I am currently reviewing our substance misuse policy within the prison .with regards to methadone titration there seems to be a huge variation between prisons re initial doses and rate of titration with regards to inmates who present with both unsupervised and supervised community prescriptions.what is considered the best ans safest means of titrating back to community dose without it potentially taking a few weeks

This sounds like one for Nat Wright. All I would say is that it should potentially be possible to titrate more rapidly in prison than is usually possible in the community due to the levels of supervision.

yes Andrea the trickiest thing in prison drug treatment is the first 24 hours when someone comes in on a methadone script that has been discontinued in police custody for a day or 2. people lose tolerance really quickly and for that reason even on high doses I'd tend not to give more than 30ml in the first 24 hours and split dosing maybe necessary. for new inductions for people who have been in the prison a while it's even lower - no more than 20 ml in the first 24 hours as their tolerance is likely to be lower on account of having been resident in prison. the key things are regular observation and titration if indicated. it is difficult starting at such low doses particularly on those who have been maintained on higher doses but for those who have come in on high doses e.g. 100 ml or above who have had a break for greater than 48 hours, once confirmed titration can be quite rapid from the initial (30 ml max) starter dose.

Great ans.
Andrea i have found over the last few months while facilitating at some of the ITDS training ( sec env equiv of SMMGP part one ) that things have changed, in some cases, beyond belief in our prisons.
I am, on the whole, incredibly heartened as an advocate that i really do not have to put that particular hat on at these training days.
Yes there are places i am sure where one would really struggle still but with this training and ITDS things seem to be on the up.
Back to topic the training is pretty clear around this. Nat Wright was spot on, as expected.
I think once you have established that they are not opiate naive you can titrate them reasonably quickly.
Due to previous restrictions, guidelines or talent you guys working in sec envs are brilliant at observing withdrawals and hence know far more than most community equivelants. Using those skills of caring, symptomatic relief and substitute prescribing the care inside will be second to none. ( a twist on CM ???).
30ml if no doubts concerns and 20ml otherwise as NW says.
Sometimes 30ml and a good explanation will be suffice and as you are aware sometimes not.
The ceiling dose in establishments is what intrigues me most.
I hope more posts from ppl working in secure enviroments will point to more, better and fairer for all 'in' and in need.
My best
TonyB

thanks for the responses,at present we are starting at between 20-30mls but its the next stage im concerned about we where increasing 10mls daily but after my last rcgp course the advice was that this is to quickly and should increase every 3 days therfore someone on 120mls + would take several weeks couple that with possible court and release within potentially a few days this causes problems with community prescriber also.what a headache.