Drugs: The Current State of Play
Frank Brady, SJ
In October 1996 and May 1997 the Ministerial Task Force on Measures to Reduce the Demand for Drugs published its first and second reports. The first report deals mainly with heroin and the problem of opiate misuse in the Greater Dublin area. The second deals with the non-opiate problem nation-wide, with drugs in prisons, and, briefly, with therapeutic communities and rehabilitation.
The Task Force identifies heroin as a largely Dublin problem, with sporadic use in Cork, and estimates the number of heroin users as 8,000, of whom upwards of 2,500 could be willing to go on methadone maintenance programmes. There are in fact many other areas throughout the country which are ripe breeding grounds for a serious drug problem. A good number are now at the stage that inner-city Dublin was at prior to the drug explosion of the 1980s. The problem is confined to a small number of users there, including \'transients\', but is well enough rooted that people can get heroin in these areas if they want it. If these areas follow the European pattern they will without any doubt develop a serious problem, unless the underlying socio-economic conditions are addressed.
The first Task Force report stresses the fact that "drug misuse is closely associated with social and economic disadvantage, characterised by unemployment, poor living conditions, low educational attainment, high levels of family breakdown, and a lack of recreational facilities and other supports". The report identifies several blackspot target areas in Dublin.
There has been considerable evidence of a lack of political will at government level to tackle the drug abuse problem. For instance one of the first things the present administration did on coming into office was to cut the supplementary budget for youth services, which was integral to the whole strategy, from £20m. to £1.3m. It was only after a concerted campaign at community level that this budget was re-established. It is worth noting in this context that the establishment of the Task Force in the first place coincided with a great rise in public demand for action from the local communities most affected. Similar action in the late 80s and early 90s also resulted in the 1991 Government Strategy to Prevent Drug Misuse. However, much of the 1991 strategy was never implemented, which is one of the reasons why the present crisis is so severe. The obvious conclusion is that public demand by those communities most affected is the only thing that will maintain the required political will.
Indications of Government Policy and Strategy: Harm Reduction
By concentrating on measures to deal with heroin in the target communities, while leaving drugs in prison, and rehabilitation, to the second report, the Task Report appears to be saying that its primary concern is managing heroin. This seems to indicate a policy of favouring a public health/harm-reduction approach, over a more individual or group clinical-therapeutic treatment model This is not to say that the emphasis on harm reduction is wrong, rather that it is only one measure among many. A first indication of the priority being given to harm reduction was the expansion of methadone services, and the provision of clean needles for drug users in response to the spread of AIDS and Hepatitis. The bulk of the recommendations centre around the provision of methadone maintenance, the expansion of the number of local clinics, and the recruitment of GPs and pharmacists, all with the purpose of reducing the numbers awaiting maintenance. This policy was driven by the public demand to provide treatment for large numbers as quickly as possible, and the best known way to do this was through methadone. However maintenance on its own is no solution.
Problems with Maintenance
There are many problems with a policy that relies heavily on maintenance:
· Maintenance without adequate counselling and rehabilitation services does not get drug users stabilised. They tend to use heroin and/or benzodiazapenes (sleeping tablets/ tranquillizers) on top of methadone.
· Clinics are currently being inundated with patients on long-term maintenance. This is putting clinics under great stress and leaving those on waiting lists on a very long finger.
· The average numbers of clients to a counsellor in the present clinics is 40 to 70, - an impossible number to deal with.
· The services provided by the clinics becomes very skewed, drawing them away from full-time rehabilitation work. Each clinic is maintaining well in excess of 150 patients on methadone, of whom only about 10/15 can get places in full-time rehabilitation. The number of places in drug-free rehabilitation in the whole country does not appear to be more than 100.
· There appears to be large-scale prescribing of tranquillisers, sleeping tablets and anti-depressants associated with maintenance.
· Maintenance without adequate provision for becoming drug free or for becoming effectively stabilised is a statement of no hope for drug users.
For many years methadone was dispensed by a number of GPs as well as clinics, and the Task Force noted the lack of definitive quantitative information in this regard. Up to recently, there was no register of drug users, so that it was possible for a drug users to get two doctors to prescribe for them, or to be getting methadone from a doctor as well as a clinic, with the extra medicines often finding their way onto the black market. Some doctors were caring for as many as 200 drug users each, charging £10-£15 per script, or even more.
A new protocol has now been introduced which will restrict each doctor to a maximum of 35 drug user patients, and this maximum can only be reached gradually over time. All heroin users are now registered in a central registry and the names of their doctors and prescribing chemists are listed, which makes double scripting much more difficult.
The Most Significant Recommendation of the First Report
The first report underlined the necessity of a co-ordinated approach, given the large number of Departments and supporting agencies involved. They recommended putting in place "administrative structures which will ensure that the strategies proposed are delivered in a coherent, cost-effective and ultimately successful manner". These structures, described as "perhaps the most significant recommendation" consists of :
· A Cabinet Drugs Committee
· A National Drugs Strategy Team; and
· 13 Local Drugs Task Forces.
This structure is to be welcomed in that its purpose is to ensure co-ordination, and involve communities, providing a strategic, locally-based response by the statutory, voluntary, and community sectors. Co-ordination is essential if drug users and their families are not to end up falling through holes in the network of services. Community involvement brings a vital element of both rootedness and knowledge of the local situation.
In practice, difficulties are appearing at various levels:
· Neither officials nor elected representatives have much experience of working with local people as equals on a team. They need training if they are not to fall into the pitfalls of side-stepping local people, not taking them seriously, meeting at times that are impossible for local people, or being unable to take inputs of local people on board when they are receiving their own instructions from above.
· The voluntary commitment required of local people, who often have families to look after, and part- or full-time jobs, can be huge. Many do not have the energy and can \'burn out\'. They can and do feel used as cheap labour.
· Local people can lack the kinds of expertise that professionals take for granted. They can lack experience of working as partners with people previously seen as "them", who had power and kept it to themselves. There can be a lack of commitment, financial and otherwise, to training of local people, to providing facilitation when groups get into difficulties, and, for instance, to provision of crèches and other facilities when needed.
Other difficulties arise at the level of implementation:
· Government funding of strategies authorised by them has a limited time span. This makes even medium-term planning impossible.
· Increased funding is crucial if successful initiatives are to be mainstreamed. There does not appear to be any provision for increased funding being channelled to the Department of Education and the Health Boards in respect of these strategies
· The co-ordinating brief of the Local Drugs Task Force does not extend to the services of the Health Boards or other government departments. Local input into overall co-ordination is limited or non-existent.
· At local level, there is little co-ordination between bodies maintaining health, education and justice services.
The lack of co-ordination at a local level is partly due to our very centralised system of government and thus will not be easy to change.
Finally, in relation to the National Drugs Strategy Team itself:
· While two assistant secretaries deal with policy, the input of the local communities and the voluntary sector is confined to the operational area. This division raises questions about the seriousness with which questions of policy arising from experience on the ground will be dealt with. This suggests that local involvement is valued only up the point were it cannot raise questions about overall structures.
I wish to thank colleagues in drug work in Dublin for their input into this article. Any feedback would be welcome.