National Drug Advisory and Treatment Centre, DTCB, Drug Addition Ireland, Drug Prevention, Drug Treatment

Geoffrey Dean, Aileen O'Hare, Aideen O'Connor, Michael Kelly, Grainne Kelly

Irish Medical Journal, May 1987, Volume 80, No. 5

Summary

The opiate epidemic in Dublin peaked in 1983 and this paper reports on more recent information from the Jervis Street Drug Centre showing a decline in the number of first attenders for opiate misuse at the Centre from 451 in 1983 to 116 in 1985. However, there were 109 first attenders in the first six months of 1986. Twenty-one per cent of opiate attenders had been using drugs for seven or more years prior to their first contact for treatment at the Centre in 1984, the majority of who were self-referred. A high proportion of opiate users (85%) attending for treatment in 1984 had needle marks, indicating the preference in Dublin for injecting rather for sniffing or smoking heroin. Sixty-five per cent who admitted heroin misuse in 1984 were unemployed. While the overall drop in the numbers contacting the service for treatment for the first time for opiate misuse since 1983 is to be welcomed, there is need for concern at the ruse in the number of first contacts during the first six months of 1986, and at the major health hazard that may result from infection by the HIV virus responsible for AIDS. In a sample of 398 intravenous opiate users, 27% were positive for the virus.

In 1982 the Eastern Health Board's report on the non-medical use of drugs concluded that there had been a startling increase in heroin misuse in the Dublin area compared with the situation described in an earlier report in 1971 and this conclusion was supported by evidence from local residents, gardai, clergy and politicians,^1,2 A study in 1983 conducted by the Medico-Social Research Board in a central city area of Dublin revealed that 10% of young people aged 15-24 had used heroin during the previous 12 months, many injecting the drug daily.³ An investigation, also carried out by the Board in the Dun Laoghaire area, using similar methodology, showed a lower proportion, 2.2% of young persons aged 15-24, were regular heroin users in the year under review, 1983-1984.⁴

A joint study by the Medico-Social Research Board and the National Drug Advisory and Treatment Centre⁵ or as it is commonly referred to, the Jervis Street Drug Centre, of patients attending the Drug Centre from 1979-1983 showed that during this five year period there had been a six fold increase in the number of persons making their first contact with the Centre and a four-fold increase in re-contacts. Males exceeded females by a ratio of three to one and the majority of attenders, approximately 60%, were aged under 25 years. Opiates were the principal drugs of misuse and in particular, heroin. Between 1979 and 1983 the numbers contacting Jervis Street Drug Centre for the first time for treatment of opiate misuse rose eight-fold from 56 to 451. This increase, together with evidence from the Garda Drug Squad of a dramatic increase in the number of persons charged for heroin-related offences and of seizures of the drug, confirmed that there had been an "opiate epidemic" in Dublin between 1979 and 1983.⁶ When the attendance at the Jervis Street Drug Centre was analysed for area of residence the attendance rates were highest from north and south central Dublin. The Medico-Social Research Board and the Jervis Street Drug Centre continued their collaboration in a study of patients who had received treatment at the Centre in 1984. This paper reports on the characteristics of the 1984 attenders making some comparisons with those of previous years and also comments on information collected for the first time in 1984. More recent information, as it is available, for 1985 and 1986 is also presented.

Patients and Methods

As described in the previous study,⁵ the following information was obtained for each patient: folder number, sex, age group, marital status, area of residence, drug use (ICD 9 codes), first or recontact for treatment, result of liver investigation and biopsy where present, length of time on drugs prior to first contact, and admitted heroin misuse in the year under review. Additional information collected in 1984 included educational and employment status, referral agent and presence of needle marks. Preliminary data are available on 398 opiate users attending the Centre in 1985 who were tested for the antibodies to the human immunodeficiency virus (HIV) responsible for the Acquired Immune Deficiency Syndrome (AIDS).

Results

The pattern of attendance for treatment at the Jervis Street Drug Centre for 1979 to 1985 is shown in the Figure. All patient contact increased from 294 in 1979 to 1,314 in 1983 and, since then, declined to 1,218 in 1984 and to 1,150 in 1985. opiate users attending the Centre accounted largely both for the increase and decrease in the all patient numbers. Table 1 distinguishes between persons who made first or re-contacts during the years under review. First contacts for opiate misuse as a proportion of all first contacts declined markedly from 72% in 1982 to 30% in 1985 and then increased to 59% during 1986. Opiate users as a percentage of all patients returning for treatment to the Centre rose from 74% in 1980 to 95% and fell in the first six months of 1986 to 79%.


Table 1 First contact and re-contact with the Centre for all patients, including opiate users*


	1980	1982	1984	1985	1986**

First Contact
All patients	250	633	506	387	184
Opiate users	168	455	321	116	109***
(% of all patients)	67.2	71.9	63.4	30.0	59.2
Re-contact
All patients	179	371	712	763	497
Opiate users	133	306	626	726	395
(% of all patients)	74.3	82.5	87.9	95.4	79.5
All contacts	429	1004	1218	1150	681

* ICD codes 303.0, 304.7 and 305.5
** First six months only
*** 208 first contact opiate users for all 1986. 59.1% of all first contact patients

Table 2 provides information, again for selected years, n the length of time opiate users have been misusing drugs prior to their first contact with the treatment Centre. In 1980 and 1984 more than half the first contacts had been three or more years on drugs prior to their contact. In the coding of 1984 data a more detailed breakdown of the three year plus category demonstrated that 21% in that year had misused drugs for seven or more years before making their first treatment contact at Jervis Street.


Table 2 Opiate Users* - length of time on drugs prior to first contact

			1980	1982	1984

Under one year			14.3%	17.3%	14.1%
1-2 years			27.9%	41.1%	30.6%
3-4 years	3 or more years	{			21.7%	}	55.2%
5-6 years			54.2%	36.1%	12.9%
7 or more years					20.7%
not known			3.7%	5.4%	0.1%

Total			301	761	947

*ICD codes 303.0, 304.7 and 305.5


Table 3 Admitted heroin use and employment status in 1984


Admitted heroin use 1984	Yes	No	Not available for work	Total

Yes	253 (27.4%)	600 (64.9%)	71 (7.7%)	924 (100%)
No	145 (49.8%)	118 (40.5%)	28 (9.6%)	291 (100%)

Total	398	718	99	1251*

*Cases with missing information excluded (n = 3)
Chi square 57.33 2df p < .001

There was a statistically significant association, Table 3, between employment status and admitted heroin use with 65% of those who misused being unemployed as compared to 27% who were employed and 8% who were not available for work. In contrast, among those attenders who did not admit heroin use 50% were employed. Eighty-five per cent of opiate users attending Jervis Street had needle marks, confirming the preference of Dublin drug users to inject rather than smoke or sniff heroin. Two-thirds of the opiate users were self-referred whereas only one-third of those on other drugs were self-referred. Opiate users who were not self-referred were referred by the courts, by hospitals, by general practitioners, by the family or other concerned adults, by the Drug Squad, the gardai, or by counselors from the Eastern Health Board.

The highest rates for attendance for treatment of opiate misuse were for those resident in north and south central Dublin, but there were attenders from all areas of residence in the Dublin and Dun Laoghaire County Boroughs. Approximately half (398) of all opiate users attending the Centre in 1985 were tested for the antibody to the AIDS virus by the ELISA test, and 27% were positive. Males exceeded females in a ratio of 3 : 1.

Discussion

Data from this paper show a drop in the number of persons presenting for the first time for treatment of opiate misuse at the Jervis Street Drug Centre in 1984 and 1985. These findings support evidence from the gardai,⁷ from data on hepatitis patients from the virus reference laboratory, U.C.D. (personal communication) and from a recent study undertaken in a north central Dublin area⁸ that there has been a marked decline in opiate misuse in Dublin for these two years compared with previous years.

The reasons for this fall are no doubt complex. However, some responses to the epidemic of opiate misuse, which peaked in 1983, can be identified. The government reacted by introducing more punitive legislation for drug-related offences with the Misuse of Drug Act 1984, and the implementation of sections of the Criminal Justice Bill in 1985. The submissions of the Special Government Task Force of Ministers in 1983 were responsible for creating greater awareness among the public of the dangers of drug misuse through the introduction of a Diploma Course in Addiction Studies in Trinity College and the development of "life skills" programmes by the Health Education Bureau which were introduced into a number of schools on a pilot basis. Research projects at the request of the Government were carried out by the Medical Social Research Board which has greatly increased knowledge of the problem. A National Co-ordination Committee on Drug Abuse was set up to advise the Government on an ongoing basis on general issues regarding the prevention and treatment of drug misuse. There has been an increase in the success of the Dublin Drug Squad in dealing with major drug pushers and knowledge about drugs has been disseminated through drug courses in Garda Headquarters since 1981 and to Gardai of all ranks. The Garda Annual Report on Crime. 1984,7 showed a drop in the number of persons charged for drug-related offences and in drugs seized, especially heroin, suggesting that there was less coming into the country than formerly. The churches have played an active role in discouraging drug usage and in assisting those with drug-related problems. The success of local residents' associations, including the Concerned Parents Group, in their stand against drug pushing has also been an important factor.

It is difficult to estimate at all accurately the current number of opiate users in Dublin. During the seven years, 1979-1985, there were 1,877 first contacts for opiate use, usually heroin, at the Jervis Street Centre. This figure reduces to 1,783 for the greater Dublin area, as we know that approximately 5% of opiate users attending the Centre came from outside Dublin for treatment.⁹ Earlier studies showed that roughly 65%-70% if users identified in the community had attended the center,3-5 while findings from a study in a north central Dublin area⁸ show that about one-quarter of those misusing opiates two to five years ago, and who were not in prison, were not at the time taking opiates. A rough estimate, therefore, including the first contacts at the drug center in 1986 would be that there have been about 3,000 opiate users in the Dublin area of whom perhaps 2,000 are still taking opiates when they can get them.

Evidence of a decline in opiate misuse in the Dublin area in 1984 and 1985 is welcome. In particular, the noted drop in the number of first contacts attending the Jervis Street Centre and the proportion shown from community based studies who appear to have "matured out" of heroin - an occurrence also observed in some other countries¹⁰ is encouraging. However, it is disturbing to find that 27% of heroin users attending the Centre in 1985 were positive for antibodies to the AIDS virus. This virus was only identified in 1983 and new information about it is becoming available all the time. It was formerly believed that 5%-10% of those with AIDS antibodies would go on to develop AIDS, but recent information from the United States suggests it may already by as high as 30% within five years.¹¹ Furthermore, as the virus is spread by blood to blood contact and by sexual intercourse, intravenous drug users run the risk of becoming infected through sharing needles and syringes and, if infected themselves, of passing on the infection to their sexual partners and to other intravenous drug users with whom they share their "gear". A further problem is that pregnant women can pass on the virus to their unborn babies.¹²

There can be no complacency regarding the drug problem in Dublin. A decline in opiate misuse for the two year period 1984 and 1985 could easily be reversed by a subsequent ruse or by misuse of other drugs. There was a considerable increase in 1986 in the number of first contacts for opiate misuse. This rise could represent a real increase in opiate users in the greater Dublin area or a shortening of the period between starting on the drug and attending the Centre. Further analysis should settle this question.

Evidence from this paper and from previous studies of drug use in the Dublin area3,4,8 shows that opiate misuse is predominantly a problem of the inner city area and that it is associated with unemployment and poor living conditions. A previous study¹³ which matched the age sex of heroin users with non-heroin users in the north central Dublin area revealed that 95% of heroin users were unemployed at the time of interview, compared with 48% for the control group, the norm for that area. Two recent studies in parts of Glasgow¹⁴ and the Wirral area of Merseyside¹⁵ suggest a more than incidental link with unemployment and deprivation and high heroin use. In the Glasgow study the author suggests that a sense of futility in young people living in areas of high unemployment together with the ease of access to heroin may mean that they are more willing to seek immediate gratification without thought of the future. A strikingly similar picture emerged in the Wirral area where 80% of known heroin users were unemployed and areas of deprivation and heroin misuse overlapped. The established association between high levels of unemployment and heroin misuse in the Dublin context should be addressed by providing, as a matter of urgency, opportunities for employment and social activities for young people from the inner city areas. There is also need for comprehensive education and prevention programmes using all the available media and person to person contact to dissuade people from experimenting with drugs.

Acknowledgements

We wish to express our thanks to Deirdre Carey for her help in the data processing and preparation of the tables and to Margaret Sullivan who typed the manuscript.

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