Summary of the impact

The key impact focuses on the underpinning research contributions to the health and wellbeing of individuals who are dependent on heroin in Northern Ireland, where an estimated 828 "problem heroin users" resided just prior to substantial changes in the provision of drug services. The impact on extremely marginalised individuals who were dependent on heroin is linked to the implementation of substitute prescribing and needle/syringe exchange in Northern Ireland. These services can contribute to recovery from drug dependence and can help reduce the spread of blood-borne viruses, e.g., HIV, among these individuals. Additionally, the diffusion of impact has occurred with increasing numbers of individuals accessing these services over time.

Underpinning research

Anecdotal reports about emerging heroin use began to surface in 1996, initially by astute community workers and general practitioners who were faced with increasing numbers of patients presenting with heroin dependence. At the time, Northern Ireland drug policy lagged well behind those of other regions in western Europe. Needle/syringe exchange services, designed to reduce the loaning and borrowing of needles among injectors, was not available in Northern Ireland. Methadone maintenance treatment (MMT) was not permitted, despite scientific evidence that had demonstrated its effectiveness for treating heroin dependence. At the time, these services had been available in Dublin, England, Scotland and several other European regions for well over a decade. In the late 1990s, heroin use in Northern Ireland began to escalate considerably. In the absence of MMT, some general practitioners reluctantly began to prescribe benzodiazepines or dihydrocodeine to their patients, although neither drug was considered to be an effective intervention for treating heroin dependence, and both had strong potential for additional dependency.

The underpinning body of research consisted of three studies and one critical review (2001; 2002; 2003; 2005), conducted by Dr Karen McElrath, a lecturer at Queen's University from 1996-2000 and Reader thereafter. The collection of work focused on marginalised individuals who were dependent on heroin.

References 1 and 3 are based on the first study of heroin use in Northern Ireland (other than a master's thesis which included interviews with a few individuals who had used heroin). McElrath conducted the study which drew on qualitative interviews with a hidden population of adults who had used heroin in the region. Interviews were conducted between 1997 and 1999. The study highlighted individuals' difficulties with the limited treatment options that were available in Northern Ireland, the stigmatised nature of drug addiction in Northern Ireland, and how wider factors (limited access to new needles/syringes) placed people at risk for blood-borne viruses, e.g. HIV.

Reference 4 was a capture-recapture prevalence study that estimated the number of problem heroin users in Northern Ireland to be 828 (range 695-1,018 individuals). This figure equated to 13 per 10,000 persons aged 15-29 years and 6 per 10,000 persons aged 30-54, during a 12-month period in 2000-1. Prior estimates had been based on anecdotal information described by news media or treatment sources that omitted individuals who were not in contact with treatment services. McElrath was the author..

The prevalence study was followed by Reference 5 which was based on a critical review of the international literature into the effectiveness of substitute prescribing. McElrath conducted the review and wrote the report in 2002. The review included several recommendations to which the Department of Health, Social Services & Public Safety (DHSSPS) responded in the Appendix of the report (pages 95-103).

Reference 6 is a study of 90 adults from a number of areas in Northern Ireland, who had injected illicit drugs (namely heroin) within the 30-day period prior to interview. Data were collected in 2003-4. Ms Michele Jordan, a former undergraduate student in the School, was initially hired to assist with the interviews. She contributed to the study in several other significant ways, and McElrath asked Ms Jordan to be co-author of the final report. A key research insight arising from this study was that despite its region-wide implantation in 2004, MMT was not an option for individuals residing in the Southern Health Board. Substitute prescribing was limited to Subutex, a restriction that ignored the diverse needs of individual clients and the neglected the importance of matching treatment to clients' needs.

References to the research

Details of the impact

Key findings from Reference 3 led to the author's recommendations for policy change in Northern Ireland, including: a) to implement needle/syringe exchange schemes in hopes of reducing the spread of blood-borne viruses, e.g., HIV, and minimising other health problems among people who inject drugs, and b) to develop street outreach initiatives that cater to the needs of people who inject illicit drugs. Service provision for people dependent on heroin changed considerably beginning in 2001, with the introduction of pharmacy-based needle/syringe exchange schemes in Northern Ireland. In the first year that scheme data were collected, 5,213 visits to needle/syringe exchanges were recorded. In the same year, McElrath was asked to serve on the Drug and Alcohol Information and Research Working Group, DHSSPS, which provided further opportunity to engage with service providers and drug policymakers, and share research insights. In 2002, she was appointed as Specialist Advisor to the Northern Ireland Affairs Committee to assist in its investigation into the drug trade in Northern Ireland (see below, Section 5, Sources 1-4). That role provided her with the opportunity to compile a list of witnesses (e.g., community workers; voluntary sector) for the Committee that they had previously overlooked. Over time, needle/syringe exchange schemes had expanded to include other pharmacies, and 15,828 visits to exchanges were recorded in 2009-10. These visits involved the collection of 153,625 syringes (see below, Section 5, Source 5).

McElrath's first recommendation in Reference 5 was that methadone maintenance be made available as a treatment option. The DHSSPS accepted that recommendation and agreed to establish an implementation group. Substitute prescribing in the form of methadone or Subutex maintenance was introduced in Northern Ireland in 2004 (see below, Section 5, Source 6). Annual reports from the DHSSPS continue to state that References 3 and 5 were important contributing factors for the introduction of substitute prescribing in Northern Ireland (see below, Section 5, Source 7). The cumulative impact from the underpinning research (References 4 and 5) is demonstrated in the annual reviews of the substitute prescribing database, issued by the DHSSPS. In 2009-10, 576 clients were in receipt of substitute prescribing treatment in Northern Ireland (see below, Section 5, Source 7).

Reference 5 also recommended the development of drug outreach initiatives to work with out-of-treatment heroin users in particular. In 2003, two community workers met with McElrath to discuss strategies for the development of drug outreach in South Belfast. In 2004, the first drug outreach team (DOT) was implemented in Northern Ireland. Organised initially in the voluntary sector, the Drug Outreach Team gained a permanent place in drug service provision when it was incorporated into the statutory sector. It continues to serve dozens of clients who inject drugs or smoke heroin in the Belfast region. Michele Jordan, co-author of Reference 6 subsequently worked for several years as a drug outreach worker in the Northern Board (see below, Section 5, Source 8). Her outreach work focused primarily on women who were injecting drugs, hence the diffusion of impact through Ms Jordan's outreach role.

A number of drug services extended invitations to McElrath to speak with staff in treatment services (e.g., Northern Ireland Community Addiction Service; Northern Ireland Community Addiction Team Forum; Community Addiction Service, Northern Board). These requests created opportunities to discuss research findings with individuals (e.g., service providers) who were in a position to facilitate change. The author's appointments to three advisory boards also helped to integrate research findings within the context of service provision. These boards included: Dunlewey Substance Advice Centre (2004-2009), Drug Outreach Team, South and East Trust (2002-2005; 2008-2009), and Turas Counselling, Dundalk, County Louth (2008-2010).

In 2004, McElrath was interviewing two respondents who participated in the study described in Reference 6. These individuals resided in the Southern Board where clients were not permitted to be prescribed methadone, despite the region-wide implementation of that service. As a consequence, the respondents made two or three trips each week to the Republic of Ireland in order to participate in the MMT programme in that jurisdiction. McElrath helped the clients liaise with a legal team, and the case was accepted for judicial review (see below, Section 5, Source 9) which subsequently found that the clients had a right to obtain MMT in the Southern Board. The additional impact from Reference 6 was that the underpinning research contributed to changing service delivery in a health board area.

In summary, the reach of these impacts extended to individuals who have experienced heroin dependency. The significance of the impacts is the expansion of service provision for marginalised groups.

Sources to corroborate the impact

Source 1: Northern Ireland Affairs Committee, House of Commons (2003). The Illegal Drugs Trade and Drug Culture in Northern Ireland. Reference 4 above is described under items 28 and 31 (http://www.parliament.the-stationery-office.co.uk/pa/cm200203/cmselect/cmniaf/1217/121705.htm)

Source 2: Northern Ireland Affairs Committee, House of Commons (2003). The Illegal Drugs Trade and Drug Culture in Northern Ireland, Appendix 8, Memorandum submitted by the Chief Medical Officer, Dr Henrietta Campbell. References 4 and 5 (above) are mentioned in Point 4 (http://www.parliament.the-stationery-office.co.uk/pa/cm200203/cmselect/cmniaf/1217/1217we09.htm)

Source 3: Northern Ireland Affairs Committee, House of Commons (2003). The Illegal Drugs Trade and Drug Culture in Northern Ireland. Reference 4 is described in Point 33 (http://www.parliament.the-stationery-office.co.uk/pa/cm200203/cmselect/cmniaf/1217/121705.htm>)

Source 4: Northern Ireland Affairs Committee, House of Commons (2003). The Illegal Drugs Trade and Drug Culture in Northern Ireland. References 4 and 5 (above) are mentioned in Point 206, section on Substitute Prescribing (http://www.parliament.the-stationery-office.co.uk/pa/cm200203/cmselect/cmniaf/1217/121712.htm)

Source 5: Department of Health, Social Services and Public Safety (2010. Statistics from the Northern Ireland Needle and Syringe Exchange Scheme: 1 April 2009 - 31 March 2010. (http://www.dhsspsni.gov.uk/nses_annual_bulletin_2009-10.pdf)

Source 6: Department of Health, Social Services and Public Safety (2004). Northern Ireland Guidelines on Substitution Treatment for Opiate Dependence. References 4 and 5 (above) are described as influencing the implementation of substitute prescribing (see Page 2, Section 2.4). These guidelines are still in operation still in operation.
(http://www.dhsspsni.gov.uk/niguide_substitute_treatment.pdf)

Source 7: Annual reports published by the (Northern Ireland) Department of Social Services and Public Safety, entitled, Statistics from the Northern Ireland Substitute Prescribing Database, e.g., the report dated 31 March 2010. References 4 and 5 (above) are mentioned in Section 1.2 of the latest report and each annual report that preceded it: "Subsequently NICDM asked the DHSSPS to commission research to establish more accurately the number of problem heroin users in Northern Ireland. The report: Prevalence of Problem Heroin Use in Northern Ireland was published in March 2002 and estimated that there were between 695 and 1250 problem heroin users in Northern Ireland. The DHSSPS also commissioned a report: Review of Research on Substitute Prescribing for Opiate Dependence and Implications for Northern Ireland. This report, together with the DHSSPS's response to the recommendations in contained, was published in January 2003, and recommended the development of Substitute Prescribing services."
(http://www.dhsspsni.gov.uk/substitute_prescribing_report_2009-10.pdf)

Source 8: Northern Drugs and Alcohol Co-Ordination Team (2007). NDACT News, March. Michele's outreach work is mentioned on page 5, section entitled, "Drug Outreach Services." (Report available on request)

Source 9: Judicial Review, Northern Ireland. Robert Lewis and Lisa Rochford vs Southern Health and Social Services Board. (2005). A print copy is provided of McElrath's witness statement. Additionally, a brief slide presentation by clients' solicitors at a national conference on drug treatment is found here:
(http://www.exchangesupplies.org/conferences/NDTC/2006_NDTC/presentations/gerry_hyland.html)

Source 10: The EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) is a decentralised agency that distributes data on drug misuse and drug problems to EU member states. Collectively, references 1 and 4 (above) were cited seven times in Reitox National Focal Point (2001). Report to the EMCDDA: United Kingdom Drug Situation, 2001
(http://www.emcdda.europa.eu/attachements.cfm/att_34844_EN_NR2002UK.pdf)