Barriers to and Facilitators of Opioid Substitution Therapy in Penal Institutions: A Qualitative Study from Baden-Wuerttemberg, Germany

Abstract

BACKGROUND: Opioid use is prevalent throughout prison populations worldwide. To date, opioid substitution treatment (OST) is considered as one of the most effective treatments for reducing drug-related harm associated with opioid dependence. Yet, large gaps prevail in the access and availability of OST in detention facilities in Germany. We investigated the views and attitudes of health professionals working in prisons in the federal state of Baden-Wuerttemberg towards OST and identified barriers and facilitators to the implementation of prison-based OST.

METHODS: We conducted semi-structured expert interviews with nine physicians and one psychologist working in prisons in Baden-Wuerttemberg. The data was analyzed in MAXQDA using a qualitative content analysis approach. 

RESULTS: A majority of study participants (90%) held positive attitudes towards OST. Our findings suggest that concerns about OST medication diversion and the co-consumption of illegal drugs, insufficient staff capacity, and difficulties in ensuring continuity of care post-release posed barriers to prison-based OST. Additionally, the prison setting, an adequate personnel infrastructure, and the availability of technical equipment were perceived as facilitating the implementation of OST. The participants highlighted the need for an increase in medical personnel capacities and for improved transition management between intra- and extramural treatment settings. 

CONCLUSIONS: To improve drug using prisoners’ health, intramural OST needs to be adapted more to the particularities of­­ the prison setting such as offering less-divertible medication options and ensuring continuity of care after imprisonment. Research is needed on the acceptance of new OST medications among incarcerated populations and actionable treatment approaches.