For Dr Patrick O’Donnell, GP with HSE Social Inclusion and Clinical Fellow at the University of Limerick School of Medicine, overdose awareness is an important aspect of the work he carries out on a daily basis.

Having trained as a GP in Sligo, Patrick found himself returning to Limerick when a job came up in the University for a GP with a special interest in Social Inclusion: “The post was set up by Diane Nurse (former HSE National Social Inclusion lead), Tony Quilty (former CHO3 Social Inclusion lead) Prof Anne McFarlane of the University of Limerick and Dublin based GP Dr Austin Carroll.  Part of the work was to develop a clinic to meet the needs of people from marginalised groups in Limerick. This clinic was initially run with the support of Safetynet Primary Care, but it is now a HSE service.”

Outlining his role, Patrick explains that he works with the Social Inclusion Team across HSE Mid-West Community Healthcare:  “There are addiction services, homeless services, Traveller Health and we also cover migrant health services. I work alongside the Assistant Director of Public Health Nursing, Community Mental Health nurses, specialist homeless and Addiction nurses, outreach workers and others.  It operates like a Primary Care Team.”

As with many others working to support people with addiction, Patrick points to the importance of the Naloxone Project as an intervention in recent years:  “I’ve been prescribing naloxone pretty much since the programme began here in the Mid-West.”

Naloxone is prescription medication used to reverse the effects of opioid drugs it is recommended by the World Health Organisation, and it works in seconds.   It is available as an intramuscular injection) or intranasal spray form. Emergency services and acute hospitals in Ireland have had naloxone available, but the idea with this HSE programme was to bring naloxone into the community for used by people who use drugs, their family members, key working staff in drug and homeless services once they had received training.

“The difference between dispensing and prescribing naloxone in Limerick compared to Dublin is that we probably are dealing with people who are more geographically spread, and so potentially more marginalised. Some of the NGOs, such as Ana Liffey, provide support services for people who use drugs in rural towns.   In terms of naloxone availability when you think about it, they are probably more in need of it there because of their situation as they are probably further away from an acute hospital or an ambulance in case of emergency.  Yet services in those areas may be less used to dealing with individuals in acute overdose situations”.

On that basis, Patrick says it underlines the importance of the work being carried out by the various teams in the HSE and NGOs who are developing services, information, training and education.  Reflecting on the impact of the pandemic Patrick notes, “The Covid pandemic has forced many drastic changes on us in the health service, but it has also allowed us a little bit more room for flexibility and innovation. 

“It means that every person who needs naloxone doesn’t need to see us face to face now – just as every patient we engage with in General Practice doesn’t see us face to face because we have modified our ways of doing things – all within the rules and guidance in order to keep people safe.  The most positive stories we have regarding naloxone use are from peers – peers who may also be using heroin when someone overdoses. Training peers and supporting them to do that is a very empowering thing to do. I have conversations with people all the time about keeping an eye out for each other, knowing the signs and using naloxone.

“Part of the message of International Overdose Day in the context of carrying naloxone is that while of course it can signal that someone is taking risks with their drug use, it is also a statement showing that the individual is empowered and has done training on overdose management.  It shows that the person is eager to prevent bad side effects or death for themselves or for others.

“It’s like anything to do with harm reduction – people can see it as one solitary intervention, but it’s part of a much bigger piece.  I have met many people who initially came for a conversation about naloxone but we ended up talking about wider harm reduction measures. For example, we may end up discussing Methadone, or I may ask if they have any injecting sites that they are concerned about.

“So it is a relationship builder, it’s about building trust, and it’s a gateway to engaging people.  Sometimes just getting people here in the first instance is the biggest challenge. Even though I am sitting here in Limerick in a free low-threshold clinic, it’s still a bridge too far for some people.  So key workers will often come and support a person before, during and after a consultation here.”

Patrick describes the “naloxone conversation” as a “great conversation” to have because “it’s really positive and there aren’t that many situations like that.  I had a woman here in the early days who told me no one had ever taught her First Aid before.  No one had told her she could be useful in an emergency situation. 

“She went and did the overdose management training and got that certificate.  That told her she was capable, and that she was well able to protect herself and those around her.  The conversations I am now having with people who have managed an overdose is that they are ringing the ambulance, speaking to the dispatcher, they are going through CPR, doing the naloxone medication delivery, waiting until the ambulance comes, having that conversation with the paramedics on how much they have given them.  But to go from that flight instinct, where in the past people may have felt powerless – it’s a very different conversation.”

Patrick also notes that “a lot of people who use drugs like heroin have seen people overdose, and have seen people die young.   And that’s such a scary and disempowering experience.  So at least with naloxone, it’s something that’s tangible – it means there’s something you can do about it. And with it comes training and support.  And of course you have conversations about it whereas before, there was a lot of stigma.

“One of the goals of Overdose Awareness Day is about encouraging people to come forward if they have someone they are worried about.  If the stigma about drug use and overdose could be set aside and discussions had in an open manner, then more families would be encouraged in coming forward and more at risk people may come forward to get naloxone.”

In terms of making services appropriate and accessible, for Patrick it’s about having a low-threshold and open door policy:  “It’s about trying to have a suite of options available where and when the patient shows up.  For example, the clinic I am standing in here at the minute – I know two doors down the corridor there is the HSE needle exchange and two doors down the other direction is the nurse in charge of the Methadone Clinic. 

“So if someone comes in and is open to it – we have something akin to a one stop shop.  If they come to me here today and say, I am just here for naloxone that’s fine as well.  But it can be a conversation starter. A lot of people who have chaotic addiction have probably had more downs than ups with formal health services, so they can be a bit reluctant to attend services; they can be more likely to attend out of hours or emergency services, and they sometimes feel that the broader health services are impenetrable and unfriendly places. “So for us it’s about re-assuring and reminding them that there is the time and space there for them, whenever they want support.  We have the scope to be able to be a bit more flexible - that is what Social inclusion is about. The door is open to them to return, always.”

While acknowledging that there are many tragic situations with drug overdoses, Patrick does note that there are some positive stories too:  “I saw a woman this morning who only a couple of years ago would have been on my naloxone list having had at least one hospital stay as a result of overdose.  She has now had her Hepatitis C treated, she is off methadone and she’s in her own accommodation. 

“The conversations we are having now are so different; we are almost afraid to say it, but she is in a really good place. She is someone with whom initial engagement a long time ago would have been about naloxone, then it was about treating her Hep C, and then it was about methadone, and so on. And it’s worked out well. But that said, there are others who have died unfortunately – whether they had naloxone with them or whether they didn’t – overdose is still an issue.  And while for many people there aren’t those multiple interventions or impacts, for that woman I saw this morning – she is streets away from where she was all those years ago. And naloxone was an important part of that story for her.”

In his other sphere of work – teaching in the UL School of Medicine - Patrick lectures on social inclusion issues and brings students to the various clinics:  “It’s really important for them to see and learn about people experiencing social exclusion, including those with addiction issues.  Those students will all end up at some stage seeing patients with addiction, or people who are homeless or people who are undocumented. 

“I think you need to have some understanding of where people are coming from in order to fully look after them properly. “And for me, being able work in this area, teach on these topics and carry out research in this area is very fulfilling. It involves a lot of teamwork, advocacy and problem solving.  Sometimes part of the job is just reminding the health service that there are people out there who are struggling to engage and that we all need to be a little bit more flexible in our approach to our work”

For Patrick, the impact of the work he and the team do every day is summed up by the experience of the woman he had encountered who had recovered and had turned her life around: “That woman’s son is the same age as my son.  She had him in here this morning with a small issue.  But the important thing is that she is here, that she has him and that they are back together as a family unit.  And that’s because of her progress – of course it may not be forever, we never know, but for now his life has been changed utterly in having her back – and that’s from her surviving an overdose and continuing to make progress every day.”