Mr. Gerry Kearney (Secretary General, Department of Community, Rural and Gaeltacht Affairs) called and examined.

Chairman: I draw everyone’s attention to the fact that while members of the committee enjoy absolute privilege, the same privilege does not apply to witnesses appearing before the committee. The committee cannot guarantee any level of privilege to witnesses appearing before it. I remind members of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official, either by name or in such a way as to make him or her identifiable. Members are also reminded of the provisions within Standing Order No. 158, that the committee shall also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies.

I welcome Mr. Gerry Kearney, Secretary General of the Department of Community, Rural and Gaeltacht Affairs. Mr. Kearney, please introduce your officials.

Mr. Gerry Kearney: The Department official accompanying me is Ms Kathleen Stack, assistant secretary in charge of the national drugs strategy.

Chairman: I also welcome Ms Gretta Crowley, HSE acting assistant national director with responsibility for primary, community and continuing care. Ms Crowley, please introduce your officials.

Ms Kathleen Crowley: I have with me, Mr. Joe Doyle, national rehabilitation co-ordinator from the Health Service Executive.

Chairman: I also welcome an official from the Department of Finance.

Mr. David Moloney: I am David Moloney from the Department of Finance.

Chairman: Mr. Buckley, please introduce Special Report No. 64 on drug addiction treatment and rehabilitation.

Mr. John Buckley: The two main objectives of the National Drugs Strategy 2001-2008 related to the treatment and rehabilitation pillars - first, to enable those dependent on drugs to avail of treatment and encourage them to do so; and second, to minimise the harm to those who continue to engage in drug taking activities that put them at risk. A new strategy for the period 2008-16 has been presented to Government and will be published in the near future.

Today’s meeting focuses on the co-ordination role of the Department of Community, Rural and Gaeltacht Affairs and the services delivered directly by the HSE and the bodies that it funds to provide services in the areas of treatment and rehabilitation. A further meeting is planned to examine the role of the justice system.

This examination looked back at the progress over the strategy period and focused on three main questions: whether required treatment was being made available in a timely way; the arrangements in place for evaluating treatment effectiveness; and how well the services were co-ordinated. Before turning to the results of the examination it may be useful to give some context. Illicit drug use falls into two categories, the use of opiates such as heroin and the use of non-opiate drugs including cannabis, cocaine and ecstasy. Different addictive patterns are associated with each category which in turn impacts on the nature of the response by the health services that may be appropriate or possible.

It is estimated that 0.5% of the population aged between 15 years and 64 years use opiates such as heroin. Up to recent times its use was concentrated in the greater Dublin area, but more recently it has spread countrywide. The response to heroin addiction has been to put a needle exchange programme in place for active users in order to prevent harm and infection, to provide substitutes mainly under the methadone treatment programmes, to assist misusers who have reduced their drug dependence to an appropriate level to detoxify and to provide residential rehabilitation programmes for those abstaining from drugs.

In the case of opiate addiction, the audit found that needle exchange facilities are not provided in five of the ten HSE areas. The north east and south east areas do not or did not at the time of the audit have needle exchange facilities, in spite of evidence of a significant problem with intravenous drug use. There has been a steady increase in the provision of methadone treatment, the main substitute for heroin. By the end of 2007, just over 8,000 people were receiving treatment compared with 5,000 at the end of 2000.

In regard to the timeliness of response, we found that treatment for opiate addiction was provided to 61% of those who were assessed within the target period of one month, the period set in the strategy. We found also that services for this type of addiction are not well developed in areas such as the midlands and south, which had waiting times of more than a year for methadone treatment. The number of individuals undergoing detoxification is low compared with the numbers in treatment and represents 1.25% of those on methadone maintenance treatment. We have suggested that it would be useful to set targets for progression from methadone maintenance to detoxification and rehabilitation. The existence of these targets would provide a challenge in this area and give a focus to capacity planning.

I will deal with non-opiate drug use. The use of cannabis and cocaine among the general population is rising. In addition, polydrug addiction, that is addiction to a number of drugs, including alcohol at the same time is an emerging problem. Whereas methadone is the main response to opiate addiction, in the case of non-opiates the main helping interventions take the form of counselling, which is availed of by two thirds of clients, and cognitive behaviour therapy which is the other main intervention. On our examination of the treatment of non-opiate addiction, we found that the number of individuals treated for non-opiate addiction has not increased substantially during the life of the current strategy. In 2007, 2,000 individuals received treatment. One apparent trend is that a much lower proportion of the non-opiate drug users enter treatment in the capital than outside Dublin. It would be useful to do some research to get to the underlying cause of this. In regard to the timeliness of treatment in the non-opiate area, we found that almost all of the treatment was provided within the one-month target time set in the strategy.

Turning to the evaluation, the State needs complete, accurate and timely information if it is to focus its treatment and rehabilitation efforts and evaluate their effectiveness. Better information on the demand for treatment and the results of that treatment could be generated by standardising the recording practices of treatment providers so as to get a better handle on the actual demand for treatment and the time people are waiting to be assessed for that treatment, and finding a way of recording treatment completion rates and outcomes by tracking the progress of individual clients and improving the information on the costs of the various treatment services.

On a more general level, it would be useful to identify the extent to which the use of illicit drugs actually develops into problem drug use. The lack of good information on the costs of treatment and the numbers treated, and the type of treatment delivered and the outcomes of that treatment, hampers any evaluation of cost effectiveness. However, it must be acknowledged that the findings of a study which followed the progress of a sample of 400 clients in treatment for opiate addiction suggests that retention rates are high, with 69% of clients still in treatment three years later and a general reduction in drug misuse being reported.

Evaluating the effectiveness of treatment in the non-opiate addiction area presents a challenge, but it may be possible to design a similar follow-up study capable of assessing the outcome of different interventions in that area. While some pilot projects on the treatment of cocaine abuse have been conducted, it would be useful to distil any lessons learned from them so that the results can be used to identify effective treatment approaches. Co-ordinating the efforts of the many agencies involved at national and local level proved to be a challenge during the life of the strategy. National structures, such as an interdepartmental group designed to provide co-ordination at a national level did not work as well as intended and this was mainly because the group did not have representation from all of the agencies involved in the delivery of the treatment and also because agencies were often not represented at the required level of seniority.

In addition, while an objective in the strategy was to establish protocols that govern interagency arrangements and thereby ensure smooth transitions for the client between the different phases of his or her treatment, in general this has not yet happened. Overall, the audit concluded, based on the best practice identified in Ireland and abroad, that in order to deliver services at the optimum level and effectively operate the continuum of care model, there would be a need to have an individual care plan for each client of the service, an identified care manager for that client in order to co-ordinate services envisaged in the care plan, and an assigned key worker in each of the agencies involved in the service delivery. 

[For the full debate, click on this link to the Oireachtas website]

[See also, resumed debate 17 September 2009]