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Review of Harm Reduction Approaches in Ireland and Evidence from the International Literature

Research Team

• Gerard Moore
• Philomena McCarthy
• Padraig MacNeela
• Liam MacGabhann
• Mark Philbin
• Denise Proudfoot

Dublin City University

Background

• Harm reduction was introduced as a strategy in the 1980’s when concerns about the transmission of HIV emerged
• Worldwide there may be as many as two to three million past and current drug users living with HIV/AIDS and more than 110 countries now report HIV epidemics that are associated with injecting drug use (WHO 2003)
• Action 100 of The National Drug Strategy 2001-2008 (2001) outlines the need for research to be conducted into the effectiveness of mechanisms to minimise the sharing of drug taking equipment

Report Outline

• An overview of drug taking techniques and the paraphernalia used in the administration of drugs
• A review of international approaches to harm reduction
• A review of national approaches to harm reduction
• An international review of alternative and innovative initiatives which may have potential application to Ireland
• A review of the uptake, effectiveness and limitations of harm reduction approaches nationally
• A review of the issues involved in operating such schemes

Methodology

Literature Review
Research Foilseacháin published in the English language up until July 2003 were included in the literature review

Research
An exploratory empirical study was conducted to obtain information directly from Irish service providers

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Defining Harm Reduction in Relation to Sharing Drug Taking Paraphernalia

• A concept aiming to prevent or reduce negative health consequences associated with certain behaviours (WHO 2003)
• In relation to drug use the aim is to prevent the transmission of infections that occur through the sharing of non-sterile equipment and drug preparations

Harm Reduction Interventions

• Information education and communication
• Health care in relation to infectious diseases
• Needle exchange programmes
• Drug substitution treatment
• Drug consumption rooms

Methods and Tools of Drug Administration

Tools
Syringes, needles, spoons, filters, water containers, pipes and drugs

Methods

• Smoking / Inhalation
• Snorting
• Injecting both skin popping and intravenously

Risk Taking Behaviours Associated with Drug Use

• Sharing any drug taking paraphernalia
• Front or back loading of drugs (having) – the transfer of drug solutions from one syringe to another
• Borrowing – using equipment received from another injector
• Lending (donor sharing) passing used equipment to another person

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Messages Emphasised in the Literature in Relation to Sharing Drug Taking Paraphernalia

• Within Needle Exchange Programmes it is necessary to target both changing behaviour and perceptions around risk
• Harm reduction messages need to include discussion about both borrowing and lending

Key Findings in Relation to Sharing Equipment

• All drug taking routes that require the use of equipment increase the risk of transmitting HIV, Hepatitis B virus and Hepatitis C virus
• Characteristics most frequently associated with the sharing of equipment include youth, a shorter injecting history and being involved in a sexual relationship with another intravenous drug user
• Needle exchange programmes have been successful in reducing the risk of sharing needles and syringes but have not been as successful in reducing the sharing of other drug taking paraphernalia

Sharing Drug Taking Paraphernalia in Ireland

• The research reviewed indicates that 70% of intravenous drug users attending services reported syringe borrowing (Smyth et al 2001)
• Almost ¼ of intravenous drug users who borrow syringes do so frequently and less than 13% of this sample avoid borrowing spoons or filters (Smyth et al 2001)
• Irish needle exchange programmes are effective in reducing incidents of borrowing and lending needles and syringes but have not shown significant changes in sharing other injecting paraphernalia (Cox et al 2000)

Intravenous Drug Use in Ireland

• Since 1992 the Irish Government have pursued a policy of harm reduction by providing methadone maintenance and needle exchange programmes
• The number of opiate users in the Eastern Regional Health Authority area in receipt of methadone rose from 150 in 1992 to 3,000 by 1997.
• There is a relatively high rate of opiate drug use in Ireland generally estimated at 5.6 per thousand of the population (Kelly et al 2003)

Quantifying the need for Service Provision in Ireland

• There were 6,883 intravenous drug users accessing treatment from a range of services in December 2003 (Central treatment list ERHA 2003)
• Almost 800 attendees were accessing needle exchange services on a weekly basis in 2003 (Working Group on Needle Exchange 2003)
• The NACD currently estimate that there are 14,500 heroin users in the country

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Service Provision in Ireland

• Harm reduction services are mainly concentrated in the Eastern region
• Where services exist opening hours vary extensively. Limited opening hours is cited in the literature reviewed as contributing to sharing drug taking paraphernalia
• In some areas ‘back packing’ a form of outreach needle exchange service is utilised
• The range of harm reduction equipment and advice available differs between services

Self Reporting on Harm Reduction Services in Ireland

Differences in the quality of services

• Services in the ERHA self-reported harm reduction programmes that offered, education, needle exchange and methadone maintenance
• Outside of the ERHA harm reduction programmes mainly consisted of methadone provision
• However even within the ERHA where needle exchange programmes were available differences existed in the range of drug taking paraphernalia available to service users

Purpose of harm reduction programmes

• Nationally similar responses were made in relation to the purpose of harm reduction services
• Some service providers reported specifically targeting marginalised groups
• The majority of services reported that specific issues such as the transmission of infectious diseases and sexual health were addressed

Differences in the range of advice on offer

• Providing information on choosing, rotating and caring for injecting sites was reported by all of the ERHA services, however only a minority of services outside of this region reporting offering advice in this area
• No respondent reported delivering advice about alternative methods of drug administration, which contradicts recommendations highlighted in the literature

Access to services

• In the main services were described as opening during office hours
• Some services reported some evening opening hours weekend opening hours were reported by two services outside the ERHA
• The literature indicates that people share paraphernalia when clean equipment is inaccessible

Alternatives ways of providing access to clean paraphernalia

• Countries including Germany and Switzerland use vending machines to minimise the problem associated with limited opening hours
• Other countries such as England operate needle exchange services through community pharmacies

Staff education and training

• Variations exist in the level and frequency of training in harm reduction
• Respondents reported training that occurred at various times between 6 months and 5 years
• Respondents in the ERHA reported ongoing education in the form of team meetings, discussions and consultations with colleagues

The influence of policy on practice

Nationally the majority of respondents reported that developing protocols especially around under-age users and new policies remain a challenge. Balancing confidentiality and informing parents of under-age users was reported as a challenge

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Alternative Approaches to Delivering Harm Reduction Services

• Needle exchange through vending machines and pharmacies
• Heroin provision
• Drug consumption rooms

Vending Machines and Pharmacy Exchange

• Pragmatic approaches to Needle Exchange Programmes recognise that personal Teagmhálacha is not always feasible, and in these incidents, services have been augmented with vending machines
• Pharmacy based Needle Exchange Programmes are cost effective and provide an extensive network of Teagmhálacha s for drug users, not all of whom take part in formal programmes (Anderson et al 2003)

Heroin Provision

• Heroin provision is part of treatment in the UK and trials have been conducted in both Switzerland and the Netherlands
• Heroin trials have not fully examined whether improvements in health status are casually related to heroin provision or as a result of the impact of the whole programme
• Injecting prescribed opiates does not reduce the risk of blood borne infections, it is the use of clean drug-taking paraphernalia that achieves this aim

Drug Consumption Rooms

• Safe Injecting facilities are part of harm reduction approaches in the Netherlands, Switzerland, Spain, Germany and Australia
• The goals range from reducing public nuisance, increasing Teagmhálacha ed with marginalised drug users, providing access to sterile equipment, encouraging people into treatment and reducing death from overdose
• The attempt to show the benefit of safe injecting facilities by scientific research is a difficult task…it is impossible to create a potential control group, because drug users are mostly a hidden population (Hammig 2003)

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Marginalised Groups

Marginalised groups in society, such as the homeless, people involved in prostitution and prisoners, are more likely to be involved in risk behaviour such as sharing drug taking paraphernalia

Prisoners

• Drug use in prison and its implications are a major problem
• In a national sample of Irish prisoners 52% reported a history of opiate use, 43% report a history of injecting drug use (Allwright et al 1999)

Drug use while in Prison

• An Irish study found that over half of intravenous drug users reported sharing needles in prison and almost a fifth reported starting their injecting habit there (Long et al 2001)
• Estimates indicate that the rate of HIV among Irish prisoners is over 10 times greater than in the general population
• Evidence suggests that the rate of infection with Hepatitis C virus also exceeds that of the general population

Addressing Drug Use in Prisons

• Prisons in Germany, Spain and Switzerland have established Needle Exchange Programmes both as trials and part of comprehensive harm reduction programmes (Nelles et al (1988), Jacob et al (2000), Rinkin et al (2000) and Hunt et al (2003))
• The research indicates that HIV amongst this population has consequently decreased and there is no evidence to indicate an increase in drug consumption

Harm Reduction and the Law

Controls relating to importing, exporting cultivation, licensing, administration, supply, record keeping, prescription writing, destruction and safe custody of Schedule II drugs are provided for in; The Misuse of Drugs Act 1977 The Misuse of Drugs Regulations 1988.

International treaties exist to limit the use of drugs to medical and scientific purpose only.National legislation outlines a number of controls on the prescription possession and consumption of controlled drugs.

There is scope in Irish law for the prescription of Schedule II drugs by medical practitioners and other defined agents.

Conclusions

• Harm reduction messages need to highlight risks of sharing equipment such as spoons, water and filters as well as needles and syringes and promote safer ways of using drugs
• Sharing of equipment occurs where access to harm reduction services is limited, poor or not available
• Those at greater risk of infection are young drug users, those with a shorter injecting history and those in an intimate relationship with another drug user

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