Continuing medication-assisted treatment (MAT) between the community and prison treatment settings
Patients who are on opioid maintenance therapy prior to admission to prison should have their medication continued inside prison. However, there are many barriers to such continuity of care. The most significant barrier is that many patients have their maintenance therapy interrupted if they spend time in police custody prior to prison. This can result in significant loss of opioid tolerance. Wherever possible users should have their opiate maintenance therapy continued at their prescribed dose whilst held in police custody. One exception to this principle is when the user is intoxicated at the point in time when he/she is due their daily dose of maintenance drug (note if patients are arrested intoxicated this should not be the reason for withholding maintenance therapy). Also, if the user enters police custody outside of normal working hours when it is not possible to confirm with the community drug/pharmacy service the user’s reported dose (typically at the weekend) then the dose administered in the police cell after physician’s examination should not exceed 30mg and should only be given following confirmation of recent use by an on-site urine or oral fluid sample that is positive for opiates.
There is a need for a joined-up approach to MAT in the criminal justice system as currently even where prisons are offering MAT most police forces do not provide MAT or medication-assisted withdrawal treatment. This can be particularly problematic where detainees do not go direct to prison but to Police Arrest Houses where they can stay in some countries for up to 6 months (or even longer) and then to prison.
Another difficult situation is when detainees go to the arrest house, then to prison and then back to arrest houses to attend court for example and then back to prison. Generally, police are under the Ministry of the Interior while prisons are under the Ministry of Justice which makes in some countries cooperation even harder.
MAT should be negotiated with community agencies, police, courts, prisons and probably Ministry of Health in order to provide seamless substitution treatment provision for those with problematic drug use.
For users admitted to first night prison reception purporting to take methadone maintenance therapy, confirmation of their dose, level of supervision and time of last consumed dose should be sought from the community drug service/pharmacist. If such confirmation can be obtained that the user has received their full dose supervised within the last 48 hours then the user should be provided with maintenance therapy at the dose level he/she received in the community. However, obtaining such confirmation is often not possible as patients are admitted to prison outside of normal working hours. In such circumstances the initial dose of methadone after physician’s examination should not exceed 30mg (for other low/uncertain users until the confirmation is received). However, for those admitted claiming to be taking a high dose of methadone, it could be necessary to offer a period of intense observation where emerging withdrawal symptoms can be monitored and the dose titrated accordingly.