Hand out the heroin?


The Republic has the fifth-highest incidence of heroin addiction in Europe, and the average age of addicts, at 24, is the youngest in the EU, a full decade lower than in the Netherlands. There are two ways of addressing this social epidemic: one pragmatic, the other moralistic.

Moralists believe that the only solution to addiction is detoxification and AA-style group therapy with a goal of lifelong abstinence. But there is a difference between a socially stable celebrity checking herself into the Priory Clinic for a spot of rehab, and a street addict who is surviving on crime and the next fix. "To say we have to have abstinence is unreal. It's ideal, but not practical. In reality that does not work," says Shane Butler, addiction studies specialist at Trinity College Dublin. Butler believes addiction is linked to a deeper set of practical and emotional life problems involving poverty and disadvantage. Unless these problems are eased, any addict attempting to remain drug-free is doomed to failure.

Butler and his fellow "pragmatists" - who represent the vast majority of those treating drug addiction in the Republic - take a "harm reduction" approach which entails "engaging" addicts by offering needle exchange, by prescribing opiates such as methadone and by providing social and psychological support in an attempt to stabilise addicts' lives, with consequent benefits for addicts and society. Whether or not the addict becomes drug-free is not seen as a measure of success or failure of such programmes.

"Methadone has been likened to insulin for a diabetic; it enables the addict to lead an ordinary life," says Butler.

The moralistic view is represented by the anti-drugs crusader Grainne Kenny, whose training as a counsellor comes from "all over the place". Widowed last year, Kenny is the founder and international president of Europe Against Drugs (EURAD), a 20-year-old body with no current funding source, and which Kenny says she runs on an overdraft from a premises in Dun Laoghaire. Kenny is totally opposed to "harm reduction" of any kind, whether it involves needle exchange, methadone maintenance or prescribed heroin. She sees the fact that only 10 per cent of harm-reduction clients worldwide kick the habit as a measure of failure.

It was she who stirred up controversy recently by calling on the Franciscan Friars to pull their funding from the Merchant's Quay Project. Kenny made the call in response to a publicly reported comment by Merchant's Quay director Tony Geoghegan. He believes that heroin could be used therapeutically - as it is in the Netherlands and Switzerland - in highly controlled residential harm reduction programmes as part of a spectrum of treatments, a view which the Franciscans support. Geoghegan does not advocate "handing out free heroin willy-nilly", but does believe that "if we are serious about treating heroin addiction, we must look at all the options". For a minority of hard-core heroin users, prescribing heroin may be the only way to get them to stop committing crimes, harming others and destroying their own health. A Swiss Ministry of Health study of a heroin distribution project showed a 60 per cent reduction in robbery and an 85 per cent reduction in theft by addicts. The health of the addicts also improved as they got off the crime/drugs treadmill and had an opportunity to look at the wider issues in their lives.

Geoghegan's call for prescribed heroin to be considered, was rapidly interpreted as a call for "free heroin for junkies" and was likened by Grainne Kenny as giving alcohol to alcoholics. Kenny rejects the Swiss research results, quoting Dr Ernst Aeschbach, a psychiatrist and psychotherapist who believes that "the assertions of positive results from the Swiss heroin distribution projects are inconsistent with the goal of abstinence". Dr Aeschbach also argues that the study did not establish that the improvements in health of addicts in the study were due to heroin distribution.

You could argue the research results all day, but what really matters in this controversy is that misinformed public reaction might influence political decision-making. Kenny's reaction "panders to the fears of those people who are not au fait with the area", making it even more difficult to establish drug treatment programmes at local level, believes Geoghegan. This public spat has, however, highlighted a larger issue, which is that heroin addiction is as complex as it is difficult to treat, although great strides have been made in the Republic in the past 10 years.

"It's easy to detox people and put them out on the street drugfree, but they are certainly not going to stay drug-free unless they address all the other peripheral issues. Otherwise you are setting them up to fail," says Geoghegan.

An interim drugs advisory group has been sitting to discuss the setting up of a National Drugs Advisory Body, based on a UK model. Among the group are civil servants, representatives of Merchant's Quay, Shane Butler of Trinity College Dublin, Mary Ellen McCann of the Ballymun Youth Action Project and Gary Broderick of the Ana Liffey harm reduction agency, which was founded in 1982. Butler, McCann and Broderick have their own views on the use of heroin in harm reduction programmes. Butler supports limited, well-controlled heroin use in the context of harm reduction for the same reasons as Geoghegan, while McCann is reserving judgment until she sees more research. She is also concerned that any treatment be offered in the "context of holistic care for the addict".

Broderick takes a social perspective, believing that if the public is opposed to therapeutic heroin use for addicts, then this method would do more harm than good by further alienating addicts. Social and cultural approval of treatment methods is essential for them to succeed, in his opinion.

Butler believes that communities are becoming more sophisticated in their views of the drug problem and accepting that stable, monitored and controlled lifelong drug use may be the only way some people can work, go to school and have a normal life. His view is that it's easy for some middle-class people to pontificate because they have never had to deal with a heroin problem in their own communities. Once you get a heroin problem on your doorstep and learn to know addicts as mothers, fathers, sisters, brothers and children - you realise your approach may have to be pragmatic.