Delphi were one of the first community drug services in England to offer a flexible-dose, prolonged-release buprenorphine (PRB) solution for subcutaneous injection. In 2021 Delphi proposed to introduce a PRB trial at HMP Manchester and HMP Buckley Hall – the trial began with an expectation of ten clients maximum, shared across two groups.
PRB has multiple advantages within prison settings. Firstly, the subcutaneous injection route allows for completely supervised administration, with a NICE evidence review for PRB finding no risks for diversion. Additionally, the prolonged release formulaÂtion allows for long-term inÂjecÂtions which reduces the frequency of dispensing and thus also supervision. The weekly or monthly doses also remove the daily administration requirements necessary for oral methadone and sublingual buprenorphine – this supports future recovery by allowing individuals to attend work in prison regimes and may facilitate easier transition post-release.
The HMP Manchester and HMP Buckley Hall trial was led by the head of medicines management within the DARS (drugs and alcohol services) team. The proposal and costings were approved by Greater Manchester Mental Health NHS Foundation Trust and Delphi proposed to complete case studies for each PRB client to measure qualitative and quantitative data.
INCLUSION CRITERIA AT INITIAL PROPOSAL
Group 1 maintenance option (three clients)
• Currently maintained on buprenorphine tablets
• Sentenced for more than six months and not likely to be transferred or released
• Actively engaging with DARS psychosocial interventions
Group 2 detox option (seven clients)
• Currently prescribed methadone, maximum of 30mg
• Sentenced for more than six months and not likely to be transferred whilst on treatment
• Actively engaging with DARS psychosocial interventions
• Looking to be abstinent from OST within four weeks
IN THE PRISONS DELPHI INTRODUCED PRB:
• To offer services that mirror the community
• To provide choice in detox options
• To support plans for future recovery
• To allow clients to attend work in prison regime
• To remove the daily requirement for methadone
• To reduce diversion chances
In June-July 2021 preparations began and the DARS team started speaking to clinical clients who met the criteria. The head of prisons shared information about the trial with governors across both prisons, the commissioner, and the regional drug strategy lead, and the PRB trainer delivered an administration session to all staff.
Following the information session 16 clients in HMP Buckley Hall expressed interest and the head of medicines management reviewed their records to plan 1-1 sessions. In November 2021, a delivery test order was made to HMP Buckley Hall with a start date of December. The maintenance clients were prioritised at this point, recognising their previous feedback about detox over Christmas with January for detox options.
A smaller number of clients at HMP Manchester were identified as ready for review and change. PRB officially started at HMP Buckley Hall on 1 December 2021 with two doses successfully delivered. The prison governors and commissioner were updated, and the numbers increased to five clients by 17 December.
CLIENT FEEDBACK FROM THE INFORMATION SESSIONS
• ‘I found it interesting and want to change over.’
• ‘I love the idea of this. It will be a game-changer, I just hope I can get on it.’
• ‘I think this will be great for being released. I also think it will help break the cycle.’
• ‘Very good that you can have this from an injection and I want this for myself and the trial run.’
• ‘I found it very helpful and informative. All questions and worries were answered. I feel completely at ease after the talk and would definitely go on [it] if I was given the opportunity.’
• ‘Very important. A shame it’s not everywhere in the community.’
• ‘It was very good. I want to go on it as soon as possible. It sounds something I’d like to continue when I come out.’
For the clients who commenced PRB, the key workers supported them with a review within the week to assess any issues and identify solutions – for example around occupying their time or distraction techniques.
The plan now is that prescribers will attend weekly and review as needed, and PRB will be an agenda item on drug strategy meetings. New starters are reported on a spreadsheet so we can keep a continued record with feedback and the prescriber attends the service once a week to review prescriptions and administer doses. This is then followed up as required and as per prescription via the prescriber and nurses on site.
There are some clients who state they are feeling great, while another who had mental health issues before the transition feels the change of medication while accessing mental health medication has been a challenge.
The outcome in both prisons was favourable and the following recommendations were made: At Buckley Hall it was proposed to have treatments as an agenda item at drug strategy meetings, allowing the prison to be involved in the work and raise awareness of progression in the DARS service; to improve awareness of PRB as an option of treatment with HMP service providers; and for clients to be reviewed on a regular basis in addition to the prescriber clinic.
Emerging evidence supports the economic viability of PRB usage in correctional contexts. Cost estimates from 2020 demonstrated that switching just 50 incarcerated individuals, in a standard English prison, from methadone to PRB would reduce overall costs by £8,665 and save more than 3,000 hours of staff time. A recent Canadian cost comparison between PRB injections and sublingual buprenorphine/naloxone identified that whilst PRB did cost more than buprenorphine/naloxone, the reduction in staff time in preparing, administering, dispensing, and monitoring meant that PRB was more cost-efficient.
Currently Scotland and Wales recommend, based on evidence of previous trials, switching over to PRB if cost-effective within the prison. While it is now standard practice within Wales to prescribe PRB as part of release planning, NHS England have not recommended it because of operational and continuity of care challenges.
Our non-randomised multicentre mixed-methods trial of PRB with psychosocial intervention adjuncts aims to assess the treatment outcomes of both maintenance and detoxification options in incarcerated populations in England. Delphi will continue with PRB in HMP Manchester and use the lessons learnt from Buckley Hall to improve client care on PRB.
Claire Illingworth is head of operations central at Delphi