THERE’S A DIRECT link between the failure of opium crops in the Middle East in 2010-2011 and a change in the law introduced by Simon Harris, the Minister for Health, which took effect this month.
That crop failure led to a heroin shortage in Dublin around the time. Drug users deprived of their usual fix increasingly turned to benzodiazepines instead – leading to a rise in addiction cases, and presenting gardaí with a legal headache.
Benzos, as they’re called on the streets (also ‘dollies’, ‘blueys’ or ‘yellows’), weren’t in the same category as heroin or cocaine. Gardaí could stop people and confiscate them, but the prescription drugs existed in something of a legal grey area.
Long-mooted restrictions on unlawful possession, which took effect last week, changed all that - putting new controls on the pills that placed them in the same category as methadone.
Cast your eyes to the kerb as you walk down any side-street or laneway around the capital and evidence of benzo use – like discarded packets of Valium and Xanax - isn’t hard to spot.
You might also see packets of of z-drugs or ‘zimmos’ (Zopiclone and Zaleplon, which are used to treat insomnia) which have become an increasing problem in the city over the last two years or so.
That said, you have to have some idea what you’re looking for to spot litter from prescription drugs.
Needles are far easier to spot. More than three decades after Dublin was first ravaged by the heroin epidemic of the 1980s, discarded syringes can still be found in pretty much any backstreet or lane.
Improvised pipes for crack-cocaine have also been discovered tucked in corners and doorways in areas frequented by drug users in the city recent months.
And, this week, the chief medical officer in Northern Ireland issued a warning about heroin laced with an opioid up to 10,000 times more potent than morphine. The discovery of carfentanyl - which is more commonly used to sedate large animals - prompted a vigilance warning from a Dublin addiction service.
Homelessness crisis
The ongoing housing and homelessness crisis has compounded the problems experienced by habitual drug users in the city in recent years – many of whom have incredibly complex underlying mental health issues.
Figures released this week from the Health Research Board showed that the proportion of cases where a person treated for drug issues was homeless increased from 5.6% in 2009, to 9.2% two years ago. Overall, almost 10,000 cases of problem drug use (excluding alcohol) were treated in 2015 – the latest year for which figures are available.
The number of people who inject in the public domain in Dublin each month could be in the thousands, according to doctors and organisations who work with drug users in the city. And polydrug consumption – use of a combination of substances – remains a major problem.
Attempts to crack down on open drug dealing in the city centre have been met with mixed success over the years.
More recently, there have been an increased number of calls for possession of small amounts of drugs for personal use to be decriminalised so that a health-led approach to the problem can instead be prioritised.
And in a move that could mark a sea change in Ireland’s attitude to the ‘war on drugs’, legislation to set up the country’s first supervised injecting centre passed the Seanad this week, and is expected to be signed into law by President Higgins.
TheJournal.ie spoke with a drug project worker, a specialist in addiction, and a habitual drug user who has been homeless for a decade to try and get a snapshot of the issues being faced in the streets of the capital in 2017.
“I see a lot of the social fallout of drug use in my practice on a day-to-day basis,” Dr Garrett McGovern, an addiction specialist and GP, says, as we speak in a HSE centre off Cork Street, near the Liberties in the south inner city.
I don’t treat this any different to any other sort of medical thing.
McGovern, who works in clinics at a number of locations in the city, was part of the campaign to bring in the supervised injecting centre. He hopes to see the first centre up and running soon. But the issue of addiction, he says, is a complicated one. There are no simple solutions.
Many of McGovern’s patients are longtime heroin users.
I ask about the sort of health problems they might be experiencing when they begin seeking help to go drug-free.
Some of may be smoking heroin and accruing a lot of debt, he says. Some might be injecting “but really and truly it’s got the better of them”.
“It’s a very addictive type of drug. A lot of these people are not just using it for a few months, some of them are using it for many years.
I think they realise enough is enough, they’re in trouble. They’re usually quite cachectic - you know, no weight on them …. malnutrition almost, some of them, because they’re just not eating.
Their dental care is not good. Some of them will come in with abscesses having injected into their groin – or with superficial infections in their skin.
There’s a whole host of motivating factors that might lead to someone seeking medical help, he says.
But a lot of it is that they can’t deal with that lifestyle any more.
Opiate substitution therapy – methadone – is the most common course of action. The methadone programme was formally introduced in 1998, and is delivered by drug treatment centres and accredited GPs around the country. Most homeless street injectors in Dublin are sent to the National Drug Treatment Centre on Pearse Street, near Trinity.
Often, though, getting people through the door to seek help can be the biggest problem, McGovern says. Some are afraid they’ll bump into people they know – others may be wary of clinics with a punitive philosophy, where doses of methadone are reduced, if patients don’t pass drug tests.
“That sort of stuff – it’s being phased out but nonetheless still happens,” McGovern says.
All the evidence worldwide says testing doesn’t affect drug use – so whether you test loads or don’t test at all people will take drugs.
He continues:
“Without getting too scientific about this … Very small doses, they get rid of withdrawal symptoms – you know, those horrible Trainspotting-type symptoms.
That’s not enough to keep them away from drugs. There’s a thing called craving… If you don’t get rid of craving, they’ll probably use heroin – probably not as much as they used before they were on methadone.
So you’ve got to abolish craving and to abolish craving sometimes their dose has to be cranked right up.
Doctors, he says, worry about patients also taking alcohol and other drugs – so may be cautious about upping the dose of methadone. “So it’s a balancing act - getting that dose right, and trying to manage these other problems.”
There are around 10,000 people receiving treatment for opiate dependence in the State. But McGovern says there are likely thousands more heroin users in the Dublin area who are injecting, but not receiving treatment.
And while street injecting in the city centre may be the most obvious manifestation of drug dependence in the capital – the problem isn’t limited to people from poorer suburbs or deprived inner-city areas. McGovern also has patients from middle-class areas who he has seen for years – many of whom are receiving methadone treatment and continuing to live normal lives.
“A lot of people don’t understand this,” and expect people on methadone treatment to have sunken cheeks and other problems typically associated with chaotic drug use.
Says McGovern:
“A lot of people think [heroin] is a terrible, lower-class drug – it’s only ‘the great unwashed’ that get this problem… A lot of people use pejorative terms like junkie, scumbag etcetera.
I don’t look at it that way, in the sense that I get to know them very, very well. I sometimes get to know their families very, very well.
Many patients he sees at his city centre clinics “aren’t saints by any means” and often carry out acquisitional crime – shoplifting and pickpocketing – to feed their habit.
But in the background, “it’s a fairly ugly, sad story you’ll find generally”.
Nearly always with a drug user – particularly at that sort of level where they don’t have a roof over their head – there usually is not an awful lot of good that’s happened, in general.
While it’s not always the case, “starting off, usually, they’ve gone through many, many homes with no role model in their life”.
Housing and health issues may be the most immediate problems they need to face. But there are very often deeper issues that may take far, far longer to address.
Housing is a big one and because they’re using drugs it’s nearly impossible to get in anywhere, so a lot of those guys are living a hand-to-mouth existence really.
Day-to-day health issues can include poor circulation and diabetes. In some cases, legs need to be amputated as the limb has become unviable due to heavy injecting drug use. There are also “massively high incidents among drug users of HIV and Hepatitis C”.
In terms of supports, often, “you’ll find that in terms of significant others in their life there are either very few or they’re fractured relationships. Yeah, in the background, there’s some horrendous abuse – both perpetrated by them and as victims.”
It’s all very grim. “An ugly existence,” is a term McGovern uses, several times.
A person’s dignity needs to be respected, when it comes to talking about solutions, he adds.
If you had a brother or sister or someone you really care about … it’s not very dignified to be injecting down a back alley.
A bag of heroin costs around €25 in the city centre. Drugs like Zopiclone cost around €20 a tray. Some injecting drug users may go through two bags of heroin a day – for others, it can be many more.
Methadone is also being sold along the Liffey and surrounding streets, alongside the benzos and the z-drugs. Alcohol – often cheap vodka, bought from discount supermarkets – is carried around in paper and plastic bags.
People swap phone numbers to arrange their drug purchases, or they know who to go to around the city centre to arrange their deal.
Evidence of drug use is most prevalent in the area around O’Connell Street on the northside of the city, and along a route down to the Four Courts and Smithfield.
Across the river, the area around Christchurch and up along Thomas Street’s alleys and laneways is also littered with syringes, citric acid packaging (which is used in the preparation of heroin for injecting) and discarded prescription packs.
I speak to Miranda O’Sullivan, a project worker at the Ana Liffey Drug Project at the café at Arnotts, just around the corner from the service’s drop-in centre on Middle Abbey Street.
Set-up in 1982, the ALDP was established to offer an alternative to the dominant abstinence-based approach of the day. The blurb on its website says it provides a welcoming space where active drug users can look at their life “and their options for positive change in a non-judgmental environment”. In essence, workers at the project will tell you, it’s about ‘meeting people where they’re at’ and keeping up an ongoing conversation.
O’Sullivan, who has worked with Ana Liffey since 2001, says homelessness is much worse now than it was then – although there has been some improvement in the last year or so in terms of securing medium-term beds for people.
She’s based at the Abbey Street drop in centre, where people can come to talk to staff, ask for help with everyday problems, and even just stay for a while for a cup of tea and a chat. She also visits prisons, and works on the detox programme at Mountjoy, along with other agencies. “My role,” she says, “is to get to know the client group”.
In terms of the day-to-day issues that come up at the centre, it could be pretty much anything. People may need a bed for the night, or have questions about medical cards, “but it might be something much simpler like their feet are sore – because they’re walking around the whole time”.
Whether they’re sleeping rough or staying in a hostel for the night, people who are homeless and using drugs tend to be up quite early in the morning, O’Sullivan says.
But they’ll get going, if they’re active drug users, to find some way of getting money… If it’s pay day they’ll be the first at the post office, you know.
They generally come from deprived areas of the inner city; Sheriff Street; and poorer areas of suburbs like Ballymun and Clondalkin.
Says O’Sullivan:
Every sociologist will tell you they come from very similar areas.
Many of her older clients have spent time in industrial schools or other State-run institutions. A large number have received settlements from religious orders.
There are exceptions. Not everyone who comes on their radar is homeless, and not everyone comes from poorer areas. Often, however, they are from the same estates – the same streets even. They often know each other. “It’s really blatant when you see it.”
There’s a common thread of problems in the background too: lack of education, parents with drink issues, institutional abuse, years in the care system.
Young people, straight out of care, still come to look for help at the centre. Her older clients tend to become more stable as they age, “the way we all do”.
A lot of people work the methadone and top up with a few benzos.
She’s seen some incredible stories, over the years, of people managing to change their lives. ”People totally street homeless, in a total mess, abscesses all over them, physically weak… I’ve seen them go drug-free, look really healthy, take up roles in some of the homeless and drug services, or study at university.
“You’d just be so surprised at what you see – it’s incredible the change that can be made sometimes when somebody manages to pull it together.
Unfortunately I don’t think that’s possible for everybody. Their need to self-soothe may be so great they can’t ever turn their back on drugs permanently, and that happens.
And that happens with many of our clients, being so damaged.
It can be a relief, sometimes, to visit someone in prison.
“It’s a terrible thing to say – but if it’s somebody who’s living out on the streets the whole time, they’re usually fed three meals a day and they have somewhere to sleep. They get healthier, they look better.
Of course they feel restless. None of us would like to be in prison – but sometimes you can be very relieved. I don’t like saying it to the clients but sometimes they say it themselves – that they needed a bit of time out, almost.
The ethos of Ana Liffey is to focus on ‘harm reduction’. Says O’Sullivan:
We take a client where they’re at. We’re also trained to look for a chance to get somebody to make a change.
Providing help can be as simple as referring someone to St Vincent de Paul for fresh clothes. Longer term solutions can include options like stabilisation beds, detox beds and rehab.
Since 2014, the organisation has also run what’s called an Assertive Case Management Team, which works with a range of charities and organisations, including the gardaí, with the aim of getting people the help they need.
There has been an increase in new cases of HIV diagnoses in Dublin among people who inject drugs in recent years. Links between a former head-shop drug known as ‘snow blow’ and a surge in cases were investigated by the HSE in 2015.
A recent study by the Health Research Board found that over 12,000 people who inject drugs in Ireland have Hepatitis C – a blood borne virus that affects the liver. More than 9,000 drug users are chronically infected.
The latest figures on drug-related deaths show that almost two people die in Ireland each day as a result of poisoning, trauma or medical causes linked to drug use.
Rachel (not her real name), who I spoke to at Ana Liffey’s drop-in centre this week, has been homeless for over 10 years, and is receiving treatment for both HIV and Hepatitis C.
She is in the methadone treatment programme, and also takes ‘zimmos’ whenever she can. She’s in her mid-40s, and her longtime partner recently died of an overdose in a public area at a Dublin building complex.
Our conversation is difficult. She breaks down several times talking about her partner, and her day-to-day life. She takes drugs because “I just want to get away from it”.
She has a bed lined up for treatment, starting this weekend. But she’s tried to go drug-free “umpteen times”. It’s hard, she says, to stay off drugs when you find yourself back on familiar streets, surrounded by familiar people.
Rachel fits the profile of the ‘older’ client group described above by O’Sullivan. A former heroin user, she’s now on methadone. She tops up with pills, she says, because the dose isn’t high enough. She sleeps on the street, insisting it’s preferable to a temporary hostel where people might try and sell her a range of heavier drugs.
We speak around midday. Rachel’s been up since six-thirty, and says she has almost no energy due to the low level of methadone in her system. “I got sick this morning twice … that yellow bile coming out of me.”
Rachel is upfront about her drug use, and where she gets her money. In addition to welfare, she borrows cash and runs up debts. She’s pick-pocketed in the past, she says – but “never old people or foreigners”.
We don’t get into any in-depth conversations about her background – she’s already broken down sobbing, twice, talking about her late partner. She says she uses z-drugs because “it takes me away from this world for the day”.
When I talked to Garrett McGovern (the addiction doctor) about the planned supervised injecting centre he described it as a proven way of getting people who need help in contact with the professionals trained to provide it.
There are already over 100 such centres around the world already in countries like Germany, Spain, Canada and Australia. There’s been some opposition to placing the first Irish centre in a central Dublin location – but McGovern dismissed the suggestion that it could be placed anywhere else.
“Does it mean that everyone’s going to start coming here and start dealing drugs? That’s not what the international experience is.
The staff in there are extremely well qualified to deal with this, and if there’s any suggestion that people are outside dealing drugs that’s going to be stamped out straight away. It won’t be tolerated.
Miranda O’Sullivan, the drug project worker, said it would “definitely save lives”.
“I’m being realistic – [people] need to have a place to go where they’re constantly being encouraged to do the right thing for their health.
“And hopefully there’ll be some of those people who will survive their injecting drug use ways in their life, and go drug-free.
Those who do, society will have to mind them less if they’re a healthier bunch of people. If their veins aren’t screwed up… If they don’t have abscesses…
I asked Rachel if she would have chosen to go to a safe place, overseen by doctors, when she was injecting heroin.
“I would, yeah,” she said.
To embed this post, copy the code below on your site
have your say