with young children, and is designed to help women in recovery develop the skills they need to live a drug-free independent life. Ashleigh House is the only mother-and-child residential treatment programme in Ireland. The PUP programme was designed in Australia to cater for the needs of high-risk families, including families with parents in recovery for substance misuse. The programme recognises that parents who are receiving treatment for substance use quite often experience difficulties coping with other areas of life, such as family functioning, child behaviour problems, and mental health difficulties. The programme includes 12 core modules that are manual based and combine psychological principles with a case management model; it is delivered over a 20-week period. The programme is an assets-based intervention and promotes the development of empowerment and resilience in the target group.

 

The workshop heard that the PUP programme was introduced to the women in recovery in Ashleigh house when staff identified a gap in service provision. Staff noticed that although the women were making progress in their recovery, for some of them it was difficult to develop an emotional attachment to their children. Their difficulties in forming these emotional attachments mainly stemmed from their feelings of guilt around letting down their children when they were in active addiction. These feelings of guilt were often exacerbated by their feelings of anxiety and depression, which staff believed, if left untreated, could undo a lot of the progress they were making on other matters. The main results from a recent evaluation of the PUP programme in Ashleigh House were cited in the workshop, and reported that women experienced reductions in depression, anxiety and stress when measured as part of the before-and-after assessments when the programme was introduced.

 

Key points presented in the workshop:

  • The PUP programme provides an opportunity for the women to engage in incremental learning, which means they have the chance to move at their own pace.
  • A key mechanism of the programme is when the women accept that they do not need to be a perfect parent; a good enough parent will suffice, and being recognised as a parent is invaluable to the women.
  • Women engaged in the programme build their own sense of belief through their efforts to become better parents, and the sharing of this belief with other women spreads the collective impact for many.
  • The PUP programme has also been delivered through the day service recovery programme in Coolmine, and retention in the day service delivery is sometimes higher than that achieved in the residential setting.
  • In some cases, the fathers of the children are also engaging with the PUP programme.
  • The PUP programme provides the women with an opportunity to identify and develop their strengths as parents – vital to sustaining their progress and recovery.

 

Recovery coaching as a mechanism to build recovery capital

Paul Duff, Recovery Academy Ireland

 

Recovery Academy Ireland primarily comprises people in recovery from substance addiction and includes their supporters, advocates, researchers, and professionals who want to promote and champion the concept of recovery. The key objective of the academy is to create a community for those in recovery and give them, their families, and allies a voice and a vision of hope for the future. The Recovery Academy is instrumental in developing and supporting ‘recovery coaches’ to mentor and give practical assistance to people in early recovery. A recovery coach is someone who has established and sustained their own recovery, has completed a training course in recovery coaching, and is committed to promoting recovery in the community and making recovery an attractive option.

 

The core training course for recovery coaches is run over five days and involves talks and group work around the following topics: overview of recovery coaching; recovery pathways; ethics and professional practices; exploring the helping relationship; your own boundaries; disclosure and risk; communication and coaching skills; understanding and applying models of wellbeing and motivation; relapse; recovery check-ins; and next steps. The training is accredited by OCN Learner Recovery Coaching Education. This is equivalent to QQI/FETAC Level 3 and is recognised in the United Kingdom.

 

Plans to expand the number of recovery coaches in Ireland were outlined to the workshop. It was proposed that a total of 32 coaches will be trained in two rounds of training from 2019; this will include 17 coaches from the Greater Dublin Area and 15 nationally, from outside Dublin. In addition to the formal training, they will do 12 hours a week voluntary work over a 25-week placement in relevant services with additional training. They will be supervised by a mentor with oversight from the coordinator over the 25 weeks of placement.

 

Key points presented in the workshop:

  • Recovery coaches help to build recovery capital in communities.
  • Recovery coaches draw on their life experiences, which is an invaluable resource, to improve outcomes for others and their communities.
  • The work of the Recovery Academy and in particular the development of recovery coaches has helped people to celebrate their recovery.
  • There remains much work to be done to promote recovery from substance addiction, as people in recovery often face a double stigma; they are stigmatised for their addiction and for being in recovery.
  • People in recovery often contend with multiple recoveries and require additional support to what has traditionally been delivered via the 9–5 service delivery model; self-help groups and communities of recovery can provide this additional support.

Peer Leadership Development and Integration programme

Nicola Perry, Community Response

 

The Peer Leadership Development and Integration programme is delivered over 30 hours in total and spans six weeks’ delivery. The programme includes 10 modules with the aim of developing a range of competencies required to build capacity in peer leadership and underpin facilitation and engagement in a group environment. The overall aim of the programme is to build individual resilience, capacity, and social capital to sustain recovery and community inclusion.

 

The workshop learned about the results of an evaluation of the programme that included 20 participants completing two programmes of training. Participants were assessed before and after they engaged with the training. It was claimed that participants reported a 25% improvement in motivation, a 40% increase in their capacity to provide peer support, and 92% indicated an improvement in their own health and wellbeing. In addition, participants reported an increase in levels of knowledge, skills, and competencies in relation to the programme modules.

 

Overall, improvements were noted in motivation, ambition, personal development, peer support, and personal stability; it was claimed that the outcome areas assessed were deemed material to building social capital to help sustain rehabilitation and build capacity for peer leadership. It is planned to roll out four more programmes to create a wider base of participants in 2018/19.

 

Key points presented in the workshop:

  • The programme benefitted from a mid-programme review which integrated feedback from participants and allowed for real-time changes to be made to the modules and the delivery of the programme to incorporate learning that participants identified as part of their training needs.
  • The programme benefitted greatly from the input by participants and intends to include former participants in the next roll-outs, for development and inclusion.
  • The programme coordinators plan to have inputs about post-course training options built into the core programme for greater clarity.
  • Key to the success of the programme is creating a safe space where participants can feel free to experiment with change.

 

WORKSHOP 4: Harm reduction services: engaging with people who use drugs

 

Assertive Case Management: a collaborative approach to target supports at those most at risk

Dawn Russell, Ana Liffey Drug Project

 

This presentation described two of Ana Liffey’s low threshold projects ongoing in Dublin city which provide case management based on National Drugs Rehabilitation Framework (NDRF) tools. These projects are delivered by a multidisciplinary team targeting clients with complex needs or those not currently engaging with existing services through outreach, in-reach, or home visits where required. The projects are slightly varied as they catered for different groups in two different parts of the city. The projects had input from a wide range of stakeholders, including An Garda Síochána.

The outcomes were measured using care plan goals, the Pulse system, and self-assessment using standardised questionnaires. Given the client group, there were indications of success in both groups, such as improved engagement with health and addiction services and reduced antisocial behaviour.

 

Summary of presentation, highlighting what had worked well in the two different projects:

  • Multiagency oversight group
  • Clear tasks and targets
  • Regular, action-focused case meetings
  • Case meetings with An Garda Síochána (where appropriate).

 

And what did not work so well:

  • Clients unable to meet the current entry criteria for detoxification services
  • Application of Outcomes Star (an assessment tool for measuring change)
  • Lack of shared care plans under NDRF
  • Lack of clarity about continuum of care and access criteria.

 

A collaborative response to chemsex in Ireland

Kiran Santlal and Adam Shanley, Gay Men’s Health Service

 

The presenters first gave a detailed overview of chemsex, that is, the use of drugs (frequently GHB) to facilitate or enhance sexual experience and the often complex issues related to the practice. There was a summary of a recent study which found in the target group that 27% of those who responded had engaged in chemsex in the previous 12 months. For example, one-quarter reported that chemsex had a negative impact on their lives and one-third felt that they would like help or advice about it.

 

The collaborative approach to addressing this issue was described by the presenters. It involved the Health Service Executive, the Gay Men’s Health Service, HIV Ireland, Gay Switchboard Ireland, BeLonG To, Healthy Ireland and Drugs.ie.

The goal was to address not just drug use but also sexual and mental health in any intervention. The primary intervention was the provision of harm reduction advice and information in clubs, universities, etc.

 

The secondary intervention was to assess the harmful use of GHB in services where LGBT people access health or addiction services, for example, Gay Men’s Health Service or Ana Liffey Drugs Project. The tertiary services manage the harmful effects of using GHB through treatment, for example, detoxification in the National Drug Treatment Centre (NDTC). There have been 98 referrals for GHB detoxification since 2014, where the majority received treatment as outpatients.

 

Key points presented in the workshop:

  • The Chemsex Working Group needed to involve many different agencies in order to address this complex issue and is a good example of multiagency cooperation.
  • There are significant health and psychological risks related to chemsex, which require specific interventions, some of which need to be long term to prevent relapse.
  • GHB detoxification can be successfully managed in the NDTC clinic as an outpatient.
  • To address the problems associated with chemsex, agencies must continue to look for innovative ways to target these high-risk populations.

 

‘I’m not a lone soldier’: a multidisciplinary response to the management and treatment of benzodiazepine use within the general practitioner setting

David Gibney and Brian Foley, Ballymun GP Community Partnership Addiction Project

 

This multidisciplinary partnership for problem benzodiazepine use is located in the Ballymun Family Practice, delivered by staff from Ballymun Youth Action Project and funded by the Ballymun Local Drug and Alcohol Task Force. It has been running since 2006, in response to a study in the area which highlighted the problems with benzodiazepines.

 

The aim of the partnership is to provide a service for people who want to address their benzodiazepine use, including accessing detoxification or further treatment. Every week, nine dedicated hours of counselling are provided either at the GP practice or at another centre by a trained addiction counsellor.

 

The project allows better, more flexible (and more discreet) accessibility to treatment, earlier intervention, and integration of medical and psychosocial services. It improves links with other services and does reach other problem drugs, such as alcohol and methadone.

 

The majority of clients are men and most receive counselling. The most common presenting drug was Valium or a Z-drug, followed by alcohol and cocaine. Many have a dual diagnosis. There were positive outcomes for many of the clients.

 

The presentation summarised some of the important lessons learned in relation to improving GP knowledge of current street tablet use, addiction counselling, importance of providing a non-stigmatising location, and multidisciplinary cooperation.

 

SAFE campaign

Emma Fox, Clondalkin Drug and Alcohol Task Force

 

The SAFE campaign developed initially because of concerns raised by An Garda Síochána and Irish Rail about a rise in public drug use and antisocial behaviour around the train station in Clondalkin, Dublin. This led to the creation of an interagency group to look at solutions to the issue, comprising initially Clondalkin Drug and Alcohol Task Force (CDATF), An Garda Síochána, Irish Rail, various local addiction services, and then joined by the South Western Regional Drug and Alcohol Task Force (SWRDATF), the Health Service Executive and other addiction services to provide support along the Kildare–Dublin railway line.

 

At the initial meetings, the partners raised their individual concerns and together the joint initiative was formulated. SWRDATF, Ana Liffey Drug Project, South Dublin County Council and the HSE Addiction Services Outreach Team were brought on board to provide the interventions. The aim of the initiative was to provide information to the target group about services available locally. Additionally, the initiative wanted to reduce drug litter, levels of public drug use, and antisocial behaviour in the train stations. A steering group was set up to progress the initiatives. The presenter stressed that all this was done with no extra resources but with ‘goodwill and genuine buy-in’.

 

In March 2018, the SAFE programme was rolled out on a pilot basis, where an outreach team would try to engage with those in the identified location once a week. It was officially launched in October 2018.

 

Part of the remit of the steering group was to collect information on the situation. Clondalkin’s location on the edge of Dublin made it easily accessible to people from Kildare, Laois, Westmeath and Tipperary. People reported coming to Clondalkin to buy drugs or to access services anonymously. The age ranged from 21 to 58 years and 60% were women. Noted among the group were limited information about safe injecting and limited access to services in their own area. The problem of crack cocaine was also highlighted.

 

Positive outcomes and successful factors:

  • Some very positive outcomes included: 257 client engagements; 240 clients availed of clean safe equipment; reduction of drug litter and antisocial behaviour.
  • The successful factors identified in the process were:

                        – There was a collaborative approach from all partners, building professional relationships, with commitment to the process.

                        – There were clear roles and responsibilities for the steering group, providing guidance and delivering outputs.

                        – There was an experienced outreach team able to make contact and build trust and relationships with the clients.

                        – There was regular communication between the outreach team and the steering group, with a lead driver for the project locally.

 

Key points presented in the workshop/made in the discussion:

  • A gap or need was identified by different agencies which brought them together to work collaboratively.
  • Each partner was able to bring their own experience and perspective to the process and pool resources to address the issue. This process needed transparency.
  • Goodwill and buy-in, along with a common goal, enabled the process to succeed in the four examples.
  • Any interventions or approaches need to be client-centred, because what they identify as important may not be what drug services feel is most important. This is vital as the target group for these interventions cannot or will not access services through the traditional pathways either because of complex needs or fear of stigma, for example.
  • The interventions therefore also need to be appropriate. This often calls for novel or innovative approaches to meet the needs of this client group. Such new interventions can sometimes be met with resistance; therefore, time is needed to build trust and relationships between services and clients.
  • The success of the projects not only depended on the good interagency cooperation but very much on the skill, dedication, and expertise of the staff delivering the interventions.

 

The reports on the workshops were compiled by Lucy Dillon, Chris Purnell, Martin Keane, and Suzi Lyons. The workshops were chaired by Tara Deasy, William Flannery, Joe Kirby, and Eamon Keenan.

 

The National Drugs Forum would like to thank the chairs and rapporteurs of all these sessions for their generosity and professionalism and for their excellent work prior to, during, and following the forum.

 

Dr Karen Minyard speaking at the National Drugs Forum

Not criminals – decriminalisation in Ireland
by Lucy Dillon

Decriminalisation of limited amounts of drugs for personal use in Ireland would involve changing the current law that defines possession of drugs for personal use as a criminal offence.1 This does not mean that possession for personal use would be legal, as an administrative offence and civil sanctions may still be applied. Furthermore, it would not affect the law that makes the possession of drugs for sale or supply a criminal offence. Decriminalisation is currently being considered by a working group jointly led by the Department of Health and the Department of Justice and Equality. The group was established in December 2017 to deliver on a commitment in the national drugs strategy to ‘consider the approaches taken in other jurisdictions to the possession of small quantities of drugs for personal use with a view to making recommendations on policy options to the relevant Minister within 12 months’ (p. 58).2 The group has undertaken research and consultation to identify alternatives to the current system and to ensure that any alternatives would be appropriate in the Irish context.


Decriminalisation of limited amounts of drugs for personal use in Ireland would involve changing the current law that defines possession of drugs for personal use as a criminal offence.1 This does not mean that possession for personal use would be legal, as an administrative offence and civil sanctions may still be applied. Furthermore, it would not affect the law that makes the possession of drugs for sale or supply a criminal offence. Decriminalisation is currently being considered by a working group jointly led by the Department of Health and the Department of Justice and Equality. The group was established in December 2017 to deliver on a commitment in the national drugs strategy to ‘consider the approaches taken in other jurisdictions to the possession of small quantities of drugs for personal use with a view to making recommendations on policy options to the relevant Minister within 12 months’ (p. 58).2 The group has undertaken research and consultation to identify alternatives to the current system and to ensure that any alternatives would be appropriate in the Irish context.

 

Civil society

The debate has attracted the attention of many of those working with people who use drugs, including the Ana Liffey Drug Project (ALDP) and the CityWide Drugs Crisis Campaign.3 Since 2015, the International Drug Policy Unit at the London School of Economics and Political Science (LSE) has been working with ALDP with the aim of advocating for and supporting progressive drug policies in Ireland. As part of this work, they have informed and facilitated discussions in Ireland about the decriminalisation of small amounts of drugs for personal use. There have been two recent outputs from this collaboration: a series of ‘town hall’ type meetings and the publication of the report Not criminals, which explores various aspects of decriminalisation.4

 

Town hall meetings

The first of a national series of town hall style meetings to increase awareness and understanding of what progressive drug policy is, with a particular focus on decriminalisation, was held in Wood Quay Venue, Dublin on 12 June 2018. Panel members were Dr John Collins, director of the International Drug Policy Unit at LSE; Tony Duffin and Marcus Keane of ALDP; and Anna Quigley of CityWide Drugs Crisis Campaign. Contributions were also made by GAA sportsman Philly McMahon and writer and actor Emmet Kirwan. Panelists highlighted the change in the Government drugs strategy towards a more health-led approach, away from dealing with drug use and addiction as a criminal issue. The current legal situation in Ireland was described, alongside what decriminalisation might look like here, all of which were placed in the context of international evidence on the topic.

 

Not criminals

In October 2018, Not criminals was launched.4 Speakers at the launch were Marcus Keane, Dr John Collins, Prof Catherine Comiskey of Trinity College Dublin, and Dr Nuno Capaz, vice-president of Portugal’s Drug Addiction Dissuasion Commission. The report provides ‘an evidence source on the adoption of a health led approach to the possession of small amounts of drugs for personal use’ (p. 3).4 Ireland is described as being at a pivotal point in drug policy. The national drugs strategy offers an opportunity for policymakers to act on its health-led focus by legislating for decriminalisation. The report maps the evolution of international and national drug policy; describes in detail the law in Ireland as it relates to simple possession; presents evidence of the impact the current system has for users; and provides an overview of decriminalisation in Portugal and the Czech Republic.

 

Health-led policy

There has been a shift in the international policy debate away from considering criminal law as the best way to address personal drug use. The harms of criminalising the use of drugs are well documented and alternative approaches are being considered internationally. While Ireland’s current national drugs strategy reflects a health-led position in line with this shift, through an analysis of Oireachtas debates the authors found that a focus on users’ health is not new in Irish drug policy. While possession for personal use has been criminalised in Ireland since the introduction of the Misuse of Drugs Act in 1977,5 punishment was not a primary focus of policymakers at the time. The debates that preceded the introduction of the 1977 Act illustrate that they were concerned about the health of people using drugs and considered them in need of care rather than punishment.

 

Irish law

Despite this, section 3 of the 1977 Act allows for the punishment of those found in possession of controlled substances for personal use. The penalties applied vary and depend on a number of factors, most importantly whether the substance is cannabis or another controlled substance, and whether this is the person’s first offence. While penalties can include up to seven years in prison, the report concludes that in practice the system takes a more humane approach. It notes that the Director of Public Prosecution elects for summary disposal in all cases of simple possession. Despite this more humane approach, a significant number of people are affected by this law each year: ‘In 2017, there were 12,201 recorded incidents of possession of drugs for personal use, representing over 70% of all drug related offences. The District Court received 20,746 drugs offences involving 13,033 defendants in 2016’ (p. 35).4

 

Impact of criminalisation

The negative impact of criminalising people for their drug use is illustrated, for example, by stigmatising people and limiting their future employment opportunities. Indeed, criminalising possession as a policy response is not considered effective – it is reported that there is no clear link between the harshness of a country’s policy on possession of drug use and levels of drug use. In turn the available evidence does not support the argument that decriminalisation has an effect on broader trends such as prevalence. Indeed, where it has been introduced, as part of a comprehensive policy approach, decriminalisation has been found to be associated with a range of positive health and social outcomes.

 

Report recommendations

Based on their examination of the international evidence and the legal and policy context in Ireland, the authors make three recommendations (p. 5):4

 

1     That Ireland decriminalise possession of small amounts of drugs for personal use. Continued criminalisation of people who use drugs is unsupportable by the best available evidence as a policy choice, and is in stark contradiction to a health-led policy for drug use.

 

  That, in designing such a policy, the focus is on pragmatic interventions which focus on health, and include the following:

 

(a)    Threshold limits which are reasonable, reflect the lived experience of people who use drugs and which serve as broad guidelines, not as inflexible standards. To protect against people attempting to thwart the system, intent should also be a key consideration for decision makers where people are in possession of small amounts

(b)    Sanctions which are not punitive, but solely health based, supportive, voluntary and with as many opportunities afforded to the individual as needed. The sanctions chosen should recognise that not all drug use is problematic, and where possible, utilise existing structures and services, with defined pathways and interventions set in advance

(c)    Decisions that are taken as close to the first point of contact as possible

(d)    Training for health workers, educators, law enforcement and judiciary on the aims and implementation of the new system

 

 That any policy that is introduced be independently evaluated in terms of implementation and impact, and that adequate resources be made available for this purpose.

 

Concluding comment

At both the town hall meeting in Dublin and the launch of the report, audiences overwhelmingly welcomed the proposal to decriminalise. However, there were concerns expressed by some attending the events that decriminalisation could be perceived as sending a message to young people that drug use is no longer problematic and that the prevalence of use might increase. Feedback at both sessions would also suggest that there is a lack of understanding among some of those working in the area and the public more generally about what decriminalisation is and how it differs from legalisation and regulation. The working group was due to report to the Minister of State with responsibility for Health Promotion and the National Drugs Strategy by the end of 2018.

 

1   The term ‘decriminalisation’ is used for the remainder of this article to refer to the decriminalisation of possession of drugs for personal use.

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   The CityWide Drugs Crisis Campaign website on decriminalisation was covered in issue 63 of Drugnet Ireland. It can be accessed on: https://www.drugsandalcohol.ie/28230/ and https://www.citywide.ie/decriminalisation/

4   Keane M, Csete J, Collins J and Duffin T (2018) Not criminals: underpinning a health-led approach to drug use. Dublin: Ana Liffey Drug Project and London School of Economics and Political Science. https://www.drugsandalcohol.ie/29791/

5   Misuse of Drugs Act 1977. Available online at: http://www.irishstatutebook.ie/eli/1977/act/12/enacted/en/html

 

Minority communities and the press
by Lucy Dillon

On 24 October 2018, the Press Council of Ireland and the Office of the Press Ombudsman held a seminar on ‘Minority Communities and the Press’. The aim of the event was ‘to hear about the critical role the print media plays in advancing the participation and representation of minority communities in society’.1 Presentations were made by those working in the areas of disability, homelessness, and drug use, as well members of the print media.


On 24 October 2018, the Press Council of Ireland and the Office of the Press Ombudsman held a seminar on ‘Minority Communities and the Press’. The aim of the event was ‘to hear about the critical role the print media plays in advancing the participation and representation of minority communities in society’.1 Presentations were made by those working in the areas of disability, homelessness, and drug use, as well members of the print media.

 

Opening address

The opening address was given by writer and disability campaigner Sinéad Burke. Sinéad drew on her personal experiences of working with the media to highlight some of the key issues facing members of minority groups in getting their voices heard. While there is a lot of good and responsible reporting, she finds negative stereotypes continued to be perpetuated by the media. She talked about the unacceptability of what she termed ‘inspiration porn’, whereby the achievements and experiences of people with disabilities are used in the media to inspire non-disabled people. As the media has the power to inform people, it also has a responsibility to frame articles in an accurate and respectful way.

 

Panel discussion

Presentations were made on three topics as part of the panel discussion.

 

Drug use

In February 2018, CityWide Drugs Crisis Campaign launched a campaign that focused specifically on the issue of stigma called ‘Stop the Stigma: Addiction is a health issue not a crime’. Anna Quigley of CityWide outlined the theory underpinning the campaign.2 She made particular reference to how the media can perpetuate the stigma experienced by drug users. The use of pejorative language (in particular the term ‘junkie’) adds to an environment in which there is a lack of understanding of the complexities of addiction and the issues faced by people who use. Users are solely defined by their drug use rather than being seen as, for example, a mother or an employee. Even where the content of articles takes some consideration of the complexities and the challenges facing people who use drugs, the headlines can be stigmatising.

 

Homelessness

Mike Allen of Focus Ireland highlighted the misrepresentation of people experiencing homelessness in the media. While only 1% are rough sleepers, approximately 23% of the images used by the media when reporting on homelessness are of rough sleepers. Furthermore, the monthly homelessness figures tend to be accompanied by the same images, despite rough sleepers not being included in the figures. The impact of this misrepresentation includes that the wrong services are funded and that people experience stigma. If homelessness is equated with rough sleepers, then the service response is to build more emergency shelters and family hubs. However, if it is seen as a lack of a place to call home, then the response would be affordable secure homes.

 

Print media

There were recurring themes within the messages from the two media representatives: Neil Cotter, head of news at The Irish Sun and Niall Donald, news editor at the Sunday World. Both argued that their publications do not set out to cause harm to people, but they recognised that sometimes lines were crossed and lessons needed to be learned. The language within reporting was seen to be changing and both described ‘junkie’ as unacceptable language in their publications. Despite this, it had appeared in some content. They felt the media was progressing in its understanding of its role when reporting on the issues under discussion and that there would be an openness to learn more through contact with advocacy groups.

 

Open discussion

There was a lively discussion, with contributions from a variety of advocacy groups representing the Travelling community, other minority ethnic groupings, and LGBTQ. A number of key messages came from it:

  • Language matters. The use of pejorative language dehumanises people, adding to their stigmatisation. It prevents people from accessing services, their voice from being heard, and perpetuates a lack of understanding among decision-makers and the general public about the complexity and variation of people’s needs.
  • The media should question the relevance of always reporting a person’s ethnicity when they are a member of a minority group. It was argued that this always happened when the story was negative, even though the person’s ethnicity was irrelevant to the story.
  • While it is important that real-life stories are heard in the media, dealing with the media as an advocate can be problematic. It draws a lot of attention and judgement on the individual and can open them up to their story being unpicked. If people are to be asked to do this, then they need to be supported.
  • While collaboration between advocacy groups was encouraged in educating the media about the issues faced, it was also highlighted ‘how different the differences are’. While homelessness is a chapter in someone’s life, being a Traveller is a fundamental identity. This would need to be acknowledged in any collaboration.
  • There is a need for greater representation of minority groups among those working in the media.
  • The issues facing minority groups and the role of the media should be covered in journalist courses. Training journalists at an early stage to consider the issues and identify sources of support would benefit everyone.

 

In conclusion

The Press Ombudsman concluded the event by welcoming the outcomes of the discussions. He highlighted the independent role of his office and noted that it is now easier than 10 years ago to make a complaint about the media and for it to be upheld. However, he noted that it is hard to uphold complaints about opinion pieces as his office has to balance freedom of expression and offence. He encouraged advocacy groups and members of the media to pursue a more collaborative approach to working together.

 

1   For further information, visit: https://www.presscouncil.ie/about-us/recent-decisions-and-news/“minority-communities-and-the-press”-seminar  

2   See Dillon L (2018) Reducing stigma in Ireland. Drugnet Ireland, 65: 1–3. https://www.drugsandalcohol.ie/29093/

 

‘The voice of the street’
by Lucy Dillon

Public consultation was carried out as part of the development of Ireland’s current national drug strategy, Reducing harm, supporting recovery.1 In a bid to ensure that the voice of those most affected by the new strategy would be heard, the Union for Improved Services, Communication and Education (UISCE) carried out a consultation with people who use drugs (PWUD). While central to any drug policy, the stigmatisation and criminalisation of drug use are just two of the reasons why the voices of PWUD tend not to be heard in the policy-making process. A paper has been published on the ‘peer-led street outreach approach’ undertaken by UISCE to fill this gap. The paper provides valuable insights on how to engage with PWUD to inform policy development.2


Public consultation was carried out as part of the development of Ireland’s current national drug strategy, Reducing harm, supporting recovery.1 In a bid to ensure that the voice of those most affected by the new strategy would be heard, the Union for Improved Services, Communication and Education (UISCE) carried out a consultation with people who use drugs (PWUD). While central to any drug policy, the stigmatisation and criminalisation of drug use are just two of the reasons why the voices of PWUD tend not to be heard in the policy-making process. A paper has been published on the ‘peer-led street outreach approach’ undertaken by UISCE to fill this gap. The paper provides valuable insights on how to engage with PWUD to inform policy development.2

 

Peer-led outreach

UISCE focused its efforts on what might be considered the most hard to reach of the cohort of PWUD in Ireland – those who are ‘injecting on the street’. The authors describe this as presenting a number of challenges: how to access these PWUD, ethical issues of safety and consent, and the logistical demands of carrying out the consultation in the time available. UISCE decided to build on its experience of taking a peer-led approach to its work, whereby PWUD use their knowledge and contacts to engage with other PWUD. Through this work, the views and experiences of 51 PWUD were included in the consultation.

 

Key issues in using this method of consultation:

  • Prior to carrying out the consultation, UISCE had to address the ethical concerns of informed consent, confidentiality and safety. It did this by complying with various ethical frameworks that guide its work more broadly.
  • The research tool (a questionnaire designed by the Department of Health for the public consultation more broadly) needed to be adapted to be appropriate for PWUD. The wording was made more accessible through consultation with PWUD.
  • Success depended on how well-known the peer carrying out the recruitment was to the potential participants. Furthermore, reassurances were needed where PWUD were suspicious of others because of concerns, for example, about the police or drug debt.
  • The weather also presented a barrier to recruitment – people were less willing to complete the survey when it was cold and wet.

Findings

Given the nature of the questionnaire as a broader public consultation document, the findings were limited in terms of depth. Findings included that 72% of PWUD identified heroin as the most harmful drug; 60% agreed that it was difficult to access treatment; and 68% were not aware of the existence of the 2009–2016 national drugs strategy. A full report of the findings is available from UISCE.3

 

In conclusion

This consultation ensured that the voices of PWUD were heard in the development of the strategy; however, this paper highlights how time consuming a process it can be and the challenges faced. UISCE is represented on the National Oversight Committee and as such it might be expected that further consultation exercises of this kind will be undertaken to ensure the voices of PWUD are heard to inform the ongoing implementation of the strategy.

 

1   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/

2   Melaugh B and Rodrigues H (2018) ‘The voice of the street’: using peer led outreach with people who use drugs to inform the development of Ireland’s National Drug Strategy. Social Work and Social Sciences Review, 19(3): 7–16.                                                       https://www.drugsandalcohol.ie/29784/

3   UISCE (2016) Your voice: 2017 national drug strategy. Brass Munkie, 30, Winter 2016

Prevalence
Polydrug use in Ireland: 2014/15 survey results
by Seán Millar

The National Advisory Committee on Drugs and Alcohol (NACDA) has recently published Bulletin 41 in a series of reports on the 2014/15 survey on drug use in the general population in Ireland.2 The bulletin focused on polydrug use in the adult population. Polydrug use was defined as the use of any two or more substances, legal, illegal or prescribed, within a one-month period.


The National Advisory Committee on Drugs and Alcohol (NACDA) has recently published Bulletin 41 in a series of reports on the 2014/15 survey on drug use in the general population in Ireland.2 The bulletin focused on polydrug use in the adult population. Polydrug use was defined as the use of any two or more substances, legal, illegal or prescribed, within a one-month period.

 

All adults

Twenty-three per cent of survey participants had not used any substance (either legal or illegal) within the last month. The most commonly used substance was found to be alcohol, with 32.7% reporting alcohol consumption in the month prior to the survey. The most common combination of substances in the population was found to be alcohol and tobacco (10.5% reporting use of both in the last month), and the percentage of those reporting the use of alcohol and other legal drugs was found to be 8.1%.

 

The combination of alcohol, tobacco and any illegal drug was 2%, which is higher than the proportion reporting use of tobacco and other legal drugs (1.1%), or alcohol and antidepressants (0.8%). All other combinations of polydrug use reported were 0.5% or less.

 

Gender

A higher percentage of females (26%) than males (20.3%) had not used any substance (legal or illegal) during the last month. A greater proportion of males consumed alcohol (36.8%) compared to females (28.7%), which was also true for the combination of alcohol and tobacco used in the last month (13.2% males vs 7.9% females). Males were also more likely to report the use of illegal drugs combined with alcohol and tobacco (3.2% males vs 0.8% females). However, a higher percentage of females reported that they had used alcohol with other legal drugs compared to males (9.2% vs 6.9%).

 

Age

The prevalence of alcohol and tobacco use in young adults aged 15-34 years was found to be 12.6%, which was higher than that reported by older adults aged 35-64 years (10.9%) and over 65s (4.3%). Polydrug use of alcohol and other legal drugs was found to be similar for younger and older adults (8.5% and 8.7%, respectively), and lower in participants who were over 65 years (5%).

 

In younger adults, illicit substances were most commonly used in combination with alcohol and tobacco (4.3%), while 0.9% of older adults reported this combination in the month before the survey. Older adults were more likely than younger adults to have used alcohol and antidepressants (1.4% vs 0.2%).

 

Relationship between use of particular substances and of other substances

Patterns of association between pairs of substances are presented in Table 1. For respondents who indicated using alcohol in the previous month, 30.2% had also used tobacco, while 5.9% had also used cannabis. A high percentage of people who used tobacco also reported the use of alcohol (71.5%), while 13.2% had also used cannabis and 7.7% also used antidepressants. Participants who indicated using cannabis in the month prior to the survey were also more likely to report alcohol use (87.4%) and/or tobacco use (82.9%), while 20.2% of people who used cannabis also reported the use of amphetamine-type stimulants (ATS).

 

A majority of people who used ATS had also used alcohol (97.1%), tobacco (90.9%) and cannabis (87.4%), while 25.1% had also used cocaine. Among respondents who had used cocaine in the previous month, 83.6% had also used tobacco, 76.6% used cannabis, and one-half of people who used cocaine (50.1%) had also consumed ATS.

 

Since the 2010/11 survey, there has been a significant increase in the proportion of people who drink alcohol, who use tobacco, and who use cannabis among people who use ATS (+1.4, +3.1 and +18.0 percentage points, respectively). The proportion of those who used alcohol, tobacco or cocaine in the last month, and who also reported using cannabis, has also increased significantly since 2010/11 (+2.6, +5.6 and +35.7 percentage points, respectively).

 

Other findings

  • Other main findings from the NACDA survey include the following:
  • Among people who use alcohol, males are more likely than females to have smoked tobacco (33.5% vs 26.2%) in the last month, or to have used cannabis (8.3% vs 3.1%).
  • The proportion of males who use cannabis and who also report the use of cocaine is almost double that of females (10.0% vs 5.4%).
  • Since 2010/11, the proportion of people who use tobacco, and who also use alcohol, has decreased significantly for males and females (from 83.1% to 76.7% in males and from 72.5% to 64.9% in females), while the percentage of people who use tobacco, and who also use cannabis, has increased significantly (from 11.2% to 17.6% in males and 3.1% to 7.7% in females).
  • The proportion of respondents who use sedatives or tranquillisers and who also use antidepressants has increased since the 2010/11 survey (+6.8 percentage points). Similarly, the proportion of those using antidepressants who also use sedatives or tranquillisers has increased by 4.6 percentage points.

1   National Advisory Committee on Drugs and Alcohol (NACDA) and Department of Health (UK) (2018) 2014/15 Drug prevalence survey: polydrug and new psychoactive substances results. Bulletin 4. Dublin: NACDA.

2   National Advisory Committee on Drugs and Alcohol (NACDA) and Department of Health (UK) (2016) Prevalence of drug use and gambling in Ireland and drug use in Northern Ireland. Bulletin 1. Dublin: NACDA. https://www.drugsandalcohol.ie/26364/

 

 

 

 

 

Cannabis use in Ireland: new findings from the fourth general population survey

The National Advisory Committee on Drugs and Alcohol (NACDA) has recently published Bulletin 31 detailing findings from the fourth drug prevalence survey regarding the use of cannabis in Ireland.2 This survey followed best practice guidelines and used a random sample of households throughout the island of Ireland. Of the household members contacted, 7,005 agreed to take part. The sample was weighted by gender, age and region to ensure that it was representative of the general population. This article highlights major findings from this bulletin.


The National Advisory Committee on Drugs and Alcohol (NACDA) has recently published Bulletin 31 detailing findings from the fourth drug prevalence survey regarding the use of cannabis in Ireland.2 This survey followed best practice guidelines and used a random sample of households throughout the island of Ireland. Of the household members contacted, 7,005 agreed to take part. The sample was weighted by gender, age and region to ensure that it was representative of the general population. This article highlights major findings from this bulletin.

 

Age at first use and age at first regular use

The median age of first use of cannabis in the Republic of Ireland was found to be 18 years for those who reported ever having used cannabis in their lifetime. The median age for males, females and young adults was also 18 years, and slightly higher for older adults (19 years) and over 65s (25 years). Among those who said that they had regularly used cannabis at some point in their lives, the median age of first use was 17 years; this was the case for both males and females and is unchanged since 2010/11. The median age of first use was found to be 17 years for young adults (compared to 16 years in 2010/11) and was also 17 years for older adults (compared to 18 years in 2010/11). The median age of first use was found to be 20 years for adults aged over 65 years. The period of time between first using cannabis and regular use was one year for all adults.

 

Cannabis dependence and cannabis abuse

Among people who used cannabis in the last year, 19.7% fulfilled the criteria for cannabis dependence (Table 1). The rate was higher for males (22.8%) than for females (11.8%) and higher for young adults (22.3%) than for older respondents (10.4%).

 

In the general population, 1.5% of those aged 15+ were classed as cannabis dependent. This rate was found to be significantly higher in males (2.5%) than females (0.5%), and also significantly higher in young adults (3.6%) than older subjects (0.4%). Over 65s reported no cannabis dependence or abuse.

 

Type of cannabis most commonly used

Participants were asked to state what type of cannabis they most commonly used. The possible options and their relevant frequencies are shown in Table 2. The results demonstrate that almost 50% of those who used cannabis in the last month reported using ‘weed’; 28.1% used ‘grass’; 2% used ‘herb’; and 2% had used ‘skunk’. Resin was reported by 16.3% of people who used cannabis in the last month and the types mentioned were ‘hash’ (14.9%) and ‘resin’ (1.4%).

 

Method by which cannabis is used

Survey respondents were asked about the most common method used to take cannabis (Table 3). The most common method reported was smoking a joint (96.2%), while 2% said they used a pipe. Results by gender show that smoking joints was the most common method reported by females (94.8%), while 3.1% of females reported eating cannabis. Smoking joints was also the most common method reported by males (96.7%), followed by a pipe (2.6%) and a bong (0.7%). In terms of age, smoking joints was the method used by a majority of young adults (96.3%) and older adults (95.9%) who used cannabis, while using a pipe was more likely to be reported by older adults than young adults (4.1% vs 1.5%).

 

Other findings

Other main findings from the NACDA survey include the following:

  • The majority of people who used cannabis in the last year reported that it would be easy or very easy to obtain cannabis in a 24-hour period (87.1%), with 2.6% reporting that it would be difficult or very difficult.
  • Respondents who had used cannabis regularly at some point in their lifetime were also asked about attempts to stop. Of this group, 72.1% said they had managed to stop and 7.4% stated they had tried without success.
  • Most respondents (74.5%) agreed that people should be permitted to take cannabis for medical reasons. Males were more likely to agree with this statement than females (77% vs 72.1%). Older adults were more likely to agree than young adults (78.4% vs 73.9%) and over 65s (64.2%).
  • A majority of survey respondents disagreed with the recreational use of cannabis (66.4%) and 74.3% disapproved of people smoking cannabis occasionally.
  • Lifetime rates of cannabis use were highest among people who were in middle management, senior civil servants, managers, and business owners at 28.7%. Last-year and last-month rates were highest among semiskilled and unskilled manual workers, trainees and apprentices, with 8.4% having used cannabis in the last year and 5.9% in the last month.
  • Lifetime rates for cannabis use were highest in the group classified as ‘renting from a private landlord’ (38.9%). Last-year and last-month rates were highest for those living with their parents/other family (14.2% and 8.6%, respectively). Cannabis abuse was highest for those living with parents/other family (4.9%), and 4.3% met the criteria for cannabis dependence.
  • The results show that levels of cannabis use increase with education. Lifetime rates were highest among those who ceased education at 20 years of age and over and among those with a third-level education. Rates were lowest among those who ceased education at 15 years or under and among those with primary-level education only. Conversely, rates of cannabis abuse and dependence were found to be highest among those who ceased education aged 15 or under (2.2% and 1.5%, respectively).
  • Lifetime, last-year and last-month rates were highest among those classified as cohabiting or single.

 

 

 

Seán Millar

 

1   National Advisory Committee on Drugs and Alcohol (NACDA) and Department of Health (UK) (2017)  2014/15 Drug prevalence survey: cannabis results. Bulletin 3. Dublin: NACDA.

2   National Advisory Committee on Drugs and Alcohol (NACDA) and Department of Health (UK) (2016) Prevalence of drug use and gambling in Ireland and drug use in Northern Ireland. Bulletin 1. Dublin: NACDA. https://www.drugsandalcohol.ie/26364/

Pregabalin and gabapentin reclassified as controlled drugs in the UK
by Suzi Lyons

In October 2018, the United Kingdom (UK) reclassified pregabalin and gabapentin as class C controlled drugs, which will come into force in April 2019.1 This is in direct response to the increased number of deaths linked to both these drugs in the UK and a consultation process around this issue.2


In October 2018, the United Kingdom (UK) reclassified pregabalin and gabapentin as class C controlled drugs, which will come into force in April 2019.1 This is in direct response to the increased number of deaths linked to both these drugs in the UK and a consultation process around this issue.2

 

Speaking of the announcement, the British Minister for Crime, Safeguarding and Vulnerability Victoria Atkins MP stated: ‘Any death related to the misuse of drugs is a tragedy. We accepted expert advice and will now change the law to help prevent misuse of pregabalin and gabapentin and addiction to them.’

 

What this means is that it will be illegal to possess these drugs without a prescription but also illegal to supply or sell them to another person. Class C controlled drugs in the UK cannot be dispensed using an electronic prescription but require a doctor to physically sign the prescription. They also must be dispensed within 28 days from the date of prescribing.

 

In Ireland, data from the National Drug-Related Deaths Index show there has been a notable increase in the number of poisoning deaths where pregabalin has been implicated, from 26 in 2014 to 44 in 2015, a jump of 69%.3

 

 

 

1   Home Office (2018) Pregabalin and gabapentin to be controlled as class C drugs. London: Home Office.               

      https://www.gov.uk/government/news/pregabalin-and-gabapentin-to-be-controlled-as-class-c-drugs

2   Home Office (2018) A consultation on proposals to schedule pregabalin and gabapentin under the Misuse of Drugs Regulations 2001. Government response to the consultation. London: Home Office.                                                                                                                   https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/748439/consultation-response-pregabalin-gabapentin.pdf

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

 

 

Rise in first-time treatment admissions for older adults who use opioids
by Anne Marie Carew

International agencies such as the United Nations and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) have recently highlighted their concerns about increased drug use among older people.1,2 An Irish study published in the journal, Drug and Alcohol Dependence, demonstrates that the proportion of older people starting treatment for opioid use is growing, and many have used opioid drugs for a relatively long time prior to seeking treatment.3

 

The study analyses data from the National Drug Treatment Reporting System (NDTRS) over the 19-year period from 1996 to 2014 inclusive. The NDTRS is an epidemiological database on treated problem drug and alcohol use in Ireland. Treatment records where an individual started treatment for the first time and an opioid was the primary drug problem were selected and the data were explored using statistical techniques to assess changes over time.


International agencies such as the United Nations and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) have recently highlighted their concerns about increased drug use among older people.1,2 An Irish study published in the journal, Drug and Alcohol Dependence, demonstrates that the proportion of older people starting treatment for opioid use is growing, and many have used opioid drugs for a relatively long time prior to seeking treatment.3

 

The study analyses data from the National Drug Treatment Reporting System (NDTRS) over the 19-year period from 1996 to 2014 inclusive. The NDTRS is an epidemiological database on treated problem drug and alcohol use in Ireland. Treatment records where an individual started treatment for the first time and an opioid was the primary drug problem were selected and the data were explored using statistical techniques to assess changes over time.

 

A total of 18,692 individuals entered treatment for the first time for opioid use during the study period. The number of treatment admissions peaked in 2009, with numbers declining in subsequent years. Heroin was the main problem opioid across all years, accounting for 92.7% (n=17331) of all treatment entries, while methadone accounted for 2.2% (n=417), over-the-counter and other prescribed opioids accounted for 4.6% (n=852) of treatments. A small number of other opioid types were reported (0.5%, n=92), including opium and unspecified opioid drugs.

Population figures were used to calculate annual treatment incidence rates, which were analysed for trends over time. Trends in admissions fluctuated across the period and several significant trends were observed. Overall, age-adjusted treatment incidence has declined over the last 18 years. Significant downward trends were observed in age-adjusted rates for the years 1996−2004, with an annual percentage change (APC) of −7.0% (CI: −10.1 to −3.9, p=0.003), and also in the period 2009−2014 (APC=−8.6, CI: −14.6 to −2.9, p=0.012). However, in the interim years (2004−2009), the trend was upward and significant (APC=13.4, CI: 3.1−24.9, p=0.012).

 

The examination of incidence by age revealed a downward trend among younger age groups and an upward trend among older age groups. In early years (1996−2002), incidence was concentrated among younger age groups and became more dispersed as time passed. The largest significant downward trends were observed among 15−19-year-olds in the years 2009−2014 (APC=−25.0, CI: −36.2 to −11.9, p<0.001) and among 20−24-year-olds in the years 2010−2014 (APC=−12.9, CI: −21.5 to −3.3, p<0.001). Upward trends were detected among older age groups, and two groups were evident: (1) incidence was low in early years among those aged 25−49 years and increased by varying amounts, and (2) there was a rising incidence that did not previously exist among 50−74-year-olds. The largest significant upward trends were among 35−39-year-olds in the years 2003−2009 (APC=27.4, CI: 9.2−48.6, p=0.003), and also among 40−44-year-olds (APC=14.6, CI: 10.7−18.6, p<0.001) and 45−49-year-olds (APC=13.6, CI: 9.2−18.1, p<0.001) right across the study period.

 

Other key findings

Other key findings from the study included the following:

  • The results show evidence of subgroups within the treatment population; those who seek treatment quickly and also those who take much longer to seek treatment. There is evidence of late-onset drug users – individuals who begin drug use later in life.
  • The profile of people entering treatment for opioid use has changed; people are now older, are injecting for longer, and are taking longer to enter treatment.
  • The median age commencing opioid use increased by 3 years (from age 18 to age 21 ) (U=326141.5, p<0.001).
  • The median age entering treatment increased by 11 years (from age 20 to age 31) (U=145465.5, p<0.001).
  • The median opioid-using duration prior to treatment increased by 5 years (from 2 to 7 years) (U=170807.5, p<0.001).
  • One-half of the individuals started injecting within 1 year of first using opioids. The median time between first injecting and commencing treatment increased by 6 years for men and 2 years for women.

 

The study authors highlight that:

  • In recent years, more and more people aged 50 years and older are entering treatment for opioid use, a trend not previously observed.
  • Results show how service need has changed over the last two decades and provide an indication of future service need, which is essential for planning purposes. These findings also highlight how treatment data can be used to identify hidden groups at risk of chronic harm which may require prioritising in policy and practice.

 

The authors note that although drug treatment data are collected across 30 European countries, this study is the first large-scale examination of ageing and opioid use trends. The study provides evidence to underpin policy development and changes in practice. Current drug policies and treatment services are predominately focused on the needs of the known profile of younger drug users, and it is inevitable that existing services need to adapt to the ageing population. The changing composition of this group suggests a wide range of services will be required into the future and integrated approaches across addiction and healthcare services would be beneficial in identifying and treating addiction problems among ageing drug users.

 

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

2   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/

3   Carew AM and Comiskey C (2018) Rising incidence of ageing opioid users within the EU wide treatment demand indicator: the Irish opioid epidemic from 1996 to 2014. Drug and Alcohol Dependence, 192: 329–337. https://www.drugsandalcohol.ie/29783/

Responses
The place of drug education in Ireland’s response to drug use
by Lucy Dillon

A recent paper examines the position of drug education workers who work with children and young people in non-formal education settings in Ireland.1 Drug education is described in the article as ‘a range of interventions across multi-disciplinary settings and includes education programmes, policies and guidelines’. While not unpacked in the paper, the author highlights that the terms ‘drug prevention’ and ‘drug education’ are often used interchangeably but they are distinct activities. Drug prevention’s primary aim is to change people’s behaviour around drug use, whereas drug education is more about delivering factual information about drugs to people.2 This article is only interested in the latter.


A recent paper examines the position of drug education workers who work with children and young people in non-formal education settings in Ireland.1 Drug education is described in the article as ‘a range of interventions across multi-disciplinary settings and includes education programmes, policies and guidelines’. While not unpacked in the paper, the author highlights that the terms ‘drug prevention’ and ‘drug education’ are often used interchangeably but they are distinct activities. Drug prevention’s primary aim is to change people’s behaviour around drug use, whereas drug education is more about delivering factual information about drugs to people.2 This article is only interested in the latter.

 

Research and analysis

There are three main strands to the author’s research and analysis.

 

Origins of drug education in Ireland

In 1974, the Committee on Drug Education recommended that drug education should be included as part of a broad health education programme to be delivered in schools. The author describes the development of drug education programmes as ‘slow’ (p. 363) but the introduction of programmes such as On My Own Two Feet and the Social, Personal and Health Education (SPHE) curriculum meant that the provision of drug education for children and young people was ‘placed firmly’ (p. 363) within the remit of the formal education sector. However, there was also scope for it to be delivered within non-formal education settings. When local and regional drug and alcohol task forces were established (late 1990s and early 2000s, respectively), funding was made available for drug education workers. The provision of community-based drug awareness programmes was reinforced by the national drugs strategy that ran from 2001 to 2008 (p. 62).3

 

Development and demise of Drug Education Workers Forum

The Drug Education Workers Forum (DEWF) was established in 2000 as a voluntary organisation. Among its aims were to provide drug education workers with the opportunity to network, exchange drug-related information, and influence policy through the forum’s collective voice. As part of its work in 2007, it published A manual in quality standards in substance use education (QSSE)4 – this was ‘an overarching framework and guidelines for practitioners of drug education and those commissioning drug education programmes’ (p. 364). The start of the recession in 2007, however, meant cuts to funding and a redeployment of staff. The author argues that this resulted in a significant reduction of drug education workers being funded by the task forces, and ultimately led to the demise of the DEWF. While an evaluation of the QSSE was published in 2013, the author describes drug education workers as being ‘largely voiceless at national platforms’ since then (p. 365).

 

Drug education as part of response to illicit drug use

Secondary analysis of the three national drug strategies covering the period 2001 to 2018 was carried out, along with the 2016 annual reports from the local and regional drug and alcohol task forces. The purpose was to explore the prominence of drug education workers in the national response to drug use, and an estimation of the numbers working in the field. The overall picture was one in which drug education as such has become a less prominent feature of the strategic response. The author describes a ‘sheer absence’ (p. 368) of references to drug education in the current national drugs strategy (2017–2025),5 other than one within the context of harm reduction activities. He also identifies the number of drug education workers within the local and regional drug and alcohol task forces as ‘very low’ (p. 370). It is important to note however that many of those working in the task forces in prevention rather than drug education as such will be delivering drug education as part of their work.

 

Conclusion

The author concludes that drug education as a field in Ireland has diminished over time and workers are in a precarious position. While he acknowledges that this may partly be due to a lack of evidence of its effectiveness as a form of drug prevention, he argues that the efficacy and effectiveness of drug education should be measured in an education rather than a prevention framework. This would make it possible to ‘measure the learning that takes place in drug education programmes and document the educational benefit to participants’ (p. 371). However, the author does not provide further evidence of why these specific outcomes are important within the context of a national response to illicit drug use. Therefore, while drug education is ongoing in Ireland within the broader contexts of prevention and harm reduction activities, it would be interesting to have clarified why educational outcomes alone are of value as this is not suggested as a priority internationally.2

 

1   Darcy C (2018) The precarious position of drug education workers in Ireland. Economic and Social Review, 49(3): 361–372.     https://www.drugsandalcohol.ie/29721/

2   See for example Warren F (2016) ‘What works’ in drug education and prevention? Edinburgh: Scottish Government.     https://www.drugsandalcohol.ie/26557/

3   Department of Tourism, Sport and Recreation (DoTSR) (2001) Building on experience: national drugs strategy 2001–2008. Dublin: Stationery Office. https://www.drugsandalcohol.ie/5187/

4   Drug Education Workers Forum (DEWF) (2007) A manual in quality standards in substance use education. Dublin: Drug Education Workers Forum. https://www.drugsandalcohol.ie/6339/ 

5.  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/

Reitox Academy on Universal Prevention Curriculum (UPC-Adapt)
by Richie Stafford

This Reitox Academy was organised by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the UPC-Adapt Group1 in collaboration with the First Faculty of Medicine, Charles University in Prague, and the Czech National Monitoring Centre for Drugs and Addiction, within the framework of the final conference of the Universal Prevention Curriculum (UPC)-Adapt project, funded with the support of the European Commission. It took place on 28–29 November 2018 at the Lichtenstein Palace in Prague.


This Reitox Academy was organised by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the UPC-Adapt Group1 in collaboration with the First Faculty of Medicine, Charles University in Prague, and the Czech National Monitoring Centre for Drugs and Addiction, within the framework of the final conference of the Universal Prevention Curriculum (UPC)-Adapt project, funded with the support of the European Commission. It took place on 28–29 November 2018 at the Lichtenstein Palace in Prague.

 

The UPC-Adapt generated a set of curricula for application in training of prevention professionals in Europe. Nine European Union (EU) member states (Belgium, Czech Republic, Croatia, Estonia, Germany, Italy, Poland, Slovenia and Spain) piloted these materials in 2018. Given the significance of the work and interest in the topic among the experts in the EU member states and beyond, the EMCDDA together with the UPC-Adapt project will extend the beneficiaries of the project through train-the-trainer events and other activities planned in 2019. The Reitox Academy was organised to present the results of the work done and to discuss the possible dissemination of the programmes across Europe.

 

The objectives of the academy were to: (1) increase understanding of the European UPC’s (EUPC) potential and the motivation of the Reitox partners to launch the EUPC in their respective countries; (2) provide a short introduction and an overview of the EUPC and to motivate participation in future train-the-trainer events; and, (3) explore liaison with universities that implement the full UPC within their academic syllabi. The conference was also an excellent opportunity to network with prevention practitioners and learn from approaches and initiatives across Europe.

 

Conference agenda

The conference was attended by nominees from 21 EU member states and potential candidate countries to the EU. Day 1 of the conference opened with plenary presentations from Gregor Burkhart (EMCDDA) on what works in drug prevention and from Peer van der Kreeft (University College Ghent) on the history of the UPC-Adapt project and core issues in the adaptation process.

Three parallel workshops on the ‘Content and method of EUPC training’ were held in the afternoon. The group was split into three, covering the following topics:

          EUPC for school-based and community-based prevention

          2  EUPC for environmental and media-based prevention

          3  EUPC for workplace and family-based prevention.

 

The earlier part of day 2 looked more closely at the training component of EUPC and which conclusions did the pilot deliver. This portion of the day contained presentations on the training of decision, opinion and policy makers (Rachele Donini, ASL 2 Savonese); the online version of training (Roman Gabrhelík, Charles University); and the academic version (Martina Ferić, University of Zagreb). The second part of the day focused on next steps and the dissemination of EUPC across Europe.

 

The curricula developed by UPC-Adapt are an interesting proposal in the Irish context. A recent article2 examined the prominence of drug education work within the statutory response to drug use in Ireland. The author argues that drug education is underfunded, and without national representation since the disbanding of the Drug Education Workers Forum (DEWF). The precarious position might be explained by question marks over the perceived value of drug education. A HRB Drug and Alcohol Evidence Review3 highlighted a lack of good-quality evaluation in the field: ‘When considering the current state of the evidence and the accompanying evidence gaps, it is worth noting that the absence of evidence should not be taken as evidence of absence’ (p. 36). Coupled with a lack of rigorous research, expectations of drug education are often unrealistic and contradictory. These factors have combined to create the conditions for bad practice in drug education to not only survive but to thrive. EUPC offers the potential to improve practice with regard to drug prevention and to convince decision, opinion and policy makers of the value of evidenced practice, and a firmer footing for those working as drug education and prevention practitioners.

 

1   For further information on UPC-Adapt, visit: http://upc-adapt.eu/

2   Darcy C (2018) The precarious position of drug education workers in Ireland. Economic and Social Review, 49(3): 361–372. https://www.drugsandalcohol.ie/29721/

3.  Munton T, Wedlock E and Gomersall A (2014) The efficacy and effectiveness of drug and alcohol abuse prevention programmes delivered outside of

     school settings. HRB Drug and Alcohol Evidence Review 2. Dublin: Health Research Board. https://www.drugsandalcohol.ie/23079/

 

Chrysalis launch their latest strategic plan on 20th anniversary of service
by Suzi Lyons

On 14 November 2018, the Chrysalis Community Drug and Alcohol Team, led by Passerose Mantoy-Meade, launched their strategy plan for 2019-2021. At the same event, they celebrated 20 years providing a range of drug and alcohol services in Dublin's north inner city. Master of ceremonies was Dr Des Crowley, who is also chair of the Chrysalis board of directors. The event was attended by many past clients of Chrysalis and representatives of other services.


On 14 November 2018, the Chrysalis Community Drug and Alcohol Team, led by Passerose Mantoy-Meade, launched their strategy plan for 2019-2021. At the same event, they celebrated 20 years providing a range of drug and alcohol services in Dublin's north inner city. Master of ceremonies was Dr Des Crowley, who is also chair of the Chrysalis board of directors. The event was attended by many past clients of Chrysalis and representatives of other services.

 

Dr Crowley introduced the event and Passerose Mantoy-Meade gave an emotional and heartfelt speech about the work of Chrysalis and how it had grown to meet the challenges of those with drug and alcohol problems in their community. 

 

Dr Suzi Lyons from the Health Research Board gave an overview of drug treatment trends over the past 20 years.  Colman Ronayne from Chrysalis gave an insight into what case management really means. Michael McGoldrick, pharmacist from the Mews Clinic, spoke of the cooperation between the Health Service Executive and Chrysalis and how they worked to meet the needs of the clients. Dr Marguerite Woods spoke about trauma-informed practice, while Eamonn Geoghegan from Chrysalis gave an overview of the peer-led initiatives in the service. Finally, Wendy Lyon spoke about human rights and sex work.

 

Chrysalis already offers a wide range of services, ranging from harm reduction, early intervention, case management and integrated care planning to counselling and aftercare. Its new strategy looks to extend the range of services offered and has a new team leader to support the key workers, peer works, and therapists currently providing care to Dublin's north inner city.

 

Dr Des Crowley, chair of the Chrysalis board of directors, and Passerose Mantoy-Meade, Chrysalis Community Drug and Alcohol Team, at the launch of the strategy plan (Photo: Derek Speirs)

New publications
Recent publications

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


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

Prevalence and current situation

Rising incidence of ageing opioid users within the EU wide treatment demand indicator: The Irish opioid epidemic from 1996 to 2014

Carew AM and Comiskey C (2018) Drug and Alcohol Dependence, 192: 329–37.

https://www.drugsandalcohol.ie/29783/

Literature identifies older people who use opioids as a neglected population. Little is known about temporal changes, or about treatment demand among this population. The EU Treatment Demand Indicator (TDI) for Ireland (1996–2014) was analyzed for trends in new opioid treatment admissions, ageing and drug using behaviors. A Joinpoint analysis was conducted.

The study utilizes European TDI data and finds that those entering treatment in Ireland is older, are injecting longer and are taking longer to enter treatment. These findings highlight how TDI data can be used to identify hidden groups at risk of chronic harm which may require prioritizing in policy and practice.

 

‘The voice of the street’: using peer led outreach with people who use drugs to inform the development of Ireland’s National Drug Strategy

Melaugh B and Rodrigues H (2018) Social Work and Social Sciences Review, 19(3): 7–16.

https://www.drugsandalcohol.ie/29784/

The purpose of this article is to share how an Irish drugs advocacy organisation, UISCE conducted a consultation with ‘People Who Use Drugs’ (PWUD) to inform the development of Ireland’s National Drugs Strategy: Reducing Harm Supporting Recovery. People who use drugs are considered a ‘hard to reach’ or ‘hidden’ population’ who, because of their marginal status, are often absent from research and drug policy. Indeed, there is a lack of published data on how to engage with PWUD to inform policy development. The paper aims to extend the literature by highlighting how UISCE, employing a ‘peer-led street outreach’ approach, included 51 PWUD in the consultation to inform the Irish national drug strategy. Central to the paper is a description of the steps taken to conduct the consultation with a review of the challenges and benefits of using a ‘street based recruitment’ strategy to engage with hard to reach people who use drugs.

 

Prevalence of smoking and provision of smoking cessation advice during hospitalization

Najeeb N, Halawani M, McElvaney NG and Doyle F (2018) Irish Medical Journal, 111(9): 821.

https://www.drugsandalcohol.ie/29809/

We aimed to determine the prevalence of smoking and smoking cessation advice received by inpatients in Beaumont Hospital and compared results to previous similar studies.

There remains limited provision of smoking cessation advice to inpatients.

 

Symptom-triggered therapy for assessment and management of alcohol withdrawal syndrome in the emergency department short-stay clinical decision unit

Ismail MF, Doherty K, Bradshaw P, O'Sullivan I and Cassidy EM (2018) Emergency Medicine Journal, 36(1): 18–21.

https://www.drugsandalcohol.ie/29777/

In this study, we aim to describe the feasibility of symptom-triggered therapy (STT) in an emergency department (ED) short-stay clinical decision unit (CDU) setting.

STT is potentially feasible as a rapid and effective approach to managing alcohol withdrawal syndrome in the ED/CDU short-stay inpatient setting where patient LOS is generally less than 24 hours.

 

Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

GBD 2016 Alcohol Collaborators (2018) Lancet, 392(10152): 1015–35.

https://www.drugsandalcohol.ie/29555/

With our comprehensive approach to health accounting within the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we generated improved estimates of alcohol use and alcohol-attributable deaths and disability-adjusted life-years (DALYs) for 195 locations from 1990 to 2016, for both sexes and for 5-year age groups between the ages of 15 years and 95 years and older.

Alcohol use is a leading risk factor for global disease burden and causes substantial health loss. We found that the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimises health loss is zero. These results suggest that alcohol control policies might need to be revised worldwide, refocusing on efforts to lower overall population-level consumption.

 

Global, regional, and country-level estimates of hepatitis C infection among people who have recently injected drugs

Grebely J, Larney S, Peacock A, Colledge S, Leung J, Hickman M, et al. (2019) Addiction, 114(1): 150–66.

https://www.drugsandalcohol.ie/29394/

This study estimated the prevalence and number of people with recent injecting drug use living with HCV, and the proportion of people with recent injecting drug use among all people living with HCV infection at global, regional, and country-levels.

Although, globally, 39.2% of people with recent injecting drug use are living with hepatitis C virus (HCV) and 8.5% of all HCV infections globally occur among people with recent injecting drug use, there is wide variation among countries and regions.

 

Borderline personality disorder: resource utilisation costs in Ireland

Bourke J, Murphy A, Flynn D and Kells M (2018) Irish Journal of Psychological Medicine, Early online.

https://www.drugsandalcohol.ie/29512/

The objective of this study is to determine the use of direct health care resources by persons with BPD in Ireland and the corresponding costs.

There is a dearth of data on health care resource use and costs of community mental health services in Ireland. The absence of this data is a considerable constraint to research and decision-making in the area of community mental health services. This paper contributes to the limited literature on resource use and costs in community mental health services in Ireland. The absence of productivity loss data (e.g. absenteeism and presenteeism), non-health care costs (e.g. addiction treatment), and indirect costs (e.g. informal care) from study participants is a limitation of this study.

 

It's not all about price: factors associated with roll-your-own tobacco use among young people – a qualitative study

Breslin E, Hanafin J and Clancy L (2018) BMC Public Health, 18(1): 991. https://www.drugsandalcohol.ie/29424/

Smoking prevalence in Ireland is falling in all age groups, but the prevalence of roll-your-own (RYO) tobacco use is rising among young people. This qualitative study aims to explore and understand the factors associated with young people's use of RYO products.

While the lower cost of RYO products is very important for young smokers, other product characteristics and influences also incentivise and disincentivise use. A more comprehensive understanding of the multi-dimensional appeal of these products will assist policymakers to target strategies to reduce the attractiveness to young smokers of these products.

 

The precarious position of drug education workers in Ireland

Darcy C (2018) Economic and Social Review, 49(3): 361–72.

https://www.drugsandalcohol.ie/29721/

This article examines the position of drug education workers who deliver drug education in non-formal education settings to children and young people in Ireland. Employing secondary data and document analysis, the paper analyses three national drug strategies and the annual reports of 21 local and regional Drug and Alcohol Task Forces (DATFs), in order to determine the prominence of drug education workers within the statutory response to illicit drug use in Irish society.

 

Presentations to the emergency department with non-medical use of benzodiazepines and Z-drugs: profiling and relation to sales data

Lyphout C, Yates C, Margolin ZR, Dargan PI, Dines AM, Heyerdahl F, et al. (2019) European Journal of Clinical Pharmacology, 75(1): 77–81.

https://www.drugsandalcohol.ie/29713/

The aim of this paper is to describe presentations to the emergency department in Europe related to the recreational use of benzodiazepines and Z-drugs and compare regional differences in these presentations with legal drug sales of benzodiazepines and Z-drugs within each country.

 

Health status of the homeless in Dublin: does the mobile health clinic improve access to primary healthcare for its users?

Swabri J, Uzor C, Laird E and O'Carroll A (2018) Irish Journal of Medical Science, Early online.

https://www.drugsandalcohol.ie/29635/

This paper aims to explore and determine the specific health reasons for attending the mobile health unit and to investigate whether the MHC (mobile health clinic) improves access to primary healthcare for homeless people.

While the findings of this study are limited by the small sample size, they nevertheless indicate that the MHC promotes access to primary care service. Results also highlight the need to expand the healthcare approaches on the MHC to adequately meet the health needs of its target population.

 

Socio-demographic, health and lifestyle factors influencing age of sexual initiation among adolescents

Burke L, Nic Gabhainn S and Kelly C (2018) International Journal of Environmental Research and Public Health, 15(9): 1851.

https://www.drugsandalcohol.ie/29613/

This research explores relationships between contextual socio-demographic, health and lifestyle factors and the timing of first sexual intercourse among 15–17-year-olds in Ireland.

The study found that initiation of risk behaviours such as smoking, alcohol use, drunkenness or cannabis at younger ages was predictive of early sexual initiation among girls and boys.

 

Responses

Allen Carr's Easyway to Stop Smoking – a randomised clinical trial

Keogan S, Li S and Clancy L (2018) Tobacco Control, Early online. https://www.drugsandalcohol.ie/29870/

To determine if Allen Carr's Easyway to Stop Smoking (AC) was superior to Quit.ie in a randomised clinical trial (RCT).

All AC quit rates were superior to Quit.ie, outcomes were comparable with established interventions.

 

A cost-effectiveness analysis of school-based suicide prevention programmes

Ahern S, Burke LA, McElroy B, Corcoran P, McMahon EM, Keeley H, et al. (2018) European Child & Adolescent Psychiatry, 27(10): 1295–1304.

https://www.drugsandalcohol.ie/29779/

We aimed to conduct a full cost-effectiveness analysis (CEA) of the large pan-European school-based RCT, Saving and Empowering Young Lives in Europe (SEYLE). The health outcomes of interest were suicide attempt and severe suicidal ideation with suicide plans.

This CEA supports Youth Aware of Mental Health (YAM) as the most cost-effective of the SEYLE interventions in preventing both a suicide attempt and severe suicidal ideation.

 

Dissociable psychosocial profiles of adolescent substance users

Fitzgerald A, Mac Giollabhui N, Dolphin L, Whelan R and Dooley B (2018) PLoS ONE, 13(8): e0202498.

https://www.drugsandalcohol.ie/29577/

The aim of the present study was to examine the role of the individual, family, school, peer, and social environment on alcohol (lifetime and risky), tobacco (risky only), and cannabis use (lifetime and riskiness).

This study indicates that the relationship between the environment and substance use is more complex than previously thought.

 

Feasibility of recruitment to a behavioural smoking cessation intervention combined with ongoing online support

Reynolds CME, Egan B, O'Malley EG, Kennedy RA, Sheehan SR and Turner MJ (2019) European Journal of Public Health, 29(1): 170–72.

https://www.drugsandalcohol.ie/29559/

The aim of this randomized controlled trial was to determine whether a behavioural intervention in pregnancy supported by online information would improve smoking cessation rates. However, due to a number of challenges, recruitment to this trial was reluctantly halted. We aimed to recruit 220 maternal smokers within 2 years and after screening 1995 women, just 22 enrolled over a 8-month period. Only three women accessed the online element of the intervention and, at follow up, no women reported quitting. We report our findings as they may inform the design and powering of future smoking cessation interventions in pregnancy.

 

Individual differences in learning from probabilistic reward and punishment predicts smoking status

Rai LA, O'Halloran L, Jollans L, Vahey N, O'Brolchain C and Whelan R (2019) Addictive Behaviors, 88: 73–76.

https://www.drugsandalcohol.ie/29569/

The ability to update reward and punishment contingencies is a fundamental aspect of effective decision-making, requiring the ability to successfully adapt to the changing demands of one's environment. In the case of nicotine addiction, research has predominantly focused on reward- and punishment-based learning processes among current smokers relative to non-smokers, whereas less is known about these processes in former smokers.

Current smokers and ex-smokers were less likely to learn from rewards, supporting the hypothesis that deficient reward processing is a feature of chronic addiction. In addition, current smokers were more sensitive to punishment than ex-smokers, contradicting some recent findings.

 

A multi-faceted intervention to reduce alcohol misuse and harm amongst sports people in Ireland: a controlled trial

O'Farrell A, Kingsland M, Kenny S, Eldin N, Wiggers J, Wolfenden L and Allwright S (2018) Drug and Alcohol Review, 37(1): 14–22.

https://www.drugsandalcohol.ie/29526/

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

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

 

Advances in management of neonatal abstinence syndrome: what’s the score?

Shanahan KM and O'Grady MJ (2018) Irish Medical Journal, 111(7): 785.

https://www.drugsandalcohol.ie/29434/

Neonatal abstinence syndrome (NAS) is a constellation of symptoms and signs of withdrawal developing in infants following intrauterine exposure to opioids. In Ireland currently, this is typically methadone substitution for treatment of heroin addiction. In the United States, NAS has been declared an epidemic with a 5-fold increase in incidence between 2000 and 2012 and a current prevalence as high as 2% of live births. In Ireland, data from the Hospital Inpatient Enquiry (HIPE) system indicates that between 2012 and 2016, 501 infants were treated for NAS; half of whom were in the three Dublin maternity hospitals. The most recent survey of practice within neonatal units in Ireland and the UK identified widespread variation in methods for assessment and treatment of NAS, reflecting the lack of quality evidence upon which current treatment regimens are based.

Cannabis oil in an Irish children’s critical care unit

Fennessy P, Murphy L and Crowe S (2018) Irish Medical Journal, 111(8): 807.                                                            

https://www.drugsandalcohol.ie/29642/

We present a case of a five-year-old female admitted postoperatively to the Paediatric Critical Care Unit with a history of refractory seizures for which her parents were administering cannabis oil.