Gabapentinoids in Ireland 2010 to 2020: An observational study of trends in gabapentinoid prescribing, law enforcement drug seizures and postmortem toxicology.

AIMS: We explored trends in gabapentinoid prescribing, drug seizures and postmortem toxicology using a national pharmacy claims database, law enforcement drug seizures data and a population-based postmortem toxicology database. METHODS: Gabapentinoid prescribing rates per 100 000 eligible population (2010-2020), annual number of drug seizures involving gabapentinoids (2012-2020) and gabapentinoid detection (positive) rates per 100 postmortem toxicology case (2013-2020) were calculated. Negative binomial regression models were used to evaluate longitudinal trends for gabapentin and pregabalin separately. RESULTS: Gabapentin (adjusted rate ratio [RR] 1.06, 95% confidence interval [CI] 1.05-1.06, P < .001) and pregabalin (adjusted RR 1.08, 95% CI 1.08-1.09, P < .001) prescribing increased annually, with higher rates of pregabalin (vs. gabapentin) observed every year. Drug seizures involving pregabalin also increased over time (RR 1.54 95% CI 1.25-1.90, P < .0001). Of the 26 317 postmortem toxicology cases, 0.92% tested positive for gabapentin, and 6.37% for pregabalin. Detection rates increased for both gabapentin (RR 1.28, 95% CI 1.11-1.48, P < .001) and pregabalin (RR 1.13, 95% CI 1.11-1.48, P < .001) between 2013 and 2020. A total of 1901 cases (7.2%) tested positive for heroin/methadone; this sub-group had a higher detection rate for pregabalin (n = 528, 27.8%) and gabapentin (n = 41, 2.2%) over the study period, with a high burden of codetections for pregabalin with benzodiazepines (peaking at 37.3% in 2018), and pregabalin with prescription opioids (peaking at 28.9% in 2020). CONCLUSION: This study raises concerns regarding the wide availability of pregabalin in Ireland, including a growing illicit supply, and the potential for serious harm arising from poly drug use involving pregabalin among people who use heroin or methadone.

Prescription drugs with potential for misuse in Irish prisons: analysis of national prison prescribing trends, by gender and history of opioid use disorder, 2012 to 2020.

BACKGROUND: Pharmacotherapy is essential for the delivery of an equivalent standard of care in prison. Prescribing can be challenging due to the complex health needs of prisoners and the risk of misuse of prescription drugs. This study examines prescribing trends for drugs with potential for misuse (opioids, benzodiazepines, Z-drugs, and gabapentinoids) in Irish prisons and whether trends vary by gender and history of opioid use disorder (OUD). METHODS: A repeated cross-sectional study between 2012 and 2020 using electronic prescribing records from the Irish Prison Services, covering all prisons in the Republic of Ireland was carried out. Prescribing rates per 1,000 prison population were calculated. Negative binomial (presenting adjusted rate ratios (ARR) per year and 95% confidence intervals) and joinpoint regressions were used to estimate time trends adjusting for gender, and for gender specific analyses of prescribing trends over time by history of OUD. RESULTS: A total of 10,371 individuals were prescribed opioid agonist treatment (OAT), opioids, benzodiazepines, Z-drugs or gabapentinoids during study period. History of OUD was higher in women, with a median rate of 597 per 1,000 female prisoners, compared to 161 per 1,000 male prisoners. Prescribing time trends, adjusted for gender, showed prescribing rates decreased over time for prescription opioids (ARR 0.82, 95% CI 0.80-0.85), benzodiazepines (ARR 0.99, 95% CI 0.98-0.999), Z-drugs (ARR 0.90, 95% CI 0.88-0.92), but increased for gabapentinoids (ARR 1.07, 95% CI 1.05-1.08). However, prescribing rates declined for each drug class between 2019 and 2020. Women were significantly more likely to be prescribed benzodiazepines, Z-drugs and gabapentinoids relative to men. Gender-specific analyses found that men with OUD, relative to men without, were more likely to be prescribed benzodiazepines (ARR 1.49, 95% CI 1.41-1.58), Z-drugs (ARR 10.09, 95% CI 9.0-11.31), gabapentinoids (ARR 2.81, 95% CI 2.66-2.97). For women, history of OUD was associated with reduced gabapentinoid prescribing (ARR 0.33, 95% CI 0.28-0.39). CONCLUSIONS: While the observed reductions in prescription opioid, benzodiazepine and Z-drug prescribing is consistent with guidance for safe prescribing in prisons, the increase in gabapentinoid (primarily pregabalin) prescribing and the high level of prescribing to women is concerning. Our findings suggest targeted interventions may be needed to address prescribing in women, and men with a history of OUD.

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users.

BACKGROUND: Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID. OBJECTIVES: To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants). SEARCH METHODS: We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA: We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low. AUTHORS' CONCLUSIONS: We found low to very low-quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

Progressive white matter impairment as a predictor of outcome in a cohort of opioid-dependent patient's post-detoxification.

White matter impairment is associated with opioid dependence. However, the specific neuropathology related to opioid dependence is still not fully understood. The main aims of this study were to: (1) assess the association between white matter impairment and duration of dependence; (2) examine whether this impairment correlates with treatment outcome measures in opioid-dependent patients post-detoxification. Fifty-eight opioid-dependent patients participated, 20 females and 38 males, across three groups: less than 10 years use (n = 18), 10-15 years use (n = 26) and 16-25+ years use (n = 14). Diffusion tensor imaging was used to assess white matter impairment; whole brain voxel-wise analysis of fractional anisotropy, mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) were performed by Tract-Based-Spatial-Statistics to pinpoint abnormalities in white matter. The longer the subjects were dependent on opioids, the more widespread and severely the white-matter integrity was disrupted. A general linear model was used to examine patients who relapsed compared to those who were abstinent at follow-up. No statistical difference was found between groups (p > 0.05). Partial correlations were performed to investigate the relationship between clinical outcome measures (physical health, psychological well being and quality of life and hope for the future) and white-matter microstructural differences. Significant correlations were found between AD in the posterior corona radiata (L) and MD in the superior longitudinal fasciculus and a clinical measure for HOPE at 9-month follow-up. Nevertheless, it must be noted that the calculation of numerous correlations raises the possibility of a type I error, namely; to incorrectly conclude the occurrence of a significant correlation. The ability to investigate the structure-clinical relationship may improve our understanding of the pathological abnormalities associated with opioid dependence and has promise for use in evaluating future therapeutic outcomes in this population.

Barriers to progressing through a methadone maintenance treatment programme: perspectives of the clients in the Mid-West of Ireland's drug and alcohol services.

BACKGROUND: The 'perfect' journey through an Irish Methadone Maintenance Treatment Programme (MMTP) would have a client engage appropriately with all relevant services available to them, inclusive of psychiatry, counselling, out-reach support, nursing and psychology. Concurrently, a client would ideally adhere to their prescribed methadone-dosing regimen, until a client is stabilised allowing them to function optimally. At this point, a client should transfer to the GP community setting. Unfortunately, this fails to occur. To date, very few studies have specifically investigated the reasons why a cohort of clients remain 'trapped' in the high risk, specialist clinical setting. METHODS: Qualitative detailed semi-structured interviews were undertaken with 17 clients of one of Ireland's Health Service Executive (HSE) Drug and Alcohol Services, entitled 'HSE Mid-West Limerick Drug and Alcohol Service'. Each client had a severe Opioid Use Disorder (OUD) and clients had spent on average 7.5 years engaging with the MMTP. RESULTS: Participants' life journey prior to an OUD included Adverse Childhood Experiences (ACEs) and early exposure to illicit drug use. Shared life events resulting in their initiating and sustaining an OUD involved continuous hardship into adulthood, mental illness and concurrent benzodiazepine use disorder, often resulting in harrowing accounts of participants' loneliness and lack of life purpose. Their living environments, an erroneous understanding of their illness and poor communication with allied health professionals further perpetuated their OUD. Positive factors influencing periods of abstinence were familial incentives and a belief in the efficacy of methadone. Clients own suggestions for improving their journeys included employing a multi-sectorial approach to managing OUD and educating themselves and others on opioid agonist treatments. If clients were not progressing appropriately, they themselves suggested enforcing a 'time-limit' on clients to engage with the programme or indeed for their treatment to be postponed. CONCLUSIONS: To optimise the functioning of the MMTP, three tasks need to be fulfilled: 1) Reduce the incidences of ACEs, 2) Diagnose and treat clients with a dual diagnosis 3) Educate clients, their families, the public and allied health care professionals on all aspects of OUD. A cross- departmental, inter-governmental approach is needed to address opioid misuse as a societal issue as a whole.

Tailoring a brief intervention for illicit drug use and alcohol use in Irish methadone maintained opiate dependent patients: a qualitative process.

BACKGROUND: The World Health Organization (WHO) recommend the tailoring of a brief intervention (BI) programme of research to ensure that it is both culturally and contextually appropriate for the country and the environment in which it is being tested. The majority of BI research has been conducted with non-opioid dependent participants. The current study developed a tailored BI for illicit drug use and alcohol use to a methadone maintained opioid dependent polydrug using cohort of patients. METHODS: Focus groups with staff and one-to-one qualitative interviews with patients guided the tailoring of all intervention materials for use in a subsequent cluster randomised controlled trial (RCT). This was done to make them contextually appropriate to an opioid dependent cohort and culturally appropriate to Ireland. Thematic analyses were utilised. RESULTS: The BI was modified to ensure its compatibility with the culture of an Irish drug using population, with elements of motivational interviewing (MI) and personalised feedback incorporated. Example scripts of a screening and BI were included, as was an algorithm to facilitate clinicians during a session. Modifications to the 'Substance Use Risk' cards included weighting the severity of the problems, writing the language in the first person to personalise the feedback and including tick boxes so as to further highlight the relevant risk factors for individual patients. Photographs of key risk factors were included to display pictorially risks for illiterate or semi-literate patients. Examples of the interaction of particular substances with methadone were of particular importance to this group. Modifications of the 'Pros and Cons of Substance Use/Reasons to Quit or Cut Down' included additional categories such as addiction, crime and money that were salient to this cohort. The manual was used to standardise training across trial sites. CONCLUSION: The research team was faithful to WHO recommendations to tailor BI programmes that are culturally and contextually appropriate to the treatment cohort and clinical environment. Outcome data from the cluster RCT have demonstrated that the tailored intervention was effective.

Feasibility of alcohol screening among patients receiving opioid treatment in primary care.

BACKGROUND: Identifying and treating problem alcohol use among people who also use illicit drugs is a challenge. Primary care is well placed to address this challenge but there are several barriers which may prevent this occurring. The objective of this study was to determine if a complex intervention designed to support screening and brief intervention for problem alcohol use among people receiving opioid agonist treatment is feasible and acceptable to healthcare providers and their patients in a primary care setting. METHODS: A randomised, controlled, pre-and-post design measured feasibility and acceptability of alcohol screening based on recruitment and retention rates among patients and practices. Efficacy was measured by screening and brief intervention rates and the proportion of patients with problem alcohol use. RESULTS: Of 149 practices that were invited, 19 (12.8 %) agreed to participate. At follow up, 13 (81.3 %) practices with 81 (62.8 %) patients were retained. Alcohol screening rates in the intervention group were higher at follow up than in the control group (53 % versus 26 %) as were brief intervention rates (47 % versus 19 %). Four (18 %) people reduced their problem drinking (measured by AUDIT-C), compared to two (7 %) in the control group. CONCLUSIONS: Alcohol screening among people receiving opioid agonist treatment in primary care seems feasible. A definitive trial is needed. Such a trial would require over sampling and greater support for participating practices to allow for challenges in recruitment of patients and practices.

Screening and Brief Interventions for Illicit Drug Use and Alcohol Use in Methadone Maintained Opiate-Dependent Patients: Results of a Pilot Cluster Randomized Controlled Trial Feasibility Study.

BACKGROUND AND OBJECTIVES: The present study evaluated the effectiveness of a single clinician delivered brief intervention (BI) to reduce problem alcohol use and illicit substance use in an opiate-dependent methadone maintained cohort of patients attending for treatment. METHODS: Four addiction treatment centers were randomly assigned to either treatment as usual (TAU; control group) or BI (intervention group). Clinicians screened patients using the alcohol, smoking, and substance involvement screening test (ASSIST) screening tool at baseline and again at three-month follow up. Fidelity checks were performed to ensure that training was delivered effectively and uniformly across all study sites. Feasibility of administering a BI within daily practice was assessed through intervention fidelity checks, patient satisfaction questionnaires and process evaluation. RESULTS: A total of 465 patients were screened (66% of the overall eligible population) with a total of 433 (93%) ASSIST positive cases. Randomization was effective, with no differences in the control versus the intervention arms at baseline for key demographic or clinical indicators including substance us. There was a statistically significant difference between global risk score for the intervention (x = 39.36, sd = 25.91) group and the control group (x = 45.27, SD = 27.52) at 3-month follow-up (t(341) = -2.07, p < .05). CONCLUSIONS: This trial provides the first evidence that a single clinician delivered BI can result in a reduction in substance use within a methadone maintained opiate-dependent cohort, and this effect is sustained at three month follow up.

Injection of new psychoactive substance snow blow associated with recently acquired HIV infections among homeless people who inject drugs in Dublin, Ireland, 2015.

In February 2015, an outbreak of recently acquired HIV infections among people who inject drugs (PWID) was identified in Dublin, following similar outbreaks in Greece and Romania in 2011. We compared drug and risk behaviours among 15 HIV cases and 39 controls. Injecting a synthetic cathinone, snow blow, was associated with recent HIV infection (AOR: 49; p=0.003). Prevention and control efforts are underway among PWID in Dublin, but may also be needed elsewhere in Europe.

Psychosocial Interventions for Problem Alcohol Use in Primary Care Settings (PINTA): Baseline Feasibility Data.

OBJECTIVE: Many individuals receiving methadone maintenance receive their treatment through their primary care provider. As many also drink alcohol excessively, there is a need to address alcohol use to improve health outcomes for these individuals. We examined problem alcohol use and its treatment among people attending primary care for methadone maintenance treatment, using baseline data from a feasibility study of an evidence-based complex intervention to improve care. METHODS: Data on addiction care processes were collected by (1) reviewing clinical records (n = 129) of people who attended 16 general practices for methadone maintenance treatment and (2) administering structured questionnaires to both patients (n = 106) and general practitioners (GPs) (n = 15). RESULTS: Clinical records indicated that 24 patients (19%) were screened for problem alcohol use in the 12 months prior to data collection, with problem alcohol use identified in 14 (58% of those screened, 11% of the full sample). Of those who had positive screening results for problem alcohol use, five received a brief intervention by a GP and none were referred to specialist treatment. Scores on the Alcohol Use Disorders Identification Test (AUDIT) revealed the prevalence of hazardous, harmful, and dependent drinking to be 25% (n = 26), 6% (n = 6), and 16% (n = 17), respectively. The intraclass correlation coefficient (ICC) for the proportion of patients with negative AUDITs was 0.038 (SE = 0.01). The ICCs for screening, brief intervention, and/or referral to treatment (SBIRT) were 0.16 (SE = 0.014), -0.06 (SE = 0.017), and 0.22 (SE = 0.026), respectively. Only 12 (11.3%) AUDIT questionnaires concurred with corresponding clinical records that a patient had any/no problem alcohol use. Regular use of primary care was evident, as 25% had visited their GP more than 12 times during the past 3 months. CONCLUSIONS: Comparing clinical records with patients' experience of SBIRT can shed light on the process of care. Alcohol screening in people who attend primary care for substance use treatment is not routinely conducted. Interventions that enhance the care of problem alcohol use among this high-risk group are a priority.

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users.

BACKGROUND: Problem alcohol use is common among illicit drug users and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opiate overdose in opioid users. OBJECTIVES: To assess the effects of psychosocial interventions for problem alcohol use in illicit drug users (principally problem drug users of opiates and stimulants). SEARCH METHODS: We searched the Cochrane Drugs and Alcohol Group trials register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 11, June 2014), MEDLINE (1966 to June 2014); EMBASE (1974 to June 2014); CINAHL (1982 to June 2014); PsycINFO (1872 to June 2014) and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; 2) online registers of clinical trials: Current Controlled Trials, Clinical Trials.org, Center Watch and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA: Randomised controlled trials comparing psychosocial interventions with another therapy (other psychosocial treatment, including non-pharmacological therapies, or placebo) in adult (over the age of 18 years) illicit drug users with concurrent problem alcohol use. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Four studies, involving 594 participants, were included. Half of the trials were rated as having a high or unclear risk of bias. The studies considered six different psychosocial interventions grouped into four comparisons: (1) cognitive-behavioural coping skills training versus 12-step facilitation (one study; 41 participants), (2) brief intervention versus treatment as usual (one study; 110 participants), (3) group or individual motivational interviewing (MI) versus hepatitis health promotion (one study; 256 participants) and (4) brief motivational intervention (BMI) versus assessment-only (one study; 187 participants). Differences between studies precluded any data pooling. Findings are described for each trial individually.Comparison 1: low-quality evidence; no significant difference for any of the outcomes considered Alcohol abstinence as maximum number of weeks of consecutive alcohol abstinence during treatment: mean difference (MD) 0.40 (95% confidence interval (CI) -1.14 to 1.94); illicit drug abstinence as maximum number of weeks of consecutive abstinence from cocaine during treatment: MD 0.80 (95% CI -0.70 to 2.30); alcohol abstinence as number achieving three or more weeks of consecutive alcohol abstinence during treatment: risk ratio (RR) 1.96 (95% CI 0.43 to 8.94); illicit drug abstinence as number achieving three or more weeks of consecutive abstinence from cocaine during treatment: RR 1.10 (95% CI 0.42 to 2.88); alcohol abstinence during follow-up year: RR 2.38 (95% CI 0.10 to 55.06); illicit drug abstinence as abstinence from cocaine during follow-up year: RR 0.39 (95% CI 0.04 to 3.98), moderate-quality evidence.Comparison 2: low-quality evidence, no significant difference for all the outcomes considered Alcohol use as AUDIT scores at three months: MD 0.80 (95% -1.80 to 3.40); alcohol use as AUDIT scores at nine months: MD 2.30 (95% CI -0.58 to 5.18); alcohol use as number of drinks per week at three months: MD 0.70 (95% CI -3.85 to 5.25); alcohol use as number of drinks per week at nine months: MD -0.30 (95% CI -4.79 to 4.19); alcohol use as decreased alcohol use at three months: RR 1.13 (95% CI 0.67 to 1.93); alcohol use as decreased alcohol use at nine months: RR 1.34 (95% CI 0.69 to 2.58), moderate-quality evidence.Comparison 3 (group and individual MI), low-quality evidence: no significant difference for all outcomes Group MI: number of standard drinks consumed per day over the past month: MD -0.40 (95% CI -2.03 to 1.23); frequency of drug use: MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken): MD 0.00 (95% CI -0.42 to 0.42); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days: RR 1.10 (95% CI 0.82 to 1.48); abstinence from alcohol over the last 30 days: RR 0.88 (95% CI 0.49 to 1.58).Individual MI: number of standard drinks consumed per day over the past month: MD -0.10 (95% CI -1.89 to 1.69); frequency of drug use (as measured using the Addiction Severity Index (ASI drug): MD 0.00 (95% CI -0.03 to 0.03); composite drug score (frequency*severity for all drugs taken): MD -0.10 (95% CI -0.46 to 0.26); greater than 50% reduction in number of standard drinks consumed per day over the last 30 days: RR 0.92 (95% CI 0.68 to 1.26); abstinence from alcohol over the last 30 days: RR 0.97 (95% CI 0.56 to 1.67).Comparison 4: more people reduced alcohol use (by seven or more days in the past month at 6 months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60), moderate-quality evidence. No significant difference was reported for all other outcomes: number of days in the past 30 days with alcohol use at one month: MD -0.30 (95% CI -3.38 to 2.78); number of days in the past month with alcohol use at six months: MD -1.50 (95% CI -4.56 to 1.56); 25% reduction of drinking days in the past month: RR 1.23 (95% CI 0.96 to 1.57); 50% reduction of drinking days in the past month: RR 1.27 (95% CI 0.96 to 1.68); 75% reduction of drinking days in the past month: RR 1.21 (95% CI 0.84 to 1.75); one or more drinking days' reduction in the past month: RR 1.12 (95% CI 0.91 to 1.38). AUTHORS' CONCLUSIONS: There is low-quality evidence to suggest that there is no difference in effectiveness between different types of interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

Community Pharmacy Needle Exchange Programme: What Can Analysis of the Data Tell Us about the Changing Drug Market in Ireland?

Community Pharmacy Needle Exchanges are a harm reduction measure that have been established in a number of countries to provide access to sterile injecting equipment for people who inject drugs (PWID). To ensure that they are meeting needs, it is important to monitor the use of the services. This study aimed to determine patterns of needle distribution and return in community pharmacies in Ireland over time. The number of pharmacies, needle packs, clean needles and returned packs was obtained from the Health Service Executive (HSE) Planning and Business Information Unit (PBI). Yearly totals were calculated to show patterns from 2015 to 2022. There has been an 18% decline in the number of pharmacies providing the service since 2015, with a 19% decline in the number of packs provided and a 21% decline in the number of packs returned. The proportion of packs returned was 23% in 2015 and 18% in 2022. There has been a 16% decline in the number of sterile needles provided and a 6% reduction in the average number of needles per individual since 2017. Declining needle use and low rates of used needle return (against a backdrop of large numbers of PWID that have not significantly reduced over time) suggest that there is a need to investigate if community pharmacies in Ireland have the scope to improve their harm reduction impact. This raises questions in terms of the need to both improve and adapt the service against a backdrop of changing drug markets. Key recommendations include the need to review the harm reduction services employed by participating pharmacies when providing new equipment and organising the return of used equipment.

Problem alcohol use among problem drug users in primary care: a qualitative study of what patients think about screening and treatment.

BACKGROUND: Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment. This paper aims to describe patients' experience of, and attitude towards, screening and therapeutic interventions for problem alcohol use in primary care. METHODS: This qualitative study recruited problem drug users (N = 28) from primary care based methadone programmes in the Ireland's Eastern region, using a stratified sampling matrix to include size of general practice and geographical area. Semi-structured interviews were conducted and analysed using thematic analysis, and audited by a third reviewer. RESULTS: We identified three overarching themes relevant to the purpose of this paper: (1) patients' experience of, and (2) attitude towards, screening and treatment for problem alcohol use in primary care, as well as their (3) views on service improvement. While most patients reported being screened for problem alcohol use at initial assessment, few recalled routine screening or treatment. Among the barriers and enablers to screening and treatment, patients highlighted the importance of the practitioner-patient relationship in helping them address the issue. Nevertheless, patients felt that healthcare professionals should be more proactive in the management of problem alcohol use at a primary care level and that primary care can play an important role in their treatment. CONCLUSIONS: Problem alcohol use is an important challenge in the care of problem drug users. While primary care is well placed to address this issue, little data has reported on this topic. The development of interventions which promote screening and brief interventions in practice are likely to benefit this at-risk group and further research and education, that help achieve this goal, are a priority. Strategies such as dissemination of clinical guidelines, educational videos, academic detailing and practice visits, should be explored.

Primary care and youth mental health in Ireland: qualitative study in deprived urban areas.

BACKGROUND: Mental disorders account for six of the 20 leading causes of disability worldwide with a very high prevalence of psychiatric morbidity in youth aged 15-24 years. However, healthcare professionals are faced with many challenges in the identification and treatment of mental and substance use disorders in young people (e.g. young people's unwillingness to seek help from healthcare professionals, lack of training, limited resources etc.) The challenge of youth mental health for primary care is especially evident in urban deprived areas, where rates of and risk factors for mental health problems are especially common. There is an emerging consensus that primary care is well placed to address mental and substance use disorders in young people especially in deprived urban areas. This study aims to describe healthcare professionals' experience and attitudes towards screening and early intervention for mental and substance use disorders among young people (16-25 years) in primary care in deprived urban settings in Ireland. METHODS: The chosen method for this qualitative study was inductive thematic analysis which involved semi-structured interviews with 37 healthcare professionals from primary care, secondary care and community agencies at two deprived urban centres. RESULTS: We identified three themes in respect of interventions to increase screening and treatment: (1) Identification is optimised by a range of strategies, including raising awareness, training, more systematic and formalised assessment, and youth-friendly practices (e.g. communication skills, ensuring confidentiality); (2) Treatment is enhanced by closer inter-agency collaboration and training for all healthcare professionals working in primary care; (3) Ongoing engagement is enhanced by motivational work with young people, setting achievable treatment goals, supporting transition between child and adult mental health services and recognising primary care's longitudinal nature as a key asset in promoting treatment engagement. CONCLUSIONS: Especially in deprived areas, primary care is central to early intervention for youth mental health. Identification, treatment and continuing engagement are likely to be enhanced by a range of strategies with young people, healthcare professionals and systems. Further research on youth mental health and primary care, including qualitative accounts of young people's experience and developing complex interventions that promote early intervention are priorities.

A Systematized Review of Drug-checking and Related Considerations for Implementation as A Harm Reduction Intervention.

Drug-checking services (DCS) provide people who use drugs (PWUD) the opportunity to have their substances tested before consumption. Though some suggest they may have adverse consequences, DCS have been introduced as a harm reduction (HR) strategy. A systematized review of the literature regarding drug checking (DC) methods and testing locations, advantages and disadvantages, and legal frameworks with an emphasis on HR was conducted referencing PRISMA guidelines. The primary search of PsychInfo, PubMed, Medline, CINHAL, CORE, and Web of Science was conducted between the 4th and 10th of September 2020, and 51 literature pieces were included in the final article. Most of the literature focuses on the benefits of currently available DCS. The services identified varied significantly in terms of testing methods, location of operation, primary goal, and the surrounding legal framework. The results suggest using multiple DC methods to be most beneficial. Further, DCS and the personalized interventions they provide can positively influence behavior change, minimize harm, and reduce mortality. DCS are a viable public health intervention that requires cross-sector support beyond the legal frameworks and testing methods. Services will need to be tailored to meet the needs of their chosen setting, local drug market, and target audience.

Deterrence effect of penalties upon adolescent cannabis use.

OBJECTIVE: Penalties are used in an effort to curtail drug use by citizens in most societies. There are growing calls for a reduction or elimination of such penalties. Deterrence theory suggests that use should increase if penalties reduce and vice versa. We sought to examine the relationship between changes to penalties for drug possession and adolescent cannabis use. METHOD: Ten instances of penalty change occurred in Europe between 2000 and 2014, seven of which involved penalty reduction and three involved penalty increase. We conducted a secondary analysis of a series of cross-sectional surveys of 15-16-year-old school children, the ESPAD surveys, which are conducted every four years. We focused on past month cannabis use. We anticipated that an eight-year time span before and after each penalty change would yield two data points either side of the change. A simple trend line was fitted to the data points for each country. RESULTS: In eight cases, the trend slope in past month cannabis use was in the direction predicted by deterrence theory, the two exceptions being the UK policy changes. Using the principals of binomial distributions, the likelihood of this happening by chance is 56/1024 = 0.05. The median change in the baseline prevalence rate was by 21%. CONCLUSIONS: The science seems far from settled on this issue. There remains a distinct possibility that reducing penalties could contribute to small increases in adolescent cannabis use and consequently increase cannabis-related harms. This possibility should be considered in any political decision-making influencing drug policy changes.

Impact of changes to the delivery of opioid agonist treatment, introduced during the COVID-19 pandemic, on treatment access and dropout in Ireland: An interrupted time series analysis.

BACKGROUND: Following the emergence of COVID-19, Ireland introduced national contingency guidelines to ensure rapid and uninterrupted access to opioid agonist treatment (OAT). This study aims to assess the impact of changes introduced to the delivery of OAT on the number of people accessing treatment and treatment dropout. METHODS: The study conducted interrupted time series analyses, with separate segmented regression models (March 2019-February 2020) vs (April 2020-March 2021), for (A) total number of people accessing OAT, (B) the number initiating treatment, and (C) the number dropping out of treatment, using data from the National OAT treatment register. The study examined immediate (change in level or intercept: ß2) and long-term impacts (change in slope; i.e., the difference between the slope before and after the intervention: ß3). We performed total and stratified analyses by gender, age group (<40/≥40 years), and OAT drug (methadone or buprenorphine). RESULTS: A total of 10,251 people accessed OAT in Ireland in March 2019 (2 % buprenorphine, n = 178), increasing to 11,441 (4 % buprenorphine, n = 471) in March 2021. The study observed an immediate (ß2 = 504.3, p < 0.001) and continued (ß3 = 31.9, p < 0.001) increase of people accessing treatment following the introduction of the OAT contingency guidelines. In contrast, observed changes in level and slope were not significant for treatment initiation or dropout. The study did find, however, a modest reduction in dropout among those receiving buprenorphine (ß3 = -0.6, p = 0.036). CONCLUSIONS: Changes introduced to the delivery of OAT, under the COVID-19 contingency guidelines, are associated with increased access to OAT in Ireland, with no evidence of increase in treatment dropout. Whether these effects will be maintained over time remains to be seen.

Prescription drugs with potential for misuse: protocol for a multi-indicator analysis of supply, detection and the associated health burden in Ireland between 2010 and 2020.

INTRODUCTION: There is an increasing concern about the misuse of prescription drugs. Misuse refers to the intentional repurposing of prescribed drugs and/or the use of illicitly sourced prescription drugs, which may be counterfeit or contaminated. Drugs with the greatest potential for misuse are prescription opioids, gabapentinoids, benzodiazepines, Z-drugs and stimulants. OBJECTIVE: The aim of this study is to provide a comprehensive analysis of the supply, patterns of use and health burden associated with prescription drugs with potential for misuse (PDPM) in Ireland between 2010 and 2020. Three inter-related studies will be carried out. The first study will describe trends in supply of PDPM using law enforcement drug seizures data and national prescription records from national community and prison settings. The second study aims to estimate trends in the detection of PDPM across multiple early warning systems using national forensic toxicology data. The third study aims to quantify the health burden associated with PDPM nationally, using epidemiological indicators of drug-poisoning deaths, non-fatal intentional drug overdose presentations to hospitals and drug treatment demand. METHODS AND ANALYSIS: A retrospective observational study design, with repeated cross-sectional analyses, using negative binomial regression models or, where appropriate, joinpoint regression. ETHICS AND DISSEMINATION: The study has received approval from the RCSI Ethics Committee (REC202202020). Results will be disseminated in peer-reviewed journals, scientific and drug policy meetings and with key stakeholders via research briefs.