Oireachtas Joint and Select Committees
Wednesday, 13 October 2021
Joint Committee On Health
Impact of Covid-19 on Addiction Services: Discussion
Apologies have been received from Senator Hoey.
We are meeting representatives from the Rutland Centre, Alcohol Forum Ireland and the Ballymun local drugs and alcohol task force to get an update on the challenges facing organisations working in the area of addiction, including the challenges resulting from Covid-19.
I must take care of some housekeeping before we begin. Are the draft minutes of the meetings on 13 and 20 July, 6 September and 5 October agreed? Agreed.
I welcome the witnesses, who will be providing us with an update on the challenges facing organisations like theirs. From Alcohol Forum Ireland, I welcome Ms Paula Leonard, national lead on community action on alcohol, and Dr. Helen McMonagle, alcohol-related brain injury rehabilitation co-ordinator. They are appearing via Microsoft Teams. From the Ballymun local drugs and alcohol task force, I welcome Mr. Hugh Greaves, co-ordinator, Ms Marie Lawless, policy and research officer, and Ms Katy MacAndrew, manager of the STAR project and a member of the Ballymun local drugs and alcohol task force and interim funded project. They are present in the committee room. From the Rutland Centre, I welcome Mr. Gerry Cooney, senior addiction counsellor, and Ms Serena Bryans, addiction counsellor.
Members and all in attendance are asked to exercise personal responsibility in protecting themselves and others from the risk of contracting Covid-19. They are strongly advised to practise good hand hygiene and leave at least one vacant seat between themselves and others attending. They should also always maintain an appropriate level of social distancing during and after the meeting. Masks, preferably of a medical grade, should be worn at all times during the meeting except when speaking. I ask for everyone's full co-operation in this regard.
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 remind members that they are only allowed to participate in this meeting if they are physically located in the Leinster House complex. In this regard, I ask all members to confirm prior to contributing to the meeting that they are on the grounds of the Leinster House campus.
I call Ms Leonard to make her opening remarks.
Ms Paula Leonard:
I thank the committee for the opportunity to appear before it and for placing this issue on the agenda. I am here to reflect on some of the concerns of staff and volunteers and on the experiences of individuals and families who have been supported by Alcohol Forum Ireland over the past 18 months. Alcohol Forum Ireland is a charity that provides a range of supports and services to individuals and families across the Border counties of Cavan, Monaghan, Sligo, Leitrim and Donegal. We also work at the wider level to support communities across Ireland in changing and challenging Ireland's problematic relationship with alcohol. As such, I will also reflect on the work of the Irish Community Action on Alcohol Network, ICAAN, which comprises member organisations from 14 regional and local drugs and alcohol task forces, including some of the colleagues appearing from Ballymun.
The theme of this meeting allows us to reflect on and, I hope, respond to the challenges that have been faced by those struggling with alcohol and other drugs during the pandemic. They have struggled considerably, largely in silence, throughout the past 18 months. That cannot be overstated.
There is little doubt that alcohol is a major public health issue in Ireland. Before we all go to bed tonight, at least another three people will have lost their lives as a direct result of alcohol-related harm. Alcohol is implicated and present in more than 50% of all completed suicides in Ireland and in more than one third of all self-harm presentations. As a carcinogenic substance, it is a risk factor for at least seven different types of cancer. Unfortunately, we have the dubious record of being among the top five countries internationally for foetal alcohol spectrum disorders, which are lifelong and permanent disabilities that result from exposure to alcohol during pregnancy.
I will focus on a small number of areas. Since it is difficult to point to a significant health or social issue in Ireland in which alcohol does not play a role, I will limit myself to the impact of Covid-19 on alcohol consumption, the challenges that have been faced by family members, including domestic violence, and the increased challenges for those living with alcohol-related brain injuries and their families.
In terms of the wider picture, we are seeing emerging research that acknowledges that alcohol is an immunosuppressant and that people with substance use disorders are particularly vulnerable to contracting Covid, more likely to suffer from a greater psychosocial burden, and at a greater risk of worse Covid-19 outcomes in the long term. At grassroots level, we were hearing early on that local services were concerned by the volume of alcohol that was being consumed by clients, which was associated with anxiety, isolation and deteriorating mental health.
We were also concerned about the proliferation of drink delivery services and how deliveries, particularly those from 24-hour drink delivery services, were contributing to high-risk drinking occasions and about youth access to alcohol.
According to the Revenue Commissioners, alcohol consumption in Ireland decreased by 6.5% during 2020. That is a relatively small decline when one considers that on-trade sector was fully closed for five months and wet pubs were closed for nine months. Off-licences were classified as an essential business and remained open throughout the most strict period of Ireland’s lockdown. There was a steep increase in off-trade alcohol sales with sales data from Nielsen showing that within the first four weeks of lockdown we spent €158 million on take-home alcohol. That was an increase of 44% on the same period in 2019. What is important to highlight is that there was no single one way in which people’s drinking behaviours were impacted by the pandemic. Some evidence is emerging that many reduced their consumption or stopped drinking entirely. What we have seen emerging is a worrying picture of increased bingeing and increased consumption among certain groups, although it is too early to say what the long-term impact on our drinking behaviours in Ireland will be. In my written statement I outlined a number of studies which estimate that between 20% and 30% of people reported either reducing their alcohol consumption or stopping drinking entirely during the pandemic. Therefore, questions arise about those who were drinking and drinking significantly more.
In April 2020, the CSO carried out a survey which reported that 22% of those who consume alcohol said their consumption had increased. The highest increases were reported among those who felt downhearted, depressed or lonely at least some of the time in the previous four weeks. In May 2020, the Irish Community Action on Alcohol Network, ICAAN, and the Alcohol Forum Ireland undertook a Red C poll. We found one third of adults reported they had increased their consumption. Most worryingly, 37% of those with children said they had increased their consumption and 9% of those, roughly one tenth of families, said that they had increased their consumption significantly during this period. That raises concern about children's increased exposure to alcohol consumption in the home and what the long-term impacts of the period will be on their health and well-being.
In September 2020, the Global Drug Survey indicated that half of people had been drinking more frequently, earlier in the day and had increased the number of days on which they drank. Some 20% of those people said that was because they felt lonely or depressed and 30% said they were drinking more as a way of coping with the pandemic. While it is still to early to tell the full impact of this what we are seeing emerging is an increase in home drinking, which is unregulated with no closing hours and increased exposure to children of alcohol consumption in the home. Very worryingly, we are seeing an increase in drinking that is associated with stress, loneliness and isolation.
Drink deliveries have been a concern in Ireland, even at a policy level, for more than a decade, but the speed with which this practice grew during the pandemic could not have been predicted. During the past year, ICAAN network members have raised concerns relating to underage access, with young people having alcohol delivered to lockdown parties, parks and beaches without any effective age verification. Concern is also growing about the use of these services by people who are drinking alone and by those who have alcohol dependency issues.
It is important for members to note there is no definition of drink deliveries in Irish licensing law and while on- and off-licences can legally deliver alcohol to customers there are loopholes in the existing code, which mean age verification and the responsibility of licence holders not to sell to those who are so intoxicated they could be a risk to themselves and others are difficult to ensure in a drink delivery situation. Section 9 of Public Health (Alcohol) Act states clearly that alcohol must be sold, paid for and the contract completed before it leaves the licensed premises, which means, in effect, licence holders have to sell the alcohol before they have eyes on and can verify the age or lack of intoxication of the customer. While Irish licensing law is very clear on the hours when alcohol can be sold, there is no stipulation in alcohol licensing law around the hours at which it can be delivered. Within this unregulated environment, we have also witnessed the growth of unlicensed 24-hour dial-a-drink services that are widely advertised online, operating outside the law and hiding in plain sight. It is very easy to look at Facebook or a range of other social media platforms and find quite a number of these on any given day in Ireland.
I wish to refer to the impact increased alcohol consumption has had on families. When parents misuse substances it can and does cause serious harm to children and it is extremely important parents experiencing difficulties receive timely, compassionate and non-judgmental support. Not all parents who misuse substances experience difficulties with parenting capacity and not all children exposed to parental substance misuse are affected adversely either in the short or long term. However, most children exposed to parental alcohol misuse will need some form of support. Unfortunately, children are often the silent witnesses to domestic violence. Lockdowns and social restrictions came with heightened risk of children witnessing, experiencing and, very worryingly, perpetrating violence and abuse. Alcohol is a factor in one in three of the most serious domestic violence cases in Ireland. It is not the cause of domestic violence, but it can act to remove inhibitions in carrying out the abuse and can be used by perpetrators as an excuse for their behaviour, a way for denying responsibility. There is also international evidence that alcohol use increases both the frequency of violence and the and severity of intimate partner violence. While we do not have any Irish research in this area to date, a study in Australia found that 51% of its support services working with victims of domestic violence reported increased involvement of alcohol as a stressor in family violence situations since restrictions were introduced. In Ireland there has been much concern about the increase in reported domestic violence incidents during Covid but the role of alcohol has received relatively little attention.
In our family programmes we saw the duration of time family spent together increased during the pandemic, substance use increased, peers, friends, colleagues and other professional support was limited to virtual or to no support. The primary reasons for referral to our family support services during the pandemic were substance use, violence and mental health. Particularly prevalent was parent to parent violence but also significant was child to parent violence. Alcohol Forum Ireland has been using the non-violent resistance response, NVR, since 2018. NVR is a brief, systemic and cognitive behavioural response to child to parent violence. During Covid we have also seen that the isolation and shame parents who are experiencing violence from their children increased.
in 2020, Parentline noted a significant increase in the number of calls in which it was reported that anger and aggression from a child was the main reason for the call.
Ms Paula Leonard:
Perfect. Parentline received 211 calls in 2019 and 428 in 2020.
Alcohol-related brain injury refers to a group of conditions that arise due to changes in the structure and function of the brain resulting from the long-term consumption of alcohol. My colleague, Dr. Helen McMonagle, hopefully, will get to speak more about this later. The lack of provision for people with alcohol-related brain injuries became all too clear and was magnified during the Covid-19 pandemic. We have seen among high-risk dependent drinkers a significant shift in drinking patterns and a sharp shift towards home drinking. That resulted in alcohol intake rates far beyond what we had seen in this service in more than a decade of work. In the case of people with alcohol-related brain injuries currently being supported by family members, family members often become the full-time carers for people with such injuries as a way to avoid their loved ones living their lives out in nursing homes for older people. The caring role is significant and often involves intensive 24-hour a day support. The isolation those families experienced reached a tipping point during this period. In the case of people with alcohol-related bring injuries currently residing in inappropriate settings such a nursing homes, the impact of the pandemic on residents of nursing homes was devastating. As many as 70% of people with severe alcohol-related brain injuries will end up resident in a nursing home environment due to the lack specialised rehabilitative and assisted living services.
For these individuals, the Covid-19 pandemic compounded further the inappropriateness of these services for this young client group, with a lack of physical contact with their families and little or no stimulation beyond the confines of the nursing homes environment, which was a further assault on their desire for independence.
Today, I have focused narrowly on a small number of issues and challenges arising from the pandemic but I am going to use the remainder of my speaking time focusing on what we need to see happen. We in ICAAN and Alcohol Forum Ireland believe-----
I must interrupt Ms Leonard. There will be a lot of time during this morning's session and we can come back to her on the recommendations and all of the other issues she wants to touch on today. I am anxious that we bring in the other groups. There will be lots of time for Ms Leonard to share what she wants to share and to get everything across. I call Mr. Hugh Greaves of the Ballymun local drugs and alcohol task force to make his opening remarks. He is very welcome.
Mr. Hugh Greaves:
I am grateful for the opportunity to address the committee. To do this, we consulted with a range of the different partners we work closely with in the Ballymun area. They were very happy to provide their experience of what it has been like over almost two years of lockdown in trying to provide services to an already overloaded community. The Ballymun local drugs and alcohol task force is a partnership that works with statutory services, local people, local services, voluntary agencies and local public representatives to provide a cross-cutting response to drug and alcohol issues in the local community. It represents a broad range of experiences all coming together to address drug and alcohol issues in a local setting. The information conveyed is garnered from a range of different services, such as youth services, community drug services and homeless services all working together. The issues that were presented are similar to some of the issues mentioned by Ms Leonard earlier and they are also reflective of feedback that was garnered from different drugs and alcohol task forces throughout the country by the Department of Health recently, and a paper is being presented soon by the Department on some of the difficulties experienced by those services.
In terms of an overview of the key issues, as I said, we work in an already overloaded community where there is a large concentration of intergenerational drug and alcohol use and, in some cases, some families are experiencing their fourth generation of people getting involved in serious and problematic drug use. Covid, which nobody could have legislated for, then came on top of that. What we found was that this added extra loads onto already overloaded families in the community in general. We have broken the issues down under various headings, as follows: connecting, connections and support; risk, safety and danger; coping and stress responses; access to service provision and engagement; drug and alcohol behaviour and patterns; and maintaining service delivery and practices. I will try to paraphrase my speaking notes as much as possible in order to keep my speaking time short.
With regard to connecting, connections and support, considerable work has been undertaken by all of the services in an ever-changing environment to provide supports to clients, their families and the local community. There was an increase in client needs and that resulted in a whole range of different things, with much higher and more dangerous levels of drug and alcohol use and people who had been doing very well relapsing because of the lack of daily contact with local services. It took a while for services to reorientate and to provide online and phone support and so on. Those were the overarching issues. We saw that where people had already experienced high levels of trauma in their family environments when growing up and in their current family environments, the isolation and the unknown factors led to that coming out in all sorts of negative ways for people. There was a serious rise in anxiety and stress, and this resulted in issues like domestic violence and so forth. Individuals using drugs and alcohol services indicated the resurfacing of feelings of loneliness, emptiness and abandonment. That led to heightened levels of stress and anxiety, social anxiety and depression, and there was a lack of structured connection with their peers and with the services people relied upon.
Parenting issues came to the fore and became much more acute, with an increase in stress in homes for both parents and children, and Ms Leonard mentioned child to adult violence. Services reported there was a lot of difficulty in emotional regulation when dealing with children’s stress. For children who were being cared for by other family members, such as siblings and grandparents, the separation for both child and parent was challenging, with people experiencing lost opportunities and missed milestones, and we have all seen the missing of things like communions, school graduations and similar milestones.
I will turn now to risk, safety and danger. Vulnerability within home environments or family dynamics associated with increased drug and alcohol use surfaced in regard to issues like financial debt, intimidation, loss of employment and relationship breakdowns. There have been increases in reports of suicidal ideation among those using alcohol or drugs, which did not feature too much as a self-identified concern pre-Covid. Family members experienced more conflict within the home as their loved one’s drug and alcohol use increased. They experienced constant pressure for money due to reduced income, which led to issues like food poverty, although services tried to respond as best they could to some of those issues. Family members’ awareness and anxiety was heightened in terms of their loved one’s increased use due to greater visibility from them being out of work, working from home or being constantly at home. There was increased aggression and domestic violence, and a rise in support in regard to seeking barring orders and protection orders. There was experience of inconsistent or non-use of mental health medication during Covid, which is linked to patterns of drug and alcohol use, disconnection from supports, limitations on phone support or regular reviews or both. Physical health issues also emerged as an issue.
Young people who were being groomed for various criminal activities became much more susceptible and vulnerable due to the withdrawal of key supports, such as youth supports. Anecdotally, there was an increase in the number of young people holding drugs and weapons for organised gangs and getting involved in low-level dealing for very little money. We are currently seeing the consequences of this, with a palpable increase in reports of coercion, violence and so forth.
In terms of coping and stress responses, there was a fear of Covid transmission, especially in families where their loved ones were still out on the streets, doing their drug dealing, drug scoring and so on, in that there was a fear of what they were bringing to the door.
Outreach services engaged with young people reported difficulties with young people understanding the ever-changing situation, although that was the case across the country and there is nothing unique in that. It was also observed that people were sharing coping techniques and responses with one another. For example, those in contact with services were sharing the support they received, such as breathing techniques and so on.
With regard to access to service provision and engagement, delays in access to residential treatment due to Covid became a real issue as there was reduced bed capacity in the residential treatment services.
Appointment dates were either delayed or extended thus making it difficult for clients to maintain progress and motivation. There were experiences of undertaking detoxes without the same support systems in place making things very problematic.
Ongoing issues with access to adult mental health services and long waiting lists for the adolescent service were exacerbated during Covid.
The phone supports were not always suitable. There was a reluctance to use, or unsuitable technology available, in terms of people accessing online services. Some people reported that they had low self-esteem or confidence so did not like seeing themselves on screen and, therefore, chose not to avail of the support.
There were also tech literacy issues, Wifi issues and a lack of devices. A big issue was people having little or no privacy in the home environment. People had nowhere to avail of supportive services because of overcrowding.
Individuals with addiction and homeless issues found it difficult to access personal care arrangements such as showers and safe sleeping environments. All of this had a negative impact on self-esteem and increased stigma.
There was a decline in motivation and goal setting was disrupted which made care and case management processes more difficult. People were anxious arising from court dates being rescheduled and delayed. Not knowing the situation and an inability to plan also increased anxiety.
In terms of drug and alcohol behavioural patterns, drug use increased. There were particular concerns about the rise in the use of stimulants, particularly crack cocaine, which increased in a much bigger way during the last couple of years.
We witnessed among young people a rise in the use of party-type substances such as nitrous oxide, which reflects the trend that happened in other areas of the country. We note that the sale of nitrous oxide is completely unregulated.
As Ms Leonard said, there was an increase in the frequency and quantity that people were drinking. People made all sorts of local arrangements to facilitate drinking. This was exacerbated by the free and easy delivery of drink to local parks, local shebeens, etc. at any time of night. It was reported that there were consequences on people and their families because of this changed use.
There was feedback that there was isolation, boredom and worry, which was attributed to a large level of relapse. The people in recovery found it difficult to remain drug free without the support of things like their fellowships and local support services.
As has been mentioned earlier, there was a big increase in reports of service users being attacked and beaten up in connection with drug-related debts. At the beginning of lockdown when Garda checkpoints were visible on the roads many dealing networks were denied a lot of their income so called on people to collect debts, which led to a large level of increased violence.
In terms of maintaining service delivery and practices, a number of services developed new ways to engage with their client groups. This included the creation of walk and talk sessions, garden games, balcony chats and food distribution. In terms of the latter, a lot of services thought that they understood the needs of individuals and families but when their staff called to people's doors they were shocked at the level of need. When the front door opens and one sees the state in which children and families are living, it becomes a completely different animal.
Once restrictions eased everyone welcomed the resumption of one-to-one sessions, in-house group work for indepth personal work, and the efforts to restore and rebuild shared feelings of belonging, hope and resilience. The stop-start engagement highlighted unmet needs and increased vulnerabilities for many.
Funding was challenging. With the ongoing restrictions and new environment in which we work there is need for capital funding to be provided so that premises can facilitate more specific service provision, and separated service provision.
I have given a snapshot of the feedback from a range of different local services that work in partnership on the Ballymun local drugs and alcohol task force. We thank the committee for listening.
Mr. Gerry Cooney:
We welcome the opportunity to address the committee and discuss the challenges that Covid-19 has presented over the past 18 months, and take questions. My opening statement will be brief in comparison with earlier. It is fair to say that our experience is very similar to what both Ms Leonard and Mr. Greaves have shared with us this morning. Some of the challenges posed by the last 18 months are familiar and resonate.
The Rutland opened in 1978 in Walkinstown before moving to Knocklyon in 1983 where it remains today. In April of last year, the centre was forced to close for the first time in 42 years due to the challenges presented by the pandemic that was impacting on all our lives. Thankfully, clients who were engaged in early recovery at that time were supported online and maintained regular contact with the service until the centre reopened in mid-June after two very challenging months for the management, staff and clients.
The centre had to undergo extensive changes to adapt to the protocols recommended by the HSE to provide a safe and supportive working environment for both residents and visitors to the service. Today, the programme again provides a 16-bed residential facility, and an outpatient support group for eight individuals and their families. At present, the centre has between 240 and 280 individuals in our aftercare and continuing care programmes. The centre was forced to adapt to the changes and challenges that Covid-19 created. In fact, having to move online allowed us to reach out to more individuals who may have struggled to access support and recovery options. Many changes had to be made to the service, including providing secure online platforms, extensive training programmes for on-site staff and changing the daily programme in order to follow all the guidelines recommended.
Since reopening in June 2020, the centre has been extremely busy responding to the volume of calls and demands for places in all of our programmes. Without a doubt families have been affected by the confinement and, for many, issues have been magnified by the lockdown. Alcohol remains the issue that creates most problems for individuals and families who are desperately looking for help. Among those seeking intervention and support for drug and substance use cocaine is still the drug of choice for the majority of those presenting.
Regarding process addictions, we have seen some increase in calls for help to tackle online gambling and pornography, which may in time translate to a greater demand for these services. The lack of support for families is a particular concern and an area that requires urgent resources and attention. From a practical point of view, it has been a real challenge to support families as before with the restrictions to visiting and physical meetings on site at the centre.
It is also important to mention that the past 18 months have also noticeably brought a growing number of more complex cases among those presenting for help due to the closure of services elsewhere. The Rutland is eager to continue to build relationships with the HSE in order to respond to the request for places for public beds. We believe that treatment should be readily available and accessible to all.
While it has been a very challenging time at Rutland, the staff remain highly motivated and determined to continue to provide a supportive environment for those who continue to seek help. Early intervention and the possibilities of providing much-needed support for families before, during and post treatment remain high on our list of priorities, and these are the areas that can perhaps be supported most urgently by those in a position to influence policy and funding. We are always happy to engage with other services and share our experiences to create greater awareness of the presenting challenges that we suspect all addiction services face at this time. We would welcome questions and are happy to share our thoughts and experiences on any of the issues raised.
I thank the witnesses. There was really good information in their presentations. As someone who has worked in addiction services right across Dublin for most my adult life, I hear their pain in some of the stuff they mentioned. I was also on the board of the Clondalkin drugs and alcohol task force for a long time and one of the problems we had was budgetary constraints, which led to us being more reactive than proactive. As much as we tried to fight against that, it led to reactive measures.
One of the things I picked up from the witnesses representing Ballymun is the grooming of young people by criminals. I have seen that in my area. Mr. Greaves said it was anecdotal but it is quite prevalent across all areas of high poverty. Young people are attracted to the flash cars, the money, the new runners, the so-called being a somebody - all that stuff. I notice that the Ballymun local drugs and alcohol task force's report states there has been an increase in the number of young people holding drugs and weapons and getting involved in low-level dealing for very little money and that the task force is seeing the consequences of that with increased coercion and violence. What actions does the task force see that can be put in place to combat this? Would multi-annual funding be part of that solution?
Mr. Hugh Greaves:
People have sought a number of things. One thing people are worried about is that while drug use is spreading across the country, and cocaine can be found in most towns and villages across the country, in certain areas there is still a complete overload in terms of frequency. That is reflected in opiate use as well. As for Dublin, the Rabbitte report of 1996 identified 12 areas. Those 12 areas are still the areas with the highest level of problematic drug use and the areas where you see the grooming of young men. It is not confined to those areas. It has spread to other cities, including Cork, Limerick and Athlone. We all know that. If we look into the various estates where this is happening, we can predict fairly accurately what kinds of estates it will happen in.
We have looked for a number of different things. From the point of view of Ballymun, we have looked for a huge rise in community policing. There has been an increase in drug policing, which is covert and undercover and is based on seizures and so forth, and that is very welcome. What the local community is looking for is visible policing. For example, when a garda arrests someone with an amount of cocaine on them, it takes two gardaí to process that. They are off the street for a couple of hours while they process that person. There has to be someone in the cell to supervise the search and so on. That might result in a garda being removed from the community for up to a day or maybe even two days, depending on the size of the seizure and so on. The local community then misses that garda for those couple of days while he or she does that really important drugs policing work. What they really want to see is high-visibility policing and people walking around the area. People might have seen the "Prime Time" programme that looked at drug dealing in the Ballymun area recently. What people were really looking for from that was visible policing that discourages people from gathering and disperses crowds and so on. That is one thing.
Another thing is that we know that some attempts have been made at grooming legislation to make it an offence to groom people for criminal offences. We would like to see that go further if possible and be much more specific on the offences surrounding organised crime and drug dealing in that area. Those are two things straight off.
In addition, a lot of money has been removed from youth services funding since 2008 and there has not been any particular visible increase in that funding. That needs immediate restoration.
I thank Mr. Greaves for that. We have been calling for community policing. The community gardaí in my area are really good; there are just not enough of them. When they are out on the beat they engage and have conversations with young people but they cannot be everywhere at the same time and there are just not enough of them. The gardaí themselves are feeling that frustration.
Residential services were mentioned. One of the things is the continuum of care. You know yourself: if there are gaps in services, people will fall through those gaps. Cuan Dara is a primary methadone detox service down the road from me, in Dublin 10. People were moving from Cuan Dara into the Keltoi unit in St. Mary's, in the Phoenix Park. Keltoi closed during the Covid pandemic and has not reopened. There is no timeframe for it to be reopened. Have the witnesses seen that or seen a lack of rehabilitation services as a barrier for people from exiting addiction?
Ms Katy MacAndrew:
There is definitely a plethora of services closing during the Covid pandemic. In Ballymun many of our staff were redeployed. We tried to leave core staff in the services but it was very hard. As for case management, we could not even get hold of other agencies, particularly early on, until things got sorted out, so there was an absence. It was a feeling of tumbleweed, in that everyone had gone. Clients were trying to access services. They were trying to come into recovery or trying to address their drug use. It was really difficult to take new referrals. We had clients coming into us saying they had gone to X, Y and Z but could not get a hold of people, so there was confusion. There was definitely a sense of everything closing. It was not until a little later that we were told we were essential services. That was a bit unclear at the beginning. I understand why but there is a big lesson to be learnt from this that we are essential services.
One of the problems is that such services have closed and have not been reopened yet. There should be no reason they should not be reopened now. People are finding that really difficult. As the witnesses will be aware, there is sometimes only a small window of opportunity when somebody is at that moment in time and ready to look at their addiction in a worthwhile way. I thank Ms MacAndrew for her response.
I have a little time left so I will speak to the representatives from Alcohol Forum Ireland. We had a similar initiative in Clondalkin on combating alcohol abuse when I was out there. I know Ms Leonard did not get a chance to discuss her recommendations at the end because of time constraints but one of our findings was the saturation of alcohol advertisement that was going on, especially in sports. For example, during the last Six Nations match between Ireland and Scotland, there were 690 alcohol ads, one every 15 seconds. I read Ms Leonard's report before this meeting. She said one of her recommendations was to implement the Public Health (Alcohol) Act in full but does she see a reduction in alcohol advertisement as part of the solution?
Ms Paula Leonard:
Absolutely. We know that alcohol advertising has a huge impact on people's consumption patterns and the decisions they make. It has a particular impact on young people. Young people are particularly susceptible to the lure of alcohol advertising. The Public Health (Alcohol) Act contains some measures on alcohol and advertising, some of which have been introduced. They are really welcome and we very much support them.
In the case of alcohol, we know it is necessary to do many things at the same time. Things must happen in the area of alcohol advertising, but we also must see the introduction of minimum unit pricing, which is scheduled to come in early next year.
The other worrying thing regarding alcohol advertising concerns the provisions in the Public Health (Alcohol) Act 2018. Senator Black will be all too familiar with those and she worked hard on that agenda for many years. Our worry is that those provisions relate to place-based and physical advertising and advertising in traditional media, such as on television. Alcohol advertising, however, has moved online rapidly and our children are living digital lives. As a member state, Ireland has an opportunity, until November, to support measures in the new global alcohol action plan and we must see intergovernmental action on agreements to address children's exposure to alcohol and alcohol advertising online. These are interactive and attractive advertisements, and young people share them. We must, therefore, see that this issue is dealt with.
Another worrying thing regarding what is having an impact concerns the recommendations in the report of the night-time economy task force. I refer to a proposed extension to the hours in which alcohol can be sold and that it may be made easier for certain venues to access an alcohol licence. Those aspects do not relate directly to alcohol advertising but they are things that all members present and all Members of the Oireachtas should consider and have a position on when the proposed sale of alcohol Bill comes before the Houses for debate early next year.
I thank the witnesses for being with us. The opening statements and submissions have been excellent. I thank the witnesses for them.
To continue the point made by Deputy Ward regarding advertising, Ballymun is only a hop, skip and jump over from my constituency, where temporary gambling advertising for particular events is a major problem. Gambling services are using their own buildings. They are well aware that they are breaching planning permission regulations, but these advertisements are temporary and there is plenty of time to take them down within the confines of the current legislation. This is an ongoing issue.
Mr. Cooney brought up the next issue I wish to address. I refer to the intersection of alcohol, gambling and addiction. How has that played out during the Covid-19 pandemic? In our services and legislation, do we recognise that intersection and interaction between the two issues enough?
Mr. Gerry Cooney:
Perhaps not, and this is an important point. We are always interested in trends and what is presenting now is a close overlap between people struggling with alcohol and gambling. On the issue of advertising and marketing, and this is a personal hobby horse, it is incredible what the gambling industry is getting away with in this regard. The situation must be regularised and addressed urgently, because we have noticed from our contacts and calls that online gambling is one of the subjects where there has been quite an increase since the beginning of the pandemic.
I completely agree. I can only speak from the experience of my constituency. Mr. Greaves raised the issue of increased violence associated with drug debts but I see that with gambling as well. Increased societal unrest seemed to arise during Covid-19 from that issue too.
Mr. Gerry Cooney:
Very much so. It is part of the issue raised by Ms Leonard earlier. I refer to the secrecy associated with staying at home and being online. Gambling is extremely seductive anyway but online account gambling and the lack of tell-tale signs is a real worry. It is especially an issue for young people. There is no regulation of age range online and young people can open accounts. We have heard stories in the Rutland Centre of people as young as 16 and 17 years old accessing gambling forums easily, and even accessing their parents' credit cards on occasion, without any oversight. It is a major issue and one we cannot ignore.
The issue of younger people was touched on and I am sure those representing Ballymun, and everyone else speaking here, will have had experience of this issue. When we are talking about grooming in this context, we are talking about young children being involved. Some research implies that children being included in the drug trade can be as young as ten or 11 years old. Can we explore how that aspect relates to services? I ask that question because there is a difficulty with policing and in services when dealing with children of that age. They are, however, being introduced to a whole world of addiction early on. How do each of the witnesses' services address this challenge?
Mr. Hugh Greaves:
Yes, it is done consciously. We are aware of this, and in our local area we have tried to link up all the local, statutory, youth and social services with An Garda Síochána in a network to try to pool the experiences and information we have as much as we can. The general data protection regulation, GDPR, has made that difficult to do in a constructive way. It has got in the way of people sharing concerns and we have had to cite the Children’s Act sometimes in respect of that taking precedence over the GDPR issues in serious cases. We have tried to undertake our efforts in this regard in a local setting but a vacuum still exists. Someone needs to lead on this at a level that involves different communities to say that this is the main issue and that children are being criminalised before they get to secondary school.
Mr. Hugh Greaves:
Yes. To touch on the crossover between gambling and drug use, in recent work we have identified a group of young men aged approximately between 20 and 29. It is a group with that sort of age profile. Much of the time they have jobs, and may be driving vans and working on sites. These young men have serious cocaine, alcohol and gambling issues. People are being sucked into a vortex of problems. Then they present at services with all sorts of issues and they do not know which way is up. There could be family issues, debt issues, drug debt issues and resulting threats of violence. When we look at these issues at a community level, it is sometimes possible to see things not visible at a national service level or in a psychiatric service. These patterns that happen all at once can be seen at the local community level and that is why there is such a need for the local partnership approach provided by the local drug and alcohol task forces. They bring people together, and once information is pooled, action must be taken when the problems become evident.
That makes total sense. The local drug and alcohol task forces are doing incredible work.
I have several questions on staffing. I will ask all the questions first and then whomever wishes to answer can come in. Ms Leonard will want to address some of them, I am sure. We have heard in this committee before about the difficulty regarding staffing in some roles, such as psychologists, for example. Several of the witnesses raised this issue of staffing. What are the barriers and challenges which exist? Is it particularly difficult to attract staff to certain disciplines? What are the barriers and difficulties in respect of recruitment? Ms Leonard's submission referred to midwives and their training in respect of drug and alcohol liaison. How many of those do we have? How many are working now and how many should we have? What should the complement of staff be in that role?
The next subject might overlap with the issue of capital funding. We talked about capital funding for premises, which I absolutely accept. Do we need capital funding for other infrastructure? We are moving online with some services and, hopefully, we will hold on to some of those online services that we put in place to address Covid-19.
Is there a need for capital involvement in that kind of infrastructure? Does that require its own set of staffing that would not have been there before?
Ms Paula Leonard:
I thank the Deputy. I ask Dr. McMonagle to come in because there are a number of matters we could discuss in relation to staffing and additional resources. One issue we as a charity would like to raise is the lack of a national rehabilitative framework and supports and services for people impacted by alcohol-related brain injury.
Dr. Helen McMonagle:
I am thankful for the opportunity to address the committee. I am here to represent the needs of people affected by alcohol-related brain jury. Our experiences of the Covid-19 pandemic brought into sharp focus the extensive health and social care inequities that exist for this group. While many other groups experience reductions, changes or delays in services being delivered, for the vast mast majority of people with alcohol-related brain injury the pandemic highlighted further the absence of any specific resources for the group across the island of Ireland. That is perpetuated by a lack of specific provision for this group of people who have dual needs in the area of addiction and around early identification, management and rehabilitation of their brain injury. There is a dearth of services that meet both of those needs simultaneously.
We know from models of best practice internationally that multidisciplinary neuro-rehabilitation teams are best placed to meet the needs of people with alcohol-related brain injury. That involves intensive input from addiction services and input from psychology, occupational therapy, social work and neuropsychiatry. We do not have that capacity at the moment. Those difficulties are reinforced by the lack of a specific policy or strategy that recognises the needs of people with alcohol-related brain injury. We spoke before the health committee in 2019 and made a recommendation for the establishment of a multi-directorate national working group that could come together to tease out the barriers we experience extensively in relation to alcohol-related brain injury across the island of Ireland and try to find a means of moving forward in mapping out clinical care pathways for this condition, identifying resources required, putting business plans together, getting them funded and getting services up and running. I very much reinforce the recommendation about the need for that national working group.
Ms Katy MacAndrew:
I stress the importance of supporting staff emotionally and psychologically through Covid. Staff are trying to work with emotional regulation with clients. If staff are not regulated properly, that is an issue. We increased clinical supervision during the Covid period. Staff needed it, particularly initially and halfway through. We saw that was a good way to increase the supports clients got. If the staff were regulated, the clients could co-regulate with them. Supervision, in terms of making sure staff were really supported, has been crucial.
I welcome our speakers online and in the committee room. Some of the statistics and impacts mentioned have been shocking, particularly in the areas in which the witnesses are experts. I thank Ms Leonard from Alcohol Forum Ireland, Mr. Greaves, co-ordinator with Ballymun local drugs and alcohol task force, and Mr. Cooney, senior addiction councillor at the Rutland Centre. They have given a stark outline of the impact of alcohol and drugs on people, including young people. I represent rural and regional areas in Roscommon and east Galway but there is a lot of alcohol and drugs in towns and villages around Ireland as well as in our urban centres. I lived for many years in Dublin. I lived on the North Circular Road close to Summerhill and worked in Glasnevin. I went to the swimming pool in Ballymun and worked part-time job in Finglas many years ago. I worked with communities there and know the strength of community and the pride in that area. I also understand the immense challenges that face so many people, including young people, in that area.
Ms Leonard spoke of the impact of 24-hour drink delivery on young people. The culture and attitude to alcohol can be dangerous. I have checked and confirmed, as Ms Leonard mentioned, that a new scheme of the sale of alcohol Bill will be published by the year end. Ms Leonard raised restrictions on delivery and easy access to alcohol and those are key points. I know they are considering those in putting the Bill together. We will probably have more opportunities to discuss that later this year. She also highlighted the global alcohol action plan and the World Health Organization. I think she mentioned the SAFER initiative. Those are all key points.
Mr. Greaves mentioned the breakdown of family connection during the lockdown. The influence that older members of families such as grandparents had on younger people has been crucial. Maybe those connections have been lost. I am sure grandparents play a huge role with young people, through childcare and everything else, from a very young age. He spoke about safe community spaces to study and access to devices. Funds have been allocated through the education and training boards, ETBs. I am curious about how that is being promoted within the area. Are families able to access any of that? How do family resource centres operate in Ballymun and other urban areas? How are those linkages happening?
Ms Leonard spoke about domestic abuse, the parent helpline and coping mechanisms. It was said the evidence is the rise in requests for barring orders. Now that society is opening up again, are changes under way or is domestic abuse continuing at the same level? Are we seeing the same rise in barring orders and engagements with the Garda?
Dr. McMonagle mentioned the multidisciplinary area. I worked in health innovation and so on. How is she linking in with public health under the community healthcare organisations, CHOs? I assume it is CHO 1 in her area. I have had loved ones who have gone through alcohol abuse. Locally, I am working with somebody whose partner increased their drinking throughout the lockdown and is now dealing with early onset alcohol-related dementia, which is incredible. That person is probably in their late 50s and it is having such a toll on the family, as well as the person enduring this. Dr. McMonagle mentioned the national working group and talked about mixing addiction psychology and neuropsychiatry services. Will she expand on that a little bit?
What is strong with Mr. Greaves's group is that he mentioned it is a mix of residents, a task force, which is dealing with associations and local representatives.
Promoting those areas might be strong for their local community as well.
Mr. Hugh Greaves:
As I said, we are a partnership of agencies. The local family resource centre is one of our partners. Throughout lockdown, family resource centres were very involved with families delivering food. They would have provided services like communion dresses for families so there is a great connection to families that really needed it through using those as a means of engagement.
Mr. Hugh Greaves:
Families obviously benefited from not having to spend €400 or €500 on a dress. Removing that took away one of their big connections with the families that really need that support. The food deliveries became significant. Agencies partnered to access food banks and get to people's doors. They continued. If anything, it showed there is a need for move investment in family resource centres. They are on the ground in local areas they need to be in and they do provide that-----
I was just reading while Mr. Greaves was speaking and I remembered he said how the task force connected with walk-and-talk sessions and balcony chats. I thought that was so innovative. It really got out there and into the communities. I thank him for all that work.
Ms Paula Leonard:
The last speaker emphasised the fact that she represents rural areas. It is really important to acknowledge that as part of Alcohol Forum, I delivered across the Border counties with the exception of Louth. It encompassed Sligo, Leitrim, Cavan, Monaghan and Donegal. Those counties along the Border necklace in the Republic of Ireland have twice the national rate of poverty according to the new spatial data that has come out. The poverty rate is roughly 22%. There were downsides, include isolation, increased drinking and problematic drinking. We do not know what the long-term outcomes of this will be as a result of Covid. However, there were also some innovations. We talked about the balcony chats. Probably not many people in our area had balconies. What we have seen is that our experienced family practitioners pivoted to online delivery and phone support. One of our programmes is called HOPE, or Have Only Positive Expectations, which involved meeting with families in crisis throughout Covid. It was a six-week evidence-based programme. We found that we were able to deliver that programme to people in rural areas who otherwise might not have been able to attend in person. The future needs to be blended. We need to think about other innovations for rurally dispersed and isolated families who may experience different types of isolation so we need to look at some opportunities in the future.
It is essential that three things happen with the proposed sale of alcohol Bill. The first is that we provide for drink deliveries. Part of that will require us as a country to look at what proper age verification looks like. There is an opportunity in that to also look at proper age verification for online gambling, as has been raised here this morning. That is really important. At what point do we do it, how do we provide information around identification and age verification online, are there secure ways of doing that and how are we protecting young people?
I also want to talk very briefly about what we are very concerned about at a community level. We are concerned about a number of the recommendations in the report of the night-time economy task force report. There is a lot in it that is really welcome. It is saying that we want to have a night-time product that is not overly dependent on the sale of alcohol or chaotic drinking. However, there are provisions within the report that recommend an extension of the number of hours alcohol is being sold and the number of venues in which alcohol is sold. That completely goes against the grain of all of the international evidence that the WHO would cite that basically says there is a fairly simple relationship and that if one increases the availability of alcohol, one will increase the harm from alcohol. There will be increased hospital admissions, increases in antisocial behaviour orders and increases in night-time violence. It is really important that after today, people consider what actually ends up in the sale of alcohol Bill and what we can leave out. I really welcome the fact that Government is considering consolidating alcohol licensing law. This is something that really needs to happen so that communities, An Garda Síochána and licence holders are very clear around what is in the law and what their responsibilities are.
I think my time might be up and I am conscious that we must allow other speakers in. I know Ms Leonard is very passionate about the topic. Indeed there are high levels of poverty and disadvantage in my own area so it is fairly crucial. E-health, or how we engage with people using telehealth, will be so important. We need to maintain webinars and online access, particularly for rural areas.
Dr. Helen McMonagle:
In terms of the multidisciplinary and interdisciplinary approach required for alcohol-related brain injury, while addiction services and acute services have a crucial role to play in the prevention and early identification of this condition, meaningful rehabilitation, sustained recovery, quality of life and supported independence will never be achieved without the inputs of specialists in neurorehabilitation. Addiction services and services for brain injury or neurorehabilitation exist as distinct service entities with little cross-sectoral collaboration. This cannot continue. Brain injury teams and addiction teams working together could provide the core skills required to provide ongoing rehabilitation and support for this condition. I know we are here to talk about addiction but the reality is that addiction is causing brain injury. As many as 35% of people who are dependent on alcohol will develop an alcohol-related brain injury. Between 24% and 50% of traumatic brain injuries are caused by alcohol. Those of us working in the addiction sector have a really important role in advocating for better provision for people who develop brain injuries and we need to have a really strong desire to be neuro-informed given the prevalence of brain injury within our services. We need to be willing to play a role in advocating for greater provision for people with alcohol-related brain injuries.
Brain injury and addiction services are chronically under-resourced, particularly brain injury services. I believe the Government needs to address the chronic under-investment in neurorehabilitation as a whole, which is a persistent barrier for people with all kinds of neurological conditions, including alcohol-related brain injury. I would mirror calls from other agencies, including the Neurological Alliance of Ireland and the Disability Federation of Ireland, to address the significant dearth of appropriate regional residential and localised neurorehabilitation services. These specialist services constitute a really important component of recovery from alcohol-related brain injury. What we are talking about here is a condition that has a high potential for recovery. Over 75% of people with alcohol-related brain injury can make some degree of recovery while over 85% of people can be supported to live independently in the community. What underpins that happening is the provision of specialist residential rehabilitation and this is best supported by joint working arrangements between brain injury services and addiction services.
The Senator mentioned the national working group. I do not want to oversimplify the issues associated with alcohol-related brain injury. They are complex and nuanced and are influenced by a myriad of interconnected and interconnecting systems. Most fundamentally, that social problem is a product of a network of cause and effect between multiple different systems. If we want to act to improve the responses for alcohol-related brain injury, we need the co-ordinated action of many people, systems and directorates working in a networked way across different organisations in different service areas.
That is what we need to progress with the national working group. We need buy-in from mental health, social inclusion and disability services to begin a conversation about the key barriers that we are experiencing with regard to alcohol-related brain injury.
I thank Dr. McMonagle. I appreciate it. I apologise for interrupting. Time is tight. Research pilots are crucial here. Funding does not just arrive automatically for multidisciplinary groups. We need to show the evidence behind it. I ask for a response at a later stage about what groups are engaging with universities within our departments of health, nursing and so on with regard to building this multidisciplinary group. What access to European funding is there to build a pilot that we could roll out in a particular CHO, working with the HSE, our colleges and with key researchers? That is the way to start the ball rolling.
I thank everybody for their statements. The last 18 months have been a significant challenge for everybody, especially for addiction and community services. Those who were in the throes of addiction prior to the pandemic would have found the last 18 months extremely difficult. I am sure that people found themselves addicted to something that they were not addicted to before the pandemic too. The witnesses may have seen that manifest in the services in the community. That could be a range of things including alcohol, drugs and gambling, in particular, because more people were staying at home. The rules of engagement and the game have changed in the last 18 months and have probably changed everything that we experience for a considerable time.
My questions are primarily about the Ballymun task force. Nobody has mentioned this today. I am an advocate for having a different debate about addiction and drugs. I am not saying that people are advocating for it here, but you cannot police your way out of the situation. We need to have a different debate about decriminalisation of the person rather than of the drugs. We need a debate about the regulation of drugs. We have had an ongoing debate about decriminalisation. It suits the political establishment to let people and communities rot, in some ways, because it does not care, since it is not on the establishment's doorstep. That debate needs to change. It needs to start with looking at different models, at how we treat people and the way people take drugs. People take drugs for all sorts of reasons. This merry-go-round of vast resources going into criminalising people and all that simply does not work in my eyes. It is a waste of resources. I have a question about the task forces. How would they view the decriminalisation model? There is evidence from Portugal that decriminalisation saves lives and takes people out of the criminal justice system, with better outcomes for everybody.
I have a question which goes beyond decriminalisation, which I think we need to go beyond. It is about regulation of some drugs. Criminalising people for cannabis use is a waste of time. There needs to be a regulated system where people are not criminalised or sanctioned for cannabis use. I would like to hear witnesses' views.
Mr. Hugh Greaves:
The Deputy asked for the task forces' view. I cannot give that view because each task force represents its own range of community services and local people. There would be a general welcome of a debate. In the recent drugs strategy, there is a health-led approach so that people with first offences for drug possession will have a health intervention rather than a criminal intervention. A diversion system is being introduced, which is welcome. The issues that I raised at a community level about the disruption caused by drug dealing in a local neighbourhood will not be dealt with by a discussion about criminalisation or decriminalisation. We need community policing to make those communities feel safe, reassured and so on. I think a discussion of it would be generally welcome. It is a complex issue. Even decriminalisation of cannabis presents all sorts of issues relating to psychological damage done by the strength of the cannabis products that exist. The way they are currently sold is a concern, with cannabis edibles that people get, including deliveries from sources on the Internet of jelly babies that are cannabis-infused and so on, which has led to damage for children. There was some publicity about that recently.
Local communities demonstrated their view of how they feel about criminalisation or decriminalisation when the head shop debate happened a number of years ago. I remember a protest about a shop in Enfield where people voted with their feet and it closed down quickly because people saw that there was no place for it. That is reflective of the complexity of some of the issues. For example, if alcohol was a brand new product and was introduced in Ireland, there is no way that it would be introduced as an unregulated, free-for-all substance that anyone can access because of the damage that it does and the lives that have been lost year-on-year. It would be introduced with strong regulation. The issue of decriminalisation needs to be carefully debated. We have not seen the research about what legalisation, as has happened in parts of the United States, will do for psychological health for young people in states such as Colorado.
Ms Katy MacAndrew:
We have started the trauma informed approach in the community in Ballymun. All of the agencies, both statutory and non-statutory, are involved and we are starting to gain momentum. That is an offshoot of decriminalisation and a more compassionate way of understanding why people use drugs and alcohol. We are trying to get the gardaí involved in that too. It is separate but part of what the Deputy asked about with regard to how we look at substance use. People in some services or agencies do not really understand this. There has been substantial buy-in to the Ballymun trauma informed approach. It is in the early stages but it is happening. It is a subset of the decriminalisation issue.
Mr. Gerry Cooney:
This is more a personal point of view. I come from an abstinence model but I have friends, colleagues and family who might have a different view. I can only share my own experiences. I always say that if people can take and leave cannabis or so-called recreational drugs, I do not see them, but I see many people who have significant difficulties as a result of extensive cannabis use. For that reason, I find it difficult to support a suggestion of decriminalisation. That is a personal view. My colleague, Ms Bryans, might have her own views.
Ms Serena Bryans:
I share that view. Evidence is emerging that there is a link, especially in young men, between cannabis use and psychological difficulties.
As Mr. Cooney said, if there are people who can take or leave them, we do not see them. We see the people who cannot, in addition to those who may not present to us with cannabis as a primary issue, but cannabis is often where they started.
I have to say I found some of the contributions slightly depressing. I mean no disrespect to people but some of their views are quite out of date. There are myriad views on regulation or deregulation but, at the moment, and this cannot be disputed, we have a situation where all the drugs we speak about are illegal to have and possess. Can anybody say to me, with a straight face, that the Misuse of Drugs Act 1977, which was meant to control those drugs, has done so? There is no control or regulation. One has a situation where the black market has filled that vacuum and has done all sorts of damage to communities. Can anybody seriously say to me that that system works? It does not. Anybody who says that it does is fooling themselves. The present situation is unsustainable and is costing thousands of lives every year because of the lack of political will from many people in Leinster House. That is a fact.
I will come in here. The discussion today is about the impact of Covid on addiction services. I hear what the Deputy is saying, and while it is a discussion we need and there absolutely needs to be more debate and engagement around the issue, we are veering off the topic for today. We need to bring the issue he raised to the committees on health, mental health and justice. I totally hear what he is saying and I understand his frustration, but we have to move off that topic because today is about the impact of Covid on addiction services. I hope that is okay. I appreciate the Deputy making the point, but we have to move on.
I thank the witnesses for their honesty. I will try to keep it brief. We are talking about the impact of Covid. My first question is very simple. If the witnesses could predict the future, do they envisage a bigger demand, or a tsunami of demand, on services within the next 12 months? I ask that because when it comes to addiction and mental health problems, it takes people who are stuck in that rut time to realise they are in trouble. Most of the time, unfortunately, it is when they are in too deep. It is only then, if they are lucky enough to have the support of family and friends, they will try to access help.
Deputy Ward mentioned alcohol advertising. We see advertising with graphic images on packets of cigarettes to try to discourage people from smoking. Is there a barrier, or is it due to lobbyists within the alcohol industry, to facts about the side-effects of alcohol misuse being advertised? It is okay to have a cigarette. People like a cigarette even though they know it is bad for them. It gives some people peace and solace, as does a social drink. I ask that because the educational factor is more important since prevention is better than cure. The Samaritans were in front of the committee a number of weeks ago. They go to concerts to give out information on drugs, drink and so on. It is about getting information. Do the witnesses get supports for any campaigns like that? This is the national side of it. Dr. McMonagle talked about supports and joined-up thinking. What are the supports for a national body? I take it the Alcohol Forum covers the 32 counties. Is there a slight difference in the attitude to health, and helping and getting supports in, within the Six Counties compared with here?
The issue of supporting staff in all the centres was mentioned and it is vital. I am glad to hear they are getting support and are looking after their staff. I recently spoke with a Samaritans' volunteer. As I said, we had a very in-depth discussion with representatives of that organisation at the committee a number of weeks ago, but I still did not pick up on the fact, until the volunteer said it to me, that the volunteer could be the very last person a caller at the other end of the line talks to before they die. That is a very serious scenario. When the witnesses talk about community-led initiatives, what is the vision? There used to be a stigma around suicide, which is probably still there in certain sectors for obvious reasons. How do we destigmatise the fact that people have an alcohol or drug problem, so they are not victimised when they go to seek help? That is a major issue.
The Garda was mentioned, which is overstretched and under-resourced, including in community policing. What about getting information into youth clubs? How are schools dealing with this? Are they willing to come on board? It is a campaign where information, and letting people know, is key. Not everybody will be stopped. I am a smoker. I hate smoking, but I am addicted to it. Not everybody will be stopped but if I at least had the opportunity, a long time ago, to know the facts about it, I may never have taken it up. I know there is a lot in that but I will not come back in.
Ms Serena Bryans:
I thank the Deputy for that question. I welcome the opportunity to address some of the issues he raised. On whether we are facing a tsunami, we are already in one. We certainly have seen that in the Rutland Centre with the number of phone calls from desperate people, who are desperate to get a place where they can address their addiction. We are a 16-bed facility, so we are constantly in a state where we have a waiting list. As part of my work there, I worked in assessments, part of which often involved ringing other services to see if there were any places or any way to help. It is the same with those services ringing us. We just do not have the facilities, beds, supports and infrastructure in place to deal with the tsunami that is already here. There is a larger one coming and I am sure all my colleagues here will agree with that.
To come to some of the Deputy's other points, and it is something very close to my heart, my colleagues and I are all reacting to people who are looking to address addiction. We are in a very reactive space much of the time. When people come to us, we deal with them however our supports allow us to and then we send them back out into the community. It is what happens to them then that is also falling down. I ask the committee to also take a broader view that is not just about what we can do within the services, and the reactive response to addiction, but looks at it in a broader way.
The Deputy spoke about stigma, which is very real. If people say they are "in recovery", and my colleague Dr. McMonagle used that term to refer to recovery from brain injury, that is perceived very differently than a person saying he or she is in recovery from addiction. For example, if people say during a job interview that they are in recovery from a brain injury, they will get a very different response, I would imagine, than if they said they were in recovery from addiction. Part of that is due to a lack of education because people do not understand what being in recovery from addiction means. I ask the committee to consider the broader aspects of that. Again, education is part of it. It is really about building recovery capital at a personal, community and wider country level, so that people who have addressed their addiction and are moving into recovery have the recovery capital to allow them to continue on that journey. Education at school level is a very basic start for that so people can understand, be educated and, therefore, addiction recovery can be destigmatised.
Visibility is also important. It was National Recovery Month in September and we need a lot of visibility for such initiatives. My colleagues said earlier that young people are seeing what drugs do and they are seeing the perceived good stuff that comes from them such as the fancy shoes, clothes and jewellery. Recovery and what it looks like does not have the same visibility. If there is an enticement to go into drug dealing or criminal behaviour then recovery does not have the same enticement. We need investment to see that change.
Mr. Hugh Greaves:
I refer to information and education. The experience of our many different issues over the years has been that information on its own does not change behaviour. Motorbike helmets, seat belts, cigarettes, alcohol and speeding all had information campaigns that did not do anything until regulation was brought in that helped people make those changes. There are a number of areas where information is welcome, as are school programmes when they are done in a structured way but on their own those measures do not bring about change. We are all aware that the drinks industry in particular loves information campaigns because they do not have any impact on their profit margins. We welcome education and information campaigns but they are no replacement for proper regulation on advertising and drink deliveries, etc.
On my behalf and on behalf of Sinn Féin I thank the witnesses for the work they did during Covid, from working with people who are in active addiction and the challenges Covid posed to provide the services to helping those people in their recovery journeys. It was a major undertaking and, without being dramatic, the organisations represented today certainly helped to save some peoples' lives and keep some people in recovery. Unfortunately, from what we have heard, many people might have relapsed. I thank the witnesses and everyone who was involved in that work; they are owed a debt of gratitude by the country.
I will go to Ms Leonard and Dr. McMonagle. Dr. McMonagle touched on alcohol-related brain injuries. Is there more the Department could do on that? Ms Leonard discussed some of her recommendations and I ask her to elaborate on how she would like them to be implemented.
Dr. Helen McMonagle:
I thank the Deputy for his questions, some of which relate to previous questions. I might pick up on the chronic underinvestment in rehabilitation, which is an area the Department could address. Specialist rehabilitation units are important but we also need to recognise that people will eventually move on from them. They will want to live in the community, live independently and reach their full potential. There needs to be a wider provision of personal assistant and home support hours in assisted living accommodation with wrap-around supports. I welcome the announcement from the Minister of State, Deputy Rabbitte, yesterday of the additional 120,000 personal assistant hours as part of budget 2022. It is paramount that those with alcohol-related brain injuries are afforded accessibility to these additional resources. Without such support the long-term rehabilitation and the maintenance of gains made through any efforts or in specialist rehabilitation will not be sustained. That is an area we would look for support from the Department on. I also refer to the importance of the establishment of a multi-directorate national working group. Ministerial support around that would be crucial in driving that forward.
Ms Paula Leonard:
I might pick up on a couple of the other points that were raised previously as they relate to the Deputy's points. In the recommendations we talked about many of the people who are appearing today being in the crisis intervention and service delivery spaces and dealing with the size and magnitude of the issues that are impacting families and individuals. The Deputy asked about what needs to happen. If we circle back to what Deputy Gino Kenny said, we recognise that there is a need for an informed debate that is based on research and good evidence and that is not based on opinion or strong belief. We need investment in youth work and the restitution of youth work budgets to at least what they were in 2018. The guests from the Rutland Centre have also emphasised the need for investment in family supports and any step-down care and after-care, which are essential. We have talked a lot about the impact on the individuals who are struggling with dependency and on the people who live around them, the people who love them and the people who care for them, and I am glad we did so. We know there is great potential if we support families. People have a right to recovery in their own right but families can also motivate their loved ones towards recovery and support them on that journey.
The UN has described the impact the Covid pandemic has had on children as perhaps being even more significant than the impact the pandemic itself has had in the coming years at a global, health and well-being level. We do not yet know what those outcomes will be but we know that children in homes where there are pressures, such as poverty, social exclusion and dependency, live under huge pressure every day. They have done so for a long period; we are 18 months into this pandemic. We need investment in children, youth work and family support. That needs to be a specialised family support that understands addiction. That is important and I know a lot of the people here today understand the work that goes on in that area.
I appreciate that. What the witnesses say is important and it is taken on board. I would like to ask our guests from the Ballymun Local Drugs Task Force about the priorities in the national drugs strategy. Have they seen them? Are those priorities the same as those of the task force? Do they have thoughts on the priorities as they have been outlined?
Mr. Hugh Greaves:
The priorities are sound and good. The priorities of the drugs task forces have been emphasised to the Minister of State, Deputy Feighan. Major budget cuts were imposed on the drugs task forces and on youth services that work hand-in-hand with the local drug services in 2008. Those cuts have not yet been reversed, by and large. In recent years we have had money for new initiatives, which is welcome and which has led to some interesting projects being developed, but there has been no restoration of funding at all. There are major sustainability issues for projects. Rent, insurance, fuel and so on have gone up in price and there has been no recognition that there is a need to increase the budgets for the drugs task force projects that are in place. That is the one thing the drugs task forces would be unanimous in saying. The priorities are fine as they are but there is no recognition of the need to support what is there.
New initiatives are built on what is already there rather than letting them collapse, which would leave us in a different position altogether.
On the question of task forces, from meetings I have held over the past 12 months with different groups, each of them has said what the witnesses have just told us. There is the matter of funding going back to 2008 levels either for task forces or youth work. How frustrating is it for the groups here today, working on the front line, in trying to provide services? Much of the new funding is being specifically allocated so task forces do not have autonomy to deal with matters in their local area. The Department gives them money for a certain project, for example, but each task force needs funding to tackle problems with services specific to them. The groups I have spoken with have been very animated and upset by this. The task forces are key and if we support them and give them the funding and help they need, they will deliver locally in their areas.
The representatives from the Rutland Centre made some good points on addiction, particularly with regard to gambling and the various links in that respect. Last week I introduced a Bill to the Dáil that would ban the use of credit cards for gambling online and in shops. It is only a small step and we need the Government to bring out its gambling control Bill, along with the appointment of a gambling regulator. There was a small mention of this in yesterday's budget but it looks like the earliest that measure will be implemented will be 2023.
My colleagues and many of the witnesses have spoken about the many issues involved with this, including age verification, whether that is for alcoholic drink delivery or children going online and being able to gamble for two or three days before they must verify their age. Over the summer I published a strategy to combat gambling and, at a minimum, there should be no advertising for gambling before the watershed. As a father with two young children but also a person involved with GAA and youths in my community, I am aware that children are vulnerable and are being targeted by the likes of alcohol and betting companies. As Ms Bryans spoke about this earlier, perhaps we could get some more of her thoughts on the matter. Some of the points she made were excellent.
Ms Serena Bryans:
Some of the diversion from antisocial behaviour is often into sports. People think they will put their kids, whether it is a son or daughter, into GAA or some other sport and they will be safe. In some respects they are but we see many people coming to us, and young men in particular, who gamble primarily because they have been involved with sports. They also have problems with cocaine, with one offsetting the other. Cocaine use takes these people away from the worries caused by gambling, for example. It is a very real issue and it absolutely must be addressed.
Mr. Gerry Cooney:
The Deputy mentioned small steps and all those small steps are really important. Anything that makes it difficult for young people, especially, to gamble is an improvement. We are talking about people who are out of control. "Control" is an important word that is not highlighted enough. The young people we are seeing who are getting into difficulty with gambling have lost control and anything that takes back that control can only be a plus. Deputy Buckley raised some of these matters earlier too. This is about small but important steps.
That is fantastic. I thank the witnesses. I have been on my phone trying frantically to push out my next meeting so I could stay here and listen to them. Meetings like this and the information we get from them are like gold dust. As has been mentioned, we are the legislators and we can go out to make the necessary changes to make the lives of the witnesses easier in meeting the needs of the communities they serve.
Without getting into too much detail, I will touch on the criminalisation and deregulation aspects briefly. I do not know if Deputy Gino Kenny is still on the call but I represent the same area and he knows from where he is coming. What was said will not fix the problems that the communities are currently experiencing. There are parts of my community experiencing trauma and they feel abandoned by a lack of visibility of gardaí. There are people selling their homes because they cannot live there any more but they cannot complete the sales because people coming to view the properties are being intimidated. Parts of our community need enough visible community policing to solve these problems and allow people to breathe. At that stage, by all means, we can have a debate around criminalisation and deregulation.
Any high-level criminal putting drugs into the hands of a 10-year-old or 11-year-old to make themselves rich must be criminalised. Legislation must be brought in for this.
The Rutland Centre is not too far from my area and I know a few people who went through that organisation. They always spoke well of it. A line from Mr. Cooney's opening statement caught my eye, when he stated "It is also important to mention that the past 18 months have also noticeably brought a growing number of more complex cases among those presenting for help due to the closure of services elsewhere." Will the witnesses expand on that? Do any of these cases relate to eating disorders, as I know the group works with people who have eating disorders? My office has been contacted by many people crying out for help and seeking services for eating disorders.
Mr. Gerry Cooney:
The Deputy mentioned earlier the closure of the Keltoi unit in the Phoenix Park. After that, we noticed an increasing number of inquiries post-detox in Cuan Dara. There was a time when people graduated from Cuan Dara to Keltoi in a seamless and effective way. Since the closure of Keltoi, we have notice a huge increase in requests for places in residential treatment for drug use in particular. That is what I referred to.
There are complex cases involving people who tend to be younger and more chaotic. There may be a number of mental health as well as addiction issues. They are more challenging but at the same time we are eager to respond where we can. Ms Bryans touched on the huge demand for few places.
Ms Serena Bryans:
We are seeing many cases of eating disorders in the Rutland Centre. Mr. Cooney and I work together in the outpatient programme and there in particular we see clients presenting with another addiction and not primarily with an eating disorder. The eating disorder is underneath it or has been in the past. These people may have dealt with or recovered from the eating disorder only for it to come up in an alcohol disorder, drug use or something like that. It is not always the primary problem but if it is not treated effectively - again, there are not enough places in Ireland to deal with eating disorders effectively - it can be put to the side and only to come out in the form of comorbidity with alcohol. We are seeing a lot of that at present.
There was mention of people with mental health disorders and dual diagnoses presenting to the Rutland Centre. We find there is a big gap in this respect all the time. People have mental health and addiction issues and are falling through the cracks. If there are any cracks in services, people tend to fall through them and it is just not good enough.
Deputy Gould and I had a Bill advocating a "no wrong door" policy. This means that if somebody presented to an addiction or mental health service, he or she would get a service at that point and there would be a shared care plan across both involved organisations. Would that work?
Mr. Gerry Cooney:
Every organisation is trying to match people's needs with what services can provide. Sometimes people are directed towards certain centres that are not a position to support the primary challenges. It is about matching needs.
The Rutland Centre does its best to match the needs of people who are presenting in other services. I have a long-term association with Ballymun dating back many years. People are trying their best. There is one thing I wish to say before we finish because it was not highlighted enough. The Deputy asked what would help. It relates to families, and this is something I am sure the Chairperson would agree with given her work with Rise Foundation. The practical challenges Covid has brought in offering family support has been a huge issue, even with regard to people being able to visit centres. We have not been able to involve the families as much as we would like. We always felt that the more support families get, the more support individuals get and the better the outcomes.
Thank you for that clarity, Chair. I am not sure if it was Ms Leonard who mentioned families earlier and the support that is needed, especially during Covid. Mr. Cooney mentioned not being able to engage with families because of Covid when trying to work with people in addiction services or recovery during Covid. The restrictions and the fact one could not meet people in person were an issue. For me, families are the core of helping people on their journey. That is why I believe a national forum is so vital.
Somebody mentioned earlier that we lost 120 rehabilitation and detoxification beds during the pandemic because of the 2 m rule and social distancing. Those have not been replaced. The witness spoke about a tsunami and about people who are desperate contacting the organisation, trying to find a bed and trying to get a person in who is in the throes of addiction. We believe it is urgent that those 120 beds be returned. Then there is the situation regarding Keltoi, which Mr. Cooney referred to earlier. That was a vital service. Now it is gone, and it is a missing link that has to be replaced. With regard to beds, there are waiting lists now of up to six months. We know that is not good enough for anybody who needs supports and services.
There are two questions there. Witnesses might wish to comment on the impact on families and say a little more about that because it has arisen a great deal today. There is also the issue of there not being enough services available, which is significant as well.
Ms Paula Leonard:
It is important that we recognise and acknowledge the tremendous work not just in the past 18 months but also in the past 20 years that regional and local drug and alcohol task forces, charities, voluntary organisations, family support centres and resource centres have done in this area.
We have a number of evidence-based programmes happening in Ireland to support families. We know that skills-based programmes teach families coping skills, understanding addiction, understanding services and how to navigate them and maintaining support for a family when they are going through treatment. All those things are based on evidence. Task forces and voluntary organisations such as mine, the Alcohol Forum, have done significant research and work over ten to 15 years to see what works. We have programmes such as Parents under Pressure. In the Alcohol Forum there is the moving parents and children together, M-PACT, programme. The strengthening families programme is delivered in 18 sites across the country. We know what works, we know how it works, we know how to replay it to families and work with families.
What we do not have is investment in those programmes and enough joined-up thinking about them. Tusla and the HSE came some way and made a major step forward with the publication of a joint Hidden Harm strategic statement, which looked at the impact that parental alcohol and other drug use is having on children. What we have not seen following that is a budget that would increase the availability of the types of programmes and support services that are needed at community level. In Ballymun, and others will be able to talk about this, there are some very effective programmes. I must credit the colleagues who have been working on this agenda throughout the country, but what we need now is investment and more involvement of families in the treatment end.
I appreciate that, and all the people who are working with families. As Ms MacAndrew and Ms Leonard said, this is vital work. I know from my family and friends the importance of having families involved. As Ms Leonard said earlier, there are people suffering the addiction but there are also the effects they have on families. It all has to be dealt with. It is disappointing that, given it is such vital work, the supports and the funding are not being put in place to deliver. We also need to have it tied in nationally. In Cork, there are some excellent groups doing great work. What we want is that type of work across the State for all families who need it. I appreciate what the witnesses are saying and what people in Ballymun and other groups are doing. I thank them for all their work.
Does anybody wish to comment on the issue Deputy Gould raised about the lack of services with Keltoi closing down and the impact that might have had on the addiction community? On the lack of services, I am sure each of your organisations is stretched to the limit. Does anybody wish to say a little about that, the waiting lists and whatever is going on for their organisations?
Ms Katy MacAndrew:
It is a great shame that Keltoi has closed. I am not sure of the circumstances around it. Some of it is a bit of mystery, to be honest. It provided a great service. Community detoxifications have increased as a result of a lack of some of those services, which is interesting. Through a co-ordinated approach in Ballymun there is a high uptake of community detoxification, and that can work well.
Mr. Gerry Cooney:
It was mentioned earlier that timing is very important. There is a window of opportunity for young people in crisis and sometimes if the response is not there with the closure of services, there are opportunities being lost. We see that a great deal. When people come to us there is a window and if the response is not available it is a problem. It is a progressive problem because if a problem is serious, it is going to become more serious. It is not even going to maintain. That is a sad reflection on where we are.
I have a brief question about access to services. We have heard with regard to other aspects of mental health that there is difficulty in getting access to services. This is probably a two-part question. Is it easier to access the witnesses' services than mental health services or child and adolescent mental health services, CAMHS or are they having capacity issues whereby they would wish to provide more? With regard to the marginalised people in society such as people with disabilities or members of the Traveller community, do they use the witnesses' services or is there a gap there because of information or access? I am trying to get the picture because we want to find out what additional resources should be provided because people are, perhaps, being left behind.
Ms Katy MacAndrew:
I was recently asked by the drugs task force to talk to all our service users about accessing mental health services, what the distinction is and how those services work for them. There is definitely a division between the two. Their experience of accessing mental health services with dual diagnoses was that they felt like they were being treated differently. From the interviews I did with people, I know that they definitely felt stigmatised if they were using substances. People whose cases were more serious and who needed to be hospitalised within the mental health system felt that they were given very high levels of medication during that time, particularly if they were suicidal and so on. It gave them and their families respite but they then had to come out and face stuff again. The division that has always been there is still there. I do not know if that answers Deputy Buckley's question.
As I have said in other committees, particularly the Joint Committee on Health, people with disabilities are not sick but they are labelled and put into a particular section because it makes it easier to tuck them away. These people have the exact same feelings and it is just as possible for them to develop an addiction and so on. I hate using the word "disability", but when talking to people who are less fortunate, you always see that they face greater barriers and are treated differently. Ms MacAndrew is right in what she said about medication. A number of years ago, we were spending approximately €10 million on cognitive therapy, play therapy and so on while spending more than €400 million on antidepressants. Is there a pathway to which you can point someone with a disability or who has been less fortunate in their education through which they can access services? Is there a simple one-, two- or three-step process? We hear people talking about online access and so on. That is fine if you can afford Internet services and a computer and if you know how to use them but a lot of these people have been left behind over the years. The Covid pandemic must have been absolutely desperate for them. I keep going back to the disabilities sector but, on a normal day, people with disabilities face challenges even getting on a bus or train or crossing the road at a traffic light. In our own town, we put in a footpath a few years ago. It won a European mobility award because we listened to the services users and then improved the footpath. What would be on the witnesses' wish list for changes to legislation that would make access to all the services they provide easier? That is my final question.
Ms Serena Bryans:
I am not sure I can give that question with the answer it deserves, but I will tell the Deputy where we would come from on it. This goes back to what I said earlier about building and investing in recovery capital. Part of that relates to the destigmatisation of recovery. If people, and particularly those in marginalised communities, can see recovery normalised in their communities and in the country, it would go some way towards helping them to begin to access services. In some of the forgotten communities the Deputy spoke about, there is a particular stigma attached to accessing recovery services. If we can destigmatise that and build recovery capital for communities and personal recovery capital, it would provide more of an opportunity for people to access these services. Again, it comes back to funding, as it has time and time again. Do we have the wherewithal to deal with these people adequately when they access these services? However, the problem at the moment is that they are not accessing the services.
Ms Marie Lawless:
To lead with a pictorial vision, Ms Bryans mentioned recovery month this year. In Ballymun, we made the town purple by placing purple footprints in different areas, going from shops to park benches and other buildings. The idea was to say that, wherever people's journeys start, they will be supported along the way and we will be there with them. With regard to access, the Deputy brought up a really important point. The nature and extent of service user involvement from the very beginning helps to define the nature and type of services that are provided to meet their needs and that are openly accessible to them. Again, it is not necessarily about bringing people to services, but about bringing the services to the community. Covid really put a spotlight on that. We also need to change our practices and have those doors open. That mirror image must be very visible in the community. I cannot remember who, but somebody mentioned getting to people before the issue arises. It is about the community mobilisation sites Ms Leonard referred to, about having those conversations in the community and about the community having ownership and a role in designing those interventions so that, when an alcohol issue presents itself, people will know who to go to because they will remember people mentioning different things. The Covid pandemic presented a really great opportunity for those conversations. Conversation was the greatest tool and resource we had. I just wanted to mention that image of the footprints, guiding people along the way. For next year, we are thinking about purple ladders to the sky.
May I ask a question since Ms Leonard is talking? With regard to alcohol-related brain injury, Dr. McMonagle said earlier that 75% of people who go into treatment can recover. I just wanted to raise that since Ms Leonard was talking. That is a phenomenal recovery rate for a treatable illness. The recovery can be great. Since Ms Leonard is speaking, will she return to that point?
Ms Paula Leonard:
I thank Deputy Gould very much. I will be brief. What Ms Lawless has just said about the importance of communities is really important. Communities can identify problems and issues as they are emerging. They can work across services and build intersectoral collaborative partnerships at the local level. They can bring local government, An Garda, education providers, family resource centres and those working in treatment together to decide what services should look like in the community. We can only do that by listening to people. Ms Lawless has emphasised the importance of conversations. The listening part of conversations is really important. I have done quite a bit and I have learned from my colleagues this morning.
The question raised was on access to services. The people working in the services might be better placed to discuss that. However, there are no services for a number of alcohol-related conditions in this country. There are no diagnostic services for children and families that have been impacted by foetal alcohol spectrum disorder. One cannot get one's child a diagnosis of foetal alcohol spectrum disorder. There is no specialised family support, there is no care and there are no specialised interventions for those families. When we appeared before the Joint Committee on Health in 2019, we talked about the need for agreed diagnostic criteria, for the establishment of multidisciplinary teams and for the putting in place of support for those families who are raising children with foetal alcohol spectrum disorder. It is really important that the Joint Sub-Committee on Mental Health think about the profound impact that foetal alcohol spectrum disorder can have right across a person's lifespan. Some 50% of people who have foetal alcohol spectrum disorder will serve time in jail or will spend time in a residential drug treatment or psychiatric facility. Some 92% of children who have foetal alcohol spectrum disorder will receive a formal mental health diagnosis in their adult lives.
We also know there are 428 co-occurring physical disabilities and conditions that are associated with foetal alcohol spectrum disorder, including epilepsy, heart defects, compromised auditory function or hearing and compromised immunity. It is important to talk about dual diagnosis, access to timely support and intervention for people when they are in addiction. We also need to acknowledge and talk about the complete lack of services for people with foetal alcohol spectrum disorder. I will ask my colleague to talk about the issue. We have the only specialised rehabilitation service for people with alcohol-related brain injury in the country. There are no similar services in the parts of the country other than the Donegal area in which Dr. McMonagle works. We need to see similar services. I will hand over to my colleague.
Dr. Helen McMonagle:
I will pick up on the Deputy's point about the 75% recovery rate associated with this condition. I would absolutely mirror his enthusiasm for investing in rehabilitation when outcomes such as that are possible for what is a serious and significant condition. In the absence of the input of rehabilitation, those issues are contributing significantly to the burden of homelessness. For example, a study in Scotland has shown that alcohol-related brain injury affects 21% of homeless hostel dwellers. It accounts for 10% of cases of dementia, and 12.5% of cases of dementia in people under the age of 65. It contributes significantly to delayed discharges at a hospital level. On the flip side of that, when financial and resource investments are made in multidisciplinary rehabilitation for this condition, between 75% and 85% of people can be living in the community. Hospital bed day usage can be reduced by 85%. Most significantly, the long-term relapse rate is only 10% when such an intensive multidisciplinary approach to rehabilitation is taken. Anybody working in an addiction service or residential service will look at a 10% relapse rate and recognise it as a fantastic outcome, particularly for people towards the more complex end of the spectrum. There are very significant cost savings to be made when we invest in this area. The pay-offs are enormous, including for the quality of life for those affected as they go through their lives.
I have a few comments I would like to make and a question might arise. We have a little more time. Some of those attending this meeting know that I feel the impact on family members is vital. We require an holistic approach with regard to recovery for family members who have somebody that they love with an alcohol, drug or gambling problem. That is important. Dr. Stephanie Brown, who is one of the leading addiction professionals in the world and is based in the USA, has often spoken about children who have been reared in homes where there has been alcohol harm often grow up to be in addiction themselves or get into a relationship with somebody who is in addiction and the cycle continues. It is about breaking that intergenerational trauma that happens for family members but it is also vital to break the cycle of addiction when it comes to approaching recovery as a matter for the whole family. When addiction presents itself within the family dynamic, everybody is impacted. A whole family approach is important. As Ms Lawless said, catching addiction before it gets to a certain point is very important. That is why family recovery is vital when it comes to the individual who is in addiction. It can break that cycle of addiction and the intergenerational impact of trauma, going forward.
I have a question about gambling and process addictions. We are only starting to get an understanding of it and it is a minefield. We know about alcohol and drug addiction and, in a way, we can see it. You will know if a person has taken a substance. However, it is different when it comes to gambling, Internet or pornography addictions, which are going to be a tsunami. Can our guests say a little bit about the impact of those process addictions on the individual and on the family? It is important because people do not understand the impact on the individual who is in that dark place of gambling addiction and cannot stop. Perhaps our guest would like to speak about that.
Mr. Gerry Cooney:
I do not mind sharing my thoughts. Gambling is an issue with which we are very familiar. Apart from the obvious financial implications, the impact on families, relationships and the individual is immense. The secrecy is a big issue, as the Chairman said. The other addictions are obvious and noticeable but because gambling is so secretive, people can get into serious difficulty before anybody else is aware it is happening. As I said earlier, all addictions are very progressive. What might start somewhat manageable becomes less so until it is completely unmanageable. Early intervention, as we agreed earlier, is very important but it is very hard to achieve in the case of gambling. It is a serious problem and we are coming across it more often. The people concerned are becoming younger because younger people have access to online betting and smart phones have increased the accessibility of gambling compared to the way it was years ago. There is something tangible about handing one's money over across a counter whereas tapping on a screen does not have the same connection at all. Unfortunately, people run into difficulties at a serious level very quickly. The Chairman is right that it is an issue that needs attention. It needs to be addressed and acknowledged. As is the case with everything, we need to accept that there is a problem there before we can attempt to do something about it.
Does Ms Leonard feel she covered everything she needed to? I am aware I shut her down at the very beginning. Has she any more recommendations or anything else that she wants to highlight? Does she think she has covered everything?
Ms Paula Leonard:
The Chairman did not cut me off. I apologise for my poor timekeeping in the morning. The Chairman was absolutely right. I have found this meeting very useful and want to thank everybody for the opportunity to come here. The Chairman was talking about process addictions, including to gambling and pornography. I agree with her that many people have been spending a lot of time at home by themselves with their phones. We are not going to see the impact of that until six to 12 months have passed. There is a significant comorbidity in relation to gambling and alcohol addiction. The high-risk behaviours that are associated with gambling are facilitated and enabled by alcohol. We know that alcohol reduces inhibitions around risk-taking and, therefore, the stakes can become higher very quickly and a person can get into trouble very quickly. It is important that we have a comprehensive understanding of addiction and look at it across the board. Some of that conversation has started today and I would like it to continue. I thank all the other people who have appeared before the committee this morning. It has been difficult to listen to in parts but it is also important to know and understand the wonderful work that has been happening right across the community and voluntary sectors over the past 18 months. I thank the committee for the opportunity.
Mr. Hugh Greaves:
I thank the committee for the opportunity. It has been a great learning experience. We mentioned connectivity earlier and it is great to feel connection with the national Legislature. It comes back to community. People always say that addiction is the result of a lack of connection. To push that logic further, if communities are connected to the highest level of the national perspective, they will not feel abandoned and will not be abandoned. It is great to have that opportunity.
Mr. Gerry Cooney:
I echo what has already been shared. We are delighted to be part of a discussion and to do anything that raises awareness and helps services interact with each other. A plus that has come out of the pandemic is the services are in more regular contact and people are pooling their resources and sharing their experiences. That is something that can only be welcomed. I thank the sub-committee again for the opportunity.
Thank you all very much. As Cathaoirleach of the Joint Sub-Committee on Mental Health, I say a huge thank you for the wonderful work the witnesses dedicate their lives to doing, particularly through the whole Covid pandemic. They are front-line workers and sometimes they do not get the credit for the amazing work they are doing so on behalf of the committee and of the Houses of the Oireachtas, I thank them for the great work they are doing. Please keep in contact with the sub-committee and let us know how you are getting on. We would like to support as best we can. I thank everyone for their very helpful contributions.