New recommendations for opioid agonist treatment in Australian prisons

A new consensus statement on opioid agonist treatment (OAT) in custodial settings has been published in the Medical Journal of Australia.

Opioid use and dependence are prevalent among incarcerated people in Australia, contributing to high rates of overdose and other harms in this population. OAT is an effective intervention to mitigate these risks.

The consensus statement outlines 19 recommendations for custodial health services and relevant government and health authorities to address gaps in national policy on OAT in Australian prisons.

“This consensus statement aims to improve quality, consistency and continuity of OAT for people who are incarcerated in Australia by promoting a nationally coordinated and evidence-based approach to OAT provision and identifying targets against which to monitor progress,” the authors wrote.

The recommendations are divided into five sections:

Induction or continuation of OAT

The consensus statement recommends that custodial health services:

• continue OAT for people entering custodial settings without interruption;
• screen all people entering custodial settings for opioid dependence and risk of withdrawal, and treat those at risk of withdrawal within 24 hours;
• offer OAT to all who meet opioid dependence criteria; and
• offer a health assessment to people seeking OAT at any time during their incarceration.

“Evidence supports initiation of OAT in custodial settings rather than initiation at or after release,” the authors wrote.

“In addition to evidence for positive outcomes during imprisonment, initiation in prison improves treatment retention and reduces illicit opioid use after release compared with initiation at release or counselling only.”

OAT options and administration

Custodial health services should:

• use a person-centred approach and provide people with a choice of medication;
• maximise access to long-acting buprenorphine depot, which could limit potential for treatments to be diverted to non-medical use; and
• avoid withholding or discontinuing OAT as a disciplinary measure.

The authors note, “systematic reviews from the broader mental health literature indicate incorporating patient preference improves treatment engagement and patient satisfaction,” while, “forced withdrawal increases the risk of substance use during incarceration and decreases treatment engagement on release, thereby increasing the risk of death.”

Transition of care to the community

There is a significantly increased risk of mortality from opioid overdose in the period after release from custody, which can be mitigated by OAT.

The consensus statement recommends:

• people on OAT should be linked with community-based OAT providers before release;
• providing individuals with a bridging prescription and accessible dosing location on release; and
• implementing programs to provide psychosocial support on release, such as peer or patient navigators.

“A systematic review of qualitative evaluations of prison release programs identified factors associated in program success, including access to structural supports, particularly housing and employment, and continuity of care, through fostering the formation and maintenance of a therapeutic relationship throughout the pre-release and post-release periods,” the authors wrote.

Special populations

The consensus statement recommends collaboration with Aboriginal and Torres Strait Islander community representatives to ensure OAT care is culturally appropriate.

“Aboriginal and Torres Strait Islander communities have a strong history of providing holistic, culturally appropriate health care and leading responses to reduce drug-related harms,” the author wrote.

OAT is also strongly recommended for pregnant people with opioid dependence.

“In addition to reductions in opioid use and risk of opioid overdose, systematic reviews of observational studies indicate that treatment with methadone or buprenorphine (including buprenorphine–naloxone) during pregnancy is associated with improved adherence to antenatal care and lower incidence of preterm birth and stillbirth.”

Organisational support

The consensus statement recommends that custodial health services:

• maintain up-to-date protocols or guidelines for OAT service delivery; and
• implement harm reduction education programs that cover OAT, overdose prevention and stigma for people in prison, health care providers and correctional staff.

It also recommends that government and relevant health authorities should:

• ensure adequate and sustained funding for OAT services;
• implement jurisdiction-wide electronic medical records in custodial settings to promote continuity of care; and
• monitor key OAT program indicators to inform ongoing improvement.

“Through improvement in OAT provision, both in prison and after release, we anticipate significant gains in health outcomes and a reduction in post-release morbidity and mortality among this highly marginalised population,” the authors conclude.

Read the consensus statement in the Medical Journal of Australia.

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