The ninth wave of the Healthy Ireland Survey, commissioned by the Department of Health and carried out by Ipsos B&A, involves a representative sample from the general population aged 15 years and over to increase knowledge of the population’s health and health behaviours.¹ The survey is in accordance with Ireland’s Well-being Framework 2023, which seeks to measure the current status of Ireland’s performance as a nation based on a set of indicators. These focus collectively not only on economic standing but also equality issues and sustainability.² A number of these indicators are incorporated into the survey.

Minister for Public Health, Wellbeing and the National Drugs Strategy, Hildegarde Naughton TD, speaking at the National Drugs Forum 2023 in Croke Park, Dublin

A special supplement of this issue of Drugnet Ireland presents an overview of the Citizens’ Assembly on Drugs Use, which completed its work in late 2023 and published a final report in January 2024. Ireland’s experience with citizens’ assemblies is recognised internationally as a bold experiment in deliberative democracy and an example of pluralism and inclusion in the policy decision-making process. Unlike some of the previous assemblies, the members of the Citizens’ Assembly on Drugs Use were not offered a binary choice and they completed their work with a detailed and nuanced series of recommendations on all aspects of the topic that had been discussed. The members demonstrated exemplary commitment and a remarkable capacity to learn and absorb great detail on the topic. The citizens’ assemblies are evidence of a robust democratic process, an engaged citizenry, and a political environment that allows expression of opposing views and political opinion.

Since the early 2000s, the evaluation of drug policies and strategies has increasingly featured as part of the drugs landscape at European Union (EU) and member state levels. Evaluation is a critical part of the policymaking process. It supports effective policymaking by helping it adapt to changes over time, ensure lessons are learnt from previous successes and failures, and therefore strengthens value for money in the approach taken by the EU and member states to dealing with the drugs issue.

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) considers policy evaluation a priority (see Box 1). In December 2023, it updated its online content for the topic overview on drug policy evaluation in Europe.¹ Stakeholders can find links to sources to support policy evaluation, as well as examples of EU and member state outputs on the topic. The overview presents the state of play at the end of 2023 on the focus of national drug strategies and their evaluations.

Background

The first Health Research Board (HRB) conference solely dedicated to alcohol research was held on 14 September 2023 in partnership with the Department of Health. The event was opened by the HRB CEO, Dr Mairéad O’Driscoll, who welcomed the support of the Department of Health, which, along with the HRB, recognises the importance of and is committed to progressing alcohol-related research.

One of the objectives of the HRB Strategy 2021–2025 is to collect and report alcohol-related data for policy and service planning purposes, and the event included speakers from across the organisation presenting the work of the HRB.¹ The strategy (key action 3.4) also promotes primary research and secondary data analysis to support drug and alcohol strategies at a national and European level. The HRB also has a responsibility to ‘assist the Department of Health to monitor the Public Health Alcohol Act through data collection, validation, analysis and dissemination’ (implementation action 3.4.4). This important obligation is achieved through the work of the team in the HRB Evidence Centre and through the alcohol overviews published periodically. Dr O’Driscoll acknowledged the work of the HRB, particularly that of the evidence team and the drugs and alcohol policy team, whose work has been instrumental in providing evidence to influence policy. An important example given was of collating key evidence of alcohol-related harm directly influential in the eventual passing of the Public Health (Alcohol) Act in 2018.²

The Medical Cannabis Access Programme in Ireland¹ currently provides access to cannabis to patients with one of three conditions when other treatments have been unsuccessful. The three conditions are spasticity (stiff and/or rigid muscles) associated with multiple sclerosis, nausea and vomiting associated with chemotherapy, and severe epilepsy.

An evidence review was conducted by the Health Research Board (HRB) to inform a Department of Health review of the current Medicinal Cannabis Access Programme on the suitability of cannabis-based products for medical conditions.

Background

In January 2022, Ireland introduced minimum unit pricing (MUP) at EUR 1.00 per 10 grams of alcohol as per Section 11 of the Public Health (Alcohol) Act 2018.¹ The Act was introduced in response to the high level of alcohol use and related harms in Ireland. Alcohol-related hospital discharges are collected through the Hospital In-Patient Enquiry (HIPE) Scheme; however, the burden of alcohol-related harm in emergency departments (ED) in Ireland is largely unknown, as this information is not routinely collected.² One study in 2018 estimated that 6% of ED presentations are alcohol related.³ A study by Maharaj et al. in 2024 sought to determine the impact of alcohol on ED presentations and hospital admissions and to investigate if the introduction of MUP impacted such presentations or admissions.⁴

Suicide is a complex, major public health issue globally. While people who use drugs (PWUD) are known to be at increased risk of suicide, there is limited information on the specific candidate risk factors for this group, which could help to inform targeted interventions to reduce their risk. To this end, a scoping review was conducted with three aims: (1) to map the extent, range, and nature of available evidence on factors associated with death by suicide among PWUD; (2) to identify knowledge gaps and limitations in this body of evidence; and (3) to inform suicide prevention policy and best practice guidelines for working with PWUD, where appropriate.¹

Methods

The aim of scoping reviews is to systematically search for and then map all the evidence in relation to the research question. Scoping reviews encompass all available literature, both published and grey, with stakeholder consultation an important component. Unlike systematic reviews, this method in general does not include a quality appraisal of the literature.

Globally, there are an estimated 15.6 million people who inject drugs (PWID).¹ Among PWID, the risk of acquiring HIV is more than 30 times higher than the rest of the population.² However, HIV incidence has declined among PWID in Western Europe over the last two decades. In light of this improved situation, a 2023 study investigated changes in HIV incidence in Ireland among PWID from 2000 to 2018.²

In this study, published in the journal Addiction, data on new diagnoses of HIV among PWID, as reported by the Health Protection Surveillance Centre, were examined. New HIV cases in two time periods (2000–2009 and 2010–2018) were compared by sex, age group, area of residence, and country of birth.

Drug use during pregnancy is a worldwide problem and the consequences of continued drug misuse in pregnancy can be significant.¹ Pregnancy may provide opportunities to engage vulnerable women in essential healthcare. However, women with an addiction may have poor adherence with prenatal appointments, presenting late in pregnancy or not until labour. Hence, drug liaison midwives (DLMs) were appointed to the three Dublin maternity hospitals in 1999.

A 2023 retrospective observational cohort study was conducted at an Irish tertiary maternity unit.² In this study, published in the European Journal of Obstetrics & Gynecology and Reproductive Biology, all women with opioid use disorder (OUD) or substance use in pregnancy delivered under this service between 2010 and 2019 were included. Data were collected by combining electronic and hand-held patient records, and trends and outcomes were analysed by year of delivery.

The annual report published by the Mental Health Information Systems Unit of the Health Research Board, National Psychiatric Inpatient Reporting System (NPIRS) annual report on the activities of Irish psychiatric units and hospitals, 2022,¹ shows that the rate of new admissions to inpatient care for alcohol disorders has decreased.

In 2022, some 806 cases were admitted to psychiatric facilities with an alcohol disorder, of whom 263 were treated for the first time. Figure 1 presents the rates of first admission between 2002 and 2022 for cases with a diagnosis of an alcohol disorder. Trends over time indicate an overall decline in first admissions. Just over one-third (35.3%) of cases hospitalised for an alcohol disorder in 2022 stayed just under 1 week, while 26.5% of cases were hospitalised for between 1 and 3 months, similar to previous years.

The inaugural More Than That Festival to mark recovery month was held in Naas, Co. Kildare, on 30 September 2023. It was organised by the South Western Regional Drugs and Alcohol Task Force (SWRDATF) area to celebrate recovery from addiction.¹ A series of activities and events were held throughout the day, beginning with the Recovery Champions 5K Run, which featured famous Kildare faces such as former Gaelic footballer Anthony Rainbow, leading out a run/walk in support of addiction recovery.

Background

The Alcohol Programme in the Health Service Executive (HSE) was established in 2016 to address the impact of alcohol-related harm on individuals, families, and children. The programme aims to decrease per capita alcohol use to 9.1% (10.2 litres in 2022), in accordance with the Healthy Ireland Framework 2013–2025.^1,2 The work of the HSE Alcohol Programme involves collaborating with the Department of Health, Alcohol Health Alliance Ireland, and other stakeholders to actively support the Public Health (Alcohol) Act 2018. This involves identifying national priority areas, supporting effective policies, and advocating for evidence-based interventions and community action as well as informing and supporting the public in reducing alcohol use and signposting to support services through the AskAboutAlcohol campaign and website.³

Purpose of scenario development in drug policy

All foresight work involves developing a capacity to identify weak signals, considering how they may react within a specified environment, and determining the level of attention they deserve. Epidemiologists and drug policy experts anticipate greater diversity in patterns of drug use as the plant-based drugs that have dominated the picture in recent decades are partially replaced by synthetic drugs and polydrug use becomes increasingly common. Geopolitical changes, the emergence of new trafficking routes, and other supply-related factors add further complexity. As with any complex system, it is problematic to assign significance to a particular variable in the drugs field, especially if it is difficult to discern. We can easily overlook signals or fail to recognise their potential significance or predict what signals will become trends. There are cognitive as well as imaginative factors that can impede a thoughtful consideration of possible future events, but foresight helps us to identify what these barriers are and allows us to be more playful and open in considering signals. It is a valuable tool for developing anticipatory capacity and considering the range of possible outcomes from currently observable trends.

Merchants Quay Ireland (MQI) is a national voluntary agency providing services for homeless people and those that use drugs. There are 22 MQI locations in 13 counties in the Republic of Ireland (see Figure 1). MQI aims to offer accessible, high-quality, and effective services to people dealing with homelessness and addiction in order to meet their complex needs in a non-judgemental and compassionate way. This article highlights services provided by MQI to people who use drugs in Ireland in 2021.¹

A visiting committee is appointed to each Irish prison under the Prisons (Visiting Committees) Act 1925 and the Prisons (Visiting Committees) Order 1925. Members of the 12 visiting committees are appointed by the Minister for Justice for a term not exceeding three years. The function of prison visiting committees is to visit, at frequent intervals, the prison to which they are appointed and hear any complaints that may be made to them by any prisoner. They report to the Minister for Justice regarding any abuses observed or found, and any repairs which they think are urgently needed. Prison visiting committee members have free access, either collectively or individually, to every part of the prison to which their committee is appointed. Information from prison visiting committee reports relating to drug use in prisons for 2021 (n=8) is summarised below.¹

The Ana Liffey Drug Project (ALDP) is a ‘low-threshold, harm reduction’ project working with people who are actively using drugs and experiencing associated problems. ALDP has been offering harm reduction services to people in the north inner city area of Dublin since 1982, from premises at Middle Abbey Street. ALDP offers a wide variety of low-threshold, harm reduction services that provide pathways for people who use drugs out of their current circumstance, including addiction and homelessness.

The services offered in Dublin include:

In October 2023, An Garda Síochána (AGS) published its annual report for 2022.¹ This article first reports on activities related to national policing, followed by national security and intelligence, community safety, and finally statistics for detections of incidents related to the sale and supply of drugs and Garda drug seizures for 2022.

National policing

Gardaí work in various units to fight crime across Ireland. What follows is a brief outline of a selection of the work undertaken by some of these units.

The European Working Group on Drugs Orientated Research (EWODOR) Conference took place on 23–24 October 2023 in Trinity College Dublin, in partnership with Coolmine Therapeutic Community. EWODOR was established in 1983 as a forum for researchers in the drug and alcohol field to share their work and learnings, with a particular focus on drug-free therapeutic communities. It is the oldest European network of researchers working in the sector. Its work has expanded with practitioners becoming members of the group; while maintaining a focus on recovery pathways, EWODOR also explores drug treatment more broadly.

The Courts Service annual report 2022was published on 27 September 2023.¹ While the report presented data for all criminal cases arising within the Irish justice system between January and December 2022, this article only reports on statistics of prosecutions for drug offences.¹ The data provided are for overall drug law offences. The Courts Service in Ireland does not distinguish between the different supply offences and possession/use offences (Courts Service, personal communication, 2017).

Coolmine Therapeutic Community is a drug and alcohol treatment centre providing community, day, and residential services to men and women with problematic substance use and to their families in Ireland. Established in 1973, Coolmine was founded on the philosophies of the therapeutic community approach to addiction treatment. This is primarily a self-help approach in which residents are responsible for their own recovery, with peers and staff acting as facilitators of change. Participants are expected to contribute to the general running of the community and to their own recovery by actively participating in educational activities and in group and individual therapy. This article highlights services provided by Coolmine in 2021.¹

The Danger of Viral Exposure (DOVE) Service in the Rotunda Hospital, Dublin was established to meet the specific needs of pregnant women who have or are at risk of blood-borne or sexually transmitted bacterial or viral infections in pregnancy. Exposure may also occur through illicit substance use. Figures from the service for 2022 were published in the hospital’s annual report in 2023.¹

The Tabor Group is a provider of residential addiction treatment services in Ireland. It aims to offer hope, healing, and recovery to clients suffering from addictions through integrated and caring services. In addition to two residential facilities, the organisation provides a Continuing Care Programme to clients who have completed treatment to assist with their recovery as well as a community-based programme. Its Family Support Programme offers counselling to families whose loved ones are struggling with an addiction. In 2023, the Tabor Group published its annual report for 2022.¹ This article highlights services provided by the Tabor Group to individuals with a substance use addiction in 2022.

Ireland’s Citizens’ Assembly on Drugs Use ran from April to October 2023 and provided the opportunity for an unprecedented in-depth discussion on the drugs situation in Ireland, reflecting all its complexities. Following consideration of the extensive body of evidence presented to them, the assembly members made 36 recommendations to Government. These address legislative, policy, and operational changes that the State should make to reduce the harmful impacts of illicit drugs.

The assembly’s final report was published in two volumes in January 2024.¹ It presents a comprehensive record of the assembly’s six meetings and their recommendations. The report is an invaluable resource for those interested in understanding the drugs situation in Ireland.

Ireland’s Citizens’ Assembly on Drugs Use, which published its report in January 2024, is the first time that the topic of illegal drugs use has been considered by a deliberative forum of this type in any country. This article is a brief introduction to the concept of deliberative democracy and the ideas from which it developed.

Deliberative and aggregative democracy

Deliberative democracy is a political exercise in which deliberation is the defining feature, and so differs from aggregative democracy, which primarily involves the counting of votes. Citizens’ assemblies, citizen juries, mini-publics, or other mechanisms for deliberative democracy invariably focus on topics where there are sharp differences of opinion. Deliberative democracy does not seek to replace aggregative systems or become the only or even the main form of public policy formation. Accounts of the origins and development of deliberative democracy emphasise its equally important epistemic and normative aspects; reasons are weighed and their strength is determined through a political process that supports equal participation and produces a collective judgement on the matter being considered. The opportunities for deliberative input into policymaking are limited, but deliberative democracy can add a further level of legitimacy for policy decisions in that public justification for a position is built through reasoning among equals.