LIFE AS A PRISON GP

Dr Ben Sinclair MRCGPLead GP HMP Lindholme High Security GP HMP Full

Sutton

York VTS January 2015

With Thanks to Dr Mark Pickering for contributing material to this presentation

WHAT DO WE HOPE TO COVER?

National and Local prison service Prison medicine – commissioning/provision Prescribing challenges – inside and outside Secure Environment Hazards and opportunities CASES Communication – how can GPs help each other? Resources and opportunities in prison medicine Questions – ask as we go along

THE PRISON POPULATION – ENGLAND/WALES

July 2014 – 85,600 prisoners 81,700 male & 3,900 female

127 prisons Category A-D (male) Female (closed/open) Young Offender Institutions Immigration Removal Centres ‘Mains’ or ‘VPs’

Also secure psychiatric hospitals High, Medium, Low Secure (nearest Stockton Hall)

LOCAL PRISONS IN SOUTH YORKSHIRE HMP Doncaster ‘Marshgate’ SERCO Cat B local/remand ~1,100 inmates

High turnover – From courts, short sentences

“off the Streets” Chaotic population

LOCAL PRISONS IN SOUTH YORKSHIRE HMP Moorland near Doncaster

Cat C working ~ 1,000 inmates YOs, sex offenders, foreign nationals,

mains

LOCAL PRISONS IN SOUTH YORKSHIRE HMP Lindholme near Doncaster

Cat C working ~1,000 inmates Young drug crime population “Best Prison Gym in the UK”

LOCAL PRISONS IN SOUTH YORKSHIRE HMP Hatfield near Doncaster

Cat D working ~260 inmates “Open” prison

HMP LEEDS “ARMLEY”

HMP FULL SUTTON NEAR STAMFORD BRIDGE

COMMON PROBLEMS IN PRISON MEDICINE

Musculoskeletal (often neglected) Occupational hazards – barbed wire, police

dogs… Chronic Pain incl. neuropathic

Mental health – inc. forensic psychiatrists

Addiction – opiates, alcohol, POMs, Benzos Consequences – Hep C, DVT, liver disease Hep C inreach service – good treatment

results

SECURE ENVIRONMENT PRESCRIBING Population characterised by addiction/abuse Concentration of tradeable, abusable meds

‘chemical haze’ and pocket money Balance of efficacy v security Risks – overdose, trading, addiction In Posession Medication Risk assessment

observed, weekly, monthly – patient v medication.

Verifying with community GPs – false claims “You can’t stop my meds! I want mi pregabs!”

SECURE ENVIRONMENT HAZARDS PAY OFF Threats of legal action / complaints =

cpd Challenging consultations = new skills /

SEAs Volatile situation = admin time no QOF

no visits Low risk of physical harm but be on

guard

WHATS IT LIKE? 1

Officers Locked waiting room Language Vulnerable vs manipulative patients Violence and gang culture Healthcare building protected Systm 1 “prison” sealed from outside Prison liasons

WHATS IT LIKE? 2

Disturbances Hospital transport issues re triage Small close team

PATIENT MR G

20yr old NFAW with URTI Reports dry skin dry scalp asks for e45

coal tar Has prison tattoos what issues?

CASES MR M Age 82 Serving Life for murder

MR M

Elderly Bangladeshi, DM,COPD < BMI- issues?

Brings another inmate to translate – issues?

Begins to cough c/o sweats – Differential?

Diagnosed with TB – what prison issues arise?

Admitted for Rx; returns to prison frail: subdural

Admitted bedbound non communicative…

What issues surround his care now? Infective disease, compassionate

release, suitable location, death in custody, coroner.

MR J R HIGH SECURE VIOLENT PATIENT Diagnosis shizotypal dissociative PD

DSH Numerous assaults on Medical staff Epileptic but intermittent compliance-

issues? Begins to breath hold to induce fits

then assault staff- expressed wish to die – issues?

Transported to YDH in status from non compliance – 16 police restrain him 2 NHS staff injured

Also claims transgender issues while in prison?

MR NM

MR NM PAIN MANAGEMENT

37 yr old in prison for burglary on Methadone

Fall in another prison causes back injury?

On gabapentin 800mg tds asking for increase?

Seen in pain clinic who advise pregabalin?

Threatens to sue you if no Px Pregab 300mg bd

Spot audit shows no meds in possession?

Where do we go from here?

THE CHALLENGE OF ‘NEUROPATHIC’ PAIN Easy to claim, hard to evaluate eg

“sciatica” Tenuous links to old injuries/ Scars Addictive, tradeable medications

sought Gabapentin, pregabalin, tramadol

Discrepancies of history and function Due diligence required to verify

backstory Warning signs: pt asks for named drug

declines all other options and threatens legal action

MR K EPILEPTIC

34 year old epileptic On pregabalin and clonazepam for

epliepsy? Lost to neurology FU had normal EMG

+ MRI? D+V on the day of neurology appt

hence DNA Also claims chronic anxiety problems?

PREGABALIN AND GABAPENTIN – 1

• Both potentiate the effects of opioids/alcohol• Anxiolytic, sedative, relaxant & euphoriant

• ‘ideal psychotropic drugs’ • Not routinely tested by urine drug screens• Learned behaviour (“I got this Shooting pain”)• Easy to get from secondary care & some GPs• Requested by name in drug-using patients• Concern in those already on opiates

PREGABALIN AND GABAPENTIN – 2

Patients’ statements about pregabalin:-

• “If you get the dosing right then you only need to be conscious for a few hours every day”

• “They are better than crack!”• “I rattled for weeks when you took them off

me last time.”Pregabalin = the new diazepam

We should have similar caution in prescribing it.

BMJ – Des Spence article 8 Nov 2013

Gabapentin is better if you feel it’s necessary – it’s less euphoriant, less addictive.

SECURE ENVIRONMENT PRESCRIBING

NICE guidance generally unhelpful – CG96 (Neuropathic Pain) Cost-effectiveness only, little awareness of addiction/abuse Updated version makes only passing generic mention Local prescribing guidelines now recognising the problems.

RCGP Safer Prescribing in Prisons – www.rcgp.org.uk Imaginative combinations – often unlicensed but evidence-based

Neuropathic pain – amitriptyline/nortriptyline, carbamazepine, duloxetine rather than gabapentin/pregabalin.

Pain clinics may not always realise the problem Specify substance misuse when referring

TENS machines

Depression - SSRIs/venlafaxine rather than mirtazapine/trazodone Widespread abuse as ‘sleepers’ Doncaster Prison GPs no longer initiate mirtazapine/trazodone.

COMMUNICATION - INCOMING

SystmOne Prison good between prisons but no connection with community May connect with NHS Spine 2016

Prison records often limited Faxed requests from prison to community GPs

Reception screening (HMP Doncaster) – basic info – current meds (esp need to know if recently started)

Do admin or GPs deal with these? Further info (all prisons) – specific info on a

condition – hospital letters, MRIs etc We know you’re busy but any help appreciated!

COMMUNICATION – OUTGOING

Release process not connected with healthcare Court, tagging, parole – can be unpredictable Difficult to do routine ‘discharge summary’ Should always have a week’s meds and hosp appts

Not always back to previous GP May be going to bail hostel May not want you to know what we’ve done!

We’d like to improve it - call the prison for info

OPPORTUNITIES IN PRISON MEDICINE Make a huge difference to a vulnerable

population Neglected field – lots of opportunity Small pool – leadership opportunities

Will only stop being a dead-end job if we make it so!

Special interests – MSK, mental health, men’s health, Hep C

Sessional/salaried opportunities in GP

RESOURCES IN PRISON MEDICINE

RCGP Secure Environment Group Regional peer educational meetings

RCGP Substance Misuse and Allied Health Certs in drug/alcohol misuse, Hep B/C etc

BMJ article series – Stephen Ginn http://www.bmj.com/content/345/bmj.e5921

Email : drben@sinclairhealth.co.uk