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Drug Treatment – The Irish context

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Written by Dr Garrett McGovern, GP Specialising in Addiction Treatment.
Dr McGovern discusses the state of drug treatment in Ireland.

Veröffentlicht in: Gesundheit & Medizin
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Drug Treatment – The Irish context

  1. 1. Drug Treatment – The Irish contextDrug Treatment – The Irish context Dr Garrett McGovern GP Specialising in Addiction Treatment Priority Medical Clinic Dundrum Dublin 14 Garrett McGovern MB BCH BAO, MSc. (Addictions)
  2. 2. BackgroundBackground • GP Specialising in Alcohol & Substance Abuse. • Working in the field since 1998. • Level 2 accredited with ICGP on the Methadone Treatment Protocol • MSc. Clinical Addiction from the National Addiction Centre in King’s College London • I treat 300 patients and work at many locations and different settings in South Dublin. • I also have a small private practice where I treat a wide range of addictions • Competing interests – I have received honorarium from Lundbeck Ireland and Reckitt Benckiser in the past for professional advice on addiction related issues
  3. 3. Methadone Treatment -History • Injecting heroin use arrived in Ireland in 1970s • Methadone services arrived around 1992 • Public health response owing to spectre of a HIV epidemic and soaring crime rather than a concern for the well being of drug users and their families • Treatment model philosophy favoured abstinence over harm reduction • Heavy reliance on urine testing • Punitive practices rife. Patients suspended from treatment
  4. 4. Structure of treatment in Ireland • Treatment delivered through large clinics, community projects, satellite clinics and General practice • There are approximately 10,000 in receipt of methadone treatment. Less than 80 prescribed buprenorphine • 95% of patients treated by a GP; 5% by psychiatrists • There is no key-working system in Ireland. Traditionally, patients are seen weekly by a GP • A number of reviews of services which have highlighted positive and negative aspects of treatment. Much of the recommendations of reports ignored (Farrell 2000; Farrell 2010; Priyadarshi 2012, Pilling 2014)
  5. 5. The language • Often pejorative and stigmatising • ‘Clean’ ‘dirty’ ‘junkie’ ‘addict’ ‘stable’ ‘unstable’ • Clinicians and treatment providers are often among the worst culprits • Service users often made feel lucky they are receiving treatment • This does not occur in other areas of medicine • Human rights issue
  6. 6. The media and methadone
  7. 7. The media and methadone
  8. 8. The media and methadone
  9. 9. The media and methadone
  10. 10. Stigma and ignorance
  11. 11. Stigma and ignorance
  12. 12. Stigma and ignorance
  13. 13. Stigma and ignorance
  14. 14. The standards • The evidence base for methadone efficacy is very strong and dates back to the 1960s • Irish treatment services emerged in the early 1990s and was formalised in 1998 with the introduction of the Methadone Treatment Protocol • Despite the strong harm reduction evidence base practices were often punitive. Lowest possible doses (often subtherapeutic). • The rate determining step for success was ‘clean urines’ • Treatment standards largely ignored the international evidence base in favour of a ideological abstinence based approach • Treatment guidelines were developed by a small group with similar opinions.
  15. 15. Urine testing • Weekly or two weekly testing common in treatment services despite poor evidence despite findings of the Farrell Report • Urinalysis is the centrepiece of barometer of treatment progress • Results of tests often determine dose e.g. positive tests either result in no further increases (despite heroin use) or a reduction in methadone dose • Take-home doses assessed largely on positive or negative opiate or cocaine results. • Research evidence ignored and almost distrusted by many clinicians
  16. 16. Punitive practices
  17. 17. Punitive practices
  18. 18. Punitive practices
  19. 19. Punitive practices
  20. 20. Taking the Piss
  21. 21. Taking the Piss
  22. 22. Chronic medical condition “Virtually all questions concerning the treatment of opiate dependence can be answered if one applies precisely the same orientation that governs all other forms of chronic medical management. In this case: when should urine toxicology tests be ordered? When the clinician believes they might be helpful!” Dr Robert Newman
  23. 23. The Introduction of the Opioid Treatment Protocol (The Farrell Report)
  24. 24. Farrell Report Recommendations Prof. Michael Farrell • Significantly less urine testing • Elimination of direct observation of passing urine • Relaxing of restrictions on the numbers of patients GPs can treat in general practice • Development of evidence based, peer reviewed clinical guidelines by September 2011 at the latest • Development of care planning for patients
  25. 25. Clinical Guidelines • To date in Ireland there has never been peer reviewed treatment guidelines. As of 2016 the national clinical guidelines are not completed • The Irish College of General Practitioners (ICGP) have published guidelines in 2003 which were updated in 2008 • Concerns raised by GPs about the quality of the guidelines in 2008 • Long protracted (and on-going!) process to change the content of the 2008 guidelines • A review took place in 2012 of the clinical audit of GPs treating opiate users and the standards underpinning the criteria • The lead reviewer was critical of the standards and made a number of recommendations
  26. 26. Removal of name from guidelines Dr Cathal O Sullióbháin
  27. 27. ICGP Audit review - conclusions
  28. 28. National Clinical Guidelines •GPPSA representation denied •Several drafts •No nearer completion •Heavy emphasis on urine testing (17 pages!) •Peer review process vague •Body of expertise in Ireland is limited
  29. 29. Why not use the Orange Book as the standard?
  30. 30. But it’s not all bad news………
  31. 31. But it’s not all bad news………
  32. 32. But it’s not all bad news………
  33. 33. END Questions?

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