After giving a speech at the London School of Economics in November last year, Minister of State with responsibility for New Communities, Culture and Equality, Aodhán Ó Ríordáin caught the attention of the media. In the most public forum yet, he detailed a central position in relation to his recently-acquired Drugs portfolio: decriminalisation.
Media swarmed and the public listened. This compounded upon his Ally status, socially-liberal stances and utter cuddlability to earn him the affectionate title “Minister for Hugs and Drugs”. Cited lower down in the articles of the time was the Minister’s support for Medically-Supervised Injecting Centres (MSICs). Ahead of his talk at LSE, Ó Ríordáin had confidently told the Irish Times that such facilities would be opening throughout 2016. His work in regard to both of these new tacks had however begun much earlier.
In April 2015, Minister Ó Ríordáin was appointed responsibility for the National Drugs Strategy, having deemed it as a natural solute for his Equality portfolio. Fresh from spearheading the Marriage Equality campaign and championing progressive, liberal values, Ó Ríordáin turned his full attention to his new charge. The governmental policy he was about to grapple with here however was stagnant and long since sclerotic.
The National Drugs Strategy Team (NDST) had produced a 2008 paper on Needle Exchange Provision, reviewing drug policy and expressly considered MSICs. The National Drug Strategy 2001-2008 had stated that “it does not consider that the introduction of [MSICs] warranted.” There was little will for such a development. In their review the NDST cited concerns that “the introduction of supervised drug consumption rooms would require changes in national legislation and careful consideration of the impact of such strategies in reference to international treaties.”
Nailing the coffin shut, the NDST looked at a study from 2007. Despite extensive interviews with injecting drug users, services providers and policy makers all of whom welcomed MSICs, they seemed to garner one resounding conclusion: the author’s reservation that “the introduction of [MSICs] in the current political climate would be controversial, could create resistance from the general public, and would demand a very significant policy shift on the part of government.”
MSICs were “a ‘bridge too far’ in the current political climate” and “the necessary policy shift is most likely to arise from service providers initiating change from the bottom up.” The NDST deemed MSICs “an inherent contradiction” to the current policy and the perennial two-pronged, patchwork approach of Drug use prevention and supply reduction was perpetuated.
Never one for being dissuaded by assumed consensus, Ó Ríordáin sought out new conversations. He took a soft approach, quietly building relationships with committed stakeholders, among them, the Citywide Drugs Crisis Campaign, Merchant’s Quay Ireland and the Ana Liffey Drug Project. Deferring to their insight and compassion, he was met with unanimity. The words were the same: decriminalisation, the Portuguese Model, harm reduction, MSICs. In the following July, the Minister organised a Think Tank with every regional Drugs taskforce represented, the different state agencies and people with most importantly, service providers and service users. Together they looked at decriminalisation, the rise of polydrug use and, particularly, the prospect of MSICs in Ireland.
Throughout this time, Marcus Keane, a practicing barrister and head of policy and advocacy at Ana Liffey, had been at work. With the help of a voluntary assistance scheme from the Bar of Ireland, Keane created draft legislation for the introduction of MSICs. With over 60 studies on the benefits of MSICs, Keane said convincing people became “an easy case to fight”.
Ó Ríordáin channeled the unanimity he found among NGOs and stakeholders to create a political force which was then catalysed by Keane and his colleagues’ contribution. Annexing their legal construction providing for MSICs onto the imminent Misuse of Drugs Amendment Bill, the question was put to Cabinet. Influencing their decision was the Health Research Board’s report looking at Drug-related deaths and deaths among drug users in Ireland. This took the most recent numbers available, from 2013, and was released in compelling synchronicity the day before the decision was due. On the 15th December 2015, a decision was made by the Cabinet approving MSICs as a head for the Bill.
Ó Ríordáin, applauding the decision, placed stock in the power of this evidence, and reverence in the terrible reality: “387 people died in 2013 due to drug poisoning, and 1 in 5 of these deaths was caused by heroin. The establishment of supervised injecting facilities will allow for earlier medical intervention in the case of overdoses and can also act as a gateway to treatment for drug users’. Keane’s clever construction means that, once passed, the Minister for Health can issue licences allowing for the establishment of an MSIC. Whether these are tendered out to an NGO with a HSE service agreement, or carried out by the HSE directly is all to be debated.
The day Ó Ríordáin spoke at LSE, he met Liz Evans, founder of InSite, a pioneering presence in international drug policy. In February of this year, she sat in the Guinea Room, a small conference space in Dublin’s Westin Hotel, as a small group of organisers flustered to accommodate a stream of people emerging from the rain to attend her talk, Out of Harm’s Way. Hosted by Ireland’s Help Not Harm campaign, Evans was there to tell the story of InSite, the Vancouver-based Medically-Supervised Injecting Centre. Not having anticipated such interest, the organisers scurried to find means to manoeuvre the extra attendees in. The small space housed close to 100 people by the time Evans began.
Her calm, melodious voice had been washing out over the Irish airwaves that morning. Sean O’Rourke rattled out the numbers which were to be repeated throughout the evening “[I]n North America, the one and only [MSIC] has been in existence for 13 years. It has seen more than 2 million injections, it has prevented an average of 25 fatal overdoses per month, and it refers around 400 people into treatment every year”. These numbers grew ever more striking as the evening went on, as their reality sunk in. She had told her story, the story of InSite, many times that day, keeping within timed segments and column inches. Now, in front of an audience there to listen and learn, she took her time.
Her surprise at the event’s popularity and the media frenzy throughout her day was evident and she began by thanking those attending: “this is an issue that a lot of people would rather shy away from, frankly. It’s complicated, it’s messy, it’s often so full of stigma that people don’t want to begin the conversation.”
Evans’ story began as a young nurse working in Vancouver in 1991, where, at the age of 25, she set up a housing system for people considered ‘unwelcome’ in other forms of accommodation. Besides other supports and approaches the housing provided, they had a fundamental No Evictions policy.
In the Downtown Eastside where she operated, many people were using drugs and struggling to survive. The small inner city area had a population of 15,000, 6,000 of whom were injection drug users. Involvement in the criminal justice system was rampant and many lives were defined by isolation. People were selling their bodies for drugs and third world diseases like TB and syphilis had a vicegrip over sections of the community. 81% of the people living in her housing project were malnourished. 90% were injection drug users, half of whom were HIV positive. “In our community HIV infection rates were higher than Botswana, and overdosing numbers were skyrocketing” Evans noted, the latter accounting for about one death every day. “This is all the while living in one of the world’s richest and most beautiful cities.”
Speaking about the early days of the housing project she said “there was a lot of negative media, imagery of people using our housing, who were generally referred to as ‘junkies’. They were told they were shit, by the media, by each other, by themselves, and particularly by the police. They were told they were filth and that they deserved to die.”
The loss of life was desperate and unrelenting “I watched as people I knew, people I cared about stopped breathing. As their bodies turned blue I’d shake their limbs and pound on their chests and give them my breath. I was terrified. I was threatened with arrest for using Narcan™ (the medication used to counter opioid overdosing). I was viewed as insane.” She spoke about confronting her own ignorance and naivete: “When I met people who were using, I wanted to help them by getting them to stop, by getting them into detox, to ‘get clean’. Surely, I thought, they had already hit rock bottom”
It became apparent that, there was not one telling of stories of addiction and suffering. “Simplistic narratives are often used to define complex situations,” she warned, “and these prevent us from questioning deeper social issues.”
Working in this community, she began to see what she called ”the fall-out of our failed policies”, the ‘Just Say No’ educational prevention campaigns, and enforcement emphasis on criminal crackdown as a means of deterrence. These were, she said, “insidiously and sadly perpetuating people’s suffering.”
Inspired by the implementation of supervised injection in Frankfurt, Evans and her colleagues sought to create a safe space for users. In Canada and around the world, policies and programs existed at either end of the addiction narrative. Prevention programs in schools and the healthcare system warning people about the risks were established, to limited success. Zero tolerance policies among service-providers and law enforcement and interventions on supply both sought to curtail uptake and the spread of drug use. Together these constituted the ‘War on Drugs’. On the far end, detox and rehabilitation services were available for those able to cease using. A lacuna lay in the centre however, with no consideration or care given for people who were using and who could not so readily stop.
In 2003, InSite opened it’s doors. “We were able to bring in the most marginalised people inside”, says Evans “where they could inject safely, out of the alleys and off the front doors of the local businesses.”
She becomes emotional when she describes the facility. As she spoke and the images slid past on her powerpoint, the feeling was affecting. A simple, obvious and humane solution was being rendered clearly to the room.
After walking through InSite’s doors, the process begins with a conversation. A user, having registered with an anonymous codename, will tell staff what substances they have with them, they speak about their drug use patterns and why they need to use the facility. “We make sure they know the site is for them, it’s for their healthcare, it’s an important place of social contact, it’s a place of respite” says Darwin Fisher, InSite Manager, in a short film Evans played about the service and their political battles to stay afloat against a Conservative government and a Supreme Court Challenge. Users are shown in the Injection Room, where they are assigned a mirrored booth backing onto an open space were medical personnel (usually specially trained ER nurses) are observing. Clean equipment is provided. It’s a quiet, calm space. The light is bright and warm. It’s meditative, not hectic. “They are shown a sink where they can wash their hands before injecting… they can talk to a nurse while injecting, be shown safer injection techniques, they can see the nurse afterward for wound treatment if necessary.”
The indispensable worth of the service is that it acts as a safe space and link to basic human connection, but also as a primary interaction with a larger system of care.
“Afterwards,” Fisher continues “they can then grab a cup of coffee or juice in the Chill Lounge and we can then talk about the broader issues: What it’s like to live in the Downtown Eastside. If the person is homeless we can talk about housing, if they need methadone we can connect them, and if they want to talk about detox, we can show them OnSite upstairs.” The service is basic, simple and essential. “This is a place where people can come, be treated as a human, be treated with respect and asked “what are your needs?”.
What’s more, it’s cost effective. InSite estimates that for every dollar spent on their services, $4 are saved from the public healthcare system. More importantly, it saves lives. With supervision, advice on safe use and a supply of Narcan and medical expertise, overdoses are prevented regularly, around 25 per month. Further, drug users are 73% more likely to detox after having been involved in InSite’s service, with 4000 referrals being made to date.
Despite the success of the centre and the it’s importance in the lives of it’s users, theirs was not a simple path. InSite is a story of perseverance and dedication. Users, advocates and service providers fought together in ceaseless public activism to be heard and, later when a Conservative Government came to close their doors, to survive. Evans says “We were able to convince the people of that city that the lives of drug users actually mattered. In Vancouver we convinced them enough to go out and change their policies.”
With a Dáil in disarray, and no effective Government to speak of, the Bill and the decision, remains shelved yet to pass the houses of Oireachtas. This powerful tool for those who would treat addiction with compassion, understanding and reason is yet to be materialised. Ó Ríordáin, since having narrowly missed out on being reelected in a gruelling marathon count in Dublin Bay North, has announced his candidature for the Seanad and is keeping progressive drug policy as a central tenet of his work.
— Aodhán Ó Ríordáin (@AodhanORiordain) March 22, 2016
Liz Evans spoke to that room in the Westin in the aftermath of the murders of Eddie Hutch and Dave Byrne. The city was unnerved. She knew there could be no more delay. “In Dublin today I was hearing about the fears of heightened gang violence, fears that threaten the communities, families and security of people who use drugs. These brutal conditions are things we have created. They cause us to react with fear, stricter enforcement policies and more battles to fight in the seemingly endless War Against Drugs – a war in which the victims are users, their families and the community.”
Medically Supervised Injection Rooms are an indispensable provision of care and contact for drug users. As the state wages on in its interventions in drug supply and dealing, and rehabilitation services continue to help people unburden themselves from addiction, drug users deserve more. Political stagnation is denying oxygen to progression. The Misuse of Drugs Amendment Bill sits untouched. Only by providing a service which acknowledges them and their situation without judgement or reprimand, can drug users be shown their lives matter. Perhaps then, for the victims of this war, we can call an armistice and some sustained healing can begin.
Illustration: Sarah Moloney