People with opioid dependence are overrepresented in correctional settings (AIHW, 2013; Indig et al., 2010). Opioid substitution therapy (OST) is an effective treatment for opioid dependence, reducing illicit opioid use (Mattick, Breen, Kimber, & Davoli, 2009, 2014) and mortality (Degenhardt et al., 2011). OST is provided in correctional settings in many jurisdictions around the world (HRI, 2014), but there has been limited examination of the patient experience of opioid substitution therapy (OST) in correctional settings. Unexplored issues include reasons for entering (or not entering) treatment; patient perceptions of advantages and disadvantages of OST in prison; and preferences to cease or remain in treatment on release from prison. This latter issue is of particular importance, as clinicians report that patients often wish to cease OST prior to release, even when informed of the risk of overdose and benefits of remaining in treatment.
This qualitative study aimed to examine patient motivations for, and perceptions and experiences of, OST in prisons in New South Wales (NSW), Australia. Forty-seven participants were recruited from seven correctional centres across NSW between September 2012 and October 2013. All participants had a recorded history of opioid use and/or dependence. To ensure a broad range of perspectives were obtained, participants were selected on the basis of specific exposures to OST:
- Exposure group A (n=7): New inductions to OST. These individuals were within 28 days of commencing OST at the time of interview. They may have been in OST previously, in community or custodial settings;
- Exposure group B (n=11): Continuing OST from the community. This group of patients had been in OST prior to custody, and were in treatment in custody for at least 28 days before interview (i.e. had some familiarity with the opioid treatment program in prison).
- Exposure group C (n=10): Commenced OST in custody. These participants were in treatment for at least 28 days before interview (i.e. had some familiarity with the opioid treatment program in prison).
- Exposure group D (n=9): Voluntarily ceased OST in custody.
- Exposure group E (n=10): Patients who reported heroin use on reception to prison, but have not entered OST or have declined to be placed on the OST waiting list during this custodial sentence.
The sample was predominantly male (n=32; 68%), and 18 participants (38%) identified as Aboriginal and/or Torres Strait Islander. The average age of participants was 35 years. Three-quarters (n=35, 75%) of the sample were sentenced, 11 were on remand, and one participant was unsure of sentencing status. The majority (n=42; 89%) reported a previous incarceration history. Twenty-eight participants were currently prescribed OST (methadone n=27, 57%; buprenorphine-naloxone-naloxone n=1, 2%).
Findings by exposure group
Among new OST inductions (Group A, n=7), reasons for commencing OST included wanting to abstain from drug use in prison and in the community upon release, as well as to aid with opioid withdrawal. Some participants noted the role of OST in the management of chronic pain. Benefits of OST identified by this group included elimination of opioid cravings, and the financial advantages of not buying drugs in prison. Criticisms of the opioid treatment program reported by this group included the waiting period to enter the program, with over half reporting drug use during this period in order to manage withdrawal symptoms. All participants in this group reported a willingness to stay in OST post-release, with two participants noting that they would prefer to be switched from methadone to buprenorphine formulations due to the lower frequency of administration (every second day) and higher number of ‘take-away’ doses available, which was deemed more practical for meeting employment commitments.
Almost all (10/11) Group B patients (continuing OST from the community) were satisfied to remain in OST. Most (7/11) were willing to continue with OST post-release, so as to avoid drug relapse. As in Group A, two participants reported a preference to switch from methadone to buprenorphine-naloxone formulations post-release. For those who were wanting to cease treatment prior to release, reasons for this included pressure from family members and friends, the stigma attached to OST, the long-term nature of OST, and the perceived side-effects of poor dental health and appearing ‘stoned’.
Group C (n=10) were current OST patients who had commenced OST during this custodial period. Participants in this group reported drug use and unsafe injecting practices while in prison before commencing treatment. Most (6/10) reported that they would remain in OST post-release, at least until they felt they were stable and had a daily routine in the community. Those who wanted to cease treatment prior to release reported that they were primarily on OST for the management of their chronic pain and that on their release, they would seek other medication, often the preferred opioid analgesic they were prescribed prior to custody.
Group D (n=9) had ceased OST during their current incarceration period. Around half (4/9) of participants in this group expressed interest in re-starting OST. Motivations for restarting OST included wanting to cease drug use in prison, and prevention of opioid withdrawal. Again, it was reported that drug use and unsafe injecting practices occurred during waiting periods to enrol in treatment. Reasons for ceasing OST related to release from prison and a reluctance to continue in OST due to the long-term nature of treatment, daily stressors of obtaining methadone in the community, and previous unsuccessful attempts OST episodes in the community.
Group E (n=10) were people with a history of opioid use and/or dependence who had not entered OST in this period of incarceration. Seven participants in this group reported prior OST in the community or during previous incarcerations. Six of the ten participants in this group reported that they would like to be in OST, preferably prescribed a buprenorphine-naloxone formulation.
Recurrent themes across groups
Perceptions of opioid treatment program operation
Participants were critical of the time taken to be assessed for OST and commenced on treatment. Participants perceived that this process was expedited if they reported drug use in prison to health centre staff; however, drug use is not a high priority indication for treatment entry per se (unlike pregnancy or HIV seropositivity, for example), so it is unclear if this perception was valid. Once treatment had commenced, participants perceived that there was a lack of monitoring and limited discussion of long-term treatment plans, particularly in relation to ceasing OST.
Some participants questioned the motivations of other OST patients; for example, people with no recent history of opioid use who requested assessment for the opioid treatment program, or patients who deliberately requested higher doses of medicine than necessary in order to feel intoxicated.
Intentions to cease OST prior to or on release
Around one-third of current OST patients reported an intention to cease OST prior to or on release from prison. Participants identified aspects of OST in the community that they perceived as restrictive (e.g. daily dosing; difficulties in travelling to clinics within opening hours; difficulties going away from home). Some participants expressed concern that attending an OST clinic would result in drug use and/or crime as a result of exposure to past associates. Participants also expressed concern about the long-term nature of OST, with the perception that OST was replacing one addiction for another and in conflict with the goal of being ‘drug free’. Participants also identified the stigma attached to OST as a reason for ceasing treatment prior to release. For some participants, this issue was framed in terms of where best to withdraw from OST, specifically methadone – in custody, or in the community. These participants identified the prison setting as a more fitting environment for managing withdrawal.
Drug use in prison, including buprenorphine-naloxone diversion
Across groups there was consensus that drugs including cannabis, heroin, methamphetamine, and buprenorphine-naloxone diverted from the opioid treatment program. Availability and pricing of drugs varied by prison.
Drugs were injected and smoked. Awareness of the risk of blood borne virus transmission via sharing of needles and syringes was high, with specific mentions of risk of hepatitis C virus (HCV) and HIV transmission. Participants reported use of needles and syringes by multiple people despite these risks.
The issue of buprenorphine-naloxone diversion from the opioid treatment program was mentioned by 18 participants. Diversion appeared to occur largely in the context of patients being ‘stood over’; that is, being forced to give their buprenorphine-naloxone to someone else. Participants reported that people engaged in stand over behaviour to obtain buprenorphine-naloxone for their own use (medicating withdrawal symptoms, or getting intoxicated) or to sell for profit.
Use of OST for chronic pain
Five participants were prescribed methadone for the treatment of chronic pain. Participants generally stated a preference for other analgesic medicines. Methadone was, however, perceived as more effective for pain relief than other options available in the prison setting (e.g. ibuprofen).
Naltrexone for the treatment of opioid dependence
Over half of participants (27/47) had heard of naltrexone (either oral or implant formulation). There was some scepticism regarding the utility of naltrexone treatment for opioid dependence in the prison settings, primarily because participants believed that those prescribed naltrexone would continue to use, or commence using, non-opioid drugs.
Discussion and conclusions
Treatment seeking was often precipitated by drug use and injecting in prison. OST was also sought to medicate opioid withdrawal symptoms. Keeping prison-based OST numbers within a range that results in safe management both in custody and upon release to the community has led to delays in accessing OST for those patients seeking to commence treatment in prison, and patients clearly have strong negative views about this approach. Among some participants, the waiting list appeared to act as a barrier to initiating the process of commencing OST. Balancing the needs of opioid dependent patients against operational and capacity issues, and safety and security concerns, are ongoing challenges for clinical staff.
With some exceptions, benefits of OST in prison were largely framed in terms of avoiding negative experiences or outcomes, rather than as direct positive benefits of treatment. These findings highlight that although OST is perceived as preventing negative outcomes, it is not necessarily seen as producing positive outcomes for the individual, such as better health or quality of life. This is line with previous research that has reported the considerable ambivalence that many opioid dependent persons have towards OST (Harris & Rhodes, 2013).
Diversion of buprenorphine-naloxone from the opioid treatment program appeared to most commonly occur in the context of patients being ‘stood over’ for their medicine, although there may also be patients who voluntarily engage in diversion. The potential for diversion of buprenorphine products used for OST in correctional settings has been previously identified (Gordon et al., 2014; Kinlock, Gordon, Schwartz, & Fitzgerald, 2010; Magura et al., 2009), and the combination buprenorphine-naloxone film was introduced into NSW correctional centres specifically in response to concerns regarding diversion of the mono-buprenorphine formulation (administered sublingually). Policies and procedures for reducing the incidence of diversion and for responding to identified cases of diversion are in place in correctional health centres in NSW.
Despite the identified benefits of OST in prison, there was considerable ambivalence among patients regarding continuation of OST once released. Balancing the preference of many patients to cease OST prior to release against patient safety post-release is a substantial challenge for correctional health care providers. The weeks immediately after release from prison are associated with an elevated risk of drug-related death (compared to other time at liberty) (Merrall et al., 2010), and exposure to OST during this period is highly protective against mortality (Degenhardt et al., 2014). As such, correctional health care providers in NSW are trained to advise patients to remain in OST through their transition to the community, and are reluctant to assent to patient requests to cease OST prior to release. This tension between patient preference and evidence-informed clinical practice appears to be perceived by patients as a lack of consultation and/or poor treatment planning. Further work is needed examining provider perspectives of OST in prison, and determining models of care to enhance post-release engagement in OST.
Participants reported that injecting drug use occurred in prisons. Awareness of the potential for HCV or HIV transmission through the sharing of injecting equipment was high; nonetheless, participants reported that sharing of needles and syringes was common. Participants perceived a needle and syringe program as feasible for the prevention of re-use of injecting equipment.
This study has generated unique data on patient perspectives of OST in correctional settings. We have described patient perspectives on entry to, experiences of, and retention in, OST in prison and post-release. Our findings have highlighted the challenges facing opioid treatment providers in prison in addressing patient ambivalence towards OST and preferences to cease OST prior to release, and can inform the development of policies and clinical practices that are mindful of patient perspectives and concerns. These results are suggestive of the need for further work examining how best to attract and retain opioid dependent prisoners in treatment, including provider perspectives; evaluation of programs designed to increase post-release retention in OST (and other care), and quantitative analyses of retention in OST in prison and post-release.