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Opioid misuse in Dublin
Opioid misuse tests the extent to which we can adhere to a multisectoral approach to public health. It reflects the intersection between healthcare, criminal justice and cultural issues in a phenomenon that is harmful to the health of individuals and communities. A review of how opioid misuse has been tackled in Dublin over the past two decades can operate as a case history of how a public health issue was dealt with by a particular society and political system.
EVIDENCE AS A FORCE FOR CHANGE
Being an island on the edge of Europe with a very conservative tradition contributed largely to the fact that up to the end of the 1970s opioid misuse was rare in Ireland. In the early 1980s it became apparent that an epidemic of opioid misuse among young adults had developed in Dublin's inner city.1 Throughout the 1980s this problem continued to develop, but was confined within inner city Dublin. The health sector response was mediated through the National Drugs Treatment and Advisory Centre, which operated primarily from an abstentionist model. Detoxification was offered to opioid users who were prepared to express a commitment to ceasing opioid misuse. HIV testing began in Ireland in 1985 and it was clear within a short time that a large proportion of people with HIV infection in Ireland acquired their infection from injecting drug use. This was in marked contrast to Britain where HIV was more commonly associated with sex between men.2 This contrast was partly explained by the fact that the epidemic was on a much smaller scale in Ireland and a relatively high HIV transmission rate in Dublin's injecting drug using community at the beginning of the epidemic accounted for a large proportion of the cases from the 1980s onwards. In 1991 and 1992 the Department of Health in Ireland published two policy documents: Government Strategy on Measures to Prevent Drug Misuse,3 and The National Aids Strategy Committee Report.4 Both of these documents recommended a shift from an abstentionist based approach to what is commonly called a harm reduction approach, with the active promotion of methadone maintenance and needle exchange for injecting drug users. This policy shift was given added impetus by the publication in 1992 of a report on HIV in the then European Community,5 which showed that Ireland had a southern European type AIDS epidemic (higher rates among injecting drug users than among gay men). This necessitated a more proactive approach to harm reduction in drug users than might otherwise have happened.
The medical responsibility for leading and implementing this change was transferred from psychiatry to public health. The need to move from an abstentionist approach to a harm reduction approach was agreed very early by the policy makers at central government and health authority level. However, the key actors on whom this policy would be dependent had not been consulted and, not surprisingly, were resistant to change. General practitioners were identified as a key group in terms of implementing harm reduction and normalising the care of chronic opioid misuse in general practice. It took five years, the production of two policy documents on methadone prescribing in general practice,6,7 a change in the law,8 negotiation of a generous remuneration package for general practitioners and the development of a network of health board satellite clinics and addiction centres and supports, before it got to the stage where 25% of general practitioners in Dublin took part in the methadone prescribing scheme. Over the same time period the response of pharmacists in Dublin has been better, to the extent that 65% of pharmacists in Dublin now participate in the dispensing component of the methadone protocol. The development of this response to methadone prescribing in Ireland, compared with other European countries, has been summarised in a recent European Monitoring Centre for Drug and Drug Addiction report.9
With the exception of those consultant psychiatrists who have a specific brief for addiction treatment, other psychiatrists have been reluctant to get involved and opioid addiction treatment within the wider psychiatric services has been disappointing. This is unfortunate considering the rate of psychiatric comorbidity among attenders at opioid treatment centres.
POLITICIANS, THE PUBLIC, AND THE MEDIA
The 1991 and 1992 policy shifts in Ireland were further developed in 1996 by publication of a revised Government Strategy on Measures to Reduce the Demand for Drugs.10 This policy document endorsed the harm reduction approach and made more explicit than any previous government policy the very strong links between opioid addiction and urban poverty and social exclusion. The multisectoral nature of problem drug use was also acknowledged and as a result, a National Drug Strategy Team has been set up with representatives of key government departments, the community and voluntary sectors and the relevant statutory agencies. Local Drugs Task Forces in the areas of greatest need were established and considerable funding was earmarked and subsequently spent on community based initiatives to deal with drug misuse. These initiatives cover prevention and education, treatment, rehabilitation and supply control and have recently been externally evaluated.11
Two factors in 1996 had a profound impact on the government of the day and certainly speeded up the publication of the revised strategy. Firstly, a series of street protests over many months in Dublin acted as the primary precipitant of the involvement of the community sector in the revised strategy. Secondly, on 26 June 1996, the campaigning anti-crime journalist, Veronica Guerin was murdered. The murder provoked unprecedented public reaction in Ireland. Two individuals have been convicted of her murder. Although the gang of which they were members has been broken up, others have filled the void and heroin is still plentiful on the streets of Dublin.
There has been a change of government as a result of each general election in Ireland since 1969. The dominant party in government each time has been a centre party and all governments since 1991 have supported the harm reduction approach. Reporting of drug issues in the national media has not mirrored the shift in moving from an abstentionist to harm reduction approach. The national television station, RTE, and the main newspaper of record, the Irish Times, have both assigned reporting of the drug issue to their crime correspondents rather than their health correspondents and the opportunity for leadership from the “quality” media has not been grasped.
No group in Ireland suffers more than prisoners from the fact that drugs are perceived as a criminal rather than a health issue. About half of all Irish prisoners use opioids and 20% of injectors in prison began injecting in prison.12 Hepatitis C is endemic in Irish prisons. However, efforts to transfer responsibility for prison healthcare from the department of justice to the department of health are consistently resisted.
WHY IS THERE POLITICAL SUPPORT FOR A HARM REDUCTION APPROACH TO ADDRESSING PROBLEMS OF DRUG MISUSE?
In Dublin there is no doubt that the initial impetus was related to the HIV epidemic. Ireland was not unique in this by any means. Tracking of the epidemiology of blood borne viruses in Dublin's opioid users in the past decade shows that, while there has been a dramatic decline in the prevalence of HIV infection in opioid takers, the prevalence of hepatitis C in drug users that peaked in 1993 at 84% has declined much more slowly.13 The second reason why politicians support harm reduction is the belief that it leads to a reduction in drug related crime. Evidence in other countries bears this out and anecdotal evidence from the Garda Síochána (Irish police force) supports this. Thirdly, there is evidence internationally that harm reduction works at an individual level for drug users from the point of view of reducing mortality and providing a framework within which other health needs can be addressed. Political support for harm reduction is something that has to be constantly garnered and maintained. Since January 2001 a drug court programme has been introduced on a pilot basis in one part of Dublin. This is a voluntary programme that comprises a supervised comprehensive treatment programme for non-violent offenders. The aim of the programme is to encourage persons who have committed offences to engage in treatment organised by the health services, including harm reduction treatment (methadone maintenance). Implicit in the programme is the idea that health service intrventions have a better chance of changing behaviour than incarceration. The Irish government has just published a new national drugs strategy Building on Experience - National Drugs Strategy 2001 -2008.14 This strategy has a number of action plans; (1) an evaluation of the pilot drug court model to see if it should be extended to the rest of Dublin; (2) an enhancement of harm reduction policies within the prison service; (3) an extension of the model of the local drugs task forces that bring together statutory, voluntary and community representatives. The strategy was put together after a public consultation process in the autumn of 2000. During that consultation process there were many views given on harm reduction and some criticism of both methadone maintenance and needle exchange. Methadone associated deaths are being monitored closely as is methadone diversion (leakage of prescribed methadone to those for whom it was not prescribed). The overall thrust of the new strategy in relation to harm reduction is to expand its provision while simultaneously increasing mechanisms for monitoring potential adverse effects at individual or community level of this expanded provision.
Opioid misuse in Dublin