IRELAND 25 May 2013
VFM Report 64: Drug Addiction Treatment & Rehabilitation Report Summary
Summary of Findings
Drug addiction treatment and rehabilitation services are provided through a wide range of publicly-funded agencies. These include the Health Service Executive (HSE), community-based GPs and pharmacies under contract to the HSE, a range of community and voluntary groups, parts of the criminal justice system and FÁS. In addition, 24 area-based drugs task forces are involved in planning and coordination of drug-related services in their respective areas.
Strategic objectives for drug addiction treatment and rehabilitation service delivery were set in the National Drugs Strategy 2001-2008. These were
- to encourage and enable those dependent on drugs to avail of treatment, with the aim of reducing drug dependency and improving overall health and social well-being and, ultimately, leading a drug-free lifestyle
- to minimise the harm to those who continue to engage in drug-taking activities that put them at
A number of government departments have functions in this area. The Department of Community, Ruraland Gaeltacht Affairs has overall responsibility for coordinating the implementation of the National Drugs Strategy, and has established a number of coordination structures. The Department of Health and Children is responsible for the national policy on drug misuse treatment generally. The Department of Justice, Equality and Law Reform has responsibility for policy in dealing with drug treatment provision in the prison and probation systems.
This examination looked at all the main publicly-funded treatment and rehabilitation services provided for persons with addiction to illegal drugs (mainly cannabis, cocaine, ecstasy and heroin). In particular, it looked at the extent to which the demand for treatment and rehabilitation services is met, and the timeliness of access to treatment. It also looked at the extent to which the effectiveness of treatment and rehabilitation services are evaluated, and the effectiveness of the arrangements for coordination of treatment and rehabilitation at an individual case level, and nationally.
Delivery of Treatment
Treatment for Opiate Drug Use
It has been estimated that less than 0.5% of the population use opiates of which heroin is the most commonly used. In the past, its use was concentrated in the greater Dublin area, but there is evidence that the use of heroin has increased in other areas in recent years.
Methadone-based substitution treatment is the main form of treatment for heroin addiction. At end 2007, just over 8,000 people were receiving methadone treatment. Around one third of these are treated under the supervision of community-based GPs.
Needle exchange services are provided in some areas with the aim of reducing the risks associated with the sharing of injecting equipment. While there was some increase in the provision of needle exchange services over the life of the Strategy, gaps in service provision remain.
Detoxification treatment for opiate users and follow-on rehabilitation treatment levels are very low, when compared to the numbers receiving methadone treatment. It is estimated the annual level of detoxification treatment is in the region of 100 courses of treatment, at most — around 1.25% of those receiving methadone treatment.
While long-term methadone maintenance is likely to be the best outcome that can be achieved for a significant proportion of heroin users, it would be desirable that the HSE would set target rates of progression through the various forms of treatment. Service capacity planning could then be based on what is required to meet the progression targets.
Treatment for Non-Opiate Drug Use
The prevalence of cannabis and cocaine use among the general population is increasing. The habitual use of a number of drugs at the same time is also on the increase. Despite this, there does not appear to have been a commensurate increase in the number of cases treated for problem use of non opiate drugs over the life of the National Drugs Strategy.
Changes in the pattern of drug misuse creates a challenge for service providers to reconfigure a system geared predominantly to dealing with one drug type in a defined area (e.g. heroin addiction in the greater Dublin area), to one that is capable of dealing with different kinds of addiction in different areas and increasingly, with clients with multiple addictions. The current pattern of drug use suggest that there are, in effect, two separate contexts in which drug treatment has to be provided
- a largely opiate-based addiction problem, concentrated in certain marginalised and poor sectors
of society, and in certain geographic areas
- problem use of non-opiate drugs, spread more widely across social groups and geographic areas,
and where many of those being treated may have access to more social supports and economic
Although there is a higher prevalence of misuse of all kinds of non-opiate drugs in the greater Dublin area than in the rest of the country, the rate at which users of non-opiate drugs in Dublin enter treatment appears to be significantly lower than for the population elsewhere. There is a risk that this pattern derives from the available facilities and the priorities in the two areas rather than the objective need of the populations served.
While there may be overlaps between the two populations of drug users, the future management of service delivery appears to demand differentiation in targets set, performance measures used and performance reporting.
Demand for Treatment
Information about the level of demand for treatment for problem drug use is very important for service planning purposes, but is incomplete.
A database on treated drug (and alcohol) use in Ireland is compiled and managed by the Health Research Board (HRB). This database, the National Drug Treatment Reporting System (NDTRS) relies on treatment service providers to collect details on each individual who presents for treatment. The information is transmitted to the HRB, but without the personal identification details (e.g. name or address) of the individuals receiving treatment. The result is that while the number of courses of
treatment delivered can be identified, it is not possible to track the progression of an individual from one
service provider to another.
The NDTRS has the potential to generate better estimates of demand for treatment, but greater compliance by service providers with the NDTRS data input rules would be required if this is to be achieved.
In the case of methadone treatment, delivery is recorded on a Central Treatment List, which is a statutory register of all patients receiving methadone as an opiate substitute in Ireland.
Ways of recording treatments sought and provided on an individual basis and in a manner that ensures security of the information need to be established. This should be tackled by the HRB in liaison with service providers and with the Data Protection Commissioner. In this context, consideration could be given to upgrading the current NDTRS case recording and reporting system, perhaps moving to an internet-based system.
Access to Treatment
This examination found that the NDTRS data may underestimate the extent of waiting for assessment. The practice in some areas is that recording of information for NDTRS purposes starts only at the time of assessment, rather than at the time of initial presentation or referral. Some service providers also operate informal waiting lists only calling those on the list when an assessment appointment becomes available. In addition, where drug users are aware of long waiting times for access to local services, they may be deterred from presenting for assessment.
The HRB needs to put more emphasis on ensuring that all service providers record information completely and accurately so that the true extent of waiting for treatment may be gauged.
Subject to these reservations, analysis of NDTRS data indicate an estimated 82% of those beginning methadone treatment in 2007 commenced treatment within the one month target following assessment. In almost all non-opiate cases, treatment was provided within the target one month from date of assessment.
While a high proportion of individuals commenced treatment within the one-month target, approximately 460 people were recorded as waiting for methadone treatment in April 2008. The average waiting times for those on the lists in some areas were over a year. A target of carrying out an assessment within three days of presentation (or referral) for treatment has been set. Of the opiate cases recorded by the NDTRS for 2007, an estimated 61% were reported to have been assessed within three days of initial presentation. Almost one in eight of those assessed were reported to have waited more than a month for their assessment. For persons presenting for assessment for cocaine use problems in 2007, around 56% were recorded as having been assessed within the threeday target. Of those presenting for assessment for cannabis or stimulant use problems, less than 40% were assessed within the target time.
Effectiveness of Treatment
Evaluation of treatment effectiveness is complex. Nonetheless, some sound and informative work has been done in relation to treatment of opiate addiction in Ireland.
A large-scale longitudinal study was carried out to identify the outcomes achieved for a sample of over 400 persons receiving treatment for opiate addiction or availing of needle exchange in 2003/2004 (referred to as the ROSIE study). The study team carried out follow-up interviews after a year and again after three years. The rate of response for both rounds of the follow-up interviews was high, and was significantly better than response rates for similar studies carried out elsewhere.
The study found that the level of retention in treatment was high with 69% of respondents in treatment at the three-year follow-up (some may have dropped out and re-entered). Of those still in treatment, 86% were on methadone maintenance treatment. The report also found that there had been reductions among those interviewed in the reported rates of illicit use of drugs and of involvement in crime, and increased rates of employment and independent living. No significant improvement in health status was noted.
It could be useful to carry out a further follow-up on the respondents to the ROSIE study in order to help identify the long-term outcomes for those that receive treatment for opiate addictions. Consideration should also to given to commencement of a similar study of a new cohort of individuals presenting for treatment for opiate addiction. This would help identify the extent to which current treatment and rehabilitation services are effective for opiate misusers presenting for treatment now.
The effectiveness of treatment for non-opiate addictions also needs to be formally evaluated in order to inform the design of treatment programmes.
Significant resources have been invested in pilot schemes with the aim of identifying the best approaches to provision of treatment for problem cocaine use. At this point, the evidence from these pilot projects should be distilled in order to identify effective treatment approaches. The most effective approaches could then be taken into account in designing national treatment capacity and in setting target outcomes for publicly-funded programmes to tackle problem cocaine use.
Drug Treatment and Rehabilitation in the Justice System
Many users of illegal drugs, and in particular heroin users, end up in contact with the criminal justice system.
Drug Treatment in Prisons
Overall, information about the incidence of drug use among prisoners needs to be improved in order to have a better picture of the progression of those treated in prison and their treatment outcomes.
In regard to treatment provision, methadone treatment is provided in eight prisons that together accommodate 74% of the prison population. Annually, between 12% and 15% of those committed to prison are admitted to methadone maintenance treatment. At the end of 2007, around 500 prisoners were on methadone maintenance.
Where methadone maintenance treatment is not provided to a prisoner, a short methadone-based detoxification may be provided instead. The Prison Service does not routinely compile or report data on how many prisoners undergo this kind of treatment.
A rehabilitation programme is provided at Mountjoy prison. There is capacity for around 70 prisoners a year on the programme. Participation in the rehabilitation programme, and the rate of completion have varied. This may reflect the level of availability of methadone maintenance treatment.
Drug Treatment as Part of Community-Based Sanctions
In cases where offenders have drug use problems, undergoing treatment or rehabilitation may be a condition of community-based sanctions. The Probation Service is the agency responsible for supervising offenders sentenced to such sanctions Most of the treatment availed of by offenders under supervision is provided in the normal community-based services. Offenders are not given priority for access to treatment.
The Probation Service is taking steps to improve and enhance its case management data, but there is scope to manage the referral process more effectively. It should, in particular, monitor the length of time that offenders wait for assessment or treatment and the number of offenders that are unable to access required treatment places. The Service should also monitor the outcomes of court-ordered treatment for the cases it supervises.
The Dublin Drug Treatment Court
A Drug Treatment Court (DTC) was established in Dublin in 2001. A drug addict who has been convicted of a non violent crime may volunteer to be referred to the DTC for inclusion in a supervised programme in return for a reduction or striking out of charges. Admission to the DTC programme depends on an offender being both eligible and suitable. An individual plan is developed for each participant found suitable for admission to the programme.
When the DTC was established, it was envisaged that it would handle around 100 cases during the initial 12-months of operation. In practice, an average of 22 offenders a year were admitted to the programme from January 2001 to July 2008 i.e. just over one fifth of the initial annual target.
Excluding those still on the programme around 83% of those admitted had their participation terminated by the Court and were referred back to the original court for sentencing. Just 17% of programme participants (22 individuals) completed the full programme to the satisfaction of the Court.
The DTC currently serves the Dublin 1 and 7 areas only. The Courts Service has proposed its expansion, but the necessary commitments from other agencies involved have not yet been made to give effect to this expansion.
The effectiveness of the DTC needs to be evaluated, now that a significant period of operation has elapsed. The evaluation should compare the cost and effectiveness of the Court with the cost and effectiveness of orders made by other courts that include treatment of those sentenced to communitybased orders. This should help identify the most appropriate way to develop the service in the future.
Social Support and Reintegration
Drug use problems are often associated with significant difficulties in the personal lives of the users and/or of their families. These may include breakdown in family life and personal relationships, money problems, poor educational achievement, and loss of employment or of the home. Where these difficulties arise, other forms of social support and reintegration interventions may be required if treatment of drug addiction is to be effective in the long-term.
In the future development of care planning and key working systems in the context of treatment and rehabilitation for drug use, consideration should be given to the wider social supports required by the individuals concerned e.g. accommodation, education and training.
Many of those receiving treatment for problem drug use are early school leavers, with low educational attainment and a history of unemployment. FÁS has provided for up to 1,000 Community Employment places to be made available for drug users in rehabilitation but these have not been utilised in full. Further special programmes in the areas of basic education and training — such as the pre-Community Employment stabilisation initiative — are now envisaged, aimed at ensuring that those with the greatest skill and competence deficiencies have an opportunity to progress to other forms of training and education.
FÁS should regularly review the outcomes of special education and training programmes for those receiving treatment for drug use problems. The effectiveness of special Community Employment schemes for people in drug rehabilitation should also be evaluated from time to time.
Waiting times for accessing required social support services should be formally monitored and reported on.
Care Planning and Management
The National Drugs Strategy envisaged that treatment services would be based on a continuum of care model and a key worker approach. The aim of this approach is to provide coordination of services and smooth transition between the different phases of treatment. The relevant key worker was envisaged as being a central person for primary care providers (e.g. GPs and pharmacists) to contact in connection with an individual drug user in their care.
Achievement of a continuum of care in the delivery of treatment and rehabilitation depends on effective care planning and management systems, including arrangements for effective coordination between agencies. A planned national framework for care planning and management has not been developed by the HSE. Nonetheless, examples of good practice have developed in some areas.
As a result, in areas where coordination arrangements remain under-developed, there is scope to learn from good planning and management structures in areas with more advanced systems. Good practice opportunities identified during visits to local areas and service providers in other jurisdictions in the course of this examination include
- assignment of a care manager for each individual seeking treatment, to plan and oversee delivery
of the full range of services required, including treatment, support and rehabilitation
- identification of a key worker in each of the service providers to ensure that the planned services
are delivered for the individual
- an individual care plan, setting out the ultimate treatment objective and the planned progression
for the individual, and identifying the services to be provided and the sequence and timing of
- scheduled review of case progress and amendment of the plan in response to the individual’s
- timely availability of the planned treatments.
Coordinating and Monitoring the Strategy
Concerns have been expressed about how well the co-ordination system works, not least in the 2005 report of the mid-term review of the National Drugs Strategy. The proposal in the 2007 Report of the Working Group on Drugs Rehabilitation to establish a further co-ordination structure for rehabilitation, and a separate pillar to focus more attention on the needs of service providers in that area, suggest that the existing coordination was not fully effective.
Coordination mechanisms need to be improved in order to ensure that consultation and decision making structures are streamlined and effective.
A significant amount of treatment and rehabilitation effort is delivered through a variety of local projects, overseen and monitored by drugs task forces, which are comprised of representatives of relevant state agencies and of local communities. This structure is designed to ensure that projects continue to fit in with local needs and priorities for services. It is important in order to maintain a focus on delivery that all local projects whether operating on an interim or mainstreamed basis, be governed by service level agreements that specify the services to be provided and the standards to be met.
The main focus in the monitoring of the National Drugs Strategy has been on progress in delivery of planned actions by the various responsible agencies. While a focus on implementing actions is necessary, it needs to be supplemented with programme achievement information so that the effect of those actions can be gauged.
There is also a need for greater transparency on the cost of treatment and rehabilitation services. Performance in terms of both targets achievement, and budgetary outcome should be reported regularly.