1. Background and purpose of this study
It is well known that there is a strong relationship between substance use and crime, as well as substance use and reoffending. Substance use can threaten the health and safety of the people who live and work in prisons, as well as the security and stability of the prison environment. The prevalence of opioid dependence is substantially higher in prisons than in the community. Opioid Substitution Treatment (OST) is the main treatment for people addicted to heroin and other opioid drugs and has been used in Scotland's prisons for approaching twenty years. OST most commonly consists of daily oral doses of methadone administered under supervision throughout the prison stay. Research has demonstrated a very strong association between receipt of OST and lowered mortality among opioid-dependent people in prison. However, it carries some risks for patients including overdose and if they seek to divert their medication for illicit use by others within prisons. Diversion of prescription medication and the bullying, intimidation, and the adverse health effects associated with it are especially pertinent for OST provision in prisons. Additionally, the logistics of supervised daily dosing is burdensome for prison health centres, patients, and prison operations because it requires each individual to be taken to and from a dispensing area by Scottish Prison Service (SPS) staff and have their medication supervised by at least two NHS staff. It has been estimated that approximately 25% of people in prison in Scotland receive a daily supervised dose of OST. This is resource-intensive in terms of healthcare and prison officer staff time and also has a detrimental impact on patients' daily routine, limiting their ability to participate in prison life.
Progress has been made over the last decade or so in developing new forms of treatment for opioid addiction, including prolonged release buprenorphine (PRB) injections. These provide sustained medication release at a controlled rate over the dosing interval and are thought to represent a significant development in treatment for opioid dependence. Current formulations of PRB enable weekly or monthly doses. The shift from daily to weekly or monthly dosing is expected to reduce the treatment burden for clinicians and patients, improve patient adherence, and remove the risk of diversion. Early studies of PRB show sustained reductions in illicit opioid use and good treatment retention. Surveys and qualitative research have demonstrated positive perceptions and probable benefits of PRB, including the potential for reduced stigma and negative rituals and habits, greater patient choice and flexibility, and a decreased need to frequently attend pharmacies and clinics.
1.1.1 Buvidal as a COVID-19 contingency measure in Scottish prisons
On May 1st, 2020, the Scottish Government requested that all daily oral OST patients in custody, who were currently serving a sentence of six months or longer, be offered the opportunity to transfer onto Buvidal, a type of PRB, where clinically appropriate. This was intended as a contingency measure in prisons to respond to COVID-19. As noted above, the daily administration of OST places a considerable burden on the SPS and those who live and work in prisons, and there were significant concerns about how daily OST could be sustained while SPS officers and prison health centre staff were also responding to the pandemic and particularly if there was a significant outbreak within a prison. To support the Buvidal programme, the Scottish Government issued National Clinical Guidance and made available up to £1.9 million to support Health Boards to transition to Buvidal in prison settings as part of NHS Board Mobilisation Plans. The funding covered the cost of the medication for a four-month period from May to August 2020, which was then extended to September 2020 to accommodate the one-month lead-in time. The Scottish Government conducted a rapid evaluation of the Buvidal programme to inform decision-making beyond the initial contingency period (May - September 2020). Coronavirus (COVID-19) - Opioid Substitution Treatment (OST) in prisons was published in December 2020. Based on the outcome of this rapid evaluation report, and a review of NHS Boards' spend to date, the Scottish Government took the decision to extend financial support for NHS Boards for the cost of Buvidal in prison settings until 31 March 2021.
To ensure continuity in the administration of OST for patients and to support prison and healthcare staff during the COVID-19 pandemic, the Scottish Government worked with partners to explore OST contingency options and identified Buvidal injections as the most pandemic-appropriate PRB as an alternative to daily OST arrangements. Buvidal is fully licensed and has been approved, on a restricted basis, by the Scottish Medical Consortium (SMC) for use by NHS Scotland for the treatment of opioid dependence.
A summary of evidence about Buvidal produced by the National Institute for Health and Care Excellence in 2019 suggested that it may have a place in treating opioid dependence in people in custodial settings, where the risk of diversion and time needed for supervised consumption currently leads to challenges in supplying supervised medicines safely. Recent research has documented that Buvidal may offer specific benefits for OST patients in custody because of the practical elements (i.e. not having to receive medication everyday) and the discretion of the treatment, which could lead to a reduction in bullying and intimidation encountered as a result of being an OST patient. The switch to Buvidal may also reduce incidences of people diverting their OST medication, which is commonly reported in prisons and is associated with bullying and drug misuse. Buvidal also exerts a blocking effect when taking other opioids which means it could prevent some drug related overdoses and deaths both in prison and after a person is liberated. Although Buvidal offers no protection from the other non-opiate/opioid polypharmacy substances that are typically present in drug related deaths. Offering Buvidal also increases the treatment options for people on OST in prison, thus widening patient choice. Allied to this, the guidance issued by the Scottish Government set out how people could switch back to their previous OST if they felt Buvidal was not an effective treatment option for them.
1.2 Study objectives and methods
Data-collection, analysis, and reporting for this research were undertaken in-house by Scottish Government Health and Social Care Analysis Division between December 2020 and March 2021. The previous rapid evaluation Coronavirus (COVID-19) - Opioid Substitution Treatment (OST) in prisons in 2020 had focused on Buvidal as a COVID-19 mitigation strategy, including factors related to uptake levels and impact on prison healthcare services and operations. The aim of the research presented in this report was to explore patient experience at a more granular level, now that Buvidal has been in place as a treatment option in prisons for several months. This research is based on qualitative semi-structured interviews with Buvidal patients in custody and prison healthcare staff. As this research was an extension of the previous service evaluation, the study did not need NHS Ethics approval and it was screened using the NHS Ethics decision-making tool. As with the earlier study, the SPS Head of Research consented to the research. The Data Protection Impact Assessment and Scottish Government Social Research Ethics Checklist completed for the initial phase of evaluation were updated. Updates included addressing concerns around the additional potential vulnerability of female patients. Women in the criminal justice system tend to have experienced violence and victimisation at disproportionately greater rates than the general population, and the harms and traumas suffered by women in prison are often tied to drug involvement and addiction. Participant comfort and wellbeing are considerations for any social research project, but particularly so for research involving vulnerable groups. Measures to improve participant comfort and wellbeing can include matching interviewers and respondents by age and gender. Accordingly, it was decided that any interviews with female Buvidal patients would be conducted by a female social researcher.
Prison health centres located within a single Health Board were invited to participate. This location was chosen because it was one of the earliest adopters of Buvidal, so had patients who had been taking it for several months, and because it had a mix of male and female patients. Healthcare staff were asked to approach Buvidal patients who met at least one of the following criteria: 1) they had been taking Buvidal for several months; 2) were female; 3) or were approaching release. A participant information sheet and consent form were sent with the recruitment email to prison health centres. Interviews were conducted virtually at a time that was convenient to patients and healthcare staff. Verbal consent was sought from all participants prior to the interview starting, and interviewers made it clear to participants that they could decline to answer any questions and could choose to end the interview at any time. Interviews explored patients' motivations for switching to Buvidal, benefits and drawbacks from taking Buvidal, and overall satisfaction. Interviews with patients and healthcare staff were recorded with a digital dictaphone and then transcribed. Once transcribed, interview transcripts were anonymised through the de-identification of personal information and then analysed for common themes. The processing of personal data was in line with GDPR and fully documented in the Data Protection Impact Assessment.
1.3 Study participants
For this study, fourteen interviews were undertaken between 3rd December 2020, and January 4th, 2021, with nine patients (6 men and 3 women) and five healthcare staff. Initially 18 Buvidal patients had consented to participate but eight declined to attend their interview when scheduled and one could not go ahead for security reasons. At the time of their interviews, all patients were receiving Buvidal, although we are aware of one participant who has since reverted to methadone. The following observations were made about the sample of Buvidal patients recruited for this study. However, given the small numbers, these should not be seen as representative of the larger population of Buvidal patients in Scottish prisons.
- Patients' ages ranged from mid-30s to mid-50s.
- Length of patients' opioid addiction varied, but all had been using opioids for several years and in some cases for over 20 years.
- Patients interviewed in this study had all been taking Buvidal for several months - the shortest period someone had been taking Buvidal was two months while some had been receiving it for up to six months.
- Eight of the nine patients had previously been prescribed methadone - the one patient who had not been taking methadone had developed an illicit opioid habit while in prison but had previously refused the offer of methadone.
- Patient date of liberation ranged from some being released a few days after their interviews, while others were serving life sentences.
The five healthcare staff interviewed included prison health centre managers, and nurses and addiction workers with active caseloads of Buvidal patients. The staff interviewed had a range of experience of healthcare in prisons, with most having worked in prison settings for several years. Of the staff interviewed, one had participated in the initial Buvidal research by the Scottish Government.