They Said We Couldn’t do it….So We did

1. They Said We Couldn’t do it….So We did Making positive changes to support recovery in HMP Birmingham Anna Taylor HMP Birmingham IDTS Service Manager

2. Disclosures Anna Taylor has received funding for this conference; travel and subsistence from Martindale Pharma.

3. Who? • Birmingham & Solihull Mental Health Foundation Trust • Clinical SMS • Mental Health • Pharmacy • Birmingham Community Healthcare NHS Foundation Trust • Primary care • Midlands Partnership NHS Foundation Trust • Psychosocial SMS

4. HMP Birmingham Substance Misuse HMP Birmingham IDTS supports an average of 220 patients on mediation with an average stay of 6 weeks when at full capacity. An additional 100-150 are supported by the psychosocial team We have a deep commitment to enabling recovery and have introduced Naloxone on release and changed to Espranor to maximise recovery potential. This workshop discusses some of the barriers we overcome- and how

5. Part 1 Naloxone

6. Naloxone Naloxone is an emergency antidote to opiate overdose It is: • Simple to administer • Cost effective • Recommended for widespread distribution among opiate users (ACMD and WHO) It does not: • Promote or encourage risky behaviour • Have any psychoactive properties Prior to October 2015 it was available on prescription/PGD to current or previous illicit opiate users (including prison leavers)

7. Who is it useful for? • Current or previous illicit opiate users (including prison leavers) • Carers, family members or friends who may be nearby in case of overdose • Named individuals in hostels (or other facility where drug users gather and might be at risk of overdose) e.g. manager or other staff • Non drugs treatment outreach workers • Police officers (supplied by Police medical officers) • The list goes on…

8. What do you think the barriers were? Quick discussion with your neighbour

9. January 2015 Do we provide Naloxone? No! We can’t do that here We tried before…. Why not?

10. Why? The Governor said No…. Who will pay for it….? Public safety! Giving out needles!!!…. ”They might stab someone” The Head of Healthcare said No…. It can’t be done! Prisoners didn’t want it

11. Do you want to save lives???

12. So now what?...Proposal

13. Proposal: • Each prisoner with a history of opiate use to be released with a naloxone pack, to reduce the risk of overdose on release and ultimately DRD. Cost • Naloxone kits are around £18 each. • In terms of cost effectiveness, getting Naloxone into the hands of patients most liable to DRD should not really be questioned as: • It is a cheap intervention (less than two bags of heroin, or two weeks of average dose buprenorphine) • Shelf life of three years. • Epipens are given to everybody who gets slightly swollen lips with peanuts, and they cost £60 each (3 times as much as naloxone kits). • Average numbers 59 per month = £1062/month or £12744/year (if all can have Naloxone kit). This can be taken forward for funding. This number includes court release and so the number covered in the plan below may well be lower. Training Free Permissions gained

14. They said it couldn’t be done • So we did it…. • Lots of partnership • Service User Reps promote • DART (Inclusion) Identify the individual and do the training • BSMHFT do the knowledge quiz; arrange the Naloxone and fund the Naloxone • BCHFT give the Naloxone on release • G4S support the system

15. 24th December 2015

16. Since then • 23rd December 2015 – Zero naloxone ever given on release from HMP Birmingham • In Feb 2016 the Birmingham Naloxone Steering group reported 43 known opiate overdose reversals using Naloxone in the West Midlands over the previous year. Anecdotally there are 3-4 reversals per month • Dec 24th 2015- end Jan 2016: • 154 trained in HMP Birmingham- so have knowledge • 78 doses given on release (trained twice, early release, transfer…) • Actual cost • Naloxone pre-filled syringes cost £16.80 per syringe + 20% VAT = £20.20 • Total cost for 24/12/2015 to 31/01/2017 (78 doses) = £1572.48

17. Changes and recommendations • Looking at why decline (both at the quiz and to collect on release) • Explored opportunities to have in property • Originally PGD (even though not legally required) – now prescription • Communication between DART and IDTS key – timely referral before release (not 400 days) • Every prison should have facility for all patients regardless of • Current using status • Home location

18. Summary- learning Find out what’s true and what is fiction Joint working Preparation… preparation… preparation….

19. Part 2 The next challenge…

20. What is it? • A freeze dried wafer (oral lyophilisate) containing buprenorphine (2mg or 8mg). • Due to its faster dissolution rate (approx. 15 seconds) it is harder to divert and faster to supervise • Has similar clinical outcomes to Buprenorphine. • Contains gelatine • Does not need to be crushed – no off licence implications

21. What do you think the barriers were? Quick discussion with your neighbour

22. Do you want to reduce diversion and make treatment safer? Do you want to save time? Do you want to save lives???

23. So now what? 25 page proposal

24. Numbers and costs • Numbers in Treatment in HMP Birmingham • Snapshot • Average over time • Cost • Calculated per person for generic buprenorphine • NHS cost Espranor per dose • Snapshot day (all doses): • Cost for those doses • Average per person • Average per year • How much more than generic buprenorphine

25. It’s not (just) about the money…

26. Time : • To dissolve • To supervise • Costed time saving based on 2 NHS staff mid band salary (plus 1 prison staff): • 1 hour/day for 2 staff = 730 hours • 1 x band 5 plus 1 x band 3 Total = £8149.44 saving/year • 2 x band 5 = £9565.25 saving per year • CQC – observations of patients • What we would use the time for • Safety – diversion

27. Protocols • Commencing treatment from nil product to Espranor • Moving from Methadone onto Espranor • Moving from Buprenorphine onto Espranor • Leaving prison Additional requirements • Discussions and information on how to continue/change preparation with the following: • Local treatment agencies • Local prison • Request to amend the West Midlands Transfer protocol to address Espranor as without this receiving prisons may refuse to accept • Process of administration. • Summary • Recommendation

28. Recommendation To transfer from use of Buprenorphine (tablet) to Buprenorphine oral lyophilisate -Espranor for IDTS patients within HMP Birmingham

30. Preparation

31. Consultation & Training… • Email to all Local Drug teams • Email to all prisons Meet consultant from Birmingham Prison council & user groups Visit to every prisoner on buprenorphine Chaplaincy Health and Justice Health Wellbeing Programme Manager Clinical Advisor PHE Criminal Justice Team Training for staff Awareness raising sessions

32. Nervous… 1:1 and urine sample for all on buprenorphine Head of Healthcare email all Local Drug teams Head of Healthcare email all potential receiving prisons

35. Not one… Followed by… • Attempts to conceal • Cling film • Dentafix • Regurgitate saliva and evaporate Concern Complaint

36. Learning It does: • Reduce concealing • Save time • Add to security measures • Use • Resources available (e.g. training) • Prepare to re-train and revisit Its not: • Instant (staff and patient training) • Necessary to wait to fully dissolve (took time) • A “magic bullet”

37. Feedback Espranor • When used properly – very positive • Supervision still needs to be in place but is faster Naloxone • Extremely positive • Feeling valued • Adding to the West Midlands strategy

38. Learning • Preparation • Preparation • Preparation…. • Sometimes • Silence is golden

39. Any questions