Download 1 - Houses of the Oireachtas

Submission to the Joint Committee on Health and Children, 15 September 2011.
Rutland Centre
15 September 2011
Submission to the Joint Committee on Health and Children
Houses of the Oireachtas
Leinster House
Dublin 2
1. Introduction to Clinical Director, Dr. Fiona Weldon.
I am the Clinical Director of Rutland Centre since 2009. I am a Clinical and Counselling
Psychologist having completed an undergraduate degree in psychology at UCD, a
Masters in Counselling Psychology at Trinity College Dublin, and a Doctorate in Clinical
Psychology at Trinity College Dublin in 2004.
2. The Rutland Centre: History and Treatment Approach
Rutland Centre is a 25 bed Residential Treatment Centre for Addictions to Alcohol,
Drugs, Compulsive Gambling, Sex Addiction and also Eating Disorders.
Summary of services at Rutland Centre
The Rutland Centre offers a full range of services including the following:
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Assessment service
Pre -treatment prep group
Five week residential programme incorporating group and individual therapy
Family support and intervention groups
Relapse prevention programme
Continuing Care programme (at least one year)
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Submission to the Joint Committee on Health and Children, 15 September 2011.
Rutland Centre
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10 week General Outpatient programme
12 week Dual Diagnosis outpatient programme
CHKS Accreditation
The Rutland Centre is fully accredited with CHKS. On 2nd December 2009 the centre
was awarded this full Accreditation by CHKS Healthcare Accreditation Standards.
3. Current trends in drug use.
Rutland Centre has witnessed significant changes in the presentations of those seeking
help. In 2011 thus far 20% of all assessments were for illicit drug use, and 5% were for
primary prescription drug addiction. There has been a significant rise in addiction to
prescription medications as a primary addiction. When poly substance addiction is taken
into account this figure rises significantly.
4. Medical Card Holders
In 2005, the Rutland Centre treated 47 medical card holders. In 2009, the Rutland Centre
treated 11 medical card holders. In 2011 thus far we have treated 0 medical card holders.
A very small portion of those with substance use disorder are accessing residential
treatment. The National Drugs strategy 2009-2016 recommends greater access to
alternative treatment to methadone maintenance, however this remains the primary care
pathway for an individual addicted to opiates.
Methadone treatment outcome research is flawed in reporting outcomes, often stating that
individuals are “abstinent” in their outcome studies, however “abstinence” being defined
as not using heroine. It is clear from the ROSIE report (2009) that in fact many of these
individuals may be abstinent from heroine but are continuing to use other substances such
as alcohol, abusing prescription medication, or other illicit drugs such as cannabis or
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Submission to the Joint Committee on Health and Children, 15 September 2011.
Rutland Centre
cocaine. It is clear that in many instances addiction is still very active, although the
substances used may vary. Rutland Centre recommends that an approach to addiction
that provides intervention for the addictive processes as a whole (and thereby improving
quality of life for the person and family as a whole) is a vital starting point in policy and
service development.
According to the ROSIE report (NACD, 2009) opiate use reduced over three years from
approx 75% to approximately 45% - however alcohol use at intake of the interviews was
N=204, and at 3 year follow up this figure was N=157. “Daily consumption remained
constant throughout the study period” (NACD, 2009) reporting the average daily
consumption at 9.1 units of alcohol. This is significantly concerning in the context of
addiction processes for two reasons: 1) alcohol raising risk of relapse to opiates and 2)
highlighting the fact that in many cases the addictive processes are still evident, but the
substance has just changed. Treating addiction to one substance and targeting services
and intervention towards one substance is likely to be non effective, and outcomes will be
deceptive and skewed. If treatment is targeting one substance, little else may change in
terms of other substances, mental health and general well being of the person and family.
5. Dual Diagnosis
The National Advisory Committee on Drugs (2004) found no systematic provision for
those with dual diagnosis (those with substance use disorder and a co-existing mental
health diagnosis. (Mental Health and addiction services and the management of dual
diagnosis in Ireland, NACD, 2004).
Rutland Centre has developed programmes to address the needs of those with a dual
diagnosis. There has been an increase in individuals presenting with pre-existing mental
health issues and Rutland Centre assesses and develops individual care plan interventions
based on assessment.
Cognitive
Behavioural
We use evidence based psychological interventions such as
Therapy,
Dialectical
Behaviour
Therapy,
Motivational
Interviewing and group psychotherapy.
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Submission to the Joint Committee on Health and Children, 15 September 2011.
Rutland Centre
6. Cost/Benefit Analysis
Cost of addiction related health problems to the Health Service Executive:
(i)
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In 2008 the HSE reported that in a ten year period alcohol related illness
accounted for 841,161 bednights in hospitals (HSE, Alcohol related harm in
Ireland, 2008).
(ii)
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Liver disease has increased by 190% between 1995 and 2007 (Morgan,
McCormick, O’Hara, Smyth & Long, 2011).
(iii)
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The cost of addiction to the Health Service annually has been estimated at 3
billion.
However there is little funding available for detoxification and
rehabilitation (residential or outpatient) by comparison. This makes little
economic or social sense.
It is estimated that the cost of methadone
maintenance was 14 million in primary care in 2007 (Drug addiction,
treatment and Rehabilitation, Comptroller and Auditor General, Department
of Community, Rural and Gaeltacht Affairs, 2009). This does not include
inpatient detoxification costs. There is currently no ringfenced funding for
residential drug free treatment, rather virtually no funding in 2011 thus far.
Considering the cost of methadone maintenance and the concerns about
outcome considered from the ROSIE report, it is recommended that increased
funding be allocated to residential services which target addiction, mental
health and the person as a whole (not just one substance that can change).
Those that enter residential treatment are unlikely to require multiple
treatments, the majority only ever having treatment once.
When this is
compared with the multiple detoxifications that can be required (and
associated cost) notwithstanding the cost of methadone maintenance to our
health system, it is clear that this approach is neither effective nor cost
efficient. The multiple detoxifications that are often required whilst a person
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Submission to the Joint Committee on Health and Children, 15 September 2011.
Rutland Centre
is on pharmacological replacement therapy is a significant indicator that the
treatment of physical dependence is not sufficient to break the psychological
pattern of addiction – and this is evidenced clearly in the ROSIE report where
individuals are using alcohol or other illicit substances whilst on methadone.
Whilst we recognise the value of methadone therapy in terms of stabalising,
this is insufficient as an approach to longer term sobriety and recovery.
Addiction treatment requires adequate psychoeducation on the process of
addiction, significant family involvement, and evidence based psychological
interventions to address the underlying issues that are often present.
Residential treatment costs approximately €10,000 which includes a full year
of continuing care support, not just for the individuals but also for the
families.
7. Comments on National Drugs Strategy (Interim Report) 2009-2016
The National Drugs Strategy includes the following points:
(i)
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A recommendation for access to treatment within one month of presentation.
(ii)
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The main strategy for opiate users in methadone maintenance. The national drugs
strategy 2009-2016 noted that the long term effects of methadone maintenance
was a concern.
(iii)
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The national drugs strategy recommended combining alcohol and drugs treatment
services.
(iv)
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Tier 3 and 4 were found to be underdeveloped with little provision for residential
treatment.
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Submission to the Joint Committee on Health and Children, 15 September 2011.
Rutland Centre
(v)
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The policy focuses on providing an appropriate and timely intervention for
substance use tailored to individual need.
(vi)
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Alcohol is seen as a gateway to illicit drug use (poly-drug use is the norm among
illicit drug users).
(vii)
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At the end of March 2009 the Government agreed to include alcohol in the
National Substance Misuse Strategy.
(viii)
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A focus on the provision of easily accessible and affordable treatment services for
people with alcohol and drug related disorders.
(ix)
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A recommendation that options other than methadone maintenance be developed
for opiate users including increased access to residential treatment (only 7% of
those offered methadone maintenance were offered residential treatment).
(x)
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Methadone treatment outcome research is flawed in reporting outcomes, often
stating that individuals are “abstinent” in their outcome studies, however
“abstinence” being defined as not using heroine. It is clear from the ROSIE
report (2009) that in fact many of these individuals may be abstinent from heroine
but are continuing to use other substances such as alcohol, abusing prescription
medication, or other illicit drugs such as cannabis or cocaine. It is clear that in
many instances addiction is still very active, although the substances used may
vary. Rutland Centre recommends that an approach to addiction that provides
intervention for the addictive processes as a whole (and thereby improving
quality of life for the person and family as a whole) is a vital starting point in
policy and service development.
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Submission to the Joint Committee on Health and Children, 15 September 2011.
Rutland Centre
(xi)
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The National Advisory Committee on Drugs (2004) found no systematic
provision for those with dual diagnosis (those with substance use disorder and a
co-existing mental health diagnosis. (Mental Health and addiction services and the
management of dual diagnosis in Ireland, NACD, 2004).
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The Rutland Centre wishes to thank the Joint Committee for Health and Children for its
consideration and time and we hope that these issues will be addressed in order to meet
the identified gap between Governmental policy and treatment provision for medical card
holders. To facilitate this, Rutland Centre requests that a commitment to ringfenced
funding for residential treatment for medical card holders be made given that they
achieve standards of excellence in clinical outcome and cost effectiveness.
Rutland Centre seeks to work more closely with government, and we already contribute
significant data annually for the Health research Board. We provide a cost effective
service, with integrated evidence based care, and continuing care for at least 12 months.
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