Reducing harm, supporting recovery: a health-led approach to drug and alcohol use in Ireland 2017— 20251 was launched on 17 July 2017 by An Taoiseach Leo Varadkar, alongside the Minister for Health Simon Harris TD, and the Minister for Health Promotion and the National Drugs Strategy, Catherine Byrne TD.

 

A health-led approach

The strategy follows through on the commitment made by Government in May 2016 ‘to pursue a health-led rather than a criminal justice approach to drug use’.2 At the launch of the strategy, all of the speakers emphasised the importance of this shift in approach.3,4,5 The Taoiseach said that ‘treating substance abuse and drug addiction as a public health issue, rather than a criminal justice issue, helps individuals, helps families, and helps communities. It reduces crime because it rebuilds lives’.3 Compassion has been identified internationally as an ‘essential ingredient’6 of a health-led approach to drug policy and is a recurring theme both in the strategy document and in what was said at the launch. In her speech, Minister Byrne said ‘there is one word that runs like a thread throughout the strategy, and that word is “compassion” — compassion is the basis for a health-led approach to addiction’.4

 

Integrated drug and alcohol strategy

Reducing harm, supporting recovery is the first ‘integrated’ drug and alcohol strategy in Ireland. In his foreword to the strategy, the Taoiseach notes that ‘many Irish people engage in harmful drinking patterns and alcohol has become a major drugs issue’ (p. 3). While a Government commitment was made in 2009 to produce ‘a combined National Substance Misuse Strategy to cover both alcohol and drugs’ (p. 5),7 this did not happen. The new strategy takes account of what the Expert Review Group for the 2009—2016 strategy described as this ‘elephant in the room’ (p. 4)8 for Irish drug policy, i.e. alcohol. The strategy defines substance misuse as ‘the harmful or hazardous use of psychoactive substances, including alcohol, illegal drugs and the abuse of prescription medicines’ (p. 7).1 There is an explicit commitment to ensuring ‘an integrated public health approach to drugs and alcohol is delivered as a key priority’ (p. 22). The strategy complements the Public Health (Alcohol) Bill and reinforces some of the key elements of the alcohol-focused National Substance Misuse Strategy from 2012.9 However, illicit drug use continues to be the primary focus of many of the actions of the new strategy from 2017 to 2020. It is not clear from the strategy and its accompanying action plan how the challenges of implementing such an integrated approach will be overcome.

 

Additional funding for 2017

At the launch, Minister for Health Simon Harris TD expressed the Government’s commitment to ‘making progress on the delivery of the actions in the strategy in the current year’.5 An additional €3 million was allocated to drug initiatives in Budget 2017 to:

• Commission 105 new treatment episodes from residential and rehabilitation services.
• Implement a pilot supervised injecting facility in Dublin City centre (expected to be open by the end of 2017).
• Support the phased increase from Q3 2017 in the availability of buprenorphine/naloxone treatment as an alternative treatment for the identified cohorts of patients for whom methadone treatment is not suitable.
• Fill gaps in addiction service provision for under 18-year-olds.
• Provide more detoxification places in community and residential settings in 2018.

 

2 Government of Ireland (2016) Programme for partnership government. Dublin: Department of the Taoiseach. https://www.drugsandalcohol.ie/25508/

3 Varadkar L (2017) Speech by An Taoiseach Mr Leo Varadkar TD to launch Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017—2025. https://www.drugsandalcohol.ie/27650/

4 Byrne C (2017) Speech by Catherine Byrne TD, Minister of State for Health Promotion and the National Drugs Strategy at the launch of Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017—2025. https://www.drugsandalcohol.ie/27651/

5 Harris S (2017) Speech by Simon Harris TD, Minister for Health at the launch of Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017—2025. https://www.drugsandalcohol.ie/27611/

6 Pike B (2016) What’s in a drugs strategy? Drugnet Ireland, 57: 10—11. https://www.drugsandalcohol.ie/25490/

7 Department of Community, Rural and Gaeltacht Affairs (2009) National drugs strategy (interim) 2009—2016. Dublin: Department of Community, Rural and Gaeltacht Affairs. https://www.drugsandalcohol.ie/12388/

8 Griffiths P, Strang J and Singleton N (2016) Rapid expert review of the national drugs strategy 2009—2016. Dublin: Department of Health. https://www.drugsandalcohol.ie/27289/

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

 

 

Structure of the new drugs strategy

The new strategy1 indicates a departure from the pillar structure of the two previous drug strategies.2 It is underpinned by a set of core values and is structured around a vision and five goals — each goal has a set of objectives, accompanying actions and performance indicators. While the structure has changed, its overall direction is very similar to previous strategies.

 

Vision and values of the new drugs strategy

Vision

The strategy’s vision is for: A healthier and safer Ireland, where public health and safety is protected and the harms caused to individual, families and communities by substance misuse are reduced and every person affected by substance use is empowered to improve their health and wellbeing and quality of life.

 

Values

To deliver on this vision, the strategy is underpinned by six values:

Compassion: A humane, compassionate approach focused on harm reduction which recognises that substance misuse is a healthcare issue.

Respect: Respect for the right of each individual to receive person-centred care based on his or her specific needs and to be involved in the development of their care plan.

Equity: A commitment to ensuring that people have access to high-quality services and support, regardless of where they live or who they are.

Inclusion: Diversity is valued, the needs of particular groups are accommodated and wide-ranging participation is promoted.

Partnership: Support for maintaining a partnership approach between statutory, community and voluntary bodies and wider society to address drug and alcohol issues.

Evidence-informed: Support for the use of high-quality evidence to inform effective policies and actions to address drug and alcohol problems (p. 16).

 

Action plan

The strategy covers an eight-year period (2017—2025), and is accompanied by a shorter-term action plan (2017—2020). The previous seven-year strategy had actions set out for its duration from the start. A review of that strategy found that the actions could not be reactive to change in the drug situation over time, which contributed to an overall perception of a decline in the strategy’s ‘relevance and momentum’ (p. 6)3 over its timeframe. At the launch of the strategy, the Taoiseach noted that having a new action plan from 2021 to 2025 ‘will ensure the continued relevance of the strategy until the end of its term’.4

 

Synergy with other strategies

A noticeable feature of the new strategy and its action plan is a synergy with other Government strategies and policies. To minimise duplication, the waste of scarce resources and to maximise the impact of strategies, the Expert Review Group on the 2009—2016 national drugs strategy emphasised the importance of having clear ‘synergy and complementarity’3 (p. 31) between the new strategy and other related strategies. These include broad strategies such as Healthy Ireland and the Action Plan for Education 2016—2020, as well those that target the needs of specific groups, such as the National Traveller and Roma Inclusion Strategy 2016—2020. The enactment of the Public Health (Alcohol) Bill would be critical to delivering on a number of the alcohol elements of the strategy. In her foreword to the document, Minister Catherine Byrne TD described the Bill as ‘a key step forward’ (p. 4), and in the main body of the document it is described as containing ‘the proposed legislative provisions to provide a public health response to issues associated with alcohol consumption in Ireland’ (p. 20). However, it is not mentioned in the action plan.

 

2 Department of Community, Rural and Gaeltacht Affairs (2009) National drugs strategy (interim) 2009—2016. Dublin: Department of Community, Rural and Gaeltacht Affairs. https://www.drugsandalcohol.ie/12388/

3 Griffiths P, Strang J and Singleton N (2016) Report of the rapid expert review of the national drugs strategy 2009—2016. Dublin: Department of Health. https://www.drugsandalcohol.ie/27289/

4 Varadkar L (2017) Speech by An Taoiseach Mr Leo Varadkar TD to launch Reducing harm, supporting recovery: a health-led response to drug and alcohol use in Ireland 2017—2025. https://www.drugsandalcohol.ie/27650/

 

 

Goals of the drugs strategy

Five goals form the core of Reducing harm, supporting recovery: a health-led approach to drug and alcohol use in Ireland 2017—2025.1 Broadly speaking, they cover similar themes to those in the previous strategy’s pillars: prevention, treatment, rehabilitation, recovery, supply reduction, research and evidence. Goal 4 reflects an increased focus on supporting the participation of individuals, families and communities in responding to the drug situation. Below are brief descriptions of each goal, its objectives, and elements of the 50 accompanying actions.

 

Goal 1: To promote and protect health and wellbeing

This goal focuses on prevention. It aims to:

Protect the public from threats to health and wellbeing related to substance misuse by preventing early use of alcohol and other drugs among young people, influencing behaviour and challenging social norms and attitudes and providing targeted interventions aimed at minimising harm for those who have already started to use substances. (p. 17)

 

There are three objectives to this goal: 1.1 To promote healthier lifestyles within society

Actions include:

• To ensure that the commitment to an integrated public health approach to drugs and alcohol is delivered as a key priority by developing a relevant initiative and promoting the use of evidence-based approaches to mobilising community action on alcohol (1.1.1).
• To improve the delivery of substance use education across all sectors (1.1.2).

1.2 To prevent use of drugs and alcohol at a young age Actions include:

• To support the Social, Personal and Health Education (SPHE) by promoting effective communications between schools and Drug and Alcohol Task Forces (1.2.3).
• To improve supports for young people at risk of early substance use by prioritising initiatives under the new DEIS [Delivering Equality of
• Opportunity in Schools] programme to address early school leaving; and providing a continuum of support for young people encountering difficulty in mainstream education (1.2.5).
• To facilitate increased use of school buildings, where feasible, for afterschool care and out-of-hours use to support local communities (1.2.7).
• To improve services for young people at risk of substance misuse in socially and economically disadvantaged communities by developing a new scheme to provide targeted, appropriate and effective services (1.2.8).

1.3 To develop harm reduction interventions targeting at risk groups

Actions include:

• To mitigate the risk and reduce the impact of parental substance misuse on babies and young children by developing protocols between addiction services, maternity services and children’s health and social care services (1.3.9c).
• To strengthen early harm reduction responses to current and emerging trends and patterns of drug use by establishing a working group to examine the evidence on responses such as drug testing and amnesty bins (1.3.11). 

Goal 2: To minimise the harms caused by the use and misuse of substances and promote rehabilitation and recovery

This goal focuses on the range of treatment, rehabilitation and recovery services available to users. It recognises that ‘timely access to appropriate services relevant to the needs and circumstances of the person concerned is of fundamental importance’ (p. 33). There are two objectives to the goal:

 

2.1 To attain better health and social outcomes for people who experience harm from substance misuse and meet their recovery and rehabilitation needs This objective focuses on improving access to a range of services, for users generally and for some groups in particular. These include women, children and young people, groups with ‘more complex needs’ (p. 44), and prisoners.

Associated actions include:

• To strengthen the implementation of the National Drugs Rehabilitation Framework (2.1.12).
• To enhance the quality and safety of care in the delivery of opiate substitution therapy (OST) by implementing the HSE National Clinical Guidelines on OST (2.1.15).
• To further strengthen services to support families affected by substance misuse (2.1.17).
• To help individuals affected by substance misuse to build their recovery capital by monitoring and supporting the Framework for Community
• Employment Drug Rehabilitation Schemes (2.1.18a); and utilising the Social Inclusion and Community Activation Programme (SICAP) (2.1.18b).
• To increase the range of progression options for recovering drug users and develop a new programme of supported care and employment (2.1.19).
• To improve outcomes for people with comorbid severe mental illness and substance misuse problems by supporting the Mental Health Clinical
• Programme to address dual diagnosis (2.1.24a); and develop joint protocols between mental health services and drug and alcohol services (2.1.24b). 

2.2 To reduce harm among high-risk users This objective focuses specifically on people who inject drugs and the issues of overdose and drug-related deaths.

Among the associated actions are:

• To provide enhanced clinical support to people who inject and mitigate the issue of public injecting by establishing a pilot supervised injecting facility (2.2.29).
• To continue to target a reduction in drug-related deaths and non-fatal overdoses by expanding the availability of naloxone to people who use drugs, their peers and family members (2.2.30b). 

Goal 3: To address the harms of drug markets and reduce access to drugs for harmful use

This goal focuses on the range of activities that aim to reduce the supply of illicit drugs and deal with those involved in supply activities. It also considers the ways in which users are dealt with in the criminal justice system. There are three associated objectives:

 

3.1 To provide a comprehensive and responsive misuse of drugs control framework which ensures the proper control, management and regulation of the supply of drugs

Associated actions are:

• To map the future direction and objectives of the Drug Treatment Court by carrying out an independent evaluation of it (3.1.34a).
• To consider the approaches taken in other jurisdictions to the possession of small quantities of drugs for personal use with a view to making recommendations on policy options to the relevant Minister within 12 months (3.1.35). 

3.2 To implement effective law enforcement and supply reduction strategies and actions to prevent, disrupt or otherwise reduce the availability of illicit drugs

Actions include:

• To support the role of law enforcement authorities in monitoring drug markets, in particular new drug markets, surface web and darknet drug markets (3.2.36).
• To consider the case for the use of Community Impact Statements within the criminal justice system in Ireland (3.2.37). 

3.3 To develop effective monitoring and responses to evolving trends, public health threats and the emergence of new drug markets

Actions include:

• To strengthen the response to the illegal drugs market by developing systems to monitor changing drug trends in line with the EU Early Warning
• System (3.3.38a); and to complete the development of the HSE public alert system for adverse events due to drugs (3.3.38b). 

Goal 4: To support participation of individuals, families and communities

This goal recognises the need to support communities by building on their capacity to respond to the drugs situation. It also emphasises the need for meaningful involvement of service users and their families in the planning, design and delivery of effective services. There are two objectives:

 

4.1 To strengthen the resilience of communities and build their capacity to respond

Actions include:

• To support and promote community participation in all local, regional and national structures (4.1.39).
• To measure the impact of drug-related crime and wider public nuisance issues on communities by piloting a Community Impact Assessment
• Tool (4.1.40).
• To strengthen the effectiveness of the Drug-Related Intimidation Reporting Programme (4.1.42). 

4.2 To enable participation of both users of services and their families

Actions include:

• To build capacity within the problem substance use sector to develop a patient safety approach requiring services within a Quality Assurance Framework (4.2.43).
• To promote the involvement of service users and their families in decision-making structures and networks at all levels (4.2.44). 

Goal 5: To develop sound and comprehensive evidence-informed policies and actions

There are no objectives under this goal but its actions include:

• To strengthen Ireland’s drug monitoring system (5.1.45).
• To strengthen the National Drug Treatment Reporting System by requiring all publicly funded drug and alcohol services to complete the NDTRS (5.1.47).
• To improve knowledge of rehabilitation outcomes by undertaking a study on outcomes that takes into account the experiences of service users and their families (5.1.49). 

Implementing the drugs strategy

The final substantive chapter of the national drugs strategy (NDS) focuses on what is termed ‘strengthening the performance of the strategy’.1 There are two elements to this: measuring performance and the structures that will support the implementation of the strategy.

 

Measuring performance

The strategy sets out a number of ways in which progress on the delivery of the strategy will be monitored and assessed:

• A number of performance indicators appear at the end of each goal. However, the detail of which objective they relate to, how they will be used, and timelines for delivery are not included.
• Bodies charged with delivering the different actions of the strategy will be required to report to the Minister with responsibility for the NDS on an annual basis.
• The strategy aims to operationalise a new Performance Measurement System by 2020. The system that was developed by consultants will ‘support Reducing Harm, Supporting Recovery, improve accountability across the statutory, community and voluntary sectors and strengthen the Drug and Alcohol Task Force model’ (p. 74). It focuses on ‘the net effects of the strategy at the population level, in particular, the effects on the health wellbeing and quality of life of people living in local and regional DATF areas’ (p. 73). Essentially, it makes predictions about what it would expect the level of problem drug use to be in a small area, based on a selection of social indicators linked to deprivation, urbanity and social class. It then compares these with the predicted level of problem substance use. If the model finds significant changes over time, or differences are found between DATF areas, then analysis will be carried out to explore why this has happened. 

Implementation structures

The new strategy makes some changes to the existing organisational structure for the implementation and delivery of the drugs strategy. Among the aims of the restructure are that the structure of the previous drugs strategy would be streamlined to better deliver on the key functions of the strategy; and that participation in the strategy would be optimised in a way that avoids ’duplication and overlap’ (p. 76). The Report of the rapid expert review of the National Drugs Strategy 2009—20162 identified the ‘strong role of community organisations’ in both strategy development and delivery as one of the ‘key features of the Irish context’ (p. 9). However, they noted that in some areas of the strategy, the coordination between local, regional and the national level became less effective over time.

 

The new structures represent what is termed a ‘more streamlined structure’1 (p. 76). As with the previous strategy, the challenge will remain for the structures to be able to sustain the active membership of those who are in a position to take action, and to ensure that community voices are heard at all levels. In her response to such concerns expressed at the launch of the new strategy, Minister Byrne gave assurances that the structures would deliver on this for the duration of the strategy.

 

Ministerial responsibility: The Minister for Health continues to have overall responsibility for the NDS. There also continues to be a Minister of State in the same department with responsibility for Health Promotion and the National Drugs Strategy.

 

National Oversight Committee: This will be a senior official level committee ‘sponsored’ (p. 76) by the Minister of State for the NDS. Membership will include representatives from the statutory, community and voluntary sectors and expertise from both a clinical and academic representative. Membership from the statutory sector will be at the level of Assistant Secretary. The committee is to meet on a quarterly basis and has five main functions, as outlined in its terms of reference:

• To give leadership, direction, prioritisation and mobilisation of resources to support the implementation of the strategy.
• To measure performance in order to strengthen the delivery of drug initiatives and to improve the impact on the drug problem.
• To monitor the drugs situation and oversee the implementation of a prioritised programme of research to address gaps in knowledge.
• To ensure that the lessons drawn from evidence and good practice inform the development of policy and initiatives to address the drug problem.
• To convene subcommittees, as required, to support implementation of the strategy (p. 77). 

Standing subcommittee: A standing subcommittee will be set up to support the implementation of the NDS and promote coordination between national, local and regional levels. It will meet on a monthly basis and will be chaired by a senior official of the Department of Health. Membership will include representatives from the statutory, community and voluntary sectors. Its terms of reference are:

• To drive implementation of the NDS at national, local and regional level.
• To develop, implement and monitor responses to drug-related intimidation as a matter of priority.
• To support and monitor the role of Drug and Alcohol Task Forces in coordinating local and regional implementation of the NDS with a view to strengthening the task force interagency model.
• To improve performance, promote good practice and build capacity to respond to the drug problem in line with the evidence base.
• To ensure good governance and accountability by all partners involved in the delivery of the strategy.
• To report to the National Oversight Committee on progress in the implementation of its work programme. 

The strategy specifically requires drug-related intimidation to be on the agenda for the committee’s first meeting. Members are expected to develop what is called a ‘liaison relationship’ (p. 78) with task forces to support effective coordination and communication between delivery bodies and stakeholders at all levels.

 

Subcommittees: The national committee will be able to establish subcommittees to address specific issues and draw on any expertise necessary to support it on delivering its functions.

 

Drugs Policy Unit, Department of Health: This unit will be responsible for:

• Analysing the implications of research findings for policy and design of initiatives to tackle the drug problem.
• Providing the national committee with advice on the commissioning of new research and development of new data sources, having regard to current information and research deficits and advice and changing patterns of drug use and emerging trends.
• Providing a secretariat to the committee and the standing subcommittee. 

Health Research Board (HRB): The HRB will continue to be the EMCDDA’s national focal point. It will manage the commissioning of any research that the national committee decides should be undertaken to address gaps in their knowledge.

 

Early Warning and Emerging Trends Committee: This committee will receive, share and monitor information from national and EU sources on new psychoactive substances of concern and any emerging trends and patterns in drug use and the associated risks. Membership of this committee is to be extended to include representatives of the network of coordinators of the Local and Regional Drug and Alcohol Task Forces.

 

Drug and Alcohol Task Forces (DATFs): The current terms of reference of the DATFs are referred to in the strategy. Based on these, their role will continue to focus on assessing the extent and nature of the drug and alcohol problem in their areas and in coordinating action at local level so that there is a targeted response to the drug problem in local communities. They will continue to implement the NDS in the context of the needs of their region or local area through action plans. They will also provide an annual report on their activities to the Minister of State with responsibility for the NDS. It is envisaged that the new performance measurement framework will provide the DATFs with information that will support them in the delivery of their role.

 

2 Griffiths P, Strang J and Singleton N (2016) Report of the rapid expert review of the national drugs strategy 2009—2016. Dublin: Department of Health. https://www.drugsandalcohol.ie/27289/