Ireland has high levels of alcohol use and not surprisingly there are correspondingly high numbers of people who have problems with alcohol and who might need professional help.
Treatment services for alcohol exist on a continuum and range from brief interventions, to community addiction services, detox facilities and residential rehabilitation. The last of these – residential – comprises around 37% of treatment cases annually and is a well-established intervention for some people requiring assistance for problems with alcohol.
Health Research Board data indicates that there are up to 250,000 dependent drinkers in Ireland and international data suggests that at any one time 10% of such a cohort may be seeking treatment. However, in Ireland there are only about 3,500 new cases per annum entering treatment, so clearly there is a significant gap between treatment needs and provision and alcohol treatment simply does not get the resources required for a problem that causes so much harm not only to the drinker, but to families and communities.
In order to explore some of the issues around the residential treatment landscape in Ireland, AAI carried out a snapshot survey of alcohol treatment services in Ireland. Approximately half of all residential providers took part in the survey as well as a small number of community providers.
Based on the insights services shared, and the findings of a desktop research review, AAI is proposing a number of recommendations, including the development of a national strategy for alcohol treatment services and a HIQA inspection regime for residential treatment services – first mooted in a HSE expert group report in 2007.
This report is the start of a programme of work from AAI focusing on our strategic goal to advocate for services for those affected by alcohol harm. From this opening exploration of these matters we believe a public discussion on our proposed recommendations can advance a better understanding of how Ireland could enhance the provision of alcohol treatment services.
This report is all the more timely given what we have seen occurring during COVID-19 – that is, Ireland’s alcohol users substituting most of their drinking from regulated licenced premises to consumption in the home. We know that some people have used alcohol as a coping mechanism and the increase in home drinking was further fueled because people were cut off from their regular social outlets and activities.
Survey data from the Department of Health, published in January 2021, further demonstrates the trend that alcohol use became increasingly problematic during COVID.
The report surveyed all drug and alcohol treatment services, asking to what extent they had observed changes to their client’s behavior since the start of the COVID-19 pandemic. Increased alcohol consumption was the most prevalent change observed. As the report notes: ‘increased alcohol consumption was observed among clients to some extent by 92% of services.’
Additionally, rates of clients relapsing were high, with 48% services reporting this behaviour to a high extent.
Given this information, and what we know from other data sources such as Revenue figures and indeed CSO and Mental Health Ireland surveys, it is likely there will be a demand for alcohol treatment services, whether in the community, or for more serious problems, in residential treatment.
The National drug and alcohol strategy, Reducing Harm Supporting Recovery: 2017-2025, has adopted a health-led approach to addiction, as such, alcohol treatment services should be regarded as part of the health system.
To date, a comprehensive and complex set of policies, protocols, standards and workbooks, which emerged from a Working Group on Drugs Rehabilitation in 2007, and developed by the National Drug Rehabilitation Implement Committee in 2010, have largely sought to ensure that individual rehabilitation pathways and quality standards are provided by all rehabilitation services.
However, AAI believes, having reflected on the views of a number of both Tier 3 and 4 service providers, that there is an opportunity to revise a national strategy and standards for Safer Better Healthcare that could set out the specifics of interventions that constitute best practice for alcohol treatment and that clarifies national standards of service against which providers can be inspected – like all other residential treatment services whether in disabilities, older persons, etc.
AAI propose a HIQA type inspection regime, as recommended in the 2007 report of the HSE Working Group on Residential Treatment and Rehabilitation (Substance Users) that identified: Key Issues and Recommendations regarding Quality Assurance of Inpatient and Residential Services for Alcohol and Drug Users.
This would ensure that Ireland’s treatment services are re-calibrated and tailored to provide the best possible care to people in need of alcohol treatment services.
By shaping person-centred, trauma-informed services Ireland can ensure that people’s rights are at the centre of policies and practices. A trauma-informed approach recognises that trauma plays a role in mental and substance use disorders and should be systematically addressed in prevention, treatment, and recovery settings.
We now know that trauma is an almost universal experience of people with mental and substance use problems.
Addiction rarely exists where there is no underlying emotional pain and evidence now makes it clear that it is critical to address trauma as part of substance abuse treatment and that “misidentified or misdiagnosed trauma-related symptoms interfere with help seeking, hamper engagement in treatment, leads to early dropout, and make relapse more likely.”
Almost all of the services AAI interviewed spoke about the unmet mental health needs they see in people coming to their services, including anxiety, depression and other serious mental health problems. All of the services also recognised trauma in the client population, though there were differing views on how best to address this. A number of service providers noted the intergenerational patterns that are all too often a feature of people with substance use problems.
This issue of ‘dual diagnosis’ – where both alcohol misuse and a mental health problem occur together, is generally thought to mean people with a serious and chronic mental health problem. However, it is clear that there is a significant cohort of people attending services with complex needs and who are struggling with anxiety and/ or depression, linked to their life circumstances and alcohol use, and who may also need a mental health professional as part of their treatment.
Service providers advocated that a shared approach to client’s mental health was the best approach but said additional funding for staff and/or training was required. Addiction services must have the skills and resources to respond to the mental health needs of clients with responses tailored to the needs of each individual.
Again, a national strategy for residential services would help to inform how services should develop in this regard.
Children and families
The current national drug and alcohol strategy highlights the need for developing and adopting evidence-based family and parenting programmes for high-risk families impacted by problematic substance use. The strategy states that “awareness of the hidden harm of parental substance misuse with the aim of increasing responsiveness to affected children should be built,” and that “protocols between addiction services, maternity services and children’s health and social care services to facilitate a coordinated response to the needs of children affected by parental substance misuse, should be developed.”
The importance of that commitment in national policy cannot be understated, but it is unclear what actions have been taken to make it a reality. A Mid Term Review of the national drug and alcohol strategy, Reducing Harm Supporting Recovery is currently being finalised within the Department of Health. When published it will give some indication as to progress achieved on this objective.
Treatment services could and should play an important role in identifying parents in their services, and provide interventions, or pathways to reduce the harmful impact of addiction on children. This is essential if we are to break the cycle of intergenerational problem substance use that is so often a feature of addiction.
Unpublished data from NDTRS indicates that 50% of people in treatment have children. Where treatment providers do not have the resources to provide their own services to young people, government should adequately resource supports. Investment is required in primary care psychology services, school psychology infrastructure and trauma-informed training for all professionals working with young people. Services like these could provide a vital professional support when a parent is going through addiction- and indeed whether they are in treatment or not.
The Health Research Board’s latest report on alcohol consumption and harm, Alcohol consumption, alcohol-related harm and alcohol policy in Ireland, starkly outlines how continuing high levels of alcohol consumption in Ireland is affecting the nation’s health and well-being.
As noted at the outset, HRB data on alcohol use in Ireland suggests that there are as many as 250,000 dependent drinkers in Ireland. However, although the numbers of dependent drinkers are increasing, treatment services and options remain woefully short of expectations and requirements.
An analysis of HRB data from 2013 to 2019 shows that although there has been an 8% increase in the number of people accessing inpatient substance misuse treatment, all of it has been in relation to illicit drugs.
Furthermore, the data indicates that the number of cases treated for problem alcohol use actually decreased by 3.5% from 7,819 in 2013 to 7,546 in 2019.
We must interrogate why more people do not – or indeed cannot – access treatment for alcohol problems. It could be, as some survey respondents noted, that there is a stigma about getting help for alcohol or that there are other barriers such as finances, access to detox services or coming from a diverse population group such as LGBT+ , people where English is not their first language, older people and rural dwellers. Or indeed it could simply be that there are not enough services and getting help is difficult without private health insurance.
If we are serious about a health-led approach to alcohol treatment we must invest in services that are evidence-based and evaluated against updated and robust national standards and that are easily accessible.
Understanding the costs of alcohol-related treatment services is an important aspect of public health policy. For 2021, the HSE has allocated in the region of €159M to Social Inclusion much of which goes towards funding drug and alcohol treatment services across the country. However, this figure includes funding for access to health services for a range of vulnerable groups including people experiencing domestic violence, homeless people, Travellers and Roma, asylum seekers, and LGBTQI people.
An in-depth analysis on how this money is spent is required and how much exactly is spent for alcohol treatment and on what kind of services. Without robust and transparent data it is very difficult, if not impossible, to build a clear picture of what is required for modern, effective service provision.
In the words of the World Health Organisation, we must ensure that solutions are proportionate with the scale of the public health problems caused by harmful use of alcohol.