COVID-19 has created new challenges for the delivery of treatment and care to individuals with a drug problem within the prison population. Dr Steve Conroy tells us how the rapid rollout of a successful pilot scheme involving Healthcare Improvement Scotland has helped both prisoners recovering from addiction and the staff who are there to treat them.
Treating opiate addiction takes time. The most frequently prescribed treatments (opiate agonist therapy, or OAT) need to be taken every day, and it’s estimated that there are 1800 people in prison in Scotland who need it. Every day, each individual will be taken to and from a dispensing area by Scottish Prison Service staff and have their medication supervised by at least two NHS staff. That’s around 12,500 contacts between patients, the clinicians who treat them and the prison staff whose role is to facilitate that treatment every week.
In HMP Shotts where I work, over 170 of the 545 people in custody are prescribed OAT. That amounts to 63,145 interactions with them across the space of a year simply to administer their medicine. That’s a lot of time on the part of both staff and prisoners that might be better spent on work which can support them to recover from addiction in other ways. It’s also time that could be spent supporting other prisoners with other vital rehabilitation work. Throw a pandemic into the mix, where physical distance and constant cleaning of contact surfaces is vital, and those timeframes increase even further.
A vital decision
Generally, the OAT of choice is methadone, with far fewer patients on oral buprenorphine products. Buprenorphine, although a very valuable medicine in treating addictions, comes with many problems in the prisons, where it can be used as currency – creating problems with diversion, bullying and coercion. But it’s used because methadone is not a suitable treatment for all patients. Thanks to a decision taken by the Scottish Medicines Consortium in August 2019, there is now an alternative to daily treatment.
Buvidal is a form of buprenorphine which is a longer acting treatment and can be given monthly or weekly through a slow-release injection compared to daily doses of oral forms. When given within a framework of medical, social and psychological treatment, it may enable patients to focus on recovery and returning to normal daily routines without the daily visits to a pharmacy to receive treatment.
Time for change
Following the SMC’s decision, Healthcare Improvement Scotland’s Prisoner Healthcare team, with whom I work closely, began looking at a pilot scheme for the medicine in prisons. A business case was approved by Scottish Government in January 2020. But as the COVID-19 pandemic progressed, it became clear that the reasons to support the pilot became even more compelling and the team was asked to scale up their proposals.
Under our revised plan, all prisoners with at least six months left to serve of their sentence would be transferred to the new form of buprenorphine during the pandemic, provided patients gave consent to switch treatment.
As well as supporting social distancing measures, our proposals also meant, in theory, that staff and patients alike would have more time to spend on other activities which could support recovery from drug addiction – within the parameters afforded by COVID-19 restrictions. While it’s too early for data to confirm this, logic tells us that if we only see someone twice in 28 days rather than 28 times, staff and prisoners will have more time to spend on other things. In addition, the reduction in the quantity of controlled drugs being used prisons would help to reduce the potential for their use as currency, and improve overall safety.
To support the move to the prescription of this slow release form of buprenorphine in prisons, the team engaged with clinicians with experience of prescribing the medicine at local, national and international level in order to develop guidance. Crucially, given how the pandemic affected supply chains, we also worked closely with the pharmaceutical company to ensure there was sufficient stock of the product to meet requirements.
The decision to move to slow-release buprenorphine has been widely welcomed by prison staff and those receiving treatment alike. People have described it to me as “a game changer”, “nothing but good” and “the way forward”. In HMP Shotts, we have only had two people choosing to come off the treatment and going back to their previous medication. Those I’ve prescribed it to have said they feel better generally, enjoy the clarity of thought and really appreciate not having to wait in the daily “methadone queue”. Prison staff, meanwhile, have said that they have noticed a marked improvement in the general condition of people prescribed this medication. It’s incredibly satisfying to have worked with colleagues at Healthcare Improvement Scotland to have delivered a simple and effective change that has made such a difference to people’s lives.
Dr Steve Conroy is Lead Medical Practitioner in NHS Lanarkshire’s Addictions Community Prescribing Service.
Read our position statement on long-acting buprenorphine for opioid substitution therapy.