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

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. 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. 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. 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. 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. The media and methadone

7. The media and methadone

8. The media and methadone

9. The media and methadone

10. Stigma and ignorance

11. Stigma and ignorance

12. Stigma and ignorance

13. Stigma and ignorance

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. 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. Punitive practices

17. Punitive practices

18. Punitive practices

19. Punitive practices

20. Taking the Piss

21. Taking the Piss

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

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. 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. Removal of name from guidelines
Dr Cathal O Sullióbháin

27. ICGP Audit review - conclusions

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. Why not use the Orange Book as the
standard?

30. But it’s not all bad news………

31. But it’s not all bad news………

32. But it’s not all bad news………

33. END
Questions?