A qualitative study of reasons for seeking and ceasing opioid substitution treatment in prisons in New South Wales, Australia

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Monitoring medication and illicit drug consumption in a prison by wastewater-based epidemiology: Impact of COVID-19 restrictions

Drug consumption in prisons is a concern for the safety of incarcerated people and staff. Typically, drug use prevalence in prisons is estimated through urinalysis and intelligence operations, which can be intrusive and stressful. An alternative approach, wastewater-based epidemiology (WBE), was used in this study to estimate the consumption of licit and illicit drugs for the entire population of a prison in Australia. Wastewater samples were collected from March to December 2020, covering periods of no restrictions and periods when prison access was restricted to prevent the transmission of COVID-19. Target biomarkers were analysed by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). The average consumption of common illicit drugs (MDMA, methamphetamine and cocaine) over the sampling period in the prison (0.5 - 4.5 mg/1000 people/day) was two to three orders of magnitude lower than in the community population (254 - 1000 mg/1000 people/day). Comparison of WBE estimates against pharmacy dispensing data suggested potential illicit buprenorphine consumption at the prison. Methamphetamine and buprenorphine use decreased when no visitors were allowed (18% - 72% decrease for methamphetamine; about half decrease for buprenorphine) and increased once these restrictions were eased (22% - 39% increase for methamphetamine; 44% - 67% increase for buprenorphine). The changes in drug use may be attributed in part to a reduction of drug trafficking into the prison from visitors or non-essential staffs and in part to the reduced contribution of urine from staff who used toilets within the prison. This study provided useful information on the scale of illicit drug use and extra-medical use of licit drugs in prison, and its changes under different security conditions.

The Lived Experience of Medication for Opioid Use Disorder: Qualitative Metasynthesis

PURPOSE OF THE STUDY

Buprenorphine and methadone, when used as maintenance therapy in opioid use disorder (OUD), can significantly reduce the risk of death after an opioid overdose. Despite the many benefits, medication for OUD (MOUD) remains controversial and underutilized. The aim of this study was to (a) identify studies that explicate the lived experience of MOUD, (b) conduct a methodologically sound critical quality assessment, (c) conduct a metasynthesis of identified qualitative studies, and (d) analyze the results through the lenses of critical social justice, feminist standpoint, and social theories to inform a more culturally responsive, effective, and holistic approach to treatment to increase the utilization of and receptivity to MOUD in the treatment of OUDs.

DESIGN AND METHODS

Metasynthesis is the deliberate process of synthesizing data from multiple qualitative studies to create a new interpretation of previously published research. Our metasynthesis focused on forming a new interpretation of the lived experience of MOUD. Of the 292 studies identified, eight met inclusion criteria. The overall quality of the studies was variable. The study population included adults aged ≥ 18 years with OUD or dependency.

RESULTS

Metasynthesis produced three overarching themes: (a) The duplexity of MOUD creates ambivalence in how a person experiences MOUD; (b) the structure of treatment and systemic influences matter, and (c) MOUD as a stepping-stone with multiple meanings in recovery.

IMPLICATIONS

Understanding experiential dualities allows professionals to see from other perspectives and can inform interventions and treatment structures as well as serve as a backdrop for social change. The synthesized new meaning of MOUD was an ambivalent experience influenced by intersectionality.

Perceived access to opioid agonist treatment in prison among people with a history of injection drug use: A qualitative study

INTRODUCTION

Opioid agonist treatment (OAT) is associated with a reduced likelihood of hepatitis C incidence, nonfatal overdose, and (re)incarceration among people who inject drugs (PWID), yet factors underpinning decisions to access OAT in prison and postrelease are not well understood. The aim of the qualitative study was to explore the perspectives of OAT access while in prison among PWID recently released from prison in Australia.

METHODS

Eligible participants enrolled in the SuperMix cohort (n = 1303) were invited to take part in a semi-structured interview in Victoria, Australia. Inclusion criteria were informed consent, aged ≥18 years, history of injection drug use, incarcerated for ≥3 months, and released from custody <12 months. The study team analysed data via a candidacy framework to account for macro-structural influences.

RESULTS

Among 48 participants (33 male; ten Aboriginal), most injected drugs in the prior month (n = 41), with heroin most frequently injected (n = 33) and nearly half (n = 23) were currently on OAT (primarily methadone). Most participants described the navigation and permeability of OAT services in prison as convoluted. If not on OAT pre-entry, prison policies often restricted access, leaving participants to withdraw in cells. In turn, some participants commenced OAT postrelease to ensure OAT continuity of care if reincarcerated. Other participants who experienced delayed access to OAT in prison stated no need to initiate while in prison or postrelease as they were now "clean". Last, implementation of OAT delivery in prison (e.g., lack of confidentiality) frequently led to changes in OAT type to avoid peer violence (pressure to divert OAT).

CONCLUSION

Findings draw attention to simplistic notions of OAT accessibility in prisons, illuminating how structural determinants influence choice in PWID decision-making. Suboptimal access and acceptability of OAT delivery in prisons will continue to place PWID at risk of harm postrelease (e.g., overdose).

Economic, social, and clinic influences on opioid treatment program retention in Dar es Salaam, Tanzania: a qualitative study

BACKGROUND

Medications for opioid use disorder (MOUD) are associated with positive health outcomes. People remaining on MOUD have a reduced likelihood of drug overdose and mortality. Tanzania supports a national opioid treatment program (OTP) offering MOUD, but retention is a continual challenge. To date, most research on MOUD retention in Tanzania and other Sub-Saharan Africa settings has been focused on the individual-level, with little attention to economic, social, and clinic-level factors.

METHODS

We qualitatively examined economic, social, and clinic factors that affect retention on MOUD, specifically methadone maintenance therapy, among former and current clients attending an OTP clinic Dar es Salaam, Tanzania. We conducted in-depth interviews with a total of 40 current and former clients receiving MOUD and four focus groups with an additional 35 current clients on MOUD between January and April 2020. We utilized a thematic analysis approach.

RESULTS

Daily OTP clinic attendance posed a financial burden to current and former clients and was a barrier to remaining on MOUD. Though treatment is free, clients described struggles to attend clinic, including being able to afford transportation. Female clients were differentially impacted, as sex work was the most common income-generating activity that they participated in, which presented its own set of unique challenges, including barriers to attending during set clinic hours. Drug use stigma acted as a barrier to MOUD and prevented clients from securing a job, rebuilding trust within the community, and accessing transportation to attend the clinic. Being able to rebuild trust with family facilitated remaining on MOUD, as family provided social and financial support. Caretaking responsibilities and familial expectations among female clients conflicted with MOUD adherence. Finally, clinic level factors, such as clinic dispensing hours and punitive consequences for breaking rules, posed barriers to clients on MOUD.

CONCLUSION

Social and structural factors, both within (e.g., clinic policies) and outside of (e.g., transportation) the clinic impact MOUD retention. Our findings can inform interventions and policies to address economic and social barriers to MOUD, that can contribute to sustained recovery.

Pathways connecting socioeconomic marginalization and overdose: A qualitative narrative synthesis

PURPOSE

This qualitative narrative synthesis sought to identify pathways connecting socioeconomic marginalization (SEM) and overdose for people who use drugs.

METHODS

We included studies with qualitative examination of SEM and fatal and non-fatal overdose published in English between 2000 and 2021. Studies were systematically identified and screened by searching MEDLINE (Ovid), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), Google Scholar, Cochrane Central Registry of Controlled Trials (CENTRAL), and Cochrane Drug and Alcohol Group (CDAG) Specialized Registry, citations, and contacting experts. Risk of bias and quality assessments were performed using the Critical Appraisal Skills Programme checklist and the Confidence in the Evidence from Reviews of Qualitative Research approach. Data were synthesized using a thematic synthesis approach.

RESULTS

The primary search strategy found 5909 articles that met the initial screening criteria. The review and screening process led to a final dataset of 27 qualitative articles. The four key findings of this narrative synthesis revealed aspects of SEM which shaped drug poisoning risk for people who use drugs: (1) resource insufficiency, labor market exclusion and deindustrialization, (2) homelessness and housing, (3) policing, criminalization, and interactions with emergency services, and (4) gendered and racialized dimensions of inequality. Findings led to creating a typology that includes material, behavioral, psychological, social, and environmental pathways that contain multiple mechanisms connecting SEM to overdose. This review revealed reciprocal connections between overdose and SEM via institutional pathways with reinforcing mechanisms, and interrelationships present within and between pathways. Quality assessments indicated moderate confidence in three of four findings (Findings 2,3, and 4 above) and high confidence in one finding (Finding 1).

CONCLUSION

SEM is strongly linked to drug poisoning, and the mechanisms establishing these connections can be classified within four pathways. The interconnectedness of these mechanisms can lead to intensification of overdose risk and reinforcement of SEM itself.

A qualitative analysis of barriers to opioid agonist treatment for racial/ethnic minoritized populations

INTRODUCTION

Clinical guidelines strongly recommend opioid agonist treatment (OAT) as first-line treatment for opioid use disorder (OUD). However, racial/ethnic minoritized patients are less likely to receive OAT compared to non-Hispanic White patients. Reasons for this treatment gap must be elucidated to address racial/ethnic disparities in OAT. Our objective is to evaluate perceptions of and barriers to OAT across racial/ethnic groups in individuals with OUD (not on OAT).

METHODS

This qualitative study used semi-structured telephone interviews of adult patients (n = 41) with OUD (not currently being treated with OAT) from the Boston area from September 2020 through February 2021. We developed a codebook through author consensus based on review of themes in initial transcripts. We performed qualitative thematic analysis of the transcripts. We evaluated patients' perceptions of treatment for OUD across the study population and analyzed differences and similarities in perceptions between racial and ethnic groups.

RESULTS

Across all racial/ethnic categories in our sample, anticipated stigma was the most frequently reported barrier to OAT and most patients preferred non-OAT methods for treatment. Non-Hispanic White participants had more favorable opinions of OAT compared to racial/ethnic minoritized participants. Racial/ethnic minoritized participants reported social support as the main facilitator to addiction treatment, while non-Hispanic White participants reported self-motivation as the most important factor. Racial/ethnic minoritized participants preferred treatment for OUD via non-OAT treatments and their second most preferred option was residential treatment. Non-Hispanic White participants preferred naltrexone and their second most preferred option was non-OAT treatments.

CONCLUSIONS

Racial/ethnic minoritized patients' preference for residential treatment and social support, along with their distrust of OAT, illustrates a desire for psychosocial and peer recovery-based care that addresses social determinants of health. Addiction specialists may improve engagement with and treatment of racial/ethnic minoritized groups with culturally tailored interventions for OUD that offer psychosocial treatment in combination with OAT, and by partnering with organizations with strong ties to racial/ethnic minoritized communities. This kind of response would reflect the structural and cultural humility that is needed to adequately address the OUD needs of these underserved populations.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada

Introduction

Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada.

Methods

This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants’ release. Data were thematically analyzed.

Results

The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of ‘take-home’ OAT medications were common barriers.

Conclusions

Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.

A randomized, sham-controlled, quintuple-blinded trial to evaluate the NET device as an alternative to medication for promoting opioid abstinence

Background

There is an unmet need for non-medication approaches to illicit opioid discontinuation and relapse prevention. The NET (NeuroElectric Therapy) Device is a non-invasive, battery-operated, portable, re-useable device designed to deliver bilateral transcranial transcutaneous alternating current electrical stimulation, and is intended to treat opioid use disorder (OUD) without medication. The device is a CE-marked Class IIa, non-significant risk, investigational medical device.

Objective

This prospective trial (NRC021) tests the hypothesis that the NET Device provides safe and effective neurostimulation treatment for persons with OUD who express a desire to be opioid abstinent without medications for opioid use disorder (MOUD).

Methods

NRC021 is a randomized, parallel-group, sham-controlled, quintuple-blinded, single-site study. Persons with OUD entering a residential treatment facility for opioid detoxification are assigned to active or sham treatment (n = 50/group). Group assignment is stratified on presence of any current non-opioid substance use disorder and by sex. The biostatistician maintains the blinding so that the study sponsor, principal investigator, research assistants, treatment staff, and participants remain blinded. Following discharge from the inpatient facility, participants are assessed once weekly over 12 weeks for substance use (using timeline followback interview and video assessment of observed oral fluid sample provision and testing). The primary efficacy endpoint is each participant's overall percentage of weekly abstinence from illicit opioid use without use of MOUD. The secondary efficacy endpoint is each participant's percentage of non-opioid drug-free weeks. Safety outcomes are also measured.

Conclusion

NRC021 is designed to assess the efficacy of a novel non-medication treatment for OUD.

Clinical trial registration

ClinicalTrials.gov with the identifier NCT04916600.

Medications for opioid use disorder in state prisons: Perspectives of formerly incarcerated persons

Background: Opioid use disorder (OUD) is common among incarcerated persons and risk of overdose and other adverse drug-related consequences is high after release. Recognizing their potential to reduce these risks, some correctional systems are expanding access to medication for opioid use disorder (MOUD). This study explored the experiences and perspectives of formerly incarcerated individuals on MOUD use while incarcerated and after release. Methods: We interviewed 53 individuals with self-reported OUD who were released from New Jersey state prisons. Interviews explored motivations to use MOUD while incarcerated and after release, and experiences with prison-based MOUD and transition to community-based care. We performed cross-case analysis to examine common and divergent perspectives across participants. Results: A common reason for accepting prerelease MOUD was recognition of its effectiveness in preventing drug use, overdose, and other drug-related consequences. Participants who chose not to use MOUD often were focused on being completely medication-free or saw themselves as having relatively low-risk of substance use after a prolonged period without opioid use. A few participants reported challenges related to prison-based MOUD, including logistical barriers, stigma, and once-daily buprenorphine dosing. Most participants effectively transitioned to community-based care, but challenges included insurance lapses and difficulty locating providers. Conclusions: Many formerly incarcerated persons with OUD recognize the value of MOUD in supporting recovery, but some hold negative views of MOUD or underestimate the likelihood that they will return to drug use. Patient education on risks of post-release overdose, the role of MOUD in mitigating risk, and MOUD options available to them could increase engagement. Participants' generally positive experiences with MOUD support the expansion of correctional MOUD programs.

A social ecological model (SEM) to exploring barriers of and facilitators to the implementation of opioid agonist treatment (OAT) programmes in prisons

PURPOSE

Opioid agonist treatment (OAT) programmes in prisons play a significant role in preventing the human immunodeficiency virus (HIV). Despite its proven effectiveness, both the availability and coverage of prison OAT programmes remain low. This Indonesian study explores facilitators of, and barriers to, the delivery of methadone programmes in prisons using the social ecological model (SEM).

DESIGN/METHODOLOGY/APPROACH

The study used a qualitative case study approach comprising two prisons with, and one prison without, methadone programmes. Purposive and snowball sampling was used to recruit study participants. In total, 57 in-depth interviews were conducted with prison governors, health-care staff, prison officers and prisoners. Data was analysed thematically.

FINDINGS

The study findings identified facilitators of and barriers to the delivery of prison OAT programmes at all three levels of the SEM as follows: intrapersonal barriers including misperceptions relating to HIV transmission, the harm reduction role of OAT programmes, methadone dependency and withdrawal symptoms; interpersonal barriers such as inflexible OAT treatment processes and the wide availability of illicit drugs in prisons and; social-structural barriers, notably the general lack of resources.

RESEARCH LIMITATIONS/IMPLICATIONS

The findings highlight the importance of and overlap between, organisational and inter-personal, as well as intrapersonal factors. Such an approach is particularly important in the context of the implementation and delivery of methadone programmes in low/middle income countries, where the lack of resources is so significant.

PRACTICAL IMPLICATIONS

Three main strategies for improvement were suggested as follows: the development of comprehensive education and training programmes for prisoners and all prison staff; the re-assessment of practices relating to the delivery of methadone, and a comprehensive review of harm reduction strategy in prisons, that should consider the role of prisoners' families to increase support for prisoner participation; the re-assessment of prison policies to support the delivery of methadone programmes in prisons.

SOCIAL IMPLICATIONS

The author suggests that ongoing international support and national drug policies are vital to the continuation and sustainability of methadone programmes in prisons.

ORIGINALITY/VALUE

This study contributes to the overall evidence base for OAT programmes in middle-income prison contexts.

Intervention Stigma toward Medications for Opioid Use Disorder: A Systematic Review

Medications for opioid use disorder (MOUD) are evidence-based treatments, yet can be controversial among some populations. This study provides a systematic review of prejudice and discrimination toward MOUD, a form of "intervention stigma," or stigma associated with a particular medical treatment. A systematic search strategy was used in PsychInfo and PubMed to identify studies published between 1998 and 2018. Studies that empirically examined stigma toward MOUD were included if the manuscript was of moderate or high quality. Studies were analyzed using thematic synthesis. The search yielded 972 studies, of which 28 were included. Most studies utilized qualitative methods to examine intervention stigma toward methadone or buprenorphine, with one including naltrexone. Studies demonstrated that intervention stigma among healthcare providers was influenced by lack of training and abstinent treatment preferences. Providers equated MOUD with illicit substance use and at times refused to care for MOUD patients. Stigma among peer patients seeking treatment was also influenced by abstinent treatment preferences, and among the general public stigma was influenced by lack of MOUD knowledge. Intervention stigma was also driven at the policy level by high regulation of methadone, which fueled diversion and hindered social functioning among patients. Few studies indicated how to reduce intervention stigma toward MOUD. Intervention stigma affects both provision and perceptions of methadone and buprenorphine, decreasing access and utilization of MOUD. Future research should further develop and test MOUD stigma reduction interventions in a variety of social contexts to improve access to care and reduce patient barriers.

A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder

BACKGROUND

The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery.

METHODS

This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review.

RESULTS

There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD.

CONCLUSION

This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.

Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study

BACKGROUND

Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans.

OBJECTIVE

The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system.

DESIGN

This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder.

PARTICIPANTS

Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12).

APPROACH

We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach.

KEY RESULTS

Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention.

CONCLUSIONS

Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.

Redemption from plight: a qualitative study on reasons behind treatment decisions among Iranian male opioid users

BACKGROUND

Opioid use remains a significant cause of harm to individual health. Perceived motives are of the main factors that help lead a patient into seeking treatment voluntarily to obviate that harm. The current study expands on the literature by exploring when and how male users of opioids become motivated to voluntarily seek treatment services.

METHODS

In a qualitative study in Isfahan city from January 2018 to March 2019, 55 male participants who had already started a variety of treatment services to withdraw their dependence on opioids were recruited. Selection of participants was based on a maximum variation purposive sampling strategy. Each participant took part in a unstructured interview to identify his motives for seeking opioid use treatment. Interviews were undertaken in eight different treatment centers. An inductive thematic analysis method was used to analyze the interviews.

RESULTS

The findings highlight that Iranian male opioid users have different motivations to seek treatment. To be precise, the findings illuminate three global themes and six themes as treatment-seeking motives among the participants including; motives related to family (reason for family and reason of family), quality of life (adverse effects on personal lifestyle and health) and economic motives (financial failure and job failure).

CONCLUSIONS

The findings can improve our understanding of the motives for seeking treatment from the perspective of opioid patients who entered themselves into treatment. Particularly, these findings could help policymakers and treatment providers to better understand opioid-use patient's perceived concerns and fears as motives for treatment-seeking.

A Scoping Review of Barriers and Facilitators to Implementation of Medications for Treatment of Opioid Use Disorder within the Criminal Justice System

BACKGROUND

Policies aimed at addressing the high rates of opioid overdose have prioritized increasing access to medications for treatment of opioid use disorder (MOUD). Numerous barriers exist to providing MOUD within the criminal justice system and/or to justice-involved populations. The aim of this study was to conduct a scoping review of the peer-reviewed literature on implementation of MOUD within criminal justice settings and with justice-involved populations.

METHODS

A systematic search process identified 53 papers that addressed issues pertaining to implementation barriers or facilitators of MOUD within correctional settings or with justice-involved populations; these were coded and qualitatively analyzed for common themes.

RESULTS

Over half of the papers were published outside of the U.S. (n = 28); the most common study designs were surveys or structured interviews (n = 20) and qualitative interviews/focus groups (n = 18) conducted with correctional or treatment staff and with incarcerated individuals. Four categories of barriers and facilitators were identified: institutional, programmatic, attitudinal, and systemic. Institutional barriers typically limited capacity to provide MOUD to justice-involved individuals, which led to programmatic practices in which MOUD was not implemented following clinical guidelines, often resulting in forcible withdrawal or inadequate treatment. These programmatic practices commonly led to aversive experiences among justice-involved individuals, who consequently espoused negative attitudes about MOUD and were reluctant to seek treatment with MOUD following their release to the community. Facilitators of MOUD implementation included increased knowledge and information from training interventions and favorable prior experiences with individuals being treated with MOUD among correctional and treatment staff. Few systemic facilitators to implementing MOUD with justice-involved individuals were evident in the literature.

CONCLUSION

Barriers to implementing MOUD in criminal justice settings and/or with justice-involved populations are pervasive, multi-leveled, and inter-dependent. More work is needed on facilitators of MOUD implementation.

Combined treatment and prevention strategies for hepatitis C virus elimination in the prisons in New South Wales: a modelling study

BACKGROUND AND AIMS

Australia is currently on track to meet the World Health Organization (WHO) global hepatitis C virus (HCV) elimination goals by 2030, reflecting universal subsidized access to testing and direct-acting antiviral (DAA) treatment. In New South Wales, DAA treatment in prisons has scaled-up substantially, with 1000 prisoners treated in 2017. However, HCV prevalence and incidence in this setting is high, which could undermine elimination efforts. This study aimed to test the preventative effects of DAA treatment scale-up, opiate substitution treatment (OST) and needle and syringe programme (NSP) strategies for prisons.

DESIGN

Modelling study using an individual-based mathematical model of a typical prison setting. The model was calibrated against Australian epidemiological data sets and executed in-prison events for each individual daily, including movements between prisons, changes in risk behaviour and uptake of prevention measures such as OST and NSP, as well as DAA treatment. Scenarios were projected from 2018 to 2030.

SETTING

New South Wales prisons.

PARTICIPANTS

New South Wales prisoners.

MEASUREMENTS

Variables including prison populations, prevalence and incidence rate were calculated. Prisoners were described by demographic characteristics, HCV infection history, risk behaviours and accessing treatment and prevention measures in varied security settings.

FINDINGS

Increasing the number of prisoners treated for HCV to 2000 annually was projected to reduce the HCV incidence rate to 8.69 [95% confidence interval (CI) = 8.17, 9.20] per 100 person-years (100 p.y.). Combined treatment and prevention strategies were necessary to reduce the projected incidence rate to 5.22 (95% CI = 5.13, 5.52) per 100 p.y. Considering the expected reductions in the prevalence of chronic HCV in the Australian community, incidence rate was predicted to drop to 0.93 (95% CI = 0.92, 0.98) per 100 p.y. by 2030.

CONCLUSIONS

This model, which simulates prison scenarios to inform Australia's national hepatitis C virus elimination efforts, suggests that continued direct-acting antiviral (coverage in the community combined with a moderate increase of direct-acting antiviral treatments in prisons, and introduction of improved harm reduction via opiate substitution treatment and/or needle and syringe programmes, makes hepatitis C virus elimination feasible in Australian prisons.

Implementation of opioid maintenance treatment in prisons in North Rhine-Westphalia, Germany - a top down approach

BACKGROUND

Opioid Maintenance Treatment (OMT) is a well-evaluated treatment of opioid use disorder (OUD). Especially, under the condition of imprisonment, OMT is a preventive measure regarding infectious diseases such as hepatitis C. However, only a minority of prisoners with OUD are currently in OMT in numerous countries. In 2009, the Ministry of Justice of the federal state of North Rhine-Westphalia (NRW), Germany, launched the process of implementing OMT in prisons with various elements (e.g. development of recommendations regarding the treatment of prisoners with OUD, monitoring the number of prisoners in OMT, education of prison doctors). In the recommendations OMT was defined as the gold standard of treatment of OUD.

METHODS

To assess the effectiveness of the implementation strategy a survey on the prevalence of OMT in prisons in NRW was carried out twice a year by the Ministry of Justice between 2008 and 2016. Participants were prisoners in NRW, Germany. The diagnosis of OUD at admission to prison and the treatment state on survey dates was measured.

RESULTS

The number of prisoners in NRW dropped from 17,301 in 2008 to 16,432 in 2016. In the same period, the number of prisoners with OUD (mainly males) dropped from 4201 persons to 3650 persons and the number of prisoners in OMT increased from 139 persons (3.3%) to 1415 (38.7%) persons.

DISCUSSION

Currently, the percentage of prisoners with OUD in OMT in NRW is almost reaching the treatment rate outside prisons in Germany (45-50%). However, after release from prison there is still a high risk for a discontinuation of OMT.

CONCLUSIONS

Overall, the top-down approach of implementing OMT in prisons in the federal state of NRW was effective.

Effectiveness, safety and feasibility of extended-release naltrexone for opioid dependence: a 9-month follow-up to a 3-month randomized trial

BACKGROUND AND AIM

This is a follow-up study of a previously published randomized clinical trial conducted in Norway that compared extended-release naltrexone (XR-NTX) to buprenorphine-naloxone (BP-NLX) over 3 months. At the conclusion of the trial, participants were offered their choice of study medication for an additional 9 months. While BP-NLX was available at no cost through opioid maintenance treatment programmes, XR-NTX was available only through study participation, accounting for why almost all participants chose XR-NTX in the follow-up. The aim of this follow-up study was to compare differences in outcome between adults with opioid dependence continuing XR-NTX and those inducted on XR-NTX for a 9-month period, on measures of effectiveness, safety and feasibility.

DESIGN

In this prospective cohort study, participants were either continuing XR-NTX, changed from BP-NLX to XR-NTX or re-included into the study and inducted on XR-NTX treatment.

SETTING

Five urban, out-patient addiction clinics in Norway.

PARTICIPANTS

Opioid-dependent adults continuing (n = 54) or inducted on (n = 63) XR-NTX.

INTERVENTION

XR-NTX administrated as intramuscular injections (380 mg) every fourth week.

MEASUREMENTS

Data on retention, use of heroin and other illicit substances, opioid craving, treatment satisfaction, addiction-related problems and adverse events were reported every fourth week.

FINDINGS

Nine-month follow-up completion rates were 51.9% among participants continuing XR-NTX in the follow-up and 47.6% among those inducted on XR-NTX. Opioid abstinence rates were, respectively, 53.7 and 44.4%. No significant group differences were found in use of heroin and other opioids.

CONCLUSIONS

Opioid-dependent individuals who elect to switch from buprenorphine-naltrexone treatment after 3 months to extended-release naltrexone treatment for 9 months appear to experience similar treatment completion and abstinence rates and similar adverse event profiles to individuals who had been on extended-release naltrexone from the start of treatment.

Exploring synthetic heroin: Accounts of acetyl fentanyl use from a sample of dually diagnosed drug offenders

INTRODUCTION AND AIMS

Acetyl fentanyl, a fentanyl analogue emerging onto the recreational drug scene, has been responsible for numerous recent fatal overdoses in the USA, Europe and Russia. Studies reporting acetyl fentanyl use are presently limited to case studies and mortality reports. This study explores the nature of acetyl fentanyl use through the collection of first-hand qualitative data from users to inform public health and drug control policy responses.

DESIGN AND METHODS

A series of focus group interviews within a correctional setting-Delaware County (Ohio) Jail, USA. Participants were 102 individuals in one of two US Bureau of Justice Assistance Second Chance Act substance use treatment initiatives participating in at least one focus group session. Five of these individuals reported acetyl fentanyl use. Semi-structured qualitative focus group sessions queried subjects' drugs of choice and nature of drug use. Responses were explored through follow-up organic discourse.

RESULTS

Acetyl fentanyl users were generally unaware that they had administered the substance until after use (initially believing that they were administering heroin). They described the effects of acetyl fentanyl as stronger and qualitatively different from heroin. These individuals showed no interest in using acetyl fentanyl again describing it as unpleasant and more risky, both because of potency and the threat of a 'bad batch'.

DISCUSSION AND CONCLUSIONS

Acetyl fentanyl is reaching heroin users, some of which administer it unknowingly. Regulation of acetyl fentanyl is recommended in all countries as is increasing public awareness that the substance is distinct from and being sold as heroin. [Miller JM, Stogner JM, Miller BL, Blough S. Exploring synthetic heroin: Accounts of acetyl fentanyl use from a sample of dually diagnosed drug offenders. Drug Alcohol Rev 2018;37:121-127].

Monitoring a Prison Opioid Treatment Program Over a Period of Change to Clinical Governance Arrangements, 2007-2013

BACKGROUND AND AIMS

Opioid substitution therapy (OST) is an effective treatment for opioid dependence that is provided in many correctional settings, including New South Wales (NSW), Australia. In 2011, changes to the clinical governance of the NSW prison OST program were implemented, including a more comprehensive assessment, additional specialist nurses, and centralization of program management and planning. This study aimed to document the NSW prison OST program, and assess the impact of the enhanced clinical governance arrangements on retention in treatment until release, the provision of an OST prescription to patients at release, and presentation to a community OST clinic within 48 hours of release from custody.

METHOD

Data from the NSW prison OST program were obtained for the calendar years 2007-2013. Outcomes were analyzed quarterly using log binomial segmented regression.

RESULTS

8577 people were treated with OST in NSW correctional centers, 2007-2013. Over the entire study period, patients were retained in OST until release in 82% of treatment episodes; a prescription for OST was able to be arranged prior to release in 90% of releases; and patients presented to a community clinic within 48 hours of release in 94% of releases with prescriptions. Following the introduction of the changes to clinical governance, there was a significant increasing trend in retention in OST until release, and in provision of an OST prescription at release. There was an initial increase, followed by a decreasing trend, in presentation to a community clinic within 48 hours of release.

DISCUSSION

This large prison-based OST program has high rates of retention in treatment and continuity of care as patients transition from custody to the community. Strengthened clinical governance arrangements were associated with increased retention in treatment until release and increased provision of an OST prescription at release, but did not improve clinic attendance following release from custody.