Report of the HSE Working Group on ResidentialTreatment & Rehabilitation

(Substance Abuse)

Report of the HSE Working Group on ResidentialTreatment & Rehabilitation (Substance Users)

Dr Des CorriganDr Aileen O’Gorman

on behalf of theWorking Group

May 2007

Table of Contents

Foreword ................................................................................................................................................3Executive Summary..................................................................................................................................4Chapter OneIntroduction ............................................................................................................................................9Background and Strategic Context ..........................................................................................................10Terms of Reference of the Working Group ..............................................................................................10Time Frame and Process........................................................................................................................11Outline of the Report ..............................................................................................................................12Chapter TwoOverview of Trends in Drug and Alcohol Use in Ireland ............................................................................13Background ..........................................................................................................................................14Overall alcohol trends ............................................................................................................................14

Alcohol use among young people..................................................................................................14Trends in alcohol use in Ireland in a European context ..................................................................14Impact of alcohol use ..................................................................................................................15Impact of alcohol use on health services ......................................................................................16

Trends in drug use ................................................................................................................................16Cocaine Use ..........................................................................................................................................17Drug use among young people and other vulnerable groups ....................................................................18

Drug Use and Homelessness ........................................................................................................18Dual Diagnosis ............................................................................................................................18

Summary and conclusion ......................................................................................................................18References ............................................................................................................................................19Chapter ThreeThe Role of Inpatient Treatment in Substance Misuse ..............................................................................21The Four-Tier Model of Care ..................................................................................................................23

Tier 4 Services ............................................................................................................................23The effectiveness of inpatient treatment approaches................................................................................24

Specialist versus general settings ................................................................................................26Length of Stay ............................................................................................................................26Provision of Rehabilitation following Detoxification..........................................................................26

Residential treatment for those with alcohol-related problems. ................................................................26Client - Treatment matching ..................................................................................................................27References ............................................................................................................................................28Chapter FourExisting Service Provision ......................................................................................................................31Methodology..........................................................................................................................................32Commentary and analysis ......................................................................................................................33Table 1: Estimation of current capacity of national drug and alcohol residential services, 2006 ..................34Map 1: Residential Drug and Alcohol Services, 2007 ..............................................................................35The treatment of drug and alcohol problems in General and Psychiatric Hospitals ....................................36

Potential Savings..........................................................................................................................36Map 2: Location of General and Psychiatric Hospitals reporting drug and alcohol treatment, 2005 ............38

1

Key issues ............................................................................................................................................39Specific services ..........................................................................................................................39Inadequate level of residential services..........................................................................................39Community-based services ..........................................................................................................39Range of services ........................................................................................................................40Polydrug use................................................................................................................................40Gender ........................................................................................................................................40Dual Diagnosis ............................................................................................................................40Waiting lists ................................................................................................................................41Staffing........................................................................................................................................41Prison drug treatment services ....................................................................................................41

Chapter FiveNeeds Assessment ................................................................................................................................43Methods for measuring needs ................................................................................................................44Local needs assessments and reports ....................................................................................................46

Data limitations in Ireland ............................................................................................................46Model adopted by the Working Group for assessing inpatient need ..........................................................46Table 2: Estimate of Future Need ............................................................................................................47Table 3: Current and Recommended Estimate of Need ............................................................................48Issues ..................................................................................................................................................49

Factors influencing regional provision and recommendations..........................................................49Recommended level of under 18s drugs/alcohol provision..............................................................49

The Needs of Vulnerable Groups ............................................................................................................50Meeting diversity and increasing cultural competence....................................................................50

Step-Down/ Halfway House Accommodation............................................................................................50Staffing ................................................................................................................................................51Need to Review the Provision..................................................................................................................515.0 Conclusions and Recommendations ..............................................................................................51References ............................................................................................................................................53Chapter SixQuality Assurance Framework for Residential Services in the Context of Addiction ....................................55

QuADS and DANOS......................................................................................................................56Monitoring quality standards of care ............................................................................................57

References ............................................................................................................................................58Appendix 1: Membership of the HSE Working Group on Residential Treatment & Rehabilitation ..................60Appendix 2: Submissions made to the Working Group..............................................................................62Appendix 3: Estimation of Current Capacity of Drug and Alcohol Residential Services, 2007 ......................63Appendix 4: Hospitals with a primary discharge diagnosis of alcoholic or drug disorder, or a drug/alcoholprincipal procedure, who reported to the HIPE and NIPRS databases in 2005 ..........................................77Glossary ................................................................................................................................................78

2

ForewordIn presenting this report from the HSE WorkingGroup on Residential Treatment and Rehabilitation(Substance Users), I wish to pay tribute first of all tomy colleagues on the working group for theirthoughtful contributions and hard work during thepreparation of this report. It is true to say that thisreport is their report because it embodies theirknowledge, their expertise, their commitment andtheir experience of working in the area. The report isvery much strengthened by their insights derivedfrom working with individuals with alcohol and otherdrug-related problems.

The hard work and attention to detail displayed bymembers of the group at our meetings and betweenmeetings has greatly facilitated the task ofcompleting this report. For all of us involved it hasbeen an invaluable learning experience, not leastbecause we have been able to produce acomprehensive survey of existing inpatient andresidential rehabilitation services for drug andalcohol users in Ireland. That achievement is due, inno small way, to all those in the statutory andvoluntary drug and alcohol services and thoseresponsible for the HIPE, NDTRS and NIPRSdatabases, who so readily shared information andwillingly responded to further queries. To all those,the group offers its heartfelt thanks.

We are also enormously indebted to our technicaladvisor, Dr Aileen O’Gorman, and her assistant, MsMarie Lowe, not only for their painstaking efforts torecord and verify the existing level of serviceprovision, but also for the excellence of their input tothe overall work of the group. In particular, Aileen’swork in producing this final report is especiallynoteworthy and my admiration of her expertise andprofessionalism is shared by my colleagues on thegroup.

All of us owe much to Vinny Crossan of the HSE forhis administrative and logistical support in ensuringthat meeting rooms and minutes were alwaysavailable and for keeping us refreshed. On a

personal note, I am grateful to Alice O’Flynn and herformer colleague Cathal Morgan for inviting me totake on the task of chairing the group and forputting together such an excellent panel ofmembers.

Our report charts a way forward for theinpatient/residential drug and alcohol services in thiscountry in line with the strategic development ofRehabilitation as the Fifth Pillar of the NationalDrugs Strategy. We do not underestimate the variouschallenges involved in implementing the manyrecommendations we have made, but we hope thatthose involved in policy making and servicedevelopment in the drugs and alcohol areas will,having studied our report and its conclusions, shareour belief that provision of the resources required todeliver on what we recommend will result insignificant benefits for everyone affected byproblematic alcohol and/or other drug use in oursociety.

Dr Des Corrigan Chairperson of theWorking Group

3

ExecutiveSummary

The National Drugs Strategy (NDS) 2001-2008Building on Experience provides the policyframework for drug services in Ireland. The strategy,based initially on four pillars – supply reduction,education and prevention, treatment and research –identifies a series of 100 individual actions to becarried out by a number of Government departmentsand agencies. Through the NDS, the Health ServiceExecutive (HSE) is mandated to provide a range oftreatment and rehabilitation options, includingresidential components, to drug users experiencingproblems.

In 2005, a mid-term review of the National DrugsStrategy recommended that rehabilitation beadopted as the fifth pillar of the strategy.Consequently, the issue of residential treatmentcapacity has arisen. - In 2006, the HSE appointedan expert working group to provide a detailedanalysis and overview of known current residentialtreatment services and to advise on the futureresidential requirements of those affected by drugand alcohol use.

The working group commenced work with an in-depth mapping of existing inpatient detoxificationand residential rehabilitation services in Ireland.Subsequently, different needs assessment modelswere examined and a population-based approachadopted to estimate the level of residential servicesrequired.

Arising from the detailed discussions within thegroup, analysis of submissions received by it, and areview of international literature and experience, thefollowing have been agreed.

Key Issues and Recommendationsregarding the Role of InpatientDetoxification and ResidentialRehabilitation (Chapter 3)

3.1 The concept of the Four-Tier Model of Careas the framework for the future organisationof alcohol and drug services in Ireland isendorsed.

3.2 All four tiers of this model need to be fullyresourced for the model to be fully effectivebecause one tier cannot be developed orfunction in isolation from the others.

3.3 While not all problem alcohol or drug userswill require Tier 4 (inpatient/residential)services, client outcomes are generallyrecognised as being superior for inpatientversus outpatient provision for those whosecare plan calls for Tier 4 services.

3.4 The Four-Tier Model of Care implies thatclients should be offered the least intensiveintervention appropriate to their need whenthey present for treatment initially. Where thisdoes not succeed, more intensiveinterventions should be offered.

3.5 The working group highlights the need for astandardised assessment protocol whichallows for the systematic identification of theneeds of the client ensuring that they arereferred to the most appropriate treatmentmodality in the most appropriate setting.

3.6 The group recommends that where inpatientdetoxification is required, it should be, as arule, provided in dedicated units. The use ofgeneral hospital or psychiatric beds fordetoxification should be the exception sincethe evidence base indicates better outcomesfrom specialist units.

3.7 Attention is drawn to the fact thatdetoxification itself is not an effective

4

treatment and that it must be followed up bypost-detoxification psychosocial interventionsas part of a client-centred rehabilitationprogramme.

3.8 The group emphasises that the transitionfrom detoxification from alcohol or any otherdrug into rehabilitation should be seamless soas to avoid waiting lists and delays which canresult in client relapse. It is recognised that inthe case of relapse to opiate use, there is amajor risk of fatal overdoses occurring at thistime.

Key Issues and Recommendationsregarding Existing Service Provision(Chapter 4)

4.1 The working group calculated that currently inIreland there are:

• 23 dedicated beds for medicaldetoxification and stabilisation;

• 15 beds for community-basedresidential detoxification;

• 634.5 residential rehabilitation beds, ofwhich a significant proportion (31%) arefor the treatment of alcohol problemsonly; and

• 155 step-down/halfway house bedsmost of which (76%) are for men only.

4.2 The group estimates that currently theequivalent of 13 beds are used fordetoxification in general hospital settings andthe equivalent of 66 beds in psychiatricfacilities; which is not in accordance with bestpractice.

4.3 The group recommends that clients with co-morbidity issues who are in residential drugand alcohol services should be provided withadequate support by the mental healthservices, and that clear pathways intoresidential mental health services for thoserequiring them should be agreed, as outlinedin the NACD commissioned report on Mental

Health and Addiction Services and theManagement of Dual Diagnosis in Ireland(MacGabhann et al., 2004)

4.4 The group further recommends that thereshould be flexibility across catchment areasto refer people with co-morbidity where anappropriate psychiatric service is not availablein their own catchment area.

4.5 The group recommends that a similarNational Working Group be established toestimate the current capacity of community-based services within Tiers 1, 2 and 3 as wellas looking at the balance between all fourtiers.

4.6 The working group recommmends that GPswith Level 2 training be resourced to workwithin community-based residentialprogrammes to provide residentialdetoxification.

4.7 The group also highlights the need to reviewcommunity-based or outpatient detoxificationservices, including the role of Level 2 GPs intheir provision.

4.8 The working group noted that prison providesan opportunity for both detoxification andrehabilitation and the group would welcomethe extension of the existing programmeswithin Mountjoy prison as well as theestablishment of similar programmes in allother prisons within the State. In this regard,there is a particular need to integrate alcoholtreatment into overall programmes within Irishprisons.

4.9 The provision of step-down or halfway houseaccommodation for newly-released prisonerswho have been detoxified or who have startedrehabilitation programmes is particularlyimportant, not least because of thevulnerability of such individuals to relapse andoverdose.

5

4.10 A mechanism to track progression fromtreatment services to rehabilitation isrequired. This linkage can be achieved by useof a unique identifier which the grouprecommends be used for all contacts withdrug services to enable integrated careplanning in line with the rehabilitation strategyso that, with appropriate confidentialityprocedures, cross referencing can be carriedout.

4.11 The group recommends that a regularlyupdated directory of current residentialservices be made publicly available whichwould detail the programme approach andtype of service provided.

4.12 In preparing the analysis and overview ofcurrent residential rehabilitation facilities, thegroup noted the need for an initiative whichwould examine in depth the configuration ofexisting services available, their programmeapproach, ethos and so on.

Key Issues and Recommendationsrelating to the Assessment of Need forInpatient Detoxification, Stabilisationand Residential Rehabilitation (ChapterFive)

5.1 There is a need for more refined data on drugand alcohol-related problems such asaccidents at work, absenteeism and drug-related deaths, in order to allow the use ofmore sophisticated needs assessment modelsin future.

5.2 The working group based their estimation ofneed for inpatient detoxification andstabilisation services on the SCAN ConsensusProject (a population-based model); theresidential rehabilitation requirement wasbased on the transition from inpatient andoutpatient detoxification to residentialtreatment; and the number of adolescents

requiring treatment was based on populationsurveys and estimates of problematicsubstance use.

5.3 The working group calculated that:• Overall, 127 dedicated beds are

required in Ireland for medicaldetoxification and stabilisation, 50%each for drug and alcohol detoxification.

• In total, 887 residential rehabilitationbeds are required, of which between 14and 37 beds are required for a separateadolescent service(s).

• These 887 residential rehabilitation bedswill address the following needs: 205 forillicit drug users transferring frominpatient detoxification services; 382 forproblem alcohol users transferring frominpatient detoxification services and 300to address the needs of both drug oralcohol users who have attendedoutpatient detoxification services.

• A minimum of 30% of clients attendingresidential rehabilitation will requirestep-down/halfway house beds andtherefore at least 296 step-down/halfway house beds are required.

5.3 The working group calculated that:• an additional 104 inpatient unit beds (for

medical detoxification and stabilisation);

• 252.5 residential rehabilitation beds;and

• 141 step-down/halfway house beds arerequired.

5.4 In highlighting a deficit of 356.5 beds (104IPU and 252.5 rehabilitation) the workinggroup notes the estimated 66 beds currentlyin use for alcohol and drug problems in thepsychiatric hospitals and units will no longerbe available as a result of the restructuring

6

proposed in Vision for Change and thenecessity of ensuring that the currentresource involved continues to be appliedwhen remedying the deficit in dedicatedbeds.

5.5 The group recommends that 50 inpatient unitbeds for illicit drug users should be providedbetween the Dublin Mid-Leinster and theDublin North East HSE areas as the availabledata points to a significantly higher level ofneed there at present. The remaining 13 IPUbeds should be divided between the HSESouth and HSE West areas. The groupdrawsattention to the fact that the results from the2007 Capture-Recapture Study of Opiate Usecurrently being undertaken for the NACD mayrequire a revision of this recommendation inthe future.

5.6 In the case of services focusing primarily onthe treatment of alcohol problems, the grouprecommends that the services be evenlyspread over the four HSE areas since the datasuggests a more even distribution of alcohol-related problems throughout the country.

5.7 The group’s strong preference is that suchbeds should be provided in fully-staffed,dedicated units but recognise that problemsof patient and family access may militateagainst this in some parts of the country.

5.8 The group recommends as a matter ofurgency that, where there is unused capacityat present in a service or unit because ofstaffing shortages, such capacity be broughton stream immediately by providing thenecessary staff.

5.9 The staffing of IPUs as well as of residentialrehabilitation services must be in line withrecognised best practice to ensure fulloccupancy, maximum client safety and thehighest standards of care. Since thetreatment approach adopted by a particularservice will determine the staff mix required,it is neither possible nor desirable to be

prescriptive about numbers or type of staff atthis stage.

5.10 Arising from the group’s recommendation thattransitions from detoxification to residentialrehabilitation and then into step-downaccommodation be seamless (3.8), the grouprecommends that an appropriate residentialrehabilitation place must be available for eachperson admitted for inpatient detoxification.

5.11 The group recommends that the treatmentneeds of problem drug and alcohol users whoare homeless should be prioritised, sincehomelessness is one of the key criteriaindicating client suitability for inpatientadmission.

5.12 The increased provision of inpatient unit bedsthe group have recommended will allow forthe stabilisation and respite needs of drugusers including pregnant women, cocaineand/or polydrug users. Such stabilisation bedsmust be physically separated fromdetoxification beds.

5.13 The needs of recovering drug users withyoung children present particular challengeswhen it comes to inpatient/residentialtreatment. The group would welcome theinvestigation of innovative approaches suchas providing the necessary supports so thatfamily members can act as short-term fosterparents.

5.14 In general, the group were of the opinion thatfamilies of drug and alcohol users could bemore involved in the overall care plan forrecovering users. In particular, the groupdraws attention to the recommendations inthe NACD commissioned report A Study intothe Experiences of Families Seeking Supportin Coping with Heroin Use (Duggan, 2007)and to the specific recommendations onsupport for families and carers contained inthe National Institute for Clinical Excellence’s(NICE) guidelines.

7

5.15 The group agreed that the specific needs ofsubstance users with disabilities and thosefrom ethnic minority communities can be metwithin the increased facilities recommended,provided that staff training is used to enhancecultural competence within the service. Suchtraining should form part of the proposedquality assurance framework for Tier 4services outlined in Chapter Six.

5.16 The group recommends that the level ofprovision set out in this Report should bereviewed in March 2010 and that, in themeantime, the timeliness and completenessof the data required for more preciseprojections of need should be improved.

Key Issues and Recommendationsregarding Quality Assurance ofInpatient and Residential Services forAlcohol and Drug Users(Chapter Six)

6.1 The working group fully endorses the conceptthat the quality of the residential facilities, theorganisation, the delivery and evaluation ofservices, and also of the staff involved in thedelivery of the service must be of the highestpossible standard. It is vital, therefore, that allthree components be subject to regularauditing using recognised benchmarks andtargets.

6.2 The group therefore recommends that anational quality assurance scheme for all fourtiers of the alcohol and drugs services beestablished following the necessaryconsultation, negotiation and training.

6.3 We recommend that the Quality in Alcoholand Drugs Services (QuADS) suite oforganisational standards and the companionDrug and Alcohol National OccupationalStandards (DANOS), as developed for the UKby Alcohol Concern and Drugscope and by

the Management Standards Consultancy forSkills in Health respectively, should beadapted for use by drug and alcohol servicesin Ireland.

6.4 The group also recommends that there mustbe standards for the quality of the residentialfacilities themselves and believe that the HSEshould enter into discussions with the HealthInformation and Quality Authority (HIQA)about the inclusion of residential services fordrug and alcohol users within the range ofservices to be regulated by HIQA’s socialservices inspectorate. This would help avoidduplication of effort when quality audits areundertaken.

6.5 The group also recommends that the HSE putin place an Internal Quality Audit functionwithin the drugs and alcohol services in orderto assist both HSE-funded and HSE-providedservices to prepare for and respond toexternal audits of the facilities, organisationand staff.

6.6 There was particular concern expressed bythe group about the need for relevantstakeholders to ensure that all detoxificationprocedures meet the highest standards ofclinical governance, care and patient safety.

6.7 The group highlights the need for ongoingstaff training and support to assist in roledevelopment. Managers and those who leadrehabilitation teams should ensure that staffare clear about their role definition andpurpose, and that they possess or are activelyworking towards the required qualification(s).

8

Chapter 1

Introduction

Background and Strategic ContextThe National Drugs Strategy (NDS) 2001-2008Building on Experience provides the policyframework for drug services in Ireland. The strategybased initially on four pillars – supply reduction,education and prevention, treatment and research –identifies a series of 100 individual actions to becarried out by a number of Government departmentsand agencies. Through the NDS, the Health ServiceExecutive (HSE) is mandated to provide a range oftreatment and rehabilitation options, includingresidential components, to drug users experiencingproblems.

In 2005, a mid-term review of the National DrugsStrategy recommended that rehabilitation beadopted as the fifth pillar of the strategy and that aworking group be set up to develop an integratedrehabilitation provision. This working group onrehabilitation has consistently acknowledged theneed for additional rehabilitation/treatmentresidential capacity. As a result, the Health ServiceExecutive proposed that a working group beestablished in order to advise the HSE in relation tothe future residential treatment requirements (interms of range, scope, need and quality) of thoseaffected by drug and alcohol use.

Terms of Reference of the WorkingGroupThe scope and parameters of the HSE WorkingGroup on Residential Treatment and Rehabilitation(Substance Users) were set out in the Terms ofReference (ToR) as follows:

a. To provide the HSE with a detailed analysisand overview of known current residentialtreatment facilities offered to those affectedby problem drug and alcohol use in Ireland.For the purposes of this expert workinggroup, residential treatment/rehabilitationincorporates the following modalities knownto be on offer:

i. Stabilisation Unitsii. Community-Based Residential

Detoxification Unitsiii. Medical Detoxification Units

iv. Residential Rehabilitation Unitsv. Step Down or Halfway Accommodation

b. To provide the HSE with an expert view as tothe future range, scope, type and method ofdelivery (e.g. tiered service provision asprovided for in the National TreatmentProtocol for Under 18s in the UK) ofresidential treatment required going forward.In particular, the working group should adviseon the following basis:

• What is the optimum type, range andscope of residential treatment serviceswhich should be on offer based oncurrent available prevalence studies (asprovided via the Central Treatment List,HRB Drug Misuse Research Division[now the Alcohol and Drug ResearchUnit], and the National AdvisoryCommittee on Drugs). That is, per headof population, we should have ‘x’ bedsavailable delivered using ‘x’ model in ‘x’setting’.

• What is the current range and typeavailable in both the statutory and NGOsector in respect of the above. Thegroup is asked to map and verify currentresidential treatment services known tobe available.

• Advise on the appropriate geographicallocation and setting for all residentialtreatment units (i.e. whether thereshould regional, national and localservices).

c. To examine current internationalquality/standards frameworks existing forresidential treatment providers operational inother jurisdictions and advise the HSE interms of what overall standards/qualityframework are required for implementationthroughout all HSE-funded residentialtreatment facilities.

10

d. To take into account and be fully cognisant ofthe report and recommendations arising fromthe working group on establishingrehabilitation as the fifth pillar of the NationalDrug Strategy once produced.

The working group is required to forward a set ofrecommendations via the Chair as in keeping withthe ToR. Whilst the HSE will endeavour to implementthe recommendations of the working group subjectto available resources, it is not bound in absoluteterms to the recommendations arising from theworking group’s deliberations andrecommendations.

Time Frame and Process

In July 2006, the HSE appointed an independentChair, whose role was:

• to ensure that the group met the terms ofreference as set out above in parts a), b), c)and d);

• to ensure that all requested reports werefurnished to the HSE within the agreedparameters and timelines;

• to ensure that a work programme was agreedwith the working group in order to fulfil theToR;

• to act as a liaison (with field workerassistance) on behalf of the working groupwith all external stakeholders.

In early August 2006, the HSE issued a letter ofinvitation to individuals and organisationsrepresenting all facets of the response toproblematic substance misuse to become a memberof the working group. The multidisciplinary workinggroup thus included those with expertise in the fieldof addiction, particularly in residentialtreatment/rehabilitation; policy/strategic andoperational management, and the service userperspective - (see list of members in Appendix 1).Later that month, a technical advisor to the workinggroup was appointed by the HSE.

The inaugural meeting of the working group washeld on 6 September 2006 and seven further

meetings were held. In mid October, a formal,written Progress Report was submitted to the HSEby the Chair of the working group. At the group’sfinal meeting on 7 March 2007, the text of a finalreport with recommendations was agreed andsubsequently submitted by the Chair to the NationalGroup Care Manager, Social Inclusion, HSE.

At its first meeting, the working group noted andaccepted the ToR as presented to it with oneamendment – namely that ToR (c) should now read“To examine current international quality/standardsframeworks existing for residential treatmentproviders operational in other jurisdictions andadvise the HSE in terms of what overallstandards/quality framework are required forimplementation throughout all HSE-fundedresidential treatment facilities and act as abenchmark for all services (amendment in italics).

Subsequent meetings examined in turn each aspectof the work laid out in the ToR such as: reviewingthe literature on inpatient treatment; collating andverifying current residential service provision;examining needs assessment models for drug andalcohol services; calculating the extent and range offuture residential service provision for substanceusers in Ireland; and assessing an appropriatequality framework for such services. In addition, anumber of written submissions were made to theworking group which informed discussions (seeAppendix 2). In addition, the working group notedthe recently published joint report from theNACD/NDST An Overview of Cocaine Use in IrelandII and, in particular, the impact of cocaine use on thedelivery of treatment services and also the work ofthe Department of Health and Children examiningsynergies between the national drug and alcoholstrategies.

In preparing the analysis and overview of knowncurrent residential treatment facilities offered tothose affected by problem drug and alcohol use inIreland, the group proceeded on the assumption thatthe configuration of types of residential rehabilitationavailable actually meets the differing needs ofdiverse client populations. It was recognised that,

11

while it was not possible to examine theconfiguration of existing services during this presentexercise, there is a need for such an initiative, takinginto account international best practice, differingclient profiles and changes in drug-using behaviour.

Outline of the Report

Chapter Two presents an assessment of trends andpatterns in drug and alcohol use in Ireland. This isfollowed by a review of the findings of relevantliterature regarding the role of inpatient treatment insubstance misuse in Chapter Three. Chapter Fourassesses existing service provision for residentialtreatment and sets out what is known to date aboutexisting residential drug and alcohol services interms of service type, programme details, capacityetc. (Further details are presented in Appendix 3).Chapter Five examines international needsassessment models for calculating the number andrange of residential drug and alcohol services, andapplies the most appropriate model to available Irishdata. The report concludes with an assessment ofquality assurance frameworks.

12

Chapter 2

Overview of Trends in Drug and Alcohol use in Ireland

BackgroundThis chapter presents an overview of trends in theprevalence and patterns of alcohol and drug use inIreland. In recent years, considerable advances havebeen made in our evidence-based knowledge ofdrug and alcohol use. Nonetheless, significantinformation gaps remain, particularly with regard tolocal patterns of use and current patterns of use.Notwithstanding that much of the available data isnow a number of years old, the group’s analysis ofalcohol and drug trends in Ireland indicates a highlevel of risk behaviour in relation to alcohol and druguse.

Overall alcohol trendsFindings from the drug prevalence household survey2002/3 (NACD/DAIRU, 20051) report a lifetimealcohol prevalence rate of 90% for adults aged 15-64 in Ireland, with rates for recent (last year) andcurrent (last month) use at 84% and 74%respectively. Similar rates of current use werereported by younger (15-34) and older (35-64)adults, though males (78%) reported higher currentrates than females (70%). Overall, higher rates ofalcohol consumption were reported in urban areas,particularly on the eastern seaboard. (NACD/DAIRU2002; SLAN 2002).

The SLAN 2002 Health and Lifestyle Surveyreported that almost a quarter (23%) of respondentswere regular weekly drinkers and over therecommended weekly limit for alcohol consumption.The survey also noted that though traditionally moremen than women were regular drinkers, the ratio ofmale to female drinkers is now much less marked,particularly in urban areas and among the youngerage groups (Kelleher et al. 2003).

Alcohol use among young peopleAlthough there are some indications that theprevalence of alcohol use has decreased amongyounger people, levels of use remain a concern. TheHealth Behaviour in School-Aged Children (HBSC)survey (2002) reported that among the 12-14 age

group, 16% of boys and 12% of girls were currentdrinkers. And, in the 15-17 age group, about half ofthe boys and girls were regular drinkers anddrunkenness was also prevalent (60% boys, 56%girls), (Kelleher et al. 2003).

Trends in alcohol use in Ireland in aEuropean context The Department of Health and Children (2002)define high-risk drinking as the type of drinking thatis likely to increase the risk of harm for the drinkeror for others, such as binge drinking2, drinking tointoxication and regular heavy drinking. They notethat binge drinking and drinking to intoxication isparticularly linked to an increased risk of short-term(acute) harm such as accidents, injuries, violenceand poisoning; and that drinking above theguidelines of more than 14 standard drinks perweek for women and 21 for men is linked toincreased risk of long-term (chronic) harm, such ashigh blood pressure, cancers, cirrhosis and alcoholabuse.

Notwithstanding difficulties in comparing drug andalcohol statistics across countries, the availableevidence indicates that the level of high-risk drinkingin Ireland has increased in recent years and issubstantially higher compared to other Europeancountries.

Ireland's per capita litre consumption of alcohol3 hasalmost doubled from 7.0L in 1970 to 13.5L in 2003– the third highest level after Luxembourg andFrance (OECD, 2006).

Similar evidence from Eurostat (2002) indicates thatIrish people are twice as likely to be regular drinkersof alcohol compared with the European average.One in two (51%) Irish people are regular drinkers ofalcohol compared to the EU average of one in four(25%). Over half (53%) of Irish men are regulardrinkers, compared with the EU average of a third(33%). This figure increases to 80% for men in the25 to 34 age group, compared with an EU averageof 36%. And, half (50%) of Irish women aged 15 to

14

1 A repeat of this survey for 2006/7 is currently underway.2 Binge drinking - defined by the World Health Organisation (WHO) as six or more standard drinks (60 grams of pure alcohol).3 Population aged 15+

24 are regular drinkers, compared with the EUaverage of 19%.

The European Comparative Alcohol Study (ECAS)study showed that though Irish respondents4 had thelowest rates of everyday drinking, they had thehighest rates of binge drinking5. Binge drinking wasseen to be the norm among Irish men; out of every100 drinking occasions, 58 result in binge drinking.Among women, 30 occasions out of 100 result inbinge drinking. In addition, young Irish men (18-29age group) reported the highest consumption ofalcohol and had more binge drinkers than any othergroup in the population. (Ramstedt and Hope, 2002)

A similar trend of high-risk drinking is evidentamong younger Irish people in comparison to theirEuropean counterparts. In 2003, the EuropeanSchool Survey Project on Alcohol and Other Drugs(ESPAD) found that the proportion of Irish studentswho had drunk any alcohol during the last 12months to be a little higher than the ESPAD average(88% compared to 83%). However, the proportion ofIrish respondents reporting having been drunkduring the last 12 months (72%); being drunk threeor more times in the last 30 days (26%); and bingedrinking three times or more in the last 30 days(32%) was substantially higher than the ESPADaverage6.

Impact of alcohol useThe impact of high-risk drinking is seen tocontribute to a variety of physical and mental healthproblems in Ireland. Standardised mortality rates forliver cirrhosis doubled among Irish men from 5.4 per100,000 per year between 1957 and 1961 to 11.1per 100,000 between 1997 and 2001. Thecorresponding figures for Irish women were 3.9 and6.5 respectively. In comparative terms, the mortalityrate in Ireland was the third highest of 14 Europeancountries analysed; the rate in women in the 45-64age group was the joint highest with Scotland. (Leon& McCambridge, 2006)

Results from the 2003 SLAN Health and LifestyleSurvey found that the top three problems resultingfrom one’s own drinking were identified as: beingdrunk (35%); feeling they should cut down theirlevel of alcohol use (14%); and feeling the effects ofalcohol while at work (14%). The top three problemsresulting from someone else’s drinking wereidentified as: having arguments with family andfriends about drinking (6%); being verbally abused(6%); having family/marital difficulties (3%).(Kelleher et al: 31)

In addition, the Health Promotion Policy Unit hasidentified a number of alcohol-related harms whichthey note as having increased in line with theincreased rate of alcohol consumption in recentyears. These include:

• Alcohol intake is a factor in 40% of all fatalroad accidents in Ireland and in 30% of allroad accidents.

• Almost half (48%) of all criminal offencescommitted by adults are alcohol related. Thisincludes 88% of public order offences, 48%of offences against the person and 54% of allcriminal damage offences.

• A 370% increase in intoxication in publicplaces by underage drinkers since 1996.

• A third (34%) of those seeking legal advicedue to marital breakdown cite alcohol as themain cause of their marital problems.

• Over a third (35%) of sexually activeteenagers say alcohol is a factor in theirengaging in sex – overall, sexuallytransmitted infections have increased by165% in the last decade.

• In 1999, the economic cost of alcohol-relatedproblems in Ireland was roughly €2.37 billion(1.7% of GDP). This figure encompassedhealthcare costs, accidents, crime,absenteeism, transfer payments and losttaxes. It represents 60% of the total revenuefrom alcohol to the Exchequer for that year.

15

4 Respondents aged 18-64 years.5 Defined in this study as drinking at least one bottle of wine, or 7 measures of spirits, or 4 pints of beer or more, during one drinking occasion (75/80 grams of pure alcohol).6 Defined by ESPAD as having 5 drinks or more in a row.

Impact of alcohol use on healthservicesIn 2005/6, the ICGP Alcohol Aware Practice Initiativerandomly screened 4,584 patients in surgeries.Results showed that 61% of these patients were inthe low/no risk category, while 22% were in the“hazardous” zone and 17% were“harmful/dependent”. Many of these patients wouldbenefit from community-based alcohol services ifmore were available.

Recent data from the Hospital Inpatient Enquiry(HIPE) database7 show that almost 11,500 episodesof care provided in Irish public hospitals in 2005had a discharge diagnosis relating to alcohol – thisaccounts for 1.14% of all episodes reported to HIPE.Almost three-quarters of these episodes of carewere to male patients (n=8447). The HPU (2002)have noted that 30% of all male patients and 8% offemale patients in an Irish general hospital werefound to have an underlying and unidentified alcoholabuse or dependency problem.

Data from the National Psychiatric InpatientReporting System’s (NPIRS) database showed that ofthe 22,279 admissions to psychiatric units andhospitals in 2004, 3,217 (14% of all admissions)were for alcohol disorders (ICD-10 Code F10) – thethird highest after depressive disorders andschizophrenia. Admission rates for alcoholicdisorders were 106.2 per 100,000 population aged16 years and over, with the male rate of admissions(149.7) more than twice that of the female rate(64.1).

A pilot study on the role of alcohol in Accident andEmergency Room attendance carried out in 2001showed that alcohol was a contributory factor forone in four patients attending the A&E department(HPU, 2002). Hope et al (2005) examined theassociation between injury and alcohol use amongpersons attending A&E departments in 2003/4. Ofthe 2,085 patients who participated in the study,

almost a quarter (23%, n=478) had an alcohol-related injury. Over three-quarters (77%) of theparticipants were clinically assessed as moderatelyor severely intoxicated.

Trends in drug useThe European Monitoring Centre for Drugs and DrugAddiction (EMCDDA) defines problem drug use asinjecting drug use or long duration/regular use ofopiates, cocaine and/or amphetamines. Most drugtreatment in Ireland is targeted at this level of use.In addition, polydrug use (in particular cocaine andalcohol) and dual diagnosis have been identified assignificant concerns to the HSE both in terms ofservice development requirements and in relation totreatment responses8.

The 2002/3 Drug Prevalence Survey (NACD/DAIRU,2004) found almost one in five (19%) respondentsreported ever taking an illegal drug, of whichcannabis was the most commonly used drug.However, household prevalence surveys do not tendto capture more problematic levels of drug use and,as expected, the prevalence rates reported forheroin, cocaine and amphetamine use were lowalthough higher rates were reported in the easternurban regions and among the younger age groups.

Using capture-recapture methodology to identifymore hidden and problematic levels of drug use9,Kelly et al (2004) estimated that in 2001 there were14,452 opiate users in Ireland – 12,456 in Dublinand 2,225 in the rest of Ireland. The overall rate per1,000 population aged 15–64 years was 5.6, withhigher rates for men than women in all age groups.The study indicated that opiate use was stillpredominately a Dublin phenomenon with a rate of15.9 per 1,000 population aged 15–64 years inDublin compared with a rate of just under 1.2 per1,000 population aged 15–64 years outside Dublin.

Most recent data from the Central Treatment List (ofall individuals receiving methadone treatment for anopiate problem) show 8,291 people attending for

16

7 HIPE records the primary and secondary diagnoses of all patients discharged from Irish Public Hospitals (private hospitals are not included). Each HIPE discharge recordrepresents one episode of care and patients may have been admitted to hospital(s) more than once with the same or different diagnoses. The records therefore facilitateanalyses of hospital activity rather than incidence or prevalence of disease.8 HSE Terms of Reference Residential Expert Working Group9 Capture Recapture Methodology used three national data sources for the years 2000 and 2001 - clients in methadone substitution treatment, individuals known to be opiateusers by An Garda Síochána, and patients discharged from hospitals with an ICD code relating to drug dependence.

17

treatment in February 2007, over two-thirds (69%)of whom are male. The vast majority of people wereattending clinics and GPs in the Dublin area.However, an increasing number of people are beingtreated in clinics and by GPs outside of the (former)Eastern Regional Health Authority area.

Data from the National Drug Treatment ReportingSystem (NDTRS) indicates a continued growth in thelevel of demand for drug treatment services10 and inthe number of drug treatment services. The NDTRSdata indicates that though a substantially higherproportion of numbers treated for problem drug useare living in the HSE Eastern Region than the rest ofthe country (71% compared to 29%), the proportionof numbers treated of those living outside the HSEEastern Region has almost doubled from 1998(15%) to 2003 (29%), (Long et al 2005).

According to data from the General MortalityRegister, in 2003 there were almost 100 drug-related deaths11 (n=96) – a marginal increase whencompared to 2001 (n=93) and 2002 (n=90).Between 2001 and 2003, 60% of direct drug-related deaths were opiate related. Between 2000and 2003, there was a sharp decline in direct drug-related deaths in Dublin, from 83 in 2000 to 46 in2003. During this period there was a continuedincrease in drug-related deaths outside Dublin, from30 in 2000 to 50 in 2003. In 2003, the number ofdrug-related deaths outside Dublin exceeded thenumber of drug-related deaths in Dublin for the firsttime (DMRD, HRB, 2006).

Since 2000 there has been a steady increase inheroin-related prosecutions in the Eastern Region(Carlow/Kildare, Laois/Offaly, Longford/Westmeath,Louth/Meath), from 24 prosecutions in 2000 to 128in 2005, and to a lesser extent in the South Easternregion (Tipperary, Waterford/Kilkenny,Wexford/Wicklow) – further evidence that, althoughheroin use remains predominantly a Dublin-basedphenomenon, it is no longer confined exclusively tothe capital (DMRD/HRB, 2006:81-82).

Cocaine UseThe 2002/3 Drug Prevalence Survey (NACD/DAIRU2005) found that lifetime cocaine use was muchhigher in the three former health board areasaround Dublin than in other areas (former EastCoast Area Health Board (6%), former Northern AreaHealth Board (5%) and former South Western AreaHealth Board (5%) confirming anecdotal evidencethat cocaine use is primarily an urban problem. Datafrom this survey also suggests the extent ofnormalisation of cocaine use among recent users –one third (33%) had been given the drug by familyor friends; almost one fifth (19%) had shared thedrug amongst friends; one quarter (25%) hadbought the drug from a friend; and over half (52%)said they had obtained cocaine at the house of afriend. The majority of recent users (68%)considered if “very easy” or “fairly easy” to obtaincocaine within a 24-hour period.

NDTRS data also indicates a growth in the level oftreatment demand for problem cocaine use. During2004, almost one third of cases (31%, n=352),reported cocaine as a problem drug. Of those whoreported cocaine as their main problem drug, overhalf (58%) had entered treatment for the first time;20% were female; and almost half (49%) were agedbetween 20 and 24 years, while 16% were agedbetween 15 and 19 years. Eighty six per cent usedmore than one drug; the most common additionaldrugs were cannabis, alcohol, stimulants andopiates. One in seven of the treated cases reportedinjecting cocaine (DMRD/HRB, 2006:98).

In 2005, the number of cocaine-related offencesunder the Misuse of Drugs Act (n=1,224) wasgreater than heroin-related offences (n=1,022).Cocaine-related offences accounted for 13% of alloffences – the most common drug cited aftercannabis and cannabis resin (An Garda Siochána,2006).

The increase in cocaine use and its impact onservice delivery has been further noted in the recent

10 Treatment is defined here as “any activity which aims to ameliorate the psychological, medical or social state of individuals who seek help for their drug problems.” 11 The National Drug-Related Deaths Index was launched in 2005. The index will provide an accurate mechanism for recording Drug-Related Deaths compiling data from anumber of sources including the coroner service, Hospital Inpatient Enquiry Scheme, Central Treatment List and General Mortality Register.

18

(March 2007) NACD/NDST report An Overview ofCocaine Use in Ireland II. This report also noted thatcocaine consumption is more likely among men andamong people in the 15-34 age bracket, and in theeast, south and south east of the country.

Drug use among young people andother vulnerable groupsSmyth and O’Brien’s (2004:68) profile of childrenpresenting to addiction treatment services in Dublinduring the 1990s found there was a sharp increasein the number of children seeking treatment after1993, with almost half (48%) of the cases relatingto opiates. As the decade progressed, the proportionof girls increased. Injecting was reported morefrequently and there was a dramatic rise in heroinmisuse. Child heroin users were more likely to befemale and to be homeless compared to their adultcounterparts.

The Youth Homelessness Strategy, which focuses onyoung people and children under the age of 18,reports that 98 (17%) of the 588 children whopresented to the health boards in 2000 ashomeless, attributed their homelessness to theirparents’ or their own abuse of alcohol and/or drugs.The strategy notes that homeless young people whowere not yet involved in drug misuse wereparticularly at risk of becoming involved in suchmisuse because of their own vulnerability and lackof resources (DMRD/HRB, 2006:90).

Drug Use and HomelessnessData from a number of prevalence studies haveindicated higher levels of drug and alcohol useamong more vulnerable groups. Almost one third(30%) of the homeless population had used heroinin the past year (compared to 0.1% of the generalpopulation) and over a quarter (28%) of homelesspeople had used cocaine within the past year(compared to 1% in the general population). Alcohol,however, was the substance most used with almostthree-quarters (73%) being classified as problematicalcohol users. Many were polydrug users, were likelyto be dependent on drugs (30% in Dublin) and wereusing drugs in riskier ways (such as injecting and

sharing injecting paraphernalia). Many wereHepatitis C positive and many had concerns abouttheir psychiatric health though only 42% had everhad a psychiatric assessment (Lawless and Corr,2005).

Dual DiagnosisSeven hundred and twenty four (of 22,279)admissions to psychiatric units and hospitals in2004 were for other drug disorders12 (Daly et al,2005). This figure may underestimate the level ofdual diagnosis as many of those with co-existingdrug and mental health problems find it difficult toaccess treatment services (MacGabhann et al.,2004).

Internationally the prevalence of dual diagnosis isestimated to lie between 15-60% of substancemisusing clients (EMCDDA Annual report 2004). Thelimited Irish data ranges from 26% reported by theNational Inpatient Psychiatric Reporting System(EMCDDA, 2004) to 43% in a community sample(Condren et al 2001). Kamali et al (2000) reported37% of inpatients meeting criteria for dualdiagnosis. More recently, Whitty and O’Connor(2006) reported that 37% of a group of patientsattending the Drug Treatment Centre Board had adual diagnosis. Major depression was diagnosed in26% and 11% had psychoses.

Because those with co-morbid substancedependence and psychiatric problems are seen as amajor target group particularly in need of inpatientinterventions, the level of such dual diagnosis isimportant in assessing treatment needs.

Summary and conclusionOverall, the available evidence indicates high levelsof risk behaviour in relation to the consumption ofalcohol and drugs, particularly in urban areas,among young people and vulnerable groups andincreasingly among women. The implications of thislevel of use for treatment services and, in particular,for inpatient treatment is discussed in ChapterThree.

12 ICD-10 Code F11-19, F55

19

Furthermore, the reliance on dated and patchy datato conduct an analysis of current alcohol and drugtrends has implications for the working group interms of adapting international models of treatmentneed assessment (particularly inpatient treatmentneed assessment) to the Irish context, as isdiscussed in Chapter Five.

ReferencesAn Garda Siochána (2006) Annual Report 2005.Dublin: An Garda Siochána

College Lifestyle and Attitudinal National (CLAN)Survey (2005) The Health of Irish students Dublin:Health Promotion Unit.

Condren, R.M., O’Connor, J. and R. Browne (2001)‘Prevalence and patterns of substance misuse inschizophrenia: a catchment area case-controlledstudy.’ Psychiatric Bulletin 25:17-20.

Cox, G. (2003) Approaches to Estimating DrugPrevalence in Ireland. Dublin: National AdvisoryCommittee on Drugs

Daly, A., Walsh, D., Comish, J., Kartalova O’Doherty,Y., Moran, R., and O’Reilly, A. (2005) Activities ofIrish Psychiatric Services 2003 Dublin: HealthResearch Board.

Department of Health and Children (2002) StrategicTask Force on Alcohol Interim Report. Dublin: HealthPromotions Unit

Department of Health and Children (2004) StrategicTask Force on Alcohol Second Interim Report.Dublin: Health Promotions Unit

Drug Misuse Research Division, Health ResearchBoard (2006) National Report (2005 Data) to theEMCDDA by the Reitox National Focal Point.IRELAND: New developments, trends and in-depthinformation on selected issues. [Online] Availablefrom http://www.ndc.hrb.ie/ebooks [Accessed 10January 2007]

EMCDDA (2004) Annual report 2004. The State ofthe Drugs Problem in Europe Luxembourg: Office forOfficial Publications of the European Communities

Eurostat (2004) Health Statistics - Key Data onHealth 2002. [online] Available fromhttp://epp.eurostat.ec.europa.eu [Accessed 10January 2007]

Health Promotion Unit (2003) Statistics on AlcoholRelated Harm [online] Available fromhttp://www.healthpromotion.ie/topics/alcohol/alcofacts/statistics/ [Accessed 25 November 2006]

Hope, A., Gill, A., Costello, G., Sheehan, J., Brazil, E.and V. Reid (2005) Alcohol and injuries in theaccident and emergency department – a nationalperspective. Dublin: Department of Health and Children.

Kamali, M., Kelly, L., Gervin, M., Browne, S., Larkin,C., and E. O'Callaghan (2000) ‘The Prevalence ofco-morbid substance misuse and its influence onsuicidal ideation among patients with schizophrenia.’Acta Psychiatrica Scandiavia 101 (6) 452-456.

Kelleher, C., Nic Gabhainn , S., Friel, S., Corrigan, H.,Nolan, G., Sixsmith, J., Walsh, O. and M. Cooke(2003) The National Health & Lifestyle Surveys 2003- Regional Results of the National Health & LifestyleSurveys SLÁN (Survey of Lifestyle, Attitudes &Nutrition) & HBSC (Health Behaviour in School AgedChildren) Dublin: Health Promotion Unit.

Kelly, A., Carvalho, N. and Teljeur, C. (2004)Prevalence of Opiate Use in Ireland 2000-2001: Athree source capture recapture study. Dublin:National Advisory Committee on Drugs

Kilbarrack Coast Community Programme (2004) Aprevalence study of drug use by young people in amixed suburban area. Dublin: National AdvisoryCommittee on Drugs

Lawless, M. and C. Corr/Merchants Quay Ireland(2005) Drug Use Among the Homeless Population in Ireland Dublin: National Advisory Committee on Drugs

Leon, D.A., and J. McCambridge (2006) “Livercirrhosis mortality rates in Britain from 1950 to2002: an analysis of routine data.” Lancet 367:52-56.

Long, J., Lynn, E. & Kelly, F. (2005) OccasionalPaper No. 17. Trends in Treated Problem Drug Usein Ireland, 1998 to 2002.Dublin: Health Research Board.

Long J, Lynn E and Keating J (2005) Drug-relateddeaths in Ireland, 1990–2002. Overview 1. Dublin:Health Research Board.

MacGabhann, L., Scheele, A., Dunne, T., Gallagher,P., MacNeela, P., Moore, G. and M. Philbin (2004)Mental Health and Addiction Services and theManagement of Dual Diagnosis in Ireland Dublin:National Advisory Committee on Drugs

National Advisory Committee on Drugs (NACD) &Drug and Alcohol Information and Research Unit(DAIRU) (2005) Drug Use in Ireland & NorthernIreland - 2002/2003 Drug Prevalence Survey:Health Board (Ireland) & Health and Social ServicesBoard (NI) Results (Revised) Dublin: NationalAdvisory Committee on Drugs

National Advisory Committee on Drugs and NationalDrug Strategy Team (2007) An Overview of CocaineUse in Ireland II Dublin: National Advisory Committeeon Drugs

OECD (2006) OECD Health Data, 2006. [online]Available from http://www.oecd.org/ [Accessed 10January 2007]

Ramstedt, M. and A. Hope (2002) The Irish drinkingculture - Drinking and drinking-related harm, aEuropean comparison [online]. Available fromhttp://www.healthpromotion.ie/research/ [Accessed25 November 2006]

Smyth, B. and M. O’Brien (2004) ‘Children attendingaddiction treatment service in Dublin, 1990-1999.‘European Addiction Research 10 (April) pp. 68-74

Whitty, P. and J.J. O’Connor (2006) Violence &aggression in the Drug Treatment Centre Board. IrishJournal of Psychological Medicine 23 (3), 89-91

20

Chapter 3

The Role of Inpatient Treatment in Substance Misuse

The use of a variety of psychoactive substances(alcohol, medicines and illicit drugs) results in aconsiderable public health burden in Europeancountries (Rehm et al 2005 (a) & (b)). The WorldHealth Organisation’s Comparative Risk Analysisreferred to by Rehm et al estimated that 2.1% of theburden of disease in Europe was attributable to theuse of illicit drugs such as opioids, cocaine andamphetamines. This is in addition to the 10.2% ofall disease burden due to alcohol. The point hasbeen made that the public health impact of illicitdrug use is underestimated if it is judged solely onthe basis of burden of disease and also, thatestimates of the prevalence of problematic illicitdrug use are too low.

A variety of treatment responses and interventionshave been made available to individuals with AlcoholUse Disorder (AUD), Drug Use Disorder (DUD) orboth. This is because of the health and socialconsequences of AUD, i.e. alcohol dependence andabuse (Diagnostic and Statistical Manual of MentalDisorders - IV) or harmful use (InternationalClassification of Diseases -10), and of DUD, i.e. drugdependence and harmful use (InternationalClassification of Diseases -10; Diagnostic andStatistical Manual of Mental Disorders - IV). Studiesof the effectiveness of treatment are consistent inreporting reduced substance use, improvements inpersonal health and social functioning and reducedpublic health and safety risks (McLellan et al 1997,ROSIE 2006). These gains have been shown inclients with different types of problems, usingdifferent interventions and in different treatmentsettings (Gossop 2006).

A diverse range of interventions (described byGossop as specific change techniques) is availablefor those with AUD or DUD. Some involvepharmacotherapy e.g. methadone maintenance, orprescription of Antabuse®; some involvepsychosocial treatments such as motivationalinterviewing and relapse prevention; while othersinvolve harm reduction programmes. Manyinterventions build on abstinence from alcohol andother drug use e.g. Alcoholics Anonymous, NarcoticsAnonymous and the Therapeutic Community

approach. These interventions are dependent onclients becoming abstinent through some form ofdetoxification process. It has been known for over20 years that detoxification itself is not a treatmentfor either alcohol or drug dependence as it is noteffective on its own in producing long-termabstinence. Detoxification can be provided in bothresidential and outpatient settings using eitherpharmacotherapy to alleviate the acute withdrawalsymptoms or non-pharmacological interventions or acombination of both.

It is well recognised that no single treatment isuniversally effective for drug dependency. A range ofdifferent interventions is required which can meetthe needs of diverse clients at different stages oftheir drug-using careers. In practice, treatmentprogrammes provide a package of differentinterventions and services to clients who have, in allprobability, received several treatment episodes.Because addiction is now seen as a chronic,relapsing disorder, the ultimate goal of long-termabstinence often requires sustained and repeatedtreatment episodes.

In both the UK and USA there is agreement thattreatment should be tailored to the individual, guidedby an individualised treatment plan and based on achoice of treatment levels where the preferred levelof care is the least intensive one which meets thetreatment objectives while ensuring the safety andsecurity of the patient (Mee-Lee et al 2003).

In the UK this concept has been enshrined inModels of Care for the Treatment of Adult DrugMisusers published by the National TreatmentAgency for Substance Misuse in 2002 and updatedin 2006. In this conceptual framework, services forsubstance users were grouped into four broad tiers.Inpatient drug or alcohol misuse treatment wasdesignated as a Tier 4(a) service within Models ofCare, alongside residential rehabilitation services,whereas highly specialised, non-substance-misuse-specific services such as liver units and forensicservices for mentally ill offenders were labelled asTier 4 (b).

22

In the Irish context, this tiered model of treatmentwas recommended as the basis for service deliveryto child and adolescent problem drug users by theWorking Group on Treatment of under 18-year-oldspresenting to Treatment Services with Serious DrugProblems (DOHC & HSE 2005).

The concept of tiered service provision wasspecifically referred to in the Terms of Reference forthis working group. Arising from this, the workinggroup considered the concept as set out in the UKdocumentation and agreed that its views on theprovision of inpatient detoxification and residentialrehabilitation services would be framed in thecontext of a Four-Tier level of Care concept. Thisassumes, however, that such a four-tier Model hasbeen brought into existence in Ireland; that it is fullyfunctioning and that most important of all that alltiers are fully resourced.

The Four-Tier Model of CareIn this model, Tier 1 interventions include theprovision of drug-related information and advice,screening and referral to specialised drug treatmentservices. They are delivered in general healthcaresettings (A&E, liver units, antenatal clinics,pharmacies, or in social care, education or criminaljustice settings [probation, courts, prison]).

Tier 2 interventions are delivered through outreach,primary care, pharmacies, and criminal justicesettings as well as by specialist drug treatmentservices, which are community- or hospital-based.The interventions include information and advice,triage, referral to structured drug treatment, briefinterventions and harm reduction e.g. needleexchange programmes.

Tier 3 interventions are mainly delivered inspecialised structured community addiction servicesas indicated above, but can also be sited in primarycare settings such as Level 1 or Level 2 GPs,pharmacies, prisons, and the probation service.Typically, the interventions consist of community-based specialised drug assessment and co-ordinated, care-planned treatment which includespsychotherapeutic interventions, methadonemaintenance, detoxification and day care.

Tier 4 ServicesTier 4 is of direct interest in the context of thisreport and includes residential specialised drugtreatment, which involves care planning andcoordination to ensure continuity of care andaftercare. The care is provided by specialised anddedicated inpatient or residential units or wards,which provide inpatient detoxification (IPD) orassisted withdrawal and/or stabilisation. Somepatients will require inpatient treatment in generalpsychiatric wards. Acute hospital provision withspecialist “addiction” support will be needed forthose with complex needs e.g. pregnancy, liver andHIV-related problems. Others will need IPD linked toresidential rehabilitation units to ensure seamlesscare. “Step-down” or halfway house accommodationmay be required to be made available away fromthe individual’s area of residence and drug-usingnetworks.

In the alcohol treatment field, the Department ofHealth in the UK has recently published Models ofCare for Alcohol Misusers (MoCAM) which it statesis informed by the 2002 drug misuse document(now abbreviated to MoCDM and updated to 2006).In the case of alcohol, Tier 1 consists of a range ofinterventions that can be provided by genericproviders including those designated Tier 4(b) inMoCDM e.g. care delivered by inpatient liver units.In the new alcohol model i.e. MoCAM, Tier 4interventions include provision of residential,specialised, alcohol treatments which are care-planned and co-ordinated to ensure continuity ofcare and aftercare. These are set in specialisedstatutory, independent or voluntary sector inpatientfacilities for detoxification, stabilisation andassessment, as well as residential rehabilitationunits. MoCAM states:

dedicated specialist, inpatient alcohol unitsare ideal for inpatient alcohol assessment,medically assisted alcohol withdrawal(detoxification) and stabilisation. Inpatientprovision, in the context of general psychiatricwards, may only be ideal for some patientswith co-morbid, severe mental illness, butmany such patients might benefit from adedicated addiction-specialist inpatient unit.

23

A significant driver for both MoCDM and MoCAM isan increase in the effectiveness of treatment partlyensuring that treatment is evidence-based andunderpinned by good audit or clinical governancemechanisms.

The effectiveness of inpatient treatmentapproachesThere is ample evidence from national (ROSIE 2006)and international treatment outcome studies(NTORS, DATOS and ATOS) that substance misusetreatments can be effective, and the belief is thatthe research question should no longer be whethertreatment is effective, but rather how it can betailored to the needs of different clients. Whilestudies of treatment outcomes in general arecommonplace, studies of inpatient services arerelatively rare. In a 1996 article entitled “Aredetoxification programmes effective?” in The Lancet,Mattick and Hall dealt in detail with the impact ofthe setting on alcohol and opioid detoxification. Inrelation to alcohol, they noted the following (page98):

Setting for, and types of, alcoholdetoxificationUntil a decade or so ago, standard alcoholdetoxification was inpatient, fully medicalisedtreatment in a specialist drug and alcoholunit, usually with pharmacologicalmanagement of withdrawal symptoms bydecreasing doses of sedative drugs such aschlormethiazole or diazepam. The majorchange in the past decade has followed therealisation that a broader range ofdetoxification approaches can deal with thewide range of withdrawal symptoms. Althoughresidential specialist detoxification continuesto have a role, it need no longer be themethod of first choice, although itunfortunately still remains so in many places.

Many people with mild-to-moderatewithdrawal symptoms can be detoxifiedsafely, successfully, and much more cheaplyat home under the supervision of a visitingnurse to administer anxiolytic drugs, with

medical practitioners providing necessarymedical support. Even severely dependentdrinkers may be detoxified safely andeffectively at home with a minimummedication and the support of a visitingnurse. Rates of completion for outpatientdetoxification are sometimes, but not always,lower than residential detoxificationprogrammes, probably because of greateravailability of alcohol. Outpatientdetoxification, however, is more acceptable toa wider range of dependent drinkers, many ofwhom are reluctant to be treated in adesignated detoxification unit because of theattendant stigma. Even when patients do notcomplete ambulatory detoxification, there islittle evidence of serious medical orpsychiatric complications.

Residential treatment seems necessary forthe small proportion of dependent drinkerswho are at risk of experiencing severewithdrawal symptoms (e.g. those with ahistory of such symptoms, or a recent historyof very high alcohol intake) and those who donot live in an environment that supportsoutpatient detoxification (e.g. the homeless, orthose living in boarding houses where thereare other heavy drinkers). Residentialdetoxification need not, however, bepharmacologically assisted or medicallysupervised. Clinical experience in “non-medical” detoxification units in Canada andAustralia shows that in many caseswithdrawal symptoms can be safely andsuccessfully managed without medication in aquiet, safe, supportive environment, withcounselling, reassurance, and social supportfrom non-medical staff to manage withdrawalsymptoms. For safety reasons, such facilitiesusually have ready access to medicalassistance in the event of one of the rare life-threatening complications of alcoholwithdrawal, though transfers to specialistmedical care are hardly ever necessary. Inone Australian series of over 4000 patients,for example, less than 0.5% of casesrequired hospital care for acute alcohol

24

25

withdrawal. Deaths during alcohol withdrawalare now very rare.

Inpatient medically assisted detoxification isneeded by those at greatest risk of life-threatening delirium tremens or seizures:those with a previous history of eithersymptom, those with severe symptoms on thecurrent presentation, or those with concurrentmedical or psychiatric disorders that maycomplicate their management. The preferredagents for minimising withdrawal symptomsare long-acting benzodiazepines, either aloneor with other medications such as clonidineand beta-blockers. Suitable regimens are welldescribed elsewhere. It is generallyrecommended that all moderately to severelydependent drinkers who are undergoingwithdrawal (including those in “non-medical”detoxification programmes) should also begiven doses of thiamine as prophylaxisagainst Wernicke’s encephalopathy.

The particular comments about the value ofoutpatient detoxification have to be interpreted inthe context of whether adequate outpatientprogrammes are in place.

In the case of opioid detoxification, Mattick and Hall(1996) state (page 99):

Setting for opioid detoxificationThere is more reason for choosing inpatientrather than outpatient detoxification for opioiddependence. Several investigators have foundinpatient detoxification to be superior tooutpatient detoxification in terms of theproportion of patients who complete theprocess; in one study, rates of 81% and 17%,respectively, were achieved. However, othershave reviewed retention rates in studies ofinpatient and outpatient detoxification andconcluded that the completion rates differsubstantially, clearly favouring inpatientprogrammes, with outpatient retention ratesof about 20% and inpatient rates between50% and 77%. It may be the case thatopioid-dependent people are more likely thanalcohol-dependent people to live in

environments (e.g. with other opioid users)that are unsupportive of detoxification andabstinence, and hence are less likely tocomplete outpatient detoxification. Theinterpretation of these studies is complicatedby the fact that the intensity of interventionand support has typically been greater in theinpatient than in the outpatient setting.

More recently, the evidence base for inpatient opiatedetoxification has been reviewed for the UK NationalTreatment Agency by Day who was also one of theauthors of the 2005 Cochrane Review on “Inpatientversus Other Settings for Detoxification for OpioidDependence”. The authors concluded that only onestudy met the rigorous inclusion criteria applied tosuch reviews. The published data from that studyallowed a deduction that 70% of participants in theinpatient group were opioid-free on dischargecompared with 37% in the outpatient group,although the numbers involved were too small toreally provide good evidence about outcomes orcost-effectiveness. In his more detailed analysisOpiate Detoxification in an Inpatient Setting for theNTA in 2005, Day concluded that:

The rates of successful completion of opiatedetoxification are generally higher in studiescarried out in inpatient settings than inoutpatient settings. There is a degree ofconsensus about the type of client who maybenefit from inpatient treatment includingthose with complex needs and those insituations where residential treatment isrequired for medical or social reasons.Inpatient treatment can also be beneficial formore stable patients, and although it is moreexpensive than community-based treatmentoptions, the higher costs are at least partiallyoffset by improved detoxification completionrates in the inpatient setting. Detoxificationand other interventions in an inpatient settingcan therefore be cost-effective.

The factors that influence the likelihood of treatmentsuccess and improved outcomes include: the lengthof stay; the linking of detoxification withrehabilitation and aftercare; and the provision oftreatment in specialist facilities.

26

Specialist versus general settingsThe mapping exercise of existing inpatient provisionin Chapter Four suggests that the use of non-dedicated or non-specialist facilities for alcohol anddrug detoxification is relatively common in Ireland. Astudy by Strang and colleagues in the UK (1997)has provided evidence that this is not the mosteffective use of resources. They found thatadmission to a specialist inpatient drug-dependentunit compared to a general psychiatric ward wasassociated with a greater completion ofdetoxification and a greater likelihood of opioid-freestatus at two and seven months’ follow-up.

The SCAN Consensus Document (2006) noted thatthe disadvantages of general ward-based servicescompared to specialist services included: fewerbeds per service; lower bed occupancy; shorterplanned and actual admission periods; greaterlikelihood of being closed or unavailable; less inputfrom specialist staff; and a narrower range ofavailable medical and psychological treatmentoptions.

Length of StayThe large-scale outcome studies have shown thatpatients who received less than 90 days oftreatment (inpatient or outpatient) did less well thanthose receiving more than 90 days. The UK NTORSstudy reported that a period of at least 28 days ininpatient or short-stay rehabilitation programmeswas associated with the greatest chance ofabstinence.

Provision of Rehabilitation followingDetoxificationDay notes that detoxification can be problematic if itis not integrated into a comprehensive treatmentsystem. The risk of accidental overdose with opioidsis increased immediately after a period ofdetoxification. Treatment outcomes were significantlybetter among those who completed detoxificationand went on to spend at least six weeks in arecovery and/or residential rehabilitation unit(Ghodse et al 2002). MoCDM (2006) emphasisesthat:

Continuity of care is essential for preservinggains achieved in residential treatments.Therefore there is a compelling argument forproviding, for suitable patients, inpatientdetoxification beds attached to residentialrehabilitation units (provided that there areadequate medical supports). Other patientsneed detoxification first in an addictionspecialist inpatient unit (e.g. because ofseverity and complexity) but this still requiressignificant strengthening of the links withresidential rehabilitation provision to ensurethe seamless transition of clients between thetwo.

The working group wholeheartedly endorses theidea that transition from detoxification (whereverachieved) to residential rehabilitation should beseamless so as to avoid destabilising waitingperiods and lack of continuity in care. A recentreport (Mark et al 2006) which looked at factorsaffecting readmission after detoxification noted thatengaging patients in post-discharge treatmentresulted in improved drug abstinence, reducedreadmission rates and increases in time toreadmission.

A follow-up survey of clients who had attendedKeltoi13 (a therapeutic residential facility within theDublin North East Region of the HSE) found that51% were abstinent from all drugs includingalcohol, while 60% were abstinent from all illicitdrugs.

Residential treatment for those withalcohol-related problems.MoCAM highlights the newer evidence whichchallenges the traditional view that outpatienttreatment is more cost-effective than residentialservices. A number of studies (five) reported asignificantly better outcome for residential over non-residential while seven studies reported a generalequivalence. Other studies have shown that highlyalcohol-dependent individuals benefited more frominpatient involvement as did clients with cognitiveimpairment. MoCAM notes the evidence that

13 Personal communication to the Working Group from Brendan McKiernan, Keltoi, 30th January 2007.

residential treatment is of greater benefit for thosewith more severe alcohol problems or with co-morbidity. This mirrors the evidence that forsubstance users in general, those with the “greatersocial deterioration, less social stability and higherrisk for relapse benefit more from residentialtreatment” (MoCAM 2006).

Client - Treatment matchingThere is widespread acceptance that matchingclients to treatment is a good idea even though theevidence base does not provide complete backingfor the concept. The evidence is, however,supportive of the effectiveness and efficiency ofreserving the more intensive services for patientswith the more severe problems. The researchliterature indicates that residential and inpatientprogrammes are more suitable for those whorequire more intensive services because of theseverity of their drug/alcohol and other problems.There is a belief that clients should be offered lessintensive interventions initially and those who fail torespond be subsequently offered more intensiveinterventions. But it is important to point out that itis the needs of a particular client that are theimportant determinant of the level of interventionmade available to them at each stage of what isnow referred to as their “treatment journey”.

The working group notes that experience (nationaland international) points to a number of criteriawhich can be used to determine if a particularindividual will require and/or is likely to obtainparticular benefit from inpatient provision. These areset out below:

Patient/Clients for whom inpatientdetoxification is indicatedAlcoholThe following criteria indicate a need forinpatient approaches:• Home detoxification attempt failed• Risk of suicide• Epilepsy• Confused or hallucinatory state• Poor home environment• Acute physical or psychiatric illness

• Evidence of Wernicke’s Encephalopathy• Confusion, staggering gait• Uncontrolled eye movement• Coma, low BP, hypothermia• Unexplained neurological signs• Injectable Thiamine needed

Drugs other than alcohol• Those dependent on more than one drug• Physical complications e.g., cardiac

conditions associated with cocaine• Co-morbidity/Dual diagnosis• History of complications during previous

withdrawals• Chaotic polydrug use• Pregnant women• Patients who have failed outpatient

withdrawal• Those unlikely to cope with outpatient

withdrawal due to isolation, homelessness, orlack of family support.

In addition, residential services may also benecessary for socially stable individuals who do nothave co-existing medical or psychiatric conditions,but who would benefit from psychological and socialrespite by removing them from their drug takingenvironment and supporting them in their drug-freefunctioning. (Gossop, 2004)

The SCAN Consensus document on InpatientTreatment of Drug and Alcohol Misusers in theNational Health Service was drawn up in 2006 bythe Specialist Clinical Addiction Network (SCAN) withthe UK Department of Health, the NTA and the RoyalCollege of Psychiatrists as additional stakeholders.In the document there is a description of theservices a “good” inpatient unit should providewhich emphasises that it should have care pathwaysfocussed not only on detoxification (which it refers toas assisted withdrawal), but also on assessment,psychological interventions, harm reduction issues,relapse prevention and notably stabilisation. Suchstabilisation procedures can help ameliorate theimpact of chaotic drug use particularly of cocainepowder and of crack as well as of other drugs andmedication in addition to providing opportunities for

27

dose titration of methadone or buprenorphine in asecure monitored environment.

The working group draws attention to the fact thattwo groups will need intensive care on an inpatientbasis in a psychiatric unit or an acute medical ward:

• those with serious acute psychiatric problemse.g. acute psychosis; and

• those with a serious medical problem e.g. a life-threatening event resulting fromcocaine use.

In these situations it is essential that there isdetailed consultation between the addictionpsychiatrists and the mental health team in the firstcase and with the acute medical team in thesecond. In the first case, the recommendations fromthe NACD to Government arising from the NACD’scommissioned report Mental Health and AddictionServices and the Management of Dual Diagnosis inIreland (2004) are particularly important. The twokey recommendations were: (a) the need toestablish a multidisciplinary committee to developIrish guidelines for managing dual diagnosis; and (b)that any patient in receipt of a valid prescription formethadone prior to admission to a psychiatric facilityshould be continued on that prescription while underpsychiatric care.

In conclusion, the working group endorses theconcept of the Four-Tier Model of Care for bothproblem alcohol and other drug users. It recognisesthat an overhaul/restructuring of services forchemically dependent individuals in Ireland isnecessary to allow for the development of Tier 4services of the inpatient/residential type which itenvisages as a result of its deliberations. The groupdraws attention to the documented advantages ofinpatient services in improving outcomes for clients,while noting that not every individual will requiresuch services on their treatment journey to recovery.

ReferencesDay E. “Opiate detoxification in an inpatient setting”National Treatment Agency for Substance Misuse:Research Briefing 9, 2005.

Day E., Ison J., Strang J., “Inpatient versus othersettings for detoxification for opioid dependence”.Cochrane Database of Systematic Reviews 2005,Issue 2. Art No. CD004580. DO1:10.1002/14651858. CD 004580. Pub 2.

Department of Health (UK), “Models of Care forAlcohol Misusers (MoCAM) 2006”.

Department of Health and Children, “Report of theWorking Group on Treatment of under 18-year-oldspresenting to treatment services with serious drugproblems”. Dublin 2005.

Ghodse A.H., Reynolds M. et al. “Treating andOpiate-Dependent Inpatient Population: A One-YearFollow-up Study of Treatment Completers and Non-Completers”. Addictive Behaviours 2002,27: 765-768.

Gossop M. “Psychological Treatments for AlcoholDependence”. Wiener Zeit für Suchtforschung.2004:27; 13-23.

Gossop M. “Treating Drug Misuse Problems:evidence of effectiveness”. National TreatmentAgency for Substance Misuse. London, 2006.

Gossop M., Marsden J., Stewart D., “NTORS at oneyear: The National Treatment Outcome ResearchStudy – changes in substance use, health andcriminal behaviours one year after intake”.Department of Health, London. 1998.

Hubbard R.L., Craddock S.G. et al. “Overview of 1-year follow-up outcomes in the Drug AbuseTreatment Outcome Study (DATOS)”. Psychology ofAddictive Behaviours. 1997; 11Ch 1: 261-278.

MacGabhann, L., Scheele, A., Dunne, T., Gallagher,P., MacNeela, P., Moore, G. and M. Philbin (2004)Mental Health and Addiction Services and theManagement of Dual Diagnosis in Ireland Dublin:National Advisory Committee on Drugs

Mark Tl, Vandivoort R & Montejano LB. “ Factorsaffecting detoxification readmission: analysis ofpublic sector data from three states.” J Subst AbuseTreat. 2006;31:439-445.

28

Mattick R.P., Hall W. “Are detoxification programmeseffective?” The Lancet 1996; 347: 97 – 100 andreferences cited therein.

McLellan A.T., Wood G.E., et al. “Evaluating theeffectiveness of addiction treatments: Reasonableexpectations, appropriate comparisons”. In: J.A.Egerton, D.M. Fox, A.I. Leshner (Eds). “Treating drugabusers effectively”. Oxford: Blackwell. 1997.

Mee-Lee D., Shulman G.D. “The ASAM placementcriteria and matching patients to treatment”. In:Graham A.W., Schulz T.K., Mayo-Smith M.J., RiesR.K., Wilford B.B. (Eds). “Principles of AddictionMedicine”. 3rd Edition. Chevy Chase Md: AmericanSociety of Addiction Medicine. 2003: 453-465.

National Advisory Committee on Drugs. “ROSIEFindings 2. Summary of 1-year Outcomes”. 2006.

National Advisory Committee on Drugs. “ROSIEFindings 2. Summary of 1-year OutcomesDetoxification Modality”. 2007.

National Treatment Agency for Substance Misuse.“Models of care for treatment of adult drugmisusers: update 2006”. London 2006.

Rehm J., Room R., Van den Brink W., Jacobi F.“Alcohol use disorders in E.U. countries and Norway:an overview of the epidemiology”. EuropeanNeuropsycho pharmacology 2005; 15: 377-388.

Rehm J., et al “ Problematic drug use in and druguse disorders in EU countries and Norway: anoverview of the epidemiology” EuropeanNeuropsychopharmacology 2005; 15: 389-397

SCAN Consensus Project Inpatient Treatment forDrug and Alcohol Misusers in the National HealthService, Department of Health 2006

Strang J., Marks I., Dawe S., et al “Type of hospitalsetting and treatment outcome with heroin addicts”.British Journal of Psychiatry 1997; 171: 335-389.

Teesson, M., Ross, J., Darke, S., Lynskey, M., Ali, R,,Ritter, A. and Cooke, R. “One-year outcomes forheroin dependence: findings from the AustralianTreatment Outcome Study (ATOS)”. Drug andAlcohol Dependence. 2006; 83: 174-180.

29

30

Chapter 4

Existing Service Provision

32

The Terms of Reference provided by the HSE to theWorking Group on Residential Rehabilitationrequested a detailed analysis and overview of knowncurrent residential treatment facilities offered tothose affected by problem drug and alcohol use inIreland. The Terms of Reference also supplied theworking group with the following classification ofresidential treatment/rehabilitation modalities knownto be on offer:

i. Stabilisation Units;ii. Community-based Residential Detoxification

Units;iii. Medical Detoxification Units;iv. Residential Rehabilitation; and v. Step-down/Halfway accommodation.

The working group discussed the suitability of thisclassification framework and concerns wereexpressed that the framework does not fully reflectthe complexity of service provision or the overlapbetween modalities. For example, there are no standalone stabilisation units – rather, there is a smallnumber of beds available for the stabilisation ofdrug users in medical detoxification units; in oneunit these are mainly reserved for pregnant drugusers.

The classification of all rehabilitation programmesinto one category “residential rehabilitation” isviewed as inappropriate by the working group assome services are more focused on rehabilitationand others more on treatment, depending on thephysical and mental health needs of their clients.Most notably, the working group saw a distinctionbetween residential rehabilitation services, whichfocus on helping the client gain an insight into themechanics of addiction and its role in their lives andthose which focus on helping the client develop theliving skills needed to live a drug free lifestyle.

Services in the residential rehabilitation categoryalso differed in the range of abstinence-focusedapproaches and philosophies they provided, such asthe 12 step/Minnesota Model, and TherapeuticCommunities.

After some discussion, however, the working groupmaintained the classification system given in the ToR

while noting its shortcomings, but the grouprecommends the development of an updateddirectory of rehabilitation services based on a morecomprehensive classification of the rehabilitationmodalities currently available. The group also notedthat new thinking on client-centred care is likely toresult in the development of further innovativerehabilitation approaches.

MethodologyA preliminary list of services providing residentialtreatment and rehabilitation for drug and alcoholusers had been prepared by the National DrugsStrategy Team for consideration by the workinggroup. This list has since been amended as serviceprovision was checked and verified using a range ofadditional sources such as directory and websitesearches; published reports from the residentialservices; feedback from members of the HSEworking group; telephone survey of services by thetechnical assistants to the group; and data from theNational Drug Treatment Reporting System (NDTRS).Additional information on the provision of drug andalcohol treatment within the general and psychiatrichospital services was provided by the co-ordinatorsof the Hospital Inpatient Enquiry (HIPE) and NationalPsychiatric Inpatient Reporting System (NPIRS)databases.

The estimation of service capacity is calculatedusing the number of beds and average length ofstay in each service and is based on an optimal85% occupancy rate of beds – the benchmarkagainst which the need for additional bed capacityin Ireland is assessed (DoHC, 2002). The figuresgiven are best estimates. However, it should benoted that in practice a number of factors affect theannual throughput of clients through theseresidential services. For example, the lack ofsufficient detoxification facilities so that participantsare drug free on entry; the staffing levels available;and the level of non-completions of arehabilitation/treatment programme. The estimationof the current number of rehabilitation beds is alsomarginally affected where the service also treatspeople with gambling problems and eating disordersas beds are not necessarily dedicated to a particularaddiction and information on the proportion of

33

admissions relating to drug and/or alcohol problemsis not readily available. Consequently, bed numbersand capacity may be somewhat over-estimatedwhere services deal with a broad spectrum ofaddictions.

Many rehabilitation services in theory deal with bothdrug and alcohol problems, but in practice a higherproportion of beds deal with alcohol-relatedproblems. The proportion of bed numbers, andresulting capacity, dedicated to the treatment of aparticular drug is not fixed but depends on referralsetc. Consequently, the mapping exercise hashighlighted those services which deal with onesubstance only. However, this should not be taken toimply that the beds in other services are equallyavailable to drug and alcohol users, notwithstandingthat the clients may be polydrug users and that thedistinction between drug and alcohol beds may be afalse dichotomy.

Similarly, some services are gender specific and thisis highlighted in the estimation. But again, theremaining services are not necessarily equallyavailable to either men or women.

Commentary and analysis

The resulting overview of current residential serviceprovision (see Table 1) estimates that there are:

� 2 community-based residential detoxificationservices with 15 beds and an estimatedcapacity of 170 clients per annum;

� 2 medical residential detoxification units with17.5 beds and an estimated capacity of 157clients per annum. In addition the MDUsreserve a small number of beds (5.5 in total)for stabilisation purposes; these have anestimated capacity of 87 clients per annum;

� 28 residential rehabilitation services with634.5 beds and an estimated capacity of3,652 clients per annum;

� 14 step down/halfway houses with 155 bedsand an estimated capacity of 368 clients perannum.

Overall, there is a poor distribution of servicesthroughout the regions (see Map 1). There are nodedicated residential stabilisation or detoxificationbeds (either residential community-based orhospital-based) outside of the Dublin area14. And,there are no dedicated drug or alcohol residentialservices in counties Cavan, Laois, Leitrim, Longford,Offaly, Roscommon, Sligo, Tipperary North orWestmeath – which have a combined population ofover half a million people (537,409) (Census 2006).

14 Some residential services conduct detoxifications if required, but this is the exception rather than the rule.

34

NATIONAL SUMMARY

(Population 4,234,925 - Census 2006)

There are no dedicated residential services in counties Cavan, Laois, Leitrim,Longford, Offaly, Roscommon, Sligo, Tipperary North or Westmeath.

Table 1: Estimation of current capacity of national drug and alcohol residentialservices, 2006

SERVICE TYPE15 (N.)

Stabilisation Service[Note: these are not stand alone units

but beds reserved within the two MD

Units]

Community-basedResidential Detoxification(2)

52

53% (n=8) alcohol only

170

69% (n=118) alcohol only

Medical DetoxificationUnit (2)

17.5 157

Residential Rehabilitation(28)

634.5

31% (n=197) alcohol only

12% (n= 76) men only

0.04% (n=28) women only

3652

36% (n=1310) alcohol only

3% (n=106) men only

1% (n=24) women only

Step-down/HalfwayHouse (14)

155

76% (n=118) men only

10% (n=15) women only

368

78% (n=286) men only

13% (n=47) women only

General and PsychiatricHospitals(HIPE and NPIRS databases,2005)

79

16% (n=13)Illicit drugs18

84% (n=66) alcohol via

psychiatric services

3,825 (NPIRS)

718 (HIPE)

(cases not individuals)

5.5 87

NUMBER OF BEDS16 ESTIMATEDANNUAL CAPACITY17

15 As per Terms of Reference16 Some services also treat gambling and eating disorders. However, the number of beds dedicated to these is not set, hence the number of beds and the estimated annualcapacity is probably overstated for these service as the estimation assumes all beds are available for drugs or alcohol treatment.17 The estimated annual capacity of services, is calculated by dividing the number of days (or weeks or months as appropriate) per year by the duration of programme (usingthe mean duration if range is given) and multiplying this figure by the number of beds (using the mean number of beds if range is given). 85% of this figure is then calculatedto reflect the occupancy rate of services. 18 This provision may not be additional to that included under Medical Detoxification Units (number 3 above) as one of these services also report throughput to the HIPEdatabase.

35

Map 119 : Residential Drug and Alcohol Services, 2007

Residential Rehabilitation Service

Step-down/halfway house

Community-based detoxification service

Medical Detoxification Unit

(with stabilisation service)

19 Blank map drawn by Conor Teljeur, SAHRU, TCD

The treatment of drug and alcoholproblems in General and PsychiatricHospitals In addition to the specialised provision of drug andalcohol residential services above, services areprovided in general and psychiatric hospitals fundedby the Health Services Executive.

In 2005, the National Psychiatric Inpatient ReportingSystem (NPIRS) database recorded 3,007 primarydischarge diagnoses for “alcoholic disorder” and/or818 primary discharge diagnoses for “other drugdisorder” from psychiatric hospitals and psychiatricunits within general hospitals (Total 3,825).

In the same year, the Hospital Inpatient Enquiry(HIPE) database recorded 718 “principalprocedures” conducted in general hospitals foralcohol and/or drug detoxification (n=703) andalcohol rehabilitation and detoxification (n=15).

The geographical location of these hospitals isoutlined in Map 2: General and Psychiatric hospitalstreating patients with drug and alcohol problemsand a list of the psychiatric, general and privatehospitals involved detailed in Appendix 4.

For the purposes of estimating existing serviceprovision, the working group notes the role, to date,of general and psychiatric hospitals in providingtreatment to people with drug and alcohol problems,particularly in areas where there are insufficientspecialised services. However, the working groupnotes the evidence that treating people with drugand alcohol problems in these settings is not bestpractice and, in the case of the psychiatric hospitals,will not be an option available in the future as aresult of the restructuring of the psychiatric servicesproposed in Vision for Change.

An approximate extrapolation from the HIPE dataindicates that 13 beds in the acute hospital systemare utilised for drug detoxification with an annualcapacity of 144 (based on a four-week averagelength of stay and 85% occupancy). However, thisprovision may not be additional to the workinggroup’s estimation of current capacity of dedicatedresidential services as one of the medicaldetoxification units also reports throughput to theHIPE database.

In the case of alcohol, the number of dischargesfrom psychiatric hospitals and psychiatric units ingeneral hospitals, as reported in the NIPRS, can beused to calculate the total number of bed daysattributable to the treatment of alcohol. This gives anapproximate figure of 66 beds occupied for alcoholdetoxification in the psychiatric services20.

Potential Savings The working group wishes to draw attention to thepotential savings/benefits achievable arising fromthe reduced use of acute medical or psychiatrichospital beds by substance users, which occurs atpresent.

1. Providing for treatment in a dedicated facility is amore economic use of health resources ascompared to the current system of providingtreatment in an acute medical or psychiatric bed.We estimate that approximately €4.4 million iscurrently being expended by the general hospitalsector on drug detoxifications21. Using a similarcalculation, we also estimate that a further€7.3m is spent on inpatient treatment foralcohol disorders in the psychiatric services22.

2. As a large amount of the costs per bed night arefixed costs, these costs are being incurredregardless of the core needs of the patientoccupying the bed. It is a well documented issue

36

20 N. of discharges x average length of stay (7 days for alcohol detoxification) = Total No. of bed Days - Divided by (365 days @ 85%) = No. of beds used.21 Calculated by multiplying an average cost of an acute medical bed (€1,090 – the estimated cost of an acute medical bed in Dublin ranges from €880-€1,300 per bed night –differences relates to tertiary services which increases costs compared to smaller hospitals) by the number of bed nights (4,033) estimated as being used for drugdetoxification in acute hospitals (as per HIPE data) – 13 beds @ 365 days @ 85% occupancy x €1,090 = €4.4m.22 Calculation based on 66 beds x 52 weeks @ 85% occupancy x €2,500p.w. = €7.3m. However, the WG notes that the absence of reliable and accurate data, combined withthe large number of variables in relation to types of treatment and care across the range of psychiatric inpatient settings, makes it extremely problematic to estimate the cost ofa psychiatric bed at present. Consequently, the figure of €2,500 per week (provided by the HSE and based on available information at the time) can only be considerednotional.

that there are large demands on acute beds inIrish hospitals. Therefore, using acute facilitiesfor treatment of patients who would be moreappropriately treated in a dedicated inpatientdetoxification unit is an inappropriate use ofscarce resources and a missed opportunity foran acute elective patient to be treated.

3. The provision of dedicated facilities providesbetter outcomes for patients, thereforetreatments in these facilities provides anenhanced service for patients and also, aspatients are less likely to require repeatdetoxifications, these costs will not be incurredrepeatedly.

37

38

Psychiatric Hospital

Private Hospital

General Hospital/Psychiatric Unit inGeneral Hospital

Map 223 : Location of General and Psychiatric Hospitals reporting drug and alcoholtreatment, 2005

23 Blank map drawn by Conor Teljeur, SAHRU, TCD

39

Key issuesSpecific services A number of the residential services target specificsubstance problems. Over half (53%) of thecommunity-based residential detoxification beds andalmost a third (31%) of the residential rehabilitationbeds are for clients with alcohol problems only. Thesubstance-specific nature of existing residentialservices is captured in data from the National DrugTreatment Reporting System24 (NDTRS). Of the3,407 reported admissions to residential drug andalcohol services in 200525; three-quarters (76%)reported alcohol as their main problem drug;whereas just over one-fifth (21.5%) reported illicitdrugs as their main problem drug. The increasinglevels of polydrug use being reported by clientsattending community-based drug treatment services(Long et al, 2005) does not yet seem to haveimpacted on residential services; almost two-thirds(65%) of admissions reported to the NDTRSindicated a problem with one substance only;whereas over one third (35%) had a problem withmore than one substance. However, this may reflectthe substance-specific nature of the existingservices.

A number of residential services are gender specific:12% of residential rehabilitation beds are for menonly; and less than 1% are for women only. Thegender imbalance in services is most acute withregard to step-down/halfway house services wherethree quarters (76%) of the beds are for men only;and 10% for women only. Again, this issue isreflected in the NDTRS data where a ratio of threemen (75%) to one woman (25%) was reported asreceiving treatment in inpatient/residential servicesin 2005.

The bulk of the services deal with adults only andthere are only two specialised services foradolescents, namely Aislinn and Cara Lodge.

Inadequate level of residential servicesData submitted to the working group by the NationalDrugs Strategy Team, on residential treatment andrehabilitation needs identified in Regional Drug TaskForce plans indicated the need for: detoxificationfacilities; general rehabilitation services;rehabilitation services for women; and child-friendlyresidential services; both alcohol and drug servicesfor under 18-year-olds; services to accommodatestreet drinkers; and respite and aftercare/halfwayhouses.

The working group notes the inadequate level ofresidential services throughout the country, inparticular, detoxification services; quality assuredrehabilitation services; public residential services;and services for special need groups – such ashomeless people, young people, women withchildren, and new/ethnic communities.

The working group notes that access to residentialservices may be further limited to those in areasoutside of existing services’ catchment areas,reinforcing the need for a regional spread ofservices.

Community-based servicesThe Four Tier Model of Care for people with drugand/or alcohol problems, described in Chapter Threeof this report, provides a framework for groupingservices into tiers which correspond to the level ofneed of clients. However, for such a model to befully effective, all tiers need to be fully operational. Adeficiency in one or more tier will have a knock-oneffect on others. For example, the lack of GP and/orcommunity supported detoxification and residentialdetoxification facilities is seen to impact on theability of community-based alcohol counsellingservices to cater for the needs of their clients. Asubmission from the Statutory Alcohol Services tothe working group noted that one-fifth of theirclients would benefit from an inpatient detoxificationbut no such service was available to them.

24 The National Drug Treatment Reporting System (NDTRS) is an epidemiological database recording socio-demographic and drug use information on the number of casesattending treatment for drug, and more recently alcohol, problems. The majority, but not all, residential treatment services report to the NDTRS; the database also includesdrug users receiving treatment in a small number of acute hospitals. 25 This includes a small proportion of cases reported by acute hospitals and inpatient psychiatric units (13%, n=456) to the NDTRS in 2005 a further 3% (n=90) treated ininpatient psychiatric units where addiction was secondary to mental illness). Note, not all residential services report to the NDTRS.

The working group noted that where there is aninadequate provision of community-based services(such as drug services outside of the Dublin areaand alcohol services nationwide), the demand forresidential services is high.

In addition, the working group are of the view thatan increase in the number and quality ofcommunity-based services would attract morepeople to seek help (for example, a crèche wouldencourage more women to attend services) and inturn lead to an increased demand for these servicesand, consequently, for residential drug and alcoholservices.

The working group recognises thatrecommendations on non-residential communitydetoxification are not within its remit but notes thereis significant capacity for detoxification outside ofresidential programmes by local GPs and drugtreatment centres within the community.

GPs working within the community with Level 2training could also work with community-basedresidential detoxification units on a part-time basisto provide an inpatient detoxification service (ashappens with City Roads/Equinox in the UK). Theworking group recommmends that GPs from thecommunity with Level 2 training be resourced towork within residential programmes to provideresidential detoxification.

The working group believes that the lack ofadequate community-based services will have aknock-on effect on the ability of residentialprogrammes to function at an optimum level assuch services can enable clients to be stabilised toa level that will allow them enter residentialprogrammes. As a result, the working groupsuggests that the issue of community-basedservices urgently needs review in order to avail fullyof the potential for making safe and effectivedetoxification more accessible.

Range of servicesVoluntary organisations are the main providers ofresidential drug and alcohol services. The working

group notes that this has implications for clients interms of the cost of such a service to those withoutor with inadequate health insurance.Notwithstanding the low level of residentialrehabilitation accommodation directly provided bythe public sector and the fact that the bulk ofresidential services are provided by the privatesector, there is frequently public subvention of suchfacilities which needs to be reviewed andformalised.

Services are predominantly abstinence-based,following a 12 step/Minnesota Model and/orTherapeutic Community philosophy. Most arespiritually-based.

The working group notes the need for residentialservices where stabilisation is the goal rather thanabstinence.

Polydrug useResearch evidence increasingly shows that polydruguse rather than a problem with a specific drug is themost common scenario of those presenting to thedrug treatment services (Long et al, 2005).Although, the evidence suggests that polydrug useis more common among people whose mainproblem drug is an illicit drug, rather than for thosefor whom alcohol is the main problem drug.

GenderResidential services are also focused more towardsmen and, though research data indicates men havehigher prevalence rates than women, this trend isseen to be changing rapidly.

Dual DiagnosisBoth the National Drug Treatment Reporting System(NDTRS) and the National Psychiatric InpatientReporting System (NPIRS) report the use ofpsychiatric services for the treatment of drug andalcohol problems (see Chapter Two). However, theimplementation of the recommendations of theExpert Group on Mental Health Policy A Vision forChange (2006) will see this practice discontinuedas:

40

41

individuals [adults and children] whose primaryproblem is substance abuse and who do nothave [other] mental health problems will not fallwithin the remit of mental health services.

Mental health teams will care for adults with co-morbid substance misuse and mental healthproblems where the mental health problem is theprimary problem. Specialist substance abuse mentalhealth teams for adults with complex severesubstance abuse and mental disorders will beestablished. The expert group states that beds inacute psychiatric facilities “should not be used forroutine detoxification” and goes on to state that“more complex detoxification should take place inacute general hospital facilities”.

Waiting listsData presented to the working group on waiting listsfor admission to residential services indicated theinadequate level of service provision. Clients mayhave to wait, post detoxification, in the communityfor up to two months prior to admission.Unfortunately, in most cases they relapse and do notmake it to the residential rehabilitation service. Thisis despite the huge investment the client and theservice have made in the client getting to the pointof successfully completing a detoxification.

Data from the NACD commissioned ROSIE study ontreatment outcomes reported that participants in thestudy reported waiting for inpatient detoxificationservices, depending on the service attended, fromon average 12.4 weeks (n=24) to 9.5 weeks (n=5).

StaffingThe detoxification and rehabilitation residentialservices directly provided by the HSE reportoperating at sub-optimal level due to staff ceilingswithin the HSE.Also, community-based detoxification services reportdifficulty in sourcing support for the medicalsupervision of detoxification.

Prison drug treatment services26

The issue of drug treatment in prison wasconsidered by the working group. While this issue isnot strictly within the remit of the working group,members recognised that de facto detoxification andrehabilitation services were provided in prison andthat these provided a valuable contribution to theoverall level of service provision to drug users.

The Central Treatment List of the number of personsreceiving methadone treatment in Ireland notes that545 people received methadone treatment in prisonduring February 2007.

The working group noted the need for a through-care service for problem drug users entering andleaving the prison system and noted the high risk ofoverdose when problem drug users were dischargedinto the community without a care plan in operation.This has implications for the provision of step-down/halfway house accommodation.

The current Drug Treatment Programme (F5 MedicalUnit) in Mountjoy Prison is a seven-weekabstinence-based drug treatment programme fornine prisoners. The unit has the potential to cater for56 prisoners via seven programmes per annum. Theworking group believes that such a unit has asignificant role to play in the overall provision of“inpatient” detoxification and would welcome anexpansion of such facilities in prisons other thanMountjoy.

4.0 Recommendations on ExistingServices

4.1 Significant support is needed for thedevelopment of drug and alcohol community-based services, including the availability oflocal detoxification services, as part of theoverall four-tier model.

4.2 The demand for Tier 4 services should bedriven by the needs of clients within Tiers 2and 3.

26 Pugh submission to HSE working group on residential rehabilitation.

42

4.3 A mechanism to track progression fromtreatment services to rehabilitation is required.This linkage can be achieved by use of aunique identifier which we recommend beused for all contacts with drug services toenable integrated care planning in line withthe rehabilitation strategy, and so that, withappropriate confidentiality procedures, crossreferencing can be carried out.

4.4 A regularly updated directory of currentresidential services detailing programmeapproach, type of service provided, ethos,number of residential beds, funding profile etcto be publicly available.

4.5 The practice of using acute medical orpsychiatric beds for uncomplicateddetoxifications should be the exception ratherthan the rule.

4.6 Adequate support should be provided by themental health services for clients with co-morbidity issues in residential drug andalcohol services, and clear pathways toresidential mental health services for suchclients where necessary, as outlined in theNACD commissioned report on DualDiagnosis.

4.7 Where an appropriate psychiatric service isnot available in the catchment area for peoplewith a dual diagnosis, there should beflexibility to refer the person across catchmentareas.

4.8 There should be a similar national workinggroup to estimate the current capacity ofcommunity-based services in order toenhance Tiers 1, 2 and 3 as well as looking atthe balance between all four tiers.

4.9 With regard to drug treatment services inprison, the following recommendations areproposed:

i. The provision of accommodation formany prisoners at point of release isimportant as the first 48 hours following

release presents problems in terms ofrelapse, recidivism and even death. It isrecommended that halfway houseprojects should be set up to supportprisoners who are deemed to bevulnerable following release.

ii. There is potential within prisons to utiliseliving spaces to provide drug-free wingswith concomitant therapeutic regimes.There are embryonic drug-free wings inSt Patrick’s Detention Centre andWheatfield Prison but these requiresignificant resources and co-ordination.The medical unit in Mountjoy has thepotential to provide demarcatedresidential living and associated regimesand these could be used to: provide arelapse facility for the prisoners who aresent back, following relapse, from thedrug-free training unit; providemethadone maintenance supportprogrammes and slow detoxificationprogrammes.

iii. Other prisons could also provide similaractivities. All these activities would needto be underpinned by a casemanagement system that could providethe necessary throughcare. In otherwords, shared care planning and theprovision of integrated care pathwaysare essential for the management ofprisoners. This must be done in a way toensure clinical confidentiality.

iv. Prisons are a neglected setting for thedelivery of alcohol treatmentprogrammes and the working grouprecommends the integration of alcoholwith drug treatment programmes withinIrish prisons.

Chapter 5

Needs Assessment

The working group is required to provide the HSEwith an expert view as to the future range, scope,type and method of delivery of residential treatmentin Ireland. In doing so the members, as set out inthe Terms of Reference, considered those sectionspresented to it from a draft report from the WorkingGroup on Rehabilitation, set up under the Fifth Pillarof the National Drugs Strategy. The proposal in thedraft seen by the Working Group to increase thecurrent number of 23 inpatient detoxification bedson an interim basis (pending the outcome of thereport of this group) by an additional 25 will not, inthe view of the working group, meet the needs of allthose requiring inpatient services because of theirdrug use. It will not provide any increased responseto the needs of those whose primary drug problemis alcohol given the notable lack of alcoholdetoxification facilities in many areas, nor will itaddress the need for residential rehabilitation forthose who have been detoxified from alcohol orother drugs, either as inpatients or on an outpatientbasis.

The group notes that many substance users canand will be successfully treated on an outpatientbasis or, in some cases, within the community. Thiswill include assisted withdrawal from most drugs.However, it is well recognised that many others willmeet the criteria for admission for assistedwithdrawal on an inpatient basis. Others will requirestabilisation and respite, while a number will requireresidential rehabilitation interventions of variableduration. It is important to note that what someservices view as rehabilitation is seen by otherservices as a treatment response.

Methods for measuring needsDespite the requirement for effective needsassessment models, there is limited literature onhow to measure the need for substance misusetreatment. Because the literature on measuring theneed for inpatient treatment is limited, the grouphas considered a range of formulas used in othercountries to see if any of them might be appropriatefor Irish needs. Much of the international literaturehas been reviewed by the National TreatmentAgency in the UK and the Group has drawn heavilyon the material in those NTA documents.

One method of attempting to measure need basedon demand is the Prevalence: service utilisation ratio(PSUR) method, although this has been appliedprimarily to alcohol populations. According to thismodel (Phillips et al, 2004), around 10% of theproblem-drinking population are estimated topresent to treatment services annually and 10% ofthis group (or 1% of the overall problem-drinkingpopulation) will require inpatient treatment. Theproblem with such a model is it doesn’t measurehidden demand for treatment; it is difficult to defineproblem drinking and it is not clear how this alcoholmodel can be applied to illicit drugs.

One alternative would be a “systems approach” as itmeasures treatment by combining existinginformation about treatment demand (obtainedthrough measures such as waiting lists and numberof referrals relative to number of admissions) with”system” indicators of harms accrued in particularareas, such as liver disease, crime or drug-relateddeaths

The systems approach is based on what should beavailable and is not solely reliant on what currentlyexists. In an Irish context, data on drug-relateddeaths, for example, is incomplete and while theNational Drug-Related Death Index currently beingdeveloped by the Alcohol and Drug Research Unit(formerly the Drug Misuse Research Division) of theHealth Research Board will provide invaluable data,it will not be available for some years.

Internationally it is accepted that the efficacy of eachapproach is contingent on available data andresources. As a basic minimum, Ford and Luckey(1983) identified four key stages for assessing need:

1. Determine the geographic size of thepopulation to be served

2. Estimate the number of problem userswithin each population group

3. Estimate the number of individuals fromStage 2 that should be treated in agiven year (defined as the demandpopulation)

4. Estimate the number of individuals fromStep 3 that will require some servicefrom each component of the treatment

44

system – in this instance fromresidential treatment.

Using this approach for assessing alcohol relatedneed, Rush (1990) used existing data from anumber of Canadian provinces to extrapolate that15% of problem drinkers in Canada can beconsidered to be the treatment “target” group in anygiven year. This estimate was based on alcohol-related mortality data, national population surveydata on drinking and population data on averageconsumption levels. The problem group in this areawas calculated as 8.6% of the drinking populationwho would be referred to specialist services.

Of the 8.6% of the drinking population, therequirement of specialist services breaks down asfollows:

Of this group, 55% will be referred to outpatientservices, 30% to day treatment, 10% to short-termresidential treatment and 5% to long-termresidential treatment. However, around 20% willdrop out from each treatment modality beforecompleting these treatments. Furthermore, around4% of the original group will be directly referred toservices (i.e. after emergency or criminal justiceattendance), resulting in a total of around 950clients (or 9.5% of the original 10,000) who willactually access specialist services, with the majorityof these most appropriately dealt with in outpatientsettings. The key point is that routes to and throughtreatment are not necessarily consistent orubiquitous and are inevitably interlinked. Again, thismethod of assessing need is limited by the viabilityof available data sources, both to measure thedemand for existing treatment services and fortesting the level of unmet need that does not takethe form of explicit demand. It is also unclearwhether this approach is also valid for those usingdrugs other than alcohol.

Systems-based approachesSystematic assessment of drugs-related treatmentneed has been conducted infrequently in Englandand much of the evidence for good practice derivesfrom the alcohol field. In relation to alcohol services,Godfrey, Hardman and McKenna (1993) suggestedthe use of multiple sources for attempting to assessthe “in-need” population, using three broad datatypes to assess overall need:

1. Direct measures of substanceconsumption.

2. Extrapolation from existing survey work.3. Using substance-related problems as

indicators.

Godfrey et al included statistics on drinking anddriving, drunkenness offences, alcohol-relatedmortality and morbidity, sickness absence andaccidents at work. The group notes that much ofthis data is not routinely available in Ireland.

45

55%

30%

10%5%

0%

10%

20%

30%

40%

50%

60%

Percent of problem drinkers

in Canada

Outpatient

services

Day treatment

Short-term

residential

treatment

Long-term

residential

treatment

46

Local needs assessments and reportsMoreover, extrapolating data from alcohol to drugscan be dangerous, given the limitations of researchin this area. Therefore, one of the key approachesconsidered was to examine the existing locally-conducted, drugs-focused needs assessments inorder to identify useful data and innovative methods.This approach was disappointing, yielding relativelylittle systematic work. The dominant themehighlighted in these reports is the need foradditional provision of local residential treatmentfacilities, particularly for inpatient detoxification (IPD).This overall need is supplemented by concernsabout the limitations of provision for particularlyvulnerable populations, especially women, thosewith co-morbid mental health problems and theunder 18s.

Data limitations in IrelandIn seeking to adapt international models to the Irishcontext, the group were faced with a lack ofappropriate data to implement the needsassessment models described above as well asothers listed in the literature. As a crude example ofthe impact of different models, it is worth noting thatadopting one UK approach would result in anestimated need for 120 beds nationally whileanother (based solely on opiate users and on lengthof stay) gives bed numbers between 102 and 143.

The group found that existing Irish data sets onprevalence, treatment demand, drug and alcohol-related morbidity and mortality are insufficient toallow the use of the more advanced models ofNeeds Assessment for IPD and ResidentialRehabilitation.

The range of drugs research in Ireland has improvedgreatly in the last five or so years largely through theresearch commissioned by the National AdvisoryCommittee on Drugs (NACD) and reports from theAlcohol and Drug Research Unit27 at the HealthResearch Board. Studies such as the 2002/3General Population Survey on Drug Use(NACD/DAIRU, 2004) and the NACD commissioned2000/1 Capture-Recapture Study on the prevalence

of opiate use (Kelly et al 2003) provide us with anunderstanding of the level of use and problem useof opiates in Ireland (see Chapter 2). The updating ofthese studies, (which is being undertaken in 2007),will give greater clarity on the changes in patternsand trends in drug use. In addition, the workinggroup recommends that attempts be made to collectdata which is currently lacking in an Irish context(e.g. absenteeism and accidents at work due toalcohol or other drugs or a combination of both), sothat ongoing needs assessment exercises areconducted on a firmer knowledge basis.

Model adopted by the Working Groupfor assessing inpatient need The working group took particular interest in analternative estimation model proposed for the UK byThe SCAN Consensus Project on the InpatientTreatment of Drug and Alcohol Misusers in theNational Health Service. This recommended that aratio of 15 inpatient beds for service users withalcohol or other drug problems, per half a milliontotal population was appropriate (p. 52).

This estimate is for an Inpatient Unit (IPU) i.e. amedical facility with a multidisciplinary team whichprovides assessment, stabilization and othersupportive interventions and/or assisted withdrawal.The population served by an IPU will depend on thelocal level of alcohol or drug problems, the level ofcommunity and other medical services, the degreeof integration of local care pathways.

The ratio of 15 beds per half a million totalpopulation is in line with recommendations made bythe Royal College of Psychiatrists in 2002 of threebeds per 100,000 total population and is similar tothat put forward by Dr Mai Mannix for the formerSouthern Health Board.

In Ireland, this would amount to 127 IPU beds for apopulation of just over four million, based upon the2006 Census. The working group thereforerecommends that half (n=63) of these beds beallocated to the treatment of those who are primarilyillicit drug users and the remainder (n=64) for the

27 Formerly the Drug Misuse Research Division

treatment of those whose primary drug is alcohol(as recommended in the SCAN Consensusdocument).

The concept of an inpatient unit as set out in theSCAN document is for the provision of services with24-hour cover, seven days per week from amultidisciplinary clinical team under the leadershipof a consultant in addiction psychiatry or othermedically qualified substance misuse specialist.Based on this concept, the deficit in detoxificationbeds can be stated as 104. This is composed of 64beds for alcohol detoxification and 40 additionalbeds for drugs other than alcohol. The value ofcommunity-based residential detoxification servicesin meeting the needs of clients at present and in thefuture is well recognised by the group but we notethat such beds do not fulfil the criteria for IPU bedsas set out in the SCAN report and should not beincluded when calculating the additional bedcapacity required.

In the case of residential rehabilitation, the workinggroup believes that bed provision should be dictatedby the need to ensure that transition fromdetoxification (inpatient or outpatient) should beseamless and that a waiting list between thesephases is to be avoided at all costs. Membersrecognised that the risk of relapse was high if therewas any delay between completion of adetoxification programme and entry into residentialrehabilitation and that relapse to opiate use inparticular brought with it a greatly increased risk ofa fatal overdose. In addition, Ghodse et al (2002)provide evidence that outcomes can be improvedwith seamless progress from the drug withdrawalphase into the rehabilitation phase of recovery.Accordingly, the working group recommends that aresidential rehabilitation place be available for eachperson undergoing inpatient detoxification. Thenumber of places should also provide for those whohave undertaken a community-based or outpatientassisted withdrawal/detoxification programme andwho are deemed likely to benefit from beingseparated from drug-using networks or requireadmission for other social or medical reasons.

It is the view of the group that there is an obligationon the State to provide detoxification andrehabilitation facilities based on the principle ofneed. The issue of funding of beds is beyond theremit of this group.

Based on these recommendations the followingestimate of future need was calculated:

Table 2: Estimate of Future Need

63 detoxification beds for primary drug usersundergoing an optimum 4-week detoxification(operating at 85% occupancy) can providedetox for 696 people per year.

In turn, these 696 people transferring on to a13-week28 residential rehabilitationprogramme (operating at 85% occupancy)would require 205 beds for drugrehabilitation.

64 detoxification beds for primary alcoholusers undergoing a 1-week detoxification(operating at 85% occupancy) can providedetox for 2,829 people per year.

In turn, these 2,829 people transferring on toa 6-week residential rehabilitation programme(operating at 85% occupancy) would require382 beds for alcohol rehabilitation.

This level of provision is appropriate for the demandarising from a policy of seamless transition from aninpatient detoxification programme into residentialrehabilitation. However, this will not meet thedemand for access from clients seeking admissionto residential rehabilitation from outpatientdetoxification programmes. Information provided bygroup members shows that the existing level ofsuch demand is considerable but highly variableranging from 50% of overall intake into one serviceto 90% of intake in the case of a second. Thisvariability makes it difficult to specify a precise

47

28 Length of stay based on international best practice.

figure for the additional accommodation which isrequired to meet that particular need. The impact ofthe expansion of inpatient services as proposed bythe group on the future level of demand from“outpatient” clients is also uncertain at this stage.Regional diversity in service needs and developmentas well as differences in the primary drugs involvedmakes an accurate assessment of the needs of thisparticular client group difficult at present.

Based on the limited data available and the need toensure to the maximum extent a seamless transitionfrom detoxification into residential rehabilitation forthose whose care plan requires it, the WorkingGroup recommends that a minimum of 300rehabilitation beds be added to the overall figureabove to cater, in part, for the demand from clients

coming from outpatient programmes. The group,concerned that this initial additional provision mayprove to be inadequate in practice, recommendsthat the figure be carefully and regularly monitoredwith a view to remedial action being taken rapidly. Itis essential that waiting lists of those completingoutpatient detoxification and then seeking admissionto residential units should not develop. Any suchreview of provision should be separate from theoverall review of inpatient and residential provisionrecommended by the group later in this chapter.

Given the limitations of the data on which theworking group had to base its estimates, the groupacknowledges the appropriateness of stepwiseprovision in line with monitoring of need.

48

Table 3: Current and Recommended Estimate of Need

In highlighting the deficit of 356.5 beds (104 IPU and 252.5 rehabilitation) the working group notes theestimated 66 beds currently in use for alcohol and drug problems in the psychiatric hospitals and units andthe necessity of ensuring that the current resource involved continues to be applied when remedying thedeficit in dedicated beds.

Bed Type CurrentProvision

Estimated Need Deficit

StabilisationServices 5.5

Community-basedResidentialDetoxification

15

MedicalDetoxification 17.5

127 (IPU)

104(64 for alcohol

detoxification; 40 for

drugs other than alcohol)

ResidentialRehabilitation 634.5 887

(205+382+300)

252.529

Step-down, Halfwayhouse 155 296 141

General andPsychiatricHospitals

7930 N/A N/A

29 Includes provision for under 18 year olds – see page 72-3.30 The Working Group notes the evidence that treating people with drug and alcohol problems in these settings is not best practice and, in the case of the PsychiatricHospitals, will not be an option available in the future as a result of the restructuring of the psychiatric services proposed in Vision for Change.

IssuesAssessing the volume of residential treatment andrehabilitation services required to meet the needs ofproblem drug and alcohol users is one aspect of thisneeds estimation exercise: other issues need to beconsidered also.

The Four-Tier Level of Care concept, within whichthese proposals are framed, highlights the need fora standardised assessment protocol as part of theintegrated treatment system where the person’s firstpoint of contact involves a comprehensive needsassessment. Such a system allows the substanceuser and the services to systematically identify andaddress the needs of the client, ensuring that theyare referred to the most appropriate treatmentmodality in the most appropriate setting, providingthe highest standards of care and facilitatingoutcome evaluations.

Where residential treatment is deemed appropriate,evidence suggests that pre-admission preparation(for planned residential treatments) and post-discharge care and support (for all including earlyself-discharges) are essential elements of atreatment episode, and that their provision needs tobe factored into the estimation model in addition tothe number of “bed spaces”.

The level of service provision would also need totake into account the issue of accessibility in termsof cost, geographic location, cultural/religiousdiversity, gender, child care and disability (not only inrelation to clients but also to their visitors).

Factors influencing regional provisionand recommendationsIn the case of regional provision there is a need tobalance accessibility to smaller bedded facilities bypatients on the one hand against the value of adedicated unit with a critical mass of beds, staff andexpertise on the other hand. While population-basedprovision was the preferred model of needsassessment, there is also a need to take account ofthe differing levels of problem opiate use, inparticular between the greater Dublin area andelsewhere, when allocating resources. In looking at

regional provision, the working group noted theexcellent work of Dr Mai Mannix in relation to theCork and Kerry region and her recommendations areworth further consideration. Given the variation inregional needs and the distances involved forpatients and their families, the question of how therecommended number of regional beds is allocatedwithin each region is a matter for local discussionand planning.

Notwithstanding this, the group recommends thatfor alcohol detoxification there should be 15 bedsfor each of the four HSE administrative regions. Forillicit drugs there should be 50 IPU beds evenly splitbetween the two regions which contain the greaterDublin area (HSE Dublin Mid-Leinster and HSEDublin North East) and six beds each for the HSESouth and HSE West regions. This proposal is basedon the NACD commissioned capture-recapture studyof opiate use (Kelly et al 2004) which estimated thatthere were approximately six times more users inthe greater Dublin area than in the rest of thecountry. This proposed ratio may need to be revisedon the basis of the updated capture-recapture Studycurrently being undertaken.

There is a case to be made in the Irish context forthe retention of existing detoxification facilities inlocal hospitals in rural areas due to the difficultyclients and their families would have in accessingand travelling to a centralised unit given the largegeographical areas involved in the HSE Areastructures – even though international practicesuggests that clients have better outcomes fromspecialist units.

The working group recommends that, whereinpatient units are provided, any stabilisation bedswould be physically separated from thedetoxification beds.

Recommended level of under 18sdrugs/alcohol provisionUsing information to hand from the 2002 Censusfigures, all available population surveys whichinterviewed under 18-year-olds about their drug-using behaviour and data from the HSE Child and

49

Adolescent Psychiatric Service, the working grouphave estimated the number of rehabilitation bedsrequired for adolescents (aged 12 -17 years) liesbetween the range of 14 and 37 based on a 28-daystay and an 85% occupancy rate.

The Needs of Vulnerable GroupsSince homelessness is a major criterion indicatingclient suitability for inpatient treatment, the needs ofhomeless substance misusers will need to beprioritised.

The group agreed that pregnant women could beaccommodated within the expanded (stabilisation)services.

Parents with children present special challenges andthe working group wish to highlight and supportproposals such as those from Coolmine to expandthe use of Ashleigh House on a pilot basis to includean outpatient detoxification phase linked to theexisting rehabilitation programme. It is accepted thatsuch a proposal will not meet all of the need forresidential services for those with children but it isnot possible to quantify the total increase needed atthis stage.

The working group note the submission from theFamily Support Network outlining the role of thefamily in the process of recovery of drug users andthe recommendation from the UK National Institutefor Clinical Excellence (NICE) on the psychosocialmanagement of drug misuse, which recommendsthat carers and relatives should be involved indecisions about the service users’ care andtreatment unless the service user specifically wishesto exclude them. In particular, the group drawsattention to the recommendations arising from theNACD commissioned report A Study into theExperiences of Families Seeking Support in Copingwith Heroin Use (Duggan, 2007) and also Action108 of the National Drugs Strategy regarding therole of families as a resource in facilitating drugusers in their recovery. The group values thesuggestion from the Family Support Network thatone way in which the child-care needs of parentswith young children entering residential treatment

could be accommodated is by formally designatingfamilies as short-term foster carers.

The working group highlights the need for thetreatment services to take on board the generalrecommendations for the support of families andcarers in the 2007 NICE guidelines on bothdetoxification and psycho-social interventions.

Meeting diversity and increasingcultural competenceThe specific needs of substance users withdisabilities and those from ethnic minoritycommunities can be met within the increasedprovision but all service providers will need toprovide staff training to ensure an increased level ofcultural competence within their service. This can beachieved by including this element within aQuality/Standard of Care Framework as set out inChapter Six.

Step-Down/ Halfway HouseAccommodationThe Group recognises that there is a need toincrease provision in step-down/halfway houseaccommodation (from the current provision of 155beds with a capacity to meet the needs of 368people, predominantly men) for those leavingresidential rehabilitation. Pending detaileddiscussions with the relevant agencies, theincreased capacity for step-down/halfway houseaccommodation should be a minimum of 30% ofresidential rehabilitation provision i.e. 296 beds butis likely to be in excess of that, especially given theexisting low level of such provision for women (13%of capacity at present) and also to cater for theneeds of prisoners and homeless people. Theworking group recognises the opportunities that areavailable in working with the Homeless sector inring-fencing accommodation specifically for formerdrug users.

Again, the seamless transition from one sub-tier toanother is important, in this case from rehabilitationservices to step-down/aftercare services, both forthe client and to avoid bottlenecks in the system.

50

51

StaffingThe provision of beds has to be accompanied by theprovision of an adequate number of trainedmultidisciplinary staff including access to laboratoryservices consistent with best practice, as outlined inthe SCAN Project report, to ensure full occupancy,maximum safety and the highest standards of care.The working philosophy of the unit will determinethe staff mix.

The working group highlights the fact that there isunused capacity within the existing inpatient andresidential services due to HSE staff ceilings andrecommends that priority should be given to fullyresourcing facilities which have been unable tooperate to full capacity.

Need to Review the ProvisionInternationally it is recognised that needsassessment models require a number of cyclesbefore they can be fully implemented. Therefore, thematch between demand, need and supply can onlybe addressed adequately over a period of calibrationand refining of the original estimates.

The working group recommends that the level ofprovision set out in this Report be reviewed in March2010, during which time improvements in datacollection would be initiated which would allow moresophisticated projections of needs to be put inplace.

5.0 Conclusions and Recommendations5.1 There is a need for more refined data on

drug- and alcohol-related problems such asaccidents at work, absenteeism and drug-related deaths, in order to allow the use ofmore sophisticated needs assessment modelsin future.

5.2 The working group based their estimation ofneed for inpatient detoxification andstabilisation services on the SCAN ConsensusProject (a population-based model); theresidential rehabilitation requirement wasbased on the transition from inpatient andoutpatient detoxification to residentialtreatment; and the numbers of adolescents

requiring treatment was based on populationsurveys and estimates of problematicsubstance use.

5.3 The working group calculated that:• Overall, 127 dedicated beds are

required in Ireland for medicaldetoxification and stabilisation, 50%each for drug and alcohol detoxification.

• In total, 887 residential rehabilitationbeds are required, of which between 14and 37 beds are required for a separateadolescent service(s).

• These 887 residential rehabilitation bedswill address the following needs: 205 forillicit drug users transferring frominpatient detoxification services; 382 forproblem alcohol users transferring frominpatient detoxification services; and300 to address the needs of both drugor alcohol users who have attendedoutpatient detoxification services.

• A minimum of 30% of clients attendingresidential rehabilitation will requirestep-down/halfway house beds andtherefore at least 296 step-down/halfway house beds are required.

5.3 The working group calculated that anadditional:

• 104 Inpatient Unit beds (for medicaldetoxification and stabilisation);

• 252.5 residential rehabilitation beds;and

• 141 step-down/halfway house beds arerequired.

5.4 In highlighting a deficit of 356.5 beds (104IPU and 252.5 rehabilitation), the workinggroup notes the estimated 66 beds currentlyin use for alcohol and drug problems in thepsychiatric hospitals and units will no longerbe available as a result of the restructuringproposed in Vision for Change and thenecessity of ensuring that the currentresource involved continues to be appliedwhen remedying the deficit in dedicated beds.

52

5.5 The group recommends that 50 inpatient unitbeds for illicit drug users should be providedbetween the Dublin Mid-Leinster and theDublin North East HSE areas as the availabledata points to a significantly higher level ofneed there at present. The remaining 13 IPUbeds should be divided between the HSESouth and HSE West areas. The group drawsattention to the fact that the results from the2007 Capture-Recapture Study of Opiate Usecurrently being undertaken for the NACD mayrequire a revision of this recommendation inthe future.

5.6 In the case of services focusing primarily onthe treatment of alcohol problems, the grouprecommends that they be evenly spread overthe four HSE areas since the data suggests amore even distribution of alcohol-relatedproblems throughout the country.

5.7 The group’s strong preference is that suchbeds should be provided in fully staffeddedicated units but recognise that problemsof patient and family access may militateagainst this in some parts of the country.

5.8 The group recommends as a matter ofurgency that, where there is unused capacityat present in a service or unit because ofstaffing shortages, such capacity be broughton stream immediately by providing thenecessary staff.

5.9 The staffing of IPUs as well as of residentialrehabilitation services must be in line withrecognised best practice to ensure fulloccupancy, maximum client safety and thehighest standards of care. Since the treatmentapproach adopted by a particular service willdetermine the staff mix required, it is neitherpossible nor desirable to be prescriptive aboutnumbers or type of staff at this stage.

5.10 Arising from the recommendation thattransitions from detoxification to residentialrehabilitation and then into step-downaccommodation be seamless (3.8), the group

recommends that an appropriate residentialrehabilitation place must be available for eachperson admitted for inpatient detoxification.

5.11 The group recommends that the treatmentneeds of problem drug and alcohol users whoare homeless should be prioritised, sincehomelessness is one of the key criteriaindicating client suitability for inpatientadmission.

5.12 The increased provision of inpatient unit bedsrecommended by the group will allow for thestabilisation and respite needs of drug usersincluding pregnant women, cocaine and/orpolydrug users. Such stabilisation beds mustbe physically separated from detoxificationbeds.

5.13 The needs of recovering drug users withyoung children present particular challengeswhen it comes to inpatient/residentialtreatment. The group would welcome theinvestigation of innovative approaches such asproviding the necessary supports so thatfamily members can act as short-term fosterparents.

5.14 In general, the group were of the opinion thatfamilies of drug and alcohol users could bemore involved in the overall care plan forrecovering users. In particular, the groupdraws attention to the recommendations inthe NACD commissioned report A Study intothe Experiences of Families Seeking Supportin Coping with Heroin Use (Duggan, 2007)and to the specific recommendations onsupport for families and carers contained inthe National Institute for Clinical Excellence’s(NICE) guidelines.

5.15 The group agreed that the specific needs ofsubstance users with disabilities and fromethnic minority communities can be metwithin the increased facilities we haverecommended, provided that staff training isused to enhance cultural competence withinthe service. Such training should form part of

53

the proposed quality assurance framework forTier 4 services outlined in Chapter Six.

5.16 The group recommends that the level ofprovision set out in this Report should bereviewed in March 2010 and that in themeantime the timeliness and completeness ofthe data required for more precise projectionsof need should be improved.

ReferencesCochrane Collaboration (2006) Inpatient versusother settings for detoxification for opioiddependence (Review)

Cochrane Collaboration: Therapeutic communitiesfor substance related disorder (Review) 2006

Dewit and Rush (1996) “Assessing the need forsubstance services: A critical review of needsassessment models”, Evaluation and ProgrammePlanning. Vol.19 No.1

Duggan, C. (2007) A Study into the Experiences ofFamilies Seeking Support in Coping with Heroin UseDublin: NACD

Ford, W.E., and Luckey, J.W. (1983) “Planningalcoholism services: a technique for projectingspecific service needs”. International Journal ofAddiction. Apr; 18(3):319-31.

Ghodse A.H., Reynolds, M., Baldacchino A.M. et al(2002) “Treating an opiate dependent inpatientpopulation: A one-year follow-up study of treatmentcompleters and non-completers.” AddictiveBehaviours 27:765-768.

Godfrey, C., Hardman, G., and McKenna, M. (1993)“Assessing needs for alcohol services: Guidance forpurchasers”. Report to the Department of Health.York 1993. cited in Best D. et al National NeedsAssessment for Tier 4 Drugs Services in England.National treatment agency for SubstanceMisuse.research briefing 13. June 2005.

Kelly A, Carvalho M, Teljeur C. A 3-source capture-recapture study of the prevalence of opiate use inIreland, 2000-2001. National Advisory Committeeon Drugs. Dublin 2004.

Mannix, M (2006) Drug and alcohol detoxificationservices: a needs assessment for Cork and Kerry2005: Health Service Executive South (Cork &Kerry), Department of Public Health

National Institute for Clinical Excellence (NICE)(2007) Drug misuse: detoxification NICE GuidelineDraft January 2007.

National Treatment Agency for Substance Misuse(2005) Opiate detoxification in an inpatient settingDr Ed Day

National Treatment Agency for Substance Misuse,National needs assessment for Tier 4 drugs’services in England, Research briefing 2005

National Treatment Agency for Substance Misuse:Treating drug misuse problems: evidence ofeffectiveness. Professor Michael Gossop.

Phillips T et al. (2004) “What is the need for drugand alcohol inpatient care? An advisory report to theNorth and East Yorkshire and Northern LincolnshireStrategic Health Authority-Mental Health ProvidersGroup”. Cited in National Needs Assessment for Tier4 Drugs Services in England Best, D. et al. NTAResearch Briefing 13. July 2005.

Rush, B. (1990) “A systems approach to estimatingthe required capacity of alcohol treatment services.”British Journal of Addiction. 85:49-59.

Scottish Executive, Effective Interventions Unit(2004) Residential detoxification and rehabilitationservices for drug users: A review. Scotland:Scottish Executive.

Specialist Clinical Addiction Network (SCAN)Consensus Project (2006) Inpatient Treatment ofDrug and Alcohol Misusers in the (UK) NationalHealth Service London: HMSO

Royal College of Psychiatrists (2002) “Modelconsultant job description and recommendednorms.” London. Royal College of Psychiatrists.

54

Chapter 6

Quality Assurance Framework for ResidentialServices in the Context of Addiction

56

The Terms of Reference given to the Working Groupby HSE management require the group:

to examine current international qualitystandards/frameworks existing for residentialtreatment providers operational in otherjurisdictions and advise the HSE in terms ofwhat overall standards/quality framework arerequired for implementation throughout allHSE-funded residential treatment facilities andwhich will act as a benchmark for all services.

The working group noted that this request isgrounded in Action 50 of the National DrugsStrategy 2001-2008 which requires the HSE (as thesuccessor to the Health Boards) to “develop inconsultation with the NACD, criteria to ensure thatall State-funded treatment and rehabilitationprogrammes accord with quality standards”.

QuADS and DANOSIn November 2002, the NACD and the former HealthBoards held a seminar (Quality in Addiction Services)which was addressed by representatives of the IrishSociety of Quality and Safety in Healthcare, theNDST, ERHA and Alcohol Concern from the UK. Thislatter presentation dealt with the development of theQuality in Alcohol and Drugs Services (QuADS) suiteof organisational standards, developed jointly byAlcohol Concern and Drugscope, and theirintroduction in the UK. The seminar was informedthat the addiction service in one former Area HealthBoard had used QuADS as a template for developingminimum standards. Five standards were developedusing the QuADS approach of Standard Statementand accompanying Criteria: these were Governance,Programmes, Clients, Staffing and Accommodation.The working group noted that occupationalstandards specifying the standards of performanceto which people in the drugs and alcohol fieldshould be working and describing the knowledgeand skills workers need in order to perform to therequired standard, have now been introduced in theUK as Drug and Alcohol National OccupationalStandards (DANOS).

DANOS were developed by the ManagementStandards Consultancy for Skills for Health in 2005.DANOS are seen to be relevant to everyone who is

working to improve the quality of life for individualsand communities by minimising harm associatedwith substance misuse. DANOS are therefore notjust relevant for staff in agencies offering inpatientservices but are also relevant to teachers, socialworkers, GPs, pharmacists, prison officers etc.

DANOS and QuADS are seen to fit together as partof an overall package of quality assurancemeasures.

Because of their broad application across all fourtiers of the drug services, it would be important thatsuch standards should be introduced globally andnot piecemeal. It may be that the inpatient sectorcould be used to pilot a QuADS/DANOS approachperhaps along the lines of the Audit of ResidentialTreatment Service document as developed by theresidential treatment sub-committee in the formerNorthern Area Health Board. However, there is nodoubt that quality assurance initiatives for all tierswill require extensive consultation and negotiationfollowed by intensive training for all staff involved.The working group also noted that such aframework will require extensive resources, not onlyduring the implementation phase but also on arecurrent basis.

The working group recommends the introduction ofa suite of measures modelled on the QUADS/DANOSapproach as being necessary to ensure that qualityservices are delivered to clients by a quality-competent staff at all levels of the alcohol and drugservices in Ireland.

Because QuADS/DANOS (and the two areinterlinked) have been developed by independent UKconsultancies, there may be copyright issuessurrounding the use of paperwork developed byindependent contractors in another country. This isapart altogether from the possible need to adapt thedocumentation for specifically Irish health/socialservices which will have a totally differentorganisational and societal culture to those of theUK services. The group would welcome an effort byHSE management to seek legal advice about theimplications of using QuADS/DANOS in this country.

57

In addition to standards relating to organisationaland occupational issues, the working group alsorecognises that there is a need to considerminimum care standards for the residential facilitieswhich are provided either directly by the HSE orfunded by it. The standards for residential care fordrug and alcohol users in recovery from addictioncannot be less than those deemed acceptable bysociety for those for older people, children or peoplewith disabilities. The working group were particularlyimpressed by the standards set out in the ScottishExecutive document National Care Standards: carehomes for people with drug and alcohol misuseproblems. They also noted that in the UK, the CareStandards Act defines a home as a care home if itprovides accommodation together with nursing orpersonal care. Included are homes for persons whoare, or who have been, suffering from dependenceon alcohol or drugs. Residential services forsubstance users are required to register under theAct. Inspections are carried out by the CareStandards Commission twice a year with at leastone of those visits being unannounced. It is arequirement that all mangers and staff of residentialhomes be appropriately trained and working towardsa recognised qualification.

The working group is of the opinion that similarstandards should be applied to residential servicesin Ireland.

Monitoring quality standards of care The working group has considered the question ofthe enforcement of these three sets of qualitystandards i.e. residential, organisational andoccupational, subsequent to their introduction by theHSE. The attention of the group was drawn to thework of the interim Health Information and QualityAuthority (HIQA) and in particular the plan toincorporate the Social Services Inspectorate (SSI)and the Irish Health Services Accreditation Board(IHSAB) within the statutory HIQA. The SSI wasestablished in 1999 to investigate standards inchildren’s residential centres, foster care servicesand special care units. The CEO of HIQA is quotedas saying that “the Authority is putting in place

arrangements to establish a robust and rigoroussocial services inspectorate to regulate the provisionof care for older people, for children and for peoplewith disabilities who require residential care”31.

The working group recommends that the HSEshould consult with HIQA about the inclusion ofresidential services for drug and alcohol users withinthe range of services to be regulated by HIQA’ssocial services inspectorate. HIQA should also beconsulted about the processes of developing,introducing and monitoring the necessary standardsnot only in HSE-provided and HSE-funded residentialservices but in all other residential facilities forsubstance users.

The working group also recommends that the HSEput in place an internal quality audit function withinits Alcohol and Drugs Services regardless of thefuture statutory role of HIQA in this area, in order toprepare for and respond to HIQA audits of quality ofits residential services.

The working group notes that HIQA itself does notplan to encroach or impact on the functions of any“other body established by the Minister toinvestigate or review on his or her behalf, standardsof service or care provided by the Health ServiceExecutive or a person providing a service on itsbehalf.” It is the view of the group that, in theabsence of such a body dealing with the quality ofalcohol and drugs services in Ireland at this time,unnecessary and costly duplication could be avoidedby consultation between the HSE and HIQA.

The working group were particularly concerned thatany approach to improving the quality of inpatientand residential services would have a strongemphasis on the following:

I. That all detoxification procedures meetthe highest standards of clinicalgovernance, care and patient safety.

II. Management and leadership of addictionrehabilitation teams should ensure thatstaff employed to work in such teamsare clear about role definition and

31 Dr Tracey Cooper, CEO, HIQA in Irish Times of Nov. 17th 2006. Source:www.ireland.com/newspaper/breaking/2006/1116/breaking25_pf.html.

58

purpose, together with assurance ofrequired qualifications and experience.Ongoing training and support for staff isrequired to assist in role development.Assurance of standards of care will beenhanced by the provision of such amanagement structure.

III. Peer reviews, as, for example, that setout in documentation relating to theQuality Network of TherapeuticCommunities submitted to the group byCoolmine Therapeutic Community. Thegroup viewed such reviews as a positiveelement in the development of a qualityagenda for such services.

ReferencesAbdulrahim, D., Lavoie, D. and Hasan. S. (1999)Commissioning Standards Drug and AlcoholTreatment and CareLondon: Health Advisory Service 2000

Alcohol Concern and the Standing Conference onDrug Abuse (SCODA) (1999) QuADS: OrganisationalQuality Standards Manual for alcohol and drugtreatment services.London: Alcohol Concern and SCODA

Management Standards Consultancy (2003)Mapping of the Drugs and Alcohol NationalOccupational Standards (DANOS) against Quality inAlcohol and Drugs Services (QuADS)

Scottish Executive (2005) National Care Standards:Care homes for people with drug and alcoholmisuse problems Edinburgh: Scottish Executive

Appendix

60

Appendix 1: Membership of the HSE Working Group onResidential Treatment & Rehabilitation

Name Organisation

Dr Des Corrigan (Chair) School of Pharmacy,Trinity College Dublin.

Dr Aileen O’Gorman (Technical Advisor) School of Applied Social Studies,University College Dublin

Mr Eddie Arthurs Drugs Strategy UnitDepartment of Community,Rural and Gaeltacht Affairs

Prof. Joe Barry HSE Public Health

Dr Gemma Cox National Advisory Committee on Drugs (NACD)

Mr Willie Collins Regional Drug Co-ordinator/Area Operations Managers Group

Ms Mara de Lacy Senior Alcohol Addiction CouncillorStanhope Street

Mr Mick Devine European Association for theTreatment of Addiction

Mr Tony Geoghegan Voluntary Drug Treatment Network

Ms Sadie Grace/Mr Philip Keegan Family Support Network

Ms Grainne Hannon HSE National Hospitals Office

Ms Anna-May Harkin Department of Health and Children

Ms Linda Hutton HSE Residential Treatment Services

Dr Jean Long Alcohol and Drug Research Unit (ADRU) (formerly the Drug Misuse Research Division),Health Research Board

Mr Ruardhri McAuliffe/ Union for Improved Service and Education Ms Emily Reaper

Mr Brendan Mc Kiernan HSE Residential Treatment Services

61

Name Organisation

Dr Austin O’Carroll ICGP

Ms Patricia O’Connor National Drugs Strategy Team

Ms Marion Rackard HSE Alcohol services

Dr Siobhan Rooney/ Consultant Psychiatrists GroupDr Brion Sweeney

Mr Jim Ryan HSE Addiction Services

Mr Vincent Crossan Secretary to the Working Group

Ms Marie Lowe Assistant to the Technical Advisor

62

63

Title of submission Author/submitted by

Rosie Findings Submitted by Dr Gemma Cox

Mannix Report Dr Mai Mannix

List of residential services prepared by NDST Submitted by Patricia O’Connor

Audit of Residential Treatment Submitted by Brendan McKiernan

Article“Psychological treatments for alcohol dependents” Submitted by Marion Rackard

Information onHSE Intercultural Strategy Consultation days Submitted by Vinny Crossan

Rehabilitation report (draft form) Submitted by Fidelma Lyons

Community Alcohol Services into the year 2000 Submitted by Mara De Lacy

Alcohol and suicide - submission byAlcohol Action Ireland to the National Strategyfor Action Suicide Prevention Submitted by Mara De Lacy

Letter from Dr Brion Sweeney re Keltoiand Rutland Centre waiting lists Submitted by Eddie Matthews

Letter informing group on Prisons and Drugs Submitted by Julian Pugh.Author: Julian Pugh

Submission to the Working Group onResidential Treatment from Statutory Alcohol Services Submitted by Mara De Lacy

Description of Four-Tiered Model of Care Submitted by Dr Siobhan Rooney.Author: by Dr Siobhan Rooney

Letter from Peter McVerry Trust Submitted by Clare Williams

Towards a comprehensive drug treatment Submitted by Philip Keegan.in Blanchardstown Author: Dave Farrington

The How of Treatment Delivery Submitted by Marion Rackard

Quality Network of Therapeutic Communities Paul Conlon

Comments on Residential Rehabilitationfrom the Family Support Submitted by Philip Keegan

Appendix 2: Submissions made to the Working Group

64

Appendix 3: Estimation of Current Capacity of Drug andAlcohol Residential Services, 2007

NATIONAL SUMMARY

(Population 4,234,925 - Census 2006)

There are no dedicated residential services in counties Cavan, Laois, Leitrim,Longford, Offaly, Roscommon, Sligo, Tipperary North or Westmeath.

SERVICE TYPE32 (N.)

Stabilisation Service[Note: these are not stand alone units

but beds reserved within the two MD

Units]

Community-basedResidential Detoxification(2)

15

53% (n=8) alcohol only

170

69% (n=118) alcohol only

Medical DetoxificationUnit (2)

17.5 157

Residential Rehabilitation(28)

634.5

31% (n=197) alcohol only

12% (n= 76) men only

0.04% (n=28) women only

3652

36% (n=1310) alcohol only

3% (n=106) men only

1% (n=24) women only

Step-down/HalfwayHouse (14)

155

76% (n=118) men only

10% (n=15) women only

368

78% (n=286) men only

13% (n=47) women only

General and PsychiatricHospitals(HIPE and NPIRS databases)

79

16% (n=13)Illicit drugs35

84% (n=66) alcohol via

psychiatric services

3,825 (NPIRS)

718 (HIPE)

(2005 data on cases not individuals)

5.5 87

NUMBER OF BEDS33 ESTIMATEDANNUAL CAPACITY34

32 As per Terms of Reference33 Some services also treat gambling and eating disorders, however, the number of beds dedicated to these is not set, hence the number of beds and the estimated annualcapacity is probably overstated for these service as the estimation assumes all beds are available for drugs or alcohol treatment.34 The estimated annual capacity of services, is calculated by dividing the number of days (or weeks or months as appropriate) per year by the duration of programme (usingthe mean duration if range is given) and multiplying this figure by the number of beds (using the mean number of beds if range is given). 85% of this figure is then calculatedto reflect the occupancy rate of services. 35 This provision may not be additional to that included under Medical Detoxification Units (number 3 above) as one of these services also report throughput to the HIPEdatabase.

65

CURRENT RESIDENTIAL SERVICES BY HSE AREA

HSE AREA - DUBLIN MID-LEINSTER

(Population 1,215,711 – Census 2006)

Services based in South Dublin, Kildare and Wicklow only.

There are no dedicated residential services in counties Laois, Longford, Offaly or Westmeath

SERVICE TYPE (N.)

Stabilisation Service

Community-basedResidential Detoxification(0)

NONE NONE

Medical DetoxificationUnit (1)

10 74

Residential Rehabilitation(7)

236

72% (n=177) alcohol only

7% (n=16) men only

1539

76% (n=1822) alcohol only

2% (n=35) men only

Step-down/HalfwayHouse (0) NONE NONE

3 55

NUMBER OF BEDS36 ESTIMATEDANNUAL CAPACITY37

36 Some services also treat gambling and eating disorders however, the number of beds dedicated to these is not set, hence the number of beds and the estimated annualcapacity is probably overstated for these service as the estimation assumes all beds are available for drugs or alcohol treatment.37 The estimated annual capacity of services, is calculated by dividing the number of days (or weeks or months as appropriate) per year by the duration of programme (usingthe mean duration if range is given) and multiplying this figure by the number of beds (using the mean number of beds if range is given). 85% of this figure is then calculatedto reflect the occupancy rate of services.

66

HSE DUBLIN MID-LEINSTER

(Population 1,214,711 – Census 2006)

Services based in South Dublin and Kildare only.

There are no dedicated residential services in counties Laois, Longford, Offaly or Westmeath

NAME OFSERVICE

Cuan DaraCherry OrchardHospital Dublin

NO.BEDS

AVERAGESTAY

ESTIMATEDANNUAL CAPACITY

NOTES

3 17 days 556 Men and women.

Service available for

pregnant women.

STABILISATION SERVICE

Cuan DaraCherry OrchardHospital Dublin

10 6 weeks 7438 Men and women.

Service available for

pregnant women and

under 18s.

MEDICAL DETOXIFICATION UNIT

Rutland CentreDublin

25 6 weeks 184

[62 – NDTRS 2005]

[210 – 2005, Source:

EATA]

Men and women.

Drug and Alcohol.

Detox needed pre-

admission.

Also deals with gambling

and eating disorders.

RESIDENTIAL REHABILITATION

St John of GodStillorganDublin

12 28 days 133 Alcohol only

ForestWicklow

12 4 weeks 133 Men and women.

Majority alcohol, approx.

40% drugs.

Also deals with eating

disorders and gambling.

St Patrick’sHospitalDublin

40 3 weeks 589 Alcohol only

Also deals with eating

disorders.

NO SERVICES NONE N/A NONE

COMMUNITY-BASED RESIDENTIAL DETOXIFICATION UNIT

38 (Note: Total n. of cases in Cuan Dara = 134 (NDTRS, 2005)

67

Cuan MhuireAthyCo. Kildare

125 12 weeks 460

[652 – NDTRS 2005]

Alcohol unit.

Men and women.

3 to 4 beds available for

drug detoxification for

those continuing on into

drug rehabilitation

programme.

Deals with gambling

problems also.

Teen ChallengeNewbridgeCo. Kildare

6 12 months 5

TOTAL 236

72% (n=177) alcohol only

7% (n=16) men only

1539

76% (n=1822) alcohol only

2% (n=35) men only

Drug recovery

programme.

Targets 18+ year-olds

16 20 weeks 35 Drug rehabilitation unit.

Men only

NO SERVICES NONE N/A NONE

STEP-DOWN OR HALFWAY HOUSE

68

HSE AREA – DUBLIN NORTH EAST

(Population 926,315 – Census 2006)

Services based in Dublin North, Louth, Meath & Monaghan.

There are no dedicated residential services in County Cavan

SERVICE TYPE

Stabilisation Service

Community-basedResidential Detoxification(2)

15

53% (n=8) alcohol only

170

69% (n=118) alcohol only

Medical DetoxificationUnit (1)

7.5 83

Residential Rehabilitation(9)

120

18% (n=20) alcohol only

55% (n=60) men only

15% (n=18) women only

309

43% (n=128) alcohol only

24% (n=71) men only

8% (n= 24) women only

Step-down/HalfwayHouse (7)

87

85% (n=74) men only

201

90% (n=181) men only

2.5 32

NUMBER OF BEDS39 ESTIMATEDANNUAL CAPACITY40

39 Some services also treat gambling and eating disorders – the number of beds dedicated to these is unknown, hence the number of beds and the estimated annual capacityis probably overstated in the case of these service providers as this estimation assumes all beds are available for drugs or alcohol treatment.40 The estimated annual capacity of services, is calculated by dividing the number of days (or weeks or months as appropriate) per year by the duration of programme (usingthe mean duration if range is given) and multiplying this figure by the number of beds (using the mean number of beds if range is given). 85% of this figure is then calculated toreflect the occupancy rate of services.

69

HSE AREA – DUBLIN NORTH EAST(Population 926,315 – Census 2006)

Services based in Dublin North, Louth, Meath & Monaghan

There are no dedicated residential services in County Cavan

NAME OFSERVICE

St Michael’s Ward– BeaumontHospital

NO.BEDS

AVERAGESTAY

ESTIMATEDANNUAL CAPACITY

NOTES

2-3 3-4 weeks 32 Men and Women.

STABILISATION SERVICE

St Michael’s Ward,Beaumont HospitalDublin

7 – 8 4 weeks 83

Lantern(Arrupe Society)Dublin

6 (+1emergency)

4 –8 weeks 52

[31 since March 2006]

Methadone detoxificationClients transfer toresidential treatment oncompletion

Simon CommunityDetoxDublin

8 21 days 118

[131 – NDTRS 2005]

Alcohol service

Homeless men & women.

MEDICAL DETOXIFICATION UNIT

Ashleigh House(Coolmine TC)CloneeCo Meath

8 6 months 14

[17 in first half 2006]41

Women only.Aged 18+Therapeutic community,abstinence based.

RESIDENTIAL REHABILITATION

TOTAL 1553% alcohol only

17069% alcohol only

Coolmine LodgeBlanchardstown Dublin

30 6-9 monthprogramme

4142

[62 in first half of

2006]43

Men only.Aged 18+. Therapeuticcommunity, abstinencebased. Many patientsconnected with Dept ofJustice.

Keltoi Dublin

8 8 weeks 44

[38 – NDTRS 2005]

HSE funded service16+ year olds.Capacity for 20 beds butonly 12 available due tostaff ceilings. Currentlyhave 8 beds available.

COMMUNITY-BASED RESIDENTIAL DETOX UNIT

41 Source: Coolmine 2006:542 Note – Total for Coolmine TC = 149 (NDTRS 2005)43 Source: Coolmine 2006:8

70

Barrymore HouseStanhope CentreGrangegormanDublin

9 4-5 weeks 88 Alcohol only.Men and women.HSE-funded service.

Also deals with gamblingproblems.

Simon CommunityRehabDublin

11 12 weeks 40

[39 – NDTRS 2005]

Alcohol serviceHomeless men andwomen.

Merchants’ QuayHigh ParkDublin

14

(13 + 1

emergency bed)

16 weeks 42

[51 went through

programme in 2005]

Men and women.Integrated service whichincludes 3-week detox.As required.Targets drug users,

homeless people andother excluded groups

Avoca After Care (Arrupe Society)Dublin

6 6- 12 months 8 Homeless young people.18+ drug dependent ordrug free.

STEP-DOWN/HALFWAY HOUSE

TOTAL 12018% (n=20) alcohol only55% (n=60) men only

15% (n=18) women only

30943% (n=128) alcohol only

24% (n=71) men only8% (n= 24) women only

Victory OutreachNavanCo Meath

10(Approx)

9 months –1 year

10 Men onlyNon medically-assisteddetox.

Majority homeless andex-prisoners.

Victory OutreachDroghedaCo Louth

10(Approx)

9 months –1 year

10 Women onlyNon medically-assisteddetoxification.

Majority homeless andex-prisoners.

Victory OutreachSlaneCo. Meath

10(Approx)

9 months –1 year

10 Men onlyNon medically-assisteddetoxification.

Majority homeless andex-prisoners.

Cuan MhuireBallybayCo. Monaghan

12 3 – 6 months 27 HomelessMen only

Coolmine Integrationand Aftercareservice Dublin

15 6 months 25

[28 in first half of

2006]44

Men only (to date)Therapeutic CommunityMany patients connectedwith Dept. of Justice.

Teach MhuireGardiner StDublin

25 3-6 months 57 Men onlyAlso deals with gamblingaddiction and homelesspeople.

44 Source: Coolmine 2006:8

71

George’s Hill(Focus Ireland)SmithfieldDublin

7 6 months 12 Men and women.

St James’s Camino NetworkEnfieldCo Meath

12 14 weeks 38 Men only

Tabor HouseNavanCo Meath

10 3 months 34 Men only

18+ year-olds.

TOTAL 8788% (n=74) men only

20190% (n= 181) men only

72

HSE AREA – SOUTH

(Population 1,080,999 – Census 2006)

Services based in Carlow, Cork, Kerry, Kilkenny, Tipperary South, Waterford & Wexford.

SERVICE TYPE (N.)

Stabilisation Service

Community-basedResidential Detoxification(0)

NONE NONE

Medical DetoxificationUnit (0)

NONE NONE

Residential Rehabilitation(7)

83 718

Step-down/HalfwayHouse (3)

2836% (n=10) men only

32% (n=9) women only

8544% (n=37) men only

39% (n=33) women only

NONE NONE

NUMBER OF BEDS45 ESTIMATEDANNUAL CAPACITY46

45 Some services also treat gambling and eating disorders – the number of beds dedicated to these is unknown, hence the number of beds and the estimated annual capacityis probably overstated in the case of these service providers as this estimation assumes all beds are available for drugs or alcohol treatment.46 The estimated annual capacity of services, is calculated by dividing the number of days (or weeks or months as appropriate) per year by the duration of programme (usingthe mean duration if range is given) and multiplying this figure by the number of beds (using the mean number of beds if range is given). 85% of this figure is then calculatedto reflect the occupancy rate of services.

73

HSE AREA – SOUTH

(Population 1,080,999 – Census 2006)

Services based in Carlow, Kerry, Kilkenny, Tipperary South, Waterford, Wexford.

NAME OFSERVICE

NO SERVICES

NO.BEDS

AVERAGESTAY

ESTIMATEDANNUAL CAPACITY

NOTES

NONE N/A NONE

NO SERVICES NONE N/A NONE

NO SERVICES NONE N/A NONE

STABILISATION SERVICE

MEDICAL DETOXIFICATION UNIT

Tabor LodgeBelgoolyCo Cork

18 28 days 199

[215 = NDTRS 2005; 230

in 2005, source: EATA]

Men and women.

Adults and adolescents.

Also deals with gamblingand eating disorders

RESIDENTIAL REHABILITATION

Talbot GroveCastleislandCo Kerry

12 30 days 124

[128 = NDTRS 2005]

Adults and adolescents.Also deals with gamblingand eating disorders.

AislinnBallyraggetCo Kilkenny

12 6 weeks 88

[117 = NDTRS 2005]

Adolescent service 15– 21-year-olds.Men and womenNational catchment

Cara Lodge Co Cork

6 12 weeks 22 Boys only aged 14-18Drug and alcohol dependentwith co-existingpsychosocial problems.Developmental Model/Therapeutic Community

AiseiriWexford

12 28 days 133

[149 = NDTRS 2005]

Men and women12-step programme.Leinster catchment area.Deals with gambling also.

AiseiriCahirTipperary

12 28 days 133

[157 = NDTRS 2005]

Men and women.12-step programme.

Primarily deals with alcoholrelated problems but alsodeals with gambling and drugproblems.Munster/Leinster catchmentareas.

COMMUNITY-BASED RESIDENTIAL DETOX UNIT

74

MQI – St FrancisFarm, Tullow,Co Carlow

11

(10 + 1

emergency bed)

6 months 19

[24 = NDTRS 2005]

Targets drug users,

homeless, and otherexcluded groups.

Renewal Women’sServiceShanakielCork

9 12 weeks 33 Women only, 18+ year-olds.Linked to Tabor Lodge.

Aiseiri/Ceim eileWaterford

9 6 months 15 Men and women

TOTAL 83 718

TOTAL 28

36% (n=10) men only

32% (n=9) women only

85

44% (n=37) men only

39% (n=33) women only

Fellowship HouseTogherCork

10 12 weeks 37 Men only

Linked to Tabor Lodge.

STEP-DOWN OR HALFWAY ACCOMMODATION

75

HSE AREA – WEST

(Population 1,011,900 – Census 2006)

Services based in Clare, Donegal, Galway, Limerick, Mayo.

There are no dedicated residential services in counties Leitrim,Roscommon, Sligo or Tipperary North

SERVICE TYPE (N.)

Stabilisation Service

Community-basedResidential Detoxification(0)

NONE NONE

Medical DetoxificationUnit (0)

NONE NONE

Residential Rehabilitation(5)

195.5 1086

Step-down/HalfwayHouse (4)

4085% (n=34) men only

15% (n=6) women only

8283% (n=68) men only

17% (n=14) women only

NONE NONE

NUMBER OF BEDS47 ESTIMATEDANNUAL CAPACITY48

47 Some services also treat gambling and eating disorders – the number of beds dedicated to these is unknown, hence the number of beds and the estimated annual capacityis probably overstated in the case of these service providers as this estimation assumes all beds are available for drugs or alcohol treatment.48 The estimated annual capacity of services is calculated by dividing the number of days (or weeks or months as appropriate) per year by the duration of programme (usingthe mean duration if range is given) and multiplying this figure by the number of beds (using the mean number of beds if range is given). 85% of this figure is then calculatedto reflect the occupancy rate of services.

76

HSE AREA – WEST

(Population 1,011,900 – Census 2006)

Services based in Clare, Donegal, Galway, Limerick, Mayo.There are no dedicated residential services in counties Leitrim, Roscommon, Sligo,

Tipperary North

NAME OFSERVICE

NO SERVICES

NO.BEDS

AVERAGESTAY

ESTIMATEDANNUAL CAPACITY

NOTES

NONE N/A NONE

NO SERVICES NONE N/A NONE

NO SERVICES NONE N/A NONE

STABILISATION SERVICE

MEDICAL DETOXIFICATION UNIT

Cuan MhuireBrureeCo Limerick

10749

( 72 alcohol)

( 35 drugs)

(8 weeks

alcohol)

(13 weeks

drugs)

517

(398)

(119)

[Total 799 – NDTRS 2005]

Men and women.Adults and adolescents.Also deals with gamblingproblems -beds not ring-fenced,numbers treated forgambling vary, oftensecondary to alcohol.

RESIDENTIAL REHABILITATION

BushyparkEnnisCo Clare

13 30 days 134

[147 – NDTRS 2005]

Men and women.Also deals with gamblingproblems.

Cuan MhuireAthenryCo Galway

50 12 weeks 184 Men and women(ratio 1: 3 – women:men).

Adults and adolescents.Also deals with gamblingproblems.

COMMUNITY-BASED RESIDENTIAL DETOX UNIT

49 Estimate based on reported 1/3rd clientele with drug problems.

77

Hope HouseFoxfordCo Mayo

13/14 30 days 140

[140 in 2005, Source:

EATA]

Men and womenAlso deals with gamblingproblems.West and North WestConnaught catchmentarea.

WhiteoaksMuffCo Donegal

12 30-37 days 111

[17 – NDTRS 2005]

Donegal/Sligo/Leitrimcatchment area.

CenalocoMayo

16 At least 6months

27 Men only

Cuan MhuireGalway City

12 3-6 months 27 Men onlyHomeless

TOTAL 195 1086

TOTAL 4085% (n=34) men only

15% (n=6) women only

8283% (n=68) men only

17% (n=14) women only

Cuan MhuireLimerick City

6 3-6 months 14 Men onlyHomeless

Cuan MhuireLimerick City

6 3-6 months 14 Women onlyHomeless

STEP-DOWN OR HALFWAY ACCOMMODATION

78

Psychiatric HospitalsCarraig Mór, CorkCentral Mental Hospital, DublinCluain Mhuire Family Centre, DublinMental Health Service, SligoNewcastle Hospital, Greystones, Co. WicklowSt Brendan's Hospital, DublinSt Brigid's Hospital, Ardee, Co. LouthSt Brigid's Hospital, Ballinasloe, Co. GalwaySt Davnet's Hospital, MonaghanSt Dympna's Hospital, CarlowSt Finan's Hospital, KillarneySt Ita's Hospital, Portrane, DublinSt Joseph's Hospital, LimerickSt Loman’s Hospital, DublinSt Loman's Hospital, Mullingar, Co. WestmeathSt Luke's Hospital, Clonmel, Co. TipperarySt Otteran's Hospital, WaterfordSt Senan's Hospital, EnniscorthySt Stephen's Hospital, CorkSt Vincent's Hospital, Fairview, DublinVergemount Clinic, Clonskeagh, Dublin

Private Hospitals Hampstead and Highfield Hospitals, DublinSt John of God Hospital, DublinSt Patrick's Hospital, Dublin

General Hospitals with a PsychiatricUnitBantry General Hospital, Co. CorkCavan General HospitalCork University HospitalEnnis General Hospital, Co. ClareJames Connolly Memorial Hospital, DublinLetterkenny General Hospital, Co. DonegalLimerick Regional HospitalMater Misericordiae Hospital, Dublin

Mayo General HospitalMercy Hospital, CorkMidland Regional Hospital, Portlaoise, Co. LaoisNaas General Hospital, Co. KildareOur Lady’s Hospital, Navan, Co. MeathRoscommon County HospitalSt James' Hospital, DublinSt Joseph's Hospital, Clonmel, Co. TipperarySt Luke’s Hospital, KilkennySt Vincent's Hospital, Elm Park, DublinTallaght Hospital, DublinTralee General Hospital, Co. KerryUniversity College Hospital, GalwayWaterford Regional Hospital

General HospitalsBeaumont Hospital, Dublin 9Cavan General HospitalCork University HospitalEnnis General, Co. ClareLetterkenny General Hospital, Co DonegalLimerick Regional HospitalMater Misericordiae Hospital, DublinMayo General HospitalMercy Hospital CorkMerlin Park Hospital, GalwayMonaghan General HospitalNaas General Hospital, Co. KildareSligo General HospitalSt Columcille’s Hospital, Loughlinstown, DublinSt James’ Hospital, DublinSt Michael’s Hospital, Dun LaoghaireSt Vincents Hospital, Elm Park, DublinTralee General Hospital, Co KerryUniversity College Hospital GalwayWexford General Hospital

Appendix 4: Hospitals with a primary discharge diagnosis of alcoholic or drugdisorder, or a drug/alcohol principal procedure, who reported to the HIPE andNIPRS databases in 2005

79

Glossary

Assisted withdrawal The process of withdrawing a person from a psychoactive substance byproviding medication and psychological support. This allows theprocess to occur in a relatively comfortable and controlled manner.

Benzodiazepines The most commonly prescribed minor tranquillisers, known asanxiolytics (for daytime anxiety relief) and hypnotics (to promote sleep).

Buprenorphine (also known as Suboxone®, Subutex®, Temgesic®) is a pharmaceuticallyprepared opioid drug which may be used for the treatment of opioidaddiction.

Co-morbidity/Dual diagnosis The co-occurrence in the same individual of a substance use disorderand another psychiatric disorder.

Dependence Describes a compulsion to continue taking a drug in order to feel goodor to avoid feeling bad. When this is done to avoid physical discomfortor withdrawal, it is known as physical dependence; when it has apsychological aspect (the need for stimulation or pleasure, or to escapereality) then it is known as psychological dependence.

Detoxification (detox) Describes the way in which a drug, such as heroin, is eliminated fromthe drug user's body, often with the help of a doctor and/ or specialistdrug worker. This is often a gradual process and may take a number ofdays or weeks. It can involve the use of other drugs such as methadoneand buprenorphine and help deal with withdrawal symptoms. However,detox is only the beginning of the process of helping somebody to stayoff drugs. Other help such as counselling is usually required.

Dose titration The process of gradually adjusting the dose of a medication until thedesired effect is achieved.

Four-Tier Model of Care Framework for grouping drug and/or alcohol services into tiers whichcorrespond to the level of need of clients (see Chapter 3, p. 30-31).

Harm Reduction Focuses on “safer” drug use and aims to reduce the harm that peopledo to themselves, or other people, from their drug use.

Inpatient Unit Treatment service which includes detoxification/assisted withdrawal, butalso assessment, psychological interventions, harm reduction, relapseprevention and notably stabilisation. Ideally provided with 24-hour cover,seven days per week from a multidisciplinary clinical team under theleadership of a consultant in addiction psychiatry or other medically-qualified substance misuse specialist.

Minnesota Model Associated with the Alcoholics/Narcotics Anonymous 12-stepprogramme. It sees addiction as a disease, aims for long-termabstinence and includes spiritual as well as practical guidance.

Pharmacotherapy Treatment with prescribed medication.Polydrug use The use of more than one drug, often with the intention of enhancing or

countering the effects of another drug. Polydrug use may, however,simply occur because the user's preferred drug is unavailable (or tooexpensive) at the time

80

Primary Alcohol User A person who may use drugs but whose main problem is alcohol abuseor dependence.

Primary Drug User A person who may use alcohol but whose main problem is drug abuseor dependence

Rehabilitation (rehab) An umbrella term for the processes of medical and/orpsychotherapeutic treatment, for dependency on psychoactivesubstances such as alcohol and drugs. The general intent is to enablethe patient to cease substance abuse in order to avoid thepsychological, legal, social etc consequences of use.

SCAN The Specialist Clinical Addiction Network is a national network for UKaddiction specialists such as consultant psychiatrists, specialistpsychiatrists and associate specialists who work in the field ofaddiction.

Stabilisation Seeks to ameliorate the impact of chaotic drug use, particularly ofcocaine powder, crack cocaine and benzodiazepines, in addition toproviding opportunities for dose titration of methadone or buprenorphinein a secure monitored environment.

Substitution programme Treatment that substitutes a prescribed drug (e.g. methadone) for anillicit drug (e.g. heroin), and in doing so reduces craving and preventswithdrawal symptoms. The removal of the preoccupation with findingand using illicit drugs allows the person to focus on other problemareas in their life and to make use of psychosocial and other treatmentinterventions.

Therapeutic communities Operate a hierarchical structure which residents work through based onintense therapy sessions.

Twelve-steps A set of guiding principles for recovery from addictive, compulsive, orbehavioral problems, originally developed by the fellowship of AlcoholicsAnonymous (AA) to guide recovery from alcoholism.

Wernickle-Korsakoff syndrome A form of brain damage associated with alcohol misuse. The symptomsinclude confusion about time and place, drowsiness, poor balance,double vision, abnormal eye movements and ultimately memory loss. Itis treated with larger doses of thiamine (Vitamin B1) by intravenous orintramuscular injection.

Report of the HSE Working Group on ResidentialTreatment & Rehabilitation

(Substance Abuse)