care of drug and alcohol dependant prisoners in the … · care of drug and alcohol dependant...
TRANSCRIPT
Care of drug and alcohol
dependant prisoners in the
United States and Australia
Dr Mark Bigwood
2
"We must not forget that when every material improvement
has been effected in prisons, when the temperature has been
rightly adjusted, when the proper food to maintain health
and strength has been given, when the doctors, chaplains and
prison visitors have come and gone, the convict stands
deprived of everything that a free man calls life. We must not
forget that all these improvements, which are sometimes
salves to our consciences, do not change that position.
The mood and temper of the public in regard to the
treatment of crime and criminals is one of the most unfailing
tests of the civilisation of any country”.
Winston Churchill, Home Secretary, July 20th 1910
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Contents:
Itinerary 4
Key facilities visited 5
Acknowledgements 6
Abbreviations and glossary 7
My background 8
Introduction to my project 9
Summary of project aims 10 - 12
Methods and itinerary 13 - 14
Findings and recommendations 15 - 19
Case study 20
Conclusion and dissemination plan 24
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Itinerary
USA
Austin, Texas 1/10/1 - 8/10/16
Nashville, Tennessee 8/10/16 - 15/10/16
Orange County, California 15/10/16 - 21/10/16
Las Vegas, Nevada 21/10/16 – 27/10/16
Australia
Cairns, Far North Queensland. 6/11/16 – 12/11/16
Melbourne, Victoria. 12/11/16 – 19/11/16
Sydney, New South Wales. 19/11/16 – 26/11/1
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Key facilities visited in the United States
Travis County Department of Corrections, Texas
Davidson’s County Department of Corrections, Tennessee
Cumberland Heights Recovery Centre, Nashville
Tennessee Prison Outreach Ministry, Nashville
Second Harvest Food Bank of Middle Tennessee, Nashville
Orange County California, Department of Corrections
James A Musick Correctional Facility, California Department of Corrections
San Diego California, Department of Corrections
American College of Correctional Physicians AGM 23/10/16, Las Vegas, Nevada
National Commission on Correctional Health Care AGM 24/10/16 -27/10/16 Las Vegas,
Nevada
Key facilities visited in Australia
Lotus Glen Correctional Centre, Far North Queensland
GCS Australia. Southbank, Melbourne
Carraniche Psychology, Collingwood, Melbourne
Metropolitan Remand Centre, Ravenhall, Victoria
Melbourne Custody Centre, Melbourne
11th Australasian Custodial Medical Officers Conference, 19/11/16-20/11/16 Grace Hotel,
Sydney
Metropolitan Remand and Reception Centre, Silverwater Correctional Centre, Sydney
Drug + Alcohol Services Centre, JHFMH Parramatta Sydney
Long Bay Correctional Complex, Matraville Sydney
Darlinghurst Gaol, Sydney
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Acknowledgements
I would like to thank the Winston Churchill Memorial Trust for giving me this opportunity.
The support of the other 2016 Fellows and the team at Great Smith Street was incredibly
helpful at every stage of planning and undertaking my project.
The application and interview process was itself a great experience. Having thought about
the project in hypothetical terms for several years, travelling from Bath to Westminster to
present my ideas to the panel under Sir Winston’s portrait within sight of Parliament was
unforgettable.
I am very grateful to the following people for making my Fellowship possible. Their
enthusiasm and generosity is greatly appreciated.
Dr Marc Stern, BS MD MPH, University of Washington
Captain Juan Sandoval, Travis County Sheriff’s Office
Sheriff Daron Hall, Davidsons County Sheriff’s Office
Chief Deputy John L Ford III, DCSO
Paul J Mulloy, Director of Programmes, DCSO
C. Hsien Chiang MD, Director, CHS Orange County
Dr Katerina Lagios, Clinical Director, JH+FMH Sydney
Dr Tom Turnbull CMO, CCA, Melbourne
Dr Kavita Seth, JH NSW, Sydney, Australia
Dr Gary Nicholl, JH NSW, Sydney Australia
The constraints of Security, Confidentiality, and the ban on mobile phones in secure
environments limited opportunities to take photographs during my Fellowship.
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Abbreviations and glossary
TCSO - Travis County Sheriff’s Office, Austin, Texas, USA
DCSO - Davidsons County Sheriff’s Office, Nashville, Tennessee, USA
JH+FMH - Justice Health and Forensic Mental Health, New South Wales, Australia
LGCC - Lotus Glen Correctional Centre, Far North Queensland, Australia
Acute - sudden or recent onset
Chronic - ongoing or long term
NPS - New psychoactive Substances i.e. designer drugs sometimes incorrectly called “legal
highs”
Opioid/opiate - substances that act on receptors in the body to produce morphine - like
effects. They reduce pain and anxiety but have many other effects, induce euphoria and are
addictive
OST - Opiate substitution therapy using Methadone or Buprenorphine. These drugs are
used to treat the symptoms of opiate withdrawal but the user remains in a state of
addiction. As still habituated, the user remains tolerant of opiates and less at risk of death in
overdose
Librium = chlordiazepoxide - a benzodiazepine used in alcohol detoxification to prevent
seizures and Delirium Tremens
Valium = Diazepam - a Benzodiazepine anxiolytic tranquiliser. Widely abused street and
prescription medicine used to treat benzodiazepine dependance, and in alcohol withdrawal
in those unable or unwilling to take Librium
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My Background
I qualified in Dentistry from the University of Edinburgh in 1980 and in Medicine from
the University of Manchester in 1989. After a Fellowship in Maxillofacial Surgery and 6 years
in General Surgery I became a member of the Royal College of General Practitioners in 1996.
I have been a Partner and a GP Trainer at Hanham Surgery in Bristol for 21 years. I
became involved in Custodial Health in 2005 when our Practice took over medical care at HMP
Eastwood Park, a large women’s prison in Gloucestershire. Our involvement in custodial
medicine has grown and we now look after 7 Prisons in the Southwest of England.
Meeting my host in Nashville, Sherriff Daron Hall [on right]. His innovative and forward
looking team are doing ground-breaking work on community re-entry programmes,
reducing re-offending by as much as 75%.
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Introduction to my Project
After 35 years in the National Health Service, the last 6 increasingly involving custodial
medicine, it became clear to me that prison doctors in the UK were working in isolation in
small groups without a coherent strategy to develop and improve patient care.
To understand how this situation came about it helps to know some of the history of prison
medicine in the UK. Healthcare in prisons was sparse until the formation of the Prison Medical
Service in 1877. Care was then delivered by doctors appointed by and directly answerable to
prison governors from 1877 until 2003, when responsibility was transferred to the National
Health Service. Since that time, NHS GPs many without much previous experience of prison
work or of treating drug users, took on this work in addition, to their normal family practice.
This reorganization was certainly a step forward and sought to normalise the care of offenders
by integrating it with family practice. Deprivation of liberty is punishment in itself and medical
care should not be compromised by confinement. Because of the current well documented
pressures on the NHS and General Practice, time for administration, service design and
research is extremely limited. GPs took on the protocols and models of care already in place
and generally have adapted these on an ad hoc basis since. Due to the lack of a national
coordinating body and with a paucity of educational meetings and conferences, prison GPs in
the UK have been re-inventing the wheel without opportunity to reflect, share best practice
or question their ways of working. They are too constrained by essential clinical work to look
up from the task in hand. To borrow a phrase, they are so busy mopping the floor they have
no time to turn off the taps in the overflowing bathtub.
With this in mind I requested and was granted permission by my partners to take a Sabbatical
in 2016 to learn more about correctional healthcare outside our own practice, and to see
alternatives to the treatment regimens and policies we had inherited, adapted, or devised
ourselves.
Summary of project aims:
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1. To attend international correctional medical conferences
Although we hold bi-monthly team meetings in our Practice, like most prison doctors
I had never attended a meeting or met clinicians outside our own small group.
There is no national organization of prison doctors to give guidance, develop protocols and
share advances and best practice in correctional health care. The National Institute of Clinical
Excellence gives advice to the nation as a whole especially where cost is an issue, and the
Royal College of General Practitioners advises on clinical issues in General Practice, but prison
medicine has a low profile and needs support to develop and prosper. It is a challenging and
worthwhile specialty that requires skills and acumen additional to those needed in civilian
General Practice. The United States has the National Commission on Correctional Healthcare
and the American College of Correctional Physicians. Australia has the Australasian custodial
health medical officer’s conferences and British Dentists have the National Association of
Prison Dentists. Due to the financial and time pressures on GPs there is no national
correctional medical organization meeting regularly to organise educational meetings
promote the specialty and co-ordinate research and agree guidelines.
I was keen to learn more about correctional healthcare by attending such conferences,
meeting colleagues and seeing alternative approaches overseas.
2. Management of Drug and Alcohol dependence on arrival into custody
The primary focus of my Fellowship was the care of drug and alcohol dependant
prisoners during the first week in jail. This is the most dangerous and challenging time in any
sentence. Prisoners arrive from court or holding cells after long journeys in windowless vans.
They are often intoxicated, distressed and with simultaneous mental, physical and drug
related problems. They are traumatised and have often had appalling experiences. Many have
suffered injuries from fighting and sleeping rough. No medical history is available to the
medical team and a great deal of experience and clinical judgement is required to manage
their reception safely.
In the UK we use history taking, physical examination and near patient drug screening in
evening reception clinics to tailor complex individual detoxification regimes for each inmate.
In the morning the patient’s past medical history can be obtained from their GP and
medication and other details confirmed. This remains a stressful clinically dangerous and
challenging process. I was keen to compare notes with colleagues doing this work overseas
and learn from their experiences.
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3. Management of drug and alcohol dependence during the period of incarceration and
on release back into the community
Treating alcohol, benzodiazepine and especially opiate dependence forms the great
bulk of the work of prison doctors nurses and pharmacists in the UK. Hundreds of complex
tapering prescriptions for Methadone, benzodiazepines and other medications are written,
dispensed and reviewed every day. These are expensive, potent and potentially lethal
medicines which require constant monitoring and supervision in prison. They have huge
potential for diversion and abuse on the wings. Bullying, extortion, trading and illicit use of
drugs are widespread and prescribed medicines such as methadone and buprenorphine are
the major source, as opposed to smuggled contraband. Substitution regimes and the almost
universal prescription of Methadone and Benzodiazepines are the only therapies I and my
colleagues in British prisons have any experience of. These drugs are almost never used in the
US and Australia. I found this very surprising and was fascinated to see how alternative
therapies worked in practice.
4. Service organisation and design – recruitment, retention and burnout
As a Partner in a Practice looking after seven prisons, I shared responsibility for
recruiting, training and supporting more than a dozen doctors. I was worried by the pressures
they worked under and for their safety, and that of our patients. I wanted to learn how things
were organised overseas see if I could use these ideas to improve service design here at home.
Advanced nursing roles especially Nurse Practitioner are rare in the UK but the norm
in the US especially in prison medicine where they deliver the majority of care. There are huge
differences in doctor/nurse clinical ratios with the UK having a vastly more doctor based
staffing profile. I was keen to see how this very different skill mix worked in practice. In the
UK, doctors face relentless demands for opiates, sedatives and tranquilisers. Without robust
national guidelines on opiate and sedative prescribing, these demands inevitably result in GP
appointments. These frequent consultations become fraught contests, against the clock,
between prisoners desperate to obtain sought after medications, and clinicians trying to
make sound clinical judgements. Determining and balancing actual clinical need against
impassioned patient demand given the many factors which make these drugs so sought after
in prisons is extremely difficult. Simmering below the surface during these consultations is
the risk of physical violence, complaints and litigation. Some prisoners are quick to learn who
is a “soft touch” and can be manipulated, and will groom individual clinicians, playing one
doctor off against another. The stresses these difficult consultations place on physicians is
very high and is a potent contributor to compassion fatigue, burnout and resignation. It is vital
we find a way of prescribing these medications rationally and appropriately, not by who
shouts the loudest.
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5. Chronic pain and the use of prescription opiates in prison
When I began working with prisoners I was immediately struck by the volume of daily
requests for all forms of sedative and pain medication and especially Opiates and sleeping
tablets. Opiate and sedative medication-seeking dominates almost every consultation in
prisons. I could find little information about this aspect of prison medicine in the literature
and was keen to learn more and understand the causes better. Though very obvious and
universally acknowledged by correctional clinicians, there is little research taking place in
prison health, and this issue is not getting the exposure in mainstream medical journals that
it deserves.
6. Chronic pain and the use of prescription opiates in the general population
The extraordinary rise in the prescription of Opiates in the US has been highlighted by
the deaths of celebrities like Prince, Michael Jackson, Whitney Houston and many others. The
annual consumption of Opioid analgesics in America rose 600% in the 10 years to 2007, and
the US now consumes 80% of worldwide Opioid production. As a result 83% of the world’s
population have no access to these drugs even in war zones or for end of life care. There are
many signs of a similar rise in the UK, and this is a major factor in the salience of medication
seeking as discussed above. I was keen to learn what drove this increase in order to prevent
its happening here in the UK.
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Methods
I felt the best way to achieve my aims would be to visit centres overseas, attend
educational meetings and directly observe clinical practice. I chose the USA and Australia for
several reasons.
Having previously visited hospitals in the United States and Thailand during Medical and
Dental school elective periods, I was aware of how much nuance you miss and how difficult it
is to understand social and cultural differences if you do not speak the language. I felt this
would make travelling to English-speaking countries essential.
The US was ideal as it represents a very different health and judicial culture in a society with
such close cultural ties to this country. Trends seen first in the United States often reach the
UK in time. I was reasonably familiar with travelling in the US but had never visited the
Southern states. I felt sure I would see stark contrasts to British practice and was not
disappointed.
Australia represents a less extreme contrast being based on the British healthcare model but
with a mix of private and state funding from general taxation. The custodial culture and use
of a holistic General Practice as the gateway to secondary care is much like our own. Where
the US might show extremes and contrasts, I reasoned that Australia might use ideas we could
more easily implement here at home.
I decided a week in each of several centres would be optimal, allowing time to get to know
individuals, take advantage of opportunities and invitations as they arose, and to get a better
understanding of the centre I was visiting rather than a generic visitors tour.
The initial process was slow as I had no contacts or understanding of how prison care was
organised in each country. I wrote, faxed, telephoned and emailed for six months without any
progress until I discovered the website of the American College of Correctional Physicians. I
contacted them by phone and was put in touch with their President Dr Marc Stern who helped
enormously. He put me in touch with numerous key health and justice officers. They in turn
offered to be my hosts during my visit to the United States and through their international
operations, in Australia as well.
I cannot overstate my debt to Dr Stern, without his help my Fellowship would not have been
possible. I am extremely grateful to him for his generosity.
Through the correspondence that ensued I learned of two major conferences, one in Las
Vegas in October and another in Sydney in November. This was very fortunate and by
deferring my departure for four weeks I was able to attend all three of these events and was
able to contribute by speaking at the ACCHC in Nevada and the ACCHO in Sydney. These
meetings proved to be highlights of my Fellowship providing six days of high quality
presentations and many opportunities to meet and chat with colleagues from around the
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world. At the NCCHC in Las Vegas over 2000 delegates attended the 3 day meeting with up to
5 lectures or events taking place simultaneously. Choosing what to attend was often difficult
with so much choice. A great opportunity and a very memorable experience.
In all the centres I visited in the United States and Australia I was looked after with great
kindness by my hosts. I was allowed unlimited access to health, educational and
rehabilitation centres at all levels of security both on the custodial side and in the community.
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Findings:
1. The scale of Mass Incarceration in the United States
The greatest impression my Fellowship left me with was the vast scale of incarceration
in the United States. With around 2.3 million Americans in jail the cost in financial terms
and in human suffering is enormous. Even within the corrections community there seems
little awareness of how far out of step America is with the rest of the world, or discussion
of how things could be improved. America imprisons a 9 fold greater proportion of its
citizens than the UK or Australia, more than any other country on Earth except the
Seychelles which has a population of 82,000. America’s incarceration rate per 100,000 of
its population is 724, Russia’s 581. Australia, England and Wales are mid table at around
145. See graph below.
Until 1980 the US prison population was around 500,000 but since then it has
risen by half a million per decade. Three main judicial policies appear to have been
the drivers in this change.
The “War on Drugs” declared in 1980 resulted in harsher penalties for drug
related offences. Assessing the proportion of inmates convicted for drug related
offences is difficult, as drug dependence, drug dealing or intoxication may be the
cause or underlie many crimes, but estimates suggest this constitutes around
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50% of convictions in the US and 15% in the UK. Sadly, there seems little if any
evidence that this is effective in reducing drug use and the relentless criminal
activity required to fund drug addiction undoubtedly causes immense damage to
society and the users themselves.
Habitual Offender or “three strikes” laws mandated harsh penalties for third
federal offences and finally Mandatory Minimum Sentencing removed judicial
discretion for certain crimes again resulting in an increase in sentence duration.
Promising to be tough on crime is popular in manifesto speeches, but the social
impact may be very destructive especially where rehabilitation and social re-
entry programmes are insufficient or overwhelmed.
Many believe that the multi-billion dollar corrections industry itself, having a
vested interest in maintaining or increasing incarceration rates, promotes
tough sentencing, and lobbies against liberal policies such as decriminalisation.
2. Lack of organisational structure in British prison healthcare
Both the US and Australia appear to have better funded and better organised
correctional health administrations than the rather haphazard NHS system. In the UK
prison healthcare is provided by local General Practices alongside their usual Practice
activities rather than by large specialist correctional healthcare organizations as is
usually the case in the US and Australia. The size of these organizations allows a
degree of administrative organization and professionalism lacking in the UK.
Professional skill mix is very different in the Australia and especially the USA where
there are fewer doctors in clinical roles and far greater reliance on protocols and
nurse practitioners. As a result the in the UK most decisions devolve to the individual
GP working without the buffer of a clinical team and without consensus collegiate
guidelines to support clinical decisions which, if they result in a reduction in narcotic
prescribing, may be fiercely contested and highly unpopular with inmates.
3. Need for a national association of correctional physicians
As discussed above we have in this country a very traditional doctor lead
service. This relies on individuals and small teams to devise protocols and negotiate
care with inmates on a case by case basis. This is wasteful in time, hard on clinical
staff, and results in inequality and inconsistency in care. Prescribing protocols are
negotiated ad hoc locally as there is no national consensus body to refer to.
Clinicians frequently have to justify and defend unpopular prescribing decisions in
the face of hostile responses from patients intent on accessing opiates and
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sedatives. These one to one consultations can be frightening exhausting and
dangerous and the temptation to give in or give the benefit of the doubt against
your better judgement can be great. In the US and Australia inmates are aware of
national prescribing protocols and do not request opiates or hypnotics as here in the
UK where these consultations form such a major part of clinical workload.
We badly need a national body or college of correctional care to promote and direct
custodial care, and for NICE or an equivalent national body to review key areas of
correctional prescribing and give robust evidence based advice on which to build
policy. Custodial physicians are uniquely placed to advise and share their expertise
but lack time and a forum to do so. No other group of doctors has as much
experience in caring for patients with these complex needs, and correctional doctors
have much to contribute to service improvement if given the opportunity to do so.
4. Opiate overdose prevention policy
Prisoners who have been treated for Opiate addiction in prison become Opiate
naive and are at high risk of death by overdose if they resume drug use on release. In
the UK, great efforts are made to prevent this and to support these individuals through
community drug treatment teams, using OST or “re-toxing” them by re-habituation
onto methadone prior to release if necessary. Any death within 30 days of release
from jail in the UK is thoroughly investigated as a death in custody. In the US an
entirely different approach is taken, no such support exists and nor are reliable figures
available for opiate overdose deaths. The US Surgeon General estimates that 28,647
Americans died of Opioid painkiller and heroin overdoses in 2014, the highest figure
ever recorded. In the US, waiting times for methadone treatment programmes are 90
days or more in many cities. Prisoners are often released at midnight without support,
entirely opiate naïve and thus at high risk of overdose. Though they do not have
preventative policies to avoid overdoses, American police forces in some areas are
using the opioid-reversing drug Naloxone and making this available to drug users via
pharmacies. Police and prison officers are being trained to use this drug in emergency
situations. Prevention works well in the UK and Opiate overdose is thankfully a much
smaller problem. The Office for National Statistics estimates illicit Opiate overdose
deaths in England and Wales in 2015 were 2,479. Naloxone could help save lives in
emergency situations reducing this figure further, and should be made more freely
available in the UK.
5. The opiate pain medication epidemic in the United States
This is now rightly regarded as a national emergency. The US Surgeon
General Dr Vivek Murthy’s report addressing this issue in 2016 described the issue as
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a crisis and a moral test for America. There has been a six-fold increase in Opioid
painkiller consumption in America in the 10 years between 1997 and 2007. With
4.6% of the world’s population, the US consumes 80% of all Opiates produced. 83%
of the world thus has no access to these drugs even for end of life and post-
operative care. Though not yet such a huge problem in the UK, it is vitally important
we avoid it becoming so. We must increase awareness of the problem and reduce
the prescribing of these drugs to the smallest quantities for the shortest possible
period of time. We must make doctors and nurses more aware of the dangers of
dependence, habituation and overdose. The Centre for Disease Control in the US has
published and circulated in leaflet form clear guidelines on their advice and made
prescribers aware of them. Having these written guidelines to hand carries great
weight in consultations with patients and inmates. We must do the same in the UK
and NICE appears to be ideally placed as our equivalent of the US CDC. There are
guidelines on the use of Opiates in the UK but they concentrate on terminal and
post-operative care and require review and greater prominence given what we know
of the American experience.
6. Methadone or buprenorphine opiate substitution therapy [OST]
This is the default therapy for Heroin addiction in the UK. Like almost every
clinician in the UK, I had never seen Opiate withdrawal managed in any other way.
Negotiating, prescribing, reviewing and titrating OST takes hundreds of hours every
day in British prisons. This potentially lethal therapy requires very close monitoring.
Long acting Opioids accumulate insidiously and can kill silently via coma and
respiratory failure. Methadone and Buprenorphine are widely diverted, traded and
abused in prison, and supervised consumption dispensing is hugely time-consuming
and problematic. The cost in doctor, nurse, pharmacist and prison staff time is
incalculable. This therapy is hardly ever used in the US and Australia. Patients are
detoxed over three to five days with combinations of simple analgesics, anti-emetics
and other “comfort medications”. During my Fellowship I was able to interview
prisoners at each stage of this process and was amazed at how well they appeared,
and how minor the discomfort of their withdrawal symptoms. By day three or four
many appeared completely recovered. Without exception they told me they felt
Benzodiazepine withdrawal was more difficult. In the UK, almost all of these inmates
would have been inducted onto increasing doses of methadone and maintained on 30
to 40mg or more daily for six months before considering compulsory detoxification. If
detoxification did then take place it would usually be by a 5mg per fortnight reduction,
which from the average 40mg [some are on much higher doses] would take at least
another four months. In my experience, inmates describe this process as every bit as
unpleasant as the three-to-five day rapid detox used in the US and Australia. I believe
we need to re-evaluate our policy in this regard.
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7. Decriminalization of drug use
Although exact figures are impossible to know due to the complexity of
individual cases, best estimates are that around half of all prisoners in the US are
serving sentences for crimes relating to drug use. Estimates from the Prison Reform
Trust in the UK and the Australian government put this figure at around 15% in these
countries. Illegality and the incessant criminal activity required to fund drug addiction
I am now convinced, does vastly more harm to these damaged and marginalised
individuals and society in turn, than drug use itself. The prohibition of drugs like the
prohibition of alcohol in the 1920s has not stopped drug use, merely made it vastly
more damaging than regulated and controlled use would be. Those who fall into this
underworld are not robust healthy individuals but the most damaged and vulnerable,
who need help and support not incarceration and punishment. Although there is an
understandable fear that legalisation would lead to an increase in drug use, it is very
clear that what we are doing is not working and we should explore other models. The
war on drugs appears to be lost and indeed unwinnable. Portugal, Holland and
Switzerland are having success with medical rather than criminal models of controlling
drug use and crime has fallen in areas of the US where cannabis has been legalised.
My Fellowship has lead me to the me to the conclusion that we should adopt this
approach and decriminalise drug use in the UK.
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Hypothetical case study
Amy is a 23 year old white female with drug and alcohol dependence and a chaotic lifestyle.
She was arrested for shoplifting, breaching her antisocial behaviour order and causing a disturbance
on a Saturday in south Wales. This is her 23rd Offence.
She spent the weekend in Police cells and was remanded to Her Majesty’s Prison Eastwood Park from
court on Monday to await reports and adjudication.
When seen by the medical team at 8.15 on Monday evening she had travelled for 5 hours in a
windowless prison transport vehicle and hadn’t seen her children or family for 3 days. She was in
established withdrawal having had no drugs or alcohol apart from holding doses of dihydrocodeine
and Valium given by the Police surgeon in the cells on Sunday evening.
On arrival at HMP Amy was seen by nurse. She was assessed and asked about her medical and drug
history. Opiate withdrawal scale [OWS], Alcohol dependence [ADS], Depression and Self Harm risk
screening tools were used. Alcohol related vitamin deficiency risk was also evaluated.
She was found to be highly dependent on heroin, Valium and alcohol so was at high risk of seizures
and ongoing withdrawal symptoms.
Her urine pregnancy test was negative, but her urine tested positive for methadone, heroin and
Valium, confirming her stated history of drug use, and the clinical impression of multiple drug
dependence.
Assessment by Doctor
Amy was withdrawn and hostile when seen. She was underweight, agitated and unkempt. She was
focussed entirely on drug withdrawal and her drug needs. She described using £200 worth of heroin
intravenously every day along with 20 units of alcohol and 60mg Valium in addition to regularly
smoking crack cocaine and cannabis. She stated that she had epilepsy and claimed she could not
have her Valium reduced or she would have seizures which would be the medical teams fault. She
claimed to use inhalers for Asthma but did not have any with her. She claimed to be prescribed
clonazepam [a drug similar to Valium now rarely used for Epilepsy but popular among drug users as
a Valium substitute], pregabalin and tramadol for chronic back pain, zopiclone a sleeping tablet, and
60mg of Methadone daily from her drug treatment team with daily supervised consumption in her
local pharmacy.
Medication prescribed by Doctor
1.Comfort medications package = paracetamol, anti-sickness and anti-diarrhoea tablets.
2.Vitamins by mouth and by injection, [dangerously low vitamin levels occur in chronic alcohol
excess].
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3. Acamprosate , a 10 day course of medication to reduce alcohol craving and reduce brain cell
death on alcohol withdrawal.
4. Librium to prevent seizures and reduce withdrawal symptoms from Alcohol and Diazepam,
starting at 40mg four times daily reducing to over 10 days.
5. Methadone titration regime begun with 10mg the first evening. Gradual increases in dose are
required to establish the amount of methadone required to balance withdrawal against sedation
and overdose.
6. Any prescription medicines validated by labelled tablets or a printed NHS prescription, or, as with
asthma inhalers in this case, prescribed on a “best interests” basis as withholding some medicines
till proven to be bona fide would be dangerous.
Amy became angry and abusive to staff at not receiving tramadol pregabalin clonazapam or
zopiclone.
She was assessed and felt not to be at risk of self-harm or suicide, she denied any suicidal ideas or
plans so did not require an ACCT [the prison term for suicide watch].
At this point Amy was escorted to the observation wing for drug dependant or vulnerable new
receptions. Highly disturbed or dangerous patients are cared for in a smaller unit where continuous
one to one observation is possible.
In the morning Amy was be seen again by a nurse for assessment and her morning medication, then
reviewed by the doctor. After discussion and at her request she was booked into the sexual health
screening clinic as she has been a sex worker, and after appropriate counselling, for Blood Born Virus
Screening to check her HIV and Hepatitis B+C status.
The Medical administration team had meanwhile contacted her GP Practice with her consent and
obtained a summary of her medical records and last 12 months prescriptions.
Valium and Methadone prescriptions were confirmed but the last methadone dose was collected over
a week prior to her arrest so could not be used as a pointer to her current dose requirement. Epilepsy
and Borderline Personality Disorder had both been suspected by her GP but neither was confirmed
due to Amy’s failure to attend appointments at specialist clinics. She had no other current
prescriptions but other medications had been issued in the past, including zopiclone and pregabalin.
On review Amy was calmer, more settled and cooperative after comfort medicines a shower, fresh
clothes and a good night’s sleep.
There was no clinical need for further medications despite Amy’s requests for sedatives sleeping
tablets and painkillers.
On review with the Doctor at the end of Amy’s first week in Prison, she was calm and settled on
Methadone 40mg but still showed some signs of withdrawal so her Methadone dose was reviewed.
She had been on 60mg daily in the community and regularly used street heroin “on top”, her urine
screen had already confirmed the presence of both Methadone and heroin. Her Opiate Withdrawal
Scale was moderately positive and she complained of withdrawal symptoms so a staged increase to
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50mg methadone daily was agreed. She was gaining weight and eating regularly but complained of
poor sleep and again requested sleeping tablets and other sedative medication’s . Sleep observations
by the nursing team on three occasions had shown her to be asleep when checked during the night.
There was no clinical need for other addictive sedative or sleeping tablets despite Amy’s reluctance
to accept this. BBV blood tests sent. Referral to Mental Health team was made about her postulated
Personality Disorder. A referral was made to the Specialist Epilepsy clinic. Sadly neither referral was
completed as Amy was released on licence before her appointment in the Hospital epilepsy clinic and
she declined to attend on the morning of her mental health review. She was strongly advised to
contact her GP on release to re-arrange these appointments and details were passed to her GP to act
on if she made contact. Sadly the likelihood of her doing so after release appeared low.
Librium was stopped as her alcohol detoxification was progressing well and Valium withdrawal was
now emerging. A valium detoxification regime was started instead, tapering to zero over 8 weeks.
When seen a week later she appeared stable and free from withdrawal symptoms. She was
maintained on 50mg of Methadone until handover to the community prescribing team on her release
after 17 week in custody.
This scenario is very typical and could be seen on any evening in many British Prison reception
clinics.
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The key therapeutic difference I found on my Fellowship was that substitution therapies with
methadone, the cornerstone of opioid dependence treatment in the UK, are almost never used. I
found this very surprising especially in Australia which in so many ways is similarto the UK. American
social policy is different though and places much more emphasis on individual responsibility. This
contrast is especially clear when looking at Heroin overdose which is felt to be the unfortunate result
of an individual’s law breaking rather than a failure of medical and social care, as it would be in the
UK.
Within a few days prisoners are certainly sober and drug free in the US and Australia but the early
days in custody are less comfortable and carry greater risk of complications. The UK approach entails
an enormous amount of extra medical input and prescribing which some would see as simply
prolonging the addiction.
Seeing rapid Heroin withdrawal without substitution therapy for the first time I was amazed at how
relatively painlessly this can be achieved. Patients appeared to suffer no more withdrawal discomfort
than our patients who would undergo months of milligram by milligram reduction. Valium and Alcohol
withdrawal was rather a different matter and clearly an unpleasant experience. However releasing
drug users with no opiate tolerance back into the community is dangerous and opiate overdose in
custody due to illicit use is another danger, killing around 15 per year in Californian prisons.
It is difficult to make comparisons as there are many confounding factors even when figures are
available, but opiate related deaths in Scotland [population 5.3M] averaged 400 per year, compared
to 1,265 in Tennessee [population 6.5m] in 2015. About 30,000 people are prescribed Methadone in
Scotland versus an estimated 8,660 Tennesseans. In Tennessee Methadone is not available to
prisoners, only to privately funded clinics outside prison at a cost of around $95 per week. 85% of
those attending were seeking treatment for prescription opioid dependence rather than street heroin.
There are several arguments against our current practice of methadone for all on a harm reduction
basis, but despite its drawbacks it does appear to substantially reduce overdose deaths.
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Conclusions, recommendations and dissemination plan
My Fellowship was a fascinating experience. I achieved my original aims and much more.
I increased my knowledge and understanding of all areas of correctional healthcare and
experienced very different approaches to our own. Many of the things that struck me most
forcefully were unexpected or aspects I had been unaware of when designing the project.
These additional insights and reflection on my return have lead me to question our model of
universal Opioid substitution therapy, and to become an advocate for the decriminalization
of drug use.
Summary of observations and recommendations
1. The need for a national review of the United Kingdom’s policy of Universal Opioid
Substitution Therapy in Prisons.
2. The need for a National College of British Correctional Physicians to foster and
develop this important specialty.
3. To encourage proper funding and organization of UK custodial healthcare from the
ad hoc and locally improvised structure we have today.
4. To promote the widespread availability of Naloxone to drug users and first
responders including police and prison officers to reduce deaths in opiate overdose.
5. To call for a review of Opiate pain medication use in the UK by NICE and to raise
awareness of the scale of the American opioid epidemic.
6. The scale of mass incarceration in the United States and the contrast in policy with
the rest of the first world nations.
7. To encourage decriminalization of drug use and a medical model for the care of drug
dependant individuals.
Some of the recommendations above are outside my scope as an individual to influence
directly, but some are not. I can raise awareness of the major issues in all of my talks and
presentations and have already begun to do so, but the more practical points like establishing
a National College of Correctional Healthcare, asking questions and promoting a discussion
about the use of OST in UK prisons I can raise directly in meetings with colleagues in the
coming weeks and months.
I have begun the process by raising these issues in conference presentations in the US,
Australia and the UK. I have been invited to submit an article to the journal of the American
College of Correctional Physicians. I have been interviewed for a Podcast for BBC6 Music and
a second interview is planned. I hope to support and become involved in the work of the
Prison reform council and the Law Enforcement Against Prohibition [LEAP UK] group.
Whether I am able to significantly influence policy remains to be seen but I hope I can, and I
certainly intend to do try.