Joint Committee on Drugs Use díospóireacht -
Thursday, 17 Oct 2024

A Health-Led Approach: Discussion (Resumed)

Senator Lynn Ruane took the Chair.

An Leas-Chathaoirleach

We have apologies from Deputy Stanton and Senators O'Hara and Seery Kearney. Deputy Quinlivan is substituting for Deputy Gould. Members will come in and out given they are needed at other meetings.

Parliamentary privilege is considered to apply to the utterances of members participating online in a committee meeting where their participation is from within the parliamentary precincts. There can be no assurances in relation to participation online from outside the parliamentary precincts, and members should be mindful of this when they are contributing.

I welcome all our witnesses and wish them a good morning. The topic of this meeting is a health-led approach to drug use policy. Committee members are obviously very interested in hearing from experts in drug policy. We have heard from various sectors over recent months and I hope we can continue over the next few months to meet all the stakeholders. For this session I welcome the representatives from the school of nursing and midwifery in Trinity College: Dr. Peter Kelly, assistant professor in mental health nursing, Mr. Barry McBrien, assistant professor, and Professor Catherine Comiskey, professor in healthcare modelling and statistics. I thank them for agreeing to be here.

I invite Dr. Kelly to give his opening statement.

Dr. Peter Kelly

I thank members of the committee for the invitation to present to them. I am an assistant professor in mental health nursing at the school of nursing and midwifery in Trinity College Dublin. I have almost 20 years of clinical experience working with people who are dependent on drugs and alcohol and nearly ten years as a researcher in this area. I am a founding member and former chair of the Ireland chapter of the International Nurses Society on Addictions where I currently sit as a board member.

I also currently sit on the national oversight committee for drugs. IntNSA submitted 13 recommendations to the Citizens' Assembly on Drugs Use, all of which relate to supporting a health-led approach to people who use drugs. IntNSA continues to advocate for the implementation of these recommendations.

Drug treatment services are part of a complex ecosystem composed of many interdependent parts. This ecosystem can support the delivery of a health-led approach to drug use. To help us to conceptualise how that ecosystem might work, we could consider a range of desirable practices, many of them evidence-based, as seeds, such as, for example, collaborative care plans, the non-punitive use of drug testing, trauma-informed care, and human rights-based and person-centred care. The growth of these seeds will always remain aspirational unless appropriate attention is given to the ecosystem in which these seeds can grow. All too often in Irish drug policy and treatment systems, we have tried to plant the seeds, or a range of evidence-based practices, while overlooking the capacity of the ecosystem that determines their growth.

While a lot of good work happens in our services, and there is evidence to show that some services have become more person-centred in the past decade, there is too much evidence of our failure to implement good practices. Many important recommendations have not been implemented and there is little oversight, with no consequences or accountability. It is fair to say that stigma, discrimination and punitive practices are implicit within the policies, structures and practices that underpin the delivery of treatment services for people who use drugs. That is evident in a range of areas.

While the health-led emphasis within the current national drugs strategy is welcome, the strategy itself is not characterised by specific and measurable targets under each action, making it more challenging to hold lead agencies to account. Although some progress has been made, there is significant room for improvement in the processes that underpin the oversight and governance of the current strategy.

Another systemic example of stigma is that most services that cater for other marginalised groups, such as older adults, those with mental health difficulties and people with intellectual disabilities, are subject to independent inspection, while services that cater for people who use drugs are not. While most front-line workers are benevolent and have at heart the best interests of people who use drugs, anecdotal and research-based evidence of poor, disrespectful and punitive practices are all too common and go unsanctioned.

Another example is that the pay, tenure, career progression and workloads of professionals and other workers in addiction services are often unequal when compared with those who work in mainstream services. Service models are also too often determined by tradition rather than clinical effectiveness or best use of resources. Many recommendations, such as those contained in the Farrell report and the national drugs rehabilitation framework, have not been implemented. While many other areas of healthcare, such as cancer care and other mainstream services, have a strategic workforce development strategy, there is not one in place for people who use drugs.

Closer scrutiny of the journey of nurse prescribing of opiate substitution therapy, OST, since the initial legislation was drafted in 2007, tells an important story about the implementation and oversight of drug policy in terms of who makes decisions, why, and who does or does not hold decision-makers to account. In 2010,an independent review by Professors Michael Farrell and Joe Barry of the opiate treatment system in Ireland gave a clear recommendation to develop nurse prescribing of opiate substitution therapy, and an exploration of this practice is mentioned in the current national drugs strategy. Yet today in Ireland, a nurse prescriber can legally prescribe opiates for a range of conditions for someone dependent on opiates, but not for opiate dependence itself. There is no doubt people who use drugs have been and are put unnecessarily at risk because of an unwillingness to develop this safe and cost-effective model.

To ensure that a health-led approach to drug use can be supported, it is imperative the personnel, structures and oversight of the drugs strategy are independent from the delivery of the strategy itself. As per the recommendations of the Citizens' Assembly on Drugs Use, we must implement a strategic workforce development strategy. This should include the mapping and resourcing of services and their staff to population needs, including prison populations, and a comprehensive long-term recruitment, education and training strategy with meaningful peer involvement.

To ensure equal access to healthcare across the country, greater standardisation of service models may be necessary. Drug treatment services must be subject to independent oversight to underpin this strategy effectively. Only when a whole-systems approach is used can we ensure we will have an ecosystem that can sustain the growth of a health-led approach.

An Leas-Chathaoirleach

I thank Dr. Kelly. I now invite Mr. Barry McBrien to give his opening statement.

Mr. Barry McBrien

I thank the committee for the opportunity to present to it. I am an assistant professor in general nursing in Trinity College Dublin. I also work as an advanced nurse practitioner in a large urban emergency department in a very socially deprived area of Dublin. Prescribing is a core component of my role and many of the patients I manage have an opiate dependency syndrome. These patients require opiate substitution therapy to be prescribed as part of their consultation. Although I can prescribe opiates to this cohort, I do not have the authority to prescribe opiate substitution therapy, which negatively impacts on a patient's clinical outcome.

Nurse prescribing was legalised in many countries around the world, including the United States of America in the late 1960s. In Ireland, nurse prescribing commenced in 2007, based on the recommendations in the review of nurses and midwives. Currently, there are 1,945 registered nurse prescribers in Ireland. This number is set to increase due to policy drivers such as Sláintecare that require additional nursing posts, including clinical nurse specialists and advanced nurse practitioners, where prescribing is essential.

Studies have examined nurse prescribing from a variety of stakeholder perspectives, including patients, prescribers and the wider nurse community in Ireland. These studies reported that patient groups benefit from nurse prescribing. This is achieved through improved symptom management and care that is more efficient. Drennan also reported that prescribing was perceived as a beneficial practice. The benefits included patient satisfaction, comprehensive medication education and reduced waiting times. Because of nurse prescribing, the intent of patients to comply with medication increased and, importantly, the number of healthcare professionals the patients had to interact with during an episode of care was reduced, which in turn reduces the potential for conflicting advice.

In Ireland, nurse prescribing is delivered through open prescribing whereby nurses can prescribe any drug from an agreed protocol, including opiate-based medication. However, in the case of patients with opiate dependency syndrome, nurses cannot prescribe methadone as an opiate substitute. The impact of this is that patients will either leave the hospital setting before their treatment is complete to source methadone, or a doctor will be called away from critical clinical work to prescribe the methadone. Internationally, the safety and efficacy of nurse prescribing of OST and methadone is well established, and its expansion to the Irish context can provide a range of advantages to people who are dependent on opiates and to the healthcare settings they attend. Consequently, there is an urgent need to change legislation in order that nurses have the authority to prescribe OST and methadone.

I thank the committee. I am happy to answer any questions related to nurse prescribing in the context of OST or methadone.

An Leas-Chathaoirleach

I thank Mr. McBrien. I invite Professor Comiskey to make her opening statement.

Professor Catherine Comiskey

I thank the committee for the opportunity to present to it. I am the former chair of the European Union's scientific committee of the European Monitoring Centre for Drugs and Drug Addiction, EMCDDA. I am the ministerially appointed academic expert to the national oversight committee for the implementation of the national drugs strategy. I have acted as an expert consultant to the United Nations Office on Drugs and Crime, UNODC, and I have also been an external consultant to the United Nations International Narcotics Control Board, INCB. I am the sole author of two books: Addiction Research and Evaluation and Addiction Debates, published by Sage. I have also published more than 150 research papers, including work on estimates of prevalence. I was the first person to look at the number of people using heroin in Dublin in the late 1990s. I also published a research paper on treatment outcomes. I was the first person to show that treatment works. I was also the first person to look at ageing and opiate use. In addition, I was the first person to quantify and examine the children of parents who use substances. I am also a teacher and professor at the school of nursing and midwifery at Trinity College Dublin. I hold a PhD in biomathematics, epidemiology and statistics and I have a primary degree in mathematics and philosophy. I like to think I know how to read, write and do arithmetic, the three Rs of our educational system. On the personal side, I am a wife and a mother of four almost adult children. The reason I told the committee all of that is to give the background to the research, how I came to it, and the credibility of the research.

Given my background, I would like to speak not only about research but about policy and the impact of our collective policy and societal decisions. There are three main points I want to make: first, we must tackle stigma; second, I urge the committee to implement progressive policy; and three; I urge the use of independent research evidence and education. Those three points speak to the two points my colleagues have made.

If we are successful in developing progressive, evidence-led policy, then tackling stigma and improving education will also be achieved. I remind the committee that we as a country have done this before and I believe we can do it again. Let us consider the case of Patricia, who in my view is a hero. She was born in 1965, before we had these progressive policies, and she is currently 59-years-old if she is still alive. This is a real person I have come across in my research a number of times.

When she was seven, an age when most little girls were preparing for their first holy communion and were excited about their new dress, Patricia was sexually abused. We have addressed that now in our country and are working on that on an ongoing basis. When she was 15 in 1980, as most were thinking about school, friends and the pending junior cert, Patricia first injected drugs. The junior cert results were released last week. Can the committee imagine what Patricia was doing when she received her junior cert results? She was injecting drugs.

At the age of 20 in 1985, while same-sex partnership was a criminal offence and would remain so until 1993, Patricia had her first relationship with another woman. This was another reason to criminalise her and add stigma to Patricia; we let her down. At the age of 24 in 1989, when homosexuality was still illegal and AIDS raged across the globe, after many relationships with men and injecting drugs, Patricia was diagnosed as HIV positive because we did not have the needle exchange at that stage. At the age of 45 in 2010, when harm reduction was supposedly the prevailing treatment philosophy, Patricia, a woman who we remember had been sexually abused, was still required to undergo supervised urine screening before she was given her methadone.

This country has tackled many of these past challenges within our society. It is time now to be progressive once again and enable evidence-informed policy in nurse led prescribing - our research has shown people want it and it works and I can quote that research for committee afterwards if it wants. It is now time to tackle decriminalisation. I am not telling the committee to decriminalise but we need to tackle it. We need to reduce community and personal stigma, because communities are also stigmatised as well as people, and expand opportunities for addiction research and education to address Dr. Kelly's point about the workforce.

We are entering an era of global political and societal transformation which we see through our politics. I was at the UN last week and listened to how that shift is happening. We have a collective responsibility to be future ready. I really believe that because the future is actually now. I urge the committee to be progressive in their policy - the research is there - and I am happy to answer questions on the research as best I can.

Deputy Mark Ward

I thank all the witnesses for coming in. I do not know if Dr. Kelly remembers me but I was in his class in 2012 in UCD. I tried to see if he was outside and I did not recognise him but I did when he came in to speak. It is good to see him again after the council on intervention skills in UCD back in 2012. That is neither here or there.

My first question is to Mr. McBrien. He mentioned nurses can prescribe opioids but they cannot prescribe opiate substitutions.

Mr. Barry McBrien

That is correct.

Deputy Mark Ward

That makes no sense to me. The thing about common sense is that it is not very common but that is something we absolutely need to challenge. Has Mr. McBrien had any conversations with other nurse practitioners who are able to prescribe and do they share the same view as him? Do they see any challenges in prescribing opioid substitution therapy?

Mr. Barry McBrien

As I say, the prescribing in Ireland is delivered through open prescription. Effectively, we can prescribe any medication that we want. In a very practical sense, if somebody comes into me and they are opioid dependent and I need to do a procedure, I can prescribe IV morphine to them, which is effectively an opiate. If they then need to wait for admission to hospital, I need to prescribe their methadone. I cannot prescribe their methadone and I cannot complete their episode of care. What effectively happens is the patient will leave the department and try to source methadone. Usually, that is not sourced in a pharmacy; it is sourced from the street and there are huge complications with that because we do not know what is in that methadone.

The patient then comes back with additional problems and additional needs. It has a really negative impact on the patient. From the perspective of nurse practitioners and the perspective of prescribers, they cannot see any difficulty with it at all. They do not understand why we cannot prescribe methadone. In fact, I teach nurse practitioners in Trinity College Dublin and I spoke to one of them about this on Monday. She said if we could prescribe methadone, it would be hugely positive and would improve waiting times and access to methadone clinics, etc. I cannot identify any obstacles and it is really something that is urgently needed.

Deputy Mark Ward

If somebody in the situation Mr. McBrien described came into his service and they were already on a methadone prescriber programme but they had to get out and get their daily doses, whatever it might be, is there any co-operation between his department and the methadone dispensers? Does that work in tandem at all?

Mr. Barry McBrien

If they come into the department when they need it, I need to call a senior doctor away because it cannot be a junior doctor. I have to call a senior doctor away from the department and I work in an emergency context; that doctor could be dealing with critically ill patients. That is all then delayed.

The doctor has to come, replicate everything I have done such as taking the patient's history and medication history. That leads to a very long telephone call with the methadone centre to identify how much methadone the patient is on, which protracts everything as well. It really has massive workforce implications as well because we take people away from critical work to do things that nurse prescribers could do.

Deputy Mark Ward

Dr. Kelly mentioned at the start he made on 13 recommendations to the citizens' assembly. Were they all accepted or were any barriers faced in getting some of them accepted?

Dr. Peter Kelly

That is a good question. The recommendation on workforce was carried and I am not actually sure about the rest. We made another recommendation about an independent inspectorate and I have not seen any progression on that specific one. I need to re-examine the rest of the recommendations to give a clear answer on that.

Deputy Mark Ward

Did Dr. Kelly meet any barriers when speaking at the citizens' assembly? What was the feedback on the recommendations he put forward?

Dr. Peter Kelly

When I presented at the citizens' assembly, I did not specifically present on that submission. I presented on the workforce piece. There was massive interest in governance and oversight of the drug treatment system. There definitely was an appetite for a strategic workforce development strategy but the operationalising of that is really complex. I found it difficult to articulate that and I do not even know myself exactly how that would work. There are documents and guidelines on it but they have to be adopted to the nuances of the Irish context.

There is a general structure that people mostly understood but the piece on strategic workforce development was carried into the recommendations of the assembly.

Deputy Mark Ward

Professor Comiskey said we should enable evidence-informed policy and nurse-led prescribing and she has research to support that. She said she wanted to expand on that research.

Professor Catherine Comiskey

There are two pieces to that. I did a study in north Dublin and looked at the health and well-being of 131 people in opioid substitute treatment. I left an open question at the end: is there anything else they wanted? I did not ask about nurse prescribing and a load of people came back to me and said we want our nurse to prescribe. They do not see the doctor.

I did not look for that; it came to me. We were really surprised about that because we looked at their health, well-being and mental health and asked them if there was anything else they wanted to add. Out of the 131 people, many came back and said they wanted to work more with our nurse and they wanted the nurse to prescribe. The nurses understand them and they want to engage with them.

Being academics, we then went and did some research on this aspect. We looked at all the international literature on nurse prescribing for people on methadone. It works. It works in other countries and is cost-efficient. We published that work. I am able to say I would support this because the research has supported it. It actually came to me. I did not go looking for it.

Deputy Mark Ward

It is anecdotal.

Professor Catherine Comiskey

Yes. I was delighted. I thought, "Gosh, people know what they want".

Deputy Mark Ward

It is fantastic. I thank the Chair.

An Leas-Chathaoirleach

The Deputy can have another ten minutes. The clock was not working.

Deputy Mark Ward

I was not sure what the time was, but I am fine.

An Leas-Chathaoirleach

Next up, we have Senator Mary Fitzpatrick.

Senator Mary Fitzpatrick

I thank all the witnesses for coming in and for their submissions. Professor Comiskey made one comment I would like to understand better. She referred to tackling decriminalisation but do not decriminalise. I think that is what I heard.

Professor Catherine Comiskey

I said I am not telling the committee what to do.

Senator Mary Fitzpatrick

Okay. What would the Professor's opinion be?

Professor Catherine Comiskey

I rarely give an opinion. I give the research because I am a professor. I am on this EMCDDA scientific committee and I have been there for ten years. I am on the new committee as well, because it brought me back. The EMCDDA looked at this issue not once but twice. It has looked at young people aged between 18 and 30 and cannabis use. It has said-----

Senator Mary Fitzpatrick

I am sorry for interrupting. It is specifically looking at decriminalising the individual.

Professor Catherine Comiskey

Yes. It has looked at all the different policies and to see if we have increased cannabis use where we have reduced the penalties. The answer has been found to be "No". The research looked at where we have had increased penalties and made them worse to see if we have decreased use and if there is a relationship. It was found there was not a single relationship. The number of people going to use cannabis has nothing to do with the legal system. People are going to use it or not use it.

Senator Mary Fitzpatrick

Okay.

Professor Catherine Comiskey

May I say a little more?

Senator Mary Fitzpatrick

Yes.

Professor Catherine Comiskey

I am also doing some research on prevention. The Government gave out five big grants for work on prevention and I am involved in two of them. I have been learning about European prevention. Regarding what Mr. McBrien and I were talking about this morning, it is not about just saying no. That does not work. It is about giving young people the skills to make informed decisions. In the context of all the preventions now, the evidence refers to showing young people how to make a decision. An example would be if someone were asked if they would like another drink and replying, "Ah no, my father is collecting me and he'd kill me". Other examples would be someone being asked if they wanted to smoke something and replying, "Ah no, I have football in the morning" or if it was suggested having sex, someone replying, "No, if my mother found out, she'd kill me". It is about giving young people the resilience and not about the legal approach. It is about giving young people resilience. If we give them that, it will carry over to consent, alcohol and drugs. This is what I am seeing in the research. The EMCDDA has looked at this issue twice.

Senator Mary Fitzpatrick

I thank Professor Comiskey for that comment. Turning to the nurse prescribing issue, I am not very familiar with health legislation. I cannot understand why clinical decisions would be captured in any legislation. Those are for clinical professionals to make. Can Professor Comiskey please explain to me why it is the legislation that is dictating nurse prescribing of methadone?

Mr. Barry McBrien

It might be better to ask Dr. Kelly this question.

Dr. Peter Kelly

I have a timeline here.

Senator Mary Fitzpatrick

No. I got the timeline and read it. Can Dr. Kelly help me to understand the thinking behind it being captured in legislation?

Dr. Peter Kelly

It is a controlled drug, so-----

Senator Mary Fitzpatrick

Are all controlled drugs controlled under legislation?

Mr. Barry McBrien

Opiates, which are controlled drugs, are not. They are something I can prescribe. If someone who is a heroin addict needs to come in to get a procedure, I could give them IV morphine. If a person needs their methadone, legislation absolutely dictates that I cannot prescribe it.

Senator Mary Fitzpatrick

We can go and find this out ourselves, but do the witnesses have any insight into why methadone was captured in the legislation? I ask this because it just seems bizarre to me.

Dr. Peter Kelly

I think the initial legislation was written between 2008 and 2010. I am aware that a group of nurses from the south east made representations at that time. My understanding, and I have heard this from two nurses in the south east, is that a letter was written by Professor Sir John Strang from the National Addiction Centre in the UK supporting the introduction of legislation specifically for methadone. To this day, I have no idea why that aspect was not included in the legislation. Various representations have been made to the Department of Health since then. I outlined a recommendation made by two independent medical professors to introduce it into the Irish system and it has not been done. It is also in the current national drugs strategy as something to be explored. In my view, that has not happened appropriately or with a balanced view of the evidence.

Senator Mary Fitzpatrick

I can imagine it just does not seem to make any sense at all on a practical basis in an accident and emergency room situation.

Mr. Barry McBrien

It is horrendous. The one caveat to this is that with other opiates we do not have as many checking procedures. With methadone, though, it is necessary to ring the methadone clinic and to confirm the dose and that the patient is actually on methadone. There are a few more steps in the process of prescribing that drug, therefore, but we are all educated professionals and graduates. We know how to use telephones and to communicate with other professionals, so I cannot see why that restriction is there.

Senator Mary Fitzpatrick

Okay.

Dr. Peter Kelly

We conducted a scoping review at Trinity College Dublin. The evidence overwhelmingly shows that where the legislation is introduced, prescribing will progress and this increases the number of people in treatment. Where it is supported, then, the evidence is that what I referred to occurs, particularly in relation to hard-to-reach people, people in rural areas and people from lower socioeconomic groups. There is another aspect of this work too because we are conducting focus groups now. We have done one in Australia and two in the US. What is overwhelmingly coming through there is that most medical practitioners, or at least those I have spoken to, are in favour of nurse prescribing. It makes sense to them and would probably free up their time in the clinics. Where this has been obstructed, it is often because of a territorial issue and it can come down to financial incentives too. If nurses were to come in, those financial incentives might be removed. There is a territorial issue here as well. I think it is pretty safe to say that at this stage.

Senator Mary Fitzpatrick

Regarding the trade union representatives for the various professionals who would be involved in implementing a change, if such a change to allow for nurse prescribing were affected in legislation, have all the trade unions bought into the proposal? The easier way to answer this question might be to tell us which of them do not support such a change.

Dr. Peter Kelly

I am not aware of anybody who does not support it. The head of the Irish College of General Practitioners addiction faculty stated in the press last year or the year before that he supported such a change. I know the trade unions support it. There is, again, probably a little bit of marginalisation of drug users. Prescribing is prioritised for oncology and all the mainstream services, but drug users often get forgotten and are not a priority. This happens.

Senator Mary Fitzpatrick

They are deprioritised.

Dr. Peter Kelly

Yes, and it happens with professional groups as well.

Senator Mary Fitzpatrick

I think it is inherent and a consequence of our attitude towards drugs. There is no fundamental, comprehensive commitment to having a health-led approach. This is probably the reason the situation is as it is. The issue was raised of real and strategic investment in the human resources needed to properly respond to, address and care for addiction.

Dr. Peter Kelly

Yes, absolutely.

Senator Mary Fitzpatrick

I guess it was a reactive thing initially. There was an expectation or hope, however naive it was, that it would be a short-term emergency thing. There has never been a real acknowledgement that this is something real - it is here, it is going to be here for the long term and it needs to be invested in and resourced.

An Leas-Chathaoirleach

I apologise but we have a second session in the afternoon so I have to move people along. I appreciate that our witnesses are being extremely diplomatic regarding the whys in this regard. Perhaps I will get time to dig into that at the end. One of the whys - financial incentives - was touched on and I am sure there are more. I call Deputy Shanahan, who is joining us online.

Deputy Matt Shanahan

I thank the witnesses for attending. It is important to go back - the Cathaoirleach has signalled that this issue will probably be revisited - to try to understand what is the blockage to nurse prescribing. It happens in other areas of medicine, especially with the advanced clinical nurse practitioners.

It is an obvious efficiency outcome and as the witnesses said, doctors may not be available but it is not enough for the committee to accept that there are territorial and remuneration issues here. This to me would speak to a very significant service advancement if this could be got over. I understand that we are dealing here with dangerous drugs in terms of what is being prescribed, particularly if nurses are prescribing opioids or methadone or whatever, if that is what is being suggested. These are trained healthcare professionals who take their work very seriously. This is a significant advancement and something the committee would want to be strident on.

I want to go back to the members on this point. They are before the committee today and they have privilege here. This may be their only opportunity to lay the case as to what is happening in the system whereby we cannot get approval for nurses prescribing.

An Leas-Chathaoirleach

If any of the witnesses wish, they may take that up.

Dr. Peter Kelly

I will give the Deputy one example. It is in the current drugs strategy and I was very much pushing for progress on it. In November 2022, the HSE produced a document on nurses prescribing OST, which stated it was not a priority and the evidence did not support it. I put forward a view to the Department of Health that the document was neither accurate nor credible and that a more balanced argument should have been put forward. That was not necessarily to do with the outcome but with the process.

I asked to be given the opportunity to challenge that document. Bear in mind, I was invited onto the national oversight committee as a clinical expert and my background is in nursing. This document related to the strategic development of nursing. More importantly, it related to service users getting into treatment and I have many figures which look at waiting times, etc., since the initial recommendation was made. I was told that I am not allowed to have my evidence submitted or to challenge the document because the HSE was the lead agency relating to that specific issue. That has not changed. I have a recent email I sent to the Department of Health about that and I raised the issue again. It still has not happened. I do not know why. The committee will have to draw its own conclusions. I have my own.

Deputy Matt Shanahan

Would any other speaker like to take that on as well?

Mr. Barry McBrien

It might also be the perception that the people who use methadone may be from the lower strata of society. That is a perception people may have but opiate dependency syndrome impacts every stratum in society. It is not just people who are homeless or unemployed, etc. It impacts every stratum of society. The other thing I will say is it is very difficult for a patient to come in and admit they are on methadone. It is very complex for them to do that and they do not want to openly admit to it. By us not being able to prescribe it to them, we are also re-stigmatising them. It is a very complex issue but I think some people may have a perception that those who use methadone are from lower strata of society.

Deputy Matt Shanahan

I want to ask both witnesses about monitoring. Dr. Kelly referenced a high level document he was not allowed to contribute to because the HSE was the lead agency evaluating all of this. What awareness do the witnesses have of the monitoring of their efficiency metrics in the system in order to understand where they are going in getting patients through the system, the waiting times and the outcomes? How involved are the witnesses in that process or is that all done at a remove and based on some database and reporting at the HSE head office?

Professor Catherine Comiskey

I will say something on that. In our research with people on methadone, I have had somebody say to me that they were using heroin for two years and have been on methadone for 11. There is no movement of people through the system. If people want to stay on methadone and that is their recovery, that is well and good but some people want more contact with healthcare professionals and they see the nurse as the person they have the relationship with. When you go into the clinic, you do not see the doctor. When you go to collect your methadone, you do not see a doctor but you might see the nurse because the nurse is there all the time. The doctors come and go. They are not necessarily resident in the clinic all the time.

That is what we are seeing in our research. People have been on methadone for an average of approximately seven or eight years. There are people ageing on methadone. The wait times have certainly lessened in Dublin but that may not necessarily be the case in rural areas. My worry is, and I see it in Europe and the early warning systems, we need to be future ready. We need to have the systems, people and prescribers in place now if these fentanyls or synthetic drugs come here. That is what I am saying. When I told that story about Patricia, we were not ready then but we have had progressive policy and we have moved on as a country. The evidence is there. That is why I am saying to have progressive policy so that we can be ready. These things will come.

I am hearing the most horrific stories and they are really worried in Europe about the South American cartels coming here with Kalashnikovs and articulated lorries full of drugs. That is what I am hearing on mainland Europe. If we do not protect our people now we are going to have more Patricias and I do not want us to have more Patricias because we do not need to. We are mature and we can make mature policy. I really admire the work the committee is doing but I think we need to be brave. When we are brave, we are lauded internationally for it. We were the first to bring in the smoking ban. We were brave and we were lauded. I think we could be lauded again.

An Leas-Chathaoirleach

I thank Professor Comiskey and Deputy Shanahan. I am going to move on now to Deputy Quinlivan.

Deputy Maurice Quinlivan

First, I thank those who submitted their contributions. They were very interesting to read.

On the nursing issue, the witnesses said there were 1,945 registered nurses. I assume they do not believe that is enough. I hope this committee comes up with a recommendation and I should say I am not a full member of the committee. I am just substituting for Deputy Gould today. However, I am also a director of the local mid-west region drug and alcohol forum and I have been for ten or 11 years. I know the issues on the ground. I never say I am an expert on drugs but I am an expert on the outcomes of them and dealing with the families and communities that have been destroyed by it in my local area, especially by organised crime gangs. We have a really good project going in Limerick called the LEAR project, which the mid-west drugs task force does with Ana Liffey. We refer people not to the Garda but to services if it is their choice.

Going back to Mr. McBrien, how does he see it progressing? Can he clarify, for instance, if a nurse can prescribe methadone to someone who is not on opiates, that is, if he or she was a cancer patient or something like that?

Mr. Barry McBrien

As far as I am aware, they cannot. Methadone is used in a cancer care context but as far as I am aware, the legislation also excludes them in that context also.

Deputy Maurice Quinlivan

They are excluded in that context also. I have a close relative who is on methadone for cancer treatment.

Mr. Barry McBrien

That is correct. They use it in that context as well.

Deputy Maurice Quinlivan

Can Mr. McBrien give us some examples? I represent Limerick City and we have a huge crisis in our emergency department. I would hate to think, as the witness has just explained to us, and I do not mean to downplay someone who has an addiction problem, that doctors might be taken away from a crisis intervention to prescribe methadone. Does that happen all the time?

Mr. Barry McBrien

I am not saying it would happen all the time but if I am in a context where I am looking after someone who requires methadone and I need his or her episode of care to be completed, I have to go and ask a senior doctor to come away from what he or she is doing. Such doctors might be looking after someone who is having a heart attack or someone who is having breathing problems, etc. They would have to come away from that to go to another area of the department to duplicate or replicate the work I have just done in order to prescribe the methadone for that patient. It is complete replication and duplication of work and as I said, it is also re-stigmatises the patient.

Deputy Maurice Quinlivan

To be crystal clear, for us to change that and what the nurse can do we need to change the legislation.

Mr. Barry McBrien

Yes.

Deputy Maurice Quinlivan

I thank Mr. McBrien for that. I agree with Dr. Kelly's issue regarding pay tenure, career progression, workload in the profession and other workers in addiction services and some of the remuneration and perks. It is not necessarily the case for nursing but some of the people working in that sector have not had a pay rise for a number of years, ten or 11 years in some cases. As I said, I am a director of a drug task force and those cuts made in 2008 and 2009 have never been fully restored. People have been working really hard with no progression.

What does Dr. Kelly suggest should be done? Will he expand on what he said about pay, tenure and progression?

Dr. Peter Kelly

A lot of the services need guaranteed funding over long-term cycles as opposed having to apply for funding year on year. Strategic workforce development was looking at population needs. A little work has been done on that. One of the strategic groups of the national oversight committee looked at population needs and resources, and the longitudinal evaluation of what workforce will meet the needs of that specific population, looking at changing drug trends, demographics, etc. I have already said security of tenure, supervision and exploration of workloads. A big piece of research has been done in nursing called the RN forecast and it looked at general hospital settings. It looked at the ratio of nurses to patients and mapped that onto outcomes. There is a lot of evidence to say that the more highly qualified nurses and other healthcare professionals you have, the lower the mortality rates. There are particular ratios that change those outcomes. There is not any research like that done in community addiction treatment services. It is probably hard to do and is expensive. However, there is no reason we could not extrapolate from that research to say if you have happy, well-supported staff you will have happy service users. There is lots of evidence to support that where there are high levels of burnout and less educated staff who feel less autonomous, then the outcomes for service users are worse. It is about examining those things and then creating a strategy that recognises those.

Deputy Maurice Quinlivan

Will Dr. Kelly briefly explain how he sees independent oversight working? He also referenced that in his opening statement.

Dr. Peter Kelly

There are already a few examples. HIQA would be the obvious port of call, as would the Mental Health Commission. I worked as a mental health nurse. Mental health services are not without their problems but I have seen the transformational effect the Mental Health Commission has had on mental health services, both in influencing culture and increasing accountability. An independent inspectorate with statutory powers is the type of model. All other things will flow from that. We talk about funding and service user representation. All the other things will flow from robust and independent inspection of services.

Deputy Maurice Quinlivan

Professor Comiskey addressed stigma and how we deal with it. What are the easy wins on that front?

Professor Catherine Comiskey

I will also go back to the workforce. At undergraduate nursing and midwifery education, they get no education on addiction. I was amazed when I joined the school. They still do not. They get one or two lectures in mental health and these nurses are going into emergency, chronic, elderly and children's units and they get no education on addiction, which is everywhere. If you are a community nurse giving the injection and that mother comes in, the nurse has no education on addiction. We really need to provide more education and room for that. It is not prioritised in this country. It is not prioritised in the professions. If we educate people and our staff across those services that will also reduce stigma. I do my bit that I can, in that I have developed a course in Trinity but it is what we call an elective; you do not have to do it. It is full every year, however, and the nurses love it. They change their attitudes. We start discussing these difficult topics. These are only young girls and boys going into nursing aged between 18 and 20. They are out in clinical practice in first year, and they have absolutely no training. They are coming with some attitudes and I am addressing those attitudes.

In terms of stigma, we have heard of what we called the adverse childhood experiences that people have. There are also adverse community experiences. If a community is stigmatised, you do not have to be using drugs, but you are known as the person who comes from the community that uses the drugs. That is why I am looking for this committee to be progressive. The research is there. It reduces stigma and improves people's lives.

Deputy Neasa Hourigan

I welcome our witnesses. I want to touch on stigma but before that I will go back to nurse prescribing. A lot of the discussion we are having today reminds me of when I followed the nurse prescribing journey in diabetes. It reminds me of that a lot, in that it is a lifestyle-based treatment and is very much about who you meet when you go into a clinic. At the front line that is often nurses who are almost the patient advocate. I know they have to go back into their everyday lives but it strikes me from seeing the process where nurse practitioners started being empowered to supply and bring people on board with pumps in the case of diabetes, that it was absolutely life changing for loads of people. One thing we saw they were struggling with was a model of care that has a legacy of being quite top down and consultant led. There seemed to be tension in implementing a cross-disciplinary team and empowering nurse practitioners to begin the journey with a person for a particular treatment. I say that on the record because I do not want the witnesses to have to say it on the record. That is a long-term difficulty but I also think that with any of those treatments based in how you live your life every day, it is incredibly important that nursing is empowered in those.

I return to stigma. In preparing for today's session, I read some of the research and came across American research on the idea that within medical professions, there is a higher level of stigmatising attitudes among health professionals than there would be in the general population. What would be the witnesses' attitude to that finding? There seem to be multiple papers. There is not just one paper, there are approximately seven of them looking at primary care physicians and the rates of stigma. It seems they are associating it with, let us say, chaotic behaviour and behaviour that is more difficult for them in a clinical setting. Is there any reason to believe that Irish care providers are different from their American counterparts?

Professor Catherine Comiskey

One of my PhD students has written a paper on stigma among the healthcare professions. Yes, it exists, because they are not educated. When she was doing the interviews nurse to nurse, they trusted her and used words like "frequent flyers" and we were shocked by that, because this is the profession. That is not necessarily the front they presented to the patient. Again, that goes back to the education about stigma, and not getting it. There are also no common definitions. When she asked what was understood by recovery, people understood that differently as well. There was quite a bit needed. There is some stigma among healthcare professions.. They are dealing with the challenges. It is easy for me to be the researcher behind and having an opinion. They are dealing with difficult and challenging situations but that is why we need to bring the education into the professions and it is not there.

Deputy Neasa Hourigan

I presume we should have non-elective modules within training for all medical professionals. Would that be specifically on addiction or would it be more useful for it be about what trauma-centred care looks like?

Professor Catherine Comiskey

Trauma is part of the understanding of addiction. This can also be for schoolteachers. We need trauma-informed schools as well. I know teachers have to do an awful lot, because I am doing a lot of work in schools, but we need some more education across those services that are meeting people like Patricia when they are children. When that child went into school, somebody knew she was not right. The teacher would see the dirty clothes and the upset child. We need to educate our professionals too.

Deputy Neasa Hourigan

Would the other witnesses like to come in on addiction versus trauma led?

Mr. Barry McBrien

I teach the nurse prescribing course in Trinity. There is a consortium, standardised approach to teach prescribing. What Professor Comiskey has said resonates with me because we do not have anything specific about addiction. If we had something put into that programme, that would help with managing the stigma. As Professor Comiskey has said, it does exist. People unfortunately have those perceptions about how people on methadone are problematic patients, frequent flyers or just drug seekers. I am not saying everybody is like that, but there are perceptions that people are like that, and the Deputy's research correlates with that.

Deputy Neasa Hourigan

The research suggests that when you are on the front line, those attitudes become more prevalent.

Mr. Barry McBrien

Yes.

Deputy Neasa Hourigan

That would take care of all of our new cohort. There are hundreds of thousands of people working in services that are central or tangential to our health service. How do we hit all of them? Do we need to get everybody into a continuing professional development course on addiction and trauma-like care?

Professor Catherine Comiskey

Yes. We need to do that online.

Deputy Neasa Hourigan

How far along are we on that journey?

Dr. Peter Kelly

We have HSeLanD. Online resources are available for most healthcare professionals. It would be up to the regulator to decide what is mandatory training. Pressure could come from the employer.

Deputy Neasa Hourigan

Working in an emergency department is different from working in a laboratory.

Dr. Peter Kelly

Of course.

Professor Catherine Comiskey

The principles would be the same. You could develop a massive open online course, MOOC, that anybody could access. It only costs approximately €30,000 to develop something like that. I have done one. Anyone can access the course at any time. This is not rocket science.

Deputy Neasa Hourigan

I will return to the question of the inspection of services. I am a member of the Joint Committee on Health, where we talk a lot about the inspection side of things in the context of oversight, performance indicators and outcomes. Who would do that? Perhaps that is not fair. What kind of a body could the witnesses imagine undertaking that piece of work?

Dr. Peter Kelly

HIQA. I cannot remember the name of the relevant inspectorate in the UK but it has a similar set-up to HIQA. It inspects drug treatment services.

Deputy Neasa Hourigan

Could Dr. Kelly give me an idea of the breadth and level of that service? Would it include all the third-party and NGO services?

Dr. Peter Kelly

It would include all drug treatment services.

Deputy Neasa Hourigan

Would it influence how drug task forces work?

Dr. Peter Kelly

You cannot do everything overnight. You could start with HSE statutory services and then branch into non-statutory services. All services that treat people who use drugs should be subject to independent oversight. It is crazy that they are not. Stigma is explicitly built into the system. We inspect services for other marginalised groups but drug users are not worthy of an independent inspectorate. That is not acceptable in this day and age.

Deputy Neasa Hourigan

It is crazy.

Dr. Peter Kelly

It is crazy. We are talking about nurse prescribing, trauma-informed care and stigmatisation. If we had an independent inspectorate, it would go a long way towards solving many of the challenges we have. If, all of a sudden, a service is being closed down in the constituency of a powerful politician, money will come in to support the service and changes will be made because they will be forced.

Deputy Neasa Hourigan

By proxy, there would be a benchmark that you could fall below and therefore-----

Dr. Peter Kelly

That is exactly right. It has happened with mental health services. I can say from first-hand experience that the Mental Health Commission has helped to create massive and transformational change in the culture of mental health services since it started in 2006.

An Leas-Chathaoirleach

This has been a great conversation so far. We need to extend prescription power to nurses. If we do not, it is a clear indication of a further stigmatisation. There is a kind of paternalistic idea that a nurse cannot determine a safe amount to prescribe. It means that where the healthcare service is working with an individual who needs methadone, there is suspicion off the bat. We are suspicious of someone who is looking for methadone. It is as if we think that someone is trying to one-up the system and source free methadone. There is automatic suspicion. People need to prove that they need methadone, attend a methadone clinic or are on drugs. Who decides to arrive somewhere and take methadone if the reasons to do so do not already exist?

I am curious about the difference between methadone and morphine. People have ideas about the types of groups of people who are on methadone and automatic suspicion comes in. We are going to see more and more people on methadone because of morphine addiction. A decision to put someone on morphine for an extended period will probably result in their needing methadone. People who are addicted to tramadol are now being offered methadone by their doctors. That cohort is stretching out beyond heroin users. I am wondering about the financial incentive. If a nurse has done all the work and a consultant is then brought in, is the consultant reimbursed for signing off on the methadone?

Mr. Barry McBrien

I cannot give an honest answer. I do not think consultants are reimbursed. There may be such a thing in primary care but in a hospital setting, consultants are not given any additional fee for prescribing morphine. Perhaps the situation is different in a primary care centre or addiction service.

An Leas-Chathaoirleach

That is what I thought. Perhaps there is a difference between a hospital setting and a primary care setting. Within the GP contract, a GP may be reimbursed. Do we know how much per annum per person a methadone patient would cost within a GP contract?

Dr. Peter Kelly

I have struggled to find that out. There are two different payment schemes under which people are paid. I tried to find out when I was doing my PhD but I could not. Perhaps the information is there and I just could not find it. I do not know the answer to the question.

An Leas-Chathaoirleach

That should be transparent. We do not want a situation whereby methadone patients do not receive the care they should be receiving while also being seen as an additional resource to a GP. That could inhibit the other professionals, such as nurses, stepping into that space and prescribing.

I am interested in the rights-based approach. This is a bit of a side note, but I am thinking of people in places of detention and Garda stations. I have a long history of friends being left in Garda stations to the point of sickness. They are left without access to methadone and are told to wait for the doctor. That does not mean that people are not questioned. They are brought to a point of sickness and further questioned. They are told that when they engage with and talk to the gardaí, the doctor will come. I am wondering about the role that nurses can play in such circumstances. I would hate to think that methadone was being used as a tool in a coercive style of policing. If that is not the case, and doctors are required to prescribe, are nurses also being leaned on in places of detention? Should we be making sure that option is considered? If nurses were to become prescribers, that could happen not only in hospital and primary care settings but also in the justice system.

Professor Catherine Comiskey

There is a case in the International Court of Human Rights, Wenner v. Germany. Mr. Wenner took a case because he was not given his methadone when he went into prison. He took and won that case. There is precedent but people do not necessarily know about it. I know about it because I have written about it and have done the research. There is precedence there. This man took the German Government or the appropriate authority to court and won his case to assert his entitlement to the same treatment in prison as outside. He was not to be given detoxification, or whatever. He was to be given his methadone. The case law is already established.

An Leas-Chathaoirleach

The rights-based stuff has already been established.

Professor Catherine Comiskey

It has already been established.

An Leas-Chathaoirleach

It is about ensuring it is implemented across the professions and in the different sectors. I will go back for a moment to differentiating between methadone and morphine. Is there a stigmatisation of methadone? If methadone changed its name and was just called an opioid, would things be different? Methadone has become synonymous with a particular group. Can the witnesses explain the differences between methadone and morphine? I know that one is more slow releasing and long acting. From a scientific perspective, what is the difference between them?

Dr. Peter Kelly

I have to put this in lay terms. Both drugs work on the same receptor sites. When I talk to students, I say that methadone is like diesel and heroin is like rocket fuel. That is true in terms of its action and half-life.

My understanding is that it works on the same receptor sites, but it is just how quickly it goes in and out of the body and what kind of peaks and troughs there are. The advantage of methadone is once-a-day dosing, but it does take time to build up the plasma levels, whereas there are more peaks and troughs with pure morphine.

To go back to the Leas-Chathaoirleach's question about prisons, there is a big aspect to the prisons for data monitoring. As far as I know, the number of overdoses is not monitored. The data on the number of people coming in, and I stand corrected on this, who are dependent on opiates and get prescriptions is not there. I know, for example, that Mountjoy Prison had six addiction nurses. They do have counselling provided by Merchants Quay Ireland, but that does not mean people are going down on the wings and actively screening and assessing people who are dependent on opiates. From talking to nurses in the prisons, I know that people are left in prison in cells in withdrawals. Recidivism was mentioned. They then have to spend money on expensive drugs. Their relatives are on the hook in the community for hiding a gun or holding drugs and the cycle continues because they do not get the script in quickly. There were six in that particular area and now there is none. If you monitor and measure, you will start to see that things are done that are not being done. If a nurse were to prescribe, that additional time delay would be removed, because protocols are in place whereby prescriptions up to a certain amount of medication can be made without the presence of a doctor. A doctor still has to be consulted, however. If that is removed, an increase that is needed can be given on the spot, but it gives a lot more flexibility in terms of meeting the person's needs.

An Leas-Chathaoirleach

I refer to the monopolisation, in one sense, of prescribing and the gatekeeping and the potential personalities driving that gatekeeping. Going back very briefly to the point about methadone and morphine, the methadone is slow release and longer acting. It is ticking along, whereas morphine can have much more of a flow in terms of its highs and lows. They are both of a similar nature and work on the same receptors. While they may make their way through the body a little bit differently in the course of a day, methadone is not more dangerous in determining its dosage in comparison with morphine. There is no danger that exists with methadone that exists with morphine.

Dr. Peter Kelly

That would have to be decided on a case-by-case basis. I have worked in clinics that use Subutex or buprenorphine and I have managed groups of people who have been prescribed diamorphine as an injectable, but it would have to be decided case by case.

An Leas-Chathaoirleach

I was trying to explain that in the context of a nurse prescribing morphine or methadone the precautions and assessments needed during their prescription. There would not be an increased risk in the assessment in the prescribing of methadone versus morphine.

Mr. Barry McBrien

The only additional thing regarding methadone, as I referred to previously, is the checking procedure. The Drug Treatment Centre would need to be called and the dose would need to be confirmed.

An Leas-Chathaoirleach

That is a mapping and follow-up issue with the person, rather than a clinical decision regarding the millilitres required or the safe dosage to give somebody in a particular setting or whatever.

Dr. Peter Kelly

Morphine is potentially more dangerous if it is not used in the right way. Risk wise, there is very little difference.

Mr. Barry McBrien

I will go back to the Leas-Chathaoirleach's last point regarding the Prison Service. When an inmate goes into withdrawal, ultimately, they will end up back in the emergency department. It is another complication. Financially, inmates going to an emergency uses more resources, etc. That delay is causing another presentation to an overstretched emergency department, the difficulties of which we read about in our newspapers every day.

An Leas-Chathaoirleach

It is an economic decision as well, if the State wants to look at it as such. Does anyone have any final comments? As there will be a second session, I do not know if we have time for a full second round of questions, but any member who has outstanding questions may ask them.

Deputy Mark Ward

Professor Comiskey mentioned Patricia, who was abused at the age of seven. She was injecting at the age of 15. She was criminalised for her sexuality at the age of 20 and got HIV at the age of 24. Now aged 45, she is still subjected to supervised urine testing. I spoke about this last week, but part of a previous role when I first started was supervising male urine samples. I always found they were used for punitive measures, rather than clinical measures. What are the witnesses' thoughts on supervised urine testing in 2024? Are they still relevant? Do witnesses feel they are used punitively? I have seen take away tests being taken away and people having to turn up daily. Some doctors have said not to mind about urine tests and that they will deal with the person, while another doctor insist on them. What are the witnesses' thoughts on that?

Professor Catherine Comiskey

I have a paper on this. I must be the only person who can get excited about 7 million urine analysis results.

Deputy Mark Ward

I will not say what popped into my head. Just taking the piss.

Professor Catherine Comiskey

It is very glamorous. I mapped it over a period of years. I managed to get all the urine analysis data, because people give data to independent researchers. I am not part of the HSE or a nurse, which has worked to my advantage. That is why I am confident in what I am saying and why I gave that introduction about me. I found there was no protocol, rhyme or reason as to why some did and did not. It made no difference in terms of the treatment outcomes. I thought about the cost of this and how much this is costing those services and why. The work is there. Obviously maybe it is done for safety initially, I do not know, the Deputy would have to talk to medical experts. In terms of routine urine screening, however, it was just ridiculous. There was no pattern, rhyme or reason. All I could think of was the cost the tests. They were not even doing the same tests on the urine for the same drugs. It was up and down and ad hoc. There was no rhyme or reason to it. All I could think about was what Dr. Kelly referred to as bad practice. That is where education comes in as well. We need to start building those foundation blocks. I agree with Deputy Ward.

Dr. Peter Kelly

I agree with everything Professor Comiskey said. It is implemented inconsistently. To give a good example, I worked on the drugs policy Tackling Drugs to Build a Better Britain in the early 2000s. There was a lot more urine testing when I worked in clinics in the UK. People were punished if they used drugs on top of their dosage. It was not a direct punishment; it was under the guise of safety that people would be moved on to more regular collection of methadone.

When the orange guidelines came out, it completely changed. I had been there for the first set of guidelines, went away and came back to work ten years later. It completely changed the dynamic between me and the service user. People would come in and say they had used on top of their dosage or that they had a slip last week. The response was to say "Alright" and ask what we can do about that, whereas before we were being lied to because the person was in fear of being punished. It was a massive change and the noticeable thing for me was how it changed the dynamic. It was a lot more open and honest. Urine screening has to be done for safety reasons, and maybe it is done once or twice a year for safety. People understand that. If drugs are found in the urine, the results state that drugs are in the urine.

Deputy Mark Ward

Not once or twice weekly, however. There is no benefit there.

Dr. Peter Kelly

No.

Deputy Mark Ward

That was my experience. At some stage it was once weekly and if a doctor had concerns it was twice weekly. It was being used punitively.

Dr. Peter Kelly

Even in terms of methadone pick-ups and the frequency of clinic visits, I know Professor Comiskey mentioned that in certain clinics people will see nurses first. I did research which went further around the country and approximately 80% of people said the person they saw the most often when they went into a clinic was a medical practitioner. Medical practitioners, the most expensive and probably in some cases the best-trained person in the building, have to see every single person coming through the door. That model is really outdated and not fit for practice. Most doctors and nurses are brilliant, but the training they get to prescribe is one day. It is three months for a level 2. The training is not sufficient in this regard. We spoke about this earlier on. The GP training has massive implications for the experience people have when they come into clinics.

Deputy Neasa Hourigan

I have a question about data which struck me when talking about the prisons. I was reading something about it. Do we have the data about how many persons are eligible for OST or who would be appropriate for OST? Not somebody who has tried a drug once, but somebody who would benefit from OST. How many are actually in treatment? One statistic I read stated 35% of people who should be in OST or that kind of therapy were actually taking it up.

Professor Catherine Comiskey

The last time I looked at the figures, we had approximately 13,000 or maybe a little more people on opiate agonist treatment, OAT, which is methadone, and more than 20,000 people were using opiates. That is the estimate of the numbers. We had more than 50% the last time I looked at it. I may not be fully up to date. However, not everyone who uses opiates or heroin needs to go on methadone. They may use it at weekends.

Deputy Neasa Hourigan

Yes, of course. To be honest, my question was not just what the number is but whether we are recording the data. When I ask a question about health, I am often told it is not recorded. As a result, I was wondering whether we have a sense of the data.

Professor Catherine Comiskey

We know how many people are on OAT, but we do not have up-to-date numbers for people who use heroin problematically. We have done estimates.

Deputy Neasa Hourigan

Why is that?

Professor Catherine Comiskey

It is quite difficult to do. It is a statistical calculation, and time has to be spent getting the data. We have estimates but they are quite out of date.

Deputy Maurice Quinlivan

Dr. Kelly mentioned counselling in prisons and that there were six counsellors. Did he say there are now none?

Dr. Peter Kelly

That was specialist addiction nurses in the prisons. There were six. Now there is none.

Deputy Maurice Quinlivan

Is that because funding was withdrawn, it was not possible to recruit or the programme ended?

Dr. Peter Kelly

I do not know. I just know that there were six and now there is none.

Deputy Maurice Quinlivan

It is pretty stark. I visited the prison in Limerick a few years ago. Eight people were crossing the yard when I was crossing to visit someone. Of those eight, seven should not have been in prison because the issue was just drugs. I grew up with most of them. It is insane.

An Leas-Chathaoirleach

Does anyone want to make any final comments on any matters they were hoping we would cover?

Dr. Peter Kelly

I will make one if the Vice Chair does not mind. I draw people's attention to something members may have come across. The Irish Government's Economic and Evaluation Services carried out a review of labelled and unlabelled expenditure under the national drugs strategy which found that limitations in the availability and quality of data in the performance indicators have constrained the conclusions that can be drawn on the performance of the strategy. There is a massive piece around data collection and measurement, which leads into accountability and stigmatisation. I urge members to prioritise that. It is important.

Professor Catherine Comiskey

I urge people to be progressive. The research is available. In my work, I always put the research out front so that it is not me saying something, it is the research. People accept that. The research is available for the committee to use in its decisions. I urge it to be progressive so we do not have Patricias in the future. We have addressed those difficult topics in the past. We should address them again as the research is available. Education is also important.

An Leas-Chathaoirleach

If this committee comes out with anything that is not progressive, it will be against the evidence. That is how I will reframe that contribution.

Professor Catherine Comiskey

Yes, the Vice Chair can blame me.

An Leas-Chathaoirleach

It has been an engaging session and very helpful, especially for homing in on some of the subjects that have not come up to date. It was specific and helpful. I thank Professor Comiskey, Dr. Kelly and Mr. McBrien.

Sitting suspended at 10.54 a.m. and resumed at 11.30 a.m.

Deputy Gino Kenny took the Chair.

An Cathaoirleach

I welcome our guests to the third module of our discussion on a health-led approach to drugs policy. From An Garda Síochána, I welcome Deputy Commissioner Justin Kelly. I congratulate Mr. Kelly on his promotion. I also welcome Detective Chief Superintendent Séamus Boland, who is with the national Garda National Drugs and Organised Crime Bureau. The witnesses are very welcome. I invite Mr. Kelly to make his opening statement.

Mr. Justin Kelly

Good morning. I thank an Cathaoirleach for the kind remarks. It is very much appreciated. On behalf of the Garda Commissioner, I thank the committee for the opportunity to speak with members today.

I have organisational responsibility for tackling organised and serious crime. Naturally, a significant amount of our focus in the area of organised crime is on the disruption and dismantling of the drugs importation routes into the country. Our aim is to make Ireland a difficult environment for global drug trafficking networks to operate. We place particular importance on identifying not only those directing these, but also on those who facilitate and enhance them. One of our key strategies is to deny and deprive them of their ill-gotten gains, in whatever form these assets may be. I have been in An Garda Síochána for over 32 years and have worked in the drugs area at various levels from street supply in the 1990s to today where much of my focus is on partnerships with international law enforcement agencies. Detective Chief Superintendent Boland, who leads the Garda National Drugs and Organised Crime Bureau, GNDOCB, joins me here today.

The function of An Garda Síochána, as set out in section 7 of the Garda Síochána Act 2005, is to provide policing and security services to the State. The committee will be aware that An Garda Síochána is a community-based police service and that our mission is to keep people safe and protect the most vulnerable in society. An Garda Síochána enforces the laws enacted by the Oireachtas. We are committed to upholding the law, which, of course, is the basis of democracy. An Garda Síochána must, however, prudently apply the law in a manner that is ethical and fair to all. An Garda Síochána is supportive of the Government’s policy on drugs use as set out in the national drugs strategy, Reducing Harm, Supporting Recovery 2017-2025. We support the health-led approach to drugs use set out in the strategy. We work closely with our health and criminal justice partners to reduce harm and ensure community safety.

By the very nature of policing, members of An Garda Síochána frequently encounter individuals addicted to drugs who often lead tragic and chaotic lives. In such encounters we endeavour always to take a human rights-based and humane approach. The law enforcement focus of An Garda Síochána is not the prosecution of those addicted to controlled drugs, but on disrupting drug trafficking supply lines and dismantling the transnational organised criminal groups behind these. We are resolute in our work to identify drugs networks and prosecute those who do so much harm to our communities by supplying controlled drugs, particularly those we deem to be high value targets.

At the forefront of this work is GNDOCB, which undertakes intelligence-led operations that lead to the seizures of substantial amounts of drugs, firearms and cash. An Garda Síochána is involved in many policing operations with our colleagues abroad, as well as with our partners here in the Naval Service, Customs and Excise and Revenue. We also have a network of local drug units in every part of the country that focus on local, street-level drug suppliers who do so much harm to our communities. We co-ordinate all our activities nationally under what is known as Operation Tara.

Controlled drugs cause untold damage not just to the health of individuals but also to the environment. The demand for drugs in Europe and North America has caused severe environmental destruction in parts of South America. There is a direct nexus between those who use drugs here in Ireland and this damage, as well as to the violence inflicted by the criminal gangs involved in this illicit trade. We also know that the profit from drugs supply is used to fund other serious criminal activity such as narco-corruption, sexual exploitation and human trafficking. Drug trafficking is a priority at European and international level. We know that 40% of criminal networks in the EU are involved in drug trafficking and 60% of criminal networks use violence.

Drugs-related intimidation, DRI, is one of the methods criminal groups use to enforce debts. The effects of this can be devastating on individuals and their families. An Garda Síochána is often at the forefront in supporting families in such situations. We have developed a strategy to counter DRI, which involves collaboration with external partners. Should members wish, Detective Chief Superintendent Boland can provide more details to the committee of our work in this area. An Garda Síochána are also willing and supportive partners in a number of initiatives designed to prevent drugs harm, for example: the early warning emerging trends committee, EWET; the festival back-of-house monitoring programme; the proposed supervised injecting facilities, SIFs; the issuing of naloxone to members of An Garda Síochána; and the proposed health diversion scheme. An Garda Síochána are supportive of the diversion of persons from the criminal justice system where appropriate. Our organisation has significant experience in this area. for example the Garda youth diversion scheme for children under 18 years and the adult caution scheme available for a range of offences, such as certain assaults, theft, public order offences, and in the context of today’s discussion, the possession of cannabis.

Last year, An Garda Síochána was privileged to have been given the opportunity to address the Citizens’ Assembly on Drugs Use. We provided inputs on three separate occasions on requested areas. We also participated in a number of question-and-answer sessions to address the queries of the members of the assembly. An Garda Síochána welcomes the recommendations of the citizens' assembly and we look forward to playing our part in the implementation of these. The recommendations complement the current governmental health-led approach which, as I have said, we are supportive of. We welcome any questions members may have and of course will provide the committee with any further information that may be of assistance to it.

An Cathaoirleach

I thank Mr. Kelly.

Senator Lynn Ruane

The witnesses are very welcome. It is positive to hear it reiterated that An Garda Síochána will support a health-led approach and that this approach will potentially - and hopefully in my view - be very different from the one proposed by the Department.

It is not a health-led approach, as it is understood in terms of decriminalisation, from a legislative perspective. Policing or user policy obviously will have to change if there are legislative changes. Across Mr. Kelly's 32-year career, have other parts of policing developed in terms of having public health approaches to policing? In respect of mental health, psychosis and so on, have other types of policing evolved over the years that could feed into the trajectory of policing moving more towards being underpinned by public health? Have other policy areas existed over the years?

Mr. Justin Kelly

I thank the Senator for the questions. As she rightly said, from when I joined in 1992 to today, the approach that we take to these very unfortunate individuals, that is, those leading such chaotic lifestyles, has evolved beyond comprehension. To answer that question directly, in Limerick we have moved on from a pilot scheme and currently have Garda officers on the front line with mental health professionals attending calls in the one vehicle. As I said, we are trying to bring that humane approach towards the individuals we deal with. For us, there are many challenges around people who use drugs, particularly the ones who have real problems with that. As for the public order situations with which our front-line officers are dealing, particularly with cocaine, we are seeing aggression at levels that I would not have seen when I was on the front line. Even those four areas that I spoke about show our commitment to doing things differently to how we did them before.

I will not delay too long but to choose one of those areas, we have been supportive of the supervised injection facility that is hopefully to come soon. That is a very complex area for us to police. As members can imagine, there are going to be drug addicts in possession of drugs that are currently illegal. They are going to be going to that facility. How we deal with that will be to take a nuanced approach to it. The chief superintendent and superintendent in that area have had regular meetings with Merchants Quay. It is exactly the same with the festivals. At the festivals, as we know, people are in possession of controlled drugs that are illegal and we had to do a lot of work to get over the perception that we were going to be waiting outside those tents and try to arrest people. We have done a lot of work and I note Dr. Eamon Keenan from the HSE has been before the committee previously. Examples like that, however, show how we are trying to evolve. At senior management level the Commissioner, myself and the other members of the senior leadership team are trying to push through many things organisationally. Naloxone is one members have heard of. The Chair is very familiar with it. That is another thing we are trying to get across the line. All these things are complex, however.

Senator Lynn Ruane

It is that balance of police having a particular function in society in terms of control or detecting illegal activity and so on and having to change that culture somewhat. Changing that culture also can add to public safety in general. It is not necessarily about waiting outside tents or pulling people over as they go into a safe injection facility. Not doing that in fact extends, rather than shrinks, public safety in a sense but I understand the balance.

When we look at the idea of decriminalising drugs, a lot of conversations will happen around violence. Sometimes substances are less of an issue for people in their everyday lives in a concentrated community setting than high levels of violence. That is often the thing that people will point to most when it comes to what of concern to them or in terms of what makes them feel comfortable or for businesses to feel as though they can operate as normal in a safe environment. If the Government implements decriminalisation, there is also the element of violence. That is another where area I would love to see a drive towards, for example, recognising, as does the World Health Organization, that violence is also a public health crisis. How do we begin to look at violence through that lens? Some of it is obviously drug-related and there are threads that flow between them. Are there discussions at present around that? I have conversations coming up with the Scottish violence reduction unit and the police force there and many allies have been asking how communities can respond to violence without it always being a police response, especially if we are trying to reduce retaliatory violence. Ireland does not yet have those projects at a community level. Are there many discussions as regards An Garda Síochána and how we need to move towards viewing violence as a public health crisis? How do we address that going forward at societal level from a policing perspective?

Mr. Justin Kelly

That is a very good point. An Garda Síochána is only one part of this situation. What Detective Chief Superintendent Boland and I concentrate on is the supply level end of it and the violence that comes with that. Without going into detail, particularly where there are deaths and murders, we put so much work into that. We have in excess of 50 people from one of the main organised criminal groups serving sentences. The reason we put so much work into that particular group is because as the Senator says, they were the ones inflicting that violence here in Dublin.

Senator Lynn Ruane

They were inflicting it on one another also. Even though they are in prison, the lives of those that are dead were also lost as they were caught up in it too. They become their own victims in a sense, which at times gets lost.

Mr. Justin Kelly

To pick up on the point the Senator made and the public may not fully understand this, we have spent a lot of time mounting operations to save the lives of people who are active criminals. It does not make a difference to us whether a person is a high-level organised criminal member. We have put considerable surveillance operations and all sorts of resources towards saving the lives of criminals, even some people who are involved in directing and facilitating these groups. For us, it is not even particularly about them but about their families and communities and the wider impact that what are colloquially known as gang-related murders have. That is the really important part. Mr. Boland has all the details of the numbers around this, but as I say, the violent end of it is one of our top priorities.

I referenced drugs-related intimidation earlier and what we are seeing in that area has really evolved. I realise we have limited time but while drugs-related intimidation has always been with us as part of the supply business, it has really evolved and the stories that we hear of the victims and families are very challenging. On a policing side, it is difficult for us to deal with them and try to maintain confidentiality. Obviously people are reluctant to come forward to us. Working out how to work through that is a real challenge for us.

Senator Lynn Ruane

I thank Mr. Kelly.

An Cathaoirleach

The next speaker is Deputy Ward.

Deputy Mark Ward

I thank our witnesses for their opening statements. It was very interesting to listen to them. I am from Clondalkin and over the past few years, we have been lucky enough to have some very progressive community gardaí, particularly with regard to people in the throes of addiction. They see these people as people and not as a burden on society. Once that relationship changed, we could see the difference it made in the community. Both Garda members I am thinking of are so progressive that they are no longer gardaí and are working in the addiction sector. They went off their own backs and studied addiction to give themselves an insight into the problems they were seeing in the area on a daily basis. What training do Garda members get and what training should they get when it comes to addiction and people experiencing trauma?

Mr. Justin Kelly

I was an inspector out in Clondalkin myself not too long ago. I know the area quite well. We have a comprehensive foundation level training programme for our new recruits and as part of that, we bring in NGOs and people who are involved in the area of rehabilitation to talk to them.

That is the first thing we do. Relationships at community policing level are important to us. Deputy Ward gave an example of two gardaí who left to join addiction services. While that is a loss to the Garda, it shows the motivation of some of the officers we have.

Treat drug addicts humanely is key for us. Only the week before last, I visited the Garda College where I had the opportunity to speak to a brand-new cohort of Garda trainees. There were several hundred of them and I had a few key messages for them. One was on how important it is in policing, that when gardaí interact with people who are in difficult situations, they treat them humanely. The key message from me is that even one bad interaction causes untold reputational harm to the organisation. It is one that senior management is trying to reinforce with our officers.

Deputy Mark Ward

That daily interaction with people, when done humanely, trickles back into the community, families and the organisations the people may be engaged with. Community policing, especially at that level, really works.

Mr. Justin Kelly

I know we are tight on time but I will add one other point. We emphasise to those officers who are predominantly involved in enforcement, for example, in drug units, that they should deal with people humanely, even though they are involved in searching people's homes and all that sort of stuff. I worked at street level for five years in the drugs unit in Tallaght. That was key for us. We were interacting with these people on a daily basis. People would probably be surprised to know that many of the front-line officers and members of the drugs unit have really good relationships with people who are badly addicted to drugs. We do not have an adversarial relationship with these poor individuals.

Deputy Mark Ward

Are conversations taking place with members of the force in relation to potential changes in drug policy? For example, if we move from decriminalising the person but not the drug, how would that affect gardaí on a daily basis? What are their thoughts on that?

Mr. Justin Kelly

When I spoke at the citizens' assembly, one of the first things I said was that we police whatever the legislation is. Whatever legislation comes in, and not only in this area, we will police it. If there is new legislation coming in, we will give our views and observations on it. We were very consistent last year with the citizens' assembly on what our views were and they remain the same. Sometimes our views and observations are taken on board with new legislation and sometimes they are not. Whatever the end result of that is, we will police exactly to that legislation when it comes in.

Any significant changes around legislation mean a lot of work for us because we have got to look again at how we do things and at our policies and procedures. We have that and then we have a whole cultural change then. Any changes around drugs policy, and we have made some ourselves, involve considerable change projects for us. I am sure we will touch on the health diversion programme. People have different views on whether that goes far enough but even that coming in will be a huge organisational change for us. That will be the biggest change in drugs policy since-----

Deputy Mark Ward

I am sorry to cut across Mr. Kelly. He referred to the organisational change the Garda has to make and there could be more organisational change if some of the recommendations are carried into legislation. Does the Garda get support on that? Does it get resources to implement that change or it is doing that out of existing resources?

Mr. Justin Kelly

An Garda Síochána has gone through a lot of change in all areas, particularly in the past five or six years. We are well used to change and pivoting to different legislation, oversight bodies or whatever. People are interested in stop and search as well. That is another area on which change will come in and when those changes come, we have to prepare the whole organisation for it. We often have training that goes with changes. If there is change, not only in drugs legislation but any legislation, we have to train. The most important part is how it practically works on the ground, so that everyone has a good understanding of what they are supposed to be doing or not doing. I hope that answers the Deputy's question.

Deputy Maurice Quinlivan

I thank the witnesses for the presentation. Mr. Kelly spoke about one of the projects in Limerick. There are two projects ongoing at present. The law engagement and assisted recovery, LEAR, project has been in place for a couple of years. Under LEAR, the Garda can refer people to Ana Liffey. It is working really well and I commend the gardaí and the staff of Ana Liffey who are involved in it. It is a very good project.

Two weeks ago, we launched the community access support team. It is in mental health but obviously there is a crossover there. The team is due to be operational early in November.

Under the proposed health diversion scheme to which Mr. Kelly referred, does he envisage the LEAR project in Limerick or an enhanced version of it being rolled out elsewhere? How has that project gone so far?

Mr. Justin Kelly

Around the country, what we often see, and not only with LEAR, are pockets of really good practice. For us, it is about evaluating and reviewing them and seeing how they are working, particularly the impact on us around resourcing and finances. If a project is one that we think we can roll out across the country or we can be involved in around the country, we will do that. As I said, we have lots of different pockets of really good work, and not just in this area. Organisationally, to get them across the whole country, we have a strategic transformation office that any of this big projects would have to go through. We have done it in lots of different areas, particularly around domestic violence and sexual crime. If we see good pockets of interaction similar to LEAR but in the crime area, we will introduce those across the country. We would, therefore, definitely consider it.

Deputy Maurice Quinlivan

We have a progressive, forward-thinking and common-sense approach. Chief Superintendent Derek Smart is excellent at his job and inspires confidence. While we are dealing with people with addiction, we need to look at organised crime gangs which, unfortunately, operate in my city. They have a stranglehold in parts of the city. Crack cocaine did not just appear in Limerick. As I have said publicly previously, they marketed and designed it. They knew exactly what they were doing and targeted heroin users, who are the most vulnerable people. The Garda has carried out very good operations in Limerick targeting those gangs in the past couple of years. In responses to parliamentary questions, I see there have been dozens of house searches in a particular area.

We get funding every now and again. We have had various operations, including Operation Tara. When money is available for those, including additional money for overtime, etc., we can do really good stuff. Unfortunately, we do not have the money for overtime. Is that a frustration for the Garda? As I keep saying, gardaí cannot respond if they do not exist.

Mr. Justin Kelly

It would be remiss of me to say we do not have resource issues. The Garda Commissioner has said publicly we are probably down 1,000 officers on where we should be. We have to currently supplement a lot of our work, as the Deputy well knows, with overtime. We are fortunate in that we have a substantial budget provided to us by the Government. Resourcing is an issue, however. For high-level organised crime, resourcing is never a problem. When targeting international organised crime gangs and some of the bigger gangs, including in the Deputy's area, resourcing is never an issue for us.

The Deputy rightly said Chief Superintendent Smart is an excellent officer. We have a good system where a chief superintendent, such as Chief Superintendent Smart, would make contact with Superintendent Boland, who is here with me, to say they are running an operation, do not have enough resources and need them to be supplemented. We always do that. One of the most important aspects of the area that I lead - organised and serious crime - is supporting our colleagues around the country. One of the key things we do is support the types of operations the Deputy referred to. Resourcing is always a challenge but that is not unique to An Garda Síochána. It is the same with all my colleagues I meet internationally or around Europe.

Deputy Maurice Quinlivan

My time is nearly up and I have to go to another meeting. The interventions the Garda has done in Limerick recently, in particular, in the Ballinacurra-Weston area, have probably prevented deaths by not having a gang war break out, probably between certain factions of the same group. The Garda has done that already in the St. Mary's Park area. That was fantastic work. There is still a sense that an awful lot more needs to be done. It is not particularly the Garda's fault. There are a number of organised crime gangs, as there are in other parts of the State. Limerick in particular has that problem.

Mr. Séamus Boland

I thank the committee for the invitation. For the record, like Deputy Commissioner Kelly, I have 35 years' policing service in An Garda Síochána. The first 20 of those years were policing the drugs issue in the north and south inner city, so we are aware of all those issues. Regarding the targeting of organised crime and the gangs at local level, as the Deputy said, we are conscious of these forces and our finite resources. We changed our operating model from a targeting perspective, going back as far as 2016, when organised crime hit a sad peak in Ireland with the Regency attack. With our collaboration, which has happened with our international colleagues under the direction of Deputy Commissioner Kelly, we focus on much analysis across the country at a national level. Data is important in all these circumstances. It is important for us to identify which groups and networks have been impacting areas across the country. That process takes place. We identify our priority targets at national level and link in at local level. At a national level, in the Garda National Drugs and Organised Crime Bureau, we are linking in with all the local, regional and divisional policing units around the country. That is continuously developing.

We identify that seizures alone do not deal with many issues on the ground. For many years, we have liked to say that we like to focus on quality rather than quantity because if you can have the right people being apprehended and sent to prison, and if you disrupt and dismantle the groups that are behind this - the decision-makers and the people who are facilitating and enabling them - that is when you have an actual impact.

It is important to highlight that in policing, every time we discuss something around a table, we find that it tends to have negative connotations and we would think we live in a terrible world. However, given the manner in which we have tackled some of the organised crime issues in Ireland in recent years, it is important to point out that Ireland currently has the lowest level of organised crime-related murders that I have experienced in my career. That is not by chance. That is a net result of targeting the right sections and having the right resources. The challenge for us in policing is to try to maintain a positive situation like that going forward. In many presentations in the past, I have harped on about a global peace index which measures many different aspects of society in more than 163 different countries worldwide. It is printed in many years. Ireland used to have an average index on that. It is not just related to crime but also to social status, employment and many issues. Crime and corruption, including the level of crime and fear of crime, are taken into account. Only one country, Iceland, is ahead of Ireland this year on the global peace index. We have achieved second place. Law enforcement is part of that. It is not just law enforcement but there are some positives stories.

We are aware of the local issues. Similar to the drug-related intimidation and the analysis of data that is involved in that, as an organisation, we have recognised this as a significant issue since 2013, when we first established our drug-related intimidation reporting programme in each division in the country. Now we have the drug-related intimidation and violence engagement, DRIVE, project. I know the citizens' assembly had much detail about the DRIVE project, which is a cross-agency issue. The data that will be received in that will help all of us to identify where the problems are and perhaps even who the problems are in certain areas. Our internal data on that is already quite interesting. That will determine where our focus is in all our efforts to try to deal with these issues. We all live in communities; gardaí live in communities too. We do not want these issues taking place. Drug-related intimidation and some of that violence go across the spectrum of society. Nobody holds a monopoly on it, even though it affects some communities more than others.

Deputy Neasa Hourigan

I welcome the witnesses. I congratulate Mr. Kelly on his new appointment. We might stick with that matter for a moment. I often ask a question about data and not just data but its relevance. As somebody knocking on doors at the moment, I do not disagree that people feel we need another 1,000 officers or so. I imagine we also need ICT resources. It is not just about data, which is a broad word, but resources relating to information-gathering in a digital sense. In a practical way, where are we with regard to our sufficiency in collecting data on this? Do the witnesses feel they have enough resources for data- and information-gathering and for all the policing that is not done on the street - the other side of policing? I presume it involves gardaí sitting at a desk and looking at people's phones or whatever. I do not know how it works. Does the Garda have enough resources? Where are we with that? What challenges does the Garda face? Does it have the skills and expertise in-house? It is using proprietary tools or buying things in? Do the witnesses have a sense of that?

Mr. Justin Kelly

If the Deputy does not mind, I might take that. She has hit on many different areas there. I will congratulate on intelligence first. We have the expertise. We buy in some expertise and we develop some of our own. I will give the example of telephone analysis, which is important for us. We have trained about 200 officers around the country. They are all spread around the country to do that type of work. We have the Garda National Cyber Crime Bureau that does the high end of that. These people are trained to world-class standards. We spent a huge amount of money sending them abroad for training. The software packages for any of these areas, including cyber, phones and intelligence, are very expensive. A significant amount of our ICT budget is spent on software and programmes in these areas. That relates to intelligence.

The other area the Deputy spoke about is data. We have done much work to try to better understand the data that we are gathering ourselves. We are doing that because we want to deploy our resources in the most efficient manner we can. We have a new GardaSAFE system, which is our new dispatch system. That has given us information to a level that we have never had before. That is one thing we are doing.

At a management level, in the last year, senior managers around the country have had access to a dashboard where they can see all the crime types in their own areas. They can work out what is happening in particular areas. It is a system called Power BI. It has been a game-changer for local managers and even us at national level to get a good understanding of crime areas and what is going on. We have our Garda Síochána analysis service. In any big areas that we want to look at and do a deeper dive-----

Deputy Neasa Hourigan

Mr. Kelly is describing highly specialised work. I imagine for practical reasons that much of that is centralised. What is the experience of the average garda dealing with it on the street? How does that work? Do they feed into those systems?

Mr. Justin Kelly

Yes. We have a divisional system of policing. We have our new model of policing, which the Deputy has probably heard about. What that means is that, at regional and divisional level, we provide locally all the resources that they need to operate themselves, so in all the regions and divisions, they have all the specialist functions they need at a local level.

In all regions and divisions, they have all the specialist functions they need at a local level. For complex and particularly challenging or difficult cases, whether on the technical side or something like really specialist interviewers, we hold them all centrally. Many are under my area. We augment and support any operations running. We have done a lot for the officer on the front line around their abilities and what they can now do on the street with hand-held devices. You will see officers on the front line with hand-held devices and they can check people. With the most recent iteration, we can check insurance on the side of the road and so on. Body-worn camera feeds into that; that is the next part. Front-line officers have access to stuff I could only dream of when I was a front-line officer. We looked at the United States and places like that and said to ourselves, "Oh my god, if we had that" but now we actually have it. We have been progressive in that area around providing front-line officers with support. For any of the more complicated cases they come up against, there are local specialists, local specialist detectives, phone analysis or CCTV people - whatever they need - locally.

Deputy Neasa Hourigan

Then, there is the more national service. Do I have time for one more question, Chair?

An Cathaoirleach

Of course.

Deputy Neasa Hourigan

I am trying to get a sense of what that international piece looks like in a practical way. Mr. Kelly spoke about linking up with international counterparts. When I did some reading for today, many of the stories that came up about Irish drug gangs were in The New York Times or on BBC News. We have graduated to a new era. How does that work? How often do they meet? What bodies does the Garda deal with? We see changes in legislation across other jurisdictions. Germany, for example, is moving towards regulating some drugs. We have been living with it in Europe for a while because different countries deal with different substances in different ways. That was in place but now we seem to be in a different era in which things are changing rapidly. How does the Garda navigate that? Does it present a challenge in policing? I presume the EU wants to work completely in lockstep on this but we all have different laws at the moment. Is that a challenge?

Mr. Justin Kelly

There are two parts to the question. On the first, international co-operation, Europol is key. It is a policing agency for all of Europe. Interpol-----

Deputy Neasa Hourigan

Is it that when something happens, the Garda contacts Interpol and Europol or do they meet quarterly?

Mr. Justin Kelly

I will concentrate on Europol. It is an agency that co-ordinates a lot of policing activity around Europe. We have EMPACT, which co-ordinates all the work of police forces across Europe. I am the national representative for EMPACT here. I think next week I will go to Europol and meet all my colleagues. We will decide our priorities for the coming years, what crime areas we will look at and what we will concentrate on. We have operations in all those areas which then devolve down. For example, if they come down to Mr. Boland, we will say we are concentrating on a certain crime type - it could be human trafficking or various other crime types. That then becomes completely operational. We set up operational groups and joint investigation teams with our colleagues around Europe.

Deputy Neasa Hourigan

On the ground.

Mr. Justin Kelly

On the ground.

Deputy Neasa Hourigan

When EMPACT sets the goals for the year, how many times during that year does it meet as a group?

Mr. Justin Kelly

As the Deputy can imagine, it tiers down but where the rubber meets the road - the important part - the guys and girls who work in this area meet every single week. Practically every day of the week, we have people travelling to Europol, people coming to us from Europol or people who work for Mr. Boland going to various member states for operational action, intelligence, etc. We are in a new building called Walter Scott House. Practically every day of the week, we have people coming from North America or Europe. We had a delegation of Colombian generals with us only two weeks ago. Our colleagues in the US Drugs Enforcement Administration, DEA, are really important for us, as are those in the US Department of Homeland Security. Our closest neighbours are the PSNI and the National Crime Agency in the UK. To answer the Deputy's question, it is daily.

Deputy Neasa Hourigan

It is completely integrated.

Mr. Justin Kelly

The second part of the Deputy's question was around changes to legislation and different laws. Generally, everyone is co-ordinated around supply and drug trafficking. Possession may be slightly different. Transnational organised crime groups and the targeting of them, firearms, human trafficking, economic crimes-----

Deputy Neasa Hourigan

Effectively, gang activity is the same whether there is decriminalisation or not.

Mr. Justin Kelly

Yes. There are nuances in different countries - different drugs may be more popular, there are different things going on or different gang methodologies - but generally it is similar. If there is an organised crime group in Slovenia and we have one in Ireland, the police there target it the same way we do. It is easy to do joint operations. We run joint operations constantly. To emphasise, it is not quarterly meeting stuff. Quarterly meetings are at a high level looking at strategy, resources and finances - at a EU Commission-type-level - whereas we try to sort out some of the less-----

Deputy Neasa Hourigan

It is interesting that the slight variations do not act as a barrier to prosecuting or dealing with gangs.

Mr. Justin Kelly

Even in North America, as everyone in the room will be well aware, where there is a completely different landscape legally, we work with the US Department of Homeland Security and the DEA. There is constant interaction. Mr. Boland and I were in Athens two weeks ago at the DEA annual international conference, which brings together all the people involved in this type of work around the world. These interactions are important for us. The key is not just operational action but horizon scanning to get an understanding of what is going on in other countries to see what is coming at us. That is important around fentanyl and nitazenes, for example.

Deputy Neasa Hourigan

I thank Mr. Kelly.

An Cathaoirleach

I have a number of questions. My first is about the adult caution scheme and cannabis. It was introduced in 2021. There is controversy about the numbers particularly since it was introduced. What are the witnesses' opinions on how that has worked out? The figures I have seen are that the cautions and those directed towards court are very imbalanced. The idea is to give a person a caution if they have cannabis in their possession.

Mr. Justin Kelly

I may ask Mr. Boland to come in. There are a number of criteria for someone to be accepted in the adult caution scheme. If you do not meet the criteria, you cannot be adult cautioned. That set of offences is not confined to drugs. An easy example to understand is assault. For section 2 assault, you will be given the benefit of adult caution but if you deny it and say, "I did not assault Justin Kelly", you cannot be in the adult caution scheme. One of the criteria is that you have to admit it. There are four criteria. Another is there has to be a prima facie case, so the case has to be good enough to go to court. The offender must admit it, he or she must understand the significance of it and there has to be informed consent. Some people do not want to be part of the adult caution scheme, but want to go through the court process so they will not admit it. That is one cohort. The idea of an adult caution, not just in the area of drugs but in all areas, is to divert people away from the criminal justice system. Unfortunately, there are people who have hundreds of previous convictions. The adult caution system will not do much for them, realistically. Unfortunately, some people have been in the criminal justice system for decades. There are myriad reasons people would not go into the adult caution system, on a high level, but we support it.

We have had discussions about the extension of the adult caution scheme to other drugs.

An Cathaoirleach

Does Mr. Kelly think that will happen?

Mr. Justin Kelly

There are complications with it. I could spend the next hour talking about it, but on a straightforward level, one issue is that there is legislation and there are cases that state the garda's opinion about whether it is cannabis is accepted. Other drugs, however, such as the more complex ones like nitazines, need full examination. There is a range of areas to consider before extending it. If the Chair is happy, I will ask Mr. Boland to elaborate because I know the numbers are useful for getting an understanding of it. I think Mr. Boland might be able to add to that.

An Cathaoirleach

Yes.

Mr. Séamus Boland

It is a question I am interested in. I will clarify some misunderstandings that have been created as a result of general data. I was quite surprised when a specific report by the Centre for Justice Innovation was quite critical of the adult caution scheme. I have had a look at the data. To go back to what the Cathaoirleach said, the adult caution scheme has been in place since 2006 and covers approximately 24 different criminal offences, including the possession of cannabis. I took a quick, raw look at the data in the past 48 hours and tried to look at the same period the original report was written about, which I think was around 14 December 2020, when cannabis was introduced to the scheme, up to 20 February 2024. In total, more than 20,000 people were detected for simple possession of cannabis and more than 5,000 or 25% were dealt with via the adult caution. More than 15,000 seem at an immediate look not to have benefited from the adult caution, but when I drilled-----

An Cathaoirleach

What is the main reason, or is there any reason, for that?

Mr. Séamus Boland

When I looked at the data, the reality is that 67% of that figure did not fit the criteria to allow them to be accepted into the adult caution scheme. That may be because, as the Deputy said, they did not wish to be accepted or they may have previously received an adult caution - some of them may also be counted in the 5,000 figure - and there may be people who had multiple other criminal offences which are not included in the adult caution scheme. It was considered, however, and they did not fit the criteria. We can see immediately from the data that 67% of the figure did not fit the criteria, which leaves us with 8%, which is a small figure. It is approximately 1,500. To analyse why the 1,500 people did not benefit is quite a large project because I would need to extract the exact details of the cases. They are people who do not seem to have had any previous footprint. We can say they did not benefit from the adult caution in the past, but they may not have wished to accept the adult caution. It is possible the offence was part of numerous other offences that took place at the same time. They may have been found in possession of multiple different types of drugs from polydrug use, which we all know is a problem. They may have been arrested for domestic violence or other violent crimes where drugs are involved. It is to identify the exact reason for that, but it is about the original interpretation of the data, and 67% of those people were never going to benefit from the adult caution scheme because they did not fit the criteria.

An Cathaoirleach

I presume that each of the people who were cautioned had in their possession a small amount of cannabis.

Mr. Séamus Boland

It is important that I should have highlighted that some of the 67% could have also been charged with possession of drugs for supply, because everyone who is charged with a drug trafficking offence is also charged with simple possession. That is the process. It is a section 3 charge. A drug trafficker will also get a simple possession charge. A good percentage of those could also have been drug trafficking cases. From my analysis of the data, the adult caution scheme is being applied. When I was at the rank of inspector, I spent two years as the prosecuting inspector at a local District Court. While cannabis was not included in the schedule of offences for the adult caution scheme at that time, anyone who appears before a court will have legal representation and I remember many cases where people appeared before the court for public order offences, for instance, or minor theft offences, which are included in the adult caution scheme, and one of the first submissions of every defence lawyer to the sitting judge was that the client had not benefited from the adult caution scheme. They would ask whether it had been considered and whether the client could benefit. All those cases were referred back after legal advice and a decision was made and the grounds explained as to why they did or did not benefit. There is that safeguard if people who did not benefit from the adult caution scheme end up in a court. The legal representatives are the safeguard as they will point it out to the court.

Mr. Justin Kelly

If I could add something very quickly, the adult caution is generally given once, but it can be given a second time if the DPP agrees. We frequently write to the DPP to give a person that second chance. That is one point.

On the other point Mr. Boland made about the supply cases prosecuted - the Cathaoirleach can imagine that there are many in the whole year - the reason we also charge them with possession is that it is a direction from the DPP. It is not our decision. The DPP tells us which charges to use and section 3 always goes with the trafficking and supply cases. That has always been the way it has been done. Some of the cases in the statistics could never receive an adult caution. People who are caught with €50,000 worth of cocaine or whatever are charged with possession for supply but also with a simple section 3 possession offence. Obviously, they will not receive an adult caution for that.

An Cathaoirleach

If someone is caught with €50 worth of cocaine, is it more than likely that they will end up before a judge?

Mr. Justin Kelly

Yes. At the moment, cannabis is treated differently from all other drugs. That is the way it has always been. It is interesting because a lot of people probably do not fully understand the difference between the two. For cannabis at the moment, people will receive an adult caution the first time. The next time, the only thing that can happen is that the person is fined. After that again, it will be a fine. There is no possibility of imprisonment. That is the third one. On the fourth occasion, if people appear in the criminal justice system, a District Court judge can sentence them to imprisonment for up to 12 months. That is the fourth time. The reality is, however, that that is not what happens. We have a superb Judiciary and they take an approach under section 3 where they look at all the circumstances, and the reality of people going to jail for section 3 on that fourth time does not happen in our system. I prepared some statistics for the citizens' assembly. Back in 2022, there were 11,000 section 3 possessions.

An Cathaoirleach

Will Mr. Kelly explain briefly for anyone listening what section 3 is?

Mr. Justin Kelly

It is section 3 of the Misuse of Drugs Acts 1977 to 1984, which covers pure possession. As the Cathaoirleach correctly said, it applies to small amounts. It is the same for all drugs. I am sure people will wonder how we work out where the threshold is. There is simple possession and then supply. Generally, the smaller amounts, particularly of cannabis, are quite straightforward. There could still be a relatively small amount, however, such as an ounce or two of cannabis, but if people were also found in possession of cash, a list of names or whatever the circumstances may be, they could be prosecuted for supply, even though they had a small amount.

Going back to the 11,000 section 3 possession charges in 2022, only 261 people ended up going to jail, and when we looked at the 261, every one of those had previous convictions.

Of those, the median number of previous convictions was 74. The reality of that, which I am sure is not lost on anyone, is that no one is being sentenced to prison for the first time they are caught with drugs. That just does not happen in our system, although some people believe it does. The reality is that does not happen. That is in respect of cannabis. With all other drugs it moves from the fines section to the imprisonment section for a first offence. Cocaine is treated differently from cannabis. Again, the Judiciary’s approach comprises many different alternatives, ranging from probation to drugs court. There are lots of different options when it actually gets to court. No one, including the Garda Síochána, the Judiciary and the defence lawyers, wants to see people going to jail for having small amounts of drugs. No one has any interest in that. As I said in my opening statement, our focus is not on prosecuting drug addicts for small amounts of drugs. We have no metrics for that. There is no measurement of it. It is not a target we aim for. That is not our focus whatsoever.

An Cathaoirleach

I thank the witnesses for attending today's meeting and engaging with the committee in its important work over the coming months. I thank committee members and the staff.

The joint committee adjourned at 12.31 p.m. sine die.