The first Drugnet Ireland was published shortly before the launch of a drugs strategy committed to the development of the evidence base on drugs issues and pursuance of policies based on this knowledge. In this article we reflect on what has actually been learned over the past 10 years and what changes in research practice and output have made a difference. We look forward to your continued support in 2012.

 

Drug prevalence surveys of the general and school-aged populations are important sources of information on patterns of drug use, and, when repeated, reveal changes over time. These surveys increase understanding of drug use, which, in turn, help in the formulation and evaluation of drug policies. They also enable informed international comparisons, provided countries conduct surveys in a comparable manner. There are two key drug prevalence surveys undertaken in Ireland.

 

The All-Ireland Drug Prevalence Survey, first administered in 2002/3 and twice subsequently (2006/7 and 2010/11), seeks to obtain prevalence rates for the more commonly used illegal drugs, such as cannabis, ecstasy, cocaine and amphetamines, on a lifetime (ever used), last year (recent use), and last month (current use) basis. Similar prevalence questions are also asked of alcohol, tobacco, and other drugs such as sedatives, tranquillisers and anti-depressants. Attitudinal and demographic information is also sought from respondents. In the most recent survey, measures to assess the prevalence of dependence on cannabis were included.

 

The questionnaires are administered through face-to-face interviews with respondents aged between 15 and 64 normally resident in households in Ireland and Northern Ireland. Thus, persons outside these age ranges, or who do not normally reside in private households, are not included in the survey. This approach excludes those living in institutions (for example, prisons, hostels). Therefore this type of survey is not a good measure of drug use among marginalised populations, nor of drugs that are more commonly used among such populations, such as crack cocaine or heroin; different research approaches are required among such groups.

 

The European School Survey Project on Alcohol and Other Drugs (ESPAD) is a collaborative effort of independent research teams in about 40 European countries, including Ireland. Data on alcohol and illicit drug use among 15–16-year-olds have been collected every four years since 1995, using a standardised method and a common questionnaire. Data were collected for the fifth iteration of ESPAD in spring 2011 and the survey findings will be published in 2012. The rationale for the survey is that school students are easily accessible and are at an age when onset of substance use is likely to occur. By definition, early school leavers, a group known to be vulnerable to alcohol and drug use, are not represented. The ESPAD survey reports are available at www.espad.org/espad-reports

‘Problem drug use’ is defined by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) as ‘injecting drug use or long duration/regular use of opioids, cocaine and/or amphetamines’. This definition includes regular or long-term use of prescribed opioids such as methadone but does not include their rare or irregular use or the use of other drugs, such as ecstasy or cannabis. Currently, estimates of problem drug use in Ireland are limited to opioid use, using three-source capture–recapture methods for 2001, 2002 and 2006 (Kelly et al. 2003, 2009); owing to methodological limitations, the 2006 estimated figures are likely to be inflated. In 2010 the National Advisory Committee on Drugs (NACD) commissioned the Centre for Drug Misuse Research at the University of Glasgow to examine the methods and data sources available to estimate the prevalence of problem opiate and cocaine use. The researchers recommend that the best national estimate of problem opiate use can be obtained using four national datasets and that the capture–recapture estimate begin at county level and build to national level. This estimate would be validated using the multiplier method and multiple indicator method.

Problematic drug use can be associated with a number of other health conditions or lead to a range of health consequences, including drug-related infectious diseases. This key indicator collects data on the incidence and prevalence of, primarily, HIV, hepatitis C and hepatitis B infection among people who inject drugs. The incidence data are collected through routine surveillance of newly diagnosed cases which identifies injecting drug use as a risk factor, or through cohort studies. In Ireland the Health Protection Surveillance Centre (HPSC) has recorded new cases of HIV among injecting drug users since 1985, and of hepatitis B since 2004 and hepatitis C since 2007. Reporting to the HPSC of risk factors for HIV cases and hepatitis C cases is high, but for hepatitis B is much lower than desirable. The prevalence of HIV, hepatitis B and hepatitis C among injecting drug users has not been reported since 2002.

Established in 2001, the Early Warning and Emerging Trends Sub-Committee of the NACD advises the Irish government on emerging drug trends or practices and their consequences. The members of the committee are recruited from a wide range of government departments, professional disciplines and services, including police and customs, human, chemical and forensic toxicology, pharmacology and pharmaceutical science, emergency medicine, drug treatment, harm reduction, public information and research, including the EMCDDA’s national focal point in Ireland, which is located within the Health Research Board.

In the early years of Drugnet Ireland one of the dominating issues in drug treatment was problem opiate use and the provision of opiate substitution treatment. 

 

The ROSIE study, commissioned by the NACD, was Ireland’s first national, prospective, longitudinal drug treatment outcome study. The main objective was to ‘evaluate the effectiveness of treatment and other intervention strategies for opiate use in Ireland’. In 2003/04, 404 opiate users who entered treatment were recruited and, of these, 289 (72%) completed the follow-up questionnaires one year and three years later. Despite methodological limitations, the overall results showed positive outcomes for opiate users in treatment over the three-year period, including a reduction in the use, number and amount of drugs; an increase in abstinence; a decrease in the proportion of participants who were homeless; and an increase in the proportion who were in employment over the three-year period. Since the study was completed its results have been used to inform a number of strategies, in addition to providing a wide range of additional information through numerous journal articles.

 

In response to the heroin problem in Dublin and, in particular, concern about the spread of HIV, the first Irish methadone treatment protocol (MTP) was published in 1998. The protocol has been reviewed internally (Methadone Prescribing Implementation Committee 2005) and externally (Farrell and Barry 2010). The external review concluded that the original protocol had achieved its aims, particularly in regulating and improving poor prescribing and quality practices. These improvements occurred against a background of  increasing numbers receiving methadone and increasing availability of methadone treatment. The number of continuous care clients attending methadone treatment, as recorded in the Central Treatment List has steadily increased, from 3,681 in 1998 to 8,727 in 2010. The numbers of clients attending Level 1 GPs and receiving methadone in prison have also increased over the same period.

 

The external review of the MTP also recommended that buprenorphine/naloxone should be routinely available as a treatment option, to which end the review was entitled The introduction of the opioid treatment protocol. Other recommendations included expanding clinical governance and audit, increasing the number of Level 2 GPs, reviewing the current urinalysis regime, creating guidelines of treatment in Garda stations, and improving data collection and analysis.

 

An issue associated with problem opiate use is drug-related deaths. For several years prior to 2005 a theory had been in circulation that the number of drug-related deaths in Ireland was being under-recorded. This theory was supported by a number of small studies, one in particular (Byrne 2001, 2002) which found that annual numbers of opiate-related deaths recorded by the Dublin coroners were consistently higher than those recorded in the General Mortality Register.  In addition, families of substance users in Dublin, through the auspices of the Family Support Network, had been calling for an accurate measurement of the extent of premature death among drug users.

 

Action 67 of the 2001–2008 National Drugs Strategy called for the development of a system for recording drug-related deaths and deaths among drug users to enable the State and its agencies to respond in a timely manner, with accurate data. In compliance with this action, the Irish National Drug-Related Deaths Index (NDRDI) was established in September 2005. The strength of the NDRDI is that it records data from four sources – the Coroner Service, the Hospital In-Patient Enquiry scheme (HIPE), the Central Treatment List (CTL), and the General Mortality Register (GMR) – in order to ensure that the database is complete and accurate. To date, the NDRDI has shown that the number and extent of drug-related deaths in Ireland is increasing, and the data have been used to inform policies at both national and European levels. Reports on the data collected in the NDRDI are available at https://www.drugsandalcohol.ie/ hrb publications   

 

 

One issue that has come to the fore in recent years is the extent, and effects, of problem alcohol use among the Irish population. The National Drug Treatment Reporting System (NDTRS), established in 1990, was originally designed to record problem drug use and only recorded problematic use of alcohol in cases where it was an additional problem substance. In 2004, the remit of the NDTRS was extended to include cases who reported alcohol as their main or only problem drug. These data provide valuable information and improve our understanding of the extent of the problem, the characteristics of those seeking treatment, and trends in treatment over time. Reports on the data collected in the NDTRS are available at https://www.drugsandalcohol.ie/ hrb publications    

 

The remit of the NDRDI was also extended, and the index has now retrospectively collected information on alcohol-related poisoning deaths and deaths among those who were alcohol dependent, which, together with the treatment data, increases our understanding of the burden of problem alcohol use in Ireland today. In the future, these databases will allow us to measure the impact of any national policy changes on alcohol-related harm in the Irish population.

 

In one of the first reviews of research on the prevention of drug use published in Ireland, Morgan(2001)  summarised the factors that increase the risk of substance use among young people. He identified a number theoretical categories and the context in which the risk factors in these categories arose, including the individual’s interactions with family, peers, schools and communities. A number of these categories relate to the social and interpersonal sphere, culture or attitudes that young people experience in their immediate environments. 

·         The lack of commitment and social attachment category emphasises the risks associated with deviant impulses which are not held in check when bonds to society, families, schools and belief systems are weakened. 

·         The social cognitive learning theory category refers to the risks associated with young people’s acquisition of their beliefs and behaviours from significant others, such as parents, peers and media celebrities. 

·         The family interaction theory category underlines the risk of maladjustment when a young person’s parents fail to exhibit conventional values or norms or provide affection or discipline.

·         The communal risk factors category highlights how young people are disincentivised to commit to conventional norms and society when communities are disorganised and crime and unemployment are common.

 

Some theoretical categories emphasise those intrapersonal characteristics and biological predispositions which increase risk. 

·         The biological models of vulnerability category stresses genetic susceptibility and inherited characteristics. 

·         The self-derogation and substance use category explains how negative evaluations, by self and others, result in poor self-esteem and greater risk.  

·         The problem behaviour theory category focuses on the behaviour itself rather than on causative factors. It demonstrates how one form of problem behaviour, such as rebelliousness, is associated with other types of problem behaviour.

 

A recent study by Haase and Pratschke (2010) examined the association between a number of risk factors and substance use among a group of early school leavers and a group of school attendees. The findings aligned with several of the theoretical categories identified by Morgan. For example, Haase and Pratschke found evidence of family and peer influence on young people’s behaviours, including both risk and protective factors, which was consistent with both social cognitive learning theory and family interaction theory. They also found evidence consistent with problem behaviour theory, e.g. aggressive behaviour or ‘acting-out’ and substance use, and strong interactions between the use of different substances. The connection between low self-concept or self-esteem and substance use posited by self-derogation and substance use theory was demonstrated by the increased likelihood of smoking cigarettes among both early school leavers and school attendees.

Research done by young people from the Dáil na nÓg Council for the Office of the Minister for Children and Youth Affairs (2010) on the experience of post-primary school students receiving Social Personal and Health Education (SPHE) found that 83% indicated that alcohol, drug and solvent use was the most emphasised theme in the SPHE syllabus. The study identified a number of benefits from participating in the SPHE programme: learning how to make decisions and the chance to discuss interesting subjects were regarded as benefits by more than half the participants; nearly half reported improved self-respect and improved emotional and physical health and well-being, while slightly fewer had developed personal and social skills and had improved mental health and well-being.

 

A study of the contribution of the SPHE curriculum to the experience of junior cycle students and to the junior cycle curriculum (Nic Gabhainn et al. 2007) found that it contributes positively to students’ attitudes to health, especially in their future lives. SPHE helps students to think about and discuss health issues relevant to their age group; it also provides opportunities to develop personal and social skills.

Smyth and McCoy (2009) undertook interviews with parents, children and principals from DEIS (Delivering Equality of Opportunity in Schools) schools, and with key professionals working in a range of educational bodies and statutory organisations and a national postal survey of school principals. The DEIS programme is a targeted intervention delivered in communities that have been identified as having higher than average scores on a number of indices used to assess the extent of disadvantage. This targeted approach can in theory deal with problems more directly than the universal approach. However, the evidence in the report indicated that the problems faced by children attending DEIS schools were so great in number and intensity that the number of families that might benefit from the DEIS programme could be quite small.

Research showed a fall between 2001 and 2006 in the percentage of treatment contacts in employment, despite unprecedented economic growth in the country over this period. Two separate reviews of measures taken to improve the employability of recovering drug users through the FÁS Special Community Employment scheme concluded that the scheme was less focused on improving employability and more inclined to operate in a crisis management mode by providing generic support to recovering drug users. The Bridge-to-Workplace, an inter-agency initiative developed to help recovering drug users return to education or secure work placement in the labour market, reported that between August 2005 and December 2006 over half of participants had completed or were engaged in a work placement.

 

 

The evidence base on the association between homelessness and drug use in Ireland improved considerably during the last decade. In particular, the factors that lead some young people into homelessness have been documented in a number of studies. Studies with homeless young people in Dublin and in Cork (Mayock and Vekic 2006; Mayock and Carr 2008) reported that being in state care, experiencing abusive family situations and developing problem behaviours constituted their pathways into homelessness; once homeless, their substance abuse often exacerbated their experience and led to episodes of insecure accommodation and engagement in high-risk behaviours. Follow-up interviews with the young people in Dublin showed that young people who maintained supportive contact with their families were able to access treatment and make the transition to supportive living conditions. On the other hand, young people with weak family ties and poor education were more likely to remain trapped in homelessness and substance misuse. The legacy of becoming trapped in homelessness was vividly captured in a recent snapshot study of homeless adults using the services of the Simon Communities of Ireland (2010): study participants reported high levels and different combinations of alcohol and illicit drug use; physical and mental health problems were also prominent among these people and many had spent long periods in homelessness.

The National Drugs Strategy 2001–2008 and the National Drugs Strategy (interim) 2009–2016 both sought to address the harm caused to individuals and society by drug misuse through a concerted focus on supply reduction, prevention, treatment, rehabilitation and research. The research pillar of the two strategies has sought to eliminate gaps in knowledge so as to ensure that policy is evidence based.

 

Although the link between drugs and crime has been firmly established in the public consciousness in Ireland, there has been little sustained examination of the precise nature of this link. Murphy (in O’Mahony 2002) suggests that, in Ireland, ‘the notion of a definite causal connection between drugs and crime is assumed rather than examined’ (p. 202).

 

The primary focus of research in this area has been on examining the economic motivation model of drug-related crime, which emphasises the way in which drug dependency amplifies offending behaviour, particularly in relation to property crime and other crimes such as prostitution. The economic model also highlights the way in which the control of heroin use through closely supervised treatment can lead to a reduction in both drug use and crime. The NACD ROSIE study, mentioned in a previous section, has provided strong evidence that treatment reduces the level of crime.

 

Other aspects of the drugs–crime nexus remain under-researched – for example, the links between illicit drug use and driving offences, alcohol use or illicit drug use and violent crime, polydrug use and offending, and drug-use, drug-related crime and gender.

 

Another aspect of drug-related crime highlighted in the literature is ‘systemic crime’, i.e., crime associated with the illicit drug market. Knowledge about how the illicit drug market operates is an important prerequisite for effective interventions and responses to it. Although the issue of drug-related ‘gangland’ violence has received a great deal of media attention and has been the subject of numerous journalistic exposés, until recently Ireland’s illicit drug markets have not been the subject of any in-depth research and analysis. A recent study on Dublin’s crack cocaine market (Connolly et al. 2008) and a forthcoming national study published by the NACD and the HRB (Connolly et al. in press) have begun to address this gap. Studies of illicit drug markets are, by their very nature, difficult to conduct. They require researchers to negotiate access to participants in illicit drug markets, both those involved in the production and distribution of drugs and professionals responding to them. They also require the regular compilation of key data sources such as drug seizures, drug prices and drug purity analysis for example.

 

The last 10 years have also seen a significant intensification in the response of law enforcement agencies to drug-related crime. The Garda National Drugs Unit was established in 1994, and a broad range of legislative provisions has been introduced, including the establishment of the Criminal Assets Bureau, changes to Garda detention and investigation powers, and to the laws on bail and, more recently, legislation tackling organised crime. The emergence of a number of local community policing partnerships in Dublin has also been a positive development, with a commitment in the 2009–2016 drugs strategy to establish similar fora in all local drugs task force areas.

 

Drug law enforcement activities may have contributed to the relative containment of illicit drug use, and the authorities have had some success in disrupting drug markets and dismantling organised crime groups. However, there is little evidence in Ireland or internationally that such strategies have halted the expansion of the illicit drug market or reduced the criminal activities associated with it for any sustained period of time. Indeed, the consistent demand for illicit drugs often ensures that the removal of one drug trafficker creates a vacuum which is inevitably filled by another.

 

A recent international review of evidence-based drug policy (Babor et al. 2010) reached the stark conclusion that ‘there is virtually no scientific research to guide the improvement of supply control and law enforcement efforts… Independent of how strongly a policy maker values law enforcement and supply control as policy tools, it is difficult to understand why policymakers would not want their policies to be based on good quality evidence. The lack of careful study thus continues to pose a major barrier to applying these policies effectively’ (p. 258).

 

Finally, with regard to penal policy, in his seminal study, Mountjoy prisoners: a sociological and criminological profile (1997), Paul O’Mahony found that 63% of prisoners had a serious dependency on a ‘hard drug’, the average age of first imprisonment was just under 19, and there were high rates of recidivism, with prisoners having served an average of ten prison sentences. Fifty-six per cent of the prison population came from six areas in Dublin that were characterised by severe levels of socio-economic deprivation and chronic unemployment. The majority still lived with their parents or other relatives, were from large and often broken families, with 80% having left school before the legal minimum age of 16, and 88% of prisoners having been unemployed prior to their imprisonment. A more recent study on prison recidivism (O’Donnell et al. 2007) has confirmed that the general profile of the Irish prison population remains largely unchanged. Although health services for dependent drug users in Irish prisons have improved significantly in the past ten years, such services are often provided in overcrowded conditions as the numbers in prison have increased by almost 100% in the past 14 years.

 

 

Notable developments in Ireland’s National Drugs Strategy (NDS) since 2001 have included the expansion of the four pillars to include rehabilitation alongside treatment and harm reduction, and recognition of the role of families in tackling the drugs problem. These developments happened on foot of the mid-term review of the first NDS in 2004/5 and the review at the expiry of this same NDS in 2008. While the first NDS included an action calling for a mid-term review, the second NDS, covering 2009–2016, does not include any actions calling for either a review at the mid-way point, in 2012, or an evaluation when the strategy expires in 2016.

 

The top drug-related policy priority for the government currently is how to combine drug policy with alcohol policy, responsibility for both of which rests with the Department of Health. As well as the growing body of research evidence highlighting the problematic aspects of alcohol use in Ireland, noted in a previous section, several regional drugs task forces, in their first strategic and/or action plans completed in 2005, acknowledged the problems associated with alcohol misuse in their areas and included specific responses in their plans. Public consultations on the NDS have also routinely raised the issue of problem alcohol use. An announcement on the preferred approach to combining the policies was expected as this issue of Drugnet Ireland went to press.

 

Ever since a recommendation by the Ministerial Task Force on Measures to Reduce the Demand for Drugs (1996), Ireland’s drugs policy and strategy have been located within the wider policy context of social inclusion. As a result, successive national anti-poverty strategies, social partnership agreements and national development plans have all impacted on the design and delivery of drug policies. The adoption of a lifecycle framework for social policy, following publication of the National Economic and Social Council (NESC) report The developmental welfare state in 2005, has had implications not only for the delivery of drug-related policies but also for drug-related research. Longitudinal studies are now required in order to assess accurately the impact of policies on individuals over the course of their entire lifetime.

 

Following the reorganisation of drug-related policy functions in early 2011, the new government’s view on the wider policy context of the drugs issue has become less clear. Prior to the February election, responsibility for drugs policy was located in the same government department as community and local development, equality and social inclusion policy, suggesting a common goal or shared aspiration among all these policy domains. The new government has separated these four policy areas and assigned them to four different government departments. How the Department of Health will co-ordinate implementation of the national drugs strategy remains to be seen.

Over the past decade Ireland’s drug and alcohol policy frameworks have been the focus of academic research and critical commentary. Since the publication of Shane Butler’s Alcohol, drugs and health promotion in modern Ireland (2002), there has been a steady trickle of studies, published mainly in the international peer-reviewed journal Drugs: education, prevention and policy, around the need to move Ireland’s policy responses away from concepts such as the ‘disease model’ of alcoholism or the ‘war on drugs’ to exploring how a health promotion, or more recently, a population health, model might be applied. In The Irish war on drugs: the seductive folly of prohibition (2008), criminologist Paul O’Mahony argued that Irish society would make substantial gains from accepting the libertarian view that there is a right to use drugs so long as others’ rights are not infringed. He suggested that a non-coercive harm reduction approach could eliminate many of the ill-effects of prohibition and create a positive attitudinal dynamic that lowers the irresponsible and destructive use of drugs.

 

The policy process itself has also been the focus of attention. Brigid Pike (2008) reviewed Ireland’s first national drugs strategy as a ‘policy instrument’, in order to gain insights into how structural elements such as the hierarchy of aims and objectives or governance arrangements might influence the strategic outcomes. She highlighted underlying tensions in the areas of goal-setting, information gathering, co-ordination, and responding to changing circumstances and needs, which have the potential to adversely affect outcomes. In a study of the research/policy interface and the extent to which drug policy in Ireland might be deemed to be a rational, evidence-based process, Niamh Randall (2011) concluded that drug-related policy making in Ireland is unlikely ever to attain the degree of rationality suggested by the managerialist rhetoric of the national drugs strategy.

(Johnny Connolly, Brian Galvin, Martin Keane, Jean Long, Suzi Lyons, Brigid Pike)

 

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