The drug use landscape in Northern Ireland has changed considerably in the last five years, especially in Belfast’s city centre area. What’s been happening? Chris Rintoul, at Drugs and Alcohol Consultancy Service by Extern, sheds light on the work currently being conducted, the tasks ahead – and why we must not be deterred.

Once upon a time drug use in Belfast’s city centre area was mostly located within the ‘night-time economy’, accompanying alcohol use in and around pubs and clubs. Cocaine use became particularly prevalent in the post-ceasefire era. Fast-forward to today and a much larger proportion of the time, drug use is unconnected with the night-time economy.

Drugs used include heroin, alprazolam (and other benzodiazepines), pregabalin and alcohol purchased from off licenses rather than pubs and clubs. I refer to this example of polydrug use as ‘the fearsome foursome’ because of the number of overdoses resulting from any combination of the four. In the meantime use of other drugs in Belfast’s city centre, such as the aforementioned cocaine, continues to be mostly associated with the night-time economy. The fearsome foursome is however not limited to those locations or those times. It often seems to coincide with business opening hours, in the vicinity of businesses and causes concern to the business community.

Around five years ago heroin use escalated in Belfast as a result of a change in how it was sold. Before then heroin was generally sold by ‘user-dealers’. These individuals sold heroin to others to afford their own habit. The networks were small and often the seller was the only one who knew the entire network. Such networks were closed in order to protect the identity of those within it, and typically limited to less than 10 people. The reason for this was to avoid detection by police and more so, community representatives.

That scene changed when the user-dealers were replaced by a wholly ‘dealing from profit’ operation which was highly organised. It offered a more stable availability of heroin and quickly took existing customers away from their user-dealer. The new era was one where those selling were often not users, or at least not at the outset. The motive is profit and they are well-organised by comparison to the individuals they replaced. However, some of those who are the current street-level dealers are themselves vulnerable; there have been instances of young men who were trafficked to Northern Ireland with the promise of well-paid work. Upon entry to the country their passports were removed and they were forced under threat to sell heroin. The threats could be directly to them, or to their families back home, or both.

The Impact

Over time, with such stable and predictable supply, heroin use escalated. This is evidenced by the number of people seeking treatment for heroin dependency, the rise in overdoses, the amount of injecting equipment given out, and an emergent ‘street scene’ reminiscent of other cities of similar size across Europe. The differences are that these other cities experienced what we are now, 30 or so years ago, and the legacy of transgenerational trauma resultant from the ‘troubles’. The latter provides fertile ground for heroin to flourish.

The major impacts are often first found within the known-to-be vulnerable groups. These are those who already had substance use problems, those with poor mental health or mental illness, the prison population, and especially the homeless population. It is now impossible to work within the homelessness services in Belfast and not work with people who use heroin. These services are the barometer of the scale of heroin use. They administer naloxone to overdosed casualties on a daily basis. I know this because I lead on the training and supply of naloxone to those services and staff. These staff are in my view the real life-savers; effective in responding to overdoses with naloxone, and so buying vital time for paramedics to arrive.

What to do?

With all the changes afoot, it can be difficult to know how best to respond. An obvious and well-known issue has played out alongside: the unacceptably long waiting time for opioid substitution treatment (at one point well over a year). This has meant that people have no way out of their heroin predicament and hopelessness sets in. The more people waiting for treatment, the more obvious the issue has become in the city centre. The analogy of the pressure cooker comes to mind.

You might ask why the PSNI haven’t been able to stamp it all out. If this was a realistic possibility other police forces around the world would have managed that when heroin flooded their cities from the 1970s. None have. The PSNI are actively working with other stakeholders, like Extern and Belfast City Council, to respond to this new era. They are honest enough to admit that they will be ‘unable to arrest their way out of the situation’ on BBC Radio Ulster on 7th March, in a live broadcast from our Royal Avenue offices.

Extern have tried to respond as best we can to the increase in heroin use, especially in the Belfast city centre area. In 2017 we conducted a scoping exercise, engaging with those who inject heroin on the streets to get an idea of the scale of the problem. This led to the formation of a new service, called SISS or ‘Street Injectors Support Service’. Within six months the staff who operated it removed almost 4,000 pieces of injecting equipment from the city centre and inner-city areas. They engaged with 105 people who inject in these areas, signposting them to housing and treatment services, often also supplying naloxone to them and giving brief advice on their injecting practices. We learned that many, but not all of these people, were homeless. They were injecting in alleyways, behind bins, in scrub land, in public toilets, and in risky environments, such as beside railway lines and along the River Lagan’s towpath. Many had physical and mental health problems. More recently the SISS team have been attending to overdoses and administered naloxone to those with opioid overdose symptoms. While we believe that this service has undoubtedly saved some lives, it has also seen first-hand much human suffering and hopelessness. We do what we can to support them and foster a sense of hope for a better future.

Extern provide a range of drug services across Ireland, as well as services for homeless people in Northern Ireland. We believe in low threshold and harm reduction approaches. This means that we make it as easy as possible for those who need and want our help, to access our services rapidly. We don’t necessarily aim for total abstinence from substances, however nor do we exclude it. Often those with the most chaotic lives need a great deal of support and time to stop using drugs. Our aim is to reduce the attendant risks in the interim, put simply, they need to be alive for long enough to find the stability, motivation and social capital which would support abstinence. If we provide sterile injecting equipment we can prevent the contraction and transmission of blood borne viruses such as hepatitis C. Similarly, if we provide foil for smoking heroin, we can reduce the frequency of injecting, associated with much higher levels of risk and harm, as well as the severity of dependence.

Positive Signs

Upstream of all that Extern can do at ground level we are glad to hear that the Belfast Health & Social Care Trust have reduced their waiting time for assessment of heroin use to around six weeks at the time of writing. This is welcomed by all working in the homelessness sector, where the problems are so evident. If the result of their assessment indicates that Opioid Substitution Therapy (OST, usually methadone or buprenorphine) is the preferred option, this should be started as soon as possible thereafter. The patient can then be rapidly titrated to an optimal, therapeutic dose as per the ‘Orange Guidelines’. Optimal dosing is associated with reducing the frequency and duration of injecting. Within a small number of weeks the visible and positive differences of OST are not just possible, but probable.

Medications used to support those with drug problems are ever-evolving. There are different formulations of buprenorphine entering the market, mostly to reduce diversion of these drugs into communities and prisons. Naloxone is available as an injectable solution and a nasal spray. The Home Office have granted a license to a drug service to provide supervised, injectable diamorphine for those whom other substitute drugs has been unsuccessful. Any and all of these options are useful tools if integrated with structured psychosocial interventions and practical assistance with housing etc.

The Future

While much of the above can make depressing, if realistic, reading; we are not deterred. We know that people very often do well when they have the following trio; meaningful activities to engage in, pro-social relationships, and sound pharmacological management. It is a joy to witness and perfectly juxtaposed to the sadness of fatal overdoses.

Today, Belfast is a changing city with respect to drug use. We can, and do, learn from other areas, countries, and cities about what has worked elsewhere. We can also learn from their mistakes and adapt our response(s) in light of that learning. As a result of what we have seen over the last five years, Extern are convinced of the need for a Drug Consumption Room in Belfast city centre. Such a facility would remove the unsightliness of street-based injecting, reduce drug-related litter, and prevent disease transmission and fatal overdoses, while connecting the users with healthcare professionals.