Lisbon visit gives Cork officials positive insight into supervised injection facilities
Portugal's medically supervised drug injection centre.
Bopping his head happily to music on his headphones, a young man calmly cleans his arm, draws a syringe full of heroin and plunges the needle into his veins.
Next door, five men sit around a table chatting as they smoke crack cocaine, unbothered by people walking past the large windows into the room that permit supervision.
Framed posters hang on the walls with clear, well-designed graphic messages about needle safety and the benefits of naloxone — a drug to counteract opioid overdose.
A delegation from Cork City Council, the HSE, and An Garda Síochána visited the facility in Lisbon, located in an area known for drug trafficking and drug use, to study its systems and learn whether their learnings could help reduce the drug problem in Cork.
Seventeen men and three women waited for the medically supervised drug-taking service called the Servicio de Apoio Integrado in a large entrance hall, some relaxing on sofas under a TV, others sitting around a café.
Years of drug abuse had already moulded many of the users’ faces. Eyes stared blankly ahead over hollow cheeks as one man waited for his turn.
But other users looked healthy.
The service helps to keep people healthy, providing clean needles, a sterile space and vital health intervention to some of those who need that help most.
The medically supervised injection centres (known as MSIFs or SIFs), reduce the risk of overdose deaths. They also protect people’s dignity while injecting and can foster a sense of community and human connection which helps staff then link users in with other healthcare and community services that they may desperately need.
Staff also collect useful data on drug taking and the emergence of new trends in substances, allowing for real-time warning systems if a substance turns up which is particularly potent, dangerous or impure.
Psychologist Roberta Reis, works at the service.
“Drugs become the most important relationship in some of these people’s lives, they can lose their family and friends. But we are often the second-most-important relationship for them. When one man’s partner died recently, we were the first people he told,” Ms Reis said.
The centre has an area where people can leave their pets and also has showers and collects clothing donations for service users.
Some 25% of clients are homeless, so providing integrated services is crucial, Ms Reis said.
One service user had not showered in two years before the centre opened with a shower facility.
They can also provide education to empower people to better protect themselves.
Drinking water is important for harm reduction because when someone is dehydrated it is harder to find veins when injecting drugs, increasing the risk of needle injury and infection, but many drug users did not know that before they were told at the centre, Ms Reis said.
The centre, which is open from 9am to 7pm Monday to Friday and 9am to 3pm at weekends, opened in 2021 but took some 20 years of planning.
Choosing the right location, where the people who will use the service are already based, is vital, experts say.
And the location for the centre, on the outskirts of Lisbon, was already “a drug supermarket”, Ms Reis said, with many people dealing and using drugs.
Previously, hepatitis C and HIV were common in the area. People would use drugs in the neighbourhood with “no dignity”, sharing needles and injecting in public places, Ms Reis said, but the centre has changed that behaviour.
The service is busy and can be oversubscribed, with 300 entrances a day and 106 acts of drug usage daily. More than 2,000 people have signed up with the service.
“We thought we would have 300 entrances by the end of the year — not 300 per day,” Ms Reis said.
“So if you think you’ll have 200 users, plan for more,” she told the Cork delegation.
She said that 68% of their service users only smoke; 21% inject and 11% both smoke and inject.
Injecting has increased slightly among service users from 20% to 21% since the pandemic and the escalating cost of living crisis, causing some concern for staff as injecting is the most potentially dangerous form of drug consumption.
But it had been decreasing with less young people injecting drugs, a trend mirrored in Ireland. The average age of injecters at the facility is 44.
However younger people also use the service.
“We are concerned to see people aged 20-25 — we didn’t expect to have such young people coming to the service.
“And since the economic crisis we have seen injection drug use increase which is also concerning.
The centre has seen an 8% increase in young users, many of whom are migrants from Nepal and India, she said, although young Portuguese are arriving too.
An increase in cocaine use, particularly crack cocaine, has also been noted among service users, a trend also seen in Ireland.
Some 85% of service users are male and establishing a special service for women, where they can feel safe, is important, she said, as this cohort can be hard to reach.
Pregnant women are allowed in the centre.
“They are going to use anyway. When we had a pregnant woman here we had a chance to talk to her and link her in with services, it was good and she had her baby in a hospital.
“But we had a woman come here with a baby and we could not allow her in to use with her baby. It’s complex.”
Users have to be honest with staff and show them what they plan to use before using it in the centre.
The centre has no security staff but they have a good working relationship with local police who they can call for backup when required.
Sometimes users become aggressive and staff have been attacked, Ms Reis said.
“We have to prioritise safety of staff, that includes training so staff know how to act. And it means staff not being too tired, when the team is tired, they are not able to deal with clients shouting at them."
One of the cleaning staff was injured by a needle left somewhere it shouldn’t have been by a service user and education and vigilance is key to keeping staff and users safe, Ms Reis said.
The back of the building is a secure space where staff can go to decompress.
Work at the centre can be tough, she said, and having space for staff away from service users is vital, she said.
“Protecting our team is the most important — if we’re tired and reactive it reflects to the customers.
“But it is a job and we have to remember that and remember that we’re not heroes, we’re just doing a job.”
Naloxone, a drug which neutralises or reduces the effects of opioids is carried by staff to save people from overdoses.
But supply is too short to be able to give to people to take home — something planned for the Dublin medically supervised injection centre.
“It’s very important that people can bring it home. We’re not open all the time,” Ms Reid said.
“We have a budget, but it’s very limited.
“So we have to find ways to fund things beyond initial proposal budget — like food, clothes, shaving equipment, someone to cut hair, art classes, gardening projects.”
The records are not shared with police or other agencies.
“The police are our best partner. They used to stop outside the door so no one came, but they now understand our work.
“They even bring people here to use if they are craving before going to court.”
A housing crisis is also biting in Lisbon, with staff frustrated by having nowhere to send homeless service users and long wait lists for accommodation.
Finding the right solution to address the scale of the problem in Cork is underway. Work is to begin to establish the number of potential users, the best location for a fixed site or a mobile MSIF and the impact it could have.
Lord Mayor Deirdre Forde said more must be done to address drug use in Cork City, to save lives, make the streets safer, reduce antisocial behaviour and remove drug paraphernalia from littering the streets.
“It’s a modern world now and we need to deal with reality,” she said. “It’s very important that we inform ourselves before we decide on a strategy.
“But we should have a strategy, be ahead of the curve. All of us want to see Cork City as a beautiful city, safe for communities, businesses and visitors alike.”
Saving lives is the primary priority for a MSIF, reducing the likelihood of overdose deaths and contraction of blood-born diseases like HIV and hepatitis.
But another key function of medically supervised injection facilities is their ability to access and build trust with traditionally hard-to-reach vulnerable populations and link them in with other services — including healthcare, psychology, addiction services, and social workers.
A mobile injecting site may be a solution for Cork. The Cork delegation visited one run by the international charity Doctors of the World which is partially funded by the charity but is also funded by the Portuguese local and national governments.
The small van distributes sterile injecting paraphernalia and has a bench and table where a user can sit down and inject.
The van is always staffed by a nurse while a psychologist, social worker, a community worker, and drug-using peer rotate days, so that users can access additional health services and psychological support.
Community nurse Adriana Almeida said users get one-on-one contact with healthcare staff in the intimate environs of the van, which supports relationship building with people who can find it hard to trust.
The mobile injecting facility is under the clinical direction of a psychiatrist.
The van also distributes sterile pipes for smoking crack cocaine and aluminium foil, but it does not permit smoking in the van. Crack smoking has been increasing, she said.
Injecting packs distributed to users include needles, citric acid, and condoms.
Ms Almeida quit her hospital job to work in the mobile drug injecting centre full time.
“I like working with vulnerable people. People coming here usually don’t trust other people but here, you can build relationships,” she said.
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