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Treatment is a vital part of reducing drug and alcohol related harm to individuals, families and communities. The National Drug Treatment Reporting System (NDTRS) defines treatment as

Any activity targeted at people who have problems with substance use (excluding tobacco), and which aims to improve the psychological, medical and social state of individuals who seek help for their problem.

Drug Misuse Research Division (2003)

The National Drugs Strategy treatment objectives are:

• To encourage and enable those dependent on drugs to avail of treatment with the aim of reducing dependency and improving overall health and social well being, with the ultimate aim of leading a drug free lifestyle.
• To minimise the harm to those who continue to engage in drug-taking activities that put them at risk.

The growing evidence for the cost effectiveness of addiction treatments must be acknowledged and acted upon. If properly resourced, comprehensive treatment services were provided, Irish taxpayers could expect a ten-fold return on their investment, in terms of lower utilisation of other health services, reduced criminal activity, decreased dependence on social welfare and increased work productivity ( Irish College of Psychiatrists, 2005).

• Western HSE Addiction Counselling Services
• HSE Western Area Drugs Service
• Hope House, Foxford, Co. Mayo
• Harristown House, Co. Roscommon
• Cuan Mhuire, Athenry, Co Galway

The Task Force recognises and values the work of the existing staff in the statutory health services and the voluntary sector. We need to draw on the strengths and expertise of those currently working in the field. The Task Force hopes to forge links and relationships with all the main agencies to enhance service provision and create integrated care pathways.

In order to increase the uptake of service provision, it is essential to have a range of direct access treatment services easily available. The services need to accommodate people who experience drug problems at all levels, from experimentation to dependence. The range of service provision should include local provision of both community and inpatient detoxification, access to residential rehabilitation programmes as well as aftercare relapse prevention and support programmes.

Treatment services should enable access by people from all user groups. Services need to identify and remove any barriers that limit access and explore new ways of working that are flexible to the needs of clients, in order to increase uptake. Homeless clients or clients from many marginalised groups may require assertive outreach and community programmes that will provide for them in more appropriate setting.

To improve any individual's overall health and help them to achieve a drug-free lifestyle, service delivery should focus on contributory factors that impact on personal health status such as mental health, diet and nutrition, stress management, employment status and living conditions.

Drugs and alcohol impact not only on the individual drug user but also on partners and families. It is important therefore that support services are aware of the negative impact of drug misuse on significant others. Programmes should be made available that offer people support to deal with a problem drug user in the family, through education or by offering practical support and intervention to protect vulnerable family members from potential drug-related harm.

It must be recognised that not every drug or alcohol misuser is going to want or be able to achieve a drug/alcohol free lifestyle. Treatment service provision needs to accommodate those who continue to engage in drug/alcohol taking activities that put them at risk and work to engage them in treatment programmes. Treatment programmes need to be flexible and meet the clients needs. They need to follow best practice guidelines and be subject to regular monitoring and evaluation.

Whilst there is general recognition of the work done by the existing counselling services, the consultation process highlighted the considerable gaps that remain in service provision. In particular there was significant anger expressed that a valuable inpatient service was closed down in Ballinasloe without consultation or forward planning to accommodate clients' treatment needs in the community.

5.1.1 Gaps in service provision identified in the consultation process

• Lack of a consistent primary health care screening programme
• Insufficient dedicated detoxification beds for alcohol in the region
• No dedicated detoxification beds for drug users in the region
• No clear treatment pathway for people requiring inpatient stabilisation
• No clear treatment protocol in Accident & Emergency departments
• No standardised referral process for rehabilitation
• Inadequate funding of rehabilitation
• No community-based alcohol detoxification programmes
• No specialist substance misuse consultant
• Inadequate treatment for drug users with concurrent mental disorder
• No standardised relapse prevention programmes
• No residential services to accommodate street drinkers
• No needle exchange programme for injecting drug users
• Very few user support groups
• Very few workplace Employee Assistance Programmes
• No targeted back-to-work rehabilitation programmes
• No consistent access to family therapy or long term psychotherapy
• No counsellors targeted at homeless drinkers or drug users
• No protocol for drug screening
• No recording of drug and alcohol related harm data
• No clear treatment protocol for under 18s
• No supportive accommodation for homeless people undergoing community treatment programmes.
• Lack of anger management interventions

5.1.2 Questions of priority
This long list of gaps raises questions of priority in health service policy and provision:

• Where do drug and alcohol issues fit in the new health service structures?
• Why has drug misuse been prioritised when alcohol misuse is a far bigger problem?
• How do we square the circle of 'deregulation' of the sale of alcohol with the lack of funding or priority for treatment service provision?
• How do we deal with the impact of drugs and alcohol on public order offences, personal safety, domestic violence, drink driving, suicide, work-related accidents, and sexually transmitted diseases?

There are many more negative impacts of drug and alcohol misuse: increased reporting of drug-related mental health problems, drugs as a conduit to criminal activity, drug-associated behavioural problems, ever-earlier experimentation and, for some, subsequent problem drug misuse. It is essential that the Task Force address these and other important issues in the coming years.

• Reduce illicit drug use and drug related harm
• Reduce the harm caused by alcohol misuse
• Improve all aspects of health
• Reduce involvement in criminal activity
• Improve personal, social and family functioning
• Improve education and employment prospects
• Improve stability of housing and accommodation.

Therapeutic alternatives
It is timely therefore that we explore the appropriateness of having a range of therapies readily available. The talk therapies such as counselling, psychotherapy and family therapy are well recognised as successful interventions and support mechanisms for people with dependence problems. It would also be helpful to consider the value of other safe and effective complementary therapies as supportive options for those experiencing substance misuse problems.

Suicide and substance misuse
Careful consideration must be given to the apparent link between substance misuse and suicide. Since little is known about the real nature of the association, it is very important to research this issue further and to explore interagency developments that can reduce the incidence of suicide.

Dual diagnosis: substance use and mental disorders
Comorbidity or dual diagnosis (simultaneous drug problems and mental illness in the same person) is often underestimated and underdiagnosed. Research has shown that many problem drug users also suffer from mental illness, and a significant proportion of people diagnosed with a psychiatric illness have a history of substance misuse (European Monitoring Centre on Drugs & Drug Addiction, 2004). Concurrent problems of this nature place individuals at high risk, but services are not there to meet the need. For example, a recent study of drug use among the homeless found that one third of problem drug users had been diagnosed with a psychiatric illness, yet providers of services for the homeless reported that there was "no service which was prepared to deal with drug use and mental health problems simultaneously" (Lawless & Corr, 2005). In Ireland, as in many other European countries, "health and social policy is still in its infancy in terms of recognising and planning for service provision in this field" (MacGabhann et al ., 2004:50). Much work needs to be done to develop an understanding of the nature and extent of comorbidity in Ireland and the GMR region, and to create a framework for an integrated service response to this complex issue.

Evidence-based practice
The Task Force is anxious to ensure that all treatment services adhere to and demonstrate evidence-based practice. There is a large body of evidence to support the effectiveness of opportunistic screening and brief interventions for alcohol and drug misusers in a wide variety of settings (Babor et al ., 2003). Early intervention is essential.

Screening
The use of validated screening tools is invaluable in the early identification of substance misuse problems. For example, the CAGE questionnaire is a simple method of screening to assess the presence of an alcohol problem, and the World Health Organisation AUDIT questionnaire includes questions about alcohol consumption, alcohol related problems and alcohol dependence.

Brief interventions
In patients with minimal alcohol dependence but who are drinking above safe limits, brief interventions have been demonstrated to have lasting beneficial effects. The most effective method of brief intervention is motivational interviewing. A follow up interview can help to reinforce change or prompt the investigation

Access to treatment services
When a client of a service is assessed as possibly having an alcohol or drug problem, there should be a clear treatment pathway and quick access to a range of services at local level. It is possible currently to get assessment and counselling services, but there is a lack of community-based detoxification programmes and no clear access route to inpatient detoxification or treatment.

Community-based detoxification
It is essential that community-based alcohol detoxification services are developed in the Western region. These programmes can support people in their own community and/or prepare them for rehabilitation.

Inpatient detoxification
Service provision in the region should include access to local beds for people requiring inpatient detoxification for problem alcohol and drug use.

Rehabilitation
There are three inpatient rehabilitation units in the Western region: Hope House, Cuan Mhuire and Harristown House. Funding is required to support these programmes and there is no clear rehabilitation budget from the Health Service.