A recently completed review analyses the outcome of pharmacist–patient structured methadone detoxification in Mountjoy Prison between June 2010 and May 2014. 

Drug treatment pharmacists were introduced in Mountjoy Prison in 2008, primarily to ensure the safe, accurate and efficient dispensing of methadone. The pharmacists currently dispense in 13 different locations in the Mountjoy complex. While the safe dispensing of methadone remains the priority, since 2010 pharmacists have also been supervising and managing pharmacist–patient structured methadone detoxification, otherwise known as self-directed detoxification (SDD). 

Unlike other detoxification regimes, which are prescribed and have a fixed regime, SDD allows prisoners to opt to detoxify at times when they feel they are ready for and capable of change. The pharmacists offer SDD in 12 locations within the Mountjoy Prison Complex (excluding Dochas Women’s Prison). All SDDs must be requested 24 hours in advance by the prisoner in order to eliminate impulsive decisions. SDD may be undertaken if it is deemed clinically appropriate and is provided within certain parameters, i.e. up to a maximum amount, which reduces each week, and is communicated to the addiction specialist doctor. The addiction specialist writes up the prescription weekly. If, at a later date, the prisoner chooses to return to their previous dose (increase their consumption), they must see the addiction specialist. The prisoner is supervised on a daily basis by the pharmacist so any changes in demeanour and behaviour can be easily observed by a professional familiar with them and interventions can be made where appropriate. 

Anecdotally this system has proved successful. However, it was decided to conduct the review in order to determine the exact number of prisoners involved in SDD and assess the outcomes. This review analysed the outcome of pharmacist–patient structured methadone detoxification in Mountjoy Prison between June 2010 and May 2014. 

Methods

Three different cohorts of prisoners were chosen for the purposes of the review:

1. Those on methadone maintenance therapy (MMT) who reduced their maintenance dose by over 20mls (or 50% of their dose) between their committal to Mountjoy and their final movement out of Mountjoy. This cohort included those who returned to the community or were transferred to another prison.
2. Those on MMT who detoxified completely and came off methadone while in custody in Mountjoy. For the purposes of the review, a prisoner on MMT was considered detoxified when sequentially reduced to a prescribed dose of 7mls or under. At this dosage, a prisoner will often stop their methadone completely but get prescribed lofexidine or another drug to aid with any symptoms of withdrawal.
3. Those receiving lofexidine therapy as an adjunct to SDD.The review excluded two cohorts of prisoners: 

• Prisoners who were in receipt of MMT but who were in custody in Mountjoy for only a short period of time (less than 60 days consecutive days).
• Prisoners who were prescribed a ‘21-day standard detoxification’. This group were not in receipt of any MMT prescription but tested positive for opiates and/or methadone and did not have an MMT clinic place externally. The prison can only offer a ‘21-day standard detoxification’ until a clinic place is confirmed for when they are released to continue their care. This regime consists of 20mls methadone for two days, 30mls for four days, and then a 5mls dose reduction every three days to zero. As such their dose reductions cannot be considered an SDD.Data pertaining to all methadone and lofexidine prescriptions in Mountjoy Prison during the period June 2010 to May 2014 were examined. The number of prisoners eligible for inclusion in the study were as follows:

Methadone – 13,698 prescriptions, of which: 

• 572 prescriptions were for ’21-day standard detoxifications’. This equated to 390 prisoners who were excluded from the review.
• 13,126 prescriptions were for 1,207 prisoners on MMT. Of these, 405 were excluded as they had not been in custody in Mountjoy for 60 or more consecutive days.
• In total, 805 prisoners were included in the review.

 Lofexidine – 138 prescriptions. 

Results

Of the 805 prisoners on MMT included in the review, 416 (52%) chose to undertake SDD. Of these, 202 (49%) reduced their MMT dose by a significant amount of 20mls or more, and 214 (51%) detoxified off MMT completely while in Mountjoy. Of the 214 who detoxified off methadone completely:

• 134 (63%) used lofexidine to complete their SDD. Four prisoners had two courses of lofexidine but have also completed SDD successfully.
• 80 (37%) did not use lofexidine to complete their detoxification but did the programme to completion with the support of the pharmacists.
• 27 (13%) either relapsed temporarily or went back on MMT.

Conclusions 

1. The practice of SDD through the pharmacists is routine in Mountjoy prison.
2. Over half of all prisoners prescribed methadone (for 60 or more consecutive days) in Mountjoy were able to reduce their methadone dose significantly using SDD.
3. Half the prisoners who undertook SDD were able to detoxify completely off methadone while in Mountjoy.
4. Lofexidine as an adjunct to MMT, to treat withdrawal symptoms, was used by 63% of those who chose to undertake SDD to complete their detoxification.
5. Over a third of those who undertook SDD chose to complete their detoxification without lofexidine and completed it in the main prison with the support of the drug treatment pharmacists.
6. At least 13% of prisoners who underwent SDD and detoxified completely relapsed, some only temporarily.
7. Information on what happened to the prisoners on release from Mountjoy is not known, e.g. did they relapse or return to treatment? It would be important to investigate this in order to gauge the overall success of the programme. This would require a further study using the HSE’s Central Treatment List.The review was done by Brian Cronin BSc (Pharm), MPSI, and Gordon Ryan BSc (Pharm), MPSI, both of whom work as Drug Treatment Pharmacists in Mountjoy Prison, with assistance from Suzi Lyons, Health Research Board.