Joint Committee on Drugs Use debate -
Thursday, 3 Oct 2024

We have received apologies from Deputy Jennifer Murnane O'Connor.

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

I welcome all the witnesses to the meeting. The committee has four modules and this one concerns the health-led approach. I welcome from the SAOL Project, Ms Paula Kearney, BRIO co-ordinator, and Mr. Gary Broderick, director; from Merchants Quay Ireland, Mr. Eddie Mullins, CEO, and Mr. Geoffrey Corcoran, head of operations and delivery; Dr. Sharon Lambert, school of applied psychology, University College Cork; Dr. Richard Healy, research and policy officer with AHEAD; and Dr. Barry Cullen, youth and community development worker. They are very welcome to this committee today.

Each member has seven minutes to make a contribution and ask questions. I will be strict in that regard. There will then be a second round of four minutes for each contributor. That is the timeframe.

I invite Ms Kearney to make her opening statement.

I work at the SAOL Project in the north-east inner city in Dublin. SAOL is a project that works with women who use substances and are working towards positive change in their lives. We support women in that journey through change. We are a women’s rehabilitation project, and all of our programmes are designed with a gender lens on addiction. I am the team leader for the BRIO programme within SAOL. BRIO works with women who have the co-occurrence of substance use and criminality in their stories.

I want to tell the committee a story about one woman to give members a clear understanding of what life is like for women who use substances. I hope that through this story, we will have a shared understanding of what is needed to support women. I wish to introduce the committee to Davina, which is not her real name. Davina is a 35-year-old woman who is also a loving mother to her beautiful son and daughter. Davina grew up in a home where she experienced multiple forms of violence and abuse. Her father was an alcoholic who would regularly beat her mother while Davina watched in terror. He had also abused her from a very early age.

As Davina grew up, she began hanging with friends and like many people she experimented with substances which then led on to cocaine and heroin. She never thought she could become dependent because many of her friends did not. Maybe her friends had not experienced the same traumatic experiences that she did, and Davina soon found herself using more because it helped her suppress the pain she was feeling from her childhood.

Davina met her partner Dave, who is the father of her first child. Dave was confident and strong, and she thought she had finally found somebody that could take care of her and protect her. Within two months of meeting Dave, she found out she was pregnant and Dave began treating her differently. He would beat her and isolate her from her friends. He also began injecting heroin and soon introduced Davina to the needle too. She was scared at first but her addiction to heroin was severe and it was much cheaper to inject because she would need less. She then began committing petty crimes - Davina, not Dave. He had her committing petty crimes such as shoplifting to feed both their habits, and even though she was the one paying for it she then still had to wait for Dave to get himself together to have the first hit and all that, before she would actually get a turn. That put her at further risk because a lot of the time they had to share a syringe. It was getting later in her pregnancy, and she started to worry about her unborn baby, so she started a methadone programme and was doing fairly okay.

Let me tell the committee about how well she gets on when she tries different treatment and rehabilitation agencies. Davina was attending the DOVE clinic in the Rotunda Hospital and instead of being yet another mother who was waiting to welcome her baby into the world, she experienced stigma and discrimination at the hands of the people who were supposed to be there to support her. Every urine test she provided was tested for drugs and she felt scrutinised if she happened to have a sleepless night, which many women do. Many pregnant women find it difficult to sleep. If she looked in any way tired, she was asked what she was taking, and she experienced all the other pieces that come along with that, which other women generally do not experience through their pregnancy.

Davina would be tired and have to face a barrage of questions. She was always honest but always felt doubted. She had her son and faced the dreaded monitoring of her baby which all women on methadone or using substances do, where every sneeze, cough and tremor their babies have - like any other baby - is charted and scored as if they are competing for the Eurovision. The nurses are not specifically trained in addiction either, so many would give her dirty looks when they were filling in the scoresheet, making the already worried mother feel like a failure.

Davina was not allowed to leave the hospital with her baby as the baby was showing signs of withdrawal. Davina wanted that child home so badly that she decided to try to get more help for her addiction. She put a care plan in place which consisted of some support services and Tusla. After her son got well, she was delighted to take him home.

Davina tried the drop-in service for a short time and Davina was happy because it was the only place available to her with her son, but she felt many of the staff were constantly asking questions about the baby and her relationship with Dave, and never focused on Davina's needs. They also offered her unwanted advice about parenting as if she was incapable, they were pulling her up about every little thing and making her feel like she was doing things wrong. She wanted support for herself but felt that it was about everything else but her and she also felt that if she talked about or disclosed what was really going on, she would be judged as a mother, so again, she felt stigmatised.

Davina tried a CE scheme. The CE scheme that Davina started was like many other addiction-specific schemes in Ireland. It was predominantly male and Davina found it difficult to open up or be honest about everything in her life. Many of the issues she was experiencing were things it would be easier to talk to women about because she felt that men could not relate to her. Some of the men also displayed traits of toxic masculinity and constantly flirted with her, which made her feel even more unsafe. There were also no childcare facilities, so she could not fully commit to the service. She decided to drop out.

She and Dave had got a flat together, but they slipped back into addiction. This was around the time of Covid and she could not earn money from shoplifting because many of the shops were closed due to lockdown. Dave encouraged her to turn to sex work. She was terrified. This brought all the trauma she had buried to the surface. She would be out until late at night and then go get their heroin. They were also using crack cocaine by then. They used it together and, as usual, Dave would go first, but when the drugs were gone, Dave's jealousy about her sleeping with other men would come out even though he had forced her into it. One night, he left her so battered that a neighbour called the police. When they came, instead of being treated as another woman would be in that situation, she was made to feel like a complicit victim and as if, somehow, his rage was partly her fault. Tusla was called and her son was taken into care.

She left Dave and tried to get into a women’s shelter but, because she was a woman who had used substances and was on methadone, she could not get a shelter and ended up sleeping in a friend's home. She was there without her son. At the time, she was extremely vulnerable and this friend, who was a male, took advantage of that. They began a relationship that was also toxic. She also found herself pregnant again. This time, Davina got the strength to leave him. She did not stay with him and went through her pregnancy alone. She tried residential detox. She could not concentrate because she was worrying about her son. All she wanted was for her child to be with her, but she felt that she was being punished for all the trauma she had experienced in life.

She blamed herself for ending up in yet another situation like that. She did not know that victims of such abuse are vulnerable to it happening many times in their lives. This is why she really needed a female-specific service where she could finally begin to heal. She finally began a female-only service where she began to build an analysis of what her life had been and what were the contributing factors. She also had her baby girl. She was just on methadone at the time and her baby was born healthy and happy. With the right supports, there was finally a trajectory plan put in place, and Davina got her son back home with her. Now, she wants to come off methadone in a residential centre that caters for children, but she can only take one with her, and only the youngest. The thought of leaving her son again is too hard for her to bear, so she is waiting until she is in a place where he feels secure and her children are old enough to understand her making those decisions.

Society treats women who use substances as less than, and this feeds into how they feel themselves. Women are under-represented within treatment services and policymakers can sometimes miss the clues and not ask the right questions. There needs to be gender-specific services that are trauma-responsive. They need to be not just trauma-informed but to actually respond to the trauma that women experience. We need to create supports that are tailored to the complex intersectional needs of women, instead of them being an add-on to services that are made for and predominantly used by men. Women's health and societal needs are different from men's, so they require a gendered lens and more funding for services that also provide childcare.

I will also highlight that I read something the other day about 1,100 new prison places. There need to be alternatives to prison, specifically when we talk about women. The issues women have do not get fixed in prison. I firmly agree that nobody should be in prison for petty crimes anyway, but when it comes to women, we have to look at the damage that does to a family as a whole rather than just putting women in prison. That should always be a final alternative, with every other avenue having been explored first. I thank the committee.

I am the CEO of Merchants Quay Ireland, MQI. I thank the Cathaoirleach and members of the committee for the invitation to speak here today.

Merchants Quay Ireland is a registered charity providing a wide range of services to people who are in addiction and who may also be experiencing homelessness or be struggling with their mental health. Last year, over 13,500 people came to Merchants Quay Ireland for support. Our services range from harm reduction needle exchange to prison counselling, family supports and recovery services. We provide low-threshold day services offering crisis intervention, food, showers, harm reduction and primary healthcare. Our healthcare service includes a doctor, nurse, dentist, counsellor and mental health team, as well as chiropody. Merchants Quay Ireland offers residential detoxification, rehabilitation and aftercare services, which are aimed at supporting people in their recovery journey. We also run Jane’s Place, an all-female service offering one-to-one and group support to women dealing with complex issues of homelessness and addiction.

As a front-line service working daily with people who are homeless and struggling with their mental health and drug problems, MQI is an expert in the field of addiction. As such, we are well positioned to contribute to the debate on drug use in Ireland. In our submission to the Citizens' Assembly on Drugs in June 2023, Merchants Quay Ireland proposed 24 evidence-based recommendations. We believe the implementation of these recommendations would ensure a health-led response to drug use that would, in turn, reduce the harmful impact of illicit drugs on individuals, families and wider society, and would also support more people into recovery.

Due to time constraints, I will summarise MQI’s recommendations as follows. First, we recommend increased investment in recovery services. We need to provide people with greater access to residential and community-based detox, rehabilitation and aftercare programmes. Importantly, people leaving these programmes must have access to secure accommodation. Nobody should be facing homelessness in the early stages of their recovery because it makes an incredibly difficult journey an almost impossible one.

For those people who want to access recovery but who are struggling in active addiction, MQI recommends the establishment of a rapid access stabilisation service and the appointment of specialist addiction nurses to emergency departments.

To support people using drugs today, we recommend increased investment in harm reduction services. The opening of the medically supervised injecting facility later this year at MQI’s Riverbank centre will be a vital harm reduction measure. This facility will save lives and help to create a safer community for everyone. Drug use in Ireland is constantly changing and, given the increased prevalence of cocaine and crack cocaine, MQI recommends legislating for the provision of drug consumption rooms.

MQI also recommends that the Government introduce legislation to decriminalise the possession of drugs for personal use. Decriminalisation, coupled with increased investment in treatment and harm reduction services, will give people the best opportunity to rebuild their lives.

MQI recommends increased investment in drug-related research. Given the growing complexity of drug use, research is crucial to responding effectively to future challenges and emerging drug trends.

To meet the complex needs of women in addiction, MQI believes the State must invest in female-specific services. Women often feel too ashamed, stigmatised and afraid to seek the help they need. Female-only spaces give women greater emotional and physical safety, especially those women who have experienced gender-specific violence, transactional sex and coercive control.

Ensuring a compassionate, health-led approach to drug use will also help to reduce stigma. This is important because stigma is one of the biggest barriers to treatment and recovery and can make it difficult for our clients to ask for help when they need it. These recommendations, if implemented, have the power to save and transform lives.

Drug use is pervasive throughout Irish society, regardless of age, gender or socioeconomic status. Every day, MQI witnesses the harmful impacts of drug use on individuals, families, communities and our wider society. It must be acknowledged, however, that areas of poverty and social deprivation are significantly more impacted by drug use and drug-related intimidation. We believe it is vital to maintain focus on the prevalence of addiction and to adopt a compassionate health-led approach to delivering services which reduce harm and support recovery. The national drugs strategy, which forms the current policy background against which the committee considers these matters, is fundamental to addressing the needs of the most vulnerable in our society.

On behalf of Merchants Quay Ireland, I look forward to today’s discussion and I hope our professional insights relating to the committee's work will prove useful.

Substance dependence represents a significant public health challenge globally, affecting millions of individuals, their families and communities. People use drugs and they always have. Archaeological evidence has identified drug use by humans dating back tens of thousands of years. Drug use tends to emerge during adolescence, a developmental stage marked by experimentation and sensation-seeking. Most young people who use drugs stop or engage in less risky drug use as they move into adulthood, but some young people develop problematic relationships with drug use which leads to them interacting with other systems, such as child welfare and justice.

The majority of adults who use drugs do so recreationally and, depending on the substance they use and the route of transmission of that substance, they may not experience any harm. Harm can be viewed as physical, psychological and social. Physical and psychological harm within recreational drug use primarily occurs when there are contaminated and synthetic substances within unregulated markets or in the way in which people use substances. For example, smoking cannabis comes with the risks associated with smoking, whereas ingesting cannabis in other ways has reduced risk.

Social harm occurs when drug use is criminalised. In these situations, contact with the criminal justice system can be viewed as a social harm. A criminal conviction carries with it a stigma, with consequent barriers to education, employment and housing. This places individuals at further risk of social exclusion, which is detrimental for both physical and mental health. There is often an attempt to view these issues as a simple linear process, that drug use leads to negative outcomes. There can be a failure to see how a range of systems interact with one other. For example, a minor conviction for drug possession limits a person's future opportunities and prevents that person reaching his or her full potential. This can generate cycles of problem use.

When we speak about drug use in public domains, we focus on the people who are experiencing chronic substance dependence, estimated to be between 10% to 25% of people who use drugs. This will also be the focus of my submission but it should be noted that people who use drugs in a non-problematic way are at risk of harm from a system that punishes them and increases their risk of social exclusion. The UN Human Rights Office in 2022 stated:

Data and experience accumulated by UN experts have shown that the “war on drugs” undermines health and social well-being and wastes public resources while failing to eradicate the demand for illegal drugs and the illegal drug market. Worse, this “war” has engendered narco-economies at the local, national and regional levels in several instances to the detriment of national development. Such policies have far-reaching negative implications for the widest range of human rights, including the right to personal liberty, freedom from forced labour, from ill-treatment and torture, fair trial rights, the rights to health, including palliative treatment and care, right to adequate housing, freedom from discrimination, right to clean and healthy environment, right to culture and freedoms of expression, religion, assembly and association and the right to equal treatment before the law.

In my current role and my previous role in the community, the focus of my work has been with people who are involved in chronic problem drug use and understanding why a cohort of people develop a different relationship with drugs. People take drugs because of the effect it generates. Mostly, people take drugs and it generates pleasure, but for some people the purpose of their drug use is to medicate overwhelming emotional pain. The way in which we understand the trajectory of this use has evolved. Traditionally, there was a view that drug dependence was a moral failure and a choice. Research data, however, now indicates the majority of people engaged in substance dependence had a pre-existing mental health difficulty, experienced social exclusion and-or had experienced traumatic events. The Health Research Board has identified that while drug use exists at similar levels in affluent areas and areas of economic deprivation, the harm experienced by people who already experience social disadvantage is greater. Financial and social resources are, therefore, a protective factor in preventing drug dependence. Our research in applied psychology has indicated that people who have experienced traumatic events are at increased risk for problem use and there is a cumulative effect to this risk. The more trauma an individual experiences, the greater the risk of problem use. Other findings of note from our work show that people with the highest levels of trauma histories are more likely to self-report their mental health difficulties and do not have an objective diagnosis. This group struggle to access services and are frequently viewed as difficult instead of traumatised. People with substance dependence have frequently experienced a range of social and psychological harms and have co-occurring mental health difficulties. I believe drug dependence is a mental health issue and should be managed by health services.

We know from decades of research that people use drugs, people will continue to use drugs and punitive approaches have not decreased this, yet we continue to follow a policy that generates no effective results. Measures such as incarceration have been shown to be largely ineffective in reducing drug use and they exacerbate health problems. These measures fail to address the underlying issues that lead to substance dependence, such as mental health disorders, trauma and social disadvantage. Further, the stigma associated with criminalisation can prevent individuals from seeking help, leading to increased health risks. Understanding drug use as a mental health issue shifts the focus from punishment to treatment and recovery. This perspective acknowledges the complex interplay between substance use and mental health disorders and underscores the need for integrated treatment approaches. By addressing the root causes and providing comprehensive care, we can improve outcomes for individuals struggling with addiction and promote better mental health across populations.

Ireland has the highest level of drug-related deaths in the EU and it stays in the top three. I will go back to the train station today and I will see young people there who are drug dependent. Sometimes I talk to them. A lot of them have care histories and have experienced trauma. I know some of those young people will be dead before Christmas.

I thank the committee for inviting me to share my perspectives and research findings and engage with members on the topic of a health-led approach to drug use and policy in Ireland. Today, I will be discussing the research output of Service Users Rights in Action, SURIA, which is a service user-led group that campaigns for rights-based methadone maintenance treatment and other forms of opioid substitution treatment. One of our principal objectives is to recognise service users as consumers and partners as opposed to passive recipients of public healthcare. As such, we advocate for a symmetrical partnership dynamic to inform the doctor-client interaction in both clinical and GP settings. I am referring exclusively to methadone care here. We also advocate for a review of the overuse of urine sampling and the promotion of dignity and respect, with a renewed emphasis on re-integration, to inform any health-led response to drug policy and practices pertaining to opioid substitute therapy treatment in Ireland.

SURIA and my own research argue that Irish methadone maintenance treatment, as an example of harm reduction, often paradoxically produces harm in the lives of clients. We highlight the lack of progress in clients' lives, poor reintegration, the overextension of power into the lives of clients, including in matters that have little to do with drug use, and the poor quality of life for those who expected to be helped by methadone services. There are currently approximately 12,000 people availing of methadone services in Ireland.

My own research, and that of SURIA, is routinely underpinned by the service-user narrative and experiences of those engaging with OST, primarily methadone, using a human rights perspective that traces the progressive realisation of rights instruments pertaining to the highest attainable level of healthcare, that is, Article 12 of the International Covenant on Economic, Social and Cultural Rights, among a number of other rights instruments. Our rationale for this approach stems from the fact that methadone is a public health service and therefore clients should enjoy the same rights and treatment as others who are accessing treatments for other illnesses.

The current profile of the Irish service users suggests that many are trapped in clinical settings with little opportunity to engage with society in a meaningful manner. To give a brief overview of this cohort, according to SURIA's research, I will go through some points. Some 66%, or two thirds, are aged 35 years or over; almost half are engaging with OST or MMT services for up to ten years; one fifth are using methadone maintenance treatment services for over 20 years, and one in ten for over 26 years; and 83% are not engaging in employment or education.

I wish to reiterate that I am not critiquing the amount of time people are spending on methadone services. That is their own choice and it is a perfectly fine choice if that is what they want to make. What I am highlighting is that people are trapped in these clinical settings for long periods of time, where they do not have a high standard of life and poor opportunities to enter, or sometimes re-enter. We talk about reintegration; sometimes it is integration we are talking about here.

SURIA research continuously demonstrates that those using methadone services often allude to institutional stigma - that is, stigma from within services - poor treatment practices and not being afforded any input into their own service provision. This briefing is underpinned by five datasets. SURIA has been carrying out this research since 2012. It is a longitudinal monitoring of how methadone services are provided to service users. We are tracing the progressive realisation of a number of rights instruments, with a particular emphasis on the right to health. As part of this longitudinal research approach, our work has repeatedly highlighted that these services are substandard, stigmatising and often harmful for those seeking refuge from problematic drug use.

SURIA’s work is underpinned by four key principles that have continuously emerged from our research. They include supervised urinalysis, the lack of a care plan, choice of treatment and meaningful review, and the absence of any form of an independent and robust avenue for complaint for clients who are coming across issues in their service provision.

SURIA is not the first to draw attention to the shortcomings of the Irish methadone system. Apart from a number of research articles that illustrate the poor practices, inept training and other failings of methadone services in Ireland, the HSE itself commissioned the publication of the Farrell report back in 2010. This was an independent evaluation, funded by the HSE, of methadone services in Ireland. The report was a damning indictment of Irish services and suggested that MMT was entrenched in urinalysis. The practice of continuous and relentless testing embodies the infantilisation and perception of surveillance that many clients allude to. However, it is the over-reliance on testing that advances this critique. Urinalysis is used to routinely test service users and to restrict heroin use but SURIA's prior work demonstrates that urinalysis is not just an important facet of contemporary methadone services in Ireland; rather, the entire service is predicated upon the result of a test.

We have come across service users after collecting qualitative data across our five longitudinal tests and this statement always stands out to me. I remember a woman saying to me in an interview, "I do not even think my doctor knows what I look like because when I go in and see him, he stares down at the screen, and my whole progress, my whole dose and my takeaways are all determined by a sample on whether I am drug free or, like the language used in the clinics, clean or dirty." This becomes internalised. If you get told you are dirty every week, that is going to have severe ramifications. What we are talking about here is meaningful engagement with service providers.

I wish to allude to some of the reservations I have from my own personal experiences and those of others I have encountered in a decade of research on Irish methadone services, and this is around the pivot to a health-led response. I believe it is crucial that a health-led response is clearly defined, drawn from international literature and best practice, and underpinned by the contemporary evidence base. I would caution about the overmedicalisation of methadone services, considering that addiction is a complex nexus of factors, many of which are associated with low labour-market engagement, low educational attainment, and generational socioeconomic deprivation and poverty.

An overemphasis on health has the potential to undermine reintegration into society. Recent SURIA research explicates that 83% of our research participants, from a cohort of 337, are not currently in employment or education. While I see the health-led approach being really beneficial in taking drug use away from the criminal justice system, I believe we need to reassess that when we are talking about methadone services because it could potentially turn into an even greater emphasis on urinalysis and testing, and less emphasis on reintegration and quality of life. These are the most important things for methadone care.

It is crucial that methadone services are holistic, addressing all aspects of addiction and promoting recovery in all its forms. This should be underpinned by a clear move away from continuous sampling, with standardised care plans alongside meaningful review of treatment. This should replace urinalysis as the principal tool of determining the trajectory and conditions of treatment.

The continued employment of control through sanction, again underpinned by urinalysis, does little to promote dignity and respect. This is particularly evident in the use of language by service users throughout our five reports. Many participants express a desire to be “clean” - that is not my language - which suggests that they were once “unclean” or “dirty”. This is the language that is routinely used by services, and by those employed to form therapeutic relationships with clients. Instead, the asymmetrical power imbalances that we repeatedly discuss in our reports are still central. The normalisation of poor, non-evidence-based treatment leads to internalised low expectations of anything being different from the service user's perspective. SURIA research is an avenue for these unheard voices to be brought into the policy landscape, like they are today. Some examples of qualitative data we have collated from service users include: “I am [being] treated like a scumbag junkie”; “I can’t get a job because I have to go to the clinic every day except Christmas ... when it is closed”; and “I hate the way people look at me differently [when I walk] ... into the clinic”.

It should also be noted that Irish methadone services are inhibited by poor practices, a lack of training of staff and a resistance to follow international best practice and literature. I wish to reiterate that methadone is not the primary problem here as a medication. Methadone does what it says on the tin. It is not perfect. Every service user who enters that arena is well aware of this. It is not perfect but it has the potential to change lives if people are trained properly in how to prescribe and treat service users.

I am almost finished. SURIA research has continuously captured a life in which vulnerable people are regularly dehumanised, disempowered and have arguably been forgotten by stakeholders who are responsible for their care. As Irish harm-reduction services still fall short in the realisation of the highest attainable level of healthcare, our public health sector continues to hurt, punish and blame many service users who are homeless, have experienced trauma and struggle to navigate a world of frenetic competition during a cost-of-living crisis. To continue to do so casts a dark shadow on Irish society. For Service Users Rights In Action, the current Citizen’s Assembly on Drug Use in Ireland will be considered a failure if the plight of Irish methadone service users continues to be overlooked.

Again, I thank the committee for inviting me today and given the extent of the issue, I urge members to consider the evidence-based points I have made today. I would be more than happy to answer any questions the committee might have when everybody else has finished speaking.

I thank the Chair and members of the Oireachtas committee for the invitation to this session on a health-led approach. My input draws from my work experiences. I first commenced work in this field in 1976 in Ballyfermot, and have since worked in the south inner city, the Ana Liffey Drug Project, and in Dún Laoghaire.

I have also researched policy issues and commissioned other research and have been involved in training people on the front line. My experiences are recounted in my book The Harm Done: Community and Drugs in Dublin, which concludes with the need for substantial legal reform.

The assembly's TOR specified, inter alia, that it would make recommendations on legislative changes. Of the 36 recommendations, only recommendation 17 refers to the prospective need for legislative change - in this case for decriminalisation. It is my overall contention that this committee should go a step further than recommendation 17 to recommend legalisation and regulation and that it should advocate a single public health framework for managing drugs and alcohol together into the future, as currently happens within several EU countries. I outlined a number of points to assist the committee's deliberations, as per the written submission, which I have cut back a little for time purposes.

A discussion on the health-led model should always differentiate drug use from problem drug use. Most people who use illegal drugs regularly do not need health interventions, although they experience other problems arising from their legal predicament. For perspective, the largest substance use problem in Ireland is alcohol use disorder, estimated at a staggering 578,000 people. Health-led schemes are not new. Others include custodial treatment, the drugs court and adult cautions for cannabis, initiatives that have either lacked implementation or had little overall impact.

Recommendation 17, as it stands, would also have little impact as it would simply transfer procedural tasks from the courts system to the overburdened health services.

Rather than simply adopting the assembly report, I urge the committee to ask why recommendations continuously do not get implemented. I refer to the other 35 non-legislative recommendations in the assembly's report, most of which have previously been recommended, some of which have been implemented and a lot of which have been abandoned. Rather than reiterate old ideas, therefore, the committee should focus on the need for new legislation and a new departure.

Internationally, public policy on drugs vacillates between two contrasting perspectives, namely criminal justice and the health-led model. The justice perspective prevails. Its enforcement negatively impacts social determinants of individual health such as housing, neighbourhood support, education, income, unemployment and friendships, thereby exacerbating all the key tools in health-led interventions. This needs to change.

Front-line addiction personnel are confronted with a dilemma: should they follow the criminal justice model, get people drug-free and thus crime-free, or should they focus on harm reduction and accept that their clients will continue to use drugs but more safely, while knowing also that because harm reduction is often unpopular electorally, they risk being accused of giving in to the war on drugs and not having enough drug-free, crime-free client outcomes? This dilemma creates overbearing tension and pressure on the front line, where morale is hugely affected and frequently undermined. This is all mirrored in the lack of security and proper terms and conditions for people who work on the front line.

Within the health system generally, drug addiction is seen as being outside the mainstream of hospital and community services and mental health services, and little progress has been made in getting mainstream services to participate in the normal treatment of drug problems. A parallel rather than integrated system has been in operation for more than four decades.

The major drug programme within the health-led sphere, methadone maintenance, as summarised by Dr. Healy and backed up by other research, including that by Paula Mayock and Shane Butler in Dún Laoghaire, has consistently shown these services to be unsympathetic to clients. In contrast, where people develop health issues arising from the legal drug alcohol, the health system responds differently, without moralising or stigma. The same normalised approach towards alcohol is needed in respect of use of all drugs. Stigma will not go away by redefining the meaning of health-led. Legal change starting with cannabis is needed, especially as cannabis has least negative impact on morbidity and mortality. Members might not know that cannabis was not referred to once in the recent report on drug-related deaths and it accounts for up to 80% of illegal drug use.

In the briefing material attached to my opening statement, I summarise the main elements of a pragmatic public health approach to alcohol and drugs together. This type of framework, which is used across the other health issues, is important for understanding that progress on overcoming drug and alcohol problems requires integrated interventions at all three levels of the public health system: primary, secondary and tertiary.

I urge the committee to concentrate on the bigger picture and focus on asserting the State's role, not through continued prohibition, nor through simply sanctioning limited health-led initiatives, but through legislation and regulation in accordance with the health risks of individual substances, with taxation and proper enforcement. The war, which tends to be fought out in the more vulnerable places, needs to end.

I am happy to take any questions or comments. I again thank the committee for the invitation to come here.

I thank the witnesses for their exceptional opening statements and the wealth of knowledge and input we will experience during this meeting. I will need to leave at 10.30 a.m. to take the Order of Business in the Seanad as Acting Leader, but I will follow the proceedings here thereafter.

It cannot be said enough - I do try to say it every week - that people are not drug addicts but babies who were once brought home from hospital and cherished, sons and daughters, brothers and sisters, fathers and uncles, and people with dreams, ambitions and hopes for themselves. More than anything, we need to state that. We cannot state it enough. Each of the witnesses reflected in different places and in different ways that we must have a very dramatic intervention on stigma, on attitudes, on not treating people as whole individuals who happen to have a particular issue that requires a comprehensive health treatment that includes mental as well as physical health.

I am chair of a drugs task force. I was very heartened yesterday that we got an update from the Minister of State, Colm Burke, on the implementation of the budget and in it he mapped the recommendations from the citizens' assembly report onto how that is reflected in the budget strategy. It is the first time I have seen that since the report came out. Number one on that was reducing stigma and what the Government was going to do about ensuring that people are, as holistic human beings, treated with the dignity and the support they deserve.

Davina's story demonstrates how invisible women are. I recently had to engage with a group that talked about young girls being courted, to use an old-fashioned word, with Marc Jacobs bags and all the rest. Then they are groomed into carrying drugs by guys who they think love them and, because of their home background and their emotional vulnerability, they mistake what love is. Part of it is a strategy because gardaí often travel as two men walking so they cannot search a woman if they do a stop-and-search or anything like that. We are all probably on the same page in our views on the merits of stop-and-search. Young girls are being groomed and then it is only a matter of time before they go down the Davina route, and it is important that we intervene.

Where I want to get to is culture. How do we dramatically intervene in the culture, even in health services, even in the context of people not being pigeonholed into one aspect of a part of their life such that it does not define who they are? How do we tackle that in the short term? We all agree that we are moving to a health-led approach. I certainly see my colleagues in government moving to such an approach.

Legislation will follow in time from the recommendations of this committee and so on, but how do we seize that culture by the scruff of the neck and go for it?

Reintegration would speak to that. We published a report a while ago, entitled “Lives on Hold”. Simultaneously, ICON published a report, entitled “Trapped in Treatment”. These titles were not deliberately linked, but they spoke to what was happening. I will speak to methadone services. Access to methadone is much better than it was a couple of years ago when there were waiting lists of months or years, but of 12,000 people, few are making the transition into the workplace or education. As part of its decriminalisation model, Portugal is incentivising employers to employ people with addiction issues. This will go a long way towards changing culture and making treatment more acceptable, in that someone will not have a stigma attached to him or her when trying to enter the labour market or education. Incentives along those lines would go a long way towards helping reintegration. We are discussing long-term issues – culture will not be changed in a single budget – but there are steps we can take to get it started. That would be a good thing. There should be a greater emphasis on reintegration instead of keeping people in long-term care. I have cited the statistics. There are people who have been on methadone for 26 or 30 years. It is not a problem if that is what they want to do, but with Ireland’s current services, there is nothing else they can do. If people are on methadone, it is difficult to get educated or enter the labour market, as they must give urine samples three to four times per week and collect their methadone three to four times per week or even every day. They cannot be seen in the workplace or education. Therefore, we have this stigmatisation and almost discrimination of methadone users.

Dr. Healy made some tangible suggestions. That we are here today in the national Parliament discussing stigma and how people are treated is important. We must show leadership and call out the ways people who take drugs are described. We need to call out the media when it uses particular language. I remember how a group of young lads in the north inner city were recently described as “feral”. When language like “feral” is used, how does it sit with people in communities? We have to call people out when we get the opportunity.

My apologies. The Traveller committee is reliant on me to be quorate at 10.30 a.m., so I thank the Chair and other members for allowing me to jump up the speaking list.

I will go straight into my three primary questions. As I have said at nearly every committee meeting, 218 people died of drugs in 2020 in Northern Ireland where I am from and 213 died in 2021. The UK’s overall data obscures the picture somewhat, but our drug death rate in the North is 115 per million. Unfortunately, I will get on a train later today and see exactly the same thing. The situation is not being addressed in the North in any way like we are trying to do here.

My first question will be a quick one for the panel. There has been something of a détente at this committee on the grounds that, if we do not have the right services in place, then drug decriminalisation is not a good idea. I am emphatically of the opinion that we need to move straight ahead on drug decriminalisation. I would like a sense of the witnesses’ opinions on this. If services are not as shiny, fantastic and holistic as we need them to be, should that inhibit us in moving on decriminalisation?

No. We need to get started because, in criminalising people’s drug use, we are criminalising their trauma. It will just prolong their trauma. However, there needs to be investment in services, including female-specific ones to create safe spaces. SAOL and Coolmine carried out research on children being taken into care. Of the 45 women interviewed, more than 50% had been in the care system. We need to start investing in early education and putting services in place to stop young people from entering drug dependency. Drug use will always be here, but we need to make it safer for people through supports. Criminalising people is not the way out of this. Drug use should never be criminalised.

The story of Davina sat with me. I have known Davinas. I grew up with Davinas. I was born at an interface in working class north Belfast, so I know exactly what was meant.

I wish to discuss the tension between specialist and mainstream services. My background is in community health and well-being, particularly in the LGBT sector. There was an argument we always had about how we needed to shift mainstream services culturally so that they were more accessible to women and minority communities but how we also needed to provide specialist services for women and minority communities that were culturally competent. What is the panel’s sense of where we are currently and how much we need to grow distinct provisions?

We sometimes forget that, when discussing drugs, we are generally discussing men. All of our services were set up for men because approximately two thirds to four fifths of service users are men. A point was made about changing the culture, in that, if we stopped viewing addiction services as a generic, big picture and instead looked at specific groups that needed particular attention, our thinking would change. One cannot think about women without thinking much more widely about all of the different issues they are facing. If we are drug focused, then we miss all of the integrated issues – systemic stigmatisation, discrimination and poverty – that are making those drug problems worse. Were we able to attend to women drug users better, it would change the way we provided other services.

Across any particular health area, specialists and generalists are required and they need to work together. My experience of the drug issue over a long period has been that the generalist practitioner is happy enough to let the specialist run with it. While there is a need for integration among those who work within the specialist system so that they work together on providing continuity of care and a framework has been in place for more than 12 years that supposedly facilitates that – it is called the national drug rehabilitation implementation committee, NDRIC – I do not believe there was any reference to it at the citizens’ assembly, primarily because it had not been rolled out properly. There is a framework for the agencies on the front line to work together, but in the absence of engagement with the mainstream, every single element within the specialist sector that requires a mainstream segment just creates another specialism, leading to there being many fragmented specialist services within the addiction arena. Guiding this is the fact that, overall, people working in mainstream services do not want to work with people who are caught up in illegal behaviour. That is a large part of the problem.

NDRIC was mentioned. We have a good framework called the interagency case management framework.

When I worked in services with young people in the community, we used that, but there were what we would call missing partners. Some people regularly did not turn up. We are talking about young people. Statutory mental health services and mainstream education were the two biggest things we needed for those young people. Those young people would get further pushed into specialist services meaning they were in places where they were meeting the same people all the time, people who were chronically unwell. We are starting that quite young. We need both. People who are using drugs should be entitled to use mainstream services and feel dignity and respect.

We have talked about culture and I actually think it is easier to change. Anyone who is my age or older will remember that we did not talk about mental health or suicide. It was very stigmatised. There was a huge national campaign to challenge the stigma of mental health. People are now okay going to their doctor or their employer and saying they have anxiety or depression. They are not okay going in and saying they are having difficulty with drug or alcohol use. It is the same thing; it is a mental health issue.

Mr. Broderick mentioned female-specific services. We have Jane's Place, which is new service that has been open for a year now. The demand from females to use the service has been incredible. It is also a service designed specifically for the needs of women. We would be delighted if committee members were to visit and see this service because they would see it is a new departure and a new approach.

I briefly want to mention a group who really struggle and they are people who leave prison. I worked in the Prison Service for a long time. I now meet clients accessing our services who have left prison and within three or four weeks of leaving prison, their health status has deteriorated rapidly because of the level of services. It is an indictment on society to say that the services are better in prison than they are in the community but that is certainly my experience.

I thank all the witnesses for all the work they do, much of it unseen and much of it necessary. This builds on the meeting we had last week with the Prison Service when we discussed cultural and societal inequity. Much of the discussion today deals with the vulnerable in our society. Dr. Cullen highlighted that many people who take drugs for pleasure do not seem to run into addiction problems for whatever reason. Those who use drugs to mask emotional pain are the ones who become caught up in drug addiction and are often also those who come from disadvantage.

Talking about culture, the health area is something I have been close to for years. One of the stigmas around drug use is that people waiting in an accident and emergency department to see a doctor believe that the drug-addicted people who are also in the accident and emergency department have a problem that they could get rid of if they wanted to. People may have an illness or a family member may have an illness and they are trying desperately to get seen. That is just a small part of it but it is a simple example of how we stigmatise drug users and categorise them as people who could change their situation if they wanted to. As the committee spends more time listening to people, we get to understand there are deep-seated psychological and trauma issues underlying drug addiction.

In his opening statement, Dr. Cullen spoke about drug use versus problem drug use and not continuing with prohibition. He went on to say that we need to move to regulation, licensing and bringing drug supply under public government control. How would he envisage that happening in reality? I ask him to explain the mechanism that would underpin that policy.

At one stage we had to do it with alcohol. At the foundation of the State, alcohol was completely out of control. It was being bought in shebeens. A lot of it was illegal and highly dangerous. Somehow in the early stages of the State, we managed to put a control system in place. Some people gave out about it but over time it worked and became regulated. I would start with the drug that is easiest, cannabis, because there are many international models in place. It would be a game-changer if we managed to get on top of that.

Currently all other countries in the European Union have moved in the direction of legalising cannabis. I expect that within approximately ten years there will be large industries dealing with the manufacture, distribution and sale of those drugs. There will be a huge demand among the industries that supply those drugs to extend their markets into Ireland and other places. At that stage, it may be impossible for the Irish Government to resist that because of European competition law. I believe the Government needs to get on top of that issue at an early stage and start with cannabis. It needs to get on top of it in such a way that it is not leaving it to the market. We have recently seen how the Government has been behind the curve regarding vapes, which I know very little about other than the private market has set the pace with the distribution of vapes in Ireland. It is only more recently that the Government has begun to try to put a regulatory framework around it but it may be too late for that.

We need to look at what is going on in other jurisdictions. I do not accept some of the criticism that has been made at the citizens' assembly for instance about the cannabis roll-out in Canada. Some misinformation was provided on that, particularly relating to drug-driving and the coexistence of illegal and legal markets. More recent research on cannabis in Canada has illustrated that this is not the case.

Regarding Dr. Cullen's point about vapes, they were introduced as a smoking cessation tool. We could argue over whether they are or not but the fact is that the genie is out of the bottle in that respect. We have allowed big tobacco to buy into that sector and we now see the way the vapes are marketed and they have nothing to do with smoking cessation. People are starting on vapes through culture and fashion and all that type of thing, which is a danger.

Regarding the legalising of cannabis, I am sure Dr. Cullen has heard a number of people in the healthcare area, and particularly mental health care, talking about the dangers of cannabis for young people taking it. He may be right and we may have to legalise it if it is legalised in countries close to us. How do we get the balance right here? That is what I am struggling to understand.

Young people's use of cannabis has been quite stable over the past ten years. The latest research done on people's use of cannabis illustrated that young people are not using cannabis as much as they were five years previously. We need to keep that in focus. We need to be careful about some of the information that sometimes comes from clinical samples. The medical people have clinical samples and are not necessarily working off population samples.

Over the past 15 years or so young people have managed to differentiate between the dangers relating to heroin and the dangers with cannabis. They have opted to use cannabis instead of heroin, which was devastating when young people were using it. They have the capacity to make the differentiation between cannabis that is highly dangerous and cannabis that is not so dangerous. Having said that, a legal framework around the supply of cannabis would certainly make those choices much easier.

We have been invited to see the Merchants Quay facility soon and I certainly hope to get to see the work going on there. I often pass it at night and early in the morning and I see many people who are trying to avail of services there. I am sure the work done there is very necessary and I look forward to getting down there.

I thank the witnesses for their presentations and their work. There has been a powerful contribution from all of the witnesses this morning and we appreciate it.

In considering some of the issues that have come up in the past at the committee, we looked at the so-called Portuguese model, and I went there myself 15 years ago and saw what they were doing. They decriminalise small amounts for personal use across the board. When we are talking about decriminalisation, regulation and so on, are we talking about all substances and all drugs? The idea was that if it was beyond a small amount for personal use in someone’s possession, the person was prosecuted. Will the witnesses comment on that kind of thinking?

I am a bit conflicted about the decriminalisation argument. The people we work with every day are on the margins of society. Ms Kearney referenced people having to shoplift and engage in criminal behaviour to maintain - I do not like to use the word “support” - an addiction they are experiencing. Decriminalisation will not help these people, who will still have to engage in criminal behaviour to maintain their addiction. They may carry larger or smaller amounts for personal use because part of the transaction and part of their personal use is minding drugs, holding on to drugs, passing on drugs or distributing drugs to other people. Personally, I believe decriminalisation will benefit the middle class and people who use drugs at the weekend, who can afford to buy their drugs and spend €200, €300 or whatever it might be out of their disposable income, and they will continue to do so with impunity. However, people who are in very difficult situations will still engage in criminal behaviour.

That is my view and it is borne out by the years of experience I have of dealing with people. Some 70% of the people in prison today have an addiction issue. The vast majority of them are not big drug lords. They are people who have chronic addiction and have ended up in prison primarily because of their addiction and the criminal behaviour resulting from that addiction. While our objective might seem very progressive, I am not sure we will reach the outcome we hope to reach or that the people who are most affected and most marginalised by drugs will see any change in their lives.

I echo what Mr. Mullins has said. When we talk about decriminalisation, if we say it is just for a specific drug or a specific amount, that will bring benefit to a cohort, and that is primarily the middle class, particularly young people who might get caught with something small at the weekend. The people we are talking about, who are very unwell, sometimes need to buy more to sell a little bit, which pays for their own and keeps them out of shoplifting and other types of crime.

When talking about decriminalisation, we sometimes hear people refer to "three strikes and you're out". That is never going to work for people who are very unwell. We need to think about mental health and trauma. If I have experienced trauma and one of the ways I am helping to soothe my emotions is to cut my arms, for example, which can be quite common as pain relief, that would be like saying to somebody that if they cut themselves more than three times, they are out. That is what we are talking about if we really think about addiction as a mental health issue.

I was in Porto this year and visited the consultant rooms there. It highlighted a point about the female-specific piece. We heard a presentation about the service there and found that 85% of the service users were male and only 15% female. When I asked why that is, they said it had been much higher but when it came to core funding, the hour they had provided for female-only was gone.

With regard to decriminalisation, we need to look at the broader picture. In Portugal, the quantity is ten days’ worth of drugs for personal use, but ten days’ worth of use for me might be one day’s worth for you, so we need to look at that. Decriminalisation should be a first step and it should be taken quickly but I think we need to look further. Decriminalisation will not stop people from overdosing because the drugs people are using are still being given in an unregulated supply that is killing people. That is my view.

It is an interesting question. I am kind of repeating what my colleagues have said. A lot of the work and research I am involved in concerns problematic drug use and helping people to have a better quality of life within the harm reduction system we ostensibly have in Ireland. Decriminalisation is potentially a step away from the problem caused by the fact the harm reduction model is co-existing alongside strict prohibition. That does not work. We cannot have a needle exchange in Merchant's Quay and then someone walks outside and is immediately searched by a police officer. We need to look at what is being done in other countries to remedy this problem. I have lived as a drug service user in three different countries and believe we should learn from what has been done in other countries.

Holland, England and here. In Holland, there was a consumption room, AMOC, where people could get food and they were given an identification card. If people had their personal drug supply and whatever they needed on them and they were stopped by a police officer, the police officer could not take that off them because they had the ID card. We need to have some kind of avenue that brings these two processes together. We cannot have strict prohibition and harm reduction services. It is not working, it has not worked and it is never going to work. Decriminalisation is potentially an avenue in the right direction but, as has been said, it is not really going to help with problematic drug use. What is ten doses to one person might not be ten doses to another. Decriminalisation is the next step but it has to be a step towards something more.

I also have two other committees at the same time. We learn the skill of bilocation very quickly in this place. I have read some of the opening statements and I am aware of some of the contributions made earlier. I have limited time and I want to hear from the witnesses.

In terms of pursuing a change through decriminalisation, depenalisation or legalisation, will the witnesses give examples where interaction with the criminal justice system, or where the element of the criminal justice system is involved in someone's recovery, has impaired the ability of the person to recover? I am thinking of a direct comparison between people seeking recovery from alcohol or from an illegal drug. I know polydrug use makes it more complicated but I am thinking about those two pure streams. Somebody who is trying to seek recovery from alcohol does not have to deal with the criminal sanctions that may come from that. Although they still have to deal with stigma, they do not have to deal with the stigma associated with being a criminal or committing a crime. Do the witnesses have examples where, because one drug rather than another is illegal, that has restricted or impaired a person’s ability to recover?

We have been talking about women in addiction. One of the things that happens is that someone might start a process of a recovery journey and then, due to a past arrest, has to go to court, the charge goes through and they get a sentence. When talking about women, not only are they focusing on the impact on themselves when they have to be in custody for three or six months, but there is also the utter destruction that causes to the family unit, given that women are still more responsible for the family unit.

That is where it is most visible for us. It is seeing almost the complete undermining of that family unit - the impact on the children and the family - and that sets everything back. The effort of trying to stabilise drug use or becoming drug free is very difficult for people, particularly when it is linked with other ongoing issues. For example, a woman in recovery will be managing her trauma and that will be rising for her as her drug use is falling, so she will be trying to manage those two things together. When society says it does not really care what she is doing, it will put her in prison anyway, it just throws a lot of that up. A lot of the motivation and the hope just dissipates. You undo loads of work that way.

I have worked in the Prison Service. I worked as a training and employment officer for IASIO. I have seen people being inhibited from entering the labour market because of reasonably small criminal charges relating to cannabis. This causes difficulty with re-entering or entering the labour market. We also have a standard, uniform way of treating people but it has to be bespoke. Is it a good idea to send an 18-year-old who might have taken heroin a few times to Coolmine Lodge for a year or Trinity Court, one of these centralised clinical settings? I am not saying they are not good places but are they a good place for someone who is 18 years old and is just dipping their toe into addiction or drug use? Instead we have these uniform, standardised approaches. We have an assumption that everyone who takes drugs is the same and should be treated in the same way. I understand there are resource issues but the question is whether we can-----

Some of this is quite straightforward in relation to work, education and housing. In an immediate sense, one of the main objectives of a practitioner in the field is to try to mobilise family and neighbourhood support around an individual. That family relationship structure and neighbourhood structure is impaired as a result of the criminality. There is the constant knocking on the door by the police, the young people being stopped and searched and so on. A whole framework develops around the individual that confines them and inhibits the capacity of the family and the neighbourhood to instrument the type of support that would be necessary in their recovery and alienates them within that system.

I would say so for alcohol primarily. With methadone, as per Dr. Healy’s research, it illustrates that people are still perceived as in the criminal system.

A previous speaker mentioned sitting in the emergency department and how people were probably getting a bit cheesed off that drug users were presenting for treatment that might inhibit their capacity for treatment. We do not feel that about alcohol at all and we never ask that question when a huge amount of what is coming through emergency departments is alcohol related.

It brought to mind an individual who had come through, had done huge work in a recovery journey, had come through aftercare programmes and was suitable and ready for employment, and an old charge from three and a half to four years ago came up. That criminal nature meant there was an obvious block to him there in terms of Garda vetting and trying to move into training or employment. That was a huge challenge.

That is the beginning of the journey. We need to change that and the criminal sanction is an impairment to recovery. I should say happy recovery month and well done on all the work on that. The other end of the spectrum is full legalisation, allow a commercial model regulate and have a for-profit element as with any other product. I hear what Mr. Mullins says, because there is a fear, even among the communities I work with, that any sort of legalisation would actually increase addiction and make the situation worse. We are trying to decide where on that spectrum the committee will sit. Will Mr. Mullins comment given that he voiced some concern about decriminalisation?

One of the strong arguments for legalisation is that the level of drug-led intimidation in communities is off the scale. It is almost unknown because people are living in such fear about going to State services or reporting the level of intimidation they are going through. The difficulty I have, and I am very conflicted on the whole issue of legalisation, is that I also believe we should be focusing much more on supports and recovery for people than going down the route of legalisation. We talked about alcohol but it is by no means a good example of legalising something for the better because alcohol is still our biggest problem. Addiction to alcohol is far higher than it is to any other substance.

I do not think anyone is suggesting that drugs are good. We all know that drugs do huge damage but we also need to trust society. I will give an example. Say it is Thursday night and I have to get up and go to work the next day but I decide to play bingo or something where I will have a few drinks. If I go out at the weekend to a party, I would probably have a couple of glasses of Captain Morgan. I can make that conscious choice that I will have a blue WKD. If things are regulated, there is an element of having informed choices, but what people are getting on the streets now is so dangerous. We have seen the level of overdoses happening. I do not think anyone wants a free-for-all for all drugs or whatever people want, but I do think we need to start being grown up about it and start looking at it realistically, because at the moment it is damaging communities and feeding gangland crime. We talk about people buying drugs and feeding into gangland crime. No, it is the policies that are doing that. Drugs affect all communities but the policy-----

I am watching the clock because I am due to speak in the House in a few minutes. I thank everyone for coming in. There is a wealth of experience on their side of the table. It is absolutely fantastic. I am really enjoying the discussion and getting a lot of information from the conversations that are going on.

I worked in community-based addiction services for years. I worked in outreach, drop-in services, with people like that girl Davina. I would like to think we treated people where they were at and not where we wanted them to be, but that was not always the case. I take the points about Davina’s experience on board 100%.

What Dr. Healy said brought me through my journey. When I first started working, it was in a community-based methadone service. I loved my time working in addiction services but I am thinking of one of the things I absolutely hated doing. One of my jobs was supervising people doing urine samples. It was very uncomfortable for me but it was very degrading for the person who had to produce the sample in front of me. Dr. Healy just brought me back to that. To me, it was sometimes a pointless exercise. I did not think there was a need for it. When we first moved with methadone from a detox-based programme to a maintenance programme, the problems started happening then. I am from a disadvantaged community. I have friends, people I grew up with, people I am still friends with and some people who are no longer here, who would have been put on methadone at the age of 13. Some of them are still on methadone, some are not and some are no longer here. It is different for different journeys. They often describe being on methadone as being in liquid handcuffs because you have to be at a certain place at a certain time. The goal was, which I always thought was a false goal, to go from having daily methadone and going to the clinic daily, to twice a week, to weekends and then the goal was to go to the doctor and get a prescription. That was seen to be the whole thing and I felt there was very little done about getting help for people who wanted to come off methadone and start over, because so many barriers had been put in place.

Dr. Healy mentioned that 12,000 people are currently on a methadone maintenance programme. I am not looking to simplify this because I know it is a complicated matter. In the time that we have, what one thing would Dr. Healy change which would help those 12,000 people if they wanted to make choices to move on in their recovery? What changes would he put in place?

The changes would include regular care plans, regular interaction with a doctor, bespoke treatment plans based on who you are as a person, what your goals are and where you want to be, as opposed to these standardised treatment plans that are thrown onto these 12,000 people. Urine analysis should be taken away altogether. There is no empirical evidence that it does any good. Ward, Mattick and Hall have produced literature that it does not deter drug use in any way. I know as a former service user that it certainly did not stop me. It costs between €5 million and €7 million a year to test samples. That money could be put anywhere else. The key is a good therapeutic dynamic between you and your doctor, who knows you and what you want, and that you are being properly dosed. We have this stereotype of a methadone client who is walking around the inner city and the boardwalk stoned. Let us just use the word stoned. That is not methadone. Methadone does not impair how you feel unless you are abusing it in some way, adding on street tablets or whatever. That is usually done because the staff are not trained properly. That is accepted by the doctors I know who work in the HSE and who actually train people themselves.

The changes would include better training, better, more individualised care plans, and regular updates on what the person needs for care. Urine analysis should be completely eliminated. There should be more of a personal touch in a plan. I know from 20 years of engagement with methadone services that I was never asked once, "How are you doing today?" I will not use the word for what I was asked. I was told to go to the toilet in this hub and that they would deal with everything from the results of that urine sample.

That determined everything. It determined my takeaways, my dose, and what I was doing tomorrow, whether I was coming back to that clinic or not. There was no opportunity to get into work or education because if I did not turn up to give that urine sample, I would have been thrown off the clinic. I am lucky I made it away from the clinics. I am one of the few who did.

I thank Dr. Healy. Mr. Mullins mentioned the safe injecting facilities and the one that is due to open later in the year. From talking to him and other people, I know they faced some barriers along the way. Will Mr. Mullins elaborate on some barriers that he faced? How did he overcome them? What conversations did he have with An Garda Síochána? I mentioned that going to the clinic could be deemed an illegal activity, because the person could have a substance that is deemed illegal. How did Mr. Mullins overcome these barriers and what conversations did he have with An Garda Síochána?

Since we last spoke, I visited the consumption room in Portugal. It really reinforced my view that it is the correct approach to people who inject drugs or, more importantly, people who use drugs. Obviously, our legislation is about an injection facility as opposed to a consumption room. It is a complex area. It has been in planning for eight years. There have been many objections, many of which reflect people's genuinely held beliefs. There are many concerns about what a facility like this could do to the local community. We have tried to engage as openly as possible with all our stakeholders, including business, local residents, the school and various other stakeholders in the community, about how the service will look and what way it will operate, and to dispel as many fears as we can about this notion that it would be a honeypot for all those who inject across the city and country. That is not the case. The international evidence would demonstrate that these are local facilities used by local people who use drugs. We do not envisage any other outcome here other than what we have seen in other jurisdictions.

Many of the concerns are born out of ignorance. I do not mean that people are ignorant, but that they are ignorant of the reality of what this facility will provide. It will be a safe, health-led approach to people who inject drugs. I look at the Health Research Board, HRB, statistics. The most recent statistics show that 439 people died of drug poisoning in 2020. The highest number are people who overdosed on methadone. A total of 129 people in 2020 overdosed on methadone. Methadone is a legal substance. It is prescribed. It advances the need for health-led facilities where people can come in and be monitored and supported. Naloxone or whatever we need to administer can be administered in a timely fashion when a person goes into a state of overdose. It is a facility that I have urged people to be patient about and to judge it on its outcomes as opposed to on perceptions about it.

From looking at the international experience, we absolutely do. I do not take away from the fact that to open a medically supervised injection facility is a really positive development. It shows grown-up thinking from the policymakers but the next step after this pilot should certainly be to look at drug trends and mirror that. The drug trends suggest that we need consumption rooms at some point in the future to support people who are in addiction.

I thank everyone for being here. Apologies for my late arrival. I was in the Seanad. I wish I could have been here earlier. I thank the witnesses for their opening statements and all the work that they and the organisations they represent do. I heard some of the witnesses' earlier contributions. I was listening before I went to the Seanad. The witnesses were talking about stigma. It certainly resonates. I come from a perspective that if we want to change stigma, we need to change the way that we as a society think about addiction. We need to accept that addiction is just a symptom of trauma, pain and disadvantage. I guess as a culture and a race that we have generations of that trauma, from the Famine to economic depression, to social repression, the Troubles, the crash and Covid. That trauma is part of us as a race. Not all of us can cope as well with that all the time. As we get older, coping and recovery are so much more challenging.

When I think about it, I wonder how we start to address that pain and trauma and provide support to those individuals who need it before that problem manifests as addiction. How early does the intervention need to be made? I think Mr. Mullins, or perhaps the Prison Service, spoke to us about how 70% of those in custody finish school before 14 years of age. That means that before 14 years of age, they have disengaged from society. Society has allowed them to fall by the wayside. Some 80% of those in custody have an addiction. How early does society need to make the intervention? We need to identify that, pinpoint it and call it out. If, as a State, we start to do that, that will start to address the stigma and change society's view of what addiction is. That is one question.

The second question is on regulation of drugs. Ms Kearney has clearly articulated how it works from an alcohol perspective. In practice, how would regulation of drugs work here? I think we have all bought into decriminalisation and a health-led approach. I do not think that is a debatable issue anymore. How would regulation of drugs work in practice? I have four minutes and would love to hear from all the witnesses.

I wanted to respond to the matter of how early the intervention needs to be. In the SAOL Project, we have a children's project where we work with one- to three-year-olds. We are already a little late. Part of it involves helping families to regulate and get used to mainstream services. You are then able to respond to the children's needs, including any developmental delays and recognising the impacts of generational trauma and parental trauma on the children.

That is present in every case we work with in the SAOL Project, but we do not get to work with every one of the children. If we could invest more in the children, that would be much better.

This ties into how we resource social workers and how they respond to women who have issues with addiction, because we are getting that wrong. It is brilliant that we focused attention with Hidden Harm on the way drug use can impact on children, but our response is not working. Putting children into care is putting them into a system that we have plenty of evidence to suggest is not working for other women.

I am not sure about the answer to the other question but Dr. Cullen spoke to it well earlier. Decriminalisation or legalisation cannot stand on its own. It is about how we invest, work on destigmatising and run the kinds of programme to which Dr. Lambert referred, which we have been running in respect of suicide and mental health. Over a period, we have changed public perceptions on that. It is about the destigmatising work and the investment. If we are to save money by decriminalising or legalising, it has to be channelled into the kinds of services we want.

I would be interested to hear Ms Kearney's perspective because the female experience is important and is a large determinant for children being born into addiction. If, as a society, we are to make young women believe and have value in themselves, identifying young women who are at risk, before they ever become a mother, is very important.

A lot of investment is needed to create the conditions for young women to feel empowered, but that is very hard to do in some communities. I come from the north inner city of Dublin and live in Finglas. Those are two communities where it is very hard to create those conditions. Someone was talking about handbags and women being groomed into this life, but it applies also to men being groomed into this life. You can totally understand how easily they can be sucked into it because there are not many other options for them.

To return to the question as to how a criminal conviction can impact on recovery, if someone falls into addiction and is trying to move on with their life but has been groomed into it such that it is all they know, and if they have any convictions for, say, having had enough for a few joints, as opposed to for having been drunk and disorderly, they could have been working on themselves and done a lot of work but then decided to go back to college because they wanted a job. Unfortunately, a lot of people who come from that background go into social care work because, a lot of the time, that is all that is on offer for them, and it relates to the Garda vetting and so on. Having a conviction for possession of drugs can lead an employer to just put the person's CV aside and not ask what the conviction related to. It can really impact on the person moving forward.

It is about investing from a young age but I must re-emphasise that in the context of women and girls, we must really invest in female-specific services. Nobody knows what is going on for girls in their homes, what they carry when they go out with their boyfriends and so on. All of that leads to trauma over trauma, and if they do not have a safe space to talk to someone and express that trauma, that will just continue.

On early interventions, there was the opiate epidemic in the eighties, which continued into the nineties and began to phase out afterwards. One of the reasons it phased out was that there was a massive injection in local communities, especially into young people's services. The young people's services and facilities fund was set up, and by the time a new service was set up for the treatment of people under the age of 18 with opiate problems, led by Bobby Smyth, it had no clients. Nobody under the age of 18 presents with opiate addiction nowadays, and in respect of methadone maintenance, the numbers are falling, not increasing, as they previously were. That investment worked but, unfortunately, it was pulled.

On where we should start, I will deal with the decriminalisation aspect first because of the Senator's question. I fully agree with Mr. Mullins. Decriminalisation is yet another example of us believing we are doing something but not really doing it, because we are missing the point. There will be discretionary application of decriminalisation that will, in my view, be class based. That is the reality.

We need to start somewhere with regulation, and I would start with cannabis for the simple reason other countries are doing it. That is what we need to home in on-----

The Government would regulate it, and we would have to look at the models that are used elsewhere, but there would be rules around locations such as cafés or clubs. I think the idea of clubs is a really good one. In fact, I think a large proportion of the alcohol that is sold should be distributed through clubs in any event. I do not mean sports clubs. It is probably the case that the private industry rules the alcohol industry in Ireland to too great an extent, although that is a different question. There are models out there that we can use. I thought some of the presentations relating to the experiences of other jurisdictions in respect of cannabis understated their success.

I thank the witnesses for attending. On decriminalisation, Mr. Mullins pointed out that the middle class will probably get the benefit of it, whereas for people who are working class or come from disadvantaged areas, it might make no difference, and that made sense. We are looking to make a change here on foot of the citizens' assembly. The war on drugs has not worked. Everyone knows that now. What can we do, therefore, to make a difference? It is our job in the Dáil to legislate. There has been a lot of food for thought. On a political note, I was very disappointed that the word "addiction" was not mentioned in yesterday’s budget. A citizens' assembly made 20 recommendations for more investment or supports and there was not a bob in the budget for it. The question I am asking today is what stage we are at here. The witnesses spoke about investment and about how, when money was put into youth services and they were targeted and supported, benefits were seen.

Dr. Lambert wrote an article recently on bereavement and the grief felt by those who work in the addiction sector. That is probably an overlooked issue that people who are on the front line go through. Will she comment on that?

Daniel Callaghan recently finished his PhD, and I have looked at various aspects of that. When somebody dies as a result of drugs, it is called a bad death. In bereavement, there are good deaths and bad deaths. The former is one relating to a natural cause, whereas the latter is one associated with stigma. Families who have been bereaved as a result of a drug-related death do not get the same sympathy. It is as though their son or daughter made that choice. That is what we used to say about suicide 20 or 30 years ago but we are still saying it about drugs.

Moreover, this impacts not just families but also communities and workers. People who work in front-line services, especially out in the community, develop very long-term close relationships with the people they support, and when they die, they are devastated. They also experience it as a bad death. It does have an impact. We have an issue with recruitment and retention in front-line services, especially homelessness and addiction, because people get really burned out from the demands outweighing the resources.

The Deputy spoke about the budget.

An additional €4 million was allocated. That is slightly less than the €4.1 million provided for greyhounds and horses.

The Deputy asked what we are going to do about it and when will we intervene. This is fundamentally about structural inequality. This is fundamentally about the fact some people experience more harm from their drug use as a result of poverty and classism. In the UK, the British Psychological Society wrote a White Paper on why classism should be added to the list of discrimination. People from working class communities do not get the same access. Members could probably count on one hand how many are from working-class communities. They are probably the ones who are coming in here and turning up to these kinds of events, because people who are not from working-class communities are not experiencing the same harm. We do not even have equal representation in the context of the people who make policy and formulate the rules. Someone who has not experienced poverty does not understand things like it being cheaper to tax a car for 12 months than for three. The people who can only afford to tax their car for three months are penalised by the State for having less money. That is the State. I can understand when private companies do that, but we could stop them. Buying a card for €10 to top up my electricity meter costs more per unit than it does for a person who can take the risk of having a direct debit coming out of their account. We think poor people are bad at managing their money, but we make it really hard to be poor and to get out of poverty. When you are poor, it causes poor mental health. People sometimes people use drugs and alcohol to manage that.

I thank Dr. Lambert for that. To go back to what Mr. Mullins said about supervised injection facilities, we hope that will go ahead and be positive. There is a facility planned for Cork. What can be learned from the experience in Dublin that will make the delivery of one for Cork go more quickly and smoothly?

The main obstacle to the development of the MSIF in Dublin was public concerns about the impact on safety and business. All those fears should have been allayed at this point. We have had extensive engagement with all the stakeholders. The big lesson would be to ensure it is fit for purpose. We know drug trends are the way they are. We know cocaine and crack cocaine are big issues. Perhaps when we review this 18-month pilot - there will be a comprehensive report on its outcomes - the one in Cork should be a consumption room as opposed to a medically-supervised injection facility.

I have a point to raise on the medically supervised injection facility. It is an important aspect of drug treatment, but recovery, detox and aftercare are the main ones. We see people who go through a detox or recovery programme and into aftercare and how they have rebuilt their lives and their connections with their families and that is where we really have to concentrate. There is a chronic addiction issue, but there are barriers to people getting into recovery every day of the week. The cost of a ten-week detox programme with Merchants Quay is approximately €10,000 to €12,000. It is nearly double that to keep somebody in prison. We can provide detox followed by a 12-week recovery programme, then aftercare and then obviously on to stable and suitable accommodation. That can transform a person's life, and not just theirs but their family's as well. I showed Senator Fitzpatrick a letter I received from a lady in a part of Dublin. She had lost her daughter to suicide. Her daughter had addiction issues. Through all that grief she was writing to me to thank Merchants Quay for the support it had given her daughter. The last thing she said was she would send us a few bob when she had it. This woman clearly does not have a few bob. I know from her background she does not have a few bob. I am thinking of the connection she had with and the empathy she had for people in addiction. She saw recovery as the key to that.

To go back to the question about medically supervised injection, there is an independent evaluation panel that will be run by the Department of Health. One of the main delays related to planning permission, planning appeals and judicial appeals, which is all fine. However, with the evaluation at the end of the 18-month pilot period, we have to lodge another planning application in order to continue. That opens up planning appeals and objections again. Maybe when the Cork one is going forward, the evaluation could be based on the performance and the outcomes for the people who use the facility rather than having to go back through the planning system. It is a more appropriate way to evaluate a programme.

I might go back to some of the practicalities around receiving treatment as well as the requirement for urine analysis, which is something we discussed last week as well. It seems we have a model that is trying to catch people out. Ms Kearney spoke about that earlier. It is about catching people out and putting them on the spot. I am wondering about service users' rights and how we get those. Now we are talking about decriminalisation, one of the changes it might bring around is that a drug user is not immediately a criminal. It would change the context we are all having a conversation in and the mentality of trying to catch people out would be removed. That might be a significant benefit when people are seeking treatment. I want the witnesses to talk a little about the gender side of it as well. On service users' rights, are we missing a trick when it comes to things like peer-led systems? How can we optimise that? Surely all the focus on testing runs completely contrary to people's rights because, ultimately, it is not really consent based.

There is no doubt it is a culture of control. It is coercive confinement. It is a method of governing 12,000 individuals who are, in some people's perception, difficult to govern and, perhaps, not ready for the labour market. It becomes a place to keep people stagnating and potentially keep people out of crime.

What was the Deputy's second question?

Our last research study was called Lives on Hold. We were getting some funding from the HSE but that stopped during Covid. We needed to access funding, so through the Community Action Network, CAN, we engaged with local drug task forces that provided some funding. We trained up other service uses who designed the survey with us as well as carrying it out and collecting the data. I wrote it up and then ran it by everybody. We had some meetings about whether they liked what we were doing. We launched that research in the Irish Human Rights and Equality Commission. It was a small launch with about 100 people there and about 30 service users who were involved. It was a real empowerment piece. It was really beautiful to be a part of and see service users standing there saying that this was what they wanted to hear, that this was what they have been saying and that this is their voice being heard by the Irish Human Rights and Equality Commission. These were people who have never even been to these buildings and who do not feel like they belong. We were seeing them standing up and really feeling part of it. That empowerment piece is massive because not only are we empowering service users to be agents in their own social change, we are also producing credible, reputable and brilliant findings to inform policy. The unfortunate thing is that these findings, which SURIA has been repeatedly launching - five times, as I stated earlier - are not making it into the policy landscape. The funny thing about this is they are being used in other countries. The UK is using SURIA research findings to review its policy.

That is crazy. Will Ms Kearney speak a little about peer-to-peer experience, bringing somebody through and that culture, especially when someone is pregnant? Even when you are not a drug user and you go in as a young person who is pregnant there is a bit of feeling like you had better be on your best behaviour.

In SAOL, we really promoted a peer-led approach. There is an absence of female-specific services in Ireland. There is Jane's Place and all, which is welcomed. It is brilliant there are other places now. In SAOL we have targeted services within the project. There is the DAVINA programme. That is the reason I gave the woman that name. It comes from a programme, but that is a woman's story and we user her name. DAVINA means domestic abuse and violence is never acceptable.

This is a targeted, peer-led programme for women who have the co-occurrence of substance abuse and domestic abuse. Then we have the BRIO programme, of which I am co-ordinator. This programme works to build recovery inwards and outwards. The first phase involves working with the women on personal development and identifying what their goals are. It is about getting them to a place where they feel comfortable to start sharing and to wanting to speak out. In many instances, women with substance abuse issues are pushed aside and told to shush. It is as if our voices are not important enough. A lot of that comes from their fears. Going back to pregnant women, any young girl having their first child, in particular, is already feeling judged and anxious about making mistakes and being so careful.

Yes, exactly. When it is a woman who uses drugs, that fear intensifies tenfold. With a peer-led piece, women start to feel comfortable and able to share. It is also important that we start to work on building women's skills within that. In BRIO, as I was saying, we do the personal development piece first and then we work with the women to train them to deliver programmes such as reduce the use, recover me and the DAVINA programme. These are all women who have had that experience. When women come in, they get the feeling that these are people who understand where they are coming from and will listen to them. There is a feeling of genuine empathy, where they feel comfortable to talk. We need to give these women skills. There is no point in just taking women's stories and expecting them to constantly regurgitate their life story.

Exactly. We have started a new group of women in BRIO and we are on their personal development piece at the moment. Then, in a few weeks, if I am doing the reduce the use programme in SAOL, one of the women will help to facilitate that, once she has the training. In the Dóchas Centre, there are three levels to the programme. In the third level, one of the women will come with me and co-facilitate that.

I will give an example. The BRIO programme started in 2017 and I took part in the first group as a participant. Because of the training I got, it encouraged me to go back to college. It gave me an understanding of how things work. I went back to college, then worked in the community development sector for a couple of years and I am now the co-ordinator of the programme. It was that investment into it and that building of social capital that most people who use drugs do not get. We need to start pushing the reintegration piece that Dr. Healy was talking about by making use of the strengths that people who use drugs have and not just looking at them as lesser people.

I am really struck by what Ms Kearney has said. It is so true that the strength and resilience of anybody who has achieved recovery is so much beyond any of us who have not been tested in that way and this is generally not recognised. Those who work closely with or support people in recovery do recognise it. This is a huge opportunity for us as a society to recognise, celebrate and champion the extra powers, strength and capacity that people who have achieved recovery bring to every setting. This has to be part of our recommendations.

I was thinking about what Dr. Cullen said about the other models for the regulation of drugs. I agree with him that starting with cannabis is the obvious one. I think as a committee that is the consensus. Is it possible to ensure that it does not become - as alcohol is - a commercial, private, profit-driven activity?

Okay. When I was growing up in the 1970s, my mother always warned me when I was going out to parties that it was okay to drink a few beers but never to drink poitín. It reminds me that at the time there was seriously bad alcohol around that is not around today. Some of it comes back to common sense, pragmatism and believing that young people - because they are the ones most at risk - can differentiate between products. They have shown themselves to be able to do this with heroin and other opiates by choosing to use cannabis rather that getting stuck into heroin. The fall-off in the use of heroin over the last 20 years has been incredible. We can copy aspects of the alcohol model, particularly regarding regulation of the types of products available, the licensing systems, the type of outlets, availability to young people and so on. The situation with alcohol is not perfect and it never will be. No regulation system is going to be perfect but we have to start somewhere.

Canada was the western society that started this and other countries have followed its lead. I think there will be less success in the United States because the dollar controls everything there, whereas Canada and the European countries have better regulation systems. We should be looking to those as models.

I want to make a point about how methadone is currently managed. We all have different ailments and illnesses and we deal with different consultancies about different aspects of our bodies all the time. The one person who holds everything together is our GP. If we found a way to get family doctors to take more control of the management and treatment of people who are on methadone, we would dilute all the negativity that goes with specialist treatment centres.

I know Davina. I grew up with her and I have family members who are in the same situation. I am well aware of the story. I know that a different name is being used to protect her identity but it is very common. I worked in front-line addiction services in drop-in centres. It is a fine line to be trained to try to assist people where they are, not where you think they should be, and to do so without being intrusive. This was explained very well in Davina's story. Ms Kearney also mentioned the importance of being not only trauma-informed but also trauma-responsive. What would that look like as a model?

Dr. Lambert has done amazing work researching trauma-informed pieces. In all the services we work with, the majority of us understand that the people we work with have had huge trauma in their lives. However, not all services are equipped to work with that trauma. If we are not trauma-responsive and not considering all aspects of the lives of the people we work with, we can cause further damage because they are stigmatised in society and by the media.

They do not need to be stigmatised when they come to services for help. A trauma response means recognising that even if people have not opened up and told their whole life story, there is a good chance it includes trauma and makes sure we are not making it worse for them by being intrusive, niggling at people and constantly wanting them to go out and share their stories.

To be trauma responsive needs constant reflection on practice. To use the example of urine analysis, when dealing with people who have been sexually abused, we do not need to know about that abuse, but if we force them into observed urine analysis, it will retraumatise them, as will not believing people or not giving them safety when they come into a service. That requires constant reflection by the team providing the services.

Dr. Lambert made an interesting statement that drug use should be seen as a mental health issue. I just came from a debate with the Minister about Keltoi. Dr. Lambert will be aware it is a residential dual diagnosis service that has been closed since 2020. I wanted to know whether there is money in budget 2025 to reopen it as a residential service. It does not look like that will happen in 2025. That is my reading of the Minister's response, between the jigs and reels. Will Dr. Lambert elaborate on the absolute need to have a safe residential place for people who have mental health and addiction issues?

The reality is that research we have done in this jurisdiction and abroad shows the level of mental health issues among people who access addiction services is between 80% and 90%. Not everyone who has ended up in substance dependence has experienced trauma, though a large number has. We have not looked at this yet, but we potentially have many older men and women who are in addiction who have undiagnosed autism or other neurodivergence. We live in quite a social country where people have to go the pub to drink and if they do not, there is something wrong with them. How many men and women of the 1980s and 1990s were alcoholics as a result of us not understanding that? People have to change and adapt to the culture around them by drinking and that will have a totally different impact.

The other matter we need to look at is menopause in women. Women who enter addiction treatment services are often older. Sometimes that is because, as Ms Kearney said, they cannot look for help if they are mothers, because their children might be taken away from them. The other thing we know is that women who are entering menopause are drinking more because menopause is having a detrimental impact on their mental health. These things cannot be easily separated. There was always a view that drug use caused mental health problems, but actually a huge study by Kessler et al that looked at thousands of people found that the majority of mental health issues start before the age of 18 and the majority of substance use dependence diagnoses happen after the age of 18. Studies of cannabis use and youth mental health were mentioned earlier. Correlation is not causation. If someone comes to a service and says, "I had psychosis", these are the things we do not know. If I go into hospital tomorrow and am having a psychotic incident and I am tested for drugs - which we rarely do because if someone says they have used cannabis and that is why they are psychotic, we accept it - we will not always know whether it is one of those new psychoactive substances. I might test positive for THC, but there might have been something contaminating the cannabis that we do not know about. We therefore have to be very careful about how we interpret information and the expertise of the people using it. Are they coming from a biomedical model? The issues are across the bio-psycho-social area. We are not doing enough to support people with a dual diagnosis.

Davina comes from a community where there is a lack of investment. People might think there is a lot of investment, such as the north east inner city initiative and other things, but given the issues that are there, a lot more investment is needed. As that story says, Davina came from a household where there was domestic abuse and sexual abuse and no one was minding her as a child. More investment in youth services is needed.

The story was covered in "The Two Norries Podcast". Her partner, James Leonard, was also in prison and in addiction. Ms Butler's story is probably one of the most powerful stories I have heard because I come from the same area as her. I am the first person from Knocknaheeny to be elected to the Dáil. However, my experience growing up was completely different from Ms. Butlers because of my mother, God rest her soul, and my father. I had a strong family unit, but we lived yards from where she came from. The difference between her life and my life was because I had a stable family unit, I was involved in St. Vincent's GAA and I had friends around me. I was not very good at school. I was a bit of a messer but I had those supports to keep me. When I look at Davina's story and Ms Butler's story, I think what if there had been early intervention?

I will turn to the point Dr. Cullen made about GPs. I had a nephew who died at 21 after taking his first dose of methadone. He was prescribed a minimal amount. His name was Eric Gould, a beautiful young man. He had got on to drugs through prescription medication, including sleeping tablets and painkillers. He had never taken a drug until he was 18 and he was dead at 21. If his GP had been asked a simple question, whether Eric was suitable for methadone, the answer would have been, "No", because he had a history of a heart issue. People should not take methadone if they have a heart problem. It goes back to the points made earlier, including by Dr. Healy, about stigma. If people are in addiction, they are considered to be scumbags or not to have families. Eric had been with the same doctors who had a full medical history. All that was needed was for someone to link in with his GP. Will Dr. Cullen and Dr. Healy comment on the importance of treating people in addiction like human beings with lives and families? Some people might not have anyone, but many people have people who support them.

I agree totally with the Deputy. I was raised in Ballyfermot and I know a lot of people who were raised at the same time and did not do well in the system. Family is definitely a huge factor, among others. We do a lot of research into drug problems, but we do not do enough into protection and preventative factors. We need to take a long-term perspective and ask what we need to know about what protects young people from risk in their communities. What do we need to do in the long term to turn it around for others? I recall working in the Ana Liffey Project many years ago. Mr. Broderick was there too, but long before that. We used to have the view that we perhaps needed to look at changing the children of the children who were coming in with their parents, because a long-term perspective was needed. We are constantly looking for immediate solutions to problems.

We are never going to get them, but we take a long-term perspective, like the investment that was done in community facilities and services that suddenly stopped when the recession came and was never reinstated. The health budget, for example, has escalated since the recession ended, but the budget for drug services and community and youth services stayed at the same amounts they were at in 2009. That was a reflection of policy decisions. Dr. Lambert mentioned something like €4 million being allocated for this year. The accumulated deficit in some of those services is huge. If we want to rectify the situation with regard to the withdrawal of money from front-line services in 2008 and 2009, we are talking about a huge amount of money before we talk about an increase of €4 million and so on. It is about priorities at the end of the day.

I will speak to the question about central clinical care. I understand there are resource issues and that certain areas may think they need these clinics. This really speaks to the topic today of a health-led response because I hope that does not lead to more of these centralised clinics. They are open for four hours per day. They are beyond capacity. They are obviously going to be a magnet for people who will sell street tablets and this, that and the other outside them. In other countries, they are open 18 hours per day and people can collect their methadone at 6 o'clock in the morning and go to work. I really hope this health-led response does not entail one of the solutions being to open loads more of these huge clinics all over the place.

Individualised care with a GP is just so much better. A person is literally a number in these clinics. A lot of the things I spoke about in my opening statement, such as it involving a urine test and nothing else, is because they are so under-resourced. The training is poor in these clinics as well. It is not up with the international evidence base. There is no evidence behind it whatsoever. It is a test and that is all.

Deputy Gould's story about his nephew is really sad. It is most likely linked to exactly what we are talking about here. If he had that individualised care, he would have been asked those important questions we talk about. In these clinics, because of limited resources, we end up with these uniform care models and the assumption that everybody who presents at these clinics has the same problems. As we know, addiction is so complex and so many different things come into it. Individualised care is the way forward. I hope that is taken into consideration in this health-led response we are speaking about today.

I thank the Chair for letting me in. I thank all the witnesses. I missed a large part of their contributions but an intern was listening and she filled me in. Anyway, I will cut a long story short and get to my questions. What I have heard has been hugely interesting, especially the points that were made about menopause, which is something I had not factored in or come across. That is mind-blowing. The statistics Dr. Healy provided show that 80% to 90% of participants may have come from trauma. I thought the figure would be much higher than that. I wonder about generational trauma and the impact that is having, which Dr. Healy alluded to already. The children of those parents are obviously being impacted and experiencing some level of trauma from growing up in that kind of environment. Do we have any statistics relating to generational trauma and the impact that is having? Is that included in the trauma statistics or is there a gap there?

Okay, I figured as much. Dr. Healy talked about reducing stigma. That is hugely important in west Clare. I represent County Clare. In west Clare in particular, however, there is a huge issue around drug use but also societal isolation and not being able to get support when it comes to housing. This is a big issue for me with a few lads who are in west Clare. They actually have the mentality that they do not deserve a house. That is what they tell me. That struck a chord with me because having shelter is a basic human right, in my view. Everyone should have it regardless, so it is sad to hear that they have basically lost the fight to even want to have shelter. Their health is deteriorating. Their mental health is deteriorating even more. I cannot see how it is going to improve for those individuals, especially if they are not going to get access to shelter. This is a major obstacle in County Clare. I believe it has an awful lot to do with the stigma, which is probably to do with those working in public office, for example. Do the witnesses have any thoughts in respect of how I can tackle that? Is decriminalisation the only way forward in terms of having a serious impact on reducing stigma? I ask that question because my thought process is that this is the only way we are going to make headway.

The other issue is centralised care. What I am getting from Dr. Healy is that we need to move away from that. It needs to be individualised care. We have an issue with a lack of GPs in County Clare, however. West Clare is so far removed even from Ennis, the main town in County Clare. I know individuals who have never left Kilrush, which sounds crazy but that is the reality for them. They are 45 minutes away from Ennis. The best way to put it is that it feels like being in a whole different country. When you go to west Clare, it just feels so detached from everywhere else. There are people who do not leave that locality, so accessing treatment and services when it is 45 minutes to Ennis and further again to Limerick is too big of a task for them. We also have issues relating to transportation and the cost. That is another issue people have reported to me. They really want to get help but it is just too difficult and they cannot afford to go. They may also have issues with the pass. They may have been in prison and may lose their disability allowance and their pass. It is a whole obstacle to try to get all that back into play. I agree with Dr. Healy in that regard. There are too many obstacles for them. I was hoping there might be an opportunity for the Government to put in place a Leap card or something else to facilitate that, or even a shuttle bus.

My other question is in respect of supports and services. Do we have a database in place yet that acts as a one-stop shop to which we can point people?

I will speak to the one about individualised care. We have 12,000 methadone service users and I understand it is going to be very difficult to facilitate 12,000 people. There is the potential to make smaller clinics with fewer clients work if there is no other option in places like west Clare. What I was critiquing would mainly be Dublin inner city-----

-----where they are packed to the rafters. It could potentially work in a smaller setting in places like Clare, particularly when there is no other option. They need more staff, more trained staff, less emphasis on urine and to be accessible to the local area. It may not be ideal, but it could certainly work. What I was critiquing was more the huge inner city places, but there is potential for that to work.

I can identify with the piece about not deserving housing, as can the people we work with in SURIA. People think methadone clinics are doing them a favour by giving them methadone, so if the clinical staff ask people to give a urine sample or jump through a hoop, people ask how high they want them to jump and how many urine samples they want them to give. Those people think they do not deserve anything. SURIA is made up of service users and former service users. Most of us changed our lives through that empowerment piece and being involved, being agents in our own social change, being aware of what rights and obligations we had and being aware that the way we were treated was wrong and that we deserved better. That is how we changed our lives. That empowerment piece is huge.

I am conscious of what the Deputy said with regard to the rural aspect of west Clare. The key workers at one of our support services in the midlands, for example, meet the clients where the clients are. They travel around the counties of Westmeath, Meath, Laois and Offaly to meet the clients. That might be in a primary healthcare centre or a GP's office.

Ana Liffey and Coolmine also replicate that service in the region. There are services. They may not be established in the local community but GPs can refer them to the likes of ourselves or other organisations where the key worker can go and meet the client. For people who feel isolated, the GP is the first port of call in accessing services.

The Deputy mentioned housing. It is clear that the biggest barrier to continued recovery is stable accommodation. When somebody who has completed a detox or recovery programme is back into unstable accommodation in an environment were drugs are prevalent and where the temptations, to use an old Catholic word for want of a better one, are there, it makes it even more difficult for that person to sustain the recovery journey that he or she is on. We would always say that one of the most critical aspects of a recovery programme is access to good suitable and stable accommodation where a person can rebuild his or her life and reconnect with the old life he or she may have had before the addiction took hold.

I just want to acknowledge the work of the GPs and the doctors in methadone clinics and the individual care that they give, in case it is coming across in any way negative, for the work that they are doing. It was mentioned earlier that the case management model we operate, when it was written through NDRIC in 2010, was very much centred around what the service user wanted. What has happened with case management is that we have gone with what the service wants and what is driving that. We have to go back to that model where we are asking the service users what they want and building from there. That is the kind of work that we need to do.

To come back to Mr. Mullins on housing, I was working with a lady in Cork who was refused housing because when the Garda check was done, she had a conviction for having cannabis for personal use. This is a woman with four children, three of whom are on the spectrum, and she was taken off the list for a year. Thankfully, she was housed recently, after a year or maybe a year-and-a-half's battle. She had been a victim of domestic abuse and what she had gone through only all came out afterwards in court. When we are looking at decriminalisation, it would probably have made a huge difference for this woman. She was blocked from getting a house for at least a year and a half just for having cannabis, and it turned out she had been forced to hold it for her ex-partner, her abuser.

As regards women in particular, Ms Kearney may be interested to know I met a group last year from the Belfast women's trust. They had a one-stop shop that offered services for women in addiction. We do not have that in Cork.

To come back to a point Mr. Mullins made earlier, in Cork at this moment in time, if you are in recovery and you are homeless, your best bet is to sleep on the streets because if you go into Cork Simon Community, which does great work and of which I am a great supporter, you are in the middle of people who are in the throes of addiction. If you are in recovery, your best bet is to sleep on the streets. How could that be right in this day and age? What should we be doing to stop it?

It is not right in this day and age; that is the first answer. I do not wish to sound repetitive, but the evidence is there. We know the best chance of a sustained recovery is when the person has stable suitable accommodation, with a door they can close behind them, in order that they feel safe, respected and part of society. We talk about stigma. When people are stigmatised to that extent, it has an enormous impact on their mental health, how they feel, their self-confidence and their connection to society. They are outcasts because of the way they are treated. I cannot stress enough that the missing piece in a recovery programme is sustained suitable accommodation.

I agree with Mr. Mullins about the importance of having stability. For example, in the job I was working in before I came back to Saol, a woman came in to me for support around applying for housing. She had been going through issues with addiction, etc., and had given her children up for voluntary care. At the time, she was in a two-bedroom apartment. With the trauma of her children being taken into care, etc., she ended up slipping back into addiction. There was a raid on her home. She lost her home and she ended up in homeless accommodation. I refer to the criteria for her to even get her children back, even though she was doing well in her recovery. I will state I do not look at recovery as someone going through detox. Recovery is people making a change, making positive changes in their lives, whether they are on methadone for the rest of their lives or on Buvidal, Suboxone or any of the other treatments there are now. Recovery is making those positive changes. This woman was doing all that. She was still on treatment but that was her recovery. She was attending services and doing everything she could but what was stopping her from getting her children back was the fact that, because she was in a hostel, she no longer fitted the criteria for the three-bedroom house she needed to get her children back. That stable accommodation piece is really important. When we look at expecting people to jump through hoops, we need to start looking at the barriers the State is putting there through its policies.

I have a final question for Dr. Lambert on the points she raised about 80% to 90% of people with mental health issues who have addiction issues, maybe changing the way we view people in the throes of addiction and what we could do. Ms Anna Quigley, who was here last week, said that, in the past, there was a much better integrated co-operative system between the HSE, the different Departments, the different community groups and service providers. Do we need to get back to that kind of system, getting everyone around the table to develop policy and deliver what needs to happen? Ms Quigley and a lot of the groups we were talking to seem to think there is a major disconnect between the Departments and what is happening on the ground.

I referred earlier to the inter-agency case management. When people come into an addiction service, it is rarely the drugs that are the problem. It is things such as housing and mental health. Deputy Wynne talked about how we define trauma. One of the issues is that poverty is a trauma. Homelessness is a trauma. We have not spoken here today about the impact of discrimination on the Traveller community. All of those things are traumas but we do not necessarily think of them like that when we are talking about it. There is a problem with how we define trauma. If somebody comes in to you and they are experiencing challenges and difficulties as a result of their addiction, you cannot just look at that. You have to look at their access to mental health, housing, education and employment. I will go back to the fundamental point about structural inequality, however. I would much prefer that we tackle structural inequality so that we are not sitting around having inter-agency case management meetings. A lot of what we are talking about is a response to a chronic problem but if we did not have people in poverty or locked out of education, employment and housing, we would not need to address all of those problems and we would save a whole lot of money.

I thank the Chairman. Deputy Gould was the first person from his area to be elected. I was going to say I was the first person but Deputy Gino Kenny took that crown off me.

I was interested to hear Dr. Lambert's remarks on women experiencing menopause entering into addiction. It brought me back to when I was working in a methadone clinic and we had women - I do not know whether they were experiencing menopause - of a certain age who entered the treatment centre for codeine addiction and were placed on methadone. I do not think the menopause was taken into consideration. People came in with an addiction and were placed on methadone because that was the substitute for it. I wonder whether Dr. Healy, who has done a lot of studies, and maybe Dr. Lambert can comment on that. Have there been any studies or research done on this?

Not that I am aware of, around menopause. There has been a little bit of work on over-the-counter Nurofen. That has all stopped now. It was creating a lot of issues and people were put on methadone because of it. I am not party to exactly what was going on but it speaks to that uniform care that is going on. We do not ask questions: "Whatever's in the urine, here's methadone. End of story."

It is still not asked. As a woman of that age, if I presented in the morning because, for example, I was concerned about my drinking, we would go through a standardised test. Nobody would stop to think I am a middle-aged women and consider the possibility I am going through menopause. If we do not ask that and deal with menopause alongside the drinking, it will make things much more complicated. I would be interested to know how many addiction services, when they meet women of a particular age, ask them about menopause and whether they are linked in with their GP and have had their bloods done. I am not aware of any who do.

It is important that certain witnesses have outlined they see recovery differently from most. People making the decision that they want change is the start of the recovery. If there are no signs of somebody trying to make that choice, that is a big issue in County Clare. I cannot get shelter for them, even emergency accommodation. According to the council, there is a requirement that they be actively trying to enter recovery. Are the witnesses also seeing that without the decision to change, there is no access to even shelter?

The criterion is somebody has to be attempting some sort of recovery. If someone is in a clinic, even if they are not engaging in services, they are making that attempt, and that should be recognised. It is not always. We do not really see ourselves, though, that there is a requirement for people to prove they are trying to enter recovery for housing and things like that.

Women come in to us who are sleeping on the streets. Sometimes their level of engagement is not coming in and engaging in a group; they come in for a cup of tea and a bit of food. We have a shower we can provide and always have a few clothes for women who come in. Our service runs seven days per week. We have set programmes Monday to Friday. On Saturday and Sunday, we run a brunch and a lot of that is women in hostels and so on coming in for company during the day and a space for them because they often have nowhere else. Their level of engagement is coming in just for that social space to feel met with positivity instead of the stigma they face on the streets.

That is at play in the location I am referring to. There is somebody who owns a property so that is where they have to take refuge because they have nowhere else to go. Soliciting is an issue and it will only continue to get worse. I am trying to support a young lady who is trying to bring a mobile shower facility to Clare, just to provide access to basic sanitation and to feeling good.

A separate but related issue is we know how many young people will leave care or prison every year and need housing. Plans should be put in place. Sometimes it is a transitional housing model, sometimes it is a Housing First model and sometimes it is independent and supported accommodation. There are steps we can take to prepare. If 70% of people in prison have addiction, we know people will come out and need these supports in communities and that communities will need support. There is plenty that can be done and planned. Statistics from a county in the midlands show it built four units last year. Apparently it overshot its social housing targets by approximately 100% but, of that, there were four single units built. Are we building the right types of housing? If everything being built down the country is three-bed houses, that will not meet the needs of the people we are talking about.

I just have one question. This has been a really informative conversation thus far. Mr. Paul Reid said after the assembly's publication that this was an historic opportunity to address the wrongs of the past 50 years around drug policy. I do not want to misquote him but Mr. Mullins spoke about the limitations of decriminalisation. I agree there are limitations to decriminalisation, particularly the Government's interpretation of it. It does not go near far enough. Given the limitations in what the Government proposes, where would that lead us in terms of this historic opportunity? It is a broad question but I would like the witnesses' opinions on it.

The citizens' assembly was a monumental moment that gave us an opportunity to put centre stage an issue in society that has been pushed to the background. Only people working in the sector were passionate about it but we are now having a great conversation about it. That in itself is progress. There are pros and cons to every aspect of the decriminalisation argument. Codeine was mentioned and I recall not that long ago when Solpadeine was endemic across the State and it was primarily used by women. There was a major issue around Solpadeine. It was over the counter and legally readily available, yet there was still a problem, so legalisation will not necessarily address the issues we are confronted with daily. One of the recommendations was for greater investment, and that would have to be on a proportion we are nowhere near. We need significantly increased investment in supports for people and it has to be more targeted that it is. We spoke about how people who do not need universal payments are getting them. One citizens' assembly recommendation was about targeting supports at the areas of greatest need.

We are talking about multiples of what we are investing at the moment. That is an opportunity and we should not forget that.

In the citizens' assembly report, the recommendation related to this issue is recommendation 17. It is nuanced about what the legal instrument is around decriminalisation. It more or less states that it is up to others to make that decision, that is, the Oireachtas.

My view is that if we go down a route that maintains an overriding punitive model with regard to the criminal justice system, whereby it has the capacity to neutralise health interventions or the capacity of health interventions to help people deal with their housing, education, employment and social interaction, in other words, if the model of decriminalisation has a negative impact on that, it will not work. It will have a negative impact on that if it results in a resource investment that continues to extend and exacerbate some of the bad practices that are there already. That is a really possible outcome. There are some very good practices but there are some very poor practices.

There is a bigger picture here and it behoves parliamentarians to consider that bigger picture. That picture has to be about trying to change that narrative and trying to envisage turning this around by looking at a different model that involves a form of legalisation to start with, and then see how that works out. Give it time, look to other models and see what they are doing. I also advise that, in the long term, some of these models, particularly in Europe, will come knocking on the door in due course and saying, from a commercial point of view, that they have a right to provide cannabis products in Ireland, that we are blocking that through our laws, and that they will take Ireland to the competition court. They will probably do that. If we get to that point, we will be leaving it to the private market to determine the type of system. We will not be getting in quickly enough with our own public health considerations, and framing supply around the public health consideration.

One thing that is really important when we talk about drug use is that we often find it difficult not to think about our own personal opinions or views. The most important thing is that going back, we have a huge amount of information from our own jurisdiction and other jurisdictions. The big question for the State is why we have so much information and so little implementation. If we take cannabis as an example and look at it in respect of risk of harm to oneself and others, it is one of the least harmful substances. Codeine is more dangerous than ecstasy. The problem is that we have these moral judgments. There are things I feel uncomfortable with but that is irrelevant. When I feel uncomfortable that is based on my value system and how society has structured our views and opinions. It is actually very easy to do the right thing by just looking at what exists. We know that the criminalisation of people who use drugs has caused horrendous harm. It has not reduced the number of people who are using drugs. It has not reduced the amount of drugs that are coming into the country. In fact, it has made things much more dangerous. That is what the evidence shows.

Decriminalisation will be useful in some ways, and I want to say that those middle-class young people who get caught also deserve to not experience harm. With regard to people who want to use cannabis, that is a rights issue. What we need to do is look at the existing evidence, and the existing evidence is that criminalisation does not work. Decriminalisation reduces some of the harm but it will not go far enough. We probably need to look at the states that have introduced legalisation and where they have made mistakes. America is a very good example. It allowed the private market to control cannabis. That meant that people who live in communities where there is very little money cannot go into one of these places and buy cannabis that costs a lot of money. That left a black market. Sometimes the people who argue against these things will say we should look at America where legalisation made no difference to that illegal market. That is because we introduced a middle-class cause and took a middle-class approach to how we have designed our society without thinking about everybody who should be sitting around the table.

I know decriminalisation is about decriminalisation of drugs for personal use. We also need to look at the petty crimes that are committed to fund people's drug use. Instead of putting in funding for more prison spaces, we should start investing heavily in community-based organisations that work with people on their misuse to create alternatives to prison for people.

When we are talking about decriminalisation and changing contemporary drug policy in Ireland, there is a tendency to put decriminalisation and the Portuguese model up on a pedestal, as if it is almost a perfect model. If you really look at the statistics, it did not have any impact on the number of people using drugs but it had a huge impact on the harms of drugs, in that rates of hepatitis C, HIV and so on dropped. We also need to think about the fact that current drug policy has caused more harms than the actual substances themselves, in my opinion. I will say that again. Drug policy has caused more harms than drugs themselves. It is urgent we change this straight away. As Dr. Cullen and everybody else have said, there are a number of models around the world that we can learn from, not replicate but learn from and cherry-pick and come up with something that works for this country and makes things better for everybody.

I thank Dr. Healy. That concludes the meeting on a very good note.

I thank the members and especially the witnesses for their contributions. We had a very good conversation. Let us see what happens in the time ahead when the committee finalises its work. I thank the witnesses for their time. I also thank the staff here.