Long-acting injectable buprenorphine - 'best practice' opioid agonist therapy for Australian prisoners

Feasibility and effectiveness of extended-release buprenorphine (XR-BUP) among correctional populations: a systematic review

Background: Medications for opioid use disorder (MOUD) reduce risks for overdose among correctional populations. Among other barriers, daily dosing requirements hinder treatment continuity post-release. Extended-release buprenorphine (XR-BUP) may therefore be beneficial. However, limited evidence exists.Objectives: To conduct a systematic review examining the feasibility and effectiveness of XR-BUP among correctional populations.Methods: Searches were carried out in Pubmed, Embase, and PsychINFO in October 2023. Ten studies reporting on feasibility or effectiveness of XR-BUP were included, representing n = 819 total individuals (81.6% male). Data were extracted and narratively reported under the following main outcomes: 1) Feasibility; 2) Effectiveness; and 3) Barriers and Facilitators.Results: Studies were heterogeneous. Correctional populations were two times readier to try XR-BUP compared to non-correctional populations. XR-BUP was feasible and safe, with no diversion, overdoses, or deaths; several negative side effects were reported. Compared to other MOUD, XR-BUP significantly reduced drug use, resulted in similar or higher treatment retention rates, fewer re-incarcerations, and was cost-beneficial, with a lower overall monthly/yearly cost. Barriers to XR-BUP, such as side effects and a fear of needles, as well as facilitators, such as a lowered risk of opioid relapse, were also identified.Conclusion: XR-BUP appears to be a feasible and potentially effective alternative treatment option for correctional populations with OUD. XR-BUP may reduce community release-related risks, such as opioid use and overdose risk, as well as barriers to treatment retention. Efforts to expand access to and uptake of XR-BUP among correctional populations are warranted.

Using the Alcohol, Smoking and Substance Involvement Screening Test to predict substance-related hospitalisation after release from prison: A cohort study

BACKGROUND AND AIMS

Poor substance use-related health outcomes after release from prison are common. Identifying people at greatest risk of substance use and related harms post-release would help to target support at those most in need. The Alcohol Smoking and Substance Involvement Screening Test (ASSIST) is a validated substance use screener, but its utility in predicting substance-related hospitalisation post-release is unestablished. We measured whether screening for moderate/high-risk substance use on the ASSIST was associated with increased risk of substance-related hospitalisation.

DESIGN

A prospective cohort study.

SETTING

Prisons in Queensland and Western Australia.

PARTICIPANTS

Participants were incarcerated and within 6 weeks of expected release when recruited. A total of 2585 participants were followed up for a median of 873 days.

MEASUREMENTS

Baseline survey data were combined with linked unit record administrative hospital data. We used the ASSIST to assess participants for moderate/high-risk cannabis, methamphetamine and heroin use in the 3 months prior to incarceration. We used International Classification of Diseases (ICD) codes to identify substance-related hospitalisations during follow-up. We compared rates of substance-related hospitalisation between those classified as low/no-risk and moderate/high-risk on the ASSIST for each substance. We estimated adjusted hazard ratios (aHR) by ASSIST risk group for each substance using Weibull regression survival analysis allowing for multiple failures.

FINDINGS

During follow-up, 158 (6%) participants had cannabis-related, 178 (7%) had opioid-related and 266 (10%) had methamphetamine-related hospitalisation. The hazard rates of substance-related hospitalisation after prison were significantly higher among those who screened moderate/high-risk compared with those screening low risk on the ASSIST for cannabis (aHR 2.38, 95% confidence interval [CI] 1.74, 3.24), methamphetamine (aHR 2.23, 95%CI 1.75, 2.84) and heroin (aHR 5.79, 95%CI 4.41, 7.60).

CONCLUSIONS

Incarcerated people with an Alcohol Smoking and Substance Involvement Screening Test (ASSIST) screening of moderate/high-risk substance use appear to have a significantly higher risk of post-release substance-related hospitalisation than those with low risk. Administering the ASSIST during incarceration may inform who has the greatest need for substance use treatment and harm reduction services in prison and after release from prison.

The predictive validity of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for moderate- to high-risk cannabis, methamphetamine and opioid use after release from prison

BACKGROUND AND AIMS

Illicit substance use is common among people entering prisons, as is returning to substance use after release from prison. We aimed to assess the predictive validity of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) for returning to substance use after release from prison.

DESIGN

A longitudinal design with baseline survey conducted between 2008 and 2010 in the 6 weeks before expected prison release and up to three follow-up surveys in the 6 months after release.

SETTING

Prisons in Queensland, Australia.

PARTICIPANTS

A total of 1054 adults within 6 weeks of expected release from prison.

MEASUREMENTS

The ASSIST was used to assess problematic use of cannabis, methamphetamine, heroin and other non-prescribed opioids in the 3 months before incarceration. Post-incarceration substance use was measured at 1, 3 and 6 months after release. We calculated the area under the receiver operating characteristic curve (AUROC) and the optimal ASSIST cut-off score for each substance, using Youden's index (J).

FINDINGS

Forty-one per cent (n = 434) of the cohort reported any substance use during follow-up: 33% (n = 344) used cannabis, 20% (n = 209) methamphetamine, 10% (n = 109) heroin and 9% (n = 97) illicit other opioids. The optimal ASSIST cut-off score was ≥ 4 for heroin, methamphetamine and cannabis and ≥ 1 for other opioids. Using these cut-offs, the AUROC was highest for heroin in predicting both any use (AUROC = 0.82) and weekly use (AUROC = 0.88) in the past 4 weeks. AUROCs for other drugs ranged from 0.73 to 0.79.

CONCLUSIONS

The ASSIST shows promise as an accurate and potentially scalable tool that may be useful for predicting a return to substance use after release from prison and could inform service delivery. The substantial rates of returning to substance use after release from prison suggest that prison serves to interrupt rather than cease substance use.

'I just thought that was the best thing for me to do at this point': Exploring patient experiences with depot buprenorphine and their motivations to discontinue

INTRODUCTION

Long-acting injectable depot buprenorphine is a recent addition to the suite of opioid agonist therapies (OAT) used to treat opioid use disorder (OUD). However, there has been little research that focuses on the lived experience of people receiving depot buprenorphine treatment and reasons for why people decide to discontinue. The aim of this study was to explore what it is like to receive depot buprenorphine and to understand the motivations behind why people discontinue.

METHODS

Open-ended, semi-structured interviews were conducted between November 2021 and January 2022 with individuals who were either currently receiving depot buprenorphine or had discontinued or were in the process of discontinuing depot buprenorphine. Liberati, et al.'s (2022) adaptation of Dixon-Woods's (2006) candidacy framework was used to analyse the participant experiences.

RESULTS

40 participants (26 male, 13 female, 1 undisclosed; mean age 42 years) were interviewed about their experience with depot buprenorphine. At the time of the interview, 21 were currently receiving depot buprenorphine and 19 had discontinued this treatment or were in the process of discontinuing. Participants cited 4 key reasons why they decided to discontinue depot buprenorphine:1) feeling forced into the program, 2) experiencing negative side-effects, 3) finding the treatment ineffective, and 4) wanting to stop depot buprenorphine/OAT to use opioids again or feeling 'cured' and no longer in need of OAT. Participants were ultimately discussing issues related to clinician-patient power relations, agency and bodily autonomy, and the pursuit of well-being.

CONCLUSION

Depot buprenorphine remains a promising treatment for OUD and offers potential to improve treatment adherence. Instances of restricted OAT choice and consumer concerns regarding a lack of agency must be addressed in order to enhance therapeutic relationships. Clinicians and other healthcare workers in this field also need greater access to information about depot buprenorphine to better address issues patients face during treatment. More research is required to understand patient and treatment choice given the options of these new treatment formulations.

A prison mental health network in the RANZCP

OBJECTIVE

Consider the unique features and challenges of prison psychiatry.

CONCLUSIONS

A Prison Mental Health Network within the Royal Australian and New Zealand College of Psychiatrists would serve many useful functions including improving the quality of mental health services by promoting high clinical standards and ethical practice by psychiatrists working in prisons.