Recent annual reports highlight the complexity of Ireland’s drug culture, writes Dr Des Corrigan
A number of State bodies published Annual Reports in mid-December that provide a fascinating but worrying insight into the increasing complexity of drug-taking in Ireland. Those reports came from Forensic Science Ireland (FSI), the State Laboratory, the Medical Bureau of Road Safety (MBRS) and
the National Drug-Related Deaths Index (NDRDI) compiled by the Health Research Board.
That NDRDI report describes the most serious consequence of drug-taking for the 343 individuals who died in 2022 as a result of drug poisoning (overdose) as determined by a Coroner. This figure does not include deaths among known drug users or where drugs were detected post mortem, but the cause of death, according to the Coroner, was due to trauma (drowning or hanging) or to cardiovascular events triggered by cocaine, for example.
Data on these ‘non-poisoning’ deaths has yet to be published, but going on the 2020 report, they are likely to more or less match those for overdoses, and so the overall figure for drug-related deaths is probably in the region of 800. This is a truly staggering figure and one can only imagine the heartbreak of the families involved and lament the waste of lives. As has been the case for a number of years, over 80 per cent of overdose deaths have involved one or more prescription drugs, with the report noting that the main drug groups were opioids (mainly methadone), implicated in 65 per cent of deaths; benzodiazepines (48 per cent); cocaine (33.5 per cent); antidepressants (26.8 per cent); gabapentinoids (22.4 per cent); zed drugs (17.5 per cent) and antipsychotics (14 per cent). Therefore, pharmacists have a direct stake in efforts to reduce this very preventable loss of life. It will be interesting to see if representatives of the profession are in any way successful in persuading Government to include specific mention of the role of pharmacists in the prevention of overdoses and the treatment of problem drug-taking, including (but not limited to) naloxone provision and the dispensing of methadone and buprenorphine in the new National Drug Strategy.
I make this point because the previous Strategy mentioned Pharmacy only once and there was no mention whatsoever of its role in supplying naloxone, or that the whole opioid substitution treatment system could not work without the input of the 834 pharmacies nationwide that dispense medication to approximately two-thirds of the 10,718 patients on the Central Treatment List. Quite simply, the system would grind to a halt without pharmacists and the least we might expect is that this is specifically recognised in the new Strategy.
The report also looked at trends over the 10 years from 2013 to 2022, highlighting a 259 per cent increase in cocaine-related deaths. There was also a 350 per cent increase in deaths involving pregabalin and even though such fatalities have fallen from a peak in 2020, the total over the 10 years is 589. Despite this, there is sadly still no sign of the Dept of Health grasping the nettle of controlling the black market in pregabalin by including the gabapentinoids within the Misuse of Drugs Act, even though they scheduled 14 other drugs as Controlled Substances as recently as last July. A missed opportunity to save lives!
Although at least 23 per cent of the victims were known to be drug injectors, I was surprised to read that only 9.3 per cent were injecting when they died, of whom half were alone at the time of death, which suggests to me that supervised injection facilities are likely to have a limited impact on the overall number of fatalities. In that regard, it is also worth noting that deaths from heroin have declined over the 10-year period, but those involving methadone have increased, as have those linked to other opioids such as tramadol, codeine, oxycodone and morphine.
In the case of codeine, there have been 236 deaths since 2013; 139 linked to oxycodone, and 293 in which tramadol was implicated. In view of what has happened in North America, this increase involving other opioids may not yet cause official alarm bells to ring, but they should at least prompt increased vigilance among prescribers and dispensers.
All of the toxicology testing that underpins the NDRDI is done on behalf of the country’s Coroners by the State Lab, whose Annual Report for 2024 refers to the increased workload arising from such requests, but the only details provided concern the detection for the first time of a new designer benzodiazepine
called chlorobromazolam in a suspected overdose case. Bromazolam itself was controlled under the Misuse of Drugs Act in July, and it is arguable that the Dept missed an opportunity to control its derivatives at the same time.
Bromazolam was detected in a number of seizures analysed by FSI, as set out in its 2024 Report. One case involved blister packs labelled ‘Alko-1’, thought to contain alprazolam but actually contained bromazolam and even more worryingly, given its high potency and extreme toxicity, the synthetic opioid metoniatazene. FSI also detected protonitazene in a powder. Thankfully, it and metonitazene were among the eight nitazenes controlled by the Dept in July.
The vast bulk of the specimens analysed by FSI involved, not surprisingly, cannabis in its various forms ranging from the more traditional leaf and flower, to more exotic oils and waxes and also ‘edibles’, including chocolate bars, jellies, cake and biscuits. Again, it is no surprise
Quite simply, the system would grind to a halt without pharmacists
that cannabis drugs were the main substances detected by the MBRS in blood and urine samples from drivers as reported in its 2024 Report.
Cocaine, followed by benzos and then opioids, were the next most frequently detected. As in the case
of drug-related deaths, polydrug use was quite common and in two cases, a staggering (pardon the pun) five different drugs were detected. As ever, when one looks at the ‘minor’ drugs detected in terms of numbers, possible warning signs of trouble ahead emerge. It is noteworthy that there were 24 samples recorded as being positive for fentanyl. Whether this had been prescribed or whether it was a ‘street’ product is impossible to say.
Antihistamines get a mention in 15 cases, with five cases involving diphenhydramine. Given their widespread presence in numerous OTC products, some discreet professional advice about not driving while using them might save unsuspecting patients from a drugged-driving charge.
Dr Des Corrigan, Best Contribution in Pharmacy Award (winner), GSK Medical Media Awards 2014, is an Adjunct Associate Professor at the School of Pharmacy and Pharmaceutical Sciences at TCD where he was previously Director and won the Lifetime Achievement Award at the 2009 Pharmacist Awards. He was chair of the Government’s National Advisory Committee on Drugs from 2000 to 2011, having previously chaired the Scientific and Risk Assessment Committees at the EU’s Drugs Agency in Lisbon. He chaired the Advisory Subcommittee on Herbal Medicines and was a member of the Advisory Committee on Human Medicines at the HPRA from 2007 to 2024. He has been a National Expert on Committee 13B (Phytochemistry) at the European Pharmacopoeia in Strasbourg and served on the editorial boards of a number of scientific journals on herbal medicine.
