JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 20 Mar 2003

Vol. 1 No. 5

Alcohol Consumption: Presentation.

Chairman

We are now in public session. I welcome Dr. Eamon Brasil from the Mater Hospital, Dr. Mary Holohan from the Rotunda Hospital, Dr. Chris Luke from Cork University Hospital, Dr. Tony Martin from Galway Regional Hospital, Mr. Coleman O'Leary from Limerick Regional Hospital and Dr. Paul Gaffney from Castlebar General Hospital. I will ask each consultant, commencing with Dr. Brasil, to make a contribution on the high level of alcohol consumption among young people and the effect this is having on accident and emergency services nationwide. We will revert then to questions and answers from members. Many members are away at present and I have received apologies from a number of them. I hope, however, this will not detract from the main focus of the meeting.

I draw the witnesses' attention to the fact that members of the committee have absolute privilege, but that this does not apply to witnesses appearing before it. I also remind members of long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the House or any official by name or in such a way as to make him or her identifiable.

Dr. Eamon Brasil

The emergency department of the Mater Hospital, which is situated in the inner city, deals with approximately 60,000 patients a year. In October 2001, we performed an audit of about 1,500 consecutive attendances to the department - which would work out at roughly a week on a 24 hour basis - to see the effects alcohol had on patients. We received completed forms in respect of 76% - just over 1,000 - of those cases. Alcohol was a factor in 24% of all attendances. On a 24-hour basis, 13% of those presenting were deemed by medical or nursing staff to be clinically intoxicated. Consumption of alcohol was the direct cause of the presentation to the emergency department in 10% of cases and indirectly involved in approximately 14% of cases. If we look at the timeframe, almost half of the attendances in which alcohol was a factor occurred after midnight. Surprisingly, however, 17% of attendances occurred between 8 a.m. and 6 p.m.

The final matter we considered was the average alcohol consumption of patients presenting to the emergency department, regardless of whether alcohol was a factor in their presenting. Some worrying figures emerged in that regard. In the case of women, where the cut-off would be 14 units of alcohol per week - anything above that would be unhealthy - we found that 10% were drinking between 15 and 35 units and approximately 7% were drinking in excess of 35 units per week. The figures were worse for men, with 21% drinking between 20 to 50 units per week and 13% drinking in excess of 50 units of alcohol per week.

This has a significant impact on an inner city emergency department. We categorise patients in two ways. There are chronic alcoholics who attend on a regular basis with the long-term effects of alcohol abuse, namely, liver disease, depression and psychological and cardiac diseases. The other category are young binge drinkers who consume too much at weekends and end up involved in fights, having falls or being involved in road traffic accidents. This has a significant impact on how we operate.

From an "on-the-floor" point of view, we see between 150 and 180 patients a day. Of these, 25% would have consumed alcohol and 13% would be clinically intoxicated. We are, therefore, looking after approximately ten drunk patients a day and we spend most of our time waiting for them to sober up in order that we can fully assess them. This has an impact on physical space in the department. It is quite a problem for an inner city hospital.

Dr. Mary Holohan

I am a consultant obstetrician and gynaecologist, rather than an accident and emergency consultant. I am the director of the sexual assault treatment unit in the Rotunda Hospital. It is through my work in this area that I have become aware of the significant problem that alcohol consumption is causing among young people. A total of 60% of the clients we see at the sexual assault unit have ingested alcohol.

While the background incidence has not increased in the past ten years, the pattern of alcohol ingestion by our clients has changed markedly since the middle 1990s. Spirits are being consumed at home before people go out. Younger clients are drinking in mixed sex groups, often in parks or abandoned buildings. While boys continue to drink beer, in the main girls are drinking undiluted spirits. Later, in clubs and bars, the concentration of alcohol in the individual drinks being consumed is very high, often three or four units in a single drink, as the youngsters call it. Also worrying is the fact that alcohol is mixed with stimulants. The median number units of alcohol remembered by clients coming to us is eight but 20% of our clients in the past three years remember ingesting 12 to 22 units.

The worrying aspect is that between 1998 and 2002 there was an increase, from 6% to 27%, in the number of cases where we were asked to evaluate the possibility of a sexual crime because the person concerned could not remember what had happened. It has been suggested that these cases are due to the administration of drugs - drug facilitated or drug assisted rape. While the drug especially named in this context is Rohypnol, administered by the assailant, we do toxicology testing and have never had a positive for Rohypnol. However, the toxicology service has remarked to us that the levels of alcohol in the samples we send are only seen in one other service - the coroner's office. The girls concerned are comatose from drink. In the majority of cases of memory loss, we cannot determine if a sexual incident has occurred. Psychological recovery is hampered in that respect.

In Irish law the alleged perpetrator is guilty of rape if intercourse occurs in circumstances where the victim cannot give full consent. This includes incidents where the victim has consumed significant amounts of alcohol. However, the perpetrator is frequently very drunk also and finds himself being questioned by the Garda regarding a crime of which he has no memory and which may not have occurred.

This is just one aspect of the problem of excessive consumption of alcohol that especially affects young girls. There are certain strategies we should examine to deal with this issue, one of which is the reduction in the profile awarded to drugs such as Rohypnol as having a significant role in facilitating rape. I thank committee members for their attention.

Chairman

Thank you, Dr. Holohan. I now call Dr. Chris Luke from the University Hospital, Cork.

Dr. Chris Luke

I have been an accident and emergency consultant for the past ten years, seven of which I spent as a consultant in Liverpool in one of the biggest adult emergency departments in Europe where we had an enormous problem with youth culture substance misuse, particularly drinking. I have a long-standing interest in preventive health initiatives to deal with problems ranging from joyriding to night-clubbing and so forth. I concur with my colleague, Dr. Holohan, that the date rape drug idea is an urban myth.

Alcohol misuse is an enormous problem, one of the top three problems for accident and emergency departments both here and in the United Kingdom. As scanty figures are available for the epidemiology of alcohol in Ireland, we can usefully refer to the figures available in the United Kingdom where the issues are broadly similar.

Alcohol related presentations to accident and emergency departments here occur in four major categories. I will refer briefly to my single paper submission. Patients are either acutely intoxicated, in which case they come in following accidents, injuries, assaults or with impaired consciousness - if intoxicated, they are difficult to manage - or come in suffering from the complications of long-term alcohol misuse, which include liver dysfunction, strokes and blood pressure in young people, or alcohol withdrawal syndrome, which means they are in a state of agitation, paranoia, engage in violent behaviour or have seizures, or notably, because they are the third party victims of those who are drunk on the street. The majority of cases of child abuse and domestic violence and most cases of public disorder and violence on the streets of our cities are associated with drunkenness.

Let me give some crude figures to indicate how alcohol pans out in terms of its incidence. Summarising the figures available over the past ten years, over three quarters of patients attending the big accident and emergency departments in our cities after midnight are intoxicated. Between half and three quarters of all assault victims have been assaulted in alcohol related incidents. Over half of all serious road crashes involve alcohol. Just over 50% of domestic violence cases against females are alcohol related. In addition, there is a great degree of inappropriate ambulance misuse. At least 20% of inappropriate ambulance call-outs are due to alcohol intoxication.

These figures are broadly extrapolated from the United Kingdom but comparable with my experience and that of others in this country. While we are similar to the United Kingdom, we are probably worse because we have fewer resources. Reportedly, Ireland is second only to Luxembourg in per capita consumption of alcohol, and our young people are said to drink more than anybody else.

In preparation for this session we examined an entire weekend's work in the Mercy Hospital in Cork city centre, two or three weekends ago, and found that between 15% and 20% of all attendances were alcohol related. This meant they were either intoxicated or the victims of chronic alcohol misuse or people who were intoxicated.

I have put down in my paper one or two thoughts about what we might do to reduce the problem. I have said, somewhat light-heartedly, that doctors are part of the problem. They have some interesting ideas and can offer some leadership but the solutions lie with people like alcohol specialist nurses who have been effectively deployed in large emergency departments throughout the United Kingdom in the past five years. They are professionals recruited from the experienced nursing staff of accident and emergency departments, for example, and take the lead in dealing with alcohol issues. They educate their colleagues and keep an eye on the figures for alcohol related presentations. They give feedback to their staff and lead the response in terms of detoxification, rehabilitation and follow-up.

It is not a matter of whether alcohol marks the final straw for the health care service. It also presents a golden opportunity for intervention. Doctors have traditionally been very nihilistic about alcohol. They have wrung their hands in despair and looked elsewhere but if we take a slightly more proactive view and realise there is an opportunity in accident and emergency departments to prevent much of the dereliction in homelessness, for example - many homeless people who come to us have increasing brain injury as a result of alcohol consumption - by providing for appropriate nutritional support and vitamin supplementation and following up in the community, there is an opportunity to reduce the overall workload of the health care service in the future.

Dr. Tony Martin

I have a slightly different attitude to alcohol than most other speakers. We recently breathalysed one in five people who passed through our department over a period of one week and found the incidence of alcohol abuse to be approximately 12%. There were other cases which may have been alcohol related but those involved had sobered up by the time they saw us. The main age group was 20 to 30 year old males. There was another blip involving 60 to 70 year olds which interested us. Occasionally, females were very drunk but mainly after midnight.

The main problem period was between 12 midnight Thursday night - students night out in Galway - and 2 a.m. Friday morning, which we had long suspected. We find that most people attend us because of assaults and what we call collateral damage due to alcohol. During the day we get people who are alcoholics from detox programmes but personally I do not have much experience of this. I am not saying it does not occur but it does not go past me as often as other cases.

I have said for some time that when people who are drunk are put on the street at the same time, there will be trouble. When people drink to deadline, there is also trouble. I have not visited a pub for a year or two and I am not sure about closing times but when they drink to a deadline, people drink two or three drinks very quickly, their alcohol level rapidly hits the ceiling and they become footless. This is the danger time. I propose a number of solutions to this, one of which would be to abolish closing time. Others include a ruling, as in Finland, that drinkers can have only one drink in front of them at any one time. They should not be allowed to buy rounds. If a person goes out with four others, he or she is expected to drink five drinks. If people were only allowed to buy one drink, they could never have one lined up. They would not drink to the deadline and would not be forced to drink too much.

Affluence has much to do with the collateral damage. As we can afford more, we drink more. I am especially worried about stimulant drinks, especially those taken by young girls. Heretofore, people drank a certain amount, got drunk and began to lose control. Stimulants allow them to drink more, keep going and get ossified. They are also in control and do damage if they want. A drunk with a stimulant drink can engage in an assault whereas a drunk without it would probably miss and fall over.

When the first drink driving laws were introduced, they were strictly enforced over the Christmas period eight or nine years ago. The number of RTAs, road traffic accidents, in our department was reduced by 67% over the period. A strict enforcement of the drink driving laws and the penalty points system influences people. In Japan there is a law that if one is a passenger in a car with a drunk driver, the passenger is guilty of co-operating with a drunk. The same goes for any other crime.

We need to look at these matters, including asking people to leave pubs at the one time. They all congregate in fast food restaurants where they do not queue but fight. These are the big problems. Perhaps food should be available in pubs to serve to people before they go home or perhaps there should not be a closing time. Perhaps pubs should be closed down. To move the closing time by one hour is irrelevant, it is either imposed or not.

We have a different psychological attitude to drink in Ireland. People on the Continent drink with their meal over a number of hours. While they may drink as much, they do not drink as quickly and do not attain our levels of alcohol. That is one of our problems.

Dr. Coleman O’Leary

I am the accident and emergency consultant at Limerick Regional Hospital, or the Mid-Western Regional Hospital as it is now known in Limerick. While I have no specific figures for the percentage attendance of patients in my department who are intoxicated with alcohol, I have a strong suspicion that they range somewhere between 4% and 20% of the entire practice we see, 55,000 patients per annum. My unit is similar in size to most of the major units in the country. The predominant difference is that Limerick is a smaller city and, essentially, a traditionally non-university city, being the home of a new university for the last ten to 15 years.

The problem concerning alcohol and its use in young people is prevalent in Limerick. Abuse with alcohol gives us at least one victim per night, predominantly a young female drunk to coma levels who appears to be the subject of a specific pattern of crash drinking. A previous generation may have taken to drink driving but among the young crash drinking is now the issue.

Alcohol is a huge area of concern in all forms of accident and emergency presentations. It has a role as a disinhibitor, removing societal safeguards or boundaries from all patients and persons. Its effect in terms of causing significant amounts of road trauma is reducing. Road trauma is also reducing, thanks to recent helpful legislation.

With regard to personal harm, the disinhibition effect of alcohol is almost a sine qua non, in that somebody who takes sufficient quantities of alcohol will now, either by being over-loquacious, voracious or mischievous, assault the person alongside them. It is an extremely difficult circumstance and very difficult to control.

Personal relationships, divorce and violence in the home are not significant factors of which I am aware in terms of presenting to an emergency department consequent on a single episode of alcohol abuse. They may be substantially involved in other more chronic sustained episodes of abuse but not in the context of acute presentations.

My predominant concern is with the young female, particularly those within the 12 to 15 year age group, those we would regard as doing the junior certificate or middle grade examinations at second level. The drinking appears to be designed to suit the pocket. There is massive sudden indulgence in spirits, possibly followed by one or two fruit drinks. The sustained use of designer spirits may well facilitate this. I have had recent experience of at least three cases, one involving a massive sudden indulgence of vodka alone, that is, half a bottle, in a 15 year old. We were told it was her first night drinking and within an hour she was in a deep coma having vomited repetitively in the interim.

The pattern seems to be to drink as much as possible in terms of concentration of alcohol initially to be blitzed. If a recovery is made, well and good. It is a very significant problem and a common feature with most young female drinkers.

With regard to young male drinkers, the traditional volumes of alcohol are sustained but at a younger age group. However, because of the volume involved, they usually tend to vomit earlier with the result that the system is cleared. They then suffer from the after-effects of being inebriated. Violence is involved in many of these episodes. In many instance they are the victims and found wandering the streets of our cities in various states of disarray and having lost more than one article of their clothing. They are sometimes found lying in areas they have no recollection of being to.

This is a significant problem in Limerick and many other cities. Particularly in Limerick, it appears a younger age group is involved in the most sustained drinking, perhaps because their older siblings have moved to the larger urban areas or areas where it is more acceptable. They can get quietly drunk in clubs, pubs and domiciles of their own.

Dr. Paul Gaffney

One of the problems with speaking last is that most of what one has to say has already been said. Rather than wasting time, I will dwell on points that may differ from what has been already said. Unlike my colleagues, I come from a county hospital which is somewhat different from practising in a bigger town or city. Nonetheless, alcohol is, without doubt, a significant problem for our accident and emergency service on a day-to-day basis.

From my experience and in the context of background research I have carried out in this area over recent days, I would make the following points. Alcohol presenting acutely in a teenager after a binge is a well recognised cause of sudden death, whether as a result of coma, aspiration, pneumonia or hypoglycemia, all recognised killers of young people following acute bingeing on alcohol. Presentation following chronic alcohol use has already been covered by a previous speaker. Alcohol is strongly associated with interpersonal violence, road traffic accidents and deliberate self harm, whether by physical or chemical means.

One point that may not have been emphasised is that alcohol is strongly associated with violence and aggression against staff working in emergency departments. This is often verbal and can be physical and it has been well documented in the literature on emergency medicine. The effects can occasionally be serious, both physically and psychologically. The importance of this subject is emphasised by the fact that six of us have taken time out today to travel to Dublin or across the city to this committee, missing a day of our normal working lives.

All staff can be affected by this, not just doctors but clerical staff, ambulance staff and particularly nursing staff who are often in the front line and very much the first port of call for many patients. The relatives and friends of the genuinely sick, for whatever reason, can also be affected and can be very put out by drunken behaviour. Young people under the influence of alcohol can often demonstrate pack behaviour. While a hospital may be presented with one patient, he or she is often accompanied by four or more "mates". It might not even be the patient who is causing the trouble but his or her friends who are under the influence of alcohol. Alcohol, while traditionally taken in isolation, is now often taken by young people in combination with other illicit drugs.

The burden placed on accident and emergency services by alcohol is very significant and at times, particularly out of hours, is a massive drain on available resources.

Chairman

Thank you. That contribution was extremely helpful. I am glad the delegation took the time to attend the committee because we all regard this as an extremely serious subject and one that needs to be addressed.

A number of common issues ran through all the presentations. One is with regard to the emphasis on binge drinking among young people and the impact this is having on accident and emergency departments. A number of questions arise from that. In all of these cases, is there a problem in terms of self-concept with the young people involved? Have the members of the delegation a view on the issue of parental control given that some of those presenting at accident and emergency units are so young?

In many ways - this was signalled by Senator Henry - the use of rohypnol has exploded. That does not appear as being a contributory factor in regard to rape, and it is important that is stated. Is date rape given as an excuse by young females by way of explanation to their parents?

Dr. Martin

With regard to those who claim to have had their drinks spiked, there is a computer programme that records how much they drank and their alcohol levels. Invariably, they drank so much alcohol that they were comatose. In my view, alcohol was the only reason for that.

Parents sometimes must be called, particularly those of young girls though we also get young boys absolutely over the limit. The parents are always shocked and their reaction is, "Oh, not my child." They do not realise what is going on and that is a big problem. Children go out drinking, come home and go to bed and the next morning they are usually alright. It is not realised how heavily they are drinking until they take that extra amount and go over the top.

Dr. Luke

I support the suggestion that date rape drugs are an urban myth. I have been looking at this for six years in urban and metropolitan accident and emergency departments. Drugs have been screened for over five years and the incidence of benzodiazapine or rohypnol poisoning is tiny. I tell people that their drink was spiked, but only with drink.

I attended a conference on alcohol in Belfast last month where I heard of a study from Manchester pointing out the emergence of new drinking patterns. People are not just drinking pints or spirits and mixers; they are now drinking psychoactive alcohol in the form of flavoured alcoholic beverages. There are saccharine sweet drinks which have incredibly high alcohol concentrations, similar to whiskey, and young men and women may drink five or six of these in addition to spirits and mixers. They are as comatose or semi-comatose as they would be if their drink had been spiked.

Dr. Holohan

With regard to the self-concept of those involved, there is an attitude that, "My drink was spiked." There is a need among young people to believe that is what has happened rather than to accept that they have had far too much to drink. It is reported to rape crisis centres that people's drinks were spiked and that is why there is such a high reporting of the spiking of drinks by counselling services. Young girls feel a need to excuse their behaviour. We must find a way to move away from that in as tactful a manner as possible.

Parents are not aware of the level of alcohol intake engaged in by their children. Some years ago in October, I was trying to schedule the roster for my unit when the junior certificate results were about to come out. I had not been long as director of the unit and found that nobody wanted to work that night because the results were being released. None of my doctors would cover that night. It was no surprise that when I went back on the figures for that night and the night of results in the two previous years, it was the unit's busiest of the year.

I mentioned this to the Evening Herald which had contacted me about this. To be fair to the newspaper, it took my comments on board and that year and the following year there was a huge media campaign aimed at parents, telling them to be careful of their children on the night the results came out. Partly because of that, the level of attendance fell to none for the last three years on the night of the results. It is possible to do something to raise awareness among parents of the responsibilities they have to their children.

Senator Glynn

I thank the delegation for their presentations.

It is true that alcohol is a mood-altering drug, hence the various degrees of behaviour. The quietest person may take a few jars and become violent or start singing. The Chairman mentioned parental control. In many instances, the control lies with the children who control their parents. Do the members of the delegation consider that, as with other aspects of life, parents feel their children will drink and may as well do so with them rather than having them drink behind their backs? Is there a case to be made for encouraging parents to tell their children at 16 - I know that is below the legal limit - they may learn the uses rather than abuses of alcohol?

Chairman

Is that a question?

Senator Glynn

Yes. I am not so sure about the question of earlier closing because, as a Celtic race, we can be lead but we cannot be driven.

Regarding accident and emergency services, I worked in psychiatric services and inappropriate bed occupancy in psychiatric acute units is another problem related to the abuse of alcohol. I sympathise with the delegation. I know it is a major problem.

Deputy F. O’Malley

I apologise for being late. I was 20 minutes waiting for a train. I have read a little of the presentations, which to an extent concentrated on the very young who present in hospitals. It is quite alarming.

When the young person who was 15 presented - I cannot remember who mentioned it - were his or her friends giving information freely about the casualty, if I can use that term, because they were terrified? How is information gathered?

A softly-softly approach does not always work. We are seeing advertising which is horrific and revolting in its content but which is the only way progress will be made. People will have to realise that what is portrayed in these advertisements will happen to them when they are drunk. This is the only way to make them stop. Does the delegation find that people who get into dangerous situations with friends are terrified and change their behaviour?

I was interested in the comments on abolishing opening times, which was debated recently in the Dail in respect of whether the extended times have made this problem worse. I am inclined to agree with the latter view. When there is a deadline, people line up their drinks. However, I am not sure extending the time in which alcohol is available is the answer. The delegation has presented some solutions. Although everyone is aware of the problems, few people present solutions.

Regarding stimulant and psychoactive drinks, the delegation said they were in test tubes. What are they? Is there not a limit on the potency of alcohol available? These drinks sound highly potent. Are they in danger of being illegal? It sounds as if they should be banned. The associated cost to the State of this tolerated drug, as outlined by the delegation, is such that we only need to look at how alcohol is consumed and at its place in our society.

Dr. Luke

To address both questions, we should aspire to a continental culture of drinking where it is all in the open and families drink together. When one sees the cleavage between parents and children, there is concealment and therein lies the problem. People enjoy a drink and why not? It is a divine gift. However, we drink too much too fast and we should aspire to the continental system for solutions. There is a relaxed, sophisticated system where they drink in a familial environment and they mix their drinks with food over three or four hours. We all know this from our holidays abroad. They do not sell alcohol the way we do.

Regarding the test tubes, these are FABs, or flavoured alcohol beverages, which are pure alcohol with whatever colourings one wants - cooking colourings and flavourings. Due to the fact that they are so sweet, one does not have the sense of drinking the equivalent of brandy or pure vodka.

Mr. O’Leary

To answer Deputy Fiona O'Malley, I support Dr. Luke. The role of sugar in alcohol mixes is extremely important because it potentiates the effect of alcohol chemically. It enhances whatever fermentation takes place in some yeast alcohol and potentiates the effect of spirit. It can also mask the taste for human beings of what must be a very tasteless chemical drink.

Regarding Senator Glynn's points, it is important to have a mature attitude to drink. However, I know of no parent in this room who would allow their 15-year old to drink at home to the extent of intoxication or soiling themselves. The cost to the family economy would be enormous, but that is what is happening on the street. We might have a mature attitude to alcohol in this generation, but the younger generation seems intent on crash drinking very early. I do not know of any way out of that other than by limiting the supply of alcohol available to those in that age group. I favour the restriction in the supply of alcohol to those over 21, as is the case in many parts of the US.

There are other methods of dealing with addiction, such as photographing heroin addicts in the gutter in Vancouver and then showing them those photographs when they have detoxified. That is making a substantial difference as people are amazed by what they turn into. If we photographed young people when drunk and showed them the photographs as well as telling them to show those photographs to their mothers it would highlight family distress.

Dr. Brasil

As to where young people get their influences in drinking, family is one such influence. I have no problem with a family sitting down together for a drink. However, most problem drinking arises as a result of peer pressure. As has been said, one can have a cosy drink at home, but out in the real world one's friends in the pub will pressurise one to drink more. That is difficult to counteract. The continental system is different because there is no pub culture; here there is huge pressure from that culture.

Regarding the question about friends being astonished when they bring someone to hospital, the stark reality I see is that the friends do not come in with people. If I ever got into a state like that, God forbid, someone would look after me. However, I have noticed, both in the UK or Ireland, that people are abandoned and the friends keep on partying. If we are fortunate, someone turns up hours later to claim the person found in the street. They call an ambulance and that is the end of their responsibility. They carry on. It does not make a great difference for their friends to get into a state; they do not even see it.

Senator Feighan

I welcome members of the delegation and thank them for their frank presentation. I wish to preface my questions by saying that I ran a pub many years ago. I noticed men coming in and having a few pints, which did not seem to do any harm. I live over a shop in the middle of a town and I did not notice any major problems. Approximately ten years ago, however, I noticed students on a work scheme coming in. I could not understand that, after consuming two pints, they were drunk. I subsequently realised that they had been binge drinking before coming into the pub. This seems to be a huge problem. As a result of the affluence, confidence and sophistication of students, in particular, they are drinking at home and then going into pubs when their courses are over.

Should there be an extra tax on drinks such as shorts? Perhaps we should adopt the approach taken in states in America whereby one drink is put in front of people and the publican could be penalised if people have more than one drink in front of them. Should the alternative closing times be enforced so that there could be staged closing times in different towns such as 10 p.m., 12 p.m., 2 a.m. and 4 a.m.?

Deputy Connolly

Statistics bear out the fact that there is a major problem in the hospitals and accident and emergency units. Hospitals are fighting a losing battle. I would like to hear the doctors' views on the advertising industry, which seems to be winning the battle hands down. Advertisements are mainly aimed at children, suggesting that they will be a success if they drink certain drinks, including alcopops or shots containing spirits. The concept of someone beginning by drinking a shandy is gone by the wayside.

I would like to hear some views on how alcoholism is diagnosed. Is this a medical or psychiatric problem? Would alcoholism be better treated in a specialised unit where one could be detoxified or in a medical unit? The problem is causing the health service a great deal of money and my health board is putting a lot of resources into the community. Would it be better to treat people in specialised units because, regrettably, people are voting with their feet? When there is a problem, people attend hospitals such as St. John of God's in Dublin or Sister Concilio's in Newry.

Dr. O'Leary referred to the concept of film, education and so on. Should this be part of the education system, whereby children would be shown videos of a nice home atmosphere, nice company later, a few drinks and, suddenly, the whole thing goes wrong when they hit the fresh air? If this aspect was highlighted for children it would achieve a lot.

Dr. O’Leary

In reply to Deputy Connolly, I do not know if I recommended introducing a nice happy family and the schismatic effect on it of alcohol. I wanted to show the individual who was lucky to survive an episode of intoxication and self-soiling what they were like when we saw them. They should be able to take this home to their parents to show them what we saw the previous night. We could give them the soundtrack, which usually includes profanities and threats to kill nurses and medical staff. This is what happens on a nightly basis. That might prove therapeutic in a limited way.

I do not believe we should medicalise the use of alcohol, per se. It is fundamentally a behavioural problem, a legal problem, a problem on the streets and a problem for the Legislature. It is only when all these seem to have left a gap that the hospital services and A&E departments throughout the country have come into play. It is an issue for legal control. I believe that shots and designer drinks should be banned.

Dr. Martin

I am going to focus on what exactly alcohol does. Each measure of alcohol contains approximately 15 milligrams of alcohol. In England, a shot has ten milligrams. Each 15 milligrams increases the blood alcohol level of a young girl to approximately 33 and a young man to approximately 25. Girls are, therefore, more susceptible. It is maximally absorbed at 10% concentration and it is absorbed faster if one has a fizzy drink with it. If one has a vodka with a fizzy mixer, one will get a quicker shot than if one takes it concentrated. A person who takes a pint and a chaser has a much more rapid rise in alcohol than a person who just takes pure spirits.

When I refer to stimulant drinks, I am not talking about alcoholic drinks but to brand names, which I have been told I should not use. This contains no alcohol. It contains just caffeine and so on which stimulates one and keeps one going. It is a bit like four or five cups of coffee. This allows people to lose their inhibitions and still keep moving, which is when it becomes really dangerous. As the stimulation goes off, one goes right down and one has been able to drink more than is good for one. At approximately 150 milligrams percent, which is about six shots, most girls are "out on their ears". Anything over that is dangerous. Three double vodkas would put one out on one's ear.

In regard to closing times, in a particular town, if one closes a pub and leaves another open, people will just move from one to the other. It should be either all or nothing. If there is a deadline, people will down the drinks before they go out.

Dr. Holohan

I wish to comment on what Senator Feighan said about the role of the licensed trade. Young girls and young men are getting the alcohol somewhere if they are not old enough to drink. Perhaps their friends are going into off-licences and buying the drink for them. I do not think they are getting it primarily from their parents. Occasionally it is being taken from the home, but that is noticed quite quickly. Someone is buying the alcohol for these youngsters and, therefore, we must cut down on the sale of alcohol in off-licences to young people.

If we choose a legal age of 18, we must ensure that those who are drinking in pubs are over the age of 18. We must ensure that vintners are not selling to people who are already inebriated. This is against the law, which must be enforced. We must cut out the idea of a double measure of alcohol with an alcopop mix, which is three units of alcohol in one glass. This is common. We must cut down on the amount of alcohol per drink being given to young people.

We must also deal with the problem of youngsters congregating in parks. I live near a park and two nights a week a small group gather at the top of the hill to drink. I have not seen gardaí checking who is there, what they are doing there or whether they are old enough to drink. We have measures in place that we can enforce. We just have to enforce the law.

Dr. Luke

Like Senator Feighan, I have a confession to make. Both my parents were employed by Arthur Guinness. The phrase, "Alcohol, the ambiguous molecule" is apt. Alcohol presents many paradoxes. A recent paper from Australia suggested that alcohol consumption prevents more deaths than it causes.

Regarding the idea of moving to the continental system, I am convinced that much of the ability to change the system lies in the hands of publicans.

Chairman

I must interrupt. Deputies are required to attend in the Dáil for a vote. The committee will adjourn for 15 minutes. We will resume at 10.55 a.m.

Sitting suspended at 10.42 a.m. and resumed at 10.55 a.m.

Chairman

Dr. Luke, do you want to finish the point you were making?

Dr. Luke

It was directed at Senator Feighan and related to the paradox about the brewing and spirits manufacturing industry. I point to Guinness which was once associated with the employment or domestic life of a quarter of the people of Dublin. Both my parents were employed by it and I have had access to its medical records. I know that at the turn of the 20th century the medical service in Guinness was ahead of the NHS. There is a history of Quaker-like decency on the part of the industry. Therefore, to discount its role for good in this debate would be unhelpful and counterproductive.

I like to encourage people to adopt good practice and always refer to the project in Liverpool where we worked with Cream, the huge night club, which was threatened with closure because of difficulties at the door and so forth. It reached out for advice to the police, the city council and the health board. It got its act together and five years later became a multi-million pound global industry. A comparable club in a comparable city 40 miles away was closed down because it rejected the idea it was possible to be proactive and adopt good practice. We should encourage good publicans, good advertising and good brewing practices and move towards a genuinely sophisticated approach that encourages genteel as opposed to violent drinking.

Deputy Costello

I apologise for the delay in getting back; I was waiting for the Taoiseach's contribution.

Chairman

Is the Deputy a constituent of his?

Deputy Costello

He is my constituent, obviously.

I welcome the members of the delegation and thank them for their contributions. It could be said what they have told us is very sobering to say the least. It was amazing to hear there had been no proven incidents of spiked drinks being a contributory factor to people coming before the Rotunda Hospital sexual assault treatment unit. I assume the same applies in other areas. I was also surprised at the statistic that, apart from the samples mentioned by Dr. Mary Holohan, the only other excessive levels of alcohol found in the region were in the coroner's office.

I would like to ask about proprietors and publicans. When a person arrives at an accident and emergency department or sexual assault treatment unit, what happens if the case is drink related? Is there any follow-up by the Garda, for example? If a person arrives at an accident and emergency department having consumed a colossal amount of alcohol, such as 12 to 22 units, there is a reasonable suspicion that he or she was served alcohol in breach of the law or that somebody has provided alcohol for them from an off-licence. Other laws have been breached if the person in question is under the age of 18 years. Is there any mechanism for transmitting the names of the licensed premises attended by a young person before he or she arrived at an accident and emergency department or sexual assault treatment unit? If alcohol has been served to a person in an illegal fashion, the matter should be pursued. It seems that an extremely small number of publicans or proprietors of licensed premises are prosecuted in this respect. It is possible that action could be taken if a link was made between the person arriving at a hospital and the premises where the damage was caused. Do hospitals have a system of contacting the Garda to inform it that they suspect that a crime was committed?

There has been a great deal of criticism of drinks known as alcopops - soft drinks mixed with alcoholic spirits. Is there an argument for a distinction to be made between such drinks and beer or wine which do not have the same alcoholic volume as spirits? Most young people were raised on soft drinks and are easily tempted by dangerous drinks - spirits masquerading as soft drinks. The taste of alcopops is virtually the same as soft drinks but their alcoholic content is potent and deadly. Should there be a distinction between the age at which one should be allowed to drink alcopops and other drinks? One could be allowed to drink beer and wine at 18 years and spirits and spirit mixtures at 21. Can I ask the members of the delegation for their opinions on this suggestion? It has been argued that designer drinks should be banned altogether. It is possible that such a move would be preferable to drawing the distinction I have outlined.

What are the views of the representatives of the hospitals on mandatory identity cards? Public representatives are always being told by publicans that they cannot determine the age of a young person in the absence of such a card. It is said young people now look much older than young people of previous generations as a result of the way they dress.

Deputy Fitzpatrick

I am interested in Dr. Holohan's observations. She mentioned that the Evening Herald published a report about the levels of teenage drinking at the time of the year when examination results are issued. Does she think the matter could be taken further? It is obvious from what has been said today that accident and emergency departments have changed since I worked in them; they have become more horrific. Are video cameras used in such departments? If so, why is the footage not released into the public domain to be seen by the general public? As a parent, I feel people are not really aware of the extent of teenage drinking, the damage it is doing and the cost it is imposing on society. I agree with Mr. O’Leary that the responsibility for doing something about this matter rests with legislators. I ask him to outline on a single page the steps he would like to see taken in this regard. If he was a legislator, how would he tackle the problem?

Dr. Holohan

I would like to address the question directly put to me and the remarks made by Deputy Costello about information that could be given to the Garda. As the director of the sexual assault treatment unit in the Rotunda Hospital, I am encountering an acute situation as a consequence of staffing difficulties which result from the fact that doctors do not want to work in the area, rather than a lack of funds with which to pay them. The Garda is involved in 96% of acute cases which involve immediate alcohol testing as alcohol is a short acting drug. If the Garda is not involved, the people involved are seen during office hours the following day. A detailed statement is taken by the Garda and the blood removed for the purpose of testing for alcohol is sent to the State Laboratory. The continuity of evidence is maintained for a possible court scenario.

If there is a will to pursue publicans who serve the drink that causes damage, a formal statement is available to assist the investigation in over 90% of the cases with which we are involved. It is possible for the Garda to ask publicans the reason they served such a large amount of drink, based on the evidence we retain in acute cases. Publicans will claim that they did not sell so much alcohol and that those involved must have acquired it elsewhere, before or after being on their premises. The details of alcohol levels are available and could be used in court. The formal statement made by the client to the Garda is also available. It is possible to provide information for the Garda, although there may be difficulties in relation to the veracity of the statement if the publican says the alcohol was acquired elsewhere but it could be pursued.

Deputy Costello

Is the Garda contacted automatically when somebody arrives at a sexual assault treatment unit and alleges that his or her drink might have been spiked? Where is the connection made?

Dr. Holohan

Not many of the unit's clients approach it directly - most contact organisations such as the Rape Crisis Centre or the Garda which have the sexual assault treatment unit's telephone number. An appointment is usually made for an hour or an hour and a half after the first contact has been made. Those who contact the unit first are in a minority. The Garda is involved in almost all acute cases through the formal statement process. The unit measures the blood alcohol levels of all its clients for reasons other than those mentioned. It is in place for everybody if there is a wish to pursue the issue.

Deputy Costello

Has it ever been pursued?

Dr. Holohan

I am fairly certain it has never been pursued.

Deputy Costello

It has never been pursued by the Garda Síochána.

Dr. Holohan

Not in that sense, no.

Deputy Costello

In relation to contacting publicans where——

Mr. Brasil

Patients who arrive in accident and emergency departments in a comatose condition as a result of alcohol intoxication are either brought by ambulance or by the Garda Síochána. When gardaí find such people in the street and wonder what is wrong with them, they bring them to hospital. In a service that is over-run, as a consequence of a lack of funding, not a lack of people trying to help, one must ensure one does not take on too much. There is no possible way we could ascertain which publican served which patient and inform the Garda of the details. We cannot do anything if patients do not want to give such information.

More information on where incidents take place is needed to help us to provide emergency services. The Department of Health and Children has funded a research project which will start in the near future to examine the relationship between alcohol and injury. The study will focus on ascertaining where people who receive injuries are being served with a view to identifying problem areas. If 20 people in an intoxicated state arrive in an accident and emergency department from a certain night club each weekend, it may be possible in the future to penalise the night club.

The introduction of identity cards is a great idea, not only because they will prevent alcohol from being served but also because such cards are often the only means of identifying a person in a coma. It would be great, from our point of view, if people were obliged to carry formal identity cards. There should not be a distinction made between beer, wine and spirits. The problem is people's attitudes to drinking. Young people want to get blitzed and get drunk as fast as they possibly can. They will do it some way or other, so bringing in separate penalties for beer, wine or spirits will not make much difference. It is the attitudes of young people that must be changed.

Dr. Luke

I am going to over-lap with the previous speaker who hinted at the idea of naming and shaming clubs. We have started to do this in Cork, and we have had a couple of conferences with the Garda assistant commissioner and superintendent for the city. We have begun to compile details anonymously in the sense that we do not link the names of pubs or clubs with particular individuals. There are ethical and legal issues involved. Two years ago, we broached the idea of creating an index of offenders, and the club owners and publicans are coming to meet with the Garda and ourselves informally to have a quiet word and urge us to get our act together because they know what is happening.

The greatest deficiency in our entire approach is inadequate data. We do not have adequate figures and are only beginning to look at this issue now. I would like to see routine measurement of alcohol levels in accident and emergency departments. It should be done routinely as part of the medical or clinical process, without any palaver or equivocation. We can routinely build up the figures which can then give some impetus to legislation and to an overall response.

Mr. O’Leary

Just to reply to the queries put I, as the son of vintners, have an appreciation of the concern amongst vintners, who see abnormalities and criminality developing as a result of their justifiable trade. By and large, the ordinary vintner is not responsible for the problems that societal trends are imposing on them. They are suppliers, certainly, but they cannot be responsible for policing society. They should receive support. The problem with designer drinks and celebratory binge drinking is probably confined to certain clubs and non-traditional members of the licence trade. Massive sums of new money have been poured into the establishment of clubs, and it is extremely important to get a handle on regulation of this. Society and the Legislature must ensure strong policing of this element of club land. The ordinary vintner in the ordinary rural town does not need to be rigidly controlled. There is sufficient legislation in place already for that.

In terms of what could be done immediately to legislate for the excessive volumes of alcohol consumed, by very young girls in particular, the most outstanding initial advance that could be made would be to remove alcopops immediately from sale. If that was done, there would be a change in the volumes of alcohol consumed. Young girls may well still get drunk, but they would be much safer when they get drunk because the alcohol levels would be far lower.

I could draw a significant reference from a 1981 report on drunken drivers by the coroners of Meath, Kildare and Dublin, which recorded the alcohol levels of dead drivers. Dead drivers under the age of 25 had alcohol levels of approximately 125 milligrams, whereas dead drivers over the age of 40 had alcohol levels between 200 and 400 milligrams. The inference to be drawn from this is that young people are far less able to handle alcohol, an extremely important point. Young drinkers become lethally ill far sooner.

Dr. Martin

I go back to the issue of mandatory ID, about which the Chairman asked. It is probably essential, not just for young people but for everybody. People over a certain age are not expected to carry ID, so people can claim to be over 25 even if they are not. This leads to another problem, namely, young drunk people who we take in giving us the names of a friend instead of their own names. There are a number of cases at present where we sent bills out to individuals, only for them to point out that they were never in our accident and emergency department and that their name and address has been falsely supplied by somebody else. The record of being drunk is going onto the charts of the wrong people, which is a serious problem. For reasons other than just controlling access to alcohol, we need a mandatory ID system.

Chairman

We would not want to advertise that too loudly or the problem would increase even further.

Dr. Martin

Yes, it is a huge problem. We should distinguish between different types of drink. Wine is generally considered a drink to be consumed moderately with food, and if the objective is to reduce heavy drinking, it is illogical to tax it at the same level as drinks that are consumed purely for the purpose of getting drunk. Alcopops are aimed particularly at young people. The fact that they are called alcopops is something that needs to be redressed.

Chairman

A number of things are coming across quite clearly, and I would like to conclude with a number of recommendations. I sensed that we were reaching agreement in terms of banning alcopops altogether, but Dr. Brasil was emphatic in opposing a ban. Why is that?

Dr. Brasil

It does not address the problem, which is young people's attitudes to alcohol. Young people have been getting drunk for donkey's years. They may find alcopops a little easier to consume initially, but even if they were banned, people would find alcohol somehow. It would do nothing to decrease what I see on a daily basis. I see very few male drunks who would own up to drinking alcopops.

Chairman

What about a ban on advertising alcopops?

Dr. Brasil

Yes, I would support that.

Chairman

Is there general agreement on that?

Dr. Martin

It may be useful to ban the sale of stimulant drinks in places where alcohol is sold so that they cannot be consumed together.

Deputy Costello

Just to widen the discussion a little from alcopops, do people agree that any alcohol that is targeted at young people should be banned, or is that going too far? Like cigarettes in the past, drink has been marketed as forming part of an attractive, outdoor lifestyle. Many of the new spirits-based drinks, however, are directed specifically at young people. Should all advertising of such designer drinks be banned?

Mr. O’Leary

One of the things which concerns me about advertising and alcohol is the inter-sexual play that is made on many of the advertisements now with regard to drink. This advertising is not aimed at the outdoor lifestyle but is club-focused and sex-focused. It depicts the meeting of sexual partners and comparisons of attributes, physiological or otherwise. Advertising needs to be regulated. Last night I saw an advertisement on one of the satellite channels for a certain model of car. As the rear of the car is a unique design, the advertisement featured a shot of a moving female behind. This was how the car's main attribute was portrayed. A strange kind of advertising is developing. Perhaps we need to examine the advertising industry.

Chairman

The advertising code will be raised at our next meeting which will be attended by representatives of the drinks industry.

Deputy Fitzpatrick

I am glad to hear from this distinguished gathering that the older generation appears to be able to handle its drink a little better than younger people. They are probably more experienced.

Chairman

I thought our age group was in trouble too.

Dr. Martin

The age groups most affected are those aged between 20 and 40 years and over 60 years.

Chairman

Deputy Fitzpatrick still has a few years to go.

Deputy Fitzpatrick

Is blood testing not routine in accident and emergency departments?

Dr. Luke

This is one of the curiosities of the past 20 years. In the 1970s we used to regularly breathalyse people. However, clinical studies carried out, for example, in Edinburgh demonstrated that if a doctor can smell alcohol on a patient's breath, the patient is medically drunk, which rendered breathalysing no longer relevant to the medical management of patients. Therefore, it was discarded as additional work.

I suggest we routinely measure for both drink and drugs in the same way we measure for sugar and blood pressure. It would be good medical practice and, more importantly, we would obtain a much more accurate assessment from the point of view of public health and the national picture. Without such an assessment there is too much room for debate and dispute. We should be getting on with addressing the issue as we know what is going on. The problem is we do not have the figures to copper-fasten what we are saying which is the reason Dr. Holohan's figures from the Rotunda Hospital are so important.

Dr. Holohan

There are a few very effective advertisements on television. One, which relates to the wearing of seatbelts, has a major impact on me every time I view it. The second shows a man returning home from a football match and crashing his car through a garden fence. Both are shocking and effective. Some shocking advertisements on alcohol are also needed. They could, for example, show the physical state people are in when they attend accident and emergency departments or the effects of an assault on a person following binge drinking. One could even address the issue of possible sexual crimes, that is, people living with the possibility that they may have been sexually assaulted while drunk.

One could even go as far as portraying a young man being questioned by the Garda on the possibility that a sexual incident occurred in circumstances where nobody can accurately remember the events in question and that his life has been ruined due to a night out drinking. The National Safety Council has a role to develop some advertisements in this area to frighten young people into behaving a little more responsibly and alerting their parents.

Chairman

It would also increase awareness among parents of what is happening in accident and emergency departments.

Mr. O’Leary

The financial costs to society of the effects of the misuse of alcohol are enormous. We need to bring home much more clearly to those who chronically abuse alcohol that there is a cost not only to themselves, but also to the wider economy. For this reason, they should be penalised by the Garda for the costs they impose on the health service by attending accident and emergency departments. This could be enshrined in legislation, for instance, patients who are ridiculously intoxicated and undoubtedly put other road users at risk could be charged with failure to take care of one's person. A recent television programme on alcohol would lead one to believe that driving through Dublin at night is more hazardous for drivers than for pedestrians, many of whom are so intoxicated they fall onto the street.

Dr. Gaffney

To follow on what Dr. Holohan said, as many accident and emergency departments have closed circuit television, it would be easy to get a picture of what happens in waiting rooms when people arrive in a drunken state. The one issue that would be important to us is confidentiality. However, provided certain constraints such as blacking out faces are imposed, the issue could be easily addressed.

Chairman

I do not believe we will or could go down that road. However, as is the case with some of our other shocking advertisements, it would be easy to concoct a scene and make people aware of the problem.

Deputy Fitzpatrick

Is there anything stopping hospitals routinely testing for alcohol and drugs persons presenting to accident and emergency departments? Is it possible to introduce notices such as the surgeon general's warning on bottles of alcohol in the United States?

Deputy Costello

If there is routine testing for alcohol and drugs, is there anything to stop hospitals divulging the results to the Garda or asking patients where they consumed or purchased alcohol and divulging this information to the Garda to allow it to follow up the matter to ascertain if an offence has been committed?

Dr. Luke

I encourage all doctors in the city and county of Cork to routinely measure for drink and drugs. We are increasingly doing this and leading by example. Predictably, alongside high alcohol levels we are finding striking levels of hitherto unsuspected substance misuse. The reporting of named cases to the police is fraught. We do not have the resources in our overloaded departments to address these kinds of delicate forensic issues. Legal questions, which I would not be able to answer, would also arise and would require expert legal opinion. We need to make a start by gathering the figures.

Chairman

Have the witnesses established a link between those who present themselves at accident and emergency departments with drink related problems and suicide among young people? Is it possible to make a connection in this regard, given the substantial number of young people, in particular young males, committing suicide and the high incidence of parasuicide? Do accident and emergency departments have systems or programmes in place to allow people who are addicted to alcohol and possibly suffering from psychological problems or suicidal tendencies to be referred for psychological care and community care at a later stage? This kind of service appears to be absent in certain hospitals.

Dr. Luke

This is where the alcohol specialist nurse I suggested would come into play. Beyond dialogue and ideas, doctors have a limited role in terms of providing a solution. Specialist nurses, who combine the experience and capability of working in accident and emergency settings with a dedicated interest in alcohol, are required to identify and follow all the patients who present in accident and emergency departments with alcohol related conditions. While some patients are fortunate enough to be referred psychiatrically or psychologically, this currently takes place haphazardly.

Mr. O’Leary

The Mid-West Regional Hospital and, I understand, some of the Southern Health Board hospitals where ongoing research into suicide and its effect on society and patients concerned is well developed, have full clinical pathways in place. Certain steps and processes are triggered when patients are admitted at night who for whatever reason may have attempted suicide or overdosed. They are provided with access to psychiatric services within eight hours while still in hospital.

As to the role of alcohol in suicide, in my experience it is highly significant. Alcohol is the final disinhibiting trigger for those considering an overdose of medication. A couple of glasses of brandy or whiskey will sort out the problem straight away by disinhibiting the person from taking pills. Alcohol is present in almost every overdose case we encounter. I estimate it is a facilitating precipitant in 70% of cases.

Dr. Brasil

I agree with Dr. Luke about the need for a liaison specialist nurse dealing with addiction to alcohol and other drugs of abuse. John Sheehan did a study of in-patients in the Mater Hospital and found that 20% of them had drink-related problems. On the basis of that finding, he got approval for an alcohol counsellor for in-patients. We would like to see that service brought into an emergency department setting also, where the problem is just as bad.

Dr. Martin

One of the problems is cost. To provide this to everybody who comes to us on a 24 hours a day, seven days a week basis would probably require four or five extra members of staff. That very often inhibits what we want to do.

Chairman

It may save a lot of money, however, in the longer term.

Dr. Martin

It may, but it will not benefit our department. It may save a lot of people money down the road, but those savings are very often not forwarded to us, where the problems are initially addressed. Suicide and alcohol are very closely related, but very often, the first time we see victims is when alcohol and suicidal tendencies have already come together. Identifying in advance the people likely to end up in this situation is very difficulty.

Deputy Fitzpatrick

In political terms, teenage drinking and alcohol related problems are just beginning to enter public consciousness. We will not make any progress or do anything about the problem unless we get these figures, and they have to come from accident and emergency departments. These do not have to be individual figures but ball park figures. If we can get these figures into the public domain, pressure will then arise for a change in society.

Dr. Brasil

Yes, we need all the figures, but it will cost roughly €30 per person for alcohol screening and drugs of abuse screening. That is not including the person who is carrying out the screening. In my hospital, that means a cost of about €5,000 per day to do the test.

Dr. Luke

I am suggesting that patients who fit certain criteria are measured. I am not talking about blanket screening. That is important. Doctors know enough to suspect when to screen.

Dr. Holohan

I do not know if the committee intends to explore this issue at other meetings, but we must do something now. Liver specialists are already seeing a significant increase in the incidence of serious liver problems in women in their mid 20s. I am talking about cirrhosis of the liver, progressing on to liver disease. The Department of Health and Children will have to pick up that bill in years to come. We really must start doing something now.

Chairman

Thank you very much. There are a number of issues today on which we have general agreement, and the committee will take them up again in the future. There is general agreement on the need for identity cards. Some people believe that all citizens should have an identity card. There is general agreement that there should be a certain curbing of what we call stimulant drinks. There is general agreement that the situation in hospitals should be reflected in some way in advertising in order to raise awareness of the actuality of what is happening. There is general agreement that it would be extremely helpful to have a liaison nurse within accident and emergency departments. Ongoing co-operation and liaison between the Garda, accident and emergency consultants and the vintners is crucial. People can then be brought to account. It is ironic that there is security on the doors of various public houses, but then when people cause trouble inside, they are thrown out onto the street so that somebody else can deal with the problem.

This meeting has been extremely helpful, and I thank our witnesses for coming and giving us a better understanding of the harsh reality on the ground. We commend you on the work you are doing, despite all the difficulties. This committee will continue its investigation into this issue and will bring the various other strands and interest groups before the committee. Hopefully, we can then integrate all of the various factors and considerations into a report that will lead to greater understanding and higher levels of awareness in relation to alcohol.

The joint committee adjourned at 11.35 a.m. sine die.