Service stakeholders' perspectives on methadone maintenance ...

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Journal of Vocational Rehabilitation 40 (2014) 49–58 DOI:10.3233/JVR-130664 IOS Press

Service stakeholders’ perspectives on methadone maintenance treatment, Special Community Employment schemes and client recovery pathways Marie Claire Van Houta,∗ and Tim Binghamb a School b Irish

of Health Sciences, Waterford Institute of Technology, Waterford, Ireland Needle Exchange Forum, Ireland

Revised/Accepted: June 2013

Abstract. BACKGROUND: Previous Irish research on client perspectives on the ‘lived social world’ of methadone maintenance treatment (MMT) and participation in Special Community Employment (SCE) schemes have illustrated how MMT offers clients the opportunity to commence recovery and community reintegration, with participation in the SCE schemes acting primarily as therapeutic support mechanism with improvement needed in work based support and employment related outcomes. OBJECTIVES: The research aimed to explore service providers’ views on MMT client experiences of participation in SCE vocational training, education and employment seeking. METHODS: Five in depth interviews and three focus groups (n = 14) were conducted with key specialist treatment and rehabilitation service providers’ in Dublin, Ireland. RESULTS: Narratives were thematically analysed, and indicative of the positive role of MMT in recovery pathways in terms of stimulating initial client stabilisation, reducing client chaotic lifestyles, initiating new positive health and social behaviours with partners, children, families, and facilitating renewed vocational training on SCE schemes. Outcomes whilst positive in terms of personal development when in recovery are compromised by lack of employment prospects and dedicated work-based supports on exit. CONCLUSIONS: Recommendations were made around the need for long term integrated community care, vocational certification, supported volunteer, employment planning and back to work schemes. Keywords: Methadone maintenance, vocational training, support work, rehabilitation for addicts

Methadone maintenance treatment (MMT) is the most common form of treatment for opiate dependency in Ireland and has been available in Ireland since 1992, with initial provision of treatment in Dublin. ∗ Address

for correspondence: Marie Claire Van Hout, Ph.D, M.Sc, School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland. Tel.: +353 51 302166, +353 86 389 3530; E-mails: [email protected] (M.C. Van Hout), [email protected] (T. Bingham).

It is provided in Ireland in addiction clinics and for stabilized patients in primary care (Delargy, 2008) under guidance from the Methadone Treatment Protocol which provides a series of systematic protocols for methadone prescribing and patient management (Butler, 2002). MMT is well evidenced in the literature on opiate treatment for its capacity to stabilize the opiate user’s lifestyle, reduce criminal activity, poly drug use and harms relating to injecting drug use, and

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M.C. Van Hout and T. Bingham / Service stakeholders’ perspectives

improve health, social, educational and employment outcomes (Amato, Minozzi, Davoli, & Vecchi, 2011; Ward, Hall, & Mattick, 1999). However, MMT is not without its problems which relate to long term treatment retention, treatment dropout, relapse cycles and client stigma (Simpson, Joe, & Rowan-Szal, 1997; Lloyd, 2010; Coviello, Zanis, Wesnoski, Lynch & Drapkin, 2011). Commentaries have discussed these issues as grounded in MMT’s status as ‘non treatment’ where one drug is essentially replaced by another, and its challenge of abstinence focused ideologies (Lloyd, 2010; Luty, 2013). Whilst half of clients on MMT can almost completely abstain from heroin use (Gossop, Marsden, Stewart, & Treacy, 2001; Simpson et al., 1997; Ward et al., 1999), research shows that abstinence is far less effective that maintenance, with low rates of successful recovery defined as abstinence from prescribed methadone with no treatment reuptake within 18 months reported (Amato, Davoli, Ferri & Ali, 2003; Amato et al., 2011; Nosyk et al., 2012). Additionally, great variation of health professional and public attitudes toward MMT exists (Lloyd, 2010; Gjersing et al., 2010). Low rates of employment, lack of prior employment history, poor literacy and employment related skills, poor motivational levels and training needs remain a key area of need for MMT clients (Dunlap, Zarkin, Lennox & Bray, 2007; Shepard & Reif, 2004; Svikis et al., 2012; Wong, Dillon, Sylvest & Silverman, 2004; Zanis, Coviello, Alterman & Appling, 2001). The support of MMT clients via vocational rehabilitation and employment directed training initiatives can potentially contribute to a pathway toward renewed community reintegration, socialisation, empowerment and financial security (Ruefli & Rogers, 2004). In Ireland, on foot of EU Drugs Strategy 2005–2012 and the EU Drugs Action Plan 2009–2012 recommendations stabilized clients are encouraged to partake in paid vocational training initiatives called ‘Special Community Employment’ (SCE) schemes as part of the social benefit system. These SCE schemes operate alongside mainstream community employment (CE) schemes for the long term unemployed, and are dedicated for individuals in recovery (Irish Working Group on Drugs Rehabilitation, 2007). Reported outcomes for SCE schemes in terms of their approach, ethos and related drug stabilization, abstinence, community rehabilitation and employment outcomes are mixed. In general SCE schemes appear to act positively as adjunct therapeutic support mechanism by developing personal social capital, wellbeing and introduction to

training activity for rehabilitating ex addicts (Lawless, 2006; Van Hout & Bingham, 2012b). However, SCE outcomes in terms of providing assistance to secure employment remain poor. The research was undertaken as part of a longitudinal research project focusing on SCE activity in north inner city Dublin, Ireland (Van Hout & Bingham, 2012a; 2013). We report here on the views of key specialist treatment and rehabilitation service providers’ views on MMT client recovery and participation in SCE schemes in the Dublin North East remit.

1. Methodology Ethical approval for the study was granted by the Waterford Institute of Technology’s Research Ethics Committee in January 2013. Stakeholders in the form of key specialist treatment and rehabilitation service providers operating in the Dublin North East remit were invited to partake in the research, with assistance from the Dublin North East Drug Task Force (DNEDTF) Treatment and Rehabilitation sub group. 5 in depth interviews and 3 focus groups (n = 14) were conducted with participants available and agreeing to partake. Prior to seeking informed written consent, each participant was given a comprehensive information leaflet, which provided details of the research aim and written consent procedures. This information was repeated vernally prior to commencement of interview and focus groups, and participants were encouraged to ask for clarification if needed throughout the course of the study. All participants were assured of anonymity and allowed to withdraw if and when they wished. Focus groups and interviews were audio-taped with permission. Names and other personal identifiers (i.e. project name) were not collected. Identifiers that inadvertently appeared in tapes were removed within 24 hours of the data collection. Tapes were transcribed within two days of focus groups and interviews. Interview and focus group topics included perspectives on MMT, stabilisation, detoxification, recovery, community reintegration and SCE participation. Participants were probed and encouraged to discuss and explore their own observations, opinions and attitudes. The analytical strategy commenced with several reads of the interview and focus group data. A simple thematic analysis was conducted (Krippendorff, 2004). The analysis of qualitative data generated a listing of relevant key words, phrases, narratives and ideas, which was subsequently formulated into categories by


situating these identified ideas and narratives into sub topics, and by choosing the most prevalent and illustrative narratives for each category. Through discussions and spider diagram mapping, the team noted emerging themes and categories, and developed coding schemes. Preliminary patterns in the data were analysed, followed by a system of corroboration and comparison with other cases. As patterns and outliers emerged, periodic briefing sessions between authors were held. Outliers were analysed under the conditions which outliers might be explained. Five themes emerged from the data set.

2. Results 2.1. MMT, stabilisation, abstinence and recovery Perceptions of the meaning of recovery were described by participants as centring on the initial client recognition of having a drug problem and client pathways toward the attainment of ‘normality’, improved quality of life and renewed social connections with peers, family and their local community. ‘Recovery means to me facilitating the individual getting them to help themselves to get to a point where they can live a very healthy rewarding lifestyle and I mean rewarding to themselves and obviously to their friends and family and community and in harmony with family and community.’ Participant No 3 ‘Recovery to me is somebody that is in recovery from drugs that is either no longer on drugs or reducing their drug use, they are making changes in their drug pattern.’ Participant No 9 Views on MMT and its role in recovery pathways were positive in terms of stimulating initial client stabilisation and the opportunity to reduce client chaotic lifestyles, initiate new positive health and social behaviours with partners, children, families, and facilitate new educational training opportunities and progression toward employment seeking. The majority of participants criticised the long term and high dose prescribing of methadone, with MMT clients observed to be stuck in the recovery continuum. This was observed to impact negatively on levels of social integration, and vocational, educational and employment outcomes. Whilst described by all participants as valuable in its ability to assist the process of recovery from opiate dependency, one quarter of participants empha-

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sised that methadone maintenance treatment must not be viewed as the ‘endgame’ in itself. A minority of participants voiced concerns for client sourcing and use of street methadone, client attempts to self-detoxify and taper methadone without medical permission or supervision. ‘It depends sometimes on a person at any given time. I know methadone has saved lives. I know it has allowed people to get into a place that is much better than they were in previously, and I would never say that it’s not useful, but then I do see characters that are on high doses of methadone for very long periods. Some people end up in a kind of a halflife for long periods of their lives, that’s not good.’ Participant No 2 ‘I think methadone helps initially and is what probably what prevents people from living chaotic lives and not being involved in crime and prostitution. Having said that, I do think there should be the option for people to come off methadone if they wish.’ Participant No 9 2.2. Treatment and rehabilitation service pathways Varied approaches to ‘drug free’ entry to residential treatment were described. This was viewed by half of participants as negative to client outcomes, particularly in relation to the continued use of benzodiazepines (‘benzos’) whilst engaging in treatment and counselling. The majority commented on how funding availability dictates client placement in certain residential detoxification settings within the DNEDTF remit. One third of participants described client uptake in residential detoxification as rushed and inappropriate to the stage the client was at, with negative repercussions relating to client vulnerability in post detoxification time frames. The majority of participants emphasised the importance of time needed to develop inner personal and peer, family, service and vocational training level network level supports so as to provide a safety net for individuals on re-entry to the community after residential detoxification. ‘Some of the tragedy I see is that sometimes I find that clients are rushed to register in residential detox. It’s not that I would begrudge it to them but before they are sufficiently prepared . . . before they have the supports in place . . . before they have learnt to generate supports within themselves and around them. There aren’t sufficient supports put in

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place for the day or the week or the month they come out. The tragedy is then they are at very significant risk and sometimes they go backwards.’ Participant No 3 The timely, intensified and long term community supports needed for detoxed individuals were described by all participants to include more structured formal aftercare services, stabilisation groups, dedicated key workers, community medical assistance and support, family programmes, vocational training activities and plans, psycho-social therapy and supported ‘back to employment’ initiatives. ‘There is a gap when people leave the detox facility, they kind of fall into a bit of a grey area. There is no place for them to go. That’s a massive problem because they can detox today and be out within a few days. People are very vulnerable no matter what care plan you put in place - the weekends happen and life happens as well.’ Participant No 4 Two thirds of participants described the new community detoxification protocols in the DNEDTF area as working well and in a holistic and client centred manner. Access to community detoxification was described by all participants as working well with few barriers to uptake, and hinging on individual client receptiveness, operation of integrated medical and community based supports and the implementation of inter-agency care planning. Outcomes were described as generally positive with all participants supportive of community detoxification and supports as a way forward. ‘Therapeutic and practical support and I think there has to be a really good care plan, the goals have to attainable, they have to be celebrated. Where people are slipping or struggling, it needs to be recognised and addressed as part of recovery . . . well stabilization first and the rest follows.’ Participant No 6

2.3. Consideration of specific group and cultural needs Certain client groups were identified by participants as necessitating particular targeted outreach and supports for individuals attempting access MMT, and residential or community detoxification. These groups were Travellers, Lesbian, Gay, Bisexual and Transgender (LGBT), prisoners and homeless. Experiences of social exclusion and discrimination for these groups, over and above the stigma of opiate dependency was viewed by all as impacting negatively on client requests for MMT, treatment and detoxification uptake, levels of trust with community, medical and social professionals, experiences of stabilisation and recovery, and involvement in vocational training, education and employment based initiatives. Particular reference was made to the stigma attached to drug dependency within Traveller and LGBT communities. ‘Some of Travellers, LGBT etc may feel there is a stigma. A lot of Travellers won’t access services, whether they feel that’s a stigma for Travellers being on drugs or whether Travellers like to deal with their own problems. I am not sure, but I do think there needs to be more awareness, more openness about anybody going into treatment regardless of their sexual orientation, their living accommodation or culture.’ Participant No 9 Two thirds of participants identified the need for setting up and delivery of specific culturally appropriate treatment and community detoxification pathways, projects and key-worker supports in the area. Mixed comments were made around the benefits or advantages to having specific projects catering for certain minority or simply improving existing projects to be seen as friendly, approachable and accessible to these groups and individuals.

Rehabilitating client experiences of adjunctive complimentary therapies (acupuncture, accu pressure, reiki, stress management and yoga) were described by all participants as positive and assisting in the process by introducing opportunities to relax and reflect.

‘We have a Traveller project in the area that would have identified that Travellers find it quite difficult to engage in treatment because there can be issues around making appointments and stuff like that. Sometimes it’s to do with kind of not felling connected with the community.’ Participant No 2

‘I think it gives the clients themselves a bit of respite and gives them a little bit of re focus and I think this is very important. They do gain benefit from it and they do use it.’ Participant No 1

With respect to the organisation of community prison links for individuals released from prison, three quarters of participants described the need for pre release planning, improved information, timely key working, care planning and vocational training placements for


ex prisoners, in order to offer a safety net system for those re entering the community. ‘It’s important that they are made aware of the opportunities coming up to their release date, that they are not just left out the door with no information, with no referrals made on their behalf.’ Participant No 5 Homelessness and inter agency difficulties in addressing client homelessness was described by all participants as impacting negatively on treatment outcomes and vocational training retention, with ‘drug free’ or ‘stable’ individuals often housed alongside active drug users. This was viewed as catastrophic in many instances in terms of individual client vulnerability and reintroduction to drug use and drug using networks. In contrast, those housed alongside other recovering or stable individuals post detoxification were viewed by some participants as more successful in their recovery and vocational training pathways. ‘We used to have little groups of people in recovery who were totally drug free or stable, where you knew where you could put people, and the whole peer thing kicked in and it worked wonderfully. Now whether somebody is using 8 bags a day [heroin], or drug free, they could end up in the same apartment. So I am drug free and living beside somebody that is scoring every day. You know it’s not as safe as it was.’ Participant No 6 One fifth of participants observed the need for specific mother and child detoxification settings, with drug dependent mothers experiencing a host of barriers to service uptake. ‘I know from working in the community and hearing quite regularly that there is not enough mother and baby units or mother and children units, women tend to not go into treatment for that reason. They may not have anybody to mind their children. They don’t want to place their children in temporary foster care because they have a fear they may not get them back. It does tend to hinder women not having enough units for women and children.’ Participant No 9 2.4. MMT, vocational training and education Client participation in methadone maintenance treatment was viewed by all participants as both assisting and hindering uptake and participation in vocational and educational training initiatives. In particular, their discussions centred on levels of methadone dosage,

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with higher dosage described by three quarters of participants as influencing individuals’ readiness and capacity for education and learning, and their ability to socialise. Dosage was observed to impact negatively on potential level of training activity and employment pathway the client could successfully undertake. ‘It would depend on the level of methadone going from high to low, from somebody on a high level of methadone goes down to basic social skills. Then someone that’s on a low level that needs to go back into society and wants to work, it’s down to basic training whether it be forklift or carpentry or whatever. But to me really it does depend on the level of methadone for the training that is required.’ Participant No 6 Despite funding constraints, SCE schemes were described by all participants as doing their utmost to facilitate client learning and progression, with all schemes commencing with personal development, art, computer, life-skills classes and maths classes (stage one). For many clients, accredited training and certificate awards was introduced thereafter (stage two), and illustrated as follows; ‘Generally speaking we would never jump in first with two feet with any kind of accredited training. We would start with softly, softly, kind of personal development and confidence building. Accredited training is way down the end of the road. Stage one is to encourage them into education, make them comfortable, make them enjoy it and it does not matter whether it’s an art class that’ s mainly therapeutic, or if it’s a class that they are earning real skills. The important thing is to introduce them to education and make them feel comfortable and happy. If when they get to that stage [Two] they decide they want to do accredited programmes, they have done a range of personal development, computer programmes, communication skills, math’s that kind of thing.’ Participant No 8 The value of individualised learning as medium for peer integration and the opening of new horizons (‘they are getting the value of books’) were emphasised by all participants. ‘If we had got the funding, we would be able to look at the different of levels that people are at in their lives and have different sections set up to give them the support to enable this, but it’s really all down to funding.’ Participant No 1

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The majority of participants highlighted how the process of learning, retaining and retrieving information was affected by previous client schooling experiences (in some instances negative), how client personal development was key during initial stages of recovery, and how internalisation of new nine to five daily routines for clients helped to prepare individuals for normal social lives and ultimately for work. ‘I think that SCE schemes do very valuable work and I think that you miss the entire point if you only look at it as a bridge towards employment because these people have probably lead chaotic lives for most of their lives. Three years on a scheme, that’s not going to bring them to the level where they are going into the work force with the same level of understanding and level of maturity as everybody else, but I think what it does do, is it helps to impose a structure on people’s lives. If all you learn is that you get up in the morning, you go to bed at night, you have a structure to your day, you’re getting your kids to school . . . that’s enormously beneficial, far more beneficial than getting a job because it has longer term consequences for how you lead your entire life, not only your working life.’ Participant No 8 Specific client needs assessments and development of personal goals in vocational training was viewed as vital in back to employment pathways. Some SCE clients were reported to have second level education, and necessitated higher level specific training courses and progression onto third level. ‘I do believe that the schemes very much assist clients. . . . .from speaking to clients they would often tell you that having somewhere to go to and something to get up for every day, and be around people that understand you and work with you and help you and assist you to get your life back on track, with the one goal whether that is education, training, or employment.’ Participant No 9 Some comments were made around the current length of SCE of three years. ‘It helps them with their personal development and their educational needs. I think there are a lot of clients floating about who have been in prison and done all sorts of different qualifications and courses in prison, and then would go to a CE scheme and maybe do the same thing again, because they have not remembered doing it the first time. The special

CE schemes are a way of catching up all that they have built on and what they have done.’ Participant No 6 ‘I think the special CE schemes should be a lot longer than three years, because what I have seen is somebody coming right to the garden gate and then the three years is up and the gate is closed and I see them go back to square one.’ Participant No 1 The process of moving an individual along the learning continuum was described by all participants as supported by positive staff relationships, trust building, motivational interviewing and other support initiatives. Three quarters described client readiness to change and engage in learning and personal development initiatives as easily affected by individual and environmental stressors. Instances of dropout and reuptake were described by all participants as common. ‘There are times you know at the end of the day with all the motivation in the world there are other factors in the client’s life. They are not quite ready to make that change. . . . start to slip away from us . . . they are not in a position to connect and do the work, so we let them go for a while. We have had quite a number of such people come back to us when they are ready. They know the support is here. We continue to offer them support through the following months and when they and we see that they are ready to make a meaningful attempt, well then we kind of re-introduce them back onto the programme.’ Participant No 3 One fifth of participants referred to the impact of the recent revised Social Welfare Bill changes which had removed entitlements for double payments of disability and lone parent’s payments for scheme participants, and which had resulted in reduced SCE uptake. ‘It is a carrot. The motivation is that they got paid. I think initially that’s what brought a lot of people onto SCE and particularly when there were double payments. It may not be the case now. I think once they are there, they then begin to see the value, they begin to get that structure in their life, they are getting themselves up every morning to attend, their social skills improve and they can see all these changes happening for themselves. I always used to question myself whether or not you really had people because they wanted to be there.’ Participant No 6


In light of disincentivisation and reduced numbers, the majority of participants underscored the need for the government to provide training grants, childcare support and retention of social welfare payments for those MMT wishing to continue with vocational training. ‘What it will do is separate those who are serious about rehabilitation and those who are not.’ Participant No 9 ‘Numbers are significantly down. Anybody starting or consider starting a project like ours are going to be ambivalent at that stage and there is a part of them for any excuse not to make a commitment.’ ’Participant No 3 2.5. Employment seeking All participants observed the usefulness of the SCE schemes in providing recovering individuals with a renewed focus on training and vocational certification, and potential routes toward supported work experience and employment. Comments were made by one fifth of participants around the negative effect of the economic downturn in Ireland (at the time of writing), as impacting heavily on scheme participant chances of securing employment on exit. The lack of specific training and supported work placements on exit was viewed as restricting employment opportunity on scheme completion after three years. Additionally, the disclosure of the client being in recovery, on methadone, having the ‘wrong’ home address or having a criminal record was viewed by all participants as further complicating client employment seeking and successful outcomes. ‘I know from talking to clients they are not quite sure about admitting they are in recovery. They are not sure if that is going to prevent them from getting a job. Some clients may feel that it is going to stop them, that the job will be given to somebody else over them. Maybe clients are still on a small dose of methadone. That may be an off put for employers. Employers are sometimes not aware of how functional clients on methadone can be.. Participant No 9 ‘People still have records and it travels around with them. That’s just the reality of where some people have been at. I wonder from what point do you stop being an addict and if you have that kind of history behind you, it tends to go with you. ‘Participant No 2

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One participant described how the personal appearance of some clients seeking employment deterred prospective employers. ‘The problems that some of them have faced is that their physical appearance has let them down, even though they are clean, they will always have the look . . . “I will always look like a junkie”. That stands in their way immediately.’ Participant No 2 Other complications viewed by half of participants included clients using SCE schemes as curriculum vitae (CV) reference points for prior employment experiences, making it problematic for the SCE schemes to provide in depth references which would not be viewed as stigmatising. ‘Another barrier is where they give the SCE as a reference . . . we end up in the dilemma. If we are asked what was the nature of the work? And questioned in any depth, we either have to say “sorry I can’t answer any further questions in that area”, where in effect you are giving an answer anyway or you have to say they were employed as a client here. They may well have been with us for the previous two or three years and the CV looks very empty and that is a challenge.’ Participant No 3 Many favourable comments were made with regard to development of ‘back to work places’, ‘fair recruitment programmes’ targeting the disclosure of client criminal conviction, and client involvement in community volunteering. ‘If they cannot get a paid job, the thing we like to explore with clients, particularly in our aftercare programme is whether or not, they are prepared to do voluntary work because it is risky and destructive for people to have too much time on their hands in their recovery.’ Participant No 3

3. Discussion The study provides an illustrative account of key specialist treatment and rehabilitation service providers’ perspectives on the interplay between MMT pathways and vocational training, education and employment based social integration initiatives. We recognise the findings are context specific to SCE schemes operating in the Dublin North East remit. However, the DNEDTF has recognised that the consideration of service provider’s views is vital for improved treatment

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and vocational training, education and employment care planning (European Monitoring Centre for Drugs and Drug Addiction-EMCDDA, 2011; Laudet, 2009; Olszewski, Hedrich & Montanari, 2012). The study is intended to stimulate policy and practitioner debate on further improvements required in the delivery and operation of SCE schemes for recovering addicts in Dublin, Ireland. MMT was viewed by service providers as positive in its capacity to improve the individual functional ability and present a window of opportunity for the individual to create a new daily routine, create new relationships with partners, children, peers and friends, and improve readiness for engagement in learning, vocational training and employment directed outcomes (see Gossop et al., 2001; Lawless, 2006; Van Hout & Bingham, 2012b). Similar to extant literature, stakeholder concerns also included the diversion of methadone onto the street (Kreek, La Forge, & Butelmann, 2002; World Health Organisation, 2004) and client attempts to selfdetoxify (McDonnell & Van Hout, 2010, 2011; Van Hout & Bingham, 2011, 2012a). Given the frequency of client attempts to self-detoxify, the availability of community detoxification in the Dublin North area was viewed by participants as preferable to residential settings. They underscored the need for continued development of these dedicated community detoxification supports with dedicated key working for vulnerable or stigmatised individuals (i.e. Travellers, LGBT, ex-offenders, homeless) with enhanced interagency working. Findings are similar to extant literature by highlighting the need for ensuring access to secure appropriate housing accommodation for those in recovery (Brooke, 2011; Cork Simon Community, 2012; Kertesz, 2009), pre and post prison release planning (Binswanger et al., 2011; EMCDDA, 2012; Prison Drug Treatment Strategy Review Group, 2010) and building of positive trusting relationships with culturally sensitive community projects (Beddoes, Sheikh, Pralat & Sloman, 2010; Mayock, Bryan, Carr & Kitching, 2009; Van Hout, 2011). We recommend further research on the experiences of homeless, ex prisoner, Traveller and LGBT’s in accessing detoxification, MMT and vocational training pathways. We know that participation in vocational training, education, intermediate and supported employment market schemes can improve drug treatment outcomes (Dunlap et al., 2007; Shepard & Reif, 2004; Svikis et al., 2012; Van Hout & Bingham, 2012a; Wong et al., 2004; Zanis et al., 2001). Longer MMT duration is correlated with positive recovery outcomes for opiate

dependents (Luty, 2013; Nosyk et al., 2012; Strang et al., 2012). However, stakeholder criticisms centred on the long term prescribing of methadone, and in high doses, which were observed to hamper social activity, engagement and retention of information when in vocational training, job seeking and employment prospects on exit. Specific personal and training needs assessment and care planning were described as vital for client personal development and progression along training and learning pathways. Schemes appeared to focus primarily on the therapeutic value of participation for recovering addicts, by virtue of increased personal social capital, well-being, renewed quality of social life and health, new purposeful daily routines achieved by provision of computer, art, life-skills and numeracy/literacy classes. The study builds on earlier organisational evaluations of SCE (Lawless, 2006) and client perspectives of scheme participation (Van Hout & Bingham, 2012b) in Ireland which have highlighted the need for continued Drug Task Force and educational provider debate around future direction of SCE schemes, whether simply as capacity building in the improvement of personal lifestyles, renewed interest in learning and progression, and community reintegration for recovering addicts, or for the provision of supported specific job training, certification and back to work initiatives. The ‘one cap fits all’ approach within the three year SCE term in our view appears restrictive and for some recovering individuals not the best use of time given the wide variation of educational level and readiness for participation. A vital outcome often neglected in these three year SCE schemes is the attainment of specific employment related certifications and work related skills on exit. Similar to other research on employment outcomes of ex addicts (Lloyd, 2010; Luty & Grewal, 2002; Ormston, Bradshaw & Anderson, 2010; Vigilant, 2004), attempts to secure employment on completion of SCE schemes are hampered by lack of specific training and work experience, empty curriculum vitaes, disclosure of criminal records, having the ‘wrong home address’, personal appearance and employer attitudes to prospective employees on MMT. Additional difficulties occur on the scheme provider side in the form of requests to write references in evidence of paid attendance of the three year training scheme. Similar perspectives have been recorded in the literature (Dunlap et al., 2007; French et al., 1992; Platt, 1995; Shepard & Reif, 2004; Wong et al., 2004; Zanis, Metzger & McLellan, 1994). Client experiences are no doubt further compromised by the economic downturn in Ireland at the


time of writing. Reduced payment of social welfare entitlements for SCE scheme participants has disincentivised uptake. Having nothing to do during the day is of grave concern given potential for relapse and renewed involvement in local drug markets. SCE schemes must discover and implement new mechanisms for attracting and retention of clients in recovery. We recommend further development of specific training pathways, ‘back to work places’, ‘fair recruitment programmes’ targeting the disclosure of client criminal conviction, and encouragement of client involvement in community volunteering placements. Such specialist employment and active citizenship led interventions offer some success in supporting community rehabilitation and transitioning onto the labour market. 4. Conclusion The research supports earlier studies evaluating SCE scheme provision in Dublin North East, Ireland. Integrated community services tackling treatment, housing, cultural minorities, prison release, vocational training, supported employment and volunteering initiatives will improve ex addicts’ successful reintegration into society. SCE must diversify from their fundamental approach as adjunct therapeutic mechanism toward that of targeted work based development, active citizenship and transitioning into the employment market. Acknowledgments The research was funded by the Dublin North East Task Force, Ireland. The opinions expressed in this article are of the researchers and are not necessarily those of the Dublin North East Task Force. References Amato, L., Minozzi, S., Davoli, M., & Vecchi, S. (2011). Psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification. Cochrane Database Systematic Review, 9, CD005031. Amato, L., Davoli, M., Ferri, M., & Ali, R. (2003). Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database Systematic Review, 3, CD003409. Beddoes, D., Sheikh, S., Pralat, R., & Sloman, J. (2010). The impact of drugs on different minority groups: A review of the UK literature part 2: Lesbian, gay, bisexual & transgender (LGBT) groups. London: Office for Public Management. The UK Drug Policy Commission (UKDPC).

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