The 'safer' route from harm


In the second of our two-part series on Ireland’s heroin problem, we visit Limerick’s first mobile needle exchange unit – just one of the approaches being taken to deal with heroin addiction outside Dublin

IT’S 2PM ON a dreary Tuesday afternoon on the quays in Limerick. Just to the side of the road, beside the quay wall, the white van I’m in pulls up and several of the workers get out and hop into the back. Inside, it looks for all the world like a mobile office, with space for files, a swivel chair and portable heaters. The laminated board on the table is the first giveaway though, with images of a male heroin addict injecting himself and a narrative underneath outlining the correct way to do it. There are unused needles on the table, and packages of silver foil which addicts will later use to smoke heroin.

Welcome to Limerick’s first mobile needle exchange unit, which is operated by the HSE several times a week in various part of the city. While the programme has been operating in Limerick, in partnership with some pharmacies around the city, the mobile unit is up and running only a few months. It allows for the transfer of clean needles to addicts, and the team of social workers and health workers who run it can assess the needs of those who use the service, initiate harm reduction methods and encourage take-up on methadone programmes.

It takes a while before someone comes and knocks on the door, but over the course of an hour, several addicts call to use the service. Some have hoods and hats pulled low over their heads, and none of them want to be identified or hang around for long. They have a glassy look in their eyes and are anxious not to be seen entering or leaving the unit. The majority of those who called into the unit seemed to be under 35 and the split between male and female clients was roughly 50-50.

Many of the workers running the mobile unit have been involved in treating heroin addicts since the 1980s, mostly in the Dublin area, and some in the UK. Outreach worker Kevin O’Callaghan arrived in the midwest some years ago.

“When I came here first I spoke with the Garda drugs squad and they said there were around 100 or 150 heroin users within the midwest area.”

His colleague, Justin Sherin, remembers that time too: “Back in the 1980s, it was mostly confined to Dublin and then a lot of the problem was spread through the prisons and the roads coming out of Dublin.” During our conversation, all of the workers noted the increase in the number of female heroin users. “Even five years ago there were not as many females,” said Geraldine Payne.

“We also currently have about seven or eight pregnant girls on the methadone programme and another issue we are seeing now is multi-drugs use. So we’re not only dealing with methadone or heroin, but it’s combined with tablets and alcohol.”

Of the clients willing to speak was a man in his late 30s, who identified himself as John. He was known to the workers and has been using heroin for several years. He says that only one other person in his circle of family and friends is aware of his heroin habit and he has managed to hold down seasonal work for large parts of the year. Like others I spoke to, he had reservations about going on a methadone programme. Some addicts believe methadone was harder to come off than heroin and were worried that they would be unable to control it if they signed up for a treatment programme. “The mobile unit is ideal here for me. It takes care of everything as it gives me easy access as I live reasonably close,” he said.

“Before this you’d go to chemists for needles. You don’t even have to say anything. In some, you just put out your finger and say ‘one’ and they’d know what you wanted,” he said. Of the heroin problem in Limerick, this person said it has increased since he began using a decade ago.

“It’s a lot more widespread and rampant here than a decade ago. It is frightening. It was a taboo years ago. If you’re not seeing it, then you have blinkers on. I’m dabbling over a decade and dependent about four years. I try to keep on top of it. Only one family member knows. I just say it is a weed and tablets thing. There’s no labelling with those addictions, no stereotyping or putting you in a box and saying that’s what you are, like there is when you say heroin. It has changed me in certain ways. I’ve begged and borrowed but I still haven’t stolen.”

John says he is reluctant to go on a methadone programme, despite appearing an ideal candidate, admitting as he does to long-term heroin use. “There is a stigma there with heroin and by right, really, because there are some people that will go to extreme lengths to feed the habit. With methadone, I can see the good it would do, at the same time I have seen in very small cases where people would break out and they would be on both methadone and heroin,” he says.

“It is one of them things. I would be more inclined to get a load of tablets and get out of town for a few weeks and try cold turkey. I’ve done that a few times. It is a full-time job for me keeping the addiction hidden. I suppose as the saying goes, never underestimate the power of denial.”

In Arbour House treatment Centre in Cork, on the grounds of St Finbarr’s Hospital, David Lane, co-ordinator of drug and alcohol services in the HSE South, and Dr Declan O’Brien, clinical director of HSE addiction services in Cork and Kerry, highlight the issues faced in the Munster region. Additional funding in recent years has meant that extra staff and community outreach workers have been provided both in Cork and also in several towns in Kerry. Some of those projects are now under pressure due to cutbacks and this at a time when the heroin problem is increasing.

“In a real sense we had a very small heroin problem in the south until five years ago,” says Dr O’Brien.

“In the space of 12 months, there was an enormous increase. We used to see about 20-30 heroin addicts a year. Now we are seeing approximately two to three new clients a week. Also, in the past it was contained in small pockets of the city – you could almost name the areas where it was confined to. It just mushroomed from there and while our injecting population would be small, it is increasing.

“The types of person on heroin are about 4-1 male/female divide and mostly in their 20s and early 30s. About 10-15 per cent of them we would have treated previously for other addiction problems.”

The service in Cork and Kerry received a cash injection in response to this alarming rise in the problem and at present there are only 10 people on a waiting list to be seen at the facility, while 200 people are on methadone programmes in the region. If someone rings up looking to be seen, they will generally have an appointment within two weeks. Much work has been done to get local communities on board outside the urban areas as well as enlisting the support of family doctors and pharmacists. Budget cutbacks, however, threaten to undermine much of the work done in certain areas, and this at a time of a rising national heroin problem. It seems to make little sense.

“We are looking at possibly closing a project and that is really difficult for us to swallow,” says David Lane. “We have put services into local communities in small towns like Fermoy, Mitchelstown, Cobh, Youghal, Killarney and Tralee and we are looking at cuts every year for the next three years. This means some of our projects face threat of closure, and like I said, having worked hard to put them in place, it’s very hard to take, given the need.”

Because of its relative proximity to Dublin, Athlone town too has had a particular problem with heroin for several years. Merchants Quay Ireland has now established an outreach clinic in the town which treats addicts from many parts of the midlands. It’s contained in the ground floor of a retail unit and operates below the radar, so much so in fact that the Italian restaurant 200 yards away, where I ask for directions, doesn’t know anything about it.

Inside, Merchants Quay Ireland chief executive Tony Geoghegan has called to visit and an outreach worker, Anthony Rodden, is attending those who call. They are offered needles of various sizes as well as methadone, contraception, foil, antiseptic wipes and are asked to bring back their used needles.

There had been a vocal local opposition some years ago to the provision of in-patient treatment services in Athlone, but as the problem has worsened, there appears to be more acceptance now of Merchants Quay and the work they do.

Anthony Rodden, who is outreach worker for Westmeath/Athlone area with the Merchants Quay Ireland Midlands Project, says that there has been a significant rise in the numbers assessing the needle exchange programme. “We’ve gone from seeing 20 clients a month to over 40 in the last few months,” he says. “They’re not just coming from the Athlone area, but from areas outside the county like Roscommon.”

Several workers I spoke to in both Limerick and Cork alleged that pharmacies in certain areas were refusing to co-operate with methadone or needle exchange programmes and so it can be a challenge getting buy-in into methadone services in certain areas. Merchants Quay Ireland has worked closely with GPs and the local community in Athlone and they are now seeing more understanding of the need to treat the addict, to the benefit of local society. But it seems an area of public health education which needs tackling on a broader national level.

“Some GPs have done some training in the area of drug use and are more understanding now with patients,” says Rodden. “GPs have now trained in methadone, but you still have some in certain areas not wanting to deal with drug problems at all. I think that’s a bit like Ireland as a whole. Until all of society begins to address this problem, it will remain a struggle.”

‘Going for a smoke of heroin is nearly like going for a pint these days’

‘David’ 34, is from Athlone and on the methadone programme:

“There is a serious problem in Athlone and it has escalated over the last few years. I was smoking heroin for a long time before I went to inject. It is hard in a small town, as everyone knows each other.

“I decided enough was enough and gave methadone a shot, and through the Simon Community I got stable on methadone first and then began to get more treatment. I’m clean the last 12 weeks, and trying to find myself an apartment. I’m still in contact with my mam but I’m not speaking with my dad. Slowly, I hope to get back their trust. I’ve lost girlfriends, apartment and jobs through heroin.

“The methadone is in liquid form and you take it like you would Calpol or something. You’d be a bit drowsy and that, but without methadone you wouldn’t be able to survive.

“I first started on heroin when I was 29. Curiosity killed the cat, and I would have tried other drugs over the years, like hash and pills and speed. I tried heroin because everybody seemed to be using it. It starts off costing about €25 a day and then when one bag doesn’t work, you’re on to two bags and so on and so on. I’d get my dole on a Wednesday and I’d be just handing it over for heroin.

“Heroin is different to other drugs. Most accept cocaine. It is socially acceptable. But heroin you associate with robbing to feed the addiction. It is a nasty drug. You have to go and steal and do whatever else to feed the habit and it turns people from normal humans into zombies. I come in here twice a week to get needles. I stopped smoking because it is cheaper and lasts longer if you inject. Once on methadone, I don’t need anything. I can go to the gym and hold down conversations with most people.

“For such a small town, there is a serious problem with heroin in Athlone and it is only getting worse. I used to even buy methadone on the street from people and it was €25 for 1,200 millilitres. Some people who are on big doses will end up selling some of their methadone to buy heroin. Years ago, you would never hear of heroin outside Dublin. Now it is as big a problem in places like Tullamore, Athlone, Clara and all these small towns are flooded with heroin. Going for a smoke of heroin is nearly like going for a pint these days with some people.”