Oireachtas Joint and Select Committees
Thursday, 26 March 2015
Joint Oireachtas Committee on Health and Children
Drug Addiction and Recovery Models: Discussion
I remind members, delegates and those in the Visitors Gallery that all mobile phones should be switched off or left in airplane mode for the duration of the meeting because they interfere with the broadcasting of proceedings and cause unnecessary disturbance on staff members' headsets. We had an episode last Tuesday evening with some type of mobile device.
At this meeting, the first of several, we will examine drug addiction and recovery models. I welcome Professor Joe Barry, chair of population health medicine, Trinity College Dublin; Mr. Tom O'Brien, addiction services manager, Health Service Executive; and from Soilse Mr. Gerry McAleenan, head of services, and Ms Sonya Dillon, project worker.
By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the joint committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.
I invite Mr. McAleenan to make his opening statement.
Mr. Gerry McAleenan:
I thank the joint committee for giving us the opportunity of appearing before it to discuss the contents of a report entitled, Addiction Recovery: A Contagious Paradigm, which has been circulated. I will start by giving an overview of Soilse, the addiction rehabilitation service, from which the report came. I will then go through the main issues related to the report in a question and answer format.
Soilse is the HSE's daytime drug rehabilitation project in Dublin’s north inner city. It was established in 1992 and works with people who are either preparing to detox or who have completed a residential drug treatment programme and are in the early stages of recovery. Our service users are former heroin addicts.
What is the status of drug use in Ireland today? In the 1970s, 1980s and 1990s the drug abuse problem was mainly opiate, primarily heroin, addiction. Today people are using not just heroin but also benzodiazepines, alcohol and other drugs. This is known as poly-drug abuse. Since the 1970s the response has been to treat opiate addiction by substituting methadone for heroin. Known as the public health model, it seeks to reduce harm to society by reducing the need to commit crime to get heroin and eliminating the use of heroin and the sharing of needles. Prescribing methadone and needles exchange reduce the health risks associated with heroin addiction. About 10,000 people are in methadone treatment, one third for more than a decade. Their struggles are captured in the case studies in Addiction Recovery: A Contagious Paradigm and the characteristics of the four case studies are very telling. All have family dysfunction, were early users of drugs and early school leavers, grew up in chaos, have been on methadone and benzodiazepines programmes, have been associated with prison or charges, have suffered homelessness, health problems, suicides and death within their immediate circumstances.
What can recovery offer? In Ireland and internationally there is an emerging focus on recovery from addiction. This view of recovery sees services being re-framed around service users. Unlike the public health model, a recovery model puts service users at the centre of treatment and rehabilitation responses and looks to enhance their quality of life by involving them fully in their own care. This means reorienting treatment and rehabilitation services towards a recovery paradigm, recognising that service users' voices are important and enabling them to direct their own goals and thus change and re-frame their lives. Essentially, it is a service user, service-led response.
What evidence supports this approach? The concept of recovery was first introduced in the addiction research literature in 1999 with the work of Granfield and Cloud. They showed how 46 individuals had been able to overcome their addiction independently of services primarily because they had had what Granfield and Cloud called "recovery capital"; in other words, pre-existing jobs, qualifications, income, family support, social networks and a home. Subsequently, Cloud and Granfield published their theory of recovery. It comprises four elements: social capital – relationships, supports and groups to which we belong; physical capital – property and income; human capital – education and skills, positive health and aspirations; and cultural capital – values, beliefs and attitudes. Focusing on these assets helps a person to build recovery capital. This approach has been taken in England, Wales, Scotland and further afield as the main organising construct for addiction services. The approach in Scotland is that recovery should be the explicit aim of all services providing treatment and rehabilitation for those with problem drug use and the service delivery principle is that recovery should be the focus of care. Assessment and recovery plans should address the totality of people's lives.
Does Ireland want to move towards a recovery framework? Addiction Recovery: A Contagious Paradigm sets out the case in Ireland for a move towards a recovery framework to deliver addiction services. Over a decade ago the mid-term review of the drug strategy in 2005 showed that stakeholders felt service users should not be kept on methadone indefinitely but assisted in "moving on"’ towards recovery and social integration. The report of the working group on rehabilitation that emerged from the mid-term review elaborated on this and signposted the key elements of social integration: housing, work and education. These are the key indicators from the European Monitoring Centre for Drugs and Drug Abuse. It stated the overall aim of services should be "to maximise the quality of life, re-engagement, independent living and employability of the recovering problem drug user in line with their aspirations".
In 2011 Martin Keane conducted research in Soilse and showed how an adult learning approach that fused education and recovery could help service users to develop recovery capital, progress in education into college and successfully move away from the drug culture. The HSE Dublin north addiction service review in 2013 recommended this recovery focused approach and the addiction services in north Dublin are putting structures in place to enable recovery. In the review recovery was defined as "a person-centred journey enabling people to get a sense of control over their own problems, the services they receive and their lives and providing opportunities to participate in wider society".
The national drug rehabilitation implementation committee's evaluation in 2013 which was authored by Professor Barry also reviewed the mechanisms which would underpin a recovery approach and found broad support for them. Therefore, at both a practice and policy level, momentum has been building in the past decade towards a recovery response in Ireland. The HSE's 2015 primary care division operation plan states each service user should have a key worker and care plan, that service users should be transferred from HSE clinics to GP surgeries and that regular client satisfaction surveys should be carried out. Again, it puts the service user at the centre of the process.
Addiction Recovery: A Contagious Paradigm describes in detail the principles of recovery which give shape to the emerging framework and also supports each of the principles with a substantial amount of research and literature. The principles are the key drivers of many of the responses in the countries I have listed. There are 12 principles, the first of which is that there are many pathways to recovery. Again, we speak in the document about natural recovery, about which Sheedy and Whitter spoke. Granfield and Cloud talk about recovery capital. Our own work in Soilse is about a continuum of care. There are other forms of recovery, for example, fellowship recovery and Christian enlightenment recovery.
The second principle is that recovery is self-directed and empowering. The paradigm shift means that the service user is the agent of his or her own change and fully involved with the goals and targets being addressed. When I thought about coming here today, I remembered how during my early days working in this area a man had broken down in a group and began to cry. I asked him why he was crying and he said it was the first time in 15 years that he had been asked his opinion. Very often people are treadmilled through processes and not actually engaged at their centre.
The third principle is that recovery involves a personal recognition of the need for change and transformation. One of the big goals people will have is to move from being in services or treatment to abstinence. Again, McKeganey said 56% of service users in Scotland saw this as the type of transformation they wanted. The third principle is that recovery is holistic. It is not one-dimensional treatment but concerns broader quality of life issues. Again, a process of life change involves the physical, social, emotional, spiritual and mental health needs of the individual. That is what the process of recovery should work towards.
The fourth principle is that recovery has cultural dimensions. There will be drug problems in other groupings such as Travellers, the LGBT community and new communities and cultural dimensions that need to be addressed. Our own people face challenges when they leave the safety and security of our services. In his research Keane looked at how these cultural dimensions changed the person.
The fifth principle is that recovery occurs in a continuum of improved health and well-being. De Maeyer talks about quality of life and states improved health and well-being means new relationships, being independent, having work and feeling good - having a meaningful life. These are basic, simple things, but to a recovering drug user, they are imperative.
The sixth principle is that recovery emerges from hope and gratitude. People in recovery become models of success. In communities where there is little positive at which to look in terms of the drugs problem people who become drug free, get their lives back together, find work, get back with their families and give back in terms of voluntary activity are seen as models of success and inspire others.
The seventh principle is that recovery involves a process of healing and self-redefinition. Owing to the needs I mentioned and the characteristics of addiction, multiple recoveries are needed and lead to complete identity transformation.
The eighth principle is that recovery involves addressing discrimination and transcending shame and stigma. Drug use discredits identity. Therefore, there must a complete shift in social functioning which is facilitated by the pursuit of mainstream activities.
The ninth principle is that recovery is supported by peers and allies.
When people get into recovery, they rekindle old relationships and form new ones, find a sponsor and receive family and community support. Again, there is a massive social support network available. People who interact with the services and work towards recovery will seek strength from others in the services and the groups with which they are involved. Recovery involves rejoining and rebuilding life in the community. On page 35 of the report Buchanan, in relation to the wall of exclusion, is quoted. The vast majority of service responses work below what is termed the line of control into the area of chaos. This is where treatment is focused in the main.
There is a disparity in terms of the resources devoted and attention paid to support and recovery. One of the contentions is that the paradigm should shift to prioritise recovery. Recovery is a reality. The document was launched in the Mansion House in July, at which time I recall Mannix Flynn saying there was such a thing as "recovered". It is so simple a word, but it is so real and telling. Through my work over many years I have met hundreds of people who have recovered. However, given the phenomenal level of stigma attached to drug addiction, they are unwilling to appear before the committee or on camera. When we asked a few people how they felt about appearing before the committee, they said they could not do so because of their families, children and so on. In terms of recovery being a reality, Sheedy and Whitter reckon about 58% of people can achieve recovery. I know from research undertaken by Soilse that the outcomes for those who recover and regain a holistic quality of life when drug free are significant. These principles were put together after 20 years of research and widespread consultation. They are well grounded and scientific.
I will now move to how recovery services operate in other countries. The United Kingdom, including Wales and Scotland, the United States and Australia have recovery academies which are groups of people, including researchers, service users, families and community support workers, who come together to research and advocate on behalf of those in recovery. Recovery champions are people who are positive role models in the community who are in recovery, icons for the possibility of recovery and drivers of change. Recovery coaches are people who give advice and support on addiction and life issues. This is a major plank of the support provided for people in other countries getting into recovery. Fellowships such as Narcotics Anonymous, Alcoholics Anonymous and Gamblers Anonymous are operational countrywide. In other countries events such as International Recovery Month are celebrated. In September last year a parade was held in Manchester to celebrate recovery. This shows that other jurisdictions have a better infrastructure in place and that the paradigm has moved more considerably towards this. Recovery infrastructure such as cafés and houses is common in many of the main towns in the United Kingdom where more than £1 million has been provided for the development of a new facility in Birmingham called "Recovery Central". This facility is due to open this year and will include a one-stop-shop for recovery information and services, including work experience, volunteering, employment opportunities, community-based social enterprises, furniture restoration, bike repairs, car maintenance, property maintenance, an art and design studio, a recording studio and a drama studio. It is a creative holistic response. As I said, the facility will be called "Recovery Central", an icon that will send the message from a high street location that recovery is important and possible.
I will focus on how all of the aforementioned relates to Ireland. Soilse is an example of services implementing a recovery response. We believe people have fantastic potential and will get their lives back together and achieve things that they would never have dreamed of because their expectations had been reduced by the fact that they had been in treatment for so long. Soilse is part of the HSE addiction services' continuum of care. We provide clinical pathways, which means that the service can stabilise people and prepare them for detoxification in an in-house residential detoxification unit, Cuan Dara. Drug free residential treatment follows in Keltoi. This is followed by a drug free day time programme in the Soilse facility in the north inner city. We are in partnership with the VEC and thus have a balance of therapeutic and educational inputs. The service has been vocationally designed and developed. We are very clear on the outcomes we want to achieve. We want people to abstain from drugs and alcohol; to have support structures around them in terms of counselling, after care, meetings and sponsors and to become involved in day time or education programmes. That is a recovery package.
Soilse is also involved in an innovative European Union lifelong learning project called RECOVEU. It involves five countries - Ireland, England, Cyprus, Romania and Italy. Following a review of policy and practice in these countries it became evident that there was a dearth of channels and opportunities for people from an addiction background who wished to move to the mainstream, be it in the area of work or education. A leaflet setting out where we are at in that regard has been circulated. We are about half way through the project and the real work begins in the next couple of months. What we are trying to do is design facilitation packs and learning modules that will facilitate people in their journey to recovery and into college.
Soilse uses recovery coaches who are trained by the Finglas addiction support team and Dublin City University. We have eight recovery coaches who help people with resourcing, advocacy and lifestyle issues. Soilse also supports International Recovery Month and in this regard, held a number of activities in Dublin last September which, unfortunately, were not widely covered by the media. We held three large events, including a conference in the Ashling Hotel, a health and fitness event in the Phoenix Park which was attended by more than 200 people and various social activities. A lot happened during recovery month. We need to focus on making people aware that there is a recovery community and movement and getting them to buy into it.
Soilse has been consistently involved in research, including, as I mentioned, the Keane research and has also contributed to research by the Northern Area Addiction Service. The document made available to members is the result of two years' work.
Many service users and service providers see recovery as a viable option. I engage consistently with service users, many of whom have fantastic ideas. In terms of the outcomes in the four case studies, one of those involved has travelled the world, while another spent 15 Christmases in prison at great cost to the State. He is now in recovery and cannot believe that when his neighbours go on holidays, they leave the keys to their houses with him. There are many good anecdotes that support this transformation. Recovery offers hope and a vision for those caught in services long term. The model will challenge fatalism and stigma. As I said, stigma is a huge issue. Recovery also contributes to building inclusive communities and options for those who want to change.
The document before the committee was triggered by a symposium which brought together more than 100 people in recovery to talk not about war stories or the desperation and depression associated with drugs but about their futures and what they would like to see happen. The solutions and ideas proposed are embodied in our recommendations. They include the use of recovery champions, coaching, existing community assets and a reconfiguration of some services to ensure they will be more holistic and outcome focused. The emphasis is on solutions. The desired outcome of today's meeting and as a result of the document is that recovery will become a central plank of the drugs strategy review which is due for completion next year. As I said, the report reflects stakeholders' views and their principles, case studies, workshops and literature on recovery.
I will be happy to answer questions members may have.
Professor Joe Barry:
My presentation will be shorter. It was important for the joint committee to hear about the reality of addiction from Mr. McAleenan. It sounds simple, but it is hard work that requires dedication across the board.
I thank the committee for giving me the opportunity to speak to it on this topic. I have been involved in the drugs service since the early 1990s. Mr. McAleenan and I are now almost dinosaurs in the service.
In the summer of 2012 I attended the 20th anniversary celebration of Soilse, the symposium that Mr. Gerry McAleenan mentioned. It was a moving and very powerful experience, involving a mix of service users, service providers and community activists as well as those with an interest in the country’s response to our heroin epidemic mostly, although this goes beyond heroin. It was very well attended and inspiring.
Shortly afterwards I was asked by Mr. McAleenan whether I would be interested in contributing to a document with the aim of promoting recovery among drug users in Ireland. I was very happy to do so and we were joined by Mr. Martin Keane from the Health Research Board, who has prepared much of the literature on this, including much of the international literature Mr. McAleenan quoted. Over the course of the following year we worked on the document and spoke to four of the people who had presented their stories at the symposium. We asked if they would be happy to have their stories published in the report. Personal stories make more of an impact than statistics. Mr. McAleenan has alluded to the stigma. People were very brave in standing up in public and talking about their problems and allowing those problems to be in the document before the committee today.
The document was launched in the Mansion House and we had a couple of meetings with the then Minister of State with responsibility for the national drugs strategy, Deputy Alex White. We have since been in contact with Department of Health officials and are hoping to arrange a meeting with the Minister, Deputy Leo Varadkar, subsequent to our attendance here today.
Mr. McAleenan has given the details of the many benefits and we can come back to them during the discussion. However, it will not happen by just wishing it to happen. We prepared the document to try to turn what everybody believes is a good idea into practice. It is a reorientation, obviously. The public health model is still part of the strategy within the HSE, but there is much more scope for recovery if people are given the supports Mr. McAleenan mentioned. There are 10,000 people on methadone and more people can recover if they are given the supports. They are very basic supports; they are not high-flying or technology based. Our document outlines a series of recommendations which we can come back to. We are very keen that members of the committee are aware of the challenges and how we can make recovery a reality.
The document is essentially based on hope. Many people claim that people addicted to opiates have no hope, but that is not true. Of course, opiate addiction causes many problems and kills a number of people in Ireland. About one person dies from an overdose of drugs in Ireland every day. People die, but people can also recover. People want to take control of their lives and many drug users are parents who want to do the best for their children. The recovery model would give them the skills and capacity for parenthood as well as everything else. For any of us who are parents, parenthood is probably the most important activity of our lives.
People will respond positively if offered supports. These supports include access to second-chance education, or maybe even first-chance education for people who have not had it, and literacy training. Obviously the economic recession has not helped drug users and with us, one hopes, coming out of that, there is potential for employment and self-esteem to be restored.
Many drug users are also caught up in the current homelessness crisis. We talk about people who have been squeezed by the recession. Most of the people who are addicted to opiates were squeezed well before 2007. They have had a lifetime of being squeezed and there is a lot to be made up. The community of Dublin's north inner city has been disproportionately affected, but there is enthusiasm.
As Mr. McAleenan mentioned, I was involved in an evaluation of the HSE's recovery model document, The National Drug Rehabilitation Framework. Many of the staff in the drugs services are enthusiastic and are keen to be part of this recovery, but it needs structure and support. This does not apply just to north inner city Dublin. Addiction affects every community in the country, particularly when alcohol is factored in. The principles of recovery apply to alcohol as well as to other substances. There is not as big a difference between alcohol and other drugs as people think. There is polydrug use and benzodiazepines. There has been an explosion in the prescribing of benzodiazepines in this country and it is an increasing cause of death. It is a huge problem and is costing the State a fortune. There are ways of finding money to support things like recovery.
We point out in the document that much of what we are recommending has been the policy of the Department of Health and the national drugs strategy for about ten years. Some excellent documents promoting a way of doing things have been published. We have a bit of a difficulty in Ireland; we are better at writing documents than implementing them. This is about the reality of implementation. The devil is always in the detail. We have the detail here and Mr. McAleenan has given a flavour of it. We hope the members of the committee will take some time to read it in more detail because obviously today is, we hope, the start of a process to push for this to be done in a better way in the future.
The current national drugs strategy is due to end in 2016 and we are aware that discussions are taking place with regard to its successor. We want these principles to become mainstreamed in a more effective way in the new drugs strategy. That is our timescale. We are only three people and Mr. Tom O'Brien from the HSE is very supportive. Obviously Ms Sonia Dillon and all the staff in Soilse work on this every day. They have enormous expertise. We need to disseminate that in other parts of the country. Mr. McAleenan can outline the success stories. There is capacity for more success if we re-orientate. It would be a terrible mistake not to grant recovery a much higher profile in the new strategy.
We urge the committee to support recovery across all Departments. It is not just a health issue. It also affects education and I mentioned homelessness, so it is a housing issue. There is a big problem with a shortage of accommodation. Drug users in recovery are having to be placed in wet hostels and hostels where people are taking drugs. Obviously the public consciousness about housing problems is about people stuck in mortgage arrears, etc. However, there is a continuing housing and accommodation issue among the drug-using community.
What we are suggesting is completely in line with the Government strategy, Healthy Ireland. It is about a multi-sectoral approach because the issue of drugs is not just a medical issue but it is also a social issue. There are issues in Cork and there is also a drugs task force in Cork. There are problems throughout the country. The heroin issue is still concentrated in Dublin with approximately 9,000 of the 10,000 people on methadone in the Dublin area. However, when benzodiazepines, tranquilisers, pills and alcohol are added in, this is a national issue.
I thank the members of the committee for their attention.
I thank the witnesses for their presentations. We have had this debate on an ongoing basis. Professor Barry noted that we are very good at writing reports but that the implementation sometimes lacks commitment. I wonder about our treatment programmes for opiate addiction. I have often got the impression that while there is great goodwill in terms of the effort of the HSE and others at the coalface, deep down as a society we are saying to keep giving them the methadone and as long as they leave us alone on the street, we will keep moving on as a society. I do not believe we have confronted the real challenges that individuals face in their chaotic lives as drug addicts. The collective view of society seems to be that if they are not hassling us on the boardwalk or wherever, we are happy enough once we think they are getting their methadone.
Given that there are individual cases and individuals lives, we need to accept that we need individual pathways for recovery. We have to assess more deeply the individuals' problems rather than just having them queue up for a cup of sugary methadone every morning and letting them off. I know it will take huge resources. I know that methadone is cheap, but it does not really succeed in getting users to move from heroin abuse to involvement with the health services and into a recovery treatment programme. That pathway is fairly poor to say the very least.
It is poor for many reasons. Clearly, one of the main reasons is that it is not resourced. As a result, people fall back on methadone, fall out of the treatment programmes and go back on heroin.
I have no in-depth knowledge of the matter. I come from Cork. We do not have a major heroin problem in Cork, but I can sense little clusters of the problem developing in certain parts of the city. We know what happens if people in a community turn a blind eye to heroin. This was evident in the late 1970s and early 1980s in Dublin, where it quickly becomes an epidemic and caused major social problems.
I am highlighting all the problems while I look blankly when someone asks me for solutions. Many people have referenced the Lisbon approach. If we legalised or decriminalised drugs would we have more engagement? That may involve looking at it from a social and health point of view. The idea is that we would not have heroin addicts walking around, ducking the law and trying to avoid any form of contact with the State because of the threat of criminal convictions and everything that flows from that. If they engage and come out of a system with criminal convictions, that does not look great on anyone's curriculum vitae.
Have the witnesses examined other trials? Let us be honest. I presume that, collectively, society is experimenting all the time with how to deal with these issues. I have read a number of reports on Lisbon and how the city is dealing with the problem as well as other areas that have tried this approach. Is there any merit in examining it? Would we be simply wasting our time by examining what they have done? Should we instead work on the strategies in place at the moment?
Professor Barry said that with the upturn in the economy, there would be more resources and potential to do more. Previously, we had an economy that was rather upturned for a while, so to speak. Was there any correlation between a drop in heroin use or abuse and better outcomes for heroin addicts when we had endless resources and a lot of money to spend on everything and anything? Is it the case that we have to think smarter now about how we use our resources? My view is that it did not seem to reduce substantially. I recall walking the streets of Dublin at night during the Celtic tiger and seeing major heroin problems. Perhaps we were less inclined to notice them because we were so busy booking flights to Spain and elsewhere. I do not mean to be flippant but I believe we should examine it, because if we are turning into an economy that will have more resources in the coming years, we must not repeat the same mistakes or take the view that money will solve the problem without inherently addressing the underlying issues. That remains a concern.
The witnesses commented on how the pathways to drug addiction are fairly defined, including dysfunctionality in the family, unemployment, poor educational outcomes, lower socio-economic backgrounds and so on. I presume the quid pro quois that if we could address these problems, we would have fewer people taking the path to drug addiction. Even during the Celtic Tiger, when we experienced unemployment at 4%, which is full employment in a modern economy, we still had that problem. How can we address it?
I am asking questions rather than having any solutions in mind. One thing is for sure, and that is a review of the drug strategy will be completed next year. As with any strategy, we should review how successful it was and where it failed. There is no doubt that we still have a major problem in certain areas of 10,000 people who are consistently on methadone. I do not expect people to be critical of their employers but I am seeking an honest appraisal of whether we should look at other programmes in other parts of the world. Are we stuck with what we have? Is it a question of trying to make the best of it?
I appreciate the presentation from the witnesses. I am mindful that people are substance misusing. The witnesses referred to the recovered. It is a question of the transition period and the services during that transition period. Professor Barry commented on the homeless wet hostels. I was thinking of that because I have received representations from Dual Diagnosis Ireland about the issues of mental health and substance misuse. Often we have different pathways for someone to get support, help and recovery, but we do not always see the interconnectedness. Let us consider the homeless situation. I am not trying to compound the issue but the reality is that there is interconnectedness between these issues. How we as a society response to these issues is relevant. Often we force people into homelessness because we do not have an appropriate mechanism to deal with it.
I am still trying to work it out in my head. I agree with everything I hear from the witnesses. How do we move from being good on paper to actual implementation? What are the tangible items that, as parliamentarians, we should be calling for? The idea is that I can leave here saying clearly what is needed.
How do we ensure the approach is replicated throughout Ireland? While I understand that methadone is rather Dublin-based, the reality is that on the basis of the figures given by the deputation, it is not limited to one area. Certainly, we have no wish to be moving people into an area simply because that is where they will get services and support. How do we ensure the approach is agreed? We have a geographical lottery and, therefore, a consistent approach is important.
The drugs strategy is due to end in 2016. We seem to have a number of strategies that will end of 2016. What work has been done? How much consultation has there been with the organisations and those involved with the delivery of services? Is there a move to consider an implementation plan rather than an additional strategy? Perhaps we could take some of the principles from the current strategy and move the document more towards deciding which Department should take a lead. Ideally, it should be a Government strategy rather than a departmental strategy. That is what occurred in the children area and with the Healthy Ireland initiative. I am trying to see where the process lies. It is something about which I am concerned.
I thank the deputation for the presentation. I compliment a former colleague and Deputy, Mr. Pat Carey. Any time he had to deal with this issue as a Minister of State, he always made clear the role of addiction in families. The same applies to the previous Minister of State with responsibility in this area, Deputy Alex White.
I will set out where I am going with this. We should have a Minister at the Cabinet table with responsibility for this area rather than a Minister of State. He or she could make decisions on these issues. If we are ever to go the road of recovery, we must have someone who is batting all the time at the Cabinet table on behalf of people. I will lay my cards on the table in that sense.
The report is excellent. I have not read it all but I have read most of it. I come from an area that has had serious drug problems for many years. We still have people using not only drugs but also alcohol. It has become a serious problem in poorer communities.
I read the four stories of the recovering addicts. It was clear from the stories that I had met them all in my life in the community centre where I worked as a youth leader. When children came in at the age of seven years, I probably knew by looking at them that they were not going to reach the age of 18 years or, if they did, they would have multiple problems along the road. Many families lost not just one but two or three members. It is devastating for every community when this happens.
One of the biggest problems I have found through the years is that all these services are based on one particular area with a poorer social class of people, or whatever we are called. Although there may be five or six services within less than a kilometre, that does not lend itself easily to the rest of the community who may not believe that they have a role to play in helping people to recover. It brings significant problems and that is still the case today.
While I could go on, I will not because the Chairman will not let me, so I will ask two questions and try to make them brief. I am going to read the rest of the report.
I will certainly make it my business as a member of the Fine Gael parliamentary party to speak to the Minister, Deputy Leo Varadkar, and the Taoiseach on what I believe is a very serious issue that has never been addressed properly by any Government. It is not just about the addict; it is about families and communities as well.
What is needed to implement Cloud and Granfield's theory of recovery in Ireland? It is operating in Wales, Scotland and England, as was said. Will the witnesses tell us what is needed here? What role do they think the national drugs task force and the local drugs task forces should have in making Cloud and Granfield's theory of recovery happen?
I will finish with a personal opinion. Down through the years I have always believed there are too many organisations in this area. Many people who are trying to recover or get away from addictions seem to wander physically from one service to another. I have tried to find out if there is a register anywhere where we can see all these people's names and who they are, whether they are men or women, their age group and where they have come from. Is there some kind of register like this? I always feel that when some people do not get what they want in one service, they continue on to the next service. They seem to go in a vicious circle and some, unfortunately, do not come out of that circle. My personal view, from working in the community, is that there is duplication of services.
There is only one way to deal with addiction in this country, particularly around drug abuse and alcohol abuse, and that is to have a specific Minister who will take on the challenges that face every Government and do something about them. That is why I started off by speaking about the former Minister, Pat Carey, and the Minister, Deputy Alex White. I want to mention Pat Carey especially because I know him a long time. When he worked as a teacher in Finglas many moons ago, he had a theory on addiction and on working with people who came from poorer families and socially deprived backgrounds. That never changed, even when he was elected to the Dáil. I cannot find words to describe the man only that I have never met anyone in my lifetime who had such a passion about this service.
Today has been very uplifting. The witnesses spoke about stigma and discrimination. I read in one of the reports that people with drug issues and drug problems are a target of moralistic judgments, and I often hear that as a Deputy in the community. It is gratifying and uplifting, therefore, to read that the witnesses are talking about recovery because sometimes drug addicts are just written off. We will give them methadone, which is fine, and let them get out of town as quickly as we can get them out, and everything is back to normal.
I want to ask about methadone, given I only know what I hear, which is that 30% of patients have been attending drug clinics for more than 20 years. As a question to Professor Barry, if methadone were withdrawn, and there are those in the community who say it should be, what would be the outcome? I understand the issue of education, but education and issues like housing are long-term solutions, although we have to work towards that. In the short term, if methadone were withdrawn, what would be the result?
The service in a town is called the drugs clinic, which I think is a terrible name. It should be the recovery clinic. One would think people were going there to get drugs. Is counselling among the services currently provided in different towns?
I loved the sound of Mr. McAleenan's model and what he is doing. He should, please, keep doing it. I hope we can talk to him later about what we as Deputies can do in our areas. Those are the questions I wanted to ask.
I thank the Chairman and the clerk for allowing this debate to take place. It vital that we keep recovery as the optimum aim for people in addiction. Harm reduction measures certainly have a role to play but they cannot be at the expense of full recovery for individuals. It is only when we see people in recovery that we realise the difference it makes to their lives. Although harm reduction measures are important, sometimes it is almost like throwing in the towel when it comes to addiction. We can give a person a needle exchange or methadone and do this, that and the other, but the person continues in their addiction.
Professor Barry mentioned the north inner city drugs task force. I acknowledge it was the very first to include a person from the user's forum, UISCE. They were listening to the voices of the users right from the very beginning in talking about this issue.
Back when heroin hit the north inner city, it gradually became a one-size-fits-all approach to recovery, and not even recovery, given the use of methadone. I have no doubt methadone has saved lives but, because of what we have seen in terms of the increase and the variety of drugs, it is not the answer in many cases now. What Mr. McAleenan has outlined today is very heartening. It is only when we go to Soilse and the other projects I know in the north inner city and we see people in recovery that we can know the difference it makes to them, their families and their communities. It is really important that recovery is with the Committee on Health and Children and it is to be hoped it is going to be central.
I am glad the fellowships and the 12-step programmes were mentioned because I do not think they get the credit they deserve. They do not cost anything, except perhaps putting a euro in a bag at the end of the meeting, but they continue to do amazing work, as they have done through the years. They have saved lives.
Accommodation is a major issue. It became a crisis because of the other issues with homelessness. I know we have a problem with accommodation, but when a person is in recovery, that should not be jeopardised by bringing people who are using and who have chaotic lives into the same accommodation. I know about supported temporary accommodation. If a person is in recovery, however, we cannot put a limit on how long they can stay in that accommodation. For some people it might be three months, but for others it could be nine or ten months. It must be based on the individual. I know the difficulties with housing accommodation, but given the price people pay to get into recovery, we cannot jeopardise that. While great work is being done with prisoners, if a person has become clean in prison by getting into a programme and going to a fellowship, only for them to be released and go back into homelessness, it is a recipe for disaster.
I ask that the committee would ensure that recovery would be part of whatever submission it makes or paper it sends to the national drugs strategy, and I ask that recovery would be at the heart of that strategy. My own private focus at the moment is on prevention and education, which are undoubtedly the Cinderella of the national drugs strategy. Perhaps that might be a debate for another day. I thank the committee for allowing me to speak.
We have had correspondence with and I have met a gentleman from Cork, Mr. Jim O'Connell, who has carried out a great deal of work on the issue. He has lobbied the committee regarding the excessive use of methadone. Professor Barry might comment on his surveys.
Professor Joe Barry:
I will take that item first. I received a copy of Mr. O'Connell's report and know there is a lot of detail in it. Many of the issues he raises are being raised by this committee. I e-mailed him back about two months ago and said I would meet him. He responded and said he was not quite sure what that would do. I reiterate my offer to meet him. I do not know whether the committee has seen this letter.
Professor Joe Barry:
He is raising many of the issues we and this committee are raising. These are about methadone, benzodiazepines, alcohol and the framework of drug policy in Ireland. Much of what he is saying makes a lot of sense.
I turn now to the answers to some of the questions, and my colleagues may then wish to come in. I have underlined the issues I think I need to cover, but if I forget anything, the committee members can let me know. I have been involved in the drugs issue for about 20 years. As Deputy Maureen O'Sullivan outlined, methadone has a place - about that there is no doubt - and it has helped many families.
There was a review of the opiate treatment protocol carried out in 2010 by Professor Michael Farrell, who is a professor of addiction in the Maudsley in London. Some type of public health approach is needed in most communities where there is opiate addiction, but it should not be the overall emphasis. That review stated that there needed to be shift to promote recovery. If we stopped prescribing methadone in the morning, we would have major problems.
We have discussed needs assessments and care workers, which Mr. McAleenan mentioned. Every single person on methadone needs a full and proper assessment of his or her needs, desires and wishes, a point which needs to be repeated and has been recommended in several reports. That is how I would approach the issue. I may be wrong and Mr. McAleenan might disagree with me. We agree on most things, but we do not necessarily agree on everything. If one took methadone away, one would immediately have organisational problems. Our approach is to focus on recovery. They are not mutually exclusive, but the balance needs to shift in terms of resources towards recovery. A person assessed on day one may have a certain opinion and may return in six months time to say he or she is ready or wants to stop.
Professor Joe Barry:
Some people have been on it for 20 years. I do not know whether they have had an assessment or it is what they want to continue doing. People need to have a full assessment. They should have an annual assessment. If that were happening, fewer people would be on methadone for a long time.
Professor Joe Barry:
Yes. Many people are now working with drug users. Most are trying to move people along, but that requires more concerted action. The model Mr. McAleenan mentioned needs to be available on a much more widespread scale. People who do well and come off and stay off methadone do not necessarily want to be the poster boy or girl for recovery for the reasons of stigma we mentioned. I would approach the issue of how many should be on methadone in terms of a thorough needs assessment of everyone. Methadone was introduced to eliminate or reduce blood-borne viral transmission, which has happened.
Professor Joe Barry:
It was introduced because of HIV. As Deputy O'Sullivan said, we have had heroin in Ireland since the late 1970s. In the 1980s the response to the problem was to tell people if they came off drugs, they would receive help, but that did not work. Perhaps the approach was not well resourced, but there was chaos, riots, shootings and protests. A structured drug service shifts drug users from dealing exclusively with a criminal environment and dealers to working with social care professionals, nurses, doctors and counsellors. It involves a shift in emphasis to recovery. One will not do everything in one day. We would like this issue to be taken on board and to have a genuine implementation plan. That would make a significant difference.
In terms of measuring outcomes and the register, which Deputy Byrne mentioned, there is a register of people on methadone and it has been recommended in numerous reports that there should be data linkage to follow, with appropriate privacy protections. That has not happened, and not just in the drugs area. I do some work with the HSE and I am quite often asked to answer parliamentary questions. We receive questions on the success of a programme or what is happening. It is very difficult to measure some outcomes if one has no way of following someone on a longitudinal basis.
The Health Identifiers Act is not enough. There needs to be a next stage, which is a step that has long been advocated outside of the Oireachtas. If we want to measure outcomes in the health services generally, the next stage of the legislation needs to be commenced. The only information available is on cancer, and the national cancer registry can measure outcomes and survival rates because it is a good register which is appropriately staffed and confidential. We need something like that for drugs services.
I refer to legalisation, decriminalisation and considering things in another way. Legalisation and decriminalisation are different. I do not think drugs should be a criminal issue, but that is not to say that I would support legalisation. Members may remember head shops opening in 2009. People who had never thought of taking drugs took them when they were legal. The world is made up of two types of people, those who are risk takers and those who are risk averse. We would have a much larger problem with pills than we currently have with other substances if we legalised them. Decriminalisation is different.
Mr. McAleenan will discuss recovery academies. In terms of an all-Ireland approach, we currently have 14 local drugs task forces in the Dublin area, including Bray, and Pat Carey is the chair of one. I have worked on this issue for 20 years and it has been a genuine cross-party initiative. We have had Ministers and Ministers of State from three parties involved. It helps to have a focus because it is not just about medicine and clinical matters but a much wider issue encompassing homelessness and so on.
We have ten regional drugs task forces. In each part of the country there is a structure of people who are trying to help, but that is not enough. There is a framework and more of a consensus, which is not absolute, among those working in the area that we need to do things differently. We all need a wake-up call, which is what this is about.
Mental health was mentioned, which is a major issue. The dual diagnosis rate is about 30%. Some 30% of those who use opiates have mental health issues. The Vision for Change document excludes addiction, which is crazy and needs to change.
Professor Joe Barry:
A Vision for Change is a blueprint document on mental health which is quite good in many ways, but it explicitly excludes dealing with addiction which does not make sense.
I am not sure if I covered everything. If I have forgotten to answer a specific question members can ask it again. I have tried to cover everything.
Mr. Gerry McAleenan:
I will address a few of the points. What we are discussing today was known 30 or 40 years ago. A paper written by Gerald Bury in 1979 stated heroin affected the communities which had the least ability to deal with it the worst. Ever since then the problem has involved trying to deal with it.
Deputy Kelleher asked about individual care pathways. Everyone should have an individual care plan, key worker, case management, SMART goals and the totality of their needs named and actioned. That is the approach we take in our work. Within a two-year spectrum, a person can go from being on the streets to being in recovery, off drugs and engaging in daytime programmes, housing and quality-of-life issues.
On decriminalisation and legalisation, we mention in the report the issue of spent convictions. One woman mentioned in the case studies discussed her life. She went to college when she finished using drugs in 2003 and got a degree.
Again, as there was a drug experience and prior convictions, she has lost several jobs. She is drug free for 12 years but it is still an issue that reappears. We advocate along the lines that the spent convictions Bill should address people who are in recovery and enable them after a period, such as five years, to have a conviction quashed. Generally, if a person is drug free for five years, there is more than a 90% chance that he or she will be drug free for the rest of his or her life.
There are other jurisdictions and models and, as I noted, we are involved in a European project. There is a dearth in responses in the countries we are discussing, including ourselves, England, Romania, Cyprus and Italy. This relates to access to learning programmes or work options. If we are talking about recovery and normalising people's lives, these are key elements that redefine how people see themselves. That is important. We have examined other European countries, and Spain, for example, has co-operatives where people can set up and train for the first year before getting a business start-up in the second year and becoming independent in the third year. This exemplifies the social economy options in other countries that are very viable. We have never had a cultural tradition of co-operatives in Ireland. On the Continent, there are approximately 300,000 co-operatives with 60 million people working in them. We are involved with Italy and that country works with a co-operative model.
There may be other models and there are certain models regarding housing. In England, it is very much like a continuum of care. If a person is detoxing, he or she can go to a housing facility and when that person is drug free, he or she goes to another facility in the recovery community with people who are drug free. Those people can move to permanent accommodation afterwards. Deputy O'Sullivan raised the housing issue. There are models we can consider.
There is the question of how to move this forward. We are talking about events on the ground and Professor Barry mentioned a Minister with responsibility for drug issues with respect to the task force in the north inner city. It is relevant across the city. On the ground, the feeling is that the issue is off the political agenda. Having a Minister with responsibility for drug issues is important. The next drugs strategy should be oriented to a recovery paradigm, and again that will send a message to services that we must focus on more integrated qualitative approaches in how we do our work and delivery. We must be more ambitious for service users, focus on outcomes and ensure people are not languishing for years in medication processes. Quality of life issues must be addressed.
The narratives of people in recovery will give us insight and guidance and provide hope, demonstrating that recovery does happen. That is part of the issue on the ground, as people do not believe that recovery happens. When one is stuck in a void for years, all one can see is the recycling of failure. We must promote recovery and demonstrate that success does happen. By addressing stigma, making this more of a public issue and getting people who have gone through it successfully talking about their experiences, we can hope that, in turn, it will infuse the idea and notion in others.
There is an implementation committee and there has been an attempt to try to implement what is laid out through strategies and documents. The big challenge is to get key agencies working together. The HSE does its work well with respect to methadone and the process has plateaued. The required people are in place now. As we heard earlier, we need to work with the likes of the housing bodies because there is a massive homelessness problem. We need to work with the mental health services, with what is now SOLAS and with the education and training boards. There is poor educational attainment and a consequent lack of marketability and progression options. For example, literacy is also a problem. Dyslexia stands out, and we have found it is far more common within our cohort than within the general population. There is a dearth of response, as there is only one project in Dublin dealing with the issue. These are the elements facing us in the implementation area. A small but empowered group of approximately five or six senior people can make these decisions and get these matters progressed. It would be an effective working group.
Mr. Pat Carey, the north-east drugs task force chairman, visited our project before Christmas. He was there for more than three hours and went back over some of what he would have liked to have happened when he was Minister. The housing issue was important to him as he pioneered housing changes and policies, and he said the process had gone in a direction he did not foresee. He does not believe it is conducive to the needs of people. Outcomes in the housing area are very important.
There is an array of clinical services, with counselling offered to people and other interventions concerning mental health needs or any other medical conditions. Detoxification is also offered along with residential treatment. There was a report in 2007 by Dr. Corrigan and Dr. O'Gorman which indicated we should elaborate on the options for bed capacity in the detoxification and residential treatment areas. If we are to make a major change and liberate people from services, there must be options for moving forward. We need more residential beds and detoxification options. The 2007 report is good and comprehensive.
Deputy O'Sullivan spoke eloquently about recovery and that supports the notion of getting this discourse going in the north inner city. That is appreciated. We can see a change, even at task force level, with people looking at outcomes. It may sound trite despite the times we live in but one of the goals for all the projects has been for everyone in the services to have a meal every day. That is the basic level we are talking about when we are starting to work with people. It is about getting them some nourishment, something to do during the day and getting a roof over their heads at night. It is about getting some company and friendship. These are the basic needs we start with and people respond to this, buy in and become inspired.
There is an issue with prisoners and we should be far more effective in dealing with them, planning for their release and having the array of options we are talking about. There are planned releases but there must be work and education options when prisoners are released. They should have other support as well. I spoke about a model involving a recovery coach, which would be a good link or buddy system for people when they emerge from prison.
I apologise that I was not present for the beginning of the presentation. I pay tribute to the great work ongoing in the area of drug rehabilitation and treatment, harm reduction and population safety. When I was elected to the Seanad a few years ago, I set off on a personal series of fact-finding missions. I visited Merchant's Quay, Hyde Park and other treatment centres. Quite a few people came to chat with me. I feel quite strongly about drug policy and we are doing it wrong. I am delighted to hear some of the opinions aired at this meeting.
I like to think I am a rationalist and an empiricist. One does a bit of research, looks at the results and sees if something has worked. What we have done in the war on drugs has clearly not worked, and by any logical definition what the western countries in general have done in trying to contain the drugs problem and reduce the associated harm, particularly to individuals with drug problems, has not been successful. We have as high a number of drug addicts as we have ever had.
I get accused of a little inconsistency in this but we can consider the different types of substance problems, and one size does not fit all. We should be aiming for the elimination of legal commerce in tobacco at some fixed stage in the future. If people want to sell tobacco at that point, they will not be doing it in a boardroom in New York or London but in the way the Medellin cartel does its business. It would not be feasible. As a society we need to acknowledge that we probably drink two or three times too much compared with what we used to, and in individual cases this may be much more or else just fine. We need to reduce the number of units of alcohol consumed in society.
The different forms of illegitimate non-alcohol and non-tobacco drugs have different problems as well. I have always been of the opinion that opiate or opioid heroin or morphine addiction is a specific problem. I saw some data approximately two years ago that suggested if we considered a timeframe before the economic bubble, during it and afterwards, cocaine use went up as we got more money and went down as we lost it. Heroin use, on the other hand, stayed the same, which told us something very powerful about heroin. Heroin addiction is as much a medical problem as cancer or diabetes, and the treatment must be medical. I took a tremendous amount of a flak a couple of years ago when I suggested that we medicalise heroin. It is something we need to consider.
I apologise for my absence earlier. The delegates may have given us the figures, but do we know how many heroin or opiate addicts there are in Ireland and how many are regularly engaged with treatment, rehab and other services? I have kept asking this question and nobody seems to be clear on it, but I get the sense that many are not engaged with services. For some, this is owing to a lack of access. When I first came here, I was surprised to discover how centralised methadone services were and that many people on methadone programmes had long commutes to access them, which is a disincentive in some cases. How many of those who are not engaged with services are not engaged because methadone does not do it for them and they still want heroin? How many of those outside our net of interaction with caring social, medical and rehabilitation services and are instead buying drugs on the street from some of the worst elements of society could be brought into the net if we were giving them heroin and not methadone? There is an element of a guesstimate in this regard. I thank the delegates for what they do.
Professor Joe Barry:
In Ireland we use a capture-recapture methodology to estimate the numbers of problematic opiate users. It has been done three times in Ireland, in 1996, 2001 and 2007, and is being examined again by the National Advisory Committee on Drugs and Alcohol, NACDA. It is done by counting the persons in receipt of methadone treatment, the people on charges with the Garda and those who have been in an acute hospital and using mathematic modelling. We know how many problematic opiate users there are and, depending on the size of the overlap, we estimate the number of hidden users. It is technical. According to the most recent estimate, there were approximately 14,000 to 15,000 problematic opiate users. Some of them would not take much heroin, for example, those who are participating in methadone programmes but also taking a little heroin as they are still addicted to opiates. Approximately two thirds are reckoned to be in treatment or contact with services. Of the one third outside treatment, I can only speculate. Some do not want to have any contact with the State and the HSE, as people in low threshold programmes tell us. They are taking drugs - people take drugs for many reasons. In Dublin the level of access to treatment is high and outside Dublin it has improved. Most people who are not engaged are not engaged because it is not attractive. Some would engage if they were to receive heroin instead of methadone. On a cost-benefit analysis, it would not be very effective to do this.
Patterns of use have changed. Injecting was the norm in the 1990s, but it is less common now. The culture has changed, as drugs go out of fashion. Opiates have gone out of fashion somewhat, but stimulants are a major problem. Given that there is no opiate response to these non-opiate drugs, we need to provide a psycho-social response to them. There are heroin droughts from time to time and we see many changes. Heroin supply is controlled by the criminal gangs. Some opiates such as morphine are given in medical settings. Morphine is a good drug in treating certain conditions. Although specialists in palliative care use methadone for pain relief, it is not part of the methadone protocol.
We are asking that the time be shortened between a person being on the street and entering recovery. Mr. McAleenan referred to a period of two years and knows much more about it than most people or I do. We are talking about narrowing the gap and then reappraising. Given that every policy change can have unintended consequences, we must examine the upsides and downsides of everything.
Deputy Maureen O'Sullivan mentioned prevention and education, which are important. In the parts of the country where heroin use is most common, particularly Dublin, the vast majority of youngsters do not take opiates. Among those who do, there is a pattern of early school leaving. If I could do one thing to try to reduce the need to take psychoactive substances, it would be to improve the level of school retention. Many children do not make the transition from primary to secondary school. We have forgotten what it is like. While primary school is very sheltered, secondary school is a completely different environment into which young people are thrown and some just fall and cannot sustain it. I would also invest more in preschool services. Other European countries put much more emphasis on it. We need to invest in children if we want to reduce the chances of people taking drugs, but we will never eliminate drug use. There are many issues related to marginal benefits such as giving people self-esteem and teaching them skills. While the schools SPHE programme can and does do it, there is a limit to what it can do if the child's environment is moving in a different direction.
This morning we have heard about the theory of recovery. I understand what Mr. McAleenan said, that the people participating in the programme do not wish to come before the committee because our meetings are televised and they wish to remain anonymous. However, we have missed out on hearing the voices of those who have gone through exactly what Mr. McAleenan has set out. If the proceedings were not televised, we could hear from one or two people who could show how the theory worked in practice.
I have a question on methadone and our obsession with it. Although individual pathways for users were mentioned, they always end up on methadone treatment programmes. One can argue that we do not have individual pathways to recovery. Is there any use of other heroin substitutes such as buprenorphine? We seem to have no individual pathways to recovery because everybody is on methadone. It cannot be suitable for everybody.
I apologise for not being present for the entire briefing. I had to deal with a matter in the Seanad.
The delegates have much experience in the dos and don'ts based on what has happened during the years in Dublin. In Cork there has been a major increase in heroin use. What should we do, or not do, in areas outside Dublin, particularly in Cork, to deal with the issue, given the mistakes that were made?
Mr. Tom O'Brien:
The HSE is only one part of the continuum of care. The external review has suggested recovery is the way to go. In the past it was treatment based. It was a 15 to 20 year old service that was focused on methadone. There are discussions at the methadone implementation committee on using buprenorphine and naloxone treatments. We have also recognised that there is a serious gap when somebody leaves one of our recovery centres and moves into a treatment or homeless environment in which others are using. We have met Mr. McAleenan to discuss a new step-down facility which will, I hope, have no time limit in getting people into a new facility where there would be ongoing treatment and counselling supports available for them. The area manager in HSE Dublin North has passed this. We are developing a national approach to service provision.
In Waterford where I am from and Dublin there is a difference in the treatment options available for clients. The national addiction advisory group, together with the HSE and Mr. Pat Dunne, assistant national director for primary care, are looking at standardising the clinical approaches to treatment. That is also a recovery model. We know that in many cases people have been on methadone for too long and that we need to offer alternatives to them. We are, therefore, looking at that issue also.
I am working as part of a sub-committee of the advisory group on an ICT system with a case management piece which will follow clients through their recovery process. I hope that ICT programme will produce data indicating the gaps in an individual's treatment options. The HSE is also bringing service users on to its boards of management and boards of rehabilitation and we are looking at producing updated leaflets for clients on what types of care service are on offer to them outside methadone maintenance only.
There is a great deal going on. Our review coincided with the report and it is interesting that both found that the recovery model and the service user are central to the process.
Professor Joe Barry:
Senator Colm Burke asked about services in Cork. What would be of help is what we are trying to do nationally. I do not know what the numbers are, but I would make a proper needs assessment with a recovery focus. We are trying to shift the balance and that needs to happen all across the service. That is what I would do if I was in Cork. I reiterate this in replying to Deputy Mary Mitchell O'Connor's question because it is the hardest one. What happens if the giving of methadone stops? We are trying to shift the focus. Most people want to do this, but that does not mean it will happen. Treatment and rehabilitation were always linked in our previous drugs strategies. Therefore, we are recommending a new strategy of recovery to give it a focus, but it needs people with knowledge who have seen it work. There are pathways to recovery, including Soilse, but there are just not enough of them. It might not take a huge amount to flip the coin around in order that when somebody addicted to opiates presents to the health service, the professionals will sit down with him or her in a few sessions and outline the options to genuinely involve him or her more. Equally, issues such as dyslexia and so on can be game changers. The devil is in the detail of the assessment which has to have a recovery focus. Initially when methadone was introduced, it was meant to be detoxification.
On the issue of dyslexia, I assume, without having to conduct a detailed analysis, the reason they are drug addicts is the condition was not dealt with during their time in the education system and that they experienced a poor educational outcome. For example, they sat at the back at the class and were ignored. Traditionally, that is what happened to such persons in the education system, although the position has improved in recent times.
Mr. Gerry McAleenan:
A failure to identify can lose somebody 20 to 25 years. Dyslexia should be identified when a person is at school, but there is now greater awareness. We are seeing a correlation between adults and their children also, but, as the Deputy said, outside the classroom, they become disruptive, get a bad name before being expelled and are out on the street. They end up having difficulties with the Garda and begin to use drugs at ten, 11 or 12 years of age. That is what happens. It is small, but it has huge significance.
Ms Sonya Dillon:
In response to Senator Colm Burke, our thought in coming here was that we had to promote recovery, but this is about people exiting services and preventing them from becoming dependent on services across the board. Early intervention needs to start with teaching people how to be parents. Breaking the cycle is the only way we will alleviate this problem in 20 years time. We need a seamless recovery process. There is a window of opportunity with clients and if they can go from door to door, from service to service, and have two years with a good solid foundation, as Mr. McAleenan said, they will not be attending services in ten years. That is part of the learning we have gained during the years. Recovery has to be part of a package which must start early. We need to do the groundwork and provide options, but that will only be done through care planning.