International Journal of Drug Policy 16 (2005) 415–422

‘An Irish solution to an Irish problem’: Harm reduction andambiguity in the drug policy of the Republic of Ireland

Shane Butlera,∗, Paula Mayockb

a Addiction Research Centre, Trinity College, Dublin 2, Irelandb Children’s Research Centre, Trinity College, Dublin 2, Ireland

Received 12 July 2005; accepted 17 July 2005

Abstract

While policy makers in the Republic of Ireland had been concerned with illicit drug use since the late-1960s, it was only from 1980 onwardsthat the emergence of a culture of intravenous heroin use in areas of generalised social deprivation in Dublin gave urgency to this policyprocess. This paper traces the gradual introduction, on public health grounds, of harm reduction practices and services – such as methadonemaintenance, needle exchange and the creation of outreach and locally-based services – following the identification in the mid-1980s ofn that harmr articipatedi re system’sr iferation off sparent ande tendencyw ambiguityw is concept,b ave delayedt©

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eedle-sharing amongst injecting drug users as one of the key routes for the transmission of HIV in this country. It is arguededuction in the Republic of Ireland has been largely implicit, in the sense that political leaders have generally not encouraged or pn explicit public debate on this topic, nor have they ever publicly announced that this concept now underpins much of the healthcaesponses to illicit drug use. It is also argued that this covert style of policy making has persisted, despite the more recent prolormal policy-making structures and the dominance of a rhetoric which emphasises strategic management and the allegedly tranvidence-based nature of drug policy. This tactic of shrouding drug policy in ambiguity is discussed in the context of the widerithin Irish political culture to manage sensitive and potentially divisive social issues in such a manner. It is concluded that thehich surrounds harm reduction in Ireland has been functional in that it has confused and frustrated ideological opponents of thut dysfunctional in that it has not facilitated the emergence of more tolerant or respectful attitudes towards drug users and may hhe introduction of a wider range of harm reduction practices.

2005 Elsevier B.V. All rights reserved.

eywords: Harm reduction; Ambiguity; Roman Catholic Church and Irish Social Policy; Strategic management

ntroduction

Although there is no consensus as to its precise meaningnd certainly no agreed definition, the termharm reductionas been increasingly used over the past 20 years to refer

o international drug policy developments which deviate ide-logically from the previous orthodoxy in which criminal

ustice systems and healthcare systems appeared to be largelyt one in their ambition to rid society of illicit drug useInciardi & Harrison, 2000). It is, nonetheless, relatively easy

∗ Corresponding author. Present address: Department of Social Studies,rinity College, Arts Building, Dublin 2, Ireland.el.: +353 1 608 2009; fax: +353 1 671 2262.

E-mail address: sbutler@tcd.ie (S. Butler).

to identify the broad tenets of this burgeoning policy pspective. Firstly, harm reduction assumes that legal meato create a drug-free society lack the popular supportessary to achieve total success and, furthermore, thatlegal measures may inadvertently contribute to an incrin the scale and intensity of drug-related problems bothindividual users and the wider society. Secondly, in acdance with this fundamental assumption, priority is gito strategies, practices and forms of health and sociavice provision which are aimed at reducing a wide raof drug-related harms while not necessarily reducinguse per se. Thirdly, and to varying degrees, harm redufacilitates the development of more tolerant and less mistic attitudes – both on the part of relevant professioand the general public – towards drug users, as well a

955-3959/$ – see front matter © 2005 Elsevier B.V. All rights reserved.oi:10.1016/j.drugpo.2005.07.002

416 S. Butler, P. Mayock / International Journal of Drug Policy 16 (2005) 415–422

acceptance that users, even while continuing to use illicitdrugs, can actively and successfully collaborate with profes-sionals in reducing drug-related harm. These harm reductionideas are clearly at variance with international conventions ondrug control which, strongly influenced by the United States(US) (Bewley-Taylor, 1999), evolved throughout the twenti-eth century and which, particularly within the US, still tendto be expressed in highly authoritarian, militaristic terms –commonly including references to thewar on drugs, zerotolerance towards users and dealers, and allocation of man-agement responsibility for this entire prohibitionist regime toa drugs czar.

Within the broad church of harm reduction, debates anddivisions have arisen in recent years (Hathaway, 2001; Hunt,2004; Keane, 2003; Reinarman, 2004) concerning the extentto which it is possible or desirable for the movement to agreeand articulate a single, coherent philosophy – most radi-cally one which would regard freedom to use psychoactivedrugs as a basic human right – which might underpin harmreduction policy and practice internationally. To date, how-ever, no such coherent philosophical basis for harm reduc-tion has achieved consensus, and it would appear as thoughharm reduction practices – including opiate substitution pro-grammes, needle and syringe exchange schemes, outreachprogrammes and the provision of safe injecting facilities –have been introduced internationally in a variety of piece-m aimo ctioni iewt tro-d hichb f pol-i bes over ap duc-t orp thath plicita e asa dt duc-t hat ‘ac nota rm’( wille Ire-l urew tiont marya ss ofh , butr achw ser-v N)d avilys

The political culture of modern Ireland

The Republic of Ireland, as it is politically constituted atpresent, had its origins in the Anglo-Irish Treaty of 1921which conferred a high degree of political autonomy fromBritain on 26 of the country’s 32 counties; it was not until1948, however, that this new state left the British Com-monwealth and declared itself a republic (Lee, 1989). Thispartition of the country, with six counties in the north–eastremaining part of the United Kingdom, constituted an ongo-ing source of internal tensions between north and south and ofexternal tensions between Britain and Ireland. It led to a briefcivil war immediately after partition and thereafter to periodicbouts of paramilitary activity, the most protracted of which– known colloquially as the ‘Troubles’ – lasted from 1969to 1994, when a successful albeit precarious peace processwas initiated. While it has retained its tradition of militaryneutrality, Ireland has not generally pursued an isolationistcourse in international affairs, participating in the League ofNations during the 1930s, joining the United Nations (UN) in1955 and seeking membership (eventually granted in 1973)of what is now known as the European Union (EU) in 1961(Laffan & Tonra, 2004).

Following almost 70 years of unremitting economicgloom, the Irish economy began a process of dramatic growth,with improvements in all major indicators and the virtuale arso 8o ado st b-t ofu hichm rugp e ofI cietyw f Ire-l iety– tureso ed toh rvini ana uingp ss ofc

ther aren e ofog romB tingie elyf entso teste were

eal and pragmatic ways. Against this background, thef this paper is to examine the progress of harm redu

n the Republic of Ireland since the mid-1980s, with a vo identifying: the specific services which have been inuced under this rubric; the policy-making structures wrought about these changes; and the level and nature o

cy debate which accompanied their introduction. It willhown that Irish health and social service systems have,eriod of 20 years, shifted substantially towards harm re

ion practices, albeit with the minimum of public debateolicy transparency. Responding to critics who believearm reduction practices should be based upon an exnd unequivocal commitment to psychoactive drug usfundamental human right,Reinarman (2004)has argue

hat this position is excessively idealistic, that harm reion can be based upon more than one foundation and tertain amount of philosophical and logical ambiguity isn obstacle to meaningful harm reduction or drug law refo240). Drawing on these views of Reinarman, this paperxplore the introduction of harm reduction strategies to

and as one example of ambiguity within a political culthich has long been characterised by ambiguity in rela

o some of its most fundamental value systems. The priim of this paper is not, therefore, to asses the effectivenearm reduction as implemented in the Republic of Irelandather to gain an understanding of how this policy approas introduced in the first instance to a traditionally conative society which is signatory to the United Nations (Urug conventions and within which drug users are a hetigmatised group.

limination of unemployment during the ‘Celtic Tiger’ yef the 1990s. Early studies (e.g.Allen, 2000; Sweeney, 199)f this boom were concerned with explaining why it hccurred, but a more recent study (Garvin, 2004) approache

his topic from a different angle, asking explicitly in its suitle: ‘why was Ireland so poor for so long?’. In termsnderstanding those aspects of Irish political culture wight best help to illuminate the country’s approach to dolicy, the Garvin study – which juxtaposes the imag

reland as a modern, cosmopolitan, English-speaking soith a successful, free-market economy against that o

and as a stultified and inward-looking post-colonial socoffers a convenient summary of some key historic feaf this society. In enumerating the various factors deemave contributed to such prolonged economic failure, Ga

dentifies two in particular: the dominant influence ofuthoritarian Roman Catholic Church and the continolitical emphasis on completing the unfinished businereating a 32-county and Irish-speaking republic.

Garvin’s views about the nature and importance ofole played by the Catholic Church in modern Irelandot, of course, unique but are broadly reflective of thosther social scientists (e.g.Inglis, 1998; Whyte, 1980). Theeneral view is that, having achieved political freedom fritain, the new state was less concerned with promo

ndividual liberties than with defining itself as amoral soci-ty, with its ethical principles being drawn almost entir

rom the doctrines of the Catholic Church. The elemf the Church’s social and moral teaching given greamphasis during the first half-century of the new state

S. Butler, P. Mayock / International Journal of Drug Policy 16 (2005) 415–422 417

those concerned with the regulation of the body and sexualmorality, and in this sphere the Church’s rigid and paternal-istic views were reflected constitutionally, legislatively andin broad policy terms in such areas as censorship of publi-cations and films, prohibition of divorce, contraception andabortion, and the criminalization of prostitution and homo-sexuality. The Church’s influence within Irish society hasgradually waned over the past 25 years (Coakley, 2004), aprocess which, ironically, has been hastened by continuingrevelations of sexual abuse of children by priests and otherreligious leaders. While it might appear as though this tran-sition to a more conventional, secular political culture wouldcreate conditions favourable to a public debate about harmreduction – possibly indeed stretching as far as to a con-sideration of drug use as a fundamental human right – nosuch debate has taken place. It will be argued here that amajor reason for this failure to create a national debate aboutdrug policy is that the process of moving towards secularismand liberalism has at times been a deeply divisive and trau-matic experience for Irish society generally and particularlyfor the political system. For instance, since 1983 Ireland hashad three referendums on abortion and two on divorce, eachreferendum being marked by intense and highly polariseddebate on the morality of the issues; in relation to abortion,for instance, the debate focused on women’s rights to infor-mation, to travel and to actually avail themselves of abortions ted int ’r Forp riodd uc-t inga tingt en-t tiousd licyc

mi-n wast ery-d s thisl andc 3 oft vedi f theU icle8 . In1 rt oft torialc gra-t vantt ccu-p uageo micd ifieda nal

ideals or symbols without feeling any obligation to matchrhetoric with actions likely to realise these ideals. While theIrish language remains the country’s first official language, ithas continued to decline as an everyday language of commu-nication, is not understood by a majority of the populationand is neither spoken nor understood by many political lead-ers. Similarly, the territorial claim to the six Northern Irelandcounties was rarely seen as anything other than an aspira-tion, and those who sought to vindicate it by military means,rather than being applauded for such action, could expect tofind themselves subject to the full rigours of the law. Overthe past decade, this situation has been complicated even fur-ther by virtue of the fact that the developing peace processhas drawn into conventional democratic politics groups whowere simultaneously involved in paramilitary and criminalactivities. In short, Irish society may be viewed as one withinwhich citizens have been accustomed to high-level ambigu-ity and within which abstract statements of political idealsare not regarded as literal truths demanding action. It canplausibly be argued, therefore, that this is a political culturewhere the concept of a war on drugs would be unlikely tobe seen in literal terms, and where it might not arouse toomuch controversy if the state was seen to be implementingstrategies which appeared to be ideologically at odds with itsinternational obligations.

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ervices. The divisive nature of these debates is refleche title of a study (Hesketh, 1990) of the so-called ‘Pro-Lifeeferendum of 1983: ‘The second partitioning of Ireland’.olitical leaders this debate, which coincided with the peuring which the advent of HIV/AIDS made harm red

ion a relevant policy issue in Irish society, was a bruisffair which may well have reinforced an already exis

endency to introduce policy change covertly and incremally, where possible avoiding abstract and highly contenebate about the moral principles involved in such pohange.

The second element of Ireland’s political culture noated by Garvin as having delayed economic progress

he official commitment to the restoration of Irish as the evay language of the country and – although Garvin argue

ess strongly – the related determination to end partitionreate a 32-county Republic of Ireland. Articles 2 andhe country’s Constitution, which was drafted and appron 1937, defined the six counties which remained part onited Kingdom as part of the national territory, and Artdeclared Irish to be the country’s first official language999 Articles 2 and 3 were altered by referendum, as pa

he ongoing peace process, transforming the stark terrilaim into a peaceful aspiration towards national reinteion, but Article 8 remains unchanged. What is most releo the analysis of drug policy is not whether these preoations with the restoration of Irish as the everyday langr with the ending of partition adversely affected econoevelopment but, rather, the way in which they exempltendency within Irish society to pay lip-service to natio

rug policy in contemporary Ireland

Butler (1991)suggested that the historical evolutionrish drug policy could be understood as consisting tooint of three identifiable phases:

an early phase (1966–1979) in which the state gradcame to the view that illicit drug use, in retrospect orelatively low prevalence and low risk variety, was a feaof Irish society which demanded a policy response;a middle phase (1980–1985) in which the state, againsome reluctance accepted that Ireland now had an elished heroin-injecting scene;a third phase (1986–1991) dominated by public hefears stemming from an awareness that injecting heusers, by virtue of their sharing of needles and other pphernalia, were a high risk group for the transmissioHIV amongst one another and, ultimately, through secontact into the wider community.

Public health concerns have continued to be a major ince on Irish drug policy in the period since 1991, so, notwtanding the necessity to extend the third phase by 14 yhis chronological framework may still be regarded as a vnd convenient tool to be used in understanding the intro

ion of harm reduction strategies in this country.It is perhaps understandable that a society which t

ionally had such a strong emphasis on the moral importf controlling the body found it difficult to accept that where perceived to be hedonistic patterns of psychoactive

418 S. Butler, P. Mayock / International Journal of Drug Policy 16 (2005) 415–422

use could become established here. A journalistic account ofthe early phase of drug use in Ireland (Flynn & Yeates, 1985)describes the reluctance of the Department of Health, the cen-tral government department with primary responsibility forlegislation in this area, to accept that illicit drug use couldbecome an enduring feature of Irish life, andButler (2002a)has a similar account of that department’s lengthy disbe-lief concerning the wave of intravenous heroin use whichcharacterised the second phase. However, from a harm reduc-tion perspective, what emerges as being most important inconsidering these first two phases of the Irish drug experi-ence is the way in which all of the underlying assumptionsabout ‘drug abuse’ were accepted without critical scrutiny indebate which took place both amongst voluntary – and largelyreligious-based – groupings and in official policy discourse.An early pamphlet (O’Byrne, 1969), written by a well-known Franciscan priest who styled himself ‘The Teenagers’Priest’, presented drug use as a self-evidently problematicphenomenon about which medical doctors and moral theolo-gians were in full agreement, and which the author proposedto tackle through aCatholic Youth Crusade. Three years lateran inter-church committee (Irish Council of Churches/RomanCatholic Joint Group on the Role of the Churches in IrishSociety, 1972) published a more reasoned discussion of thisissue but stopped considerably short of raising fundamentalquestions about the morality of drug use. Similarly, the reportoP eda andt t; ther hcarew tionm sys-t andm lisediD na icalp nity–D

From the mid-1980s, however, Ireland was faced with thesame dilemma as that confronting other societies which hadan injecting drug scene: it could continue to offer healthcareinterventions based solely on abstinence models or, alterna-tively, it could move pragmatically towards what was comingto be referred to as a harm reduction approach, one which pri-oritised HIV prevention and was prepared to tolerate varyinglevels of ongoing drug use among its clients. In line with thispaper’s stated aim, therefore, there are now two questionswhich need to be addressed: the first asks whether the Irishhealthcare system moved away from its historical commit-ment to abstinence-only interventions, while the second asksto what extent the adoption of harm reduction strategies waspresented to the public in clear, unambiguous terms as rep-resenting a policy shift. The first question will be answeredbriefly in the remainder of this section, while the second ques-tion will be considered at some length in the next sectionwhich deals with policy-making structures.

It is clear from Table 1 that despite its apparent dog-matism about the moral evils of drug use and commit-ment to abstinence-only treatment systems, Irish drug policychanged considerably, albeit incrementally, from the mid-1980s onwards. The changes listed inTable 1, which shouldbe considered as indicative of major changes rather than as acomprehensive list of all change occurring during this period,are obviously reflective of many of the main features of harmr heyi sucha well asc stab-l n oft s –w ali-s feyP medM rugp dedb tedi e toF toa

TI tem, 19

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f the first governmental committee (Report of the Workingarty on Drug Abuse, 1971) to consider this matter accepts a given that ‘drug abuse’ existed and that civil society

he state were at one in their determination to stamp it oueport also assumed that, within the state sector, healtould reflect and reinforce criminal justice supply reduceasures by only providing treatment and rehabilitation

ems which were abstinence oriented. During the earlyiddle phases, therefore, service provision was centra

n one specialist medical facility – designated theNationalrug Advisory and Treatment Centre – which operated on abstinence model, while the first voluntary, non-medrogramme was an American-style therapeutic commutheCoolmine Therapeutic Community – which started inublin in 1973.

able 1ntroduction of harm reduction strategies into the Irish healthcare sys

985 Provision of statutory financial support for the Ana L987 Increased availability of methadone maintenance in989 Beginning of a new service system under the aegis o

Resource Centre and offering needle exchange, met989 Provision of statutory financial support for the Merch

harm reduction principles991/1993 Establishment by Eastern Health Board of localise

exchange995 Training of drug users as Peer Support workers by E996 Introduction of mobile clinics in Dublin997 Creation of the Dublin Safer Dancing Initiative by the998 Enactment of legislative provisions (commonly refer

prescription of methadone by family doctors and its d

eduction discussed in the introduction to this paper. Tncluded the use of specific harm reduction strategies,s needle exchange and methadone maintenance, ashanges in the style of service provision – such as the eishment of locally-based services and the regularisatiohe role of family doctors and community pharmacisthich may be considered as constituting a form of normation of addiction treatment. Interestingly, the Ana Lifroject and the Merchants’ Quay Project (later renaerchants’ Quay Ireland), the first two voluntary drojects to adopt harm reduction principles, were founy Catholic priests, with the latter being physically loca

n an inner-city Franciscan monastery previously homr. Simon O’Byrne, the ‘Teenagers’ Priest’ referredbove.

85–2005

oject, Dublin’s first voluntary drug service based on harm reduction ptional Drug Treatment Centregional health authority for Dublin (the Eastern Health Board), designat

maintenance and outreach work with drug usersuay Project, which was to become the largest voluntary drug servic

llite’ clinics, offering addiction counselling, methadone maintenancedle

Health Board

rn Health Boards the Methadone Protocol) creating a national register and regulatinging in community pharmacies

S. Butler, P. Mayock / International Journal of Drug Policy 16 (2005) 415–422 419

Policy-making structures and the policy process

Given this evidence of the introduction of harm reductionstrategies, the question which now needs to be addressedconcerns the way in which Irish policy-making structureshandled this transition. The answer, which will be spelt outin some detail here, is that the changes were introduced gradu-ally and covertly; those involved in the process made no effortto create a national debate on the merits of harm reduction, nordid they ever formally announce that harm reduction had nowbeen enshrined as the new philosophical basis to Irish drugpolicy. By way of contrast, it should be noted that in England,which because of geographic proximity would have beenfamiliar both to Irish drug users and policy makers, the debateabout and transition to harm reduction was considerably moretransparent; a much-quoted principle from England’s Advi-sory Council on the Misuse of Drugs(ACMD) concludedthat:

[T]he spread of HIV is a greater danger to individualand public health than drug misuse. Accordingly, serviceswhich aim to minimise HIV risk behaviour by all avail-able means should take precedence in development plans.(1988, p. 17)

It would be misleading to suggest that this statement,i ern-m keda n ont sti-t enceo seeni g ar em’w 926( theA pt-a t noc actoa ssuedb oma un-t kingpi verb en att yedt m.

Butler (1991)has detailed how in each of the first twophases of Ireland’s drug policy history the two apparentlykey policy structures (theInter-Departmental Committee onDrug Abuse during the early phase and theNational Coordi-nating Committee on Drug Abuse during the middle phase)had a largely nominal existence, being effectively sidelinedby the Department of Health and by occasional interventionsfrom senior politicians. By far the most clearly defined policystructures, however, are those which have emerged over thepast decade, based on recommendations of theFirst Reportof the Ministerial Task Force on Measures to Reduce theDemand for Drugs (1996)and formally presented again inBuilding on Experience: National Drug Strategy 2001–2008(2001). This latter publication, which is by far the mostlengthy and detailed drugs policy document ever producedin Ireland, is presented in the format of a ‘national drug strat-egy’ broadly in line with similar national strategies beingproduced in EU countries (European Monitoring Centre forDrugs and Drug Addiction, 2004).

What is most striking about this national drug strategy,presented in summary form inTable 2, is its rational, man-agerial tone. This was not the first time that an Irish drugspolicy document emphasised the importance of coordinat-ing the activities of a range of governmental sectors; indeedrhetoric of this kind had been a feature of policy discussionsince the first official committee was set up to consider illicitd ow-e olicys plic-iI e-m1 ag-m aina ces-s torsa nt ofdo )h tegicM as a“ cto-r atp nsurea thisn acht amedi tion

TI

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PTR

ssued by an advisory body rather than a central govent department involved in policy implementation, mardefinitive and unequivocal shift towards harm reductio

he part of the English government. It did, however, conute the publicly stated and unambiguous policy preferf an authoritative advisory group, and it may also be

n the wider history of English drug policy as reflectineturn to the pragmatism of the so-called ‘British Systhich existed for 40 years after the Rolleston Report of 1

Strang, 1990). The clarity and logic of this statement byCMD is such that one might imagine it providing an acceble basis for policy change in Ireland, but the reality is thaomparable statement about Irish drug policy or its de fcceptance of harm reduction principles has ever been iy any Irish policy-making body. In fact, what emerges frhistorical review of drug policy-making bodies in this co

ry is that ambiguity has been a feature of the policy-marocess just as it has been a feature of policycontent; specif-

cally, as will be explored here in some detail, it has neeen clear that those bodies which have nominally be

he heart of the policy-making process have in fact plahe kind of role which might rationally be expected of the

able 2reland’s National Drug Strategy 2001–2008

our pillars Organisational structure

upply reduction Cabinet Committee on Sofor coordinating the nationaStrategy Team with regular

revention (education and awareness)reatmentesearch

rug use in 1968. What was different on this occasion, hver, was that debate on the creation of appropriate ptructures for managing drug problems was now being extly couched in the terminology of theStrategic Managementnitiative (SMI), an Irish version of ‘new public managent’ (Byrne et al., 1995; Delivering Better Government,995) which saw itself as reforming an old-fashioned, frented and inefficient civil service system. One of the mpplications of SMI to the drug strategy centred on the neity for coordinating the activities of all governmental secnd agencies which contributed to societal managemerug issues.The First Report of the Ministerial Task Forcen Measures to Reduce the Demand for Drugs (1996, p. 12ad argued that: ‘The drugs problem is what the Straanagement Initiative in the Public Service describes

cross-cutting” issue which cannot be dealt with satisfaily by any one Department. . .. It is absolutely essential thractical and workable arrangements be put in place to ecoherent, co-ordinated approach’. In accordance with

ew concern for having a strategic, ‘cross-cutting’ approo societal management of drug issues, the structures nn Table 2were set in place. These included the identifica

lusion; ‘Lead’ Department; Minister of State allocated specific respogy; Inter Departmental Group of senior civil servants; National Drugng responsibility for implementation of the strategy

420 S. Butler, P. Mayock / International Journal of Drug Policy 16 (2005) 415–422

of one central government department, amongst manyinvolved with drug issues, as a ‘lead’ department, allocationof political responsibility for coordinating drug policy to anamed Minister of State (junior minister) within this depart-ment, and the creation of a range of structures – up to andincluding a Cabinet sub-committee – all ostensibly aimed atformulating and implementing a single national drugs policy.Implicit in the managerial discourse within which drug policywas now discussed was the idea that policy making was anessentially rational process and that research – identified asone of the four ‘pillars’ of the national strategy – would playa significant role in informing policy decisions. ANationalAdvisory Committee on Drugs (NACD) was established in2000 (National Advisory Committee on Drugs, 2003) andcharged with the responsibility for developing policy-relevantresearch in Ireland, while theDrug Misuse Research Divi-sion of the Health Research Board was designated a ‘focalpoint’ for the European Monitoring Centre for Drugs andDrug Addiction.

While it is clear that, by and large, these structures havean ongoing operational existence, it cannot be said that theyhave dealt decisively and unambiguously with the substantiveissue of harm reduction in Ireland. Although harm reduc-tion practices have been used here since the mid-1980s, theonly official publication to deal explicitly with this topicto date is a review commissioned by the NACD (Moore eta ithr ctions olicyc armr if notp icit,b sec-o larlyr1 uldb n of‘ rea tab-l th ofp re isn ed byo oingp tificr all itsr ross-c , thatn e off thanb tegicm e twom om-m thef ple-m (2) toi ug

users are now based on a harm reduction philosophy, and toprovide a detailed ideological justification for this position. Infact, over the past 20 years, policy makers have consistentlygone for a third option, which is to shroud the policy processin ambiguity by introducing harm reduction practices withoutdebate, announcement or a clearly presented rationale.

Perhaps the most radical policy development whichdemonstrates how policy decisions can be made quietly out-side the official policy structures, has been the introduction ofwhat is known as the ‘Methadone Protocol’ in 1998. This ini-tiative, which has been analysed in detail byButler (2002b),created a licensing system for the prescription of methadoneby family doctors, and did so in the face of much public hos-tility towards the extension of methadone treatment. In thisinstance, the policy process was orchestrated away from thepublic gaze, over several years, by a network of civil servantsand healthcare professionals; this culminated in the issuingof a statutory instrument which, as ‘secondary legislation’,had all the force of law but none of the parliamentary scrutinyor detailed media attention attendant upon conventional leg-islation. It is a mark of its success, or perhaps its hypocrisy,that it was signed into law by a health minister from thecountry’s major party, Fianna Fail, which while in opposi-tion a year earlier had published a conservative drug policydocument, criticising methadone and citing (albeit withoutacknowledgement) the mantra ‘drugs are illegal because theya re ille-g ithE rva-t

A

d int apera r thatt ses ofam etsr eve ad , thatp ivesa e pers ebatei uc-t icitlyt onalw ate-g emedu sions,t f harmr reac-t sug-g taryd ublin

l., 2004), which largely concerns itself descriptively wesearch evidence on the efficacy of various harm redutrategies and almost entirely ignores the attendant ponflicts and dilemmas. The primary dilemma is that heduction policies and strategies appear to condone,ositively encourage, styles of drug use which are illoth in national and international legal terms, and andary but important dilemma is that drug users are popuegarded (Bryan, Moran, Farrell, & O’Brien, 2000; MacGreil,996) as deviant and immoral. On this latter point, it shoe noted that despite state investment in and promotio

bottom-up’ community participation in drug policy, there ongoing difficulties for public health authorities in es

ishing locally-based treatment services such is the depopular animosity towards drug users. Furthermore, theo reason to believe that these dilemmas can be resolvbjective, scientific research any more than Ireland’s ongolicy dilemma over abortion can be resolved by scienesearch. In short, current management-speak – withhetoric of strategies, key performance indicators and cutting structures – conceals what is essential: that isational drug policies are complex and difficult becaus

undamental moral or ideological disagreements ratherecause of poor administrative systems. From a straanagement perspective, it might appear as though thain choices open to Irish policy makers are: (1) to cit themselves anew, in a public, transparent way, to

undamental truths of the war on drugs and to the sole imentation of abstinence-based healthcare strategies;

nform the public that healthcare interventions for illicit dr

re dangerous – they are not dangerous because they aal’ (Fianna Fail, 1997, p. 3) which is usually associated wURAD (Europe Against Drugs), Europe’s most conse

ive anti-drug voluntary movement.

dvantages and disadvantages of policy ambiguity

If the progress of harm reduction in Ireland is measureerms of what were described in the introduction to this ps the three main tenets of this approach, then it is clea

here are both advantages and disadvantages to the umbiguity. All of the policy initiatives summarised inTable 1ay be seen as implicitly confirming the first two ten

eferred to, namely the view that legal measures to achirug-free society are not succeeding and, consequentlyriority should be given to health and social service initiatimed at reducing drug-related harm rather than drug use. It is argued here that had there been a major public dn the Republic of Ireland about the principles of harm redion, where harm reduction was seen to challenge explhe wisdom of the UN conventions as well as conventiisdom on the war on drugs, then it is most likely that stries based upon these principles would have been denacceptable. When, as has happened on a few occa

here has been public debate about a particular aspect oeduction, this appears to have mainly served to evokeionary responses. In the summer of 2000, for example, aestion from Merchants’ Quay Ireland, the largest volunrug service based on harm reduction principles, that D

S. Butler, P. Mayock / International Journal of Drug Policy 16 (2005) 415–422 421

needed a safe injecting facility drew a much publicised rebukefrom EURAD, as well as publicity concerning the Vatican’seffective blocking of an initiative of this kind in a facility runby nuns in Sydney; the following year, a theologian from Mer-chants’ Quay (Cronin, 2001) wrote a detailed – but largelyunpublicised – moral defence of harm reduction in a nationalchurch publication. Similarly, in 2004, public debate on thequestion of introducing needle exchange – informed inter aliaby research carried out by the Drug Misuse Research Divisionof the Health Research Board (Long, Allwright, & Begley,2004) – to Irish prisons drew a stinging retort from the con-servative Minister for Justice, who described this proposalas ‘moral fuzziness’ and promised to make the prisons drug-free within a matter of months (Irish Times, September 29,2004). It could of course be argued that moral fuzziness (orambiguity if one chooses to use Reinarman’s vocabulary) hasprovided the basis for all harm reduction initiatives in Ireland.

In terms of the third harm reduction tenet referred to in theintroduction – that which refers to the emergence of more tol-erant and less moralistic public attitudes towards drug users –there would appear to be no advantage accruing from the rel-atively covert or ambiguous style of policy making discussedhere. TheMid-term Review of the National Drug Strategy2001–2008 (2005)confirmed, for instance, that the strategyhad been successful in increasing the number of methadonetreatment places, but it also reported consistent criticism oft aseds ibeda tors,w pec-t ounga eas,a andet jecti lica n fort( a-t ects,c orki tiver linew usst ers,m

D

uc-t rly-e iencea . Noto redb an

right, it even obscures what has been done to date and thefact that these developments have been primarily driven bypublic health motives. While it might be an exaggeration tosuggest that this approach to harm reduction is unique, it iseasy to contrast the Irish experience with that of other coun-tries from which it clearly differs. It is not like Switzerland,for instance, which makes regular use of the referendum pro-cess (MacCoun & Reuter, 2001), nor is it like the Netherlandsor the US which – although in radically differing ways ide-ologically – say what they do and do what they say (de Kort& Kramer, 1999; Musto, 1999). In the case of the Nether-lands, the essence of its harm reduction philosophy had beenarticulated and justified almost a decade prior to the iden-tification of HIV/AIDS, and countries which had originallybeen sceptical or uninterested began in the HIV era to show anew interest in this Dutch experience. In a spirit of rationality,one could ask whether the Irish experience of harm reduc-tion described here has lessons for other countries, but sucha rationally framed question seems inappropriate in relationto policy ambiguity. One could expect that, at least in theirpublic utterances, Irish politicians and senior civil servantswould be likely to deny the central argument of this paper andto stick to the official line that Ireland’s National Drug Strat-egy is a transparent, evidence-based system rather than theambiguous process described here. Looked at from a com-parative perspective, Irish drug policy makers are confrontedw m,t eU ecto t‘ ndp enti-c ctioni en-e thats leadt ande rlesH beT iousm aket pre-s anI db thisd aisedf d fors herei s ano m’.

rmA and.T aignp asa moret hich

his treatment modality and a preference for abstinence-bervices. Although the harm reduction initiatives descrbove have obviously been aimed at urban opiate injecho constitute the most problematic end of the drug-use s

rum, it should be made clear that Irish adolescents and ydults, both in high-risk urban settings and in rural arre just as ‘drugwise’ as their counterparts in Britainlsewhere (Hibell et al., 2004; Mayock, 2002). In this con-

ext, the covert nature of the Irish harm reduction pros severely limiting in terms of its capacity to affect pubttitudes towards young drug users and service provisio

hese young drug users. On this latter point,Kiely and Egan2000, p. 5), in their introduction to a booklet on the applicions of harm reduction concepts to drug education projomment: ‘The current climate of silence around this ws not favourable to the development of realistic and effecesponses to drugs in Irish society, particularly if frontorkers with young people do not feel comfortable to disc

heir work, or to seek endorsement or support from fundanagement representatives or other bodies’.

iscussion

To those who would criticise the international harm redion movement for its value-neutrality and lack of a cleanunciated moral basis, the Irish harm reduction expers presented here must appear especially provocativenly does it show no sign of moving in the direction, favouyHunt (2004), of viewing drug use as a fundamental hum

ith what is a common, if not quite a universal problehat of being stuck within the prohibitionist rigidity of thN drug control conventions with little immediate prospf change or reform.Cohen (2003, p. 214)has argued tha

Drug policy reform is inextricably tied to local culture aolitics. No two systems of harm reduction can ever be idal’. It appears as though the Irish approach to harm redus but one example of ambiguity in a society which is grally accustomed to ambiguity, and which has learnttrident public debate on moral issues is as likely too polarisation and policy paralysis as it is to agreedffective solutions. In 1979, the Minister for Health, Chaaughey (a controversial politician who later went on toaoiseach or Prime Minister) dealt with the then contentoral issue of the sale of condoms by legislating to m

hem available to married couples but only on a doctor’scription, famously describing this as an ‘Irish solution torish problem’ (Lee, 1989, p. 498). While frequently derideoth for his failure to tackle the issue head-on and forescription of his legislation, Haughey has also been pr

or his pragmatism in side-stepping the moral debate anucceeding where the previous government had failed. Ts a sense in which the introduction of harm reduction ingoing example of this ‘Irish solution to an Irish proble

In late-2004 a new group – calling itself the Drug Refolliance – was convened through Merchant’s Quay Irelhe emergence of such a group, which intends to campublicly for drug policy reform, can alternatively be seenpositive step which publicises the issues and brings

ransparency to the policy process, or as a development w

422 S. Butler, P. Mayock / International Journal of Drug Policy 16 (2005) 415–422

will mobilise opponents of harm reduction and ultimatelylead to the dismantling of existing harm reduction systems.To break the silence on harm reduction through the creationof a national debate on the moral issues inherent in drugpolicy might in fact prove to be counterproductive for thosecommitted to harm reduction. It may well be that in an Irishcontext there is, asReinarman (2004)has argued, virtue inambiguity.

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