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Methadone in Prisons
| This was a
programme in development at HMP the Mount between 2003-2006. It
did not
represent a sudden change in policy, but an evolution in line with modern medical
management and in
line with
modern primary care practice. Discussions had been held at all levels
and on an
almost daily basis with the staff in Healthcare, and with prison
officers over
many months in 2005 and 2006. We gave a presentation to the Senior Management Team at the Mount and also had meetings which included regional representative. In the end the Governor decided (February 2006) that any use of methadone whatsoever should be forbidden until 2008, when a wider national methadone programme would reach The Mount. O The Home Office has undertaken its own research which advocates change. We have had discussed our move at meetings with the Primary Care Trust held at HMP The Mount. We had visited two prisons which have already initiated a maintenance policy outside a national prison service national roll out. The female prison estate has used methadone maintenance for some time. We were planning a very limited programme, not that of the national prison service roll-out, which is a much larger undertaking. We had hoped to treat the few deep long term chronic heroin users. The sort of chap who started using heroin aged 15, and is now aged 39, having managed a matter of weeks off heroin since then, even while in prison. The chap’s repeat offending (to fund heroin use), adding up to a decade in prison. At the Mount there would have been 10-15 such clients at any one time. There is a national roll out of maintenance for prisons. That scheme also has protocols on detoxification; less of an issue for Cat C training prisons. Prisoners at the Mount have already been detoxed at their local prison. The National Programme would potentially involve treating up to ten times the numbers we were planning to teat at HMP The Mount. The national programme would require much more work and funding and training. That programme may not reach HMP The Mount until 2008. The doctors felt they had an ethical duty to do something in the meantime for few selected patients. An episode of needle sharing (IV use is now rare in Prison) causing time-consuming and careful contact tracing work, precipitated the need to treat. Risks of not treating is unethical and increases the risks to patients.
Our programme over the years was staged: Stage 1 was restructuring the established prescribing patterns and removing “surrogate” medications that drug dependent patients may seek. The most pernicious drug in this regard is Diazepam and all benzodiazepines, which have a paradoxical effect in this client group. 38% of people arrested are on benzodiazepines. Benzos blunts their emotions and makes them feel invulnerable. Removing these drugs from patients and formulary was a major struggle. As of April 2006 we had not one patient on any benzodiazepine at HMP The Mount, and aggression from prisoners towards healthcare staff declined with it. We suspected that we must have been the only prison in the Stage 2 was offering Subutex to those deep users who were at high risk of using heroin again on their discharge, and hence of overdosing and death within weeks. We started these patients on treatment in the last few weeks of their sentence. This group also needed clinic appointments and named G.P.s to attend after their discharge. We arranged such appointment and set up outside clinic appointments prior to discharge. We have had thank-you emails from a couple of these ex-prisoners, who had never managed not to use on the out before seeing us. Stage 3 was to use Methadone maintenance for the few deep chronic users, some of who were consuming up to £150 a day on Heroin, and perhaps the main drivers of the heroin market within the prison. This was the step too far at this time. Maintenance, Why? Because the evidence base is large and it’s what’s offered “on the out”
“We recognise that imprisonment as a punishment extends only to deprivation of liberty. Prisons should not add to that punishment by also depriving people of other human rights, such as access to health care equivalent to that available in the community, or exposure to greater risks to their health than they would face in the community” By not prescribing safe maintenance methadone we are putting prisoners at greater risk. On a practical side it is much easier to deal with a prisoner’s other problems when his addiction is being treated and maintained. The prisoners “agenda” in a consultation moves onto more fruitful grounds. The prisoner becomes a much nicer person. Treating users, such that they have no desire to use heroin, is one of the most satisfying things to do in medicine. It is like giving hormone replacement therapy for a diabetic. These patients’ disruptive behaviour stops, they no longer looked “drugged” (even on 100mls methadone a day). Many of these patients change from junkies back to people. Once treated a few do not improve altogether, as they also have other severe complicating personality disorders. These may originate from unrecognised attention deficit disorder and forms of autism in childhood. Evidence The clinical evidence of treatment with methadone is very strong, and this is mapped out on the National Treatment Agency for Substance Misuse (NTA) web site. Methadone briefing is here Also there are controlled trials in prison, of which the most famous is the Randomised Controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system: Kate A. Dolan a, James Shearer Margaret MacDonald Richard P. Mattick Wayne Hall Alex D. Wodak: Drug and Alcohol Dependence 72 (2003) 59/65 A protocol for prisons was devised by Dave Marteau at the Department of Health. He has also kindly sent us his presentation. A PCT concern was that PCT would have been funding maintenance because prison service has failed to get drugs under control within the prison. We argued that the NHS might also question why NHS is funding of maintenance outside prisons while police and society have not got drugs under control in the community at large. Huge efforts are made in reducing drugs that come over the wall and at visits at HMP The Mount, with considerable success. We could have added to that effort by reducing demand from within. These prisoner patients have severe dependency problems linked to personality disorders. They would be presenting to healthcare teams even if there was such a thing as a drugs-free prison and they were in one. The prisoners would still need treating, especially near to their release. A “Drugs Free” environment is too artificial and cannot occur on the out, so from a healthcare point of view the fact that drugs are around helps prepare for the likely situation in the real world. It is probable that these select patients would be treated with methadone even if the prison was drug free. Their need is beyond current availability. This is not about “detoxing” patients. This is a different management strategy for chaotic highly dependent patients, who may also have a personality disorder. The use of methadone in maintenance does not affect the prison’s efforts to reduce the illegal supply of drugs into the prison, nor does it alter the discipline policy, internal drug testing policy and adjudications. Treating the heavy users may help the prison service, by reducing the demand for illegal drugs supplies of dubious material of variable quality and strength. PROTOCOL FOR THE DRUG MAINTENANCE/REDUCTION PROGRAMME AT HMP THE MOUNT All referrals to Healthcare for the Drug Maintenance/Reduction Programme are to come from CARATS. The names of all those who have failed Mandatory Drug Testing went to CARATS with the prisoner’s consent. The prisoner’s CARAT worker sent a referral form to Health having identified these few high demand, high risk patients.
Methadone not to be increased at less than five day intervals, as this is how long it takes to achieve steady state plasma levels. Methadone will be increased to a level that is adequate to reduce the desire to use heroin. Patient to be seen at a minimum of fortnightly visits until stabilisation has been achieved; this usually occurs within 6 weeks although it may take longer. The stabilisation dose is likely to be between 20-80mg methadone in our population. Patients to remain on stabilisation dose for a period of at least 3 months, during which time they are to be reviewed monthly. A comprehensive review and goal setting meeting is to take place every 3 months. This is to discuss moves towards dose reduction and achievement of abstinence. HIV positive patients should be encouraged to stay on maintenance for the duration of their sentence. Extended prescribing needs to be considered in those with more complex medical needs and those with severe mental health problems. Those prisoners (if any) left at HMP The Mount who are being co-prescribed benzodiazepines will be carefully assessed and a benzodiazepine reduction programme initiated. Most prisoners would already have been withdrawn. If a prisoner fails to attend for up to 3 days – consider reduction in methadone dose by 5-10ml. If a prisoner fails to attend for medication for 5 days or more - they must be reassessed by the GP before given more methadone. Process in Healthcare
There are no statutory training requirements for the issuing of prescribed and dispensed DDA drugs by nurses (this was checked with NMC [ex UKCC]). Nurses have to fill in the Drugs Register when issuing such drugs. We have to assure ourselves of competencies in issuing of all drugs, not just methadone, as a part of ongoing education and clinical governance, since there are also other potentially lethal medicines being administered to prisoners. Methadone would never be in possession. The training includes ensuring the drug is swallowed. Our deep chronic client group that we were hoping to treat would swallow the drug with gusto, and have no intention of leaking it to other prisoners. We had already implemented a training strategy for all the staff on the programme, and have extended this to all prison staff. We had given a presentation to all Heads of Department and made a further presentation in Healthcare. Extra training would be offered if Nurse Dispensing was found to be desirable. Maintenance treatment is a primary care function. Both Dr Bulger and Dr Crabtree have the RCGP Part one certificate on drug dependency. Both have worked in East London, and both have worked at Meadowell, the Watford PCT-run practice that specialises in the care of homeless and drug dependent patients in We were seeking Community Drug and Alcohol Team involvement: we were planning on regular “teach and treat” sessions with the whole team and case review with a local consultant.
We could silt up with these users as they become “good boys” and stay at The Mount. There would be no reason on security grounds for them to move on, and indeed some will get into educational work and resist further moves of prison. At the same time new clients may come in from other prisons, adding to the numbers. Costs:  The major drugs costs at HMP the Mount was due to 19 patients on Olanzapine, of whom only 6 had schizophrenia (for which the drug is indicated). These patients cost up to 40% of the ENTIRE drugs budget of the prison. Some of the patients have severe dependency problems; when we are able to treat those problems directly, olanzapine and similar drug prescribing will fall. Costs comparison
We did not see that any extra nursing time would be necessary as these patients were already attending health in a chaotic manner. Apart from the act of issuing, it is likely that these patients would have made fewer demands on health care. |
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| Prison
Health Taskforce NHS
Magazine Article Kings
Fund Mental Health in Prisons
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