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[Irish Medical News] , Cahill, Niamh Linking prison and community addiction treatment. (30 Aug 2013)

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At the end of June there were 9,500 people in Ireland on methadone maintenance treatment (MMT). Of those, 514 were receiving methadone in prisons across the country, HSE data shows. The latter figure, according to Dr Des Crowley, Dublin-based prison doctor at Mountjoy Prison and HSE Dublin North East GP coordinator of Addiction Services, represents a dramatic improvement in addiction services for prisoners.

In the past, anyone on methadone maintenance treatment entering prison was forced to withdraw from treatment, as it was not provided. “Treatment was piecemeal,” Dr Crowley told IMN. “Initially there was a detox for people going into prison and then it moved onto putting people who were HIV positive on a methadone programme,” he outlined. “In 2004 anyone entering prison while on a methadone programme was maintained on their programme and subsequently people who were identified as requiring methadone treatment were initiated on it for the first time.”

Dr Crowley has been working with the addiction services since 1995 and as outlined above, the services have changed beyond recognition in the prison setting since this time. “Access to services, waiting times and the type of service that is now provided have all improved,” he said. “People are no longer taken out of treatment for giving an opiate positive drug screen or for behavioural issues. Doses are much more optimal…and there’s a more comprehensive treatment package available for prisoners.”

Dr Crowley has a keen interest in improving links between prison and community addiction services for patients on methadone maintenance treatment. He spoke about the issue at the recent ICGP Summer School and highlighted the challenges in ensuring that prisoners receiving treatment continue to maintain treatment when released into the community.

If someone in prison requests methadone treatment, every effort is made to ensure that they receive it, but as many committal periods are short this can make linking prisoners up with community services problematic, Dr Crowley stated.
He added that waiting lists for community methadone services outside Dublin was also a factor in prisoners’ maintaining treatment.

The Irish Prison Service (IPS) is the lead on the implementation of Action 43 of the National Drugs Strategy, which refers to the continued “expansion of treatment, rehabilitation and other health and social services in prisons”, Dr Crowley outlined. The action also states that “an agreed protocol for the seamless provision of treatment services as a person moves between prison (including prisoners on remand) and the community” should be developed.

Dr Crowley explained that there is a group in the IPS that is charged with implementing the action and with looking at difficulties in placing former prisoners in community services. “We’re looking at creating a central register held by the health directorate in the IPS for anybody in the prison who is having difficulty accessing treatment because of a block or gap within the community,” he stated.

“It’s a question of looking at the way the services are designed and looking at what the blocks are in getting people into treatment. They may not necessarily be resource issues but in some areas they may need more clinicians and services. It’s a combination of resources and management, I think.”

Turning to the culture within prisons, Dr Crowley maintained that the injecting culture had been virtually eliminated due to the introduction of better treatment programmes in prisons and the community. “The injecting culture in prisons has changed. There was a high injecting culture in prisons in the past, but that has been pretty much eliminated now.”

Previously ad hoc addiction services in some prisons have also become more streamlined and structured. In Mountjoy, where Dr Crowley tends to prisoners once a week, part of the medical unit is now totally dedicated to drug treatment. There are a variety of distinct treatment programmes in place provided by a multidisciplinary team of addiction doctors, nurses and counsellors and patients can choose to be referred to various pathways. In tandem with the expansion of the unit there are plans to introduce a new database to track patients after they are released from prison to see if they stay on their treatment programme.

“We did an audit for 2012 to see if people did attend their community clinic and all bar four patients who were discharged on methadone maintenance returned to their community clinic,” Dr Crowley imparted.


The extension of the methadone maintenance treatment programmes to open prisons and training units.

The programme has now been extended to the units so that prisoners on methadone who move to the units can choose to maintain their treatment. The infrastructure and arrangements needed to facilitate the development have recently been implemented and to date two patients on methadone have been transferred to open centres.

“That’s very exciting because it means people don’t have to choose to detox to have the option of going to an open unit to get access to different types of training,” Dr Crowley stated. “It’s a positive way of looking at methadone as being similar to other medications. Initially, with some of the open units you weren’t even allowed to be on psychiatric medication I think, so that was the first change that happened, and now we’ve come one step further.

Asked why the programme had not been provided in open units heretofore, Dr Crowley replied, “I think people found it difficult to comprehend that rehabilitation could be associated with being on methadone”.

“Often people think that the only way you can rehabilitate is if you detox but that’s not the case. There are rehabilitation pathways that include being on methadone and for people with major dependency issues it can sometimes be a more appropriate route for them to take.”

The prescribing of naloxone on discharge from prison is another matter currently under consideration. The move could see prisoners who are undergoing detoxification being given naloxone for use in the event that they overdose, Dr Crowley explained. “This would be for people who are detoxing coming out of prison, not for people on methadone as they’d be linked up with a clinic so their chance of overdosing would be low. “A national pilot is being developed and we’re looking at how that can be rolled out within a prison setting, because it would operate differently in a prison setting compared to the community.”

Those who are detoxing and who relapse into opioid use have a high risk of overdosing. If implemented, the move could reduce the incidence of overdose, especially during the first two to four weeks of release from prison. It is apparent that while many challenges remain in providing a comprehensive methadone maintenance service to prisoners through to their release into the community, improvements are taking place.

Dr Crowley, although recognising the difficulties around waiting lists for treatment outside Dublin, believes huge advancements have been made in the provision of methadone treatment services in prisons and the community. “I really enjoy the job and I feel very proud of developments and work done in the last 15 years. I think it has radically changed. Community services have radically changed but I think in the prison service there has been even greater change; it’s been dramatic.”

 

Item Type:News
Source:Irish Medical News
Date:30 August 2013
EndNote:View
Subjects:HJ Treatment method > Drugs and alcohol disorder treatment method > Drugs and alcohol replacement method (substitution) > Methadone maintenance
J Health care, prevention and rehabilitation > Health care programme or facility > Prison-based health service
MM-MO Crime and law > Justice system > Correctional system and facility > Prison
T Demographic characteristics > Prison Inmate (prisoner)
VA Geographic area > Europe > Ireland

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