The lack of adequate provision of methadone treatment in Ireland is a damning indictment of how the health service cares for one of the most vulnerable groups in society. June Shannon investigates
The number of people receiving methadone treatment in Ireland has been increasing steadily over the last two years.
However in some parts of the country, people are still being forced to wait for periods of up to a year to access treatment.
In July 2008, there were 8,661 people on the central treatment list. This increased to 8,934 in July 2009 and as of August 1st this year, there were 9,204 people on methadone maintenance.
Of the 9,204 people currently receiving methadone treatment, 5,897 are being treated in HSE clinics, 3,307 are receiving communitybased treatment from GPs, and 553 are receiving treatment in prison.
On August 1st 2010, there were a total of 464 people on methadone treatment waiting lists around the country and in some areas of the South East and Dublin Mid Leinster, people are being forced to wait for more than a year to access treatment.
As under 18s are prioritised for services, there are no under 18s on waiting lists.
The HSE Addiction Services break down the main four HSE Regions into smaller Regional Drugs Task Force (RDTF) areas. HSE Dublin Mid Leinster (HSE DML) is divided into four RDTF areas – the Midlands, the South West, the East Coast and the Drug Treatment Centre Board.
At present, the longest waiting time in this area is in the HSE DML Midlands RDTF area, where patients are waiting in excess of one year to get on the programme.
There are 122 people waiting to begin the methadone treatment protocol in the DML Midlands RDTF area – the highest number in the country.
The other three RDTF areas in this region, the South West RDTF – the East Coast RDTF and the Drug Treatment Centre Board – have 76, 28 and 55 people waiting to access methadone treatment respectively, according to the latest available figures.
The waiting times are more than a month in the South West and the East Coast, while the Drug Treatment Centre Board has a waiting time of one month.
The HSE South is divided into two RDTF areas – the Southern and the South East. Fourteen people are on the waiting list for treatment in the Southern RDTF area and the waiting time is one month, while 66 people are waiting to access treatment in the South East RDTF, which is reporting an average waiting time of one year.
The HSE West, Mid-West and Western RDTF areas had 31 and 18 on the waiting list respectively, with an average waiting time of more than a month.
The HSE West North- West RDTF was the only drug treatment service in the country where there were no clients waiting to access services, as of August 1st.
The HSE Dublin North East (HSE DNE) region is divided in two RDTF areas, with the North Eastern RDTF area recording a waiting list of 46 clients and an average wait time of more than six months.
A total of eight clients are awaiting treatment in the Dublin North RDTF area and the waiting time is less than one month.
One of the overall strategic aims of the recently-published National Drugs Strategy (interim) 2009-2016 from the Department of Community, Rural and Gaeltacht Affairs is “to provide appropriate and timely substance treatment and rehabilitation services (including harm reduction services) tailored to individual needs”.
One of the Strategy’s key performance indicators under its Treatment and Rehabilitation pillar is to have “100 per cent of problem drug users accessing treatment within one month of being assessed by 2012”.
Action 35 of the Strategy calls for a review of the Methadone Treatment Protocol (MTP) “to maximise the provision of treatment, to facilitate appropriate progression pathways (including exit from methadone treatment where appropriate) and to encourage engagement with services. The review will include engagement with the community and voluntary sectors.”
The HSE has commissioned Professor Michael Farrell, Professor of Addiction Psychiatry and Director of Postgraduate Medical Education in the Institute of Psychiatry, London, together with Professor Joe Barry, Professor of Population Health Medicine at TCD, to carry out the review.
The final review is expected to be published next month.
The Medical Independent has received copies of more than 50 submissions to the MTP review under the Freedom of Information Act.
The vast majority of the submissions highlighted the lack of access to methadone treatment outside Dublin, which is reflected in the long waiting times in areas such as the South East.
The HSE South Eastern RDTF area covers Waterford, Wexford, South Tipperary, Carlow and Kilkenny and as of August 1st 2010, the average waiting time recorded in this region was one year, with 66 people waiting to access treatment.
Two of the submissions from the south of the country cite the complete dearth of methadone treatment in this area as a major concern. There has never been a methadone service in Wexford. While, there is a clinic in Waterford, there is no local GP to service it.
Consequently, a level 2 GP has to make the 300km round trip from Dublin once a week to provide the service.
According to a submission to the MTP from the Waterford Substance Misuse Service, “there is a huge increase in opiate IV users presenting to services in Waterford with no methadone option available to them”.
“Currently a level 2 GP has to travel from Dublin once weekly to provide a level 2 service in Waterford. Three different GPs rotate their attendance between them, which can cause its own problems around continuity of care,” according to the submission.
“Ideally we should have a Waterford-based GP providing level 2 services locally, integrated with the local substance misuse service. There is little movement out of the level 2 clinic as there is reluctance among local GPs to take back stabilised clients into their care, which results in current waiting times of over two years for clients trying to access a methadone programme.”
The Waterford submission added that the GP coordinator has made several efforts to refer stabilised clients back to level 1 GP care with little success.
“With the documented increase in opiate problems in Waterford area, the GP model of service provision to opiate users is not working, as it is extremely difficult to recruit suitably-trained GPs to work in the substance misuse area.”
The Cornmarket Project is a voluntary community-based drugs treatment and rehabilitation project based in Wexford.
In its submission to the MTP, Mr Paul Delaney, Cocoordinator of the project, stated that despite the fact that the HSE has indicated that a methadone service would be provided in Wexford, “this still has not happened”.
“I would like to bring to the attention of the Methadone Review Panel the seriousness if the situation regarding the non-provision of methadone services in Wexford and the consequent implications on the health and safety of our clients who want to move away from chaotic drug use,” Mr Delaney added.
Speaking to the Medical Independent, Mr Delaney, who is also the Wexford representative on the South East RDTF and Chair of the Wexford Local Drugs Taskforce, said that the lack of a methadone service in Wexford has been a “real bone of contention” for those working with drug users in the area who, he said, have been calling for a local service for the last eight years.
Mr Delaney also explained that a recent independent report commissioned by the South East RDTF and carried out by Professor Catherine Comiskey of TCD indicated that there were more people using illegal drugs in Wexford compared to all other regions of the South East RDTF.
Wexford also topped the poll for the number of people using heroin in the region in 2006.
The report revealed that a total of 11,509 people were using illegal drugs in Wexford, compared to 9,553 in Waterford and 7,266 in South Tipperary.
Furthermore, the study estimated that there were 253 people using heroin in 2006 in Wexford compared to 210 in Waterford and 160 in South Tipperary.
Mr Delaney said that a number of clients who take part in the Cornmarket rehabilitation programmes are forced to travel to Waterford or Carlow once a week to get their methadone prescriptions.
“Plus there is a growing number of people who are long enough on chaotic heroin now who want to come off it and they just can’t gain access because there is no service.
“For some reason, the South East seems to be lagging way behind in terms of appropriate methadone services,” he said.
“I don’t know whether a presumption that there wasn’t a big heroin problem in a place like Wexford affected the lack of planning of services by the HSE, but it has been proven now that that is not the case.”
Those seeking access to methadone treatment tend to be long-term unemployed and early school leavers and very few, if any, would have access to their own car.
Therefore, the cost of travelling from Wexford to Waterford every week on public transport can be extremely prohibitive.
“A lot of them have to make their way up by bus; you can imagine the big saga. It is a day out of somebody’s life,” Mr Delaney added.
Apart from the obvious cost constraints, Mr Delaney pointed out that clients who are forced to make the 120km round trip by bus every week cannot meaningfully engage in rehabilitation.
“How can someone take up, for instance, full-time training opportunities with FAS if they are going to be missing every Thursday? They are the less obvious things in addition to the sheer drudgery and the cost of it.”
According to Mr Delaney, all the evidence to date shows that once a methadone service is established, people will access it.
“I wouldn’t go along with this idea that the HSE often says ‘oh well, we only have say five or six people who have notified us that they would be interested in going on a methadone programme’. That is a very, very unsatisfactory way of looking at it. Clients will present only once they know the service is there.
"The fact that they are all not putting their names down on a list doesn’t mean that they are not there.”
Long waiting lists obviously deter patients from accessing treatment, as naturally they are not in a position to wait for such long periods of time.
“If a client comes in to me this afternoon and wants to get off chaotic heroin use and onto methadone and I say, ‘well, let me be honest with you from the start, we will certainly help; we will do whatever we can to assist you to do that, but the likelihood is that you are going to be left for nine months and you will have to travel up and down to Waterford’, that is going to be the end of that,” Mr Delaney added.
In response to a Medical Independent query on the worrying long waiting times in the South East and the fact that GPs from Dublin are forced to drive long distances to provide the service, the HSE stated that “during the 1990s, heroin was confined to the greater Dublin area and over the last decade has spread outside the Dublin region, in particular in the South East area”.
“In order to meet the demand on services and increase in waiting times for methadone services, additional clinics are being provided in the South East, predominately in Carlow and Waterford. These clinic facilities have been sourced and clinics will be in place before the end of 2010.
"The HSE is progressing plans to provide a methadone clinic in Gorey to address waiting lists times there,” according to the HSE.
“In regard to the use of Dublin-based level 2 GPs in Waterford, the HSE has 70 such clinics in place across the country and has a cohort of trained-up level 2 GPs to provide services in these.
"These clinics respond to the demand for addiction and specifically methadone prescribing services. Due to the increased demand for services and the planned additional clinics, the ICGP on behalf of the HSE has trained a further group of GPs to level 2 in 2010 and these will now be added to the cohort.
"Methadone prescribing level 2 GP services in Waterford will be further developed using this trained cohort,” the Executive added.
According to a 2009 publication on the treatment of problem opioid use by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), “reviews of randomised controlled trials and observational studies conclude that substitution treatment with either methadone or buprenorphine can be effective in the management of opioid dependence”.
“Overall, this type of treatment has been linked to a number of positive outcomes including retention in treatment, reductions in illicit opioid use and injecting, reductions of mortality and criminal behaviour, and stabilisation and improvement of health and social conditions of chronic heroin users.
"In addition, recent randomised, controlled trials have found heroin-assisted treatment to be effective in reducing illicit drug use, improving physical or mental health, and reducing criminal behaviour among clients considered as hard to treat or having failed with other treatment modalities.”
Commenting on the average waiting time of one year to gain access to a methadone treatment programme in the South East, Mr Delaney said: “Motivation comes to pass; it doesn’t come to stay.
“If somebody is motivated to get onto a methadone programme and if they are told that they are going to be left waiting, typically that motivation passes by and they throw themselves back into drug use.”
Review of the Methadone Treatment Protocol 2010
Action 35 of the National Drugs Strategy (interim) 2009-2016 from the Department of Community, Rural and Gaeltacht Affairs called for a review of the Methadone Treatment Protocol (MTP) “to maximise the provision of treatment, to facilitate appropriate progression pathways (including exit from methadone treatment where appropriate) and to encourage engagement with services. The review will include engagement with the community and voluntary sectors.”
The review examined the MTP with regard to maximising provision of treatment including detoxification, stabilisation and rehabilitation; clinical governance and audit; effectiveness of referral pathways; the enrolment of GPs, the training of GPs, the criteria for level 1 and level 2 GPs, and the GP co-ordinator role; as well as looking at the appropriateness and efficacy of urinalysis testing.
Additional terms of reference include engaging with the Department of Justice with regard to the prescribing of methadone in Garda stations; and to review the MTP with regard to data collection, collation and analysis. The review is expected to be completed next month.