Two key harm reduction measures were included in Ireland’s National Drug Strategy ‘Reducing Harm, Supporting Recovery: A health-led response to drug and alcohol use in Ireland’ published in 2017. These were to establish a pilot for a safe injection facility, and a working group to examine the evidence base for ‘back-of-house’ drug checking (meaning testing substances voluntarily given).
It took five years for back-of-house drug checking to start, and then only as a pilot on a smaller scale of only one festival than the three festivals initially conceptualised. The safe injection facility only opened in December 2024. Both faced logistical delays like planning permission objections and slow proposal processing. This meant that people who use drugs were left without any evidence-based interventions to keep them safe from the unregulated drug market, in a period where Ireland had one of the highest overdose rates in Europe.
Our research explored what these delays in harm reduction policy meant for people who use drugs and those working in drug-related organisations. We interviewed 34 people, a mix of people who use drugs and members of the substance use workforce in Dublin, between October 2023 and January 2024 – roughly one year before the safe injection facility opened in the Irish capital, and before the drug checking pilot was expanded to additional music festivals. Our work demonstrated that participants perceived direct and secondary impacts of delayed implementation of these harm reduction initiatives.
Direct impacts of delays in drug policy reform
With no drug checking or safe injection sites in place, people using drugs resorted to makeshift safety responses. Some of these were helpful like using drugs with someone or using in a spot where they could be seen if there was an overdose.
“I know a load of people that have their houses and they are actually, like, mainly just crack houses or gear houses … they all come in and use it because it’s a safe—it’s not a safe environment, but it’s an environment that you are not sitting out in the rain, in the lashings of rain. Or if you did OD, at least there is somebody there to help ring an ambulance, get you what you need … if you do that out in the rain on your own, that’s it, you’re gone.”
Others actually increased the potential for harm, like improper overdose responses, such as using crack cocaine to respond to an opioid overdose rather than naloxone.
Those interviewed believed that policy delays compounded the existing inequalities that people who use drugs already face. Participants reported that people who use drugs were rarely seen as a policy priority, and that these types of policy delays wouldn’t occur for issues impacting people of a different socioeconomic status or did not use drugs.
“I think if you’re looking at drug testing in festivals, again it’s a certain class, it’s a certain type of person … there’s a certain cohort that go to festivals and because it’s recreational, it’s different. Because the coke is in powder form and it’s not smoking the crack cocaine, it’s different… if someone was to inject that powder, again they wouldn’t be in that cohort … I think, number one, it’s great that we can start breaking down barriers and looking at the stigma attached to drugs, but I still think people are looking at certain types of drugs and certain types of drug users.”
Participants also believed that lives could have been saved if these policies had been implemented earlier. A few speculated on what had been the human costs of these delays.
“Quite simply, people are dying. I think it’s average we have an overdose fatality every day in Ireland. So, yes, it’s as simple as that … I think in the last maybe three months we’ve amputated two limbs in the hospital due to injecting drug use … they’re going in and hitting their femoral artery and DVTs within their legs. So, yes, it’s like the proof is there that people need a safe space to inject, end of. So, yes, it just beggars belief why it’s not open … but, again, do we care enough about these people that are losing their legs or are dying? I don’t know”.
Secondary impacts
We also found that people identified a series of secondary impacts felt by these delays. The Irish drug landscape changed dramatically since the safe injection facility was first legally approved in 2017.
This meant that some of the interventions needed to be altered to meet the current needs of people who used drugs, such creating an inhalation room for people smoking crack cocaine as crack cocaine use has risen dramatically in recent years.
“I think because it’s been so long in the design that now, what’s after happening is Ireland … crack cocaine has hit Ireland like snow… Because it’s taken so long to get this off the ground, time has evolved and the drug trend has evolved and now we need safe consumption rooms rather than safe injecting rooms…”
Participants also highlighted that harm reduction interventions should anticipate incoming challenges. One crucial change was the appearance of new synthetic opioids, which some believed were already prevalent across Ireland. While many participants discussed fentanyl, overdose clusters due to nitazenes occurred during data collection.
“…we know people that have fentanyl… I have seen it with my own eyes, and I have touched the bag with the fentanyl in it and you’re telling me it’s not in Dublin. ‘Categorically it’s not’. Categorically it’s not? What about the two people that OD’d in my hostel? One of them is dead on fentanyl.”
We also saw that participants had to navigate feelings of frustration with the slow or incremental pace of change in Irish drug policy, all while the drug market rapidly changed around them.
“I feel, as people working in the area, we allowed the crack cocaine epidemic to take place. We knew it was coming. We didn’t act. I think I remember national media about three years ago saying the country is on the verge of a crack cocaine epidemic; the fact is everyone in the country working in that area knew … we were three years into that before we decided to act”.
Looking ahead
Our findings show that delays in the implementation of the safe injection facility and drug checking have concerning impacts. Policy changes are not reacting fast enough to drug market changes. These changes can seriously alter how people are consuming drugs and what risks they face: from smoking crack rather than snorting powder cocaine, to the wider availability of synthetic opioids in the heroin supply. It’s important that the current needs of people who use drugs are met with timely interventions if they’re to have a serious public health benefit.
The existing safe injection facility needs the addition of an inhalation room. Drug checking should be available in community-based settings, not just recreational venues, because the very real threat of synthetic opioids exists within all sorts of communities, not just those attending parties or festivals.
These interventions, if not implemented in a timely way, won’t meet the needs of the people who are expected to use them. Ensuring that those most impacted by drug policies are included in the planning and implementation processes of future harm reduction interventions could help reduce people’s frustrations with lacking services, and improve their ability to rapidly shift and meet the current needs of people who use drugs.
