VIEW magazine - issue 54. In-depth insight into Tackling Addiction

VIEW

An independent social affairs magazine

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Issue 54, 2020

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TACKLING ADDICTION From Belfast to Lisbon: an in-depth insight Supported by Addiction NI – part of the Inspire Group

VIEW, Issue 54, 2020

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Time for a health emergency to be declared t has been a pleasure and a challenge to oversee this issue on addiction. I’ve talked to some amazing people and organisations along the way.

But the reality is that to effectively tackle and provide support to people who have an addiction to substances such as heroin, cocaine, and prescription medicines, we need to come up with innovative solutions and matching funding.

I also believe that a health emergency and a health-first policy needs to be put in place in order to try and stem the number of drug-related deaths.

The families and friends who have lost loved ones deserve to know that they have our support and a desire to set up structures and facilities that will fully support them.

The obstacles though are huge.

We already know that the Executive and the Assembly are talking about budgetary constraints when it comes to funding decisions. The talk from some politicians of having to make ‘tough decisions’ is being heard more frequently.

And yet, if we continue to offer a very uneven delivery of services with long waiting times, then we know what the outlook will be – more pain and tears from those whose husbands, wives, brothers and sisters are dying.

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VIEW editor Brian Pelan My research for this magazine led me to Lisbon in Portugal.

In the 1990s, Portugal was in the grip of heroin addiction which affected all sectors of society. The country also had the highest rate of HIV infection in the entire European Union.

In 2001, nearly two decades later, Portugal became the first country to decriminalise the possession and consumption of all illicit substances and witnessed a huge reduction in drug use.

Rather than being arrested, those caught with a personal supply might be given a warning, a small fine, or told to appear

before a local commission – a doctor, a lawyer and a social worker – to hear about treatment, harm reduction, and support services that are available to them.

I interviewed the country’s Drugs and Alcohol National Coordinator João Goulão and a frontline organisation called Crescer for this issue of VIEW. “The decriminalisation policy change was based on the idea that drug addiction is mostly a health and social issue rather than a criminal/justice issue,” said Mr Goulão.

“Decriminalisation was important because it meant that the country moved away from the stigma and segregation of people to a more inclusive set of policies for drug users.”

My interviews with Mr Goulão and Crescer are on pages 12 to 15.

I would have liked to have interviewed the Minister for Health Robin Swann for this issue, but, despite numerous requests to the Department of Health press office, I could not secure one.

Finally, I would like to pay a special tribute to Kerry Anthony, Chief Executive of Inspire Wellbeing, and Alex Bunting, Director of Addiction Services, Addiction NI. This magazine on addiction would not have been possible without their invaluable support.

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VIEW, Issue 54, 2020

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Editorial

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VIEW, an independent social affairs magazine

By guest editor Alex Bunting, Director of Addiction Services/ Addiction NI – part of the Inspire Group was first drawn to work with people who have substance misuse issues 17 years ago when I saw the impact that alcohol and drugs were having in my own community.

Growing up in north Belfast, I lived through the latter years of the Troubles and witnessed first-hand how alcohol and other drugs became an increasing problem.

My motivation at that time was to help young people find alternatives to alcohol and drugs and support those who found themselves struggling with addiction. I wanted to help build support services that would address these evolving issues in a post-conflict Northern Ireland and I continue to strive to do that today.

When I reflect on that time I increasingly see the true impact of the Troubles on substance misuse – the links with trauma, poor mental health and the lack of resources and strategy to address such needs. The established misuse of alcohol, over prescribing of medication and lack of mental health infrastructure have created further challenges for those communities trying to deal with and recover from more than 40 years of conflict.

In the years since the Good Friday Agreement we have witnessed the impact of social inequalities on health inequalities, reflected across a range of indicators, including increases in alcohol and drug-related deaths, increases in suicide rates as well as the prevalence of certain physical health conditions.

There is no doubt that substance misuse and addiction impacts across all socio-economic levels. However, research has increasingly highlighted the links between trauma and addiction, with a disproportionate impact in areas of greater deprivation and poverty.

The evolving drug culture in Northern Ireland has also mirrored that of other developed countries. We have increasingly witnessed drugs, such as heroin and cocaine, take hold of and spread through communities while there has been a

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In the years since the Good Friday Agreement we have witnessed the impact of social inequalities on health inequalities, reflected across a range of indicators, including increases in alcohol and drug-related deaths

growing trend towards poly-substance misuse and more chaotic drug use.

The issues have been further compounded by over-use of prescribed medication with Northern Ireland being a world leader in prescribing rates of antidepressant and anxiety medications. There has also been a growing appetite for opioid pain medication. The combined impact of this is reflected by year-on-year increases in drug-related deaths with latest figures showing a 40 percent increase from 20172018 and a 112 percent increase since 2008. (NISRA, 2019). Similar trends have been observed in alcohol-related deaths with an overall increase in the last decade.

The over use of pharmaceutical drugs has been in part driven by the underinvestment in our mental and physical health services and increasing demands for services. This has created an untenable situation for health professionals who struggle to offer alternative nonpharmaceutical solutions to those in need and feel a duty to offer medication in light of lengthy waiting lists for services. The huge social cost of substance misuse in Northern Ireland is undeniable and research has indicated that the impact of alcohol costs up to £900 million per year.

It is important to highlight the excellent services being provided across Northern Ireland to help those seeking support for substance misuse. Huge efforts have been made to reduce the stigma related to substance misuse, incorporate social support, reconnect people to their community and encourage more people to step forward and seek help.

There is no doubt that we all have a role to play in addressing these issues and it is encouraging to see mental health and substance misuse being prioritised in the ‘New Decade, New Approach’ document.

I look forward to the development of a comprehensive drug strategy that encourages cross-departmental responsibility for prevention, intervention and recovery. The people who use services need to be at the core of all that we do.

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The death of your child untethers you from the world and the rest of your time is about finding an anchor Penny McCanny, above, who has joined an Opinion and Involvement group with Addiction NI, writes for VIEW about the tragic death of her son Aidan from a heroin overdose on July 27, 2013 have bad news, Aidan is dead – I received that call from my husband on July 27, 2013, whilst I was standing at the bottom of the stairs of an apartment in Barcelona. There is a line drawn on that first step dividing my life into the before time and the after time. He didn’t tell me then, but I knew that Aidan had died from an overdose of heroin.

As we waited to go to the airport, I sat at the table trying not to think about Aidan. I felt a physical pain so terrible that I thought it would be impossible to continue to live. The death of your child untethers you from the world and the rest of your time is about finding an anchor.

For me, I found it in speaking for Aidan, I had to tell people what he thought and why. I wanted people to know that I was proud of him, that it was his death and not the manner of his death that was the tragedy.

Aidan was my first child; he was brilliant, he was a giant in size, personality and intellect. He was known as BFG. He could paint a picture of the beginning of the universe, of the possibility of quantum computing and explain with great patience any political theory or the rationale for an alternate timeline in Star Trek. He hated discord but loved debate.

The first drug Aidan took was alcohol.

In fact, next to heroin, he saw alcohol as the most problematic of drugs. At what point things became a problem for Aidan and when they became a problem for me, is very different.

The problem for me lay in the use of drugs but for him it was in dependence.

Looking back, I see so many opportunities for me to have listened rather than lectured. I’m also ashamed of the hypocrisy of telling someone that drugs are dangerous whilst holding a glass of wine in my hand.

Aidan went to Queen’s University to

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Together: Penny McCanny with her son Aidan study Chemistry and later to London to do his Masters. He was still the same son and brother that he’d always been – strong and fragile – smart and caring, but I know that his difficulties increased in these years.

We still laughed and talked and debated but we also fought more frequently and more intensely.

In April of 2013, we found a syringe of heroin in Aidan’s room. Immediately everything fell into place; Aidan took off his jacket and there on his arms were the track marks. I asked what he wanted to do, and he said he wanted to be free from addiction. He didn’t want to take Methadone; he didn’t want to swap one addiction for another. His only way of stopping was to buy heroin and with support, to reduce his dose each day. He went to see a cognitive behavioural therapist and for the first time he told a friend that he took and was addicted to heroin. Many young people take illegal drugs, but some things are seen as a step too far and Aidan had felt unable to share the fact that he took heroin. There is only one way to get heroin and that is to buy it from a dealer – heroin of unknown strength and quality.

Aidan did stop using heroin by June of 2013 and he saw a world full of potential again. During this time, we argued less and we talked much more about the effects of prohibition, of the damage caused by the

‘War on Drugs’, of heroin-assisted treatment and safe injecting facilities. Two comments stay with me – when I asked why when he was reducing his use why didn’t he do it in fractions, and why the next day’s dose looked bigger than the previous one. He told me that “500mg of paracetamol is always 500mg of paracetamol but that little bag of heroin can be any strength.” On another occasion, I asked how someone could be a dealer?

I’m still ashamed of that question. He told me not to judge him, he was someone like him, but someone who had no one to help him, someone with few choices. We knew there would be lapses, anyone who has tried to stop smoking can tell you that. On July 27, 2013, Aidan had a lapse. Each year on his birthday or anniversary, we do something to raise money and awareness on Aidan’s behalf. I had heard that seven people a day die from a drug-related cause and three years ago on his birthday different friends and family walked seven mountains across the UK. Today it would be 10 mountains.

I have recently joined an Opinion and Involvement group with Addiction NI, and in many ways, it is Aidan’s opinions and experience that I bring. I am a member of Transform’s Anyone’s Child campaign. Our aim is to change not just attitudes but also drug laws and policies. I think that there is increasing global awareness that the ‘War on Drugs’ has cost too many lives. I believe that a compassionate, evidence-based approach that has legal regulation at its core is the way forward.

Aidan would be alive if we put compassion before judgement, if his heroin had been of known strength and quality, in the same way as the paracetamol tablet or the bottle of vodka or if he had taken that dose of heroin in a safe injection facility. I think he would be alive if I had understood a little earlier.

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COMMENT

Confronting the demonising of drug users Dr Stanton Peele, world renowned addiction expert, psychologist and author, argues that addiction must be defined as an involvement of any type in which people compulsively engage despite serious negative impacts for them here is a great deal of controversy about the use of the term ‘addiction’ currently. This creates difficulties for the self-naming of the organisation Addiction NI, at whose annual conference I spoke last year.

But I believe that the term ‘addiction’ retains great value and usefulness, which I hope to demonstrate here.

But first, let me list some of the objections to the term.

The American Psychiatric Association’s diagnostic manual, DSM (as well as its international equivalent, the International Classification of Diseases or ICD), doesn’t use the term addiction (except in a single instance, as we’ll see).

DSM-5 has replaced addiction and dependence with a sliding scale of “substance use disorders” (SUD), ranked from mild to severe, that can result from using a variety of drugs. This reflects the important truth that all substance use, and any accompanying problems, occur along a nuanced spectrum.

At the same time, many serious problems drug users face are not due to addiction per se: for example, infections due to sharing needles or drug deaths caused by combining drugs.

Focusing on reducing problems like these by offering users clean needles and educating them about the dangers of drug mixing (or even providing them with safe drug supplies) are extremely valuable steps to take for preserving lives, as Addiction NI does.

Finally, some in the harm reduction movement (Addiction NI is a harm reduction organisation) object to the term addiction.

Harm reduction proponents consider people who use drugs problematically as individuals making human attempts to lead satisfying lives – including integrating various substances into those lives – with different degrees of success.

Many harm reductionists contend that

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no-one merits being pathologised (and self-pathologised) as an ‘addict’. People with drug-related difficulties, they point out, are simply people seeking to do the best that they can in the circumstances in which they live.

I agree with these harm reductionists’ innovative thinking.

But the justified eschewal of the stigmatising and disempowering label ‘addict’ can sometimes extend into rejecting the very concept of ‘addiction’ — an overreaction, in my view.

Even as some people have been discarding the idea of addiction, I have been expanding the term, for example by extending it to love and sex, as I did in my 1975 book with Archie Brodsky, Love and Addiction.

Substance use is a problem only when it causes problems. Drinking alcohol or taking drugs isn’t a problem in most cases.

If no notable problems accompany drug use, then an SUD diagnosis isn’t warranted.

An addiction is a compulsive and harmful habit of any kind. As we noted earlier, DSM-5 actually does address addiction, which it had never done previously. It just doesn’t apply the term to any drugs.

What, then, does DSM categorise as an ‘addictive disorder?’

Just one thing: gambling.

But this is too narrow an application.

Instead, addiction must be defined as an involvement of any type in which people compulsively engage despite serious negative impacts for them.

Why do so? Because this model is accurate and useful, as demonstrated by precisely analogous causes, behavioural patterns and harms.

That is to say, those addicted both to sex-love and to drugs seek emotional comfort and self-acceptance through repetitive, constant stimulation while losing sight of, and damaging,

other activities and relationships.

Ultimately, addiction should be retained as a concept in the broader way I use it because it implies the need for important real-world change. Applying addiction to all damaging compulsions – including behaviours (love, eating) that we cannot eliminate from our lives – makes clear that drug demonising and prohibition are illogical responses to drug addiction.

Secondly, the inclusivity of the term emphasises that those of us who have not experienced drug addiction have nevertheless experienced addiction somewhere in our lives (just ask people you know), militating against attitudes and policies that isolate and vilify drug users.

Addiction can reach severe depths whenever, despite extreme negative consequences – health harms and risks, social isolation, the exclusion of other meaningful endeavours – the person is unable to quit repeating a behaviour.

This broader conception of addiction dictates that the treatment path and prevention techniques for addiction lie in creating more fulfilling lives for individuals – and taking action to encourage these societal changes.

Only then can we envision ways to overcome and prevent addiction through helping people to find purpose, develop skills, and open life opportunities for themselves. Our currently dominant disease view of addiction, in the meantime, offers no inkling of how to do this and only exacerbates our problems.

But making this broader conception of addiction useful and creating effective remedies requires a societal commitment to applying this new conception of addiction resolutely, and on a large scale.

• Stanton Peele, Ph.D., is cofounder, along with Website NI (websiteni.com), of the online Life Process Programme.

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Sponsored by Addiction NI

Drink Wise Age Well Campaign aimed at raising awareness amongst older people

One-to-one support available rink Wise Age Well is a comprehensive preventiontreatment programme, which aims to create a sensible relationship with alcohol for adults over 50.

Funded by the Big Lottery Fund it is led throughout the UK by Addaction and draws on expertise from across the UK through a partnership which is led by Addiction NI in Northern Ireland and delivered in the Western Trust area.

Many people over 50 drink safely, but an increasing number are experiencing alcohol-related harm. Alcohol-related deaths in Northern Ireland are at their highest since records began, increasing by 70 percent since 2001. This increase is particularly stark in older age groups with the largest number of deaths occurring among those aged between 45 and 54 years, closely followed by those aged 55 to 64.

A report published in June 2019 from Queen’s University Belfast, commissioned by the advice and support of Drink Wise Age Well, has found alcohol misuse amongst people over 50 is costing Northern Ireland healthcare services an estimated £125 million per year. A 2018 study by Public Health England found for every £1 invested in alcohol treatment services there is a social return of £3, and a similar investment would probably apply to Northern Ireland.

There are a number of reasons why older adults are more at risk from alcohol harm. Our chances of having cognitive impairment/dementia increase and symptoms can be exacerbated by alcohol.

As we age, we are also more at risk of falls/accidents which alcohol can impact on and we are more likely to suffer fractures as a result. We know that we encounter more ailments/illnesses in later years and

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Help needed to implement our Charter for Change more likely to be on prescription medication which can interact adversely with alcohol. Symptoms of menopause can also be affected.

Lack of awareness of the harm alcohol can be causing us, along with stigma and shame can prevent people seeking support but it is important to focus on the barriers older adults face seeking help. These barriers are often down to attitude and beliefs but can also be practical – mobility, transport, financial. People may also fail to recognise problem drinking in older adults as they avoid asking the questions about their alcohol consumption or assume it is not an issue for older adults.

Drink Wise Age Well tries to increase awareness and change attitudes around alcohol use and ageing across our communities and in workplaces. It is never too late for prevention. One in three older adults with an alcohol problem develop it in later life and cutting back or stopping drinking may halt or reverse harm.

Isolation and loss of sense of purpose is described by those older adults whose drinking has increased. That is why our work doesn’t just focus on people who are drinking. It targets those that are ‘at risk’ due to key life changes, such as bereavement or retirement and those that are trying to maintain their recovery from alcohol use. Through our programmes focusing on building resilience and connecting people to their community people have reported a 78 percent increase in their emotional wellbeing; a 78 percent increase in their sense of purpose and a 38 percent reduction in their alcohol consumption.

We offer one-to-one support, home visits, mutual aid meetings and family support. The home visits are particularly beneficial in overcoming barriers around

shame and stigma as it can be extremely daunting for people entering a strange building to access services. It also allows those in rural areas with poor or no access to public transport to get support they otherwise wouldn’t be able to avail of.

Our mutual aid meetings have been a lifeline for people to link with others who understand what they are experiencing, receive peer support and focus on practical solutions to help them through their days and maintain recovery. We know the work we do is effective as those who have engaged with our therapeutic work have, on average, reduced the numbers of drinking days from 19 to 11 in a 28-day period and more than than halved their unit intake. Thirty five percent indicated a reduction in feeling isolated, and there was a 29 percent reduction in those reporting having no sense of purpose and a 15 percent reduction in falls.

The main aspect of the work which people respond to best is that we are able to offer supports which are delivered at times and places which suit our clients and without judgement. Drink Wise Age Well believes strongly that everyone has a human right to age well with dignity; older adults should be able to live the best life they can, free from the negative effects and harms caused by alcohol; everyone should have access to factual and credible information to make informed choices about their alcohol use as they age; alcohol treatment and support must be easily accessible for all ages and stages in life.

We need your help to effect change and implement our Charter for Change (available at www.drinkwiseagewell.org.uk).

Doing so will mean that older adults have equal access to treatment as well as more positive experiences when getting support for alcohol issues.

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I would drink and drink until I became unconscious Alan McMillen, in his own words, writes about his hellish descent into alcoholism and how he is now striving to turn his life around with the support of Addiction NI have suffered from alcohol dependency for the last 13 years of my life. I was born into a working-class background in north Belfast. My father was a merchant seaman and was away a lot so I was brought up mostly by my mother. He died at the age of 47 from lung cancer.

I left school with five 5 GCE’s. A friend of mine who was a cyclist and who went to the same school got me interested in cycling. I started to train with him regularly.

I’ve always had a technical mindset with regard to electronic engineering and computing and was able to get work with various IT companies.

I continued riding as a racing cyclist and I knew I was good at it. I raced all over Ireland and the UK. I also took up running and ran around 60 miles a week. I ran marathons, half marathons and other races throughout Ireland, the UK and Europe.

In 2006, my mother was rushed to hospital with a severe throat infection. I thought she was going to die.

My work situation at the time was also becoming very difficult and I became lonely and isolated from my fellow coworkers. During my working hours, I started to drive to an off-licence during break time to buy a bottle of wine or a half bottle of spirits to help me cope with a very stressful situation.

This became a routine occurence with my intake of alcohol increasing.

My firm eventually found out that I had an alcohol problem and I was dismissed.

During this period in my life I became even more isolated and started to drink

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even more, mainly vodka or whiskey. I would drink and drink until I would pass. out. My mother found me unconscious one day. She called an ambulance and I was taken to hospital. I was put onto a detox programme until the alcohol had left my system. This was to happen to me on a number of occasions.

I became a binge drinker at home.

These sessions would last for around six weeks. After many visits to hospital for detox over a 13-year stretch, I knew I had to do something.

My GP got me into a residential unit for six weeks. I was very apprehensive about it as I had never attended a place with other people who had multiple addictions. The first two weeks were very difficult, but as I got to know the staff and the occupants, I was able to settle more.

I eventually finished the course, but as a ‘reward’, I crossed the road to an off-licence and purchased a bottle of whiskey. I placed it in my jacket and subsequently drank it on the three-and-a half-mile walk to my house.

I was now embroiled in the spiral of drinking again on a binge basis in my own home. The spiral of drinking and returning to hospital continued right through my 40s and into my early 50s.

I eventually met a woman at the Mater Hospital in Belfast who said she would refer me to Addiction NI. It was the first time that I had heard about this organisation.

After a couple of weeks, I received correspondence from Addiction NI and travelled over to east Belfast for an

assessment. I started to attend group meetings at Elmwood Avenue in Belfast.

The group was made up of individuals who suffered or who had suffered from substance abuse.

The whole focus of the meeting is not to dwell on what substance you had taken, but rather on how to live a balanced and structured life.

The group that I’m in has been the only treatment which has worked for me, and even after a lapse, I can still attend regularly without guilt or remorse.

Every person at the group has a similar mindset and goal in life. We gell together because we give each other respect and are able to talk freely without embarrassment or failure.

I have been to many groups over the last 10 years, but the flexibility and oneness that I feel with Addition NI has dramatically helped me.

Due to its legality, alcohol is the most accessible substance available.

The use of large quantities of alcohol to get a ‘high’ does not outweigh the negative effects of what happens when the binge session is over.

I do believe that I can live a life with purpose, meaningful, healthy and balanced without consuming alcohol.

Change can only occur through ourselves. I believe you have to want to change. Structure and planning are very important, but also having relaxation periods in a day by maybe walking, listening to music, reading or whatever helps you to wind down.

I hope my article is helpful to someone who is struggling with addiction.

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Confronting abuse Brian Pelan listens to 70-year-old Paul Smith’s story of alcoholism and sexual abuse and how he found peace in his life after he went to Drink Wise, Age Well meetings ur meeting took place in a small intimate counselling room in the offices of Addiction NI in Derry.

Paul was well dressed and quietly spoken as he delivered his story about his struggle with alcohol addiction, sexual abuse and finding contentment.

“I’m delighted to have reached 70 years of age. I grew up in the Republic of Ireland. There were four children in the family. We all went to university. I then went on to do post-graduate studies. I ended up working in finance. I loved my time in university but I hated school. It was not a good environment to be in.

Paul told me how he was sexually abused by a staff member at the school. “It wasn’t a case of telling everyone.

Everything was hush, hush.

“I thought I had a lovely balance between my working life and my personal life. I was married in 1976. My wife has been my rock in life. We have two grownup children.

“Music was always in the background of my life. I have a love for the Irish language and traditional music. During that time, drink played a fair bit in my life.

“If you were at a music session it was quite natural to pick up a pint, and one pint would lead to another. I had some crazy weekends.

“Eventually my past history of being abused started to catch up with me. I started to have a lot of flashbacks to being abused at school. I was also drinking more

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heavily – socially and at home.

“I suffered a lot of pressure during this time in my life and I was also drinking a lot.”

He went into an addiction treatment centre in 2000 and was told that he would have to deal with the fact that had been sexually abused.

After a number of years pursuing his claim for damages, Paul managed to secure an apology and a financial settlement for the sexual abuse that he had suffered.

After his case was settled he entered rehab again for his alcohol addiction problem.

“My time in this place was wonderful because it got to the core of my problems and it helped me to understand the journey I had been through. My life was changed totally by my decision to seek addiction support.

“My drinking had had a very negative impact on my family. They were very understanding though because they knew of the abuse that I had suffered.

“I still drink from time to time, but the important thing is that I can now stop when I want.

“I still feel that I need support though.

I happened to be in the right place at the right time when Drink Wise, Age Well was established.

“I connected with the programme, which was set up by Addiction NI, in September 2015.

“I was one of the first to take part.

I’ve been with them ever since.

“I have two sessions with them every week. We sit around and we discuss things.

We talk about the present and the past is mainly left behind.

“To be able to forgive myself was important as it helped me to deal with the past. This treatment has helped to make a much better future for me.

“Turmoil is now absent from my life and I have much more contentment.

“I had been a functioning alcoholic. A lot of times I wasn’t drinking in company. I was drinking quietly at home.

“My wife taught me what unconditional love meant. I also had conversations with my children and explained to them what had happened to me in terms of being sexually abused at school.

“The people who have guided me are the Drink Wise, Age Well team.

“They have a loving and caring approach to addiction with an emphasis on the present. They have wonderful counsellors. It was life-changing for me to come into contact with them.

“I depend on them greatly to help me keep my sanity. They have a 21st century approach to the massive problem in Ireland of addiction.”

• Paul’s real name has been changed to protect his identity.

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I will keep doing this work as long as there is breath in my body

Tracy Bell: “We are losing a generation to addiction and mental health”

Campaigner Tracy Bell, whose brother died from a heroin overdose, tells VIEW editor Brian Pelan why she is determined to keep on fighting for those affected by drug addiction racy Bell and her family’s world changed utterly when her brother died from a heroin overdose more than 20 years ago.

She has devoted a large part of her life since that devastating tragedy to helping people grappling with addiction in Antrim and Belfast.

Her brother Gary Cathcart was the first person in Northern Ireland to be registered as dying from a heroin overdose.

An inquest heard that, while succumbing to a life of heroin addiction spent mainly in estates around Ballymena, he had spoken out about the ignorance of Northern Ireland’s heroin problem and, particularly, about the neglect suffered by addicts.

Forty-five-year-old Tracy, who set up a charity called GUS Health and Wellbeing, did not hold back when it came to offering her views on the drug addiction problem in Northern Ireland.

“I’m a strong believer that there is always a reason behind why somebody falls into addiction,” said Tracy. “I’ve worked with drug addicts and alcoholics throughout the whole of Northern Ireland, and I’ve yet to find anybody that hasn’t trauma behind it.

“At the end of the day, it’s no life, being an alcoholic or a drug addict. There’s nothing good about it. I feel that the

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support services are lacking. It’s mindboggling why we haven’t a joined-up approach for mental health and addiction, as it goes hand in hand.

“We are in an epidemic. We are losing a generation to addiction and mental health.”

Tracy has helped numerous addicts from Northern Ireland to go to addiction clinics in England for treatment.

She also revealed to me that her brother Billy was suffering from dementia which was brought on by his alcohol addiction. Mr Cathcart was diagnosed with Korsakoff syndrome, a form of alcohol-related brain damage, in 2003.

Ms Bell said the trauma of losing his brother Gary in such tragic circumstances drove Billy to drink.

Figures obtained recently show the number of alcohol-related deaths in Northern Ireland is the highest on record.

Between 2001 and 2016, more than 3,500 deaths in Northern Ireland were attributed to alcohol.

Coroner Joe McCrisken said: “We have an enormous problem with alcohol use, misuse and abuse in Northern Ireland.

The figures are frightening because they show that the number of alcohol-related

deaths is increasing, so it's important to raise awareness about the dangers,” he added.

Tracy is a passionate advocate for a dedicated addiction facility to be set up in Northern Ireland. “We need to follow the Portugal model when it comes to treating addiction. It needs to be declared as a health emergency, “This facility would have a walk-in service, a wraparound service, beds for people who need them, and a detox unit “It would be a safe place for vulnerable people.”

“Our hospitals now have an influx of addicts – day and night. We are at a crisis point within the NHS as far as addiction is concerned. We have far too many suicides from people suffering from addiction.”

Tracy is so committed to her work that she went back to studying.

“I have a postgrad certificate in dualdiagnosis, mental health and addiction. It took me one year to do it. I really enjoyed my time at Queen’s University and studying under Professor Anne Campbell.”

She has no intention of ever giving up the fight to help those affected by addiction.

“I will keep doing this work as long as there is breath in my body.”

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‘Being kicked and spat on VIEW editor Brian Pelan talks to Andrew Horne and Caroline Phipps about the scale of the substance misuse problem in Scotland and Wales was keen to talk to Andrew Horne, Executive Director of Addaction Scotland and Caroline Phipps, Chief Executive of Barod – both heads of two organisations that are in the frontline of trying to help people grappling with addiction issues in Scotland and Wales We met up in a room at the headquarters of Inspire Wellbeing during their recent visit to Belfast.

In a frank exchange of views, Andrew, who was born in Dublin, said that the situation in Scotland is “a shame and a tragedy”.

He said: “Drug use is ever changing but we have a big cohort of heroin users, a lot of them now are in substitute prescribing.

“Last year we had more than 1,100 drug-related deaths in Scotland. We are the highest in Europe by a country mile and we are three times greater than the rest of the United Kingdom.”

Why is there such a huge number of drug users, I asked?

“It’s to block out the pain of inequality, deprivation, trauma, lack of opportunity, but it’s also very learned. It’s a learned behaviour. I remember very early going to Scotland in1994 or1995 and a person overdosed across the road from the property I was working in. We had an emergency kit and we gave him naloxone (used to reverse the effects of an opioid overdose) and they came around. I was talking to them for a bit afterwards and asked: ‘Well what was that about?’ and the response I got was: ‘Well it didn’t really matter did it?’ That was their view – it didn’t matter, life and death didn’t really matter.”

You have talked in the past about ‘a radical new approach’ being needed. What is this radical new approach, given the situation that, as you describe yourself, is so horrific?

“The first thing I’d think is that we need to look at what drugs we’re prescribing in terms of opium replacement therapy,” replied Andrew. “I wholly agree with opium replacement therapy. I just think we’re using the wrong drug and I think we should be moving towards diprenorphine or any of the other category of drugs that they fit into, in that it’s far safer, with far less chance to overdose.

“We also need outreach teams in all big urban centres.”

In your experience in Scotland, if someone does

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Andrew Horne, Executive Director of Addaction Scotland – the largest provider of drug and alcohol support services in the country

choose to interact with an outreach team and say: ‘Yes, I do have an issue. I have a problem. I want to stop this.’ How fast will their needs be met under the present structure in Scotland?

“In Scotland, the service must be delivered within three weeks,” replied Andrew. “In terms of severity or complexity of need, it could be the same day. In lots of places in Scotland it is now the same day.

What about housing needs, I asked?

“We have a Housing First policy in parts of Scotland. Housing is not difficult; it’s just about getting the right housing.”

We then moved on to discuss the provision of naloxone.

“I’m working with an organisation called GoodSAM (who have an app which enables emergency services to open any caller's mobile phone camera and instantly locate and visualise the scene/patient. This enables better resource deployment and earlier care).

Would you be in favour of safe injection facilities, I asked?

“I’m absolutely 100 percent in favour of safe injecting facilities but for those areas that can’t afford them, because it is an expensive model, I

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is not a lifestyle choice’

think we should bring back fixed-site needle exchanges everywhere.”

Andrew also hit out at the stigma which often surrounds individuals with drug addiction issues.

“Do you think somebody chose their life to be like this? Do you think at the age of 14 they said, ‘I’m going to sleep on the street. I’m going to use some dirty drugs with dirty needles. I’m going to be kicked around. I’m going to be abused and spat on and start begging. I’m going to spend my life looking at people’s feet in the pissing rain.’ Is that a lifestyle choice?

I then moved on to Caroline to find out how

Caroline Phipps, Chief Executive of Barod in Wales – who provide support to individuals affected by alcohol and drugs, and their friends and family

Wales compared to the situation in Scotland and elsewhere in the UK. “We don’t have the drug-related death rate that Scotland has. What we do have is a variety of different service provision across different areas and different treatment pathways. Some of them do serve our populations relatively well, and some of them fail them miserably,” said Caroline.

“I think that we are far from delivering services that are suited to the people that we need. I think we’ve got huge issues around leadership in our health service. We’ve got huge issues around leadership in our local authority and in our housing services. Until they work together and absolutely commit to doing the best that they can, which they’re not doing now, we will continue to see these drug-related deaths and misery for families and communities.”

I then asked Caroline about a remark she once made in an article in a British newspaper – ‘If this was the amount of people dying because of anything else, it would be a national emergency. We would be doing everything we could to stem this tragedy.’ I asked her to explain what she meant.

“The people who are dying, they’re not young children with a disease or middle-class people,” said Caroline. “We are not a tolerant society, regardless of what anybody would say. People who they see as lesser or causing crime or messing up their street, bringing down the price of their houses, they are not seen as a worthy investment of resources. Until somebody stands up, like they did in Portugal, and says: ‘No, this is a public health emergency. We’re going to do everything in our power, use every tool, to help address this, including decriminalisation’.”

Caroline also had some words of criticism for the current Welsh Health Minister Vaughan Gething. “Our strategy is reducing harm together. The Government here bought into the harm reduction strategy and they say all the right things. But when you want to do something slightly innovative, our Minister says, ‘No we can’t do that. It’s against the law.’ He is very risk averse.”

She went on to praise Portugal in terms of how they have led the way in tackling addiction.

“I was there last year at the International Harm Reduction Conference in Porto. I think they’ve been really brave. They were in a dictatorship for many years and then all of a sudden from the 1970s they had to build all these infrastructures in public health. They have some extraordinary leadership in the area of health and have key people at the top who made this change.”

As the interview drew to an end, I asked Andrew and Caroline were they optimistic or pessimistic about how their respective countries are tackling addiction and the effectiveness of their harm reduction strategies.

“I’m hugely optimistic at this moment in time,” said Andrew.

Caroline offered a slightly different viewpoint. “I would say that I’m not as optimistic as Andrew. I think that we are far from delivering services that are suited to the people that we need.”

She added: “There are obstacles everywhere but ultimately it’s important to keep the human being in the middle of it and to understand that person and make sure that whatever you build around it is in the interest of that person and their community.”

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INSIGHT INTO PORTUGAL’S ADDICTION FIGHT

Above: João Goulão, the Drugs and Alcohol National Coordinator in Portugal, at his office in Lisbon

João Goulão with VIEW editor Brian Pelan

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A health first policy VIEW editor Brian Pelan travelled to Lisbon in Portugal to hear at first hand from the country’s Drugs and Alcohol National Coordinator João Goulão on how they have led the way in Europe on tackling addiction-related issues left Ireland just as Storm Ciara was hitting Ireland and the UK. All my research on addiction for this issue of VIEW had shown that a visit to Portugal was a must. I was keen to find out how the country had found its way out of a heroin epidemic that had ravaged many of its inhabitants. I also wanted to know what lessons can we learn from its harm reduction policies.

In the 1990s, Portugal was in the grip of heroin addiction which affected all sectors of society. The country also had the highest rate of HIV infection in the entire European Union.

In 2001, nearly two decades later, Portugal became the first country to decriminalise the possession and consumption of all illicit substances and witnessed a huge reduction in drug use.

Rather than being arrested, those caught with a personal supply might be given a warning, a small fine, or told to appear before a local commission – a doctor, a lawyer and a social worker – about treatment, harm reduction, and the support services that were available to them.

I met João Goulão at the offices of SICAD (The Intervention Service on Addictive Behaviors and Dependencies) in Lisbon. He is credited as being one of the architects of Portugal’s drug policy which was established in 2000.

From 2009 to 2015, he served as chairman of the European Monitoring Centre for Drugs and Drug Addiction and has been a delegate at the United Nations Commission on Narcotic Drugs.

How important was it for Portugal to decriminalise drug consumption in 2001, I asked João?

“The policy change was based on the idea that drug addiction is mostly a health and social issue rather than a criminal/justice issue. Decriminalisation was important because it meant that the country moved away from the stigma and segregation of people to a more inclusive set of policies for drug users.

“Decriminalisation, along with a set of other policies (prevention, treatment, harm reduction and reintegration) led us to an improvement in indicators for overdoses, HIV infection and criminality since our strategy was put in place.”

Was there much opposition to these

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Facts about drugs policy in Portugal • The only thing that most outsiders know about Portugal’s laws is that all drugs for personal use are decriminalised. But what many fail to understand is that all drugs, other than alcohol and tobacco, remain illegal.

• If police find you with illicit drugs, you’ll be arrested and taken to a police station where the drugs will be weighed. If the amount is above the strictly enforced threshold limits — designed to be a 10day supply for personal use, or 25 grams of cannabis, five grams of cannabis resin, two grams of cocaine, or one gram each of ecstasy or heroin — you can be charged as a trafficker. If convicted, policies from politicians and other people who argued that decriminalisation would encourage drug use?

“Yes. It was discussed at our parliament,” replied João. “You had left-wing parties supporting the idea and conservatives opposing it who argued that drug use would increase, children would start using drugs, and that ‘Portugal would become a paradise for drugs users’.

“But now no one in Portugal keeps to that idea. Today there is a broad consensus about the benefits of decriminalisation.

“Following the world economic crash in 2008 we had a bit of a relapse with people going back to injecting drugs. After a lot of discussion we have opened our first mobile safe injecting facility in Lisbon and we are preparing the opening of two more fixed facilities in the city. We may also open one in Porto.”

I was curious to know what type of help is available if you have a drug addiction issue in Portugal.

“Treatment is free in Portugal. We have a quite solid network of centres throughout the country,” said João. “It’s an

jail terms range from one year to 14 years.

• If the amount is below the limit, you’ll be sent to the Commission for the Dissuasion of Drug Addiction — even if you’re a tourist. There, you will be interviewed by a psychologist or social worker before appearing before a three-person panel that will offer suggestions aimed at stopping your drug use.

• From there, you’re fasttracked to whatever services you’re willing to accept. If you refuse help, you can be asked to do community service or even, eventually, facing a fine, perhaps even having possessions confiscated and sold to pay the fine. open door policy for free. The outpatient clinics are the gateway to the system.

“Help for people is very fast. We do not have a big waiting list.”

What is the situation like in Portugal when it comes to alcohol consumption?

“Alcohol use is the most severe addictive issue that we have in Portugal. We have recently seen some improvement among young people. There is still a huge acceptance of using alcohol in our culture.”

He also said that people becoming addicted to prescribed opioids was not a huge issue in Portugal at the moment.

“We have a quite different tradition when it comes to prescribing opiates to the US and other countries as our doctors are very cautious about prescribing.

“It is not an issue now but we are anticipating that it might arise given the situation that people can now order opiates on the internet.”

“Our overall policy is about trying to focus on the needs of each citizen. Drug addiction is not a crime. It does not improve with imprisonment.”

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INSIGHT INTO PORTUGAL’S ADDICTION FIGHT

Américo Nave, Executive Director at Crescer, left with psychologists Rita Lopes and Mariana Santos

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Treating people with dignity ...

Brian Pelan visits a vital outreach service in the heart of Lisbon idden away in a narrow street in Lisbon, with clothes hanging from the washing lines of apartments, is the offices of Crescer – an outreach NGO which is specifically focused on harmreduction practices One of the first people I met was psychologist Rita Lopes.

“We have three outreach teams in Crescer,” said Rita. “Two of the teams work with people who use drugs and the third one works with homeless people. My team works in the main neighbourhoods where the consumption and trafficking of drugs take place.”

Since 2001, the Crescer outreach team has worked in Lisbon’s suburbs. They provide heroin and cocaine addicts with what they need for safer consumption: clean needles, tinfoil and psychological support. Each year, they help thousands of users.

“This is very important as our philosophy at Crescer is harm reduction,” said Rita.

What is the situation like now in Portugal, I asked her?

“Things have improved a lot since the law was changed in 2001.

“People have more access to services and are treated with a more dignified and human way. They have free access to health services.

“Twenty years ago we use to see people in the streets without legs and arms. Today we don’t see that.”

How long have you been working here, I asked?

“I have been working in Crescer for four years. I did my Masters in criminal psychology. I then worked for a year in prison and then I joined Crescer.

“If a person comes to us and says they want to quit drugs we might send them to a therapeutic community. They can stay in the facility for one year. It’s like a farm and is outside Lisbon.

“There are 13 projects at Crescer with a staff of 50 people. We are funded by SICAD (The Intervention Service on

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Putting food on the table “If you give a man a fish, he eats for a day. If you teach a man to fish, he eats for a lifetime” – With this saying as their guiding philosophy, Crescer set up a restaurant where homeless people with addiction-related issues could gain professional experience and training that would allow them to integrate into the community and find a job. In other words, tools for a better future.

Américo Nave, Executive Director at Crescer, said: “We believe that É Um Restaurante is good for the recovery of homeless people. We have psychologists working with them.

“Crescer is also fortunate to have a top Portuguese chef, Nuno Bergonse, overseeing the restaurant.”

Addictive Behaviors and Dependencies) and other private funding.

“We also have a Housing First project which started in 2013. It’s for people who have experienced chronic homelessness and who have drug issues. We give them a house as we think a home is a basic human right and then we give them 24/7 help for a year with a team which supports them. The main goal of this project is to integrate the person into the community.”

Crescer is also in favour of Drug Consumption Rooms.

On their website (http://crescer.org/en/the-association/) it

says: “Although there is a groundbreaking legal framework and drug consumption has been decriminalised in Portugal, we are still confronted with consumption out in the open, which lacks health conditions.

Assisted drug consumption rooms have proved to be another valid strategy for harm reduction: reducing risks of contagious infectious diseases, reducing deaths by overdose, consolidating health education and promoting contact with other social and health facilities.”

Crescer also operates a mobile consumption room in Lisbon but has lobbied the government for more of these facilities to be opened.

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COMMENT Taking a different approach to sentencing Justice Fiona Bagnall believes that the Substance Misuse Court in Belfast can make a genuine contribution to dealing with a significant cohort of offenders that continually appear in the criminal courts hen the prospect of running a substance misuse court was first suggested to me, my reaction was somewhat sceptical. I wondered how this would work. Was it simply an easy option for offenders? Would sufficient resources be committed to allow it to function properly?

As I was mulling over the difficulties, I was also sitting daily in Court 10 which is the remand court in Belfast. Many of those being sentenced had addiction problems and their offending was as a result of those addictions. The offending, while often not that serious, was continuous and generally, all sentencing options had been tried many times. I regularly have defendants with records of in excess of 150 convictions.

We all recognise that short custodial sentences do not work for a large proportion of offenders but as a sentencing judge, once all community options have been tried, there is nothing else to turn to.

It was for these reasons that I recognised that something different was at least worth trying, and while I appreciate it doesn’t work for everyone, nonetheless, my experience of the Substance Misuse Court (SMC) brings me to the conclusion that we are on the right track.

The structure and format of the court is completely different from what anyone would recognise as a criminal court; and we have followed the models which have been tried and tested in other jurisdictions with some modifications for Northern Ireland. There is a dedicated team of probation officers, counsellors from Addiction NI, as well as a psychologist and social worker. I have been really impressed by the dedication and professionalism of this team who have gone well beyond their brief to ensure defendants get a first-class therapeutic service whilst on the programme.

So how does the court actually work?

Defendants need to: • Have pleaded guilty, or been found guilty of an offence and accept that finding.

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I have been shocked at just how embedded drug taking is in our society and the impact it is having on people’s lives • The offence itself must be of a relatively low level and generally not involve violence.

• The root of the offending is an addiction.

If I identify a defendant who would benefit from the SMC, I ask him or her to be assessed by probation within one week to see if she/he is initially suitable. If this comes back to me as a yes, then they will have a more in-depth assessment which again, if positive, means I divert them to the SMC and adjourn their case to that court.

The SMC sits each Thursday. At 10am I meet with the team of probation officers and counsellors to discuss each defendant, their progress, any issues and agree what needs to be done in the next week or so.

At 11am the court itself starts.

Everyone comes in together having already

had a drugs/alcohol test taken in a room beside the court. Each defendant is called to sit at one end of a table, I’m at the other end and the hearing is a discussion between me as judge and the defendant about their progress that week. This process is very different for both the defendant and me as the judge. In the SMC they must answer to me for their progress or lack of it since the last time they were before me. Defendants must at all times know that I expect total commitment and will not take any nonsense.

The first phase of the pilot ended last June after about a year. We have had a considerable number of successes.

So what are my thoughts at this stage of the pilot?

• I have been shocked at just how embedded drug-taking is in our society and the impact it is having on people’s lives.

• Heroin is a very serious problem in Belfast and I suspect throughout Northern Ireland. I thought when we started that I would see mostly cannabis but in the first phase of the pilot more than 30 percent were serious heroin users. In the second cohort of defendants I think the percentage was even higher.

• These defendants need time in the SMC because it takes so long to stabilise them before any meaningful work can be done.

• I have been impressed by the respect and politeness of the defendants in the court.

Despite everything, in the main they recognise the hopelessness of their circumstances and are appreciative of the support that is given to them – even if they don’t succeed in the programme.

• With only a few exceptions, reoffending stopped while in the SMC. Of course, the real test is whether they stay clean and don’t reoffend in a year’s time, three years’ time or even five years’ time.

• Finally, I am convinced this is not an easy option for defendants and it can make a genuine contribution to dealing with a significant cohort of offenders that continually appear in the criminal courts.

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First supervised drug injection facility to open on the island of Ireland Marie Lynch, head of Homeless, Health and Drugs Services at Merchant’s Quay Ireland in Dublin, tells Megan McDermott that the new unit will help to tackle the number of deaths from overdoses

he basement of the Merchant’s Quay Ireland homeless shelter is dark and empty but for a pile of Christmas shoeboxes stacked in a corner. But its walls are lined with plans for what the space is to become: the first supervised injection facility on the island of Ireland.

In a prolonged planning battle, the facility was originally rejected by Dublin City Council whose concerns included the impact to tourism in the area. That decision was overruled by the independent, statutory body An Bord Pleanála on appeal. The facility was granted planning permission on Christmas Eve and will run as a pilot for 18 months, after which it will be reviewed.

Marie Lynch, the centre’s head of Homeless, Health and Drugs Services, explains the desire for the injection facility, pointing out that the number of yearly drug deaths in Ireland – of which half relate to overdoses – is four times the figure for road fatalities.

So how will it work?

Service users will initially meet with a nurse to assess their wellbeing and drug use before going to one of seven booths where up to 80 people per day can inject themselves. There will be a doctor present to supervise.

“If people needed assistance it would only be to the extent that they would help with finding a vein,” said Ms Lynch After injecting, they are free to leave or stay in a supervised and safe room. One of the main aims of the service is to bring vulnerable service users into contact with health services.

“Sometimes the journey to recovery is actually keeping people safe; letting them trust a service and be in contact with nurses and doctors who they often find it

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If we keep our heads in the sand it’s going to get worse difficult to access in the more traditional ways,” added Ms Lynch.

“There are chronic conditions related to people who use drugs frequently and they can be monitored. People who come through here often get signposted to welfare, housing, employment and how to access bank accounts.”

Among the 99 objections to the pilot project was the overconcentration of such services in this area of Dublin City and the fear that it would attract more drug use.

In response to such objections, Ms Lynch pointed out that “people congregate in the city and we need to meet people where they are at. If the service is not where people are, they are not going to use it.”

She said that similar supervised injection centres, in countries such as Switzerland, Spain and Australia, have seen no increase in drug use. There are 90 such centres worldwide.

“People won’t travel too far to inject here. We’re talking about people who are homeless, who don’t have a bus fare in their back pocket.”

Built on the banks of the River Liffey, the facility is situated close to churches, a primary school, housing, and tourist sites.

So what does the community think?

“If you look at the list of objectors, some are businesses in the area and there are people who are injecting in front of their businesses. So it’s really hard to understand,” said Ms Lynch.

“If you don’t have a safe place, you’re going to inject in public spaces or in toilets. It’s about taking the drug litter away and making the streets safer for the community and reducing that level of intimidation.

“I think it’s unreasonable to expect everybody to catch up and understand that addiction is a health issue and that we need to put the services in to keep them safe and to help them recover.”

Merchant’s Quay Ireland has a community engagement team out on the streets daily to pick up needles and respond to call-outs regarding rough sleepers. Meanwhile, a Garda delegation has been visiting similar centres in Europe to look at their policing strategies.

I put it to her that some members of the public with the best intentions may want to see money going into addiction recovery and would feel uncomfortable facilitating drug use.

“It’s not an either-or-situation. It’s both,” replied Ms Lynch.

“We are equally campaigning for more detox and rehab beds, but we’re also realistic to know that it’s not always possible for people. In fact, the risk of overdose is higher for people who have been in recovery and then relapse.

And that’s one of the reasons why you need both. If we keep our head in the sand it’s going to get worse.”

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On the frontline: Members of Extern’s support service

A helping hand in the city VIEW editor Brian Pelan goes out in Belfast city centre to see the work of the Extern Street Injectors Support Service y heart is pounding on a bitter cold day in Belfast. A young drug user has just come up to me and three frontline members from the charity Extern to say that he thinks his friend is suffering from an overdose in the heart of the city.

I had been invited by Iain Cameron, the manager of Extern’s Harm Reduction Services, to join him and two other members of his team as they took part in a daily patrol of the city centre. Their aim is to support drug users and to help signpost them to services who may be able to help them.

The scene that I witnessed was extremely depressing. A young man, perhaps in his late 20s, was slumped on a bench in a busy street. He had just taken some drugs. The Extern team were caring and professional as they looked after him.

They got him into a day hostel once they established that his life was not in immediate danger. Afterwards, I spoke to Iain to find out more about the type of services which Extern offered.

“Our Harm Reduction Services do what it says on the tin. We reduce harm related to drug and/or alcohol use. The projects I manage are mainly to do with drug dependency and more so to do with heroin injecting. We have two outreach services. One is our street injector support service. That service currently employs two people, but it’s backed up with a number of other staff for out-ofhours work. We work Monday to Friday, from 8am to 9pm; Saturday, from 8am to 6pm; and Sunday – from 9am to 5pm,” said Iain.

What sort of numbers and ages are

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Harm reduction: Iain Cameron you encountering on the streets?

“On average you’re talking to about 30 to 40 users a week. One day you might see 20 of those individuals, another day you might see only five.The breakdown is normally two-thirds male and a third female. There’s a bit of a change in terms of their ages at the moment. Previously it would have been mainly in the 25 to 35 age group. Unfortunately, we’re starting to see a younger cohort now – from 18 years of age to 20-year-olds,” replied Iain.

“Those that we’re engaging with, and seeking to engage with, are heroin injectors. They’re also using a number of other substances. The most common ones, apart from heroin, would be diazepam, pregabalin (also known by the brand name Lyrica, or the street name ‘bud’). We’re also encountering, what would have been called in the past legal high or novel psychoactive substances or synthetic cannabinoids, but which on the street is known as ‘spice’ or ‘herbal’.

I asked Iain what could Extern offer if

drug users chose to seek help.

“We try to provide as a holistic a service as we possibly can. It’s really whatever the person says they need.

There are limits to what we can do, but primarily we are asking them: ‘Have you got a bed for the night?’ or ‘Do you have somewhere to put your head?’ We’ll also refer them to some of the our other teams and services we have. We can also put them in touch with other frontline homelessness services such as the Welcome Centre, Depaul Ireland and Simon Community NI. The Extern Street Injectors Support Service also carry supplies of clean needles and naloxone, which temporarily reverses the effects of opioid overdoses.

I asked Iain what was the biggest challenge his team faces?

“The biggest problem is people with a severe drug dependence, a severe mental health issue and who are also on the streets and homeless. For those people to try and access treatment is very hard.

“They really are falling between two stools here – to try and access mental health treatment when you have a drug dependence is near on impossible. To try and access drug and alcohol treatment when you have a mental health issue is equally difficult. So, we have a big, big problem.”

I thanked Iain and his team and headed homewards. I was looking forward to a meal and a warm house. But I also found it difficult to remove that grim image from my mind of the young man, lying on a bench in the middle of the city, with a very uncertain future in front of him.

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COMMENT

Addiction linked to suicidal behaviour Professor Siobhan O’Neill, from Ulster University, believes there has never been a better time to highlight the relevance of addressing substance disorders uicide rates are higher in Northern Ireland than in neighbouring regions and the links with mental illness and the legacy of the Troubles are well known.

However, in a review of the research into suicide, and suicidal behaviour in NI, that I recently completed with Professor Rory O’Connor (1), one of the most striking findings was the link with addiction, and substance use more generally.

The intergenerational use of substances to cope with the stress of mental illness and adverse social conditions is characteristic of the years of violence.

Trauma and fear prevailed and alcohol, drugs and medication provided a way of getting relief. Alcohol and drug addictions in parents created new traumas of a different type for their children, and in the absence of other coping strategies and mental health services, they, in turn, coped the only way they knew how. Except nowadays the alcohol is stronger and the drugs more potent.

Alcohol and drug use and addiction is linked to suicidal behaviour in three key ways. Substance use creates, and is used to deal with, the effects of mental illness.

Alcohol is a depressant, drugs lead to mental illness over the long term, affecting brain chemistry in such a way as to increase the risk of illness. Addiction also creates the life events that lead to suicidal behaviour. They fracture social and family relationships, they lead to debt and employment difficulties and cause people to believe that they are a burden.

Alcohol and drug addictions also fuel impulsivity and impair the brain’s ability to problem solve and identify alternative courses of action in a time of crisis. Logical reasoning is impaired, and the ambivalence about life and death that characterise so much of suicidal behaviour, as well as the knowledge of numerous people who took the same route, mean that an all too familiar script is enacted.

The suicide rate in Northern Ireland has been high for a long time. However, the patterns are changing and the evidence for a more prominent role for drugs and alcohol in suicidal behaviour is emerging.

Self-harm or suicide attempt is the biggest predictor of suicide, and the regional self-harm registry is one of the

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Trauma and fear prevailed and alcohol, drugs and medication provided a way of getting relief most important research initiatives that is shaping our understanding of suicide in NI. The registry also operates in the Republic of Ireland and data shows that alcohol was a factor in a higher proportion of presentations here than in the Republic (almost half, compared to 37 percent in RoI), and was more common in men than women.

In terms of drug use, the differences between the North and South were stark, particularly regarding the higher proportions using tranquilisers and opioidbased drugs here (2). The problem is characterised as affecting deprived communities but in a recent study we found that one in 10 new university students were alcohol dependent (3). One of the earliest studies of suicide using the psychological autopsy method (4) found that alcohol abuse and dependence (not depression) was the most common mental illness associated with suicide.

The Protect Life 2 suicide prevention strategy includes a goal to embed suicide prevention in drug and alcohol policy and services. This would suggest that suicide specific interventions are delivered in these settings, and this would be welcomed because we know that simply treating a mental or substance disorder does not always reduce suicidal thinking and that

people may be vulnerable to suicidal thoughts following discharge.

The strategy states that there is potential for greater co-ordination in commissioning and developing drug and alcohol and suicide prevention services in future, and this aligns with our recommendation that specific psychosocial interventions are developed to take account of transgenerational trauma and community divisions, and the role of alcohol in coping with these.

The strategy also highlights the importance of close linkages between the implementation of Protect Life 2 and the regional Drug and Alcohol Strategy, as well as early intervention and substance misuse prevention programmes.

Like many, I will be watching with interest the work of the implementation group as they oversee the roll out of the strategy and the elements that refer to alcohol and substance misuse, and addiction. The momentum for suicide prevention is growing and there has never been a better time to highlight the relevance of addressing substance disorders and addiction as part of this drive.

• 1. O’Neill, S., & O’Connor, R.C. (2020).

Suicide in Northern Ireland: epidemiology, risk factors, and Prevention. Lancet Psychiatry.

2. Griffin, E., Arensman, E., Perry, I.J., Bonner, B. et al., (2018). The involvement of alcohol in hospital-treated self-harm and associated factors: findings from two national registries. J Public Health, 40, e157–163.

3. McLafferty, M., Lapsley, C., Ennis, E., Armour, C et al., (2017.) Mental health, behavioural problems and treatmentseeking among students commencing university in Northern Ireland. PLoSOne https://doi.org/10.1371/journal.pone.01887 85 4. Foster, T., Gillespie, K., McClelland, R., Patterson, C. (1999). Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland. Br J Psychiatry, 175:175-9.

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Residential unit opens for patients with alcohol-related brain damage Brian Pelan talks to Naomi Brown, lead specialist at the new Leonard Cheshire facility in Belfast Q – Can you tell me a little bit about yourself?

of alcohol abuse in Northern Ireland?

A – I am an occupational therapist. I’ve been employed by Leonard Cheshire as the clinical lead at their new specialist rehabilitation unit in Belfast for patients with alcohol-related brain damage (ARBD).

It opened at the start of this year.

A – I would say, it’s particularly bad in Northern Ireland, but there’s a lot of legacy issues as well. Nobody becomes an alcoholic because life was rosy and wonderful. All of the people we’re working with will have a history of trauma, be that Troubles-related or domestic violence.

There could be a whole range of conditions. People end up with addiction issues because they’ve had a trauma in their life. For Northern Ireland, unfortunately, we’re well aware, that as a culture, we have a lot more trauma here.

Q – Is alcohol-related brain injury under-diagnosed at the moment?

A – I would say it probably is. At the minute in Northern Ireland there are not specific services within the health trusts, so, these people will get support, but they fall between different stools. They may end up in mental health services, addiction services, acquired brain injury services. So, it depends on where they live and what services are available and what is deemed to be the most appropriate for them.

Q – It’s obviously good news that this unit has opened, but it is still relatively small. Are we effectively tackling alcohol abuse in Northern Ireland?

A – We are making a start. We can’t say there are only 14 people in Northern Ireland affected by this, that’s farcical given the research that is there. What we are doing is trying to make inroads.

Q – What sort of data do we have on the number of people who are suffering from alcohol-related brain damage?

A – The research would say that for every 100 of the population there would be two people at risk of developing alcoholrelated acquired brain injury. For every one in eight people that have an alcohol addiction it would be predicted that they would end up with an alcohol-related acquired brain injury because of their addiction issues.

Q – Do you have to be abstaining from alcohol to get a place in the new residential unit?

A – For the purposes of our residential unit, we’re asking that people abstain from alcohol.

Q – Do you test people for alcohol who come on to the programme?

A – Yes. We’ll get referrals through and then part of my job is to set up a multidisciplinary team. That will consist of neuropsychologists, physiotherapists, occupational therapists and speech and language therapists. The referral will come through to us and we’ll do a screening process. If it’s deemed appropriate for that person to come and stay in the unit, we

Q – What’s the best outcome that you would hope for when someone leaves your unit?

Challenge: Naomi Brown will then have all of their clinical assessments done.

Q – Is there a waiting list?

A – We’re only opening it to referrals. So, at the minute we have the spaces there for the new referrals to come in. Once those beds are filled there will be a waiting list.

Q – How many beds will be in the new unit?

A – There are 14 beds available. This new residential unit is the only one of its type on the whole island of Ireland. It really is quite ground-breaking what we’re doing.

Q – How bad is the problem

A – The unit is a short-term rehabilitation placement. There is a limit to how long patients will stay. We’re hoping between six months to two years. Our best case scenario is that when patients leave us they move into independent living. At the minute a lot of these cases are unfortunately placed in the likes of nursing homes or mental health homes and they could be there for a very long time. The difference with alcohol-related brain injury and the likes of dementia, which it is often compared to, is that these people are much younger. They are people who are usually fairly mobile with aspirations.

Q – What are the biggest challenges facing the treatment of alcohol related brain damage?

A – I would say one of the massive challenges is society’s understanding of these people. We still as a society see alcoholics in terms of ‘well, you’ve done that to yourself, why should we help you?’

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COMMENT

Why we need a health-led approach SDLP councillor Paul McCusker explains why he believes that a task force must be urgently set up to tackle the growing number of people who are dying from drug overdoses health-led approach is needed to deal with the increase in individuals experiencing an addiction and to respond to the increase in drug-related deaths. We are not going to police our way out of this. The warning signs have been there for years but have been ignored.

So much has changed regarding the availability of drugs and those caught up with an addiction. I have seen a huge increase in younger people who are using high-level drugs.

There has been a significant increase in opiate use in Northern Ireland, particularly heroin, over the past five years as it’s becoming more easier to get, and with the lack of early intervention programmes for those who start using drugs we then see individuals escalate to start using high-level drugs such as heroin.

The increase in deaths related to fentanyl may be due to illegally or illicitlymade fentanyl which is being mixed with dangerous chemicals thus putting the individual at serious risk.

I have seen, through my work at St Patrick’s Soup Kitchen in Donegall Street, Belfast, an increase in those who are homeless and who are using a cocktail of drugs to try and cope with their situation.

Prescription drug abuse has also been a serious concern for the past number of years. The biggest challenge for all services is poly drug use as individuals are mixing a cocktail of drugs which increases their risk of death.

We need more education, early intervention and to provide that immediate help at the time of need for those who experience an addiction and to help provide a more holistic approach that treats the reasons why people are using drugs. Many individuals are using drugs to hide their emotional pain. There is an urgent need for dual diagnosis to help treat the addiction and their mental health.

The real challenge in Belfast and the rest of Northern Ireland is that the pathways into services are not fit for purpose. This makes it more difficult for individuals to access the immediate support they require. The work around early intervention/prevention is minimal. It should be the focus to try and help reduce

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Those who suffer from an addiction deserve better and their families need support. Until we urgently have a focus to try and get a handle on this situation we will, sadly, continue to see people die the harm and allow those suffering the opportunity to get involved in a recovery programme at the earliest opportunity.

The need for more dual diagnosis services and crisis intervention centres will help not only relieve the pressure on accident and emergency departments but will ensure those individuals receive the appropriate level of support and are not discharged back into the community at great risk.

In recent weeks I have proposed a motion to Belfast City Council which received cross-party support. It called on the ministers for health and justice to implement a drug task force to respond to the increase in deaths. The figure is 40 percent higher than 2017, and has more than doubled over the last 10 years.

The primary role of the task force would be to co-ordinate services to improve the health outcomes for people who use drugs, thus reducing the risk of harm and death.

Safe injection rooms, prevention, quicker access to services, including crisis intervention with an urgent review of current provision, is required to deal with the increase in drug-related deaths.

Belfast City Council is to write to both ministers to call for this to be urgently prioritised in both departments.

We can no longer wait and watch the devastation being witnessed in our communities.

The supply of drugs is a huge problem and the PSNI must do more to stop drugs from ending up on our streets and in the hands of criminals. We have also seen an increase in criminal activity and small gangs, with access to weapons, who target individuals caught up with an addiction. Each day heroin is being transported from Dublin into Belfast on our trains and buses. Until we change the mindset and attitudes to deter those selling drugs we will continue to witness the devastation.

We have a lot to learn from other parts of Ireland, UK and Europe on dealing with an increase in drug addiction. We need to be more innovative and creative in order to give hope and the immediate access to support that everyone deserves.

Harm reduction, dual diagnosis, crisis intervention and quicker access to substitute programmes are all crucial in dealing with the increase in individuals who turn to drugs to deal with their problems.

Those who suffer from an addiction deserve better and their families need support. Until we urgently have a focus to try and get a handle on this situation we will, sadly, continue to see people die.

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COMMENT

We need to offer the hope of recovery Tommy Canning, Head of Treatment at Northlands, a residential rehabilitation centre in Derry for addiction, urges our MLAs to look at how services are funded arch 18th 1996, is a date that is forever etched in my mind. Not because I was suffering from a hangover following the annual St Paddy’s Day’s traditions. It’s the day I entered the Northlands Centre in Derry.

Northlands is a long-standing centre that offers residential rehabilitation for addiction.

Blessed with the incredible gift of recovery, I have lived a life from then until now free from alcohol and drugs. And what’s more, I am now Head of Treatment for the Northlands Centre.

But it’s not me that I want to talk about. I want to focus on the struggles and challenges facing Northlands in its tireless work, offering people the hope of recovery, a different life, a life of freedom, a life of possibility as opposed to a life trapped in the vicious cycle of ongoing addiction.

There are many wonderful committed people and organisations working tirelessly across Northern Ireland to help alleviate the suffering of addiction. Northlands has been one of those organisations since it was established more than 45 years ago.

We believe that a full recovery is possible and that it should be an option open to anyone who wishes to seek it.

However, the search for full recovery is often met with misdirection; people desperate for help are ‘signposted’ down avenues that inevitably lead them back to where they began – a life of despair, chaos and a lack of hope.

Addiction and chaos are natural bedfellows. It’s interesting from Northlands perspective that the services working towards alleviating this fatal disease also live in a world of chaos.Yet, the irony is that we, a service working towards alleviating addiction, are operating in an environment where chaos prevails in terms of funding and priorities.

For a long time, Northlands has been asking for a qualitative review of Tier 3 services in NI. Information on how many people were seen, how often they were seen, how long they waited, it’s all easily accessible.

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I am privileged and humbled daily in my workplace to sit with people who are desperate yet determined to find a way out as they struggle to find peace and contentment

The real questions that should be asked is how beneficial are existing services to the people accessing them?

What is the outcome for those availing of services, including those that attract substantial funding? Are monies being spent in the right areas, doing the work that is most needed? Are we referring people to the appropriate service?

The light is currently being shone on mental health, suicide and drug-related deaths – and rightly so. Look a little closer and you will find the insidious nature of addiction woven through all these social issues.

We all have a duty to ensure that there is a human response to these issues and that the most appropriate services are funded in a way that allows them to do the work required.

For a lot of people living with addiction, residential rehabilitation is an opportunity to find a way out of the darkness for the long term. There is no question that harm reduction, substitute prescribing, detoxification/stabilization and brief interventions have a crucial role to play in a collective approach to tackling addiction. But it cannot, should not, be at the cost of residential treatment with a tailored long-term aftercare program, such as that offered by Northlands, or in competition for funding.

As the new Assembly begins to determine its priorities, I implore each MLA to look closely at how addiction services are funded within Northern Ireland; explore how the outcomes match the funding models and the ways in which addiction services can be more meaningfully and effectively funded.

Twenty five years on from that day back in 1996, I am privileged and humbled daily in my workplace to sit with people who are desperate yet determined to find a way out as they struggle to find peace and contentment; who open up the most hidden and often darkest recesses of their lives to me, and those of us who work in Northlands. I wish I could give them all the gift that I have been given.

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COMMENT

Vital need for dual diagnosis review Queen’s University senior lecturer Dr Anne Campbell says that the introduction of more targeted integrated approaches to models of care on a regional basis is urgently required he nature and prevalence of cooccurring alcohol use disorders and mental health conditions are increasing within mental health and substance use disorder services across the United Kingdom.

Moreover, the concomitant problems for individuals, families and communities are becoming ever more complex and the absence of a coordinated approach in some regions of the UK – including Northern Ireland – are further exacerbating poor outcomes for patients and service users. Staff working in psychiatric and addiction service settings frequently encounter the challenges involved in treating these patients and balancing the management of risk with the promotion of patient empowerment.

The term dual diagnosis implies that there are only two clinical problem areas, when in fact there are usually several, all of which are specific to the individual, and are manifest in varying and multiple combinations.

These may include inter-related domains, for example, personal responsibility, social contact, managing physical health, mental and emotional health, daily lifestyle, relations, crime and accommodation.

Therefore, it may be more useful to conceptualise this group as having “complex needs” and thus consider and reflect on working models and strategies which are flexible and tailored to the needs of the individual. It is also apparent that the diagnosis of both disorders may have originally been associated with a combination of substance use disorders and more severe and enduring mental illnesses (SMIs), for example, schizophrenia and bipolar disorders.

However, the recent rise in numbers of complex morbidities that are related to SUDs (Substance Use Disorders) such as anxiety and depressive disorders is reflected in the literature and must be afforded greater importance in practice.

The high prevalence of coexisting mental health and substance use problems within mental health services is well-

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We need working models that are tailored to the needs of the individual documented via recorded prevalence rates in various UK studies. Delgadillo et al.

(2012) found 70 percent of a sample from community substance use treatment were also diagnosed with common mental health disorders. Evidence from a NICE review of the prevalence of co-occurring conditions across secondary mental health settings (NICE, 2016) highlighted rates of between 11.7 percent and 61.2 percent for substance use/misuse/dependence within the past year.

In the UK it is estimated that more than 33 percent of psychiatric patients with severe and enduring mental illness have a substance misuse problem, whilst more than 50 percent of clients currently accessing drug and alcohol services have a mental health problem (University of Manchester, 2018). However, there is a gap in the literature relevant to the prevalence of dual diagnosis in Northern Ireland which is an essential component in service planning and delivery.

In Northern Ireland, three of the five Trust areas employ specialist dual diagnosis practitioners to work with patients and service users. Two Trusts employ a dual diagnosis coordinator to upskill staff to work with aspects of dual diagnosis in different clinical areas. The role includes

supporting staff in complex cases, training staff on dual diagnosis management and development of strategies and research to provide a local evidence base. In another Trust, there are three specialist practitioners who provide a co-working role alongside key workers in the Community Mental Health Team, assessment, direct work with patients and an assertive outreach programme. In addition, there are a number of community sector organisations who work directly with service users who have dual diagnosis issues and provide direct care to individuals and families with complex dual diagnosis-related needs.

In terms of policy in Northern Ireland, the most notable regional policy review on dual diagnosis was published in 2005. The Bamford Report provided discussion on models of assessment and treatment for comorbid disorders. Since the publication of the document, there has been little reference made to comorbid mental health disorders and substance use in drug and alcohol and mental health policies in NI. As regards drug and alcohol policy frameworks, the New Strategic Direction in Drugs and Alcohol 2011-2016 made a brief reference to mental health as a specialist area within the framework with a recognition that there was a need for further coordination between mental health, drug and alcohol use and suicide (DOH, 2016).

Recent reports of an increase in dual diagnosis-related deaths in Northern Ireland have highlighted the need for an urgent and comprehensive review of policy which must be addressed immediately by the Department of Health.

Whilst there are increasing demands upon overburdened and under-resourced mental health and addictions service provision in NI, dual diagnosis is an issue which has been overlooked consistently over the last number of years. Future policy should immediately address issues related to workforce training and the introduction of more targeted integrated approaches to models of care on a regional basis.

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ON THE FRONTLINE Megan McDermott talks to Shane Hamilton, team leader at the Jobstown Assisting Drug Dependancy centre in Tallaght, Dublin hile the opioid crisis seen in the USA is yet to reach Irish shores, prescription medications have become one of the most problematic drugs for those using the Jobstown Assisting Drug Dependency (JADD) centre in Tallaght,Dublin.

The centre’s team leader, Shane Hamilton, explains the addiction issues he has seen arise from Lyrica, a pain relief medication that is widely prescribed as a generalised anxiety drug.

“Crack cocaine and Lyrica are the two biggest issues at the moment. And we hear all the time from people on Lyrica that they really regret getting onto it. Quite often they didn’t realise it was addictive when they started it.

“This is people sometimes who’ve used many different benzodiazepines through the years, prescribed and illicitly.

But when they start using this they realise the impact it has on them is much worse.”

Benzodiazepines or ‘benzos’ are a range of sedative prescription pills used to treat conditions such as anxiety or insomnia.

Although Lyrica is used as a mood enhancer, it is technically a pain killer, which means it can be prescribed more freely than a benzodiazepine.

“So if you’ve got back pain and you’re on Lyrica you can go to your doctor and get a six-month prescription. We have clients who are struggling with that: that they can get large amounts of it in four-week blocks.”

While there is now a growing awareness and screening process for Lyrica, service users face problems getting back on track with a regulated prescription as GPs may have reservations prescribing for someone with a history of misuse.

However, a changing drug landscape also means communities can bypass GPs and access

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prescription medication illicitly off the street.

“There are big organised gangs making them.You can just go on the internet and there are also shops that sell these things online and you can get it delivered to your door.”

So what is so attractive and potentially addictive about prescription medications? “Most of the substances that they’re taking on a prescription basis are anti-anxiety tablets. So if there’s anything that slows down the central nervous system, the heart rate, the anxiety symptoms, it can be quite a pleasant feeling. So they’re obviously going to be attracted to that.”

Shane explains that in this way the effect is similar to heroin. “Some people can fall into misuse: If I take one tablet I feel fine, if I take two I feel great.

“But the more you’re taking, the more your body is expecting and needing that amount. So if you don’t take enough Valium then you start getting the sweats and the anxiety again.

And also it can be lethal to stop taking things like benzos rapidly. So it’s physically addictive and lethal to stop.”

Prescription medications are increasingly being mixed with other drugs, something referred to as polydrug use.

“If you look at the data over the last 10 years, benzos are always going to be in the systems of people who overdose. Once you’re taking two substances together there’s a whole new level of risk attached. If you’re taking heroin for example, that’s a depressant so that slows down the central nervous system, your breathing, your heart rate. If on top of that you’re taking large amounts of tablets that slows down your system even more. That’s what can lead to people literally just going asleep, just passing away from it.

“The industry of prescription medication is in every community and it’s impacting many homes.

“We should be asking questions if we go to our doctor.

We should be actively cautious of how to avoid having another addiction.”

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COMMENT

Promoting health and wellbeing Michael Owen, the Public Health Agency’s Regional Lead for Drugs and Alcohol, says that there is help available for those who have substance misuse and addiction issues rug and alcohol misuse is sadly something that affects many individuals and families in our communities and the Public Health Agency (PHA), alongside its partners, is working to address the issues for those who misuse substances particularly with regard to prevention and early intervention.

According to Census of Treatment services, 6,743 people were receiving treatment for their alcohol and/ or drug use on April 30, 2019, an increase of 13 percent to the previous Census on March 1, 2017 (5,969 people).

It is something that can affect anyone and it is important to remember and recognise that there is help out there for those who have substance misuse and addiction issues. Help is also available for families too, regardless of whether a loved one or relative is in a treatment programme or not.

These services are available in your local area, making them more accessible when you need them. A list of these services can be accessed at www.drugsandalcoholni.info The overall role of the Public Health Agency is to improve the health and wellbeing of people in Northern Ireland in partnership with other health and social care organisations, the community and voluntary sector and the general public.

As part of this work, we fund and commission services and programmes delivered in local communities to help support people, which deliver real benefits and improve people’s wellbeing. This includes the provision of a range of treatment and support services to assist people impacted by drug and alcohol issues.

For example, for younger people the Youth Engagement Services aim to deliver holistic services to those aged 11-25 which, as well as giving advice and support on a range of issues, promote positive health and wellbeing through activities, volunteering opportunities and workshops tailored for young people.

As well as putting in place preventative programmes to try and address issues before they become a more serious problem, the PHA also funds a

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Alcohol is a powerful drug too and we need to be careful and consider how we use it range of services to help those misusing substances to help reduce the harm from drug taking, and at the same time reduce the health risks to the wider population.

Needle and Syringe Exchange Schemes (NSES), jointly funded by the PHA in partnership with the Health and Social Care Board (HSCB), are providing a valuable service in helping to address health issues of those who inject substances, and the community as a whole.

They give clients direct access to a health professional who can advise them of treatment options, they reduce the risk of drug-related litter, and lower the risk of the spread of blood-borne viruses, such as Hepatitis B and C. The Take Home Naloxone programme has been saving lives since it was introduced in 2012. Funded by PHA in partnership with the HSCB, this life-saving medicine can reverse the effects of an opiate overdose. It is available to anyone who uses opioids, through their local Trust Addiction Services, Prison Service and Low Threshold Services and can also be supplied to anyone who comes into contact with individuals at risk, for example, their families or staff who

work in homeless hostels.

Take Home Naloxone was administered 240 times in 2018-19 and has been successful in reversing an overdose in over 90 percent of cases, saving the lives of those who otherwise would have died without this vital medicine.

These are just some examples of the work that the PHA supports. There are also programmes in place to work with families affected by parental substance misuse; services for those are unable or unwilling to engage with conventional appointment-based services; workforce development training; and our Connections services who help deliver community responses and awareness with local issues.

The services we commission are kept under review to help ensure they are delivering for the people who need them, and we take account of evidence and best practice when commissioning new services.

When people talk about drug misuse they often separate drugs and alcohol. But something that many often overlook is the fact that alcohol is a powerful drug too, and we need to be careful and consider how we use it.

The 2018/19 Health Survey for Northern Ireland, showed that more than three-quarters of adults drink alcohol, with nine percent of males reporting that they drank quite a lot or heavily and two percent of females reporting the same.

Drinking too much has a negative impact on you and those around you and drinking too much on a regular basis has serious implications for our health and wellbeing.

Just as serious is the implication of mixing alcohol and other drugs. It’s important to highlight that using more than one drug at a time, which includes alcohol, prescription medication and illicit substances, increases the toxicity of the substances and significantly increases the risk of overdose and death.

All of us should ensure we only take medication as instructed by a health professional and never mix any drugs including alcohol.

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With addiction often being an isolating and hidden problem, it is a key issue for the charity’s helpline service Image posed by a model

Helping children affected by addiction he National Society for the Prevention of Cruelty to Children (NSPCC) helpline teams across Belfast, Manchester and London work 365 days per year to protect children in Northern Ireland and across the rest of the United Kingdom.

Last year (2018/19), the helpline dealt with almost 73,000 contacts by phone or email, with people needing advice or expressing concern about a child’s welfare.

With addiction often being an isolating and hidden problem, it is a key issue for the charity’s helpline service. Parental alcohol/drug/substance misuse alone accounted for 10,878 helpline contacts last year, with 7,496 of these resulting in a referral to external agencies like the police or social services.

The 45-strong team in Belfast deal with a range of calls relating to substance abuse. NSPCC Helpline Head of Service, Joanne McDonnell, explains: “We have people contacting not knowing what to do for the children in the house who are exposed to alcohol and drug abuse. A lot of mummies, daddies or aunties on the school run who are concerned, and a lot of family members or neighbours would ring.

“If a parent is misusing alcohol or substances, it can be a hidden or solitary thing. But often there are going to be other adults, and there are risks for children around that. Do we have drug dealers or other drug users in the house, or young people ferrying drugs? We don’t know, and you can see how it has the potential to lead off on to so much for a child. If you look at serious case reviews, it has often been other adults coming into the home who have perpetrated violence against the children.”

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Impact: Joanne McDonnell, NSPCC Helpline Head of Service With more than ever before known about how adverse childhood experiences (ACES) can affect children into their own adult lives, Joanne and her team know the importance of looking at the whole picture when someone contacts the helpline.

Ms McDonnell added: “I don’t think that people realise the impact that parental addiction can have on children. We often don’t just have the alcohol or substance abuse, you can then have domestic abuse, emotional abuse and financial problems that can lead into neglect because the family aren’t spending that money on what they should be spending it on. They [these experiences] are never in isolation. The trauma that then has on that child into adulthood and in turn what their parenting style becomes – it is intergenerational.

People carry that backpack around with them, and when it hasn’t been decoded and understood for a young child then they continue to carry it through to adulthood.

“We also get a lot of child carers. A mummy, daddy or guardian who is misusing alcohol and they come home from school; the parent is passed out after drinking all day and they have other siblings. Those

children do the dinner and they do the uniforms. They look after the home and try and look after their guardian because that’s their role.

“As a society, we shouldn’t be making a judgement on them, but try to understand why they are in that situation and what support can be given to help them get out of that. Because nobody chooses to do that. We don’t know what their trauma has been in terms of mental health, physical health, or why a family may find themselves in that situation. That’s sometimes problematic when we get those phone calls through because you may have somebody who is disparaging of a family.

We can’t find the true story behind that family and that’s what we contact children’s services for.”

Ms McDonnell added: “When we take a call we have to assume there is more to it but we never fill in the blanks. That’s why the practitioners are skilled in knowing indicators of abuse and following that line of questioning to see what the risks may be for the child. We make sure there’s an evidence base before we make that referral, to make sure we are adding value to what agencies do, and not just adding more work. Most importantly, we need to make sure that any decision to refer to agencies has the child’s best interests at heart.”

• The free NSPCC Helpline provides adults with a place they can get advice and support, share their concerns about a child or get general information about child protection. Adults can contact the Helpline 365 days on 0808 800 5000 or email help@nspcc.org.uk

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Tackling substance misuse is a priority Cheryl Lamont, Chief Executive of Probation Board for Northern Ireland, believes a partnership approach is vital in order to help change lives and deliver safer communities eventy-six percent of people who started a new probation supervised order in 2017/18 were assessed as having an alcohol or drug-related problem.

There is a well-established link between drugs, alcohol and crime. In fact, one of the most significant factors that influences whether someone will reoffend is their use of drugs and alcohol.

Probation is involved at every stage of the criminal justice process. It works in courts providing pre-sentence reports to assist judges to make decisions. It works in communities supervising sentences that must be served in the community. It works in prisons, preparing prisoners for release subject to licences. At every stage in the process we work with people whose offending is related to a drugs or alcohol problem.

In order to tackle this problem probation has put in place a number of strategies and actions.

Firstly, all probation officers are social work-qualified staff, professionally trained in the assessment and management of individuals. They are enabled and supported by psychology staff, probation services officers and others. This allows us to take an individualised approach to each person assessing the reasons for their offending and tackling those root causes which are often drugs and alcohol-related.

We have recently rolled out traumainformed training to all staff. We know there are very real connections between people who have experienced trauma and substance misuse. For example, people who experience four or more Adverse Childhood Experiences (ACEs) are 500 percent more likely to abuse alcohol.

People who report five ACEs or more are seven to 10 times more likely to report illicit drug abuse. That is why equipping staff with the most up-to-date training in this area is so important.

Probation has a range of interventions

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Tackling substance misuse remains one of the most challenging areas of our work and we know that it is also linked to poor mental health, homelessness and lack of employment and education

and programmes which directly address substance misuse. This includes a new ‘Substance Misuse Court’, which challenges offenders to tackle their drug and alcohol misuse, which has been launched at Belfast Magistrates’ Court. The new Substance Misuse Court pilot allows the judge to refer offenders, who have been convicted of an offence related to their alcohol or drugs misuse, to an intensive treatmentfocused behavioural change programme before sentencing.

International evidence suggests that this type of intensive treatment is a more effective intervention to rehabilitate offenders in cases where substance misuse is the underlying problem. The programme is delivered by the Probation Board in partnership with Addiction NI. It is part of the Department of Justice’s approach to problem-solving justice.

We also work closely with the voluntary and community sectors and refer many of the people under supervision to those organisations for assistance and support. For example, in November 2019 we set up a partnership with Ascert, a Northern Ireland-based charity, to provide a ‘Rapid Response Addiction Service’ to people under probation supervision.

It is really important that we are able to quickly respond to crisis situations at whatever time they occur and we believe that this new partnership will help us respond to those in crisis and ultimately rehabilitate people and prevent them from re-offending in the future.

Tackling substance misuse remains one of the most challenging areas of our work and we know that it is also linked to poor mental health, homelessness and lack of employment and education.

It is a priority for probation staff to tackle this problem and we will do so in partnership in order to change lives for safer communities.

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Tackling addictions through Changing Lives he Probation Board for Northern Ireland has invested in a number of ways to assist people under probation supervision to overcome their addictions. One of the ways is through the use of the ‘Changing Lives’ app.

The ‘Changing Lives’ app was developed and jointly launched by the then Justice and Health ministers in 2016, as a resource for people under probation supervision. Since then it won two Northern Ireland App of the Year awards, a runner-up in the Irish App of the Year awards and the UK App of the Year Awards.

The app has a section specifically to help deal with addictions. Developed by PBNI communications team in conjunction with PBNI psychologists, it provides information about how to overcome addiction, information about prescription medication, alcohol and illegal substances.

The app supports the work of probation officers and helps them understand how to make changes to their lives. Importantly, it contains an alcohol diary so people can monitor their use, or misuse, of alcohol.

Feedback has shown the app has been useful for service users who needed help when they were at their most vulnerable, and has been seen as useful from those who work with service users and know how chaotic their lives can be: “One of my clients resided within a hostel environment which he was finding extremely difficult. In the early hours of the morning one day he was feeling particularly vulnerable and

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‘I have become the man my partner deserves’ David was sentenced to a community sentence in January 2017. He reflects on his experience of probation and how he has been supported to make positive changes in his life.

David was 58 at the time of his offence. He recalls that his life up until that point had been characterised by chronic alcohol misuse and involvement in offending. He had only engaged with addiction support on one previous occasion at the age of 30 which involved a period of time spent in inpatient rehab. However, David relapsed within a week of discharge. Over time, life became more difficult as alcohol misuse became more prominent in his life. In 2017, he appeared in court and received a community sentence to do services in the community supervised by probation.

David’s community sentence included the additional requirements to participate with alcohol/drug counselling and a treatment programme.

Whilst on probation, David was referred to addiction counselling programmes. David believes that the support gained from his current Order has helped him change his life for the better. “The community sentence has given me the chance to stay in the community and get help from the right people. It has done me the world of good. I am now abstinent. I am happier and more contented with my life and feel like I have become the man my partner deserves.”

overwhelmed. He describes experiencing a panic attack stemming from suicidal thoughts. He accessed the app for support and states that the tips, and indeed the distraction of this, allowed him to become more rational and settled until he could access staff the following morning.” – Probation Officer A service user added: “The mental health and addiction information is very

useful. It helped me a lot.”

All this advice is available for free at any time. The app also has emergency numbers such as out-of-hours GP services, mental health advice, a mental health selfassessment exercise, information on the types of order which Probation supervises.

It also has a journal to note down thoughts, feelings and actions, and an appointments calendar.

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Why we need an addiction officer Frontline organisation says new position would play a vital role in the services it offers to women suffering from domestic violence

By Megan McDermott n addiction officer is urgently needed at a domestic abuse service in Belfast and Lisburn.

The call came from three women – Chief Executive Kelly Andrews and team leaders Liz Brogan and Siobhan Graham – who all work at the Belfast-Lisburn Women’s Aid organisation. The charity runs three refuges across Belfast and Lisburn which shelter women who are escaping from domestic violence.

Though not all of the women in their shelters struggle with addiction, those who do have issues that range from prescription drug abuse to heroin.

Ms Graham said: “They are maybe using prescribed drugs to help them cope in the house and to cope with what he’s going to do when he comes in. By the time we get them the children have probably been removed.”

In the team’s experience, a woman’s circumstances is often superficially blamed on her addiction with too little consideration given to its underlying causes.

Ms Brogan added: “When society and agencies blame them then they start to blame themselves and it spirals. They just give up and the addiction takes over.”

The main problem is that the team at Belfast-Lisburn Women’s Aid are experts in dealing with domestic violence, but not addiction treatment.

The organisation used to get help from FASA, the Shankill-based Forum for Action on Substance Abuse before it went insolvent in 2016.

Chief Executive Kelly Anderson said: “It’s a disgrace that they lost their funding when there’s so much need out there.”

According to Ms Brogan, FASA “started to work with the history and dig in deep to find out where the trauma was.

That worked really well. If there was another organisation like that who could come into the refuge, have a session with her around the addiction, and for us to carry on with the domestic violence work that would be ideal. But the funding’s not there so there’s a big gap.”

Though other addiction services exist, the flexible drop-in style of FASA suited the women of the refuges whose often chaotic lives prevented them from keeping regular appointments.

In the complex situation of domestic violence recovery, any delays in related services create an uphill battle for the women at Belfast-Lisburn Women’s Aid. To explain this, Ms Brogan described a woman using the refuge who was trafficked to Northern Ireland and had

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Liz Brogan, left, team leader at north Belfast refuge, Belfast-Lisburn Women's Aid; with Siobhan Graham, team leader, south Belfast refuge; and Kelly Andrews, Chief Executive of Belfast-Lisburn Women’s Aid experienced addiction issues and childhood sexual abuse along with domestic violence.

“It could take six to eight weeks for her to get an appointment with an addiction service. She’s been here since last May and has only got her first appointment with Nexus (a sexual abuse charity) about a month ago. It’s not their fault, it’s just because there are not enough resources.

So that girl had to wait for seven months,” said Ms Brogan.

“The support from other women in the refuge and the safety of the environment enabled her to stay straight. And that worked for her but it doesn’t work often enough,” she added.

While the communal living set up in the shelters seems to provide a support network for the women where the official resources are lacking, the reality remains that the staff are battling many ‘fires’ at once.

“Once we see a woman coming in that state there’s no point in us starting group work. It’s nonsense,” added Ms Brogan.

The team will never turn a woman away, often swapping women between shelters to avoid having more than one person with serious addiction issues in the same space.

However, if a woman’s addiction is causing distress to the other women and children, then she will be sent to a wet

hostel. Those hostels are purely for addiction and will not directly address her domestic violence trauma.

Ideally, the refuges could deal with both issues on-site so as to avoid women slipping through the cracks, said Ms Brogan.

“It means we can keep her here longer.

There would be a higher rate of success for her to keep her children, to achieve some sort of stability in her life and to get herself weaned off whatever she’s on. I do believe it could work but the resources aren’t there.”

Our conversation ended on a more positive note when Ms Brogan recounted a story about a young woman who had suffered domestic violence. She came to them heavily addicted to heroin, having had her seven children removed by social services. After going through programmes with Women’s Aid she has since detoxed, moved into her own house and has had her children returned to her.

“She was a very good mummy and she adored her kids. It was just unfortunate that the addiction went with it.You just wish people could see it more like that: let’s look at the positives of this wee girl and not just say she’s addicted, let’s get rid of her. There’s always something you can work with.

“Because you’re addicted to something doesn’t mean you’re a bad person and it doesn’t mean you’re not worthy,” said Ms Brogan.

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Addiction is cunning. It creeps up on you Writer John Higgins takes his pen to dig into our obsession with alcohol as he recounts how he once filled his empty days with endless bottles of wine as he mourned the death of his wife decade ago I collapsed into myself.

Grieving the death of my wife and jobless in a new city, I filled the savage, empty days with alcohol. I was a reservoir, drowning myself from the inside out. That’s how drowning usually works, though it isn’t usually as incremental or determinedly self-administered, bottle by bottle, gulp by gulp.

I remember very little of those days now. The images arrive in soft, buttery waves, the panic quelled by the weight of wine. Three or four bottles a day was not unusual, but it could be more. I’m told I appeared fairly normal on my rare public appearances, which is rather frightening. I was dead behind the eyes. I forgot how to sleep. My teeth began to dissolve.

It got better. It had to get better or I would have died. It is true the pain of loss never goes away but eventually you have to address it. I owned the pain; it became a part of me. I also met somebody wonderful, I drank a lot less and I learned how to smile without showing my teeth.

But addiction is cunning. It creeps up on you. Like life, which it apes, addiction finds a way. We live in a Northern European culture that does not sip: we drink as though our guts were on fire. We drink to take us away, far from the black, nullifying winters that steal half the year.

Our rites of passage are measured out

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in beer suds, and every chapter of our lives is described by our relationship with booze: I’m surprised the christening font doesn’t find us drizzling our children with a crisp Riesling. If we have a good day we crack open the fizz and if we have a bad day we drown our sorrows like wasps in cider. If nothing happens at all…well the sun is over the yardarm: looks like it’s gin o’clock.

I needed to get out of this punishment and reward dichotomy. And I needed to stop drinking a bottle of wine every evening. It’s physically unsustainable as I wade further into my forties, and it’s financially unsustainable to boot. And

frankly, it’s just no fun.

The enjoyment differential between watching an episode of Midsomer Murders sober and watching it with a bottle of wine is negligible.You can still follow the plot and everything.

It’s a dull habit, a sudden itch that comes from nowhere but tells you the Winemark is closing in 20 minutes and if you don’t get your “cure” you won’t sleep tonight.

It’s the concern of the counter staff in the off-licence if you miss a night. I half expected a whip-round and a “Get Drunk Soon” card. It’s the bottle city of Kandor encroaching on the kitchen surfaces and the bloke in Tesco’s asking you if you’re having a party. But every night is party night and every morning brings regret and broken glasses in the kitchen sink.

Maybe when I was in my 20s this was sexy and bohemian. In my 40s it’s a puffy face in the mirror, an inability to remember what I’ve done with my socks and another note through the letterbox from the neighbours.

I went cold turkey on January the first, just like everybody else. The difference is I intend to continue this new sobriety past January 31. And this may be the sternest test of all – staring Brexit in the eye stonecold sober.You may wish me luck but in truth I think we’re all going to need it.

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