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

3. Impact Of The Buvidal Programme

This section documents the qualitative impact of the programme, primarily from the perspective of GiCs and healthcare interviewees. It explores the impact of the wider prescribing of Buvidal on patients, prison operations, and health services.

3.1 Impact on patients

3.1.1 Observed impacts

Had time and circumstances allowed, the study would have sought to capture more first-hand patient views about their experience of Buvidal, including their decision-making process for changing their OST, how they experienced the transition, and the effect Buvidal had on their lives, including possible reversion to their previous OST. As stated, included in this evaluation are the perspectives of 3 OST patients in custody. At the time of their interview, 2 patients were stable on their Buvidal prescription while the other had reverted to their previous OST prescription. Interviews with healthcare staff explored their observations about how patients had responded to Buvidal, and what further benefits might be anticipated; although these carry a caveat about the small numbers and short period in which these observations are based.

Despite the limited patient experience data, almost every interviewee, including the 2 remaining Buvidal patients, were extremely positive about the potential benefits of Buvidal for OST patients over the longer-term. Additionally, there was consensus across what staff interviewees from different prisons were saying about the impact they had seen on patients, and these views largely aligned with the 2 patients interviewed who were on Buvidal at the time.

When asked about any changes they had seen in patients, those healthcare staff who had interacted with patients on Buvidal were fulsome in their praise for the impact it had on people. They described how Buvidal patients appeared happier, healthier, more lucid, and were moving forward with the recovery journey. The 2 Buvidal patients interviewed said they were happy and satisfied with the overall experience and the changes it had made to their lives. They described how taking Buvidal had improved their energy levels, mood, and made them feel like they were no longer taking OST. One described how they felt like they had become 'the person I was before I started taking drugs'. It would appear that Buvidal could have life changing benefits for some patients.

With respect to impact on patient safety, only one incident of a Buvidal patient topping up with illicit substances was reported during interviews. There were no recorded attempts of patients attempting to divert their Buvidal. Although, given the suspected limited availability of illicit substances in Scottish prisons currently, a more accurate assessment of the impact of Buvidal on illicit substance use among OST patients may only be possible once prison regimes return to something approaching normality.

3.1.2 Anticipated impacts

Healthcare interviewees anticipated a number of benefits for OST patients in prison should the Buvidal programme become more widely established. These included:

• Buvidal offered a more therapeutic and recovery-focussed form of OST because it removes the emotional peaks and troughs that people could experience associated with daily administration.
• Buvidal would provide ongoing stability to the lives of OST patients; rather than having their lives dictated to them by a medication regime.
• Because of the increased cognitive clarity experienced, Buvidal could promote greater involvement with purposeful activities in prison from OST patients.
• Having monthly appointments could support healthcare staff to build richer and more therapeutic relationship with Buvidal patients than currently possible during daily administration.
• Increased patient safety by reducing incidences of bullying, violence, and health risks (e.g. spread of blood borne viruses) associated with OST diversion.
• Reduce the stigma experience of OST, particularly among vulnerable groups, such as female OST patients, and those on Methadone.

In addition to anticipated benefits for OST patients in prison, healthcare interviewees highlighted that Buvidal could improve throughcare outcomes after patients are liberated from prison. It was described that freeing them from the need to adhere to a daily medication regime could support patients' efforts to secure and sustain employment. From a health perspective, it was also described that protective effects of Buvidal could reduce the risk of opiate overdose after their release from prison, sometimes as a result of missing OST doses in the community or being exposed to triggers that prompt relapse. It was stressed by several interviewees that the protection against overdose offered by Buvidal could be most impactful during the first two weeks after release, when drug related deaths among prison leavers are at their highest^[14].

3.1.3 Drawbacks for patients switching to Buvidal

Some drawbacks for Buvidal patients were identified by interviewees. For example, it was highlighted that the heightened cognitive clarity patients can experience was challenging for some individuals with mental health needs, often related to past trauma, and these patients mostly chose to revert to their previous OST.

It was observed by most healthcare interviewees that the process of switching to Buvidal could be difficult for some patients and required a period of stabilisation. For patients switching over from higher doses of Methadone, some had been unable to lower their doses sufficiently to change to Buvidal. It was observed that patients suffered some side effects in the first few days of switching over. Difficulty sleeping and feeling fidgety were the commonly reported side effects as were feelings of withdrawal. In some cases it was reported that while people reported feeling symptoms of withdrawal, they showed no physical symptoms when examined.

Healthcare interviewees highlighted that in order for the first dose of Buvidal to be most effective for OST patients currently taking Methadone, they needed to experience a degree of withdrawal. Consequently, it was suggested that highlighting the difficulties faced by Methadone patients during the transition should be part of discussions with prospective Buvidal patients going forward, and that additional resources could be considered to support Methadone patients through the transition to Buvidal. The need to experience withdrawal does not apply to OST patients on another formulation of Buprenorphine, who switch treatment from one day to the next.

An unexpected finding was that some healthcare interviewees described OST patients switching from oral Buprenorphine more commonly reporting feelings of withdrawal than patients switching from Methadone. It had been anticipated by several interviewees that Methadone patients would struggle more with the transition than those already prescribed oral Buprenorphine. Indeed, in one prison, for example, every OST patient who had switched over from oral Buprenorphine to Buvidal then reverted back. When asked if they could explain why this might have happened, healthcare interviewees suspected that these patients may have been involved in diverting their OST prescription, although no evidence was reported that this was the case. The annual Addiction Prevalence Testing, which involves voluntary testing of people being admitted to or exiting custody in Scotland during one month of the year for the presence of illegal or illicit drugs, gives some indication of the prevalence of the illicit use of Buprenorphine by people in prison. For example, of the 522 tests carried out on liberation in 2018/19, 26% were positive for illegal drugs, of which Buprenorphine was most commonly detected^[15].

Aside from patient experience, there were some concerns about the logistical implications of continuing to prescribe Buvidal to OST patients in prison and then after liberation. Concerns were voiced by several healthcare interviewees about the implications for throughcare of starting someone on Buvidal while in custody if they were then unable to access it in the community. Uncertainty about continuity of prescribing of Buvidal once a patient was released from prison raised questions from some healthcare interviewees about the ethics of switching patients to different OST while in prison and them possibly having to switch again after they were released. It was felt that this might be disruptive to patients' recovery and resettlement in the community, particularly if they had been stable on Buvidal before their release.

Additionally, it was described that continuity of supply could have particular importance for prisons which house national populations, such as Glen Ochil or Cornton Vale, where people are liberated to communities across Scotland. Uncertainty was also voiced by several interviewees about how the financial costs of prescribing Buvidal would be met going forward. In several cases, it was noted how Buvidal is considerably more expensive per dose than either sublingual Buprenorphine or Methadone, and they were unsure whether further funding was available. Despite concerns about the initial outlay for prescribing Buvidal, it was widely believed that having more OST patients on Buvidal would save money in the longer term because it could free up resources, lead to wider health benefits, and potentially improve outcomes for prison leavers and increase safety for people living in prison.

3.2 Impact on prison operations.

All six GiCs were clearly in favour of Buvidal being widely used in prisons and mostly expressed enthusiasm for the Covid-19 contingency programme. For them, the arguments for using Buvidal in prisons for the benefits of patients, staff and the effective function of the prison were well established and they were ready to respond operationally.

The accounts from GiCs of prisons where there is a significant proportion of people on daily OST illustrated the major impact it has on almost all aspects of prison life. The time taken up by OST not only means prison staff are unavailable for other roles, but patients cannot start to engage in other activities until they have received their prescription. One GiC referred to daily OST as having 'snarled up' the daily routine in prisons. Buvidal could be a 'game changer' for individual establishments and the wider operational effectiveness of the prison system.

The demand placed on SPS resources by daily OST can be seen from figures submitted to the Scottish Government by SPS for this evaluation, which showed the number of staff and length of time taken in supporting the administration of OST on 13^th August, 2020 on a daily basis. All fifteen prisons submitted data, however, due to possible inconsistencies in the data between institutions a break-down is not included in this report. The figures provided do give a good indication, however, of the demand placed on SPS staff supporting the administration of OST in Scottish prisons. Whilst in some prisons administering OST took less than 30 minutes in others it took up to 9.5 hours of staff time per day. The numbers of staff involved also varied from 3 or fewer staff in some prisons, and up to 20 staff in others. The time taken aligned with the numbers on OST in each prison.

According to all of the GiCs, the Buvidal programme had so far had minimal observable impacts on SPS operations, such as reducing the amount of staff time spent on supporting the administering of OST. Principally this was because insufficient time had elapsed to assess impact and only an extremely small proportion of the overall population on daily OST had switched to Buvidal. Given the changes to prison regimes as a result of Covid restrictions, it was also hard to compare what impact Buvidal may have had on the normal prison routine. The lack of observable impact arising from Buvidal on prison operations was a source of frustration for most GiCs. Several repeatedly expressed disappointment that implementation had not been swifter or more widespread in their establishment due to the approach and pace of implementation taken by the NHS. However, GiCs anticipated that the Buvidal programme could have the following benefits for prison operations:

• Reduce the bullying associated with the illicit exchange of diverted OST and the availability of OST drugs as a commodity in prisons.
• Hugely reduce the staff time and the pressure involved in administering daily OST.
• Resources previously used to administer OST could be redirected to case management activities.

A fuller understanding of the impact that Buvidal may have on prison operations will only become clear if more patients switch and the burden of administering daily OST is reduced.

3.2.1 Impact of Buvidal on diversion and non-medical use of OST

When first conceived, this evaluation sought to assess diversion and other non-medical use of Buvidal and the possible impact on the risk of violence compared to other forms of OST in custodial settings. Every healthcare interviewee and all GiCs acknowledged that diversion arose when delivering OST in prisons, and the existence and harmful effects associated with diversion in prison settings, which aligned with descriptions in other research^[16]. However, this evaluation is unable to demonstrate that Buvidal prescribing had any impact on the issue of diversion, diversion-motivated bullying or risk of violence. This is for several reasons. Firstly SPS's Public Protection Unit, which is responsible for intelligence gathering about the prison population, does not report on bullying/intimidation relating to OST as a matter of routine, and such data was not accessible within the time frame of this evaluation. Secondly, and as was raised by several interviewees, this evaluation took place during the restricted regime implemented by SPS in response to Covid-19. This meant that the movement of people within prison has been severely restricted and was felt to have curtailed many of the opportunities for bullying and reduced the dealing of illicit substances .

What this evaluation can say is that no incidences of diversion were reported among Buvidal patients and healthcare interviewees were confident that diverting Buvidal would be impossible. Previous research has highlighted that decisions about which OST treatment options to use in prisons requires careful balancing between issues of treatment effectiveness with concerns of prescription diversion and misuse^[17]. Buvidal would appear to offer considerable treatment benefits while reducing concerns about diversion and misuse. However, a clearer sense of the potential impact that the wider prescribing of Buvidal may have on OST diversion in prisons will only be understood over the longer term and once prisons begin to resume their normal regimes.

An issue related to diversion that may have some impact on future prescribing of Buvidal was the seeming reluctance of OST patients currently on oral formulations of Buprenorphine to switch to Buvidal, and the seemingly higher proportion of Buprenorphine patients who transitioned to Buvidal but then reverted back to their previous OST. When asked if they could account for why this was, the most common reflection from healthcare interviewees was that that these patients were involved in diverting their OST – either to sell or as a result of bullying - and it was highlighted that illicit Buprenorphine has a high value in prisons. The diversion and misuse of Buprenorphine by people in prison with a history of problem drug use has been reported in past research from England^[18]. The role of OST diversion in influencing patient decision-making about their choice of treatment could be explored in future research.

3.3 Impact on health service operations

Every healthcare interviewee saw benefits for patients and healthcare services from prescribing Buvidal and wanted the programme to continue. Indeed, most said they would like it to become the 'first line' treatment for OST patients in custody. Healthcare staff highlighted that administering daily OST had a clogging effect on resources, similar to the views of GiCs, and the amount of time spent each day issuing OST was not felt to be an effective or efficient use of staff time.

As with prison operations, healthcare interviewees had not seen any substantive impact from prescribing Buvidal on prison health services. Again, this was because of the small numbers of Buvidal patients. However, it was anticipated that benefits would arise should Buvidal continue. These included reducing the amount of nursing staff time spent administering OST and freeing up staff to deliver other health patient focussed services to people in custody. Examples of additional health services included a wider range of clinics for OST and non-OST patients, and increased harm reduction and recovery focussed work.

In some cases, Buvidal had created additional work for health centres, including staff training. It was strongly felt that Buvidal would likely lead to savings on staff time and resources once a patient was stable, with health centre staff describing that administering Buvidal had been straightforward. However, switching required an initial increase in workload for each patient. This included identifying eligible patients, consultations and discussions with them about Buvidal, possible additional support if a patient experienced withdrawal symptoms prior to starting or needed support while they were reducing their current Methadone dose to the required level, support to help patients to adjust to Buvidal, and possible top-up injections.

Some concerns were raised about how the changes to administering OST would work from an operational perspective, particularly if the number of Buvidal patients numbers increased. An issue raised was about how increased numbers of patients having to be individually escorted to the prison health centre for their Buvidal injection would be managed, versus the current administration of large numbers of oral doses of OST from hall dispensaries.

The increased staff resources to support patients transitioning to Buvidal and logistical concerns raises questions about the efficacy of Buvidal as a contingency response to Covid-19, particularly in prisons with larger numbers of OST patients. Allied to this, there were some concerns about the guidance issued by the Scottish Government, particularly in relation to how Buvidal would be implemented from a logistical perspective. While it was felt that the clinical guidance was sufficiently clear, some health centres were uncertain about particular issues, such as would patents need to be escorted to health centres, or could it be administered on the halls in the same way as some OSTs. From the point of view of several healthcare interviewees, the guidance issued would have benefited from wider consultation with prison healthcare centres to create more actionable and nuanced guidance that was better suited to the prison setting. The pace at which contingency plans were produced for Covid-19 was a factor here, and the process followed for this guidance, through the Chief Medical Officer clinical cell, was the same as for other rapidly produced guidance in the early stages of Covid-19, where there was reduced opportunity for consultation.