ONE OF THE enduring legacies of my time as a young consultant in emergency medicine in Liverpool, in the 1990s, has been an enthusiasm for the city’s ‘Harm Reduction’ approach in tackling the use of (illicit) drugs.

For those unfamiliar with this now-widespread public health notion, the concept translates into a (1) compassionate and (2) ‘pragmatic’ approach to drug users, that prioritises keeping them alive and well instead of abruptly enforcing abstinence or ‘criminalising’ them by reflexively involving the police when drug use is discovered.

Earlier informal ‘harm reduction’ models did exist (like the ‘crash tents’ at the Isle of Wight or Glastonbury music festivals, the Ana Liffey Drug Project in Dublin in 1982, or the world’s first syringe exchange in Amsterdam in 1984), but the “Mersey Model” in the mid-1980s is widely credited with popularising harm reduction, with the UK’s first major syringe exchange service, a radical new policy by Merseyside Police of not prosecuting people for possessing needles for exchange and the advocacy of pioneers like Dr John Marks for prescribing pharmaceutical alternatives, including Heroin and Methadone, to ‘stabilise’ users’ lives and reduce crime.

And, in 1990, Liverpool (Dublin’s twin city) hosted the 1st International Conference on the Reduction of Drug Related Harm, which led to the founding of the International Harm Reduction Association (now Harm Reduction International).

I have good reason to appreciate the harm reduction model. For most of my career in emergency medicine, I worked in the heart of cities – Dublin, Edinburgh, Liverpool and Cork – with devastating drug problems, and dealt almost daily with the medical consequences, from overdoses to injection site abscesses, cardiac infections to AIDS, as well as the ‘challenging’ behaviour of those battling with addiction, like drug-seeking or pilfering from healthcare stocks.

Does harm reduction mean no responsibility?

Moreover, I’ve always had a particular empathy for the people of the inner city: my grandmother started life in Dublin’s north inner city tenements, I spent some of my own early years in an orphanage, and I’m acutely aware of the role of a ‘lucky break’ (I was profoundly fortunate to get into medical school), as well as the importance of social justice and fairness.

In short, I know that ‘talent is everywhere, but opportunity is not’ and that it is this latter reality (a.k.a. poverty) that ‘drives’ most drug misuse.

It is perhaps paradoxical then that it is the very notion of social justice that has recently made me question the whole paradigm of harm reduction, as set out by former Taoiseach, Leo Varadkar (in his foreword to the National Drug and Alcohol Strategy Document, of 2017): “treating substance abuse and drug addiction as a public health issue, rather than a criminal justice issue”.

But, as is so often the way with world-weary healthcare professionals, it was one very real and personally relevant case in my old workplace that convinced me that there’s an urgent need to review a key precept in harm reduction, namely, the prioritisation of ‘public health’ over ‘policing’.

The case was that of an 88-year-old newly widowed farmer, who was brutally attacked in his bed at a major hospital in this country three years ago by a deranged younger patient, who was reportedly in the throes of drug-related delirium. Subsequently, in court, the perpetrator was found not guilty of murder but guilty of manslaughter, through diminished responsibility (after consuming an opioid, Cannabis and a huge amount of Xanax).

In a moving post-trial statement, the victim’s daughter said that her father had deserved to ‘slip away from this world as gently and kindly as the man he was, surrounded by his family, hearing their voices and knowing he was loved. Not lying in bed terrified, then choking on his own blood after being beaten to death by a man shouting that our dad had eaten his children’.

She went on to say, “I consider such a verdict acceptable only for genuinely ill individuals, not for those suffering delirium due to self-induced drug withdrawal… We are the product of our choices, and I will never accept excuses suggesting the perpetrator was not responsible for his actions. His own life choices led to him punching our dad to death”.

After spending decades in city-centre emergency departments and courtrooms, I’m familiar with this argument, and there was a time when I would have reluctantly accepted that this was just ‘a tragic and unusual case’. But no longer. In recent times, there’s been a growing litany of drug-related cases in all parts of the Republic that have involved what one judge described in March 2026 as “almost indescribable savagery”.

The worst of these cases have involved screwdrivers, guns, axes, knives, Samurai swords, blowtorches, heated ‘branding irons’ and flammable liquids, driven by ‘spiralling’ paranoia or hallucinations, resulting in a quick death, if the victim was ‘lucky’ (with or without ‘demonic’ mutilation or dismemberment), a slow painful death due to multiple injuries or direct immolation or sometimes subsequent suicide out of fear of a drug gang.

In terms of the harm caused by drug-using individuals to others, these killings are still thankfully relatively rare. In truth, the vast majority of ‘harm to others’ is actually caused by frightening antisocial behaviour (often on public transport or in public spaces). Much of its origin lies with negligent, chaotic or brutal ‘parenting’ by (third-generation) drug addicts. And the many other manifestations of ‘third-party harm’ include rampant drug-adjacent vandalism of parks or city-centre shoplifting.

Or widespread drug-debt intimidation (2,600 drug-related intimidation crimes were reported to Gardaí since 2020). Or drug-driving (in about 10% of road fatalities). Or drug-using prisoners (70% of inmates) with violence-inducing paranoia and hallucinations.

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Genuine harm reduction

None of this is an argument against harm reduction itself. The principle remains both humane and necessary, but we must, as a society, be clear about what harm reduction is and what it’s not. It should never be a diversion from accountability. Compassion for addiction should not extend to a tolerance of violence, because a society that prioritises public health must also protect the public. 

That means we must hold two truths at once… yes, addiction is complex and often rooted in disadvantage, but actions taken under its influence, especially those that terrorise, injure or kill, must still carry consequences. Without that balance, harm reduction risks losing both its credibility and moral footing. 

So when I think of ‘harm reduction’ now, I no longer think of the parable of the Prodigal Son, for whom a paternal welcome and forgiveness were a simple-ish solution. That notion belongs to a long-vanished era. I believe it is now a matter of common sense that the ‘harm’ we see today is not like that, mostly affecting disadvantaged users in a 1980s inner-city Heroin epidemic.

In reality, it is a calamitous epidemic mostly affecting non-drug users that we have hitherto played down, with a distorted kind of ‘charity’, or denial.

Let’s prioritise ‘Collective’ harm reduction then, and include the victims of drug crime in that. I suggest we move to a different (more ‘democratic’) public health plus policing approach, the sort applicable to a ‘major incident’, in which the scale of a disaster threatens to overwhelm the response resources available. And what we do is for the ‘greater good’, and while dealing with people who are not necessarily ‘compliant’.

Because – and believe this coming from a grizzled veteran of the healthcare frontline – it is not the ‘trauma-informed approach’ of a therapist you need when you’re dealing with a drug-fuelled and violent individual who’s threatening to kill you or your loved one.

If you’re expecting the healthcare or social welfare system to sort out that kind of threat, then you need to think really carefully about who you’re going to call regarding that very, very agitated young man or woman, who has just ended up in the next seat – or bed – to you. 

Dr Chris Luke is a retired consultant in emergency medicine and a healthcare commentator.