Tony Duffin: Irish drug policy is following a similar path to Portugal — but nothing has happened yet
' Rooms Clear Varied Reduce Do — Achieve And Consumption Are The Street Harms Namely, Drug To That With Associated Is 'the Up Many Set Based Use Drug Evidence They What
I was in Lisbon recently where I had arranged a series of meetings with people who are experts on responding to drug use. The people I met with are well placed to speak on the subject; not least of all because they have lived and worked in a jurisdiction where decriminalisation of drugs is well established; and where drug consumption rooms have recently been implemented.
In Portugal, drugs were decriminalised in 2001. This means drugs remain illegal, and the response to possession of drugs for personal use is a referral by the police to the Dissuasion Commission. There is plenty of evidence that this approach has worked better than if Portugal had continued to criminalise people who use drugs as in other European countries.
In 2019, a mobile supervised injecting facility was introduced in Lisbon, and this was followed up with the opening of a fixed-site drug consumption room in May 2021. The evidence is clear that drug consumption rooms achieve what they are set up to do — namely, reduce the many and varied harms associated with street-based drug use.
My first meeting was with Nuno Capaz, the Vice President of the Dissuasion Commission of Lisbon. Nuno speaks with authority about the benefits of Portugal’s drug decriminalisation policy.
Nuno explained that of all the Dissuasion Commission’s procedures, the 2021 national data shows that 78% were suspended, 21% were sanctioned (a fine, regular presentations, etc), and 1% were absolved.
The national data for 2021 also shows that 75% of the Dissuasion Commission procedures were related to cannabis with a minority of this total (circa 10%) relating to under-18-year-olds. Cannabis remains illegal and use of cannabis amongst under 18s is a concern. So, reaching under 18s through a decriminalised response means they are not criminalised; that they are given advice, support, and offered a referral to a range of supports, if needed.
Next, I visited the fixed-site drug consumption room, run by the NGO Ares do Pinhal, where I met Hugo Faria, Paulo Caldeira, Roberta Reis, and the team.
The drug consumption room in Lisbon has an injecting room with eight injecting booths (for one or two people to inject, at any one time) and an inhalation room with the capacity for six people to smoke drugs. There are also one-to-one rooms; group rooms; showers; toilets; offices and storage rooms.
I have visited a number of drug consumption rooms over the years and I observed something here, which I had not seen before. Namely, in the injecting room, a woman was injecting a man in the neck. This is different as, for example, neither neck injecting nor injecting another person, is allowed in the recently established drugs consumption room in Athens, Greece. Also, when I visited the Sydney medically supervised injecting centre in 2015, neither of the above activities were permitted; although at the time they were working through how they could allow people to inject themselves in the neck with the person utilising mirrors.
There is a challenge with drug consumption rooms to ensure that the management of clinical risk does not become a barrier to service provision. The approach taken by Hugo Faria, and the team in Lisbon, in this regard, is a response to injecting practices on the streets in the surrounding area. People inject each other in the neck outside — this is risky and Faria’s opinion is that it is safer for them to do this in the Injection Room. It is, of course, risky behaviour to manage in the drug consumption room; and I understand their approach to managing the reality of this risky drug-taking behaviour and not leaving people out in the street.
Importantly, between May 2021 (when the rooms opened) and April 2023, there have been 42 overdoses reversed at the fixed site service. However, they don’t include the times they have administered oxygen in that figure. Oxygen is administered when someone is technically overdosing, but not yet become unconscious, lips turned blue with skin turned pallid and grey. In drug consumption rooms across the world, people proactively have their blood oxygen levels checked and are put on oxygen when needed; meaning many more serious overdose situations are avoided.
Next, I went to Bairro Portugal Novo — Rua Al Berto to visit the mobile supervised injecting facility. Like the fixed site service, this is a type of drug consumption room; but delivered from a vehicle and only working with people who inject drugs — they don’t have the capacity to facilitate the inhalation of drugs.
Parked up across from a block of apartments and next to an open grassed area, the service is a discreet vehicle that looks like any other mobile health unit that you might see in Ireland. Bruna Alves had arranged for me to meet her colleagues — two nurses, a peer worker (someone with lived experience of drug use), and a psychologist. They explained their work; how they drive to different areas of the city to meet a cohort of people who inject drugs and offer them a safe non-judgmental service. The mobile service is a different experience to the fixed site service. It has capacity for two people to inject. However, I saw the team provide support to one individual at a time, which struck me as a more intimate experience for the client.
Whilst none of the above policies has yet been implemented here, Ireland is following a similar path to Portugal.
In 2019 the Government announced that a similar approach would be implemented here; and the new health diversion programme is being developed under the auspices of Ireland’s National Drug Strategy. The recently established Citizens Assembly on Drugs Use is discussing and debating the decriminalisation of the possession of drugs for personal use. It will be instructive to hear their findings on the Portuguese model of decriminalisation. For me, the benefits of the Portuguese model of decriminalisation are not in question —where people (found in possession of drugs for personal use) are afforded ‘each and every time’ the opportunity of harm reduction advice and/or a referral to a health/social intervention.
Similarly, Ireland has had legislation for supervised injecting facilities since May 2017. Nothing has been implemented yet. However, planning permission for the Dublin pilot medically supervised injecting facility was granted at the end of December 2022. The provider, Merchants Quay Ireland, is working with various stakeholders to open the service as soon as possible. It will be a great achievement when, at long last, it opens and begins to reduce street-based injecting in the area, improving the health of those attending the service and the many other well-documented benefits supported by evidence from across the globe.
Unfortunately, since the pandemic, smoking crack cocaine has increased among people who use drugs problematically. There is an argument that in parts of Ireland drug consumption rooms, with inhalation rooms, are needed.
A significant benefit of mobile units is that they do not require planning permission unlike fixed-site supervised injecting facilities. So, in theory, they can be established quickly once a decision to implement them is made. However, we don’t have ‘mobile’ supervised injecting facilities in Ireland. Although there is support for such services in areas across the country where street-based injecting is identified by local stakeholders as an issue. For example, HSE CHO4, Cork City Council, Cork Local Drug & Alcohol Task Force and many other local stakeholders are actively advocating for a ‘mobile’ supervised injecting facility in Cork City. Indeed, a group of delegates from Cork City are to visit the above services in Lisbon in mid-May this year on a fact-finding trip.
Finally, I’ve mentioned evidence a few times here, and drug policy must be evidence-informed, but it would be naive to think that drug policy is only based upon evidence. As the Citizens Assembly on Drugs Use begins its work in earnest, it’s important to consider that effective drug policy is informed by three elements —empathy, evidence, and experience. The Portuguese have these in spades.