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.
Back