The newsletter of IRELAND Ireland’s focal point to the EMCDDA Issue 59 | Autumn 2016 In this issue Overview of alcohol Social inclusion consumption, alcohol- and drugs policy See pages 6-9 related harm and 04 Misuse of Drugs Act alcohol policy in Ireland 09 NPS legislation in UK 12 Infectious diseases in prison 20 Addiction nurses conference 22 LGBTI people and mental health Drugnet Ireland is produced in collaboration with the HRB National Drugs Library. To have Drugnet Ireland delivered to your desktop, sign up at www.drugsandalcohol.ie Alcohol can be described as a psychoactive substance with dependence-producing Dr Deirdre Mongan and properties and is responsible for a considerable Dr Jean Long of the HRB, authors of Overview of alcohol burden of death, disease and injury in Ireland. consumption, alcohol-related harm and alcohol policy A recent report by the Health Research Board provides an in Ireland overview of the current situation in Ireland regarding alcohol consumption and harm and trends over time as well as outlining the available policy responses to alcohol-related harm.1 The data in this report were based predominantly on published Irish literature and existing information systems. Research. Evidence. Action. Contents In brief Recent work by epidemiologists examining the social determinants of health and well-being has demonstrated the adverse COVER STORY consequences of inequality, including Overview of alcohol consumption, alcohol-related increased levels of incarceration, crime and harm and alcohol policy in Ireland 1 illicit drug use. POLICY AND LEGISLATION This research concludes that it is not the overall level Misuse of Drugs (Amendment) Act 2016 4 of wealth of a society that determines the prevalence Outcomes: drug harms, policy harms, of poor health and social problems but the extent of poverty and inequality 5 the difference between the richest and the least well Where next for social inclusion? 6 off. While this link is not made explicit in Irish drugs policy, the link between socioeconomic disadvantage, Social inclusion and drugs policy 8 marginalisation and exclusion, and drug use has been New psychoactive substances: recognised in the formulation of policy in this area for legislative changes in the UK 9 nearly 20 years. This is reflected in the framing of the 2001-2008 and 2009-2016 National Drug Strategies in PREVALENCE AND CURRENT SITUATION the context of the broader social inclusion agenda. The Global Drugs Survey 2016 11 link between drug use and social deprivation underpins the rationale behind the location of local drugs task Prisoners and infectious diseases 12 forces, and the relationship between illicit drug use and Developing inside: transforming prison for social exclusion and inequality is a key consideration in young adults 12 the strategies of the regional task forces set up nearly a Factors influencing reunification between NDTC decade later. service users and their children in care 14 Homeless drug users: their health, perceived The evolution of social inclusion policy and the quality of life and use of health services 15 positioning of illicit drug use within it are examined Suicide and untimely sudden deaths in the in detail in this issue of Drugnet Ireland. Economic Donegal Mental Health Service 16 deprivation is not the sole determinant of marginalisation. Membership of an ethnic minority, sexual orientation or disability often present economic and RESPONSES social challenges - risk factors which may increase the Surveys reveal GPs have positive attitude towards likelihood of drug use. While well-established monitoring Methadone Treatment Programme 18 systems provide valuable data on population drug use, 4th International Conference on Novel Psychoactive examining the link between social marginalisation and Substances, Budapest, 30-31 May 2016 19 drug use requires more refined analysis. Research using Inaugural Irish conference for nurses in National Drug Treatment Reporting System (NDTRS) data addiction services 20 has highlighted aspects of drug use among members of the Traveller community. Recent developments in Ethnic data collection and monitoring 21 the NDTRS also provide valuable information on drug LGBT service users and mental health risks 22 prevalence in prisons and the treatment needs of Mental health and well-being of LGBTI people 23 members of the lesbian, gay, bisexual and transgender (LGBT) community. Homelessness is a particularly UPDATES important risk factor associated with a wide range of health problems, including drug use, and in this issue we Recent publications 25 look at a recent study of users of a dedicated primary care service for homeless people in Dublin. The policy, research and other documents covered in this issue of Drugnet Ireland have all been retrieved Social and economic policies designed to reduce by the HRB National Drugs Library and may be accessed inequality will impact on overall drug prevalence. on its website www.drugsandalcohol.ie Developing services which can respond effectively to the particular needs of marginalised and vulnerable groups will need to be informed by robust evidence from studies focused specifically on these groups. 3 Overview of alcohol which accounted for 11.0% of all public healthcare expenditure Is s that year. The majority of these costs (77.4%) were associated u consumption and alcohol- with discharges with partially attributable alcohol conditions. e 5 9 related harm continued This excludes the cost of emergency cases, GP visits, |A psychiatric admissions and alcohol treatment services. u tu m Alcohol consumption in Ireland Alcohol-related mortality n 2 Ireland has a high level of alcohol consumption and many Alcohol mortality data from the National Drug-Related Deaths 01 6 IIrriisshh pdreionkpeler se cnognagsuem ine hda 1r1m lifturel sd roifn kpiunrge p aalcttoehronls .e Ianc 2h0. 1T4h,i s is Ianlcdoehx o(Nl-DreRlDatI)e wd edreea athnas lbyseetdw efoern 2 2000088- 2a0nd13 2. 0Th13e.r Ien w2e0r1e3 ,6 t,h4e7r9e d r equal to 29 litres of vodka, 116 bottles of wine or 445 pints of were 1,055 deaths, which is an average of 88 deaths per month u g beer. As 20.6% of the adult population abstain from alcohol or three deaths per day. Overall, 73.2% were aged under 65 n e completely, those who drink alcohol consume even greater years, which may be described as of working age. From 2008 t quantities. Survey data from 2013 indicate that drinkers in to 2013, medical causes accounted for 4,462 (68.9%) of IRE L Ireland consume alcohol in an unhealthy pattern: 37.3% of alcohol-related deaths, poisonings accounted for 1,045 (16.1%), A N d(RrSinOkDer),s menogrea gceodm inm monolny tkhnlyo,w rnis kays sbiningglee- dorcinckaisnigo,n i nd rtihnek ing arenlda tterdau dmeaattihcs ,c wauitshe sa ascimcoiluarn tpeadt tfeorrn 9 f7o2r (m15a.l0e%s a) nodf aflecmohaolels-. D previous year; 54.3% of drinkers had a positive score on the AUDIT-C screening tool; 6.9% scored positive for dependence, Alcohol and the workplace which indicates that there were somewhere between 149,300 In Ireland, alcohol is associated with harm in the workplace. and 203,897 dependent drinkers in Ireland in 2013. At least According to the National Alcohol Diary Survey 2013,2 three-quarters of the alcohol consumed was done so as part unemployed people were twice as likely as employed people of a binge-drinking session. to have a positive DSM-IV score for dependence. Among those who were unemployed, 1.4% reported that they had lost There has been a shift from consuming alcohol in on-trade their job as a result of their alcohol consumption; when the premises to consuming alcohol bought from the off-trade, experience among this representative sample is applied to the which is reflected in Irish licence data. Between 1998 and unemployed population, it is possible that 5,315 people on 2013, the number of pub licences in Ireland decreased by 19.1% the Live Register in 2013 had lost their job due to alcohol use. (from 10,395 to 8,402). During the same period the combined The survey also indicated that 4.2% of employed respondents number of wine and spirits off-licences increased by 377% reported that they had missed days from work due to their (from 1,072 to 5,116). In 2013, there was one licence per 197 alcohol use in the 12 months prior to the survey. On average, adults aged 18 years and over. each of these respondents missed 3.3 days. Based on 2013 employment figures, we can extrapolate that of the 1,869,900 Alcohol-related harm in Ireland persons in employment, 78,536 missed work in the previous year due to alcohol. If we assume that the average daily cost Alcohol-related morbidity is €159.32 per person, this suggests that the direct cost of Alcohol-related morbidity was analysed using data from alcohol-related absenteeism was €41,290,805 in 2013. This the Hospital In-Patient Enquiry (HIPE) scheme. The analysis estimate does not include the costs associated with reduced included all alcohol-related discharges that were either wholly productivity at work or the cost of alcohol-related injury at attributable (alcohol is a necessary cause for these conditions work. Of those who reported missing work due to alcohol, to manifest) or partially attributable (alcohol must be a 82.6% engaged in monthly binge drinking and 40.8% scored component cause). The number of wholly attributable alcohol- positive for alcohol dependence. related discharges increased from 9,420 in 1995 to 17,120 in 2013, an increase of 82%, with males accounting for 72.4% of Conclusion discharges and females accounting for 27.6% of discharges. The data presented in this overview indicate that harmful In 2013, alcohol-related discharges accounted for 160,211 bed drinking has become the norm in Ireland. The health of days or 3.6% of all bed days that year, compared with 56,264 Irish people would improve if we reduce overall alcohol bed days or 1.7% of the total number of bed days in 1995. The consumption and address risky drinking patterns. There is mean length of stay increased, from 6.0 days in 1995 to 10.1 a comprehensive body of international evidence regarding days in 2013, which suggests that patients with alcohol-related the most effective policies to reduce alcohol-related harm. diagnoses are becoming more complex in terms of their illness. These include making alcohol more expensive, restricting its Alcoholic liver disease was the most common chronic alcohol availability and reducing its promotion. The new Public Health disease, accounting for approximately four-fifths of all alcohol- Alcohol Bill contains these evidence-based measures and related chronic diseases in 2013. The rate of these discharges needs to be implemented without delay. increased from 28.3 per 100,000 adults aged 15 years and over in 1995 to 87.7 in 2013, an increase of 210%. The most Deirdre Mongan pronounced increase was among 15-34-year-olds, albeit from a low base. 1 Mongan D and Long J (2016) Overview of alcohol consumption, alcohol-related harm and alcohol policy in Ireland. Dublin: The number of discharges with a partially attributable alcohol Health Research Board. http://www.drugsandalcohol.ie/25697/ condition increased between 2007 and 2011 by 8.8%, from 2 Long J and Mongan D (2014) Alcohol consumption in Ireland 52,491 to 57,110. The estimated cost to the health system 2013: analysis of a national alcohol diary survey. Dublin: Health in 2012 of dealing with inpatients with either a wholly or Research Board. http://www.drugsandalcohol.ie/22138 partially alcohol-attributable condition was €1.5 billion, 4 6 POLICY AND LEGISLATION Revocation of ministerial regulations and orders 201 Section 3 of the Act amends section 5 of the Misuse of Drugs n Act and allows the Minister for Health to revoke ministerial m u regulations and orders confirmed by the Misuse of Drugs ut Misuse of Drugs A (Amendment) Act 2015.3 The aim of this amendment is to 9 | enable the Minister to create new regulations or orders as 5 e (Amendment) necessary to control new substances under the Act. u s s ID Act 2016 TToe cahllnoiwca tlh aem ceonmdmmeennctesment of a section in the Irish N A Medicines Board (Miscellaneous Provisions) Act 2006,8 L RE responsibility for issuing licences under the Misuse of Drugs tI Act 1977 will be reassigned from the Minister for Health to e n Following increased drug-related violence and the the Health Products Regulatory Authority. Finally, following g u emergence of new psychoactive substances to the Irish alterations to the Nurses and Midwives Act 2011,9 the r d drug market, it became necessary to expedite a shortened reference to nurses and midwives in the Misuse of Drugs Act version of the Misuse of Drugs (Amendment) Act 2016,1 which 1977 will be brought up to date. was enacted on 27 July 2016. The aim of the Act is to amend schedules from the Misuse of Drugs Acts 1977-2015.2 Commencement The Act involves a two-step process. Controlling substances The Misuse of Drugs Acts 1977-2015 is the main legislation are dealt with in the first stage of the Act. This will be that aims to protect society from the impact of drugs followed by the drafting of regulations that will enable in Ireland. Protection is provided by firstly controlling legitimate users (e.g. patients with prescriptions) access access to substances that can be harmful if abused, e.g. to controlled substances. The Act will commence when benzodiazepines and heroin, via ministerial regulations and appropriate regulations are in place. orders. This ensures that controlled drugs are used safely. Secondly, protection is provided by setting up a system that Extensive debate controls substances that are viewed as unsafe or destructive As the Act progressed through the Dáil and Seanad, extensive when not used for therapeutic reasons. Due to the transient debate occurred between deputies. Predominantly, the Act and ever-changing nature of the drugs and the drug market, is welcomed by many. In light of recent events in Ireland, this Act is constantly monitored and updated. Deputy John Lahart purported that it was clear that there was a necessity to reinforce the legislation around drug Provisions of the new Act misuse (p. 597).4 Deputy Jack Chambers argued that allowing The main provisions of the 2016 Act include the addition law enforcement agencies to pursue gangs that control the of new substances, revocation of regulations and orders supply and sale of drugs was an essential route to targeting confirmed in the Misuse of Drugs (Amendment) Act 2015,3 drug-related crime in Ireland (p. 595).4 However, numerous and some technical amendments. concerns were raised that the Act was not going to address the root causes of the problem. For example: Addition of new substances A number of new substances are to be added to the existing • Deputy Jonathan O’Brien purported that the Act was being list of controlled substances: rushed at the request of An Garda Síochána and raised concerns that neither drug service providers nor medical • Zopiclone practitioners were consulted. He further argued that the • Zaleplon Act ‘will criminalise vulnerable drug addicts’ and purported that a model of decriminalisation of drugs for personal • Phenazepam use was necessary. This, he argued, should be centred • Lisdexamfetamine on evidence, based on international best practice, for • Clockwork Orange example, the Portuguese model. He cautioned that thus far the introduction of this kind of Act went against ministerial • MT-45 talk about availing of evidence-based practice, which • 25B-NBOMe seemed to be ignored in this instance (pp. 600-04).4 • 25C-NBOMe • Deputy Louise O’Reilly viewed the Act as solving only half the problem, namely drug crime, and did not address • 4,4’-DMAR any measures to provide support to help addicts, nor • MDMB-CHMICA did it address the socioeconomic impacts of addiction nor the issue of drugs overall. Deputy O’Reilly argued The inclusions will allow law enforcement authorities to that although this legislation would alter drug-related deal more effectively with the illegal trafficking in Ireland, antisocial behaviour, and increase Garda presence and for example, on-street dealing of prescription medication, capability, it was not targeting the root causes of the some of which are not controlled by current legislation.4 problem (pp. 604-06).4 In addition, it will allow Ireland to fulfil its obligations in • Deputy Maurice Quinlivan argued that ‘criminalising accordance with EU directives, such as EU Council Decision young people who, more often than not, are already 2005/387/JHA5 - which demands information exchange, risk disadvantaged is a lazy and bankrupt response of what is assessment, and control of new psychoactive substances − an exceptionally serious issue …. the legislation will not the United Nations Single Convention on Narcotic Drugs 19616 work as it offers nothing to address the root causes of and Convention on Psychotropic Substances 1971.7 5 Misuse of Drugs (Amendment) 4 (2016, 6 July). Dáil Éireann debate. Misuse of Drugs Is s (Amendment) Bill 2016: second stage, vol. 916, no. 3. u Act 2016 continued http://www.drugsandalcohol.ie/25774/ e 59 5 EU Council Decision 2005/387/JHA. Available |A this problem, which are disadvantage, marginalisation and online at http://www.emcdda.europa.eu/ utu the political indifference of the middle classes’ (p. 53).10 topics/law/drug-law-texts?pluginMethod=eldd. m • Another issue raised was the lack of resources and showlegaltextdetail&id=3301&lang=en&T=2 n 20 6 United Nations Single Convention on Narcotic Drugs 1 funding. 1c9o6n1v. eAnvtaiiolanb_l1e9 o61n_lienne. padt fh ttps://www.unodc.org/pdf/ d6 This is the first step of a series of approaches that are being r u taken to target the drug problem in Ireland. A further Misuse of 7 United Nations Convention on Psychotropic Substances g 1971. Available online at https://www.unodc.org/pdf/ n Drugs (Amendment) Bill is due to be presented in the autumn e convention_1971_en.pdf t term, which aims to establish supervised injection rooms. IR 8 Irish Medicines Board (Miscellaneous Provisions) Act 2006. EL A Ciara H Guiney Available online at http://www.irishstatutebook.ie/eli/2006/ ND 1 Misuse of Drugs (Amendment) Act 2016 as initiated. Available 9 Nacutr/s3e/se annadc tMeidd/weinve/hs tAmclt 2011. Available online at http://www. online at http://www.oireachtas.ie/documents/bills28/ irishstatutebook.ie/eli/2011/act/41/enacted/en/print acts/2016/A0916.pdf 10 (2016, 7 July). Dáil Éireann debate. Misuse of Drugs 2 Misuse of Drugs Act 1977. Available online at http://www. (Amendment) Bill 2016: second stage (resumed), vol. 917, no. 1. irishstatutebook.ie/eli/1977/act/12/enacted/en/html http://www.drugsandalcohol.ie/25797/ 3 Misuse of Drugs (Amendment) Act 2015. Available online at http://www.irishstatutebook.ie/eli/2015/act/6/enacted/en/pdf Outcomes: drug to austerity. Some people in the Clondalkin area had been subjected to a range of ‘policy induced harms’ that have put them at a higher risk of experiencing drug-related harms. The harms, policy authors argued that the current media and political debate tended to pathologise people, groups and communities that harms, poverty and experience poverty as an outcome of individual or family dysfunction. Furthermore, that ‘little attention was paid to the role government decisions and policies play in shaping inequality negative life outcomes for people’ (p. 6). Drug trends Drug use within the area was found to be characterised On 28 April 2016, Clondalkin Drug and Alcohol Task Force by polydrug use. The ‘polydrug activity’ tended to involve (CDATF) held a conference on ‘Outcomes: drug harms, policy cannabis and ‘tablets’ (e.g. benzodiazepines and the ‘Z drugs’) harms, poverty and inequality’, at which they launched their combined with alcohol. Cocaine, new psychoactive substances report of the same name.1 (e.g. mephedrone) and various ‘ecstasy type’ substances were reported to be widely used in ‘recreational settings’. The day brought together 120 delegates and stakeholders, Heroin and crack cocaine were perceived to be used by a including policy-makers, service providers, service users small proportion of habitual users in high-risk conditions, and and other representatives from community, voluntary and rarely by young people. While the drugs used varied somewhat statutory agencies. depending on what was available, there was a general consensus that drugs were widely available in the area. Key findings from the report Risk groups for drug-related harms Research aims Four groups living in the area were found to be at particularly Key findings from the report were presented by its lead author high risk of experiencing drug-related harm: Dr Aileen O’Gorman of the University of the West of Scotland. The overall aim of the research was to provide an in-depth • The in-treatment population whose needs were not understanding of: patterns of drug use and drug-related being met by the range of services available. harm in the Clondalkin area; and the needs of individuals, • Family members of those involved in problematic drug families and members of the broader community. It also set use, including children living with parental drug use. out to explore and identify the relationship between poverty, inequality and drug use, and review the effectiveness of the • Members of the Traveller community. partnership approach to the coordination and delivery of • Young people in the area who, given the multiple and community-based responses to drug use in the area. interconnected deprivations they experienced, were at risk of becoming users themselves. Furthermore, in the Poverty, inequality and policy-related harms absence of viable employment opportunities they were The report described the CDATF area as home to a at risk of becoming involved in the local drugs economy. disproportionate number of people experiencing poverty, with The study found that this economy provided ‘one of the situation having worsened as a result of political responses the few employment and economic opportunities for 6 6 Outcomes: drug harms, • Fr Peter McVerry of the Peter McVerry Trust 01 2 • Pearse Stafford, service user representative n poverty and inequality m continued u t A number of themes recurred throughout the presentations, u 9A | young people, leastways for a time, to access the status including: 5 and goods that work provides’ (p. 7). The associated e • Certain sections of society have been disproportionately u violence was an additional risk to which these young IssND Chapnegoinpgl ep owleicrye eenxvpiorosendm.ent and partnership working ayuofnfueenqcgut eapdle s obopyc lpieeo)t.ly iT tahicnisad lh aaanus s ectenorvniitrtyor inmbmueteaensdut rtieons wa ( ihpnir cophga rrpeteiscosuipvlaleerl ya re ELA The authors found that CDATF operated in a very different increasingly socially excluded. tIR policy environment when compared with that in which it had • Drug use does not occur in a vacuum and the social ne been established. They described a move towards a neo-liberal context in which people are living needs to be g policy environment in which the centralisation of decision- considered when discussing how best to tackle the issue u dr making had increasingly become the norm. This undermined of problematic drug use in an area. This is challenging in the way in which the Drug and Alcohol Task Force (DATF) had what was described as an increasingly ‘neo-liberal State’. worked traditionally and caused a shift from working in a • In the absence of ‘legitimate’ employment opportunities community-based bottom-up approach to delivering on the in some areas, participating in the drugs economy was National Drugs Strategy to a ‘hierarchical top-down approach’ perceived to offer young people an opportunity to (p. 8). They identified two ways in particular in which the generate an income and attain standing in their community. community-based interagency and partnership approach had • There has been an increasing level of violence been undermined: first, there were fewer ‘spaces’ (p. 8) for associated with the drug trade. This was affecting whole communities and community-based services to input into communities, not just drug users. decision-making; and, secondly, there were ‘extreme levels’ of monitoring, reporting requirements, and effectiveness and • There has been a tendency towards less and less value-for-money evaluations. meaningful community consultation and engagement in policy development and delivery. There were concerns Conclusion that this would continue to be the case with the development of the new National Drugs Strategy. The authors argued that there was a need to review the impact of austerity and reform policies on drug-related harms and Throughout the day the report was warmly welcomed by the ability of local services and the DATFs to respond to the conference delegates; the findings of the report echoed the increased levels of need in their areas. They called for a social experiences of those working in other task force areas. In inclusion pillar to be included in the National Drugs Strategy, addition, the findings of the report and the conference were due to commence in 2017, as well as the introduction of drug to be used to inform the following: CDATF’s forthcoming and poverty proofing for future public and social policies: strategic plan; their submission to the new National Drugs Strategy; and the debate on poverty, inequality and drug- Drug policy in Ireland has become more focused on related harm more broadly. The report was cited in Leaders’ addressing individual drug using behaviour as if these Questions in the Dáil on 25 May 2016.2 issues were context free. Little attention is paid in policy discourses to the underlying issues of poverty Lucy Dillon and inequality and even less consideration is given to the harmful outcomes of policy. (p. 8) 1 O’Gorman A, Driscoll A, Moore K, Roantree D (2016) Outcomes: drug harms, policy harms, poverty and Other presentation themes inequality. Dublin: Clondalkin Drug and Alcohol Task Force. Presentations at the conference were also made by: http://www.drugsandalcohol.ie/25577/ 2 Adams G (2016, 25 May). Dáil Éireann debate. Leaders’ • Professor Kathleen Lynch, UCD School of Social Policy, questions, vol. 910, no. 2. http://www.drugsandalcohol. Social Work and Social Justice ie/25560/ • Professor Susan MacGregor, London School of Hygiene and Tropical Medicine Where next for Programme for Government, which, while retaining the concept of social inclusion, brought two new terms to the fore in relation to social policy - fairness and equality.4 social inclusion? In 2016, as a new Programme for Government is published, and as the suite of social inclusion policy documents conceived during the Celtic Tiger reach their endpoints, In 2006-2007, Drugnet Ireland carried a series of articles it is timely to review the current status of Ireland’s social reviewing how illicit drugs were addressed in the new social inclusion policy framework. inclusion policy framework, i.e. the new Social Partnership Agreement 2006-2015,1 the National Development Plan Leading up to 2016 2007-2013,2 and the National action plan for social inclusion In 2005, the National Economic and Social Council (NESC) 2007-2016.3 In 2011, Drugnet carried an article on the new published a report, The developmental welfare state, 7 Where next for emerging issues, with the number of high-level goals being Is s expanded to include early childhood development, youth u social inclusion? continued exclusion, access to the labour market, migrant integration, e 5 9 social housing and affordable energy. |A u which proposed a new streamlined and comprehensive tu The revised action plan describes how the context of social m aApckpnrooawclhed tgoi ntag ctkhlaintg s eproivoeurst ys oacnida ls doecfiiacli tesx crelumsiaoinne idn Idreeslapnitde. 5 i‘ndcelsuigsinoend p tool iecny shuarse atlhtaetr etdh.o Tseh ee x2p0e0r7ie ancctiinogn ppolavne rwtya sa nd n 201 Ireland’s economic progress, the NESC report combined the 6 economic and the social, suggesting that this would help sdoecvieallo epxmcelunstio bne winogu aldch siheavered iant t thhea tfr tuimitse o’,f b tuhte s einccoen o2m00ic8 d to build consensus across the social partners, government r Ireland has experienced a ‘major economic recession u and wider society. It proposed two innovations in the way of g complicated by banking and fiscal crises’. The Government’s n presenting social inclusion interventions: e response to combating poverty now concentrates on t transforming the social protection system into one IR 1 I nterventions should be organised according to a EL that focuses on maximising employability, by improving A life cycle framework, comprising four categories: N effectiveness and efficiency of social transfers by providing D canhdild preeonp, lpee wopitlhe doifs awboilriktiiensg. aTgheis, oalrdreanr gpeemopelnet, training, development and employment services along with income supports, and by strengthening active inclusion both placed the individual at the centre of policy- policies, which are described as follows: making and encouraged a more joined-up and multidisciplinary approach to policy-making. Active inclusion means enabling every citizen, notably the most disadvantaged, to fully participate 2 G reater recognition and weight should be given in society, including having a job. Active inclusion to (a) the role of services in providing protection is intended to tackle various challenges including: against risks, and (b) activist measures, or poverty, social exclusion, in-work poverty, labour innovative social policy initiatives, in meeting market segregation, long-term unemployment and unmet needs and pre-empting problems, as gender inequalities. (p. 4) opposed to focusing entirely on income transfers. Programme for Government 2016 Published in 2006, the 10-year Social Partnership Agreement The new Partnership Government’s programme for a Towards 2016 was the first policy framework to adopt the ‘fairer Ireland’ contains a chapter headed ‘Creating a new life cycle approach.6 Drug-related initiatives were Social Economy’, which is the model the Government identified in the childhood and young working adult stages of will apply in order to deliver ‘a strong economy and a fair the framework. society’.12 Reflecting the shift already noted in the revised national action plan on social inclusion, the Programme for In 2007, as well as setting a national poverty target of Government identifies four foundations of a social economy, reducing the number experiencing consistent poverty to including ‘a just and fair society and a more inclusive between 2% and 4% by 2012, with the aim of eliminating prosperity’. Four tasks will be undertaken to build this just consistent poverty by 2016,7 the National action plan for and fair society and a more inclusive prosperity: social inclusion 2007-2016 (NAPinclusion) also adopted the life cycle framework, adding an extra category • developing a new integrated framework for social ‘Communities’.8 inclusion, to tackle inequality and poverty; Within this Communities category, NAPinclusion itemised • reducing poverty levels by improving the take-home a series of community-based programmes (including pay of families on low-incomes; the National Drugs Strategy) and a number of innovative • reducing poverty levels by supporting an increase in measures in areas such as the arts, sport, and active the minimum wage to €10.50 per hour over the next citizenship, which were expected to have an impact five years; and on the illicit drugs issue. • reinforcing labour market activation. In June 2010, the European Council adopted Europe 2020: a strategy for smart, sustainable and inclusive growth, Just what an ‘integrated framework for social inclusion’ which aims to promote employment, improve living and comprises is outlined in the Programme for Government: working conditions, provide an appropriate level of social protection, and develop measures to combat exclusion.9 In Our Integrated Framework will outline measures 2012, Ireland revised its national poverty target (now named to help eliminate any persisting discrimination ‘national social target for poverty reduction’) - to reduce on grounds of gender, age, family status, marital consistent poverty to 4% by 2016 (interim target) and 2% status, sexual orientation, race, disability, religion or or less by 2020, from the 2010 baseline rate of 6.3% - and membership of the Traveller Community. It will draw identified the contributions that Ireland would make to the on existing as well as new strategies, in particular the Europe 2020 poverty target.10 (i) New National Women’s Strategy, (ii) New National Disability Inclusion Strategy, (iii) Comprehensive Updated national action plan for social Employment Strategy for People with Disabilities, (iv) inclusion 2015-2017 National Traveller and Roma Inclusion Strategy, and Following the 2012 revisions, a revised national action plan (v) New Action Plan for Educational Inclusion. (p. 39)13 for social inclusion for 2015-2017 was published.11 Maintaining the life cycle approach, this revised action plan reflects new 8 6 Where next for 7 ‘Consistent poverty’ is the overlap of two component indicators: 201 at-risk-of-poverty, which identifies individuals with household mn social inclusion? continued incomes below 60% of the median, and basic deprivation, which u captures individuals lacking two or more of 11 basic necessities. t u 9A | Iinnc tlhuesi ofonl lpowoliincgy aarntdic Ilree, ltahned ’rse nlaattiioonnsahl idpr buegstw setreant esgoiceisa ol ver 8 Ofofrfi scoec fioarl iSnoccluiasl iIonnc l2u0si0o7n- 2(200160.7 D) Nubaltiino:n Satla aticotnioenry p Olaffinc e. 5 e the past 20 years is explored. http://www.drugsandalcohol.ie/13378/ u ss 9 For more information on Europe 2020, visit ID Brigid Pike http://ec.europa.eu/europe2020/index_en.htm N 10 Department of Social Protection (2012) National social A L 1 Pike B (2006) New social partnership agreement target for poverty reduction: policy briefing on the review E R addresses drugs and alcohol. Drugnet Ireland, 19: 7. of the national poverty target. http://www.welfare.ie/en/ etI http://www.drugsandalcohol.ie/11277/ downloads/2012_nptbriefing.pdf n g 2 Pike B (2007) National Development Plan and the drugs issue. 11 Department of Social Protection (2016) Updated national u r Drugnet Ireland, 21: 23-25. http://www.drugsandalcohol. action plan for social inclusion 2015-2017. Dublin: Department d ie/11342/ of Social Protection. https://www.welfare.ie/en/downloads/ 3 Pike B (2007) Where do illicit drugs fit in the new social Updated%20National%20Action%20Plan%20For%20 inclusion policy framework?’ Drugnet Ireland, 23: 5. Social%20Inclusion%202015-2017.pdf http://www.drugsandalcohol.ie/11409/ 12 Government of Ireland (2016) A programme for partnership 4 Pike B (2011) Inequality and illicit drug use. Drugnet Ireland, government. Dublin: Department of the Taoiseach. 38: 8-10. http://www.drugsandalcohol.ie/15639/ http://www.drugsandalcohol.ie/25508/ 5 National Economic and Social Council (2005) The 13 At the time of going to press, only one of the five ‘new developmental welfare state. Dublin: NESC. Retrieved 1 July strategies’ had been published. Government of Ireland 2016 from http://www.nesc.ie/en/publications/publications/ (2015) Comprehensive employment strategy for people with nesc-reports/the-developmental-welfare-state/ disabilities. Retrieved 1 July 2016 from http://www.justice.ie/ en/JELR/Comprehensive%20Employment%20Strategy%20 6 Department of the Taoiseach (2006) Towards 2016: ten-year for%20People%20with%20Disabilities%20-%20FINAL.pdf/ framework social partnership agreement 2006-2015. Dublin: Files/Comprehensive%20Employment%20Strategy%20for%20 Stationery Office. http://www.drugsandalcohol.ie/6320/ People%20with%20Disabilities%20-%20FINAL.pdf Social inclusion and 2009: The Group … notes that the Cabinet Committee on Social Inclusion, Children and Integration deals with a wide range of social inclusion policy areas, of drugs policy which drugs is one issue. While the scope for routine debate on drugs is limited, therefore, the Group acknowledges that addressing the broader social inclusion agenda ensures that the drugs issue is taken This article outlines how the concept of social inclusion into consideration, as it is an integral aspect of many has been incorporated into the national drugs policy of the social inclusion priorities. (para. 6.21) framework over the past 20 years as well as issues to consider going forward. 2017 and after? How the new National Drugs Strategy will address the links 1996-2016 between social inclusion and illicit drugs policies remains to As long ago as 1996, the Ministerial Task Force on Measures to be seen. For example: Reduce the Demand for Drugs recognised the link between problem drug use and socioeconomic disadvantage.1 The • How will social inclusion and illicit drug policy be handled task force recommended the establishment of local drugs at Cabinet level? task forces in areas experiencing high levels of problem drug use, which coincided with areas experiencing social and • How will different government departments, state economic disadvantage. agencies, drugs task forces, and community and voluntary organisations be expected to address social Ireland’s two subsequent seven-year national drugs inclusion and drug-related issues and with each other? strategies, published in 20012 and 2009,3 both set Ireland’s • How will the concepts of active inclusion, life cycle drug policy within the wider social inclusion policy context, framework and integrated social inclusion framework, to which a number of other national strategies, such as all mentioned in Ireland’s current social inclusion policy health,4 anti-poverty5 and education,6 had also been linked. framework, be applied in the drugs policy context? 2001: The Group fully recognises that, Two articles in earlier issues of Drugnet Ireland on the links notwithstanding the obvious benefits for between social inclusion and drug policy have highlighted the communities affected by the drugs problem of importance of integrated responses. having a specific drugs strategy, the best prospects for these communities, in the longer term, rest Inequality and illicit drug use4 with a social inclusion strategy which delivers much In their study of the links between health, social problems improved living standards to areas of disadvantage and inequality, Wilkinson and Pickett5 argue that policy- throughout the country. (para. 6.1.9) makers should integrate health and social problems as elements of a single policy problem - inequality - rather than approach them as separate issues: 9 Social inclusion and stage may be a consequence of difficulties in an Is s earlier stage or a precursor of later problems.6 u drugs policy continued e 5 9 The authors go on to comment that while the life cycle |A approach offers a set of lenses through which to focus u Attempts to deal with health and social problems tu through the provision of specialized services on the issues, it does not offer a ready-made set of m have proved expensive and, at best, only partially prescriptions: n 2 0 effective.... Rather than reducing inequality itself, 16 tphreo binleitmiast iavrees naeimareldy aaltw taaycsk alitntge mhepatlst ht oa nbdre saokc tiahle …thae ‘dgyennaemrailc as naanldyt itch efr lainmkesw boertkw teheant eavcecnotusn atsn dfo r d r the appropriate analytic tools’ is needed. To fully u links between socio-economic disadvantage and g the problems it creates. The unstated hope is that understand the nature of the dynamic inter-related n e people - particularly the poor - can carry on in the rpiastktse rrenqs uaicrreoss tsh teh me alipfep icnygc loef, saoncdi aaln e uxcnlduesirosnta nding t IR same circumstances, but will somehow no longer E L succumb to mental illness, teenage pregnancy, of the manner in which they combine with other AN socio-economic characteristics.6 D educational failure, obesity or drugs. (pp. 238-9) Brigid Pike Applying the life cycle approach to social inclusion policy6 1 Ministerial Task Force on Measures to Reduce the Demand In an article about the life cycle approach to social inclusion for Drugs (1996) First report of the ministerial task force on policy in Ireland, Whelan and Maître7 explain how the life measures to reduce the demand for drugs. Dublin: Stationery cycle approach marks a shift in perceptions of the nature of Office. http://www.drugsandalcohol.ie/5058/ risk. Traditionally, social policy interventions have focused 2 Department of Tourism, Sport and Recreation (2001) Building on risks associated with unemployment, disability, and on experience: national drugs strategy 2001-2008. Dublin: insufficient resources in childhood and old age, and have Stationery Office. http://www.drugsandalcohol.ie/5187/ tended to redistribute resources across the life cycle, from 3 Department of Community, Rural and Gaeltacht working age groups to children and to older people. More Affairs (2009) National drugs strategy (interim) 2009–2016. recently, social policy interventions have begun to focus on Dublin: Department of Community, Rural and Gaeltacht Affairs. risks faced by specific subgroups at particular stages in their http://www.drugsandalcohol.ie/12388/ lives, for example, risks associated with entering the labour 4 Pike B (2011) Inequality and illicit drug use. Drugnet Ireland, market, remaining in the labour market, or managing care 38: 8-10. http://www.drugsandalcohol.ie/15639/ responsibilities. These ‘new’ risk perceptions have emerged in response to the greater variability and reduced stability in 5 Wilkinson R and Pickett K (2010) The spirit level: why equality is better for everyone. Published with revisions and a new career and family patterns. postscript. London: Penguin Books. In essence, the life cycle approach seeks to 6 Pike B (2008) Applying the life cycle approach to social inclusion reconcile social and economic objectives, and to policy. Drugnet Ireland, 28: 19-20. http://www.drugsandalcohol. emphasise the ‘multidimensional’ and ‘dynamic’ ie/12148/ aspects of the social inclusion process: risks of being 7 Whelan CT and Maître B (2008) ‘New’ and ‘old’ social risks: life socially excluded are linked across problem areas, cycle and social class perspectives on social exclusion in Ireland. and difficulties experienced in any specific life cycle Economic and Social Review, 39(2): 131-156. New psychoactive Critics of the Act argue that this focus on the psychoactive properties of the substance is too broad - it means that technically the authorities could decide that any substance substances: which changes a person’s mood could be included, irrespective of any evidence of the substance being harmful. legislative changes In an effort to address this, the guidance accompanying the Act2 states that the effects of the substance are to be ‘as measured by the production of a pharmacological in the UK response on the central nervous system or which produces a response in in-vitro tests qualitatively identical3 to substances controlled under the Misuse of Drugs Act 1971’ (p. 3).2 However, the guidance also notes that the Act captures Psychoactive Substances Act 2016 all psychoactive substances that are not controlled by the The Psychoactive Substances Act 2016 came into force in the Misuse of Drugs Act or are otherwise exempt. Exempted UK on 26 May 2016. In the Act, a ‘psychoactive substance’ substances include controlled drugs (within the meaning is defined as one that ‘produces a psychoactive effect in a of the UK’s Misuse of Drugs Act 1971), medicinal products, person if, by stimulating or depressing the person’s central alcohol, tobacco products, caffeine, and food.1 nervous system, it affects the person’s mental functioning or emotional state; and references to a substance’s psychoactive effects are to be read accordingly’.1 The Act differs from the established approach to drug control under the UK’s Misuse of Drugs Act 1971 in that it covers substances by virtue of their psychoactive properties, rather than the identity of the drug or its chemical structure.2 10 6 NPS: legislative changes Health impacts 01 2 Shapiro found a growing body of international evidence to mn in the UK continued demonstrate the potential acute and chronic health harms tu associated with the use of NPS. He noted in particular the u 9A | NPS come of age: a UK overview ‘wdeervea simtaptilnicga eteffde icnt s6’2 o ffa itnajelitciteisn gin m theep hUeKd irno n2e0.1 4W, hoinlel yN sPeSv en 5 To coincide with the introduction of the new Act, DrugWise ue published a report on novel psychoactive substances (NPS) deaths were as a direct result of taking an NPS in isolation. In IssD -a gaels: oa kUnKo wovne arsvi neeww4 bpys yHcahrorya cSthiavep isruob psrtoavnicdeess. aN dPeSs ccormipeti oonf mweorset aclassoe ism, ‘ptlriacdaitteiodn.al’ drugs (e.g. heroin and methadone) N of NPS from a range of angles, including the evolution of NPS ELA in the UK; their use; how treatment services are dealing with Meeting users’ needs tIR the needs of their users; and the development of the new Relatively few people were coming forward to treatment e legislation. He compared the picture of NPS use in the UK services citing an NPS as their primary drug problem. Drug n g in 2016 as ‘not dissimilar’ to that which appeared with the workers saw more use out in the community with clients who u r emergence of crack cocaine in the UK: ‘much sensational were not accessing treatment, for example, homeless and d media reporting and dire predictions for the future, but rough sleepers. However, those working in the community ultimately finding a level in the drug scene with regular use with young people reported problems with a range of NPS, primarily concentrated among those with existing serious especially mephedrone and synthetic cannabinoids. Shapiro drug problems and other vulnerable groups’ (p. 3). emphasised the need for drug workers to ‘deal with the problem in front of you’, as the ‘whole intention’ of NPS The Internet and the lack of regulation of the substances was to mimic the effects of controlled drugs; in theory the involved were identified as enabling NPS to take their place in symptoms service users present with should be similar to the global and UK drug markets. Their arrival was described those already seen. He therefore recommended the clinical as a ‘game-changer’ in terms of the Internet becoming a guidance published by Project Neptune.5 new route for wholesale and retail supply, distribution, and information exchange on drugs’ effects between users. Legislation In terms of the range of NPS, while Shapiro accepted that Legislating for NPS is described as having provoked some there can be ‘bewilderment’ among drugs workers at the of the most heated debate about UK drug law since ongoing appearance of ‘new’ substances, the difference cannabis was reclassified from Class B to Class C in 2004. between them was not always that significant. He described The report described the legislative process gone through five groupings, and argued that many of the new compounds which culminated in the ‘blanket ban’ encapsulated in the were simply variants of the first grouping: Psychoactive Substances Act 2016. Shapiro described it as having met a ‘storm of criticism’ in the media and from drug • Synthetic cannabinoids law reform campaigners, commentators and academics. • Stimulant-type drugs (including mephedrone) In particular, it was criticised for having turned the Misuse • Hallucinogenic-type drugs of Drugs Act ‘on its head’ by effectively saying that any substance that was psychoactive was harmful. It was also • Opiate-type drugs criticised for having removed the notion of relative harms, • Tranquiliser-type drugs and there was scepticism about the legal robustness of any attempt to define ‘psychoactivity’. NPS users NPS use has increased in the UK since 2006. However, Lucy Dillon identifying patterns and prevalence of their use in official datasets was found by Shapiro to be ‘patchy’. Among 1 Psychoactive Substances Act 2016 (UK). Available online the reasons given for this was that the user groups most at http://www.legislation.gov.uk/ukpga/2016/2/pdfs/ ukpga_20160002_en.pdf affected (e.g. students in student accommodation, adult prisoners, young offenders and the homeless) were unlikely 2 Psychoactive Substances Act 2016: forensic strategy. to be identified in the UK’s routine official surveys that Home Office Circulars 2016. London: Home Office. provide prevalence data. Based on his overall assessment https://www.gov.uk/government/publications/circular- of the evidence available, Shapiro generalised that NPS use 0042016-psychoactive-substances-act-2016 is ‘most problematic in communities experiencing higher 3 ‘Qualitatively identical to’ means that the substance interacts levels of poverty and deprivation and, where young people with the same target as a known psychoactive drug controlled are involved, among those who in years gone past would under the Misuse of Drugs Act 1971. have been involved in solvent use and heroin smoking’ 4 Shapiro H (2016) NPS come of age: a UK overview. London: (p. 12). He drew particular attention to the reported high DrugWise. http://www.drugsandalcohol.ie/25551/ levels of synthetic cannabinoid receptor agonists (SCRAs) 5 Abdulrahim D and Bowden-Jones O, on behalf of the NEPTUNE use among prisoners in the UK. In particular, he noted the Expert Group (2015) Guidance on the clinical management of associated increases in levels of violence between prisoners acute and chronic harms of club drugs and novel psychoactive and against staff, debt, intimidation, self-harm and ‘general substances. London: Novel Psychoactive Treatment UK Network psychotic behaviour’. The legal status of the substances and (NEPTUNE). http://neptune-clinical-guidance.co.uk/wp- the fact that they could not be identified by the mandatory content/uploads/2015/03/NEPTUNE-Guidance-March-2015.pdf drug testing process in prisons had both contributed to the worsening situation.