Drug Treatment – The Irish context

Drug Treatment – The Irish contextDrug Treatment – The Irish context

Dr Garrett McGovern GP Specialising in Addiction TreatmentPriority Medical ClinicDundrumDublin 14

Garrett McGovern MB BCH BAO, MSc. (Addictions)

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

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

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)

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

The media and methadone




Stigma and ignorance




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.

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

Punitive practices

Punitive practices

Punitive practices

Punitive practices

Taking the Piss

Taking the Piss

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

The Introduction of the Opioid Treatment Protocol (The Farrell Report)

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

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

Removal of name from guidelines

Dr Cathal O Sullióbháin

ICGP Audit review - conclusions

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

Why not use the Orange Book as the standard?

But it’s not all bad news………



END

Questions?

Health & Medicine

Drug Treatment – The Irish context