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

1
A Review of Harm Reduction Approaches in Ireland
and Evidence from the International Literature
2

• National Advisory Committee on Drugs (NACD)

3
Research Team Gerard Moore Philomena
McCarthy Padraig MacNeela Liam MacGabhann Mark
Philbin Denise ProudfootDublin City
University
4
Background

• Harm reduction was introduced as a strategy in
  the 1980s 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

5
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

6
Report Outline

• 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

7
Methodology

• Literature Review
• Research publications 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

8
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

9
Harm Reduction Interventions

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

10
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

11
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

12
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

13
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

14
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)

15
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)

16
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

17
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

18
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

19
Self Reporting on Harm Reduction Services in
Ireland

• 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

20
Self Reporting on Harm Reduction Services in
Ireland

• 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

21
Self Reporting on Harm Reduction Services in
Ireland

• 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

22
Self Reporting on Harm Reduction Services in
Ireland

• 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

23
Self Reporting on Harm Reduction Services in
Ireland

• 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

24
Self Reporting on Harm Reduction Services in
Ireland

• 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

25
Alternative Approaches to Delivering Harm
Reduction Services

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

26
Vending Machines and Pharmacy Exchange

• Pragmatic approaches to Needle Exchange
  Programmes recognise that personal contact 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 contacts for drug users, not all of whom take
  part in formal programmes (Anderson et al 2003)

27
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

28
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 contacted 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
  taskit is impossible to create a potential
  control group, because drug users are mostly a
  hidden population (Hammig 2003)

29
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

30
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)

31
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

32
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

33
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

34
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.
35
There is scope in Irish law for the
prescription of Schedule II drugs by medical
practitioners and other defined agents.
36
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

37
Thank you