michael findlay & sophia czechowicz - sa prison health service - case study: sa prison health...
DESCRIPTION
Michael Findlay & Sophia Czechowicz delivered the presentation at the 2014 Correctional Services Healthcare Conference. The 2014 Correctional Services Healthcare Conference - addressing the gaps, promoting multidisciplinary care and improving the continuum of care into the community. For more information about the event, please visit: http://bit.ly/correctionalsvs14TRANSCRIPT
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
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• 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