Tuesday, August 31st is International Overdose Awareness Day - the world’s largest annual campaign to raise awareness about overdose, acknowledging those who have died and recognising the grief of the family and friends left behind.  The campaign raises awareness of overdose and promotes action and discussion about evidence-based overdose prevention.    It is a time for communities throughout Ireland to remember those who have died as a result of drug overdose and to raise awareness about the measures which can prevent overdose.

For Sinead Carey, Head of Homeless Services with COPE Galway, one of the most significant developments in recent years in the area of overdose has been the introduction of naloxone into the community in a planned manner.  Naloxone is prescription medication used to reverse the effects of opioid drugs like heroin, morphine and methadone if someone overdoses. Recommended by the World Health Organisation for the treatment of opioid overdose cases, it reverses the effects of opioid overdose within minutes.  It is available as an intramuscular (injection) or intranasal (a spray for the nose) and while it is not a cure, it can help keep the person alive until the ambulance arrives.  Emergency services and acute hospitals in Ireland can use naloxone and in recent years the programme was expanded so that it could also be used by family members, peers and staff in drug and homeless services once they had received training.

Sinead describes the introduction of naloxone as “transformative. For me it’s been a privilege to be able to assist, and in any cases, support people recovering from overdose.”  Having only joined COPE Galway in recent months, Sinead was previously working in homeless services in Limerick: “A lot COPE staff are currently trained in naloxone and it is used in services already. We're planning further training in the coming weeks and this will clearly aim to have a significant impact.” 

Reflecting on her cumulative experience in recent years Sinead stresses that “relative to homeless services – in the past, before the Naloxone Project came into being, whenever there was an overdose in the service, all that staff could really do was put them into the recovery position and give them CPR depending on the situation.  We then had to watch and wait for the ambulance.  It might take ten minutes, it might take twenty but each minute felt like an eternity – it was absolutely excruciating – it sent anxiety levels among staff through the roof.

“I remember myself being so worried that someone would die in that time.  And then when the ambulance would come, one of the first things the paramedics would do was to administer the naloxone.  Being trained and being able to provide that life-saving intervention has meant so much to staff.”

Explaining how difficult it is for teams working in the service Sinead notes that “generally, the person involved will be known to us and to the service for some time. Staff will have built up a relationship with that person and they really very much care about them.  There is a difference in knowing the person.  So, actually having the naloxone to hand and being trained means that teams are quick – everyone knows what to do when an emergency happens.  There is no panic. Even in the instances where somebody is lost – and it does still happen that clients are lost – at least staff, friends and family all know that everything that could possibly have been done was done.”

A qualified naloxone trainer and a member of the National Quality and Advisory Group for naloxone, Sinead explains that “the whole objective of the Naloxone Project was to empower people who use drugs to help themselves.  For me, that’s why I embraced it from an early stage – having worked in homeless services for years and knowing how capable people who access homeless services are.  And the Naloxone Project very much recognises that. It allows the person themselves to be proactive in their own care. And while it’s vital that staff in services are trained, it brings it to another level when people who use drugs and their families and friends are trained in these intervening measures.”

One of the impacts for Sinead, as the project evolved, was that staff and clients were learning alongside one another: “There was a real exchange of knowledge back and forward. Clients were teaching us about their experiences and we were in a position to debunk some myths.  I often think that I have learned a lot more from the clients than they have ever learned from me.

“It really gave me some perspective that when we talk about people who overdose we need to work out why it happened – what led to it. We look to learn ways to respond better in the future.  It’s also about recognising all the good work that people do in the community in reducing the instances of overdose and when overdose does occur, doing everything we can to prevent deaths.

“I’ve been reminded in COPE that overdose isn’t just something that affects people who inject drugs. Overdose also occurs from use of drugs such as ‘new’ or ‘fake’ benzodiazepines, pregabalin.  Overdose impacts on every community in Ireland.  International Overdose Awareness Day is a time to remember that. It brings hopeful messages and it reminds us that overdoses are preventable.”

The training and impact of the roll out of the Naloxone Project  has given rise to peer support among users and according to Sinead, this has had a positive effect in terms of “driving overdose rates down.”

Inevitably, Covid raised many challenges for homeless persons and those using drugs: “The fact that Social Welfare payments were changed from weekly to fortnightly raised overdose risk.  Of course, we understand the logistics and the necessity from a government perspective, but people became very isolated and were missing some of their usual supports. People did the very best they could. But these were clients who were already marginalised and you could just see the impact on their mental health.  So, for people being in a low frame of mind and then having access to double the money they would normally have – it meant that at times they might buy double the drugs they would normally buy – so there was a heightened risk in the days following Social Welfare payments.

“And then the following week when people would have no money there would be withdrawal symptoms and depression.  As time went on services adapted, and now that we are at a place where services are living with Covid and supports in the community have improved.  So things have got better but it’s not that long since people were isolated and unable to see friends and family members. When things move online digital poverty is another issue – not everyone can access content.  People who are living in services might find that a bit easier because they have support there – but people in the community less so.”

For Sinead, the more you talk about overdose,  the more open conversations you have,  the more it makes people stop and think.  “The Naloxone Project empowers clients themselves which is so important and in a way, that is de-stigmatising. It’s not the old fashioned model of the helpless service user – the power is given back to the client.”

Studies have shown that a very high percentage of homeless people will have mental health issues.  Sometimes they are there before the homelessness occurs and sometimes they might arise because of the person’s circumstances: “Of course there is stigma attached to having mental health issues and there is stigma attached to drug use so people are almost doubly marginalised.  Anything that can open that conversation, will help to reduce the stigma that people are enduring.

“In my experience I have seen people who use drugs in homeless settings being trained in the use of naloxone but I have also seen people in homeless services who don’t use drugs also being trained.  And that’s been really positive.  I have seen the project have a transformative effect on people’s confidence.  The more they have embraced the programme and got involved, the more confident they have become in their own ability. It means that clients reach a stage where they are able to go and talk to other clients and in turn empower those individuals.

“I have heard stories of people, who as a result of the learning, have reduced or stopped their drug taking. But of course there are many whose drug use hasn’t changed but they do remain linked in which is important to highlight because its inclusive – and while it’s great for those who may reach the point of ceasing their drug use, for those who continue its important to remember that people who continue in drug use also have a lot to contribute.

“I have seen clients go from a place where they have been really lacking in confidence to where they have been able to publicly speak – to the media, in education institutes, about their life experiences and their involvement in the programme.  It’s about giving them an opportunity and allowing for their experience and their expertise being recognised.  It can counteract, over time, the negative messages that people might have about themselves as a result of all the trauma people have experienced in their lives.  And maybe somebody hasn’t had that belief in them.” 

For John Paul Collins, Drug and Alcohol Community Development Worker with Pavee Point,  International Overdose Awareness Day is “very important.   We have been engaged with it over the last number of years in terms of trying to create awareness in the community of overdose – the process, how it happens. We have been trying to generate some discussion within the community around overdose - trying to make people understand the significance of the day – in terms of trying to understand how it can happen.”

As with Sinead, John Paul also points to the roll out of the Naloxone Programme as a key development: “We have been rolling out the naloxone training within the Traveller Community at a local level to build capacity – to ensure that if an event did happen they would be able to respond to it.  It was just prior to the pandemic that we began rolling out the training within the National Traveller Network, within the Traveller Community at a local level.” 

As with all communities, John Paul points to the stigma attached to overdose. 

“It has happened, it does happen and unfortunately it will happen again.  We know people would usually say there was an underlying problem with the individual rather than acknowledge it was an overdose.  For families often there is shame and embarrassment. It’s both a male and female problem and what has been highlighted over the pandemic has been the visibility of people in the community who have been using drugs – people weren’t as aware prior to that to a certain extent.”

One of the worrying developments in recent years according to John Paul has been the increase in drug use among Traveller women: “As a worker and someone who has been in the field for a long time, we’ve known it was there. We are trying to create spaces where the discussion can happen.  And it can be difficult because of the denial, the stigma and shame within the community.

“While we in Pavee Point are not service providers as such - we work on the policy side - we deliver good practice guidelines to Traveller Organisations within the community – in terms of substance issues and substance issue services and so they are able to cater once a Traveller presents to the service”

Among the challenges John Paul outlines is determining the actual level of drug use amongst the Traveller Community.  While the formal National Drug Treatment Recording System collates and records numbers nationally, Travellers often don’t identify their background when engaging. “The numbers are therefore underestimated.  And that leads to an underrepresentation,  which of course from a policy level,  leads to challenges delivering services on the ground.   For Travellers who present themselves around assessment,  because of their lived experience of racism and discrimination they might not initially identify their ethnicity.  But once they establish a relationship with a key worker, they may look for a mechanism to change their ethnicity at some point.”

Addressing the nature of the overall issue of drug use amongst the Traveller Community, John Paul says it’s a “massive problem and unfortunately it is increasing – unemployment, educational attainment, racial discrimination – these are all indicators that make Travellers particularly vulnerable.”  In a post Covid world, John Paul stresses that they will be able to re-engage in a fuller way again and points to the planned development and expansion of the Naloxone Project.  While there are challenges such as access to naloxone and the storage of the medication, he is confident that through a partnership approach these will be addressed.  “We will as ever create the conditions with the National Traveller Partnership and National Traveller Network and then work with the HSE in terms of access and placing it within sites.”

Overall, however he is certain of the importance of International Overdose Awareness Day and stresses how positive the impact is when awareness is raised and people are informed, educated and trained.