Street tablet use in Ireland - A Trendspotter study on use, markets, and harms - Public Health - Ana Liffey Drug Project
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se in Ireland 1
Street Tablet U
Street tablet
use in Ireland
A Trendspotter study on use,
markets, and harms
Tony Duffin
Marcus Keane
Seán R Millar
School of
Public Health
2 Street Tablet U
se in Ireland
Street tablet
use in Ireland
A Trendspotter study on use,
markets, and harms
Tony Duffin
Marcus Keane
Seán R Millar
To be cited as:
Duffin T, Keane M and Millar SR (2020)
Street tablet use in Ireland. A Trendspotter
study on use, markets, and harms.
Ana Liffey Drug Project, Dublin. se in Ireland 3
Street Tablet U
Table of contents
LIST OF ABBREVIATIONS 5
LIST OF TABLES 6
LIST OF FIGURES 6
ACKNOWLEDGEMENTS 7
SUMMARY 9
1. INTRODUCTION 10
2. THE TRENDSPOTTER METHODOLOGY 12
3. WHAT ARE STREET TABLETS? 14
4. USE AND PATTERNS OF USE 16
4.1 Overview 17
4.2 Trends in street tablet use and availability 17
4.3 People who use and motivations for use 19
4.3.1 People who use opioids 19
4.3.2 Prison population 19
4.3.3 People with complex and multiple needs 19
4.3.4 Young people 19
4.4 Consumption patterns 20
5. MARKETS 21
5.1 Understanding the street tablet market 22
5.2 Market actors 24
5.3 The role of street tablets in the market 24
5.4 What substances are being marketed? 25
6. HARMS ASSOCIATED WITH THE USE OF STREET TABLETS 26
6.1 General harms 27
6.1.1 Benzodiazepines 27
6.1.2 Z-drugs 27
6.1.3 Gabapentinoids 27
6.2 Individual harms in Ireland 28
6.2.1 Non-fatal emergency hospital cases involving medications 28
6.2.2 Intentional drug overdoses involving pregabalin or gabapentin 28
6.2.3 Drug-related deaths involving medications 31
6.3 Harms in the context of polydrug use 32
7. DISCUSSION, CURRENT RESPONSES, AND RECOMMENDATIONS 34
7.1 Discussion 35
7.2 Current responses 37
7.3 Recommendations 37
8. REFERENCES 394 Street Tablet U
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List of abbreviations
BDZs Benzodiazepines
CEO Chief Executive Officer
EMCDDA European Monitoring Centre for Drugs and Drug Addiction
HIV Human Immunodeficiency Virus
HPRA Health Products Regulatory Authority
HRB Health Research Board
HSE Health Service Executive
HIPE Irish Hospital In-Patient Enquiry
IDO Intentional Drug Overdose
NDRDI National Drug-Related Deaths Index
NDTC National Drug Treatment Centre
NDTRS National Drug Treatment Reporting System
UCC University College Cork
WHO World Health Organization6 Street Tablet U
se in Ireland
List of tables
Table 1:
Combination of drugs implicated in polydrug deaths along with alcohol,
methadone, diazepam, and heroin, 2016 33
List of figures
Figure 1:
Trends in the number of cases entering treatment for benzodiazepines
or Z-drugs as their main problem drug, 2015–2018 17
Figure 2:
Primary Care Reimbursement Service pregabalin dispensing frequency
and number of poisoning deaths with a pregabalin-positive toxicology
by year, 2013–2016 23
Figure 3:
Trends in the number of self-poisoning discharges from Irish hospitals
involving benzodiazepines, 2015–2018 29
Figure 4:
Trends in the number of self-poisoning discharges from Irish hospitals
involving antiepileptic and sedative-hypnotic drugs, 2015–2018 29
Figure 5:
Percentage of intentional drug overdoses involving a gabapentinoid,
2007–2015 30
Figure 6:
Percentage of intentional drug overdoses involving a gabapentinoid by
age group, 2007–2015 30
Figure 7:
Poisoning deaths in Ireland involving benzodiazepines and antiepileptic and
sedative-hypnotic drugs: main specific drugs implicated, 2010–2016 31
Figure 8:
Poisoning deaths in Ireland, by single/poly drugs involved, 2004–2016 32 se in Ireland 7
Street Tablet U
Acknowledgements
This report was prepared by a collaborative The report authors would also like to thank
group that was established for the purpose the following individuals who contributed
of preparing a comprehensive summary on towards this study.
patterns of use, markets, and harms related
to street tablets in the Republic of Ireland.
Mr Brian Galvin, Head of EMCDDA Irish National Focal
This group comprised representatives from
Point, HRB
the Ana Liffey Drug Project, the School of
Public Health at University College Cork Ms Claire O’Dwyer, Researcher, HRB
(UCC), the Health Research Board (HRB),
Ms Britta Thiemt, Researcher, HRB
the University of Limerick, Forensic Science
Ireland, the Health Products Regulatory Ms Melissa Scharwey, Ana Liffey Drug Project
Authority (HPRA), Health Service Executive
Ms Megan Clark, Ana Liffey Drug Project
(HSE) Addiction Services, Merchants Quay
Ireland, An Garda Síochána, and addiction/ Mr Chris McGuire, HPRA
homelessness specialist general practitioners.
Mr Paul O’Brien, HPRA
Dr Alessandro Pirona, Scientific Analyst on Health and
Sergeant Eoin Browne, An Garda Síochána
Social Responses, EMCDDA
Mr JM Burr, Team Leader, Ana Liffey Drug Project
Dr Inês Hasselberg, Scientific Analyst on Health and
Dr David Casey, Team Leader, Forensic Science Ireland Social Responses, EMCDDA
Dr Johnny Connolly, University of Limerick
Ms Katie Corrigan, HPRA
Mr Tony Duffin, CEO, Ana Liffey Drug Project
Dr Barbara Henry, HPRA
Mr Marcus Keane, Head of Policy, Ana Liffey Drug
Project
Ms Marie Lynch, Head of Drugs and Homeless Services,
Merchants Quay Ireland
Dr Suzi Lyons, Senior Researcher, National Health
Information Systems, HRB
Dr Garrett McGovern, Addiction Specialist, General
Practitioner
Dr Seán R Millar, Senior Researcher, School of Public
Health, UCC/HRB
Dr Austin O’Carroll, Homelessness Specialist, General
Practitioner
Dr Mike Scully, Consultant Psychiatrist, HSE Addiction
Services8 Street Tablet U
se in Ireland se in Ireland 9
Street Tablet U
Summary
The non-medical use of prescription drugs is a global health concern. In the Republic of Ireland,
converging signals of the ongoing non-medical use of pharmaceuticals (‘street tablets’) among
clients of community-based, drug harm reduction service agencies in Dublin were noted in
2018. These included significant levels of street tablet use among service clients, an increase
in the prevalence of pregabalin in drug-related deaths data since 2015, and reports of online
purchasing of tablets for the Irish market. To understand these recent trends, the present study
was deemed necessary.
The study adopted the European Monitoring as a source of street tablet availability and that,
Centre for Drugs and Drug Addiction (EMCDDA) through the internet and social media, distribution
Trendspotter methodology and was undertaken of benzodiazepines, Z-drugs, and pregabalin is
between May and September 2019. It commenced much easier and wider-reaching. Insofar as routes
with a phase of data collection and a literature to markets for tablets in Ireland are concerned, all
review undertaken by a team of staff from the Ana of these sources are likely to play a part.
Liffey Drug Project, the Health Research Board
Data from the Irish Healthcare Pricing Office
(HRB), and the School of Public Health at University
demonstrate an increase in the number of non-fatal
College Cork (UCC), culminating in a 1.5-day expert
self-poisoning cases involving benzodiazepines and
presentation and facilitated groups meeting. The
antiepileptic and sedative-hypnotic drugs between
meeting consisted of a group of 11 experts from the
2015 and 2018. Statistics from the National Drug-
Ana Liffey Drug Project, the University of Limerick,
Related Deaths Index (NDRDI) also indicate an
Forensic Science Ireland, the Health Products
overall increase in the number of deaths involving
Regulatory Authority (HPRA), Health Service
alprazolam, zopiclone, and pregabalin. In particular,
Executive (HSE) Addiction Services, Merchants
pregabalin-related deaths have risen year on year
Quay Ireland, An Garda Síochána, and addiction/
between 2012 and 2016, with an increase of 33%
homelessness specialist general practitioners.
between 2015 and 2016 and an overall increase of
Experts provided data on use, changing 364% between 2013 and 2016. Concurrent with an
consumption patterns, and availability, with a increase in the number of drug-related deaths in
majority indicating that there has been an increase Ireland involving benzodiazepines and antiepileptic
in the use and availability of street tablets in and sedative-hypnotic drugs, data from the NDRDI
Ireland between 2016 and 2019. Drugs which are also show an increase in the number of poisoning
commonly misused in tablet or capsule form include deaths involving a combination of substances
benzodiazepines, Z-drugs, and gabapentinoids. between 2004 and 2016.
The user groups identified included high-risk opioid
Experts who took part in this research identified a
users, prison populations, people with complex and
number of issues which could help to manage the
multiple needs, and young people. Among these
street tablet market. In terms of preventing leakage
groups, the motivations for using street tablets
from the legitimate sources, a robust electronic
included their intoxicating effects, to enhance
prescribing system could help better control
desired effects from illicit substances, to help
access, and might help prevent ‘doctor shopping’.
withdrawal symptoms, to improve sleep, and to
However, it was also noted that care is needed
reduce stress. Other potential reasons for use are
not to inadvertently divert people to the street
that tablets are cheap to purchase and are easily
market to seek access to tablets. There is also a
available.
need to understand and be effective in addressing
In terms of the importation of ready tableted why individuals are using tablets in the first place,
products, the main sources appear to originate from and therefore able to address the reasons why
the Indian subcontinent. However, as Ireland is not a people have to access the tablet market. In this
transit country, identifying the origin of drugs being context, supporting medical professionals to
transported to Ireland can be difficult. Another better understand and be equipped to address the
possible avenue of availability cited was the demand encountered is important, as is the need
healthcare system, with overprescribing resulting to get existing public health and harm reduction
in the ability for individuals to sell unused tablets messaging into novel market spaces, such as the
on the street. Online sources were also identified online environment.10 Street Tablet U
se in Ireland
1 INTRODUCTION
The non-medical use of prescription drugs
has become a global health concern. Non-
medical usage is defined as the taking of
prescription drugs, whether obtained by
prescription or otherwise, except in the
manner or for the reasons or time period
prescribed, or by a person for whom the
drug was not prescribed.1 se in Ireland 11
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Advances in the pharmaceutical industry have and the Health Research Board (HRB), with the
led to the production of powerful psychoactive, support of the European Monitoring Centre for
antiepileptic, and sedative-hypnotic drugs which, Drugs and Drug Addiction (EMCDDA), conducted
when prescribed appropriately and taken in the a Trendspotter study to examine patterns of use,
manner intended, improve the quality of life of markets, and harms related to street tablets in
those with specific medical conditions. However, Ireland.
when used inappropriately, these medications may
A Trendspotter study is a rapid information
have serious consequences for health.
assessment that uses multiple social research
The non-medical use of pharmaceuticals is a methods to explore a topic of interest or concern.2
unique category of substance misuse in a number The approach was developed and has been used
of ways, as the scale of the problem is largely by the EMCDDA since 2011 as a tool to complement
unknown owing to lack of data. This is partly due other routine drug monitoring methodologies. It
to the existence of many gaps in the monitoring has generally been utilised to explore emerging
of their legal use for medical purposes. In addition, phenomena and new trends that are in their infancy
most studies on, and monitoring instruments for, and/or not covered by existing datasets.3,4
substance abuse pertain to the use of illegal drugs
The purpose of the present study was to increase
or alcohol and tobacco.
understanding of the use of, and markets for, street
In the Republic of Ireland, converging signals of tablets in Ireland (specifically Dublin). This included
the ongoing non-medical use of prescription drugs an understanding of users, supply, demand, analysis
(‘street tablets’) among clients of community-based, on active ingredients, risks, and harms.
drug harm reduction service agencies in Dublin
were observed in 2018. Signals included trends and
concerns flagged by harm reduction services in the
inner-city area. These signals included considerable
levels of street tablet use among service clients, an
increase in the prevalence of pregabalin in drug-
related deaths data in recent years, and reports of
online purchasing of tablets for the Irish market.
In order to better understand these converging
signals, the Ana Liffey Drug Project, the School of
Public Health at University College Cork (UCC),
Specifically, the objectives of this study were to:
• Better understand the prevalence of street tablet use and the
profile of subjects who misuse street tablets in Ireland
• Better understand market supply (e.g. internet, trafficking, local
production) and availability of street tablets in Ireland
• Better understand harms related to street tablet use, both
generally and specifically within Ireland
• Better understand, through careful analysis, the risks associated
with the street tablet market in the Republic of Ireland and
inform interventions accordingly.12 Street Tablet U
se in Ireland
2 THE TRENDSPOTTER
METHODOLOGY
This research project took place between
May and September 2019, and followed the
Trendspotter methodology developed by
the EMCDDA.2 se in Ireland 13
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A study of this nature includes the triangulation of Also analysed were the databases contained in the
information collected through multiple, combined Irish Hospital In-Patient Enquiry (HIPE), maintained
research methods and techniques, with the aim by the Healthcare Pricing Office at the Health
of acquiring a better knowledge of a given social Service Executive (HSE), and the Irish National Drug
phenomenon in a rapid, reliable, and verifiable way. Treatment Reporting System (NDTRS) and Irish
National Drug-Related Deaths Index (NDRDI), which
are maintained by the HRB.
Bearing in mind the aims of the study The online survey was launched on the LimeSurvey
and the research objectives, the platform between August and September 2019,
following methods were used: combining both open and closed questions based
on the research topics, namely street tablet
• Collection of bibliographic and other data availability, prevalence, patterns of use, markets,
as well as the motivations and problems related
• An online survey (questionnaire addressed to street tablet consumption. The invitation to
to national experts) participate in the survey, which included an access
link to same, was made on the basis of a mailing
• Presentations at an expert meeting list consisting of professionals from Irish drug harm
reduction services, academics, addiction specialist
• Focus groups set up at an expert meeting. agencies and general practitioners, Forensic
Science Ireland, the Health Products Regulatory
Authority (HPRA), An Garda Síochána, and a person
with current lived experience of the street tablet
market, who, unfortunately, was not able to attend
The literature review focused mainly on publications the expert meeting.
registered in the database for recent scientific
research on street tablet use, available from the The expert meeting was held on 16/17 September
National Drugs Library (available at: https://www. 2019 in Dublin and attended by 11 professionals
drugsandalcohol.ie) as well as online publications who have direct or indirect contact with the street
from organisations such as the EMCDDA, the tablet phenomenon and street tablet users, in
World Health Organization (WHO), and the United areas ranging from chemical, forensic, and criminal
Nations. Articles published in scientific journals investigation, through treatment intervention and
between 2014 and 2018 accessible through PubMed harm reduction. Each specialist shared information
and Google Scholar search engines were also through an individual presentation and took part
consulted. The expressions used were: in one of two focus groups. The discussion topics
focused on five key issues:
• ‘benzodiazepines’ AND ‘use’ AND ‘Ireland’; (i) street tablet use and availability
‘z-drugs’ AND ‘use’ AND ‘Ireland’; ‘pregabalin/
gabapentinoids’ AND ‘use’ AND ‘Ireland’ (ii) consumption patterns
• ‘benzodiazepines’ AND ‘market’ AND (iii) markets
‘Ireland’; ‘z-drugs’ AND ‘market’ AND ‘Ireland’;
(iv) harms
‘pregabalin/gabapentinoids’ AND ‘market’ AND
‘Ireland’ (v) implications for policy and data monitoring.
• ‘benzodiazepines’ AND ‘harms’ AND ‘Ireland’; The triangulation of the information collected
z-drugs’ AND ‘harms’ AND ‘Ireland’; ‘pregabalin/ through the different methodological tools was
gabapentinoids’ AND ‘harms’ AND ‘Ireland’. used to draw a number of conclusions, which
are presented in Chapters 3–7, categorised into
different sections.14 Street Tablet U
se in Ireland
3 WHAT ARE
STREET TABLETS?
‘Street tablets’ is a generic term used to
describe drugs that come in either tablet
or capsule form. Street tablets can be
considered as any tablets or capsules which
are not obtained directly by the individual
through a doctor or pharmacist. se in Ireland 15
Street Tablet U
For this Trendspotter study, ‘street tablets’ refer The main categories of drugs that Irish harm
to any tablets or capsules which contain (or which reduction services usually receive reports on
the user believes to contain) medicine that is only in relation to street tablets are:
available on prescription, but which have not been
acquired directly from a medical professional. • Benzodiazepines: A class of psychoactive drugs
prescribed for panic disorder, general anxiety
disorder, insomnia, and alcohol withdrawal.
Therefore, examples of street tablets include: Examples of benzodiazepines include diazepam,
alprazolam, and flurazepam.
• Tablets that are legitimately prescribed and
acquired by Person A, but which Person B
• Z-drugs: A class of non-benzodiazepine
consumes, having acquired them from Person A
hypnotics, such as zolpidem, zopiclone, and
• Tablets that are acquired ‘on the street’ zaleplon. As with benzodiazepines, Z-drugs are
commonly used as a front-line treatment for
• Tablets that are ordered over the internet/on insomnia.
the dark web without formal prescribing.
• Gabapentinoids (pregabalin/gabapentin): A
class of drugs licensed for the treatment of
The following were not considered epilepsy, postherpetic neuralgia, fibromyalgia,
street tablets in this research: neuropathic pain, and general anxiety disorder.
• Ecstasy tablets (not containing medicine)
• Solpadeine (available without prescription)
• Liquid methadone (not in tablet format).16 Street Tablet U
se in Ireland
4 USE AND
PATTERNS OF USE
Research has illustrated a well-
rounded idea of the effects that
street tablets have on a wide array
of groups, including those in the
addiction services population, high-
risk opioid users, prison populations,
people with complex and multiple
needs, and young people. Research
on street tablets in the Republic
of Ireland is lacking however,
specifically regarding use and
patterns of use. se in Ireland 17
Street Tablet U
availability nationally or internationally. Importantly,
4.1 Overview a majority of experts who took part in this study
agreed that there has been a noticeable increase in
Experts who participated in this Trendspotter the use of street tablets in Ireland in recent years.
study provided data on use, changing consumption It was noted, however, that there are differences
patterns, and availability. Interestingly, from the in the prevalence and availability of tablets being
expert survey, seven out of 11 participants believed sold. For example, while broad use in general may
there to be an increase in the use of street tablets be the same, the type of tablets actually being sold
between 2016 and 2019, and six out of 11 held that and ingested are changing (e.g. benzodiazepines to
there had been an increase in the availability of pregabalin), with experts indicating that pregabalin
street tablets over the same time period. misuse is a serious emerging issue that should be
monitored (see Figure 7, Section 6.2.3).5 In contrast,
4.2 Trends in street tablet insights from day services suggested that there has
not necessarily been an increase in street tablet use
use and availability due to the fact that usage has always been high
among clients experiencing complex and multiple
Data from the National Drug Treatment Reporting needs.
System (NDTRS) show that the number of cases
entering treatment in Ireland for benzodiazepines In relation to availability, and the fact that there
as their main problem drug remained relatively appear to be more street tablets in circulation,
stable between 2015 and 2017 (see Figure 1). In there is a question about where the substances
2018, there were 999 individuals in treatment for are coming from. In general, statistics on street
benzodiazepine use, compared with 868 in 2017. tablet availability are only obtainable from law
The number of treatment cases who reported enforcement figures, providing a focused rather
Z-drugs as their main problem drug decreased than a broad idea on use and availability. It was
between 2015 and 2018. In 2018, 21 cases reported noted by experts that, in essence, it can be
pregabalin as a main problem; a further 57 cases very easy to acquire tablets abroad and bring
reported pregabalin as a secondary problem. back a large stock. Another possible avenue of
availability cited was the healthcare system, with
However, treatment data may not reflect a overprescribing resulting in the ability for individuals
complete understanding of street tablet use and to sell unused tablets on the street. Nevertheless,
1000
900
Number in treatment
800
700
600
500
400
300
200
Benzodiazepines
100
Z-drugs
0
2015 2016 2017 2018
Year
Source: NDTRS (2019)
Figure 1: Trends in the number of cases entering treatment for
benzodiazepines or Z-drugs as their main problem drug, 2015–201818 Street Tablet U
se in Ireland
some doctors refuse to prescribe benzodiazepine Feedback from recent research as well as experts in
medications at all. Experts suggested that if the this study highlighted the importance that culture
healthcare system was standardised in the way it plays in the availability and use of street tablets
cares for patients and manages patient ailments, among communities. On a cultural level, there is an
street tablet availability might decrease. However, acceptance of the misuse of street tablets as part of
it was also observed that changing the system normal life and behaviour.6 Doctors have the legal
may initially result in more people purchasing on ability to prescribe these medications on a wide
the street, leading to potential increased harm due scale, which strengthens the idea that they are safe
to unknown purity and potency. Online sources to use for long periods of time. Data from an Irish
were also identified as a source of street tablet study shed light on the use of benzodiazepines
availability and that, through the internet and social among young people and found that misuse of
media, distribution of benzodiazepines, Z-drugs, these drugs was normalised and encouraged by
and pregabalin is much easier and wider-reaching. their environment.7 Moreover, the culture among
Taking into account this improved technological different groups of people who use drugs can have
form of distribution, it is perhaps not surprising that an impact on beginning and sustaining street tablet
people are using street tablets in higher amounts, use. In particular, young people may be influenced
resulting in higher demand. In addition, internet by music and pop culture as well as peer pressure.
distribution methods may lead to a variety of Also, in addition to affecting local cultures, street
cohorts using tablets. tablet supply, trade, and distribution have become
embedded in local economies, as people are selling,
sharing, and swapping street tablets as a form of
currency.6 se in Ireland 19
Street Tablet U
population is women. The Australian Institute of
4.3 People who use and Criminology found that women in the criminal
motivations for use justice system tend to be more heavily involved
with drugs than men and that problematic drug use
4.3.1 People who use opioids in women is often linked to victimisation, mental
health problems, drug and alcohol abuse among
High-risk opioid users are characterised by the family members, and delinquency.12
EMCDDA as people who use opioids weekly or
more frequently for at least 6 months of the past 12 4.3.3 People with complex
months. This includes opioid medicines not used in and multiple needs
accordance with medical prescription.8 In a study
of an addiction treatment programme in the United
Vulnerable groups of people are often subject
States, Stein et al. found that over one-half of the
to higher rates of drug use, which also comes
population used benzodiazepines in the month
with greater harms. Experts believe that people
prior to admission, while only one-quarter reported
are using more recreational drugs in general;
having a medical prescription.9 They also found
however, women have been found to experience
that benzodiazepine users tended to have a longer
a significantly higher rate of street tablet misuse
history of opioid use and prior detoxifications;
in comparison with their male counterparts, citing
that they used higher doses of opioids; had a
the reason for taking tablets as being “to cope”.6
higher frequency of injecting, needle sharing, and
It is also important to note that benzodiazepine
combined use of alcohol and cocaine; and reported
users tend to engage in more high-risk behaviours,
greater criminal activity.
such as exhibiting a higher frequency of injecting
With regard to reasons for using, experts who their drugs, sharing needles, and polydrug use.13
participated in this Trendspotter study advised Together, these can lead to unintended health
that opioid users are taking tablets to deal with consequences and death among users, specifically
withdrawal or to improve sleep and reduce stress. those individuals who are already using opioids and
Other potential reasons for use are that tablets are mixing drugs.
cheap to purchase and are easily available. The
Of concern, it was identified that there are
heroin drought which was reported across Europe
increasing numbers of refugees engaging with
in 201010 was also identified as another potential
services due to street tablet use, and tablets are
reason for uptake, as many people who use drugs
being traded at an increased rate among this group.
moved off opioids and began using tablets at
A serious problem associated with this phenomenon
that time. Ana Liffey Drug Project service users
is that these individuals are often not reached by
reported that street tablets are mainly used for
local services due to language barriers as well as
their intoxicating effects. Service users explained
complications from post-traumatic stress disorder
that pregabalin is not only widely available, and
and other mental health illnesses. In addition,
easily accessed, but is also taken due to the relished
homelessness and street tablet usage appear to
“drunk feeling” that it provides. Consequently, use
have increased hand in hand, with subjects in the
of this drug may have increased due to its ability
homeless population reporting using street tablets
to provide users with a “good high” and a lack of
to “get through the day”.
barriers because it is an uncontrolled drug in Ireland.
4.3.2 Prison population 4.3.4 Young people
Experts suggested that the number of young people
Prisoners were another identified group of users
in Ireland experimenting with street tablets has
of street tablets. Among people entering drug
increased. Dependent young people often engage in
treatment in Irish prisons, most are entering
street tablet use due to availability and the culture
treatment for opioid use, mainly heroin, followed
around taking tablets. Furthermore, the college-
by cocaine, benzodiazepines, and cannabis use.
age population may use street tablets because
However, of all treatment entrants in prison in 2017,
of their increased popularity and peer pressure
benzodiazepines were the second most common
among this group. A 2018 study by Murphy et al.,
drug reported (13.1%), followed by cocaine (12.3%).11
which examined the experiences of young Irish
A particularly vulnerable group among the prison
people in treatment for benzodiazepine misuse,20 Street Tablet U
se in Ireland
provides a number of insights into the motivations aggressiveness; in one case, aggression reached a
and consequences around benzodiazepine misuse level where a person’s mother needed assistance
among young people.7 The main motivations from the police to remove their child from the
reported were to self-regulate negative emotions home.
and to dissociate from the environment. A
It is important to keep in mind that, generally,
consequence of this misuse was disengagement
young people are to be viewed along a continuum,
from family relationships and activities such as
with some simply experimenting on one end and
school and sports clubs. A common description
vulnerable people exposed to childhood trauma
of the effects of benzodiazepines was a stoned
on the other end. It is well documented that
feeling, an intense sense of relaxation, and increased
adolescence is a particularly vulnerable time for
confidence. There was overall agreement that
the development of mental illness. Consequently,
misuse of benzodiazepines was normalised and
for young people, misuse of street tablets can have
encouraged by their environment. Subjects also
detrimental cognitive effects in the short and long
reported accidents, especially in relation to work,
term, which may continue after the person stops
due to motor coordination. Other negative effects
using.
reported were blacking out and memory loss. Some
people mentioned paradoxical effects, such as
past where they used only one or two. Polydrug
4.4 Consumption patterns use is a well-known risk factor for fatal overdose
and accounts for a majority of poisoning deaths;
Street tablets are most often taken orally, but can in the Republic of Ireland, approximately two-
also be smoked, injected, or administered rectally, thirds of all poisoning deaths involve polydrug use,
with additional risks.14 As consumption patterns with benzodiazepines being the most common
fluctuate, specifically in relation to the injection of prescribable drug implicated.16
tablets and the link between opioids and tablets, it
is believed that the way street tablets are ingested
can be related to culture. Specifically, injecting
street tablets can be considered a culture/ritual
among individuals who already inject other drugs.
A study of police detainees in Australia found
that one in five people using non-prescribed
benzodiazepines had injected them.12 However, the
injecting culture in Ireland appears to be changing.
Among individuals currently obtaining treatment
for drug use in Ireland, the proportion of all cases
that had ever injected decreased from 36% in 2012
to 26.7% in 2018.15 Overall, experts suggested that
injecting street tablets has decreased in most cases,
with the exception of when there is a lack of access
to other illicit substances and a need to achieve a
quicker high.
With regard to consumption patterns, an important
issue in relation to street tablet use is the level of
polysubstance use observed in Ireland between
2004 and 2016. Feedback from experts suggested
that street tablet users will, on average, take four
or more drugs at a time, in comparison to the se in Ireland 21
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5 MARKETS
The most useful source for collated,
publicly available data on drug
markets in Ireland is the annual
report of the Irish National Focal
Point to the EMCDDA, in particular
the section on drug markets and
crime.1722 Street Tablet U
se in Ireland
over such enterprises (personal communication:
5.1 Understanding the street HPRA Enforcement Section, 2019).
tablet market
Although Irish data on illicit pharmaceutical
The annual report of the Irish National Focal Point to markets are currently limited, in 2018, the HPRA, in
the EMCDDA provides a number of insights which partnership with Revenue’s Customs Service and An
are useful with respect to the street tablet market Garda Síochána, detained almost 90,000 dosage
in Ireland. In terms of mapping the market from units of illegal prescription medicines, valued at over
source to ultimate user, it is interesting to note that ¤375,000, as part of the INTERPOL-coordinated
synthetic drugs are not produced in Ireland, nor, in Operation Pangea XI – which targeted the sales
general, are illicit drugs tableted. Ireland is generally of illegal pharmaceuticals.19 In addition, in line
viewed as an end source not a transit country.17 with the approach taken in Operation Pangea, the
HPRA, Revenue’s Customs Service and An Garda
However, this general point does not fully hold for Síochána targeted, on an ongoing basis throughout
some key drugs that are the focus of this study, 2018, illegal online supplies (including through
notably benzodiazepines and Z-drugs, as there social media) coming into and within Ireland. This
has been some evidence that Irish organised crime action led to the confiscation of nearly 400,000
gangs have participated in tableting pharmaceutical dosage units of illegally supplied online medicines
drugs. For example, the national report from 2018 valued at ¤1.39 million, including 1,210 dosage
records that drugs such as zopiclone, zolpidem, or units of pregabalin.20 This ongoing focus in Ireland
benzodiazepines have been obtained in powder has also resulted in 14 social media pages and 10
form and then used to produce tablets using e-commerce advertisements being taken offline. In
specialised equipment.17 Tableting machines, addition, 56 websites were investigated in order to
when found in Ireland, have tended to be slow force them to either close or cease selling medicines
and old compared with those found elsewhere in Ireland.
in Europe. Legally, the tableting process is not
seen as chemical drug synthesis, as tablets and Concerningly, the HPRA noted that the laboratory
binding agents are only pressed together and not analysis of products detained demonstrated that
synthesised.17 illicit medicines often contain too little or too much
of the active ingredient. They have also been found
In terms of the importation of ready tableted to contain harmful or undeclared substances,19
products, the main sources appear to originate highlighting the importance of national and
from the Indian subcontinent. As Ireland is not a international collaboration among enforcement
transit country, identifying the origin of drugs being agencies in preventing potentially dangerous
transported to Ireland can be difficult. Nonetheless, pharmaceuticals from reaching the public through
the most recently publicly available data on cross- illegal markets.
border crime and threat assessment published by
the Police Service of Northern Ireland and An Garda Insofar as routes to markets for tablets in Ireland
Síochána indicated that the most likely sources of are concerned, all of these sources are likely to play
counterfeit medicines were India and Pakistan.17 a part – internal information from Ana Liffey Drug
Project staff indicates that clients report tablets
It is interesting to note that in terms of internet currently available on the street market in Dublin
purchasing, as far as prescription medications are city centre as coming from a variety of sources,
concerned, there are adequate sources available including being imported without prescription
on the surface web to suggest that purchasers do (ordered online), being diverted from a legitimate
not have to be sophisticated web users capable source, or being “home pressed” tablets (personal
of operating on the dark web in order to purchase communication: Ana Liffey Drug Project, 2019).
tablets online. Increasing numbers of people use
the internet to search for health information and, Given the diversity of these sources, it is difficult
consequently, consumers may end up purchasing to estimate the size of the street tablet market.
drugs online – in particular, low-income, vulnerable Of the reported large seizure data concerning
groups.18 There are many ‘online pharmacies’ benzodiazepines for 2016, none were recorded
where medications may be purchased without as being in Dublin.17 However, it is important to
a prescription. As these sites do not have to be be aware that statistics in the 2018 report relate
registered in Ireland, or store their stock here, it can to 2016 seizures; since then, media sources have
be difficult for Irish regulators to assert authority indicated a seizure of 30,000 benzodiazepines
(worth an estimated ¤60,000) at Dublin Port in se in Ireland 23
Street Tablet U
late 201721 and a further seizure of benzodiazepines driver; tablets are cheap, often only one euro per
worth an estimated ¤150,000 in Dublin in pill. Similarly, online availability, particularly through
September 2018.22 However, as the number of cases the surface web to non-traditional user groups,
is small, it is hard to extrapolate any discernible may also be a factor influencing the size and shape
pattern. It is worth noting that there were reports of of the market (personal communication: HPRA
benzodiazepines worth ¤300,000 being discovered Enforcement Section, 2019). Finally, as previously
by “pure luck” in Dublin in 2015.23 In addition, as discussed, controls and prescribing practices may
previously mentioned, a majority of experts who have an influence as well. Following the introduction
took part in this study agreed that there has been of pregabalin in 2004, international evidence
an increase in the prevalence of street tablet use has found an increase in its prescription rates24,25
since 2016. This is consistent with a market that is and a recent ecological study demonstrated that
growing and not static. pregabalin-positive poisoning deaths are increasing
in line with the increased dispensing of pregabalin
It is challenging to pinpoint precise drivers for this
in Ireland, with an increase in prescribing strongly
increase. In discussion, experts noted a number
correlated with its role in drug-related deaths
of potential reasons from their own experiences.
(see Figure 2).26
These possible drivers included broad societal
issues, such as increased homelessness or an An interesting consideration in this context is that a
increase in people from social backgrounds not large proportion of pregabalin tablets on the illicit
typically associated with the illicit market who are market appear to be genuine in nature and thus,
now accessing tablets. It is worth noting that the to a certain degree, a known quantity, whereas
increase in use was mainly perceived by experts the same is not true for benzodiazepines available,
as being an increase in use generally, as opposed many of which are produced overseas with
to being an issue limited to one group of users. unknown quality controls.
In this context, it also appears likely that cost is a
R2 = 0.9843
100
90
80
Number of deaths
70
60
50
40
30
20
10
0
612 641 661 788 715 502 755 159
Number of pregabalin items dispensed
Source: NDRDI (2019)
Figure 2: Primary Care Reimbursement Service pregabalin dispensing frequency and
number of poisoning deaths with a pregabalin-positive toxicology by year, 2013–201624 Street Tablet U
se in Ireland
on the surface web and without engaging in direct
5.2 Market actors street-level contact, is likely to have made it easier
for newer user groups to access tablets. This has
The changing nature of the drug market in relation
been noted in relation to third-level students in
to tablets brings some more non-traditional actors
the context of ”smart drugs”,28 and could also be
into the frame. In terms of more traditional actors,
true in the context of people who seek to replenish
there is certainly a significant element of organised
supplies of drugs for which they had previously held
crime involvement. For example, there is evidence
a legitimate prescription. Such online suppliers arise
that Irish organised crime gangs have participated
as a consequence of the increasing use of online
in tableting pharmaceutical drugs. Beyond tableting,
marketplaces more generally and, as noted earlier,
and based on what we understand of the tablet
can be particularly hard to effectively regulate,
sources, there must also be actors involved in
given that they do not need to be based in Ireland in
importing pre-pressed tablets and in diverting
order to sell into the market.
tablets from legitimate sources. However, there
could be different actors engaging at different
levels in this market, or the same actors involved in 5.3 The role of street tablets
one or more chains. For example, a study in the Mid- in the market
West of Ireland noted both local and international
supply chains:27 Consistent with the broadening range of access
points and user groups, it appears likely that tablets
More often than not clients were buying play a number of roles in the market. In terms of
these on the city’s black market. Due to more traditional user groups, there is evidence that
tablet use, or at least use of benzodiazepines, is
the high demand for BDZs [benzodiazepines] co-occurring with heroin use rather than forming a
outstripping local supply, the market was separate market in itself and/or being a replacement
becoming more dependent on foreign market in times of heroin drought. The study from
suppliers, and purchasing them on the Limerick27 also noted that benzodiazepines were
being used to enhance the effects of heroin and that
internet was commonplace. subjects were consuming higher than recommended
doses:
The same study also observed that tablets were
being sold (and used) by people who were also I am after taking 6–7 sticks [Sticks
involved in the heroin market: are a potent form of street Xanax,
approximately equivalent to 2 mg Xanax] now
[before interview]. I could take 20–30 of them
Often, their supply of benzodiazepines
a day. I buy sticks over Xanax because they
was from the same supplier as their
are stronger. They are sent back from Spain;
heroin and as such, BDZ usage perpetuating
they are charging a fortune for them. I take
heroin usage was evident.
Upjohn 90s [1 mg Xanax] as well, maybe
10–15 a day.
Although that study was focused on Limerick, it
seems reasonable to assume that similar forces
might be at play in Dublin and other areas in
Ireland, and that such patterns fit with experts’
understanding of the situation in Dublin (personal
communication: Ana Liffey Drug Project, 2019).
However, in the context of non-traditional actors,
the ability to access the market online, particularly se in Ireland 25
Street Tablet U
However, the increased online availability of tablets
is likely to be engaging different cohorts of people,
5.4 What substances are being
including those who are self-medicating with tablets marketed?
at doses closer to recognised therapeutic levels.
Experts involved in treatment have noted that some In terms of what substances are being
new presentations to their clinics have included marketed in street tablets, feedback from
patients who fit this profile. front-line services familiar with the market
indicated the mid-2019 availability of the
A third possible role for tablets in the market is to
following on the Dublin street market:
ease withdrawal or comedown symptoms for other
drugs. A number of experts noted the increase
in cocaine purity, and also the presence of both • Tranax (alprazolam)
cocaine and tablets in a number of drug-related • Zimovane (zopiclone)
deaths in recent years, both of which lend some
• Valium (diazepam)
support to this belief. Finally, tablets appear to be
both widely and consistently available, and can • Dalmane (flurazepam)
play a role in satisfying demand when there are
• Lyrica (pregabalin)
shortages of other drugs on the illicit market.
Analysis from seizures conducted from 2017 to 2019
indicates that all of these substances have been
present, with alprazolam being by far the most
frequently encountered substance, accounting for
over 50% of detections among the listed drugs
in this period. Of note is the detection in testing
of substances not included above, in particular
etizolam (a thienodiazepine derivative, which is
a benzodiazepine analogue) and diclazepam (a
functional analogue of diazepam).26 Street Tablet U
se in Ireland
6 HARMS ASSOCIATED
WITH THE USE OF
STREET TABLETS
A number of physical, mental, and
social harms are associated with the
non-medical use of pharmaceuticals. As
previously mentioned, drugs which are
commonly misused in tablet or capsule
form in Ireland include benzodiazepines,
Z-drugs, and gabapentinoids.14 General
harms related to the use of these
substances are described in this section. se in Ireland 27
Street Tablet U
Data have suggested that the short-term usage
6.1 General harms of hypnotics such as Z-drugs has higher risks
than long-term usage on a per-dose or per-unit-
6.1.1 Benzodiazepines time basis due to their potential for respiratory
suppression.33 A meta-analysis of available
Benzodiazepines are a group of central nervous placebo-controlled randomised clinical trials also
system depressants which induce feelings of calm, showed that hypnotics may cause infections
drowsiness, and sleep. While benzodiazepines (p < 0.00001), including increased risk of fatal
can relieve stress, anxiety, and tension, they may pneumonia.34 Z-drugs have also been linked to
also induce short-term memory loss. In addition, depression;35 in combined clinical trials, participants
they may lose their effect after only two weeks randomised to hypnotics suffered 2.1 times as
of continuous use and may no longer effectively many incident depressions as those randomised to
control anxiety after four months of regular use. As a placebo (p < 0.002).
subjects can develop tolerance and dependence,
As with benzodiazepines, tolerance to Z-drugs
long-term use of benzodiazepines is not
can develop rapidly and efficacy diminishes with
recommended.29
prolonged use. In addition, subjects who take
Z-drugs can experience withdrawal symptoms
if they stop suddenly. These symptoms range
Other harms associated with the use from mild dysphoria and insomnia to ‘withdrawal
of benzodiazepines14,30,31 include the syndrome’ – which may include abdominal and
following: muscle cramps, sweating, tremors, and convulsions.
• They are dangerous if a user stops taking them
suddenly, with symptoms that include anxiety, 6.1.3 Gabapentinoids
confusion, and serious convulsions.
Gabapentinoids (pregabalin/gabapentin) are
• Mixing benzodiazepines with other substances, licensed for the treatment of epilepsy, postherpetic
such as alcohol or heroin, increases the risk of a neuralgia, fibromyalgia, neuropathic pain, and
fatal overdose due to respiratory failure. general anxiety disorder. Although it is believed
• Injecting tablets or capsules may cause that addiction liability for gabapentinoids is low at
septicaemia, abscess, thrombosis, gangrene, therapeutic doses, it has been noted that misusers
loss of limbs, or death. Injecting tablets also are likely to be individuals with a history of
increases the risk of contracting HIV and recreational drug use who consume doses three to
hepatitis C virus if injecting equipment is shared. 20 times the normal medicinal dose.36
• Flunitrazepam (a benzodiazepine) has been As with other misused pharmaceuticals,
linked with ‘date rapes’ and sexual assaults. gabapentinoids are usually swallowed, but there
are reports of other forms of use, such as crushing
and injecting, with concurrent risk, such as vein
damage, circulation problems, and transmission
of blood-borne viruses.14 There are also reports of
6.1.2 Z-drugs
snorting tablets, which may lead to nasal tissue
damage and respiratory problems.
Z-drugs are a class of non-benzodiazepine
hypnotics, such as zolpidem, zopiclone, and Importantly, gabapentinoids may have an
zaleplon. As with benzodiazepines, Z-drugs adverse effect on the central nervous system
have hypnotic qualities and are commonly when used in combination with other substances,
used as a front-line treatment for insomnia. which include even small amounts of alcohol,
Side-effects associated with the use of Z-drugs antidepressants, antiemetics, antiepileptics,
include impairment in judgement and dexterity, antihistamines, antipsychotics, and barbiturates –
forgetfulness, and confusion. A 2017 study32 with a risk of respiratory failure, coma, or death.30
concluded that there is sufficient, converging A University of Helsinki review of pregabalin and
evidence from epidemiological and experimental gabapentin involvement in opioid overdose deaths
studies to establish a strong causal connection reported that pregabalin misuse with high doses
between Z-drug use and motor vehicle is increasingly common and can be fatal when
accidents, falls, and fractures as a consequence combined with opioids.37
of psychomotor impairment. Other paradoxical
effects include aggression, disinhibition, and
irritability.1428 Street Tablet U
se in Ireland
Trends over time demonstrate an increase in
6.2 Individual harms in Ireland the number of self-poisoning cases involving
benzodiazepines (see Figure 3). In 2018, there were
This section reports on data from the Republic of
834 discharges, a 34% increase on 2015, when there
Ireland regarding medications involved in non-fatal
were 623 discharges involving this category of drug.
emergency hospital admissions, intentional drug
overdoses (IDOs) involving gabapentinoids, and Between 2016 and 2018, there was also an increase
drug-related deaths involving prescribable drugs. in the number of self-poisoning cases involving
antiepileptic and sedative-hypnotic drugs (see
Figure 4). Although the HIPE data do not allow a
6.2.1 Non-fatal emergency hospital breakdown of individual drugs implicated, in 2017
cases involving medications there were 311 discharges involving antiepileptic and
sedative-hypnotic substances, a 14% increase on the
HIPE is a computer-based health information previous year.
system, managed by the Economic and Social
Research Institute (ESRI) in association with the
Irish Department of Health and the HSE. It collects 6.2.2 Intentional drug overdoses
demographic, medical, and administrative data involving pregabalin or gabapentin
on all admissions, discharges, and deaths from
acute general hospitals in Ireland. Started on a Concerns about the misuse of gabapentinoids,
pilot basis in 1969, it was subsequently expanded including their consumption in IDOs, have
and developed as a national database of coded developed in recent years. Gabapentinoid misuse
discharge summaries from the 1970s onwards. Each appears to be frequent among illegal drug
HIPE discharge record represents one episode of users38,39,40 and addiction treatment patients – of
care; each discharge of a patient, whether from which a minority have been prescribed the drug.5,41
the same or a different hospital, with the same or A 2018 Irish study by Daly et al.42 examined trends
a different diagnosis, gives rise to a separate HIPE in the prevalence of gabapentinoids taken in IDOs
record. The scheme therefore facilitates analysis of in Ireland, the profile of individuals taking them, and
hospital activity rather than of disease incidence. associated overdose characteristics.
HIPE does not record information on individuals
By examining presentations to emergency
who attend emergency departments but are not
departments involving an IDO, recorded by National
admitted as inpatients.
Self-Harm Registry Ireland between 1 January 2007
and 31 December 2015, this research found that se in Ireland 29
Street Tablet U
gabapentinoids were involved in 2,115 (2.9%) of the 6) and involved a significantly greater median
72,391 IDOs recorded. Presentations involving a quantity of tablets (30 vs 21, p < 0.001), with over
gabapentinoid increased proportionally from 0.5% one-quarter (27.4%) of these involving the ingestion
in 2007 to 5.5% in 2015 (see Figure 5). The majority of 50 tablets or more. In addition, it was found
of IDOs involving a gabapentinoid were made that admission to hospital was significantly more
by females (59.9%), with over one-third (37.2%) common following IDOs with a gabapentinoid
involving alcohol. Compared with IDOs involving compared with those without (49.4% vs 41.4%, p <
other drugs, presentations with a gabapentinoid 0.001).
were made by persons who were older (see Figure
900
850
Number of discharges
800
750
700
650
600
550
500
450
400
2015 2016 2017 2018
Year of discharge
Source: HIPE, Healthcare Pricing Office (2019)
Figure 3: Trends in the number of self-poisoning discharges
from Irish hospitals involving benzodiazepines, 2015–2018
320
Number of discharges
310
300
290
280
270
260
250
2015 2016 2017 2018
Year of discharge
Source: HIPE, Healthcare Pricing Office (2019)
Figure 4: Trends in the number of self-poisoning discharges from Irish
hospitals involving antiepileptic and sedative-hypnotic drugs, 2015–201830 Street Tablet U
se in Ireland
30
25
Percentage involvement
20
in all IDOs
15
10
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015
Year of presentation
Source: Daly et al. (2018)
Figure 5: Percentage of intentional drug overdoses involving a gabapentinoid, 2007–2015
30
25
Percentage involvement
20
in all IDOs
15
10
5
0
2007 2008 2009 2010 2011 2012 2013 2014 2015
Year of presentation se in Ireland 31
Street Tablet U
6.2.3 Drug-related deaths Although opioids were the main drug group
implicated in poisoning deaths in Ireland in
involving medications
2016, prescribable drugs were implicated in 73%
(n=258) of all poisoning deaths for this year,
Established in 2005, the National Drug-Related with benzodiazepines being the most common
Deaths Index (NDRDI), which is maintained by the prescription drug group implicated. In addition,
HRB, is an epidemiological database of deaths by etizolam – a drug which is not registered as a
drug poisoning and deaths among people who use medicinal product in Ireland, but which may appear
drugs in Ireland, extending back to 1998. The NDRDI in street tablets – was first observed in the NDRDI
also records data on alcohol-related poisoning data in 2014 and was also recently detected in
deaths and deaths among those who are alcohol 3.5% of 200 urine samples from patients attending
dependent, extending back to 2004.16 the HSE National Drug Treatment Centre (NDTC)
Figure 7 shows poisoning deaths in Ireland involving who are monitored on a regular basis for drug and
benzodiazepines and antiepileptic and sedative- alcohol use.43
hypnotic drugs for the years 2010–2016. The results
demonstrate an overall increase in the number
of deaths involving alprazolam, zopiclone, and
pregabalin. In particular, pregabalin-related deaths
have risen year on year between 2012 and 2016,
with an increase of 33% between 2015 and 2016 and
an overall increase of 364% from 14 deaths in 2013
to 65 in 2016. It should be noted that pregabalin
has only been included in the routine postmortem
toxicology screen by the State Laboratory in Ireland
since 2013.
75
Flurazepam
65
Number of deaths
Alprazolam
55
Etizolam
45
Zopiclone
35
Pregabalin
25
15
5
2010 2011 2012 2013 2014 2015 2016
Year
Source: NDRDI (2019)
Figure 7: Poisoning deaths in Ireland involving benzodiazepines and antiepileptic
and sedative-hypnotic drugs: main specific drugs implicated, 2010–2016You can also read
