Safetynet Methadone Programme

Bringing Methadone to Homeless Heroin Users

A review of a new service

March 2011 Fiona OReilly & Carol Murphy

Report available from: Janet Robinson Primary Care Safetynet Coordinator Coolmine House 19 Lord Edward Street Dublin 2 mobile:086 7290900 email: janet@primarycaresafetynet.ie web: www.primarycaresafetynet.ie
Report design: Orna O Reilly Cover photos: Fran Veale for Dublin Simon Community

Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Study participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Reasons not in treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 New to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Previously on MMT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Programme outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Planned exits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Unplanned exits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Continued in treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Retention in treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Measuring change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Change in accommodation status . . . . . . . . . . . . . . . . . . . . . . . . .11 Change in drug use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Change in daily life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Participants views of the service . . . . . . . . . . . . . . . . . . . . . . . .18 Access to Methadone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 No one hanging around . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 They dont discriminate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Trusting and relaxed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Good relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Grand the way it is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Getting On and Off Methadone . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Background

In December 2007 in an attempt to improve access to methadone treatment for their patient group living in homelessness two Safetynet GPs in collaboration with Dublin Simon and the Salvation Army established a hostel based methadone programme for homeless people. The new service used the same model as the one operating for non homeless stable opiate users seeking. This model relies on GPs for methadone prescription and community pharmacies for methadone dispensing. Prior to the establishment of this programme, the Drug Treatment Centre Board (Trinity Court) was the only designated centre for the treatment of homeless individuals with opiate addiction. This is a large centrally based centre that offers methadone treatment to over 600 heroin addicted individuals annually. It also is the designated centre for the treatment of homeless people with an opiate addiction in the Dublin area. The service operates using a multi-disciplinary team including psychiatrists, nurses, counsellors, social workers and community welfare officers. Patients are dispensed methadone under supervision on site rather than at a community pharmacy. The Safetynet drug treatment service began in 2007 in two hostels providing emergency accommodation for homeless people; the Dublin Simon Harcourt Street hostel on the south side of the city and the Salvation Armys Cedar House hostel on the north side. In 2008 two Dublin City Council Hostels, Beech House and Maple House in the north city were included in the programme. The north city hostels are served by a GP who visits the hostels weekly. Each hostel provides a minimum of three months accommodation and full time key workers who help residents move out of homelessness. Cedar house has a full time nurse. The south city hostel is served by a GP and a full time nurse and key workers. Over time both GPs have moved towards using a common set of policies and protocols. Methadone prescription and dispensing from community pharmacies is governed according to the methadone protocol. Entry and exit to the programme is governed by the relevant local HSE addiction authorities. The programme aims to transfer patients to mainstream addiction services once they move out of emergency accommodation. This review aims to describes and evaluate the Safety net methadone programme in terms of its impact on patients drug use and homeless status and to describe the service users views of the programme.

Dublin Emergency Simon Shelter, Harcourt Street

The Safety net1 methadone programme is essentially the delivery of a drug treatment service to the homeless by using the Methadone Protocol (MP) based on legislation, policy2 and guidance3. A key defining feature is that the programme is delivered by GPs and nurses working in specialised primary care services based in Homeless accommodation centres. The programme aims to reduce the physical social and psychological harm associated with heroin use for both the user and his/ her fellow residents. Criteria for admission to the programme An established heroin addiction (according to ICGP guidelines) Over 18 years of age Have a long-term bed (3 months) in the Shelter with a key worker Behaviour consistent with that required by a dispensing community pharmacist e.g. no alcohol problems and absence of aggressive behaviour. The programme aims to reduce the physical, social and psychological harm associated with heroin use for both the user and his/her fellow residents.

Methodology
The target populations for the quantitative analysis were all programme participants enrolled from the programme start date to the end of March 2009. This amounted to 41 patients in total. A sub sample of 17 individuals was selected for indept interview. This sub sample was drawn to represent the full sample in terms of gender and whether they were planned or unplanned exits or continued in the programme at the end on March 2009. Service users were asked about their experience of the programme and its impact on their drug use and daily lives (interview guide see Annex 1). All 17 interviews were conducted in July and August 2009 by the research assistant who had been the nurse on the programme. Interviews were recorded and transcribed and analyzed using NVivo 2.0 for qualitative data. Monitoring indicators on patients progress in terms or drug use, accommodation, family contact and programme exit had been collected on enrolment to the programme. In October 2009 a monitoring matrix designed by the principal investigator (Annex 2) was completed. Data was accessed from patient records, through phone calls with patients themselves and from the Simon Rough Sleeper Team. Resulting data was analyzed using descriptive statistics.

Results
Forty one patients were admitted to the programme between December 2007 and the end of March 2009; Twenty seven (66%) to the Dublin Simon list and 14 (24%) to the Cedar/Maple/ Beech list.

2 3

Safety net is a HSE supported primary care network established in 2007 to establish or enhance medical and nursing services provided to homeless people. It aims to identify gaps in services and facilitated the development of new services as required. Report of the methadone treatment services review group 1998 Dept of Health and Children Working with opiate users in community based primary care. ICGP 2003 Dublin

Study participants
In August and September 2009 an attempt was made to make contact with all programme participants to establish drug use, current treatment status, accommodation status, and family contact so as to compare these indicators with those collected on initial assessment.

Number of clients enrolled by date

9 8 7 6 5 4 3 2 1 0
Dec - 07 Jan - 08 Feb - 08 Mar - 08 Apr - 08 May - 08 Jun - 08 Jul - 08 Aug - 08 Sep - 08 Oct - 08 Nov - 08 Dec - 08 Jan - 09 Feb - 09 Mar - 09

The point in time at which clients are enrolled is more a function of the system which controls access to places on the programme than of demand. A set number of 10 places were made available to both treatment sites in December 2007. At the beginning of 2009 this cap was removed in the South City and was increased to 15 in the North City. Patients are now enrolled once sanctioned at meetings with the heads of addiction services at the HSE Dublin North and Dublin South Central Local Health Offices. Consultant Psychiatrist and GP coordinators for the relevant areas attend these meetings and patients ready for transfer are identified to the mainstream services. Places are later found and patients transferred opening spaces of new patients to be enrolled. The majority of the 41 clients were male 34 (83%) with only 7 (17%) female. The male bias is reflective of the higher proportions of homeless men and opiate addicted men nationally. Age Range 16 -19 20 24 25 29 30 34 35 39 40 44 45+ CTL * % 1 7 22 31 20 10 9 Safetynet % 0 24 27 22 15 7 5

Central Treatment List Summary Report for period 01 January to 31st December 2008Compiled CTL 19 February 09

The age structure is slightly younger with 24% under 25 yrs compared to 8% in nationally.

Area of origin

25 20 15 10 5 0 Dublin Ireland outside Dublin Outside Ireland

Over half 54% were originally from Dublin with over a third (34%) coming from Ireland outside Dublin. Twelve percent came from outside of Ireland (UK, Slovakia & Switzerland.

Length of time using heroin (n=38)

16 14 12 10 8 6 4 2 0 2 years or less 3 6 years 7 10 years 11 + years

The majority of patients (89%) had been using heroin for over 3 years with 50% using it for over 7 years. Most had been on MMT before, many detoxing and relapsing. For 10 it was their first time accessing MMT. The average length of time on heroin for these 10 was 5 years. 6 of these 11 had not tried to access treatment, 4 had but could not due to waiting times and one was a recent relapse after a detox in prison.

length of time in programme

number of clients number of clients

16 14 12 10 8 6 4 2 0 < 3 months 3 6 months 7 10 months 11 + months

Ideally the patient stays on the methadone programme only as long as s/he resides in the emergency accommodation. The fact that over half were still on the programme over seven months after enrolling means that they had moved on to more permanent accommodation without moving on to mainstream addiction services.

Reasons not in treatment

Patients were not in treatment at the time of their encounter with the Safetynet service for a variety of reasons. These are categorized into three groups above. Seventeen (41%) reported that the waiting list for treatment was too long. Thirteen (32%) had not yet tried to access treatment at all. Eleven (27%) would not go to the designated service for treatment. Thirteen had not yet tried to get onto a methadone programme on enrolment to the Safetynet programme. Some had not tried as they had heard about long waiting lists. Eight of the 13 in the had not tried category had never been on a methadone programme before. Some had preconceptions about the clinics which kept them from seeking treatment:

Why not in treatment already

45% 40% 35% 30% 25% 20% 15% 10% 5% 0% could not access Had not tried would not go

Ah, I wouldnt go onto a clinicI just, Ive been over there, but Ive been over to (treatment centre) and you know what I mean, its just horrible like. I want to get away from all that ah, people sort of hanging around and, you know what I mean?
Participant 28

John had been using heroin for seven years and had bought methadone on the black market rather than enrolling on a programme:

To be honest with you, I never ah, I always thought it was a clinic, I never could, I never thought you could get on with a Doctor and go to a chemist, I thought it was a clinic and I knew by hanging around clinics and that like, it was just theyre buying and selling things inside so.
Participant 31

Patients new to treatment had not tried to access other methadone programmes yet.

Ah, the first day I came in here I was talking to a nurse and she, she put me through, saying I could get on the phy if Im really wanting to go for it so, took me chance and was on within three or four weeks.
Participant X

Four had relapsed from a detox programme and one patient had alcohol problems and was unmotivated regarding methadone.

It just, when you come outside the place people are offering you tablets and offering you gear after taking your methadone but it just, just wasnt into it you know.
Participant X

Eleven (27%) are grouped as would not go. This means they said that they were not on treatment because they chose not to go to the designated treatment centre. Four of these 11 had been on MMT and had left because they had problems with other clients attending the same clinic.

I dont know anywhere else. Cant go to (treatment centre) cos theres loads out to kill me over there and (names another treatment centre), all down that part, near _________ and all, all on the quays and all. Theres loads to kill me over there.
Participant 4

Four found that there was no point in continuing treatment as it was not helping in any way e.g. they had been put on low dose methadone.

Well, I was on (treatment centre) before and cos they had me on harm reduction I was on 80ml but they only me on 20mls a day so I stopped going down to it altogether.
Participant 22

Two had moved into homelessness and were far from their original clinic area. One left treatment as he wished to continue using.

New to treatment
In all there were 11 (27%) people admitted to the Safetynet programme who had never been on methadone before. Seven of these originated from outside of Dublin reflecting the lack of treatment services outside the capital. Four were from Dublin three of whom where using heroin for a relatively short period of time (2yrs). Access to the Dublin Simon shelter was through the Simon Rough Sleeper Team. Access to the Cedar house site was through direct contact with the doctor at the health clinic or through the three participating hostels. Some heard of the programme through word of mouth.

Previously on MMT
Twenty nine (73%) participants were identified as having been previously on a methadone programme. There are a number of ways they disengaged from these programmes. Of the 17 with whom in-depth interviews were conducted 11 (65%) were previously on methadone. Some (5) left because they felt they could not risk meeting individuals who were also on the same programme as mentioned above. Others (4) found the treatment was not working so left. Others (2) left when they became homeless and moved into the city. Four relapsed having either moved from methadone to detox, or having left prison with nowhere to go;

I was after coming off it in prison. I came off the methadone in prison which was a bad mistake. Well it was the day before that cos I stayed in her [girlfriends] B&B that night and they thrown the two of us out because she wasnt allowed bring anybody in and she did cos I ODd that night, you know.
Participant 4

Programme outcomes
One indicator of programmes success is the planned exit. This means that a patient is transferred when a suitable place is available in mainstream services or if the patient successfully detoxes through the programme. Patient turnover allows the system to work as those progressing to mainstream services free capacity to provide methadone to homeless people requiring it. This allows the Safetynet programme to act as a complementary service improving access to mainstream services and not one that runs in parallel. Patients leaving the programme in an unplanned way are seen as a negative indicator. Unplanned exits include programme defaulters4, self discharges or an unexpected prison sentence or hospital admission. Outcomes were determined six months after the cut of date for inclusion in this review (30th September 2009).

Programme outcomes

30

detoxed
25 20 15 10 5 0 planned unplanned continue

barred hosp/prison continues defaulted transfer

Planned exits
Twenty five (62%) patients admitted between December 2007 and 31st March 2009 resulted in planned exits. Twenty four were transferred to mainstream services and one to a detoxification programme. Of the 24 transferred to mainstream services 11 (46%) went to HSE clinics, 6 (25%) to the Safetynet GPs practice, 5 (21%) to non Safetynet GPs practices in the community and two (8%) detoxed.

Type of treatment facility of those (n=24) transferred from programme

12 10 number of clients 8 6 4 2 0 Clinic Safetynet GP detox

Planned Exit (Participant 7) Joe is 33 years old. He had previously completed a detox in (residential centre) and was clean for two years. He relapsed after release from prison with no where to go and ended up in the Simon shelter on Harcourt street. He came back for the interview to the hostel. He commented that hed hate to be back here. He arrived on time and was well dressed. He was now living in his own place. He gave consent to have his urinalysis checked with his prescribing doctor at the HSE satellite clinic he was attending, to confirm his self report that he was had not used illicit opiates in the past five months. He said he wasnt using any other drugs either. Prior to starting the programme, Joe had been smoking 3-4 bags of heroin daily and had never injected. When asked to suggest improvements for the Safetynet programme he recommended more options to come down he says;
4

no show at pharmacy for 28 consecutive days

Its grand [the programme], it would be better to have more options to help coming down. Be clearer about how to come downall in all its grand
He also thought that access to a counsellor might help. When asked about his future plans he echoed many of the participants who expressed a desire to be off methadone, he says;

To come off itIm half way there. I was on 200mls, now 90mls. Im coming down every week and soon ill be off it

Unplanned exits
Thirteen (32%) were unplanned exits. Of these, 8 had defaulted from the programme, 2 were barred and 3 had been unexpectedly hospitalised or imprisoned. The research assistant interviewed 3 defaulters. Dave (below) was living with his girl friend in emergency accommodation;

Unplanned exit (Participant 4)

Dave is 29 and started using heroin in his late teens. He has spent more time in prison than out of it since then. He was interviewed in the emergency shelter where he was staying. He was visibly in pain and very unwell and emaciated. His hygiene was poor. Im in the same clothes since I seen you last, he told the research assistant. This had been two months ago. His legs were swollen and he was in pain. He was injecting several times a day into his groin and neck. He wasnt eating and he felt very down. His mobility was poor. He said he really needed to get back on a methadone programme. Jim was released from prison clean having done a detox. On release he had no where to go. He relapsed and ODd. His girlfriend allowed him stay in her homeless accommodation (B&B) for the night. As a result she lost her accommodation as this was against the rules. They both ended up on the streets. They were picked up by the Simon Rough Sleeper team and were given accommodation in the emergency hostel. Here he started on the methadone programme and was stable within a few months. However Dave started dealing and using again and had to leave the hostel. Dave and his girlfriends stopped going to collect their methadone. This appeared to be a pattern for Dave as previous to being on the Safetynet programme he had been stable on 85mls in (clinic), but defaulted as he was dealing and reckoned he had enough heroin to keep the sickness away. Therefore he felt he didnt need methadone. His days now are consumed by begging and robbing to score to have a turn on (inject heroin), then sleep, wake and start all over again. He also sometimes injects cocaine and has been on benzodiazepines since childhood. Now he complains that he could not go to any of the clinics because people were out to kill him, he owed money to many. He is too embarrassed to mention the infection at his injection site to his family GP whom he saw the day before. He gets needle exchanges from merchants Quay. He desperately wants to get back on methadone;

My plan is to go on a methadone course and get me life back on track yeah? Not be on drugs, try and find me own place with (girlfriend) and see what happens after that. Just to get clean and get away from strife, Yeah?

Continued in treatment
Theoretically as the follow up assessment was conducted 6 months after the cut-off for enrolment into the study, all patients should have been moved on. Five (12%) who had enrolled between December 2007 and 31st March 2009 continued in the programme.

Continuing in the Safetynet programme (Participant 30)

Kieran was interviewed in the Beech House hostel. Though admitted 11 months previously he was still on the Safetynet programme. Kieran looked well and was wearing clean clothes. He explained that he had a key worker that he meets regularly. He uses a calendar for appointments, e.g. dentist, probation, doctor etc and keeps all appointments. He says he has nothing better to do. He was also recording daily drug use in a diary, this was mostly benzodiazepine use. His mood was low and in the end, the interview was aborted as he became upset when talking about family. He had a recent family loss. He said he would like to go for bereavement counselling. Kieran had one slip recently and had injected heroin. He was not eating or sleeping since his family loss. He visits his mother every day and the grave of his relative. He had been stable up to this. He was sober and clear during the interview and insisted on showing his arms; there were no injecting marks visible. Kieran got strung out in prison when he came out he looked for a programme and heard about the GP at Cedar house. He had previously been in treatment at a clinic but felt he could not go their as he had been arguing with a lot of people there Since starting the programme he feels his live has changed. He no longer has to beg and steal. He sees his family regularly and has no involvement in crime. When asked if there was anything he would change about the programme he says;

Am, no not really, I have a great relationship with the Doctor and with the pharmacist and what have you.
A counsellor, he agrees, would be useful if you wanted to talk but he feels he has enough support from the doctor.

Retention in treatment
Twenty nine (71%) were in treatment (either in Safetynet or another methadone programme) at follow up. A further 3 (7%) had detoxed. The remaining 9 (22%) were not in treatment (8) or lost to follow up (1).

Measuring change
This section looks at the change in accommodation status, drug use and the every day lives of participants. The first two indicators of change are measured using data collected on admission to the programme and at follow up (September 2009), which was at least 6 months later for everyone. Change in everyday life is described using interview data and reflects the participants perception of change.

10

Change in accommodation status

All of the patients were homeless at the time of assessment with all except for one using emergency accommodation or sleeping rough.

In treatment at follow up

35 30 number of clients 25 20 15 10 5 0 Yes No Detoxed Unknown

At follow up 30 (73%) of clients were living in private rented, with friends or family or in transitional accommodation. Nine (22%) were still in emergency shelter or sleeping rough and we could not find out about the accommodation of two (5%).

Accommodation status at entry to programme

25 number of clients 20 15 10 5 0 friends or family emergency hostels sleeping rough

We devised a change scale to identify direction and degree of change in accommodation status as follows: Sleeping Rough 5 Emergency 4 Transitional/long 3 Friends/fam 2 Private rented 1

A move from rough sleeping to private rented accommodation is a 4 point improvement, to friends or family a 3 point improvement etc.

11

Accommodation status at follow up

16 14 12 10 8 6 4 2 0
Private rented Friends or family transitional or emergency long term hostel rough sleeping unknown

Change in accommodation status

number of clients

14 12 10 8 6 4 2 0 no change 1 point change 2 point change 3 point change 4 point change

100% 80% 60% 40% 20% 0%

number of clients

Outcome by accommodation change

unknown 2 or more point change 0-1point change

planned exit
unplanned exit continues

On follow up those who were planned exits (61%) were more likely to have progressed further towards stable accommodation according to the point scale, than unplanned exits.

Outcome by accommodation change (number of clients)

25 20 15 10 5 0 planned exit unplanned exit continues

0-1point change 2 or more point change unknown

88% of planned exits had moved up 2 points on the scale compared to 45% of unplanned exits and 20% on those continuing on the programme. Planned exits from the Safetynet programme is associated with improvement in accommodation status.

12

Change in drug use

Thirty two (78%) were injecting users on enrolment to the programme with 12 (29%) using over 8 times per day or injecting into the groin area.

Level of heroin use on enrollment

18 16 14 12 10 8 6 4 2 0
smoking: low use smoking: midium to high use injecting: low use injecting: medium to high use injecting: very high use or groin injecting

number of clients

Smoking: low use Smoking medium to high use Injecting low use Injecting medium to high use Injecting very high use or groin injecting

smoking only < 2 yrs or < 2 bags daily smoking only > 2 yrs or > 2 bags = medium Injecting <2 yrs or < 2 bags daily or iv 1-2 times weekly Injecting >2 yrs or 2 -7bags daily Injecting >8bags or groin injecting

Self reported drug use at time of assessment and at time of follow up were compared. Twenty eight (68%) stopped or reduced using heroin, 6 (15%) continued using similar amounts and data were not available for 7(17%).

Change in heroin use by programme exit (number)

18 16 14 12 10 8 6 4 2 0 stopped reduced same unknown

continues unplanned planned

As might be expected the majority of those who stopped using drugs were planned exits (82%).

number of clients

13

change in heroin use by programme exit(%)

60% 50% 40%

stopped reduced same

30%

unknown
20% 10% 0% planned unplanned continues

Planned exits from the Safetynet programme are associated with stopping heroin use.

Change in daily life

Within a relatively short space of time patients on the Safteynet programme experienced a dramatic change in their daily lives as a result of commencing on methadone maintenance;

Its changed, it has really changed because before I got on methadone I was using 300 on the gear a day and since I got on the methadone all is Im using is 45 worth a week, which is very good. Im a lot healthier, I look fitter ah, Ive got a new house, Im back with me son every day and everything so, getting a lot better. Not having to chase gear
Much of the change experienced came from the removal of the need to chase the illegal substance (heroin) on a daily basis.

I dont have to worry about the heroin or anything like that, thats the main thing about it. Every way like (life changed), Ive structure, I dont need to go out and rob, I dont need to, its there like you know what Im saying, you dont need to go sick you know.
This provided a space within which participants could organise themselves and their lives and thus provided a new start to lead a proper or normal life;

A 100% [life has changed]. Im not on the streets anymore, Im living with a lovely girl, Ive a two bedroom apartment up the road am, Im able to go out clubbing again. I can do whatever. Its totally gone, total turnaround. Ah, me lifes been brilliant, being able to lead a normal life, you know am, get back into going out with the kids and all that sort of stuff, you know. Go for an odd pint now and then, you know.

14

Remembering the nightmare

The experience recounted by programme participants on their recent pasts chasing gear were very similar to the current daily life descriptions provided by the programme defaulters. Now on methadone programme participants looked back with a degree of horror at the constant cycle of sickness, begging, stealing and using;

Oh God. Well I was in and out of a different hostel am, on the street most of the day, hanging round with people that you wouldnt want to hang around with am. If I was on the heroin, Id have to be in here tapping to get heroin every day and I wouldnt be able to have a proper life so the phy is very good for that. Im not waking up in the morning and thinking where am I gonna get the gear from or where am I gonna get the money from. I still have money left out of me labour on a Sunday and thats, many people dont have that you know. I dont have to tap (beg), well I dont need money for heroin, not worried about money for heroin. Im now in a flat.
Descriptions of a normal day before they started on methadone shows how days were consumed

A normal day, well first, wed get up first thing in the morning and be sick, so wed have a bag and then after wed have the bag, wed go out and wed sit down and beg for most of the day, about lunchtime, wed get up, have a cup of tea, something to eat and sit back down and beg then until about six oclock that night and at six oclock that night wed go and buy a half eighth and thatd do us then until six oclock the next day and wed tap all the next day as well so we just basically tapped every day and then waited on the ? at night time. Am, wake up, sleeping out on the street, am, make sure I have a bag for when I get up, have a turn on, then wander around town, probably have to go tapping to get more money for it am, trying to get something to eat either in Failte or somewhere am, basically just drinking and doing heroin, and sitting around the streets tapping money all day. Nightmare. Ah, just sick most of the time really, you know what I mean, just trying to get money up to feed me habit like you know what I mean. Its just like you go out, you do your own thing, get your, get your gear like you know what I mean, you go off on your own like, so its very lonely, horrible, depressing drug like, you know what I mean, so. Remembering stability
The programme defaulters remembered a degree of stability being on the methadone programme while their descriptions of their current typical day reflected the current clients recent past.

A normal day with me at the moment is waking up in the morning, have my turn on, going back asleep, waking up again, if theres gear there I might have a turn on. If theres not Ill have to go out robbing to try and get money for a turn on and then mostly back here for to get the gear into me, back out robbing again.

15

Holding on to stability
Some of those who hadnt stopped using illicit drugs completely were happy with the effect the replacement drug was having, while others appeared to be having concerns about having the odd slip though they felt the dose of methadone was adequate;

I started onto the methadone, I just stopped, you know what I mean. Just having the odd Q here and there you know what I mean, but I just stopped fairly quick. Weve been talking to (Doctor) about that like, weve been explaining to him that like weve had the odd slip you know what I mean but am, like I never shared needles or anything like that, you know what I mean, the odd time Id usually just smoke, dya know what I mean. I think its great but am, 100mls a day, I think I need to be cut down on it. I think I need to come down off it, you know. Like, it is holding me, dont get me wrong its holding me, I know its holding me, I shouldnt be using heroin in between but am, like, I have an odd slip the odd time, Im not gonna lie to you am, its just lately like, since Ive found out Im pregnant I havent been using the heroin like as much as I used to if you get what Im saying. I dont use much now you understand me, one in a blue moon. I dont even want to go at it sometimes you know. Id have a bag maybe once a month, kicking myself after it.
Benefits of being commenced on methadone touched many aspects of life including contact with family, effect on health and finance and ability to access more stable accommodation (as shown above). Again the benefits arise from not having the negatives associated with illicit drug use;

I feel a lot more confident in myself, not on the street. Well, Im more trustworthy, Im back with me family, no charges, like rakes, thats what Im saying to you like you know, rakes of different stuff. Family contact
For some on the programme contact with family improved as a result of not needing to consume illegal opiates anymore

since I got on the methadone I got out to my family every week. I stay with them for three days a week and my little niece, shes only two months old and I baby-sit her and all, so unless I was on the methadone my family wouldnt let me near them and I wouldnt get to see my little niece. When I got on methadone it wasnt just me like, to me mother and that, it was the whole outer family I wasnt speaking to and then I got on the methadone, thats when I got in contact with all of them again.
For others there was a stigma attached to being on methadone and others continued to be estranged from their families.

They dont know Im on it. Me sister has a different thing towards methadone. She thinks youre on methadone and you bloat out and all this, you know, and if she ever found out that I was on methadone shed probably look at me wrong and shed probably think, dirty junkie and all this, you know.

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Life saving
The extreme hardship and risk associated with heroin addiction is evident from the participants experiences. By the time they come in contact with the Safetynet programme by definition they are high risk and extremely vulnerable. Providing methadone in this context therefore made an immediate and dramatic impact and potentially has a life saving effect;

(If you hadnt gone on methadone, where do you think youd be now?) Ah, dunno, probably dead like cos I, first time I ever had a turn on like I ah, ODd up in the park like, do you know what I mean, and ah, lucky enough I was with a couple of people like and they got me around like. If I would have been on me own that day I believe I would have been dead like so. You get sick of being sick, you get worn out, depressed, you know. You know, there are times when youd actually want to kill yourself, you know, with the sickness, you just get old and you know monotonous and ground down, you know A place to start
While participants described the change; from a life defined by drugs, as a very welcome transformation there was sometimes a hint that the removal of what had consumed every waking hour resulted in a gap that had to be filled.

Im not doing anything during the day now, you know what I mean, its wrecking me head. So the quicker I get into somewhere to do that detox, itd be better like.
Besides the fact that most had moved to more stable accommodation they were still technically homeless. The stability provided by the methadone and the accommodation as well as the support from the key workers created the potential to get out of homelessness;

Im not depressed anymore. I used to, I used to be depressed and all living out on the streets and that but since I got here, its like I actually have a home again or a place to start where I can go out and get a flat.
It was evident that methadone through Safetynet had provided the first step on what could be a long road to what they considered a normal life.

I couldnt organise anything, you know what I mean, I couldnt go out like, you know what I mean, youre gonna be dying sick, you need to be, do you know what I mean like, its not a thing you can hide like, just being on gear. Methadone like, it holds you and then you can be different

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Participants views of the service

Interviewees were very happy with the Safetynet service;

Its great yeah, its grand. I think its working well. Its been great, absolutely brilliant, its been, yeah, you know.

Access to Methadone
The service was appreciated first and foremost because it provided access to methadone which allowed participants to achieve some stability in their lives.

You know when you wake in the morning, you know you dont have to go out and lower yourself or you dont go robbing, you know youre gonna get the medicine, its legal and people, you dont even realise it, well normal people wouldnt realise it but for a junkie say that would realise it people dont look at you the same way then, when they know youre trying to help yourself its over, you get that bit of respect back.
Participant 24

No one hanging around

Some appreciated the fact that they did not have to associate with other drug users hanging around the treatment centre for homeless people.

Cos when I was going into (treatment centre) there was people standing outside the place saying, do you want to buy gear, do you want to buy tablets, do you want to buy phy. Its not in my face anymore. Its only when I go home to the (hostel). Its hard to explain. Like if theres no-one in like hanging around outside asking you if you want this or do you want that like, you know what I mean, you can just go out of the chemist and you can walk, either take a right or take a left and walk straight or whatever, theres no-one when you walk out like, you cant turn left or right or straight without someone asking you do you want this or do you want that. Well you can go down to them clinics and you know, you can see people dealing outside, selling tablets and this and all the rest of it, you know, and back in with the old faces and that, you know.

They dont discriminate

They also appreciated being treated like normal people and not addicts. The pharmacy was particularly praised in this regard. The staff were friendly and treated them like anyone else;

The chemist is great, I love the chemist, like they dont am, they dont let other people see what youre getting and they dont discriminate, they bring you into a little room and give it to you, you take it in the little room, even if youre five minutes late, they understand, they dont give out and I think its a great chemist. Cos Ive seen chemists where people were getting their phy and there was actually people wearing gloves giving the cup over and the chemist I go round to they dont do that stuff, they just hand it to you there and do you want water and all, they just treat you as if you were anyone else. The staff are very friendly, they dont make you feel uncomfortable or anything like that

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Views often suggested that service users had low self worth and expectations.

It feels like a luxury really. Going in, sitting down, you dont have to be... I know they have to keep an eye on you like, some people might think youre an addict youre gonna rob from the shop, I can understand that like, theyre looking at you, keep an eye on you. But its a lot better just to sit there, have a normal conversation with the girl thats on the counter, drink your methadone in front of them then go.

Trusting and relaxed

Participants appreciated the relationships with the staff which they found more trusting than they had found in the treatment centre. Some described it as more relaxed than other clinics they had experienced. One man provides an example.

Its, (treatment centre) like Fort Knox you have to go through security, you have to go through a metal detector. After you walk through the metal detector you have to get patted down. When you get patted down they have little sticks and they rub it up and down your legs and all that to see have you got anything steel on you. It was more, you feel like you have, that they trust you more here (Safetynet). Go down to the chemist every day and the people who work in the chemist are very kind.
Some had experiences in the past where their methadone was reduced as a sanction for continued heroin use, in this programme however methadone was increased until cravings were controlled. This was seen as a benefit;

And Id be going in getting me foy it wasnt holding me and I was on a low dose as well, for using, then giving dirty urines. So I had to buy heroin. Now Im on 120mls and when I come up here theres no one outside the door saying do you want to buy this do you want to buy this. Its not in my face anymore. Its only when I go home to the (Shelter). Its hard to explain.

Good relationships
Some enjoyed the relationship they had with the doctor and having a say in the dose of methadone prescribed;

Hes always in a happy humour he is, I just look up to the guy. Just doing me favour dont go on the gear, and I said it to him I said I wont, Ill walk through water, Ill keep me promise to him. I have a great relationship with the Doctor and with the pharmacist and what have you. Very good Doctor, very even, you know what Im saying like; he was fair do you know what Im saying to you. As long as you didnt lie with him, do you understand and he didnt find out, you were sound you know.
The pharmacies involved in the safety net programme have a good relationship with the medical nursing staff and clients. There is constant phone contact and a flexible approach is appreciated by the patients;

Theyre great, yeah. Theyre great. If I have trouble around here, like if (names the doctor) isnt here or anything like that, Id go round to (pharmacist) and say it to her and shed ring up (names the doctor) or one of (names the doctor)s contacts and say (name) is here and he needs his dosage and shell get it for me because if I, if you dont have a dosage, you can go maybe one day, one day without it but if you dont go for two or three days it can kill you..

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A good relationship with the hostel staff that, it was felt under stood the nature of what clients were going through was also seen as a plus.

I think its great because theres not many places you can go where the staff understand what youre going through and that like most places you go into its, theres no sin bins so theres not and even though youre not allowed to use in the place, most people do and the places that you see with no sin bins in, theres more people likely to overdose than people with sin bins in the house, you know.

Grand the way it is

Few had recommendations for improving the service, stating that the programme was grand the way it is. One participant wanted the doctor to be stricter about doing urinalysis as an encouragement to get clean. A few participants recommended more options in treatment like Subutex, detoxes and harm reduction.

You know there should be more like say harm reduction, cos 40mls would save a lot of people. At least youd know they were getting it. I think its like, you know, I think its wrong to be stuck on maintenance when a detox would do you.
When prompted about whether a counselling service would be a benefit there was a mixed response with some saying that it would be good to talk to someone, others said they would not use it;

Theyre only gonna bring up the past and whats the past gonna do for you.

Getting On and Off Methadone

Those who were on methadone expressed the desire to come off methadone.

Eventually, Im gonna detox down off it and come off it altogether. Get a job; eventually get into our own house. This is only transitional and am, me son will be coming back to live with me soon.
Participant 39

Well hopefully Ill get a detox somewhere, put myself in somewhere.

Participant 17

Ah, to get into the, I hope to get into the stabilisation programme there, you know what I mean, come down off me phy like.
Those who were living the nightmare of begging, scoring and using wanted to get back on methadone

Get back on maintenance

Participant 3

My plan is to go on a methadone course and get me life back on track yeah.

Participant 4

My plans is as quick as possible is to get a flat down in (names county outside Dublin) and get a Doctor down there that I can get me phy off, methadone and from then on hopefully I get work ?
Participant 11

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Conclusions
The Safety net methadone programme delivered by GPs, nurses and Pharmacists has provided access to methadone for a very vulnerable group who otherwise would not have accessed a programme at least in the short term. The impact of methadone provision is dramatic as seen both in the reduction in heroin use (68% reduced or ceased use), the improved more stable accommodation and in the improved quality of everyday life. Seventy one percent were retained in treatment as part of the national treatment protocol. The programme demonstrates the important role of addiction treatment in moving clients towards stable accommodation and conversely the importance of accommodation provision in treating addiction. Having a planned exit from the Safety net programme was associated with significant improvement in accommodation stability. Much of the dramatic change described by the participants was a result of the removal of the need to source and use heroin. As one participant put it when asked to rate the service, its better than [being on] heroin. Though his bald response is at odds with others who enthused about the service which they described as a godsend and Brilliant without which they might be dead, it nevertheless sums up a finding just beneath the surface in most of the narratives; the programmes success is largely connected to the fact that it is so much better than no treatment in which daily life involved a recurrent cycle of begging, stealing, scoring and using. Practically speaking either because they would not or could not, service users had no other option to access a methadone programme. This access to treatment, and being treated like a normal person gave rise to great praise for the programme. Similar to others studies on drug and alcohol service users views, our participants did not seem to have high expectations from services5,6 The recurrent theme of people disengaging with MMT is evident through the stories. Prison and hospital are predictable risks for both heroin relapse and homelessness. Relapse prevention particularly for known homeless prisoners seems theoretically very feasible through the provision of suitable accommodation on release. While this review is overwhelmingly a positive story there are a few recommendations which may safeguard successes to date: This model could be expanded to other temporary and supported accommodation for homeless people. While the majority of the participants moved from emergency to transitional housing they remain technically homeless. This programme and these participants require further monitoring to see if dramatic changes experienced continue. All addiction treatment services for homeless people simultaneously address their accommodation needs. Timely patient transfer to mainstream services so that length of stay is as short of as possible thereby increasing programme capacity to treat all hostel residents requiring it. Length of time on the programme should be taken as one of the programme markers of success. Expansion in the numbers of community GPs taking planned exits may further benefit service users who find associating with other drug users at clinics a risk to stability.

Etheridge RM, Craddock SG, Dunteman GH, Hubbard RL. Treatment services in two national studies of community- based drug abuse treatment programs. J Subst Abuse 1995;7:9 26 Madden A Lea T Bath N Winstock AR . Satisfaction guaranteed? What clients on methadone and buprenorphine think about their treatment. Drug and Alcohol Review 2008; 27:6,671 678

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