Illicit and licit drugs and the harm associated with their problematic use have placed increasing demands on healthcare systems. Harm reduction is a pragmatic response to drug use and a means of minimising the risks. Many see it as a caring and compassionate response to people who use drugs and their health issues.
In July 2017, a new national drugs strategy, Reducing Harm, Supporting Recovery: A Health-led Response to Drug and Alcohol Use in Ireland 2017-2025, was published, which is helping to bring harm reduction into the mainstream (see panel, p15, left). However, the concept is still sometimes viewed as condoning drug use.
Mr Tony Duffin is CEO of the Ana Liffey Drug Project (ALDP). He has worked with the ALDP for 13 years and, since 1993, has dedicated his working life to people with multiple and complex needs.
“It makes sense to me, what we are doing here,” Mr Duffin told the Medical Independent (MI).
“It’s a practical response to people who are often extremely vulnerable and misunderstood. They need help and support. I work with a great team of people here who, on a daily basis, are dealing with certain challenging behaviours… and we work towards better outcomes and better goals. It is hard but enjoyable work.”
The ALDP was the first harm reduction agency of its kind when it opened in 1982 in Dublin’s north inner city. Back then, harm reduction, as it is conceived now, did not exist. The methods devised as part of a harm reduction framework are designed to help reduce the risk of blood-borne viruses and overdoses. ALDP has a ‘low threshold’ harm reduction ethos in which it does not promote or denounce substance use.
“Essentially, that’s at the heart of harm reduction,” Mr Duffin explained.
“As harm reductionists, we deal with what’s in front of us and so we have a drop-in service where people can come along and get help; literally, they just come in off the streets. Relationship-building is key in harm reduction because, of course, [while] it’s about methadone, needle exchange and other interventions such a naloxone… it’s important to engage with people who have often lost contact with many of the support networks in their lives.”
It is an opportunity to “create a rapport” and “enables us to promote positive change in people’s lives”.
There is often a belief that decriminalising drugs will lead to their legalisation and that harm reduction is almost normalising drug use.
“I don’t agree with [the idea that] harm reduction [is] normalising drug use. At Ana Liffey, we work with people who are already taking drugs, people who take drugs recreationally and I suppose that [is the area] where people think we are normalising drugs. We see drug use as a health issue. Drugs are illegal, but we are lobbying for decriminalisation.”
Mr Duffin emphasised that the response to drug use should be health-focused.
“Decriminalising people who use drugs for their own personal use and are in possession will hopefully be dealt with as a health response, not under the criminal justice [system]. We are not trying to normalise drugs; in fact, you could say that drugs are normal in society, whether it’s alcohol or caffeine. People take drugs. [However] people don’t know what they’re taking; there are risks involved with overdosing and blood-borne viruses and abscesses.”
Under current legislation, a person who is found in possession of a controlled drug for their personal use is guilty of an offence.
Mr Duffin said there needs to be a distinction between the regulation and control of drugs, and responding to those found in possession of drugs for personal use. He argued the latter should invoke a health-led response, rather than one involving the criminal justice system.
“At the moment, the Garda Síochána deal with this, but under a decriminalised environment you would have a system where people get referred to a health intervention.”
In November 2015, a report from the Joint Oireachtas Committee on Justice, Defence and Equality strongly recommended the introduction of “a harm reducing and rehabilitative approach, whereby the possession of a small amount of illegal drugs for personal use could be dealt with by way of a civil/administrative response and rather than via the criminal justice route”.
The Committee also recommended that “discretion for the application of this approach would remain with An Garda Síochána/health providers in respect of the way in which an individual in possession of small amounts of drugs for personal use might be treated”.
The new national drugs strategy committed to considering approaches in other jurisdictions to possession of small quantities of drugs for personal use. This was with a view to making recommendations on policy options to the relevant Minister within 12 months.
Specifically, the strategy committed to setting up a working group to examine the current legislative regime on simple possession offences and any evidence of its effectiveness; the approaches in other jurisdictions; the advantages and disadvantages and potential impact of any alternative approaches; identification of the scope of any legislative changes necessary to introduce alternative options to criminal sanctions for those offences; and a cost-benefit analysis of alternative approaches to criminal sanctions for simple possession offences.
This working group was established in December 2017 and will report in due course.
Cocaine use campaign
In light of an upward trend of polydrug use involving cocaine, and the increase in cocaine-associated deaths, the HSE and the ALDP developed a campaign focused on the harms of cocaine use and polydrug use (see panel, p15, right). “We worked closely with the HSE National Social Inclusion Office [and] Dr Eamon Keenan, who is the National Clinical Lead for Addiction Services,” according to Mr Duffin.
“We designed the campaign for two types of people; one being people who use cocaine powder, and the other being people who use crack cocaine.”
Posters were designed for social environments to inform people of the risks.
“The crack cocaine posters were designed for people who are maybe seen as problematic drug-users; people who might attend ALDP or other drug services, and these will hopefully engage with them, because we have a problem with crack cocaine in Dublin and other areas of Ireland.”
According to data from the National Drug-Related Deaths Index (NDRDI), there was 354 poisoning deaths in 2014. Two-thirds of poisoning deaths involved polydrugs, with an average of four different drugs involved. Benzodiazepines were the most common drug group involved in poly drug deaths.
Prescription drugs were implicated in three out of four poisoning deaths.
The benzodiazepine diazepam was the most common single prescription drug, implicated in one-third (32 per cent) of all poisoning deaths. Methadone was implicated in more than a quarter of poisonings (28 per cent), while zopiclone-related deaths (a non-benzodiazepine sedative drug) increased by 41 per cent between 2013 and 2014
Statistics released to MI under Freedom of Information law show there was a decrease of 3.5 per cent in benzodiazepine prescriptions to medical card-holders from 2015 to 2017 (314,167 to 303,080).
According to an ICGP spokesperson, “GPs mainly use online practice guidelines in their practices when it comes to guidance on appropriate prescribing of benzodiazepines and z-drugs.” The ICGP guidelines state that dependence on benzodiazepines is recognised as a significant risk in patients receiving treatment for longer than one month.
It warns that prescribers should check whether the person might have a tendency to misuse drugs or alcohol, or a history of same, and referral to a specialist addiction service should be considered in this instance before prescribing a benzodiazepine.
Meanwhile, campaigners such as Mr Duffin are calling for the greater availability of naloxone. This medicine is recommended by the World Health Organisation for treatment in opioid overdose cases. It reverses the effects of opioid overdose within minutes, but in Ireland it is only available by prescription.
“I would like to see naloxone available for free and without prescription at the counter, which is the case for other jurisdictions. Naloxone needs to be more accessible and we know that [the] more people can use it in a situation where someone is overdosing on opioids, then more lives will be saved,” Mr Duffin argued.
Training the spotlight on cocaine
Cocaine is more available and at its highest purity in Europe today than it has been in a decade, according to the HSE. It is the most commonly used illicit stimulant drug in Europe. Ireland ranks fourth-highest in the EU for use of cocaine among young adults. In fact, three out of 10 Irish people aged 15-to-64 say they have used illicit drugs in their lifetime (cannabis, MDMA or cocaine).
The recent public awareness campaign from the HSE and ALDP was designed to show how the harm associated with cocaine and crack can be reduced.
While it is always safest not to take unknown or illicit drugs at all, if a person chooses to take cocaine, the HSE has advised them to follow harm-reduction advice.
The HSE said that when buying cocaine, it is important for the person to know the source and avoid using the drug alone. It is also important for them to use one drug at a time, and to never mix the drug with alcohol. The HSE advises to start with a small test dose and leave at least two hours between use. It also says a person should grind cocaine to remove clumps, use a sterile straw and never share.
In terms of using crack, the HSE advises people to avoid using homemade crack pipes; to avoid smoking a full ‘rock’; and if injecting, to ‘start low and go slow’ to avoid overdose. If a person feels low after using, it advises them to seek professional help, and if they feel suicidal, to immediately go to a hospital or call 112.
Supervised injecting sites
There remains a serious problem in respect of public injecting in Ireland, where two people die every day from a drug-related cause.
In February 2018, the HSE confirmed that Merchants Quay Project would operate a medically supervised injecting facility (MSIF) in Dublin city centre on an 18-month pilot basis.
According to the HSE, supervised injecting facilities provide a clean, safe healthcare environment where people can inject drugs, obtained elsewhere, under the supervision of trained health professionals. “They offer a compassionate, person-centred service which reduces the harms associated with injecting drug use and can help people access appropriate services.”
These facilities can help health service staff “to reach and support vulnerable and marginalised people who often do not, cannot or no longer engage with existing health services”, stated the Executive.
A 2017 ALDP report examining street-based injecting in Dublin city centre highlighted the harms involved, including “evidence suggesting that injecting in public places is conducive to hasty injecting, leading to safety and hygiene concerns”.
Dublin-based GP Dr Garrett McGovern, who specialises in the treatment of drug and alcohol misuse, told this newspaper that the delay with opening the centre was “very worrying”.
“We thought we would have it opened last year, and now we are at the end of 2018, and it seems to me that I don’t know if we are any nearer the outcome that we are looking for,” according to Dr McGovern.
Mr Andrew Rooney, Communications Officer for Merchants Quay, told MI that “one of the main goals of a MSIF is to provide an opportunity for health interventions in a marginalised community”.
He added: “Our intention is to renovate the basement, which is currently not used at all, and integrate the MSIF within our existing drug and homeless Riverbank Centre, where we have doctors, nurses, a mental health team, a dentist and counsellors. All the international research shows that supervised injecting facilities are most effective when they have ‘wrap-around’ services.
“Regarding when it will be opened, we are keen to see this service operational as soon as possible, but we are required to secure planning permission. At present, we are engaging with planners, architects and engineers on our planning application to Dublin City Council. It is anticipated that this will be submitted in the near future,” stated Mr Rooney.
Mr Duffin noted that pre-hospital and hospital emergency services are expensive to run. As well as considering harm reduction as a humane approach, he says it also makes economic sense.
“If we can keep people from using their [emergency] services by providing dedicated harm reduction services, like injection facilities, you can save money elsewhere. Also, our client group here at Ana Liffey — many of which are seen as super utilisers of pre-hospital emergency care because of their health issues — they often have to use ambulances that take up resources. Of course, they need help, but if you are looking after people and keeping them as safe and healthy as they could be while preventing things like abscesses and overdose, you [are] immediately preventing the use of such services.”
He adds: “There are other services that reduce harm, such as needle exchange. The World Health Organisation does say that needle exchange helps reduce the incidences of HIV and hepatitis C in a population. It’s very difficult to motivate people when their health is deteriorating and to aid them in making healthier choices, and certainly you can’t rehabilitate someone who has died. Harm reduction is about saving lives and keeping people as healthy as possible, and by happy coincidence, saves taxpayers’ money.”
National drugs strategy suggests more dynamic approach
Reducing Harm, Supporting Recovery sets out the Government’s strategy to address the harm caused by substance misuse in Ireland up to 2025. It identifies a set of key actions to be delivered between 2017 and 2020, and provides an opportunity for the development of further actions from 2021 to 2025 to address needs that may emerge later on in the lifetime of the strategy.
The strategy aims to provide an integrated public health approach to substance misuse. ‘Substance misuse’ means the harmful or hazardous use of psychoactive substances, including alcohol, illegal drugs and the abuse of prescription medicines. The public consultation, which informed the strategy, highlighted changing attitudes towards people who use drugs, with calls for drug use to be treated first and foremost as a health issue. Ireland’s previous national drugs strategies covered the period from 2001 to 2008, and 2009 to 2016, respectively.
Both strategies aimed to reduce the harm caused by the misuse of drugs, through a concerted focus on supply reduction, prevention, treatment, rehabilitation and research. The new strategy also advocates a harm reduction approach, while placing a greater emphasis on supporting a health-led response to drug and alcohol use in Ireland. Partnership between the statutory, community and voluntary sectors was a major factor in the success of previous strategies, according to the document, and continues to be the cornerstone of the new strategy.
Drug and Alcohol Task Forces (DATFs) will play a key role in co-ordinating inter-agency action at local level and supporting evidence-based approaches to problem substance use, including alcohol and illegal drugs. The new strategy is intended as a way of measuring the collective response to the drug problem through a performance measurement framework. However, Dublin-based GP Dr Garrett McGovern told the Medical Independent (MI) that progress with the strategy is slow.
“We have had a lot of strategies over the years; they are usually for about seven years,” according to Dr McGovern.
“There is a lot of stuff in the strategy that is very good. But unfortunately, a lot of it becomes aspiration and doesn’t actually come to fruition. And the thing that is frustrating me at the moment a little bit is we have a spirit of harm reduction and sensible drug policies but, actually to date, nothing has happened. We don’t have the [supervised] injecting rooms; we don’t have decriminalisation of drugs for personal use; we effectively don’t have medicinal cannabis use. It’s a slightly different nuanced and separate issue, I suppose. My worry is, a lot of these reports that are written — and we have had a number of them over the years — will become just recommendations.”
Last year, Dr McGovern and others involved in the area met with Mr John Strang, Director, National Addictions Centre, King’s College London, UK, for a rapid expert review of Ireland’s drug policies.
“The conversation was very productive and it was going in the right direction,” according to Dr McGovern.
“My worry is, the larger part of the Dáil probably don’t want injecting rooms; the larger part of the Dáil probably don’t want decriminalisation. It is a thorny issue. And I think the fact that [the supervised injection facility] hasn’t happened yet suits a lot of people. If this was something else, if this was a diabetic centre, there would be uproar over it, but because the wider population aren’t particularly well-disposed towards injecting drug-users, there is sort of a feeling of, ‘well, so what’. It is down to the likes of all of us to keep pushing it through the media and keep pushing it and pushing and pushing it.”
However, a spokesperson for the Department of Health insisted that progress was being made in implementing the strategy. The Department secured €6.5 million in additional funding in 2018 to enhance addiction services.
The funding has helped support a Competency Framework and SAOR 2 training programme developed in order to strengthen the implementation of the National Drugs Rehabilitation Framework, as well as new services and governance structures put in place in order to expand the availability and geographical spread of relevant quality drug and alcohol services.
It has also gone towards supporting 200 more people in receipt of buprenorphine/naloxone, additional Level 1 and Level 2 GPs trained to prescribe methadone; and two additional drug and alcohol liaison midwife posts filled (Cork and Limerick) in order to expand addiction services for pregnant and postnatal women, as well as other initiatives, according to the Department.