AROUND THREE YEARS ago I was parking my car in town on the way to do a clinic near Christchurch in Dublin 8.

As the car reversed into its spot, I saw the top of the heads of three people in the rear-view mirror. I got out to see what was happening and saw that two of the people were injecting a syringe into the groin of the third.

It was, in all honesty, a pitiful and sad sight. Although I have been working as a doctor treating drug problems for almost 23 years, I had rarely seen injecting drug use live and in the flesh.

I normally deal with the aftermath (skin infections, blood-borne viruses, overdose and leg clots). This was a new experience and it was invaluable, a hard reminder about how stigmatising, marginalised and disregarded heroin users are. Society, in general, doesn’t give them a moment’s thought.

I asked these unfortunate people if everything was ok and they said they were helping their friend “find a vein”. I explained that I worked in the local clinic and that if they ever wanted treatment (methadone, buprenorphine etc) they should give the local clinic a call.

I also asked them if they had a place to inject, like a safe centre or clinic, would they use it, and they said they would be delighted if such a centre existed. I told them that by the end of that year (2018) Dublin would have its first medically supervised injecting centre (MSIC) and that their days of street injecting would be coming to an end. How wrong was I?

Why the delays?

So why, despite the legislation being passed to pave the way for an MSIC, has it not opened yet? There is no simple answer to this but here is a timeline of events to date and you can judge for yourself:

1. Ana Liffey in its Strategic Plan 2012-2014 put forward the idea of a pilot for an MSIC which was supported by the Dublin Regional Homeless Executive.
2. With strong support from Labour T.D. Aodhán Ó Riordain, Ana Liffey runs a media campaign to highlight the issue of street injecting and its harms, to injecting drug users and society in general. There is a general acceptance that the presence of drug-using paraphernalia strewn in the streets and alleyways of Dublin City represents a serious hazard to public health.
3. In 2015, the Government began legislating to allow for a pilot MSIC to be established.
4. In May 2017, the Misuse of Drugs (Medically Supervised Injecting Centre) Act 2017 was signed into law by the President.
5. In August 2018 Merchants Quay Ireland (MQI) won the tender to open and operate Ireland’s first MSIC.
6. In July 2019 Dublin City Council refuses to grant MQI planning permission to open the centre following a series of objections from local residents, businesses, schools and councillors.
7. In December 2019 this decision by Dublin City Council is overturned on an appeal lodged by MQI.
8. In February 2020 a Dublin Primary school, St Audoen’s National School in Dublin 8, lodges a High Court challenge to the planning permission.
9. To date, no MISC has opened.

Obviously, the Covid-19 pandemic hit Ireland in March 2020 and caused national disruption. Understandably, the opening of an MSIC slipped down the list of Government priorities.

Priorities

Obviously, the Covid-19 pandemic hit Ireland in March 2020 and caused national disruption. Understandably the opening of an MSIC slipped down the list of Government priorities. In truth, however, the delays since the passing of the legislation in 2017 occurred well before the emergence of the pandemic and are not, in my opinion, a legitimate reason for failing to open an essential health facility, which will benefit injecting drug users and the wider public by making Dublin a safer place.

The objections to the planning permission were in my view spurious and not supported by evidence. Dublin City Council had initially refused permission for the facility on the basis that there was an over-concentration of social support services in the Dublin 8 area, a lack of a robust policing plan and because it would have an injurious effect on local residents and the tourism economy.

None of these objections stands up to scrutiny. MQI has a proven track record over many decades of treating injecting drug use and providing services for those among the most vulnerable in our society, particularly the homeless.

As street injecting is ostensibly an urban problem it is apposite that an MSIC is located where most of the injecting occurs, a fact borne out by the extent of discarded drug-using paraphernalia that litters its environs.

The role of An Garda Síochána would be central to the smooth operation of an injecting centre but this cannot be grounds for a planning permission objection. The last objection, that local residents and the tourism industry would be negatively impacted, is actually a reason in favour of an MSIC.

I cannot see how providing a safe, dignified area for injecting drug users is anything but a positive move. It is designed to take injecting from an area where it causes most harm (the streets) and into an area where it causes least harm (a medical centre with expert, trained staff).

There are approximately a hundred MSIC worldwide in countries such as Germany, Denmark, Australia, Canada, Switzerland, Luxembourg and Spain. The Netherlands has an astonishing 30 such centres, a testament to their important role in reducing the sequelae of injecting drug use.

The effectiveness of MSIC to reach highly marginalised target populations has been widely documented (Hedrich et al., 2010; Potier et al., 2014) resulting in significant and immediate improvements in hygiene and safer injecting drug use (Small et al., 2008, 2009; Lloyd-Smith et al., 2009), and other wider health and public order benefits.

Research has also shown that the use of supervised drug consumption facilities is associated with self-reported reductions in injecting risk behaviour such as syringe sharing. This reduces behaviours that increase the risk of HIV transmission and overdose death (e.g. Stoltz et al., 2007; Milloy and Wood, 2009).

Related Reads

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Policy shift?

Since Minister Frank Feighan has taken over the portfolio for drug policy it seems to me that the issue of MSIC has slipped well down his list of priorities. There seems to be a wall of silence. MQI is ready to provide this service and need the support of the Government to do so. There can be no further delays.

At least one person a day dies of an accidental overdose in Ireland and injecting drug use accounts for a large proportion of these deaths. Opiate related overdose is an acute process that can be reversed with the antidote Naloxone.

Injecting drug users and those closest to them should be armed with Naloxone in plentiful supply. As the law currently stands Naloxone is a prescription-only medicine. This needs to change and, as it is not a drug of misuse, the antidote should be readily accessible.

Additionally, the city needs safe drug paraphernalia disposal bins which would significantly reduce drug-related litter that is all too visible in our streets today. Discarded needles have the potential to unwittingly spread Hepatitis C (a bloodborne virus that can last for many days and possibly weeks outside the body) unless they are disposed of safely.

Ministers Frank Feighan and Stephen Donnelly need to intervene now and ensure that MQI is provided with all the support it needs to open this life-saving facility. Finally, as the fixed site pilot Supervised Injecting Facility in Dublin will not be open anytime soon – there should be the immediate establishment of mobile Supervised Injecting Facilities.

Mobile units can be deployed now without further delay. Amongst other benefits they would address issues associated with NIMBYism; reduce street-based injecting by offering a safer environment; engage a hard-to-reach group of people; get people through to treatment and rehabilitation, and help reduce drug-related harm – including fatal overdose.

The immediate establishment of mobile Supervised Injecting Facilities is a matter of choice. Where there’s a will, there’s a way. Every day that passes results in a drug-related death that could have been prevented.

Dr Garrett McGovern is a GP specialising in addiction medicine at the Priority Medical Clinic in Dundrum.