This year marks the 20th anniversary of the implementation of the Methadone Treatment Protocol. This followed the Misuse of Drugs Act (Supervision of Prescription and Supply of Methadone) 1998… and so began one of the most successful chronic disease management programmes in Irish general practice. It came none too soon. 

In 1993 the Department of Health published a report to advise on a protocol for the prescription of methadone. This included embryonic plans for the introduction of well-regulated prescribing of methadone in general practice.

Following the rapid growth of intravenous heroin use in Dublin in the early 1980s, the ICGP, individual GPs, the National Drug Treatment Centre, the health boards and the Department of Health strove to explore best practice and evidence based treatment options for heroin addiction. An immediate aim was treatment for distreswsed and increasingly ill heroin addicts, often brought to unprepared GPs by distraught relatives (frequently mothers). Public health was extremely worried by the increasing number of HIV/AIDS (as it was called then) cases, of whom at least 50% were intravenous drug users. Deaths from opiate overdoses were all too frequent. It was already very evident that most heroin users who had ever injected had been infected with hepatitis C.

As a GP on the ground in inner-city Dublin in those days I can vouch for the distress, misery, morbidity and extraordinary mortality figures. Antiretroviral treatment for HIV was in its infancy and many local families were losing sons and daughters to HIV or other complications of heroin injecting. To make things worse, unregulated prescribing of methadone by a tiny rogue minority of GPs for a private fee with no added care, was undermining efforts to bring rational treatment to this needy group. Fortunately, there were some courageous GP colleagues such as Kieran Harkin, Ide Delargy, Des Crowley, and the late Fiona Bradley, who took an active role in researching best practice methadone treatment in other jurisdictions. Scotland (in particular Edinburgh) seems to have been several years ahead of us in implementing evidence based treatment protocols using methadone as a harm reduction medication. Meetings were arranged and Scottish colleagues were extremely helpful in informing the future shape of methadone treatment in Ireland.

The Report of the Methadone Treatment Services Review Group (DOHC1997) recommended a change in the way methadone should be prescribed and dispensed in Ireland. It was then that the Misuse of Drugs Act 1997 was amended to enable this and in 1998 the Methadone Treatment Protocol (MTP) was launched. It was a remarkable step forward in both healthcare policy and treatment implementation for a vulnerable group of patients and for their GPs.

The ICGP has played an essential role in the design and roll-out of this system of care under the leadership of Ide Delargy, Director of the Substance Misuse Programme for the past 20 years. Firstly, in informing the protocols for treatment itself and secondly, in providing courses and standard competencies for training of the doctors who would carry out the work. Thirdly, the College also became responsible for audit and CME for these GPs. Qualified GPs then became contracted to the health board/HSE at either Level 1 or Level 2 status, to provide methadone maintenance treatment for a registered cohort of patients within their practice. Level 1 GPs can accept referrals of patients stabilised on methadone from drug treatment centres of from other GPs. Level 2 GPs can initiate treatment for patients of their own practice following assessment by a local drug treatment service and their GP coordinator. The details of treatment cards, individual chemists, urine testing and other practical aspects of the MTP are now well known to most readers. 

Apart from promoting best evidence-based practice in treating opiate misuse, the ICGP was (and is) committed to drawing vulnerable heroin addicted patients with multiple physical, psychological and social problems into the holistic care of general practice. Methadone treatment at the National Drug Treatment Centre and in drug treatment clinics is essential care for many who are not very stable. However, general practice (family and community) methadone care offers the best possible milieu for receiving maintenance (or detoxification) methadone treatment.

In late 2010 a comprehensive review of the Methadone Protocol was published, renamed the Opioid Protocol. This was so named because of an aspiration (yet to be realised) to extend treatment options in general practice to include buprenorphine. Most of the shifts in emphasis and some changes proposed in the Opioid Protocol have yet to be implemented in practice.

In 2016 the ICGP, College of Psychiatrists of Ireland and the Pharmaceutical Society of Ireland published the truly excellent Guidelines for Opioid Substitution (OST), which follows on from the recommendations of the 2010 report. 

Twenty years on, the Opioid Protocol remains a remarkable system of life-saving, health-enhancing, public health positive care in the community. The protocol has ensured that this care is now available to about 10,000 patients nationwide. Practice has changed with regard to frequency and observation of urine sampling and I hope in future there will be more emphasis on encouragement and safe care for those wishing to detox and become drug-free.