National Drugs Strategy Rehabilitation. Department of Community, Rural and Gaeltacht Affairs

Transcription

1 Natioal Drugs Strategy Rehabilitatio Departmet of Commuity, Rural ad Gaeltacht Affairs Report of the Workig Group o Drugs Rehabilitatio, May 2007

2 PN.A7/0508 Departmet of Commuity, Rural ad Gaeltacht Affairs A Roi Góthaí Pobail, Tuaithe agus Gaeltachta 2007

3 CONTENTS Miister of State s Foreword 2 Ackowledgemets 3 Chapter 1 Itroductio ad Backgroud 6 Chapter 2 Overview of Existig Services ad Gaps i Service Provisio 10 Chapter 3 Structures for the Delivery of Rehabilitatio Services 20 Chapter 4 Recommedatios 32 Appedices Appedix I Membership Of Workig Group O Drugs Rehabilitatio 44 Appedix 2 List Of Groups Which Participated I The Process 45 Appedix 3 Residetial Treatmet / Rehabilitatio Providers I The Republic Of Irelad 46 Appedix 4 HSE Fudig Outside Former ERHA Regio I Appedix 5 Ldtf Fuded Service Providers 50 Appedix 6 Projects Which Ru Drug Specific Commuity Employmet Schemes 54 Report of the Workig Group o Drugs Rehabilitatio

4 Miister of State s Foreword The developmet of a comprehesive policy for drugs rehabilitatio represets a further deepeig of the Natioal Drugs Strategy. Durig the comprehesive cosultatio phase of the Mid-term Review of the Natioal Drugs Strategy i 2005, rehabilitatio emerged as a key issue. The mai message was that, with the sigificat ad ogoig expasio i treatmet provisio, there was a eed to focus more closely ad comprehesively o rehabilitatio as the ext step i the process. Subsequetly the report of the Mid-term Review recommeded that rehabilitatio should become the fifth pillar of the Natioal Drugs Strategy ad that a Workig Group should be set up to develop a itegrated rehabilitatio provisio. This report represets the culmiatio of the work of that Workig Group o Drugs Rehabilitatio. I welcome the holistic iterpretatio of rehabilitatio take by the Workig Group. Rehabilitatio is ot just about becomig drug-free, rather it is more about people regaiig the capacity for daily life from the impact of drug use. The broad defiitio of rehabilitatio utilised by the Workig Group ecompasses a structured developmet process focused o idividuals, ivolvig a cotiuum of care ad aimed at maximisig their quality of life ad eablig their re-itegratio ito commuities. The icreased focus o rehabilitatio agai emphasises Govermet s commitmet to addressig problem drug use i Irelad i a flexible way ad i a spirit of cosultatio ad partership. I am coviced that the icreased emphasis beig give to rehabilitatio as a pillar of the Natioal Drugs Strategy will lead to sigificat advaces i that area ad will ehace the overall comprehesive strategy. Already some progress has bee made i regard to rehabilitatio, but the implemetatio of the recommedatios of the Workig Group will greatly accelerate this. At the same time, I kow that the implemetatio of the recommedatios will throw up challeges ad preset problems but, with all ivolved workig together with a shared commitmet to problem drug users, these ca be overcome. Report of the Workig Group o Drugs Rehabilitatio I would like to thak all ivolved i the productio of this report, across Govermet Departmets, Agecies ad the Commuity ad Volutary Sectors. I particular, I thak the members of the Workig Group o Drugs Rehabilitatio. Noel Aher T.D. Miister of State with resposibility for the Natioal Drugs Strategy

5 Ackowledgemets I would like to thak all who cotributed i so may ways to the productio of this report. Numerous Govermet Departmets, orgaisatios ad idividuals made presetatios, submissios ad other iputs to the process ad I am most grateful for their cotributios. I particular I thak the members of the Workig Group o Drugs Rehabilitatio for all their work. The members brought a variety of experieces to the table ad their commitmet to achievig a quality, comprehesive ad achievable outcome i regard to rehabilitatio for problem drug users lead to much robust, but amicable, debate. I hope that the implemetatio of the drugs rehabilitatio structures ad measures arisig from this report will beefit from the participative approach adopted i the formulatio of the recommedatios. I also thak everybody i the Drugs Strategy Uit of the Departmet of Commuity, Rural & Gaeltacht Affairs for their help i the productio of the report. Michael Coroy Chairperso May 2007 Report of the Workig Group o Drugs Rehabilitatio

6 Report of the Workig Group o Drugs Rehabilitatio

7 CHAPTER 1 Itroductio ad Backgroud

8 Report of the Workig Group o Drugs Rehabilitatio 1 Itroductio ad Backgroud 1.1 The Workig Group o Drugs Rehabilitatio arose from a recommedatio i the Mid-Term Review of the Natioal Drugs Strategy, which was published i Jue Extesive public cosultatios were coducted as part of the Mid- Term Review. Although it foud that the curret aims ad objectives of the Drugs Strategy are fudametally soud, the Review highlighted the eed to re-focus priorities ad accelerate the rollout of some of the Strategy s actios ad a umber of ew actios ad amedmets were icluded. I this cotext, rehabilitatio was idetified by the Steerig Group as a area that eeded to be developed, particularly i light of the sigificat ad ogoig expasio i treatmet provisio i recet years. I particular, the Steerig Group stated i the Report that:..the eed for a rehabilitatio elemet to the overall Strategy was a recurrig theme durig the cosultatios ad was see as essetial i esurig that drug users are ot kept o methadoe idefiitely. A clear defiitio of what rehabilitatio is, ad a idetificatio of the agecies ad groups that should be ivolved i providig such services, was called for throughout the cosultatio process. The emphasis throughout was that rehabilitatio services eed to be tailored to meet the cliet s eeds ad to flow seamlessly from treatmet, as part of the cotiuum of care. Aftercare was see as a key gap i terms of access to employmet, sheltered ad appropriate housig ad relapse prevetio ad to break the cycle of drug depedece. The special Commuity Employmet (CE) schemes for problem drug users ad other FÁS schemes were metioed i the cosultatio process as a very importat elemet i the rehabilitatio of problem drug users. However, there was a strog message throughout the cosultatio phase that there is a eed for more rehabilitatio services focussig o geeral life skills, as well as vocatioal opportuities I this regard, a ew actio 2 was agreed which calls for rehabilitatio to become the fifth pillar of the Strategy. The actio recommeded that a Workig Group be set up to develop a strategy for the provisio of itegrated drugs rehabilitatio services ad to report to the Iter-Departmetal Group o Drugs ad to the Cabiet Committee o Social Iclusio o the appropriate policy ad actios to be implemeted. Accordigly, this Workig Group was established i September 2005 ad was chaired by the Departmet of Commuity, Rural ad Gaeltacht Affairs. The Group cosisted of represetatives from relevat Departmets ad Agecies as well as represetatives from the Commuity ad Volutary Sectors The terms of referece of the Workig Group o Rehabilitatio were as follows: O the basis of a agreed defiitio of drug rehabilitatio ad bearig i mid the recommedatios of the Mid-Term Review ad the existig provisios i the Strategy, the Group shall examie the existig provisio of rehabilitatio services i Irelad; idetify best practice; idetify gaps; ad recommed actios, icludig timeframes, to develop a itegrated rehabilitatio service. Members of the Group shall be represetatives of their sectors ad shall be i a positio to obtai the commitmet of their sectors to the actios agreed by the Group The Natioal Drugs Strategy ( ) was developed withi the broader social iclusio cotext, ad set withi the broad policy frameworks of the Natioal Developmet Pla, the Natioal Actio Pla agaist Poverty & Social Exclusio ad the Social Partership Agreemets. I tur, the rehabilitatio pillar of the Strategy is beig developed withi this broader cotext to support the social iclusio of recoverig drug users through facilitatig ad supportig idividuals to reitegrate ito society, with sigificat beefits to families ad commuities. It will support the achievemet of key strategies with respect to vulerable groups geerally, across such areas as health, educatio, employmet ad social affairs. Process 1.5 I order to assist ad iform the Workig Group, the Natioal Advisory Committee o Drugs (NACD) prepared a paper based o a series of discussios withi the NACD s Treatmet/Rehabilitatio Sub-Committee ad the NACD mai Committee. The paper addressed issues such as defiig rehabilitatio, the importace of rehabilitatio, best 1 Mid-Term Review of the Natioal Drugs Strategy , Report of the Steerig Group, Jue Actio 105 of the Natioal Drugs Strategy 3 For a full list of Members of the Group see Appedix 1

9 practice i relatio to rehabilitatio ad challeges to the implemetatio of rehabilitatio strategies. The NACD also prepared a review of the literature evidece as to what costitutes best practice i drug rehabilitatio. This work fed ito the discussios of the Workig Group. 1.6 The Workig Group was coscious that the Mid-Term Review Report ivolved a extesive public cosultatio process. Over 120 writte submissios were received. Presetatios from over 25 Departmets, agecies ad commuity groups ivolved i deliverig the Strategy were made to the Steerig Group. I additio, five regioal public semiars were held i Galway, Limerick, Waterford, Carrick-o-Shao ad Dubli. Rehabilitatio featured strogly throughout this process. I this cotext, the Workig Group o Rehabilitatio decided to draw o the outcomes of this process rather tha coduct a separate exercise. 1.7 However, to assist them, the Workig Group decided to hold focussed meetigs with various service providers, service users ad their families, ad experts i the field of rehabilitatio. A list of those who atteded these meetigs ca be foud i Appedix 2. The issues raised were varied ad wide-ragig ad the Workig Group focused, i particular, o a umber of key issues of commo cocer. Defiitio of rehabilitatio 1.8 The discussio paper produced by the NACD was used by the Workig Group as a basis for its deliberatios i relatio to the defiitio of rehabilitatio. 1.9 Due to the complex eeds of drug users ad the variety of possible approaches to treatmet, a cocise defiitio of rehabilitatio is difficult. Some orgaisatios view it as a distict phase separate from treatmet, while others view it as a itegral part of the treatmet process. It is also importat to bear i mid that problem drug use exacerbates, ad is exacerbated by, other difficulties i a perso s life such as ill-health, poverty, uemploymet, educatioal disadvatage, housig problems, fractured family ad commuity relatioships, crimial justice problems, etc. Cosequetly, treatig drug misuse costitutes oly part of the rehabilitatio process Problem drug use is a chroic, ofte recurrig, coditio. As a result, rehabilitatio is best uderstood as a process that supports ad ecourages drug users at each stage of their drug use (from those whose drug problem is severe ad chaotic, to those who have stabilised, recovered or relapsed), ad at each stage of their cycle of behavioural chage pre-cotemplatio, cotemplatio, actio, maiteace, ad relapse Rehabilitatio ca take place prior to, durig, or after treatmet ad would therefore be accessible to curret, stabilised ad former drug users. At each stage of this process, it was agreed that all services should be cliet-cetred ad respod to the eeds of drug users. The Workig Group further agreed that there was o oe treatmet or rehabilitatio programme which will be effective for everyoe. This was particularly emphasised throughout the meetigs with service providers ad experts i the field of rehabilitatio. The Workig Group takes the view that the rehabilitatio process should ideally begi from the first time the cliet accesses a service for problem drug use The Workig Group discussed the issues surroudig the defiitio of rehabilitatio i-depth ad it was agreed that for the purposes of this work, rehabilitatio is defied as: A structured developmetal process whereby idividuals are facilitated to become fully ivolved i the process of regaiig their capacity for daily life from the impact of problem drug use; Providig a cotiuum of care to problem drug users eablig them to address their eeds, as most appropriate for them (these eeds may iclude health, social, housig, employmet, educatioal ad/or vocatioal); Beig aimed at maximisig their quality of life, ad that of their families ad commuities; ad Eablig their re-itegratio ito their commuity. The aim of this holistic process is to empower people so that they ca access the social, ecoomic ad cultural beefits of life i lie with their eeds ad aspiratios. Drug rehabilitatio, therefore, ecompasses itervetios aimed at stoppig, stabilisig ad/or reducig the harm associated with a perso s drug use as well as addressig a perso s broader health ad social eeds Chapter 2 of the report provides o overview of existig service provisio ad gaps i this regard. Best practices i relatio to rehabilitatio are idetified i Chapter 3 alog with a outlie of a proposed model of itegrated service delivery ad the role of Departmet ad agecies ivolved i its delivery. Chapter 4 details the recommedatios of the Workig Group for the developmet of a itegrated rehabilitatio service. Report of the Workig Group o Drugs Rehabilitatio

10 Report of the Workig Group o Drugs Rehabilitatio

11 CHAPTER 2 Overview of Existig Services ad Gaps i Service Provisio

12 2 Overview of Existig Services ad Gaps i Service Provisio cosiderably, from 7,900 i 2001 to 12,400 i This is due to a combiatio of factors icludig a icrease i the umber of treatmet places, a icrease i reportig to the Natioal Drug Treatmet Reportig System (NDTRS) ad a icrease i drug use. Report of the Workig Group o Drugs Rehabilitatio 10 Itroductio 2.1. While i broad terms, activities such as methadoe dispesig services, stabilisatio programmes, oe-to-oe cousellig, group therapy, holistic therapies ad eedle exchages ca be viewed as treatmet ad harm reductio services, they also form part of the rehabilitatio process. Outreach support, assessmet ad referral, preiductio programmes, drop-i services, attedace at programmes at local level ad priso support are ecompassed i the rehabilitatio process as well. Give the importace of the problem drug user actively egagig i the rehabilitatio process ad beig prepared ad motivated to fulfil their role therei, a key aspect of the process revolves aroud facilitatig him or her to develop his/her employability icludig through CE employmet schemes, vocatioal traiig or egagig/returig to educatio at a appropriate level. However to eable recoverig problem drug users to maximise their chaces of successful rehabilitatio, their societal ad family eeds must also be addressed Acillary supports which address the societal ad family eeds of a problem drug user ca make a importat cotributio to the overall rehabilitatio process ad may sigificatly icrease the prospects for a successful outcome. Therefore, it is importat that these supports, ragig from addressig housig eeds ad child-care issues to iitiatives such as the provisio of iformatio ad advice, family cousellig ad etworks, be cotiued, improved ad developed as required This Chapter seeks to give a overview of the umbers presetig for treatmet, the existig level of rehabilitatio service provisio ad the gaps i this provisio. Numbers presetig for Treatmet 2.4. The total umber of cases treated for problem drug use i the 2001/2005 period are set out i Table 2.1. The umber of cases treated icreased Table 2.1 Numbers of cases treated for problem drug use i Irelad, 2001 to Treatmet status Cotiuous care New cases N/A Previously treated Status ukow N/A N/A Total ,633 12,400 N/A 2.5. Of the 12,400 problem drug users who were treated i 2005, 5,099 etered or retured to treatmet i that year. Of these 5,099 cases, 2,790 (55%) were livig i Dubli. 2,118 (76%) of these Dubli residets had bee previously treated ad 2,520 (90%) of them reported a opiate 6 as their mai problem drug was. Of the 2,309 (45%) cases residig outside Dubli, 780 (34%) had bee previously treated ad the most commo mai problem drugs reported were caabis (981, 43%) ad opiates (748, 33%) Overall, the mai problem drug reported by cases eterig or returig to treatmet i 2005 were opiates (3277, 64%), caabis (1058, 21%), cocaie (482, 9.5%), ecstasy (125, 2.5%), bezodiazepie (77, 1.5%), other stimulats (37, 0.7%) ad volatile ihalats (27, 0.5%). More tha oe drug (polydrug use) is ivolved i 3,585 (70%) of these cases I relatio to opiate misuse, it is estimated that there are curretly aroud 14,500 problem opiate users i Irelad, with approximately 12,000 of these based i the greater Dubli area 8. Of the 14,500 problem opiate users, 8,005 were o methadoe maiteace programmes at 31 October 2006, with 5,195 of these beig treated i cliics ad 2,810 by Geeral Practitioers (GPs) 9.Over 6,500 of those participatig i methadoe maiteace 4 Source: Upublished data from the NDTRS ad Cetral Treatmet List 5 Number of cliets o the Cetral Treatmet List o the 31 December 2003, 2004 ad 2005 ad carried over to 1 Jauary for the respective year 6 Of the cases who reside i Dubli ad etered or retured to treatmet i 2005, the profile shows that just 69% were male, just uder 20% were less tha 25 years ad 45% were livig with their parets/family. I additio, 52% did ot complete secod level educatio ad oly 14% were i regular employmet. 7 Of the cases who live outside Dubli ad etered or retured to treatmet i 2005, almost 80% were male ad 56% were less tha 25 years old, ad well over half were livig with their parets/family. I relatio to educatio ad employmet, 47% did ot complete secod level educatio ad oly 28% were i regular employmet. 8 A 3-Source Capture Recapture Study of the Prevalece of Opiate Use i Irelad 2000 to 2001 Natioal Advisory Committee o Drugs; May Upublished data from the Cetral Treatmet List

13 programmes are based i the Dubli area. While the umber of problem drug users o waitig lists for methadoe treatmet varies betwee regios, the total figure at the ed of August 2006 was The overall umber of those usig methadoe as a treatmet has grow from 5,032 at ed of 2000 to 8,005 at 31 October 2006, represetig a icrease of 59%. Table 2.2 below sets out a summary of ew etrats ad the umber of those who have successfully completed treatmet per two-year period sice 2000 as recorded o the Cetral Treatmet List. Table 2.2: New etrats ad completio i period 10 Year Summary per 2-year period of umbers comig o the Cetral Treatmet List (CTL) for the first time. Numbers of Persos who successfully completed treatmet. 2000/01 2, /03 1, /05 1, This data reflects a dowward tred i the umber of ew etrats presetig for methadoe treatmet. The rate of this decrease has slowed over that period from 24% betwee 2000/01 ad 2002/03 to 5% betwee 2002/3 ad 2004/5. A hearteig feature is the steady icrease i the umbers successfully completig treatmet i that period I Dubli the umber of ew opiate users eterig treatmet has decreased from 889 i 1998 to 438 i While the total umbers are smaller outside of Dubli, there has bee a icrease from 71 i 1998 to 413 i The umbers i treatmet outside the mai populatio cetres ca preset major challeges i relatio to meetig both treatmet ad rehabilitatio eeds where umbers are low ad those ivolved are dispersed across large geographic catchmet areas The capacity of curret systems to idetify the progress of cliets through treatmet is limited. The Natioal Drug Treatmet Reportig System (NDTRS) is the key mechaism curretly available i that regard but this has limited capacity. There is a eed to develop ehaced trackig ad moitorig of problem drug users as they progress through treatmet ad rehabilitatio. This presets sigificat challeges give the rage of agecies ad service providers ivolved i deliverig services. OVERVIEW of EXISTING REHABILITATION SERVICES The level of curret service provisio available for the rehabilitatio of problem drug users is ot easily determied give the broad ature of the defiitio the Workig Group has adopted, the difficulty i distiguishig betwee what costitutes treatmet ad what costitutes rehabilitatio ad the scope for problem drug users i rehabilitatio to avail of what ca be cosidered as maistream services, may of which have bee expaded over the last umber of years. While some services that lik elemets of their programmes directly to the rehabilitatio of problem drug users ca be idetified ad quatified (some LDTF programmes, FÁS CE Schemes ad projects fuded by the Probatio Service), others caot be readily quatified (e.g. some services provided by the HSE, ad through the Departmet of Educatio & Sciece) LDTF, FÁS ad Probatio Service expediture that is specifically aimed at the rehabilitatio of problem drug users is estimated to be 28.73m for Table 2.3 below breaks this figure dow betwee the curret LDTF programmes 11, the FÁS Special CE schemes ad projects fuded by the Probatio Service. Table 2.3: Idetifiable direct expediture o rehabilitatio Agecy Amout millio LDTF Programme (Rehab elemet) FÁS Probatio Service 2.30 Total With respect to the LDTF elemet, approx. 8.74m (73%) of this fudig is chaelled to projects through the HSE, with 1.18m (10%) chaelled through FÁS. The balace of fudig is primarily for educatio or priso lik services The HSE, as the mai provider of addictio services i the coutry, provide a rage of services from educatio ad prevetio, through treatmet, harm reductio, stabilisatio, rehabilitatio 12 ad aftercare for problem drug users. The HSE estimate that their expediture i 2005 was 92.71m 13 at a miimum, up 12% o the correspodig 2003 figure. Table 2.4 below sets out the mai compoets of this provisio: 11 Report of the Workig Group o Drugs Rehabilitatio 10 Figures supplied by the HSE 11 The actios idetified i the iitial plas of the LDTFs were maistreamed from The curret cost of those projects trasferred to the HSE is idetified i Table Of particular iterest i the cotext of this report is the work of the Rehabilitatio Itegratio Service set up i 2000 i the former Norther Area Health Board to develop a co-ordiated ad itegrated respose to idividuals seekig to develop progressio pathways out of problem drug use. The service ivolves itesive perso-cetred rehabilitatio assessmet, guidace, plaig ad referral/ brokerage with aftercare support. 13 Drug ad alcohol services are treated differetly i compilig the figures. With respect to what was the Easter Regioal Health Authority, oly expediture icurred o Drug services are icluded i the expediture whereas with respect to the remaider of the coutry Drug ad Alcohol services are icluded i the figures as they caot be distiguished.

14 Table 2.4: HSE provisio for addictio services i 2005 HSE Services Amout millio Maistream Services Drug Treatmet Cetre Board 9.48 Sectio 65 Fudig 14 (Commuity) 9.98 LDTF Maistreamed 8.02 YPFSF Maistreamed Total Parterships (e.g. Back To Educatio Iitiatives, Local Employmet Services) Commuity Developmet Projects (varies sigificatly but may projects have developed commuity based services, such as childcare ad commuity/adult educatio, with fudig provided by relevat Departmets/Agecies) Departmet of Social & Family Affairs (Iformatio Offices ad Employmet Support Services, Family Support Agecy, Moey Advice ad Budgetig Services) Report of the Workig Group o Drugs Rehabilitatio The maistream services ad the services provided through the Drug Treatmet Cetre Board cosist of a combiatio of treatmet ad rehabilitatio services provided through the HSE. Icluded here are services ragig from those provided by GPs, pharmacists, ad psychiatrists through to cousellors/therapists, outreach workers ad educatio officers. While the Drug Treatmet Cetre Board service is a atioal service, approximately 80% of the maistream services are provided iside the former ERHA regio ad would be cocetrated o LDTF areas However, there is a rage of other services provided by the HSE for the geeral public, which ca be accessed by problem drug users. These iclude services provided through Primary Commuity ad Cotiuig Care (PCCC) - such as the rage of iitiatives aroud childre ad families (e.g. High Support Uits, Sprigboard Iitiative, Resource Cetres), metal health ad social iclusio (e.g. homelessess iitiatives); the Natioal Hospitals Office ad Populatio Health (or NGO services via Sectio 65 etc.); ad the Hospital Directorate. Each of these services ecouter, with varyig itesities, issues related to addictio ad it is ot feasible to disaggregate the elemets therei or to estimate the cost ivolved Similarly, other Departmets/Agecies provide services that ca be availed of by problem drug users i rehabilitatio but those services ad their associated costs caot be disaggregated. The key Departmets/Agecies ivolved are: Departmet of Educatio & Sciece/VECs (Adult/Commuity Educatio icludig literacy services, Social Iclusio Iitiatives, Youth Affairs) FÁS (Employmet Services) Probatio Service (Priso Lik services ad support services through a rage of commuity ad volutary based projects) Gardaí (Juveile Liaiso Schemes ad Garda Diversio Programmes) Local Authorities (Housig primarily) Homeless Agecy (housig ad other issues aroud homelessess) Further iformatio o the roles of Departmets ad Agecies are set out i Chapter As the above brief overview idicates, sigificat levels of services are available for access by those i rehabilitatio. As regards gaps i these services, it is felt that problems ca arise at the poit whe cliets move from oe service to aother, or where a cliet is availig of multiple services without the ecessary co-ordiatio betwee the service providers beig i place. It is ackowledged by the Rehabilitatio Workig Group that assistace for those i recovery, through the mechaism of ehaced case maagemet, is a key eed ot oly to eable those i rehabilitatio to access these services as required but to esure that appropriate support is available at crisis times i their rehabilitatio. The issue of case maagemet is addressed i Chapter 3. TREATMENT ad REHABILITATION ISSUES Treatmet ad rehabilitatio complemet each other i very sigificat ways. The view from research, ad the cosesus of those who iputted to the work of the Workig Group, is that a seamless cotiuum of care for recoverig problem drug users is desirable. The 4 Tier service delivery model, which is to be used i tacklig the addictio problems of uder-18 year olds, represets oe possible framework for rehabilitatio services Treatmet optios ca iclude medicatio (substitutio programmes, methadoe reductio, detoxificatio) ad/or therapeutic services such as 14 Sectio 65 relates to Sectio 65 of the Health Act, These projects are fuded by the HSE but are provided by the commuity/ volutary sector. 15 Youg People s Facilities ad Services Fud (YPFSF) maistreamig relates to Waterford where 4 projects were maistreamed from 2004.

15 addictio cousellig, group therapy, psychotherapy ad/or life skills traiig. Views i respect of treatmet rage from abstiece to harm reductio, both of which are cosidered as valid approaches. This duality of approach must cotiue to be catered for ad be reflected i the services provided for treatmet ad rehabilitatio I lie with the above, some see the cotiued use of methadoe (or other substitutio programmes) as a successful outcome for those problem drug users whose aim is harm reductio while others see methadoe use as a trasitioal measure i the treatmet/rehabilitatio process rather tha as a successful log-term solutio May existig treatmet ad rehabilitatio services focus o the treatmet of opiate users. I the past few years cocaie use, the misuse of alcohol ad prescribed medicatio i cojuctio with illicit drug use ad polydrug use geerally have posed challeges to the delivery of services. I the future, ew drugs ad ew drug treds will udoubtedly arise ad it is importat that services are adaptable to meet the diverse eeds of a rage of problem drug use It is clear that sigificat variatios will arise i the type of rehabilitatio eeded by, ad appropriate for, various cliets i the target populatio. For example, residetial rehabilitatio may be a effective optio for chroic problem drug users, while commuity detoxificatio, with the assistace of a local GP, may be more appropriate for other problem drug users who may have strog family or commuity based support. A key issue to be addressed is the balace to be achieved betwee the provisio of rehabilitatio i (i) residetial ad (ii) commuity settigs. Some service users have expressed the view that there is scope for service providers to improve the level of commuicatio with them i regard to their care-plas The treatmet ad rehabilitatio services available o a residetial ad commuity basis are set out below. A. Residetial Detoxificatio ad Rehabilitatio Services A breakdow of the umber of residetial places curretly available from service providers i Irelad is attached at Appedix 3. This iformatio, which has ot bee audited, was compiled from a self-assessmet exercise that the HSE udertook with the services ivolved i mid A total of 794 beds are documeted, of which 405 are potetially available to problem drug users. However, the umber of dedicated beds for problem drug users could ot be established ad the umber that are occupied by these at ay give time ca vary. Some service providers observed that some of those beig treated for alcohol addictio ca also be ivolved i polydrug misuse. The residetial services provided ca be separated ito three categories as follows: (i) Specialist Residetial Detoxificatio Treatmet; (ii) Commuity Based Detoxificatio Programmes with Residetial Support; (iii) Abstiece Based Residetial Rehabilitatio Programmes. (i) Specialist Residetial Detoxificatio Treatmet These services are aimed at idividuals presetig with a high level of presetig eed, complex patters of problem drug use ad associated physiological problems (e.g. Hep C). They ivolve ipatiet drug/alcohol detoxificatio or stabilisatio services. These services are uder the directio of a Medical Director/Cosultat Psychiatrist with specialist skills i the area of substace misuse ad ivolve multi-discipliary teams coverig Psychiatry, GP, Nursig ad Cousellig/Therapy. Twety-three beds are provided uder this category by the statutory sector. (ii) Commuity Based Detoxificatio Programmes with Residetial Support These services are aimed at problem drug users who have bee assessed by a GP as appropriate for commuity based detoxificatio but who require a high level of support, i terms of their evirometal/psycho-social eeds, i a residetial settig. Cliets i this category usually have less itese medical eeds that do ot require i-patiet medical care. Providers offer sigificat psycho-social/therapeutic support ad/or skills based traiig to those i treatmet. There is a close liaiso betwee the provider ad the desigated commuity based GP i relatio to the detoxificatio elemet of care plas. Nietee beds are provided withi this category through the volutary sector. Residetial Detoxificatio Summary I Britai, the Natioal Treatmet Agecy for Substace Misuse briefig o Tier 4 services (2003), citig Matrix 2003, estimated that oe ipatiet detox bed is eeded per 48,000 of populatio. Give a populatio of approx millio 17 this would suggest a detox bed requiremet of 89 beds 13 Report of the Workig Group o Drugs Rehabilitatio 16 The Workig Group o Drugs Rehabilitatio recogises that the Workig Group o Residetial Treatmet/Rehabilitatio, set up by the HSE i September 2006, is udertakig a comprehesive review of residetial rehabilitatio provisio ad the figures used here should be take as idicative. 17 Jue 2006 CSO Populatio Report.

16 Report of the Workig Group o Drugs Rehabilitatio 14 for Irelad. While cosideratio of the adequacy of the level of residetial services provided is to be pursued further by a Workig Group established by the HSE i September 2006, there is a clear cosesus i the Workig Group o Drugs Rehabilitatio that there is a urget eed for a icrease i the umber of detoxificatio beds available i the coutry. The group recogise that a rage of issues eed to be cosidered before a fial figure o the umber of beds required is determied, ivolvig the respective roles of both statutory ad o-statutory providers, but feel that steps should be take ow to implemet a iterim icrease of 25 detoxificatio beds 18. (iii) Abstiece Based Residetial Rehabilitatio Programmes: These programmes cater for cliets who are drug ad alcohol free. The programmes are abstiece-orieted ad the emphasis is o uderstadig ad maitaiig a drug or substace free lifestyle. The ethos uderlyig the programmes varies i orietatio, ragig from the 12-step model to the therapeutic commuity approach to the systemic/psychotherapeutic model. All services are therapeutic by ature ad, to varyig degrees, emphasise skills ehacemet, vocatioal skills traiig ad persoal resposibility. Most programmes are coected with HSE addictio service treatmet providers i terms of treatmet support/cosultatio. A total of 546 beds are provided uder these programmes, of which 363 ca cater for problem drug users, though the umber occupied by problem drug users at a give time varies ad ca be quite small May of these service providers, who are predomiatly from the volutary sector, provide commuity based day services as well. They also offer aftercare ad reitegratio programmes after completio of the residetial programmes. These give support ad guidace durig this key phase of recovery as people move towards full reitegratio. B. Commuity Based Treatmet ad Rehabilitatio Service A key elemet of both treatmet ad rehabilitatio services is the service provided by both local GPs ad pharmacies ivolved i the dispesig of methadoe. With respect to the provisio of treatmet services, GPs are ivolved i methadoe maiteace programmes atiowide (183 of these are based i the Dubli area, with 43 elsewhere). A total of pharmacies dispese methadoe to recoverig problem drug users (226 of these are based i the Dubli area, with 149 elsewhere). The level of service provisio is ot uiform throughout the coutry ad curret efforts eed to be maitaied to address this, as recommeded by the Mid-term Review of the Natioal Drug Strategy No-residetial commuity based rehabilitatio services for problem drug users is most advaced i Local Drug Task Force (LDTF) areas, with a less developed service provided i RDTF areas across the rest of the coutry (See 2.32 ad 2.33). I RDTF areas some rehabilitatio services have bee developed primarily fuded through the HSE uder Sectio 65 of the Health Act, Figures (supplied by the HSE) for Addictio Services provided outside what was formerly the Easter Regio Health Authority (ERHA) area are outlied i Table 2.5 below. Appedix 4 breaks dow these figures by regio. Table 2.5 : Addictio Services provided outside the former ERHA area i 2005 HSE Services 21 Amout millio Maistream Services Sectio 65 Fudig 2.64 LDTF Maistream YPFSF Maistream Total The developmet of commuity-based resposes is most developed i the Easter half of the coutry with little drug specific support provided towards the Wester seaboard With the establishmet of the 10 RDTFs, full Task Force coverage of the coutry has bee achieved ad this is ow facilitatig a more coordiated respose to problem drug use. Their Actio Plas have bee agreed ad fudig has bee provided for implemetatio. A key challege to be faced by RDTFs is the developmet of services for large catchmet areas withi which there are small dispersed umbers of problem drug users. Commuity based rehabilitatio services i LDTF areas LDTFs operate i areas experiecig the highest levels of drug misuse. Twelve of the 14 LDTFs are located i Dubli, with the others i 18 The Departmet of Health ad Childre ad the Health Service Executive are reservig their positio o this issue pedig the completio of the report of the Workig Group o Residetial Treatmet / Rehabilitatio. 19 as of 31 October 2006 (Drug Treatmet Cetre Board). 20 as of 31 October 2006 (Drug Treatmet Cetre Board). 21 The Drug Treatmet Cetre Board provides a Natioal Service ad is excluded. 22 Relates to Cork City projects maistreamed i 2001 uder Roud 1 of LDTF Programme. 23 Relates to Waterford City projects maistreamed i 2004 uder YPFSF.

17 Bray ad Cork. LDTFs provide a mechaism for the co-ordiatio of maistream services i these areas (see 2.12 above), while facilitatig the participatio of local commuities ad volutary orgaisatios i the plaig, desig ad delivery of those services Rehabilitatio of problem drug users has bee a key elemet of all LDTF plas. Workig from the defiitio of rehabilitatio, service provisio has evolved aroud four themes: (a) Commuity Drug Teams egagemet (icludig re-egagemet), referral ad egotiatio/ provisio of support to problem drug users. (b) Provisio of therapeutic support. (c) Employmet access, traiig ad educatio. (d) Acillary supports (family, childcare, housig, welfare). I additio to the above, a umber of projects were specifically aimed at high-risk groups such as the homeless, ex-prisoers, Travellers ad those people ivolved i prostitutio Some commuity supports have also bee provided. These revolve aroud helpig commuities to become more iformed, ad to acceptig the rehabilitatio of problem drug users withi their ow commuity Each LDTF area has, to varyig degrees of itesity, services that cater for each of the above four themes developed uder the LDTF umbrella with fudig provided by the Departmet of Commuity, Rural & Gaeltacht Affairs, ad by the relevat State Agecies ivolved. Appedix 5 sets out the service providers, umber of projects ad chael of fudig for each LDTF area. I total there are 109 providers ivolved, with a average of approx. eight providers i each LDTF area - ragig from 5 to fiftee per area Services have bee developed uder two rouds of the LDTF programmes (with some capital provisio through the Premises Iitiative) ad the Emergig Needs Fud, which the Departmet of Commuity, Rural ad Gaeltacht Affairs have fuded. The outcome of the forthcomig evaluatio of most of the projects uder the LDTF programme should iform the rehabilitatio framework goig forward. Also, a umber of projects uder the Emergig Needs Fud target ewer aspects of the drug problem (i particular the emergece of cocaie ad polydrug use ad the eed for rehabilitatio services). (a) Commuity Drug Teams Eleve LDTF Commuity Drug Teams (CDTs) have bee supported uder the Drugs Strategy sice May of these were developed through local residets ivolvemet from the outset to address their cocers regardig drug problems i their areas. Services are developed i partership with volutary ad statutory sectors assistig the local commuities. CDTs focus o a specific geographic commuity. Alog with treatig idividuals ad families, they see the wider commuity as a cliet of the service. The rage of service reflects local eeds ad ca iclude treatmet, cousellig ad support for idividual ad families affected by drugs misuse, promotig drug awareess i the commuity, outreach to families ad specific target groups such as prisoers. I additio, the CDTs provide a focal poit for other state services to access ad support cliets. (b) Provisio of Therapeutic support A umber of cousellig ad other therapeutic services are provided uder the LDTF programmes. The CDTs are ivolved i some of these services. Those ivolved i educatio, traiig ad employmet may also avail of these services. (c) Educatio, Traiig & Employmet Services have bee developed i each LDTF area aimed at assistig recoverig problem drug users to access opportuities relatig to existig educatio, traiig ad employmet services. These latter services are catered for predomiately through maistream providers ad a issue for the Workig Group was to cosider how best to cater for rehabilitatig problem drug users to re-egage with this maistream provisio. As idicated earlier, problem drug users, depedig o a variety of factors, will have differet eeds with respect to these services. For a miority, oly some assistace towards re-egagemet with work may be required while others will require more itese levels of support. For those who are almost ready to retur to work, or to take up employmet for the first time, maistream service provisio should be sufficiet. Others will eed more itese help through educatio, commuity employmet, commuity services provisio ad day programmes 24. (c.1) Educatio To date low levels of formal educatio predomiate amog people who preset for treatmet ad cosequetly there is a eed to facilitate the re-egagemet of problem drug users i rehabilitatio with the educatio process, whether through maistream provisio, the iformal 15 Report of the Workig Group o Drugs Rehabilitatio 24 A example of a respose is the Bridge to Workplace Iitiative developed by the Health Service Executive Rehabilitatio/Itegratio Service, FÁS, the Local Employmet Service Networks (ad Area Based Parterships) of Figlas/Cabra, Blachardstow, Dubli North East, Ballymu ad the North Ier City ad which was fuded i part by the Figlas/Cabra LDTF (Dept CRGA). This iitiative sought to expad the progressio potetial of 40 people with addictio problems, through the establishmet of a work experiece stimulatio programme. The aim of the itervetio is twofold: - to provide a quality work experiece opportuity ad the skills ad support framework to access ad maitai participatio; ad - to create a forum whereby the parters ivolved ca work together to holistically meet the eeds of people with drug misuse issues.

18 Report of the Workig Group o Drugs Rehabilitatio 16 youth educatio sector or adult/commuity based provisio. Sigificat chages have occurred, ad are ogoig, withi both the adult ad the iformal youth educatio sectors, with respect to the level of resources made available to these sectors over recet years. However, it is clear from the cosultatio process that there is a eed to build upo the efforts already made to eable a fuller reegagemet by problem drug users with both the formal ad iformal educatio sectors A umber of sigificat reports poitig the way forward with respect to addressig educatioal disadvatage have bee published, icludig the report of the Miister for Educatio & Sciece s appoited Educatioal Disadvatage Committee i 2005, ad the implemetatio of the recommedatios of this report should eable the eeds of problem drug users to be more adequately addressed With respect to youg recoverig problem drug users, iitiatives such as Youthreach ad VTOS (Vocatioal Traiig Opportuities Scheme) are available to those ot immediately able to retur to maistream educatio for whatever reaso. For adult recoverig problem drug users, literacy ad umeracy courses are ofte a key iitial step o their educatioal pathway Whe recoverig problem drug users move beyod literacy ad umeracy, they may wish to access further educatio, whether through commuity educatio or maistream provisio. Supports, such as the Back To Educatio Iitiatives (BTEI) or commuity support will geerally be required to varyig degrees to achieve such trasitio There ca also be difficulties i movig forward to maistream educatio whe literacy/ umeracy work ad commuity educatio has bee achieved. While this gap is beig partially addressed through the developmet of accredited courses withi the commuity educatio sector (icludig i drugs work), some support issues persist, with few progressio paths (particularly to third level educatio) Issues such as childcare costs, trasport cost, fees etc. eed to be take ito cosideratio whe assessig whether the supply of courses is adequate i meetig demad, as such issues ca affect the take up of the available optios Overall, it is felt that there is a eed for closer cotact betwee educatio providers, i particular local VECs, ad the services ivolved i the rehabilitatio process. VECs, buildig o the efforts already made, eed to become more proactively ivolved i meetig the eeds of problem drug users i rehabilitatio. (c.2) Commuity Employmet Provisio Commuity Employmet is provided by FÁS ad there are curretly 1,000 places available o the scheme across 65 projects (see appedix 6 for list of projects). The Review of the Natioal Drugs Strategy refers to FÁS CE Programmes as a very importat elemet i the rehabilitatio of problem drug users (outlied i Actio 74 of the Natioal Drug Strategy) Projects have developed wide-ragig programmes to meet the idividual eeds of their cliets, both at a persoal ad vocatioal level. A wide rage of both skills-based ad persoal developmet traiig is beig provided. Projects also provide persoal support services, icludig oe-to oe cousellig, family support ad referral to therapies. Advocacy work o behalf of cliets forms a key elemet of the work of projects ad deals with a rage of issues such as housig, social welfare issues, legal issues etc A major evaluatio (Bruce Report 25 ) of CE Special Drug Projects was udertake i 2004, the mai fidigs of which are set out below. (The North East LDTF also evaluated the Special CE Drug Projects i its area ad this evaluatio reached similar coclusios to the Bruce report). The mai fidigs of the Bruce Report were: participats surveyed as part of the evaluatio geerally fid the schemes beeficial i meetig their therapeutic ad rehabilitative eeds. the challege of usig a labour market mechaism as a rehabilitative tool, ad the difficulty i balacig the rehabilitative ad employmet-orieted dimesio of the scheme to meet idividual eeds, was highlighted. while iteratioal evidece shows itegratio o a traiig scheme ad a focus o employmet have tagible beefits, the timig of these schemes durig the rehabilitatio process has a major impact o the likelihood of a successful outcome. progressio to employmet was ot see as a realistic optio for may participats, partially because it would take loger tha three years (5 to 7 years was metioed) ad also because of the importace of socio-ecoomic backgroud issues (e.g. educatio, housig). The Bruce Report states that from moitorig progressio i Cork CE schemes it ca be see that 10% of scheme participats have secured, ad remaied i, employmet. Figures are ot available for the Dubli schemes. 25 Report of the Review of the Drugs Task Force Project Activity for FÁS Commuity Employmet Participats Dr Ala Bruce; 2004.

19 The coclusios of the evaluatios highlighted fudametal challeges, which eeded to be faced to stregthe the approach. Gaps idetified icluded the followig: - eed for greater iter-agecy co-operatio; - the overall maagemet of a itercoected service; - the provisio of additioal perso cetred ad family supports; - the primary role that the Health Boards eed to play i relatio to rehabilitatio; - CE oly makes sese if delivered as part of a coheret ad iterliked programme of rehabilitatio ad support for the cliet group. (d) Acillary supports Acillary services relate to services provided to facilitate access to treatmet ad rehabilitatio ad to provide family support to problem drug users ad their families. With respect to this latter elemet, the services developed i LDTF areas ivolve the provisio of iformatio ad advice, oe-to-oe or group cousellig, discussio groups, residetial respite breaks, childcare services ad drop-i services I additio, ad otwithstadig the recogitio of the eed for family support structures i all LDTF programmes developed, a view was expressed that the families of problem drug users should be facilitated i becomig more ivolved i the process of rehabilitatio ad that more iformatio ad support should be made available to these families. (c.3) Commuity Services Programme Curretly oe of the projects ru uder this programme (formerly the Social Ecoomy Programme ad ow the resposibility of the Departmet of Commuity, Rural & Gaeltacht Affairs) specifically target recoverig problem drug users. This programme is project drive, which meas that specific projects will eed to be idetified ad developed that could cater for the target group. The 2006 call for expressios of iterest for the programme, however, does iclude projects which support ad employ stabilised ad recoverig problem drug users i the categories of projects eligible for cosideratio. Also existig projects ca be approached to see if they could accommodate problem drug users at a appropriate stage i their recovery (as has happeed o some projects i the past) Access to childcare was highlighted as a key issue i relatio to rehabilitatio. The availability of childcare facilities for the childre of cliets wishig to access treatmet/rehabilitatio is a sigificat factor ifluecig their participatio i programmes Female problem drug users ted to preset later for treatmet ad ca have sigificat cocers about the implicatios for their childre of presetig for treatmet. Partly as a result of later presetatio, they ted to have multiple health problems, ad they experiece particular health problems i relatio to pregacy. They are ofte ecoomically depedet o illicit drugusig parters ad ca have experiece of abusive relatioships. All of these factors eed to be take ito accout i providig rehabilitatio programmes for wome. 17 (c.4) Employmet The aim of progressig problem drug users ito employmet is a key target of ay rehabilitatio strategy. While drug specific Commuity Employmet schemes allow participats to gai work experiece ad to develop a workig routie, these schemes are ot a ed i themselves ad there is a eed to build i progressio routes to maistream employmet As idetified i the Bruce report with respect to CE, recoverig problem drug users have difficulty i movig o to secure, ad remai i, employmet. This area should to be researched i greater depth with icreased egagemet at both a atioal ad local level, with employer ad trade uio orgaisatios, to idetify iitiatives that might be implemeted to achieve greater reitegratio of rehabilitated problem drug users i the workforce. Specific risk groups (a) Homeless Lack of suitable housig is oe of the mai barriers to rehabilitatio. Also, this is oe of the factors, which if ot addressed adequately, icreases the likelihood of relapse followig rehabilitatio. The beefits gaied from a residetial rehabilitatio programme, with a emphasis o routie ad structure were see to be short-lived uless followup ad post release support was made available, ad accommodatio eeds were met. This issue ca ofte arise also i the case of those leavig priso. (b) Ex-Prisoers Both those i priso ad those comig out of priso are high-risk groups with respect to problem drug use. While problems are still beig experieced i priso settigs, treatmet ad rehabilitatio provisio withi prisos has improved sigificatly i recet years. The Workig Group welcomes the Irish Priso Service Drugs Policy ad Strategy published i May 2006 which recogises Report of the Workig Group o Drugs Rehabilitatio

20 Report of the Workig Group o Drugs Rehabilitatio 18 the importace of cotiuity with respect to the provisio of treatmet, care ad support services post-release ad their commitmet to achievig this objective The Review Group would reiterate the eed to esure the expasio ad ivolvemet of the commuity ad volutary sectors i priso drug policy i lie with Actio 24 of the Natioal Drug Strategy May drug users receive a crimial covictio that impacts o their access to employmet ad this ca prove a serious impedimet to rehabilitatio ad make successful re-itegratio ito maistream society more difficult. The developmet of rehabilitatio of offeders legislatio, which would allow for certai categories of crimial covictios to effectively become spet after a specified period of time, was idetified by the Steerig Group who compiled the Mid-Term Review of the Natioal Drugs Strategy as a issue which should be cosidered. The Rehabilitatio Workig Group is advised that the Law Reform Commissio is examiig the cocept of expugig the seteces of recoverig problem drug users after a period. (c) Childre of drug usig parets While the impact of the drug use of parets o their childre, i terms of persoal, social ad educatioal developmet, has ot bee studied i ay comprehesive way, it is accepted that such childre costitute a particular at risk group. (d) Prostitutio People ivolved i prostitutio are a highrisk group i relatio to problem drug use. While a umber of projects are targeted specifically at this group, it is particularly difficult to egage this group i treatmet ad rehabilitatio. They ted to have multiple issues besides problem drug use that also eed to be addressed. (e) Travellers While historically uder the Natioal Drugs Strategy, Travellers were cosidered to be less at risk from illicit drug misuse 26, there is evidece of icreasig levels of drug misuse withi that commuity. The recommedatios of the recet NACD report examiig the ature ad extet of illicit drug use amog the Traveller Commuity 27 eed to be cosidered i the cotext of rehabilitatio, with particular focus o culturally appropriate accessible services. (f) Metal Health A sigificat umber of people have coexistet metal health ad substace misuse problems (commoly referred to as dual diagosis). Research carried out by the Natioal Advisory Committee o Drugs i foud that a lack of systematic co-ordiatio of care is evidet i relatio to dual diagosis cliets. (g) New Commuities As madated uder the Natioal Actio Pla agaist Racism, the HSE is curretly developig a itercultural strategy that will take ito accout the diverse eeds of ew commuities i respect of addictio issues. The patter research carried out to date i this area is a 2004 exploratory study udertake by Merchats Quay Irelad o drug use i ew commuities 29 that foud that drugs services eeded to develop i a accessible ad culturally appropriate way. SUMMARY It is clear that a rage of services are already i place to support the rehabilitatio of problem drug users. The challege is to implemet measures to adapt ad build o this i a co-ordiated ad cliet-cetred way. 26 See Natioal Drug Strategy See pg A overview of the ature ad extet of illicit drug use amogst the Traveller Commuity: a exploratory study Natioal Advisory Committee o Drugs; October Metal Health ad Addictio Services ad the Maagemet of Dual Diagosis i Irelad Natioal Advisory Committee o Drugs; November Drug Use Amog New Commuities i Irelad. A Exploratory Study fuded ad published by the Natioal Advisory Committee o Drugs; October 2004.