THE RECENT CABINET reshuffle has seen responsibility for the issue of substance misuse return to a senior Ministerial brief, as Minister Varadkar takes direct responsibility under the health portfolio. This news has been welcomed by Non-Government Organisations (NGOs) who operate drug and alcohol services, as it’s an important step in keeping substance misuse close to the top of the political agenda.
However, it is also important to remember that drugs and alcohol are part of the Minister’s portfolio in the context of a health budget which is significantly overspent, and in circumstances where saving money across state supported services very much remains the order of the day. In this article, I look at some key issues to consider in ensuring that addiction services provide both high quality care for service users and value for money for the taxpayer.
We need to follow the evidence
How best to deal with drug and alcohol use is, at this point, fairly well understood. Drug and alcohol use is both an unavoidable reality of the human condition and an expensive burden to states on a number of fronts, not least in healthcare and costs in relation to lost working time. As a result, it has been the focus of reasonably extensive studies in a number of disciplines, from economics to psychiatry, and there are reputable sources for good practice readily available. The European Monitoring Centre for Drugs and Drug Addiction has a best practice portal, for instance. Both the National Institute of Clinical Effectiveness in the UK and National Institute for Drug Abuse in the US publish good practice guidelines on a variety of issues related to the treatment of addiction.
Simply put, there is reasonable consensus in relation to ‘what works’, and this is where the focus needs to be. Modern addiction services need to be able to point to the evidence base for what they do; they need to ground what they’re doing in the academic literature. Being there for people, being empathic, being supportive, being advocates for those that use addiction services – these are all taken as given. They are necessary conditions to running a good service; but they are not sufficient.
More needs to be done, and it is up to everyone within the addiction sector to do more. Addiction services need to be strategic in how they spend their time. There is a need for flexibility in work practices so that we can ensure that the service users of addiction services are receiving high quality care in line with the best available evidence. In this regard, it is worthwhile remembering that one of the best ways for services to obtain and retain funding is to show objective evidence for the efficacy of the interventions that they provide.
We need to find efficiencies
We need to not only question the services that we provide, but also how we provide them and the systems that we use to administer them. ‘Top down’ and ‘bottom up’ approaches to service implementation have often been cited as opposing methodologies, the reality is both are required. What services are required is largely a matter of demographics and population health. For example, once it is known that a town has an issue with injecting opioid use, no discussion is needed on whether interventions like needle and syringe programmes or opioid substitution treatment are necessary – they are. Of course, it is still necessary to provide those services on the ground, and in a manner that fits the profile of service users in the area. This is where local knowledge is best used – in the how, as opposed to the whether a service is delivered.
The reality is there is a finite amount of funding available – as much as the interventions we pursue should be those which are evidence based and have the maximum impact for the cost, so it is incumbent on us to ensure that the systems and organisations which decide on and implement services are run as efficiently as possible.
We need to be brave
In following evidence and finding efficiencies, we need to be brave. We need to be willing to innovate – there are evidence based interventions which are commonplace elsewhere, but are not yet being implemented in Ireland.
For example, medically supervised injecting centres are widely used interventions in Europe, Canada and Australia where public drug use and unsafe disposal are public health concerns, such as is the case in Dublin. Naloxone is widely used in community settings, including by certain police forces in the US as an intervention to counter opioid overdose. However, it is not yet available in Ireland, other than in very limited circumstances.
Finally, there are residential stabilisation services in the UK where presenting need is the main criterion for entry; this is not the case in Ireland, where most services require a certain level of stability in type or level of drug use before residential treatment is a possibility. Such interventions need to be trialled, evaluated and either discontinued or continued depending on their impact. Naturally, to do so will require change. Funding will need to be redirected, with the overriding focus on a system that provides the best outcomes for service users and the best value to the taxpayer.
Thus, for service providers, following evidence and finding efficiencies cuts both ways. In calling for what is right, like the delivery of services supported by the strongest evidence, addiction services have to be prepared to change. Addiction services need to be prepared to lobby for brave decisions, and recognise that what is best for those that use their services may mean significant change for individual organisations.
If, as taxpayers, we are only going to fund those interventions that are evidence based and can show their value, the logical corollary is that we are not going to fund those that are not. And, if that is the position, then addiction services need to be brave; and the government needs to be brave too, because it is government that will take the political brunt of (de)funding decisions, as the recent difficulties around the Scheme to Support National Organisations shows. In considering this, it’s important to note that reform need not be ad hoc; there need not be any unstructured and unplanned withdrawal of state funding; the process can be measured. A transparent and open tendering process is one possible route.
Tony Duffin is the Director of the Ana Liffey Drug Project. The Ana Liffey provides social and health services to over 3000 individuals every year, most of whom use drugs problematically. In addition to this, Ana Liffey run a number of online and digital services, including the aldp.ie and drugs.ie websites. You can contact Ana Liffey onFacebook, Twitter, and at info@aldp.ie.
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