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  • Calls for radical change to chaotic addiction services across Ireland

    Posted on March 25th, 2013 TimB No comments

    Existing guidelines for those working with opiate users are controversial and heavily criticised, and a report seen by MI recommends a radical overhaul of how services are delivered. James Fogarty investigates

    The struggle to both balance the books and keep the health services afloat is an all consuming one. Drug addiction services are perhaps one of the casualties of this focus. Although recent figures compiled by the Health Research Board (HRB) said the annual number of drug-related deaths and deaths among drug users in Ireland decreased from 652 in 2009 to 575 in 2010, problems remain. Budget reductions, a continued scarcity of services outside the capital, and concern over the ICGP’s opiate treatment guidelines have combined to make a difficult area of medicine even more challenging.


    The ICGP’s 2008 guidelines Working with Opiate Users in Community Based Primary Care have deeply concerned GPs working in addiction since their publication. A number of issues with the guidelines – its impact on patient care, the frequency and efficacy of urine tests, the reduction in methadone doses, and complaints about lack of consultation – became major sources of contention. However, the controversy has taken another turn in recent days. The Medical Independent (MI) has seen a copy of the yet unpublished ICGP-commissioned Evaluation of the Audit of the Methadone Treatment Protocol in Ireland. The document makes recommendations, which if followed, will radically change methadone treatment practices and governance structures in Ireland.

    Following interviews with GPs and other interested groups, the evaluation team, led by Dr Saket Priyadarshi, Senior Medical Officer, Greater Glasgow and Clyde Addiction Services, carried out the review last May.

    The evaluation found that the audit’s criteria were seen as “not currently evidence based, not conforming to practice in most other countries…inflexible and in some cases may be restrictive to recovery and person centred care. They are based on the 2008 guidelines, but not consistent with current evidence base”.

    “These findings relate mostly to weekly appointments, frequency of urine testing and dosing limitation of methadone to 80mg/day. Criteria measuring patient outcomes are not part of the audit and we agree with this view of the vast majority of stakeholders,” the document read, adding that it noted that a review of the ICGP guidelines was underway to integrate the recommendationsof Prof Michael Farrell’s report, The Introduction of the Opioid Treatment Protocol (See panel 1).

    It recommended that new criteria based on a review of the ICGP guidelines incorporating Prof Farrell’s recommendations should be developed, with as much opportunity for GP engagement as possible.

    Furthermore, the ICGP’s audit procedures should be reformed with criteria developed to include dropout rates, deaths and recovery indicators. Critically, it said that fora should be established where deviations from guidelines could be discussed.

    “There should be scope to improve the audit process and have enhanced opportunities to discuss individual deviations from criteria that are based on a safe, person centred approach, perhaps to a local clinical lead such as a GP coordinator, or in person at the audit review group (ARG).”


    Although the evaluation found that the ARG had clear administrative processes, terms of reference and a professional approach, it recommended a number of reforms.

    “A pre-meeting screening process involving the audit nurse and local GP coordinators would ensure only audits causing concern would be discussed at ARG and that GPs involved could be asked for clarification and/or invited to attend.”

    The evaulation also noted that post audit, a process of this type is already in place. The ARG is heavily dependent on the audit nurse for information and insight and the evaluation report recommended that the role of GP coordinators in the ARG be strengthened.

    It was also noted that the ARG does not have a regular GP representative other than GP coordinators, who are employed by the HSE, and that service users are not represented on the ARG. The HSE’s role in the ARG also needs to be clarified.

    “Are they monitoring a group they contract or is the HSE collecting information for purpose of contract monitoring or quality assurance?” it asked.

    Elsewhere, it was also found that the audit invitation letter should promote participation in a more positive and supportive manner, “with more emphasis on collaborative working and the audit’s importance in improving quality and reflective practice”.

    Following an audit, communication from the ARG should highlight the positives as well as areas for improvement and be clear about any resulting action plan, including timescales and responsible persons/agencies.

    Awareness amongst GPs that they are able to attend the ARG meetings, particularly for audits where criteria have not been met, should also be improved.

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