I thank the joint committee for giving us the opportunity of appearing before it to discuss the contents of a report entitled, Addiction Recovery: A Contagious Paradigm, which has been circulated. I will start by giving an overview of Soilse, the addiction rehabilitation service, from which the report came. I will then go through the main issues related to the report in a question and answer format.
Soilse is the HSE's daytime drug rehabilitation project in Dublin’s north inner city. It was established in 1992 and works with people who are either preparing to detox or who have completed a residential drug treatment programme and are in the early stages of recovery. Our service users are former heroin addicts.
What is the status of drug use in Ireland today? In the 1970s, 1980s and 1990s the drug abuse problem was mainly opiate, primarily heroin, addiction. Today people are using not just heroin but also benzodiazepines, alcohol and other drugs. This is known as poly-drug abuse. Since the 1970s the response has been to treat opiate addiction by substituting methadone for heroin. Known as the public health model, it seeks to reduce harm to society by reducing the need to commit crime to get heroin and eliminating the use of heroin and the sharing of needles. Prescribing methadone and needles exchange reduce the health risks associated with heroin addiction. About 10,000 people are in methadone treatment, one third for more than a decade. Their struggles are captured in the case studies in Addiction Recovery: A Contagious Paradigm and the characteristics of the four case studies are very telling. All have family dysfunction, were early users of drugs and early school leavers, grew up in chaos, have been on methadone and benzodiazepines programmes, have been associated with prison or charges, have suffered homelessness, health problems, suicides and death within their immediate circumstances.
What can recovery offer? In Ireland and internationally there is an emerging focus on recovery from addiction. This view of recovery sees services being re-framed around service users. Unlike the public health model, a recovery model puts service users at the centre of treatment and rehabilitation responses and looks to enhance their quality of life by involving them fully in their own care. This means reorienting treatment and rehabilitation services towards a recovery paradigm, recognising that service users' voices are important and enabling them to direct their own goals and thus change and re-frame their lives. Essentially, it is a service user, service-led response.
What evidence supports this approach? The concept of recovery was first introduced in the addiction research literature in 1999 with the work of Granfield and Cloud. They showed how 46 individuals had been able to overcome their addiction independently of services primarily because they had had what Granfield and Cloud called "recovery capital"; in other words, pre-existing jobs, qualifications, income, family support, social networks and a home. Subsequently, Cloud and Granfield published their theory of recovery. It comprises four elements: social capital – relationships, supports and groups to which we belong; physical capital – property and income; human capital – education and skills, positive health and aspirations; and cultural capital – values, beliefs and attitudes. Focusing on these assets helps a person to build recovery capital. This approach has been taken in England, Wales, Scotland and further afield as the main organising construct for addiction services. The approach in Scotland is that recovery should be the explicit aim of all services providing treatment and rehabilitation for those with problem drug use and the service delivery principle is that recovery should be the focus of care. Assessment and recovery plans should address the totality of people's lives.
Does Ireland want to move towards a recovery framework? Addiction Recovery: A Contagious Paradigm sets out the case in Ireland for a move towards a recovery framework to deliver addiction services. Over a decade ago the mid-term review of the drug strategy in 2005 showed that stakeholders felt service users should not be kept on methadone indefinitely but assisted in "moving on"’ towards recovery and social integration. The report of the working group on rehabilitation that emerged from the mid-term review elaborated on this and signposted the key elements of social integration: housing, work and education. These are the key indicators from the European Monitoring Centre for Drugs and Drug Abuse. It stated the overall aim of services should be "to maximise the quality of life, re-engagement, independent living and employability of the recovering problem drug user in line with their aspirations".
In 2011 Martin Keane conducted research in Soilse and showed how an adult learning approach that fused education and recovery could help service users to develop recovery capital, progress in education into college and successfully move away from the drug culture. The HSE Dublin north addiction service review in 2013 recommended this recovery focused approach and the addiction services in north Dublin are putting structures in place to enable recovery. In the review recovery was defined as "a person-centred journey enabling people to get a sense of control over their own problems, the services they receive and their lives and providing opportunities to participate in wider society".
The national drug rehabilitation implementation committee's evaluation in 2013 which was authored by Professor Barry also reviewed the mechanisms which would underpin a recovery approach and found broad support for them. Therefore, at both a practice and policy level, momentum has been building in the past decade towards a recovery response in Ireland. The HSE's 2015 primary care division operation plan states each service user should have a key worker and care plan, that service users should be transferred from HSE clinics to GP surgeries and that regular client satisfaction surveys should be carried out. Again, it puts the service user at the centre of the process.
Addiction Recovery: A Contagious Paradigm describes in detail the principles of recovery which give shape to the emerging framework and also supports each of the principles with a substantial amount of research and literature. The principles are the key drivers of many of the responses in the countries I have listed. There are 12 principles, the first of which is that there are many pathways to recovery. Again, we speak in the document about natural recovery, about which Sheedy and Whitter spoke. Granfield and Cloud talk about recovery capital. Our own work in Soilse is about a continuum of care. There are other forms of recovery, for example, fellowship recovery and Christian enlightenment recovery.
The second principle is that recovery is self-directed and empowering. The paradigm shift means that the service user is the agent of his or her own change and fully involved with the goals and targets being addressed. When I thought about coming here today, I remembered how during my early days working in this area a man had broken down in a group and began to cry. I asked him why he was crying and he said it was the first time in 15 years that he had been asked his opinion. Very often people are treadmilled through processes and not actually engaged at their centre.
The third principle is that recovery involves a personal recognition of the need for change and transformation. One of the big goals people will have is to move from being in services or treatment to abstinence. Again, McKeganey said 56% of service users in Scotland saw this as the type of transformation they wanted. The third principle is that recovery is holistic. It is not one-dimensional treatment but concerns broader quality of life issues. Again, a process of life change involves the physical, social, emotional, spiritual and mental health needs of the individual. That is what the process of recovery should work towards.
The fourth principle is that recovery has cultural dimensions. There will be drug problems in other groupings such as Travellers, the LGBT community and new communities and cultural dimensions that need to be addressed. Our own people face challenges when they leave the safety and security of our services. In his research Keane looked at how these cultural dimensions changed the person.
The fifth principle is that recovery occurs in a continuum of improved health and well-being. De Maeyer talks about quality of life and states improved health and well-being means new relationships, being independent, having work and feeling good - having a meaningful life. These are basic, simple things, but to a recovering drug user, they are imperative.
The sixth principle is that recovery emerges from hope and gratitude. People in recovery become models of success. In communities where there is little positive at which to look in terms of the drugs problem people who become drug free, get their lives back together, find work, get back with their families and give back in terms of voluntary activity are seen as models of success and inspire others.
The seventh principle is that recovery involves a process of healing and self-redefinition. Owing to the needs I mentioned and the characteristics of addiction, multiple recoveries are needed and lead to complete identity transformation.
The eighth principle is that recovery involves addressing discrimination and transcending shame and stigma. Drug use discredits identity. Therefore, there must a complete shift in social functioning which is facilitated by the pursuit of mainstream activities.
The ninth principle is that recovery is supported by peers and allies.
When people get into recovery, they rekindle old relationships and form new ones, find a sponsor and receive family and community support. Again, there is a massive social support network available. People who interact with the services and work towards recovery will seek strength from others in the services and the groups with which they are involved. Recovery involves rejoining and rebuilding life in the community. On page 35 of the report Buchanan, in relation to the wall of exclusion, is quoted. The vast majority of service responses work below what is termed the line of control into the area of chaos. This is where treatment is focused in the main.
There is a disparity in terms of the resources devoted and attention paid to support and recovery. One of the contentions is that the paradigm should shift to prioritise recovery. Recovery is a reality. The document was launched in the Mansion House in July, at which time I recall Mannix Flynn saying there was such a thing as "recovered". It is so simple a word, but it is so real and telling. Through my work over many years I have met hundreds of people who have recovered. However, given the phenomenal level of stigma attached to drug addiction, they are unwilling to appear before the committee or on camera. When we asked a few people how they felt about appearing before the committee, they said they could not do so because of their families, children and so on. In terms of recovery being a reality, Sheedy and Whitter reckon about 58% of people can achieve recovery. I know from research undertaken by Soilse that the outcomes for those who recover and regain a holistic quality of life when drug free are significant. These principles were put together after 20 years of research and widespread consultation. They are well grounded and scientific.
I will now move to how recovery services operate in other countries. The United Kingdom, including Wales and Scotland, the United States and Australia have recovery academies which are groups of people, including researchers, service users, families and community support workers, who come together to research and advocate on behalf of those in recovery. Recovery champions are people who are positive role models in the community who are in recovery, icons for the possibility of recovery and drivers of change. Recovery coaches are people who give advice and support on addiction and life issues. This is a major plank of the support provided for people in other countries getting into recovery. Fellowships such as Narcotics Anonymous, Alcoholics Anonymous and Gamblers Anonymous are operational countrywide. In other countries events such as International Recovery Month are celebrated. In September last year a parade was held in Manchester to celebrate recovery. This shows that other jurisdictions have a better infrastructure in place and that the paradigm has moved more considerably towards this. Recovery infrastructure such as cafés and houses is common in many of the main towns in the United Kingdom where more than £1 million has been provided for the development of a new facility in Birmingham called "Recovery Central". This facility is due to open this year and will include a one-stop-shop for recovery information and services, including work experience, volunteering, employment opportunities, community-based social enterprises, furniture restoration, bike repairs, car maintenance, property maintenance, an art and design studio, a recording studio and a drama studio. It is a creative holistic response. As I said, the facility will be called "Recovery Central", an icon that will send the message from a high street location that recovery is important and possible.
I will focus on how all of the aforementioned relates to Ireland. Soilse is an example of services implementing a recovery response. We believe people have fantastic potential and will get their lives back together and achieve things that they would never have dreamed of because their expectations had been reduced by the fact that they had been in treatment for so long. Soilse is part of the HSE addiction services' continuum of care. We provide clinical pathways, which means that the service can stabilise people and prepare them for detoxification in an in-house residential detoxification unit, Cuan Dara. Drug free residential treatment follows in Keltoi. This is followed by a drug free day time programme in the Soilse facility in the north inner city. We are in partnership with the VEC and thus have a balance of therapeutic and educational inputs. The service has been vocationally designed and developed. We are very clear on the outcomes we want to achieve. We want people to abstain from drugs and alcohol; to have support structures around them in terms of counselling, after care, meetings and sponsors and to become involved in day time or education programmes. That is a recovery package.
Soilse is also involved in an innovative European Union lifelong learning project called RECOVEU. It involves five countries - Ireland, England, Cyprus, Romania and Italy. Following a review of policy and practice in these countries it became evident that there was a dearth of channels and opportunities for people from an addiction background who wished to move to the mainstream, be it in the area of work or education. A leaflet setting out where we are at in that regard has been circulated. We are about half way through the project and the real work begins in the next couple of months. What we are trying to do is design facilitation packs and learning modules that will facilitate people in their journey to recovery and into college.
Soilse uses recovery coaches who are trained by the Finglas addiction support team and Dublin City University. We have eight recovery coaches who help people with resourcing, advocacy and lifestyle issues. Soilse also supports International Recovery Month and in this regard, held a number of activities in Dublin last September which, unfortunately, were not widely covered by the media. We held three large events, including a conference in the Ashling Hotel, a health and fitness event in the Phoenix Park which was attended by more than 200 people and various social activities. A lot happened during recovery month. We need to focus on making people aware that there is a recovery community and movement and getting them to buy into it.
Soilse has been consistently involved in research, including, as I mentioned, the Keane research and has also contributed to research by the Northern Area Addiction Service. The document made available to members is the result of two years' work.
Many service users and service providers see recovery as a viable option. I engage consistently with service users, many of whom have fantastic ideas. In terms of the outcomes in the four case studies, one of those involved has travelled the world, while another spent 15 Christmases in prison at great cost to the State. He is now in recovery and cannot believe that when his neighbours go on holidays, they leave the keys to their houses with him. There are many good anecdotes that support this transformation. Recovery offers hope and a vision for those caught in services long term. The model will challenge fatalism and stigma. As I said, stigma is a huge issue. Recovery also contributes to building inclusive communities and options for those who want to change.
The document before the committee was triggered by a symposium which brought together more than 100 people in recovery to talk not about war stories or the desperation and depression associated with drugs but about their futures and what they would like to see happen. The solutions and ideas proposed are embodied in our recommendations. They include the use of recovery champions, coaching, existing community assets and a reconfiguration of some services to ensure they will be more holistic and outcome focused. The emphasis is on solutions. The desired outcome of today's meeting and as a result of the document is that recovery will become a central plank of the drugs strategy review which is due for completion next year. As I said, the report reflects stakeholders' views and their principles, case studies, workshops and literature on recovery.
I will be happy to answer questions members may have.