Shifting Paradigms Of

Opioid Substitution Case Study of South Australian Prison Health Service Review

Into Prison Opioid Substitution Treatment

Dr Michael Findlay & Sophia Czechowicz

36%

6%

45%

1%

12%

Metro

Women

Country

JNH

MGP

Metropolitan Sites

899

Adelaide Remand Centre

=305

Yatala Labour Prison =534

Pre-Release Centre =60

Adelaide Women's

Prison=158

Country Sites

1147

Pt Augusta

Prison=485

Mobilong

Prison=328

Cadell Training

Centre=179

Pt Lincoln

Three Government Departments

of Care David Brown

DCS Chief

Executive

David Swan SA

Health Chief

Exceutive

Chief Justice

Chief Judge

Chief Magistrate

The National Opioid Pharmacotherapy

Statistics Annual Data 2013

Source: Australian Institute of Health and Welfare, National Opioid Pharmacotherapy Statistical Annual Data 2013

SAPHS Patient Activity Within the

POST Program Vs State & National

20%

67%

13%

Suboxone®

Methadone

Subutex®

39%

59%

2%

40%

60%

Based on the Australian Institute of Health and Welfare, National Opioid

Pharmacotherapy Statistical Annual Data 2013

SAPHS Treatment Numbers

247 patients currently on

the POST Program

10% of total prison

population

Higher rates in some

prisons versus others

Illustration retrieved from http://www.suboxone.com/medical-treatment/how-to-take-suboxone

Introduction of Suboxone®

SAPHS commenced

Suboxone® in April 2012

Drug approved by TGA in

March 2011

Marketed as difficult to

divert:

“the risk of diversion for

illicit use is reduced

because of the difficulty

of removing the soluble film from the mouth once

it is in place” – TGA 2011

TGA Australian Public Assessment Report for Buprenorphine/Naloxone Proprietary Product Name: Suboxone

Sublingual Film

Sponsor: Reckitt Benckiser (Australia) Pty Ltd

SAPHS Reported Diversions

January 2013-January 2014

0

5

10

15

20

25

30

Suboxone® Methadone Unspecified

Site 7

Site 6

Site 5

Site 4

Site 3

Site 2

Site 1

Data collated from SAPHS Safety Learning System (incident management

database)

What does diversion

look-like

• Diversion and diversion

techniques are constantly

evolving

• Sleight of hand

• Utilising a vessel hidden in

the throat, teeth or gums

• Regurgitation

Why is Suboxone® diverted • The film is paper thin, and easily

disguised

• It is a relatively cheap on the community “black market”, however can bring the dealer profits of approx 3-5 times as much on the inside

• Prisoners report that a high can be sourced from Suboxone® if the patient is opioid naive or in withdrawals

• Prisoners will remove alcohol from other products as it is their belief it increases the Suboxone® bioavailability.

• Suboxone® can be brought into prisons undetected through the mail, visits or though other corrupt means

Problems Across the Globe

Kentucky jailer battles ‘prison heroin’ Suboxone [video file}

Sourced from: https://www.youtube.com/watch?v=42tm4Z9KEOI

Review Into The POST Program

within SAPHS

Why perform a review?

Overdue

To assess the efficacy of the program

Important for all parties to be convinced of the benefits

of the program

Results of the Review

A consultancy workgroup was formed to discuss the current POST program, it consisted of interdepartmental key stakeholders.

• Drug and Alcohol Services South Australia, Department for Corrections, SAPHS Medical and Nursing Staff

• The importance and benefit of the program was agreed on – no opioid deaths on discharge for more than 10 years

• Changes needed to be made to minimize diversion

• It was agreed that Methadone would be the first-line therapeutic agent

• Suboxone® dosing has been capped at 16mg and then to be phased out by early 2015

• A strict Suboxone® treatment regime would remain for pre-release and for rapid detox

Results of the Review Continued

Focus Nursing education on identifying a patient

requiring detox and how to engage with patients

therapeutically

It was also recommended to develop Naloxone training

for patients who do not want opioid substitution but

still may be at risk of using on release.

Feasibility review was recommended to supplying

Naloxone on release

Treatment Contract

Please provide a copy to the client and file a copy in Client’s notes

Q:\Administration\Business Unit Operations\Shortcut Folder To All Forms\Medication\POSTp_POPT\POSTp_Contract.pdf

South Australian Prison Health Service

PRISON OPIOID SUBSTITUTION TREATMENT

PROGRAM

CONTRACT OF AGREEMENT

Affix patient identification label in this box

DCS No: ............................................................................

Surname: ..........................................................................

Given Name: .....................................................................

D.O.B: .............................. Sex: …………...........

Date of Agreement ______/_____/_______ SAPHS Commencing Site: ______________________

1. Behaviour

I agree to comply with the program rules as explained to me, and understand that a breach of these rules may result in removal from the program.

I acknowledge that taking either Suboxone® or Methadone may potentially impair my ability to drive or operate machinery and will inform SAPHS staff immediately if I feel affected

I understand that I will be removed from the program if I;

Attempt to divert, trade, sell or give away my Suboxone® or Methadone,

I understand that my position on the program may be compromised if I;

Use heroin or any other drugs that are not prescribed by the prison medical officer

Do not treat all staff with courtesy and respect

A drug screen test either shows non-compliance to the program or shows traces of other drugs not prescribed

Use abusive language or threatening behaviour in the Health Centre or dosing area.

2. Dosing

If I bring anything with me other than my ID card, this includes containers, tobacco pouches, hats, sunglasses I will

be asked to leave it outside the dosing area

Methadone will be given to me in no less than 100mls of water to consume this will be followed by a second cup of

100mls of water. I must speak to the nurse after my Methadone dose and will be asked to cough.

Suboxone/Buprenorphine medication will only be placed under my tongue, films will not overlap or double up. I will

be required to drink 100mL of water before my dose. My dose will be completely absorbed and I will be required to have a second drink of 100mL of water before I leave the dosing area, my mouth will be checked, prior ,during and after if requested, I must speak to the nurse after my Suboxone dose and will be asked to cough.

If I have a dental plate, or any other foreign object in my mouth, I will remove it before I receive my dose.

I will not talk while the dose is being absorbed or touch my face or place my hands in my pockets. I MUST bring my ID card to receive my dose. If I do not bring my ID Card my dose will be withheld.

3. Changes

If I want my dose changed it must be documented in writing on the daily sign card

My dose will be changed on the next pharmacy delivery day if my script allows, otherwise I will need to wait until I

have seen the medical officer.

4. Pre Release

If commenced on Suboxone® pre release this will be commenced one week prior to confirmed release date

If I am not released on this date my doses of Suboxone will be reduced and stopped after one week

If commenced on Methadone pre release this will be commenced four weeks prior to release date

If I am not released on this date my doses of Methadone will be reduced and stopped after four weeks

I can reapply when a release date is confirmed.

5. Discharge

When I am released from prison there are two possible options of treatment available to me:

A public Suboxone® / Buprenorphine program

Private prescriber with a community pharmacist - if you reside in a country area or have had a private community

prescriber previously this will involve paying a daily fee.

I sign this contract acknowledging that I understand the information and what is required of me regarding to continue on the POST program.

I am also aware that;

The Department for Correctional Services may become aware that I am on the POST Program.

All relevant information and documentation pertaining to Buprenorphine/Suboxone/Methadone is forwarded to the

Prescriber/pharmacist after I am released from prison.

SAPHS may collect confidential data for evaluation of the program.

The final decision of the POST Program as an appropriate treatment sits with the Drug of Dependence Unit

Patient’s Signature _______________________Witness Signature ______________________ Designation ________

SAPHS

Revised

Jul 2014

SA

PH

S P

OS

Tp

Co

ntra

ct o

f Ag

ree

me

nt M

R X

• Designed to outline program

rules

• Patients may be asked to

cough after dosing

• Acceptance on the program

is ultimately given to the SA

Drug of Dependence Unit

New indications for Suboxone®

Suboxone® to be used for rapid detox and pre-release

only

Rapid detox is a 5 day protocol that can be initiated by

nursing staff

Pre-release commences 1 week prior to confirmed

discharge date and is ordered by the Medical Officer

Once these become the only access points to

Suboxone®, arrangements will need to be made with

DCS to minimise standover

Questions?

References Australian Institute of Health and Welfare, National Opioid Pharmacotherapy

Statistical Annual Data 2013

http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129547305

TGA Australian Public Assessment Report for Buprenorphine/Naloxone

Proprietary Product Name: Suboxone Sublingual Film

http://www.tga.gov.au/pdf/auspar/auspar-suboxone.pdf

• Suboxone Website Reckitt Benkiser

http://www.suboxone.com/medical-treatment/how-to-take-suboxone

• Kentucky jailer battles prison heroin Suboxone

www.youtube.com/watch?v=42tm4Z9KEOI

• Addiction Treatment With a Dark Side, New York Times

http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-

street-bupe-can-be-savior-or-menace.html?pagewanted=all