Violence and intimidation are threatening one of the best treatment options for drug addicts, writes Dr Muiris Houston, Medical Correspondent
The Methadone Treatment Protocol, first introduced in 1998, means thousands of former heroin addicts have been treated in a community setting, with enormous benefit to society, health professionals and individuals affected by drug addiction.
"It represents a huge improvement to what went on 10 years ago, when heroin was openly sold in front of my practice premises," one southside Dublin GP told The Irish Times.
Working in a four-doctor practice he reckons that half of the 40 patients they treat as part of the scheme are "super-stabilised", able to hold down full-time jobs and lead a relatively normal life.
However, not all addicts achieve such stability. Those treated by doctors in satellite clinics range across the entire spectrum of addiction (see panel below).
People recently released from prison, those with a cross-addiction to alcohol or benzodiazepines (sleeping tablets and relaxants) and patients with active psychiatric problems can be unstable. Such instability can render the person violent and unable to tolerate short-term hitches in the supply of methadone.
One northside Dublin pharmacist says 50 per cent of his methadone clients come from such clinics. "A typical problem patient may have had their medication changed or have fallen out with the clinic doctor and arrive at the pharmacy upset and angry," he says.
Recently, such a client became violent in the pharmacy, forced his way into the dispensary area, grabbed a bottle of methadone from a pharmacy assistant leaving her traumatised. But other attacks throughout the eastern region have involved more than just threatening behaviour.
In one satellite clinic a gun was held to the head of a staff member. In a separate incident a southside pharmacist was confronted by a person covered in blood who stabbed him with a syringe before stealing a quantity of methadone.
It is incidents like these that led the Irish Pharmaceutical Union to ask for a review of the Methadone Programme. In a submission to the Department of Health in September, 2002, it stated: "at this point in time there is no way of dealing with patients who are disruptive and abusive and the whole issue of discipline, including withholding methadone medication, is a litigious minefield."
In contrast to those working in health board treatment clinics, community pharmacists are not provided with security guards. "Security of staff and premises is a major issue and yet no proper consideration has been given to it," the IPU says. A spokeswoman for the union said yesterday: "None of these issues have been dealt with to date."
The problems outlined by individual pharmacists and the IPU appear to contravene a commitment given under section 16 of the original 1998 "Protocol for Initiation of Methadone Dispensing Service in Community Pharmacy". It states: "as far as possible, more difficult patients, those with dual diagnosis, in particular personality disorders, history of serious violence, alcohol problems or psychiatric disorders, will not be dispensed methadone by community pharmacists but will be treated at central level."
But another northside pharmacist told The Irish Times that "90 per cent of methadone patients are fine. It is the other 10 per cent who are causing a crisis within the system. We need Department of Health/health board protocols strengthened to deal with the situation".
Six years after its launch, the Methadone protocol may well be a victim of its own success. The latest figures show treatment facilities increasing by over a third in areas outside the Eastern Regional Health Authority (ERHA). An internal ERHA review of the programme for 2002/2003 says "there has been an increase in the number of patients being treated". It also noted a 13 per cent increase in the number of patients awaiting treatment in October, 2003, compared to a year earlier.
A recent report from the National Advisory Committee on Drugs (NACD) found it was seven to 12-times more cost effective to treat methadone patients in a community pharmacy setting compared to a State-run clinic. This finding underlines how important pharmacists are to the national drug treatment strategy.
Prof Tom O'Dowd, professor of community health and general practice, at Trinity College, Dublin, says: "the pharmacies are a crucial part of the methadone maintenance programme. The drug problem could not have been addressed without the community pharmacy. There is a need to have this recognised by the Department of Health and Health Boards."