Coronavirus (COVID-19) - Opioid Substitution Treatment (OST) in prisons: process evaluation

2. Buvidal Uptake In Scottish Prisons: May-August 2020

2.1 Overview of Uptake

Prior to Buvidal being recommended by the Scottish Government, there had been no estimate made of the eligible prison population on OST – i.e. patients who were serving a sentence of six months or longer and where switching to Buvidal was clinically appropriate. To move towards some understanding of the potentially eligible population, and therefore contextualise the uptake of the Buvidal programme across the prison estate, it was necessary to understand the potential size of the population who might be eligible for the switch. It was not feasible to address the 'clinically appropriate' criterion within the time and resource limits of the evaluation, as this would likely need exploration of patient-level data. This section discusses instead how the data that is available can provide a sense of scale and context.

The prison population has declined since the onset of the pandemic and at 17 August 2020, out of a total population of 7,364 people in prison, 2,645 (36%) had a release date of more than six months from that date. Based on an estimated 26% being on OST, this would equate to 688 patients on OST with more than 6 months remaining on their sentence. This estimated figure, however, does not tell us what proportion of OST patients would be clinically appropriate to transfer to Buvidal, but offers some basis for comparison with the figures who have moved over since May 2020.

The proportion of people in each of Scotland's 15 prisons who are on OST also varies, in part due to demographic variations in the populations in different prisons, mainly in terms of age, gender, the length of the sentence, and nature of offence. Table 1 presents a snapshot of the latest available OST prescribing figures from February 2020 for the entire estate (provided by the Scottish Health in Custody Network), against the known population of each establishment at that time.

Data were not available to indicate the proportions of who would also be beyond six months of release to allow more detailed estimates by establishment. Instead, Table 1 gives a more broad brush indication of relative numbers in different prisons.

Although the Scottish Government asked for all eligible patients to be moved over, Health Boards adopted different approaches to prescribing Buvidal. Some sought to make Buvidal available to as many clinically eligible patients as possible, whereas others took a more limited approach. For example, some adopted a Test of Change method, while others only targeted certain groups of OST patients, such as those already on a formulation of Buprenorphine. Additionally, it was noted that in some prisons there were too few eligible patients on OST, or that the prison itself had very low numbers of OST patients overall, for Buvidal to be adopted at this time. These factors, when combined with a reluctance shown by some patients, help to understand why the current numbers of patients who have switched to Buvidal is low as a proportion of the total number of OST patients in prisons.

Health Centre Managers were asked to provide the Scottish Government with the following data where possible: numbers of patients who had been moved from another OST to Buvidal since the guidance had been issued; the numbers still on Buvidal after one month; numbers of adverse incidents associated with Buvidal; numbers of patients reverting to their previous OST. However, some were unable to provide this level of detail. Data are also not comparable across institutions due to the different start dates of the use of Buvidal, the differing populations and numbers on OST, and the lack of prescribing data beyond February.

Data were received for seven institutions which had initiated the prescribing of Buvidal across five Health Boards, which represented a range of different types of institutions and populations. Based on the data in Table 1, the numbers of people in these individual prisons on OST varied from below 50 to over 230; and the proportion of people in individual prisons on OST ranged widely. At the February snapshot, the seven prisons contained approximately 44% of the Scottish prison population and almost 50% of the total prison population on OST.

At the time of writing, a total of 66 patients in these seven prisons had been transferred across to injections of Buvidal. This represents around one tenth of the total prison population of the estimated 688 people in Scotland who were on OST and had longer than 6 months left on their sentence on 17 August. Assuming these prisons continue to house almost half of patients on OST, as shown in Table 1, and that the estimate of 36% of OST patients have longer than six months in custody hold true, this would suggest that these prisons have transferred almost 20% of eligible patients onto Buvidal.

The proportion of each prison's population on OST who had moved to Buvidal varied widely and is not quoted here as it would only be meaningful alongside data on eligible numbers, which were not available. In some cases, additional patients were reducing their Methadone prescription in preparation for a switch to Buvidal. If further research were carried out it could seek to understand what proportion of this cohort are clinically appropriate to be offered Buvidal and explore how that may vary by institution. Due to the small numbers and given the various caveats around data limitations and comparability, figures have not been broken down in this report for individual prisons or Health Boards.

The proportion of patients still on Buvidal after a month was extremely high on the basis of data from five of the health centres, although the numbers reported are too low to draw quantifiable conclusions about long-term adherence. Numbers of adverse events were low and mainly to be expected in relation to side effects of people experiencing withdrawal from Methadone.

Looking beyond the current Covid-19 contingency programme, and to understand the potential uptake and impact of Buvidal, it is essential to take into account that the prison population is not static over a year. Therefore, future planning should consider the wider population passing through the prisons and who could be eligible for Buvidal if it were continued beyond the Covid-19 contingency measures. Figures for the 2018-19 financial year show that 17,294 individuals at some point were in prison during those 12 months (3,417 were in for the full year; and 13,877 for a part-year).^[13] This needs to be taken into account in forward planning by Health Boards, the SPS, and others involved in providing care and support to those with opioid dependency in the criminal justice system.

2.2 Patient perspectives on switching to Buvidal

Qualitative insights offered some indication about the motivations patients gave for switching to Buvidal, why some did not want to change their OST, and why some reverted back to their previous OST after starting Buvidal.

2.2.1 Motivations for switching to Buvidal

According to healthcare staff, patients' motivations for switching to Buvidal included thinking that it would improve the quality of their lives and the relationships they have with loved ones, who were often unsympathetic to them using Methadone. It was also described that patients wanted to switch to Buvidal because it would give them greater stability in the community, with Buvidal removing the need for them to attend a pharmacy on a daily basis, which may allow them to maintain more purposeful lives after release, including employment and even going on holiday. Lastly, it was described that Buvidal offered some patients the chance to start taking Buprenorphine who had previously been unwilling to do so because they did not want to be bullied for their OST. Two patients who were interviewed said they wanted to come off Methadone because of the side effects they experienced, including feeling sluggish and lacking motivation.

2.2.2 Motivations for not wanting to change their OST

According to healthcare interviewees, the most common reason given by patients for not switching to Buvidal was the newness of the treatment. Multiple healthcare interviewees described how patients said they did not want to be 'guinea pigs'. Others recalled patients citing pre-existing mental health problems, including needle phobia related to their past drug use and PTSD, which they felt would be too complex to deal with currently were they to switch to Buvidal. Additionally, it was described that patients were concerned about whether or not they would be able to access Buvidal in the community, and that patients might continue to be reticent about switching over until continuity of access to Buvidal after their release was more clearly established. Lastly, it was described that some patients were reluctant to switch over to Buvidal because of concerns that it was a only a short term measure and they would then have to switch back to their previous OST.

2.2.3 Reasons for reverting

Healthcare interviewees described that patients were making the decision to revert to their previous OST because they were unable to cope with the withdrawal symptoms they experienced after starting Buvidal. This was the reason given by the one patient interviewed who had reverted back to their original OST. Other examples were given where patients said they wanted to detox entirely from OST, rather than revert to their previous treatment.