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

4. Conclusions

4.1 Buvidal in Prisons as a Covid-19 Contingency Measure

The data available for this evaluation has shown that almost 20% of eligible patients were OST transferred onto Buvidal. While this might seem like a small proportion, there were several factors which may have limited uptake. These included a seeming uncertainty among patients themselves about starting a new treatment and different Health Board responses to the Scottish Government request. It is encouraging to note that very few patients who switched to Buvidal then reverted back to the previous OST, based on the data available.

From a qualitative perspective, interviewees had mixed views on the efficacy of a rapid introduction of Buvidal as a contingency response to Covid-19. Reservations were mostly expressed by healthcare interviewees; whereas GiCs were fully supportive. Several healthcare staff felt that there were ethical questions raised by switching patients onto a different OST for a period of only up to four months if they then might have to be moved back again, particularly if patients did not want to change.

It is difficult to assess the efficacy of Buvidal as a contingency response to Covid-19 because one of the problems it was intended to solve (i.e. ensure continuity of OST in the event of a large number of people living in prison being infected or wide scale SPS or healthcare staff absence) had not occurred at the time of this evaluation. Infection rates among people in prison in Scotland have remained low and staff absence rates, whilst higher than normal, have not fundamentally compromised prison operations or healthcare services. However, this evaluation has identified areas of learning and reflections which allow some conclusions to be drawn about the efficacy of Buvidal as a Covid-19 response, and may prove useful in the event of future outbreaks within prisons. Recent outbreaks at HMP Low Moss and HMP Barlinnie are a reminder of how easily Covid-19 can be transmitted in the prison environment.

Key lessons from evaluating Buvidal as a contingency response to Covid-19 are around the timing of the request and guidance from the Scottish Government, and a recognition of the logistical challenges of making changes to OST provision in a short period of time. Although switching to a form of OST which removed or reduced interactions between patients and healthcare staff, at a time of potential operational risks from high rates of staff absence, makes logicalsense, to do so during a pandemic presents logistical challenges. For example, another OST contingency option considered by the Scottish Government was to provide pre-measured daily doses of Methadone, which could be administered by non-healthcare staff, through the current national pharmacy contract for prisons with Lloyds Pharmacy. However, while Lloyds indicated they may be able to do this on a prison by prison basis, they did not have the capacity to provide this level of service across the whole estate at the same time. Further, this may only have been possible in some of the smaller prisons. In the case of Buvidal, transitioning potentially hundreds of people, from May 2020, presented its own logistical challenges at a time when OST contingency measures based on existing treatments had already been in place in Scottish prisons for several weeks. This conclusion is derived from several observations.

Firstly, there was a degree of unfamiliarity with Buvidal and no pre-existing localised systems in place to deliver the treatment. Prison health centres proved themselves adaptable to be able to support a third form of OST, which sometimes increased workloads and, in many cases, came after they had already implemented localised OST contingency plans. Secondly, whether prison health services would have had the capacity to support switching potentially hundreds of OST patients to a new treatment is unknown. Lastly, it would appear that the lead-in time and additional clinical support and monitoring required to transition some Methadone patients from daily OST onto Buvidal had not been fully appreciated when the Scottish Government guidance was issued. It can take several weeks for patients to switch over and requires several points of contact with healthcare services, in addition to continuing their daily OST. How this process could have been managed in the event of a large-scale Covid-19 outbreak in a prison is uncertain.

4.2 The future potential of Buvidal as an OST for patients in custody.

Following this research there is now much increased knowledge about Buvidal across prisons in Scotland. A strong sense of enthusiasm for the treatment from healthcare staff and GiCs was evident from the research. This level of buy-in and strong appreciation for the seemingly wide-ranging benefits for transitioning an increasing number of OST patients to Buvidal would suggest that uptake could grow in the coming months.

Despite some concerns raised about implementing the measure during the Covid-19 lockdown in Scotland's prisons, healthcare and SPS interviewees were unanimously positive about the longer-term benefits of prescribing Buvidal. Indeed, the transformative potential of Buvidal for OST provision in Scottish prisons was stressed repeatedly by healthcare professionals. These views were based on observations of changes seen in patients and they were closely aligned with the perspectives of the 2 Buvidal patients interviewed for this research. On this evidence, Buvidal presents a treatment option which can enable people in prison to more fully engage with purposeful activities in custody and which may lead to improved throughcare outcomes after liberation. The potential to improve the lives of OST patients in the community in Scotland was highlighted in a pilot study with patients from several Community Care and Treatment teams in Glasgow^[19]. Patients overwhelmingly reported the positive impact of avoiding opportunistic drug use via daily pharmacy contact with drug using associates. Additionally, a significant increase in engagement with structured activity was demonstrated.

From an operational perspective, it was strongly felt that having more OST patients in custody on Buvidal would free up NHS and SPS resources and lessen the disruptive impact that OST medication rounds have on the day to day activities in Scotland's prisons. Spending less time supporting OST could free up SPS operational staff to focus more on case management activities which may lead to improved outcomes. For the NHS, spending less time each day administering OST could allow health centre staff to deliver more clinics and harm reduction work with patients including those not on OST.

Whilst this evaluation was primarily concerned with exploring the impact of Buvidal in prison, the implications for throughcare were clearly a high concern for interviewees and part of the decision-making processes for Health Boards. The harmful and scarring effects of imprisonment have long been established, however time in prison can provide an opportunity to engage vulnerable people with health services^[20]. Interruptions to key support for people leaving prison, such as OST prescriptions, could undermine progress people have made in custody in terms of their addiction and recovery and may increase the risks of them reoffending and returning to prison.

In light of the decision by The Scottish Government to continue supporting the provision of Buvidal to eligible OST patients in prison until the end of the 2020/21 financial year, Scottish Government Health and Social Care Analysis is currently undertaking a further piece of qualitative research. This research is seeking to gather more in-depth and richer understandings of patient experience and is based on interviews with Buvidal patients currently in custody, which only formed a small part of this rapid evaluation. It is intended that this further research will include the perspectives of male and female Buvidal patients and the views of those Buvidal patients who are approaching release. It is anticipated this research will report towards the end of the 2020/21 financial year.