Professor Gerard Bury:

I thank the Chairman and the members of the joint committee for the opportunity to speak this afternoon. I am a GP and I work in the Dolphin's Barn area of Dublin. As I have been working in the south inner city since 1984, I have some experience of the conditions that have led to the serious drug problems that have been experienced in that area over the past three decades. I am also a professor of general practice at the UCD School of Medicine. One of my functions in that role is as director of the centre for emergency medical science, which is responsible for training paramedics, advanced paramedics and GPs in the care of pre-hospital emergencies. The centre is the only body in the State that is recognised as a trainer of advanced paramedics for all the statutory emergency medical services.

It is also worth mentioning that along with other doctors in my unit, I work as a volunteer to support the emergency medical services in the greater Dublin area. Approximately 100 GPs throughout the country provide similar services on a voluntary basis in extreme emergencies. My experience is of providing that service largely in the north inner city. Over the last year and a half or so, I have been providing care in cases of cardiac arrest. The three backgrounds I have mentioned give me some basis on which to comment on what is proposed.

Perhaps I will repeat the context for this proposal. Approximately 10,000 people in this country currently receive treatment for opiate dependence from the State on an annual basis. Opiate substitution therapy, using methadone, was formalised in 1998 and is delivered by drug treatment centres and accredited GPs throughout the country. However, injecting drug use, chaotic lifestyles, overdoses and drug-related deaths remain common and continue to devastate families in Dublin and elsewhere. I welcome the committee's interest in this matter because it highlights a health problem for Irish society which sometimes attracts little interest or urgency.

The first issue I want to highlight is the legislative proposal to provide for supervised injecting facilities. My colleagues have spoken very well about the mounting evidence that injecting rooms are an effective harm-reduction measure for certain groups of injecting drug users. The proposed initiative should certainly be supported in so far as it assists those with chaotic or uncontrolled drug use. While I am very happy that the Misuse of Drugs (Supervised Injecting Facilities) Bill 2016 is to be supported wholeheartedly by this committee and by those who want to see lives saved and improved, I am concerned that it may have a more limited effect on some of the more strategic issues relating to our drug treatment services. I will refer briefly to some of those issues.

Opiate substitution therapy has grown to the point where it has almost become an end in itself within our health services. Few services or incentives exist to help doctors, therapists or patients to reduce and stop methadone use, or to be of assistance in the recovery phase thereafter. I have no wish to undermine the key and absolutely role played by opiate substitution therapy. I was involved in the initiation of opiate substitution therapy and the introduction of methadone in the mid-1990s. It has saved countless lives and improved others. I emphasise that opiate substitution therapy should not be a de factolife sentence. It seems that research and service development to achieve the goal of offering discontinuation to those who are in a position to take up that offer should be explored and prioritised within the research and development plan of our drug treatment services.

Opiate overdose and access to naloxone is a further issue. Naloxone is a rescue drug which can reverse the respiratory depression caused by opiates. It must be given within minutes of the overdose. In Ireland, more people die from opiate overdose each year than are killed in road accidents. Some 387 poisoning deaths occurred in 2013, of which 203 involved opiates and 93 involved methadone. Access to naloxone is inappropriately restricted in Ireland. Urgent action is needed to allow GMS access to the drug for prescription to patients. A second possibility is co-prescription with methadone or other opiates.

A third is the prescription of the drug to the family or friends of those who are on methadone. We have had some legislative change in recent months to allow rescue drugs to be introduced but the limitations on those rescue drugs, in particular naloxone, are inappropriate and inhibit its effect.

On the investigation of opiate overdose deaths, any patient who receives opiate substitution therapy and dies from an overdose has died in the care of the State's mental health services. Each of those deaths should be regarded as a serious adverse event and investigated in precisely the same manner as, for example, a suicide which occurs in a patient attending HSE psychiatry services. That does not currently occur.

The purpose is, of course, not in any way to create a culture of discipline, blame or attribution. However, in each of these awful events there is learning and the possibility for improvements in carers and services. The opportunity to have a root cause analysis of those events and explore the learning that is possible within them is something we, as a caring community, would benefit from.

I want to take this opportunity to thank those who care for those who are in difficulty because they are dependent on drugs. The NGOs like those represented by my colleagues have done an outstanding job and continue to do so. It is extraordinary to see the circumstances in which they work and the care and quality of that care.

I also thank my colleagues in the emergency medical services. Their work is also extraordinary, and is often without thanks. I thank my colleagues within mental health services and general practice who work within drug treatment systems. They also have long, arduous and tough jobs. They deserve to be acknowledged for the work they do. I again thank the Chairman for the opportunity to put some points to the committee.