The National Advisory Committee on Drugs (NACD) commissioned Moore and colleagues1 at Dublin City University to review the international evidence for harm reduction approaches and the availability of such approaches in Ireland. This article will concentrate on the section of that review that profiled harm reduction services in Ireland.1 For the purpose of the review, a harm reduction approach was defined as one ‘that focuses on reducing the harm that substance misusers do to themselves and their families.’  The aim of such approaches was ‘to reduce the transmission of HIV, hepatitis and other infectious diseases and to maximise service users’ health.’  The harm reduction approaches asked about in the study were needle exchange (including types of injecting equipment distributed), methadone maintenance, replacement drugs, smoking or snorting pipes, and provision of information on safer injecting. Methods to prevent or manage overdose were not specifically examined in the study, nor was the availability or uptake of hepatitis B vaccine. 

With assistance from the regional drug co-ordinators and area operations managers, a purposeful sample of services and key informants (n=16) was chosen to take part in a thirty-minute telephone interview. The telephone interview was administered using a pre-tested questionnaire containing a combination of open and closed questions. Of the 16 service providers interviewed, nine worked in the Eastern Regional Health Authority (ERHA) area and one from each of the remaining seven health boards. Three informants from outside the ERHA reported that their work did not include harm reduction with drug users who used paraphernalia to administer drugs and these interviews were discontinued at that stage. It was unusual that three participants selected in a purposeful sample had no experience working with injecting drug users, since such drug users live and are treated in each health board area. This limited the researchers’ ability to provide a national picture.

The nine service providers working in the ERHA area reported working with injecting drug users, mainly opiate users. In addition, three service providers worked with cocaine users. Some service providers also reported treating cases reporting problem benzodiazepine use. According to service providers outside the ERHA area, the main problem substances were alcohol, cannabis and ecstasy.

All services providers in the ERHA area reported that methadone maintenance and one-for-one needle-exchange facilities were available in their area. With the exception of filters, all other types of injecting equipment were provided to clients attending these services. Half of the service providers in the ERHA area reported that filters were not available at their service. In contrast, service providers outside the ERHA area stated that methadone maintenance was the mainstay of their harm reduction services and no injecting equipment was distributed. Pipes were not provided at any service in Ireland.

All service providers in the ERHA area and a tiny minority outside the area reported providing information on specific injecting techniques and care of an injection site. The service providers in the ERHA area also advised clients on safer smoking and polydrug use.

With respect to health promotion practices, the majority of service providers in the ERHA area said that their services provided information and demonstrations on safer injecting practices in line with current evidence. The authors do not report whether such information was provided by services outside the ERHA area.

On a national basis, the vast majority of service providers reported that the main purpose of harm reduction approaches was to reduce the harm that drug users did to themselves. Some service providers reported that harm reduction services reduced the transmission of infectious diseases. Two services providers mentioned that harm reduction services were a pathway to other health care services. Half of the health service providers in the ERHA area reported that these services promoted safer injecting practices.

All service providers reported similar vulnerable groups, such as women, children and homeless clients. In addition, service providers reported that priority groups included polydrug users, those with mental illness, and those testing positive for HIV. It is interesting to note that those testing positive for hepatitis C were not regarded as a priority or vulnerable group. Yet, it is accepted that hepatitis C is common among injecting drug users, that co-infection between hepatitis C and HIV leads to more aggressive liver disease, and that individuals with co-infection have a poorer prognosis than those with a single blood-borne viral infection.

All of the service providers in the ERHA area and half of those outside it reported that specific issues, such as blood-borne viruses, localised bacterial infections at injection sites and sexual health, were addressed in their programmes. It is not clear from the research the extent to which these issues were addressed.

According to the service providers both in and outside the ERHA area, services were normally available without appointment and were mainly provided during office hours, with a small number opening in the evenings (in the ERHA) and at weekends (methadone services outside the ERHA). The service providers said that the main means of advertising was by word of mouth. Services were also advertised through published directories and posters in clinics.

All service providers reported either formal or informal links with other health and social care services. Many reported working closely with persons from the justice system. The service providers in the ERHA area reported links with self-help groups.

In general, service providers in the ERHA area reported that policy did translate into practice, although the majority stated that there were occasions when they had to ‘bend the rules’ to facilitate patient care. In contrast, the majority of service providers outside the ERHA area reported that policy did not translate into practice, and unofficial practices occurred at one service, in that needles, syringes and condoms were distributed.

The service providers in the ERHA suggested a number of developments to improve the current service, such as:

• Expansion of outreach work
• Greater access to low threshold services
• Increased variety of needle exchange outlets
• Adaptation of current services to deal with cocaine
• Provision of respite houses
• Greater inter-agency collaboration 

The service providers outside the ERHA area requested:

• An increase in resources
• Clear policies and structures with respect to needle exchange and methadone maintenance
• Evidence based practice in relation to harm reduction interventions
• Strategies to reduce waiting lists for treatment
• Community-focused outreach services 

1. Moore G, McCarthy P, MacNeela P, MacGabhann L, Philbin M, Proudfoot D (2004) A review of harm reduction approaches in Ireland and evidence from the international literature. Dublin: Stationery Office.