The number of heroin users in Ireland is the highest in the EU while deaths of people on methadone programmes increasing. In the first of a two-part series on Ireland's heroin problem, we ask how addicts are being treated here, writes BRIAN O'CONNELL
ACCORDING TO data released at the end of last year, Ireland is top of the table of EU countries when it comes to heroin use. The report, which came from the European Monitoring Centre for Drugs and Drug Addiction, showed there are now eight cases in the 15-64 age group per 1,000 population in Ireland, while recorded drug offences here have doubled since 2004.
It’s worth noting that some of the data used in the survey may be more than a year old, and that waiting times for drug treatment services, including methadone and detoxification programmes, have improved significantly in the past 12 months.
Notwithstanding these factors, ask those working at the front line of drug treatment services in Ireland and many will tell you that Ireland has a very significant problem with heroin use, and that it is now invariably combined with other drug and alcohol abuse issues.
New figures released by the HSE show that by the end of October 2011, there were 9,264 people on HSE methadone programmes nationwide. It is estimated that there are another 10,000 heroin users among the population not on methadone. Close to 60 per cent of those on a methadone programme are on it one year or less, while almost 1,000 are on methadone for a period of three years.
This data is based on clients’ current treatment episodes and does not take into account other times they may have been on methadone programmes, so it’s worth pointing out that someone on a programme now may have tried and failed with methadone before. The average cost to the State for each person treated on a methadone programme is €2,714.52 per annum.
Dr Chris Luke, a consultant in emergency medicine at Cork’s University and Mercy Hospitals, moved to Cork in 1999, and says he generally saw one case of heroin abuse or death a year, up until 2007. “From then on I began to see a stream of overdoses and deaths and most of those were from a mixture of heroin, methadone or sleeping tablets.”
Luke says that his experience at the very front line of emergency medicine has caused him to now think more deeply about the manner in which heroin addicts are treated in Ireland. “I am a sinner serving other sinners. We have had a broadly liberal approach to the whole thing and we were encouraged to think of methadone as insulin. I bought into the idea that you could see a 40-year-old heroin addict bringing their children to school and keeping their job down and not causing public disorder as an untreated addict might.
“I bought into that and I still believe in it, but methadone is also a great source of death and destruction and chaos in the market out there,” he says. “It is grossly misused and bartered and traded on the black market and is frequently a source of death. I expect to see as many deaths from treatment of methadone as heroin itself, which is a hell of an indictment of any treatment. It is not just a fairytale that the treatment is worse than the disease. There is very little evidence that methadone gets people off addiction. I am ambivalent about it. For years the establishment in Cork resisted it. I thought it was illiberal. Now in retrospect, with the provision of services and the heroin problem, I am less convinced than I used be.”
The 2009 National Drug Treatment Reporting System showed that only 27 per cent of clients complete their methadone treatment, with a further 10 per cent transferring to other services and reported as stable. One-third of clients either left their methadone programmes or were refused further sessions, while 16.6 per cent of those on the programmes left, having classified themselves as stable.
Recognising the problem, the HSE has concentrated on providing access to treatment services, with in-patient services in Cuan Dara in Ballyfermot and St Michael’s Ward in Beaumont, which provides 23 beds for stabilisation and detoxification, and some other limited availability outside these beds.
The focus, however, has been to prioritise access to methadone programmes, and in 2009 and 2010 HSE South provided two additional methadone services in Cork, coupled with services in Wexford, Waterford, Kilkenny, Tralee, Limerick city, Drogheda and Dundalk. The agency is also looking at additional facilities in the midlands, Cork city and in Gorey, Co Wexford. The scale of this new mobilisation of methadone programmes highlights that the heroin problem in Ireland is now a truly national problem with an indiscriminate geographic spread.
Tony Geoghegan, chief executive of Merchant’s Quay Ireland, was witness to the heroin problem in Ireland in the 1980s and is now battling to open outreach offices and increase services to deal with the present-day problem.
“On one level, if you look at the recent report, we scored well, in that about 50 per cent of heroin users in Ireland are on methadone programmes, which is above the EU average,” he says. “When you talk about the success rate of methadone, I’d much rather see methadone than street drugs, where there is no quality control. Having said that, perhaps there hasn’t been as much of a progressionfrom that. The first stage has been to engage as many active users as we can in treatment.
“Equally though, it should be about trying to encourage people to realise their potential and develop more. You could argue that we have large numbers of people coming in for treatment, but they’re not coming out the other side. The reason for it is financial in that methadone provision is a relatively cost-effective intervention. As a resource, methadone is not as intensive as rehabilitation or re-education or added social skills. For example, the ratio of client to counsellor in HSE clinics can be high, as much as 50:1, I believe. Some could argue cynically that methadone is more of a holding exercise.”
But what then are the alternatives? In the 1980s and 1990s, one of our European fiscal colleagues, Portugal, had a big problem with drugs-related HIV and heroin use. By 1999, it was estimated that 100,000 people, or 1 per cent of the population, were heroin addicts, and the problem was posing major issues for Portugal, impacting on tourism, as well as health and other sectors of society.
Controversially, the government decided to decriminalise all personal drug use, including heroin, and diverted resources to public health campaigns among users and positive discrimination in assisting them back into the workplace, as well as providing more opportunities for ongoing rehabilitation. So a person caught with up to 10 days’ personal supply of any drug does not receive a criminal record in Portugal (although dealers are still either fined or jailed). Instead, the user faces a type of committee, which usually includes a lawyer or judge, a psychologist, a social worker or a doctor. They can recommend a small fine, a period of drug treatment or for nothing to happen. While it is perhaps too early to say conclusively what impact this has had on drug use in Portugal, some tentative statistics are showing that the numbers presenting for treatment have doubled while heroin use among certain sectors of the population, particularly younger groups, has fallen.
Dr João Goulão, the president of the Institute for Drugs and Drug Addiction in Portugal, believes it is not just decriminalisation that has had an impact on the numbers of heroin users in Portugal and that other countries, such as Ireland, can learn from their experience.
“We have had policies on prevention, treatment and reduction. With our methadone programmes, the key for us was the spread of this programme and making them available all over the country,” Goulão says. “This led us to a very positive evolution in terms of the health of the addict population. It also led to a decrease in petty crimes and delinquents, which had a positive impact on everyday life for families and society. So it is an important tool to deal with addiction.”
Goulão says that public health workers in Portugal are coming to view heroin addiction as an illness that can be difficult to cure and that prolonged periods on medication may be necessary. “We are assuming more and more in the scientific community that drug addiction in terms of opiates is a chronic illness, so we have to drop the ideological view of it as a self-inflicted disease. We need to think about it like we do diabetes. In fact, with methadone it is possible to lead a normal life. Latest studies show that 40 per cent of our patients on methadone are now working or studying. I believe that the decision of decriminalisation came from a societal feeling and not the opposite. It was not top-down. It was something that came from the bottom-up in our society.”
The key for Portuguese society is that those who are on methadone programmes have been given every opportunity to fulfil their potential. Much of the emphasis in Portugal from a public policy point of view has not been so much on the act of drug decriminalisation, but on ensuring those addicted to drugs, such as heroin, have access to opportunities. The approach then has not only been about treating the addict, but about treating Portuguese society as a whole.
