We have apologies from Deputy Devine and Senator Ryan. Deputy Ó Murchú is substituting for Deputy Devine.

I am delighted to open the 13th public meeting of the joint committee and our first in this module on treatment, recovery and rehabilitation. I welcome our witnesses today from the Aiséirí treatment centre, Ms Sara Cassidy, head of clinical services, and Ms Mary Hennessey, chief executive officer; from Cluain Mhuire, Mr. Gerry McElroy, chief executive officer, and Ms Nicola Kelly, manager of Cluain Mhuire Athy; from Soilse, Mr. Noel Murphy, manager the HSE social inclusion addiction service, and Mr. Brian Kirwan, general manager of the HSE social inclusion addiction service; Dr. Garrett McGovern, who has worked in this field for almost 30 years; and from the After Care Recovery Group, Mr. Tony Keogh, project manager. They are all very welcome.

All witnesses and members are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him or her identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their marks. It is imperative they comply with any such direction.

I remind members of the constitutional requirement that in order to participate in public meetings, they must be physically present within the confines of the Leinster House complex. Members of the committee attending remotely must do so from within the precincts of Leinster House. This is due to the constitutional requirement that in order to participate in public meetings, members must be physically present within the confines of the place where parliament has chosen to sit. In this regard, I ask any member partaking by Microsoft Teams that prior to making their contributions to the meeting, they confirm they are on the grounds of the Leinster House campus.

All opening statements have been circulated to members and will be published on the Oireachtas website after the session. As agreed, each opening statement will be limited to five minutes to allow plenty of time for questions and answers. I am conscious of the wide range of issues to be discussed today. If necessary, further or more detailed information can be sent to the clerk to the committee for circulation to the members. I also wish to mention that members will be in and out of the committee because we will have requirements to be in the Chamber and elsewhere. I ask witnesses not to read any more into that.

I invite Ms Cassidy to deliver her opening statement on behalf of Aiséirí.

I thank committee members and esteemed guests for the opportunity to address them today. I am head of clinical services in Aiséirí, and I am joined by Mary Hennessy, CEO. Aiséirí was established in 1983, and has grown into a national, leading provider of addiction treatment in Ireland. Aiséirí provides a unique continuum of care and recovery, from residential detoxification, addiction treatment, secondary addiction treatment, sober living and recovery support to our progression programme, which provides education and career development. We also run Aislinn, the only residential addiction treatment service in the State for young people aged 15 to 21.

Over the past four decades, Aiséirí has continuously developed to meet the complex and changing needs of individuals affected by addiction and their families. We are a national service located in four counties across the south-east. Our collective goal here today is treatment, recovery and rehabilitation. It is important to stress that a residential treatment programme is the first pillar of support for an addict but recovery support and ongoing rehabilitation are the other two. Individual transformation comes from the services that continue to support and enable ongoing recovery and healing.

Aiséirí is steadfast in its vision. We believe in the priceless potential of people and that recovery from addiction is possible for everyone. Aiséirí is among the addiction treatment centres and national voluntary drug and alcohol services of Ireland, and we continue to advocate for people requiring addiction treatment services. As regards the ongoing challenge of addiction, mainly with young people in Ireland, substance misuse is undoubtedly a pervasive problem in Irish society, and the age of people requiring treatment has dropped dramatically in recent years, as reflected in the citizen's assembly's findings. Early intervention and addiction treatment is crucial. Aiséirí provides treatment for young people who are the most vulnerable and often marginalised in society. This is truly a preventative and life-changing service, unique in the State and focused on managing the complexity of this group's needs from neurodiversity, mental health, trauma, intergenerational family addiction, educational deficits, housing and deprivation. Our admission data currently shows that 40% of our adolescent clients have ADHD and other forms of neurodiversity, which adds to the responsibility, challenges of care and cost that face Aiséirí Aislinn now and into the future. The major challenge is Aiséirí Aislinn has capacity, but is underutilised by the State, despite a massive and growing national addiction problem.

The HSE national funder holds the purse strings but is also in control of referral pathways. The current HSE drugs strategy of trying to meet the needs of young people in the community is valid but it should also consistently enable referral to residential care at local, regional and national level when required. Referrals should not be a postcode lottery. Similarly, in the judicial system, the youth diversion programme has stopped the referral pathway into early treatment for young people as they no longer have a probation officer. These changes in referral pathways have reduced access for young people requiring residential treatment. In 2020, we had 177 referrals and in 2025, 140 young people were referred to the services. The most vulnerable people who have the most complex needs require long-term recovery and rehabilitation.

Aiséirí Céim Eile is more than 20 years developing the secondary treatment services in Waterford, offered to both male and female clients. This work provides six months additional residential therapeutic work, followed by three months sober housing and engagement in the progression programme. The programme focuses on the following four principles: health, overcoming or managing one's diseases, as well as living in a physically and emotionally healthy way; home, a stable or safe place to live that supports recovery, purpose, meaningful daily activities such as a job, school, volunteerism, family, caretaking or creative endeavours; the importance of independence, income and resources to participate in society; and community; relationships and social networks that provide support, friendship, love and hope. The ongoing progression programme is key to successful rehabilitation from addiction. Post-admission rehab care that brings vulnerable persons back to beneficial life in the community needs to be supported, standardised, scaled and funded consistently by the State. Our progression model shows an 87% success rate and can be the template nationally. It needs to be supported by the State as it provides healthcare, housing, education and jobs in a safe and supported environment within the community. It is very much a win-win. The challenge is that there is no sustainable State funding for this service, despite its efficacy and alignment with the national strategy focusing on recovery and rehabilitation. There is no recognition of the service as being the most effective way to prevent recidivism and to reduce further cost to the State. Our programme is consistent with Sláintecare’s mission of integrating person-centered care in the community, and with the mission of the 2010 national drugs rehabilitation framework document. It is also consistent with the Department of Health’s Reducing Harm, Supporting Recovery 2017–2025 strategy. Our programme joins up the dots of care and addiction, providing comprehensive, integrated care from recognition, through rehab and into full recovery in the community.

I would like to leave members with a few key messages. First, we all agree there is a national problem with substance misuse, and Aiséirí has solutions. We are innovative and manage a range of addiction services focused on the needs of individuals and their families. Second, we are serious about helping young people, families and communities. Early intervention is the most important factor in successful treatment. Changes in referral structures have blocked access for young people to our Aislinn service. We ask for support in prioritising referrals for vulnerable young people and facilitating them in accessing help they require. Finally, treatment funding is a core pillar of the process and relatively well-funded and understood. However, the model for continual recovery post treatment and engaging in rehabilitation through progression in education and career development lacks appropriate funding structures. Recidivism and failure happen when people leave treatment and return to their previous lives, unsupported. Appropriate funding for secondary services must be front and centre. Our collective goal as a society must be the support of the individual and prevention of return to active addiction. I thank members for their time.

I thank everybody here. I welcome this opportunity to address the joint committee.

Inspired by her belief in the value of every human being, Sister Consilio Fitzgerald founded Cuan Mhuire in 1966 to set up a centre or home primarily for those who were marginalised as a result of their addiction. Over the past 60 years, Cuan Mhuire has evolved and grown into the largest voluntary provider of residential addiction treatment and rehabilitation services in Ireland. Its doors are open to anyone seeking freedom from addiction, a challenge that touches lives across all backgrounds. All are welcome irrespective of faith, ethnic background or financial circumstances.

We have four treatment centres in the Republic of Ireland, with 92 detox beds and 352 treatment beds. Our treatment centres are located in Kildare, Limerick, Cork and Galway. For homeless persons in early recovery post treatment, we also provide 102 supported housing beds in our seven transition houses, which are in Dublin, Limerick, Cork, Galway and Monaghan. As part of our commitment to providing the best quality of care, all of our centres have CHKS accreditation and ISO certification. In our treatment centres, we provide a 12-week abstinence-based residential programme, including detox, for alcohol and gambling and a 20-week abstinence-based residential programme for drugs.

Through an holistic model of care, Cuan Mhuire supports individuals in addressing the psychological, emotional and social dimensions of addiction. Our approach is rooted in the therapeutic community model, and our treatment programmes are delivered by a multidisciplinary team qualified and experienced in addiction treatment, providing detox, group therapy, individual counselling, family therapy, relapse prevention and aftercare. An individual care plan, specific to a person’s needs, is in place for each participant.

We have over 200 staff working directly within our treatment programmes, consisting of nurses, counsellors, group facilitators and a cohort of volunteers complementing the service. We also maintain strong links with other professional supports outside Cuan Mhuire, such as GPs, housing key workers, probation officers and others.

In 2024, we had a total of 1,923 admissions for our residential programmes. Of those admitted, 63% stated alcohol was their primary addiction, 26% stated drugs was their primary addiction and the remaining 11% stated gambling was their primary addiction. However, it is important to point out that 53% of those who had alcohol down as their primary addiction and 40% of those whose primary addiction was gambling also admitted to taking drugs. Currently we have a large percentage of poly-substance users in our treatment programmes.

Like all other organisations, Cuan Mhuire has its challenges. Despite our best efforts to minimise waiting times, the demand for our services continues to increase, and with that the waiting times are growing ever longer. Another major challenge for us in Cuan Mhuire is the gap between mental health services and addiction services. A high percentage of people presenting to our service also have an additional mental health diagnosis. We urgently need supports from mental health services whereby an integrated treatment approach could be put in place for an individual with dual diagnosis to provide the best possible outcome.

Due to the current housing crisis, we are finding it extremely difficult to support our residents in finding accommodation. Many are at risk of homelessness after the completion of their programme due to the lack of social housing and rental accommodation. This results in treatment beds as well as step-down or transition places being blocked for lengthy periods as we continue in our attempts to help people to find suitable accommodation. There is no benefit to be gained if individuals who go through residential treatment programmes find themselves in temporary accommodation or on the streets, where they are surrounded by substance misuse.

Our resources, particularly our financial resources, are limited and this results in great challenges for us when responding to the ever-increasing demand for our services. As a voluntary organisation with charitable status, we rely entirely on fundraising events, donations and funding from State agencies. Despite the difficulties we are encountering, Cuan Mhuire remains deeply committed to facilitating our service users as they seek to rebuild their lives, and we continue to strive to provide the highest standards of excellence for those to whom we provide care and support. We hope our engagement with the joint committee today will support and enhance the wider discussion around emerging needs and the development of services for those seeking treatment for drug addiction.

I am thankful for the opportunity to speak to the members today. I am accompanied by my general manager, Mr. Brian Kirwan.

Much of what I say will overlap with other statements as there are many similar initiatives.

Of course.

Soilse is the HSE’s recovery-oriented addiction rehabilitation programme and it is based in Dublin’s north inner city. Soilse was founded by man called Gerry McAleenan and has been in continuous operation since 1992. We work with individuals experiencing complex and entrenched substance use issues, many of whom face multiple layers of social and health disadvantage. Our work is grounded in collaboration. We partner closely with statutory, voluntary and community organisations, including the City of Dublin Education and Training Board, which supports our educational and vocational programmes, many of which are QQI accredited. We also work alongside Recovery Academy Ireland, the north inner city drug and alcohol task force and a range of peer-led recovery fellowships. We have excellent support from our integrated health area, IHA, management team and this has allowed us to move from a primarily opiate-based treatment model to a treatment and rehabilitation approach that can meet the needs of our new service users, who are presenting with unique problems associated with the new emerging drug trends. I will speak a little about that later. Furthermore, we are aiming to develop treatment strategies to support people affected by behavioural addictions like gambling and gaming addictions, and possibly sex addiction. The Soilse team needs to be innovative and progressive in its continuum-of-care process to ensure optimum success.

Who are the people we support? We prioritise women, people living in the north inner city and individuals already engaged within the HSE continuum of care. We were one of the first organisations in Dublin to set that up. At the first point of contact, each participant undergoes a comprehensive, needs-based assessment. This originally came from the Cork–Kerry assessment. It is now being used by many different agencies to stop people from becoming retraumatised. We use the one assessment tool so we can then share. That is the reason we introduced it. It allows us to identify recovery capital, which is the concept of a man called William White and another called David Best. We work on this an awful lot in identifying the skill sets and work needed so people can go on and do well in life.

Soilse operates a structured, full-time programme from Monday to Friday. It runs from about 9.30 a.m. to about 4.30 p.m. We also have evening aftercare. Participants engage in therapeutic group work, addiction education, one-to-one counselling, health and well-being modules, creative therapies, parenting classes and physical activity, looking at the hidden harm of drug addiction. We try to teach parents on the course the effect of addiction on themselves but also on their children. The aim is counterbalancing when this is needed. Our holistic model reflects the complexity of the lives of those we support.

Referrals to Soilse emanate mainly from past participants. People who have done our programme end up in recovery and move on to fellowships, and then people come into fellowships looking for support. A lot of it is word of mouth, based on the reputation we have. Referrals are also through concerned family members, other drug projects, self-referral, probation, addiction case managers and self-help fellowships like Narcotics Anonymous, Cocaine Anonymous and Alcoholics Anonymous. Between 120 and 150 participants successfully complete the different Soilse programmes every year.

Our multidisciplinary HSE team comprises staff from a number of different disciplines. They are all very experienced and all embrace a recovery-orientated system of care and a non-judgmental approach. The team includes addiction education officers, specialist addiction counsellors, social care workers and counsellors.

We also have a consultant psychiatrist who visits every Thursday. The previous speaker talked about dual diagnosis. It can be a really big problem if there is not a psychiatrist to address these issues readily. A consultant psychiatrist was a really important addition to our team last year.

We have after-care facilitators and an administrative team. We believe in having a strong team, so we also have trained peer support workers. These are former addicts who are now in recovery and come back as workers, which creates recovery champions.

Due to high demand, Soilse operates multiple programmes on a continual basis, including four full-time drug and alcohol-free rehabilitation groups; two pre-entry programmes to stabilise individuals before they become full-time; one full-time detox preparation group, which supports people to cease taking methadone and other prescribed medications; and three aftercare groups that run in the evenings, which are packed and full to the brim. In February we will start a chemsex support group because people from the LGBTQ+ community came to us and we lost them through relapse. We found that we did not understand what was going on. We are not aware of a lot of the stuff that is going on in that community. We have two psychotherapists, both from the LGBTQ+ community, who will run the group every Friday evening.

We have identified a clear and growing need for targeted supports for members of the LGBTQ+ community involved in chemsex and related substance use. This cohort often experiences severe mental and physical health consequences, high relapse rates and limited access to appropriate services. This issue remains largely hidden and under-researched. Soilse will commence a 24-week pilot programme in February 2026, which will be facilitated by qualified psychotherapists who are also members of the LGBTQ+ community. This is a critical step in addressing this gap in national service provision.

I will stop Mr. Murphy, if that okay.

That is grand. I thank the Chairman.

I do not want to be accused of favouritism because Mr. Murphy is from my constituency. I promise I will subtly favour him over the course of the next couple of hours. We will come back, I promise. I call Dr. McGovern.

I thank the Chair, Members of the Oireachtas, colleagues and members of the public for giving me this opportunity to speak today. We are here to talk about drugs but, more importantly, we are here to talk about people with families, histories and futures. Too often, the lives of these people are shaped not by their potential but by stigma, punishment and missed opportunities for care. This broadly reflects how the Citizens' Assembly on Drugs Use approached the issue. It called for a comprehensive, health-led response and a move away from criminalisation.

I have been working in this field since 1998, or for almost 30 years. Over that time I have seen Ireland's drug landscape change repeatedly. When I started, the system was largely built in response to a heroin crisis. Today, we are dealing with something very different - widespread polydrug use. The drugs most commonly associated with harm, and with treatment demand, include cocaine, opioids, cannabis and benzodiazepines, not to mention alcohol. There are emerging harms linked to substances such as ketamine and nitrous oxide, and many more that are often used in an array of combinations. Along the way we have seen other significant trends, including the so-called "head shop" substances of the late 2000s, shifts in benzodiazepine use and, more recently, overdose clusters related to highly potent synthetic opioids such as nitazenes that have been detected in the heroin supply and appear in increasingly unpredictable ways across the drug market.

The point is simple. Drug use evolves quickly but treatment services and systems do not. We are now operating with structures and pathways that were designed for a very different drug market. In many parts of Ireland, there are limited or inconsistent treatment options for people experiencing problems related to polydrug use, including cocaine, benzodiazepines and other substances. Due to the patchwork quilt of service provision and clinical expertise, access to care still depends too heavily on where you live rather than on what you need. This is not because clinicians or services do not care. It is because the system itself is outdated, fragmented and overly rigid. Too often, people are offered whatever happens to be available or nothing at all rather than a range of evidence-informed options that reflect the realities of contemporary drug use.

A health-led approach begins with the basic recognition that problematic drug use is a health issue and not a moral failing. People do not recover because they are punished. They recover when they are supported, treated with dignity, and offered timely and appropriate care. That care must combine the right clinical responses with the right psychosocial supports. That can be delivered within existing services if there is clear leadership, investment, and consistency across the State and State-funded providers. This is not about reinventing everything; it is about modernising what we already have and ensuring it actually meets current need.

Recovery does not look the same for everyone. It is not linear. It does not always involve abstinence and does not happen to a timetable. Progress for people can include reduced use, improved health, safer use, stability and reconnection with family, work or community. All of these are legitimate and meaningful outcomes. Relapse should not be treated as failure. It should be met with care, not condemnation. The framing of the last strategy got this right: Reducing Harm, Supporting Recovery. Words matter and balance matters.

We also need to acknowledge the harms caused by criminalisation itself. A drug possession conviction can limit access to employment, education, housing and travel long after drug use has stopped. This is not public safety but is a long-term social harm. The recent nitazene-related overdose clusters are a stark reminder of what happens when drug markets change faster than systems can respond. Risk escalates quickly when services are slow to adapt. We have done well so far but there are developments that could make us safer still, including wider and properly resourced drug-checking services, and making naloxone easier to access, ensuring no cost barriers and fewer practical restrictions on supply.

What is required now is progressive leadership that ensures people across Ireland have consistent access to a range of treatment and support options regardless of geography. We require leadership that backs evidence over ideology and care over control. This approach is not radical; it is evidence-based. Jurisdictions that have invested in health-led responses have seen fewer drug-related deaths, better engagement with services and improved public health outcomes. Ireland has made progress, but implementation has been uneven and intent has too often outpaced delivery.

If we are serious about reducing harm, supporting recovery and saving lives, we must modernise our response to reflect today's drug use, not yesterday's. Compassion is not weakness, care is not complacency and a health-led drug policy is not just an option, it is our responsibility.

I am the project manager and a founding member of the After Care Recovery Group, ACRG. On behalf of ACRG and its past and present participants, I thank the committee for this opportunity today.

ACRG is a drug-free day programme that was established in 1999 to meet the needs of people upon completion of their residential treatment programmes, to address and process the issues identified in their primary care such as trauma or, oftentimes, issues that were not identified during primary care for many reasons. The recovery process from addiction is a difficult and often complex one with a high risk of relapse at this early and vulnerable stage of returning to the community. Therefore, a comprehensive programme is often needed to address the causes and conditions that led to addiction in the first place.

Conventionally, aftercare is perceived as a once-weekly support group provided by a treatment centre upon completion of the treatment process. We support and encourage all our participants to follow through with their commitment to complete but we believe that a paradigm shift is needed in how we view aftercare. As a result, we developed a comprehensive programme to address the needs of those people presenting for support post treatment.

ACRG provides a structured day programme from Monday to Friday with evening and weekend support. We have a small, dedicated, skilled, qualified and experienced team to address the complex issues that often emerge when a person comes back from the abyss of addiction. I know that the members have heard valuable contributions from individuals and service providers in relation to the difficulties, such as trauma, grief, abuse and loss in many forms before, during and after addiction. However, with the right mental, emotional, physical and spiritual nurturing support structures and experience, these difficulties can be overcome. The nature of addiction and recovery is complex. There is no one-size-fits-all approach and no quick fix. Our programme is designed in a way that involves moulding a programme around the individual rather than moulding the individual into a programme. A complex problem like recovery from addiction requires a comprehensive response, and needs time and attention to treat the underlying causes of the addiction. Also, it is a process and not an event.

In conclusion, ACRG and such programmes are doing our very best with the limited resources we have.

We are an integral and essential part of the continuum of care that our people have used to get to this point in their recovery journey. Aftercare is not just an afterthought and should not be treated as such. This is where the theory meets practice, where the research and the studies that have been undertaken to inform us of the best practice are applied. It is where the rubber meets the road, where the practical application of the information is put in place and where all the interventions from the various services throughout the continuum of care come together in one place to give the person the best possible springboard into the rest of their lives, including future employment, training or education. Aftercare is the belt and braces that protect the investment our people and the services have made, often having taken years or decades to get to this stage throughout the whole continuum to secure their future recovery and break the cycle of addiction from previous generations and for the generations to come.

On behalf of the ACRG past and present participants, we respectfully request the Committee on Drug Use to represent and advocate for aftercare to be backed and fully resourced on the continuum of care for a health-led approach. We believe ACRG and programmes like it are best placed in the community to meet those needs. There is no graduation; the work continues. I thank committee members for their service and for taking the time to hear our submission.

I thank Mr. Keogh for his contribution. We will know turn to members, who have seven minutes for questions and answers. Deputy Marie Sherlock is first.

I thank and pay tribute to all our witnesses for all the work they do. In terms of the outcomes of this committee, there are days when I wonder how many of the recommendations from this committee will be finally taken up by the Government. However, in terms of the ability of this committee to hold a mirror up through the accounts of all the representatives' various organisations and show what incredible work is being done across the country and also how inconsistently it has developed is something really stark but with really important lessons around how other areas can adopt some of the brilliant work that is being done.

To reflect on Cuan Mhuire's perspective, Mr. McElroy talked about housing being a critical issue today and the lack of integration of mental health services and disability services. So much more work is needed on that.

My first question is for Aiséirí. To think it is the only residential care facility in the country for 15- to 21-year-olds is incredible. Could the representatives talk in a little more detail about the referral pathway? Ms Cassidy reflected on the lack of probation officers. We see that there has been little or no increase in the number of probation officers across the country in the last number of years. Could the representatives talk about the blockages that are there and the drop in numbers that has been seen between 2020 and 2025?

We found that with Government initiatives a number of years ago there was a big shift to move care, certainly for young people, into the community. Increased community services have meant that young people can access certain levels of care within the community, which is a wonderful thing. The difficulty is that the substance misuse problem is increasing and there is always a cohort of young people who are going to need a higher level of care, tier 4 level of care or residential treatment. They are not being referred through the HSE. It is held by the south east as a gatekeeper so to speak but it is a national service. The difficulty is that people are not aware. A parent under pressure with a child who is struggling has absolutely no idea where to go. It may be suggested they go to drugs.ie or something like that but the actual pathway to get help and residential care is not obvious. That is throughout the country. We are battling that all the time and trying to explain how to get a child as far as tier 4. It is a major block.

There is an information gap there. Are there other blockages? Ms Cassidy mentioned a youth diversion programme.

Yes, 100%. The youth diversion programme means there is no access for those young people and no pathway for them to get to addiction treatment with us by not having a probation officer. By going to youth diversion, they no longer have a probation officer whereas they originally would have. We have had to work a lot with Oberstown directly and inform and educate the people there that this is an option for these young people if it is necessary. However, again they have to go back through a probation officer.

Does one need to be with a probation officer to be able to access Aiséirí services?

That is the referral pathway that the judicial system has in place, which is an issue.

That is for Aiséirí?

Yes. That is a blockage for the young people.

Aiséirí wants that broadened.

Regarding the HSE funding, the conundrum is that Aiséirí has funding and it has capacity, which begs the question as to why the children are not managing to get to us.

When did those changes come in with regard to the probation officer and youth diversion programme?

That is in place approximately three years now. It is a big issue because we all know the problem is out there and we are there and ready to help but they are not coming.

I thank Ms. Cassidy very much. I want to put questions now to Soilse. I thank Mr. Noel Murphy and Mr. Brian Kirwan for all the work they do in the inner city. Particularly because the project is targeted at women and is a full-time programme, Monday to Friday and 9 to 5, I am interested to know about the completion rates. How well does that work for women? Obviously it does work, but is there a demand there to do part-time? What are the childcare issues? Trying to get women into the system is a challenge because of the caring responsibilities.

Every group is 12 people and it is usually approximately four women and eight men. We prioritise women for the reasons Deputy Sherlock gave. We work with women who have to leave early sometimes or we might get them support in a crèche if the child is at a particular age. They have a lot more difficult struggles than the men have, particularly with all the other stuff that goes with that as well, depending on whether the partner is in addiction and the lack of support. That is why we prioritise them. We make sure they are first on the list and we give them extra support when they are in there and link them in with other support services such as HSE and voluntary services as well. There is a big push for us to get women through and that has been like that since I have been there and I am there over 25 years. It has always been the way. We have got really good success with them as well.

The other piece in relation to female participation is that we have an evening service that is up on Manor Street with Sonya and the first steps group where they are looking to accommodate people who cannot do a day service. They attend there in the centre on Manor Street. Every case is dealt with individually but there is a focus for us because we know it is a struggle for women to get into the treatment services and there is a lot more men in services, as Mr. Murphy said. There is a specific focus on females for us in Soilse.

There is a question I want to ask Mr. Keogh. He may not have time to answer it but I am sure it will be taken up. The aftercare piece is at the heart of the After Care Recovery Group project, whose work in the inner city I am grateful for. Soilse talked about this as well. There are competing views on what recovery is. Is it a lifelong thing? In Mr. Keogh's view, if aftercare is to be funded in a more structured fashion into the future, how does he envisage the duration of aftercare? What does that greater structure look like?

We have a day programme that is established for people and they may come for possibly six to 18 months. It is a comprehensive programme addressing the mental, emotional, physical, spiritual nature of the human. We have a small team but they are highly skilled, qualified, trained and experienced as psychotherapists, counsellors and clinical supervisors. The issues are identified in the short-term residential treatment programme, which is often for only four weeks. When somebody comes out of the abyss of addiction they might not know which end is up. We know that recovery and addiction are not linear processes, so we provide the support that is needed for the person to untangle the things they may have identified in the treatment. However, very often they have not identified those things because they did not surface or because of the fear of identifying them. That type of trauma needs to be neutralised and it takes some time before the reintegration can take place.

I thank the witnesses very much for all the work they are doing.

As was pointed out by number of speakers, it is constantly changing. Something that was effective two or three years ago now has to be approached in a different way. I very much understand the challenges the organisations face.

Many of the presentations referred to care for people with problems. I want to touch on something I came across during the Young Scientist and Technology Exhibition. A student from Glanmire, County Cork, carried out a survey of young people and their attitudes towards drugs. The survey found students had a lack of knowledge about the negative impact of taking drugs. Have we carried out any research on the approach of secondary school students to this area? People can initially start taking drugs as an experiment and then get very easily dragged into having a constant need to access drugs. Have we done research on this area? Once that research is done, in terms of setting out a clear programme we are very much focused on the health service delivering education but should we not also focus on second and third level in terms of education in this area?

Planet Youth has done a certain level of research in every county throughout the country with young people aged 15 and 16. Very good research came out of that, in collaboration with Iceland. In Clonmel we are carrying out pilot work with all of the schools and principals. We have met all of the principals, etc. The research from Planet Youth showed a level of unawareness among young people on the harms of drugs and how serious these substances are. As Dr. McGovern said, things are changing so quickly that even young people are not aware of, for example, the massive damage ketamine can do to a young person. There is also alcohol and nitrous oxide. That collaboration which we are currently engaged in will be rolled out in all of the secondary schools and we have involved the primary schools as well. That will happen this year. It will enhance the education pieces already in place, but what is in place in schools is limited. This is a push we are doing with Planet Youth, the regional drug task force and-----

Does Ms Cassidy think we should do more on this area? There is a lack of knowledge. I refer to parents. An interesting project was advertised recently by Cork City Partnership, which is providing a nine-week programme for parents to deal with adolescence. It is a good programme. Do we need to do a lot more of that to help not only students but also parents cope with what is happening?

Absolutely, there is a huge divide with parents in terms of understanding the harms and what is happening in the community. Given social media and what children are exposed to now, things are completely different from what their parents would have grown up with. There needs to be a big push in this area.

When Cuan Mhuire was set up it was focused on people with alcohol addiction. The focus is now on a number of different areas. How has that evolved? How does Cuan Mhuire see that changing, taking into account access to and availability of drugs? Are there now major challenges?

Cuan Mhuire has had to evolve massively over the past five years because of the changes happening so fast, as the Deputy said. We have broadened our criteria in order for people to access treatment. As Ms Cassidy has said, parents are at an absolute loss when it comes to what has happened to their son or daughter. We are continuously providing outreach programmes in schools and GAA clubs. Most of that work is done locally in whatever centre is available, such as in Limerick which goes to people and organisations local to the area and local organisations. If the service is based in Kildare, we will cover Leinster and the schools. This work is only done on request from schools. We are not going out to schools, if that makes sense. Rather, they look for us to go to them and we will respond. We will talk to parents or students.

Ms Kelly mentioned GAA clubs. Many children who appear before the juvenile courts are not involved in any organisation or youth, GAA, rugby or soccer club.

That is right.

Is there a need to use schools a lot more as regards getting a message across? We seem to have been able to get the message across regarding smoking, where a major campaign seems to have worked. Are we doing enough as regards education? Should there be a lot more put into the education system on this?

I do not believe we are doing enough. A lot more can be done. I cannot disagree with the Deputy.

Ms Kelly mentioned the use of sports organisations. Does she think they could be given support to help?

I do, yes. My experience of going to sports clubs is that very often the chairman of GAA clubs, rugby clubs or whatever will request that we talk to their people about drugs or alcohol. The people they want to turn up at these nights and events do not turn up.

The Planet Youth research found that there was also a massive problem for young people who are engaged in clubs. The problem is far reaching. It is not just affecting those who are not engaged, which is important. It implies that we need to reach out to organisations in a big way. I agree that more work needs to be done.

I thank the witnesses.

I thank the witnesses for being here and the incredible work they have been doing for decades. Dr. McGovern said it best when he said it is about human lives being destroyed. These organisations are saving lives. I thank all of the people who work with them and the volunteers. It is important work.

I completely identify with the statement that every human life is precious, and deserves dignity, respect and to be supported. None of us are born perfect. We all need help in different ways at different times in our lives. The witnesses are that help for many people, for which I thank them sincerely.

The referral process for Aiséirí and Aislinn has triggered me, in particular for young people. I want to be sure that I am understanding this correctly. I understand it is a national service with four centres, all of which are located in the south east, funded by the HSE and with sufficient capacity to accept more clients. How do referrals take place? Can young people only be referred if they have a probation officer?

No. Our young people come through the HSE, the Probation Service or private insurance in terms of funding or through self-pay. A GP could refer an individual to us. In terms of funding, if the family has insurance that is fine. For those of who need to go through HSE funding – the cost would be too high for many of us – they have to go to the substance misuse team in their area. There is then a process for the young person to go through in order to be referred to us. We would encourage a family to go to the substance misuse team in their area and go through the process. Once they become involved with that team, the young person and family may never get to us because the team has not referred them to us even though the family may have requested that.

Why would it not refer the young person?

The team may feel that it can work with the individual in the community. Due to the fact that there was a push strategically to do that, teams are pushing to do that and ensure young people remain in their community.

We also need to consider the age range for the people in our adult centres. I have been with Aiséirí for 20 years and, nowadays, we are looking at people aged 20 to 30 in our adult services, which implies that these young people are reaching us in their early 20s, as opposed to getting to us at an earlier stage. That is, of course, if they have survived. There are many dying out there, but it is not necessarily recognised.

For the lucky ones who get referred and accepted, how long are they with Aiséirí?

They are with us residentially in Aiséirí for six to nine weeks. We do residential detox, so depending on their requirement for detox, we can change the length of stay, but it is generally seven to nine weeks.

Are they then discharged back to their families?

There is a two-year recovery support piece.

That is aftercare.

Exactly. The point I was making in the second part of my statement was that it is an absolute crime to pull somebody into us residentially and then send them home if the home or the community is not a safe place to go. At our secondary treatment centre in Waterford, there is the possibility of having a full year of recovery under your belt by going through that process. That has been the most beneficial for those who are chronically addicted, from what we have seen. There is currently no secondary treatment house for those aged under 18, and it is only for those aged 18 years and upwards. That is a gap. In Aiséirí, we very much wish to close that gap in the short term.

For those who cannot go to secondary treatment, they would return to their home area. That is when we collaborate with community services but, again, it is completely postcode-dependent. If the person comes from Dublin, there are some good day services that can really help with the young people. There are fantastic services in Dublin, but if the person comes from another part of the country, the services are very limited. We have very good services in Cork and Dublin, and somewhat in Limerick, but anywhere else, the young person is in trouble.

Surely the HSE would operate in those areas that do not have good day services, and by “good” I mean adequately resourced day services. Surely the obvious thing to do is to refer them to the HSE.

Yes, if the substance misuse team exists. However, substance misuse teams do not exist throughout the country and are only in certain areas. If families fall down and we tell people to please go back to their substance misuse team, they will ask where that is.

It would be helpful if we could tease out this issue with the HSE, and maybe ask the HSE to provide us with a statement on substance misuse team resourcing across the country. This is an operational issue. We will make strategic recommendations but this is a real operational issue that we need to better understand, as a committee, and engage with the HSE on. I suggest we do that.

Dr. McGovern referred to a period of 30 years. He is right that drugs and drug use in Ireland have changed completely and dramatically. Our challenge, in making our recommendations, is that with the new drugs strategy imminent, we want to be informed in a way that ensures it will deliver a response and a strategy that enables people like Dr. McGovern to be properly scaled. That means sustainable funding, more universality around the consistency of coverage and resources, and so on. Will Dr. McGovern talk in more detail about this? He spoke about psychosocial supports and medical supports. To deal with the complexity of all of the substances and addictions, what type of professionals need to be identified, recruited and resourced to adequately address this on a national basis?

Let us face it. We all understand this, but it cannot be said often enough publicly that the issue of drugs is not a marginalised issue. It is mainstream. It is everywhere. I hear it from all of my colleagues all the time.

It is a great question. I will tease out the issue of drugs, where a doctor is probably vital. It is a contentious issue. Other jurisdictions, such as the UK, are looking at non-medical prescribers, such as nurse prescribers or other people being able to prescribe. One expert there said that if they were to rely on doctors to do their prescribing for detox and so on, they would have to shut down because they would not have enough funding for that. There are certain addictions where you are embarking on a detox, or sometimes maintenance, and those drugs would be like opiates - it is opiate substitution treatment. One area where there is a dearth of services - they are either patchy, do not exist at all or are at the whim of a doctor - is benzodiazepine detox. It is a huge problem. We do not have enough outpatient community services, nor do we have enough inpatient services in that regard.

I will have to stop Dr. McGovern as we are a little over time. I promise that I will allow him to answer that question shortly. I call Senator Ní Chuilinn.

I thank the witnesses for their very considered opening statements, which we appreciate. I want to pick up on dual diagnosis, which was mentioned by a couple of speakers, because we are discussing the Mental Health Bill in the Seanad at the moment. Ms Kelly and Mr. Murphy mentioned the situation on the ground. I ask both whether they feel we are catering for people adequately when they present with a dual diagnosis. When we talk of access to services, is that access to a mental health facility if they are in addiction, or access to an addiction treatment centre if they have a mental health issue for which they are receiving medication? People sometimes cannot have anything in their system, depending on what treatment centre they are going to. Does Ms Kelly have an opinion on that?

Many young guys and young girls present to us with dual diagnosis. When they come in to us, we have a GP daily, and we have nurses in our detox centre 24 hours a day, seven days a week. I find that a percentage of these young guys and young girls really struggle when they come in to us. Very often, we have to refer them back to our local psychiatric hospital. We bring them there. When they arrive at the psychiatric hospital, be it in Portlaoise or elsewhere, the staff there are very good, although they are probably inundated with the number of people they have coming through their doors. They try to help us as much as they can. However, because these people are not from the catchment area, and are not originally from Laois or Kildare, which is where we are based - they could be from Limerick - they will bounce back to us again. They will be told to go to the psychiatric department that they belong to in Limerick, Cork, Galway or wherever it is. It is like the chicken and the egg sometimes, if that makes sense.

It is an operational thing. It is also missing the holistic piece of actually treating the two things at once.

Absolutely. Some girls and guys really struggle with us under the therapy, the group therapy and the individual counselling when they are on a huge amount of medication when coming in to us.

I have been working for a long time in Cuan Mhuire. I see the need for medication at times, but as Dr. McGovern said, to detox off benzodiazepines is a huge problem for these people. It is very complex at the moment. To be honest, I could sit here and talk about it until tomorrow. There are serious issues out there.

We have not got there yet.

We absolutely have not got there yet.

I was talking to one of our managers recently. She said that we need access to a dual diagnosis consultant in each area.

Does Cuan Mhuire have access to clinical nurse specialists in dual diagnosis?

Yes.

But not a consultant.

We are very lucky in that way. We are not too far from Trinity Court, which has a psychiatric-led team that we can refer to. We also have a consultant psychiatrist who comes in one day a week. That has been a massive support for us. In our programme, we allow people to be on medication if it is for a mental health issue, and there are some people like that on our programme. The research shows that attending programmes like ours while being treated for mental health issues is of huge benefit to them. They get to engage and do educational things, including psychoeducation, and learn about their mental health.

That is a big game changer when someone understands what is going on with them. They are being told the background to why they are feeling the way they are.

Did Mr. Murphy say a consultant psychiatrist?

Yes.

This came up before with Coolmine. They have access to a consultant psychiatrist in the women's residential facility but not in the men's, and they really need it in the men's as well.

We have a man called Dr. David Weir. He is excellent at his job. He works really well with the participants. He spends a lot of time with them and supports them through. He works on recovery as well, so it is not overly prescribed. There is a lot that goes on.

It is more rounded and holistic looking at the whole person.

It works. It does work.

I turn to Ms Cassidy and Ms Hennessy with regard to Aislinn. I cannot believe it is a national service. I know it is in Ballyragget, County Kilkenny, and I know it well. I thought it was just for the south east. That is more of a communication operation piece with the HSE. They used the term "gatekeeping". I will not say that. Is Aiséirí similar? I spent a week in Aiséirí 13 or 14 years ago. I had a family member in addiction, and I did the family programme. It was a week long and it was so intense. It was hard, but it was brilliant. I used the time to try to understand things better and help my brother a bit better. Is Ms Cassidy saying that anyone could be referred from Galway to Cahir? It is the same thing. Is it just Aislinn that is not getting the same level of referrals?

It is just Aislinn with the young people. With the adults there is a normal stream of referrals coming into the adult services. It is smooth and the waiting list is not horrendous so that is good.

Will she remind me how long the treatment process it?

With the adults, if they require detox they will be in Cahir for four weeks of normal treatment and then add detox, which could be up to three weeks. The Senator also mentioned the dual diagnosis piece. In our adult service approximately 60% of our admissions are dual diagnosis. With the adolescents, 80% of our admissions are dual diagnosis. We have had to employ consultant psychiatrists for the adolescents. Dr. Bobby Smyth comes down to us in Kilkenny from Trinity Court in Dublin. We have a level 2 GP in Kilkenny and Cahir for the detox and a consultant psychiatrist for the add-on services. Again, they have to be employed to attend. That is absolutely vital. Dual diagnosis is through the roof.

What is the policy on being on medication when in treatment?

Any medications other than those which are addictive are allowed in Aiséirí.

Sometimes I hate being further down the list because I end up with a million things I want to say. I do not want to put anyone on the spot. I understand Mr. Kirwan is here as general manager of Soilse. I did not realise the HSE had a facility in relation to being a general manager of particular services. Maybe that has always been there. I am aware of him responding with a different hat on to some of the things being said in the room. I apologise for putting him on the spot, and if he does not want to comment he does not have to. As regards treatment, there is a huge number of blocks in relation to medical detox, and not only in relation to children. If Mr. Kirwan is okay he can correct me if this information is inaccurate. It seems that when you have a tier 3 service, as in the physician to do an assessment, there is a requirement that CHO 5 in particular is implementing. It is a new model that came after another “new model” that was already there regarding how funding is given for treatment in particular CHOs. I know if it is not taken up in full in some CHOs it is being sent to other CHOs where maybe there is greater need. Where the block seems to be coming in CHO 5 is that the tier 3 programme, if it has the capacity to work with an individual, is required to work with an individual for approximately six weeks. I think there is a 26-page assessment process. There is approximately six weeks of counselling or key work. That is assuming that tier 3 initiative has access to key workers to do the instance of assessment for that treatment to go into residential. There seems to be a scattered approach to how the funding is applied. The services at tier 3 to refer into tier 4 are not necessarily in every community in the first place. The counselling specific piece is a problem for many services on the ground. It is only then that the application will be assessed at the HSE level in terms of funding. That is one example in CHO 5. Other CHOs are reporting other things.

I have lots of questions. I would like Dr. McGovern to speak to the outdated treatment systems and put some of those other options on the table. We are talking about the treatment flow, and I am not sure we are getting it accurate. Maybe we need to come in at another point to lay it out further. Does Mr. Kirwan feel he is in a position to give his insight? I am getting that he thinks it is a different comparison to what we are experiencing on the ground, and I think it might be good to have it on the record.

I can speak in the north Dublin context about treatment episodes for tier 4 for Aislinn. For us it usually goes through Dr. Gerry McCarney who is our consultant adolescent and child psychiatrist. If a referral is required to go to treatment, Gerry will make that decision on whether the person should go to treatment or be treated in the community. That is his clinical opinion. I think that will be the same for any clinical team around the country. If the clinician decides that child does not need to go to treatment and can be treated in the community, then that is their clinical opinion. That needs to be put into the conversation and on the record. There is an opinion that knowing what is not coming towards the treatment centre and what does is within the community teams. I take the Senator's point that CHO 5 may have a different system. I am not aware of that and maybe they are best to talk about that if the Senator would like the HSE to make a statement. I know in our area the process is that they come in and go through the residential episode and fill out the comprehensive and initial assessment, which is for every single treatment centre in Ireland. They all follow the same process. That is what Mr. Murphy spoke about earlier. They do one assessment and that assessment travels. While it may seem overly comprehensive for a child, that is the process they have in place and that is what has been agreed-----

There are the adults as well.

It is the same.

For people fresh out of prison especially, if they are not between Des Crowley and somebody on the outside, they are getting completely lost in terms of medical detox or benzo detox. We are trying to get them into tier 3 services, which is really problematic because they may not have a counsellor or a key worker to work with them. There are people disengaging because the process is taking so long from the assessment point to accessing counselling, to filling out the form and being able to get into residential. There is definitely a block, and we should come back to it. I will give my final minute and a half to Dr. McGovern to speak to other treatment options. Obviously, the methadone protocol has been there for decades and as long as he has been in the game, and it needs to be assessed.

On the ground we are seeing fewer opiate-related presentations. We are getting more enquiries about other drugs, emerging drugs and drugs that are established. Benzodiazepine has been around for a long time. We have neglected to create services to meet that need. That need is bigger than we think. Anybody on this panel will say that when you look at the polydrug picture, benzos are in there somewhere. The one mimicking that is probably pregabalin. Again, there are no services. We do not even have guidelines. I went abroad to see if they have international guidelines about this emerging problem and they do not. Our nearest neighbours are the UK. There is cat, head shop drugs like synthetic grass and ketamine, which is a really big one now. We are seeing more and more people presenting with ketamine and the physical complications of it. There are some really awful psychological and physical complications of that.

We have nothing for them. We call it HSE addiction services, but really it is HSE opiate addiction services because without an opiate problem you do not get in. That needs to be looked at. I may be creating a rod to beat my back. People ask if we have capacity. Of course we have capacity. Of course we could take people on. We need to start doing it. The problem we have is that not all the services under the HSE addiction services umbrella are doing the same thing. There is a mishmash in terms of what people are doing. People have ideological ways of doing things. That goes right back to the punitive approach to people who at the time were being prescribed methadone only. It is buprenorphine and methadone now. We know that the current landscape is very different but the treatment has not really changed very much. It has a bit, but not really. People's hands are tied.

As members know, I work in a lot of community projects out in Tallaght, and they are getting lots of calls about these other things. There is not a huge amount you can do for them. If somebody needs a benzodiazepine detox, you can talk until you are blue in the face, and try to help and support them, which is pivotally important, but without a detox they are not going to get better.

I will finish on this point. Effectively, there are very few medical detoxes in the country and we need that to massively increase.

Yes. Absolutely.

I remember 20 years ago I used to have to fight for people to get into the three public places that were in Beaumont. This is not a new issue. I thank Dr. McGovern.

Cuirim fáilte roimh na finnéithe go léir. My first question was going to be just in relation to straightforward capacity, but a wider needs analysis is required, in the sense of what sort of service we need to offer across the board and then what sort of resources we need to do it. Nobody is shocked about the referral issues because they are the systems that we, unfortunately, create in Ireland. We cannot necessarily get the service to the people who need it. We are now talking about polydrug use across the board. Even if somebody has an opiate issue, undoubtedly, from time to time, they will have used crack cocaine, benzos and a million other things - anything goes, for the want of a better term. I get it. Not everybody is ready to go into proper addiction services, but even if we do not have the system currently-----

We do not, no.

Is Dr. McGovern saying we have the capacity but we do not have the system? I would still say we need a greater level of resourcing.

Yes, we do need a greater level of resources. To give the Deputy a simple example, there was a time when we were seeing every single patient every single week who was due to come to a clinic. The place would be just teeming with people. Then somebody asked why we were seeing patients every week and why we did not resist burnout and see people every two weeks, and now we are seeing a lot of people once a month and it creates a lot of space for us. As a result of space, we can definitely take on more patients. Back in the day, I was involved in the Irish Medical Organisation's consideration of how many patients we should see. That approach is outdated but there was a thing going around whereby you could only have 12 to 15 on your list. That is nonsense. You can have as many as you can treat. Members have to remember that I work in services where there are multidisciplinary teams. There are a lot of people doing different things. We meet once a week and discuss cases and stuff like that. There is no excuse really for not helping people who have a need for a medical detox in the community. We should be able to do it. Yes, we do need more resources and we probably will need more prescribers. I will probably get pilloried for this by my profession, but we need non-medical prescribers. There is no question about it. We are not going to be able to do this on our own. We do not have the level of expertise in terms of numbers, the quantum of experts to be able to do it.

It would be interesting to get the views of the other witnesses because a lot of them are dealing with tier 4 services. I always feel that there is this abstinence versus harm reduction sort of polarisation. We are as guilty as tier 4 is on this. The level of collaborations between tier 4 and tier 3 and other tiers is probably not as good as it could be.

At some level, is there not a requirement on the State to take a look at what is there - this goes back to the needs analysis - and then to plug the gaps as much as we can because we are obviously failing people? That is having a long-term impact, and not only on those people and their families. We all know the chaos that is caused by addiction.

People also move along those tiers. I am very lucky to be able to see patients. My catchment area interfaces with St. John of God's but, again, there are problems there relating to health insurance. It should not be that way. It should not relate to whether you can afford to pay for treatment. I have patients who cannot be managed in a community setting and who need to go into an inpatient service. The whole thing does not go in a straight line at all. There are little short roads and it stops. For others, there is a rough terrain and then there is another road picking it up. That needs to be addressed.

We have individual operations doing decent work and in some cases an awful lot - including the witnesses present - who are outliers, making it work better, but it does not all fit together.

No.

I will put a question to Gerry. In fairness, Cuan Mhuire is one of the services we have used ourselves. I have dealt personally with Pat McGinn a great deal. Gerry knows the service he wants to provide and the means for people getting into it. Where would he say that is at currently? I accept that we will never have enough resources given the issues with addiction in Ireland, but it is all those added issues where people have to come in a particular way, for example in that they have already engaged with some service. I will let Gerry answer rather than have me waffling on.

Ten years ago, for 80% of people looking to come in, we would have got them in within a week. That has changed drastically. We would be lucky to get 20% in. There is a four- to six-week waiting list. Demand outstrips our capacity. One of the areas Nicola mentioned is that we cannot get step-down housing for people. That is blocking beds, for the want of a better word, in the treatment centre. If we put a lot of work into somebody doing a programme, we do not want to send them back to the streets. That is one area.

Education about drugs is another area. Deputy Burke mentioned it earlier. That is important.

In what specific way?

Our attitude to drugs and young people's understanding of drugs and all the rest of it, and the harms that can be done.

The problem with young people is they think they are going to live forever and that nothing is going to impact on them. The "just say no" approach has not worked anywhere. It is about us having a capacity to deal with the issues that are out there. I am repeating myself at this stage. It is about needs analysis and reacting to that. All the witnesses have said it; we need a greater level of capacity, the proper type of service in the place where it is needed and then a referral system that works. How do we put that in place? Does anyone want to respond to that in 14 seconds?

That is what I was going to say.

In terms of a referral system, we have many people who self-refer and people on probation. Lots of different services refer people to us. The problem is our waiting list. Motivation for some people can be fleeting.

We must get them in the moment or we will not get them.

We have to get them in the moment. I do not see it as a window of opportunity but that is the way it is. The delays are killing engagement. I had 150 ladies and 150 men on a waiting list in Christmas week to come in to Athy. If we are taking in an average of 20 people a week, be it men or women, how long is the waiting list for those people?

Then it is the additional services.

I have to stop Deputy Ó Murchú.

I am sorry. I did not realise I was over time.

We are on to my questions now. I do not want in any to accelerate the pillorying, but I did not really understand the point about non-medical prescribers. Could Dr. McGovern explain that a little bit more for me?

As it stands, you have to have a medical degree to prescribe drugs. There are a small number of other people in this country, for example nurses, who can prescribe, but I do not think they can prescribe drugs for the purposes of detox. The UK has a fairly well-established model over many years.

For instance, they realised they would not be able to treat the opiate problem in the UK if they were just to rely on doctors. A lot of that expertise has retired. I know many of them from my earlier days. The expertise was not necessarily replaced like for like. They said they needed to sort this out so they held really well organised courses for people, not necessarily just nurses. There are other areas that can do this. That allowed them to prescribe. It started out initially in what was called a supplementary prescribing capacity, which would result in the doctor doing the main prescribing and others being supported by the doctor. It then went to independent prescribing, which means they can prescribe and have their own indemnity and all that stuff.

It has caught on over there. It has not caught on over here. There is a resistance within the medical profession against it happening. It needs to happen because in my own area of addiction treatment, I do not think there are nearly enough people to prescribe. I do a clinical lead job in CHO 8 and for years there was a waiting list there. We managed to get rid of the waiting list. While there were not many prescribers down there, one of the things Covid taught us was that we could do virtual clinics or have virtual options. We were able to get people who had capacity to take on more people in Dublin - I was one of them - to get people onto a script. They would have local supports and that has worked very well. There is an absolutely incredible service there in terms of nursing support and they are very expert. There is a lot of work in that. There are ways of doing things if people put their heads together. That idea of independent or non-medical prescribing is probably a thorny issue. Dr. Peter Kelly, who was the head of International Nurses Society on Addictions, has done some research on that. I can send that on to the Cathaoirleach.

I would appreciate if Dr. McGovern could send that to us.

He is an incredible guy and I know him. He is really pushing for this.

That is excellent. If Dr. McGovern could send that research to the committee, I will be sure to disseminate it.

I will.

We had him before the previous committee so there should actually be testimony from his appearance.

One of the more frustrating things I have heard in the past year while I have been my party's spokesperson in the area of justice is that various people have told me judges sometimes send people to prison in the absence of any treatment options. I have heard it while visiting prisons. I have even heard it from the Minister. I have heard it in different forums. Based on Ms Cassidy's engagement with people who come to her and who she offers treatment to, what sort of impact has prison had on people's lives?

For us, the level of trauma is massive, not just for the adults but for the young people too. Young people who have come to us have ended up in Oberstown, reached adulthood and ended up in Cloverhill and various places. The long-term damage is absolutely unmerciful for these young people when, realistically, they were unwell as a result of their illness of addiction and had maybe acted out in some shape or form. It was absolutely life-changing for them to have been imprisoned.

We also have people who are engaged in the recovery process in the therapeutic communities or in our day programmes. There was a recent example of somebody who had gone into prison following 18 months of abstinence from all mood- and mind-altering chemicals, having engaged with the various services through stabilisation, detoxification, treatment and then to us for 18 months. He is reincarcerated now and went back into prison just before Christmas. That is another problem. It is swings and roundabouts. The revolving door can work against you because most of the population in the main jails have drug-related issues.

It is a wider issue and there is even the fact these people are in prison. We do not see people in directly for possession of alcohol because alcohol is legal, but we see many people in prison for alcohol-related crimes. There is no doubt about that. As long as drugs remain criminalised, a huge number of people will be in prison because of drugs, one way or another. Having gone through the justice joint committee in 2022 and the citizens' assembly, we are all calling out for a health-led approach and not a punitive approach. Some people are uneasy about that. I understand that. I absolutely respect anyone who is uneasy about that and uneasy about the possibility of drugs being decriminalised or even legalised, but what we cannot do is stand still and pretend it will change on its own because it will not change on its own.

Sometimes, we have to take brave steps and we need to monitor those brave steps. One of the things I often hear is that we cannot let that cat out of the bag or that if we let it out of the bag, we will not get it back in again. That is the whole idea of evaluating anything. If we are to make changes in our drug policy, we need to evaluate what those changes are and we need to have measurable outcomes to see whether they are successful and whether they need to be tailored or dropped.

I have a final question and then I will let members in. In relation to the education programme that Aiséirí runs in schools, I know there have been a couple of different calls for education and awareness. There is a growing body of evidence that talks about the dilemmas of education. Sometimes it can also be a factor in not deliberately encouraging drug use, but when you speak a lot about drugs in a school environment, it can add awareness to the concept. There is a growing body of evidence of that. What evidence does Aiséirí base the education programmes on when it is in schools?

That is very valid but when we look at what young people can access online, it is phenomenal what they are exposed to nowadays. Within the education programme itself, we are doing it in collaboration with the HSE education officer in Tipperary. Lived experience is probably the best education tool that can be utilised. We lean heavily on lived experience within our education pieces.

The postcode lottery is a problem. A couple of witnesses mentioned it, including Ms Cassidy. It affects access to services but also the types of services that are in a local area. What kind of challenge does that present?

I pointed to the postcode lottery and Mr. Kirwan spoke about it in regard to the young people coming to us. That is an example of it working well. We have examples of it working well in different areas but, unfortunately, in many parts of the country it is not working well. People are not able to access the services, regardless of whether they are in their area. When I say access to services, I mean the funding for services. The postcode lottery issue is a huge problem.

Is there one part of the country that is known within the sector to be very poorly serviced?

As I referenced, from my perspective, we have fantastic substance misuse teams we work with in Dublin, Cork and Tipperary.

Is that it? Are those the ones Aiséirí works with or they are the only ones in the country?

They are the best established.

That is where the good stuff is happening.

They have the smoothest referral pathway. They were put in place by the national framework and that is working well, through those areas only. Senator Ruane referred to the fact there are different processes for different areas, which is very real. There are then difficulties with processes whereby in 2024, referrals stopped. We had 28 people within the HSE system nationally who needed to come to us and were ready to come to us, and that was stopped because of the funding. Some of those individuals did not make it.

What does Ms Cassidy mean by it having stopped because of the funding? I thought she said Aiséirí was quite well funded. Does she mean Aiséirí is well funded at a local level?

We are well funded for young people, but for the adult service it involves bed night capacity, so it runs out.

Okay, it is different. I am conscious that the witnesses have all made the effort to be here today and I would like to know if they are happy with what we have covered or whether there is something they came here really wanting to tell the committee. We have heard some brilliant statements from everybody today but was there something we have not covered?

There is just one thing. It is about treatment. We tend to look at treatment all the time but we should also be looking at recovery. As Dr. McGovern said, there are different journeys. We have young people who do not practise abstinence but they are on a harm reduction journey and lead a really full life. It is about building recovery capital.

It is about the aftercare piece.

Yes, but it is even more than that. It is about looking at recovery and getting people to talk about how they achieved recovery. In Waterford, we are looking at a social map of what kept those people well and what kept them in recovery. There are a lot of things that can help people stay in recovery and we need to look at those as well as other aspects.

It is like medicine and the HSE - it is very easy to count bed nights but it is hard to do so for recovery. It could be harm reduction or total abstinence. There is a whole scale that needs to be looked at and measured, including quality of life and relationship with families. That is what we need to build. That is what we work on all the time. Abstinence is the end goal but there is a lot of other good being done along the way, but it is hard to measure it.

That is what I was going to ask. How does one measure it and report it?

Social mapping. There are a load of different ways from a sociology point of view of looking at it. That is what we are looking at in Waterford. There is huge success in Waterford with the support of the Department of Social Protection through CE schemes, Pobal and Rethink Ireland. We are going every place. As was said earlier, it is a patchwork. There is Pobal, Rethink Ireland, the Probation Service, the HSE and county councils. It is a minefield. It is about trying to put it all together. It works when there is joined-up thinking and co-operation. The national voluntary drug and alcohol sector has a huge impact. We are in Tipperary. We are doing that to see if it can be copied in other towns and rural areas, working with Merchant's Quay Ireland, Coolmine TC and all the different services.

That is a great point. I do not know why Ms Hennessy did not say that sooner.

The title is recovery so we have to-----

It is really important. There is life after recovery no matter what way the recovery comes.

We have the Minnesota model. Our staff give back and believe that people in recovery can engage in volunteering and in the community. They are a phenomenal a bunch of people.

There is huge empowerment in it.

We talk about aftercare for a minimum of two years after someone has completed treatment. There are also transition houses and CE schemes. We have found them a great benefit, getting people back into employment, training and the rest.

To lead on from the conversation around recovery, we need to have it in a much more transparent and open way that we feel comfortable with. Sometimes people think when you are talking about harm reduction, and I think it was mentioned earlier, that there is something oppositional happening which services nobody. In the other breath, we constantly talk about how one size does not fit all and that we want our services and responses to be as varied as possible. That makes me think of this idea of abstinence versus stability. We need to have a conversation about how we define recovery. If we define it and then impose it, we do the same old thing but under the banner of recovery instead of working with people to define what stability looks like for them. I have long sent people in the direction of the likes of After Care Recovery Group and Soilse. I have always admired the work there. I have worked with other people I know will not fit within that space. I am wondering how we work on that so that everybody sees that recovery is not an end goal, that it is not that someone is stable now but they are still going to get to the recovery bit. Do the witnesses have comments on that? I would have to think people feel left out when they have made huge changes to their lives, they are going out to work and there may still be a small bit of substance use but their life is not in the same threat or chaos it used to be and how important that is for them.

We are based on an abstinence-based model. We do not make apologies for that anymore. We do not go down the rabbit hole of us versus them, abstinence-based versus harm reduction. Abstinence is the ultimate harm reduction but the people I serve have been in the service sometimes for decades. Currently, we have people who have been in the service for three decades because addiction, just like recovery, is not linear. There are roundabouts, swings, dead ends and T-junctions. People can get lost in the abyss of that, but when they get to the point where they want an abstinence-based model, it should be available and funded. We have been in existence and providing that for over 25 years and it has not been resourced. We are looking for that to be resourced. We are looking at the people who do research at the cutting edge - the good doctors we spoke about doing individual work and colleges giving us evidence-based models to practise. We need to operate out of evidence-based models but we also need to be able to back practice-based evidence where people are actually doing that and it is working.

I completely agree with abstinence-based facilities for people who want abstinence-based. I am not saying the abstinence-based place has to become for all. It is more around the language we apply to recovery operating out in ether and how that manifests in people's observations of themselves or whether they have been successful or not. We have harm reduction. They can all work together. People probably move between them at different stages. That is not the point I am making. It is the narrative and cultural understanding of what recovery may mean in its widest context.

You could go down a rabbit hole in relation to that. The people we serve have been on all ends of the continuum of care, from psychiatric wards to prisons, from rough sleeping to a residential therapeutic community for long periods, from methadone maintenance and stabilisation to detoxification. We are talking about the same people. As I represent After Care Recovery Group and the model of abstinence-----

The ultimate capital being that they are not a criminal. They cannot have recovery capital if they are a criminal because of their drug use.

We are breaking recidivism. We are keeping people out of prison, breaking the cycle of addiction generationally and multi-generationally. I am of an age where I have seen generations of people coming through. We are now breaking that cycle. We have not been in that rabbit hole of us versus them. We never got involved in it. We are dealing with the same people.

On the recovery capital piece, it is important when we work with people that there is always an advocacy role that should never be suppressed by the State or civil society. Suppression happens a lot in terms of people being afraid to speak out on particular things. If the people who use our services are seen by the State as criminals for the mere fact that they use drugs now or have used drugs, it is very hard to build up the other capital of education, employment and travel. They are all parts of capital and of recovery capital. They cannot ever be fully separated.

Recovery has become more visible now. That is a good thing but we are also in a situation where, with the problem we have been addressing, and it has become popular and some colleagues have alluded to it, we have lived experience. We heard no mention about recovery capital. We have operated a model out of that for nearly 30 years.

Now add in lived experience.

And the living experience. Some of the people we have been serving have been in every model - the psychiatric ward and prison, etc. Sometimes they make it into the abstinence space but it is not linear. We need to be able to operate out of models of best practice. That is what they are talking about. We also have a model that is working that needs to be backed and supported. Practice-based evidence needs to be taken into account, not just models of best practice. We have practice-based evidence that has been available for nearly 30 years.

I thank the Chair for his grace on the time.

I am very conscious we are approaching the end. I will come to Deputy Ó Murchú in a second. Is there anything anyone has not had the opportunity to say where I cut them off or are there any points they would like to make? Would Mr. Murphy like to comment?

We have a well-established continuum of care in Soilse. The question Senator Ruane asked is more of a deep philosophical question for each person to answer themselves: is this what I want? If you are still on a substance, some of your stuff is limited. You have to acknowledge that. You cannot drive a taxi, for example. There are certain things you can and cannot do. The abstinence model gives you more freedom to do things. The individual has to decide what they want. For some people we work with, that is their road they have to take. That is fine and we support them. We are lucky in the sense that we established a really good continuum of care. It is over 20 years old. We know we cannot do everything ourselves. We developed good relationships with all the different agencies, whether for detox, psychiatric services or housing. When people come in, they get a really solid care plan. Before they go anywhere, all of that important stuff is put in place. Then, it depends on the recovery capital they have.

Nowadays, with drug trends changing, people have a lot more recovery capital, with degrees, housing and family supports. Ten or 15 years ago we had opiate users and their recovery capital was limited. We still get these people in but there are fewer and fewer of them. Ten or 15 years ago we never heard a middle-class accent in Soilse. Now a lot of the people there are middle-class kids. Drug trends are changing. Everything is changing. Key to all of it is having really good continuing care so that people are not reliant on themselves. They have housing, their detox prep, their mental health support service and everything they will need to get from here to there. Within this, if someone decides they want to stay on a substance, that is fine and they should not be judged for it. That should be their journey and something they have to find themselves.

To follow on from this, people will be coming from different places on this. The widespread use of cocaine has changed the demographics of who is an addict. We could probably say Ireland was set up for this, in that it is not like we have had a great relationship with alcohol over the years. It comes back to the other stuff. When people have money and resources, it will be easier for them. I am not saying it is easy to deal with addiction, and whatever means people choose, but they are more likely not to have issues with housing or the supports that can be provided, unless they have burned everything in the family circle, and I get that every situation is different. We still have the concentrated issue in relation to drug use and abuse in working-class areas and the impact and chaos that goes with it.

I am taken with the idea of practice-based evidence. There is enough out there and we know what the need is for all of this. We know what is working, and this can mean multiple projects doing multiple things. It is a case of getting real about it, seeing the size of the problem and then putting it into practice. I have a fear that we will have a national drugs strategy, and even if it says all of the right things, it will not do anything much different and every organisation will be vying with each other for funding. We will not be any further on, the more complex cases will get more complex and we will not deal with Ireland's underlying issue with addiction. I would like somebody to be a bit more positive than I am being. Where do we go from here? Does anyone want to take this on?

I just said not a chance would I take this on. With regard to the national drugs strategy, if we do not have a basis for where we need to go, then we need something very clear. In relation to recovery, we are back to Senator Ruane's point that it needs to be there. Recovery is linear. It is not somebody who is abstinent or in recovery. It is somebody who is still using substances.

I apologise for interrupting but it has to be easily accessible at the time and wherever the person is. This is what does not exist at present.

I agree, but there is a state of being for people. We can sit here and talk about treatment episodes, rehabilitation and all of the pieces but recovery is a movement. Recovery is the person who was in the criminal justice system and may not be now, and they are back out and working. They can fall back into drug use. Addiction will continue. It is a lifelong condition.

An addict forever.

Yes. When we speak about recovery capital and all of the other pieces that go alongside it, if we do not have a framework such as a national drugs strategy that will speak to this and that has actions on this, we could all be negative and say it will stay the same. We have come from a historical place where we had a medical model based on opioids, but we are not there now. We are in GAA clubs down the country. We have lads who are farmers who are taking cocaine. We need to have an overall overarching philosophy on how we do our business. If we do not have this, they are in trouble. In future it needs to be wide open. It needs to take in recovery, harm reduction and everything. It has been too boxed for too long.

There is also the issue of resourcing, which should be based on knowing what works, knowing the projects that work, knowing the problems with communication that Dr. McGovern spoke about and interfacing them properly. Not to be overly-----

Addiction services are resourced but they are resourced to focus on opiates. Mr. Murphy spoke about the opiates earlier.

There is no flexibility.

There is a national drugs strategy there that could pivot.

This leaves us with the suspense that we will get a view on the national drugs strategy next week.

Where should it pivot? Where should it go?

This seems like a good place to leave it. I feel like the "Eastenders" music should come on. I thank everyone for their contributions. The meeting has been incredibly insightful, we have learned a lot and it is to be hoped it will be reflected in the report we bring forward in June.