Federal

Correctional Service Canada (2021) – Guidance on Opioid Use Disorder (OAT) Program: August 16, 2021¹⁶

Methadone

Risk of diversion

Buprenorphine-naloxone

Risk of diversion

Morphine

Risk of diversion

Glancy et al. (2019) – Practice Resource For Prescribing In Corrections¹⁷

Any drug at high risk for misuse

Risk of misuse

Psychotropic drugs

Risk of misuse or diversion, adherence issues

Tricyclic antidepressants

Risk of misuse

Mood stabilizers (e.g., gabapentin)

Risk of misuse

Benzodiazepines

Risk of misuse or diversion

Stimulants

Risk of diversion

Centre for ADHD Awareness (2016) – ADHD and the Justice System: The Benefits of Recognizing and Treating ADHD in Canadian Justice and Correction Systems¹⁸

Nonstimulants (e.g., atomoxetine, venlafaxine, or bupropion)

Risk of diversion

Psychostimulants (e.g., lisdexamfetamine dimesylate, osmotic-release oral system methylphenidate)

Risk of diversion

British Columbia

Adult Custody Division Corrections Branch (2012) – Health Care Services Manual¹⁹

Methadone

Risk of diversion

Buprenorphine-naloxone

Risk of diversion

Manitoba

The College of Physicians and Surgeons of Manitoba (2023) – Manitoba Opioid Agonist Therapy Recommended Practice Manual²⁰

Drugs for OAT (first line: buprenorphine-naloxone)

NR

College of Physicians and Surgeons of Manitoba – Manitoba Methadone and Buprenorphine Maintenance Recommended Practice (2015)²¹

Buprenorphine

Risk of misuse or diversion

Methadone

Risk of misuse or diversion

Nova Scotia

College of Physicians and Surgeons of Nova Scotia (2012) – Methadone Maintenance Treatment Handbook²²

Methadone

Risk of diversion

Ontario

Registered Nurses’ Association of Ontario (2009) – Supporting Clients on Methadone Maintenance Treatment²³

Methadone

Risk of diversion

Saskatchewan

College of Physicians and Surgeons of Saskatchewan (2008) – Saskatchewan Methadone Guidelines For The Treatment Of Opioid Addiction/Dependence²⁴

Methadone

NR

International

WHO (2014) – Prisons and health^25,a

Methadone

Ensure adherence, reduce risk of diversion and overdose

Buprenorphine

Ensure adherence, reduce risk of diversion and overdose.

Australia

The Royal Australian College of General Practitioners (2019) – Custodial health in Australia: Tips for providing health care to people in prison²⁶

Benzodiazepines

Risk of misuse or diversion

Opioids

NR

Justice Health (2015) – Victorian Prison Opioid Substitution Therapy Program Guidelines²⁷

Methadone

Risk of diversion

Buprenorphine

Risk of diversion

UK

Royal College of General Practitioners (2019) – Safer Prescribing in Prisons²⁸

Schedule 2, 3, and 4 Controlled Drugs

NR

Drugs prescribed for substance use (e.g., methadone)

Risk of misuse or diversion

Antidepressants with sedating or euphoric effects (e.g., mirtazapine)

Risk of misuse or diversion

Benzodiazepines

Risk of misuse or diversion

Antipsychotic drugs (e.g., quetiapine)

Risk of misuse or diversion

High potency analgesics (e.g., opioids [e.g., tramadol], gabapentinoids [e.g., pregabalin])

Risk of misuse or diversion

Hypnotics (e.g., zopiclone)

Risk of misuse or diversion

Anxiolytics (e.g., diazepam)

Risk of misuse or diversion

Certain antiepileptic drugs (e.g., clonazepam)

Risk of misuse or diversion

Drugs for ADHD

Risk of misuse or diversion

Royal College of Psychiatrists (2020) – Detainees with substance use disorders in police custody: Guidelines for clinical management (fifth edition)²⁹

For patients in police custody: all drugs

NR

Methadone

• Canada (CSC)¹⁶

• British Columbia¹⁹

• Manitoba²¹

• Nova Scotia²²

• Ontario²³

• Saskatchewan²⁴

• Australia²⁷

1. Patient ingests the full dose of methadone while being observed by the health care provider. The Australian guidelines recommend that the patient must be facing forward and cannot turn sideways or move out of direct sight.

2. In Canada, the patient then drinks a cup of water in direct view of the health care provider. British Columbia, Nova Scotia, and Saskatchewan specify 250 mL or 8 oz; CSC and Ontario do not provide a specific amount.

3. Nurse or health care staff verify that the dose has been swallowed. This can be done by inspecting the patient’s mouth or speaking to the patient.²⁷

4. In Australia, patients sign to confirm they have received the dosage.

5. Patients are observed postadministration, with most guidance recommending for at least 20 minutes after ingestion. Manitoba’s guidance does not provide a recommendation for a specific period but does recommend that the patient should be isolated from other inmates for some time to reduce the risk of diversion.

6. Nova Scotia recommends limiting access to water post-ingestion (e.g., fountains, bathrooms).

Timing: British Columbia and Australia recommend that methadone be provided in the morning or before midday.

Frisk-searching: British Columbia recommends frisk-searching patients before distribution, while Nova Scotia and Australia recommend frisking before entering and/or leaving the administration area.

Priority populations: Saskatchewan recommends that if demand for methadone is higher than the ability of the setting to manage and administer to patients safely, priority populations include people who are:

• Pregnant and currently or previously opioid dependent and at high risk of relapse

• Currently opioid dependent

• Opioid-dependent and require treatment for Hepatitis C and HIV.

Buprenorphine

• Manitoba²¹

• Australia²⁷

1. Patients place the tablet or film under their tongue to dissolve.

2. Australia’s guidance states that if the patient receives more than 2 films, the patient should drink at least 150 mL of water before receiving the next dosage, repeating as needed until the full dose is administered.

3. In Australia, patients sign to confirm they have received the dosage.

4. Manitoba recommends verifying the tablet has dissolved before isolating the patient from others post-ingestion to reduce diversion²¹ Australia also recommends supervising patients after ingestion of methadone or buprenorphine to prevent diversion: specific processes are provided by the Deputy Commissioner’s Instructions (DCIs) and conducted by custodial officers.

Australia recommends that buprenorphine be provided before midday.

Buprenorphine-naloxone

• Canada (CSC)¹⁶

• British Columbia¹⁹

1. Patient drinks a cup of water

2. The patient places the sublingual tablet or film under their tongue to allow it to dissolve while in view of the health care professional. For the film formulation, the patient should place it on one side under their tongue, with any additional film placed on the opposite side, before pressing and holding the film in place for 5 seconds.

3. After ingestion, the patient should be observed. CSC recommends for at least 5 minutes, while British Columbia recommends at least 10 minutes

4. British Columbia recommends that correctional staff inspect the patient’s mouth to check the tablet has dissolved fully.

CSC guides both the film and tablet forms, while British Columbia only provides recommendations regarding the tablet formulation.

Slow-release oral morphine

• Canada (CSC)¹⁶

1. Nurse opens capsule(s) and sprinkles on apple sauce

2. Patient ingests contents

3. Patient rinses the mouth with water, then swishes and swallows water

4. Patient is observed postadministration for at least 20 minutes

None.

Population

People who are currently in a correctional facility who require drug treatment

Intervention

Directly observed therapy (DOT)

Comparator

• Different methods of administering DOT

• Providing the same drugs without DOT

Outcomes

• Clinical benefit for people receiving the drugs

• Time to administer

Study designs

Systematic reviews, randomized controlled trials, nonrandomized studies, guidelines, program evaluations, institutional policies

Correctional Service Canada (2021)¹⁶

Canada (federal correctional settings)

Nurse

For administering methadone, the nurse must:

1. Ensure the patient ingests entire dose of methadone

2. Provide patient a cup of water of several ounces of water to be poured into the bottle of methadone

3. Observe the patient drinking the water, then require the patient to speak to them

4. Ensure the patient returns the empty methadone bottle to them

5. Postadministration security observation should be a minimum of 20 minutes.

For administering buprenorphine-naloxone tablet or film, the nurse must:

1. Ensure patient drinks a glass of warm water to modify the mouth immediately before drug administration

2. Provide the tablet in a drug cup or the envelope containing the film; must watch patients tear the envelope on the dotted line

3. Observe the patient placing the tablet under their tongue or the film on one side under their tongue, close to the base on either side

4. For the film, the patient should press and hold the film in place for 5 seconds

5. Any additional film should be placed on the opposite side, and no 2 films should overlap

6. As the manufacturer does not recommend crushing tablets, if the prescriber chooses to crush, it should be decided on an individual patient basis and the medical reason recorded

7. Postadministration security observation should be a minimum of 5 minutes

For slow release oral morphine, the nurse must:

1. Open the capsule(s) and sprinkle it on apple sauce at time of administration

2. Watch patient ingest contents without chewing or crushing the beads

3. Direct patient to rinse mouth with water and then swish and swallow water

4. Postadministration security observation should be a minimum of 20 minutes

Glancy (2020)¹⁷

Canada

Nurse

DOT should be used for any drug at high risk of misuse (e.g., stimulants), and floated in water, apple sauce, or pudding when possible. Liquid formulations may also help to reduce risk of diversion.

Adult Custody Division Corrections Branch (2012)¹⁹

British Columbia¹⁹

Health care professional

For administering methadone:

1. Check patient’s photograph to ensure correct identity before each dose. In centres using identification bar codes, the bar code is scanned and matched to the bar code on the drug.

2. Drug is administered in the morning by a health care professional.

3. After dose is taken, patient drinks 1 full glass of water (8 oz or 250 mL).

4. Inspect patient’s mouth to ensure swallowing of the entire dose.

5. Correctional staff directly observe for at least 20 minutes to reduce risk of diversion.

6. Dose administered is charted, and forms are faxed to pharmacy for stock monitoring.

For administering buprenorphine-naloxone:

1. Check patient’s photograph to ensure correct identity before each dose. In centres using identification bar codes, the bar code is scanned and matched to the bar code on the drug.

2. Drug is administered in the morning by a health care professional.

3. Before dose, patient drinks 1 full glass of water (8 oz or 250 mL).

4. In direct view of the health care professional, patient places the tablet under their tongue to allow it to dissolve.

5. Correctional staff directly observe for at least 10 minutes to reduce risk of diversion.

6. Patient’s mouth is inspected to ensure drug has dissolved.

7. Dose administered is charted, and forms are faxed to pharmacy for stock monitoring.

The College of Physicians and Surgeons of Manitoba (2023)²⁰

Manitoba

Nurse

• In correctional settings, it is recommended OUD be treated with OAT, with buprenorphine-naloxone as first-line treatment.

• The substitution drug is administered via witnessed self-administration (i.e., DOT) by nursing staff onsite at the correctional facility.

College of Physicians and Surgeons of Manitoba (2015)²¹

Nurse

For administration of methadone or buprenorphine:

1. Identify each patient before dispensing drug.

2. Check name, date, and dose on label of bottle.

3. Verify patient has completely swallowed methadone dose or buprenorphine tablet has dissolved.

4. Record dose administered.

5. Isolate patient from others post-ingestion for a period of time to reduce risk of diversion.

Registered Nurses’ Association of Ontario (2009) – Supporting Clients on Methadone Maintenance Treatment

Ontario

—

Processes specific to correctional settings:

• Confirm using photo identification before each methadone dose to ensure the correct patient receives the dose.

• Correctional staff observe patients for at least 20 minutes postadministration to reduce risk of diversion.

• To reduce risk of diversion and protect patients and staff, correctional officers support health care staff during methadone administration.

• Institution policies should be followed regarding observed patients while taking methadone.

General process for administering methadone:

1. Patient should be observed the entire time while drinking the dose.

2. Patient should be engaged in conversation after drinking the dose to ensure they have ingested the drug.

3. Nurse should ensure patient has consumed entire contents of bottle, with any remaining amount recorded and reported to the physician.

4. The container used to dispense methadone should be filled with water, and the patient should drink this as well to ensure the whole dose is taken and swallowed.

College of Physicians and Surgeons of Saskatchewan (2008)²⁴

Saskatchewan

Nurse

For delivering methadone:

1. Methadone must be administered under direct supervision of medical unit staff.

2. Nurse verifies patient’s identity before administering methadone.

3. After ingesting the methadone, the patient drinks a full glass of water.

4. Nurse verifies drug is not held in the mouth.

5. Patient is observed by correctional staff for approximately 20 minutes after administration to ensure ingestion, ideally within designated supervised areas.

If demand for methadone is higher than the ability of the correctional setting to safely manage and administer to patients, priority populations to provide methadone to include:

• Women who are pregnant and are currently or previously opioid dependent and are at high risk of relapse

• People who are currently opioid dependent

• People who are opioid dependent and require treatment for Hepatitis C and HIV.

College of Physicians and Surgeons of Nova Scotia (2012)²²

Nova Scotia

Nurse

For delivering methadone:

1. Patient show proper identification.

2. Patient should be isolated from other patients during administration.

3. After administration, patient drinks water.

4. Nurse can inspect mouth before and/or after.

5. Patients can be frisked before entering and/or upon leaving administration area.

6. Limit access to water post-ingestion (e.g., fountains, bathrooms).

7. Patients should be directly observed for 20 minutes after.

WHO (2014)²⁵

International

Nurse or guard

For OAT in correctional settings:

• Nurses or guards can supervise ingestion of methadone, depending on how and where the drug is dispensed (e.g., medical unit or in the cells or wards) to ensure the substance is swallowed (methadone) or diluted under the tongue (buprenorphine).

• There is a consensus that OAT must be supervised to ensure adherence, avoid coercion, and avoid overdoses.

Justice Health, Department of Justice and Regulation, Victorian Government (2015)²⁷

Australia

Correctional health service staff (medical practitioners, nurses, and pharmacists)

Before administering doses:

• Patients must bring identification card.

• Correctional staff must check patient is not intoxicated.

• Correctional staff must check the patient’s name and Corrections Reference Number with the current prescription.

When administering methadone:

1. Add at least 150 mL of water to the dose.

2. Observe patient drinking the methadone and water solution. Ensure they are facing forward, do not allow them to turn sideways or move out of direct sight.

3. After they have swallowed the solution, speak to the patient.

4. Ensure patient signs they have received the solution.

When administering buprenorphine:

1. Check current day is included on patient’s regimen.

2. For alternate-day or 3 times a week programs, confirm dose for the current day.

3. Patient places dose (or first 2 films of the dose) under their tongue. If patient’s prescribed dose is more than 2 films, ensure they are supervised and drink at least 150 mL of water before receiving the next 2 films. Patients should not receive more than 2 films at a time. Repeat as needed until the full dose is administered.

4. Ensure patient signs they have received the solution.

To avoid diversion, patients must be supervised in a specific area next to or near the dosing area. The Deputy Commissioner’s Instructions provide direction on specific processes and times required for postdose supervision. Custodial officers are responsible for supervising pre- and postdosing to reduce risk of diversion, including pat-searching patients before dosing, engaging and communicating with patients during the supervision period, and if diversion is suspected, pat-searching patients before leaving the supervision area.

Where practical, methadone and buprenorphine should be administered before midday.

Royal Pharmaceutical Society (2017)³⁰

UK

Registered health care professional

• Patients should have non-in-possession drugs administered to them by registered health care professionals, as well as an additional witness if necessary and as defined locally (e.g., for Controlled Drugs).

• Security staff support the health care team by managing waiting patients, maintaining patient confidentiality, identifying and acting on drug diversion, and acting when an incident occurs.

Hassan (2012)³¹

UK

Cross-sectional study

Survey of patients and staff at correctional settings in 2008 with follow-up interviews with 24 patients and 68 staff at 12 settings

Setting characteristics:

• Population: female (n = 3), adult male local (n = 5), adult male sentenced (n = 1), male youth offender institution (n = 3)

• Security: medium (n = 11), high (n = 1)

• Regions: Northern (n = 5), Midlands (n = 3), London and Southern (n = 4)

Interviewed patient characteristics:

• 21 men, 3 women

Interviewed staff included: governor/deputy (n = 6), health care management (n = 14), primary care (n = 11), mental health nursing (n = 7), first reception nursing (n = 10), pharmacy (n = 7), substance misuse (n = 4), and prison officer (n = 9).

• Empowerment considered the primary benefit of increasing availability of in-possession drug, helping prepare them for release, reduced inconvenience of queuing for and collecting medicine; patients reported it made them “feel normal”

• Staff very conscious of potential for misuse, trading, diversion associated with certain drugs, especially those with psychotropic, sedative, or analgesic properties; noted heightened risk of bullying of vulnerable patients, risk of drugs being ‘hoarded’ and potential overdose, and issues if patients have mental health issues or learning disabilities that prevent them from taking their drugs properly

• Less than half of facilities had specific storage facilities for in-possession drug; several patients noted this as a limitation

• Risk management a key aspect of in-possession medical policies to help manage (but not eliminate) risk

Identified 3 interrelated strategies influencing approaches to risk management:

• Risk assessment:

  • Surveyed settings used structured risk assessments (93%), limited prescribing lists (68%), or a combination of both (66%) to assess suitability for in-possession

  • Risk assessment tools were a mix of assessment forms (46%, mostly using closed questions), point systems yielding a final aggregate score (36%), and flow charts (18%)

  • Tools typically assessed risk of self-harm or suicide, vulnerability to bullying, ability to understand instructions, previously known security breaches (e.g., trading), and current mental state

  • 68% of settings specified drugs that would not be allowed in-possession due to clinical or security risks; examples varied between settings, though often overlapped and included controlled drugs, opiate-based analgesics, and mental health drugs, especially benzodiazepines, antipsychotics, and tricyclic antidepressants

• Monitoring of medicines given in-possession:

  • Formal procedures included written contracts signed by patients before receiving in-possession drugs, random cell searches by security staff, drug counts to check remaining supply corresponded with exceed use

  • Health care staff also frequently monitored adherence by checking of drug was collected and timing of requests for drug

  • Discipline and health care staff stressed importance of interacting with patients and remaining vigilant

• Calibration (i.e., flexibility of risk management):

  • Some establishments used risk assessment once, others were ongoing

  • Settings with more flexible approaches ruled out fewer drugs and seemed to be able to adapt approaches continually or to each patient

  • Inflexibility was viewed with frustration among some patients

• Overall, risk management approaches were used across settings but specific approaches varied on content, structure, flexibility, and complexity

Bosley (NR)³²

UK

Descriptive study

Description of a Category D Prison’s in-possession policy

• Not prescribed in-possession: benzodiazepines, controlled drugs, opiate substitution drugs

• Prescribed with caution: pregabalin (drug of choice for trading), gabapentin

• Otherwise, all drugs held in-possession; can be held in weekly or monthly quantities

• On arrival, patients sign a contract saying they will comply with standards of drug ordering, supply, and storage

• Each individual responsible for requesting repeat prescriptions in a timely manner, as well as collecting, safe-keeping, and storing their drugs

Glancy (2020)¹⁷

• Psychotropic drugs are typically delivered via DOT in correctional settings

• Self-administered drugs (particularly weekly cards) may vary with the type of drug, institution, and level of security

• Prescribers must specify a certain mode of administration when this is considered important, and should document the rationale for not using the standard of DOT

• Noncontrolled drugs prescribed by nonpsychiatric general medical providers may also be at risk of misuse; patients may be permitted to have drugs prescribed by general practitioners as in-possession

Strategies for managing misuse of drugs may include:

• Limit access to higher risk drugs using formulary controls; sites that have done this have reported reduced misuse and diversion. If benefits of prescribing a high-risk drug are considered greater than the risks for a patient, a nonformulary prior authorization process can be used to prescribe the high-risk drug

• Ongoing training of psychiatric, nursing, medical, custody staff

• Cell searches, forensic toxicology testing, and other surveillance by correctional officials

Specialist Pharmacy Service (2022)³³

• Drugs for opiate substitution and alcohol detoxification are Controlled Drugs and should never be held in-possession in any correctional facility

• Tramadol, gabapentin, and pregabalin may be held as a 7-day (weekly) in-possession in Category D open prisons following a risk assessment

Royal College of General Practitioners (2019)²⁸

• If there is any doubt regarding safety or diversion, extreme caution should be exercised when allowing patients to keep drugs in-possession

• Daily in-possession packs are not recommended where there is significant risk of diversion; they offer only marginal benefit over a weekly in-possession supply

• Develop a list of specific medicines that are restricted and not provided in-possession due to risks of diversion (e.g., Controlled Drugs, other medicines agreed locally)

• In-possession policies for medicines at risk of misuse should be decided locally in conjunction with the medicines management committee, referencing the appropriate Prison Service Instructions (PSI), allowing for exceptions on a case-by-case basis

• Each patient should have a risk assessment carried out to establish suitability for in-possession; those at risk of self-harm require supervised administration

  • this should be fully completed on admission or transfer and renewed as needed

• Prescribers should follow in-possession policy and procedures, accurately including in-possession status of all medicines

• In-possession risk assessments should be done in collaboration with the correctional facility

• A person’s risk for in-possession may change or need to be reviewed (e.g., if they have misused their medicines or at risk of self-harm, or if it is now considered safe for them to move from DOT to in-possession)

NHS England (2017)³⁴

General:

• The amount of medicines provided in-possession should be tailored to individual need and align with collaboratively developed local in-possession policies and risk assessments

Mechanisms to reduce risk of misuse or diversion of mental health drugs:

• Providers can adjust formulary choices to encourage choosing less-diverted drugs that are likely to result in the same clinical outcome as high-risk drugs

• In all health and justice settings, people should be assessed for suitability and safety to have drugs in-possession; amounts can range from 7 to 28 days

• The mental health team should contribute to the in-possession policy and actively review and adjust the in-possession status of individuals as their mental health changes

• Adherence checks during routine drug or clinical reviews can identify omitted doses as well as potential misuse or diversion, such as by checking the electronic medical chart for missed doses and frequency of prescriptions

• Identifying patients at risk of bullying (e.g., people with learning disabilities, dementia) or at risk of diversion (e.g., people with a previous history of trading)

• Secure environments can collaborate with security teams to conduct unannounced, random checks of medicines in-possession to identify non-adherences; if nonadherence is identified, patient is referred for a mental health review

• If diversion or misuse is identified, trigger a mental health and drug review; recommend a collaborative approach with the mental health team and other clinicians to manage these incidents, encouraging a united approach

NHS England (2017)³⁷

• Schedule 2 and 3 Controlled Drugs should not be routinely provided in-possession, as per national guidance

• For nonscheduled opioids, a local decision is needed based on local risks and access to DOT for the 3 to 4 times daily doses

  • If in-possession is supported, it should be restricted to weekly in-possession and additional processes should be in place to confirm adherence and identify potential diversion or misuse

Royal Pharmaceutical Society (2017)³⁰

• Recommends an in-possession policy is in place, including identifying which drugs are excluded from in-possession and which can be provided in reduced quantity in-possession (e.g., weekly)

• Schedule 2, 3, and 4 Controlled Drugs should not be provided in-possession except under exceptional circumstances or an individual case basis

• Patients should be assessed on suitability for keeping drugs in-possession using approved risk assessment tools

NHS England (2015)³⁵

• Local policies should be delivered for in-possession drug, considering other related health care and security policies (e.g., medicine management, clinical governance, security, harm reduction)

• In-possession should be the norm but is not recommended for all medicines: Controlled Drugs should be administered under direct supervision, including tramadol (a Schedule 3 Controlled Drug)

• For other pain medicines in the formulary, local policies should consider

  • patient-related factors (including population type of the correctional setting)

  • clinical and medicine-related factors (e.g., frequency of doses, timing of doses compared to access times, local drug safety incidents)

  • environmental factors (e.g., medicine storage facilities, capacity of staff to supervise patients receiving medicines)

• Most correctional settings follow these policies:

  • First-line opioids (e.g., co-codamol) and neuropathic pain formular drugs are not in-possession or a maximum of weekly in-possession

  • Schedule 2 and 3 Controlled Drugs are not in-possession

• For pain drugs provided in-possession but have a risk of diversion or misuse, mechanisms to monitor adherence or detect potential misuse are used, including:

  • Sharing outcomes of mandatory drug tests with health care teams and facility staff

  • During cell searches, conducting medicine adherence checks

  • Checking drug administration or supply records to identify omitted doses or unusual medicine collection patterns

• If these policies are used, clear clinical review and nonclinical processes are needed to follow-up with any incidents to ensure consistency and transparency with patients; nonclinical processes may include:

  • Sharing and submitting intelligence reports and/or reporting issues as patient safety incidents

  • Where diversion or misuse has occurred, issuing prison-led earning letters to patients, or other formal disciplinary actions

NHS England (2014)³⁶

• Tramadol must be supplied not in-possession, under supervised consumption.

• Recent information suggests Category D prisons allow in-possession of tramadol. These settings should review and amend their operational arrangements.

• Exceptions to this policy should be handled via local formal arrangements. In instances where in-possession tramadol is allowed, adherence checks are recommended to identify potential diversion and inform clinical reviews.

Pralong (2023)³⁸

Switzerland

Cross-sectional survey

Lockboxes were set up inside the carceral unit; each person living in the unit received a key for their drug box (whether he was receiving drugs or not). Nurses would prepare the drugs and then place them in the boxes of patients who had been prescribed treatment, along with an informational card (when, why, how to take treatment). Drugs were distributed when unit was empty (i.e., vocational training or working hours). Patients would pick up treatment and take them independently. Doctors would first meet patients to discuss treatment options and side effects. Drug adherence was monitored by doctors and nurses in individual follow-up visits.

Drugs provided by the lockboxes did not include drugs required to be administered via DOT, which included controlled substances and drugs prone to diversion.

Patients reported:

• Advantages: ease of use, increased autonomy, more confidential than in-hand distribution, lower theft risk, demonstration of trust from medical staff, increased compliance

• Disadvantages: risk of forgetting to pick up drug, lack of instructions how to use drug, no health care provider to talk to, theft risk, confidentiality issues, risk of drug misuse

• Overall were satisfied

Officers reported:

• Advantages: better role differentiation between health staff and correctional facility staff, more time-efficient; similar advantages to patients

• Disadvantages: no health provider for users to talk to, risk of drug theft or box key, confidentiality issues, trafficking, risk of misuse

Other outcomes:

• Dispensing 1 drug package takes 14 seconds with the lockbox system vs. 80 seconds with in-hand distribution

Peek (2021)³⁹

UK

Cross-sectional survey

Lockboxes were installed that use biometric fingerprints to access. Patients were informed when their drug was ready, giving them choice in how to structure their day.

• Most patients felt lockers were easy to use and were positive about the experience; feedback included that it was less disruptive and improved autonomy, consistency, ownership, and privacy

• Clinical feedback included it was quicker for nurses, improved compliance, less waiting for patients, improved privacy, and fewer drug errors

• Custodial feedback included saved time, reduced staff stress, and that it was much better for residents

Health care Improvement Scotland (2022)⁴¹

Scotland

Guideline using consensus methods based on a systematic review.

Advantages for patients in health and justice settings:

• Reduced supervision time compared to daily oral OAT, releasing time for health care and correctional staff

• Reduced miss doses for people who are unable to attend daily OAT (e.g., court hearings, work)

• Reduce risk of diversion

• May not be an operational risk saving

Disadvantages for patients in health and justice settings:

• Depending on the setting’s operational set-up and appointment availabilities, may not be cost-saving (e.g., for escorting individual patients)

• Overall cost is higher

• Require additional considerations for secure drug storage

• Potential lack of continuity of care if the person in custody moves to a place that does not provide long-acting injectable buprenorphine

MacNeill (2021)⁴²

Scotland

Cross-sectional study

• Long-acting injectable buprenorphine was introduced in Scotland during the COVID-19 pandemic to ensure continuity of drug administration

• Interviewed 9 patients and 5 health care staff

• All patients were still taking long-acting injectable buprenorphine by the interview

• Patients reported that since starting on long-acting injectable buprenorphine, they felt reduced cravings for drugs, improved health and well-being, and improved relationships with family and friends

• Reported drawbacks included withdrawal during the changeover process, headaches, difficulty sleeping; staff also noted that new sense of clarity on this drug could be an issue if their drug use is related to suppressing or coping with past traumas

• While results related to administration or wait times were not reported, the authors noted that long-acting injectable buprenorphine may help to reduce the amount of time spent on daily dispensing for daily OAT

• Concerns that the higher cost of long-acting injectable buprenorphine per dose compared to methadone would impact funding of the treatment

MacNeill (2020)^{43 a}

Scotland

Cross-sectional study

• Long-acting injectable buprenorphine was introduced in Scotland during the COVID-19 pandemic to ensure continuity of drug administration

• Interviewed 6 Governors in Charge, 15 health care staff, and 3 patients

• Patient-reported reasons for not wanting to switch to long-acting injectable buprenorphine included the newness of the treatment, pre-existing mental health problems (e.g., needle phobia related to past drug use and PTSD), concerns about lack of access in the community, and concerns they would need to switch back to their previous OAT

• Preliminary data indicated introducing long-acting injectable buprenorphine had minimal observable impact on staff time spent administering drug, likely due to the short time frame and small proportion of patients who switched, as well as changes to routine due to COVID-19 restrictions

• In some cases, the program introduction created additional work for health centres, including staff training, identifying eligible patients, and consulting and discussing with patients, though staff felt it would lead to savings on time and resources once a patient was stable

• Governors in Charge and staff still anticipated potential benefits including reduced bullying, reduced staff time administering drugs which could be redirected to other activities

• Noted that while clinical guidance from the Scottish Government was clear, they had concerns about logistics: e.g., where patients would receive the drug (in health centres, or on the halls like other OATs)

Wright (2020)⁴⁴

UK

Modelling study

• Designed a predictive model to estimate the costs of OUD care based on the public correctional system in England, considering costs of pharmacotherapy, direct service, indirect health care, and security

• Based on current standard of care (methadone) and used a representative standard correctional facility where 150 patients need OUD care

• Assumed 30% elected for long-acting injectable buprenorphine

• Based on model, estimated a cost reduction of £8,665 and saved 3,159 staff hours per year

• Sensitivity analyses indicated higher savings in settings prescribing higher doses of methadone or where more staff time is needed to deliver methadone (e.g., geography, security factors)

• Higher rate (50%) of long-acting injectable buprenorphine adoption associated with higher cost savings

Methadone

Every 24 hours

Typically, 60 to 120 mg/day, but may be lower or higher

Oral (syrup, tablets) or injectable

NR

Buprenorphine or Buprenorphine-naloxone

Every 24 to 48 or 72 hours

8 to 24 mg/day

Sublingual

NR

Sustained release naloxone

Every 24 hours

300 to 1200 mg/day

Oral (capsule)

Provided in some countries when methadone or buprenorphine is contraindicated, or when substances are not tolerated (Australia, Bulgaria, Slovenia, Switzerland, UK)

Diamorphine

2 to 3 times every 24 hours

400 to 700 mg/day

Injectable, smokable

Only available to long-term, nonstabilized opioid users in Denmark, Germany, Netherlands, Switzerland, and UK; permitted for research trials in Canada, Spain

Levo-alpha-acetyl-methadol

Every 4 to 72 hours

70 to 120 mg, 3 times per week

Oral

Not available in EU; concerns regarding safety

Levo-methadone

Every 24 hours

40 to 60 mg/day

Oral (syrup)

Only in Germany

Codeine

NR

NR

Oral (syrup, tablets)

Available for maintenance treatment in Germany