Journal of Vocational Rehabilitation 37 (2012) 6373 DOI:10.

3233/JVR-2012-0600 IOS Press

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Methadone maintenance and Special Community Employment schemes: A study of Irish participants views
Marie Claire Van Houta, and Tim Binghamb
a School b Irish

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

Abstract. Specialist vocational training for ex-drug users include employment skills training, supported placements and therapeutic work programmes. The research was peer led by Client Forum representatives of ve Special Community Employment schemes and aimed to explore participant experiences of Methadone Stabilization; Special Community Employment schemes, and Vocational Outcomes. A Client Forum consultation (n = 11) and Client Forum representative focus groups (n = 2) were used to nalize interview questions. In depth interviews with a convenience sample of participants from Special Community Employment schemes (n = 25) were conducted. Content and thematic analysis of narratives was undertaken with Client Forum (n = 11) interpretative support. The ndings are indicative of Special Community Employment schemes offering methadone maintenance participants the opportunity to commence recovery, engage in vocational training and reintegrate into the community. However, participation in these schemes appeared restrictive and operated primarily as therapeutic medium, with little individual vocational care planning, training or supported work placements. Many participants reported leaving these schemes unqualied, unemployed and experiencing little aftercare. The research underscores the need for extensive revision of Special Community Employment schemes within an interagency approach, so as to provide specic therapeutic supports dependent on individual recovery stage, and client specic vocational training needs, certication, work placement and supportive aftercare. Keywords: Methadone maintenance, employment training, rehabilitation for addicts

1. Introduction According to the European Monitoring Centre for Drugs and Drug Addiction [1], there are between 1.2 and 1.5 million opiate dependent individuals in the European Union, with an estimated 18,136 and 23,576 opiate users resident in Ireland [2]. Latest Irish prevalence statistics indicate that approximately 11,807 opiate users are known to services and are predominantly aged between 25 and 34 years, are male, early school leavers and unemployed, with decreases
Address for correspondence: Marie Claire Van Hout, Ph.D., M.Sc., M.Sc., School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland. Tel.: +353 51 302166; E-mail: mcvanhout@wit.ie.

in female opiate use and the switching from injecting to smoking of heroin reported [2, 3]. National treatment data systems reect an increase in both prevalence and incidence rates of treated opiate dependency among 15 to 64 year olds, with the majority of cases treated as outpatient, over half receiving counseling, half commencing methadone maintenance, one quarter under going brief interventions and a small minority undergoing medically assisted detoxication [3, 4]. The data also reects frequent relapse rates for the opiate dependent population with over half needing more than one treatment intervention [3] in the reporting timeframe. Methadone maintenance treatment remains the most common form of treatment for opiate dependency in Ireland and is generally provided by specialized

1052-2263/12/$27.50 2012 IOS Press and the authors. All rights reserved

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clinics under medical supervision. It is an important component of community-based approaches to treating opiate dependency insofar that the treatment is offered on an out-patient basis, resulting in signicant treatment retention rates and capacity to successfully address health risk issues, poly drug using patterns, psychological problems, family relationships, vocational training, employment and housing issues [515]. However, although methadone maintenance treatment has been proven to be cost effective [16], successful outcomes depend on timely treatment entry, adequate methadone dosage, duration, support and continuity of treatment, levels of engagement in psycho social modalities (concurrent counseling and contingency management) and presence of cohesive support networks of adjunctive medical, social and community services [17, 18]. Methadone maintenance treatment remains associated with community, pharmacy, medical and patient related stigma [19] and is considered by some critics to be problematic in its capacity as social intervention [20] and also as addiction substitution mechanism with little discourse for alternatives [2123]. Additional risk of continued use of non opioid substance use (alcohol, cannabis, prescribed medication such as benzodiazepines) is present [2, 14]. Dropout and relapse rates remain high, and are indicative of a revolving door of opiate treatment re entry patterns [2426]. Methadone maintenance can operate as catalyst for revision of day to day activity and adoption of new norms and values in social integration processes, by replacement of the prior preoccupation of drug seeking and using behaviors [27]. Once stabilization is achieved, vocational training, employment supports and community reintegration represent important therapeutic goals [28, 29]. Poor educational attainment and high unemployment are characteristics of methadone maintenance clientele [2932] with research indicating that general employment rates for those on methadone maintenance range from 15% to 44% [33, 34]. However, by supporting methadone clients via vocational training and employment initiatives, pathways toward social readjustment, reintegration into mainstream society and individual legitimization are realized [3443]. In this way, vocational rehabilitative efforts for those on methadone advocate for specialist employment interventions operating as adjunct to pharmacological and psycho-social treatment interventions, and which focus on employment skills training, supported and therapeutic work programs, case management protocols and job searching assistance and placement [4349]. According

to McIntosh et al. [41] ex drug users in receipt of vocational training and employment related assistance were three times more likely to have secured paid employment, than those not in engaging in such programs. However, whilst a majority of ex drug users report a strong interest in employment training, their expectations are often unrealistic, with low rates of employment due to poor literacy and employment related skills; lack of prior employment history, lack of access to transport and childcare, poor motivational levels and comorbidity [2931, 33, 34, 40, 43]. Platt and Mezger [35] quoted that for addicts who dont have an existing skills base; getting a job or keeping a job is a job in itself, especially for addicts who have lost or never acquired the skills and discipline necessary for sustained employment. Other impacting factors include the employer bias against methadone clientele, unavailability of certain skill specic jobs and weak labor markets [33]. Building on the EU Drugs Strategy 20052012 and the EU Drugs Action Plan 20092012, the Irish National Drug Strategy, 20092016 and its National Working Group on Drugs Rehabilitation have advocated that stabilized methadone maintenance clients are encouraged to partake in employment focused vocational training initiatives called Special Community Employment schemes, whilst in receipt of social welfare benets. The schemes are provided by the Vocational Education system (FAS). The research was undertaken on behalf of the Dublin North East Drugs Task Force Client Forum which represents the participants on ve Special Community Employment schemes in Dublin. The Client Forum expressed an interest in conducting peer led research to investigate and situate Special Community Employment scheme participants experiences of methadone maintenance along a continuum of recovery, with particular attention devoted to stabilization processes, vocational training and employment experiences, needs and outcomes.

2. Methodology Qualitative research based on bottom up subjective experiences of opiate using individuals remains most appropriate [50]. Recent movement toward participatory discourse between service users and providers in harm reduction has underscored the need for active participative research in order to generate user specic and localized outcomes [51, 52]. The research was guided by National Drug Strategy 20092016 recommendations for improved service user involvement in

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peer led research activity. The research comprised of the following four sequential and participatory phases, a Client Forum consultation (n = 11) assisting in the development of interview questions through two facilitated focus groups (n = 4), with a convenience sample of Special Community Employment scheme participants partaking in semi structured in depth interviews (n = 25), and lastly with a Client Forum data analysis feedback session (n = 11) used to assist researcher interpretation of narratives and thematic categories. Four Special Community Employment schemes agreed to partake in the research, with one declining to partake in the research. Client Forum members were asked to assist as gatekeepers in advising their peers of the upcoming researcher visits and in the recruitment of volunteers to partake. In-depth interviews were conducted in classrooms at each participating Special Community Employment scheme and ranged from 30 to 45 minutes. The interview guide contained questions pertaining to methadone maintenance and stabilization experiences, experiences of the Special Community Employment schemes, vocational training needs, employment and identied avenues for rehabilitative progression. Ethical approval for the study was garnered at Waterford Institute of Technology, Ireland in May 2011. Information regarding the research aim, assurances of condentiality, verbal consent and right to withdraw at any stage were repeated prior to commencement of each focus group and interview, and participants were encouraged to ask for clarication if needed throughout the course of the eldwork. Participants were advised not to mention any names or identities throughout the research. All Client Forum consultation meeting, focus groups, interviews and data analysis feedback sessions were fully transcribed, and supplemented by researcher held eld notes, reections and memos. Thematic and content data analysis commenced with several reads of the resultant narratives from all four phases by both researchers, with periodic brieng sessions between both researchers assisting in the identication of emergent themes and categories of data, within an inter-rater system of corroboration, comparisons and interpretations of the data.

participants) agreed to partake and were interviewed. Ages ranged from 28 years to 49 years, with some participants unwilling to disclose actual age and as alternative indicating an age range. The narratives shall be presented in the following themes; Methadone Stabilization; Special Community Employment Schemes, and Vocational Outcomes. 3.1. Methadone stabilization Most participants expressed concern at the duration of their methadone maintenance treatment, with a majority of participants observing that they were never advised of methadone health related symptomatologies and addiction potential, and that treatment pathways would be long term, and in some cases lasting over ten years. Several participants described the daily restrictions of methadone consumption on personal freedom and said; It was a ball and a chain, I had to take methadone everyday, I couldnt plan too much, I couldnt commit too much. I was always conscious I had to take methadone. . .I had to go to a doctor, I had to go to a chemist, so it was a big part of my life, it was a necessary evil... Male aged 28 years. Its like holding you to ransom. You have to be at the chemist everyday. Female aged 48 years Many participants described a lack of doctor client dialogue, in terms of reaching a mutually agreed timeframe for dose reduction and detoxication. Its just to keep people quiet. I have been on the opposite side of a doctors biro [pen] and the power they have over you. . . Male aged 39 years Tapering and detoxication attempts were frequently described to be the clients responsibility, with female participants in particular, describing personal attempts to reduce methadone dosage without medical assistance. Other participants appeared somewhat resigned to long term low dose methadone use and reported a fear to cut down completely and appeared satised to remain on low dosage methadone. Poly drug use and switching of drug dependencies whilst on methadone were described by many participants, with cannabis, prescribed anti anxiety medication and alcohol commonly used. This was described by some participants to contribute to recovery apathy. Several male participants said;

3. Results Eleven females and fourteen males (out of a potential 45 Special Community Employment scheme

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It helped me stabilise for a period of time, but after that period of time has gone, if there is no action being taken on the next step to reduce, I got bored with the methadone, I was able to justify taking other drugs, as I was taking methadone. . . . looking back on it now, it was a free drug. . . If you look out there now, there are a lot of clinical addicts, they dont have to go out and rob, they don have to go out and do anything, they sit back get their methadone, get their tablets. . . they are government junkies, these are young people growing up, they dont see any wrong, because its being given to them. . . . who would want to leave that environment. . . . thats the ip side of it. Male aged 39 years The way I look at it, it is a substitute for heroin, if you havent got heroin, they give you methadone, it is just another drug I dont want to be on. . . I was using on tablets top of it. Male aged 36 years A male participant commented on his purchasing of street methadone, in order to deal with local heroin droughts and described switching back to heroin in order to deal with unpleasant methadone withdrawals; I was on methadone for 12 years and buying it on the street. In the beginning if I was to use it properly, the purpose was to take you off heroin, what I found after a while I just got used to it. I felt that I was still missing something so I started dabbling in tablets. . . Then when I wanted to come off the methadone, I had to use heroin because the sickness off the methadone is more severe than it is off the heroin. Male aged 39 years Methadone clinics appeared to be a hive of illicit drug and street methadone trading, and represented a very real concern for some participants in their quest for drug stabilization and recovery. Several participants said; You see people coming out of the clinic with loads of take away and you know they are going to sell it. Female aged 28 years The problem is my clinic is a drone for drug dealers.., always getting asked when I leave the clinic, if I want to buy gear [heroin]. Male aged 2933 years Even if I stay away from all the guys using drugs, I am still going to bump into them in the chemist. Male aged 33 years

Recovery appeared to mean different things to each participant and ranged from simply getting onto methadone maintenance programs towards complete life change involving new friends, new environments, new relationships and employment prospects. Most participants, and especially females described how methadone maintenance treatment and daily dose consumption opened the door to a revised and positive day to day functioning which replaced prior drug seeking, purchasing and using patterns, and said; At the start it got me stable, it helped me function better in life; it took the madness out of being active and out there looking for heroin. Male aged 28 years I feel that if I hadnt had methadone I wouldnt have the stability or the life I have now, I was able to continue to be a mother and work, have a normal life, if I hadnt had methadone I would have had that. Female aged 46 years When questioned whether participants felt that methadone had helped recovery and rehabilitative processes, participant responses were generally positive, and grounded in the ability to retain some normality in day to day life, and in its capacity to offer the addict the opportunity to step onto recovery starting points, reect and consider options. Two years ago it would have just meant, going into detox and coming off drugs, but recovery to me is a lot more than that, recovery to me is getting back to the issues, that led you to the drug taking. . . Recovery is an individual thing, recovery isnt just coming off methadone, its a hell of a lot more than that, its about occupying time, trying to get back into society, trying to get back to the normal things, its lling the void that the heroin and everything that comes with the heroin use, the friends, parties. Male aged 2933 years It means getting my life back, getting back into working I have lost 15 years of my life over this stuff...I could have my own house, my own everything, but I dont have any of them, still on the welfare. Male aged 33 years Getting clean and sorting your life out, job, I would love a job Male aged 36 years Participant observations around personal denitions of being clean were mixed with some observing that clean meant on methadone maintenance therapy and

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not using heroin but using other drugs such as alcohol, prescribed medication and cannabis, and others observing clean meant completely drug free. Some participants reported that methadone maintenance treatment had hindered their recovery in its capacity as replacement long term dependency, and said; If I hadnt had the methadone I think I would have been off it along time ago, I think it is holding you in that environment. Its holding you back. Female aged 46 years The process of coming off methadone, thats what I see as my recovery. I hate the hold it has over my life. I feel like I will never be able to move away from this part of my life while I am on methadone. Male aged 33 years 3.2. Special Community Employment schemes The majority of participants described the Special Community Employment scheme to be a positive endeavour for them, with observations grounded in feelings of belonging in group contexts, improved self condence and reduced community and family labelling as junkie (drug addict). Several participants said; Positive very positive, an awful lot of people in the community support the scheme because most of their kids would have done a course. They are actually a very good community. Female aged 49 years I like it here, it is a good course, like people who I never thought would walk up to me when I went on drugs especially and now walking up to me saying fair play to ya, you look great, you are doing brilliant, I am getting the reaction off my kids, they just used to call me a junkie and that used to hurt. Its helping my recovery knowing that people are respecting you, once I get my self respect back, I get the respect back from my kids. Female aged 49 years There is a humanistic factor about it here. The scheme has helped me immensely this has helped me in my personal therapy. . . I am where I am today with the help of the scheme. Its helped me get back my self respect, dignity. Male aged 39 years Several participants described how the Special Community Employment scheme encouraged them to develop new day to day structures and said;

Its helped me by giving me a structure where I can come in, I have to get up and have to go somewhere and almost held accountable for how I behave. Male aged 28 years I want to be independent, I never had a routine because I was on drugs, its helped me in that way. Female aged 28 years Several participants remarked on the effect of partaking in the Special Community Employment scheme in challenging participants personal denitions of recovery and being clean, addressing the use of other drugs and stimulating positive decision-making around methadone dosage, reducing dosage, seeking detoxication and treatment; I love it here, I think if I wasnt here I wouldnt be clean, I was using before I came here and I think its seeing people clean, you think if they have it, I want it, if they can do it, I can do it. Female aged 28 years For the rst two years, people were saying to me about coming down, I wasnt going to let anyone tell me what to do and then one morning I asked the doctor to cut me, I was aware it was me who wanted to cut, the scheme helps and still helps. Male aged 49 years It appeared that each Special Community Employment scheme seemed to run autonomously with its service ethos dependent on the coordinators beliefs, with little individualized care planning and each scheme providing distinctly different services to each group. Some participants had become clean at earlier stages in their Special Community Employment scheme pathway, which could last up to ve years, and questioned the one size ts all approach common to each scheme and said; Its depends on what scheme your on, some people come in here not knowing how to read and write, they have no literacy skills so in that sense yes it does help those people, but for me I am learning what I know already. Female aged 34 years Youre learning how to communicate youre learning how to speak, your learning self awareness. Female aged 28 years I feel a lot more condent going for a job now than I would have before I started here. . . the personal skills they have taught me have been invaluable, learning to deal with normal people. . . its like I

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need these skills to start again just talking to people knowing what to say. Male aged 33 years Some participants mentioned specic vocational skills acquisition in the form of literacy, computer skills, horticulture, life skills and art; Its interesting we learn different things we learn meditation, life skills, choice theory, art, computers. . . its interesting. Female aged 34 years Yes I wouldnt know how to use a computer, I have done typing skills, the course has taught me things I thought I could never do, I used to be real negative. . . wouldnt get a job because of my previous convictions, sure what would I be good at, nothing. Since I started the horticulture I am now teaching my son how to grow at home. . Female aged 49 years 3.3. Vocational outcomes Denitions of vocational rehabilitation outcomes varied and hinged on the ethos of the Special Community Employment scheme; with some schemes focusing on the reduction of methadone and other drug use through positive sanctioning of urine testing, and the provision of personal development and therapeutic self care tool within group settings and others focusing specically on the development of vocational training, employment skills base training and job seeking supports. Special Community Employment progression structures appeared fragmented with certain schemes offering participants funds for continued education and others effectively creating barriers for participant progression. Several male participants said; They give me some of my college fees, this is what I have put my training money into. They have helped me with getting my college work together. Male aged 39 years This scheme here helps with your head and education, I did a security course and other courses. . .this will lead me into employment. The end of the course I want to be off methadone and drug free. Male aged 37 years Several participants reported a lack of nal tangible outcomes on completion of their ve year scheme, in terms of lack of formal training certication, gaps in curriculum vitaes and employer prejudices against

those with Special Community Employment scheme attendance, and said; It is you make of it yourself. . .there is a lot involved and when you do get clean, nding a job and to nd somebody that will take you with a curriculum vitae that says you worked 15 years ago, its not too easy. Male aged 34 years I cant put the scheme down as a reference, because people who dont know anything about recovery think we dont want her working up here . . . there are two gaps in my curriculum vitae that I cant cover. I found that people who have left here before me have gone out and done nothing . . . .they actually have done nothing, they havent got work, they havent got any more training. I think its a very vulnerable time because you have had all the support on a daily basis, to walk out that door and have nothing. Basically after 3 years on being the schemes I am not trained to do anything. I am no more employable than I was 3 years ago. Its ok to say you can do a three day course here and a three week course there, its not going to help. People on Community Employment schemes should be encouraged to look at what they are going to do when they leave the scheme. Female aged 43 years Greater levels of counselling and vocational support, and detoxication assistance were reported for those partaking in the Special Community Employment Schemes. A number of participants highlighted that they were unable to access counselling or had experienced long waiting lists for counselling and a lack of staff continuity, when outside of the Special Community Employment scheme remit. Several participants reported; I wouldnt say there is a lot of help for people who isnt involved in the scheme, if people are looking to change they need to be given the chance, something needs to be put into place, something that gives them that hope and there are people who just dont want to give it up. Male aged 49 years Several participants remarked on the lack of follow up support for those completing the scheme, which was reported to contribute to feelings of isolation, time wasting and potential for relapse, and said; There is not enough support when you leave a Community Employment scheme, once you leave youre nished you are gone, youre thrown out

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there to fend for yourself, there should be aftercare type service. Female aged 48 years I dont think the aftercare is very good. . . . I would like to see a back to work initiative or more follow on Community Employment places. Male aged 33 years Most participants reported that they had nished the schemes and wished to return. Female participants and those no longer on social welfare benet in particular appeared hampered in their progression toward employment. I think there should be something out there when they do leave, a place where you could drop in see people if they need to talk. Male aged 49 years I have an application in for a scheme, I am trying to get on somewhere, the one I was on I loved it . . . I would love to go back. Male aged 37 years

4. Discussion Qualitative research on individual experiences of overall life functioning whilst on methadone maintenance, and particularly with focus on vocational rehabilitative processes remain scant, and particularly within Ireland [53, 66, 67]. The research ndings must be viewed as exploratory and conned to the localized experiences of this cohort in the inner city Dublin area. However, the interplay between experiences of methadone stabilization and participation in vocational training and employment schemes were largely concurrent with the literature. Firstly in terms of this peer led research process, the research is intended to contribute to create dialogue from service users perspectives in relation to the improvement of methadone stabilization and vocational outcomes for individuals accessing Special Community Employment Scheme [5457]. It is notable that Client Forum representatives (as driving forces of this research) were selected by coordinators of each Special Community Employment Scheme, did not include active drug users, and did not involve the recommended democratic participatory approach advocated in current service user involvement processes [5457]. It is vital to engage with all user groups within the methadone maintenance continuum, in order to create participatory support systems and training opportunities [57]. User terminology as opposed to that of Client is supportive of an attitudinal shift toward recognition of users as

active, equal and responsible citizens within a partnership approach [57, 58]. It must be noted that services in contact with addicts traditionally view them to be manipulative, resistance, difcult to engage with and gratication seeking [58] with service provider-client power differentials grounded in Client terminology, inferring weakness, passivity and dependence [53, 54] and client mistrust of authority and experiences of drug related stigma contributing to tensions within such collaborative relations [59]. Secondly, and similar to other research on methadone maintenance [42, 60], a majority of participants described how methadone maintenance treatment created a window of opportunity for them to get life back on track, get headspace and utilized as rehabilitative medium for participation in the Special Community Employment schemes, as precursor to life changing relationships, new vocational and peer environments, and employment prospects. Although initial client satisfaction with methadone maintenance treatment was reported in a majority of clients [42] over time the medical emphasis on client retention within the treatment continuum appeared at odds with client requests to come off treatment [60]. Indeed, in this research, the effects of methadone on daily life were grounded in frustrations relating to lack of control, compromised personal freedom and personal perceptions on progression routes. This restriction of freedom and anxieties around chronic dependence is reiterated in other research [53]. Research has also identied a long term methadone maintenance cohort, considered by themselves to be stuck in treatment [60]. Disappointment lay in the lack of client-doctor dialogue and client participation in agreed treatment care pathways. Similar to recent Irish research on detoxication trajectories [61], the majority of participants described methadone maintenance treatment as a government holding pattern, and sought information regarding dosage tapering, treatment centers and modes for self detoxication themselves via informal methadone and heroin using groups. Participants also described attempts to come off treatment without medical assistance (jumping off) [60] which contributed to frequent relapses, with many observing that methadone was harder to withdraw from than heroin. Lintzeris et al. [62] has described the fear of remaining on methadone contributing to attempts of clients to avoid higher doses of methadone, and attempting to seek out short term treatment modalities. One should note that methadone stabilization and adherence to treatment protocols are prerequisites to continued participation in Special Community Employment

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schemes. Research shows that longer duration treatment with higher dose of methadone, psycho-social interventions and speed of treatment re-uptake post relapse is associated with improved rehabilitative outcomes [15, 16, 18, 63]. Although participants described varying denitions of being clean rehabilitation was reported to be (ideally) drug free and not on methadone. For some participants personal denitions of recovery were grounded in remaining on low dose methadone for life and reported difculties in letting go of their previous drug addictive lives [42, 65]. However, some participants reported that methadone maintenance carried a potential for switching of addictions, in terms of difculties to withdraw and frequent co-prescribed medication abuse. Indeed, and impacting on perceived progression routes toward third level education and employment within each Special Community Scheme, research has shown that the greatest barrier to vocational training and employment participation for ex drug users is the continued use of illicit substances [64]. In particular, the evident restructuring of daily patterns relating to both attendance at the methadone clinics, and Special Community Employment schemes provided opportunity for the participants to revise daily addictive patterns and reduce additional other drug use [66, 67]. In the absence of engagement in a positive therapeutic intervention such as the Special Community Employment scheme, positive day to day individual functioning for participants on methadone maintenance had the potential to become static. Research has underscored that the support of ex drug users through vocational and employment training, whilst in receipt of welfare payments increases feelings of control, empowerment and autonomy [40] and incurs a peripheral effect on positive social functioning as mothers, fathers, wives, husbands and partners [68]. Similar to recent research in 2011 on academic outcomes of ex drug users in Ireland [65], participants described an interplay of multiple recoveries grounded in social and family exclusion, stigma and low self esteem, and the need for developing a new work ethic typied by discipline, resilience and alternative norms and values around education, training and employment, all of which impacted on their full participation in and progression from the Special Community Employment Schemes. The majority of participants on the Special Community Employment schemes described how methadone maintenance treatment and engagement in the Special Community Employment Scheme created a new sense of identity for them, a sense of group

cohesion and togetherness, feelings of purposefulness and stimulated personal growth. Indeed, De Maeyer et al. [42] has underscored how purposeful living in the form of direction, training and employment for those on methadone maintenance is paramount to increased quality of life and improved treatment outcomes. Several participants described learning to be assertive and speaking in public situations whilst partaking in the Special Community Employment schemes, which had a reciprocal positive effect on client-doctor relations within the methadone treatment regime. One must note that evaluation and audit of current vocational, employment training and academic outcomes for ex drug users in Ireland is scant [6567]. Similar to recent evaluations of the Special Community Employment schemes in Ireland [66, 67], it appeared that not only was methadone stabilization a dead end for ex drug users, but the Special Community Employment schemes operated in a similar fashion, with vocational training and employment supports secondary to the focus on personal therapeutic development, methadone dosage and other drug use reduction, relapse management training and long term progression toward detoxication. Whilst offering support in personal growth and movement along the rehabilitation continuum, the ndings are further complicated by evidence that each Special Community Employment scheme operated autonomously and provided varied degrees of service and support to its clientele grounded in a one size ts all philosophy [66]. This relaxed approach to vocational training of ex drug users is discouraging [47]. It remains to be said that (and similar to other Irish research [66, 67]), the majority of participants in this research felt stied and dependent on the scheme coordinators ethos, and were dissatised with vocational outcomes and utilization of their time on the scheme (ve years), with many left untrained with no formal certications, unemployed and unable to access third level education. Research shows that three quarters of methadone maintenance clients desire further training and certication for professional or technical jobs [17]. In terms of attempts to seek and secure employment, many experienced difculties with curriculum vitae gaps and employer bias relating to Special Community Employment scheme stigmas, and reported that the lack of aftercare support systems on completion of the ve year scheme contributed to high unemployment rates and risks for relapse. Recent research has underscored that the provision of Special Community Employment Schemes in Ireland is compromised by a lack of interagency work

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between health and addiction treatment services, and vocational educational training providers, with vocational educational training staff often ill equipped to deal with ex drug users [66, 67]. There is a need for intensive vocational training, certications and structured job seeking supports within a client centered approach (i.e. Motivated Stepped Care, Bridge to Workplaces, and Customized Employment Supports) in order to assist methadone maintenance clients along their personal rehabilitative journey, and in the retraining, certication, and progression routes toward successful employment [41, 48, 69]. Building on these recommendations, these research ndings have been submitted as part of an interagency public consultation, in order to initiate dialogue and interagency development within a participatory consultation with all stakeholders (service users included) [48, 66, 67].

pathways, work placement and employment supports. In the absence of this, Special Community Employment schemes as sole provider in Ireland will continue to fail to provide long term solutions for ex drug users, and continue to act as a holding pattern. Future research efforts should involve a democratic and participatory approach with all key stakeholders, in order to clearly distinguish responsibilities and avoid duplicity between health and addiction services, and that of the vocational education provider within an interagency rehabilitation framework. Funding directives are needed to further develop this existing scheme structure in terms of improved vocational outcomes, and building on its success in terms of therapeutic value and advocacy functions.

Acknowledgment 5. Conclusion The ndings, whilst exploratory and context specic to inner city Dublin, Ireland are indicative of stabilization offering participants the opportunity to commence recovery and personal growth, with participation in the local Special Community Employment schemes acting as adjunctive therapeutic support mechanism. However, the Special Community Employment schemes whilst experienced in a positive therapeutic manner did little to provide specic vocational training, acquisition of employment related skills and supported work placement, with many participants left unqualied, unemployed and with little aftercare on completion of the scheme. The research underscores the need for extensive revision of the ethos and direction of existing Special Community Employment schemes in Ireland, in order to provide timely therapeutic value for ex drug users in conjunction with skills certication, on the job skills training, structured and assisted job searching, and work or volunteer placement opportunities. It is regrettable that this situation has occurred in these Special Community Employment schemes, despite the worthiness of stimulating personal growth within vocational training. Community and employment reintegration must viewed as distinct objectives, and are very much dependent on individual rehabilitation journeys [66]. The lack of uniformity of scheme provision must remain cognizant of the individual nature of rehabilitation, and provide greater intensity of client centred and directed learning, skill development and capacity building, formal certications and academic 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. With thanks to the participants of the Dublin North East Task Force Client Forum.

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