OUD Care Service Improvement with Prolonged-release Buprenorphine in Prisons: Cost Estimation Analysis.

BACKGROUND: In prisons in England, integrated treatment for opioid use disorder (OUD) is accessible and effective, commonly based on daily supervised consumption of methadone. Treatment limitations (inadequate dosing, nonengagement with care, stigma, diversion and bullying) are noted. Flexible dose, injectable prolonged-release buprenorphine (PRB) which removes the need for daily dispensing and supervision is suggested for prisoner care. This work aimed to predict the difference in costs of current standard of care vs partial introduction of PRB. METHODS: A predictive model of compared costs for the provision of OUD care in the prison setting in England evaluated current standard of care (all receive methadone) with a future situation of 30% of prisoners electing to use a monthly dose of PRB. Evidence describing costs to deliver OUD care for 150 prisoners (pharmacotherapy, direct service, indirect health care, indirect security costs) were collected, including assumptions describing how care would be delivered. Evidence sources include national data sources, scientific literature and from experience in the prison health care setting. RESULTS: For a representative standard prison population requiring OUD care of 150 prisoners in England PRB introduction is associated with a predicted reduction in direct and indirect costs of OUD care. Annual OUD care costs for current standard of care were £0.6M; with 30% PRB costs reduced by £8665, more than 3000 hours of staff time is saved. Sensitivity analyses showed greater adoption of PRB resulted in further cost reduction. CONCLUSION: PRB can address limitations of OUD care in prisons and improve outcomes. Introduction does not increase cost of care in this predictive analysis. PRB may lead the transformation of prisoner OUD care.

Optimising opioid substitution therapy in the prison environment.

PURPOSE: The purpose of this paper is to examine the current provision of opioid substitution therapy (OST) during and immediately following release from detention in prisons in England and Wales. DESIGN/METHODOLOGY/APPROACH: A group of experts was convened to comment on current practices and to make recommendations for improving OST management in prison. Current practices were previously assessed using an online survey and a focus group with experience of OST in prison (Webster, 2017). FINDINGS: Disruption to the management of addiction and reduced treatment choice for OST adversely influences adequate provision of OST in prison. A key concern was the routine diversion of opiate substitutes to other prisoners. The new controlled drug formulations were considered a positive development to ensure streamlined and efficient OST administration. The following patient populations were identified as having concerns beyond their opioid use, and therefore require additional considerations in prison: older people with comorbidities and complex treatment needs; women who have experienced trauma and have childcare issues; and those with existing mental health needs requiring effective understanding and treatment in prison. ORIGINALITY/VALUE: Integration of clinical and psychosocial services would enable a joint care plan to be tailored for each individual with opioid dependence and include options for detoxification or maintenance treatment. This would better enable those struggling with opioid use to make informed choices concerning their care during incarceration and for the period immediately following their release. Improvements in coordination of OST would facilitate inclusion of strategies to further streamline this process for the benefit of prisoners and prison staff.

Recommendations for buprenorphine and methadone therapy in opioid use disorder: a European consensus.

INTRODUCTION: Management of patients with opioid use disorder (OUD) commonly includes opioid agonist therapy (OAT) as a part of an integrated treatment plan. These interventions are associated with proven benefits to the individual and society. Areas covered: The use of methadone and buprenorphine within an integrated treatment plan in the management of patients with OUD: this work provides consensus recommendation on pharmacotherapy in OUD to assist clinicians with practical decision making in this field. Expert opinion: Pharmacotherapy is recommended as part of an integrated OUD treatment approach with psychosocial interventions, with the goal of reducing risks of illicit opioid use, overdose mortality, infection with HIV or HCV, improving health, psychological and social outcomes. Access to OAT should be prioritised in the treatment of OUD. Treatment choices in OUD pharmacotherapy should be based on the needs of the individual and characteristics of medications. Recommendations for choices of OAT are based on clinical efficacy, safety, patient preference, side effects, pharmacological interactions, quality of life, dose titration potential and outcomes (control craving, ongoing opioids consumption or other drugs, and potentially psychiatric comorbidities). Special groups, pregnant women, prisoners, patients with mental health problems have specific needs which must be addressed with expert input.

A postmarketing study of relative abuse liability of hypnotic sedative drugs.

AIMS: To demonstrate the utility of postmarketing studies using in-treatment drug and alcohol abusers as informants for assessing the relative abuse liability of sedative-hypnotic drugs. DESIGN: A survey was conducted that ascertained exposure to a variety of drugs with hypnotic/sedative properties and elicited subjective evaluations indicative of abuse liability. METHODS: Complete data were obtained from 297 admissions (78% male) to three addiction treatment sites in the United Kingdom. Subjects were asked 15 questions about 12 different drugs, including five benzodiazepines, three antidepressants, two non-benzodiazepine hypnotics and two antihistamines (plus one fictitious drug). Three of the benzodiazepines (diazepam, nitrazipam, temazepam) emerged as having substantially more abuse liability than any of the other drugs tested, as revealed by higher scores on abuse liability items (purchased on street, taken to get high, like drug, potential for addiction to drug). The antihistamines (chlorpheniramine, diphenhydramine) had lowest abuse liability profiles, while the antidepressants (amitriptyline, fluoxetine, trazadone) and non-benzodiazepine hypnotics (zolpidem, zopiclone) had similar profiles. CONCLUSION: This pilot study suggests that postmarketing information on hypnotic drug use obtained from drug addicts entering treatment produces data consistent with other measures of abuse liability. The data suggest that the risk of misuse of newer non-benzodiazepine hypnotics may be less than that of benzodiazepine drugs, and similar to that of sedating antidepressants. The new methodology may serve to clarify or validate premarketing abuse liability data, and may help to inform the regulatory process and physician practice.