Joint Committee on Health and Children

Houses of the Oireachtas Joint Committee on Health and Children A Submission From Homeless & Drugs Services Homeless & Drugs Services September 15 th 2011 1

CONTENTS Page no. 0.1 Introduction 3 0.2 Structure of the Submission 3 Merchants Quay Ireland - Background 1.1 Merchants Quay Ireland 4 1.2 Mission Statement 4 1.3 Merchants Quay Ireland Services 4 Overview of the Drugs Problem and Treatment in Ireland 2.1 Extent of the Drugs Problem in Ireland 5 2.2 Addressing the Drugs Problem - Treatment Works 5 Current Gaps / Outstanding Issues 3.1 Needle Exchange Services 6 3.2 Access to Treatment/Waiting Lists 6 3.3 Detoxification 6-7 3.4 Rehabilitation 7 3.5 Rehabilitation of Offenders Act (ROA) 7-8 3.6 Use of Other Drugs 8 Recommendations 4.1 Recommendations 8 Conclusion 5.1 Conclusion 9 References 10 2

0.1 Introduction Merchants Quay Ireland welcomes the opportunity to make this submission to the Joint Oireachtas Committee on Health and Children and hope it will be of assistance to the Committee in its deliberations. The topic under consideration by the Committee is a broad and complex one and measures to address the issue range from prevention and education initiatives to issues of supply control and criminal justice initiatives. Merchants Quay Ireland will confine its submission to the areas of harm reduction interventions and drug treatment initiatives as this which is where our significant expertise lies. 0.2 Structure of the Submission The submission will commence, by way of context, with a brief overview of Merchants Quay Ireland detailing the range and scope of services provided. The submission will then present the most up to date data on the extent of the drugs problem in Ireland including current treatment uptake information. Finally, we will outline a number of specific areas of particular concern in addressing the drugs issue and will detail a number of recommendations in this regard. 3

MERCHANTS QUAY IRELAND - BACKGROUND 1.1 Merchants Quay Ireland Merchants Quay Ireland, Homeless and Drugs Services, was founded by the Franciscan Order in 1989 as response to the growing issues of drugs and homelessness in Dublin. Since that time Merchants Quay Ireland has grown into a large independent voluntary sector organisation offering a wide range of services to people who are homeless and problem drug users. We work in partnership with a range of other statutory, voluntary and community organisations and now provide services across 11 counties around the country. 1.2 Mission Statement Merchants Quay Ireland is a community of hospitality, hope and justice. Our mission is to: Work for justice and opportunity for homeless people and drug users in partnership with those who share our aims Create a place of safety, compassion and welcome for all who enter our doors and offer high quality services to meet their needs Support all who work with Merchants Quay to enable us to achieve our full potential in our various roles Believe in and cherish the value of every human being in keeping with our commitment to social justice coming from our origins in the Franciscan Tradition. 1.3 Merchants Quay Ireland Services Merchants Quay Ireland is a voluntary organisation working towards the elimination of homelessness and the development of effective treatment and support services for drug users. The services we currently offer include: Crisis contact centre/health promotion unit National Addiction Counselling Service for the Irish Prison Service Structured day programmes Methadone treatment 3 month residential drug treatment programme (incl. assisted detox) 3 month farm based residential therapeutic community Reintegration and employment programme Training and research services Food centre offering two meals per day and washing and shower facilities Primary Health Care services: GPs, Nurses, Dentist, Counsellors, Podiatrist. Settlement Service Transitional Housing Projects In 2010, we worked with over 5,000 drug users and people who were homeless. For more information on our services visit www.mqi.ie 4

EXTENT OF THE DRUGS PROBLEM AND TREATMENT IN IRELAND 2.1 Extent of the Drugs Problem in Ireland Traditionally the drugs issue has been viewed as a Dublin based problem, however, this is now no longer the case. Drug use and heroin use in particular has spread to many urban centres beyond Dublin. A report from the Health Research Board (HRB 2004) on the extent of drug use outside of Dublin showed that heroin use had quadrupled over a four year period with many areas outside Dublin all recording much higher levels of use. The most recent research, conducted in 2006 on the prevalence of opiate use in Ireland estimated that there were between 18,136 and 23,576 problem opiate users in Ireland with the majority located in the greater Dublin area and along the eastern seaboard (O Kelly et al 2009). In addition the Central Methadone Treatment List shows that between 1996 and 2010 the number of persons involved in methadone treatment programmes increased from 1,861 to almost 10,000. 2.2 Addressing the Drugs Problem - Treatment Works The effectiveness of drug treatment is well documented from a variety of treatment outcome studies in different countries. Drug users engaged in treatment demonstrate measurable improvements across a range of areas from health and well being to increased social functioning and reduction in criminal and anti-social behaviour. A report by the Garda Research Unit (2003) on opiate use and related criminal activity showed a decrease in detected crime attributable to drug users of 38% compared to a similar report produced in 1997. In the 2003 study 75% of respondents reported an association between receipt of treatment and a decrease in criminal activity. The vast majority of these (77%) reported doing a lot less crime. Evidence for the effectiveness of drug treatment in reducing criminal behaviour comes from a range of other sources including the British National Treatment Outcomes Research Study (NTORS, 2001) which showed that after one year involvement in treatment, rates of acquisitive crime had approximately halved and this was maintained at the 2 year and 4 to 5 year follow ups. They reported that many of the greatest reductions in criminal activity occurred amongst the most active offenders. They went on to estimate that for every extra 1 spent on treatment there is a return of more than 3 in terms of cost savings to victims and the criminal justice system. They further estimated that the savings to the exchequer increased to 9 for every 1 spent when health and social welfare costs were taken into consideration. Irish research in this area is equally positive. The Research Outcome Study in Ireland (ROSIE) explored outcomes across a range of different treatment modalities at one and three year intervals post treatment. The treatment types included methadone maintenance, detoxification and abstinence treatments and indicated that across all modalities engagement in treatment has a positive impact on individuals in terms of physical and mental health, co-reductions in drug use and criminal activity. 5

CURRENT GAPS / OUTSTANDING ISSUES 3.1 Needle Exchange Services Many drug users are unwilling or unable to give up drugs. Of the estimated 20,000 opiate users in Ireland approximately half, 10,000, are involved in treatment of some form, most of these being involved in methadone maintenance treatment. Those not involved in treatment are at significant risk of suffering drug related harm, especially in light of the patchiness of relevant service provision in Ireland. The review of harm reduction initiatives in Ireland, published by the NACD concludes that there is significant scope to expand drugs services role in delivering flexible and responsive initiatives to target shared use of drug taking paraphernalia the restricted opening hours and limited number of needle exchanges may contribute to continued sharing of equipment. The report argued that where comprehensive harm reduction programmes exist, lower rates of infection are reported suggesting that harm reduction has a role in managing and limiting some of the negative outcomes associated with sustained problem drug use (Moore et al:2004). Put simply, harm reduction works. Participation in syringe exchange programmes is linked to a decrease in HIV risks and a reduction in injecting risk behaviour (Farrell et al: 2000, Moore et al: (2004). Syringe exchanges are also effective in attracting drug users into services. Forty-eight percent (n=642) of new attendees at the Merchants Quay Ireland syringe exchange had never previously been in contact with any drugs service. Participation in the Merchants Quay Ireland needle exchange programme is associated with a reduction in needle sharing and other injecting risk behaviour. It is also associated with reduced frequency of injecting and movement away from injecting drug use (Cox & Lawless: 2000). 3.2 Access to Treatment/Waiting Lists Access to treatment services is a critical issue in terms of successfully tackling the drugs issue. Methadone treatment is currently more widely available than previously but waiting lists and access to treatment remain problematical. In parts of Dublin City waiting times for access to methadone treatment are up to six months, while outside of Dublin waiting times are even longer. In some of the large urban centres around the country waiting times are a matter of serious concern. Data from the HSE in this regard clearly demonstrates the extent of the issue with waiting times for treatment of 13 months in Westmeath/Longford, 8 months in Laois/Offaly, 7 months in Louth and 5 months in Waterford. As evidenced by the Health Research Boards report on the growth of drug use around the country it is the areas that have the longest waiting lists that are also experiencing the largest growth in problem drug use. 3.3 Detoxification Over the last number of years the emphasis in drug treatment has been towards the expansion of methadone maintenance programmes. This expansion has been highly successful with up to 10,000 drug users currently engaged in methadone therapy. However, despite these successes there are less than fifty dedicated residential detoxification beds available for drug users seeking to become drug free. 6

A variety of recent reports have indicated the need for additional detoxification and residential treatment services in Ireland. The Report of the HSE Working Group on Residential Treatment & Rehabilitation (Corrigan and O Gorman, 2007) pointed to a shortage of residential detoxification beds and estimated that an additional 104 inpatient unit beds for detoxification were required to meet current need. The Report of the Working Group on Drugs Rehabilitation (Corrigan & O Gorman: 2007) also noted that an expansion of the range of treatment options, including an increase in the number of residential detoxification beds, for recovering drug users is essential. They recommended: An immediate increase in the number of residential detoxification beds100 An increase in the number and geographical spread of residential detox places provided by the non - statutory voluntary and community sectors. The needs identified by these two reports are reflected in the new National Drugs Strategy (Dept. of Community Rural and Gaeltacht Affairs 2009), which identifies the lack of detoxification facilities as a key issue requiring urgent attention. 3.4 Rehabilitation The need for additional residential rehabilitation treatment services have been highlighted in a number of recent reports. The Report of the HSE Working Group on Residential Treatment & Rehabilitation (Corrigan and O Gorman, 2007) highlighted the shortage of residential rehabilitation beds to meet current need. This report calculated that an additional 252.5 residential rehabilitation beds and 141 stepdown/halfway house beds were required. The report emphasised that the transition from detoxification from alcohol or any other drug into rehabilitation should be seamless so as to avoid waiting lists and delays which can result in client relapse. Its authors noted that in the case of relapse to opiate use, there is a major risk of fatal overdoses occurring at this time (Corrigan and O Gorman: 2007). 3.5 Rehabilitation of Offenders Act (ROA) Currently Ireland is one of the few European jurisdictions where there is no facility for criminal convictions to become spent. Many problematic drug users over the course of their drug use come into contact with the criminal justice system and acquire criminal convictions, either directly or indirectly related to their drug use. The absence of such a facility runs contrary to the spirit of the National Drug Strategy and specifically the new rehabilitation pillar, and acts as a barrier in terms of integrating former problem drug users into mainstream society We are aware that there was a Private Members Bill on this issue and this was due to come before the houses of the Oireachtas. However, since the dissolution of the last Dail we are unsure of the progress and status of this Bill. Merchants Quay Ireland welcomes such an endeavour and has long advocated for such provision. However, there has been very little meaningful consultation as to the scope and application of 7

such an instrument. Without engagement with all the relevant stakeholders the opportunity to address the issue in a thorough and effective manner may have been lost. 3.6 Use of Other Drugs At Merchants Quay Ireland we have seen an increase in numbers of clients presenting at our services with problems with prescribed medication especially anti depressants. We are concerned that there may be over prescription of these medications and doctors need to be aware of the potential to misuse such drugs. Poly drug use appears to be an ever growing trend among drug users. In a study undertaken by MQI on cocaine use for the NACD all respondents (n=100) reported being poly drug users. Although heroin was the most common primary drug for this group (59%) three-quarters of the sample were using methadone, this was prescribed for most 82% ( n=61), two thirds reported using benzodiazepines (65%) and over half (52%) reported alcohol use. (NACD: 2003). RECOMMENDATIONS 4.1 Recommendations Needle exchange services should be expanded to cover all areas affected by problem drug use. Waiting lists for access to drug treatment should be reduced to bring waiting time down to a maximum of four weeks. An immediate increase in the number of dedicated detoxification beds available to those seeking to become drug free. An increase in the number and geographical spread of dedicated detoxification beds. An immediate increase in the number of dedicated rehabilitation places Develop a Rehabilitation of Offenders Act. Develop measures to ensure increased awareness of problematic use of prescription drugs and poly-drug use. 8

CONCLUSION 5.1 Conclusion We hope that this focussed but succinct submission demonstrates two points: 1. That drug treatment unequivocally provides results i.e. it works in practice. 2. That if it is to be really effective, it needs to be underpinned by a range of diverse treatment options from crisis intervention initiatives to detoxification and rehabilitation services. We are mindful of the expenditure constraints placed by the recession and the current economic climate. Notwithstanding, we strongly assert that spending in drug treatment should not slip down the Government priority list thereby regressing the real advances made to date in the sector. Investment now will mitigate against future cost, not only in an economic sense but in terms of the health and well-being of drug users, their families, communities and society as a whole. 9

REFERENCES Corrigan and O Gorman (2007) The Report of the HSE Working Group on Residential Treatment and Rehabilitation. Health Service Executive: Dublin Cox, G. & Lawless, M. (2000) Making Contact An evaluation of a Syringe Exchange Service.. Merchants Quay Ireland. Cox, G Dr, et al (2006) ROSIE Findings 1: Summary of 1 Year Outcomes. National Advisory Committee on Drugs. The Stationary Office. Dublin Farrell. M., Gerada, C., & Marsden, J. (2000) External Review of Drug Services for the Eastern Health Board:. National Addiction Centre, Institute of Psychiatry: London Furey, M. and Browne C. (2003) Opiate use and related criminal activity in the Republic of Ireland 2000 & 2001. Garda Research Unit Health Research Board (2004) Trends in treated problem opiate use in the seven health board areas outside the Eastern Regional Health Authority, 1998 to 2002. Occasional. Paper 13. Health Research Board: Dublin Kelly, A., Teljeur, C & Carvalho, M.(2009) Prevalence of Opiate Use in Ireland 2006. A 3-Source Capture Recapture Study: A Report to the National Advisory Committee on Drugs. National Advisory Committee on Drugs. Dublin Moore, G. et al (2004) A Review of Harm Reduction Approaches in Ireland and Evidence from the International Literature. National Advisory Committee on Drugs. National Advisory Committee On Drugs. (2003) An Overview of Cocaine Use in Ireland. The Stationary Office. Dublin. National Drugs Strategy (Interim) 2009 2016. (2009) Department of Community, Rural & Gaeltacht Affairs: The Stationary Office: Dublin National Treatment Outcome Research Study (2001) The Home Office: London 10