imn.ie, September 21, 2012

Supervised injection sites in Ireland?

A number of TDs have recently expressed their frustration over inadequate needle disposal services following recent reports of nine year-old Holly Sheehy, who had to undergo prophylactic treatment for blood borne diseases, including HIV and Hepatitis C, following her contact with an inadequately disposed syringe in a residential area in Limerick. The issue has generated a lot of political focus.

Several TDs have confirmed that they see supervised injection sites as a topic of possible consideration to ensure similar incidences are not repeated in the future.

Fianna Fáil health spokespersons Billy Kelleher and Sinn Féin health spokesperson Caoimhghín Ó Caoláin, as well as deputies Jonathan O'Brien (SF), Ciara Conway (LB) have tabled questions for the Health Minister James Reilly regarding the lack of needle disposal services.

Deputies Michael McGrath (FF), Finian McGrath (IND), Mary Mitchell O'Connor (FG), Gerald Nash (LB), Charlie McConalogue (FF), Brian Hayes (FG), TerenceFlanagan (FG) and Noel Coonan (FG) either intend to or have raised the issue with the appropriate authorities, and Deputy Maureen O'Sullivan (IND) hopes to open a private members forum on addiction based on the issues raised by Holly’s case. The matter has also been referred to Minister Jan O’Sullivan of the Department of Environment, Community and Local Government.

In January of this year the Ana Liffey Drug Project (ALDP), one of the largest drug treatment centres in the country, announced plans to open a medically supervised injecting centre in Dublin and also to create a naloxone pilot programme.

ALDP’s strategic plan was endorsed by the former Lord Mayor of Dublin Andrew Montague at its launch in Mansion House, Dublin in January.

Mr Tony Duffin, Chairperson of the ALDP and member of the National Advisory Committee on Drugs (NACD), suggested at the launch that there is “plenty of evidence” that supervised injection sites can lead to reductions in  HIV cases, hepatitis C cases, public injecting, overdose deaths and non-fatal overdoses. He also suggested that, upon implementation, supervised injection sites could also provide a direct point of contact to encourage rehabilitation and treatment in intravenous drug users.

“I really believe that when you reduce the barriers, that when you start talking to people, and engage with them, you can move them on to treatment and rehabilitation; otherwise you are just playing with people,” he said.

“Currently, we have a syringe return rate of about 44-46 per cent and we hope to bring it up to 60-70 per cent by the end of the year.  Supervised injection sites would dramatically increase the return rate and help prevent situations like this occurring again,” Mr Tim Bingham, Chairperson of the Irish Needle Exchange Forum, told IMN.

A number of supervised injection sites exist throughout the world including in Switzerland, Germany, Canada (Insite) and Australia (Kings Cross). Intravenous drug users under medical supervision inject drugs using sterile equipment and dispose of used material onsite. Naloxone is a prescription medicine that treats overdoses.

“Naloxone needs to be available more readily, it would definitely have to be available onsite in a supervised injection site scenario and staff would have to be trained to use it.  People die unnecessarily because the drug is so strictly regulated.  I would like to see it roll out through Irish pharmacies in the next 12 months.  Currently, we are in the top 10 per cent of fatal drug overdoses in Europe,” said Mr Bingham.

He also suggested that supervised injectable heroin (SIH) treatment may be of use in reducing overall harm and creating stability in subsections of the problematic drug using population.

SIH treatment, that is, the direct provision of heroin to problematic drug users, increases access to non-methadone responsive intravenous drug using populations, dramatically increases safe injecting and disposal practises and reduces the requirement for problematic drug users to engage in crime to feed their habits.

A spokesperson for the Department of Health has said “there is some evidence that this treatment can be effective”.

SIH treatment programmes are in operation in Switzerland, the Netherlands, Denmark and the UK.  In 2011 there were approximately 2,500 SIH treatment users in the EU and Switzerland.

A report published by European Monitoring Centre on Drugs and Drug Addiction (EMCDDA) in April found SIH treatment to be of benefit in some chronic heroin users.

The EMCDDA stated these benefits as being: “The ‘substantially improved’ health and well-being of this group; ‘major reductions’ in their continued use of illicit ‘street’ heroin; ‘major disengagement from criminal activities’, such as acquisitive crime to fund their drug use and ‘marked improvements in social functioning’ (eg, stable housing, higher employment rate).”

The EMCDDA also compared the per person annual cost of SIH treatment and methadone maintenance treatment (MMT) programmes in Switzerland, Germany and Netherland. They found that whilst SIH treatment programmes cost considerably more (€12,700-€20,400), than MMT programmes (€1,600-€3,500), the higher cost for this highly problematic group was compensated for by “significant savings to society” – largely arising from decreased spending on criminal interventions. Savings per person, per year, were found to be €15,000 in the Netherlands, €13,000 in Switzerland and €6,000 in Germany.

However, the provision of supervised injection sites and SIH treatment is often met with both political difficulties and financial constraints according to Chairman of the EMCDDA and Portoguese National Drugs Co-Ordinator Dr Joao Goulao, Portugal, which has decriminalised drug use has neither facility; but they are now possible under its legal framework.

“We believe that pragmatic approaches must be tried when problems connected to drug use are identified and resources are available; for decades we had dramatic injectable drug use, with enormous public nuisance, and tried to install supervised injection sites, but faced a lot of political difficulties,” he told IMN.  “When we finally got political conditions for installing that kind of response, the pattern of use had changed, as users are now predominantly smoking heroin instead of injecting, and we decided not to go on with the project.

“As to supervised heroin treatment, although we believe it can be a useful resource for some patients, we had to make choices due to budgetary constraints. To have methadone programmes available all over the country, easily accessible, versus installing a response addressed to a minority of drug users. The option was the first one.”

A Department of Health spokesperson told IMN: “There are no plans to introduce SIH or supervised injection sites at this stage in Ireland.”

Florian Scheibein examines the case for the introduction of supervised injection sites
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