Dr. Barry Cullen:

I thank the Chair and members of the Oireachtas committee for the invitation to this session on a health-led approach. My input draws from my work experiences. I first commenced work in this field in 1976 in Ballyfermot, and have since worked in the south inner city, the Ana Liffey Drug Project, and in Dún Laoghaire.

I have also researched policy issues and commissioned other research and have been involved in training people on the front line. My experiences are recounted in my book The Harm Done: Community and Drugs in Dublin, which concludes with the need for substantial legal reform.

The assembly's TOR specified, inter alia, that it would make recommendations on legislative changes. Of the 36 recommendations, only recommendation 17 refers to the prospective need for legislative change - in this case for decriminalisation. It is my overall contention that this committee should go a step further than recommendation 17 to recommend legalisation and regulation and that it should advocate a single public health framework for managing drugs and alcohol together into the future, as currently happens within several EU countries. I outlined a number of points to assist the committee's deliberations, as per the written submission, which I have cut back a little for time purposes.

A discussion on the health-led model should always differentiate drug use from problem drug use. Most people who use illegal drugs regularly do not need health interventions, although they experience other problems arising from their legal predicament. For perspective, the largest substance use problem in Ireland is alcohol use disorder, estimated at a staggering 578,000 people. Health-led schemes are not new. Others include custodial treatment, the drugs court and adult cautions for cannabis, initiatives that have either lacked implementation or had little overall impact.

Recommendation 17, as it stands, would also have little impact as it would simply transfer procedural tasks from the courts system to the overburdened health services.

Rather than simply adopting the assembly report, I urge the committee to ask why recommendations continuously do not get implemented. I refer to the other 35 non-legislative recommendations in the assembly's report, most of which have previously been recommended, some of which have been implemented and a lot of which have been abandoned. Rather than reiterate old ideas, therefore, the committee should focus on the need for new legislation and a new departure.

Internationally, public policy on drugs vacillates between two contrasting perspectives, namely criminal justice and the health-led model. The justice perspective prevails. Its enforcement negatively impacts social determinants of individual health such as housing, neighbourhood support, education, income, unemployment and friendships, thereby exacerbating all the key tools in health-led interventions. This needs to change.

Front-line addiction personnel are confronted with a dilemma: should they follow the criminal justice model, get people drug-free and thus crime-free, or should they focus on harm reduction and accept that their clients will continue to use drugs but more safely, while knowing also that because harm reduction is often unpopular electorally, they risk being accused of giving in to the war on drugs and not having enough drug-free, crime-free client outcomes? This dilemma creates overbearing tension and pressure on the front line, where morale is hugely affected and frequently undermined. This is all mirrored in the lack of security and proper terms and conditions for people who work on the front line.

Within the health system generally, drug addiction is seen as being outside the mainstream of hospital and community services and mental health services, and little progress has been made in getting mainstream services to participate in the normal treatment of drug problems. A parallel rather than integrated system has been in operation for more than four decades.

The major drug programme within the health-led sphere, methadone maintenance, as summarised by Dr. Healy and backed up by other research, including that by Paula Mayock and Shane Butler in Dún Laoghaire, has consistently shown these services to be unsympathetic to clients. In contrast, where people develop health issues arising from the legal drug alcohol, the health system responds differently, without moralising or stigma. The same normalised approach towards alcohol is needed in respect of use of all drugs. Stigma will not go away by redefining the meaning of health-led. Legal change starting with cannabis is needed, especially as cannabis has least negative impact on morbidity and mortality. Members might not know that cannabis was not referred to once in the recent report on drug-related deaths and it accounts for up to 80% of illegal drug use.

In the briefing material attached to my opening statement, I summarise the main elements of a pragmatic public health approach to alcohol and drugs together. This type of framework, which is used across the other health issues, is important for understanding that progress on overcoming drug and alcohol problems requires integrated interventions at all three levels of the public health system: primary, secondary and tertiary.

I urge the committee to concentrate on the bigger picture and focus on asserting the State's role, not through continued prohibition, nor through simply sanctioning limited health-led initiatives, but through legislation and regulation in accordance with the health risks of individual substances, with taxation and proper enforcement. The war, which tends to be fought out in the more vulnerable places, needs to end.

I am happy to take any questions or comments. I again thank the committee for the invitation to come here.