A Doctor Tries to Lower Barriers to Methadone Treatment

For John, a heroin user for seven years, there were a few snags that, for a while, held him back from getting stable on methadone treatment.

Staff in two methadone clinics wanted him to give urine samples in front of them – a level of intrusion that he, like others he knows, found uncomfortable and off-putting.

“I couldn’t get stable on methadone because of the way the clinics are, the structure of having to urinate in front of people,” he says. “Somebody comes in with you and there are mirrors around the toilets.”

The metal detectors and security guards lend a hostile feel to the National Drug Treatment Centre, said John, who withheld his surname. “Trinity Court is like walking through a gaol.”

That’s how he ended up using the Safetynet service, which he dropped into on a recent Wednesday morning at the Salvation Army homeless hostel on Granby Row.

There and in other similar places in the city, Dr Austin O’Carroll holds regular clinics in a meet-people-where-they-are spirit – trying to erode some of the barriers that prevent Dublin’s homeless from accessing the methadone treatment they need.

“The main skill I have, is you learn to interact with people,” says Dr O’Carroll, stressing the importance of being upfront and honest and respectful.

But is it a good idea to make it easier for people to get methadone treatment?

Methadone programmes can reduce crime, reduce the risk of addicts overdosing on heroin, and reduce the risks that they will contract blood-borne viruses by sharing needles.

But some argue moving people from heroin to methadone is just swapping one addiction for another, and scarce resources should be focused on treatments that aim for total abstinence.

Getting Here

Back when Dr O’Carroll was still in college, he moonlighted as a youth worker with St Vincent de Paul. He has worked in the inner city ever since.

He recalls working with a group of 15 kids in Sean McDermott Street in 1982, and getting a house call about ten years later from one of the kids who had grown up. “When I met him, I said that it was amazing. But of those 15 kids, seven had died,” he says.

The HSE asked Dr O’Carroll to set up a service for homeless people, and so, in 2004, he opened his first clinic. Five years later, he launched Safetynet, which has grown to employ 10 doctors across 24 clinics in 12 homeless services.

There is also a mobile health unit that goes around to treat those who are sleeping rough on the streets, he says.

“The HSE have been very good at supporting us, they were the ones to approach me to set up the first clinic,” he says. “They identified the gap.”

As he counts it, the Safetynet service has started around 500 people on methadone.

The Clinic

The large waiting room at the hostel looks as if it were once a kitchen. There’s a cooker and a sink, and two rows of tables and chairs, where a little after 8am, two women and six men sat waiting to be seen.

The Safetynet programme is definitely saving lives, says Fr Peter McVerry, who has dropped by this morning to pick up a prescription for a homeless man who has cancer.

One of the ways it does that is by being flexible with appointments, he says.

Many homeless people find it hard to keep appointments. “Often they don’t appreciate the nature of their illness and won’t attend a medical service until their illness is very acute,” he says.

Making medical treatment available on-site in hostels and in places where homeless people feel comfortable, they are much more likely to engage in treatment, he says.

Dr O’Carroll says that if a patient misses today’s surgery in the morning, they can catch a clinic with one of his colleagues in Merchants Quay this afternoon.

“If you ring a treatment centre, they give you an appointment. Homeless people don’t keep appointments. The system is for the general population,” he says. “That doesn’t work if they are homeless or chaotic.”

There’s also the issue of missing medical cards. A quarter of homeless people don’t have a medical card, although they are likely entitled to one, says Dr O’Carroll.

He has a system in place to work around that: the HSE has granted him a general number to use for any patient in need – including undocumented migrants, who might otherwise be unable to access medical care.

More Comfortable

Some of those who have started on the methadone treatment through the Safetynet programme say that the benefits are many.

Glenn Heffernan says he would wake up every day feeling sick from heroin withdrawal. It was “flu times a thousand. I was getting aches, flu, shakes, being sick,” he says, sat on a bench in the communal garden of the hostel.

The homeless 23-year-old has dust down one side of his blue jumper, and says he slept rough the night before.

He has used heroin for five years, he says, but the methadone programme has changed how he sees the world.

“It has changed my life, it has changed my whole way of thinking,” he says. “I’m thinking about things instead of acting on impulse.”

Stephen Allen, who carries a sleeping bag and has also been sleeping rough, has been a patient with Dr O’Carroll for about seven years.

“I feel more comfortable with Austin, I can tell him things,” he says. “I don’t really lie to Austin because he knows me.”

He avoids the large methadone clinic at Trinity Court. “There’s too many people. There is five levels to the place,” he says. “You don’t know who you are going to meet there.”

A spokesperson for the HSE said that the service in the National Drug Treatment Centre is not like a prison, as John had suggested. “There are security measures in place as there are in many such facilities to ensure the safety of service users and staff alike,” the spokesperson said.

Dr O’Carroll says he encourages patients to talk openly about other drug use, and also makes use of support workers who are linked in with his homeless patients through hotels or outreach programmes.

If a patient says it’s okay, he checks in with their support worker to get more information, or, if they don’t have one, reaches out to centres such as Ana Liffey Drug Project or Merchants Quay Ireland to get them set up with one.

Heffernan, who started on methadone a month ago, says he found it a fairly straightforward process, and that he likes Dr O’Carroll. “I think he’s a lovely man, sound he is.”

More Available

A couple of weeks ago, homeless heroin user Patrick Kiely was having lunch in the Capuchin Centre, a homeless day centre near Smithfield.

He had been a couple of times to clinics to give urine samples in an effort to get on methadone, he said. (Clinics take samples to make sure a patient is actually an opiate addict.)

But he was unsure what had happened next. Perhaps he was put on a waiting list, he said, but he hadn’t head back.

“He is homeless, therefore he is vulnerable. They are the very people we should be catching and getting into treatment,” says Dr Garrett McGovern, a Dundrum-based GP who specialises in addiction.

Yet many homeless people who seek access to treatment face long wait lists.

There is a five-month wait list for treatment at the National Drug Treatment Centre at Trinity Court – where many homeless Dubliners are referred – according to a HSE spokesperson.

Dr O’Carroll says too many GPs refuse to prescribe methadone, and if more would prescribe it, then there would be shorter wait times. Clinics could transfer more patients to GPs, and work with the next cohort.

Dr McGovern says that not enough is being done to remove barriers to access to treatment. “The complete obsession with testing in Dublin, routinely monitoring patients, none of that testing is supported by international evidence,” he says.

According to a spokesperson for the HSE, “Unless requested otherwise urine samples are supervised by trained staff to ensure the authenticity of the sample.”

But, says Dr McGovern, testing doesn’t deter drug use as some argue and the tests can often be wrong. “It detects metabolites of drugs but false positive and negative results are common.”

Those urine tests have been phased out a bit by austerity. Doctors used to run them each week as standard, says Dr O’Carroll, but they only have to do them once a month now, due to cutbacks.

Too Accessible?

Dr O’Carroll, through the Safetynet programme has addressed some of these obstacles, making it easier for people who need it to get into methadone treatment. But some critics question whether that is a good thing.

After all, data from the Health Research Board shows that methadone, alone or with another drug, was implicated in more than a quarter of poisoning deaths in Ireland in 2015.

In 2014, there were 98 deaths where methadone was implicated, compared to 90 deaths where heroin was implicated.

That has spurred concerns around the amount of methadone finding its way onto the black market, where people who aren’t in treatment programmes buy it.

Dr O’Carroll says the prescriptions he gives mean that patients must collect their methadone at the pharmacy each day, which reduces the risk of it being sold on.

When a heroin user switches to methadone, they replace a short-acting opiate with a longer-acting one, says Dr McGovern, “one dose of which lasts about 24 hours”. This can allow a user to stabilise their life, attempt to get housing, possibly return to employment, and more.

The regular supply of methadone means that an opiate user has stable tolerance levels, and so – should they relapse and use heroin again – they are unlikely to overdose, he says.

“It is extremely difficult to overdose on heroin if a patient is on an adequate dose of methadone if no other drugs or alcohol are implicated,” Dr McGovern said. The vast majority of people who die by opiate overdose are chaotic polydrug users, he says.

While methadone can protect them from a pure opiate overdose by keeping their tolerance stable, it cannot protect them from the respiratory failure that can occur when someone takes opiates, benzos and alcohol, he says.

That is perhaps the reason why methadone is sometimes implicated in poisoning deaths, according to the Health Research Board data. Still, there might be more deaths if not for methadone.

One Australian study published in 1996, which tracked 296 patients over 15 years, found that the risk of death for heroin users on methadone was a quarter of that of their counterparts who were not on methadone.

In addition to pointing to the dangers that methadone poses in terms of poisoning deaths, some critics also argue that not enough is done to taper patient off from methadone, once they are on the programme.

Professor Neil McKeganey, director of the Centre for Substance Use Research in Glasgow,  says too many patients in Scotland are being prescribed methadone for too long.

Those on methadone continue to use street drugs, and he thinks methadone can prolong people’s addictions. Opiate users who are not prescribed methadone are more likely to become drug-free quicker, he says.

Prescribing methadone “should be regularly and frequently assessed, and if the patient is not progressing on methadone, it should be stopped” ,he says.

In Scotland, “in excess of 22,000 addicts are now prescribed methadone, and we have seen a year-on-year increase in the number of addict deaths”, he says.

In 40 percent of those deaths, methadone is a factor, he says, which is up from 20 percent 10 years ago.

Like in Ireland, the deaths are usually of people who use multiple drugs at the one time. “Before any doctor prescribes methadone, which is a powerful depressant drug … they need to be sure that that individual is not also using other depressant drugs,” he said.

Dr McGovern, the Dundrum GP, says he helps patients come off methadone if they want to, but full detoxification can be dangerous because opiate addicts often relapse, with potentially fatal consequences.

Dr O’Carroll, of Safetynet, says he would always encourage patients to come off methadone after a certain period of time.

“I’ve helped many people come off it, and taken them off it slowly over months,” he says. “I believe more people could come off it but I can’t force them to come of it.”

Says Dr O’Carroll: “The problem is as a doctor if you forced someone to come off it and then they overdosed then you would have done an action that caused them to overdose.”