The use of opioid-based drugs (heroin, codeine, oxycontin), increased access to opioid synthetics (fentanyl, carfentanyl) and prescription anti-anxiety medication such as benzodiazepines have skyrocketed globally over the past eighteen years.[i] This has led to an alarming rise in opioid-related disorders and deadly overdoses – from respiratory depression and cardiac arrest – worldwide.
The Republic of Ireland has a long history of opioid drug-related deaths. Since 1998, mortalities due to opioids have increased yearly. Indeed, there is now, on average, one drug-related death every day. The majority of these involve users combining two-to-four drugs mainly, heroin, benzodiazepines, methadone and pregabalin.
Historically, the Irish government’s approach to this problem has been to move towards a drug-free society.[ii] The use of harm reduction methods, a philosophy supporting a right to use drugs, was unveiled in 2001.[iii]
Harm reduction as a public health strategy, acknowledges that people use drugs and aims to reduce the harms associated with their use. This also involves addressing the social, economic and health drivers motivating drug use.[iv] However, in Ireland it was introduced as a policy goal with a focus on eliminating the harms associated with drug use alone, which in this case was the elimination of the spread of blood borne viruses into the community in 2001.
Over time, harm reduction as a policy goal was weaved into a health-lead approach to drug use and drug-related deaths. Placed under a Health Ireland framework, the Reducing harm Supporting recovery is the latest government approach to reducing drug use.[v]
However, it is designed within a market-based health framework, led, in theory, by shared decision-making between the government and communities affected by drug abuse. The main responsibility for curbing the crisis is supposed to be handed down from the government to community social partnerships. This document has been in effect for over two years yet drug related deaths have not diminished.
— EU drugs agency (@EMCDDA) July 11, 2017
The model on which the newest drug strategy rests is, in fact, contributing to drug-related deaths. Recent Dáil debates show that the drug services element of the social partnership model set up to reduce drug-related deaths is under threat of closure due to the lack of promised funding.
Moreover, the promised shared decision-making is not being passed on to community groups. Decision-making is instead centralized;[vi] while the promised national overdose strategy has witnessed continual delays since 2011. A recent inquiry as to when its publication would occur was met with an argument relying on interventions already in place.[vii]
When we look at the evaluation of current interventions, and those in the pipeline, we see a pervasive stream of government controls getting ahead of actual health outcomes that can change people’s lives.
In 2015 the first leg of the implementation of the Reducing harm policy strategy to curb opioid overdose began with the introduction of the life-saving drug naloxone. It is a medication used to reverse respiratory distress from poisoning due to opioids. It can be injected into muscle tissue or sprayed through the noise.
In Ireland, naloxone is currently used as an intranasal and intramuscular injection, available on prescription only to people who use drugs. In order for it to work, a drug user must obtain a prescription, and an able-bodied bystander must be able to intervene to save her life.
In 2016 a pilot evaluation study assessing its benefits was grossly under-distributed. The government objective was to have 600 distributions over the course of this project.[viii] Yet it was able to deliver only 95 prescriptions and just one drug user reported using it.[ix]
The success of this intervention is also dependent on an able bystander to intervene. As naloxone can only be obtained by someone who has a prescription, a bystander may not have access to the drug due to legal restrictions.
All factors point to defective policy implementations as, on the one hand, the government is claiming to support the use of naloxone, but on the other the law restricts how it can be used. Additionally, social partnerships designed to implement the intervention are at odds with the idea, while people continue to die every day.
Supervised Injection Rooms
The Supervised Injection Facilities (SIF) Act became law in 2017. Permission was thereby granted for a SIF where drug users could go and safely use drugs bought under medical supervision.
This was to be located near Merchant’s Quay Dublin. However, the business association of Temple Bar opposed the site, using emotive terms such as “drug addicts” in relation to addiction services in the city centres perceived as a threat to business.[x]
This led to a saga whereby the state support for the facility ended up as a bad business deal. The end result is a paltry eighteen-month pilot trial that will take place in a basement facility. The SIF site is illogically sited next to a secondary school. The whole affair reeks of Nimbyism, and brought accusations of drug use harming children.
The retail sector wants to see injection sites pushed out of town, but residential communities do not want these either. The facility has since been delayed a second time in response to efforts by the school to resist it. As with naloxone, although SIF is supported in the national drug strategy in practice it is met with legal and social partnership resistance.
Reducing harm and supporting recovery provides knowledge on how to save the body of the drug user by introducing interventions aimed at reducing drug-related deaths. Yet harm reduction policy goals and interventions are not given a fair opportunity due to pre-existing government legislation.
The document is designed under a market-based framework, wherein the power to curb the crisis, in theory, is passed down into community-based partnerships. But all the evidence shows that the required social partnerships needed to diminish this crisis are not being passed down the chain; communities are at odds over strategies and services are under threat of closure. This creates an environment where central government has too much control. As a result, interventions to curb drug related deaths are not being implemented at the required rate, at the expense of drug users, and the community at large.
Addressing the problem of overdoses should involve delegating control over conditions that lead to drug overdose to the community itself. This begins with a change in attitudes, recognising the experiences that leads to and perpetuates drug use.
Merchant’s Quay Ireland is a leading harm reduction provider that serves the community in overdose prevention. It supports the user of drugs and enhances their lives by providing social services that alter the conditions in which they live. They recently used the participatory research method of photovoice, a methodology where people living with a health issue use photographs to portray their experiences. This explores the topic of the lived experience of addiction and recovery. The photographs were recently showcased in the Dublin Copper House gallery.
The gallery displayed photographs of spatial location associated with recovery from addiction in and around both Northern Ireland and the Republic.[xi] The stories associated with these images were embodied experiences. Ranging from photographs of the body and images of nature. The physical environment became a space of freedom from pervasive governmentality.
Super to catch up with some of my former students @IICP_Education at our @MerchantsQuayIR #photovoice exhibition @thecopperhse today!….and so great to see so many visitors throughout the day engaging with the powerful stories of addiction and recovery 🙏🏼 pic.twitter.com/QycND1YS84
— Dr Maria Quinlan (@maria_quinlan) March 7, 2020
The identity of those who have addiction, those affected and how they recovered, was tangible and real. Images of the River Liffey, the Mourne mountains and wild ivy became the essence of the recovery experience. Themes of freedom from the bondage of recovery, the conditions that influence it, and the growing expression of their identity loudly proclaimed: “I am alive”.
The use of photovoice by MQI gave a bird’s eye view on what it is like to have an addiction and be at risk of overdose. This in turn humanized the person who uses drugs – for them to become not just a body, but an independent spirit.
As Michel Foucault shows us in his body/power essay, the state provides knowledge to society – in this case medical knowledge – about the type of body that is valued in order to maintain power and control. The body of the user does not conform to this ideal, leading to a risk environment for drug-related deaths and vicious circles of self-loathing.
Starting from the ground up, empowering people who use drugs, and those at risk of overdose by supporting their voices, provides feasible alternatives to government-controlled health. Otherwise bodies will continue to lie motionless on streets, as the government hums and haws about how life-saving interventions should be delivered.
[i] Center for Disease control and Prevention. (2019). Understanding the epidemic. Retrieved from: https://www.cdc.gov/drugoverdose/epidemic/index.html
[ii] Building on Experience: National Drugs Strategy 2001 – 2008., https://www.drugsandalcohol.ie/5187/1/799-750.pdf
[iv] Riley, D., Sawka, E., Conley, P., Hewitt, D., Mitic, W., Poulin, C., … & Topp, J. (1999). Harm reduction: Concepts and practice. A policy discussion paper. Substance use & misuse, 34(1), 9-24.
[vi] Dáil Éireann debate. Priority questions 45 – National drug strategy [28087/19]. (02 Jul 2019)
[vii] Dáil Éireann debate. Topical issues – National drugs strategy budget. (22 Oct 2019)
[viii] HSE (2012). National drug strategy 2009-2016: Progress report. Retrieved from: http://www.drugs.ie/resourcesfiles/reports/NDS2009-2016_2012PR.pdf
[ix] Clarke, A., & Eustace, A. (2016). Evaluation of the HSE Naloxone Demonstration Project.
[x] Pollack, Sorcha Irish Times, 2019 https://www.irishtimes.com/news/social-affairs/merchant-s-quay-granted-permission-for-dublin-drug-injection-facility-1.4124512
[xi] Merchants Quay (2020). Exploring the lived experience of addiction: A photovoice project. Retrieved from: https://mqi.ie/a-photovoice-project-blog/