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Drug Dependency in Prison

The first few days in prison are a very dangerous time.  Attempts to detoxify patients, or do the prisoners’ bidding, can add to the risk.  Immediate assessment with urine and mouth swab tests can only give useful qualitative information as to what drugs the patients have taken, but cannot tell us how much of each drug is being taken.  Not treating prisoners on arrival is cruel and increases other risks such as fits, acute psychosis and self harm. 

Reception assessments are often hurried and can be late at night.  I have had patients arrive at 9 pm. The prisoners are tired and upset and often nauseated by the journey in the sweatbox. 

Getting confirmation as to the exact dose patients are on is difficult.  We cannot rely on the National Electronic Health Record to help in this regard for many years, if at all.  The Spine record will not have details of aliens or those who do not have NHS numbers.  Many patients may opt out of having a National Record altogether.  There is no standard ‘street drug unit’ apart from amount spent per day, and that does not exist on any record.  Since we cannot get confirmation we have to use low starting doses for heroin detoxification, and keep detoxification safe and under careful supervision. 

In all detoxification and maintenance treatments we have to avoid “leakage” of prescribed drugs to other prisoners. 

The bigger, but less glamorous, problem may well be alcohol detoxification rather than heroin.  Some prisoners, even after a day or two in the police cells, still have some alcohol on board on arrival at prison.  It is imperative to institute a safe and rapid alcohol detoxification, including high dose vitamin B supplements.  The quantities of alcohol being drunk by some of these offenders is staggering. 

All of us would all like to see Offender Health services having a more joined-up approach so that the processes can start in the police cells…but police cells are a very risky place to start new medication.

Detoxification is one thing, but what next?  The assessments and new patient checks need to be longer, calmer and have defined purposes, which are to develop a clinical sentence plan and, in particular, start the process for discharge planning.  Once we have freed a patient from alcohol or any street drug, we need a joined-up follow-up process to help prevent recurrence.  It is difficult: simply keeping and maintaining, let alone having the facility to use, up-to-date lists of contacts external to the prison is a complex task.

Detoxification cannot be isolated from the rest of the patient’s care.  Hepatitis B and C status, liver function, HIV status, and (once again these days) T.B. screening needs to be part of the programme. Management programmes need to developed for patients with dual diagnosis and personality disorder. Other medical problems need to be teased out and treated.

A single Prison Health clinical computer record will help considerably, as many of these patients return regularly.  I have views on the proposed clinical system and I responded to the original draft specifications.  Last month I made comments on the subject to the Parliamentary Health Committee.

The turnover of prisoners, compounded by prison ‘movements’ [transfers between prisons], makes discharge planning complex…especially for the Category B local prisons. 

Each prison seems to be different in its approach depending as to how far it has got with the national Integrated Drug Treatment System in prisons (IDTS) roll-out.  Some prisons started programmes for maintenance before IDTS.  I expect that most prisons will shortly be following the guidelines in: 277393/Clinical Management of Drug Dependence in the Adult Prison published in December 2006 (Dave Marteau et al).

Many drug addicts are people with personality disorders who have self-medicated themselves for their problems, and this self medication disinhibits them – unleashing criminal behaviour.  I am not quite sure if drugs are “causing” patients’ problems (or for that matter crime).  Drugs may be symptomatic of a wider medical and forensic problem.

Dr Lefever (Promis) and others suggest that it is not the drug itself – but there is something else about that person which allows the addiction to take hold.  He suggests that it is possible to detect those individuals likely to have a dependency personality at an early age, even at primary school, no matter what the addiction will turn out to be – alcohol, work, heroin, gambling or sex.  

In many patients the driver towards dependency is a personality disorder.  Drug dependency is not easily separated from other psychiatric diseases in a prison (dual diagnosis) or indeed from personality disorder.  

Deciding which patients need to go onto maintenance treatment, usually methadone, is difficult.  There is a risk that this nay be overdone.  We must not deny prisoners the opportunities for detoxification and for them to take the “Twelve Steps” and to have aftercare set up for them.

There are a few patients, who can be identified by the prison teams, who have repeatedly failed MDTs {Mandatory Drug Testing] within the prison, and who can count only weeks in their lives when they have not used heroin, since aged 15 or even earlier.  RAPT teams will identify them as well.   These deep perpetual users may need maintenance – although by maintenance, I mean patient-led slower withdrawal. 

At The Mount we originally found 12 such patients.  We expected that the numbers would rise, as once they were treated there would be fewer wing incidents, and fewer security moves of those prisoners out of the prison; meanwhile new deep users would come in.  We do not know what the numbers are like now that the regime is run through IDTS. 

One needs to choose carefully the relatively few patients who need to be on a longer methadone programme.

In drug treatment programmes it is better practice to increase the dose of methadone until the patients have no desire to use heroin.  While doing this it is an opportunity to clear the patients of all other medications…especially benzodiazepines (including clonazepam for “epilepsy”).   Once on mono-therapy – methadone – at an adequate dose, it is easier to distinguish those patients who have a dual diagnosis, and those who have personality disorder on top of drug misuse.  

The prison service, with the obvious risks in mind, is sensibly wary of the doses used in outside medical practice.  Daily supervised dispensing and issuing is essential for these clients, both in and out of prison. Most patients can then benefit from a relatively rapid withdrawal.

Benzodiazepines in this group of patients have a paradoxical effect and make them aggressive.  Getting patients off these drugs is the priority.  39% of people arrested are on these disinhibiting drugs.

We managed it at HMP The Mount.  By March 2006 not one patient was being prescribed any benzodiazepines, and the prison staff were delighted to see how much calmer the patients had become.  The prisoners no longer looked like addicts.   

Any patient who came into prison on diazepam or clonazepam was put on a slow withdrawal regime, as from Prof Ashton’s web site (we modified her regime).  Sometimes, if there was a risk that the patient did indeed have epilepsy, then tegretol was used as the anti-epileptic medication instead. 

Drug dependency issues can dominate the care in prison healthcare centres, partly because issuing and dispensing of methadone is so time-consuming. 

GPs see, and look after, patients with Personality Disorder on the outside; these patients make up GPs’ frequent attendees in their practices.   Local psychiatric services, not unreasonably, give up on these patients (if they were ever referred to them in the first place).  Indeed psychiatric services discharge nearly all their “ordinary” cases to GP follow-up – even those with mania or psychosis; a new QOF target for GPs is to ensure that such follow-up happens.   

Any experienced inner-city GP does not feel in the least out of depth at any Category B or Category C prison, especially if they have RCGP Drug Dependency Accreditation. 

An example is the “clucking” prisoner who is withdrawing and seeks help.  This is the opportunity to assess and treat holistically – there and then – rather than missing the chance by booking him in for a separate Drug Team Clinic the following week.  At one prison, even testing for a patient’s Hepatitis C status was held to be outside the primary care and nursing team reach.  The test was only allowed to be carried out by means of booking a GUM clinic appointment on another day.   

Many resources are being invested in Drug Dependency and they must not isolate the drug issue from everything else.