Acting Chairperson, Senator Gerry Horkan: I welcome the Minister, Deputy Donnelly, to the House.

Senator Lynn Ruane: I move amendment No. 1:

In page 11, between lines 17 and 18, to insert the following:

“(I) in subparagraph (ii), after “or class of medicinal products,”, by the insertion of “to include Opioid Substitution Treatments,”,”.

This is much in the same vein as the conversation we had last week, and I note we have not had much time in between to converse on it. To reiterate the points I made on the previous Stage, this amendment would insert an explicit reference in the Bill to the capability of registered nurses to prescribe opioid substitution treatments, OST. Legislation was introduced in 2006 to facilitate nurse prescribing of certain medications, including opiates, in a range of clinical areas, but not for the purpose of drug treatment. Nurse prescribing of OST is a safe and effective mechanism and has the potential to significantly expand access to drug treatment, lifting people out of active and acute drug addiction and saving lives in the process. Nurse prescribing for OST is an established practice in other jurisdictions, including Northern Ireland, Great Britain, the Netherlands, the United States and Australia.n

The national drug strategy 2017-2025 commits to improving the availability of OST, also referred to as OAT, by examining potential mechanisms to increase access to the expansion of GP prescribing and nurse-led prescribing and through the provision of OAT in community-based settings and homeless services. Despite this fact, in response to a recent parliamentary question tabled by Deputy Gould, the Minister of State in the Department of Health stated there is currently no objective need for the introduction of nurse prescribing of OST or OAT. Perhaps the Minister in his reply would provide a little more context to understand how this need has been determined.

According to the 2023 Focal Point Ireland report on drug treatment, opioids were the second most common main problem drug reported in 2022 at 33.1% of all cases treated, overtaken by cocaine for the first time. Heroin accounted for 86.6% of these opioid cases. Outpatient OST and OAT for people with problem opioid use is presently provided only through specialised HSE outpatient drug treatment clinics, satellite clinics or specialised general practitioners in the community. Because of this, waiting lists for access to treatment are not at all unusual, particularly in many of our rural communities. Allowing nurses to prescribe OST would cut, and potentially even eliminate, waiting times and ensure a more holistic and rehabilitative response to treatment of addiction.

According to reporting in The Irish Times informed by HSE and Health Research Board, HRB, data, 70 people were waiting to be entered onto the central treatment list for OST in November 2022. From referral to assessment, the average waiting time nationally is 4.9 days. However, this ranges from less than a day in the mid-west to 12.7 days in the south east. After assessment, waiting times for the commencement of treatment outside Dublin can be as long as three months.

In a report in 2022 regarding an examination of the present approach to sanctions for possession of certain amounts of drugs for personal use, the Oireachtas Joint Committee on Justice made two key recommendations relating to OST. The first was for the Department of Health to support the continued expansion of Ireland’s opioid substitution treatment, OST, programme to ensure the treatment is more widely available to communities across the country. The second recommendation was to undertake an evaluation regarding the role that non-medical prescribers could play in treating opioid addiction in Ireland by increasing access to OST. Have any actions have been taken within the Minister's Department to give effect to these recommendations?

According to Dr. Peter Kelly, assistant professor in mental health nursing at Trinity College Dublin, implemented nurse prescribing of OST was recommended for Irish services by Professors Michael Farrell and Joe Barry in the 2010 independent review of the opiate treatment protocol with a view to expanding the availability of OST and in keeping with international best practice. Further, a 2023 review of empirical literature authored by Banka-Cullen identified that this model of prescribing is effective in increasing the numbers in OST treatment, especially for more deprived populations and in rural communities.

While the Minister may not be in a position to accept this amendment today, I urge him and his department officials to take the requisite steps to facilitate nurse prescribing of OST in Ireland as a matter of urgency. On a practical point related to empowering and expanding the role of nurses in respect of prescription of OST, we often look to the waiting lists as the reason that something should be expanded. However, on a practical level, within doctors' surgeries, clinics, community care teams and hostels, it will often be found that nurses are present to a greater degree than doctors, even in the waiting room. Many of the people I support who are on long-time opioid methadone treatment could often be left sitting in a waiting room in their doctor’s surgery for up to two or three hours, waiting to go in to see their doctor to receive what is a weekly prescription for methadone.

Nurses should be empowered in this regard to make the experience a much better one for people instead of leaving them sitting around waiting, when nurses are there, ready and able to prescribe, if the legislation saw fit to allow them do so.

Deputy Stephen Donnelly: I thank the Senator both for the amendments she tabled and her very considered contribution on what she is trying to achieve. I will not accept the amendments and will explain why. However, I fully agree with her healthcare objective, which is to make sure that people who are in addiction and need opioid substitution treatments can get them in as easy a way as possible. It is interesting that the note I got from the Department indicates it did quite a bit of work in preparation for today. I have been reading through it. The Department notes that there are not significant waiting lists for opioid agonist therapy, OAT. While that is great, as the Senator quite rightly said, people are still waiting several hours in a surgery. Even that is something we need to work on. The good news is the number of GPs is increasing. We currently have 68 GPs who are authorised. The cap on level 2 GPs has been extended this year from 35 to 50 patients. There are more GPs and those GPs can now see more people.

On the care that is needed, one of the matters raised with me by the Department in consultation with healthcare professionals is that in a growing number of cases, there is an ageing population with comorbidities. In many cases, it is important to have a GP involved because a lot more is going on and there is a lot more care. While a nurse may be able to prescribe methadone, he or she will not necessarily be trained to consider patients in their totality. More and more multidisciplinary assessment is required. The issue is one I am very happy to explore. I will just make the point that whatever we do, we have to make sure that the people we are treating and supporting can still get access to multidisciplinary support. Nursing support is phenomenal but may not be enough. We need to think that through very carefully. From a policy perspective, and this is something the Minister of State, Deputy Colm Burke, is very involved in as part of his portfolio, further work on ensuring that those in addiction have the greatest access to the best possible rounded care is something we can definitely work on. I would be very happy to talk to the Senator further about it, especially as she brings knowledge from service users as to what they need, which may not always get picked up here. That would be very useful.

Specifically to the amendment, there are two amendments to section 9. One is around including OST in prescriptions and the second is about urgent lifesaving care. I might come back to the latter, if the Senator wishes to speak to it. I will speak to the first part of it. Essentially, we do not need to include OST. In fact, the legislation as it stands is sufficient for the Minister of the day to include it by secondary legislation. The task force, which I will speak about in the wrap-up if I may, is coming to recommendations. We are starting very deliberately on common conditions and OST is more complex. It is not something the task force is recommending for now but what the Senator is very reasonably trying to do is future-proof the legislation. It is in fact future-proofed. If in the future there were a clinical recommendation to move into more complex areas, and if OST happened to be one of those, that can already be expanded under the Bill, as drafted, through secondary legislation. It would require an amendment to the Misuse of Drugs Act as well. There is more that needs to be done, but what the Senator is seeking to achieve with the amendment is already covered. It would be down to secondary legislation and expert recommendations. We would then need to update the Misuse of Drugs Act.

I will ask the Department to send the Senator a detailed note on nurse prescribing. The advice I have is that such prescribing is covered already. We need to make sure of where it is done. Where people need medical or multidisciplinary care and we are looking at comorbidities, that should also be something provided in the service for them.

Senator Lynn Ruane: On amendment No. 1 and the holistic nature of care, the ageing population, especially in respect of methadone, is a very relevant general point about addiction services. I do not know whether access to capital funding comes under the Department historically but not only is the population ageing, access to appropriate community drug services that people avail of is becoming much more difficult. These are not accessible and do not have lifts. This may not be the case in primary care services, if someone is going directly to a GP. However, we still have community drug teams that provide care, which are finding it increasingly hard to meet the needs of an ageing population when it comes to the building and the infrastructure itself.

As far as I understand it, nurse prescribing would not definitely seek to replace the involvement in its entirety of the GP. There could still be a care plan where a GP links in once a month. An individualised care plan could still be created based on what someone's needs are and that could be done in a holistic sense. It is about everyone being able to support the picture as a whole rather than having nurses entirely replace the role of the GP. They would complement each other as necessary as regards people's individual care plans.

I am happy to continue the efforts outside of this debate.

Amendment put and declared lost.

Senator Lynn Ruane: I move amendment No. 2:

In page 11, line 23, after “ailments,” to insert “or in response to the need for urgent or life-saving medicinal care,”...

[Click here for the full debate on the Oireachtas website]