Professor Gerard Bury:

I thank the members for the questions. I will address a couple of them. Mr. Duffin has dealt appropriately with a number of them.

To deal with some practical matters, on the issue of naloxone, Senator Ruane raised the possibility of an intranasal delivery device being available. We have been using intranasal naloxone here for the past three years. It is restricted to paramedic, advanced paramedic and medical practitioner use. We have been using a number of formulations of injecting naloxone and saved countless lives through the availability of those drugs for use by paramedics and advanced paramedics.

The Department introduced legislation last year on rescue drugs, which restricts lay access to naloxone to a single product that is unavailable. It is not available on the general medical services, GMS, scheme. I thought it might be a bit bulky to bring here and that I might be stopped on the way in so I took a photograph of 2 grams of naloxone we purchased a year ago on the expectation of the implementation of the rescue drugs Bill, which was going very well until the detailed regulation made it clear that a single product was to be licensed which is not used by any clinical outfit in this country. The problem is that the Health Products Regulatory Authority, HPRA, FECC and the Pharmaceutical Society of Ireland have access only to a single product, which is effective but unavailable. If the regulation were changed to allow access to the pre-filled syringe product currently used by the emergency services, and if that were made available for GMS prescription, we could very quickly move towards a situation where overdose prevention, education and treatment might become a reality. We will save some lives. It is in itself just a desperate measure to help with those at the chaotic end of the scale but it will indicate the willingness of society generally to take an extra step on behalf of those people at the margins.

The second point is about the pilot, and I want to follow the point about people on the margins. What are the outcome measures for that pilot? We use the term all the time. It is clear sometimes what we mean by success and sometimes it is not. If the measure of success to be used for a pilot site is that the streets are cleaner, tidier or possess less obvious drug use, that is not much of a pilot. The purpose of the pilot must be to improve the lives and save some lives for this very large number of people who are currently not just marginalised, but forgotten about. The measure of success has to be how better off are these individual drug users and their families. That is not an easy measure to come up with and it comes somewhat to the issue raised about registration and data collection, but it is not beyond the bounds of man to identify ways to collect good quality data and identify outcome and process measures that reflect the value of the people we are trying to serve, not the cleanliness of the streets.

The issue of access to general practice services is a thorny one. I cannot speak on behalf of my colleagues or of my profession but I can offer members some comments as an inner city general practitioner, GP, for the past 30 years. The difficulty is that this is not an evenly distributed problem for society. Opiate dependence is a reflection of societal difficulties. It has been medicalised endlessly over the past 30 years and is now regarded as a health problem - I give the health committee as an example. Many of our problems with drug dependency arise from deprivation, poor education, hopelessness, awful homes and a chronic tolerance and dependence. Those problems are characterised in certain key areas and those are the areas, particularly of this city, which are vastly under-served by medical services and by general practice in particular. It is not simply a matter of putting into a contract an obligation for each individual GP to take on one, two or three individuals. That is a hopeless approach. It is a matter, at a broader level, of ensuring that those societies are served by the sorts of services that address their needs, some of which are unique to the communities that have been devastated by drug dependency over the past 30 years.

As part of his MD my colleague, Professor Fergus O'Kelly, who was one of the leaders in Dolphin's Barn in the late 1970s and early 1980s in bringing this problem to the attention of the health services, followed a cohort of his patients from 1981 through to the late 1980s. He stopped in the late 1980s because most were dead. There were very few left of the original 120 people he had identified in his practice in 1981 who were injecting drugs. An entire layer of that community was stripped out as if by war.

This is a problem of focused need which needs innovative and effective action. I completely agree that we as GPs need to come up to the plate and take on our responsibilities here. Most have done that. In the areas affected by these problems, it is extraordinary to see the level of commitment of my colleagues and the work they do but training, licensing and support services are essential.

I will conclude in a second but to take the point about Suboxone because it relates to this, the issue about general practice and services to address very damaged communities is not about more therapeutics. Drugs are not the answer to this issue. The evidence on Suboxone is mixed. I do not believe it offers any greater advantages than good quality methadone delivery but the potential to offer opiate overdose education and prevention strategies might give us some extra saving from the current opiate substitution therapy, OST, system. The point I want to make is that if it is not simply about the class of drug we use for OST, rather it is about the psycho-social supports, the counselling, the reintegration to society and the addressing of those societal issues that have led to the drug problems in the first place. Clearly, that is a big ask but, at the end of the day, the evidence is that if we come back to whether people should be on methadone for the rest of their lives, and we would hope not, we have no well-proven method to remove people from that system safely and keep them abstinent for the rest of their lives. We know that most of the systems in use currently have success rates of not much better than 30% and the ones that work best address not just the drugs and therapeutics needs of these patients, but their psycho-social, personal development, psychological and other needs as well. Those are the services I would appeal to the members to consider in future rounds of their reflection on this problem to add to the available services we currently tap into.