Procedure - Buprenorphine Treatment

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Purpose
1.	Process
2.	Eligibility to participate in the buprenorphine program
3.	Buprenorphine in the management of heroin withdrawal
4.	Recommended short withdrawal regime
5.	Commencement of maintenance treatment
6.	Transfer to the Prison Opioid Treatment Program - Buprenorphine
7.	Patient details
7.1	Distinguishing marks, tattoos
7.2	Client type
8.	Number of drug free treatment episodes
9.	Dispensing of Buprenorphine
10.	Corrective services officer guidelines
11.	Links to existing drug and alcohol programs and services
12.	Multiple day dosing
13.	Missed doses
14.	Intoxicated offenders
15.	Medical records
16.	Court attendances
17.	Release from buprenorphine program
18.	Discharge process
19.	Diversion of buprenorphine
20.	Transfer to a low security facility

Purpose

To provide for the use of buprenorphine as part of a comprehensive approach to meeting the needs of opiate dependent offenders.

1. Process

Provision of buprenorphine treatment must reflect policies and procedures detailed in the National Drug Strategy - National Clinical Guidelines and Procedures for the use of Buprenorphine in the Treatment of Heroin Dependence and will form an important component of the management of offenders with opioid dependency.

The Department must develop and maintain buprenorphine treatment for offenders to minimise the harm associated with illicit opioid use in the correctional system and in the community.

The National Clinical Guidelines and Procedures for the use of Buprenorphine in the Treatment of Heroin Dependence forms the basis of the Department's program. Health services staff providing clinical services in relation to the buprenorphine program must be familiar with these guidelines and procedures.

2. Eligibility to participate in the buprenorphine program

Offenders will be eligible to participate in the program if they are on a community buprenorphine maintenance program at the time of incarceration and there is available space on the program. The number of program spaces available is limited.

3. Buprenorphine in the management of heroin withdrawal

Buprenorphine will become the major medication used for heroin withdrawal as it has been demonstrated to be more effective than other withdrawal medication regimes. The aim of buprenorphine in withdrawal is the reduction of withdrawal symptoms and cravings, it is not the complete removal of all symptoms or the intoxication of the offender.

Buprenorphine can precipitate opioid withdrawal in someone who has recently used heroin (within the past 6 hours) or methadone. To prevent precipitated withdrawal occurring the offender should not have had heroin for at least 6 hours and methadone for at least 24 hours. It is preferable to withhold the first dose until the offender is beginning to experience withdrawal symptoms.

4. Recommended short withdrawal regime

Day	Proposed regime	Recommended lower and upper limits
1	6mg	4 to 8mg
2	8mg	4 to 12mg
3	10mg	4 to 16mg
4	8mg	2 to 12mg
5	4mg	0 to 8mg
6		0 to 4mg
7		0 to 2mg
8		0 to 1mg
	Total dose 36mg

Some flexibility is allowable in doses to accommodate a range of factors, such as amount of heroin use and psychological condition impacting on each offender's dosing requirements and withdrawal severity.

Refer Section 4 of the National Clinical Guidelines and Procedures for the use of Buprenorphine in the Treatment of Heroin Dependence.

Note: All offenders should be reviewed by their authorised prescribing medical officer (or by a registered nurse in case of standing order) immediately prior to commencing buprenorphine, to ensure they are in opioid withdrawal.

5. Commencement of maintenance treatment

Criteria for eligibility to commence treatment include-

1. positive urinalysis or other test for opiate use;
2. presence of track marks indicating recent injecting drug use;
3. history of breaches for proven opiate use;
4. history of illicit drug use;
5. history of rapid return to illicit opiate use following release from prison;
6. history of accidental overdose in custody or after release from prison; and/or
7. offender advice that they are injecting drugs in custody.

Participation in this program is voluntary. All offenders participating in the program must provide written consent prior to commencing. When obtaining written consent the following must occur-

1. discuss the following information with the offender-
   
   
   1. an overview of buprenorphine maintenance or withdrawal treatment including advantages and disadvantages;
   2. alternative treatment options including self-help, rehabilitation programs and counselling;
   3. known side effects and contra-indications to treatment;
   4. dangers of additional drug use and overdose in prison and upon release;
   5. impact of treatment on occupational activities involving machinery;
   6. transport and pharmacy costs associated with community programs post release;
   7. continuation of community treatment requires clinical review at intervals, usually between one and three months; and
   8. rules of the program, rights and responsibilities, and conditions of involuntary discharge.
   
   
2. complete the Queensland Prison Opioid Treatment Program Contract of Agreement (file agreement in medical record);
3. provide offenders with the following literature prior to the commencement of treatment-
   
   
   1. 'Your legal obligation under the Health (Drugs and Poisons) Regulation 1996' is available free of charge from the Drugs of Dependence Unit in Brisbane (Phone: 07 3896 3900) or contact Queensland Government Printer (GOPRINT)';
   2. 'Subutex Patient Leaflet' (buprenorphine program); and
   3. 'Subutex A Guide to Treatment' booklet (buprenorphine program).
   
   
4. document in the medical file - literature provided/discussed with offender.

Refer Section 2.3 of the National Clinical Guidelines and Procedures for the use of Buprenorphine in the Treatment of Heroin Dependence.

Buprenorphine is a controlled (Schedule 8) drug which must be prescribed, administered, handled and stored in accordance with the Health (Drugs and Poisons) Regulation 1996.

6. Transfer to the Prison Opioid Treatment Program - Buprenorphine

Each offender requesting admission to the Prison Opioid Treatment Program -Buprenorphine must be admitted with the Opioid Treatment Monitoring Service (OTMS) on the day the first buprenorphine dose is administered to comply with the legal requirements of the Health (Drugs & Poisons) Regulation 1996.

The OTMS monitors clients and programs treating opioid dependence to facilitate client compliance, minimal medication diversion and safe, managed programs.

Complete the 'Queensland Opioid Treatment Program - Admission' form identifying buprenorphine as the drug name. Ensure the following is completed-

1. insert photo: firmly attach a recent, clear, passport style photograph to assist offender identification;
2. date of first dose: record date of first dose provided for this treatment episode;
3. name of drug: record buprenorphine; and
4. registration type: mark the appropriate box to indicate if the registration is new, a re-registration, transfer or amendment according to the following definitions-
   
   
   1. New registration - indicates that the offender has no previous registrations in Queensland;
   2. Re-registration - indicates re-registration to a buprenorphine program within Queensland, even if the offender is applying to the same clinic/prescriber;
   3. Transfer - indicates an offender, currently registered with a prescriber/program, transfers to another prescriber/program; and
   4. Amendment to registration - in the corrections setting this indicates an amendment to a previous registration form completed by a prescriber from the Queensland Opioid Treatment Program e.g. a change to the maximum dose requested, an offender changing from detoxification to a maintenance program (or vice versa).

7. Patient details

7.1 Distinguishing marks, tattoos

Describe and state location as this information assists offender identification and minimises an offender registering with more than one prescriber.

7.2 Client type

Assess the offender and place a-

1. mark in the therapeutic box if opioid dependence has resulted from medical treatment of another condition; or
2. mark in the non-therapeutic box if dependence has resulted from illicit or 'street' opioid drug use.

8. Number of drug free treatment episodes

This section does not refer to detoxification only. Describe the offender's drug free treatment episodes by-

1. recording the number of significant attempts at residential, drug free rehabilitation eg a therapeutic community or planned detoxification at a hospital drug and alcohol unit in the 'Residential' space;
2. recording the number of significant attempts at non-residential treatment, such as outpatient counselling, in the 'Non-Residential' space;
3. Primary drug of dependence - select one drug that identifies the opioid resulting in the offender's first dependence;
4. Significant non-opioid use - the 'other' includes the non-medical use of anti-histamines and volatile solvents;
5. Significant depressant drug use - is completed if depressant is marked under 'Significant Non-Opioid Drug Use';
6. Initial Dose - record the amount of the first dose provided for this registration; and
7. Maximum dose - indicates the maximum daily dose anticipated. Doses exceeding 32mg buprenorphine require prior negotiation with the Manager of Drugs of Dependence Unit.

Once signed by the Prison Opioid Treatment Program authorised prescriber, the completed form must be faxed to OTMS (07 3896 3815). The original (yellow) is forwarded to OTMS by post. The duplicate (pink) is retained on the offender's file. A photocopy of the form must be forwarded to the Principal Adviser, Clinical Services, Queensland Corrective Services GPO Box 1054, Brisbane Q 4001 and another copy filed on the corrective services facility's prison opioid file.

9. Dispensing of Buprenorphine

Establish offender identity by comparing photograph identification with offender and written instruction.

Determine if it is safe to administer a dose-

1. examine the written instruction to verify if it-
   
   
   1. is current; and
   2. specifies the correct date, dose amount and details of dose regime (eg sublingually daily, alternate days or three times per week);
   
   
2. determine the date of the previous dose. Withhold dose until prescriber advises if three or more consecutive days have been missed; and
3. confirm the offender is not intoxicated - check pre-dose observation record if required.

Prepare and administer the dose-

1. record the transaction in the Dangerous Drugs Book;
2. count and check the buprenorphine tablets - check number and strength;
3. crush tablets and place contents in a dry dosing cup;
4. give the cup to the offender and ask them to tip the contents under the tongue; and
5. remind the offender-
   
   
   1. to place the tablets under the tongue;
   2. not to chew the tables or swallow saliva until tablets have dissolved (3-5 minutes); and
   3. not to swallow the buprenorphine or saliva as this will reduce bioavailability by 50%.
   
   

The offender must present an identification tag with a current photograph for dosing to occur. No Identification - No Dose.

Avoid diversion - Instruct offenders that they must not handle the tablets or talk whilst the tablets dissolve to minimise diversion. Hold offenders for 8-10 minutes till crushed tablets have dissolved. Once the offender indicates the tablets have dissolved inspect mouth to verify and then ask the offender to drink a cup of water.

10. Corrective services officer guidelines

Corrective services officers have an important role in minimising the diversion or other misuse of buprenorphine. Corrective services officers supervising the buprenorphine dosing of offenders must ensure that the offender-

1. has his/her sleeves rolled up;
2. is holding nothing except an accepted means of identification;
3. has open clothing around the neck to ensure that no plastic bags or similar items or containers are being secreted;
4. has no foreign material secreted in the mouth (the offender's mouth must be inspected after 8-10 minutes to verify medication has dissolved);
5. speaks immediately after his/her dose has dissolved;
6. drinks a cup of water after medication has dispersed; and
7. if practicable, remains separate from the mainstream for a period of around 10 minutes after dosing.

11. Links to existing drug and alcohol programs and services

Buprenorphine treatment is not intended to replace other services available for offenders and those on buprenorphine should not be excluded from other services because they are on a buprenorphine program. Maximum benefit will be obtained from a combination of treatment and rehabilitation strategies.

12. Multiple day dosing

One of the benefits of buprenorphine is the ability of the offender to be dosed on a daily, 2^nd daily or 3^rd daily basis. The normal daily dose should therefore be doubled or tripled accordingly.

13. Missed doses

When an offender misses more than five consecutive days of buprenorphine the authorised prescribing doctor must review the offender prior to receiving a further dose.

Refer to Section 3.8 of the National Clinical Guidelines and Procedures for the use of Buprenorphine in the Treatment of Heroin Dependence.

14. Intoxicated offenders

Buprenorphine should not be given to any offender considered to be intoxicated. They should be assessed for dosing later in the day, or the following day, after an assessment by the authorised prescribing doctor. Urinalysis may assist determination of the cause of intoxication.

Overdose on buprenorphine is relatively uncommon. There is a greater risk of overdose when it is combined with other sedative drugs, such as alcohol, benzodiazepines, barbiturates, tricyclic antidepressants and major tranquillisers.

High doses of antagonist (naloxone) are needed for overdose reversal.

Refer Section 5.2 of the National Clinical Guidelines and Procedures for the use of Buprenorphine in the Treatment of Heroin Dependence.

15. Medical records

Documentation pertaining to buprenorphine treatment should be filed in a discrete section of the offender's medical record.

16. Court attendances

If offenders on buprenorphine treatment are required to stay overnight in police custody due to court requirements, arrangements must be made with community providers and watchhouse staff (including watchhouse nurses) so that the daily dose can be received. A letter of introduction should be forwarded at the time of transfer.

17. Release from buprenorphine program

An offender not receiving buprenorphine for fourteen (14) consecutive days must be discharged from the Queensland Opioid Treatment Program. Reasons for non-dosing may be due to-

1. completion of the program;
2. ceasing to participate in the program; or
3. transfer to another prescriber.

The Opioid Treatment Monitoring Services will not approve an offender to register with another program until notification of discharge from the Prison Opioid Treatment Program.

18. Discharge process

The following process is to be undertaken when discharging an offender from the Queensland Opioid Treatment Program-

1. complete the Queensland Opioid Treatment Program Discharge Form. Use the following guide to ensure all details are completed-
   
   
   1. date of last dose - this is the date of the last dose provided by the Prison Opioid Treatment Program;
   2. name of drug - indicate Buprenorphine;
   3. section A - Part A - indicate if offender was on a maintenance program (even if the dose is reducing) or a withdrawal (detoxification) program;
   4. section A - Part B - mark the appropriate box to indicate the status of the offender's dose at the date of withdrawal, i.e. full withdrawn (program complete), dose increasing, dose decreasing or dose stable;
   5. section B - indicates the offender's circumstances at the time of deregistration - select the most appropriate explanation; and
   6. section C - provides information regarding the offender's progress during the period of treatment with the Prison Opioid Treatment Program.
   
   

A letter of introduction including all dosing requirements and personal information about the offender must be faxed and then sent by mail to the community provider following release from custody if the offender wishes to remain on the program. This letter must include a recent photograph of the offender for identification purposes.

19. Diversion of buprenorphine

Diversion of buprenorphine can result in overdose or precipitated withdrawal. Any offender on the Prison Opioid Treatment Program suspected to have diverted a buprenorphine dose will undergo a forced reduction with removal from the program once the reduction regime is completed. This is indicated in the consent form noted and signed by all participants on the program. Forced reduction and removal from the program must be approved in consultation with Health and Medical Services in Central Office.

Refer Section 5.5 of the National Clinical Guidelines and Procedures for the use of Buprenorphine in the Treatment of Heroin Dependence.

20. Transfer to a low security facility

For offenders on the Prison Opioid Treatment Program - Buprenorphine, who are transferred to a low security facility, the following apply-

1. a community prescribing doctor and suitable dispensing pharmacist need to be arranged prior to discharge from a high security facility in the same manner as for offenders being released to liberty;
2. the buprenorphine discharge summary sent to the community prescriber must specify that the offender will not be eligible for take away doses as there is no capacity for storage of buprenorphine at low security facilties. This may require the prescribing doctor to make special arrangements for times when the usual dispensing pharmacy is closed;
3. offenders will need to go to their dispensing pharmacist on a daily basis and be reviewed by their prescribing doctor at appropriate intervals, usually monthly for offenders on maintenance treatment. More frequent reviews may be necessary if the dose is being amended;
4. dispensing costs for offenders in a low security facility will be met by the Prison Opioid Treatment budget. Low security facilities will need to record these costs and advise the Department's Health and Medical Services so that a cost transfer can be arranged. This may be reviewed if buprenorphine provision is expanded throughout the State;
5. buprenorphine does not test positive for opiates on urine testing;
6. if offenders are returned to high security facilities, they should be managed as a transfer from a community provider; and
7. if staff in high security facilities have any concern in relation to offenders on the program, these should be referred either to the community-prescribing doctor or to the Director, Health and Medical Services.
   
   
   
   

F P Rockett
Director-General

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