THE CITY CLINIC20 YEARS OF REFLECTIONS

REMEMBRANCES AND RECOLLECTIONS

1993 - 2013

PHOTOGRAPHER AND ARTISTJohn Beattie, The Fire Station Artists Studios

EDITORIAL TEAMJuliet BressanDes Crowley Jo-Anne SextonAva StapletonCity Clinic 2013

Sincere thanks to all the staff past andpresent who contributed to this work, to theservice users and the community inAmiens Street.

This book is dedicated to all those whohave ever needed to use our service,and to their friends, families and loved ones.

In memory of our dear friend and colleagueJohn O'Reilly 08/08/57 - 28/02/09

ACKNOWLEDGEMENTS

“Staying alive allthese years. Beingclean. That’swhat I’m mostproud of now.” A.K. Age 43

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City Clinic Methadone Maintenancetreatment centre is situated in two co-joined buildings in 108/109 Amiens StreetThe 1911 census recorded that a largenumber of families lived in both houses,similar to the many tenement dwellingsthat dotted the City. They had come fromplaces like Donegal and Cork to find workin Dublin and there were yeast merchants,waitresses, travelling sales men,dressmakers and tailors.

Eventually like many of the tenements inDublin City, 108/9 Amiens Street becameuninhabitable. In an attempt to addressthe housing shortage the former DublinCorporation built large flat complexes tohouse tenants. And although thetenements were for the most part torndown, these two houses were leftstanding, neglected and abandoned

The North Inner City was recognised as anarea of acute disadvantage and it wasacknowledged that “drug problems inDublin were largely explicable in terms ofthe poverty and powerlessness of a smallnumber of working class areas” (SpecialGovernment Task Force on Drug abuse1983). A grass root level response fromthe community, resulted in angry parentsand activists taking to the streets anddemanding better treatment services.They later formed a group naming itselfConcerned Parents against Drugs (CPAD).

It was a difficult time and forced evictionsof heroin users by some communitygroups caused ugly scenes across Dublin.

In 1993 City Clinic MethadoneMaintenance treatment centre was set up.In some quarters this was seen in ahostile light and there were protests andmarches against Methadone treatmentbeing provided within the community. Butthe then Health Board persevered and byeducating and funding small groups likeICON they eventually managed to bringthe community organizations on board.

City clinic opened in 1993 with a staff of acounsellor, doctor, outreach worker andGeneral assistants.

Today there is a staff of 25 includingAdmin staff, Doctors, Pharmacists,Counsellors, Nurses, Outreach, Generalassistants, Rehab and Integration workerand a Midwife. There is also direct accessto the service of a Psychiatrist and aHepatitis C Nurse Specialist. The CityClinic building is now designated as alisted building. It could be said that thesewalls have seen it all and hold the historyof an enduring community. A communitythat continues to respond to manydifficulties within this old and historicalneighbourhood.

Ava StapletonCounsellor City Clinic 2013

INTRODUCTION

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“I’m on City Clinic a long time. But to me it meansbeing able to live a normal life without having to golooking for money and drugs. It doesn’t work foreveryone but without it I don’t think I would behere now and alive. So City Clinic means having alife to me. Doing a 360 degree change is what I ammost proud of now.” Paula. Age 37

The best part of my job inCC is when I get to makea positive impact on aperson’s mental andphysical health in theirtime of need." Barry, Nurse

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City Clinic is a HSE funded drug treatmentcentre located in Dublin North inner city. Itwas established in 1993 as a public healthand harm reduction response to the heroininjecting and HIV epidemics that weredevastating the community at that time. Itwas set up in the backdrop of localcommunity activism directed at local drugdealers and anger at the lack of treatmentfacilities for those affected by opioidaddiction and HIV and the numbers of youngpeople dying of AIDS.

The Centre opened its doors in April 1993and started dispensing in June 1993. Initiallythe patient cohort were from existingtreatment facilities (Trinity Court and BaggotSt). The treatment demand wasoverwhelming and long waiting listestablished very quickly. The cohort ofpatients attending for treatment had highlevels of drug related morbidity and the earlydays of the service were marked by highlevels of mortality particularly associatedwith AIDS.

The approach to treatment from the startwas a multidisciplinary one, recognising theneed for both medically prescribedsubstitution therapy and psychosocialsupport. The initial approach to prescribingwas conservative and patients were often onsub therapeutic doses of methadone. Thiswas further exacerbated by a punitiveapproach towards urine drug screening.

Along with the mainstream services twounique services were established. A lowthreshold interim program to provide basiclow dose methadone for those waiting fortreatment and a stand alone service foryoung people (initially under 18’s).

CITY CLINIC

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“I love this job; it has itsups and downs. I havegreat respect for clients asthey have for me.” 15 years in City Clinic

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The community continued to play a veryactive role in the development of servicesand ongoing liaison ensured support for theclinic locally and also led to changes intreatment provision that improved serviceuser’s satisfaction and treatment outcomes.

With commitment from both HSEmanagement and staff waiting lists wereeliminated and the punitive approach tourine drug screening discontinued. Progresswith HIV treatment and therapy improvedsurvival outcomes and HIV disease couldnow be managed as a chronic disease.

The emergence of cocaine injecting in themid 2000s lead to a rise again in new HIVdiagnosis and brought a new set ofchallenges for the clinic.

Over the last twenty years the pattern ofdrug use and service user profile haschanged. The early cohorts of patients werelong established injectors and had very highlevels of drug related morbidity whenaccessing treatment. There was a separatecohort of very young people both injectorsand smokers with relatively short histories ofuse. Often patients have a poly substancepattern of drug abuse and significantnumbers developed alcohol dependencyonce stabilised on methadone.

High levels of Hepatitis C infection ( 80%)among injecting drug users attending theclinic along with high levels of alcohol usehas changed the morbidity and mortalityprofile of our patient group. The commonestcause of death is now alcohol and hepatitisC related liver disease.

“City Clinic has helpedme out a lot but I’m here18 years now and wouldlove to move on. I got helpin City Clinic and gotclean. Only for City Clinicthis wouldn’t havehappened. I couldprobably be dead now.The staff is very helpful.” Joanne. Age 42

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“When I started in CityClinic 10 years ago Iwas very enthusiasticabout my work as acounsellor. I still amenthusiastic. My jobdescription didn’tprepare me for the extratasks I was taking on.Making tea for clients,ringing a furniturecompany about a settee,filling in forms for themedical card or socialwelfare. Sadlysometimes attendingfunerals and listeningto the most difficult lifestories imaginable.These are just some ofthe things that happenin my office. I’m proudto say that I have neverlost my sense ofhumour and still enjoyworking with each andevery client of CityClinic.” Ava Stapleton,Counsellor

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The number of first time presentationshas reduced dramatically in the past fiveyears and those that present tend to beheroin smokers rather than injectors. Thisreflects national and European trends.

Those in treatment are an agingpopulation and their health and treatmentneeds are changing. There are verysignificant levels of dual diagnosis amongour patient group and their treatment andsocial needs are substantial.

Over the 20 years City Clinic has treatedover 1300 individual patients and providedin excess of 3,200 treatment episodes tothese patients. The number of treatmentepisodes per patient range of 1 to 34 withan average of approximately twotreatment episodes per patient. There haveonly been two new HIV diagnoses since2008. This followed a peak of seven newdiagnoses in 2007 which were related tococaine injecting. The level of newhepatitis C infection has reduced with onlysix new diagnoses in the past four years.

The success of City Clinic is substantial.Drug treatment services have changedradically over the last twenty years and theclinic has been in the forefront of thesechanges. The immediate access totreatment and the retention rates for those

in treatment (over 98%) are veryimpressive outcome measures. Thesuccess in almost eliminating the spreadof HIV infection among the drug injectingcommunity is testament to the success ofa harm reduction and public healthapproach to drug addiction and thesignificant curtailment of new hepatitisinfection is very encouraging. The verylow levels of morbidity of those intreatment are a further indication ofsuccess. The development of careplanning and risks assessment hassignificantly improved patient outcomesacross a range of measures.

There is a very unique therapeuticenvironment in City Clinic. Therelationship between staff, service usersand the North Inner City context makes fora very special treatment interface. Therichness of expression and unique senseof humour of our patients makes the clinican energetic, complex, authentic andrewarding environment to provide care.

Thanks to the colleagues I have workedwith and the patients I have met, workingin City Clinic over the past two decadeshas been a privilege.

Dr Des Crowley GP Coordinator at City Clinic since 1995

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CITY CLINIC 1993...THE BEGINNING

When the Eastern Health Board began itsDrugs/HIV programme in the late 1980s ithad only one location, Baggot St CommunityHospital, 19 Haddington Road. It was clearthat the demand and need for services wasmassive and it was one of my roles toidentify where need was greatest, to sourcepremises and to work with localcommunities. This last role was the mostimportant as it was the best demonstrationthe Health Board could give that it wascommitted to working with communitiesmost affected by drug use and HIV.

The team in Baggot St began networking andoutreaching throughout the city, from 1991onwards and more intensely from 1992.Public attitudes to drug use and drug userswere different in 1992 compared to now. TheEastern Health Board at its February 1993meeting debated on the following motion:

“That the Eastern Health Board,acknowledging that drugs are the root causeof crime escalation, accepts at the same timethat drug addiction is a serious problemcausing grave dangers to every responsibleperson in the country, particularly Dublin,calls on the Government to hospitalizethrough army involvement all persons soaffected by placing them in restrictive carecustody until their affliction is satisfactorilycured”. The motion was not passed!

These sentiments made it difficult for thestaff in their efforts to gain support in thelocal communities. Typical headlines fromthe time included:

SYRINGE TERROR IN MOUNTJOY; ROWRAGES ON JAIL DEATHS and from the STAR

“The clinic is my life.And I’m grateful forall the help I get fromStaff. Proud that Ihave come offtablets.” Tanya. Age 40

of Monday November 22nd 1993, GPs ANGRY AT DRUGS FOR ADDICTS SCHEME;PLANWILL SCARE AWAY PATIENTS.

Sometime in 1992 I got a call from Mary Cotter to say she had organised a meeting withsome public health nurses and a fella called Paddy Malone and would I come and meetthem to hear what they had to say and give an account of what the Health Board planned.We met in the Red Parrot and from that day on I knew that it would be possible todevelop a service in the North Inner City.

There was widespread community support for what the Health Board wished to do. In abriefing note to the Health Board CEO Kieran Hickey on March 31st 1993 I stated

“The Amiens Street Clinic opened for counselling at the end of January. The currentsituation is that a HIV counsellor, an addiction counsellor, a community welfare officerand four outreach workers have their office base in the clinic together with a receptionistand porter. The Inner City Renewal Group also has their office in the clinic. Thecounsellors have been seeing clients in the premises since early February. Constructionwork is being completed for the methadone dispensing and it is planned to transfer thosein the immediate vicinity from Baggot Street to Amiens Street commencing the week afterEaster”.It wasn’t all plain sailing. Objections from a local businessman and a local solicitor werealso noted in that briefing note. Objections from a small minority of politicians came laterbut were overcome. The Inner City Renewal Group mentioned above morphed into ICONwhich was always very supportive and proactive. The sense of community development inthe North Inner City was very instrumental in the development of services then and thatcontinues.

Many of the staff who pounded the streets in the 1990s so that services could develop arestill working in the area and in City Clinic and great credit is due to all for their resilienceand long-term commitment.

Since my first involvement in the North Inner City and that meeting in the Red Parrot Ihave learnt a lot from the residents of Dublin’s North Inner City and the community has alot to teach the people of Ireland. I was particularly delighted to be asked to become Chairof the North Inner City local drugs task force and to renew acquaintance on the task forcewith people who played a major part in the development of City Clinic and drug responsesover the past 20 years – Joe Dowling, Bernie Howard and Tony Dunleavy.

Joe BarryProfessor of Population Health MedicineTrinity College Dublin

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THE EARLY OUTREACH TEAM

The Aids Resource Centre was set up inBaggot St in 1988, and I joined the outreachteam in February 1992. The Aids ResourceCentre in Baggot Street Hospital already hadnine Outreach Workers/Counsellors, adirector (Dr Louise Pomeroy), and theEastern Health Board Aids/DrugsCoordinator (Dr Joe Barry), later to be joinedby a deputy coordinator (Dr Mary Scully).

The focus of the team was primarily HIVprevention. HIV testing was offered to thegeneral population 1989 and in 1990 a lowdose Methadone programme wascommenced as a harm minimisation optionfor intra-venous drug users (IVDUs).

The first needle exchange programme inIreland began in the Aids Resource Centre or“Baggot Street Exchange” as it becameknown in 1990. This was an anonymous andconfidential service aiming to encouragesafer drug use but certain information wasdocumented with consent such as drug usepractises, sexual behaviours and postaladdress codes to help identify needs andpriorities of future services. It quicklybecame apparent that many individualstravelled from various parts of Dublin toaccess clean injecting equipment, and mostwere not receiving treatment.

This needle exchange programme developedrapidly, from one afternoon to threeafternoons per week. Meanwhile theOutreach team were deployed to the variousareas of Dublin where it was knownnumbers of intravenous drug users wereliving.

I was assigned to Dublin’s North Inner Citywith David Wyse Outreach Worker/Counsellor and we prioritized intensive

“Nice Staff whocare about you.Given me stabletime and cut downon my tablets. Butit’s like a ball andchain.” Kerion. Age 26

“street work” to gain an understanding ofthe numbers of intravenous drug users wholived in this area. We did this by attendingthe main “dealing” areas. This predatedmobile phones, so the selling of mainlyheroin and other drugs was very open. Thepeople we had met in the Baggot StreetNeedle Exchange programme were veryhelpful, introducing us to their “buddies”and making our work on the street safer andmore productive. They informed their peerswe were not undercover police but wanted tolearn about drug use in the area and theneeds of drug users. Most already knewpeople who had died or were “sick” from theVirus, and many were afraid of knowingabout their own HIV status and so feltmotivated to engage with us. They oftencommented that they found it strange to beapproached in known “dealing” areas byHealth Board staff and to have discussionsabout their health and the difficulties theywere having in particular with their drug use.We also distributed condoms which wasgreeted with some amusement. Ireland wasnot liberal in the early 1990s but this alsogave us a little “kudos” on the street.

As well as approaching dug users weorganised various meetings with localcommunity leaders, local residents, publichealth nurses, community welfares officers,Gardaí stationed in the area, GPs, clergy,EHB porters and receptionists from the localhealth centres at Summerhill and NorthStrand, as well as staff from theNeighbourhood Youth Projects, the TalbotCentre and the Ana Liffey Drug Project. Allconfirmed that there was a large intravenousdrug using population in the area. Many ofthem either directed us to individuals and

“City Clinic has savedmany lives. No needto rob anymore.”G.A.B. Age 43

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families they were concerned about, ordirected and introduced them to us.

It also became evident that many peoplewho were injecting drugs and living in theNorth Inner City were reluctant to travel toofar from the area for services and that theoption of local drug treatment services wasrequired. This was also in line with policywhich recommended that drug treatmentservices needed to be placed in areas ofevidential need around the city to avoid“ghettoizing” of certain areas. With this inmind, and with the support of the abovegroups, a drop-in service was opened inSeptember 1992 in North Strand HealthCentre offering support, advice, condomsand a cup of tea. Within 6 weeks it becameapparent that sharing injecting equipmentwas a serious health issue and a needleexchange programme began in both localhealth centres on two separate afternoonsper week.

It was also decided that a treatment facilitywas needed locally for people living in thearea, and a discreet search began for asuitable building close to where people livedbut not in the middle of a flat complex orbeside a school. A building was required todeliver drug treatment options to what wasnaively believed to be between 40 and 60people. This search included viewing the“Monto” building in Foley Street which wastoo derelict, the “Arches” on Sherrard Street(too small), and the old postal sorting officein Amiens Street which looked large fromthe outside was small on the inside and alsoa listed building.

“I’m down to 8mlsand clean” L.B. Age 39

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In September 1992 a local community leader called Seánie Lambe called into NorthStrand Needle exchange programme. We often met Seánie at local community meetingsand out on the street so he had an understanding of our work. He had heard we wereviewing buildings and wanted to help us. He understood that a treatment facility such asthis would not be without opponents, so he made a suggestion that the group he workedwith (Inner City Renewal Group, ICRG) also needed a premises and perhaps it would behelpful that when a building could be located, the two agencies could share the building.Two agencies sharing the building would also help to protect the confidentiality of thoseusing the treatment services, as they could also be accessing either service. Seánie alsosuggested two joined buildings on Amiens Street that had been renovated and were to beadvertised to rent, numbers 108 and 109. This information was relayed appropriately andfollowed up with meetings and negotiations.

City Clinic was the third drug treatment clinic to be opened by the Eastern Health Board.The two previous Eastern Health Board treatment clinics were named the Aisling Clinicwhich was in Ballyfermot and Baggot Street Clinic. The thinking at the time was to namethem alphabetically and so it was decided that City Clinic was a simple and appropriatename with no reference to drugs or HIV in the hope that it would help reduce any stigmafor those attending. The clinic opened its doors in April 1993 and the first clients to attendwere those who were living in the Dublin 1 area who were already being prescribed andadministered Methadone in Baggot Street Clinic. The Outreach team began gatheringnames for a waiting list for treatment.

A small protest was held early in the Summer of 1993 involving local business people anda small number of local residents gathering outside City Clinic. This appeared to bemainly motivated by fear about the consequences of a treatment clinic in the area.Community leaders and relevant senior EHB staff met with the protesters and spoke withthem about their issues. Many believed that the clinic was only going to “distributeneedles” and that it would be open to anyone regardless of where they lived so when theywere informed it was primarily for treatment of those addicted to heroin and living in thearea and that it would be monitored, they appeared somewhat reassured.

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During the summer of 1993 and in responseto the growing need and to servicedevelopment, staff disciplines grew, withfirstly General Assistants, and then,Counsellors, G.P’s, a Psychiatrist, aCommunity Welfare Officer, a Nurse and aPharmacist. The treatment service hadinitially opened in 109 Amiens Street and theICRG operated from the ground floor of 108.Treatment was later offered in both buildingsas numbers and needs grew.

This is a brief piece describing some of mymemories of the beginning of City Clinic.Many people contributed to its beginning,too many to name. It was opened out ofneed, following a strategy and a belief that itwould improve life for those who attended.Many service users saw it as an opportunityto live a “normal” life and to attempt toovercome their addiction in a paced way.Unfortunately some people have died andare remembered at a time like this.Thankfully many individuals developed somelevel of stability in their lives and somemoved out of drug use totally. Medicaladvances in the late 1990s meant that thefocus of work with drug users changed fromprimarily HIV prevention to drug treatmentand this work continues in City Clinic today.

Mary Cotter Project Leader The Talbot Centre (formerly EHB Drug/Aids Outreach Team1992 to 2002)

“City Clinic means stability, people who care,including clients and staff. City Clinic was theend of heroin and coke abuse for me. I’m proudof getting stable. When I started Dr. Crowleytold me “one day you’ll only take what you areprescribed.” I laughed at him and headed off toget drugs. But he had faith in me. But with hishelp and the clinical team I am only takingprescribed meds now.” Mamie. Age 43

“There’s a sculpture of a flame at the corner ofBuckingham Street, to remind us of all the youngpeople who died from drugs and AIDS in the area,before we had proper Methadone treatment. People areliving much longer now with HIV and Hepatitis, andwe have had great success in treating these illnesses.Lots of my patients over the years are now granniesand granddads: they are still on Methadone and doingbrilliantly. They are all heroes.” Juliet, Doctor at City Clinic from 1998.

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“I describe it as an “Addiction A & E” and not “justa methadone clinic”.What we actually have is a very unique perspectiveon a highly complex and difficult area to work in,which is substance abuse and all the harsh realitiesof it. Days can be hard; can feel hopeless; helpless;lost; frustrated; isolated, over-whelmed…somethingwhich at times, seems to mirror the experiences ofour clients. But there are reminders all the time ofour compassion, capacity to survive, drive toimprove, “never give up” attitude, resilience, copingskills and resources, humour which gives enough ofa boost to keep us going…very valuable lessonstaught by our clients and colleagues.” Jo-Anne, Counsellor

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“I really like the way the staff run the clinic-Itmeans a lot to me because if I hadn’t got thisMethadone I’d be out robbing to feed this habit - Itkeeps me stable.” Anon. Male age 35

“A client, who was upset about not getting atakeaway, said: ‘Stop talking to me, you’re takingaway my anger.’ This highlights what City Clinicis for me. It’s not just a treatment service, it’sabout the people who give and receive it.” Siobhan Herron (Pharmacist)

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The outreach team who were at that time thescouts/outriders/community workers for theDrug Aids Service as it was then called hadidentified the possibility of opening a clinicin one of the hotspots for "drug misuse, ivdrug use and HIV” the North Inner City. Abuilding was identified by Joe Barry and hismanagement team including Mary Scullyand Isabel Somerville alongside Mary Cotterand David Wyse on the outreach side. Thisrequired considerable communitynegotiation skills and a willing group atcommunity level ably led by Seanie Lambeof ICON. The Eastern Health Board rented abuilding 108/ 109 Amiens Street, and thecommunity agreed (well, some of them didand some of the community didn’t). On theday of opening there was a local protest. Itwas like that in most areas that the Drugsaids Service tried to open a clinic. Ballymunwas a nightmare as was Blanchardstown,taking years to negotiate. The protest got abit dramatic one evening with the lighting ofa barrel in front of City Clinic. The EveningHerald had the dramatic pictures of JoeBarry trying to enter the building against abackdrop of the lighting barrel. Anyway, fireis a symbol for transformation and changeand so despite these protests it opened. CityClinic opened!

“City” was and is a bit of a rabbit warrenwith all those stairs and two mirrorbuildings. But besides that, the vibrant livelyand informative weekly clinical team meetingstands out as does the continued dedicationof staff. The detailed discussions on thoseattending who were causing the mostconcern for staff happened again and again.Staff cared and took time. We even had aCommunity Welfare Officer, and later we got

CITY CLINIC: A VERY PERSONAL VIEW

“The late John O'Reillyand Martin Evans wereinstrumental in assistingme in my earlyeducation of the rolethat I play in the MDTof an addiction clinic…They were a very goodgroup of people andclinic and their care forthe clients was topclass.” Gerard, GA (1998)

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a Drug Liaison Midwife service which took a lot of the worry about pregnant women offthe table at the weekly meeting. The staff at “City” have gone on, providing a week-in-week out, year after year, a service for so many people who have so needed it. So many ofthese patients are at the margins, ostracised and the discarded of our society. There isstill a moral ambivalence in our society about drug use, but the work of the HealthResearch Board shows otherwise. This a disease within society itself. A cure or at least aremedy for HIV arrived in 1996, but not before we lost many to the dreaded disease. Morerecently, overdoses and liver cirrhosis have taken more. Now the clients, service users,patients are getting to middle age and have to watch their cholesterol, “God damn it!”

Hardly wonder then of my next abiding memory of escorting Pat Mc Loughlin incomingCEO to Mackushla Hall at the height of the civil unrest with drugs marches on the Dail. Ifanyone has read Sarkan, it spells out this stage well: when you have nothing, you don'teven know you don't have it. Then you realise after you’re given something that you havehad nothing. Walking into Mackushla with maybe 300-400 people in somewhat angrymood was a fire baptism for Pat . . . ! We opened numerous satellite clinics over the next2 years and finally broke the log jam on waiting lists. Fair dos to Des Crowley and MaryFanning who relentlessly followed a policy of any treatment is better than none, whichwas true then. Quality initiatives would come later. I remember having to file questions onour waiting lists and this meant a lot of them, with people dying of HIV in thesecommunities. The Pat Rabbit Report on the Task Force Areas ensued acknowledging thesocietal dimension and deprivation in particular, and parties vied to redress the social

“People were desperate to be treated for theiraddictions. I had the gift of desperation whichlead me to the doors of City Clinic. . . Goinginto Counselling for me was the way forward.Trust was so important and boundaries aswell. Each week something from the wreckagewould have been shared. Tears, sadness, anger,injustices, misunderstood, abuses, and gettingdrug-free became a dream and yes, eventuallymy dream came true, I became drug free . . . Itravel the world, I work my socks off helpingAddicts, guiding them to the City Clinic wherecounselling would become part of their journey.I am so grateful . . . May the journey keepgoing forward.” Male Counselling Client26

imbalance. There is still a big issue here which is addressed by the Public Health Reportin which Joe Barry was involved, “The Hard facts”, and more recently the Lancetpublished articles on the effects of deprivation across the globe, which shows the effectson health generally.

Back at grassroots level in “City”, there were the Doctors and Pharmacists and GeneralAssistants and Secretaries. I will not name one as then it will become a litany of the backbone of the clinic. They and we know who they are. Now it feels very much its own place,wary of outsiders like me and properly so!

But never to be completely asleep, we need to acknowledge that the work of such clinicsis done. They have established drug treatment as mainstream. Now we need to de-ghettoise these large treatment centres and move our service users into main streamprimary care. This is now urgent!

Dr Brion Sweeney Consultant Psychiatrist and Clinical Director at City Clinic from 1998 to 2011

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The 1990’s saw an explosion of heroin addiction in Dublin and with it came concerns abouta possible epidemic of blood-borne virus infections. Identifying, educating and managingpatients with HIV and/or hepatitis C became paramount.

Hepatitis C virus was identified in the early 1980’s and screening was initiated in the bloodbanks in 1990. In the two decades since City Clinic commenced testing, 945 samples havebeen identified as being Hepatitis C antibody (Ab) positive. The numbers of HCV Abpositive samples significantly increased in the first five years of testing at the clinic. Thispeaked in 1998 when 158 samples were HCV Ab reactive. However, since then thenumbers have gradually tapered off, and no new HCV Ab positive patients were identified in2012 (see Fig1.)

Fig 1 Numbers of HCV antibody positive samples, City Clinic 1993-2012Numbers of patients HCV Ab +

Years 1994-2013

HIV, IV DRUGS AND HEPATITIS C

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Addiction has a major impact on individuals, families and communities. Intravenous drugaddiction has the added increased risks from transmission of blood borne viruses. Earlydiagnosis offered by City Clinic gives opportunities for education and treatment,improving the health and quality of life of the individual and importantly lowering the riskof transmission.

Dr Sara WoodsNational Virus Reference Lab, University College Dublin Doctor at City Clinic Amiens St from 2010 to 2011

Parallel to concerns about Hepatitis C infection in this cohort were the concerns aboutHIV infection and AIDS. In 1993 HIV screening commenced in the City Clinic. Since then36 people have been diagnosed with HIV.

Fig 2. Numbers of patients dignosed with HIV between 1994-2013Numbers of patients HIV +

Years 1994-2013

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The amount of people accessing treatmentservices in Dublin’s City Centre hasincreased steadily over the past 20 years. Alarge proportion of this population wouldcomprise of women of childbearing agewhich has led to a large number of babiesbeing born to women with a history of drugdependence. Maternal drug use inpregnancy is reported to cause higher ratesof mortality and morbidity among babies. In addition to drug use, other factors suchas lifestyle and social circumstances,physical and psychological health,nutrition, STI’s and the lack of antenataland postnatal care has contributed to thelarge proportion of adverse pregnancyoutcomes for this population. To addressthe complex issues surrounding substancemisuse in pregnancy the Eastern HealthBoard appointed the first Drug LiaisonMidwife in 1999.

The role of the Drug Liaison Midwife is tointegrate the maternity and addictionservices and to provide education, supportand specialised care to women who usedrugs or who are drug dependent duringpregnancy. The Drug Liaison Midwifemoves between the obstetric services andthe drug treatment services to ensure thatthe patient is followed comprehensively inboth services and that goodcommunication exists between both teams.

There are currently three Drug LiaisonMidwives in the country linked with thethree Dublin based maternity hospitals.Since their appointment, City Clinic hasbeen the base for the DLM catering for allsubstance misusers accessing thematernity services of the Rotunda Hospital.This relationship between City Clinic andthe Rotunda Hospital has evolved over theyears, reducing the stigma associated withdrug use in pregnancy by empoweringwomen to address their problems, knowingthat there is non judgemental andsympathetic support available to assistthem. This close link through the DrugLiaison Midwife, has helped reduce thenegative outcomes often associated withdrug use in pregnancy, and has strivedtowards a more positive birth experiencefor all women weather they continue to usedrug or not.

City Clinic’s Drug Liaison MidwivesMs Joan Deegan 2001-2006Ms Jennifer Lee 2002-2007Mr Justin Gleeson 2007- present

THE DRUG LIAISON MIDWIFE

“My life has improved since I cameon the clinic. It’s a support to me.Getting of the gear is what I’m mostproud of, and being on takeaways.” Jean

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“City Clinic hassupported me. Itmeans a lot to me asit has helped methroughout the yearswith my addictionand my health. I’mmost proud of theway my two boysDarren and Deanhave grown up andsupported me” Anon. Female

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“I started in City Clinic in 1993, 20 years agoand I must say, since then City Clinic has donea lot for me. First they got me a little job inSaol, where I learned to read and write. Thenmy health started to weaken and this wasbecause I was Hep C Positive. City Clinic gotme in touch with the Centre for Liver Diseaseup in Eccles Street where I used to see myProfessor. He took a liver biopsy from my liverand told me I had to go on the transplant list. So I went back to City Clinic crying to myDoctor and she said we will give you all thehelp you need. So she got me a patient liaisonnurse down to City Clinic and after a few visitswhere I saw a Psychologist and a Psychiatrist,just to make sure that you’re fit and wellenough for treatment. So I passed all the tests,ticked all the boxes and then I got started onInterferon. O.M.G. It was hard going but if Iwanted to be clean from Hep C, I had to stayon it for 12 months. So I did exactly what myDoctor and Nurse told me and here I, love lifewith my family and grandchild. 9 ½ yearsclean from Hep. C. Thank God and I’d like tothank my Doctor and all the staff at CityClinic.” Ada. July 2013

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“I feel it has a holdon my life. It’s heldme back for years.I’m detoxing at theminute with thehelp of Siobhan.I’m feeling morestable in my life.” Natalie.

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CONGRATULATIONS

Congratulations to our good neighbours,City Clinic on reaching your 20th birthday.

The SAOL Project is housed across theroad from City Clinic; we have not strayedfar from our original home (for a brief time,the then manager of SAOL, Joan Byrne,had an office in City Clinic). The staff ofwhat was the Eastern Health Board CityClinic had been central to the idea of awomen’s recovery project being formedand, along with the local community andparticularly ICRG, assisted in starting whatwas to become SAOL.

Since then, City Clinic have been our chiefreferrers (in our recent report, “I’ll havewhat she’s having”, 43% of respondentswere service users in City Clinic, by far ourleading referral source) and our nearestneighbours. And they are good neighbours.

They are good neighbours because theycare about the people who come for helpand want recovery for them.

They are good neighbours because theysupport the work of the projects aroundthem, encouraging the women who cometo them to cross the road to see if we canbe some help; and then follow-up bysupporting our staff in responding to theneeds of our shared clients. Indeed, staffhave in the past joined together in runninggroups, working on committees andplanning new initiatives.

They are good neighbours because theytake on the difficult task of providingmethadone. Methadone services are nowthe norm, but this was not the case in 1993and it was an important development forthis community that City Clinic opened.Back then there was great hope thatMethadone would be a game-changer andthat recovery would happen quickly.

Twenty years on and we know thatMethadone is part of a solution but is notgoing to bring immediate changes in and ofitself. There are a lot of people upset bythis, particularly when they see people onlong-term Methadone treatment. So we arefortunate to have neighbours willing tokeep a service going that provides animportant, if (at present anyway) anunpopular treatment for our service users.It is difficult to be the service that providesthis now unloved medicine to thecommunity. In SAOL we are grateful to CityClinic for continuing to provide Methadoneservices because we know that, whencombined with other supports, Methadoneis often key to recovery for people withopiate-based addictions.

They are good neighbours becauseservices like City Clinic are ultimately aboutthe people who operate them – the G.A.s,the Outreach Workers, the G.P.s, theCounsellors, a Midwife and thePharmacists. The kindness that underpinstheir work; the flexibility to work with the

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changes in the journeys of service users’lives; the willingness to work with projectslike SAOL, in order to help people change,is what makes City Clinic a service thathelps the community. I hope yourcommitment to helping our communitycontinues; that you are central indeveloping the case management approachthat will give service users the chance tobetter encourage change for their lives; andthat you will continue to be staffed by goodpeople.

Most of all, I hope that, even though youare good neighbours, that there will be noneed for you in another 20 years. I hopethe same is true for SAOL too. I hope wecan continue to work together to help sucha hope become a reality.

Gary BroderickDirectorSAOL Project Ltd58 Amiens StreetDublin 1

“What does CityClinic mean to me?Support from staff.But I feel trapped. Iam proud how farI’ve come.” R. C. Age 30

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“I worked in city clinic from 1995 to 1999. We used to hire abus once a month and go walking up in the Wicklowmountains. it was usually a problem with our client group torecognise where their own fitness level was and to be realisticabout hill walking and the hours and effort that was needed,SOMETIMES it came as a shock to people and it certainlytook you out of your comfort zone to find out that this wasserious stuff indeed when people bought in to the concept andrealised that they could over time get fairly fit and get a goodnights sleep it really began to take off. . . A number of GAs used to give up their lunch hour twice aweek to play football with anybody on the clinic who wantedto play. We got some funding at the time from the Operationsmanager Isobel Sommerville and we bought a football stripand equipment and we would play other agencies. We wouldusually lose but the pride of the participants when they puton their football gear was a sight to be seen. Thank youPaul Lynch, GA

In MemoriamTo those who have passed away

Service Users and StaffYour contribution lives on and enriches our lives

We will remember you.

Our work continues