May 2016 saw important developments for those working in the illicit drugs area. A new programme for government was published and a new Minister for Communities and the National Drugs Strategy appointed.

Programme for Partnership Government

A programme for partnership government was published on 11 May  2016.¹ This document lays out the direction the new government plans to take across a range of policy areas, including those related to drug and alcohol use. A number of specific commitments have been made to:

• complete and commence the new National Drugs Strategy within 12 months,
• pursue a health-led rather than criminal justice approach to drug use,
• legislate for medically supervised injection rooms,
• produce step-down services and facilities for people leaving drug rehabilitation,
• enact the Public Health (Alcohol) Bill,
• strengthen the regulation of alcohol advertising to children,
• support the expansion of Local Drugs Task Force projects and the Garda Youth Diversion programme,
• fund an expansion of youth services to early school leavers and other young people,
• reduce drug- and alcohol-related crime through a combination of policing, treatment and demand reduction activities, and
• ‘properly’ resource An Garda Síochána to be able to reduce the sale and supply of illicit drugs on the streets.

Subsequently, the Department of Health published its briefing for new ministers that describes the work of the department and those responsible for its delivery. Developing the new National Drugs Strategy, providing policy input for the legislative changes required to introduce medically supervised injecting centres, and pursuing the adoption of the Public Health (Alcohol) Bill are all identified as part of the Department of Health’s work.²

New Minister of State for the National Drugs Strategy

Following the publication of these documents, on 19 May Catherine Byrne TD was appointed Minister of State for Communities and the National Drugs Strategy. Her brief is spread across the Department of Health and the Department of Regional Development, Rural Affairs, Arts and the Gaeltacht. She is a Fine Gael TD for Dublin South-Central, a former Lord Mayor of Dublin, and was the party’s spokesperson on the National Drugs Strategy from 2007 to 2010. More recently she has been a member of the Oireachtas Cross-Party Group on Alcohol and the Oireachtas Committee on Health and Children. She attributes great importance to the role of Minister with responsibility for the National Drugs Strategy – in 2015 she called for it to be upgraded to a Cabinet position³.

Over the years Minister Byrne has made numerous contributions to the debate on drug and alcohol issues. With respect to the current Government’s priorities, she has been a long-standing advocate for the introduction of medically supervised injecting centres.^4,5 She has given her backing to all elements of the Public Health (Alcohol) Bill,⁶ in particular ‘wholeheartedly’supporting the introduction of minimum unit pricing for alcohol.⁷ However, she has argued strongly against any alcohol sponsorship of sporting events,^8,9 and has expressed the view that the Bill does not goes far enough in relation to this issue. For example, in February 2015 she urged the Minister for Health to ‘re-examine how we can curtail alcohol sponsorship of sporting events because we need to send out a strong message that alcohol has no place in our sporting events’.⁸

Minister Byrne has been critical of the way in which drug services are structured and has expressed concern about the duplication of services in some areas.^3,4 She has questioned the suitability of ‘the drugs task force model’, looking for its ‘reconfiguration’ so that the needs of users would be better met.¹⁰ Also she has sought changes to school-based drug and alcohol education programmes.⁴ At the time of writing it is unclear where the Minister stands on the issue of decriminalisation which had been put on the agenda by her predecessor Aodhán Ó Ríordáin and the findings of the Joint Committee on Justice, Defence and Equality.¹¹

Lucy Dillon

¹ A programme for partnership government (2016) http://www.drugsandalcohol.ie/25508/

² Department of Health (2016) Departmental Brief for Minister May 2016 http://www.drugsandalcohol.ie/25536/

³ Byrne C (2015, 26 March) Drug addiction and recovery models. Joint Oireachtas Committee on Health and Children. Downloaded 9 June 2016 https://www.kildarestreet.com/committees/?id=2015-03-26a.2086&s=Drug+Addiction+and+Recovery+Models

⁴Byrne C (2015, 9 July) National Drugs Strategy. Joint Oireachtas Committee on Health and Children. Downloaded 9 June 2016  https://www.kildarestreet.com/committees/?id=2015-07-09a.3440&s=Drug+Addiction+and+Recovery+Models#g3455

⁵Byrne C (2015, 23 April) Appointment of Aodhán Ó Ríordáin as Minister of State for the National Drugs Strategy. Downloaded 9 June 2016  http://www.finegael.ie/latest-news/2015/new-drugs-minister-could-/index.xml

⁶Byrne C (2015, 4 February) Public Health (Alcohol) Bill. Downloaded 9 June 2016  http://www.finegael.ie/latest-news/2015/new-legislation-rightly-r/index.xml

⁷Byrne C (2015, 23 April) ‘General Scheme of Public Health (Alcohol) Bill 2015’. Joint Committee on Health and Children Debate. Downloaded 9 June 2016  https://www.kildarestreet.com/committees/?id=2015-04-23a.3377&s=I+wholeheartedly+support+minimum+unit+pricing#g3403

⁸Byrne C (2014, 18 June) Cross-Party Oireachtas Group on Alcohol Misuse. Downloaded 9 June 2016  http://www.finegael.ie/latest-news/2014/discussion-of-alcohol-spo/

⁹Byrne C (2011, 1 December) Alcohol marketing debate. Joint Committee on Health and Children. Downloaded 9 June 2016  http://oireachtasdebates.oireachtas.ie/Debates%20Authoring/DebatesWebPack.nsf/committeetakes/HEJ2011120100004

¹⁰Byrne C (2013, 10 July) Estimates for public services 2013. Committee on Health and Children: Select Sub-Committee on Children and Youth Affairs. Downloaded 9 June 2016   https://www.kildarestreet.com/committees/?id=2013-07-10a.545

¹¹Joint Committee on Justice, Defence and Equality (2015, 5 November) Report of the committee on a harm reducing and rehabilitative approach to possession of small amounts of illegal drugs.

 31/JDAE/035.http://www.drugsandalcohol.ie/24750/

 The Department of Health has published its annual report for 2015 on progress in implementing the actions included in the National Drugs Strategy.¹  The report is a descriptive account of activities over the period – in some cases they are reported at a national level, while in others they are reported at the level of the Community Healthcare Organisations (CHOs).²

 Where there has been no change, the report tends to repeat the 2014 content. No reference is made in the report to the key performance indicators identified in the NDS and neither is there any overall assessment of the level of progress made in achieving outcomes. The overall messages under each pillar remain the same as in the 2014 report.²

 This article focuses on some of the changes reported to have happened under each of the five pillars over the 12-month period.

 Supply reduction
Overall progress in delivering on the supply reduction actions continued to be made in relation to local supply reduction initiatives, and compliance with EU-level obligations and operations. In 2015 there was progress made on policy and legislative initiatives, including the Road Traffic Bill 2016, the Public Health (Alcohol) Bill 2015, and the proposed bill to amend the Misuse of Drugs Act to restore the government’s power to declare substances to be controlled. Furthermore, some progress was made on activities that had been affected by the difficult economic situation:

• Forensic Science Ireland (FSI) received €1 million additional funding in the 2016 estimates for additional staff members.
• Funding was also allocated for a new forensic science laboratory. Construction is due to start in 2019.
• The DNA database was launched late in 2015 and is being used by the Gardaí and FSI.
• Some steps were taken to meet the need for an integrated system to track the progression of offenders with drug-related offences through the criminal justice system. A Chief Information Officer was appointed with responsibility for developing the concept of a ‘justice and equality information hub’; approval was given for three ‘Pathfinder’ projects to prove the concept.

Prevention
This area of the strategy deals with both illicit drugs and alcohol. It continued to be the case that since the start of the strategy, most progress was made in setting up education programmes and drug policies in schools, developing youth interventions and facilities in out-of-school settings, and developing online prevention and help services. Work was on-going in progressing programmes targeting families experiencing difficulties owing to drug/alcohol use and the children of drug users. Work was also under way on selective prevention measures to reduce under-age and binge drinking.

Treatment and rehabilitation  

Activity under the treatment and rehabilitation pillar is mainly illustrated by using examples of activities from CHOs. The overall message for 2015 was the same as in 2014 – the development and improvement of the range, integration and availability of treatment and rehabilitation services were reported to be on-going, as was improvement in access to these services. With regard to a drugs intervention programme (incorporating a treatment referral option) for young people who come to the attention of the Gardaí as a result of their drug use, Gardaí now have an information leaflet to give to young people.

No further action was reported since the last report in relation to the following actions:

• While work was reported to be well under way with regard to training programmes for all involved in the provision of substance misuse treatment services, treatment guidelines for treating blood-borne viruses had yet to be published.
• In response to the issue of drug-related deaths, the findings of the naloxone demonstration project were still awaited.
• No progress was reported in relation to the development of a National Overdose Prevention Strategy nor to the review of the regulatory framework in relation to prescription drugs.
• A statutory regulatory framework for the provision of counselling within substance misuse services continued to be delayed because counselling was not one of the 12 health and social care professions designated under the Health and Social Care Professionals Act 2005.

Research and information

Many activities under this pillar were on-going. The five key epidemiological indicators relating to drug use (prevalence in general population, prevalence and patterns of use of specific drugs, drug treatment demand, drug-related deaths and infectious diseases) and the associated data collection systems were all under continuous development. The HRB National Drugs Library continued to promote the use of evidence in drugs work and provide resources to those working in the area. In line with the EU Early Warning System, a communication protocol for notification of drug use emergencies was being further developed.

The 2015 research work programme of the National Advisory Committee on Drugs and Alcohol was the same as for 2014. Progress was hindered owing to the lack of a researcher and a reduced budget. However, there were some specific developments:

• The development of indicators for harm reduction, public expenditure and drugs and crime, was under way. In 2015, for the first time, data on drug treatment in prisons were included in the report on prisons provided to the EMCDDA.
• The HSE was finalising a plan for the establishment and rollout of the Individual Health Identifier (IHI).

Co-ordination

There was little change in relation to this pillar, with many of the proposed structures already in place. Some progress was made in developing engagement with specifically identified at-risk groups, including Travellers, new communities, LGBTs, the homeless and sex workers. A subgroup of the National Coordinating Committee for Drug and Alcohol Task Forces reviewed and updated the 2009 NDS Traveller Framework Document, and was identifying lead agencies to implement the recommendations in the document.

Lucy Dillon

¹Department of Health (2016) National Drugs Strategy 2009­–2016: progress report to end 2015. http://www.drugsandalcohol.ie/25365/

² Delivered through the HSE and its funded agencies, the nine Community Healthcare Organisations provide the broad range of services that are delivered outside of the acute hospital system, i.e. primary care, social care, mental health and health and wellbeing services. https://www.hse.ie/eng/services/publications/corporate/CHO_FAQ.pdf

³ Pike B (2015) National Drugs Strategy [NDS] 2009–2016: progress in 2014 Drugnet Ireland (55): 12– 13. http://www.drugsandalcohol.ie/view/journal_volume/Drugnet_Ireland/Issue_55,_Autumn_2015.html

The work of four international bodies with a particular interest in investigating just what a human-rights based approach to drug policy might look like is outlined below.

International Centre for Human Rights and Drug Policy (HRDP)

The International Centre on Human Rights and Drug Policy (HRDP) is dedicated to developing and promoting innovative and high-quality legal and human rights research and teaching on issues related to drug laws, policy and enforcement.  It pursues its mandate by publishing original, peer-reviewed research on drug issues as they relate to international human rights law, international humanitarian law, international criminal law and public international law.

In a six-page  joint submission to the 2016 UNGASS on drugs, HRDP and Amnesty International took the following view:¹

The UNGASS on drugs must be viewed as the beginning of a wider reflective process underpinned by a rigorous and inclusive assessment of the global state of drug control in the negotiations of a new Political Declaration and Plan of Action to be adopted in 2019. The lead up to 2019 is a critical moment to ensure that political commitments to drug control have clear, unambiguous articulations of international human rights law and standards.

International Network of People who Use Drugs (INPUD)

The International Network of People who Use Drugs (INPUD) is a global peer-based organisation that seeks to promote the health and defend the rights of people who use drugs. In October 2015 it published a 42-page ‘consensus statement’ on human rights, health, and the law in relation to people who use drugs.²  The statement lists  ten ‘established and recognised human rights’ to which people who use drugs are entitled:

1. human rights, which must be protected by the rule of law;
2. the right to non-discrimination;
3. the right to life and security of person;
4. the right not to be subjected to torture or to cruel, inhuman, or degrading treatment;
5. the right to the highest attainable standard of health;
6. the right to work, to free choice of employment, to just and favourable conditions of work, and to protection against unemployment;
7. the right not to be subjected to arbitrary arrest or detention;
8. the right to bodily integrity;
9. the right to found a family entitled to protection by the law, entitled to privacy, and entitled to be free from arbitrary interference; and
10. the right to assemble, associate, and form organisations.

Johns Hopkins–Lancet Commission on Drug Policy and Health

Ahead of UNGASS 2016 on drugs, the Johns Hopkins–Lancet Commission, comprising 22 experts from a wide range of disciplines and professions in low-, middle- and high-income countries, examined the emerging scientific evidence on public health issues arising from drug-control policy in order to inform and encourage a central focus on public health evidence and outcomes in drug policy debates. The Commission’s work was framed by the UN-endorsed Sustainable Development Goals (SDGs) for 2030, which aspire to human-rights-centred approaches to ensuring the health and wellbeing of all people.  In their 50-page report, the Commission made 11 recommendations regarding future drug policy, including the following:

-        Decriminalise minor, non-violent drug offences – use, possession, and petty sale – and strengthen health and social-sector alternatives to criminal sanctions.

-        Ensure easy access to harm-reduction services, e.g. opioid substitution treatment, nsp, supervised injection sites and access to naloxone, for all who need them, and recognise the effectiveness and cost-effectiveness of scaling up and sustaining these services.

-        Prioritise people who use drugs in treatment for HIV, HCV infection, and tuberculosis, and ensure that services are adequate to enable access for all who need care.

-        Reduce the negative impact of drug policy and law on women and their families, especially by minimising custodial sentences for women who commit nonviolent offences and developing appropriate health and social support, including gender-appropriate treatment of drug dependence, for those who need it.

-        Health, development and human rights indicators should be included in metrics to judge success of drug policy, e.g. access to treatment, frequency of overdose deaths, and access to social welfare programmes for people who use drugs. All drug policies should also be monitored and assessed as to their impact on racial and ethnic minorities, women, children and young people, and people living in poverty.

-        Move gradually toward regulated drug markets and apply the scientific method to their assessment.

Pompidou Group­

Part of the Council of Europe, the Pompidou Group comprises 38 states, including Ireland. Its core mission is to contribute to the development of multidisciplinary, innovative, effective and evidence-based drug policies in its member states. ‘Bringing human rights to the forefront of drug policy’ is its top priority for 2015–2018.

The aims of the Pompidou Group’s current work programme include:

-        increasing awareness of human rights obligations and reduction in human rights violations occurring in the pursuit of drug policy goals;

-        contributing to reducing stigmatisation and discrimination;

-        promoting the right of access to healthcare for drug dependent people in detention;

-        highlighting and recognising the pivotal role of the Pompidou Group, as a part of the Council of Europe, in promoting human rights as a fundamental drug policy principle; and

-        promoting the mainstreaming of gender aspects in all areas of drug policy.

Brigid Pike

¹ International Centre on Human Rights Centre and Amnesty International (2016, 12 April) Joint Submission: The promotion and protection of human rights and international drug control. Retrieved 28 April 2016 http://www.hr-dp.org/files/2016/04/12/AI_HRDP_UNGASS_Submission_FINAL1.pdf

² INPUD (2015) Consensus statement on drug use under prohibition: human rights, health and the law. London: INPUD. Retrieved 28 April 2016 http://www.inpud.net/en/news/inpud-consensus-statement-drug-use-under-prohibition-human-rights-health-and-law

³ Johns Hopkins–Lancet Commission on Drug Policy and Health (2016) Public health and international drug policy Lancet Vol. 387: 1427–1480.  Published Online, 24 March 2016, http://dx.doi.org/10.1016/S0140-6736(16)00619-X

⁴ Pompidou Group (2014) Pompidou Group work programme 2015–2018: ‘Drug policy and human rights: new trends in a globalised context’. P-PG/MinConf (2014) 4. Retrieved 28 April 2016  

http://www.coe.int/T/DG3/Pompidou/Source/Documents/P-PG_MinConf%20(2014)%204%20WorkProgramme%202015-18_ENGLISH.pdf

UNGASS 2016 has been and gone. Held on 19–21 April in New York, it comprised not only the general assembly sessions but also over 40 side events, which were organised by individual member states, UN agencies and international NGOs.¹

Two policy statements to emerge from the UNGASS process that are relevant to Ireland’s national drugs policy are described below. The language used and the points emphasised in the two papers differ, particularly in relation to demand reduction, supply reduction and human rights issues, reflecting the challenges of reaching a consensus among 28 European countries as opposed to some 200 countries from around the globe.²

EU common position

Ahead of UNGASS 2016, the European Union (EU) adopted a common position paper, which formed the basis for EU member states’ contributions.² Grounded on two general principles – the need for an integrated, balanced and evidence-based approach and a sound public health approach – the nine-page position paper is broken into ten sections, listed below, which contain a total of 36 policy statements, some of which are noted here.

-        International legal framework – there is ‘sufficient scope and flexibility within the provisions of the UN Conventions to accommodate a wide range of approaches to drug policy’;

-         Human rights – states parties are invited ‘to develop and implement, when appropriate, alternatives to incarceration and coercive sanctions applicable to persons having committed minor, non-violent drug-related offences’;

-         Role of civil society in formulating, implementing, monitoring and evaluating drug policies, ‘especially in the field of drug demand reduction’ is affirmed;

-         Demand reduction and related measures, including prevention and treatment– ‘dependent drug users should be first and foremost considered as people in need of attention, care and treatment in order to improve their health and condition and enhance social integration, tackling marginalization and stigmatization’ and, in this context, states parties ‘should make sure that access to risk and harm reduction measures is guaranteed, as such measures have proved effective in reducing the number of direct and indirect drug-related deaths and notably blood-borne infectious diseases associated with drug use’;

-         Access and availability of drug demand reduction measures­ – states parties are urged to ‘guarantee broad availability, coverage and access’ to drug dependence treatment for all members of society’;

-        Availability of controlled substances for medical and social purposes ­– ‘as regards psychoactive substances with proven legitimate medical or scientific use, a thorough and careful assessment is crucial before a decision is taken, with a view to avoiding undue restrictions on legitimate use of such substances’;

-        Supply reduction and related measures – covers drug trafficking, international cooperation, with particular attention the spreading and diversification of precursors chemicals;

-        Alternative development – to establish viable economic alternatives to prohibited cultivation of crops in source countries;

-        Drugs policy and children, youth and women – reference is made to article 33 of the Convention on the Rights of the Child, asserting the need ‘to protect children from the illicit use of narcotic drugs and psychotropic substances’, and differences in the ways men and women are affected by drugs and drug policies are acknowledged;

-        New challenges, threats and realities in preventing and addressing the world drug problemincluding new psychoactive substances and the role of new communication technologies.

UNGASS outcome statement

Agreed by member states at 59^th meeting of the UN Commission on Narcotic Drugs (CND) in Vienna in March 2016, this outcome document, entitled ‘Our joint commitment to effectively addressing and countering the world drug problem’, was adopted at UNGASS 2016.³ Having reaffirmed member states’ commitment to the three UN drug conventions and member states’ determination ‘to tackle the world drug problem and to actively promote a society free of drug abuse in order to help ensure that all people can live in health, dignity and peace, with security and prosperity and to address public health, safety and social problems resulting from drug abuse’, the 24-page outcome statement sets out a series of operational recommendations under seven headings.

Demand reduction and related measures, including prevention and treatment – under treatment, the document eschews use of the term ‘harm reduction’ but invites national authorities to consider ‘effective measures aimed at minimizing the adverse public health and social consequences of drug abuse, including appropriate medication-assisted therapy programmes, injecting equipment programmes, as well as antiretroviral therapy and other relevant interventions that prevent the transmission of HIV, viral hepatitis and other blood-borne diseases associated with drug use’.

Availability of and access to controlled substances exclusively for medical and scientific purposes – focuses on improving processes for ensuring availability and access.

Supply reduction including law enforcement, drug-related crime, money laundering and judicial cooperation ­– as well as strengthening efforts to tackle international drug trafficking and its links to other forms of organised crime, the outcome statement calls on member states to strengthen multi-disciplinary measures to ‘promote comprehensive supply reduction efforts that include preventive measures addressing, inter alia, the criminal justice and socio-economic related factors that may facilitate, drive, enable and perpetuate organized crime and drug-related crime’.

Cross-cutting issues: human rights, youth, children, women and communities – along with nine recommendations regarding youth, children and women, the outcome statement discusses the need for proportionate and effectivepolicies and responses in the criminal justice sector, in compliance with the provisions of the three UN drug conventions. Recommendations include  encouraging the development, adoption and implementation of ‘alternative or additional measures with regard to conviction or punishment of an appropriate nature’ and also promoting ‘proportionate national sentencing policies, practices and guidelines for drug-related offences whereby the severity of penalties is proportionate to the gravity of offences and whereby both mitigating and aggravating factors are taken into account’.

Cross-cutting issues in countering the world drug problem – this section contains 25 recommendations relating to new psychoactive substances, amphetamine-type stimulants, precursors, and the non-medical use of prescription drugs, as well as enhancing capacity to respond the evolving reality and emerging and persistent challenges and threats.

Strengthening international cooperation is to continue to be based on the principle of common and shared responsibility, strengthening assistance and enhancing cooperation between member states.

Alternative development­ – this section sets out the measures by which UN member states will address drug-related socio-economic issues related to the illicit cultivation of narcotic plants and the illicit manufacture and production and trafficking of drugs around the world.

Two reports – one by Ireland’s Department of Health and one by an international non-governmental organisation – assess what UNGASS 2016 achieved.

Ireland’s Department of Health

In its briefing to the incoming Minister for Health in May 2016, the Department of Health wrote:

The UN General Assembly held a Special Session (UNGASS) on drugs from 19^th to 21^st April 2016 in New York. This Special Session was an important milestone in achieving the goals in the policy document of 2009 ‘Policy Declaration and Plan of Action on International Cooperation towards an Integrated and Balanced Strategy to Counter the World Drug Problem’ which defined action to be taken by Member States as well as goals to be achieved by 2019. An Outcomes Document, adopted by acclaim at the first plenary session, contained a series of operational recommendations to counter the world drug problem. It showed progress in agreeing language on proportional sentencing, the importance of evidence-based policies, gender mainstreaming, greater consideration of human rights aspects, new psychoactive substances/NPS, and in taking account of WHO resolutions.⁴

International Drug Policy Consortium (IDPC)

IDPC is global network of 143 NGOs that focus on issues related to drug production, trafficking and use, promoting objective and open debate on the effectiveness, direction and content of drug policies at the national and international level, and supporting evidence-based policies that are effective at reducing drug-related harm. IDPC commented regarding UNGASS 2016:

 Although the Outcome Document does include some good language on some points (such as access to essential medicines, development, overdose prevention and alternatives to incarceration), it could have been a very different document if the more progressive inputs had not been overlooked.

IDPC has compiled a document containing a selection of the ‘more strong, progressive and evidence-based language’, which had been on the table during the negotiations.⁵

Brigid Pike

¹ Information retrieved 13 May 2016 https://www.unodc.org/ungass2016/

² European Union (2016) Common position on UNGASS 2016.Retrieved 13 May 2016 http://www.unodc.org/documents/ungass2016//Contributions/IO/EU_COMMON_POSITION_ON_UNGASS.pdf

³  Draft resolution submitted by the President of the General Assembly: Our joint commitment to effectively addressing and countering the world drug problem. 14 April 2016. E/CN.7/2016/L.12/Rev.1Retrieved 13 May 2016

https://documents-dds-ny.un.org/doc/UNDOC/LTD/V16/017/77/PDF/V1601777.pdf?OpenElement

⁴ Department of Health (2016) Departmental Brief for Minister May 2016 http://www.drugsandalcohol.ie/25536/

⁵ Document retrieved 10 June 2016https://dl.dropboxusercontent.com/u/64663568/Press%20releases/UNGASS-shadow-declaration_FINAL.pdf

Right to life (Art 2 ECHR)

With an average 600 drug-related deaths every year,² Ireland has almost four times the overall European Union (EU) average. ICCL identifies six harm reduction measures to help reduce this number, some of which have already been, or are in the process of being, introduced, and some of which are under discussion.

Prohibition of torture and inhuman or degrading treatment or punishment (Art 3 ECHR)

According to ICCL, persons with drug problems suffer considerably and their health is eroded by street drugs and by drug-taking practices, and there is also transmission and high prevalence of blood-borne viruses among the drug-using population. Compounded by the stigmatisation associated with substance misuse, ICCL suggests that these and a range of other conditions can be perceived by the persons suffering them as inhuman or degrading. Policies focusing on drug use as a health problem rather than a criminal problem might strike a better balance in addressing these human rights concerns. 

Drug use may be the result of lack of access to palliative treatment or failure by service providers to respond to the real or perceived somatic or mental health needs or conditions of the user, for example undisclosed traumatic experiences such as abuse suffered during childhood, that render a person more vulnerable to problematic substance use. ICCL invites policy makers to examine the degree to which suffering might be reduced or prevented, and non-medical use of prescription drugs or use of illegal drugs reduced, if doctors were to have greater prescription freedom, subject only to professional standards, without a criminal policy inspired gatekeeping role and associated sanctions for doctors perceived as over-prescribing psychoactive substances.

Prohibition of forced labour/slavery (Art 4 ECHR)

Drug policies that stigmatise, marginalise and exclude users often push them into the hands of persons who exploit them sexually or otherwise in situations that are tantamount to forced labour, sometimes modern slavery. ICCL asks whether different policies would eliminate these situations, and if so, does this raise questions from a human rights perspective. Although not under the potential scope of Article 4, ICCL notes that working conditions and work-place environments may be conducive to drug use. This may occur because of work-related stress, unreasonable performance objectives or demands, or an excessively competitive atmosphere. Performance enhancement drugs can also lead to problematic use.

Right to liberty and personal freedom (Art 5 ECHR)

Using UN estimates, ICCL points out that there may be around 30 million occasional drug users in the EU, and some 5 million problematic drug users. However, the EMCDDA reported only 1.25 million drug offences in the EU in 2014. Of these, 781,000 were for cannabis use and a further 223,000 involved use of other drugs; cannabis supply amounted to 116,000 recorded offences, with supply of other drugs accounting for 86,000 and other offences 42,000 criminal cases. Based on these figures, ICCL suggests that the application of criminal law to drugs is uneven and therefore risks being discriminatory. If use were punished systematically, ICCL asserts it would mean criminalising within the EU the equivalent of seven times the population of the Republic of Ireland, or more than once its population if only problematic users were targeted.

The ICCL asks whether drug-related criminal law fails on three counts:

-        its vocation of general non-discriminatory application, while drug trafficking continues to be rampant despite considerable law enforcement efforts; 

-        its purpose of preserving public health given the scale of the drug problem and the reported collateral damage of drug policy; and

-        its purpose of protecting children.

Right to private life, freedoms of thought, expression, association (cf. Arts 8, 9, 10, 11 …)

Referring to the right to private life, ICCL suggests this right arguably extends to enjoying an experience of one’s choice, including those that alter one’s mental perceptions or state of consciousness, especially if it does not transcend to the public or endanger others. ICCL goes on to point out that the interdiction of such activities (in terms of their mind-altering power) would be contrary to Article 8, unless provided for in law ‘in the interests of national security, public safety or the economic wellbeing of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others’. The objective pursued would have to be demonstrably necessary in a democratic society and the interference proportionate. ICCL goes on to suggest that policy makers might wish to take such matters into account when considering decriminalisation and the home-growing of cannabis.

Prohibition of discrimination (Art 14 ECHR)

ICCL notes that drug laws affect far more people in disadvantaged communities than in other communities, although drug use is roughly the same across all communities. It also notes that some people argue that subordinating the treatment of substance use disorders to criminal policy or related moral considerations, as compared to other self-inflicted conditions that remain a purely medical matter, is also discriminatory. Examples of self-inflicted medical conditions that don’t attract a criminal charge include tobacco-related cancer, alcohol-related diseases, diet-related hypertension, certain cases of diabetes, extreme sport-related injury or even suicide attempts.

ICCL suggests that these biases can affect access to and the modalities of palliative, substitution or maintenance treatment for substance use disorders, and invites policy makers to consider whether current drug policies that hinge on criminal law and repression (a) have an unnecessary, undesirable or discriminatory impact on the delivery of health care for persons suffering from substance use disorders, and (b) place the persons concerned in significantly less favourable conditions for access to and quality of treatment than people who suffer from other self-inflicted medical conditions.

Brigid Pike

¹ Irish Council for Civil Liberties (2015, 6 August) Submission to the Houses of the Oireachtas Joint Committee on Justice, Defence and Equality on the review of Ireland’s approach to the possession of limited quantities of certain drugs.Retrieved 28 April 2016 http://www.drugsandalcohol.ie/25444/

²Health Research Board (2015) Drug-related deaths and deaths among drug users in Ireland: 2013 figures from the National Drug-Related Deaths Index. Dublin: Health Research Board. http://www.drugsandalcohol.ie/24676/

According to the Irish Human Rights and Equality Commission (IHREC), ‘human rights are the basic rights and freedoms that belong to everyone. International law, including treaties, contain the provisions which give human rights legal effect.’¹ In the decades since World War Two, human rights standards have been adopted at United Nations, Council of Europe and the European Union level. Ireland has committed to upholding many of these standards.

United Nations (UN)

Adopted by the UN General Assembly on 10 December 1948, the Universal Declaration of Human Rights (UDHR) spelt out for the first time in human history basic civil, political, economic, social and cultural rights that all human beings should enjoy. It set ‘a common standard of achievement for all peoples and nations'. 

There are nine core international human rights instruments. Each of these instruments has established a committee of experts to monitor implementation of the treaty provisions by its States parties.

1. International Covenant on Civil and Political Rights (1966)

2. International Covenant on Economic, Social and Cultural Rights (1966)

3. Convention on the Elimination of All Forms of Racial Discrimination (CERD)(1965)

4. Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) (1979)

5. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT) (1984)

6. Convention on the Rights of the Child (1989)²

7. Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (1990)

8. Convention on the Rights of Persons with Disabilities (CPRD)(2006)

9. Convention for the Protection of All Persons from Enforced Disappearance (CPPED)(2006)

Ireland has ratified the first six of these Conventions.

Additional information on the UN treaties can be found at http://www.ohchr.org/EN/ProfessionalInterest/Pages/CoreInstruments.aspx

Europe

Protection of human rights in Europe (a ‘regional system’) is provided by two institutions with separate sets of laws and courts – (1) the Council of Europe system comprising the European Convention on Human Rights, the Revised European Social Charter and the European Court of Human Rights, and (2) the European Union system comprising the Charter of Fundamental Rights, the EU Directives on Equality and the Court of Justice of the European Union.

Council of Europe system

When it came to giving binding legal force to the rights in the UDHR, the Council of Europe adopted two separate treaties – the European Convention of Human Rights, which guarantees civil and political rights, adopted in 1950, and the European Social Charter, which guarantees social and economic rights, e.g. everyday human rights related to employment, housing, health, education, social protection and welfare, adopted in 1961.  The European Court of Human Rights rules on individual or State applications alleging violations of the civil and political rights set out in the European Convention on Human Rights.

Additional information can be found at

European Convention on Human Rights http://www.echr.coe.int/Documents/Convention_ENG.pdf

European Social Charter http://www.coe.int/en/web/conventions/full-list/-/conventions/treaty/163  

European Court of Human Rights http://www.echr.coe.int/Pages/home.aspx?p=home&c=

European Union (EU) system

The EU’s Charter of Fundamental Rights brings together in a single document the fundamental rights protected in the EU. The Charter contains rights and freedoms under six titles: Dignity, Freedoms, Equality, Solidarity, Citizens' Rights, and Justice. Proclaimed in 2000, the Charter became legally binding on the EU with the entry into force of the Treaty of Lisbon in December 2009. The Court of Justice of the European Union interprets EU law to make sure it is applied in the same way in all EU countries, and settles legal disputes between national governments and EU institutions.

Additional information can be found at

Charter of Fundamental Rights http://www.europarl.europa.eu/charter/pdf/text_en.pdf

Court of Justice of the European Unionhttp://europa.eu/about-eu/institutions-bodies/court-justice/index_en.htm

Ireland

Bunreacht na hÉireann (the Irish Constitution) was signed into law in 1937. Articles 38­–44 set out fundamental rights. The Irish courts have interpreted the Constitution as including certain other human rights, i.e. ‘unenumerated rights’, which are not explicitly set out in the Constitution but are recognised by the courts.

The European Convention on Human Rights Act 2003 gives effect to the standards set out in the European Convention on Human Rights in Irish law. This allows these rights to be considered before the Irish courts. The Constitution has primacy over the ECHR Act (in cases where there is any uncertainty) and, if the two conflict, the Constitution prevails.

Additional information can be found at

Bunreacht na hÉireann http://www.taoiseach.gov.ie/eng/Historical_Information/The_Constitution/

European Convention on Human Rights Act 2003  http://www.ihrec.ie/legal/europeanconvent.html

This account has been compiled with the assistance of the Irish Human Rights and Equality Commission,  www.ihrec.ie

¹ Irish Human Rights and Equality Commission (2015) Human rights explained: guide to human rights law. Dublin: IHREC, p. 6. http://www.ihrec.ie/download/pdf/ihrec_human_rights_explained.pdf

² Article 33 of the Convention on the Rights of the Child reads: ‘States Parties shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances as defined in the relevant international treaties, and to prevent the use of children in the illicit production and trafficking of such substances.’

In May 2016 the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) published the European drug report 2016: trends and developments summarising  the latest trends across the 28 EU member states, and Norway and Turkey.¹  The report highlights the increasing use of MDMA following a period of decline in recent years, with greater levels of production helped by new sources of precursors and production techniques.  The drug’s popularity with existing stimulant users has grown and a new generation of users is emerging, presenting greater health risks as more high potency products become available. 

The EU Early Warning System (EWS) reported 98 new substances, including 24 synthetic cannabinoids and 26 synthetic cathinones.  The growing number of new synthetic opioids is a cause for concern and may indicate that producers are targeting existing opioid users. Several deaths associated with NPS and stimulants have been reported in Europe but most of the 6,800 overdose deaths in 2014 were related to heroin and other opioids.  Increased heroin availability, higher purity, ageing users and changing consumption patterns may be factors in this increase. Just over half of the 1.2 million people who received treatment for illicit drug use in the EU in 2014 received substitution treatment for opioid use.

Use of cannabis among young Europeans (15–34) does not appear to have fallen and there have been increases in use in some European countries.  Potency levels of herbal cannabis are historically high, presenting health and social risks particularly to the one per cent of European adults who are estimated to be daily or almost daily users.   The numbers of those entering treatment for the first time for whom cannabis is their main problem drug has increased steadily since 2006, indicating greater levels of use, more potent products and greater availability of treatment services.

At the launch of the report, Dimitris Avramopoulos, European Commissioner for Migration, Home Affairs and Citizenship, said:

Europe faces a growing problem with drugs. New psychoactive substances, stimulants, heroin and other opioids continue to be in high demand and supply, with major impacts on public health. That is why the 2016 European Drug Report is an important addition to our evidence base on the drugs problem and a helpful tool for European policymakers to shape policies and actions to address it. With this knowledge in hand, we will continue to call on EU Member State authorities, third countries, internet companies and civil society to redouble cooperation in fighting this global challenge.

The situation described in the European drug report is presented below under a series of headings.  The EMCDDA  used the most recent data available to provide aggregate figures.  While data on some indicators, such as treatment demand, are supplied annually, the year of the most recent prevalence data can vary. 

Cannabis

• The EMCDDA estimates that around 16.6 million      (13.3%) of young Europeans (15–34) used cannabis in the last year, 9.6      million of whom (16.4% of this age group) are aged 15–24 years. 

• The most recent survey results show different trends in last-year cannabis use. Surveys for relatively high-prevalence countries, such as Germany, Spain and the United Kingdom, all show decreasing or stable cannabis prevalence over the past decade, while France shows increases in prevalence after 2010.  Countries which have historically reported lower cannabis use have seen increases in recent surveys.
• Levels of lifetime cannabis use in 2013/14 among school-aged children ranged from 5 per cent of girls and 7 per cent of boys in Sweden, to 26 per cent of girls and 30 per cent of boys in France.
• The number of first-time treatment entrants for cannabis as their main problem drug increased from 45,000 in 2006 to 69,000 in 2014, with 55 per cent of these reporting daily use.
• In 2014, 682,000 seizures of cannabis were reported in the European Union (453,000 of herbal cannabis, 229,000 of cannabis resin). There were a further 33,000 seizures of cannabis plants. The quantity of cannabis resin, transported in large quantities and over long distances, seized in the European Union is much higher than that of herbal cannabis (574 tonnes versus 139 tonnes).

Opioids (mainly heroin)

• The number of clients reporting opioids as their primary drug when entering specialised treatment for the first time seems to have levelled off, dropping from 59,000 in 2007, when they accounted for 36 per cent of all new clients, to 23,000 in 2013 (16% of new clients).  Of the 185,000 opioid clients entering treatment in Europe in 2014, 34,000 were first-time entrants.
• In 2014, 19 European countries reported that more than 10 per cent of all opioid clients entering specialised services presented for problems primarily related to opioids other than heroin including methadone, buprenorphine, fentanyl, codeine, morphine, tramadol and oxycodone. 
• Among first-time clients entering drug treatment in 2014 with heroin as their primary drug, 36 per cent reported injecting as their main route of administration, down from 43 per cent in 2006.
• The EMCDDA estimates that at least 6,800 overdose deaths occurred in the European Union in 2014, an increase from 2013.
• Viral hepatitis, particularly infection caused by the hepatitis C virus (HCV), is highly prevalent among injecting drug users across Europe, with six of the 13 countries with national data reporting a prevalence rate in excess of 50 per cent.  Drug injection is a risk factor for other infectious diseases including hepatitis B, tetanus and botulism.
• The quantity of heroin seized within the European Union had been declining steadily from 2002 until 2013 when 5.6 tonnes were seized.  A total of 8.9 tonnes were seized in 2014.  The reversal in trends is largely due to an increase in large seizures (above 100 kg) in several countries.

Cocaine

• Cocaine is the most commonly used illicit stimulant drug in Europe, although its use is more prevalent in the south and west of Europe.  It is estimated that about 2.4 million young adults aged 15 to 34 (1.9% of this age group) used cocaine in the last year. Only three countries report last-year prevalence of cocaine use among young adults aged 15 to 34 of 3 per cent or more.
• The decreases in cocaine use reported since 2008 have not been observed in the most recent surveys; of the countries that have produced surveys since 2013, six reported higher estimates, two reported a stable trend and four reported lower estimates than in the previous comparable survey.
• Overall, cocaine was cited as the primary drug by 59,000 clients entering specialised drug treatment in 2014 and by 27,000 first-time clients. After a period of decline, the overall number of cocaine first-time treatment entrants has been stable since 2012.
• In 2014, almost 5,500 clients entering treatment in Europe reported crack cocaine as their primary problem drug, with the United Kingdom accounting for more than half of these (3,000), and Spain, France and the Netherlands most of the remainder (2,000).
• In the United Kingdom, deaths involving cocaine increased from 169 in 2013 to 247 in 2014. In Spain, where cocaine-related deaths have been stable for some years, the drug continued to be the second most often cited drug in overdose deaths in 2013 (236 cases).
• In 2014, around 78,000 seizures of cocaine, amounting to 61.6 tonnes, were reported in the European Union. The situation has remained relatively stable since 2010, although both the number of seizures and the quantity seized are at levels considerably lower than in the peak years, 2006 –2008.

Other stimulants and new psychoactive substances

• Data on new psychoactive substances (NPS) are based on notifications by member states to the EU Early Warning System (EWS). In 2015, 98 new substances were reported for the first time (101 in 2014). Once again, the list of new substances reported was dominated by synthetic cannabinoids and synthetic cathinones (24 and 26 reported respectively).
• In 2014, almost 50,000 seizures of new substances, weighing almost 4 tonnes (3,990 kg), were made across Europe. Together, synthetic cannabinoids and cathinones accounted for almost 80 per cent of the total number of seizures and over 60 per cent of the quantity seized during 2014. Other groups included non-controlled benzodiazepines and potent narcotic analgesics, such as fentanyls.
• Some insights into the use of new drugs are provided by respondents to the 2015 Flash Barometer on young people and drugs, a survey of young adults aged 15–34, 8 per cent of whom reported lifetime use of these substances, with 3 per cent reporting use in the last year.  This represents an increase from the 5 per cent reporting lifetime use in a similar survey in 2011. Of those reporting use in the last year, 68 per cent  had obtained the substance from a friend.
• Despite drug injecting having declined in Europe overall, stimulant injecting is now a concern. Nearly half (47%) of new clients entering treatment in 2014 with amphetamines as their primary drug reported injecting as their main route of administration.
• Latest survey data point to increased use of MDMA in Europe following a period of decline. Around 2.1 million young adults (15–34 years) report having used MDMA in the last year (1.7% of this age group). There are also signs that the drug is moving out of niche or sub-culture dance clubs into mainstream nightlife settings, such as bars and house parties.

Accompanying the European drug report  are Perspectives on drugs (PODs), online interactive articles providing insights into specific issues in the drugs field. The three themes in focus this year are: cocaine trafficking to Europe, comorbidity of substance use and mental health disorders in Europe, and strategies to prevent diversion of opioid substitution treatment. ²

 Brian Galvin

¹European Monitoring Centre for Drugs and Drug Addiction (2016) European drug report 2016: trends and developments. Luxembourg: Publications Office of the European Union. http://www.drugsandalcohol.ie/25579/

² For further information visit http://www.emcdda.europa.eu/edr2016

On 5 April 2016 the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol published their second joint study of European drug markets.¹  This in-depth strategic examination builds on the 2013 report, which was the first attempt to bring together intelligence on the functionality and structure of European drug markets in the wider illicit drugs setting.²  The overall aim of both reports has been to inform policy and responses aimed at drug supply reduction. 

The recent report focuses on three areas.  Firstly, it examines the consequences of the illicit drug market and what drives its development.  Secondly, it examines the main drug markets, such as cannabis, heroin and other opioids, cocaine, methamphetamine and methylenedioxymethamphetamine (MDMA), and new psychoactive substances (NPS).  Each chapter recommends actions which highlight areas that should continue or need to be addressed.  Finally, the report examines policies and responses aimed at reducing the supply of illicit drugs. 

Consequences of the illicit drug market

The illicit drug market has a broad impact, not just on individuals who use drugs but also on society as a whole.  A number of impacts are identified in the report.

Legal economy

A challenge for organised crime groups (OCGs) is moving money that has been generated via illicit drug dealing into circulation.  This has an impact on the legal economy as legitimate businesses are necessary to launder the cash, and they are at risk of being linked with ‘trade-based money laundering schemes’.

Wider criminal activity

OCGs have been shown to be increasingly adaptable and flexible in their operational activities and interactions, and hence the opportunities to act illegally are immense.  The ability of law enforcement agencies to fill the knowledge gaps about these interactions is viewed as essential. The report highlights three such knowledge gaps that represent ‘intelligence-gathering opportunities’:

• drug supply carried out alongside other activities, for example firearms or migrant smuggling;
• drug supply that funds other crimes, for example terrorism or exploitation of people; and
• other crimes committed when dealing drugs, for example forcing trafficked individuals to take part in producing and selling drugs.

Terrorism

Links exist between OCGs engaged in drug trafficking and terrorist groups.  These interactions are functional in that terrorists appear to avail of the drug markets as a way of funding other activities.  From a European perspective, this link is viewed as a ‘threat’ as it has resulted in renewed interest in producing opium and other drugs in Afghanistan and its neighbours, Africa and the Middle East.  Volatility and nearness to Syria have led to the development of a ‘geographical hotspot of multiple and potentially interconnected threats’ such as drug and other organised crime and human relocation.

The risk factors associated with drug crime and with radicalisation are considered to overlap, for example disadvantaged individuals are at greater risk of being imprisoned for drug offences, and prison is a setting known to contribute to radicalisation.  The report points out that because terrorism and drugs are viewed as separate entities, knowledge gaps are extensive and links between the two areas are often missed. 

Government institutions and corruption

In the majority of EU states, a large proportion of drug-related public expenditure is used to try to reduce drug supply.  Nonetheless, there is often pressure to reassign funds to address other issues considered more urgent.  In addition, the power of governments can be damaged by corruption and coercion, for example in the judiciary or within law enforcement agencies.

Impacts on wider society and global stabilisation efforts

Society is affected by the operation of drug markets in a variety of ways, from increased acquisitive crime owing to addiction, to homicide, or feeling unsafe living in an area.  In addition, in areas where drugs are produced, the environment may be directly affected by chemicals used during production, deforestation or erosion, and indirectly, depending on the location, by migration, destabilisation and climate change.

Main drug markets

The report examines the drug markets related to the main drug types and provides insights into their development from production through to supply.  Key features of these markets include their global spread, the involvement of OCGs, the trafficking routes and the retail markets.  Based on the most recent available figures up to 2015, the most prominent drug in Europe’s illicit drug retail markets is cannabis, followed by heroin and then cocaine.

New psychoactive substances (NPS)

Although NPS are a relatively new addition to the EU drug market, their importance and growth cannot be overestimated.  In 2015, 100 new substances were identified by the EMCDDA and approximately 650 were being monitored.  As a result of the ‘rapidly changing nature’ of these substances, it is difficult to estimate NPS consumption.  The report points out that the same brand name may be used for completely different substances, resulting in individuals not being aware of what they are taking.  

The 2014 Eurobarometer Survey, which examined the use of NPS among 15–24-year-olds across EU member states,³ indicated that overall eight per cent of respondents reported using NPS, of whom one per cent reported using in the last 30 days, three per cent in the previous 12 months, and four per cent more than a year ago. Broken down by country, the highest level of NPS consumption was reported by Irish young people (22%).  This figure illustrates that NPS consumption in Ireland has increased by six per cent since the 2011 Eurobarometer Survey (16%).⁴  

Policies and responses

The final chapter of the report examines policies and strategies aimed at reducing drug supply.  The main strategic action highlighted is the EU drugs strategy (2013–20) and action plan (2013–16).  The framework in this strategy and action plan are considered to mirror the challenges identified in the report.  The report outlines the roles played by different EU institutions and agencies in the development and application of the EU’s drugs policy.

The report highlights three areas of the drug market that are being targeted:

• organisations involved at national and international level in the production and supply of drugs, for example OCGs which are multifaceted, particularly in the areas of organisational structure, technical knowledge, connections with other organisations and areas of specialism;
• factors that enable drug activities, for example money, help from other professionals, and advances in globalisation and technology; and
• social factors that result in people getting involved in producing and selling drugs, for example human trafficking, exploitation as a result of poverty, and immigration. 

 Ciara Guiney

1European Monitoring Centre for Drugs and Drug Addition, Europol (2016) EU drug markets report: in-depth analysis. Luxembourg: Publications Office of the European Union.  http://www.drugsandalcohol.ie/25357/

2European Monitoring Centre for Drugs and Drug Addition, Europol (2013) EU drug markets report: a strategic analysis. Luxembourg: Publications Office of the European Union.  www.drugsandalcohol.ie/19227/

3 TNS Political and Social (2014) Flash Eurobarometer 401. Young People and drugs. Luxembourg: European Commission. http://www.drugsandalcohol.ie/22196/

4 The Gallup Organization (2011) Youth attitudes on drugs. Flash Eurobarometer 330 Analytical report.   Luxembourg: European Commission. http://www.drugsandalcohol.ie/15497/

On 5 April 2016 the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol published their second joint study of European drug markets.¹  This in-depth strategic examination builds on the 2013 report, which was the first attempt to bring together intelligence on the functionality and structure of European drug markets in the wider illicit drugs setting.²  The overall aim of both reports has been to inform policy and responses aimed at drug supply reduction. 

The recent report focuses on three areas.  Firstly, it examines the consequences of the illicit drug market and what drives its development.  Secondly, it examines the main drug markets, such as cannabis, heroin and other opioids, cocaine, methamphetamine and methylenedioxymethamphetamine (MDMA), and new psychoactive substances (NPS).  Each chapter recommends actions which highlight areas that should continue or need to be addressed.  Finally, the report examines policies and responses aimed at reducing the supply of illicit drugs. 

Consequences of the illicit drug market

The illicit drug market has a broad impact, not just on individuals who use drugs but also on society as a whole.  A number of impacts are identified in the report.

Legal economy

A challenge for organised crime groups (OCGs) is moving money that has been generated via illicit drug dealing into circulation.  This has an impact on the legal economy as legitimate businesses are necessary to launder the cash, and they are at risk of being linked with ‘trade-based money laundering schemes’.

Wider criminal activity

OCGs have been shown to be increasingly adaptable and flexible in their operational activities and interactions, and hence the opportunities to act illegally are immense.  The ability of law enforcement agencies to fill the knowledge gaps about these interactions is viewed as essential. The report highlights three such knowledge gaps that represent ‘intelligence-gathering opportunities’:

• drug supply carried out alongside other activities, for example firearms or migrant smuggling;
• drug supply that funds other crimes, for example terrorism or exploitation of people; and
• other crimes committed when dealing drugs, for example forcing trafficked individuals to take part in producing and selling drugs.

Terrorism

Links exist between OCGs engaged in drug trafficking and terrorist groups.  These interactions are functional in that terrorists appear to avail of the drug markets as a way of funding other activities.  From a European perspective, this link is viewed as a ‘threat’ as it has resulted in renewed interest in producing opium and other drugs in Afghanistan and its neighbours, Africa and the Middle East.  Volatility and nearness to Syria have led to the development of a ‘geographical hotspot of multiple and potentially interconnected threats’ such as drug and other organised crime and human relocation.

The risk factors associated with drug crime and with radicalisation are considered to overlap, for example disadvantaged individuals are at greater risk of being imprisoned for drug offences, and prison is a setting known to contribute to radicalisation.  The report points out that because terrorism and drugs are viewed as separate entities, knowledge gaps are extensive and links between the two areas are often missed. 

Government institutions and corruption

In the majority of EU states, a large proportion of drug-related public expenditure is used to try to reduce drug supply.  Nonetheless, there is often pressure to reassign funds to address other issues considered more urgent.  In addition, the power of governments can be damaged by corruption and coercion, for example in the judiciary or within law enforcement agencies.

Impacts on wider society and global stabilisation efforts

Society is affected by the operation of drug markets in a variety of ways, from increased acquisitive crime owing to addiction, to homicide, or feeling unsafe living in an area.  In addition, in areas where drugs are produced, the environment may be directly affected by chemicals used during production, deforestation or erosion, and indirectly, depending on the location, by migration, destabilisation and climate change.

Main drug markets

The report examines the drug markets related to the main drug types and provides insights into their development from production through to supply.  Key features of these markets include their global spread, the involvement of OCGs, the trafficking routes and the retail markets.  Based on the most recent available figures up to 2015, the most prominent drug in Europe’s illicit drug retail markets is cannabis, followed by heroin and then cocaine.

New psychoactive substances (NPS)

Although NPS are a relatively new addition to the EU drug market, their importance and growth cannot be overestimated.  In 2015, 100 new substances were identified by the EMCDDA and approximately 650 were being monitored.  As a result of the ‘rapidly changing nature’ of these substances, it is difficult to estimate NPS consumption.  The report points out that the same brand name may be used for completely different substances, resulting in individuals not being aware of what they are taking.  

The 2014 Eurobarometer Survey, which examined the use of NPS among 15–24-year-olds across EU member states,³ indicated that overall eight per cent of respondents reported using NPS, of whom one per cent reported using in the last 30 days, three per cent in the previous 12 months, and four per cent more than a year ago. Broken down by country, the highest level of NPS consumption was reported by Irish young people (22%).  This figure illustrates that NPS consumption in Ireland has increased by six per cent since the 2011 Eurobarometer Survey (16%).⁴  

Policies and responses

The final chapter of the report examines policies and strategies aimed at reducing drug supply.  The main strategic action highlighted is the EU drugs strategy (2013–20) and action plan (2013–16).  The framework in this strategy and action plan are considered to mirror the challenges identified in the report.  The report outlines the roles played by different EU institutions and agencies in the development and application of the EU’s drugs policy.

The report highlights three areas of the drug market that are being targeted:

• organisations involved at national and international level in the production and supply of drugs, for example OCGs which are multifaceted, particularly in the areas of organisational structure, technical knowledge, connections with other organisations and areas of specialism;
• factors that enable drug activities, for example money, help from other professionals, and advances in globalisation and technology; and
• social factors that result in people getting involved in producing and selling drugs, for example human trafficking, exploitation as a result of poverty, and immigration. 

 Ciara Guiney

1European Monitoring Centre for Drugs and Drug Addition, Europol (2016) EU drug markets report: in-depth analysis. Luxembourg: Publications Office of the European Union.  http://www.drugsandalcohol.ie/25357/

2European Monitoring Centre for Drugs and Drug Addition, Europol (2013) EU drug markets report: a strategic analysis. Luxembourg: Publications Office of the European Union.  www.drugsandalcohol.ie/19227/

3 TNS Political and Social (2014) Flash Eurobarometer 401. Young People and drugs. Luxembourg: European Commission. http://www.drugsandalcohol.ie/22196/

4 The Gallup Organization (2011) Youth attitudes on drugs. Flash Eurobarometer 330 Analytical report.   Luxembourg: European Commission. http://www.drugsandalcohol.ie/15497/

Studies carried out in Ireland suggest that the majority of offenders detected in Ireland present with some form of drug dependency.^1,2,3   The study reported on here evaluates one approach that has been used within the justice system to treat drug dependency – drug treatment courts (DTCs).⁴

Origins

Broomfield describes how DTCs emerged in the United States (US) in response to the growing drug crisis in the 1980s.  According to Broomfield, the DTC model brings together the ‘powers of court’ and drug treatment, with the aim of supporting steps to sobriety via regular contact with the user, monitoring substance use, evaluating responses to interventions and close supervision.  Studies evaluating the effectiveness of DTCs in the US suggest that:

• reoffending and drug dependency are lower among DTC participants,
• progress is impacted by ‘severity of misuse’, previous history, and use of stimulants,
• programme completion was higher in users receiving pharmacotherapy, and
• more completions occurred when the presiding judge was there longer and when the court was smaller.⁵

However, Broomfield notes that other reviews provide evidence contradicting these findings. When pre-trial release and drugs testing were compared with parole and probation, effect sizes demonstrated that the latter were better.⁶ Another review suggested that the impact of diversions reducing drug dependency was small.⁷   

Dublin DTC

The Dublin DTC (DDTC) pilot programme started in 2001.  Similar to the US DTC, the aim was to reduce offending and drug dependency with help from addiction nursing, education and probation supervision.  There were three stages: bronze, silver and gold.  Participants were required to:

• attend court regularly (weekly, fortnightly or monthly),
• attend education programmes daily,
• meet with a probation officer regularly, and
• engage in treatment relating to their drug of choice.

During the programme, progress was reviewed by the DTC judge.  Following successful completion of the DTC, charges were ‘struck out’.  Broomfield casts doubts on the merits of using completion rewards, in particular for those with extensive offences, no desire to travel or live abroad, or those who were not afraid of having a criminal record.  Despite this, he argues that the DDTC programme provides a structure which can reduce destructive behaviour. 

Not everyone can be helped through the DDTC.  Broomfield points out that the combination of drug dependency, crime and other difficulties such as coming for a disadvantaged socio-economic background  or a dysfunctional family background (e.g. drug-abusing parents or siblings), homelessness or mental illness, result in challenging environments for addiction treatment, making it necessary to adapt interventions accordingly. 

Completers

Two separate evaluations of the effectiveness of the DDTC have indicated that the number of completers was low but offending behaviour had declined.  A review in 2002 gained insights from completers regarding the DTC process, and the pros and cons of sticking with the programme.⁸ No information was reported on attitudes or quality of life changes or on the progress of non-completers.  A second review in 2010 aimed to determine why referrals were low and to identify how ‘increased throughput’ could be attained.⁹ As in 2002, the main finding was the low number of completers; again, the progress of non-completers was not considered.  Broomfield argues that it is concerning that evidence about participants in the 2010 evaluation appears to have been obtained from professionals rather than participants themselves.

Drawing on the work of Butler,¹⁰ who examined how the DTC policy transferred from the USA to Ireland, Broomfield noted that (1) the development of the DTC in Ireland was politically driven; (2) therapeutic jurisprudence (an active, problem-solving judiciary) and the ability to buy addiction treatment evident in the US were not present in the Irish system; (3) although professionals viewed participation as beneficial, they were uncertain that credit for the positive outcomes should be attributed to the DDTC; and (4) disparities were evident in the socio-economic backgrounds of participants in the US and in Ireland – Irish participants were economically deprived and addicted to opiates while American participants were more affluent.

Non-completers

Research on DTCs has focused on completers, which could suggest that non-completers are failures.  To redress this gap, grounded theory has been used to examine the benefits (including intention-to-treat and harm reduction) of the DTC programme for non-completers.¹¹ Five themes emerged from semi-structured interviews:

• relationships with others,
• changes in substance misuse,
• changes in education and employment,
• costs and consequences of drug court participation, and
• benefits of attending drug court.

A significant harm reduction effect was identified, which led to the authors to conclude that the provision of a harm reduction model alongside the abstinence-based model would be beneficial.  Despite the limited sample size, Broomfield argues that this research has provided valuable insights.

Using narrative inquiry with DTC participants

The main finding from DTC research has been that the majority of participants are non-completers.  Determining the reasons for this has been neglected by researchers.  Broomfield suggests that a lot of information could be gleaned from the narratives or stories of non-completers regarding why programmes did not work for them and what adjustments would enable them to complete. A narrative inquiry approach would be the most apt approach to examine ‘internal and external dialogues’ that occur when deciding to remain or leave.  

Additionally, obtaining descriptions of the offending, lifestyle and addiction of non-completers would provide insights into how other individuals with similar experiences might be helped.  It would allow individual stories to be heard.  Reasons to support this argument are put forward, such as:

• Life stories of individuals would include not only the story about the addiction and treatment but also insight into their experiences of marginalisation and resilience.
• The transition into drug dependency often co-occurs with a life changing event.  Broomfield suggests it is not just the importance of the event but also whether resources are available to manage it.
• Narratives of those with addiction occur within larger narratives of emotive, financial and social systems.
• Narratives that unpack the thoughts, needs and risks faced by drug users involved with crime would provide greater knowledge and understanding to those not affected by drug use and crime.

Ciara Guiney

1. Hickey C (2002) Crime and homelessness. Dublin: Focus Ireland, PACE. Available from http://www.drugsandalcohol.ie/5440/

2.Drummond A and Codd M (2014) Drugs and health in Irish prisons 2011: a report for prisoners.  Dublin: National Advisory Committee on Drugs and Alcohol. Available from http://www.drugsandalcohol.ie/21752/

3. Martyn M (2012) Drug and alcohol misuse among adult offenders on probation supervision: findings from the Drugs and Alcohol Survey 2011. Irish Probation Journal (9): 75–93. Available from http://www.drugsandalcohol.ie/21636/

4. Broomfield D (2015) Drug treatment courts: refining successes and failures through participant narratives. The Irish Social Worker (Spring): 36–40.  Available from http://www.drugsandalcohol.ie/24713/

5. Brown RT (2010) Systematic review of the impact of adult drug-treatment courts. Translational Research (155/6): 263–274. Available from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886018/pdf/nihms190930.pdf

6. Perry AE, Darwin Z, Godfrey C, McDougall C, Lunn J, Glanville J et al. (2009) The effectiveness of interventions for drug-using offenders in the courts, secure establishments and the community: a systematic review. Substance Use & Misuse (44/3): 374–400.  Available from http://www.tandfonline.com/doi/full/10.1080/10826080802347560

7. Hayhurst K, Leitner M, Davies L, Flentje R, Millar T, Jones A et al. (2015) The effectiveness and cost-effectiveness of diversion and aftercare programmes for offenders using class A drugs: a systematic review and economic evaluation. Health Technology Assessment Database (Internet). (2). Available from http://onlinelibrary.wiley.com/o/cochrane/clhta/articles/HTA-32011000672/frame.html

8. Farrell, M (2002) Final evaluation of the pilot drug court. Dublin: Courts Service. Available from http://www.justice.ie/en/JELR/finalevalpilotdrug.pdf/Files/finalevalpilotdrug.pdf

9. Department of Justice, Equality and Law Reform (2010) Review of the drug treatment court. Dublin: Department of Justice, Equality and Law Reform. Available from http://www.drugsandalcohol.ie/13113/

10. Butler S (2013) The symbolic politics of the Dublin drug court: the complexities of policy transfer. Drugs: Education Prevention and Policy (20/1): 5–14. Available from http://www.drugsandalcohol.ie/18888/

11. Francis TR and Able EM (2014) Redefining success: a qualitative investigation of therapeutic outcomes for noncompleting drug court clients.  Journal of Social Service Research (40/3): 325–348. Available from http://www.tandfonline.com/doi/abs/10.1080/01488376.2013.875094    

In 2014 a report produced by the Garda Inspectorate drew attention to serious problems regarding the recording of crime on PULSE.¹  Issues included the non-recording of crimes, lack of timeliness in recording crimes, misclassifying crime incidents and non-crime incidents at initial stages, incorrect reclassification of incidents, and incorrect application of detection and invalidation status to certain crimes.

 Given that the CSO draws on PULSE data to produce crime statistics, it was considered essential to carry out a review of the data received by the CSO to determine their accuracy.²  The aim of the review was to determine how many legitimate offences were not being recorded on the Pulse system.  Access was provided by the Garda Síochána to crime and non-crime data including CAD (Command Aided Dispatch), paper records and non-crime PULSE incident groups, such as Attention and Complaints, Property Lost and Domestic Dispute. A random selection of CAD and paper records was checked against corresponding records on PULSE.  What follows is a summary of the main findings.

 Non-recording of crimes

Twenty per cent of validated crimes (e.g. assault, burglary, criminal damage, public damage, robbery, theft) and 23 per cent of non-crimes (e.g. bomb scares, domestic disputes/ domestic violence and sexual assault) reported on CADs were not reported on PULSE.  In addition, 16.4 per cent of validated paper records were not reported on PULSE.  The authors advised caution when interpreting these results as it was challenging to match records between CAD and PULSE, hence some records deemed not to be on PULSE may actually be there. 

 Lack of timeliness in recording crimes

Within the PULSE system a creation date and report date are recorded.   The CSO found that following a crime being reported, there was a delay of over a week before seven per cent of incidents were recorded on PULSE.

 Alteration of narratives

The narrative field on PULSE, which records details of a crime, can be amended as further information becomes available.  To determine whether narratives had been edited to justify classification decisions, the narrative lengths of all incidents were analysed to see if any reductions in length had taken place between the January 2012 dataset and the April 2014 dataset, which would indicate unacceptable editing. Not a single case was identified.   

 As it was not possible to establish what records had been amended before January 2012, the audit trails for a sample of 500 PULSE criminal records were examined.  The audit trail records every change to the narrative, the date and time of the change and who made the change.  Only one of the 500 records (a reclassified crime case) revealed evidence that an alteration had been made to justify an incorrect reclassification.

 Misclassification of incidents

There are approximately 300 crime classifications on PULSE.  How crimes are classified is essential for accurate reporting.

 The CSO focused on six classifications of serious crimes – Assault Minor, Assault Causing Harm, Criminal Damages (Not Arson), Theft from Person, Burglary, and Robbery from the Person.  The analysis indicated that three per cent of records were classified incorrectly and the classification of a further four per cent was unclear.

To determine whether non-crime incidents should have been classified as crimes, narratives from Attentions and Complaints (n=1,000), Property Lost (n=500) and Domestic Dispute (n=300) were examined.  Although the majority of records were classified correctly (91%–94%), a small number of records were either misclassified (4%–7%) or unclear (4%–7%).  Further analysis indicated that 69 records from Attention and Complaints should have been in Assaults or Fraud/Threatening Letters and one in Sexual Assault/Robbery; 18 Property Lost should have been in Thefts; and 13 Domestic Dispute should have been in Assaults or Assaults causing Harm.

Incorrect reclassification of crime incidents

Crime classifications were compared on PULSE between January 2012 and January 2013. Three areas were examined: Assault (n=57), Assault Causing Harm (n=12) and Criminal Damage (n=189).  The analysis indicated that 71 per cent of reclassifications were justified whilst 15 per cent were not.  A further analysis of ‘downgrades’ in the Assault and Assault Causing Harm categories indicated that 51 per cent were justified and 26 per cent were not.  Approximately 50 per cent of crimes were upgraded and 15 per cent were reclassified down in the Criminal Damage category.  Within this category, the highest proportion of reclassifications occurred for Burglary (44%), followed by Theft (35%).  

In non-crime categories, for example Attention and Complaints, Burglary and Related Offences (19%) and Theft and Related Offences (12%) were reclassified.  A limitation of this analysis was that data from PULSE were only received by the CSO at the end of every month; hence the CSO was not privy to reclassifications that occurred when the crime was originally reported.

Incorrect application of detection status

To determine whether ‘detected’ crimes resulted in criminal proceedings, 138,807 ‘detected’ crimes were examined, 54% were linked to a charge or summons whereas 46% were not.  A further analysis of the accuracy of ‘detection rules’ on ‘detected’ crimes with no charge or summons (n=500) indicated that over a third of crimes were wrongly assigned ‘detected’ (35%).  This accounted for a 16% (22,307) reduction in the total number of ‘detected’ crimes.

Incorrect application of invalidation status

Invalidation occurred when there was no crime or when ‘counting rules’ were wrongly applied (p.24).  Out of 528 invalidated records, 23.1% were unjustified.  The highest proportion of unjustified invalidations was shown for ‘Robbery, Extortion and Hijacking Offence’ (18.9%; n=32) and ‘Sexual Offences’ (43.3%; n=26).

Conclusions/Recommendations

The CSO estimated the impact of the problems identified in their review.  The largest percentage increases were 38 per cent in Group 03 (Attempts, Threats to Murder, Assaults, Harassments and Related Offences), 27 per cent in Group 08 (Theft and Related Offences) and 26% in Group 09 (Fraud, Deception, and Related Offences).  Alterations owing to misclassifications within groups were not considered, for example Assault Causing Harm and Assault minor are both in Group 03.

Consistent with the Garda Inspectorate report, the CSO review found discrepancies between crimes recorded on CAD/Paper and PULSE.  The CSO made a number of recommendations to improve the quality of the data.  

• The introduction of a unique identifying number between CAD/Paper reports and PULSE would enable data to be linked more effectively, and allow greater accuracy and quality control. 
• The crime narrative should match subsequent crime classification, detection and/or invalidation status recorded.  
• The decision-making process in PULSE should be centralised.  This would ensure operational procedures were followed with regard to crime and non-crime classification, reclassification, detection and/or invalidation.  

Ciara Guiney

1 Garda Inspectorate. (2014) Report of the Garda Síochána Inspectorate. Crime investigation.  Dublin: Garda Inspectorate.  http://www.drugsandalcohol.ie/22967/  

2 Central Statistics Office (2015) Review of the quality of crime statistics: Dublin: Government of Ireland.  http://www.drugsandalcohol.ie/24887/

A paper published in September 2015 outlines a case-control and epidemiological study conducted in response to an increase in recently acquired HIV infection among a population of homeless people who inject drugs (PWID) in Dublin.¹ The report defines recently acquired HIV infections as those in which the person who tests positive is p24 antigen, or has had an HIV negative test within the previous 12 months, or suffers an acute HIV sero-conversion illness.

Clinicians in the drug treatment services were concerned that the increase might be linked to injection of a synthetic cathinone PVP, with the street name ‘Snow Blow’, which was being used by homeless drug users.  In response, an epidemiological investigation and case-control study were instigated.

Between 2014 and 2015, 38 confirmed or probable cases of recently acquired HIV were reported (see Figure 1).  Of these, 16 were female, the median age was 35 years (range 24–51) and 29 were registered homeless.  Of the 20 for whom injecting information was available, 18 reported recent injecting of ‘Snow Blow’.  Twenty reported having sex with a person who injected drugs or with an HIV-positive partner. 

For the case-control study, 15 of the reported cases were recruited.  A random sample of 39 HIV-negative, homeless, chaotic drug users were recruited from National Drug Treatment Centre as a control group.  There was no difference between cases and controls in age, duration of injection or living circumstances. 

The study found that compared with the controls, the cases were more likely to have reported injecting methamphetamine and Snow Blow, and using amphetamines, other head shop drugs or benzodiazepines.  Cases were also more likely to have reused needles or syringes, and to have had sex with partners who inject drugs.

Multivariate logistic regression was used to determine which of these factors were associated with HIV infection.  The factor with the strongest association with HIV infection was injecting Snow Blow.  However, being female, reusing needles and syringes and having sex with a partner who injects drugs were all independently associated (see Table 1).

In response to the increased incidence of HIV, the authors report that the following control measures were immediately implemented:

-        provision of antiretroviral therapy to PWID diagnosed with HIV, where possible, and contact tracing to detect any additional cases among sexual or drug-sharing partners;

-        review of clients attending drug services, to identify those most at risk, and offering urgent HIV testing;

-        pilot point-of-care testing (POCT) of PWID clients attending Safetynet homelessness services (Safetynet is a networking organisation for nurses, doctors and voluntary agencies providing primary health care to homeless people in Dublin, Cork and Galway);

-        enhanced surveillance to identify new HIV cases as early as possible, including mode of transmission;

-        awareness-raising among clients, clinicians, networks of PWID and other stakeholders;

-        provision of greater access to needle exchange and other preventive activities within the drugs, homeless hostel services and prisons (the need for additional measures, including extended opening hours for needle exchanges, is being evaluated); 

-        development and distribution of communications material, aimed at raising awareness of the risk of HIV posed by unsafe injecting and unsafe sex (available on the website of the Health Protection Surveillance Centre [HPSC]); and

-        active case finding including Recent Infection Testing of possible cases, and phylogenetic analysis of cases.

Margaret Curtin

¹Giese C, Igoe D, Gibbons Z, Hurley C, Stokes S, McNamara S, Ennis O, O'Donnell K, Keenan E, De Gascun C, Lyons F, Ward M, Danis K, Glynn R, Waters A, and Fitzgerald M (2015) ‘Injection of new

The need for ongoing, prompt, cost-efficient and comprehensive monitoring and evaluation of drug treatment is well recognised_.  The scientific literature supports the use of randomised controlled trials (RCTs) as the ‘gold standard’ research design for evaluating interventions and treatment outcomes. However, in community substance-use treatment settings, the use of RCTs is not always possible or appropriate. There are ethical issues and questions about relevance, feasibility and costs.

Given the limitations of RCTs and the demand for ongoing, timely and effective monitoring of treatment outcomes, Comiskey and Snel sought to test the feasibility of linking laboratory data and client intake data and its usefulness for modelling retrospectively five-year longitudinal drug treatment outcomes in an Irish opiate treatment setting.¹

Methodology

A multi-site, retrospective, longitudinal cohort study was implemented to evaluate outcomes for opiate users across Dublin from January 2006 to December 2010.

Longitudinal urinalyses were extracted from two national laboratories which provide substance use screening tests to 17 drug treatment sites and to two buses providing mobile needle exchange services. During the five -year study period a total of 1,734,283 test results were identified for 330,802 urine samples presented by a total of 4,518 unique individuals across Dublin.

In addition to the urinalysis database, data were extracted at a number of ad hoc time points from all the treatment sites which use a client electronic record system, which is known as the Drugs and AIDS Information System (DAIS). This system records data about drug-users seeking treatment, including their demographic characteristics, assessment prior to treatment, prescriptions, hepatitis C status, treatment programmes, needle exchange programmes and rehabilitation integration services. During the study period, 5,430 records relating to 2,832 unique individuals were recorded in DAIS; of these unique individuals, 97 per cent  were Irish, 72 per cent were male, 59.7 per cent had no children and seventeen known deaths were recorded.  These data were linked, via a unique client identity number, at the individual client level to the longitudinal urinalysis data.

Once the full database of unique clients was created, with each repeat episode of treatment linked, captured and recorded for that client, the longitudinal outcome variables in the form of drug positive urinalyses results were derived. Outcomes were tracked sequentially, with the first urinalyses denoted as time point 1 (the intake/baseline measurement) and each subsequent urinalysis result was then recorded as test 1, 2, 3 … up to a maximum of 260.

Results

Across the five-year period  62 per cent of the urine samples tested positive for benzodiazepines, 43 per cent for cannabis, 40 per cent for opiates and 11 per cent for cocaine. Analysis of substances used at treatment intake, at six  months and at one- to five-year follow-ups, revealed:

Differences in urinalysis protocols: Extraction of urinalysis data from the two national laboratories revealed that treatment sites varied considerably regarding the number and frequency of urinalysis tests conducted; for example two of the seven DAIS treatment clinics requested over 83 per cent of analyses, but accounted for only 68 per cent of all DAIS clients. The researchers attribute these variations to a difference in treatment-site philosophy and practice rather than variations in client characteristics.

A further inconsistency occurred between  the stated tests conducted as part of a routine urine test and what was found in the analysis: while 99.9 per cent of urine samples were tested for opiates and cocaine as required by policy, only 72 per cent were tested for benzodiazepines.

Age of first drug use:Clients who did and did not test positive for opiate use at year five were compared on a number of variables. No significant difference was found apart from age at first drug use (mean age of 15.53 years vs. mean of 14.63 years, p=0.008)

Opiate use: The proportion of clients who tested opiate positive fell from 61.8 per cent at initial treatment intake to 12.5 per cent at the end of the five-year period. The researchers’ time series analysis of weekly proportions opiate positive had  predicted 16 per cent (95% confidence interval: 7%–25%) of clients would be opiate positive at the end of the five years.

Other drug use: Significant increases were found in benzodiazepine use, and significant increasing effects of concurrent cocaine and benzodiazepine use on the likelihood of using opiates.It was also possible to link and describe the changes in the methadone doses prescribed: analysis of the DAIS system revealed there were only minor changes in the doses of methadone prescribe over the five years.

Conclusion

With this research the authors have demonstrated that data from existing multi-sited, cross-sectional sources can be linked, matched, mined and modelled to develop prompt, retrospective, sequential outcome results that are useful for policy makers, service providers and service users.

Ita Condron

¹ Comiskey CM and Snel A (2016) Using clients’ routine urinalysis records from multiple treatment systems to model five-year opioid substitution treatment outcomes. Substance Use & Misuse (51/4):  498–507. http://www.drugsandalcohol.ie/25363/

BeLonG To has been the national youth service for LGBT young people since 2003. The organisation ‘envisions a future in which LGBT young people are safe and supported in their families, schools and communities, and all young people are equally cared for, valued, and respected’ (personal communication, Gerard Roe, Drug Education and  Outreach Worker, Belong To, April 2016). With the support of the North Inner City Drugs Task Force, BeLonG To set up a Drug & Alcohol Servicein late 2007. It was established in response to a national study of drug use among LGBT young adults in Ireland.¹ It continues to be the only designated LGBT drug service in the country.

The service follows the model of harm reduction with an emphasis on support, awareness-raising, education and empowerment. It aims to address concerns LGBT young people may have about drug or alcohol use and offers them the opportunity to access support in a dedicated ‘safe’ LGBT youth space. As outlined on its website, the drug service:

• supports young LGBT people in relation to issues of alcohol and drug use in a non-judgemental and confidential manner;
• delivers outreach work to young LGBT drug users to make people aware that the service is there and where to find it;
• carries out education, information and prevention work with the young LGBT community to raise awareness around issues to do with drug and alcohol use in the community;
• provides information and training on LGBT issues for mainstream drug services to support services in making their space safe for LGBT service users; and
• refers young LGBT to specialised agencies and services to enable them to access safe and positive support.

BeLonG To also advocates for changes in national policy. In October 2015 it made a written and an oral submission to the Joint Committee on Justice, Defence and Equality in its review of Ireland’s approach to the possession of limited quantities of certain drugs, advocating for a change in the legislation in favour of decriminalising drug possession for personal use.² In November 2015 some of BeLonG To’s service users made a presentation at CityWide’s 20^th anniversary conference.³

BeLongTo’s drug service can be contacted at drugsoutreach@belongto.org or on (01) 670 6223.

Collated by Lucy Dillon

¹Sarma K (2007) Drug use amongst lesbian, gay, bisexual and transgender young adults in Ireland. Dublin: BeLonG To Youth Service. http://www.drugsandalcohol.ie/6202/

²http://www.belongto.org/attachments/250_Submission_to_Department_of_Justice,_Defence_and_Equality.pdf; Joint Committee on Justice, Defence and Equality (2015) Submissions on drugs review: discussion. Committee Debates, 14 October. http://oireachtasdebates.oireachtas.ie/Debates%20Authoring/DebatesWebPack.nsf/committeetakes/JUJ2015101400001?opendocument

³ http://www.citywide.ie/publications/listing/belong-to-young-people-presentation/

The 2014 Annual epidemiological report from the Health Protection Surveillance Centre,¹ published in December 2015, reports 377 new diagnoses of HIV, of which almost half (n=183) were among men who had had sex with men (MSM).  This reflects a growing trend with the number of new diagnoses among MSM increasing threefold in the ten years since 2005 (from 60 to 183).  Moreover, the median age of diagnosis has decreased from 37 to 31 years. Increased access to testing explains some of the increase. 

The National Sexual Health Strategy 2015–2020² also raises concerns regarding the increasing incidence of diagnoses of HIV and other sexually transmitted diseases, particularly among young people.  One response outlined in the strategy is free, rapid HIV testing in non-traditional locations.

Dublin’s first free rapid HIV testing service was launched by the Gay and Lesbian Equality Network (GLEN) in March 2016.  The ‘KnowNow’ campaign is a one-year pilot project aimed at gay and bisexual men and offers on-site testing in workplaces, bars and other hubs.  Funding has also been provided for similar projects operated by the Cork Sexual Health Centre and the Gender Orientation Sexual Health HIV in Limerick.  Testing will be offered in gay and bisexual friendly pubs.  The test involves a pin-prick blood test and results are available in 30 seconds.  The pilot project will record and collate key data to evaluate its efficacy.

In addition to making HIV testing more accessible, the project aims to raise awareness around sexual health issues, remove the stigma associated with HIV and promote a mature attitude to sexual health.

Margaret Curtin                   

¹ HPSC (2015) Annual epidemiological report 2014. Dublin: Health Protection Surveillance Centre. http://www.hpsc.ie/AboutHPSC/AnnualReports/File,15505,en.pdf   

² Department of Health (2015) National sexual health strategy 2015–2020 Dublin: Department of Health.  http://health.gov.ie/wp-content/uploads/2015/10/National-Sexual-Health-Strategy.pdf             

A recently published paper retrospectively examined the demographics, substance use, mental health and co-morbidities of the 20 most frequent attenders at the Mater Misericordiae University Hospital in 2014.¹ 

The study found that the majority (17) of the 20 most frequent attenders were male, all were unemployed and the median age was 38.5 years (range 21 to 59).  Seven had no fixed abode and a further five were living in temporary hostel accommodation.  Nineteen were either single or separated.

Among the 20, 16 misused either drugs or alcohol: 10 were current illicit drug users, six had a benzodiazepine addiction, three a heroin addiction, and one was polydrug dependent.  The average attendance rate by illicit drug users was twice that of non-drug users. The majority (12) were alcohol dependent, with a further two reporting alcohol abuse.  Seventeen were smokers.  Thirteen had mental health issues, four of whom had depression and a further four had both depression and schizophrenia. Two had personality disorders.  Full details of the demographics, substance use, mental health status and co-morbidities of the 20 most frequent attenders are provided in Table 1.

The authors point out that a small number of repeat attenders may be responsible for a disproportionate level of emergency department attendances.  These repeat attenders generally have substance misuse and psycho-social issues.  Moreover, the authors highlight the burden of alcohol and drug dependence on the Irish health services and state that in 2007, €1.2 million was spent on alcohol-related illnesses.  The authors also highlight the high incidence of mental health problems among frequent attenders and propose that this may be due to insufficient community-based mental health services.  They conclude that frequent attenders are a complex group needing a holistic multi-disciplinary approach that would involve addressing underlying issues such as drug and alcohol dependency, mental health issues and social deprivation, with significant investment outside the hospital setting to relieve pressure on emergency departments.

Margaret Curtin

¹ Ramasubbu B, Donnelly A and Moughty A (2016) Profile of frequent attenders to a Dublin inner city emergency department. Irish Medical Journal (109/4) http://www.drugsandalcohol.ie/25379/

A study conducted between 2006 and 2007 in the National Drug Treatment Centre, a large specialist addiction clinic in Dublin, sought to discover whether women in methadone maintenance treatment (MMT) had more unmet needs and lower quality of life than men in MMT.¹ 

Any service user who had been receiving MMT for three months or more was eligible for inclusion, excluding those with a history of acute psychiatric problems or end-stage health difficulties.  In total, 190 service users were eligible to participate in the study, of whom 108 (57%) agreed to participate.  Of those 108 participants, 35 (32%) were women.  No statistical difference was found in the demographic characteristics of those who did and did not participate in the study.

Three different standardised questionnaires were used:

1. WHO Quality of Life – Brief Version (WHO-QOL-Bref),
2. Maudsley Addiction Profile, and
3. Camberwell Assessment of Need Short Appraisal Schedule, Patient Version.   

The mean age of participants was 32.7 years, with women slightly younger than men (30.7 years versus 33.7 years).  There were no differences in the demographic and social characteristics of women and men, except that women were more likely to have accessed the support of a social worker.   Recent drug use was assessed by self-report and urinalysis.  Men self-reported more use of heroin in the past month and had a higher proportion of positive urines for cocaine. 

Women were statistically more likely to report unmet needs and achieve lower psychological quality of life scores than men.  This difference could not be explained by on-going drug use, as the men in the study had higher levels of recent drug use. 

The authors note the limitation of the small sample size. In addition, the findings may not be fully representative as the study was conducted in a specialist addiction service which treats the most complex cases.  The generalisability of the study is also affected by the fact that the data were collected over ten years ago. 

The authors suggest that the needs and quality of life of women in MMT warrant further research. They also call on addiction services to ensure that the psychological and social care needs of women clients are addressed. 

Suzi Lyons

¹ Byrne P, Ducray K and Smyth BP (2016) The impact of sex upon needs and quality of life within a population on methadone treatment Journal of Addiction Medicine 10(1):60–67. http://www.drugsandalcohol.ie/24979/

 Background

On foot of the National Substance Misuse Strategy,²  the remit of the drugs task forces was expanded in 2014 to include alcohol. To support the task forces in meeting the demands of this new remit, the NCAAPP was established. Its aim was to support task forces in developing a ‘community mobilisation approach’ which would inform the development of policies to address alcohol use, and reduce alcohol-related harm, in their area.The project was delivered by the Alcohol Forum in partnership with the Drug Programmes and Policy Unit of the Department of Health and the Wellbeing Division of the Health Service Executive.

Community mobilisation

Underpinning the pilot project’s approach was the finding of the National Substance Misuse Strategy that community mobilisation is successful in bringing stakeholders together to develop alcohol and drug policies. The author of the evaluation report describes community mobilisation as a public health approach to reducing alcohol-related harm: it changes the context in which alcohol use occurs, rather than focusing on the ‘problem drinker’. It is a process through which communities work together to take action and bring about change, working with a range of stakeholders from the public, statutory and private sectors to identify the changes they want to bring about in their area. Based on the best evidence available the different stakeholders plan together how to bring about the desired changes. The community then implements the plan and monitors its progress in reducing alcohol-related harm. Some common features of the approach are shown in Figure 1.

Figure 1: Common stages in a community mobilisation process (Galligan 2016: p24)

The evaluation report contains a review of the literature on community mobilisation and shows how elsewhere it has been effective in reducing alcohol-related harm. The author identifies key elements that contribute to positive results when working in this way, including:

-        establishing well-functioning coalitions,

-        getting wider community buy-in to the process and its aims,

-        changing the policy context,

-       
taking an evidence-based approach,

-        giving the project adequate time to get established and deliver on outcomes (in excess of three years),

-        taking a multi-strategy approach, and

-        using the media to support interventions.  

Evaluation findings

Drawing any conclusions about the effectiveness of the NCAAPP in reducing alcohol-related harm was beyond the scope of this evaluation. Instead, the report explored the effectiveness of the process put in place to deliver on community mobilisation and to establish local alcohol action plans.

Five task forces were selected to take part in the project, each of which identified a project lead and established an ‘alcohol sub-committee’ with responsibility for delivering on the project in their area. Each sub-committee sent a representative on five one-day formal training sessions in Dublin. These covered a range of topics including community mobilisation, data collection, research and evaluation methods, logic models, alcohol-related harm, using the
media, and effective policy measures to address alcohol harms. The task forces then received on-site tailored support to help develop their local plans, as well as access to follow-up support via phone calls, emails, one-on-one meetings and some on-site group training. One individual from the Alcohol Forum had responsibility for delivering this programme of training and support.

Broadly speaking, the goals of the project were to train stakeholders on drug-related harm, raise awareness of policy measures, support community engagement, and develop local action plans.  The evaluation found that, overall, the project was successful in these areas. 

The training and support delivered was of a high quality and was delivered by a highly dedicated trainer. Participants improved their knowledge of alcohol-related harms and the networking opportunities afforded by the centralised training sessions were seen as beneficial. The training also led to changes in work practices, for example a public health approach to alcohol issues was adopted, evidence-based measures were applied, and a community mobilisation model was used.

At the core of the project was the production of local alcohol action plans. Four of the five task forces completed local alcohol action plans by the end of the project and the fifth had an outline plan. All the completed action plans included monitoring, review and self-evaluation measures. 

A number of critical barriers were identified. Building local leadership and commitment to the project proved challenging, as did engaging stakeholders to lead a collective approach. Limited resources presented hurdles when it came to making and implementing a plan. Finally, local policy changes to help lower alcohol-related harm needed to be reinforced by a government-level commitment to adopting such evidence-based policies.

The author made a range of recommendations at the end of the report. She highlighted the fact that community action on alcohol is a long-term process and that the pilot project was just the beginning of the process for those involved.

Lucy Dillon

¹ Galligan C  (2016) National community action on alcohol pilot project 2015: external evaluation project. Dublin: Department of Health http://www.drugsandalcohol.ie/25098/

²Department of Health (2012) Steering group report on a national substance misuse strategy. Dublin: Department of Health. http://www.drugsandalcohol.ie/16908/

The 13th annual report from the National Registry of Deliberate Self-Harm was published in September 2015.¹ The report contains information relating to every recorded presentation of deliberate self-harm to acute hospital emergency departments in Ireland in 2014, and complete national coverage of cases treated. All individuals who were alive on admission to hospital following deliberate self-harm are included, along with the methods of deliberate self-harm that were used.  Accidental overdoses of medication, street drugs or alcohol are not included.

There were 11,126 recorded presentations of deliberate self-harm, involving 8,708 individuals, in 2014. This implies that more than one in five (2,418, 22%) of the presentations were repeat episodes.  There was virtually no change in the rate of presentations between 2013 and 2014, following a 6 per cent decrease between 2012 and 2013.  The rate in 2014 remained 6 per cent higher than the pre-recession rate of 188/100,000 in 2007 (Figure 1).  The only age group in which there was significant change in the rate of deliberate self-harm between 2013 and 2014 was boys aged 10 to 14 years, among whom the rate increased by 44 per cent, from 34 to 49 per 100,000.

Forty-six per cent of self-harm presentations in 2014 were men, and just over half (54%) were aged under 30 years. People living in hostels for the homeless or of no fixed abode made up 5 per cent (n=514) of self-harm presentations.   Presentations peaked in the hours around midnight and were highest on Sundays and Mondays, with 31 per cent of episodes occurring on these two days. There was evidence of alcohol consumption in 3,860 (35%) presentations and this was more common among men (37%) than women (33%).

Drug overdose was the most common form of deliberate self-harm reported in 2014, occurring in 7,314 (66%) episodes. This was a small decrease (-2%) on 2013. Overdose rates were higher among women (72%) than among men (58%). In 70 per cent of cases the total number of tablets taken was known, with an average of 28 tablets taken in these episodes.

A minor tranquilliser (most commonly benzodiazepines) was involved in 37  per cent of all drug overdoses;  28 per cent of overdoses involved paracetamol-containing medicines; 21% involved antidepressants or mood stabilisers (most commonly selective serotonin reuptake inhibitors [SSRIs]); 10 per cent involved a major tranquilliser and 26 per cent other prescribed drugs.

There was an 11 per cent increase in the number of presentations involving street drugs, from 420 in 2013 to 465 in 2014 (following annual decreases from in 2010 to 2013).  The 2014 level was similar to the level recorded in 2008 – 461.

The next steps, or referral outcomes, for the deliberate overdose cases were 51 per cent discharged home; 28 per cent admitted to an acute general hospital; 6 per cent admitted to psychiatric in-patient care; a small proportion (1%) refused admission to hospital; and 14 per cent discharged themselves before receiving referral advice.

The report provided information on what was being or could be done to reduce the number of self-harm cases.  Particularly encouraging were the facts that over 30 self-harm specialist nurses had taken up positions in various hospitals in 2014 and that increased numbers of patients were receiving mental health assessments.   

While the total number of presentations involving drug overdose rose, there was a significant reduction in overdoses involving minor tranquillisers.  The report related this to proactive monitoring of prescribing patterns in primary care services since 2012.  The authors recommended that reducing access to minor tranquillisers should be an on-going priority.

The authors reported that, as in previous years, alcohol continued to be one of the factors associated with the higher rate of self-harm presentations on Sundays, Mondays and public holidays, and in the hours around midnight. These findings underlined the need for on-going efforts to:

-        enhance health service capacity at specific times and increase awareness of the negative effects of alcohol misuse and abuse such as increased depressive feelings and reduced self-control;

-        intensify national strategies to increase awareness of the risks involved in the use and misuse of alcohol, starting at pre-adolescent age, and intensify national strategies to reduce access to alcohol and drugs;

-        educate self-harm patients and their families about the importance of reduced use of and access to alcohol; and

-        arrange active consultation and collaboration between the mental health services and addiction treatment services in the best interest of patients who present with dual diagnosis (psychiatric disorder and alcohol/drug abuse).

The authors reported that there was variation in the next care recommended to deliberate self-harm patients, and in the proportion of patients who left hospital before receiving a recommendation.  While overall, nearly three quarters of all patients were discharged with a referral, variations were seen in referral pathways across HSE hospital groups.  The authors recommended that the national guidelines for the assessment and management of patients presenting to Irish emergency departments following self-harm be implemented nationally as a matter of priority. ²

The report highlighted the on-going work by the National Suicide Research Foundation to link data on deliberate self-harm with suicide mortality data.  This linking has shown that individuals who self-harm are over 42 times more likely to die by suicide than the general population.  Further linkage is recommended in order to enhance insight into predictors of suicide risk.

Margaret Curtin

¹ Griffin E, Arensman E, Dillon CB, Corcoran P, Williamson E and Perry IJ (2015) National self-harm registry Ireland annual report 2014. Cork: National Suicide Research Foundation. http://www.drugsandalcohol.ie/24654/

² Cassidy E, Arensman E, Keeley HS and Reidy J ((2012) Saving lives and reducing harmful outcomes: care systems for self-harm and suicidal behaviour. Dublin: HSE, and Cork: National Suicide Research Foundation. https://www.hse.ie/eng/about/Who/clinical/natclinprog/mentalhealthprogramme/selfharm/selfharm.pdf

BLDATF developed the DATMS to provide up-to-date information about drug and alcohol use among people living in Dublin 15. The monitoring system identifies the types of drug being used within the local community, and also identifies emerging trends at an early stage of development. To gather the relevant data, clients of treatment services were interviewed and outreach workers administered questionnaires in the local community.

This type of information is necessary in order to recognise key local issues and to develop appropriate strategies in response. The data will serve as a baseline for local trends from which future variations can be monitored over time.

Key research findings for treated drug and alcohol use

-         The main problem drugs for which adult drug users sought treatment included heroin, methadone, alcohol, cannabis (weed), benzodiazepines, Z drugs and cocaine powder.

-         The main problem drugs for which under-18 year old drug users sought treatment included cannabis (weed) and alcohol. Ecstasy and solvents were involved to a lesser extent.

-         Service providers reported an increase in the use of the following drugs by treated drug users: cannabis (weed), benzodiazepines and Z drugs, crack cocaine, alcohol, Lyrica/Pregabalin (prescribed pain killer) and codeine-based over-the-counter (OTC) drugs.

-         The increase in the use of weed related to both treated under-18 and adult drug users. The increase in the use of the other drugs is related to treated adult drug users only.

-         The number of heroin users entering treatment is in decline; clients are an ageing population of long-term users, with fewer young people accessing treatment.

-         Poly-drug use was reported to be the norm by the majority of both treated under-18 and adult drug users.

-         Steroid use by some men in recovery from problematic drug use was in some cases associated with relapse.