Twenty years of the methadone treatment protocol in Ireland: reflections on the role of general practice

Abstract

BackgroundOpioid dependence, characterised by socio economic disadvantage and significant morbidity and mortality, remains a major public health problem in Ireland. Through the methadone treatment protocol (MTP), Irish general practice has been a leader in the introduction and expansion of Irish harm reduction services, including opioid substitution treatment (OST), needle and syringe programs (NSP) and naloxone provision. These services have been effective in engaging opiate users in treatment, reducing human deficiency virus (HIV) and hepatitis C virus (HCV) transmission and reducing-drug related morbidities. Challenges remain in relation to choice of substitution treatments, timely access to OST services, adequate coverage of NSP, naloxone provision and increasing drug-related deaths.MethodsA narrative review was conducted and designed to present a broad perspective on the Irish MTP and to describe its history and development in terms of clinical care, stakeholder views and changing trends.ResultsThree themes emerged from the analysis; The History of the Methadone Treatment Protocol, Service User and Provider Views and Challenges and Developments. Despite the initial concern about methadone maintenance treatment (MMT) in Ireland, increased participation by Irish GPs in the treatment of opioid dependence is observed over the last two decades. There are now over 10,000 people on methadone treatment in Ireland, with 40% treated in general practice. The MTP provides structure, remuneration and guidance to GPs and is underpinned by training, ongoing education and a system of quality assurance provided by the Irish College of General Practice (ICGP). Challenges include the negative views of patients around how methadone services are delivered, the stigma associated with methadone treatment, the lack of choice around substitution medication, waiting lists for treatment in certain areas and rates of fatal overdose.ConclusionTwenty years of the MTP has been the mainstay of harm reduction services in Ireland. It has provided a network of specially trained GPs who provide methadone to over 10,000 patients across Ireland within a structured framework of training, quality assurance and remuneration. With the ongoing commitment of Irish specialists in the field of addiction medicine, further improvements to support and treat patients can be made.

Do interruptions to the continuity of methadone maintenance treatment in specialist addiction settings increase the risk of drug‐related poisoning deaths? A retrospective cohort study

“…We also excluded patients who were prescribed buprenorphine (n = 21), as they were considered to be a select group. Buprenorphine was not authorized for OST in Ireland until 2017, and a recent report indicates buprenorphine was prescribed predominantly for patients with codeine dependence or other opiate-based medications [7]. This resulted in 2899 patients (98%).…”

“…The strengths of this study include a large sample of patients in OST in specialist addiction services in Ireland with a long duration of follow-up. The external validity of the study is considered to be high, as our sample of approximately 3000 patients accounts for almost half of all patients in receipt of OST in addiction services in Ireland and registered on the CTL during the study period [7]. The use of administrative databases and dispensing records from the addiction services and primary care allowed us to record OST exposure and interruptions to treatment, including transfers between services and periods out of treatment.…”

“…The majority of patients receive treatment in the greater Dublin region (90%), with Dublin Southwest and Kildare representing one of the largest catchment areas in Ireland. OST is provided in specialist outpatient addiction clinics or primary care settings, with approximately 60% of people in treatment in addiction clinics [7]. Daily supervised methadone consumption occurs during the induction and stabilization phase.…”

“…The prison services contact the patient's previous care provider for clinical details including methadone dosing and when last dose was dispensed. Re-engagement with the OST service provider they attended prior to incarceration is also facilitated as part of the prison discharge policy [7]. Any changes in treatment provider are recorded on the CTL.…”

A national model of remote care for assessing and providing opioid agonist treatment during the COVID-19 pandemic: a report

“…There is a large national network of specialist GPs providing OAT in addiction centres and in primary care. However, treatment deficits remain, particularly in smaller towns outside the larger urban centres where waiting times for OAT can be longer than 6 months [13]. People who use drugs (PWUD) who have been unable to access OAT to date are unlikely to follow public health advice if they are suffering withdrawal symptoms.…”