Oireachtas Joint and Select Committees
Thursday, 19 September 2024
Committee on Drugs Use
Decriminalisation, Depenalisation, Diversion and Legalisation of Drugs: Discussion (Resumed)
9:30 am
Lynn Ruane (Independent)
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I have apologies from Deputy Gould, who will be represented today by Deputy Quinlivan. I also have apologies from Deputy Stanton.
Parliamentary privilege is considered to apply to the utterances of members participating online in a committee meeting when their participation is from within the parliamentary precincts. There can be no assurances in respect of participation online from outside the parliamentary precincts and members should be mindful of this when they are contributing.
The topic of our meeting this morning is engagement on decriminalisation, depenalisation, diversion and legislation. The committee members are very interested to learn from the experience of others in respect of drugs policy, especially people who are central to that discussion. I welcome the witnesses joining us today. From the Irish Pharmacy Union, we have Mr. Tom Murray, president; Dr. Denis O'Driscoll; and Ms. Sinéad McCool, head of professional services. From the Irish College of General Practitioners, we have Dr Diarmuid Quinlan, medical director; Dr. Bernard Kenny, director of the addiction management in primary care programme; and Dr. Des Crowley.
He is the clinical lead for HSE addiction services and assistant director of substance misuse. Is that correct? The witnesses are all very welcome. Dr. Crowley is indicating that he wishes to speak.
Lynn Ruane (Independent)
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Okay. That is perfect. He is then the academic director of addiction management in the primary care programme of the ICGP. Is that the correct title?
Lynn Ruane (Independent)
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We have a list here for Dr. Crowley's biography. The witnesses are very welcome. I am grateful to them for agreeing to come before the committee today. I invite the representative of the Irish Pharmacy Union to give an opening statement. I am not sure who is going to lead on that.
Mr. Tom Murray:
Gabhaim buíochas leis an choiste as ucht an gcuireadh teacht anseo. Tá mé sásta a bheith anseo chun an t-ábhar seo a phlé. The Irish Pharmacy Union is the professional and representative body for community pharmacists, with a membership of 2,300 pharmacists working in more than 1,800 community pharmacies throughout the country. IPU members are committed to delivering a quality, accessible, personal and professional service that puts the patient first and optimises society's health and well-being as their primary goal. Pharmacists are experts in medicines and have legal principles and ethical standards in place which govern pharmacists in the practice of their profession. At the core of this is that patient safety must come first and that legal and ethical standards are in place to ensure all pharmacists practise in a way that maintains and improves the health, well-being, care and safety of patients. Pharmacists are the most accessible healthcare professionals, with data to show that each year there are more than 78 million visits to community pharmacies, or 19 visits per annum per man, woman and child in the State. Pharmacies are open six to seven days a week, with many having extended late opening hours. Nearly half of the Irish population lives within 1 km of a pharmacy and 87% live within 5 km. Pharmacists enjoy public satisfaction ratings of well over 90%, with the Veracity Index poll released in 2024 by Ipsos MRBI finding that local community pharmacists were the most trusted professional group in the country with a trust rating of 96%.
The committee is very aware that drug use has profound and lasting adverse effects on the health and well-being of individuals, families, communities and wider society. The use of illicit drugs is a recognised contributor to the global burden of disease. In preparing this submission for the joint committee, we consulted a range of resources and organisations, including our pharmacist colleagues in HSE addiction services, our community pharmacist colleagues in Portugal, the PGEU and the annual European Drug Report published by the European Union Drugs Agency, EUDA. The key messages for the IPU from this work are that acute and chronic health problems are associated with the use of illicit drugs, which include acute issues such as the risk of overdose and death to chronic health issues, including long-term drug dependence and infection such as hepatitis C and HIV. These health problems can be compounded by factors such as the properties of the substance being used, the route of administration, individual vulnerability and the social context in which drugs are consumed. These health issues may often exacerbate other complex policy problems, such as homelessness, the management of psychiatric disorders, the strain on health budgets, and the social costs for communities that feel unsafe. A spectrum of responses are needed, which must be integrated and comprehensive to reduce drug-related harms. Synergies are needed with policy and practice in many key areas, including housing support, access to healthcare, youth and elderly services, mental health provision and the criminal justice system.
Research and evaluation of policy development and implementation to address drug use in Ireland must be ongoing to help identify interventions that are effective and to ensure policy can keep pace with the evolving picture of drug use and accessibility. The IPU is of the view that any considerations on decriminalisation must start with the development of a robust and comprehensive policy on decriminalisation, de-penalisation, diversion and legalisation, with input and engagement from a range of stakeholders, including health and social care services, mental health services, the Judiciary and law enforcement. The health and well-being of all our citizens must be considered throughout the development of this policy. If the policy or policies are to be implemented, they must be fully supported and resourced given the complex interactions of drug misuse with other areas of society such as homelessness, those with lower socioeconomic status and vulnerable groups, including those with co-existing mental health issues.
The IPU advocates for an increased role for community pharmacists in the implementation of any drug policy developed for decriminalisation, de-penalisation, diversion and legalisation as we believe community pharmacists have a vital role to play in the provision of services included in future policy in this area. These services include the provision of harm reduction via opioid substitution treatment, OST, needle exchange and supply of naloxone for suspected opioid overdose; the provision of patient care, health screening and targeted interventions to patients engaging with harm reduction services via their community pharmacy; and the provision of public education to local communities via their community pharmacy on drug-related harms, to include signposting to the appropriate services and supports available. Currently, community pharmacists in Ireland provide harm reduction services via OST, naloxone for suspected opioid overdose, and provide a limited needle exchange programme. However, it must be noted that OST and needle exchange are limited due to both funding and a lack of trained personnel required for the provision of services. This has resulted in inequable access for patients with addiction issues wishing to engage in harm reduction. EU policymakers have made a commitment to the WHO's global health sector strategies to end AIDS and the epidemics of viral hepatitis and sexually transmitted diseases by 2030. EU data shows there has been a long-term downward trend in new HIV infections related to injecting drug use and viral hepatitis. There has been, however, an increase in HIV notifications since the Covid pandemic and it must also be noted that the decline of 38% since 2010 falls short of the WHO target of a 75% reduction. There is currently no provision for the delivery of patient and population health education, health screening for this patient group or interventions on drug-related harm via community pharmacies.
In summary, the IPU contends that any considerations regarding decriminalisation, de-penalisation, diversion and legalisation should only take place when a robust comprehensive Government policy is developed and integrated across all relevant Departments and public services. Commitments to funding must be provided for the longer term to ensure the continuity of supports and services required for policy in this area. Decriminalisation should only be implemented as the final part of any policy developed to ensure all appropriate safeguards and supports are in place and resourced. As mentioned, research and evaluation must be ongoing to ensure policy can keep pace with the evolving picture of drug use and accessibility.
Gabhaim buíochas leis an gcoiste as an gcuireadh. Táimid sásta aon cheist a fhreagairt.
Lynn Ruane (Independent)
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I now invite the representative of the Irish College of General Practitioners to make an opening statement.
Dr. Bernard Kenny:
I am the director of addiction management in primary care. The Irish College of GPs recognises addiction as a complex, chronic, relapsing disease involving a common pathway with both physiological and psychological components. Drug use and addiction adversely impact individuals, families and communities and are associated with significant morbidity and mortality. There is a close causal relationship between addiction, social deprivation and childhood trauma. Engaging people who use drugs in harm reduction services and treatment is known to be protective. GPs see people who use drugs as our patients and members of our communities rather than criminals. The number of people seeking treatment for addiction to illicit substances is increasing annually. There are several barriers to people who use drugs seeking treatment. Social stigma significantly affects willingness to report illicit drug use, reveal addiction and access appropriate healthcare. Fear of punishment and criminal conviction are further barriers. Legislative changes should address the many barriers to treatment. The Irish College of GPs recognises the detrimental impact of penalisation and stigma on people who use drugs and those seeking addiction treatment, sustained recovery from addiction and access to meaningful employment.
The Irish College of GPs supports the overarching recommendations of the citizen's assembly report, pivoting from a narrow legalisation-decriminalisation criminal justice approach to a comprehensive multifaceted, bio-psychosocial approach addressing supply reduction, addiction prevention, harm reduction, treatment and recovery services, all underpinned by enhanced resourcing with relentless prioritisation of disadvantaged communities. A piecemeal approach to managing drug and other addictions is doomed to failure whereas, with a comprehensive approach, the gains for personal and public health are enormous.
The HSE is committed to a health-led approach to drug use in Ireland. GPs, when appropriately resourced, are well placed to offer timely equitable access to high-quality addiction management, helping reduce patient harm and support recovery. The European Drug Report 2024 noted that Ireland had 322 drug-induced deaths in 2020. These 322 fatal overdose deaths exclude other drug-related deaths associated with drug use such as accidents, violence and suicide.
This is the highest rate among EU member states at 97 deaths per million of population compared with the EU average of 22 deaths per million. A report from the Health Research Board documents that more than 13,000 people were treated for problem drug use in 2023 - the highest annual number ever recorded. The evidence is clear. Early detection and management of drug use can prevent progression to dependence.
GPs see and support families and loved ones devastated by these tragic and preventable drug-related fatal overdose deaths. Together we can disrupt the cycle of harm and stigma of illicit drug use. A strategic health-led approach to drug misuse and treatment of addiction is resource intensive. It is critical that legislative reform is underpinned by significant and targeted investment. Addiction is raised in approximately 10% to 20% of all GP consultations. Having an appropriately trained GP workforce is essential to ensure identification and treatment of both chemical and behavioural addictions. Addiction medicine training is an essential component of the GP trainee curriculum in the Irish College of GPs. GPs have different roles in managing drug use and addiction depending on the substance involved, be it alcohol, sleeping tablets, benzodiazepines, pain medication or illicit drugs such as cannabis and cocaine.
More than 350 GPs have completed additional addiction specialist training delivered by the Irish College of GPs. These GPs primarily treat people with opioid use disorder. Given the changing pattern of drug use in Ireland, the Irish College of GPs supports an expansion in access to, and a range of treatments offered via HSE specialist clinics. The expansion of services to include evidence-based treatment for all chemical and behavioural addictions is required to meet the increasing needs of patients presenting for treatment. Assessment, intervention and ongoing management of addiction is time consuming and resource intensive. There is limited access nationally to public clinical psychology and counselling. Limited access to inpatient residential recovery beds and inadequate resourcing of GPs negatively impacts the quality of care provided and restrict the availability of treatment options.
Addiction is a complex interplay of biological, psychological and societal factors. Societal factors play a significant role in the risk factors for addictions and support options for recovery. While drug use is prevalent among all socioeconomic groups, disadvantaged communities, where health needs are greatest are often neglected and at greatest risk - the inverse care law. Criminalising drug use further marginalises people in these communities. Housing insecurity and homelessness exacerbate the risk and severity of substance use disorders. Supportive housing programmes alongside addiction treatment facilities improve recovery outcomes for people who use drugs, their families and communities. Focused and sustained efforts are required to plan and deliver appropriate healthcare to these communities including easy access to primary care-led, patient-centred, holistic and multidisciplinary addiction treatment.
The Irish College of GPs welcomes this opportunity to engage with and support the Oireachtas committee to transform Ireland’s approach to drug use and people who use drugs. We see people who use drugs as our patients and members of our local communities rather than criminals. We recognise stigmatisation, penalisation and social deprivation as significant barriers to treatment, which impede chances of a sustained recovery for people who use drugs. We support a compassionate, non-judgmental, non-punitive and health-led approach to people who use drugs seeking help with drug use and addiction. We support legislative changes that reduce stigma related to illicit drug use by comprehensively supporting people suffering from and impacted by addiction. We recognise that criminalising our citizens who use drugs does not address or solve the societal problems of drug misuse. We support timely and equitable access to a human rights-based healthcare for all and a national policy to meaningfully address the social determinants of health.
We welcome any questions.
Lynn Ruane (Independent)
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I thank Dr. Kenny. We will move on to members. There are seven minutes per member. If I have to interrupt or cut someone offer in order to make sure everybody gets in the first round, I apologise in advance. There will most likely be a second round.
Mary Seery Kearney (Fine Gael)
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I thank the witnesses for attending and for their opening statements. I pay tribute to both of them as valuable and incredible members of our community. They contribute so significantly, particularly in the care of those who are caught in addiction. I am delighted that the emphasis of the Irish College of GPs at the beginning was on the humanity of the individual and is compassion led for the individual. A common theme running through the work of our committee is to say we are dealing with individuals, so having health-led approaches is important. Pharmacies have been brilliant. Especially since Covid, they have been amazing in stepping up. I would like to see them be able to do far more again, but I thank them for that.
I completely agree. Addiction is most prevalent in areas of social deprivation where there is childhood trauma and ongoing poverty and where people can be preyed upon for addiction and be drawn into criminality. The State criminalising people who are caught in addiction does not help. In fact, there is a major need to ramp up our health-led approach. On the other hand, as a Government and a State, we have a responsibility to make sure that is not an acceptance of drugs - full stop - and all the criminality that goes with that and those who are profiting on the misery of others to the point of death and suicide.
Both groups very much welcome a health-led approach, but I hear qualifications within their statements. I fully agree when they say we need huge resourcing and placements for treatment and support. We need communities to be targeted with supports. In our next module we will hopefully have the opportunity to hear fully about what needs to be said and done in communities. However, when do we know we are at a critical level because we cannot let people wait with their lives being destroyed. How do we know when we have reached that critical level of services so we can then click in? The IPU was saying that we should only decriminalise when we have reached that stage, but that could be 30 years from now. I am not willing to wait that long. I want it to be as quick as possible, and I see that through the task force that I am involved in.
I apologise as time is going and I want to give the witnesses an opportunity. What sort of indicators and metrics should we look for? Is it waiting lists? In terms of numbers how do we know we have reached a point where we can point and say we have reached the objective that Government and State need to get to?
Dr. Bernard Kenny:
We are all practising clinical physicians, in addition to our jobs with the ICGP, so the bulk of our week is made up with seeing patients day in and day out. From our point of view, we can currently see the direct harm of drug use. You can already recognise from the national numbers that our death rate from drug overdoses is far too high. Our numbers are disproportionately high compared with elsewhere in the EU. I say we have reached that critical stage currently, if we had not done so already in the past number of years. We do not believe that people who are using and are addicted to drugs should be penalised for that.
Mary Seery Kearney (Fine Gael)
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I apologise for interrupting. Is Dr. Kenny saying that we should bring in decriminalisation now, while at the same time building up the services?
Dr. Bernard Kenny:
We recognise the harms from criminalising people, and we can see the effects. A big part of recovery from addiction is a sense of hope and, as I said earlier, taking up meaningful employment in the future, having opportunities to return to education and not to be further stigmatised by society. We see convicting people and criminalising individuals as an impediment to them having an opportunity for a sustained recovery. That would be our position.
Dr. Des Crowley:
I will add a bit about treatment. The Senator asked about what time we will say we have enough treatment places to match everybody who has needs. What we recognise are the deficits in treatment. We know that treatment is protected, particularly around overdoses. The majority of people who have fatal overdoes are not in treatment. Removing all barriers possible has to be our first priority. We need to look at the services we have available for other addictions because nationally our addiction services have been opioid focused. I think the most common drug now is cocaine, and we do not really have a national cocaine treatment programme. We need to look at all behavioural and chemical addictions, look at what is evidence based and how that can be delivered. We are supporting and would encourage the committee to look at primary care as a really important location where that can be delivered without stigma and without discrimination. That would definitely be a good start from our perspective.
Mary Seery Kearney (Fine Gael)
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That is brilliant. I thank Dr. Crowley.
Dr. Denis O'Driscoll:
I concur completely with Dr. Crowley and his colleagues. Having worked in the addiction services, I have always seen that once people have criminal records it makes their lives very difficult. It is a huge impediment to them moving forward. For me, decriminalisation of the user is an important step forward. We need to look at this possibility and at diversion projects. As Dr. Crowley said, there are areas where there are treatment waiting lists that must be got rid of. We should not have waiting lists. Equally, we should have primary care more involved with other drugs of addiction, as has been said. The most important thing is that we should not be focused solely on opioids because we know that cocaine and stimulant use is increasing significantly. This cohort of people needs to be looked after as much as we look after our opioid users. From the perspective of somebody still practising in a community pharmacy, while also having worked in addiction services for a long time, it is about always being there to support the person in front of me and to be very patient-centred in respect of their recovery.
Mary Seery Kearney (Fine Gael)
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In summary, then, we need to decriminalise quickly. What I am hearing is that we have an overfocus on opioids as opposed to other substances, particularly cocaine, and we also need to be removing waiting lists. That is great.
Mary Seery Kearney (Fine Gael)
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Yes, the individual.
Mr. Tom Murray:
That should not, however, be done without putting in place the social supports for the individuals whom we are decriminalising and the communities in which they live. There is sometimes a view that by decriminalising an individual we would actually promote drug use in the community, which is not true. We must have these community supports in place urgently and prior to undertaking the decriminalisation of the individual. Decriminalising immediately without those other supports will lead to other social problems. It cannot be just one point of attack; this approach must be multifactorial.
Mary Seery Kearney (Fine Gael)
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We need to be concerned with prevention and ramping that up.
Mr. Tom Murray:
Absolutely. We need to be working on education, harm reduction and reintegration for patients, because that is what they are, going through the addiction services. All these things are important. I believe this is the case in respect of removing the stigma as well and improving the chances of people being re-employed. There is a whole tranche of social-economic and social-educational work that must also be done.
Mary Seery Kearney (Fine Gael)
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Excellent. I thank Mr. Murray.
Lynn Ruane (Independent)
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I call Deputy Ward.
Mark Ward (Dublin Mid West, Sinn Fein)
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I thank the Leas-Chathaoirleach. I was not expecting to come in so soon.
Lynn Ruane (Independent)
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Did I give the Deputy a fright?
Mark Ward (Dublin Mid West, Sinn Fein)
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Yes, you did. I thank everybody for coming in. I really enjoyed everybody's contributions, which have been very informative. These meetings are very good for the committee in respect of when we go forward with any proposed legislation. They have been very informative.
For the sake of full disclosure, I worked with Denis in front-line addiction services for several years. We were reminiscing about that time. It was good that he mentioned statistics and things like that. It is always good to be mindful and to remember there are people behind the statistics. We can get lost in focusing on the number of people who have died from overdoses and the total number of people presenting for opioid treatment. Behind each of those statistics, however, is a person with hopes, dreams, aspirations and a family, and addiction has got in their way. I must mention this point.
One of the things mentioned by the IPU representatives was the postcode lottery of care and the inequality of access for patients with addiction issues for harm reduction. Is the funding the IPU receives now adequate? What would it look like if we were to move to a different model like harm reduction or decriminalisation? What would be needed?
Mr. Tom Murray:
In general, I would say the funding we receive now is inadequate for the current level of services we provide. All our data supports the fact that we have pharmacists who are really struggling to keep the lights on and the doors open to allow them to continue to provide their current services. As I said, we are the most successful point of healthcare. More than 50% of the population visits us weekly.
We are eager to align ourselves with Government policy, as was shown in the task force, and the public want us to provide more services. We also want to provide more services. All these aspects need to be looked at in a funding model. There is certainly, however, a disparity in the provision of services in addiction care. Some of this is caused by the demand. Where I am working in rural County Donegal, I do not have huge demand. I have one patient at any one time, so there is an element of that. There is also, though, an element of funding and support for community pharmacy that needs to be looked at in the round in terms of all the services we provide to allow us to provide those additional services we are willing to provide.
Mark Ward (Dublin Mid West, Sinn Fein)
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I thank Mr. Murray. I have a question for the ICGP witnesses as well. Will they explain the current process for someone who presents to one of their members? Let us, for example, take the issue of polydrug use. A person might be looking for treatment or access to rehabilitation. What is the process now? What does it look like and what should it look like if the appropriate resources were provided?
Dr. Des Crowley:
Initially, obviously, patients present. First, we need to have a safe space where patients would be willing to reveal information about something that is criminal. Creating such a space is the first step. Second, we must be non-judgmental with patients so they will reveal their level of use. Third, we must determine the diagnosis. We must be careful in this regard. There is drug use, drug misuse and drug dependence, and the people we want in treatment are those who are dependent. Those are the diagnostic criteria we use. Once we have a diagnosis, we look at evidence-based treatment to match the diagnosis of dependence. There is a selection of evidence-based treatments for each of the different addictions.
What happens in reality, however, is that is time-consuming and we do not have the time we would need to do a comprehensive assessment. Additionally, treatment is often not available locally. We would like to think that in each region we would have a treatment service for cocaine and a treatment service for benzodiazepines. That should have an element of specialism. Where people are high complexity, they would go into specialist services. There should also be a very good primary care-based service where less complex patients could be managed. We do not have that and need to expand on it. The recovery aspect is very piecemeal as well. We have many good, well-funded organisations that are funded through the HSE, but the issue here is again about co-ordination. Some treatment services are replicated in some areas, while some regions have no treatment services at all.
Mark Ward (Dublin Mid West, Sinn Fein)
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I was listening to the radio this morning and there was a report about the launch of a document from Merchants Quay Ireland. That organisation is saying if it doubled the number of beds it has available for people going into rehabilitation, it would still not be enough. Is it difficult now to refer the people and patients who enter the services provided by the witnesses into drug rehabilitation places? What happens in that gap if people are not getting the service they need?
Dr. Des Crowley:
There is a huge gap, and there are two aspects to this. The residential beds available are mostly detox beds. There is a real deficiency of stabilisation and residential beds. There are very few places for people who need to stabilise from drug use rather than becoming drug-free. Only one or two centres are available nationally in this regard. Basically, in cases where people are referred for drug detox, often this may not be the appropriate treatment but it could be the only residential treatment available to the patient. Sometimes patients may be inappropriately referred or may not have enough supports to manage their treatment journey. Again, there is a long waiting time. If something has happened in a person's life and they are motivated to do residential treatment, they may be left waiting six to 12 months to access that service. Life will be totally different six to 12 months later compared with when they presented to us in our surgeries.
Mark Ward (Dublin Mid West, Sinn Fein)
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As was said, this window of opportunity is sometimes really small when somebody is motivated and in that space to get treatment. It is important to have the appropriate services.
One of the things I am finding out is about going through detox and into rehabilitation. We have Cuan Dara in my area where people go in for detox. There used to be a transition into the likes of Keltoi, but that service has been closed for several years and this has caused a big gap. What is happening now, therefore, is that people may be getting detox, but then they are going back out into the environment they came from. Their tolerance levels are low. If they do go back using drugs, there is a very high chance of overdosing in that situation. I agree with Dr. Crowley that the kind of connected services he described are needed.
Lynn Ruane (Independent)
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Next, I call Senator Fitzpatrick.
Mary Fitzpatrick (Fianna Fail)
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Go raibh maith agat. I thank everyone for attending, for the opening statements and, most importantly, for the work they and the members of their organisations do every day. They truly are the front line of healthcare in our country and provide incredibly valuable services. My dad was a GP and I grew up in a family practice, so I understand exactly what is involved. Pharmacies also provide an incredible service.
The opening statements led very clearly with an approach that emphasised human sensitivity.
I guess for us, as legislators, this is a different subject matter to be dealing with because it involves the human condition and human frailty. They eloquently articulate the devastation and damage that is caused by addiction and drug abuse.
In their opening statements, each of the witnesses spoke about the four steps we are considering as a committee: diversion, depenalisation, decriminalisation and legalisation. I seek clarification. I think I am hearing that neither of the two groups is in favour of full legalisation of drugs. I would like them to confirm that. The witnesses are all in favour of depenalisation and diversion, and decriminalisation in the context of a very significant and comprehensive framework being put in place that would be all encompassing. When it comes to decriminalisation, are the witnesses in favour of decriminalisation of all drugs, regardless of their potency and at the one time? Maybe I could start with the pharmacies and then come to the GPs.
Mr. Tom Murray:
Decriminalisation, for us, is decriminalisation of the individual and the user, not decriminalisation of the product. We would have a very clear line on that. It is the individual who presents for the care and is a patient in need of services. The product is still illegal. International evidence suggests that is the best approach to take in terms of reduce of harm, societal damage and, indeed, damage to the individual user, that the services are patient-centred and it is patient-led care, which is our aspiration for all the services that we provide in pharmacies. It is patient-centred, patient-driven care. That is in line with Sláintecare. It is the clinical care as per clinical need so we would not be in favour of decriminalising any product. We are in favour of decriminalising the individual user.
Dr. Bernard Kenny:
I thank the Senator for the question. The ICGP issued a statement last October in which we say that cannabis is a dangerous drug and a serious public health concern and we discourage cannabis use. Clearly, we acknowledge the dangers of cannabis.
In terms of decriminalising individuals, we have clearly stated that criminalising individual drug users and people who use drugs causes damage to them, their families and their communities and their ability to seek help. We recognise the dangers inherent in cannabis use but are very supportive of people who use drugs and recognise that criminalising individuals, such as our patients, members of our community, does not serve our greater aims.
Mary Fitzpatrick (Fianna Fail)
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Both groups are saying that they are not in favour of legalisation of any substance but the decriminalisation of the individual.
In Dr. Crowley's contribution, he said that the response the individual receives when he or she seeks help is so important. It is a question of the initial reaction, let us say, from the care provider or the potential care provider, and being honest with one's GP about one's health. Being honest with ourselves about our health is a challenge. Dr. Crowley talks about the framework and having a comprehensive framework. The inadequacies of the resources available to his members and, more generally, in society to support people to commence a journey of recovery have been articulated, but in an anecdotal sense. To get to a properly quantified and properly resourced response from the State to help people who are suffering with drug addiction, would it require the individuals to self-declare or should Dr. Crowley's members take a leading role in helping individuals to self-declare?
Dr. Des Crowley:
It is a bit of both. It is a public conversation that needs to be had. Addiction is a disease. It is a chronic relapsing disease and it should not have the stigma that it has. First, people should understand when they are coming and have problem drug use that they are coming with an illness for which they deserve compassion and to be dealt with like any other person who has a disease or an illness. Second, we need to train the GPs to pick up on cues. There are some cues, such as absenteeism and other issues regarding work, and it involves maybe adding those little questions to when we are having our normal consultations to draw out but that can only happen if one is non-judgmental about it.
The non-judgmental attitude is really important when we talk about relapse because that is a most difficult time for people to re-engage in services. They put in so much effort and there is so much attached to being drug free that relapse is a hugely difficult time for people. Re-engaging services is what prevents them from fatal overdosing and is what we need them to do but, because of the stigma attached, they will not re-link with services. That is obviously a huge problem.
Mary Fitzpatrick (Fianna Fail)
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I thank Dr. Crowley. Turning to their request to us that there would be a comprehensive framework - I appreciate there is only 50 seconds left in this round but maybe they can think about it and respond in further rounds - will they give us the headlines of what that comprehensive framework needs to include?
Dr. Denis O'Driscoll:
It would be a definitive primary care strategy towards a multidisciplinary team network between pharmacists, GPs and other disciplines who will be needed for the whole psycho-social model of support. That is probably one of the big gaps - the psycho-social model of support for individuals. Deputy Ward stated already that people are discharged without that kind of support level. It is really important that support is there.
On the whole strategy around it, the national drugs strategy is due for review. That whole piece in the national drugs strategy needs to incorporate how we interplay together as professionals, and how we involve the patient and his or her families in his or her care. It is ultimately important because in my experience patients do best when they have that leadership and empowerment to look after themselves in their own treatment progression, whatever that looks like for them, not what I think is best for them.
Mary Fitzpatrick (Fianna Fail)
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Go raibh maith agat.
Maurice Quinlivan (Limerick City, Sinn Fein)
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Unfortunately, I am not a member of this committee. I am subbing for a colleague of mine who cannot make it. I am a TD for Limerick City. I am a member of the local mid-west region drug and alcohol task force. I have been for 12 years, at this stage.
I do not have to tell anybody here, but Limerick city has unique problems with drugs. While drugs are an issue across the State, the use of crack cocaine in Limerick is probably off the scale. It is not seen in many places across the country. It did not happen by accident. It was designed. It was marketed by a drugs gang. They carefully did what they were doing and hooked a huge number of vulnerable people onto crack cocaine. People come from all over the State to buy crack in Limerick because it is the cheapest place to get it. One can see that when one looks at the bus and train stations. People are arriving in, buying the crack and coming out. The Garda Síochána will tell you this. People in the services will tell you this. I know this from dealing with some of the most disadvantaged areas. There is one particular area where it is concentrated in. The Garda has done a good job, as best it can, but there are 24-7 crack houses going non-stop selling drugs there.
The two submissions the witnesses made in their opening statements are excellent. I commend both organisations on providing them. It is good to see in black and white their commitments in what they are saying and that we need a change.
It is no surprise to me that the GPs' submission sets out that we have the highest death rate in the EU. One hundred and forty-seven people died from drug overdose in 2020. This excludes accidents, violence or whatever, and, unfortunately, suicide. God knows how many people died from drug-related suicides. If I go back to the figure of 147, it is double the number of people who died on the roads in the same year. We do not treat it with the same seriousness and we do not put the resources in there.
There is a lot of good work being done by a lot of organisations but it is just not funded enough. There are not enough people there. Waiting lists are horrendous. For instance, in Limerick, we are finally getting around to providing a dual-diagnosis programme properly whereby the task force is launching its own programme next week under its strategic review.
What concerns would the witnesses have if we moved to decriminalisation immediately? What resources would they need to make sure we can address those or whatever?
For the GPs, could the witnesses give us an idea of whether they have concerns that some of their GPs would not be aware of drug issues and would not deal with them, or would turn people away from that sort of stuff? My question for the IPU is this: do they have any statistics setting out how many of its places would have needle exchanges? Are there any statistics on that? Those are basically my questions for the moment.
Dr. Bernard Kenny:
From a GP perspective, we mentioned the broader societal issue of stigmatisation and the fear of judgment. In the population in general, there is occasionally the view that it is some sort of moral failing or willpower issue on the part of people who use drugs. We very much recognise the medical model of addiction, however. As part of the ICGP, our role is to promote the education and training of our members in addiction. We offer certificates and additional training in addiction medicine for people who are interested. As part of our GP trainee curriculum we educate people on the medical model of addiction. We emphasise the point that nobody wants to be inflicting harm on themselves through addiction. We emphasise that it is a medical disease, rather than some sort of moral failing. We try to promote this as best we can. There are areas of the country where we have excellent service provision thorough GPs who have additional training. They mainly offer opioid substitution therapy, OST, for opioid use. We would like to see this pushed out and extended into other substances, to reflect the current pattern of use. We know that cocaine is on the rise. As was mentioned, crack cocaine is huge in Limerick. Across the country, we are seeing more and more crack cocaine use and the physical and psychological damage that goes with it. We see a lot of issues with other stimulant use and other psycho-active compounds, such as benzodiazepines, which are bought on the street and not prescribed. This is a huge issue. We support additional resourcing to provide funded treatment for those other substances through GPs as well. This would be similar to the model of the opioid-agonist therapy programmes we currently have in place. We think that would make a huge difference to the provision of care.
As mentioned previously, there are also issues relating to the significant amount of time patients assessed by a GP as requiring residential treatment have to wait. There is also a huge lack of clinical psychology in addiction services throughout the country.
Regarding the dual-diagnosis clinics which are being piloted, we know there is a huge overlap between mental health disorders and substance misuse. A mental health disorder is a huge risk factor for a person developing a substance misuse issue and vice versa. GPs need to have places to refer patients to. It is often very difficult to access psychiatry for those who have a substance misuse disorder, so we certainly endorse the pilot for dual-diagnosis clinics and hope it is extended throughout the country.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I thank Dr. Kenny.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I thank Dr. Crowley. That is an additional point I was going to make.
Mr. Tom Murray:
Currently, we have approximately 100 pharmacies offering needle exchange services, which is quite a low figure out of a total of 1,800. I am not exactly sure how many are currently providing methadone services and OST. That number fluctuates depending on patient need and presentation. In response to the question, with more than 78 million visits to pharmacies per year, pharmacies need more resources and training in terms of symptom recognition, noticing and picking up on the signs of drug addiction, to be able to signpost people with addiction problems to the correct services.
Maurice Quinlivan (Limerick City, Sinn Fein)
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I know we are running out of time but does Mr. Murray think some pharmacies would need support for extensions or different rooms where people could come for needle exchanges?
Mr. Tom Murray:
Yes. We all have a consultation room but for those with high demand there would undoubtedly need to be second rooms and there would need to be supports put in place for that. The other thing is that pharmacists are in a unique position for community education. Pharmacists would like to be involved in community education in a broader context around mental health and drug addiction issues.
Mal O'Hara (Green Party)
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I thank the witnesses for coming in. With their indulgence, my first round of questions will be for the IPU and in my second round I will come to the ICGP.
My first question is on international engagement and the discussions with the Portuguese pharmacy union. Did it historically support decriminalisation in its widest context? Does it still have the same position? What has the IPU learned from the Portuguese union's role in provision over the past 20 years, with the huge success in Portugal?
Ms Sinéad McCool:
Referring to our previous statement, the Portuguese supported the decriminalisation of the patient. They were actively involved from the start of this and viewed it as a very successful model. Key to it was that the pharmacy union was integrated at the start and very well supported.
Mal O'Hara (Green Party)
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From the inception, how robust was the provision of needle exchange services and OST in Portugal?
Ms Sinéad McCool:
It was extremely robust and fully resourced and supported. It got to a stage where it was so successful that the opioid substitution programmes could be paused because they had delivered what they had set out to do. It was reinstated post Covid but that was due to issues relating to the pandemic. At the time, the leader there was a pharmacist. That helped them to understand the model and tailor it for use in community pharmacies.
Mr. Tom Murray:
One of the things we learned from talking to our Portuguese colleagues directly was that they strongly believed that without the integrated view, decriminalisation of drugs alone may not be enough in any country. It has to be seen as a holistic perspective. Portugal has a much lower incidence of drug use than many other European countries. The Portuguese see their five-pillar approach as having been successful. The five-pillar approach is: prevention, use discussion, harm reduction, treatment and re-integration. They strongly take the view that, prior to the decriminalisation, the other structures need to be embedded in society. To do it the other way around will cause serious issues.
Mal O'Hara (Green Party)
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I want to pick at that point a little bit. I get the sense we are saying that we should not let perfect be the enemy of the good. Decriminalisation in itself is already a concrete step but for additional success in that regard and to save lives, which is ultimately what we want to do, we need to put all those additional supports in place and we need significant infrastructure investment in provision of services.
I want to ask about the issue of HIV transmission. The paper from the IPU states that there has been a decline, though not as significant as we want, but that there has been a rise post Covid. Is there a sense of which groups that is among? I presume it is men who have sex with men, MSM, and new migrant communities?
Dr. Denis O'Driscoll:
Recording of HIV and HIV notifications through the HPSC decreased during Covid. There has definitely been an increase because of greater reporting and more people coming forward for treatment and testing. Within certain groups such as MSM and chemsex groups there may be a higher incidence. Post decriminalisation in 2015 using the criminal justice Bill of headshops, we saw a spike in HIV associated with the use of mephedrone at that time.
Where we need to be at is that it is an education piece for migrant population groups. That was particularly seen with recent research from Liverpool John Moores University which found that among non-English speaking groups who used steroids for body building, people did not get the concepts around harm reduction or harm minimisation that we would automatically assume or presume that our audience would understand. They did not understand about sharing "works", etc., and there was a potential issue regarding an increase in incidences, not just of HIV, but other viral illnesses, most notably hepatitis C.
Mal O'Hara (Green Party)
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It was mentioned that only 100 out of 1,800 pharmacies are providing needle exchange services. Will the witnesses give clarity on the OST? Are the 100 pharmacies situated in deprived areas? Is there a blanket approach? What is the approach in terms of those provisions and the community engagement? From my experience working in Belfast, we wanted to put a needle exchange into a community that needed it but it was mishandled by public health. There was paramilitary instigated reaction to it and there were huge problems.
Dr. Denis O'Driscoll:
I was involved in setting up the pharmacy needle exchange programme throughout the country, which was a long time ago. When we set it up, the criterion given at the time by the health services was that there were adequate needle exchange services within the greater Dublin region and other regions that had static needle exchange and outreach, such as peripatetic needle exchanges, and pharmacy needle exchanges were the lowest tier of needle exchange. When you walk into a pharmacy, you get a specific needle type and a specific syringe. It is very specific. You do not get, as the Senator suggested, a pick and mix where you can just choose what you want as a user. It is very much a low-entrance mechanism. The whole point of it when I was involved in setting it up was that it would be used only as one part of signposting. It was not intended to be a cold exchange. Patients who came in had to be signposted to services, be that a local GP service that was offering addiction support or a local centre that had a community-based project. The 100 pharmacies that were chosen are based in areas where there was a determined need and a significant waiting time for those who needed to get onto OSD programmes. That is how it was designed at the time.
There are weighings and the demand comes and goes in areas, but equally, it has to be acknowledged that the needle exchange programme in pharmacies has been very adaptive in some locations where there was no demand from, for example, intravenous drug users, IVDUs. There was a huge increase in interest from those who wanted it for Melanotan, for example, so the needle exchange pack was modified to suit them. In recent times, there has been a surge in the number of those who wanted to request it for steroid injecting and, equally, the pack is changing to suit that cohort. We are trying to make it as adaptive as possible. I appreciate that the figure of 100 sounds small in the greater scheme of things but, in fact, 100 pharmacies related to areas where zero needle exchange were being offered by HSE services at the time.
Neasa Hourigan (Dublin Central, Green Party)
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I will focus on naloxone and access to that. I appreciate that it has been touched on but I want to do a deep dive. We have high levels of injury and death due to the use of drugs in this country, and other countries have started to look at the regulation of naloxone. If I have not taken any drugs and I take a shot of naloxone, what will happen to me?
Dr. Denis O'Driscoll:
Essentially nothing. It is an extremely safe compound. There are two types of products, injectable and nasal. The nasal product is reimbursed by the primary care reimbursement scheme, PCRS, on the opioid substitution prescription, so it can be got in that way-----
Neasa Hourigan (Dublin Central, Green Party)
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If I picked up the drug off the ground, did not know what it was and snorted it, would nothing happen?
Neasa Hourigan (Dublin Central, Green Party)
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What about suboxone?
Dr. Des Crowley:
Suboxone is a partial agonist but it has an effect on the user in that it is a psychoactive substance. Naloxone is an antagonist, that is, it does nothing, except in the place where you have taken it. It takes that area off the receptor in the brain and the effect of the agonist is totally gone, while the antagonist remains on the receptor in the brain.
Neasa Hourigan (Dublin Central, Green Party)
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Is it fair to say access to that type of treatment is very important when there has been an overdose or the consuming of drugs whose effects you want to cease?
Dr. Denis O'Driscoll:
I should declare that I am the independent chair of the naloxone advisory group for the HSE. From my perspective, the answer is "Yes". Availability has increased significantly in recent times with regard to some of the changes we have brought in regarding how people are trained and access training and how community groups can now register with the Health Products Regulatory Authority, HPRA-----
Neasa Hourigan (Dublin Central, Green Party)
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I apologise for interrupting, but my understanding from having spoken recently to a GP is that if I work in the drugs sector as, say, a youth worker, or if I know somebody who I think might go into overdose, I need to go to a GP and get a prescription for that person. If I then meet someone who is in the middle of an overdose and give him or her naloxone, I then have to go back to the GP to explain myself and get another prescription. That does not lend itself to emergencies, considering that it is a drug that has no impact on somebody who takes it for no reason.
Neasa Hourigan (Dublin Central, Green Party)
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Where are we with that?
Neasa Hourigan (Dublin Central, Green Party)
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Is it Dr. O'Driscoll's position that the hold-up is because of the EU complication?
Neasa Hourigan (Dublin Central, Green Party)
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Other countries, such as France, have started to be more lax-----
Dr. Denis O'Driscoll:
Correct. In England, for example, prior to the UK's departure from the EU, it introduced a measure whereby persons could walk into a pharmacy and get the drug without a prescription. Anyone could access it that way. Ideally, that is the way the product would be able to be accessed, but there is a stepwise process. This is beyond my scope but it is within the territory of the Irish Medicines Board, the HPRA and the organisations that have the product licence on the market because they have to go through a stepwise certain process to have that happen.
Neasa Hourigan (Dublin Central, Green Party)
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All the witnesses will have seen the roll-out of defibrillators in this country over the past five years. It is totally new, and my partner is somebody who might need a defibrillator. It has been very interesting to see the roll-out of this expensive technology, which is now accessible on the roadside. Why are we not pursuing a defibrillator-style approach to naloxone? I represent Dublin 1 and we need it there.
Neasa Hourigan (Dublin Central, Green Party)
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People should be able to walk up to a machine in the street and access it.
Dr. Des Crowley:
In the context of Dublin 1, there is the peer group UISCE, which works alongside our HSE clinics, where it trains patients and distributes naloxone to them, so they get some for themselves. A really----
Neasa Hourigan (Dublin Central, Green Party)
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If I am a patient's family member, however, I need to sign something saying I am a drug user and I cannot have the drug in my back pocket to give to them. Is that correct?
Dr. Des Crowley:
That is the next point. The professional would need to look at the risk to his or her patients to see in which context they are using and in which context he or she would need to provide the training, most likely to a family member, because the drug-related deaths are telling here. Approximately 70% of drug-related deaths are opioid based, which is where naloxone is very effective, and only four out of ten die alone, so there tends to be somebody present in the house or wherever.
Neasa Hourigan (Dublin Central, Green Party)
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That person will probably try to save them.
Neasa Hourigan (Dublin Central, Green Party)
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It seems to be a lot of jiggery-pokery and running around the place, whereas if we just deregulated it, it would take away a lot of that.
Neasa Hourigan (Dublin Central, Green Party)
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Deregulation?
Dr. Bernard Kenny:
No, removing prescription requirements. We see it as a very safe medication, much safer than many medicines that are available to buy in a pharmacy, for example, so we would see removing the prescription requirements for naloxone as a good thing, and promoting the dispersion and availability of naloxone would be a priority for us.
Neasa Hourigan (Dublin Central, Green Party)
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I am under the impression that in the case of nitazenes now, for example, they are so strong that not just one nasal spray but three or four are needed to save somebody’s life. Are the representative groups putting pressure on the Department of Health to deregulate naloxone or make it prescription free?
Dr. Bernard Kenny:
As part of my role in the ICGP, I liaise with the HSE naloxone leads. We would push for that but I guess-----
Neasa Hourigan (Dublin Central, Green Party)
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To me, and I do not mean this in a pejorative way, that is upholding a system that is incorrect. From an outside point of view, is there engagement to say working around a bad law is fine for now but that the law should be changed?
From an external point of view, is their engagement indicating that working around a bad law is fine for now but the law should be changed?
Ruairi Ó Murchú (Louth, Sinn Fein)
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Cuirim fáilte roimh na finnéithe. They have been straightforward in talking about the decriminalisation of the drug user. However, none of this makes any difference without a proper framework and resources in place. We all know that the resources do not exist, regardless of whether that is politicians anecdotally saying it in relation to issues we are dealing with. We are trying to keep an engine running by using baling twine, with services operating on an ad hoc basis. They are not always available as they should be.
There is also the wider societal issue. Ireland was never great at dealing with alcohol addiction, so it is no great shock that we are not great at dealing with cocaine addiction. It is just added in. For some people, it just facilitates their going on a three-day bender. People believe it will not have a major impact on them. For some, there are health implications and for others there is the knock on the door, which we all deal with. Anybody who has been in an emergency department recently will have seen that they are dealing with drug addicts. They are dealing with mental health cases. In some instances, the grenade was released by drug use. Even regarding some of the mad stuff we have all seen online and that politicians have to deal with, I know that the first people I had conversations with around some of the conspiracy thing would have been individuals of my age who would have taken a considerable number of ecstasy tablets in the 90s.
We all accept that we are in a very bad place on this and that it is having a major impact. That is before talking about working-class areas. Obviously, there are many places in working-class areas where drug dealing has become absolutely normalised. In some cases for an awful lot of kids who do not necessarily have great horizons in front of them, all they can see is a way of making money and it has been allowed to happen for too long. That is a wider issue. With all that we have to do, we cannot allow this to happen. We obviously have to deal with multigenerational trauma, poverty and all those other issues.
Of course, everybody feels sorry for the addict. We are also talking about people who have come from really chaotic backgrounds and end up being very vulnerable people who are then used by drug dealers and whoever else. We end up with sales pitches and they create huge hassle for their neighbours and they end up going to all the services. Whether we are talking about the Garda, local authorities or Tusla, the tools and services do not exist. If we are going to deal with all this, it is a much wider question than just criminalisation versus decriminalisation and even following up with addiction services. It is even people who fall into homelessness. Some single people are afraid to go near homeless services because those services are full of drug addicts, some of whom are chaotic and very dangerous. That is the reality.
I accept that people are not always ready to go down the road with addiction services. The witnesses have said we need some means of harm reduction that is not necessarily detox. We also need to make sure we have the facilities to allow for detox and whatever addiction services are possible. Then there is the follow-through. I am dealing with a family at the moment. They have gone through the detox but are looking for something else rather than just going back to the same streets where the person took drugs and whatever else. While not in this case, in many cases all people can do is sit around and ponder the debts they owe to somebody who will definitely come calling. I do not expect anybody to have an answer to that entirely. The witnesses have already outlined what they want to see regarding decriminalisation and whatever else. None of this works without the resources. I know that is more a commentary than a question. If the witnesses can answer this, I would be delighted.
Lynn Ruane (Independent)
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Does the Deputy have a question?
Ruairi Ó Murchú (Louth, Sinn Fein)
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You have already said it. What is a framework that works and that we can put in play now? I do not expect the witnesses to deal with the fact that there is a wider issue that involves nearly every service and Department. We are not looking at this in any way shape or form. We are not in any way serious about dealing with drugs.
Mr. Tom Murray:
We need to provide community education and community preparedness for the services as well. Deputy Hourigan spoke about defibrillators being present at every street corner, which would be very welcome. If we start sticking naloxone access points at every street corner, people would have the perception that would invite drug users into the area and would normalise a taboo issue which not everybody sees.
I used to work in a drug-dependency pharmacy in England. When we started doing methadone and needle exchange, I was attacked because I was told I was attracting all sorts of undesirables into the community. Brian Mawhinney was my local MP, so it was in the middle of central Tory-land and not the most attractive place to be seeing drug use. The patients existed. The patients were in the community. Nobody came from outside the community. I did not set up a gravitational pull for drug abusers; I set up a treatment centre for patients who are dependent on addiction services. The first step in all that resourcing must be community education. There must be preparedness prior to the services so that the services are seen as health services provided by GPs, pharmacists and those in addiction services rather than facilitators of drug use. The first step needs to be patient education. We are all involved in that and would be prepared to be more involved in it.
Dr. Des Crowley:
We have the data. We have the prevalence studies and so we know how many people are using. We know the population profile. We also have the HRB data on people presenting for treatment and what they are presenting for. There is a framework against which we can match. We also have good evidence on evidence-based treatments for each of the different types of addictions. There is a great deal of information that can be put into a framework in terms of delivery of services.
Ruairi Ó Murchú (Louth, Sinn Fein)
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I spoke to somebody who was a heroin and crack addict at one stage and who was able to turn it around. They said they were not able to get treatment in Ireland because at the time they could only get methadone. Basically, they went abroad and were able to deal with their problem. There is a drug that they spoke about. I am going to pronounce it wrong. Is it Subutex or something?
Dr. Bernard Kenny:
Buprenorphine is the active ingredient. It is a combination of buprenorphine and naloxone. Since 2017 it has been readily available in Ireland. Subutex, Suboxone and Zubsolv are all brand names. Buprenorphine is the key ingredient and has been readily available as a treatment option since 2017. The numbers we are offering-----
Ruairi Ó Murchú (Louth, Sinn Fein)
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This would have been prior to that.
Ruairi Ó Murchú (Louth, Sinn Fein)
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Even a few years ago, before the Taliban decided how to deal with heroin, a local dealer told somebody after they had lost their partner, "Don't worry about the cost or whatever. I don't have a whole pile of heroin at the minute but I've plenty of crack."
This is my last question. Have the witnesses come across and increase in the use of fentanyl recently?
Ruairi Ó Murchú (Louth, Sinn Fein)
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I believe that is filling the gap.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank the witnesses for their comments which have been very insightful. I wish to follow on from what Deputy Ó Murchú was saying. Obviously, there has been much reporting in the media recently about synthetic opioids. There are horror stories from the United States and elsewhere. The supply from Afghanistan may dry up and the drug market would need to fill that vacuum with synthetic opioids.
We have heard that these drugs are extremely potent. How concerned are the witnesses about the proliferation of synthetic drugs in the event that poppy-based heroin dries up and synthetic opioids fill the vacuum?
Dr. Denis O'Driscoll:
I will set out my experience with regard to fentanyls in particular. There was a period when we saw them very briefly, but they then disappeared from the marketplace. Dr. Crowley and I had a discussion about nitazenes before. We expected it to be a much bigger problem but it has not yet come. Will it still come? We are not sure because if we look at the early warning emerging trends from Europe, we can see that the most significant types of drugs that are increasing in volume - new, novel and emerging substances - are stimulant-style drugs. You are also seeing significant synthetic cannabinoids coming through. The nitazenes have not come as we expected them to come. My experience on the hopes around the Taliban has been there is always another player in the global market who will happily step up and start growing it. My understanding is that it may become a south-east Asian product shortly and that is the new route for opium for heroin. That is not to negate anything else. It has been highlighted by the European drug agency that they seem to be going down the route of methamphetamines and into the stimulant market. There is always a risk that we will see newer products and we do not know what they are. There was a classic one in the prison service recently where we had overdoses that expressed themselves to look like an opioid overdose but it turned out that the predominant product was a novel benzodiazepine not seen before on the Irish market. The way that markets work is that you can source products, which previously you could not source, through the dark web and in various other ways. That is what makes it very difficult to say what the next big thing is going to be. There seems to be a wide range of products that can be chosen from and picked. You can get whatever one suits you at that moment in time.
Dr. Des Crowley:
I totally agree with Dr. O'Driscoll. We know that if it does arrive, it is going to be a big problem because they are very powerful and dangerous. In the meantime, we can ensure anybody who requires treatment for opioid dependence has treatment because that would be protective. Tolerance to opioids, either through use of opioids or by treatment with OST, protects you from overdoses. Engaging people who we know are using opioids into our services is what we can do. Hopefully, it will not arrive but if it does arrive we will need to have some joined-up thinking about how we manage it. Naloxone is going to be a big player in that regard because it is really the only thing we have to reverse opioid overdoses.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Obviously, this situation evolves very quickly and we are at the mercy of the drug market.
Dr. Des Crowley:
I was involved in one of the responses that happened locally. It was extraordinary how the services joined together and how they communicated. There was an overdose in a particular location on a Friday morning and by Friday lunchtime everybody was aware of the dynamics of what was going on. That was very good. It is about the information coming out very quickly when you have a collection of overdoses in a particular area. The ambulance crews and emergency departments etc. join up the data so that it is not a day later, two days later or a week later when we realise what is happening. It was very effective. I was amazed at how the word of mouth spread among the different services.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I agree. The HSE and all the allied bodies reacted very quickly in terms of this substance that is out in the open and so forth. A lot of people have to be congratulated on that. I would like to speak about the proliferation of all drugs which evolve. For example, with cannabis at the moment there is a big issue with HHC. It is a semi-synthetic cannabinoid and there are a lot of concerns. I will say where I am coming from in relation to this. We are having this debate but I am more into regulation than deregulation. One of the major issues we have had in the last 55 years of criminalising people is the lack of a debate around regulation. I am talking about the regulation of all drugs. It is probably a minority view, but I think it is a debate we should have. What are Dr. Crowley's views on the proliferation of HHC, which is a semi-synthetic cannabinoid?
Dr. Des Crowley:
The new psychoactive substances are a bit like the old drugs we had with headshops. It is a drug that has got through that system because it is connected to a non-psychoactive drug. Like everything, the discussion is about whether it is regulation or availability and there is a balance and weighing scales with that. I assume the Citizens' Assembly recommendations came clearly down on the side of the decriminalisation space rather than legalisation.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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It is probably a debate for another day. Prescribed drugs are prescribed by a doctor or pharmacist. I will use the term "leakage" to describe the phenomenon whereby where these drugs are sold on the street. There is obviously a dependency issue with these drugs. These drugs are sold by companies that make enormous profits. How concerned is Dr. O'Driscoll in terms of leakage, particularly in relation to benzodiazepines where people become dependent and then become part of the drugs market?
Dr. Denis O'Driscoll:
It is a very broad question. The drugs that concern me, and I am sure my GP colleagues would concur, are the gabapentinoids such as Lyrica and Neurontin. These seem to have gained a huge place in the marketplace as a result of, as the Deputy said, leakage. They have also started to show in our national drug-related death index of overdose and overdose-related deaths. If you look at how we legalised or regulated benzodiazepines when they were re-regulated to CD4 part one, it did slow down the whole leakage piece. There is a role to play in regulating certain compounds in order to prevent that leakage. There are always ways and means of getting these drugs, regardless of getting them through prescribing or dispensing routes. There are other routes through which people are getting them such as Internet portals, etc.
To go back to the primary question on benzodiazepines, when CD4 part one was brought in there was also a piece brought in from the PCRS whereby they monitor the benzodiazepine prescribing patterns of GPs. This has helped with regard to benzodiazepines coming through the legal channels.
Dr. Diarmuid Quinlan:
It is a really good, pertinent question. The Medical Council has an overprescribing working group, which will be producing a report shortly. I am on it and some of my pharmacy colleagues are also on it. There is serious concern at all levels about overprescribing and misuse of benzodiazepines, hypnotics and Z-drugs. We need to collectively work on the issue. The Medical Council is leading on this. I anticipate that the report will be released in the not too distant future. It is a serious problem and we are certainly looking at it.
Lynn Ruane (Independent)
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I am going to ask a few questions before I move into a second round. There will be five minutes for the second round and Senator Seery Kearney will be first. It has been a really good session and very clear and to the point. It is interesting when I say "clear and to the point" because sometimes I listen to how colleagues pose questions and wonder whether the clarity is being felt everywhere.
When this question is repeatedly put forward, we hear that resources are needed and a framework is needed. There is a suggestion that this has to happen and if it does not happen, decriminalisation is somehow off the table. That is not what I am hearing from witnesses but I am hearing it from the questioners' side. It is a political thing because if you remove from them the baton with which they can batter people, they use the excuse that this cannot happen because there are not enough resources. It slows down the process and gives people something to hide behind when the conversation on decriminalisation comes up in terms of a legislative framework.
I do not think that is fair to the contributions I am hearing today because what I am hearing is that these things can happen in parallel and that decriminalisation itself is part of the harm reduction model. People should not continue to be criminalised while we wait on full enhanced services, and what they should be, because that could never be realised. People should not have this moral stick waved over them while we are waiting on something else to happen. It works side by side. That is very clear to me so then I ask myself whether I am mishearing it from my bias in terms of what I want to hear. Would Dr. Quinlan agree that my summary of that is correct? They go hand in hand. They are not one before the other.
Mr. Tom Murray:
They have to progress in parallel and where, as our GP colleagues have outlined, criminalisation is a barrier to access to healthcare for the patient. That is fundamental. We are all patient-centred professional practitioners. That is what we do. Therefore, where you see criminalisation is a barrier to access to healthcare for a patient, that is not something we can necessarily stand over and say it is a good policy.
Lynn Ruane (Independent)
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I thank Mr Murray.
To move on from that, I was really delighted to see the sentence "human-rights based" in there. What does that look like in real terms? We had a conversation regarding alternatives to methadone as a treatment being readily available but some communication to me indicates there is no choice on that. It is health-rights-based but then there is no choice in that about whether you are going to get methadone or you can go in and have some agency or autonomy to say you would rather try Suboxone or one of the other forms. From that perspective, when somebody goes in and is being put on an OST treatment, can they chose in that moment which one they try or is methadone cheaper or more readily available? Is there a price thing or anything in that?
Dr. Bernard Kenny:
As medical practitioners, price would not come into it certainly. That is not something we ask. We would not consider that. We would consider the most appropriate treatment for that person. In certain circumstances, depending on the substances involved, different opioid agonist therapies, which is what we call methadone and Suboxone, may be more appropriate. We would always make our decisions with the patients involved. The vast majority of practitioners have moved on from a paternalistic model of care where we impose our judgments. It is all around shared decision-making now. In most practices, you would not prescribe a treatment that someone was not comfortable with, or certainly would never force somebody onto a treatment. Occasionally methadone may be the more appropriate treatment and you explain the rationale for that, depending on the risks from other substances they may be taking, interactions with medications, or certain other chronic diseases that co-exist alongside the addiction. Certain people may have advanced liver disease and other things as well and that may affect their treatment option. It should be informed shared decision-making. Certainly, the ICGP would always support that approach.
Lynn Ruane (Independent)
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When GPs carry out the training, they are granted the list and are able to take on patients for methadone or other options. There seems to be something happening in some counties outside Dublin where people need treatment. The doctors are saying they have done the training and have signed up but are not receiving any patients. However, other doctors are receiving many patients. Who decides where patients go? Will Dr. Kenny explain the process to me? When a GP says they want to go on the list and be a doctor who provides that care, what is happening in the decision-making? A patient may be saying they want to be with the doctor who is closest to them but there seems to be someone else making the decision that they are going to go to another doctor. Some doctors are saying they have been given no patients while other doctors in the next town over has loads of patients but they are also from closer to our community.
Dr. Bernard Kenny:
The process is that we offer the training to train GPs up to have advanced specialty in addiction medicine. We provide that training through ICGP. Once the training is completed and they have met the standards of that training, the HSE will offer a contract or the GPs can apply for a contract through their local HSE co-ordinator. Depending on the level of training, they are then in a position to inherit existing patients who are already prescribed an opioid agonist therapy, or if they complete level 2 training they can complete a full assessment and implement their own management from scratch in the community where they are. We recognise that is the preferential place for people to receive their therapy.
Lynn Ruane (Independent)
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Is it the HSE co-ordinators who are then deciding on where patients go or is it higher up in terms of the central list?
Dr. Bernard Kenny:
I imagine patient preference has a role, as does the HSE co-ordinator. Dr. Crowley may be able to answer more on that.
Lynn Ruane (Independent)
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Okay. They are making the decisions. As I said, there are GPs in one or two counties specifically who are saying they are trained and there are patients but they are not being sent to them. They are a bit confused by that. Perhaps that can be dealt with separately. I can ask them to make contact with the appropriate people.
I have two final questions but I will put them together. One is in relation to benzodiazepine detox within the community. I think I did benzo training with Dr. Crowley when I was probably 20. This is how long it has been. It was nearly 20 years ago. I cannot believe I am at this stage in my life where I am saying "20 years ago I...". That is how long ago - and even before that - the conversation around benzos has been going on but we do not seem to be any further regarding having a national plan or framework for benzo detox within the communities. I understand the concerns and GPs being concerned about people topping up on the streets and all of that. Are we any closer to having any sort of strategy around people having access to benzo detox within their communities? That is the first question.
The second question is regarding the likes of tramadol and oxycodone and people being outside of that ordinary framework of what people maybe consider as someone being in addiction. I refer to men and women who are going out to work but a lot of them have developed serious addictions to the likes of tramadol or Ixprim, which is the dissolving one. The only option that has been given to one or two people I have spoken to has been that they go on a methadone programme. Obviously, this would be completely outside of their realm of daily life. They are not in drug-using communities and it is not that their peers are. It is a difference culturally. Are the witnesses seeing much of that? Are many people ending up on methadone treatment programmes from the likes of tramadol addiction? I am still at a loss to understand where it is all happening. From a point of information, I just do not understand.
Dr. Des Crowley:
I will take the question on codeine dependence. Certainly, codeine dependence is equivalent to opioid dependence but it is a different drug. The Leas-Chathaoirleach is right that it is a different cohort and they have different needs. In the areas in which I work in my own practice, the first line of treatment would be to provide people with buprenorphine. We are progressing another OST option now which is depot buprenorphine. This is a monthly injection which has revolutionised a huge number of people's lives, particularly in the patient cohort we are talking about, because they only need to go once a month to get their depot. That is the type of service for which primary care is ideally placed because that is where you come into further discrimination and stigma. They need to go to their general practitioner. They need to have a GP who has that specialist skill to assess and then to provide the treatment. That is where we would be advocating for in ICGP.
Lynn Ruane (Independent)
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Does there need to be some sort of public information for people to know they can go to talk to their doctor about the tramadol addiction?
Dr. Des Crowley:
It is an enormous situation and we have tipped the iceberg on it. Part of it is the historical way our services have been set up. They were methadone-based and related to heroin use because that was the predominant opioid that was used but now codeine is definitely a sleeper and there is a huge issue there.
Lynn Ruane (Independent)
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Okay. I thank Dr. Crowley. The other question was on whether there were conversations regarding the benzo detoxes.
Dr. Denis O'Driscoll:
From my experience when I was in the addiction services, we certainly offered benzodiazepine detoxes within the confines of our addiction treatment services. They were always patient-driven because that is the only way it will work. It is pointless me dropping somebody automatically. As regards detoxes within the community, there was a project on the northside of the city which was very much based around community GPs and the patients themselves with local pharmacies to look at how benzo detox could and should work.
The challenge around benzodiazepine detox is people always ask how long. My opinion on a detox is it is as long as a person needs it for, but the whole rationale for it is that within our addiction services, we could change things more regularly. That means I could ring Dr. Crowley up and say the Leas-Chathaoirleach is not ready to drop down a dose and we need to keep her on this particular dose, so we would keep her at that. Out in the community there is a whole scope, including needing prescriptions, interventions and regular interventions. It is just a more difficult situation out in the community. I concur with the Leas-Chathaoirleach. In 2000, I think, the benzodiazepine subcommittee was set up, so it has indeed been that long. We have talked about it since that.
Dr. Des Crowley:
Many more GPs would get involved in benzo detoxification if the support structures were in place. Most GPs fear being left with a patient on a benzodiazepine prescription, finding it hard to reduce or come off it and then we get into the issue of overprescribing and being identified, whereas these patients are benzodiazepine-dependent, so the prescribing of benzodiazepines to dependent people is actually good practice.
Lynn Ruane (Independent)
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It is good practice. That collaboration piece is important to ensure a doctor is very well linked in with the local community services, so it is a more holistic approach across the board within the community. I will go to Dr. Quinlan and move on.
Dr. Diarmuid Quinlan:
I will be very brief. I absolutely get what my colleagues are saying about the detox. Equally, there is a much bigger piece about not initiating people on benzodiazepines in the community. That is a challenge in itself and one the Medical Council is addressing in conjunction with all the professional bodies. Again, we need a whole-system approach. It is not initiating people in benzos as much as possible and keeping the dose as low as possible for the shortest duration. We are very happy to work with our colleagues to try to address this problem.
Lynn Ruane (Independent)
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It is not to fully say that is where benzo addiction comes from. Obviously, prescribing is a big part, but a lot of benzo addiction is starting anyway within the illegal market without it ever having been prescribed, so there are definitely two cohorts or transitions happening there. Senator Seery Kearney is next.
Mary Seery Kearney (Fine Gael)
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I always love the Leas-Chathaoirleach's questions. I thank the witnesses, as this has been an incredibly respectful conversation, as well as unbelievably illuminating. I always hated the term "drug addict". People are not drug addicts, but mothers, sons and fathers. They are people who have dreams, hopes and everything for their lives and I am very much influenced by Gabor Maté's writings on his encounters with his patients and how honest he is about his prejudices and all the complexity of patients as they present. We are really respectful here and I hear that from both organisations in a way I just love.
I have three areas of questions. I thank Dr. Quinlan for talking about the Medical Council and prescriptions. I worked as a counselling psychologist in Ballyfermot for a number of years. I felt there was an instant prescribing. I would have someone coming through counselling and all of a sudden they had gone to a doctor who was prescribing. I often wondered whether there was an issue of fear of litigation with doctors, namely, that if somebody has a particular presentation there is a fear of not prescribing or something along those lines. Are there impediments there we should be lifting? If you are involved in the counselling process it prolongs it. I, unusually, would be of the view that my job was to get a person to a place where they had the skills to be able to live their life rather than forever coming to me. I feel prescribing is too quick, but I also respect very much what Dr. Crowley was saying around benzos, the detox and all that and that there is really good practice on prescribing. I would like to comment on that more.
I love that Mr. Murray took a stand, despite the political considerations, to ensure there was a needle exchange and that people had somewhere to come to. There is a responsibility to tackle the denial among the public and as a nation and to deal with the stigma. Every community, no matter where they are, has people who have addiction issues, especially in the area of drugs. It may be masked in more upwardly mobile communities than it is in socially deprived communities and my home constituency of Dublin South-Central particularly, but it is there and so we should have the response there. I would love for us to move so we have a response when it comes to naloxone that is almost like what we have with EpiPens.
As the witnesses speak and as I hear the amazing insights and the responses, I think of my role as chair of a drugs task force. I have had the privilege of being involved in the Dublin 12 local drugs and alcohol task force since 2019. On that, we have the Garda, the HSE, probation services and practitioners, but we have no pharmacists and no doctors. I wonder whether that could be better informed structurally because at every meeting we deal with trends and what is emerging in the community. Maybe we would have better community responses if we looked structurally at that level of greater response as part of the community change and ramping up the health response and moving to that. I am interested in hearing the witnesses' comments on that.
Dr. Diarmuid Quinlan:
I will take the first one. I agree with what the Senator says about mental health. We have broadened to mental health in primary care. I and my colleagues are resourced to provide care for people with chronic diseases such as asthma, diabetes, heart failure and so on. There is currently no resourcing at all in primary care for mental health illness. Depression, anxiety and psychotic illness are not resourced in general practice. When it is not resourced, inevitably it is competing for limited availability of GP time and space with areas that are resourced. We have the capacity to provide enhanced mental health service in primary care, but we need resourcing. We have heard a lot about the contraceptive piece in the last while, but there is no resourcing for mental health in primary care. That is a fundamental-----
Mary Seery Kearney (Fine Gael)
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We need to name that and call it out.
Dr. Des Crowley:
Going back to our original statement, we talk about increased funding for the talking therapies and there are a lot of addictions that is the only base for. I refer to cognitive behavioural therapy. That is the basis of how we make people better and it is really poorly resourced and very difficult to access.
Mal O'Hara (Green Party)
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I am a Belfast boy and I want to raise something in relation to the submission from the Irish College of General Practitioners. In Northern Ireland we had 218 deaths in 2020 and 213 in 2021. The ONS would say that is 11.5 per 100,000. Scaled up that is 115 per million, which is higher than the rate here in Ireland. The challenge of that is when we look at the European statistics we take the UK as a unitary state, but there are subtle differences in reporting across the four nations. We have a particular circumstance in the North, which is post-conflict endemic poverty and unfortunately a weak programme for government that does not talk about drug deaths. That is really disappointing.
I have a question about the diversionary threshold and the question the Vice Chair came to about being clear decriminalisation is of itself a good policy move, supported by both organisations. The caveat is that decriminalising substances, I think from the witnesses, was maybe not supported. If we follow that logic, if we decriminalise the person but not the substance, where is the diversionary threshold where it, in the witnesses' sense, potentially becomes somewhere where we have to refer someone to the police?
Dr. Bernard Kenny:
We very much take the approach that, as we said before, addiction is a chronic relapsing condition, so we treat it like that. We would not be in favour of having a limited number of strikes where a person is caught in possession because if we look at the disease model of addiction, the very nature of it is people will have periods of recovery and unfortunately many people will relapse at times in their lives. Taking that on board, we would support in those situations that they would continue to be linked in with an appropriate healthcare provider, counselling service, talk therapy, psychotherapy or whatever is needed. That includes even residential care if warranted.
We would not support hard lines in that respect.
Mal O'Hara (Green Party)
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Regarding my second question, Dr. Crowley touched on a more holistic model around primary care. We spoke about some of the significant gaps. I think they came up again in respect of mental health provision. What does that look like in an ideal world?
Dr. Des Crowley:
It is about increasing the skillset of the GP so that involves training. It involves resourcing the GP practice to have the time to do the work. The final bit is the referral pathway to other support services like talking therapies, psychosocial case workers and key workers dealing with all of the other aspects that are connected to the addiction. It is comprehensive, holistic and patient-centred.
Mal O'Hara (Green Party)
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In his piece, Dr. Kenny said that 350 GPs completed specialist training and the challenge relating to that. How much more additional resources are required in terms of that provision for GPs?
Dr. Bernard Kenny:
A funding model is in place whereby GPs are resourced to provide the opioid agonist therapy programme. That is an agreement with the HSE that works very well. A total of 350 members are actively prescribing opioid agonist therapy. Part of our role in the college would be to see that expanded and that is what we would like. That is beneficial to the community. As part of that training, we do address other addictions so it is not purely opioid. Unfortunately, there is no equivalent programme from the HSE with regard to funding other substances so it relates purely to opioid agonist therapy. As I mentioned before, we recognise that addiction is a chronic disease in many cases with relapsing so it would be a suitable programme to expand into other substances like cocaine, cannabis use disorder, etc.
Maurice Quinlivan (Limerick City, Sinn Fein)
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The witnesses from the Irish Pharmacy Union spoke about they reached out to stakeholders, particularly those in Portugal. Could they tell us what they learned from the Portuguese. I think a lot of us would have concerns about some of it but from what I have seen, other bits have worked really well. What was the Portuguese experience? Regarding the comment that it came and went, that happened in Limerick in crack cocaine. It came and went but is now back with a bang so we should be careful - as I am sure, the witnesses are. I do not wish to say anything that would be misrepresented.
Ms Sinéad McCool:
This is from a pharmacy perspective in that we met with our Portuguese pharmacist colleagues via the Pharmaceutical Group of the European Union, PGEU. Their experience was very positive. We spoke about things happening in parallel. The background was that Portugal had a serious issue with opioid misuse in the late 1990s so the government came together to form a body to put this in place with the five pillars. It happened very quickly. We said we were quite used to people having great ideas but they are very slow to happen. If memory serves me, they said the whole thing was up and running within a year to 18 months, so it was a real eye opener for us to see that it did happen. Their piece happened quite quickly within those 18 months, so they would have had the resources put in place be they needle exchange or opioid substitution programmes. It was the resourcing piece. Overall, it was a positive experience and they were very happy with it and they could see other improvements. It facilitated working within the community. The community education piece happened because there was access to these services. There was access to needle exchanges. As was talked about earlier, these were mothers, sons, daughters and families. From their perspective, it was very positive.
I will not use the word "complacency" but the one thing they said was that it was so good that they almost forgot how lucky they were to have it. Again, this is a pharmacy perspective. They did talk about how if issues arose, they were referred to commissions and took on undertakings so that no further actions were taken. They did not have a lot of experience of that but they did feel that they got referrals to services via those. Again, it fed back into decriminalising the patient and getting him or her the care and supports he or she needed. At a point, their opioid substitution programme stopped because it had been a success and there was no need for it. The needle exchanges continued because, again, they are an outreach service and a way of engaging somebody and, hopefully, starting him or her on the path to considering engaging with opioid substitution and trying to cease drug abuse. That was the perspective from our Portuguese colleagues.
Mr. Tom Murray:
From a specific practitioner point of view, it involves the accessibility of pharmacists in terms of screening, recognising and sign posting and increased patient accessibility to addiction services as well as the increased use of needle exchange, opioid substitution therapy and harm reduction services, which could become available through an Irish pharmacy if properly resourced. The Portuguese certainly built on the model of accessibility of pharmacists in the communities for that. There are 78 million visits to pharmacies in a year, so we are ideally placed to take on that role if it is resourced, trained and put into place in the correct manner.
Maurice Quinlivan (Limerick City, Sinn Fein)
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The law engagement and assisted recovery, Lear, project in Limerick, which is done with the Anna Liffey Drug Project. Gardaí can refer people to Anna Liffey as opposed to criminalising them straight off the bat and it is working really well. In the absence of legislation, we should be going down that road. HHC in cannabis is presenting anecdotally. What concerns do the witnesses from the Irish College of General Practitioners have about psychosis resulting from HHC in cannabis?
Maurice Quinlivan (Limerick City, Sinn Fein)
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When they criminalised head shops.
Neasa Hourigan (Dublin Central, Green Party)
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I will stay on the issue of access to opioid substitution therapy. I know what the witnesses are saying, namely, that it is so much more complicated than that. Can we stick to the detail of that because I am interested in accessibility of opioid substitution therapy in an meaningful way? I fully admit that part of that is because I represent an area where there is a very strong concentration of services and I am aware that people travel to my area to get services when they are in addiction and need support. A total of 350 GPs are trained in level one or level two of opioid substitution therapy?
Neasa Hourigan (Dublin Central, Green Party)
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Is that unrelated to level one and level two training?
Neasa Hourigan (Dublin Central, Green Party)
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It is basic. It is a case of "If you have had a crisis and have met with a specialist then I can be your everyday support".
Neasa Hourigan (Dublin Central, Green Party)
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Of the 350, what is the breakdown? How many of those 350 are low-level and how many are people who can initiate?
Neasa Hourigan (Dublin Central, Green Party)
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One third would be level two?
Neasa Hourigan (Dublin Central, Green Party)
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Maths is not my strong point. If 350 represents about 8% of GPs, one third are people who initiate opioid substitution therapy.
Dr. Bernard Kenny:
Probably in the eighties. That would be people based in GP community practices outside the HSE centres.
Neasa Hourigan (Dublin Central, Green Party)
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That means about 3% of GPs can initiate opioid substitution therapy.
Dr. Des Crowley:
The majority of all opioid substitution therapy patients are initiated by GPs working in HSE services.
Neasa Hourigan (Dublin Central, Green Party)
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Are the witnesses aware of the regional layout of those services and access to them? Do they feel there is a good regional spread?
I am trying to get to the bottom of why I have seen people travel to us in Dublin 1 to access services. It is not just because we have those services. There must be a lack in their own areas because people do not want to travel unless they have to.
Dr. Des Crowley:
There are regional problems with people accessing OST. Some of those problems are related to geography. If a person lives in a rural area it is hard to figure out how to provide care to them, although remote care might be one option. There are people waiting for OST treatment in the country.
Neasa Hourigan (Dublin Central, Green Party)
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Is there anything the Irish College of General Practitioners is working on to actively address that? Is there a level of discomfort for some GPs in dealing with this?
Dr. Bernard Kenny:
Like everybody in the population, GPs have their own levels of comfort or discomfort and their own experiences. Some GPs trained in inner city areas and they are used to dealing with issues associated with social deprivation and addiction. For others, it is completely outside of their comfort zone. As part of our remit, we promote addiction medicine as a specialty. I refer to part of the broader approach to destigmatisation and depenalisation of people who suffer with addiction. Enforcing that for society as a whole will help to address that demand. It is an important issue and we recognise that ideally people should be treated by their GP, but it depends on that GP's training and level of expertise.
Neasa Hourigan (Dublin Central, Green Party)
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What happens if a person’s local GP, who they have dealt with all their life, says they will not do this?
Neasa Hourigan (Dublin Central, Green Party)
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What if the person lives in Naas and they are being referred to Dublin 1?
Neasa Hourigan (Dublin Central, Green Party)
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I picked a bad example. Can we pick another example?
Neasa Hourigan (Dublin Central, Green Party)
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When there is a GP down the road.
Dr. Des Crowley:
Yes. That is the problem. There are people who cannot access their local community primary care service and they have to go to a specialist service which is a considerable distance from where they live. That has improved slightly because with Covid we were able to start providing remote care, which is very beneficial in that scenario. The advent of Healthmail, the IT system which allows us to send prescriptions directly to the pharmacy, definitely has improved things. However, there is capacity to look at those blackspots around the country and to ask what resources need to be put in, what the issue is and how can we eliminate the waiting list.
Neasa Hourigan (Dublin Central, Green Party)
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I am aware this is a question for the Department of Health to answer, but I hope there is a map that shows black holes in the provision.
Neasa Hourigan (Dublin Central, Green Party)
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I know I am out of time, but anecdotally I have been given the impression that there is a similar issue for some pharmacies, in that they do not want to stock certain OST-related products.
Mr. Tom Murray:
As colleagues outlined, some pharmacists are comfortable with certain levels of professional practice while others may not have had the demand for the service and therefore do not have experience. I do not think that means they are objectively against it, but that they need that education, training and support to offer the service.
Neasa Hourigan (Dublin Central, Green Party)
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If they are objectively or unobjectively against it, where is the point of interaction with your organisation?
Mr. Tom Murray:
We would be promoting a professional service that is patient-centred and patient care-centred. We would be providing the service of the training and supporting them through that so they could offer the service. We proactively promote that with members. I live in rural Donegal and the Deputy spoke about access to care. Sometimes it is not just whether the service exists in the county, but whether there is the infrastructure for people to get to that service.
Neasa Hourigan (Dublin Central, Green Party)
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Absolutely.
Neasa Hourigan (Dublin Central, Green Party)
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It is a huge barrier in day-to-day life.
Lynn Ruane (Independent)
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We have to move on.
Ruairi Ó Murchú (Louth, Sinn Fein)
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I may not have been clear earlier with regard to decriminalisation. I am not saying that you do not enter into something unless you have a spectacular, utterly perfect framework. If we wait for that, we will never do anything. I accept that everything we have done to date has not dealt with this situation. Mr. Murray, among others, spoke about the need to introduce that framework in parallel with other things. That makes complete sense. I also accept that at times in here there is an element of people talking out of both sides of their mouths. When talking about something novel or whatever, there can be this idea of going easy on people and where derogatory terms and the rest will be used. The problem I generally have with that commentary is that nothing radical is being proposed from a policing point of view or whatever. There is no one in this building who could say what it would take to out-police the drug problem. It is not something that people would countenance in any way, shape or form. I am very glad we are having this conversation but there is a wider conversation to be had. It has to be real.
I welcome, as Dr. Quinlan said, the piece around the whole-system basis. That is applicable across the board. Mr. Murray talked about community education and bringing people along to be sure we introduce the necessary services and get buy-in. We have a normalisation of kids seeing things they could not see 20 years ago, other than possibly in parts of Dublin and wherever else. I see how things have changed even in Dundalk over recent years and what is acceptable and what we accept ourselves from time to time. We do need to be able to deal with that. As we go down this road, it will create anomalies and unintended consequences that have to be dealt with.
As a follow on from what Deputy Quinlivan was talking about, a considerable number of kids are using vapes. Every second child is using one, or probably more. Many of them are probably putting more than bubblegum flavoured nicotine in them, such as THC and whatever else. We are seeing a significant number of issues in regard to it. I imagine the witnesses are seeing those numbers spiking at the moment. That obviously creates a lot of difficult circumstances in trying to manage those kids away from that. We are dealing with huge issues such as psychosis. Where do we go with that?
Ruairi Ó Murchú (Louth, Sinn Fein)
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The number is related to this but people have come to me in the last while about the kids.
Ruairi Ó Murchú (Louth, Sinn Fein)
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It is a separate question.
Ruairi Ó Murchú (Louth, Sinn Fein)
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Has Dr. Kenny seen an increase in kids doing this in the last while?
Ruairi Ó Murchú (Louth, Sinn Fein)
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I have seen it. I suppose it is about looking at a means of dealing with it.
Ruairi Ó Murchú (Louth, Sinn Fein)
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We are now dealing with far more intergenerational addiction and I know that anyone involved in youth services would say that where once a child could go to their grandmother, they cannot necessarily do that now. That is an awful thing to say. That means greater levels of supports are necessary to help people when they find themselves in these circumstances. We know that we do not have wraparound services, which I am sure is a situation our witnesses have come across in the last while, or is it?
Ruairi Ó Murchú (Louth, Sinn Fein)
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Again, it is about the need for that framework. What we need now is a hell of a lot more complex than what we needed ten years ago and we obviously do not have it.
Dr. Des Crowley:
The recognition of adverse events as part of the journey of addiction is very important. That is clearly documented. There is an onus on any system to try to stop that intergenerational addiction because experience of addiction is in itself an adverse childhood event for the child of the parent who is addicted. If we want to be serious about this-----
Ruairi Ó Murchú (Louth, Sinn Fein)
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If we are serious about this, we are into early interventions in families and communities. We know what we need to do and that is breaking poverty and diverting people. In an awful lot of cases, youth diversion is worth doing, but in some cases it is too late.
In fairness, that is what Dr. Quinlan said about benzos. We can stop people going down particular roads while accepting that there is no magic bullet for any of this.
Mr. Tom Murray:
Part of the education piece has to be around what is perceived to be socially acceptable drugs misuse and drugs abuse. There is a kind of snobbery whereby if you are using heroin, you are in one category, but if you are well-heeled, economically well-off and using cocaine at the weekend, then what is the harm? There is a whole educational piece around that in terms of recognition of where that drugs misuse and abuse is and around targeting services there as well rather than taking a tunnel vision view of what drugs misuse looks like.
Lynn Ruane (Independent)
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I wish to make three points. I might then give an opportunity for people to comment or deal with any unanswered questions that arose throughout the session before we wrap up.
On doctors, GPs or whomever being able to refuse care, reproductive rights is obviously one area in which that happens but that has been the subject of a constitutional debate for years when it comes to the religious context and all the different kinds of beliefs and stuff. When it comes to drug use and being able to refuse to become a prescriber, I understand that addiction exists across the spectrum but, as has been said, drug users put themselves in hierarchies. They always have adopted a view of "I am not as bad as them", "I do not do that" or "I do not use needles," but it feels as if there is a huge level of classism involved when doctors can say they are uncomfortable. If people train to a high professional level and complete extra specialist training - it is great to have such training - that is great, but what if someone has to deal with a person who has a rare disease and says that they are not comfortable taking them on as a patient because he or she is not a specialist? It seems that allowances are being made in respect of addiction and that people have to complete specialist training before they can become prescribers. What is the position culturally within the profession? I am not into shaming people because that does not solve anything, but is there a cultural push towards the view that such an attitude is not good enough from a professional?
Dr. Diarmuid Quinlan:
I absolutely agree. GPs address a broad spectrum of illnesses. I treat people from cradle to grave. I provide palliative care, antenatal care and everything in between. Having said that, there are areas that I am better at and areas I am not as good at. Yesterday, I was in the Department of Health with the rare diseases group talking about how do we identify, manage and support people with rare diseases. Most GPs will deal with a very small number of people with rare diseases, and we depend on our specialist colleagues in that situation. For many GPs, the situation is very similar with addiction services. As part of our GP training we have an understanding of the matter. We are able to identify people and direct them to appropriate services. These patients require and deserve that specialist level of care. Therefore, it is appropriate for GPs to identify these people and signpost where they should go. We cannot prescribe for every condition. There are over 500 medical conditions. These are very specialist services and it is important that we have the training and skills to identify these people and refer them to appropriate colleagues in a timely, accessible and equitable fashion.
Lynn Ruane (Independent)
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Is there an issue in the medical profession beyond GP-specific training in terms of the curriculum and being able to train to be a doctor and understand the social contexts in which they are going to work? Obviously, some social contexts are going to be different as a result of environmental factors, poverty and all of that. Doctors obviously have to choose to either become GPs or go into some other branch of medicine. Outside specialisation, should there not at least be some level of competency in order that people will be medically trained and understand people from all walks of life regardless?
Lynn Ruane (Independent)
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Diversifying the profession should be a long-term goal. Doing so would bring in all of that different learning because there are different types of people working in medicine.
On novel benzos, we saw the recent reports about the Irish Prison Service and Portlaoise Prison. We have had novel benzos in the past, have we not? I do not know if the problem is recognised as that. A few years ago, across Bluebell and Inchicore, there were several deaths. People locally stated that this was caused by a bad batch of "Nike" tablets, which are street benzos. Are we saying that, potentially, each time a novel benzo comes up, it contains different components? Are enough testing and research being done on what is contained in each iteration of novel benzos?
Dr. Denis O'Driscoll:
In my experience, you are never aware of what it is until you get hold of a sample in order to test. The issue with testing is that sometimes you are looking for a needle in a haystack. I say that with no disrespect to the testing process. There are so many varietals of the various forms of what is even contained in some of the street benzodiazepines. At one stage, etizolam was the most popular one. Then they had Flubromazolam in some others. Then they had tramadol mixed into others and a bit of paracetamol in others. It is very hard to determine exactly which one we are looking at. Much of our information comes from the European Drug Agency and from the Department of Health's early warning and emerging trends data that it gets from the Garda and Forensic Science Ireland. That is what we are seeing, and then we can determine what it may or may not be. Each benzodiazepine may or may not have higher effects, if that makes sense. Etizolam has more potency. I hate using that word when it comes to compounds. Etizolam has a more significant effect than benzodiazepines that are being prescribed. Hence, it was never made available for human use.
Lynn Ruane (Independent)
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I think it was in Canada - I apologise if I have the location wrong and I will double-check it for the record - where there was an initiative recently whereby drug dealers were encouraged to bring their supplies, especially if something had happened, to be checked and were provided with receipts. Those receipts were then shown to the people who wanted to buy the drugs. I know some people will panic the moment you mention drug dealers, but they are part of the supply chain. It is good thinking to include them in the conversation, particularly when something goes wrong. We are not there yet in Ireland, but what is the position with regard to amnesties within the community and people handing over drugs?
Dr. Denis O'Driscoll:
The Welsh Emerging Drugs and Identification of Novel Substances, WEDINOS, project is probably one of the better examples near to us. People in Wales can send their sample of product to WEDINOS, which will test it and tell them what it contains. To give credit to the HSE, doing that at the festivals here is probably the first foray into that kind of area.
Dr. Denis O'Driscoll:
It is just another step towards having openness about it and an approach whereby it is a case of "If you want to use drugs, then I want you use drugs in the safest way possible to allow me to support you". It is about going down to that level. From my perspective, I see nothing wrong with that. How it would be managed is the question. Some locations that do drug testing worry about that whole piece where you have the drug dealer sending in the drug to be tested and then saying online that they have the best product available.
Lynn Ruane (Independent)
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Regardless of people not wanting the whole trade of drug dealing, you definitely have to accept that drug dealers exist.
Lynn Ruane (Independent)
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If we can increase ethical standards, then I am all for it. Are there any unanswered questions before we wrap up? Does Dr. Crowley want to come in?
Dr. Des Crowley:
I just want to make a point. We cannot forget about the link with HIV. I would like to underline the effectives of our ST services over 20 years in really eliminating HIV infection in people who use or inject drugs. There may be one or two very occasional new infections. However, in the area I have worked in, we have not had a new HIV infection in people who use drugs for maybe ten or 15 years. It is important to look at there being no obstacles to safe needle access and injecting equipment, because not alone is it about HIV, it is also about hepatitis C, which is a much more easily transmissible virus.
We are spending millions on our hepatitis C treatment programme, which is very effective. It is now in the community and GPs are involved. If people are continuing to inject, the risk of reinfection is enormous, we have to go back over it again and we also have resistance regarding the type of drugs that can be used. If we are looking at legislation, there should be no barriers. If somebody rocks up to their local pharmacy and need a needle exchange, it should be provided there. If they are in their OSD clinic, they should be able to get it there. If they are going to a stand-alone needle exchange, that should be provided as well.
Lynn Ruane (Independent)
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On that point, I know you are not here from the HSE. I am not sure who can answer this. It is about paraphernalia such as crack pipes specifically. I am sure it is possible to transmit hepatitis C via such paraphernalia. Is procurement getting in the way of providing crack users with the pipes they are saying are the most comfortable for them? There were reports on the ground that in some of the services that were giving out crack pipes, there was a certain crack pipe that suited users, I am not sure of the reasons, they liked it, but then there was a complete change. Some of the users were saying the services had gone for a different supplier, but it is not the actual paraphernalia that is preferred.
Lynn Ruane (Independent)
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Some of them in Tallaght were ending up switching back to other ones. I am told it is the same in Ballyfermot.
Mary Seery Kearney (Fine Gael)
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Is there a role for GPs and pharmacists on the drugs task forces? Do our guests have a view on that?
Dr. Denis O'Driscoll:
I will revert back to my old HSE lands. I was a member of three different task forces by virtue of being a HSE employee, not as a pharmacist. I do think there is certainly a role for the local community providers. Essentially, the GPs and pharmacists in the local communities are probably doing the majority of the provision of services. It is a good idea for them to be on these task forces. I am not sure how that happens, as in how they could get into it time-wise.
Dr. Des Crowley:
They need protected time in their contracts. We are front of house delivering services. To get time away from that would require a commitment that acknowledges it as important. It is vital that the people providing the services are sitting around the table when we discuss it in the bigger context the issues for communities.
Mary Seery Kearney (Fine Gael)
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The next module will deal with communities. Hopefully we will get there. We are trying to visualise what this would look like and where and how we could enhance services that are already being provided. It would be important to include such recommendations in any interim report.
Dr. Des Crowley:
There is one other point. I do not want to hog the time. It is about the lived experience and being involved in the planning. It is important when decisions are being made. We talked about the development of services but you must have people around the table who have lived experience and can provide the nuance around access, where they feel stigma, where the blocks are and what they need in terms of recovery.
Lynn Ruane (Independent)
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I think that is it. I want to thank both the pharmacy union and the ICGP. That was a really good session in which we covered much that had not been covered previously. It went outside the realms of decriminalisation but the discussion was still underpinned by that being an important factor with all the other work that is being done. I thank all who contributed. I remind members that there is a private meeting on Tuesday. We will come back with a time for that.