Coronavirus (COVID-19): opiate substitution treatment in prisons - Chief Medical Officer letter

COVID-19 contingency planning - Opiate Substitution Treatment (OST) in prisons

This letter seeks your agreement to, and help with, the immediate transition from current Opiate Substitution treatment (OST) in prison settings to a more pandemic-appropriate form of OST for up to four months. The Scottish Ministers have agreed to a transition to wide-scale prescription of Buvidal and have agreed that additional costs associated with this transition should be included in local mobilisation plans, as agreed with Health Finance in the Scottish Government. A protocol for the use of Buvidal in prisons during the pandemic has been considered and approved by the Scottish Government’s Clinical Guidance Cell and the Professional Advisory Group.

As you will be aware, there are a number of particular challenges facing healthcare in custodial settings to manage and respond to the COVID-19 pandemic. I recognise that the current pandemic situation presents a risk in ensuring continuity of OST for people in Scottish prisons at a time when the workforce is greatly reduced.

Approximately 25% of people in prison receive a daily supervised OST, which is resource intensive in terms of health centre and prison staff time. In order to: ensure continuity of OST; support social isolation and restricted movement within prisons; and to support staff during the current pandemic, the Scottish Government have worked with partners, including the Scottish Prison Service (SPS) to identify alternative sustainable OST within prisons.

The Scottish Ministers are expecting Health Boards and Integration Authorities to transfer all prisoners currently on OST, serving a sentence of six months or longer, onto injections of depot buprenorphine (known by the brand name “Buvidal”) where this is clinically appropriate.

Buvidal is available as a 7-day or 28-day injection, which would reduce administration and treatment episodes. The proposal would be to move as quickly as practicable to 28-day depot injections which will significantly reduce administration and treatment episodes.

By rolling out the use of Buvidal to this cohort it would remove the need for daily administration therefore ensuring no gaps in treatment, which could lead to unplanned and unmanaged withdrawal. It would also lead to a rapid reduction in the daily number of patientstaff interactions, freeing up resources to carry out other essential patient care and SPS activities and reducing the risk of COVID-19 transmission.

The switch to Buvidal would also bring additional benefits through reducing bullying/exploitation for OST medicines (Buvidal cannot be extracted and diverted) and, as the formulation contains a protective effect that blocks the full effects of opioids, it could prevent some opioid related overdoses in prison and on liberation.

Finance

The switch to the use of Buvidal as an OST in prison is being advised for four months in the first instance in light of the Covid-19 pandemic, with a review of the pandemic situation planned in month three.

Ministers and the Scottish Government’s Health Finance Planning and Assurance Group have agreed emergency funding of up to £1.9 million for Health Boards to cover the cost of transferring OST administration to Buvidal in prisons for an initial four month period. During month four I will review whether there is a need to seek permission and further funding to extend the period of OST contingency plans.

In order to access funding Health Boards will need to procure Buvidal for those four months and add this new activity to their Mobilisation Plans in order to be reimbursed. Should Health Boards wish to continue using Buvidal in prisons beyond the pandemic then funding for this future provision is likely to have to be secured from existing OST budgets.

Supply

Buvidal is fully licensed and has been approved on a restricted basis by the Scottish Medical Consortium (SMC) for use in NHS Scotland. The proposed used of Buvidal in prisons for Covid-19 contingency planning is in line with SMC recommendations.

Health Boards will secure supply through a procurement contract which will be facilitated by our National Pharmacy Adviser, Healthcare Improvement Scotland, as with all other forms of OST.

Camurus, the manufacturer of Buvidal, has confirmed it can supply Health Boards with Buvidal immediately to switch all those currently prescribed Buprenorphine-type medications to weekly Buvidal injections.

Supply of 28-day Buvidal for prisoners who are currently prescribed methadone will be available by early May. However, a phased approach would need to be adopted to transfer patients from methadone to Buvidal in each of the prison sites.

Transition

There are clear benefits to the health system, prison regime, and to people being prescribed OST in the medium to long term. However, the initial transition has to be handled carefully. There are some sensitivities involved in transferring patients from methadone to Buvidal as withdrawal needs to be established prior to treatment initiation, therefore a system will need to be put in place to monitor people in the first few days of usage and in case of adverse reactions. However, an evidence-based approach that uses a 36-hour washout, for high dose transfer from methadone to buprenorphine, has been used in community settings by NHS Lanarkshire since 2017 with an established protocol in place. This approach minimises the level of withdrawal symptoms experienced.

A Protocol for use of Buvidal in prisons has been prepared to support healthcare staff and can be found attached. This includes a step by step approach for staff on how to manage the transfer from Methadone (including higher doses above 30mg) and Buprenorphine to Buvidal along with information on where to access additional help.

The SPS is also developing approaches to minimise risk, including introducing the switch to Buvidal. Clear, open communication with the prison population will ensure understanding of the reasons for the switch and concerns about the risk of an interruption to daily methadone supply.

Evaluation

The attached protocol includes outcomes to measure the numbers, time and cost associated with administration of Buvidal compared with current OST administration in prison settings over this 4 month period.

Conclusions

I am aware that there are ethical issues associated with changing people’s medication, however in the current pandemic situation this needs to be balanced against the risk of disruption to the supply and administration of daily OST.

I seek assurance that Health Boards will support a switch from current OST formulations to Buvidal injections for four months (May-August) to all people currently on OST in prison serving sentences of six months or longer, where it is clinically appropriate. It would be helpful if Integration Authority could notify the Scottish Government of any Health Boards within their area that have prisons and have or have not acted upon this advice.

I would like to take this opportunity to thank you for your assistance with this matter, if you have any policy enquiries in relation to this advice then please direct your enquiry to Michelle Rogers (Michelle.Rogers@gov.scot). If your enquiry relates to a clinical or implementation matter there is a contact list provided in Appendix 2 of the guidance so you can direct your enquiry to the relevant person.

Yours faithfully

DR GREGOR SMITH