Policy response to opioid misuse in Dublin.

pioid misuse tests the extent to which we can adhere to a multi-sectoral approach to public health. It reflects the intersection between healthcare, criminal justice and cultural issues in a phenomenon that is harmful to the health of individuals and communities. A review of how opioid misuse has been tackled in Dublin over the past two decades can operate as a case history of how a public health issue was dealt with by a particular society and political system. Being an island on the edge of Europe with a very conservative tradition contributed largely to the fact that up to the end of the 1970s opioid misuse was rare in Ireland. In the early 1980s it became apparent that an epidemic of opioid misuse among young adults had developed in Dublin's inner city. 1 Throughout the 1980s this problem continued to develop, but was confined within inner city Dub-lin. The health sector response was mediated through the National Drugs Treatment and Advisory Centre, which operated primarily from an abstentionist model. Detoxification was offered to opioid users who were prepared to express a commitment to ceasing opioid misuse. HIV testing began in Ireland in 1985 and it was clear within a short time that a large proportion of people with HIV infection in Ireland acquired their infection from injecting drug use. This was in marked contrast to Britain where HIV was more commonly associated with sex between men. 2 This contrast was partly explained by the fact that the epidemic was on a much smaller scale in Ireland and a relatively high HIV transmission rate in Dublin's injecting drug using community at the beginning of the epidemic accounted for a large proportion of the cases from the 1980s onwards. In 1991 and 1992 the Department of Health in Ireland published two policy documents: Government Strategy on Measures to Prevent Drug Misuse, 3 and The National Aids Strategy Committee Report. 4 Both of these documents recommended a shift from an abstentionist based approach to what is commonly called a harm reduction approach, with the active promotion of methadone maintenance and needle exchange for injecting drug users. This policy shift was given added impetus by the publication in 1992 of a report on HIV in the then European Community, 5 which showed that Ireland had a southern European type AIDS epidemic (higher rates among injecting drug users than among gay men). This necessitated …