Coronavirus (COVID-19) opioid substitution treatment in prisons - evaluation: patient experience follow-up report

3. Discussion

Substance use is a significant issue in Scotland's prisons, affecting the health and wellbeing of the people who live and work in these settings, along with impacting on regime stability and security. There is also a strong relationship between substance use and crime, as well as substance use and reoffending. The introduction of Buvidal as a treatment option for OST patients in Scottish prisons was accelerated by the COVID-19 pandemic. The purpose of this study was to gather more in-depth data about Buvidal patient experience, which had not been feasible during previous research about Buvidal by the Scottish Government. This research involved semi-structured interviews with male and female Buvidal patients and healthcare staff in prisons within one health board. The findings from this research are now discussed in the context of the previous Scottish Government research on Buvidal and with reference to the now burgeoning literature on PRB, where relevant.

3.1 The transformative potential of Buvidal

This research demonstrated a continued sense of enthusiasm about Buvidal among patients and healthcare staff. If funding were to be provided for Buvidal by Health Boards in the longer-term, the prospect of which is currently uncertain, it is likely that more OST patients in Scottish prisons would switch to Buvidal. By interviewing a larger sample of both male and female Buvidal patients who had been taking Buvidal for several months, there is now greater evidence of first-hand patient experience. As with the previous Scottish Government research, the findings from this research present an encouraging picture of the efficacy of Buvidal as an OST in prisons. Evidence suggests it offers a host of positive lifestyle and health and wellbeing benefits. Indeed, given the spectrum of impacts, Buvidal could have transformative potential as a treatment for opioid dependence in prison. Given these findings, there is now evidence to suggest that more patients would benefit from being prescribed Buvidal, if it was offered as a treatment option to everyone entering prison with a history of opioid use. To support the growth in numbers of Buvidal patients in prison, it was encouraging to note that there are plans for the formation of voluntary Buvidal peer-support groups in prisons, which could be an important facilitator to widening uptake. The sharing of knowledge, experiences, and coping strategies in such groups may be particularly important for patients who struggle with the transition from methadone to Buvidal. Moreover, the process of giving and receiving nonprofessional, nonclinical assistance between individuals with similar conditions or circumstances has been shown to benefit people with substance use disorders

Regarding the social harms caused by opioid addiction, it is encouraging that this research found that OST patients who had been on methadone for many years, and seemingly had a history of stalled progress towards abstinence or recovery, saw positive changes to their lives within a few months of starting Buvidal. This research indicates that methadone was undermining the quality of life of some OST patients in prison. As an alternative, Buvidal would appear to 'lift the veil' of suppressed emotions, cognitive impairment, and stigma that many patients reported experiencing when taking methadone. Shedding stigma may have important implications for reoffending outcomes. Desistance can be aided by people avoiding or shedding labels that can stigmatise and fix them in their past (e.g. as an 'offender', 'prisoner', or an 'addict'). Providing opportunities for people to take on new roles, perhaps as a jobseeker, peer-supporters in a therapeutic group, or as a person on the road to recovery, could prompt identity change that research has linked to desisting from offending and the recovery process^[15]. The findings from this report may be particularly impactful given that drug related deaths are a major cause of mortality among people who have been in prison, particularly immediately following their release^[16], and considering the recent increases in drug related deaths in Scotland. A need for action to address the vulnerability of people leaving prison to overdose and death in the period immediately following liberation has been acknowledged as a key priority by the Drug Death Task Force set up by the Scottish Government, which has highlighted the importance of continuity of OST provision and providing Naloxone kits to people leaving prison with a history of substance abuse as preventative measures^[17]

This research, although focused on people in prison, provides evidence to suggest that wider prescribing of Buvidal could improve outcomes for people leaving prison in the community, including protection from opioid overdose and other harms associated with substance use, improved relationships with families, and as a facilitator to employment and lifestyle stability. Notably, one of the main motivations for patients switching to Buvidal was to help them avoid attending community pharmacies on a daily basis. These are settings where Buvidal patients reported feeling stigmatised and vulnerable owing to an increased risk of opportunistic drug use via contact with drug-using associates. Switching from a daily to monthly attendance would substantially reduce exposure to these risky settings and may contribute to a reduction in opioid overdose and drug related offending. Removing the need for daily attendance at a community pharmacy would also afford people greater power and freedom to shape the course of their lives. This could lead to them being able to do many of the activities other people take for granted but can be challenging when tied to a daily supervised medication regime, such as going on holiday or holding down employment.

Indications of the potential for Buvidal to impact the lives of OST patients in the community in Scotland has been shown in the results of several small-scale pilot projects. For example, a community addiction service in West Lothian reported high patient retention rates and noted that clarity of mind had not been a barrier, including among patients with personality disorders^[18]. Experience from a community pilot of Buvidal in Glasgow^[19] highlighted that it may be of particular value to patients starting OST for the first time, those who are frequently remanded in custody, patients progressing in their recovery, and patients who feel stigmatised by their current OST. However, while the findings from these pilots and the research in this paper are encouraging, the evidence base for Buvidal would benefit from further research.

Considerations for future areas to focus on or approaches could include longitudinal studies which follow a cohort of Buvidal patients while they are in prison and then into the community following liberation. This research could explore outcomes related to drug use over time, employment, reoffending and desistance, and other benefits, including health and wellbeing, engagement in purposeful activities and changes in identity and relationships with family or friends. From a prison perspective, studies could explore variations within the population receiving Buvidal in Scottish prisons. For example, further research may determine insights related to sex, age, ethnicity, education, and recovery status. Additionally, further research could explore the impact of wider prescribing of Buvidal on safety and security within Scotland's prison by assessing impact on levels of diversion, bullying, and consumption of illicit substances. Lastly, further research within prisons could consider the role for additional mental health support to offset some of the limitations of Buvidal for patients within struggling with past trauma, particularly among female Buvidal patients.

Unlike the first piece of research by the Scottish Government, which only spoke with male Buvidal patients, this research interviewed several female Buvidal patients, who mostly described improvements to their health and wellbeing. Opioid dependent women in prison are understood to be a particularly vulnerable group, whose trajectory into custody is often associated with their drug use and, in many cases, is tied to past abuse and trauma^[20]. Buvidal as a pathway to recovery may well reduce the specific criminogenic and other drug related harms women in prison experience. Previous studies have found that women in prison tend to repeatedly return to custody after serving short sentences and drug use is strongly associated with women being reconvicted after liberation^[21]. Other notable findings in this research included how one female participant hoped that Buvidal could help them regain custody of their children and several women were returning to live with their families. While precise figures are not available, data from the Scottish Prisoners Survey shows that two thirds of imprisoned women in Scotland self-report as having children and, while nearly half of mothers in prison reported in the survey that they would be involved in caring for any of their children after they leave prison, one quarter were unsure^[22]. Buvidal, and the potentially more stable lifestyle it offers, may lead to women in custody who are uncertain about future involvement in the care of their children post-release becoming more involved. Additionally, key factors women attribute to their desistence is concern about the impact of their offending on their children^[23]. In terms of family relationships more broadly, evidence also suggests that women's relationships (with parents, partners, peers etc.) are key to desistence^[24].However, although Buvidal may potentially contribute towards desistence and improved family relationships, potential benefits could be limited because Buvidal may not be suitable for OST patients with acute mental health needs, as noted in section 3. In particular, Buvidal may not be suitable where substance misuse is related to suppressing past trauma, because of the heightened cognitive and emotional clarity compared to methadone, and as noted above, opioid dependent women in prison have often experienced abuse and trauma. This issue may be particularly relevant to Scotland's female prison population as a higher proportion of women in prison are opioid dependent compared to the male population and the drivers of their addiction and pathways into offending and prison are often quite different.

Aside from benefits to OST patients, there is potential for Buvidal to also have a transformative effect on prison regimes, security, and health care services by lightening the considerable burden of administering daily OST. It was noted in the The Scottish Government's initial research on Buvidal suggested that administering daily OST in Scotland's prisons clogged up the prison day, with dispensing taking up a considerable proportion of staff resources and time and prevented people from participating more fully in prison life as a result of not being able to start activities until after they received their OST prescription. Reducing the burden OST places on prison operations could allow people to engage more fully with purposeful activities and give operational staff more time to focus on case management support. From a security perspective, Buvidal appears to lessen the desire among patients to use additional opioids or other substances. The sourcing and consumption of illicit substances or diverted prescription medication within prisons is associated with a range of negative factors – including the spread of disease and fuelling an illicit economy that is often supported via smuggling, bullying and intimidation, and violence. Previous research highlights that decisions about OST treatment options in prisons require careful balancing between issues of treatment effectiveness with concerns of prescription diversion and misuse^[i]. Buvidal appears to offer considerable treatment benefits while reducing concerns about diversion and misuse. However, the impact of wider Buvidal prescribing on the flow and consumption of illicit substances and diverted prescription medication will likely only be more fully understood over the longer term and once prisons resume their normal regimes. From a healthcare perspective, increasing the number of Buvidal patients would likely free up resources within prison health centres, which may increase nursing time for patient facing activities^[ii].

3.2 The limits of Buvidal

Despite the evidence in this study demonstrating the positive impacts of Buvidal, it should not be seen as a panacea for the many challenges facing opioid-dependent people in prison. This research highlighted some important limitations of Buvidal and demonstrated that it may not be an appropriate treatment option for all OST patients in prison. Methadone and Buvidal are pharmacologically distinct treatments which exert effects on patients. As a partial agonist, Buvidal patients typically experience heightened cognitive and emotional clarity compared to methadone. As shown in this research, this may be a significant drawback for some, especially those whose opioid use is associated with suppressing or coping with past trauma. It was common for patients to struggle with withdrawal symptoms during the changeover from methadone to Buvidal, particularly those with a treatment history of higher doses of methadone. The example of the patient who attempted suicide highlights the potentially serious impact of increased cognitive and emotional clarity for some. While mitigations such as top-up injections of Buvidal and/or increasing dosage mostly alleviated the discomforts experienced, patient experiences highlight the importance of implementing transition strategies, particularly for high dose methadone patients. However, this study also suggests that patients mostly become stable on Buvidal after they have been given their second monthly dose. While it is currently only OST patients with a minimum of 6 months remaining on their sentence that can change their prescription to Buvidal, findings from this research suggests that this period could be shortened to potentially include people with only 3 months left on their sentence.

3.3 The uncertain future of Buvidal

The findings from this research demonstrated uncertainty among healthcare staff about the future of Buvidal within their Health Board, with no firm understanding about future funding once support from the Scottish Government ended in March 2021. Staff indicated that, although existing Buvidal patients would be retained on their prescription, funding may well be the issue that dictates the future of Buvidal in custody. The apparent absense of any further roll out of Buvidal was a source of disappointment to healthcare staff. Maintaining existing patients on Buvidal and not offering it to other would lead introducing a multi-tiered approach to OST in Scotland's prisons, where one form of treatment is closed off to some patients who may wish to change their OST. This would appear incongruent with the encouraging evidence from this and the Scottish Government's prior study about the positive impacts associated with Buvidal for patients, SPS, and prison healthcare staff and services. Additionally, not offering Buvidal limits patient choice and risks keeping some OST patients on a treatment (e.g. methadone) they are dissatisfied with, creates stigma and self-stigma, exposes them to bullying and threats of violence, and does not reduce their consumption of other drugs, either in prison or the community. Moreover, while this research did not explore potential economic benefits, several economic analyses have found that wider prescribing of PRB, such as Buvidal, could lead to reduced long-term costs for providing OST and wider savings across healthcare and criminal justice systems^[25].