Shifting Paradigms Of
Opioid Substitution
Case Study of South Australian Prison Health Service Review
Into Prison Opioid S...
36%
6%
45%
1%
12%
Metro
Women
Country
JNH
MGP
Metropolitan Sites
899
Adelaide Remand Centre
=305
Yatala Labour Prison =534...
Three Government Departments
of Care
David Brown
DCS Chief
Executive
David Swan SA
Health Chief
Exceutive
Chief Justice
Ch...
The National Opioid Pharmacotherapy
Statistics Annual Data 2013
Source: Australian Institute of Health and Welfare, Nation...
SAPHS Patient Activity Within the
POST Program Vs State & National
20%
67%
13%
Suboxone®
Methadone
Subutex®
39%
59%
2%
40%...
SAPHS Treatment Numbers
 247 patients currently on
the POST Program
 10% of total prison
population
 Higher rates in so...
Introduction of Suboxone®
 SAPHS commenced
Suboxone® in April 2012
 Drug approved by TGA in
March 2011
 Marketed as dif...
SAPHS Reported Diversions
January 2013-January 2014
0
5
10
15
20
25
30
Suboxone® Methadone Unspecified
Site 7
Site 6
Site ...
What does diversion
look-like
• Diversion and diversion
techniques are constantly
evolving
• Sleight of hand
• Utilising a...
Why is Suboxone® diverted
• The film is paper thin, and easily
disguised
• It is a relatively cheap on the
community “blac...
Problems Across the Globe
Kentucky jailer battles ‘prison heroin’ Suboxone [video file}
Sourced from: https://www.youtube....
Review Into The POST Program
within SAPHS
 Why perform a review?
 Overdue
 To assess the efficacy of the program
 Impo...
Results of the Review
 A consultancy workgroup was formed to discuss the current POST
program, it consisted of interdepar...
Results of the Review Continued
 Focus Nursing education on identifying a patient
requiring detox and how to engage with ...
Treatment Contract
Please provide a copy to the client and file a copy in Client’s notes
Q:AdministrationBusiness Unit Ope...
New indications for Suboxone®
 Suboxone® to be used for rapid detox and pre-release
only
 Rapid detox is a 5 day protoco...
Questions?
References
 Australian Institute of Health and Welfare, National Opioid Pharmacotherapy
Statistical Annual Data 2013
http...
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Michael Findlay & Sophia Czechowicz - SA Prison Health Service - CASE STUDY: SA Prison Health Experience with Suboxone

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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/correctionalsvs14

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Michael Findlay & Sophia Czechowicz - SA Prison Health Service - CASE STUDY: SA Prison Health Experience with Suboxone

  1. 1. Shifting Paradigms Of Opioid Substitution Case Study of South Australian Prison Health Service Review Into Prison Opioid Substitution Treatment Dr Michael Findlay & Sophia Czechowicz
  2. 2. 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
  3. 3. Three Government Departments of Care David Brown DCS Chief Executive David Swan SA Health Chief Exceutive Chief Justice Chief Judge Chief Magistrate
  4. 4. The National Opioid Pharmacotherapy Statistics Annual Data 2013 Source: Australian Institute of Health and Welfare, National Opioid Pharmacotherapy Statistical Annual Data 2013
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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)
  9. 9. 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
  10. 10. 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
  11. 11. Problems Across the Globe Kentucky jailer battles ‘prison heroin’ Suboxone [video file} Sourced from: https://www.youtube.com/watch?v=42tm4Z9KEOI
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. Treatment Contract Please provide a copy to the client and file a copy in Client’s notes Q:AdministrationBusiness Unit OperationsShortcut Folder To All FormsMedicationPOSTp_POPTPOSTp_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 SAPHSPOSTpContractofAgreementMRX • 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
  16. 16. 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
  17. 17. Questions?
  18. 18. 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

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