It started with a prescription. The benzodiazepine tablets Dermot was given to cope with a bereavement allowed him to escape into sleep, a sensation he got hooked on quickly. When a second prescription expired, Dermot spent the next 18 months using forgeries to wrangle more from pharmacies, escalating to near-lethal doses before finally he confided in his GP.

“He didn’t understand,” says Dermot – not his real name – who is in his early 30s and from the west of Ireland. “It was the old-fashioned west of Ireland attitude of ‘cop on, you’re fine.’ There was no talk of getting help.” Turning to an addiction counsellor only frustrated him further. “He just listened, so I didn’t feel like I was getting anything out of it.”

Dermot says the only option left was to enter residential rehab. But the one he chose said he’d need to detoxify from the medication two weeks before admission.

“I couldn’t understand,” he says, his voice strained. “If I could get off it for two weeks I wouldn’t need to go!”

Ireland has relatively few addiction-treatment programmes, and most require patients to be free of all substances when they arrive.

This policy stems from the 12-step model of recovery, the most prevalent basis for addiction treatment, and can extend to prescription medications such as anti-depressants and anti-psychotics.

“Asking a person to be drug- or alcohol-free before entering treatment is analogous to telling an asthmatic in an emergency department, ‘Stop wheezing and we’ll take you into hospital,’ ” says Dr Garrett McGovern, a GP specialising in addiction treatment with a focus on harm reduction.

“People I see are in the throes of addiction and need immediate help. It’s not pretty sometimes. You’ve got to have timely interventions that are able to meet people where they are at.”

McGovern believes that adequate addiction treatment is lacking in this country and that quality of care is not well regulated, adding that some intervention methods are ethically questionable, particularly when programmes adopt a punitive approach to patients.

“Whether you go private or public, there aren’t enough options for the amount of addiction in this country,” he says.

Ireland’s addiction-treatment facilities do not fall under the remit of the Health Information and Quality Authority, as nursing homes and children’s centres would, and the philosophy of care can vary.

The National Drugs Rehabilitation Implementation Committee is developing a co-ordinated rehabilitation strategy that will help identify what services are available, what gaps exist and what can be done with existing resources to bridge those gaps.



Clarity

With no formal standard of care, choosing the right recovery path requires clarity. Is lifelong abstinence the overarching goal? Are the family actively involved in therapy? Is there a secular alternative – such as LifeRing – to more traditional self-help groups? Is there a dual-diagnosis programme for people who may have underlying psychological conditions?

Once Dermot realised there was no one-size-fits-all approach, he researched the options until he found a private clinic that would design a programme around him. He could be brought off benzodiazepine gradually. He wouldn’t have to face group therapy if he didn’t want to. He could drive cross-country after work and be treated as an outpatient for five hours a week, his employers unaware that there had ever been a problem.

Telling his family felt “like the worst thing in the world, like I’d killed somebody”, but he needed their help to pay for the treatment.

The programme was intense and tough. Dermot relapsed after two weeks – and the lack of reproach prompted a breakthrough. The relaxation therapy he’d been sceptical of helped steer his mind back from overdrive, the treatment continued to be altered around him and the recovery followed. “I don’t know where I’d be otherwise,” he says.



Holistic approach

The integration of more holistic, person-centred approaches is still emerging in Ireland. At St John of God Hospital, a private facility in Stillorgan, Dr Colin O’Gara, its head of addiction services, is giving a tour of its refurbished facilities, stepping gingerly through bright, spacious rooms with mauve interiors. The starting point for a stay here is a five-day detox and 28-day residential programme, which costs €15,000 without health-insurance cover.

The addiction unit has a dining room with leather seats; the food is made on the premises. Patients can avail of complementary therapies such as yoga, aikido, Pilates, mindful body work and massage therapy, and can be granted weekend leave so that completing treatment doesn’t feel like “walking off the edge of a cliff”.

“For 50 years it was Minnesota [12-step] black-or-white: you were either in the group or out of it, based on strict criteria,” says O’Gara, adding that the model’s efficacy is unquestionable in many regards.

“Traditionally, the services in Ireland and abroad have been dogmatic in that way, but I think progressive addiction treatment now takes into account that relapse is part of someone’s treatment journey. I believe you have to provide different streams of care for people who are on different phases of their recovery.”

Not everyone is in a position to consider the nuances involved in rehabilitation. Access is limited in the public sphere, where just 38 detox beds are available, creating a blockage for those who need medically supervised detoxification before entering treatment.

“Money is a big determiner for many reasons,” says Tony Geoghegan, chief executive of Merchants Quay Ireland, which runs free, long-term rehabilitation programmes in Dublin and Carlow. “Most of the 10,000 people on methadone [in Ireland] would come from backgrounds of social and economic disadvantage.

“If people come from a more well-heeled background they’re starting from a higher base in terms of education and social capital, often with family support and access to employment that others don’t have – all the things that help people successfully exit drug treatment and build a new life for themselves.”

Tony Walsh knows how hard it can be to turn your life around after addiction. Breezing down the steps of Fr Peter McVerry’s open access centre on Upper Sherrard Street in Dublin, he has just returned from taking a group of teenagers to the Criminal Courts of Justice so they could see how many cases stem from alcohol and drug abuse.

He does this every week, because he wishes someone had shown him 21 years ago, when he became a heroin addict, at 14.

There was no drug education back then, he says, and almost everyone in Ballymun seemed to be using. At 15 he was homeless. By 17 he began a long cycle of drifting in and out of prison.

“When my girlfriend had a baby I thought that would be the turning point.” He shakes his head. “It wasn’t . . . I couldn’t see any way out.”

His numerous attempts to get clean only brought him in circles. “I ended up on waiting lists for so long that I fell back into drugs and crime. The wait for a bed was killing me. I was still in the same setting, getting involved with old mates again.”

Doctors at methadone clinics told him he’d never change, sapping his confidence, while the methadone itself felt like “liquid handcuffs”, binding him to dependency.

“If I had known what it does to a person I never would have gone near it. Methadone has its place in the short term, but I’ve seen people on it 20 years. Getting off heroin only takes three days.”

Walsh’s girlfriend struggled to cope with the pressures of his addiction, and when she died from an overdose of anti-depressants, 10 years ago, it sent him into a tailspin.

“I started drinking bottles of vodka in the morning, taking methadone and tablets on top.”

During his last prison sentence, Walsh remembers, his son visited him and asked, “Daddy, when are you coming home?” That propelled him towards one last stab at recovery. He asked to be put under 23-hour protection in order to come off methadone, reducing his intake by five millilitres every week, from 120ml to 30ml. “I didn’t get any sleep for three months except for half an hour here, 20 minutes there.” When he hit 30ml his body was racing with aches and sweats, the cell closing in around him.

Fr Peter McVerry, a pillar of support for Walsh since his teenage years, arranged for him to detox from his remaining methadone intake at Cuan Mhuire in Athy, in Co Kildare, before progressing to back-to-back treatment programmes at Coolmine Therapeutic Community, in Blanchardstown in Dublin, for 12 months. (Both organisations are voluntary bodies that are partially State-funded.)

“People think the hardest part of getting clean is residential [treatment],” Walsh says. “That’s actually the easiest part. You have a keyworker, a counsellor, one-to-one therapy, anger-management classes, relapse-prevention classes, doctors and nurses on site. The hard work is when you come out. You’re on your own then.”

Walsh found a sponsor and attended every Narcotics Anonymous meeting he could, moving to a new area and avoiding all the faces and places from his old life. Two years on he’s finishing a diploma at University College Dublin in drug and alcohol addiction and spends his spare time volunteering at McVerry’s drop-in service, often showing up before it’s open.



Path to recovery

For many the Peter McVerry Trust represents the first stop on that path to recovery. It runs a stabilisation service that helps people come off multiple drugs until they’re on a low level of methadone, so that, like Walsh, they can enter detox and graduate to a recovery plan.

Yet as much as Walsh is effusive about helping others, the lack of options frustrates him. The large numbers on long-term methadone treatment – 3,000 have been on it for over 10 years, according to Tony Geoghegan – raise the question of why people are not progressing further.

There’s a man sitting downstairs, Walsh explains, who has weaned himself off heroin, cocaine, benzodiazepine and 120ml of methadone only to spend 18 precarious months on a waiting list to enter detox.

“If you’ve private insurance or you can pay for it, you’ll get the best treatment and get in straight way.” He clicks his fingers. “If you’ve a medical card it’s a different ball game. You’re left on the waiting list. And I mean left . Doors are being closed in people’s faces.”



Broader scope

At the Rutland Centre, a private addiction-rehabilitation facility in Templeogue in Dublin, its clinical director, Dr Fiona Weldon, says that parking people on methadone overlooks the broader scope of addiction, as it’s never as simple as just having a problem with one substance.

That the centre often treats people who have sought help within the public sector for years, she adds, does not reflect well on the options available.

“Sometimes they’ve been through a lot of hoops before they get to us. That’s a worry for me. I think it’s the wrong way around. People are offered methadone as the first treatment for heroin, and we very often see people years down the line, when they’re trying to get off that.

“I feel that early on in someone’s addiction life they should be offered alternative treatments. The National Drug Strategy is clear on that.”

Last year an extensive report published in the US by Columbia University found a “profound disconnect between evidence and practice” in addiction care, fuelling debate about whether addiction is a chronic, relapsing neurological disorder requiring evidence-based treatment.

Among those interviewed for this article, both from the public sector and the private, the entanglement of views reflects a discordant approach. Some argue that there are no guarantees, that it doesn’t matter who provides the rehabilitation as long as it’s firm and kind. Some insist that many addicts can recover without any medical intervention. And others believe that pitting one treatment model against another, rather than seeing them on the same spectrum, helps nobody.

Back at St John of God, Dr Paul Hayes, a counselling psychologist, takes a seat in his office. Tomorrow he’ll be training staff at a treatment centre in Cork to integrate motivational interviewing, a behaviour-focused technique that some people respond to better than the 12-step model.

“In reality there’s an awful lot of grey areas in addiction. On one end there’s the traditional, moral-based approaches. On the other end there’s more choice in terms of positive psychology. In the middle is where it all happens. I think one of the issues for addiction treatment in this country moving forward is to get a levelling out of the philosophy and create a degree of clarity there. That’s the big challenge in Ireland.”