DRUGS THAT CAUSED a cluster of heroin overdoses in Dublin were purchased “across one strip” of Dublin City centre, according to the HSE.

It’s also thought that a more recent overdose cluster in Cork is “linked with the Dublin market”.

The HSE’s emerging drug trend project manager added that lessons have been learned from the response to recent clusters of heroin overdoses in Dublin and Cork.

From 9-14 November, there were 57 heroin overdoses in Dublin while there have been 17 cases in the Cork region since 6 December.

A red alert that was enacted in both areas are still in place, with the public warned not to buy new types of drugs or to buy from new sources.

Red Alerts remain in place for the Dublin and Cork Regions following the detection of protonitazepyne sold as a light brown/tan powder on the heroin market.

We will keep our 'Synthetic Opioid preparation' page updated with developments and resources: https://t.co/4gZLB6Xqil pic.twitter.com/GDGlGaSX8i

— HSE Drugs.ie (@drugsdotie) December 20, 2023

These clusters are related to a heroin batch that contain trace amounts of a nitazene-type substance.

Nitazene is a potent and dangerous synthetic opioid that poses a risk of overdose, hospitalisation and death.

Nicki Killeen yesterday addressed a Scottish Drugs Forum webinar on the HSE’s response to these incidents in Dublin and Cork.

Killeen monitors and responds to drug trends in Ireland and noted that there is a “long-established heroin-use prevalence in Ireland, with over 19,800 opiate users”.

Nitazene was first developed in the 1950s by researchers who wanted to find an alternative to morphine, but due to its potency and risk of overdose, it was never licensed for medical use.

However, Killeen said this is a “relatively new” drug to the European and Irish drug market and has presented in tablets, powders and liquids.

‘Brown powder’

In the case of the two recent overdose clusters, Killeen said it is “occurring in a light to sandy brown powder”.

She noted that it burns “to a different texture, it’s burning like a jelly”, and added that this is “something people will notice when they cook it up and that’s important for harm reduction”.

Killeen said the same powder is linked to the cases in both Dublin and Cork.

Outlining the HSE’s response, Killeen said she became aware from a “very early phone call” on 9 November that overdoses were occurring in Dublin, something she described as “concerning”.

“They were not typical overdoses, they were requiring additional amounts of naloxone,” said Killeen.

Naloxone is a medication that temporarily reverses the effects of opioids, and heroin users are advised to have it on hand when they use heroin.

“First responders very quickly identified something different is happening here,” added Killeen.

“This triggered a very urgent review from ourselves with NGOs, service providers, gardaí, and hospitals in Dublin.”

Killeen said “tireless” work was undertaken on the morning of 9 November to “review what was coming in as anecdotal feedback”.

She noted that the number of overdoses “jumped very early on” and added that it appeared that “people had bought their substances across one strip of the city centre”.

Killeen added that while the overdoses were “sporadic”, they were “contained to the city centre”.

The decision was then made to use emergency callings from ambulance and fire brigades as a “surveillance tool” to monitor the overdoses.

“That was going to be our main point of information that we got an account from twice daily, in the morning and in the evening,” said Killeen.

By 12pm on 9 November, there were reportedly 13 overdoses and by 2pm, the HSE issues risk communication to people who use heroin regarding the overdoses.

On that evening’s Six One News on RTÉ, Professor Eamon Keenan was issuing warnings to people who use heroin, with the number of overdoses by then reaching over 20.

There were 24 overdoses on 9 November and Killeen noted that the anecdotal feedback was that there was a new powder, and that the overdoses were very quick – with no high – and that “people are falling straight into overdose”.

Alert

It was then decided for the HSE to issue an alert.

“We went to the media, we went to services and we said, ‘there’s overdose clusters, something’s happening, we can’t name what it is yet, but we need those wraparound supports,” said Killeen.

“We were able to go out very late at about nine o’clock in the evening of 9 November with our red alert and we issued that for Dublin.

“We put it on road traffic signs because at that point, so late in the evening, how do you reach people?”

Killeen said the next port of call was to work with services such as the Ana Liffey Drug Project.

“We went out with Ana Liffey, who were doing face-to-face work as a trusted service, and we put posters around the city.”

Killeen added that lots of lessons have been learned, telling the forum: “What do you do on a Friday night if this kicks off? Where do you get printers? How do you get the resources?

“It was really important for us to put out that we found nitazene, as this was very concerning.”

Killeen also remarked upon the need to reserve red alerts for when they are most needed.

“We need communications to be taken seriously when they’re issued,” she said.

“We do need communities to be prepared but we also need to minimise the alerts until necessary to minimise overload.”

The HSE is “asking other areas to start preparing while they have time and start putting interim plans in place”.

“We are asking areas to use this time to prepare, to work with people who use drugs, ask them where they want to see the messages, how would you reach them on a weekend, and what type of communication resources do they want?”

She also noted the importance of working with NGOs and people who use drugs, “so they know the people that they’re working with and they can put the information into their hands”.

Killeen added that there is an emergency supply of naloxone in the treatment centres.

‘Very, very unusual’

Tony Duffin, CEO of the Ana Liffey Drug Project also addressed the webinar.

He recalled that on the morning of 9 November, he received a call from a GP advising him that there were multiple callouts in the city for overdoses.

“The fire brigade let them know they had been out to seven others already that morning at 8.45am, which was very, very unusual for Dublin,” noted Duffin.

He said he immediately informed his team of the need to get a message to people who Ana Liffey services “that there may be a problem and to make them as safe as possible with what information we knew”.

Come the evening of 9 November, Duffin said “everyone was working away getting naloxone into people’s hands”.

“By 10 November, the overdoses were continuing to occur and we continued to get naloxone into people’s hands and we worked in partnership with HSE and Department of Health to plan for the weekend,” said Duffin.

He noted that the partnership Ana Liffey developed during Covid “between the HSE and our colleagues across the board kicked in”.

“We had a crisis on our hands and we had a lot of relationships on the ground,” said Duffin.

“Over the weekend, team members went out to very specific areas where reports of the overdoses were coming in.

“We were then able to pass on information to the HSE such as the colour upon sale, its texture when burned on foil, where in the city it was suspected to have originated from, and this information came from clients who bought directly from the area or engaged in transactions with street dealers.”

‘Empathy’

Duffin added that his team was able to distribute naloxone to heroin users who didn’t possess it.

“We had a total of 38 interactions,” said Duffin, “and naloxone was distributed to 27 individuals.”

He said this mix of “informal communication” between first responders and formal communication issued early in the day by the HSE was “crucial in getting much as much information as we knew to people who use heroin”.

Duffin also noted the need to gather data on drug overdoses in an “empathetic” manner.

“The tragedy of an overdose cannot be forgotten in all that gathering of data, people are frightened and at risk.

“When responding to an overdose cluster, it should be informed by evidence, guided by lived experience by people who use drugs, and engaged with empathy.”