Since 2012, the introduction of supervised injecting facilities in Ireland has been a strategic priority of the Ana Liffey Drug Project, which works with more than 2,500 injecting drug users in Dublin, the Midlands and the Midwest. 

In 2015, following work with the Voluntary Assistance Scheme of the Bar of Ireland, the Ana Liffey Project presented draft legislation to then Minister of State, Aodhán O’Riordáin, that, if enacted, would create a framework for supervised injecting facilities to operate in Ireland. Last December, Leo Varadkar, Minister for Health, brought the matter before Cabinet and a decision was taken to introduce the legislation calling for supervised injecting facilities.

What are supervised injecting facilities?

Supervised injecting facilities are a subset of drug consumption rooms. They are places where injecting drug users can inject drugs in a clinical space, under medical supervision. They are often conflated with other types of intervention, so it is useful to set out what is meant by supervised injecting facilities and how they are conceptualised. 

Supervised injecting facilities should not be confused with heroin assisted treatment, which involves the prescription of heroin and its supervised use to entrenched users. Supervised injecting facilities do not prescribe or otherwise provide drugs to users, but rather users bring their own (often illegally obtained) drugs to the centre. 

These injecting facilities focus specifically on injecting drug use. While drug consumption rooms more broadly can (and often do) permit drug use by other routes of administration, supervised injecting facilities are restricted to injecting drug use. 

These injecting facilities are not standalone facilities. They are a focused intervention aimed at a particular cohort of hard-to-reach drug users who are often isolated from mainstream services. Such facilities need to have strong links and referral pathways to other, higher threshold, services. 

Finally, supervised injecting facilities are primarily clinical services. The focus is on ensuring addicts use drugs in the safest manner possible, that there is medical support and overdose monitoring immediately available onsite.

How do injecting facilities operate?

As with any service, there is more than one model of service provision available, and supervised injection facilities operate in different ways around the world. Regardless of the exact model used, facilities tend to follow the same basic footprint.

Users first enter into a reception area, where they either undergo a brief assessment (if it is their first time using the service) or confirm their identity (if they’ve used the service before). Basic information concerning the addict’s recent drug use and intended use in the centre can be relayed to staff in the injecting space. Following this, they move through into the injecting space. This is typically a nurse-led space where users can access clean injecting equipment and harm reduction advice. There are also injecting booths, where client can sit to prepare and use their drugs. 

Clients are monitored for medical issues including overdose and/or paradoxical reactions, and the injecting space is equipped to deal with such issues. There is no report of a death from overdose in a supervised injecting facility anywhere in the world. Once the user is finished in the injecting space they move through to a more social space, where social care staff can offer advice, onward referral to other services and other support. 

Injecting facilities have been shown to improve both health related indicators for drug users and broader environmental indicators such as the reduction of unsafely discarded paraphernalia.

In its European Drug Report 2015, the European Monitoring Centre for Drugs and Drug Addiction noted that: “The benefits of providing supervised drug consumption facilities may include improvements in safe, hygienic drug use, especially among regular clients, increased access to health and social services, and reduced public drug use and associated nuisance. There is no evidence to suggest that the availability of safer injecting facilities increases drug use or frequency of injecting. These services facilitate rather than delay treatment entry and do not result in higher rates of local drug-related crime.”¹

Similarly, a report commissioned by the Joseph Rowntree Foundation in 2006 found that there is no evidence that such services either increase or decrease an individual’s drug use, or that they act as a magnet for drug users. However, they were associated with a reduction in injecting in public places and a reduction in discarded used syringes and drug-related litter.² For example, in Barcelona, a fourfold reduction was reported in the number of unsafely disposed syringes being collected in the area from a monthly average of over 13,000 in 2004 to around 3,000 in 2012.³ Other positive findings include evidence that supervised injecting facilities can be a successful gateway to treatment⁴ and can reduce ambulance call-outs for drug overdoses.⁵

As noted earlier, it is important that such facilities are provided, not as standalone services, but as a response that is integrated into current service provision. The European Monitoring Centre for Drugs and Drug Addiction states that: “In settings where there is a demonstrable need for drug consumption rooms, their development and the extent to which they can achieve their objectives is tempered by the broader social and policy context. A qualitative assessment of the literature suggests that drug consumption rooms can only be effective if they are:

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Integrated into a wider public policy framework as part of a network of services aiming to reduce individual and social harms arising from problem drug use

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Based on consensus, support and active cooperation among key local actors, especially health, police, local authorities, local communities and consumers themselves

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Seen for what they are, that is, specific services aimed at reducing problems of health and social harm involving particular high-risk populations of problematic drug users and addressing needs that other responses have failed to meet.”⁶

It is beyond doubt, particularly in Dublin, that such supervised injecting facilities are much needed and, despite our best efforts, existing services do not meet the health needs of injecting drug users. 

A 2005 study showed that 68% of 66 homeless intravenous drug users reported injecting in a public place in the previous month.⁷ A client survey carried out by the Ana Liffey Drug Project in 2008 found that of the 16 respondents who reported where they had injected 30 days prior to interview, nine respondents (56%) stated that they had used in public places.⁸

In 2014, Merchants Quay Ireland reported that 44 (14%) people from their sample who used the needle exchange service generally injected in public places.⁹

At Ana Liffey, there is an assertive case management team tasked with working on a street outreach basis with the most marginalised and hard to engage people. Through this service, the project currently case manages over 40 individuals, the majority of whom inject in public. 

The Ana Liffey Drug Project could improve drug users’ health and service engagement greatly by being able to provide a safe space where users could inject with medical supervision. 

References 

1. European Monitoring Centre for Drugs and Drug Addiction. Drug consumption rooms: an overview of provision and evidence, 2015. Available online at: http://www.emcdda.europa.eu/topics/pods/drug-consumption-rooms#ref23Online 
2. Joseph Rowntree Foundation. The Report of the Independent Working Group on Drug Consumption, York 2006
3. Vecino C, Villalbí JR, Guitart A et al.Safe injection rooms and police crackdowns in areas with heavy drug dealing: evaluation by counting discarded syringes collected from the public space (in Spanish), Addiciones 2013; 25(4): 333-8
4. Kimber J, Mattick RP et al. Process and predictors of drug treatment referral and referral uptake at the Sydney Medically Supervised Injecting Centre. Drug & Alcohol Review 2008; 27(6): 602-612
5. Salmon AM, Van Beek I et al. The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia.” Addiction 2010; 105(4): 676-683
6. European Monitoring Centre for Drugs and Drug Addiction. Harm reduction: evidence, impacts and challenges. EMCDDA Scientific Monograph 10, 2010
7. Lawless M, Corr C.  Drug Use Among the Homeless Population in Ireland. Dublin, NACD, 2005
8. Keane M.  Ana Liffey Drug Project. Client Survey. Dublin, Ana Liffey Drug Project: 64, 2008
9. Jennings C. Re-establishing Contact: A profile of clients attending the Health Promotion Unit – Needle Exchange at Merchants Quay Ireland. Dublin: Merchants Quay Ireland, 2014