Supervised injection centre being considered to protect Cork City drug users
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A medically supervised injection centre may be considered for Cork after a delegation from Cork City Council, the HSE and An Garda Síochána travelled to Lisbon to learn from the drug policy there.
But any decision on introducing such a facility will come after data has been collected and will only be progressed if the evidence supports it, local stakeholders say.
According to drug and homeless charity Merchant’s Quay Ireland, one person dies every day in Ireland from drug abuse.
A man in his 30s died of a suspected overdose on Thursday morning in Cork. His body was found in St Francis’ Church on Liberty Street behind Cork Courthouse.
Heroin use has been decreasing in younger age cohorts in Cork, with only 6% of people presenting for treatment who are under 25 now using heroin.
But the HSE has been alerted to an increase in cocaine injecting. Smoking of crack cocaine has also been increasing.
Addiction can also fuel crime and antisocial behaviour and can result in used needles and other drug detritus being dumped on the street.
A law passed in 2017 allows for the establishment of medically supervised injection centres and planning has been granted for one to open in Merchant’s Quay in Dublin. Opening of this Dublin facility is also in the Programme for Government.
But drug injecting is also a problem in Cork and decision makers in Cork City joined forces to work cross-party and cross-discipline in a bid to find a solution to the problems associated with drug addiction.
International evidence suggests that supervised drug injection facilities save lives, link users in with necessary health and social services and reduce drug paraphernalia on the streets.
Portugal has adopted a health-led approach, where a drug user’s addiction is treated medically rather than criminally.
It has led to a reduction in overdose deaths and a reduction in illnesses like HIV and hepatitis.
In 2001, Portugal became the first country to decriminalise personal supply of all drugs, including heroin, cocaine and methamphetamine.
Drugs are not legal in Portugal, but possessing 10 doses or less, or a 10-day personal supply, does not incur criminal sanctions, although possession of more or selling drugs can be prosecuted.
The policy was introduced in response to a public health crisis.
The country was suffering a HIV/Aids epidemic with half of all cases due to drug injection. Portugal had the highest rate of HIV among injecting drug user in the EU in 1999.
Drug abuse was also burdening the criminal justice system, taking up police and court time, and costing the state in legal and prison costs.
Both overdose deaths and HIV rates fell after the country adopted a health response, endeavouring to treat rather than criminalise addiction.
Portugal now has one of the lowest drug-related death rates in Western Europe and drug use among young people is below the European average.
Under the model, instead of being charged and receiving a criminal record, police direct users to the Commission for the Dissuasion of Drug Addiction to meet with psychologists and social workers for help.
Dr Nuno Capaz of the Lisbon Dissuasion Commission said that by 1994, drugs had been identified as the country’s biggest problem.
Cross-party talks were held in government and delegations went to countries like the US, the Netherlands, Denmark, and Switzerland to learn about how they had tackled the drug problem.
It was decided that drugs should remain illegal but possession should be downgraded from a criminal to an administrative offence, something facilitated by the Portuguese legal system, which Ireland does not have.
Drug possession would not incur criminal sanction but drug users caught by police would have to go to the Dissuasion Commission for a health intervention and other sanctions like fines or community service, could also be applied.
Drug use would be treated as a health issue under the Ministry for Health.
Lisbon’s 1m population is served by one Dissuasion Commission, operated by nine people. They complete 2,500 to 2,800 dissuasions per year.
A study in 2011 found that a Dissuasion Commission intervention costs €280 per procedure while dealing with a similar offence in court 15 years ago would have cost at least €470, saving the state money, saving people from a criminal conviction, and linking people in with health and social services to prevent problems from escalating.
Some 90% of drug use in Portugal is not problematic, but 10% of users struggle with addiction, Dr Capaz said.
Irish data indicates that some 80% of drug use is not immediately problematic but approximately 20% struggle with addiction and drug abuse.
Providing a health intervention to this 10% or 20% of drug users is vital, Dr Capaz said.
The Dissuasion Commission grades a person’s drug use as low, medium, or high risk and that assessment is then augmented with a 25-40 minute interview to more accurately assess the risk level of the person’s drug use.
If someone is assessed as low risk with no problematic drug use, health information about drug use is passed on, risks are highlighted and there usually is no further sanction.
If someone is caught again, there may be a sanction, like a fine, on the second offence.
If someone is assessed as being of medium risk, information is passed on to the user and they may be referred to counselling. They may also be referred for help with any related issues — like a dual mental health diagnosis or homelessness.
Someone considered at high risk is drug addicted and they may be referred for treatment to address their dependency.
“Courts are by definition a coercive structure. You get a penalty doing something wrong. But drug users do not perceive what they’re doing as wrong so the punishment does not work,” Dr Capaz said.
Professor Eamon Keenan, national clinical lead with addiction services in the HSE National Social Inclusion Office, said Ireland’s legal system would not currently accommodate downgrading drug possession offences to a non-criminal offence like Portugal as we do not have the category of administrative offences.
But Ireland can establish medically supervised injection facilities to reduce drug deaths and improve the health of drug taking cohorts and it can increase efforts to funnel users away from the courts and into medical treatment.
He said locating any potential medically supervised injection facility where people are already injecting drugs is vital.
Studies have found that people using drugs on the street are fearful for their own safety, they can be particularly vulnerable to attack or robbery after using. Attending an injection centre can improve people’s safety and reduce fear.
But they can also protect people’s dignity, allowing people a quiet space off the streets where they can inject without being watched and judged and feared by passersby.
Injecting as a way of ingesting drugs has decreased, Paul Griffiths of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) said.
But Regina Reis who runs a supervised injection centre in Lisbon, has seen a small but worrying increase in injecting since the pandemic and spiraling cost-of-living crisis, increasing from 20% to 21% of drug users.
Injecting delivers drugs straight into the bloodstream, providing a stronger high than other delivery methods, leading to increased use of the method during times of financial hardship, she said.
“It’s a small increase, but any increase is concerning. Injecting brings more health challenges than smoking,” Ms Reis said.
Social inclusion specialist and head of drugs and alcohol services in Cork and Kerry for the HSE, David Lane said the HSE is aware of some 150 people who inject drugs in Cork, many of whom are very vulnerable with complex needs.
The HSE already has a needle exchange programme with two needle exchange workers in Cork who have been critical for gaining a deeper understanding of emerging drug trends, along with outreach workers from homeless charities like Cork Simon.
They have seen an increase in cocaine use on the streets and an interagency team is being established in the coming days to look at emerging drug use trends in homeless hostels.
An increase in cocaine or stimulants presents different behavioural challenges than heroin use, often bringing an increase in aggression and violence.
Naloxone, a drug which reverses or reduces the effects of opioids, saving people from overdose deaths, was administered 21 times so far this year in Cork and 44 times in 2022.
Eighty-five people were trained to administer Naloxone in Cork last year and 29 more people have been trained so far this year.
Prof Keenan hopes to see Naloxone distributed to users from Ireland’s medically supervised injection facility, when it is up and running.
Medically supervised injection facilities are professionally supervised healthcare facilities where drug users can inject, pre-obtained illicit drugs, under medical supervision in a safe, hygienic environment.
The centres provide clean injecting equipment, good lighting, clean surfaces, and sharps disposal.
Staff are trained to provide assistance and emergency care in cases of overdose.
Medically supervised injection facilities are associated with reductions in injecting risk behaviour such as syringe sharing, and public drug use.
They facilitate individually tailored health education, and promote access to healthcare and drug treatment.
Some 96 supervised drug consumption facilities now exist in Europe — in Belgium, Switzerland, Denmark, France, Germany, Greece, Luxembourg, Netherlands, Norway, Portugal, Spain, and Switzerland, according to European Monitoring Centre for Drugs and Drug Addiction data published in March.
The Misuse of Drugs (supervised injection facilities) Act 2017 provided the legal framework and permission to establish medically supervised injection facilities in Ireland.
It aims to reduce harm to people who inject drugs by providing for the establishment, licensing, operation and regulation of these injection centres in a bid to reduce harm to people who inject drugs.
The act provides for the establishment, licensing, operation and regulation of supervised injection facilities to reduce harm to people who inject drugs.
Some sections of the Misuse of Drugs Act 1977 will not apply in licensed injecting facilities.
Ireland’s first MSIF has been granted planning for Merchant’s Quay Ireland in Dublin.
But it has been a long road to get to that point. A working group was first set up in 2016 which included representative from the HSE, Department of Health, Dublin City Council, gardaí, and potential service users.
Extensive research and data collection began.
Injecting drug user deaths were mapped, overdose callouts to the ambulance service were mapped as were drug-related litter hotspots.
A survey of 84 opioid-dependent people, of whom 33% were homeless and 73% were male, found that 94.4% of respondents with a history of intravenous drug use would be willing to use a medically supervised injection centre.
The survey found:
- The mean age of respondents was 38.3.
- Among people who were actively injecting drugs, 46.7% said that they injected drugs in public places like streets, public toilets and parks.
- Ninety per cent of those surveyed found injecting under supervision to be acceptable.
- One hundred per cent said that washing hands before injecting was acceptable.
- However 56.7% said it would be unacceptable to allow pregnant women in the facility to inject drugs and 66.7% said under 18s should not be allowed.
Another survey found that 100% of potential service users wanted at least a brief intervention with staff when they arrived.
An invitation to tender for a medically supervised injection centre was first opened in August 2017, and in February 2018, Merchants Quay Ireland was awarded the tender and a planning permission application was submitted.
In December 2019, An Bord Pleanála granted planning permission to Merchants Quay Ireland. But in July 2021, following a judicial review launched by neighbouring St Audeon’s primary school, the High Court overturned that planning permission. The court ruled the planning body had failed to take into account the concerns of the school in its decision to grant permission.
In November 2021, the High Court sent the decision back to An Bord Pleanála for assessment under a new inspector. In December 2022, An Bord Pleanála granted planning to Merchants Quay Ireland for the injecting centre.
Construction work has not commenced yet on the Merchant’s Quay Injection Facility.
“This will be subject to a tendering process, due to commence once the relevant stakeholder negotiations have been completed,” a spokesperson for the HSE said.
“The HSE will work with Merchants Quay Ireland and engage with all relevant stakeholders throughout the project. We want to ensure that the medically supervised injection facility, the first of its kind in Ireland or the UK, will operate to the highest standards and provide appropriate care to one of the most marginalised groups in our society.
“Where such facilities have been established elsewhere there has been a reduction in drug related deaths associated with injecting and a reduction in injecting paraphernalia in the surrounding areas.
Fianna Fáil Councillor Colm Kelleher, whose brother has struggled with heroin addiction, said that something must be done to save lives and tackle the drug problem.
“I’ve seen open drug dealing and drug taking in Patrick Street. There’s a dignity piece in it, people injecting in their groin on the streets.
“These are peoples’ sons and daughters. A health approach to tackle the problem is needed.
“I don’t think enough is being done to tackle the problem at the moment. But the fact that we’re out here [in Portugal], have broad stakeholder support, we’re going in the right direction.”
Cork GP and Fianna Fáil councillor John Sheehan said that the Lisbon trip had been a good fact-finding visit.
“One of the learning points from this was about having your data and facts in terms of location, demand, numbers, substances but particularly the structures and governance of these centres and the complexity that’s involved in the wraparound services.
“As a city we have a lot of work to do in getting our data, looking at our data, putting all the sources of data together on drug abuse, particularly [intravenous] drug abuse, which will inform our decisions as to what is the best model of care that we can provide vulnerable people which is the ultimate aim.”