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Reference: CG/HMP Opiate Prescribing/03/15 Implementation Date: April 2015 Review Date: April 2018

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HMP & YOI Chelmsford dedicated to making a difference

NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

POLICY DOCUMENT

Document Title Policy For Opiate Prescribing

Reference Number CG/HMP Opiate Prescribing/03/15

Policy Type Clinical Guideline

Electronic File/Location N:\Pharmacy\Intranet

Intranet Location http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/CDAT%20Policies.aspx

Status Final

Version Number/Date Version 1 / March 2015

Author(s) Responsible for Writing and Monitoring

Head of Essex STaRS

IDTS Clinical Nurse Manager

Charge Nurse

Responsible Director Director of Operations & Nursing

Approved By Medicines Management Group

Approval Date March 2015

Implementation Date April 2015

Review Date April 2018

Copyright

© North Essex Partnership University NHS Foundation Trust (2015). All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner.

All matters or concerns regarding fraud or corruption should be reported to: Chris Rising, Senior Manager ([email protected] 07768 873701), Hannah Wenlock, LCFS Lead ([email protected] 07972 004257) Mark Trevallion, LCFS Lead ([email protected] 07800 718680) OR the National Fraud and Corruption Line 0800 028 40 60 https://www.reportnhsfraud.nhs.uk/





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Policy for Opiate Prescribing

(linked to Ministry of Justice PSI 45/2010)

Version: 01 Authors: Vitelian Ikediashi, Lidia Woods and Cheryl Carson Ratified/Approved by: Medicines Management Committee/Clinical Governance Group Effective from: April 2015 Review Date: April 2018 Targeted Audience: Healthcare, Inside Out, Prison Officers Circulated to the following people for consultation and agreement: Governor HMP Lead GP Head of Residence Head of Healthcare Head of Drug and Alcohol Services



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Contents

Section Topic Page

Number

1 Initial Reception Screening 4

2 First Night Prescribing 5

3 Detoxification 7

4 Maintenance Regimes 8

5 Substitute Prescribing Using Methadone 9

6 Substitute Prescribing Using Buprenorphine 12

7 New Clients and Existing IDTS Client Presented to IDTS from within HMP/YOI Chelmsford

15

8 Detoxification using Lofexidine 16

9 Management of an Opiate Overdose 17

10 Opiate Relapse Prevention 18

11 Protocol for Reduction 19

12 Breach of compact 20

13 Release from HMP/YOI Chelmsford prison 20

14 Summary of Changes 20

Appendices

1 Urine Testing 21

2 Objective Opiate Withdrawal Scale 22

3 Methadone Stabilisation Regime Administration Chart 24

4 Drug Recovery Wing Compact 25

4A Compact buprenorphine 26

4B Compact Methadone 28

4C Recovery Voluntary Based Drug Testing Compact 30

5 Crushed buprenorphine Leaflet 33

6 Consent to Treatment with Naltrexone 34

7A Rapid reduction 35

7B Reduction for prisoner sentenced longer than 26 weeks 36



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1. Initial Reception Screening

1.1 On arrival in the establishment all prisoners undergo initial health screening by a registered nurse in reception. IDTS prisoners identified as having a drug/alcohol dependency including requiring opiate-substitute medication, and/or a recent history of stimulant use (with a positive urine drug screen for the latter) will be located on IDTS (E Wing) for further assessment by a specialist substance misuse clinical team prior to any relevant stabilisation, detoxification and/or substitute-opiate prescribing and according to the following criteria:

(i) that a full history of previous and current opiate use and other drug/alcohol use, including previous treatment, is obtained by the duty doctor on the day of admission and recorded in the Medical Records (System One).

(ii) that a complete physical assessment is taken, including clinical observations and an objective opiate withdrawal score (OOWS), (CIWA-Ar) and/or Benzodiazepine withdrawal monitoring scale by a nurse.

(iii) that urinalysis and urine drug screen testing is taken to assist with establishing current opiate and/or other drug use on the day of admission. In circumstances where a drug screen does not detect opiates, or unable to obtain urine sample the emerging presence of objective signs of opiate withdrawal must be observed and recorded before any opiate-substitute prescribing is commenced.

(iv) that faxed confirmation is obtained from the prisoner’s community prescriber, including a community drug team and/or GP regarding any medications prescribed and a patient history (this may not happen before prescribing commences)

(v) that confirmation is sought from the community pharmacist, if relevant, to confirm date of last medication collected or taken under supervised conditions (again this will not happen prior to first night dosing)

(vi) that a comprehensive needs-led assessment is undertaken by a nurse the following day after admission which will include reception minimum data set (mds) which is then referred to Inside Out. A care plan will also be developed jointly and signed with the client and a copy given to the client.

(vii) that a Drug Compliance Compact for IDTS Prisoners is signed.



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2. First Night Prescribing

This protocol applies to all prisoners transferred to E Wing following a basic health screening in reception where drug/alcohol misuse and/or dependency is highlighted. All prisoners with a recent history of drug/alcohol use must be admitted to E wing directly from Reception.

2.1 Once the duty doctor has taken a medical history, including a drug history, the client will need to produce opiate-positive urine (Appendix 1) and/or a scoring on the OWS that indicates they are in withdrawal (Appendix 2) before the dose titration prescribed for an opiate dependence is administered.

2.2 Following arrival at HMP Chelmsford:– If the prisoner arrives early during the day and IDTS can confirm the prescribing of supervised methadone on the same day the Dr/Independent Prescriber can titrate the prisoner at a quicker rate over 2 days to their prescribed dose. If not the initial dose will be no more than 10mgs of methadone (1mg/1mL) and no further doses can be administered within 6 hours. Further doses should only be administered as withdrawal emerges after 6 hours. The period for stabilisation for methadone will be a five day period until 40mg is reached, then review if requesting further increase. (OWS will apply in some circumstances depending on withdrawals displayed).

2.3 In extreme circumstances where the prisoner is deemed at risk they will be subjected to regular observations during the night and the following day. The frequencies of observation will be instructed by the first night prescriber. This will be subject to review by the attending Dr/Independent Prescriber if required after 14:00hrs on the second day of treatment. During this time methadone titration should continue with doses of no more than 10mg 6 hourly administered as at 2.2 above. For the purpose of observations the client must be placed in a cell with a door hatch (open) on the first night and until the prisoner’s medication and condition are stabilised (this takes on average 5 days).

2.4 Any reported signs of drowsiness and other signs of opiate overdose will result in further doses of methadone and any other sedating medications being withheld until review by the Dr/Presciber. (refer to Section 11)

2.5 There will be further 10mg doses of methadone as per the methadone Titration Regime (Appendix.3) prescribed no less than 6 hours apart, which will only be administered where the scoring on the Opiate withdrawal scale (OWS) indicates that the client is still in withdrawal.

2.6 All clients will undergo an initial assessment as per 2.1. A Full Comprehensive Substance Misuse Assessment, including Risk Assessment, will be conducted the following morning of arrival to HMP Chelmsford by the IDTS Nurse. They will all be seen, if necessary, again by the Dr/Independent Prescriber after 13:00hrs. There will be an Independent Prescriber based on the IDTS stabilisation wing 7 days a week.



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2.7 The Dr/Independent Prescriber clinics run at different times at weekends therefore if a client arrives in the establishment on a Friday evening he will be seen by the Dr/Independent Prescriber that evening and, if necessary, again the next afternoon. If the client arrives on Saturday morning they will be seen by the Dr/Independent Prescriber on Saturday afternoon. There will be an Independent Prescriber based on the IDTS stabilisation wing 7 days a week.

2.8 If the client has not returned an opiate-positive urine drug screen it is good practice to offer symptomatic relief for the first night, and carry out OWS for 3 days.

2.9 Following stabilisation, some clients may choose to detoxify using Lofexidine (refer to Section 10) instead of an opiate-substitute medication and it can be used concurrently with medication prescribed for symptomatic relief. Even where a client may choose to have no substitute medication it is still good practice to offer symptomatic relief all of which must be administered under supervised conditions for the first 10 days (approx) of treatment, Lofexidine/symptomatic relief may also be used if dependency is in doubt thus making the prescription of methadone/buprenorphine potentially unsafe. If any prisoner presents using opiates illicitly then Lofexidine/symptomatic relief will be used. A prisoner in these circumstances will not automatically be prescribed methadone/buprenorphine .

2.10 Benzodiazepine Use

Where a client gives a history of benzodiazepine use, either prescribed or ‘off the street;’ and produces a positive urine drug screen a diazepam detoxification can be commenced as per the protocol for Clinical Management of Benzodiazepine Dependency. A negative urine drug screen does not necessarily mean that the prisoner is not dependent due to the potential time lapse since they last used the drug. Similarly a positive urine drug screen does not imply dependence as this may be as a result of prescribing in police custody, or recent recreational use. All prescribing should be accompanied by the use of the Benzodiazepine withdrawal monitoring scale for a period of 14 days to ensure that treatment is adequate, but not excessive, or that a decision not to prescribe does not result in the emergence of withdrawal symptoms, which would then require a clinically managed detoxification. The level of prescribing can also be tailored to the results of the withdrawal monitoring.



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2.11 Alcohol Use

Where a client gives a history which indicates alcohol dependency treatment should be commenced as per the protocol for the Clinical Management of Alcohol Dependency. If the client has been commenced on an adequate benzodiazepine prescription and the alcohol use is low then no further prescribing of benzodiazepines should be necessary. If however the alcohol dependence is moderate/severe it is preferable to commence a Chlordiazepoxide regime sufficient to cover both alcohol and benzodiazepine dependencies for the first 5/6 days of treatment. At this stage the prisoner can be transferred across to an appropriate level of Diazepam to cover the Benzodiazepine dependency, from which he can be withdrawn as per the DoH clinical guidelines.

2.12 Upon arrival to HMP Chelmsford Prisoners are expected to sign the treatment compact in order to commence treatment. Failure to do so will lead to not receiving full opiate treatment. 3. Detoxification

3.1 Following stabilisation detoxification may remain the preferred method of clinical management for some opiate dependent clients, but it is now apparent that a range of clinical treatment options are required to manage the varied and complex needs of this client group. Whatever treatment is prescribed its effects must be explained in full by the prescribing doctor and appropriate literature provided. The principle elements of this model are:

(i) prescribing management of withdrawal by a doctor in a local

prison to lower the risk of suicide and self-harm – as informed by the reception health screening and following further assessment within IDTS

(ii) stabilisation offering a licensed opiate substitute medication for

a minimum 5 days, prior to progression to one of the following two treatment options:

1) Standard opiate detoxification (minimum 14 days) 2) Extended opiate detoxification of any duration 3) Opiate substitute maintenance dependant on individual

clinical need and reviewed monthly by a doctor and as part of a general multi-disciplinary review after 3 months, at which time all treatment options are reviewed including the aim of achieving abstinence whilst in custody if this is clinically appropriate. e.g. in the cases of clients with dual diagnosis.

(iii) a validated opiate withdrawal scale (OWS) should be used to



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determine the presence of opiate withdrawal. Withdrawal from benzodiazepines, alcohol and/or stimulants may complicate the clinical picture and caution is recommended in cases of uncertainty.

3.2 During the stabilisation period where dose induction has been commenced there must be regular clinical observations (the DH guidelines recommend as a minimum twice daily for first 5 days, or until stable if longer than this). No withdrawal regime must be commenced until the client reports being comfortable on the prescribed daily dose of the opiate-substitute medication. Where withdrawal does commence it should be at a maximum of 5mgs per week or fortnight in a Local prison and no more than 2mg per week if the prisoner is transferred to a Training prison.

Note: the purity of street drugs is variable. It is therefore preferable in the prison setting to titrate against the withdrawal symptoms as per the Department of Health Guidelines (2007). 4. OPIATE SUBSTITUTE MAINTENANCE REGIMES 4.1 The option of methadone (first line) or buprenorphine maintenance after stabilisation should be considered in the following circumstances:-

Where a chronic opiate user is received into custody on remand, in order for them to enable to engage in treatment upon release

Where an opiate dependent prisoner is received into custody on a sentence of less than 26 weeks, in order to enable them to engage in treatment on release, or;

Where on the basis of a full clinical assessment, it is considered necessary to protect the prisoner from the risks of opiate overdose upon release.

4.2 However prisoners will be made aware from the outset that, if they go on to receive a sentence of more than 6 months, they will be expected to work towards becoming drug free whilst in prison. Prisoners will be placed on HMP reductions regimes once stable. (Appendix 7A) 4.3 All clients sign an agreement on conduct expected prior to commencing their medication regimes (Appendix 4) but clinical treatment cannot be discontinued punitively. 4.4 Prior to release it may be necessary to consider the possibility of re-induction for those clients at risk of opiate overdose i.e. those who have either reduced their daily opiate-substitute medication dose to a level that would not provide



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them with protection upon returning to the community, or have detoxified in prison and maintained a period of abstinence. The DoH Guidelines (2007) recommends re-induction where there is a ‘clear identifiable risk of overdose upon release’ (ref: Section 7.3.4.3, p80). Re-induction would entail commencing a previously abstinent client on a gradually increasing regime of an opiate substitute until a level had been reached sufficient to protect the individual from an opiate overdose. This process must therefore be commenced at least four weeks prior to release to enable this process to undertaken slowly and safely. 4.5 Where prisoners have been able to maintain a period of abstinence whilst in prison and due release Naltrexone should be considered. 4.6 Where a prisoner has reduced his methadone/buprenorphine to a low level whilst in prison, this may also need to be increased gradually 2 weeks prior to release in order to protect from relapse in the community, and the risk of opiate overdose. 4.7 The Inside Out team will liaise with the Criminal Justice Intervention Service (CJIS) in the client’s area of residence when preparing release plans and an appointment will be arranged for release to ensure the continuity of care in the community. The clinical team will be notified so that a copy of the assessment form, prescribing information and a Discharge Summary are faxed to the community prescriber. It is also good practice to notify the client’s GP by faxing a copy of the Discharge Summary including all medications prescribed. All discharge documentation that contains details of prescribing must be signed by Dr or Independent non-medical prescriber. 5. Substitute Prescribing using Methadone a. Methadone is a synthetically produced, long-acting opiate substitute medication which usually requires only once daily dosing. It is a controlled drug and should be prescribed in accordance with the British National Formulary. The DH (2007) advises dividing the doses during the initial titration stage to ensure tolerance and reduce any euphoric effects and to load plasma levels. methadone Sugar .Free (SF) 1mg/1mL is used in HMP/YOI Chelmsford. 5.1 Stabilisation of Clients not in Receipt of a Community Prescription 5.1.1. In this context the term ‘stabilisation’ refers to the moderation and control of withdrawal symptoms for a given period of time. In prison, in accordance with the DoH Guidelines (2007) this would be for a minimum period of the first 5 days in custody or of treatment in the event of relapse. Stabilisation is achieved through a process of dose induction – the gradual introduction of methadone in response to withdrawal symptoms. Dose induction is usually completed within 48 to 72 hours, at which point the current daily dose would be continued until at least day five, when a decision would be reached on future clinical management.



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(i) Following the brief assessment completed on the client’s first night in

prison there will be a full comprehensive assessment and risk assessment by a nurse the following morning. The client will also be reviewed by the doctor if required.

(ii) Stabilisation will be achieved through a process of dose induction i.e. the gradual introduction of doses of methadone in response to withdrawal symptoms, commenced on the first evening of custody or as withdrawals emerge. If unable to administer methadone on the evening of arrival, supportive medication will be prescribed.

(iii) Stabilisation can be completed using initial doses of 10mgs methadone, as per methadone Titration Chart given at intervals at least 6 hours apart. Peak serum level occurs at 3-4 hours after ingestion, with a trough occurring at 18 hours plus.

(iv) Stabilisation can be achieved using buprenorphine (refer to Section 6) though in accordance with NICE guidelines methadone is first line management unless buprenorphine was being prescribed prior to admission.

(v) In the event of a client continuing to experience difficulties at 40mgs methadone daily the additional titration of between 2 – 10mgs per day may be indicated. This should only be undertaken by a competent doctor who has undergone specialist addiction training or under the supervision of a substance misuse specialist with at least 70 hours experience of working in a prison of a similar category.

(vi) Where there is evidence of polydrug use and alcohol dependence, a more graduated, cautious individual approach will be necessary. The methadone regime should remain stable whist the alcohol detoxification is taking place. Such management can assist in reducing self-harming behaviour. Caution is required when commencing dose titration onto methadone and the prescribing of a benzodiazepine simultaneously.

(vii) Where the client fails to present for his medication this MUST be reported to the prescribing doctor and documented in the medical records. Every effort should be made to establish why the prisoner has not come for his medication, and issues of vulnerability considered. In cases of persistent non-attendance the client must undergo a review with the prescriber as soon as possible as opiate tolerance might be reduced and doses of methadone may need to be divided or temporarily reduced, until regular attendance has been re-established. It must be clearly documented in the client’s medical records, with the reason for non-attendance being explored. Prisoners can miss no longer than 3 days’ worth of methadone. If missed longer the prescription will be cancelled and depending on the circumstance and risks this will be reviewed by the multi-disciplinary team. This also applies to prisoners prescribed buprenorphine.



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(viii) Clients on remand should be maintained on their methadone dose until sentenced, with a review being undertaken each time they go to court as this may then indicate a revision to their care plan/treatment goals. If the sentence is greater than 6 months then once the prisoner has adjusted to the idea of the length of his sentence, a reducing regime should be discussed with the client, in some instances tailored to take account of the client’s own view of the rate of such a reduction. All prisoners are expected to follow the reduction regimes (Appendix 7A)

5.2 Stabilisation of Clients in Receipt of Continued Supervised Consumption

(i) where confirmed supervised consumption of the methadone has taken place up until the time of arrest then the continuation of a methadone regime at existing community dose can be continued providing the following criteria are met:

o the client is regarded as compliant with treatment o the client is receiving methadone under supervised consumption o the client has been receiving methadone regularly for the previous

7 days o the client had their last supervised dose within the last 72 hours o the client’s treatment details have been verified with the prescribing

Doctor and supervising pharmacist

(ii) as a further safeguard, on confirmation of a community supervised consumption dose, it is recommended that the first 2 days of methadone are evenly divided into two doses, and given at least 6 hours apart.

5.2.1. First night prescribing should be as for all other prisoners (assuming that no methadone has been given that day) with 10mg doses of methadone being prescribed. These doses can then be taken off the first day’s split dose. f unable to administer methadone on the evening of arrival, supportive medication will be prescribed. 5.3 Stabilisation and Transfers 5.3.1. Following assessment by the substance misuse nurse and completion of a minimum of 5 days stabilisation a client can be moved to the 2nd stage unit once clinically stable. 5.3.2. Where a prisoner is to be based on another wing due to security reasons he must be stabilised with the same care and precautions as he would receive



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upon the stabilisation unit. This is to be managed by the doctor/nursing staff in conjunction with the Governor and noted in the medical records. Wherever possible the client must be brought to the E Wing or the Centre pharmacy for medications. Where this is not possible e.g. due to security reasons, the IDTS Officers will accompany the prisoner to E Wing or the Centre pharmacy prior to unlocking the other prisoners. Clinical Observations will be carried out accordingly. 5.3.3. For transfers to and from HMP/YOI Chelmsford refer to the IDTS Transfer Protocol for HMP/YOI Chelmsford and for establishments in the Eastern region. 6. Substitute Prescribing Using Buprenorphine a. Buprenorphine (Subutex®) is a controlled drug and should be prescribed in accordance with the BNF. It will only be prescribed if clients meet the following criteria:

(i) there is a confirmed community prescription taken under supervised consumption up to 3 days prior to admission.

(ii) where methadone is contra-indicated (To be discussed with GP and manager) If a prisoner is not prescribed buprenorphine in the community then methadone is the first line of treatment. buprenorphine would only be considered if the prisoner is sensitive to methadone and there is clear evidence of sensitivity. This information can be obtained from community drug/alcohol services, previous medical history in prison and GP records.

(iii) where transferred from another prison on a confirmed prescription

(iv) where the doctor considers its use clinically justifiable (v) following a doctor’s assessment for re-induction prior to release

if methadone is not deemed to be suitable (vi) the initial dose of buprenorphine should be 0.8mgs to 4mgs

administered as a single dose. If commenced on 4mgs daily then increase by 2mgs daily until the client is comfortable or the recommended maximum dose of 16mgs daily is reached. If there are any signs of over-sedation stop the medication and review by the doctor.

(vii) If a prisoner is positive for opiates whilst prescribed buprenorphine (Subutex®) and not on a prescribed medication, this will be subject to review by the Multi-Disciplinary Team. Once reviewed the prisoner may be subject to swap to methadone or may be prescribed a reduced dose of buprenorphine.

However, methadone is still the preferred medication for stabilisation of opiate users wherever possible (NICE, 2007) and where the above criteria



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are not met it will only be prescribed where it is in the best interests of the client according to the prescribing doctor. For example, in mild cases of dependence e.g. younger, or short term, non-injecting heroin users or at the end of a withdrawal from methadone (10 mgs or below) with abstinence as the aim.

b. The supervised consumption of buprenorphine has a greater operational risk than methadone because crushing is essential to minimise the risk of diversion or misuse (all client’s on buprenorphine are asked sign compact about crushing (Appendix 5) and the administration, including crushing (if they consent), is more time-consuming than methadone (e.g. 4-5 minutes per client vs. 1-2 minutes per client for administration of methadone). A compact agreement between the client and IDTS must be signed before buprenorphine is administered in the crushed form. Crushing renders the product off-licence but is recommended in DoH Guidelines (2007) and needs to be communicated to the client. If the prisoner does not consent to his buprenorphine being crushed then it must be administered whole. c. Prisoners requesting to swap from methadone to buprenorphine prior to release will be risk assessed and discussed with the MDT. If swap is agreed prisoners will be swapped 7-10 days prior to release date. 6.1 Continuation of buprenorphine Regime from another Prison or Community 6.1.1. Where a client arrives in prison from the community and is currently on a ‘non-supervised’ buprenorphine prescription or buying ‘off the street’ then they should be treated in accordance with the standard dose induction regime. 6.1.2 If prisoners are prescribed Suboxone® (buprenorphine plus naloxone) in the community, this will not continue within the prison and the prisoner will be swapped over to generic buprenorphine or Subutex®. 6.1.3 Continuation of buprenorphine at pre-existing dose may only be prescribed where all the following criteria are met:

(i) is receiving buprenorphine under supervised consumption in i. community or prison

(ii) has received buprenorphine regularly for previous 7 days (iii) had a supervised dose in the last 48 hours (iv) client’s details have been verified with the prescriber and doctor in

i. community and supervising pharmacist (v) client’s identity confirmed with community pharmacist

6.1.4 In cases that meet all of above criteria, the following regime should be followed:



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6.1.5. On first night assuming the client has already had a dose of buprenorphine on the day of arrival in prison no further doses to be given. A supervised urine drug screen test must be undertaken and should be positive to buprenorphine (although note that buprenorphine has a short half-life and low doses may not show as positive). 6.1.6. On the next day (Day 2) administer buprenorphine as per the original regime on receipt of confirmation from the transferring prison or community, providing the client is also regarded as compliant with treatment. If on 8mgs daily or more commence on 8mgs titrating up by increments of 2mgs daily every 3 days until community dose reached or until 16mgs daily is reached. Symptomatic relief may be needed. If the dose is less than 8mgs daily then commence on the confirmed dose. 6.1.7. If more than 48 hours has elapsed since last dose of buprenorphine, then a low dose titration could commence if withdrawal is well established. Alternatively, symptomatic really can be offered if no withdrawals are evident. 6.1.8. Doses of buprenorphine should be divided for two days as per methadone section for those coming directly from the community. It is not necessary to split the dose if it is a prison to prison transfer. 6.2 buprenorphine Detoxification for Clients that are Opiate or Methadone Positive 6.2.1. buprenorphine can provide a very safe detoxification from opiates or methadone without the intensive interventions required for lofexidine. However, as buprenorphine can precipitate withdrawal in those who are dependent on methadone or other opiates it is recommended 36 hours is allowed to elapse between the last dose of methadone and the first dose of buprenorphine. And up to 24 hours since the last dose of heroin. 6.2.2. In addition any client considered for a buprenorphine detoxification should be on:-

(i) methadone 30mgs daily or less (ii) using less than or equal to 2g heroin smoking daily (iii) using less than or equal to 1g heroin intravenously daily

6.2.3. Once the client is comfortable they can start reducing by 0.4mgs every week 6.2.4. For transfers to and from HMP/YOI Chelmsford refer to the Transfer Protocol for HMP/YOI Chelmsford and for the Eastern region. 7. New Clients Presented to IDTS from within HMP/YOI Chelmsford



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7.1. Clients may present to IDTS from within the prison with drug/alcohol problems. This may happen if the patient has been placed outside of E-Wing because drug and/or alcohol problems have not been identified during the initial reception health screening process, and the client has started to experience symptoms of withdrawal. All such clients should be brought to IDTS for treatment and clinical observation. Where this is not possible it is to be managed by the doctor/nursing staff in conjunction with the Governor and noted in the medical records. If this is in relation to the admission to prison period then they must be admitted to E wing. 7.2. If a prisoner cannot be located on E wing for security or other reasons then his care must be managed (in the seg for example) with the same provision as if he was on E wing. 7.3. Clients may also be presented to IDTS as a new drug user, or client who has relapsed and is taking illicit substances on their wing. They may not need admission to E wing for stabilisation, but managed on an outpatient basis. However it is important that that all patients that present in relapse are seen and assessed on the day of presentation with prescribing commenced upon evidence of objective signs of withdrawal.

If clinical staff are made aware of a client with a new/recurrent presentation of illicit drugs, the nurse will take a full history and a urine (or oral fluid test if the patient cannot pass urine). The case will then be presented to the doctor.

.

All clinical observations must be performed as mentioned previously.

Prisoners admitting to illicitly using opiates and testing positive but currently not receiving treatment for opiate addiction in prison will be offered supportive or placed on lofexedine detox. If the prisoner is due to release soon a retox could be considered depending on risk factors 10 days prior to release.

8. Detoxification Using Lofexidine 8.1. Following stabilisation Lofexidine may be used if a client requests a non-opiate detoxification. It may also be used where dependency is in doubt and symptomatic treatment alone is proving inadequate. In most cases if there are signs of withdrawal methadone will be used. 8.2. There should be a minimum break of 24 hours between a final dose of methadone and the first dose of lofexidine.



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8.3. Lofexidine may cause brachycardia or hypotension in some clients, therefore blood pressure and pulse must be checked prior to the supervised administration of each dose, 2 hours after the initial dose and daily as the dose increases for the first 72 hours, and longer if there are abnormalities. 8.4. Exclusion for treatment under the protocol are:-

(i) history of sensitivity to lofexidine or other imidazoline derivation (e.g. clotrimazole)

(ii) history of cardiovascular disease (iii) history of cerebrovascular disease (iv) concomitant prescribing of medication other than described in this

protocol (v) withdrawal requiring treatment with methadone unless patient refuses.

9. Management of Opiate Overdose 9.1. All healthcare staff must be able to recognise the signs and symptoms of opiate overdose and be aware of its treatment. 9.2. OPIATE OVERDOSE is characterised by:

Constricted (pinned) pupils (though dilation can occur)

Respiratory depression/cyanosis

Pulmonary oedema (frothing from the lungs)

Sweating

Hypotension and bradychardia

Unconsciousness 9.3. OPIATE OVERDOSE should be treated by resuscitation with oxygen and EMERGENCY ADMINISTRATION of 0.8 to 2mg of naloxone should be given IM and repeated as necessary up to a maximum of 10mgs on account of its short half-life relative to heroin and methadone. If respiratory function does not improve question the diagnosis. IN AN EMERGENCY, NALOXONE MAY BE ADMINISTERED BY PARENTERAL INJECTION BY ANY COMPETENT MEMBER OF THE HEALTHCARE TEAM (HMSO 2005) 9.4. An emergency ambulance transfer to an outside hospital must also be arranged.



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9.5. Following return from hospital, the patient must be observed closely for 24 hrs, as a second episode of respiratory depression can follow the discontinuation of naloxone treatment. 9.6. In the event of a suspected buprenorphine overdose, a lot more naloxone may be required (note this would be beyond the licensed dose). 10. Opiate Relapse Prevention 10.1. Naltrexone is an opiate antagonist that can be used for those who have achieved abstinence from opiates and wish to have pharmacological support in remaining abstinent.

10.2. This should be available where requested and clinically indicated. 10.3. Naltrexone treatment should commence at least 7 days after the last dose of heroin and 10 days after the last dose of methadone and 5 days after the last dose of buprenorphine otherwise naltrexone will precipitate a severe withdrawal syndrome. 10.4. It is also recommended that bloods are taken for U&E’s and LFT’s. before treatment is prescribed 10.5. To ensure that a service user is opiate free:

Get a self-report of current use – establish exact time and date of last use and check any prescription for preparations containing codeine or morphine

Obtain a urine drug screen sample and test for opiates, including buprenorphine (if low levels of opiate is present this can still provide a negative result, so the urine drug screen is not an absolute guarantee that the prisoner is opiate free. One test (at least) should be taken at the time of request and the prisoner must produce two clean urine drug screening immediately prior to starting.

Give the initial oral dose of naltrexone, which is half a tablet (25mg), then after an hour carry out clinical observations plus monitor for opiate withdrawal for two hours. If all the clinical observations are within normal limits and no signs of withdrawal then the prisoner can have the other half of the tablet (25mg).

If there are still no signs of withdrawal a naltrexone tablet (50mg) can then be given daily thereafter under supervised administration.

10.6. Treatment should begin at least 10 days prior to release from prison and a

community prescriber with supervised administration if possible (can be a partner) arranged.



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It is not indicated for those clients with chronic pain problems or those waiting to undergo surgery

10.7. The client must sign Consent to treatment Form (Appendix 6).

11. Protocol For Clients Reducing Their Methadone/buprenorphine 11.1. As per opiate policy clients who wish to begin a reduction of their substitute prescribing will be offered a menu of options, see example below. Slow reduction from methadone of 2mg per week or fortnight 1mg of methadone daily 5mg per week/fortnight 11.2. Once clients have reduced their methadone down to a small dose of 10mgs or below, the clients will have the option to complete their reduction using Lofexidine (BritLofex). 11.3. Those wishing to reduce from buprenorphine will be offered a menu of options, see example below 0.4mg per week or fortnight, once reduced to 4mg daily If prescribed 6 mg or more, reduce by 2mg per fortnight or 0.8mg per fortnight. 11.4. Once detox is complete prisoners may need to be offered further medication in order to alleviate any residual withdrawals. The following can be offered if necessary

Ibuprofen/Paracetamol

Mebeverine

Loperamide

Metoclopramide (for short term use only – 5 days max) – for more than 5 days prescribe Prochlorperazine.

The above will be prescribed for a maximum of 14 days only

Zopiclone at night for a period of 7days maximum. 11.5. They can undertake a reduction at any point during their prison sentence and once detoxified, will be offered the opportunity to commence naltrexone. 11.6. Prisoners sentenced for longer than 26 weeks will be expected to follow a reduction regime. However prisoners sentenced for less can reduce at a level which they choose.



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11.7. Prisoners receiving Hepatitis C treatment are advised and encouraged to maintain on the dose during the start of treatment to avoid further complications. 12. Breach of compact 12.1. Clients who are found breaching any terms of the compact and jeopardising the safety of themselves or others will be placed before the MDT and reviewed. This consequently is likely to lead to a rapid reduction. 13. Release from HMP/YOI Chelmsford 13.1. At the end of their custodial sentences arrangements are made for the continuation of an IDTS client’s care in the community according to the Continuity of Care Guidance, NTA, 2011. 13.2. For transfer to another prison, the clinical team will notify the prisons’ substance misuse team. The clinical team will be responsible for faxing over a copy of the medication chart and any other relevant information. . 13.3. For planned release to the community, the Inside Out staff will notify the community substance misuse teams and arrange an appointment time and date. The Inside Out team will be responsible for faxing over a copy of the full assessment and risk assessment forms, a copy of the prisoner’s medications, and a Discharge Summary Sheet. 13.4. Where prisoners are due to attend court on a Friday or prior to a long bank holiday, FP10 (MDA) must be completed. In an emergency situation if a prisoner is released on a Friday or prior to a long bank holiday and is unable to attend their local substance misuse team then they will be provided a FP10. All prisoners on other days are expected to attend their local substance misuse teams for appointment set up by the Inside Out team or leaflets are given with contact details of the community substance misuse teams. All FP10 scripts must be photocopied, recorded and stored in the FP10 folder. 14 SUMMARY OF CHANGES

Date Page Number(s)

Summary of Changes

March 2015

First version



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Appendix 1 Protocol for Urine Drug Screen Testing Prior to Commencing Treatment (i) The sample should be taken prior to the commencement on any opiate

substitute medication or Benzodiazepine withdrawal. (ii) The client should provide a fresh specimen of urine which must be

unadulterated (discrete observation may be required). A body temperature specimen can confirm that this has been appropriately acquired. The specimen should be delivered in a clean receptacle.

(iii) The specimen should be tested as directed by the manufacturer of the

testing equipment. (iv) Clinical staff need to be aware that a false positive/negative may result,

and the client must also be clinically assessed. Note should also be made of how long the client has been in police custody as this may also produce a negative result, or a positive result due to the medication prescribed in police custody..

(v) The results must be recorded in the Medical records (SystmOne) and

nursing notes.



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Appendix 2

OPIATE WITHDRAWAL SCALE For each item, circle the number that best describes the patient’s signs or symptoms. Rate only when directly associated to opiate withdrawal. For example, if the heart rate is increased because the patient was jogging just prior to assessment, increased pulse rate would not be added to the score. CLIENT NAME: PRISON NO: DATE and TIME: REASON for ASSESSMENT:

1) Resting Pulse Rate:________beats/min* Measured after the client is sitting or lying for one minute 0 – pulse rate 80 or below 1 – pulse rate 81 – 100 2 – pulse rate 101 – 120 4 – pulse rate greater than 120 2) Sweating: over past 30 minutes not accounted for by room temperature or

patient activity* 0 – no reports of chills or flushing 1 – subjective report of chills or flushing 2 – flushed or observable moistness on face 3 – beads of sweat on brow or face 4 – sweat streaming off face 3) Restlessness: observation during assessment 0 – able to sit still 1 – reports difficulty sitting still, but is able to do so 3 – frequent shifting or extraneous movements of legs/arms 5 – unable to sit still for more than a few seconds 4) Pupil Size:* 0 – pupils pinned or normal size for room light 1 – pupils possibly larger than for normal room light 2 – pupils moderately dilated 5 – pupils so dilated that only rim of the iris is visible 5) Bone or joint aches: if patient was having pain previously, only the

additional component attributed to opiate withdrawal score: 0 – not present 1 – mild diffuse discomfort 2 – client reports severe diffuse aching of joints/muscles 4 – client is rubbing joints or muscles and is unable to sit still because of discomfort



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6) Runny nose or tearing: not accounted for by cold symptoms or allergies* 0 – not present 1 – nasal stuffiness or unusually moist eyes 2 – nose running or tearing 4 – nose constantly running or tears streaming down cheeks 7) GI Upset: over last 12 hours 0 – no GI symptoms 1 – stomach cramps 2 – nausea or loose stool 3 – vomiting or diarrhoea 5 – multiple episodes of diarrhoea or vomiting 8) Tremor: observation of outstretched hands* 0 – no tremor 1 – tremor can be felt, but not observed 2 – slight tremor observable 4 – gross tremor or muscle twitching 9) Yawning: observation during assessment* 0 – no yawning 1 – yawning once or twice during assessment 2 – yawning three or more times during assessment 4 – yawning several times/minutes 10) Anxiety or Irritability: 0 – none 1 – client reports increasing irritability or anxiousness 2 – client obviously irritable/anxious 4 – client so irritable or anxious that assessment is difficult 11) Gooseflesh:* 0 – skin is smooth 3 – piloerection of skin can be felt or hairs standing up on arms 5 – prominent piloerection TOTAL SCORE: ____________________ The total score is the sum of all 11 items Score: 5–12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal with at least three * indicators present to validate score

Signature of person completing assessment: _________________________

Date: __________________________________________________

Appendix 3

HMP/YOI Chelmsford IDTS Methadone Stabilisation Regime Administration Chart

Client Name…………………………………………………Prison No………………….………



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Date of Birth………………………………………………..

Methadone Dose Authorised by:

Date: Admin. Time: Given By:

Witnessed By:

Receipt by Inmate’s Signature:

Day 0, methadone (Initial dose) 5-10mg

Subject to Urine Test positive opiates or methadone

Day 0, Additional methadone 5-10mg if required - Once Only (only if clinically indicated)

6 hrs after initial dose

Day 1, methadone 10mg BD

AM

PM

Day 2, methadone 15mg BD

AM

PM

Day 3, methadone 20mg AM 10mg PM

AM

PM

Day 4, methadone 30mg AM 10mg PM

AM

PM

Day 5, methadone 40mg AM

AM

Dr/Independent Non- Medical Prescriber Signature: Date:

Total amount in words and figures Pharmacy



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Appendix 4

DRUG RECOVERY WING (DRW) COMPACT

From 6th August 2012, any person entering HMP/YOI Chelmsford or who currently

resides at this establishment who receives opiate substitute medication will be

designated as being part of the National Offender Management Service Drug Recovery

pilot. There will be a three tiered support system in place to address the following

phases:

a) First phase will be titration, stabilisation and referral to the psychosocial team,

Inside Out.

b) Second phase, will be an individual recovery plan aimed at the reduction of

opiate substitute medication with the support of the IDTS Clinical team, Inside

Out and Physical Education department.

c) Third phase, will be Drug Free with ongoing support from Inside Out and Physical

Education.

Elements within this compact will also inform you of the expectations of taking your

opiate based medication and the requirement for being tested under the Compact

Based Drug Testing scheme.

Please ensure that you read and understand ALL of this compact before you sign it.

If you have any queries or wish to discuss it further, please see a member of the

IDTS Clinical team.

If you are sentenced to 6 months or more you will be expected to engage in a

reduction programme, unless there is a clinical reason not to do so.

Failure to engage will result in:

1. A multi-disciplinary review of your treatment and medication

2. A review of your suitability to progress to enhanced status

Remand and less than 6 months:

If you are on remand or sentenced to less than 6 months, you will be

encouraged to engage with all the support services open to you including the

reduction programme.



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Appendix 4A

SIX-WAY AGREEMENT FOR BUPRENORPHINE (SUBUTEX®

) TREATMENT REGIME

On our part, we, (your IDTS worker, Inside Out worker, Doctor/ Independent Non- Medical

Prescriber, Pharmacist and prison establishment), agree to:

1. Help you to address your substance misuse issues, to promote recovery and

abstinence.

2. Prescribe and administer substitute medication.

PLEASE NOTE THAT FOR THE FIRST 5 DAYS OF YOUR TREATMENT, A

NURSE WILL BE UNDERTAKING SOME BASIC PHYSICAL OBSERVATIONS ON

YOU E.G. YOUR BLOOD PRESSURE, PULSE ETC. THIS IS IN ORDER TO

MAKE SURE THAT YOUR MEDICATION IS CORRECT FOR YOU AND TO KEEP

YOU CLINICALLY SAFE.

THIS WILL HAPPEN EACH MORNING, BEFORE YOU RECEIVE YOUR MEDS

AND EVENING.

3. Provide a referral to other community drug work agencies, counsellors and other

services within the prison as necessary.

4. Offer full information about treatment options and informal involvement in making

decisions concerning treatment and reduction planning.

5. Respect privacy, dignity and confidentiality as far as it is possible within the prison.

ON YOUR PART YOU AGREE:

1. To enrol on the IRIS recognition system to ensure accurate and safe dispensing of your

medication.

2. To provide a urine sample for routine/random screening when you requested

3. To have your clinical observations done BEFORE you receive your medication in the

morning for the first 5 days of your treatment and in the evening.

4. To take buprenorphine as prescribed.

5. Crushed buprenorphine must be taken under the tongue. Administering staff will give

you a full cup of water (200 mls) before and after administration of buprenorphine which

you must drink. Then hand the empty cup back to the pharmacy tech. Failure to comply

with this will result in you being seen by a multi-disciplinary team immediately and likely to

be placed on a rapid reduction.

6. Always show the administering staff that the buprenorphine is under your tongue before

sitting down or moving away from the hatch.

7. Sit down with your hands under your bottom. (For Centre ONLY – stand with your hands

behind your back). At no point should your hands be anywhere near your face.

8. You are not allowed to talk to colleagues or supervising staff while your buprenorphine

is under your tongue.

9. You are not allowed to bring anything in your hand whilst taking your medication.

10. Your mouth will be checked by IDTS officers during this process and they must be

satisfied with the way you have taken the buprenorphine.

11. To sign your prescription chart once consumed.

12. You are expected to attend pharmacy in the morning before 10:30am on E Wing and

before 12pm in the Centre. Failure to attend at the specified times will be classed as

declined. Only in exceptional circumstances where you are unable to attend pharmacy



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the medication may be administered at a different time if agreed by the IDTS

staff/pharmacy tech.

13. To attend and actively take part with any ongoing assessment and appropriate

psychosocial interventions.

14. To treat other prisoners and staff with dignity and respect

15. That we, (your IDTS worker and Pharmacist) can communicate with each other regarding

issues such as current treatment plans and options, but that additional information will be

discussed with you, the client, before it is shared between the above (unless you are at

risk of harming yourself or others).

16. Not to take any mediation that is not prescribed by us to you. If you choose to do so, you

run a serious risk of accidental overdose which could be FATAL.

17. Any evidence of diversion activity or found in possession/taking any medication which is

not prescribed for your use, e.g. Pregabalin, Diazepam, etc. or found/taking any non-

prescribed substances, e.g. smoking Spice, Heroin, etc., will result in you being seen by

a multi-disciplinary team immediately and your buprenorphine being stopped and a

rapid buprenorphine detox regime being commenced . If any paraphernalia is found in

your possession the same process will apply. There will be no warning or negotiation.

You will be placed on report by the supervising IDTS officer. The incident will be

documented in your medical records and your Inside Out worker will be informed. Using

on top of your prescribed buprenorphine could lead to accidental overdose therefore as

clinicians we take your safety very seriously and due to the clinical risk, including possible

fatality, you will be placed on a rapid detox.

18. Failure to comply with any of the above will result in your treatment being reviewed

by a multi-disciplinary team. You could also be placed on report, be subject to an

IEP review or SAFE procedures.

PLEASE NOTE THAT IF YOU ARE SENTENCED FOR 26 WEEKS OR MORE, YOU WILL

WORK TOWARDS REDUCING YOUR CURRENT PRESCRIPTION OF BUPRENORPHINE

UNLESS THERE IS A CLINICAL REASON THIS CANNOT HAPPEN.

I have read and fully understood the above, about buprenorphine treatment and I agree to

adhere to all of this while I am on the treatment. I have had the opportunity to discuss the

agreement and its meaning with the IDTS team.



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Appendix 4B

SIX-WAY AGREEMENT FOR METHADONE (PHYSEPTONE®) TREATMENT REGIME

On our part, we, (your IDTS worker, Inside Out worker, Doctor/Independent Non- Medical

Prescriber, Pharmacist and prison establishment), agree to:

1. Help you to address your substance misuse issues, to promote recovery and

abstinence.

2. Prescribe and administer substitute medication.

PLEASE NOTE THT FOR THE FIRST 5 DAYS OF YOUR TREATMENT, A NURSE

WILL BE UNDERTAKING SOME BASIC PHYSICAL OBSERVATIONS ON YOU

E.G. YOUR BLOOD PRESSURE, PULSE ETC. THIS IS IN ORDER TO MAKE

SURE THAT YOUR MEDICATION IS CORRECT FOR YOU AND TO KEEP YOU

CLINICALLY SAFE.

THIS WILL HAPPEN EACH MORNING, BEFORE YOU RECEIVE YOUR MEDS

AND IN THE EVENING.

3. Provide a referral to other community drug work agencies, counsellors and other

services within the prison as necessary.

4. Offer full information about treatment options and informal involvement in making

decisions concerning treatment and reduction planning.

5. Respect privacy, dignity and confidentiality as far as it is possible within the prison.

ON YOUR PART YOU AGREE:

1. To enrol on the IRIS recognition system to ensure accurate and safe dispensing of your

medication.

2. To provide a urine sample for routine/random screening when you requested

3. To have your clinical observations done BEFORE you receive your medication in the morning

for the first 5 days of your treatment and in the evening.

4. To take methadone as prescribed.

5. To drink 200 mls of water, following your methadone consumption and hand the empty cup

back to the pharmacy tech. Failure to comply with this will result in you being seen by a

multi-disciplinary team immediately and likely to be placed on a rapid reduction.

6. To sign your prescription chart once consumed.

7. You are expected to attend pharmacy in the morning before 10:30am on E Wing and before

12pm in the Centre. Failure to attend at the specified times will be classed as declined. Only

in exceptional circumstances where you are unable to attend pharmacy the medication may

be administered at a different time if agreed by the IDTS staff/pharmacy tech.

8. To attend and actively take part with any ongoing assessment and appropriate psychosocial

interventions.

9. To treat other prisoners and staff with dignity and respect

10. That we, (your IDTS worker and Pharmacist) can communicate with each other regarding

issues such as current treatment plans and options, but that additional information will be

discussed with you, the client, before it is shared between the above (unless you are at risk of

harming yourself or others).

11. Not to take any mediation that is not prescribed by us to you. If you choose to do so, you run

a serious risk of accidental overdose which could be FATAL.

12. Any evidence of diversion activity or found in possession/taking any medication which is not

prescribed for your use, e.g. Pregabalin, Diazepam, etc. or found/taking any non-prescribed

substances, e.g. smoking Spice, Heroin, etc., will result in you being seen by a multi-



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disciplinary team immediately and your methadone being stopped and a rapid methadone

detox regime being commenced . If any paraphernalia is found in your possession the same

process will apply. There will be no warning or negotiation. You will be placed on report by

the supervising IDTS officer. The incident will be documented in your medical records and

your Inside Out worker will be informed. Using on top of your prescribed methadone could

lead to accidental overdose therefore as clinicians we take your safety very seriously and due

to the clinical risk, including possible fatality, you will be placed on a rapid detox.

13. Failure to comply with any of the above will result in your treatment being reviewed by

a multi-disciplinary team. You could also be placed on report, be subject to an IEP

review or SAFE procedures.

PLEASE NOTE THAT IF YOU ARE SENTENCED FOR 26 WEEKS OR MORE, YOU WILL

WORK TOWARDS REDUCING YOUR CURRENT PRESCRIPTION OF METHADONE

UNLESS THERE IS A CLINICAL REASON THIS CANNOT HAPPEN.

I have read and fully understood the above, about methadone treatment and I agree to adhere to

all of this while I am on the treatment. I have had the opportunity to discuss the agreement and

its meaning with the IDTS team.



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Appendix 4C RECOVERY VOLUNTARY BASED DRUG TESTING COMPACT

PRISONERS NAME:

PRISONERS NUMBER:

DATE OF BIRTH:

This compact is made between the Governor of HMP Chelmsford and the above named. It sets

out their commitment to remain drug free and contains agreement to be subject to a programme

of drug testing. In return the prison will provide support and assistance to the above named to

help them remain drug free.

PRISONERS OBLIGATIONS:

I agree that the use or supply of all controlled drugs, alcohol, mood altering substances

and all medicinal products unless prescribed is prohibited. I will refrain from bringing

drugs into prison and agree not to deliver or supply any illicit item to any other prisoner or

behave in a way that contravenes security requirements or general levels expected; any

such behaviour will be treated as a failure to comply with this Compact and lead to a

review of my circumstances, possible removal from the programme and may be

considered a disciplinary offence under prison rules.

If I am found in possession of any illegal drugs, mood altering substances, alcohol or any

equipment used for the taking of illicit substances, this will result in adjudication.

If I agree to provide fresh, unadulterated urine samples when required and give my

consent to, at minimum a rub down and on occasion a full search prior to providing the

sample, and to indirect observation of the sample provision. I understand that refusal to

provide a sample consistently providing diluted samples, unless there are clear medical

reasons for doing so, constitutes’ a serious and immediate breach of Compact and

provides grounds for removal from the programme, review of medication and a possible

relocation move. I also agree to provide urine samples randomly for drug testing

whenever asked by the IDTS staff members and failure to comply with this will result in

you being seen by a multi-disciplinary team immediately and likely to be placed on a

rapid reduction.

I understand that I may be held in confinement for up to 1 hour, in unable to provide a

sample when requested.



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I understand that tests will be carried out according to the national contracted supplier’s

instructions in order to provide an indicative screening test result and that tests are not

subject to confirmation testing.

I understand that testing positive or refusing to provide a fresh, unadulterated sample will

not result in disciplinary proceedings, but will lead to a review of my circumstances and

eligibility to remain on the programme and Drug Recovery Unit.

Positive test results will be treated as follows:

First positive: Review by Board consisting of Head of Drug and Alcohol Services, IDTS

Clinical Nurse Manager, Inside Out Manager, Unit Manager or nominated representatives of

the multi-disciplinary team. Referral to an Inside Out worker for a structured intervention.

Review of the following, commitment to the programme, any trusted work position and

suitability to remain on the unit. If appropriate a rapid detox being commenced in consultation

with the IDTS GP.

Second Positive: Review by Board consisting of Head of Drug and Alcohol Services, IDTS

Clinical Nurse manager, Inside Out manager, Unit Manager or nominated representatives of

the multi-disciplinary teams. Removal from the CBDT programme and unit. Loss of trusted

work position. If appropriate a rapid detox being commenced in consultation with the IDTS

GP.

I understand that, if the review board consider my removal from the programme to be

warranted, they can implement this at any of the above stages. I also understand that if

there are reasonable grounds for a review this can occur at any time as required by the

Drug Strategy Team. I also understand that if I am employed as an orderly or any other

trusted position on the wing, this will be terminated.

I understand that I remain subject at all times to MDT and will be liable to be placed on

report under Prison Rules for committing any disciplinary offence including drug related

offences. Mandatory drug testing (MDT) positives or refusals will be treated as voluntary

drug testing (VDT) positives. In exceptional circumstances, that overriding importance of

public safety could result in a risk assessment MDT following a positive CBDT test.

I give my consent to the CBDT staff confirming details of my prescribed medication for

the past three months, following a positive result only, to enable them to ascertain if the

medication has potentially affected the outcome of my test, and to obtain details of pre-

existing conditions that may cause my samples to be diluted or stop me from providing

samples. A review may then take place to ascertain the best way to proceed.

I also consent to CDBT staff sharing the test results within the wider Drug Strategy Team,

including Inside Out and Healthcare. Passing this information to other Departments or

Agencies, other than the Residential manager or Employer, will only occur when I provide

my informed and written consent or when in the opinion of the Governor, the Security of

the Prison may be compromised.



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I understand that the frequency of testing I will be subject to is agreed as a minimum on

average of 2 tests per month at irregular intervals.

I understand that violence, verbal or racial abuse, threatening or anti-social behaviour will

not be tolerated and may result in disciplinary procedures including being placed on

report, be subject to an IEP review, SAFE procedures or my removal form the

programme / unit following a multi-disciplinary review.

I confirm that the terms and conditions of this compact have been fully explained and

understood by myself and by signing this compact, I am demonstrating a commitment to

comply with the terms of the compact.

PRISON’S OBLIGATIONS

1. To promote and encourage a drug recovery and drug free ethos throughout the prison.

2. To provide services such as Inside Out, IDTS Clinical, Physical Education, Recovery

workers / Mentors and Mutual Aid to encourage, aid and maintain the commitment to

remain drug free.

3. To provide CBDT in line with Prison Service guidelines.

4. To provide test results certificates to prisoners if required.

5. To provide the opportunity to complain or appeal against decisions made in connection

with this Compact, either informally or formally. This process should begin with an

informal discussion with either the Drug Services Team or Residential Management; if the

issue cannot be resolved it may continue formally via the Complaints procedures outlined

in PSO2510.

PRISONER:

Signed………………………………. PRINT NAME…………………………

Date:………………………………. Number: ……………………………….

Witnessed by: IDTS:

Signed………………………………. PRINT NAME…………………………..

Date:……………………………….

IDTS Prescriber: Signed…………………… PRINT NAME…………………………

Date:……………………………….



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Appendix 5

Client Leaflet

Supervised Crushed Buprenorphine (Subutex®

)

Your doctor has prescribed buprenorphine and stated that this is to be “supervised consumption”. This means that the following must happen.

You are under observation by a nurse, an at all times when you come to the pharmacy area.

We positively identify you using your ID card and the biometric iris recognition system

You remove any food from your mouth and dispose of it

You must present with your hands free and not carrying anything

You are to keep your arms by your sides and hands away from your mouth at all times unless otherwise instructed

With your permission the prescriber will have specified “crushed” so the tablet(s) will be broken into smaller “granular” pieces. This will have been explained to you by your prescriber as “crushing” is “off-licence”, but guidance has been given by the Royal Pharmaceutical Society with regard to crushing (a doctor / Independent Non- Medical Prescriber or nurse can explain what this means if you are unsure). Need to add consent to crushing form and instructions if patient refuses regarding close supervised administration

Prior to administration your mouth will be inspected by the pharmacist/nurse, and you will be required to drink a small amount of water.

You are expected to tip the “granules” under your tongue without touching them and hand back the measure

You must then allow these to dissolve which takes some minutes, during which time the pharmacist/officer/nurse will inspect your mouth to ensure the tablets are still there

Once the tablets have dissolved the officer will provide you with a drink of water, which you should drink under their supervision

Important

Failure to follow the points above will result in a review of your treatment

Missing 3 consecutive doses, while in prison, will also mean that you will be referred back to the Dr/ Independent Non- Medical Prescriber due to reduction in your opiate tolerance, after which smaller divided doses may be required until this has been re-established

Any attempt to divert/secrete this medication will result in a change of your treatment to methadone

Client’s Signature _________________________________ Doctor’s/ Independent Non- Medical Prescriber’s Signature ______________________________ Pharmacist’s Signature _____________________________ Date _____/_____/_____



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Appendix 6

HMP/YOI Chelmsford

Consent to Treatment with Naltrexone

Naltrexone is a medication used to help in the treatment of opiate dependence. It blocks receptors in the brain and hence prevents heroin or other opiates producing their effects.

However, if taken whilst opiates are still in the body naltrexone will initiate a withdrawal reaction. This can be severe and very difficult to treat. It is therefore essential that you inform the doctor or nurse when you last used any opiate drugs. These include heroin, methadone, dihydrocodeine (DF118s) and some other painkillers. If you are unsure ask.

In order to prevent unexpected withdrawal symptoms it is recommended that you have a naltrexone challenge prior to the start of treatment. This is not a perfect test but is likely to cause you to experience brief withdrawal symptoms if there are opiates still present in your body. You will be given a quarter tablet of Naltrexone on the first day and observed for two hours. The 2nd day you will receive a half tablet, and if all is well the full dose (one whole tablet) will be given on day three.

I confirm that Dr/Nurse………………………………….has explained the use of naltrexone. I understand what I have been told and have had the opportunity to ask questions.

Signed…………………………………………………………. Name…………………………………………………………………

Dated………………………………………………………….

Prison No…………………………………………………………



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Appendix 7A Rapid reduction for illicit using/diversion of medication or breaking compact rules.

Buprenorphine Methadone

32mg to 24mg: 8mg (3 days) 120ml 60mls: 10mls every 3days

24 to 16 mg 8mg (3days) 60mls to 40mls: 5mls every 3 days

16mg to 12mg (3 days) 40mls to 19mls: 3mls every 3 days

12mg to 8mg (3 days) 19mls to 0: 2mls every 2 days

8mg to 4mg: 2mg daily (4 days) Supportive treatment and zopiclone supplied for 7 days.

4mg to 0: 0.4mg daily or every 2 days (10/20 days)

Supportive treatment and zopiclone supplied for 7 days.

Appendix 7B HMP Chelmsford Proposed reduction plans for methadone and buprenorphine for prisoners serving longer than 26 weeks. As per Compact Prisoners will be expected to reduce once sentenced Regime 1

Buprenorphine 32mg Methadone 120mls

32mg to reduce to 8mg to 24mg 1week]

110mls to 60mls -10mls weekly reduction (6 weeks)

24mg to 20mg 1 week (4mg reduction) RC:


18-16mg 2 weeks (2mg Reduction)

16-14 mg 2 weeks (2mg reduction) 37mls- 19mls- 3mls weekly reduction (7 weeks)

14-12mg 2 weeks (2mg Reduction) 17mls -3- 2mls weekly reduction (9 weeks)

12mg-10mg 1 week (2mg reduction Supportive treatment and zopiclone supplied for 7 days.

10mg-8mg (2mg reduction) 1 week

8-6mg 1 week (0.8mg Reduction) RC: 0.8 per week down 4mg (5weeks)

4 mg (0.4mg weekly reduction to 0) (10 weeks)


(27 weeks Total) (26 weeks total)



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Regime 2

Buprenorphine 32mg Methadone 120mls

32mg to reduce to 8mg to 24mg (1week)


24mg to 20mg 2 weeks (4mg reduction)

55mls to 40mls -5mls every 7 days (4 weeks)

18-16mg 2 weeks (2mg Reduction)

14- 12 mg 2 weeks (2mg reduction) 35mls- 10mls- 5mls 10 days (60 days= 8 weeks & 3 days)

10-8mg 2 weeks (2mg Reduction) 8mls:-2mls every 10 days (4 weeks)

6mg -4mg 2 weeks reduction (2mg reduction)


2 mg (0.8mg reduction to 0.4mg) (2 weeks)

0.4mg 2weeks


(20 weeks Total) (Total 23 weeks)