Out on a limb heroin users beyond the pale/eastern heal

There are about 60 GPs trained in the HSE clinic system (GPs Specialising in Substance Abuse), but the ICGP and the Methadone Implementation Committee will not recognise their expertise, so they cannot practise as Level 2 GPs in the community.

Prof Farrells report made some important recommendations that could cilitate more rational use of resources and cilitate access to treatment for opiate users, which was one of the prime aims of the review.

In areas such as the South East, for example, where there are reportedly hundreds of untreated heroin users, money designated for the drugs problem has resulted in only a handful of treatment places. There are waiting lists so long that addicts report they dont even bother to register.

In areas such as the South East there are waiting lists so long that addicts dont even bother to register

Born in Galway, Michael Farrell is recognised internationally as an expert in the field of addiction. He has worked as POut on a limb heroin users beyond the pale/eastern healrofessor of Addiction Psychiatry at Kings College London and Director of Postgraduate Medical Education, South London and Maudsley Trust and has published extensively on the topic.

Other areas of the country, from Kerry to Donegal, are in a similar situation.

It is important to remember that HIV has not gone away. In areas of Eastern Europe with similar drug-using populations and no services, HIV rates are alarmingly high. There is also anecdotal evidence recently of increased acquisitive crime related to drug use in areas outside Dublin.

Existing Level 2 GPs who are willing to provide services in areas without access to treatment are not able to do so due to caps on numbers and limitations on practice locations maintained by these same groups.

There is no level 2 GP on the East Coast practising south of Bray. Waterford has a small clinic (about 25 places). There are no treatment cilities in Wexford, New Ross or Gorey, where there are significant numbers of heroin users.

Removal of a cap of numbers on Level 1 GPs and an increase in numbers for Level 2 GPs from 35 to 50. These changes will instantly create a large number of potential treatment places at a fraction of the cost and with none of the difficulties of opening many new methadone clinics in rural and small-town locations.

Level 1-trained GPs cannot initiate treatment and so cannot affect access to treatment.

Professor Michael Farrells recent review of the methadone treatment protocol (The Introduction of the Opioid Treatment Protocol, HSE,  December 20, 2010) came at a crucial time in the development of drug treatment services in Ireland.

Lessons need to be learned from that era.

GPs in areas of Dublin first affected by heroin use had app-ealed for resources to treat their young patients who were dying and becoming seriously sick. Very little was done until the mid-1980s when HIV testing started in Ireland and more than half the positive tests were reported to be from IV drug users. There was also a serious crime problem, fuelled apparently by the drug problem.

Detoxification alone is not a proper treatment. Intensive ongoing psychosocial supports are needed, as relapse rates run about 90 per cent and post-detox death rates due to overdose are high. There must be rapid re-access to treatment on relapse.

The worrying aspect of this is that they have all been recommended before by local experts (of a lower stature than Prof Farrell, perhaps) but have been blocked by groups and individuals with views on treatment based more on moral values than evidence.

In most other areas of the country, however, the story is very different, with one prominent drug treatment expert describing the situation regarding heroin use and resulting personal and public health and criminal justice problems outside the capital as spiralling out of control.

There is often local resistance to proven treatment modalities, such as methadone maintenance, and resources are often directed to ineffective counselling and detox programmes.

There are, of course, significant proven benefits of treatment to the individual drug user, such as improved general health, social and mily relationships and the possibility of engaging in normal activities like work or study.

The situation regarding access to drug treatment in Ireland today is very serious. Services in the greater Dublin area, on the whole, are coping with demand, having been developed in times of plenty.

We are now entering a period in this country very similar to the 1980s with a severe economic downturn, mass unemployment (especially among the youth), emigration and an untreated heroin epidemic in large parts of the country.

The harm reduction approach introduced by the then Eastern Health Board Drugs/AIDS service   methadone maintenance treatment, needle exchange services, hepatitis vaccination and treatment has been very successful in limiting the spread of viral diseases to date. The wave of acquisitive crime muggings, burglaries and robberies from businesses also diminished dramatically.

The ICGP methadone training programme has been very successful in training Level 1 GPs; however, attempts to train Level 2 GPs have iled to produce more than a handful over the past 10 years.

IV drug users

Access to buprenorphine by doctors treating opiate users. Although this medication has been licensed in Ireland for a number of years, access has been blocked. A much more expensive combination buprenorphine/ naloxone combination has been introduced in a small pilot programme. Buprenorphine has been used successfully and safely in Europe, the US and Australia for many years.

The ilure of the HSE and the Health Boards before it to provide access to effective treatment for drug users in areas of the country where there is a significant problem cannot be blamed entirely on these organisations.

Significantly reduce the frequency of urine testing; eliminate supervision of patients giving urine samples unless there is a legal requirement; introduce oral fluid testing. These measures have the potential to save millions of euro, which can be redirected to providing treatment places. There is no evidence to support the level of testing that has been in place in treatment services and demeaning practices such as supervision (both for patients and staff) do nothing to foster healthy doctor-pat-ient relationships.

Out on a limb heroin users beyond the pale/eastern heal,Dr Cathal OSullivan examines the background to the first external review of the methadone protocol in Ireland, the Opoid Treatment Protocol, and highlights some of its more important recommendations.

After alcohol, heroin is the drug that causes the most severe harm in our society. The focus of drug treatment services set up in the early 1990s (primarily in Dublin) was the treatment of heroin users. It was recognised at that time that heroin use was posing a serious threat to public health and to social stability.  Action was taken (uncharacteristically)  in a remarkably swift and efficient manner to deal with the heroin problem, not from any great desire to provide healthcare to this marginalised section of our society, but more to protect the normal population from the feared impending AIDS epidemic.

Change tends to happen slowly. However, we are living in interesting times. It will be interesting indeed to see if the Farrell Report has come at a time when practicality and pragmatism will overrule traditional vested interests in our drug treatment services.

The recommendations I have mentioned above could be easily and quickly implemented and will save money.

However, with the spread of heroin use to other areas of Ireland in recent years, which have little or no seastern health systemuch services, the potential for spread of viral diseases in the community and increased social disorder is high.

Prof Farrells report contains many other recommendations regarding the organisation, governance and development of drug treatment services, which, while very sensible, in the current economic climate must be seen as aspirational.

Detoxification alone is not a proper treatment. Intensive ongoing psychosocial supports are needed, as relapse rates run about 90 per cent and post-detox death rates due to overdose are high

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