'Lives on hold': Fifth monitoring report by Service Users Rights in Action (SURIA)

SURIA’s research is routinely underpinned by service user narratives and experiences of engaging with OST (primarily methadone), using a human rights perspective that traces the progressive realisation of rights instruments pertaining to the highest attainable level of healthcare (Article 12 of The Economic, Social and Cultural Rights among a number of other rights instruments). Our rationale for this approach stems from the fact that OST/MMT is a public health service and therefore clients should enjoy the same rights and treatment as others who are accessing modalities of treatment for other illnesses. However, our research continuously demonstrates that this is not the case and those using methadone often allude to institutional stigma, poor treatment practices and not being afforded any input in their own service provision, (Healy et al. 2022). This research is SURIA’s fifth research output, as we continuously attempt to highlight the plight of those engaging with methadone and other OST services in Ireland. We have repeatedly highlighted that these services are sub-standard, stigmatising and often harmful for those seeking refuge from problematic opiate use, (SURIA 2018, 2020).

Our research suggests that Irish OST (Opioid Substitution Treatment) and MMT (Methadone maintenance Treatment), as harm reduction modalities, often paradoxically produce harm in the lives of clients. Our work continuously highlights the lack of progress in client’s lives, poor reintegration, the over-extension of power into the lives of clients (including in matters that have little to do with drug use) and the poor quality of life for those who expected to be helped by methadone services, (SURIA 2020, 2018).

SURIA’s work is underpinned by four principals that have emerged continuously in our research. They include supervised urinalysis, the lack of care plans, choice of treatment and meaningful review, and the absence of an independent and robust avenue for complaint for clients who feel they are not being provided the highest attainable level of healthcare, as per the Economic, Social and Cultural Rights Agreement (1976) of which Ireland is a signatory. However, it must be noted that the State has not ratified the Optional Protocol, which arguably reduces the potential of this rights mechanism to propagate meaningful change.

The importance of this research lies in the timing of its publication, as Ireland enters a post lockdown landscape. COVID 19 enforced a plethora of changes to MMT practice in Ireland. Clinics and GPs were forced to allow clients to avail of more takeaways (doses that are taken home). Prior to COVID, the administration of takeaways was considered a privilege that was earned by providing urine samples that ‘marked’ the client as drug free. However, the provision of extra takeaways did not perpetuate chaotic drug use, as many key stakeholders predicted. Instead, even the EMCDDA alluded to the fact that for the vast majority of service users, extra takeaways did not lead to more opiate use. Instead, Alexis Goosdeel, the Director of the EMCDDA is on record as suggesting that COVID illustrated that service users could be granted more takeaways, more trust and that the paternalistic disposition that dominates much of MMT was in fact a misnomer. The International Network of People who Use Drugs (INPUD) echoed this sentiment, positing that COVID represented a chance to implement a “new normal” in how methadone (and other OST models) are prescribed and managed (Chang et al. 2020).

Ireland is currently in the process of a Citizen’s Assembly on Drug Use, as the State, with the help of key actors and stakeholders commence an in-depth examination of Irish drug policy. Therefore, one would assume that change is imminent, that years of advocacy and nuanced debate are potentially beginning to bear fruit. Unfortunately, this research suggests that not much has changed in how OST and MMT is practised in Ireland. The same four principals are still embedded in how service users are treated, the same four principals suggest that the human rights of this vulnerable populace are still being overlooked at best, blatantly ignored at worst. Service users are still experiencing the same levels of opprobrium as SURIA have been highlighting since our inaugural research in 2012.

The empirical evidence that informs this research is drawn from 229 service users, from three different areas in Ireland. As such, we believe that we have employed an effective, credible and cogent methodology, from which the Irish service user narrative can be captured and explored. This analysis of the data will be demarcated by the four principals that have emerged from all our research projects, 2012, 2017, 2018/19, 2020. The common themes that are repeated across all of these projects potentially suggest that little progress has been made in the provision of OST and MMT in Ireland. Lack of treatment choice, supervised urinalysis, no treatment plan and the lack of a robust and independent complaint mechanisms are shortcomings that our research has continuously identified. Within this barrage of failure, there are some signs of progress. However, the question of whether this enough is debatable. While progress is welcome, the perennial stigma and poor treatment that drug service users routinely endure is quite simply unacceptable.

SURIA is a service user-led group that campaigns for rights-based MMT/OST. One of our principal objectives is to recognise service users as consumers as opposed to passive recipients of a public health service. As such, we advocate for a symmetrical partnership dynamic to inform doctor/client interaction. We are committed to reform within the MMT/OST sector that will enable service users to be seen as partners in their own recovery plan, as opposed to engaging with services that are frequently characterised by a highly imbalanced power dynamic in favour of the service provider, (Bennett 2011, Harris & McElrath 2012). Within this system, any form of recovery is unlikely, the quality of life remains poor and services become buttressed by “us and them” relationships.

This analysis will commence by comparing some of the findings of out last project, Nothing About Us Without Us (2020). In this way, our continued tracing of the progressive realisation of the right to health provides the backdrop to this analysis. The nuances and challenges that are routinely endured by Irish service users will be captured, highlighting that the potential of methadone and other substitute treatment models are inhibited by poor practices, a lack of training and a refusal to follow international best practice and literature. As part of this cycle of continuous analyses, this report will also discuss some of the new findings that have emanated from this round of research.