I have been asked to set up a drug misuse service in our local prison. There appears to be a divide between expectations and guidelines.
The expectation is that users can be maintained on low dose, eg 40mg methadone, if they aren't detoxed. The only ones to be maintained would be those already on a script when they reach the prison. anyone presenting having used illicit drugs in the prison would be given a detox. Re-titration before discharge is being considered.
The situation seems open to development, but I haven't heard of any prisons maintaining users on their normal "community" dose (ie 60-120mg). I am inclined to go for this level of maintenance, but it seems to be going against the flow. Any thoughts?

Oh my what a compex job. Well without going into the nuts & bolts
of locality & catogary & type of HMP(open/remand/high security etc)
and for the sake of this conversation, assumeing a high level of staff
competancies & willingness & you have bugdets & your going for total
IDTS with all the treatment options & you got a team CARAT'S from heaven.


I am going to reply taking into account all the complex issues involved
in secure enviroment prescribing & apply a harm reduction & human rights
bias to my utopian dream awnser. on page iv the wonderful guidence

Clinical management of drug dependence in adult prison setting.
http://www.drugslibrary.stir.ac.uk/documents/adultprisons.pdf

it says - 3 opiate substitute maintenanc (up to & beyond, dependant on
individual clinical need)

From my perspective & experiance of enforced detox's in U.K.HMP's I would say
that there are many individuals who are physiologically & psychologically
so traumatised & of such a mind set that community dose's would be the most
humane & viable solution. It would improve there general disposition & enable
a calm clarity where a sophsitacted care plan could be formulated & navigated.
i.e. engauge in a combination of work & education & self improvement ready for
there release equiped with all the nessecary life & coping skill's along with a
trade or proffessional qualification & seamlessly reinterated back to community
prescribing to a life where they have a very real chance of non-recidivisum &
living a happier productive life style (phew! - what a mouthfull?)
Of course its all about the criteria one use's to assess such indiduals & sentance
length & settings etc etc. But I guess this is another challenge for the IDTS aim for?

I would remind everyone of the following training

RCGP Substance Misuse Unit Secure Enviroments Module

New one a half day course supplements the learning offerd by RCGP Cert 1 & 2
offering further specific skills and knowledge to ensure confidence, and safety
and goverance in executing ones clinical duties in respect of substance misusers
in the secure enviroments settig - course designed for lead proffessionals from
Safer custody prison staff - Subsatnce misuse and primary care nurses - CARAT's
teams - Prison doctors / GP'S - & I understand there are limited places available
& funded by IDTS monies. (RCGP contact Jo Betterton on 0207 173 6095)

Warm regards

Jimi of N.U.N

I am awarte of some prisons where optimal methadone doses are being used, although I don't want to name them. Nat Wright knows an awful lot about this since he has worked on a national level regarding prisons, he should be on here soon, if not it might be worth contacting him anyway(he works at Leeds prison)

Do the prison brigade not argue that there dosing arrangements are optimal for their incarcarated charges.Not sure I buy it myself, but certainly a prison habit is a lot less than a street habit.

The clinical guidlines say (section 7.3.1) prison prescribers should take into account '...The high value, relative to the patient’s limited income, of drugs'.
They also say: Treatment exits should be negotiable and revisited. As in all other environments, treatment should not be discontinued punitively. In the event of relapse in prison, the clinician should explore the reasons for this with the patient and discuss treatment options'.
and: 7.3.4.2 Reviewing dose
'Patients in prison will commonly achieve stability on doses lower than those commonly prescribed in the community, although some will require equivalent doses to achieve clinical stability.
However, prior to release, consideration should
be given to reviewing the current dose of
methadone with the patient, to optimise their
likely retention in treatment upon return to the
community (Bellin et al., 1999; Dolanet al.,2003). This may entail increasing the dose prior
to release – in consultation with the community
prescriber – and explaining to the patient why
this is appropriate'.

'
Hope this helps

Susi

Sub optimal dosing, equals, sub optimal dosing. The hunger only subsides when you titrate up
correctly. I feel an awful lot of the trouble and strife in Her Majestys Hotels', stems from
our mean prescribing philosphies. Have a quick look at this article.

BBC NEWS | UK | How drugs fuel violence in prison http://news.bbc.co.uk/1/hi/uk/7138324.stm

Frankly I feel it over eggs the pudding a bit, but one has to take into account that bad treatment
negitivly impacts on the lives of inmates & staff in a huge way. The effects are proundly unpleasant
when you have vast swaythes of the prison population just not attempting to access treatment because
they are treatment naieve & shy & totally lacking confidance in it & the word on the wing is, dont even
bother mate because it sucks. Come & buy some of my overpriced & overcut product instead. I'll give you
line of credit & lend you a set of works! (there's a bonus!?!)

I salute those with the balls & brains to think outside of the box & who evolve the system to a point
where its humane & harmonius & reduces tensions. (& the prevelance of BBV's & there's another bonus!?!)

jimi

Whilst agreeing the pudding might be over egged in the article it still is describing a lamentable state of affairs.Including people who develop prison habits.
Is it the intention to make treatment fully available in prison including prescribing or is it only available to those on IDTS. More court cases in the offing I think!

sorry folks for coming late to this debate. Yes the prison can be a very challenging place in which to deliver methadone maintenance. The main differences from community are: high prevalence of drug users in confined space; reduced supply of drugs cf community; reduced prevalence of injecting in prison drug users cf community drug using populations; increased risk of those with criminal history/personality "difficulties/challenging behaviour.
Therefore in a nutshell clinical governance frameworks need to be tighter in prison as potential diversion of meds is much higher. therefore methadone tends to be first line, though we'd recommend switch to buprenorphine if user so chooses within 1/12 of release (we give it as suboxone preparation - again as less amenable to diversion). Re the dose issue I find in my own clinical practice (and many others in prison feel the same), that our dose levels tend to be 2/3- 3/4 what they would be on the same person presenting in the community. Therefore we're doing a lot of titration to community dose levels (60-120ml) in the weeks immed prior to release. I think the main reason for lower doses in prison is the reduced prevalence of injecting in prison, and also that many users see prison as a time of "having a break", or trying to address issues. Therefore there's many who have been admitted into prison around the 80-100ml mark but wish to be released on around 60ml.
the new Orange guidelines have for the first time a section on prisons which is useful further reading.

While for the most part i understand the issues & sympathize with the complexities I will remind everyone of the most overlooked point in the equation, Inmates on 80-100 mls community doses will need to be informed & educated as to why they will ultimately be on a lower does in HMP.
In order for treatment to work it must be agreed & embraced by the client. For the record I really think IDTS is going in the right direction. The real problem is the Lack of meaningful & significant funding from the HO.

i think it's a fair point Jimi that the hardest bit of the whole community- prison - community pathway to get right is when patients are received into prison on 80-100mls. often it's either not possible to confirm the dose of methadone that evening (as received outside of working hours) or they've not had that dose for a number of days whilst held in police custody. therefore the prison doc can only start at a lower dose with gradual titration. some will obviously be titrated back to 80-100mls

Nat, one of the issues raised, is what to do with inmates who present having acquired illicit drugs whilst in prison, but who have no proven record of drug use prior to prison. the proposal is to give them a short detox only. Should some of these be considered for maintenance prescribing if they wish? If so, how to avoid "creating" long term addicts from opportunistic users?
Rob

I've not worked in prison, but i would imagine its the usual mater of engaging with the person, working out with them what they "really " want, with some hopeful life planning for their return to the outside.

If they are certain they want to join the almost 200,000 people (I see from the NTA links someone put up in another thread) who are dependant on daily doses of prescribed opiates, with all the ties that are entailed.. (drug workers, prescribers, pharmacists constantly on their case).. then maintenance prescribing may be a good idea.

If that sounds a bit of a gloomy prospect, then maybe they might try a detox, then opiate free living while inside, so that they can emerge with the "I survived heroin" badge and go to NA meetings with their proud head held high.

I suppose which they choose would depend on a thousand personal factors.. first of which perhaps is how much of a hold they feel the prison opiates have already taken. I have met several patients over the years, whose first taste of heroin was inside.

I always try to face new and naive opiate users in a particularly focussed and intensive way, and try to help some of them to wriggle quickly free and avoid getting a name plate on a chair in my boring surgery waiting room. Usually its those who have a life who achieve this, which may be a challenge for the prison group.

The drudgery of prison life makes methadone an ideal way to ameliorate the surroundings, cloaked in the warm fog with some respite from the impersonal brutality.Any one for a top up?

Yes, well I can see that. Probably I am a bit naive.

"Legalise" the production, sale and use of all mind altering substances (regulating them a bit , like alcohol and cigarettes) and empty the prisons, might be better?

quote:

Originally posted by judith yates:


"Legalise" the production, sale and use of all mind altering substances (regulating them a bit , like alcohol and cigarettes) and empty the prisons, might be better?

anybody think we should be doing this?

quote:

Originally posted by judith yates:

quote:

Originally posted by judith yates:


"Legalise" the production, sale and use of all mind altering substances (regulating them a bit , like alcohol and cigarettes) and empty the prisons, might be better?

anybody think we should be doing this?

Judith,
Do you have any easier Friday morning questions?
I do have some leanings towards legalising and taxing drugs.

thank you Simon. I have to admit, its not a question with any very easy answers, but when I hear about the amount of time my local policemen are spending on setting little traps to ensnare my local NFA users into helping some shivery little RADA trained police man to get a bag of heroin, and thus earn their ticket to gaol, I feel there must be some other way to spend my taxes. There's a long sentance for a Friday night.

Judith can you imagine a 16 yr old wondering into your surgery when he or she could get some Diamorphine on prescription legally from you. Said teenager opiate naieve, wonder what does you'd start them on.
'Morning Dr.Yates I've heard Diamorphine is great fun can I try some? I'd pay my prescription cahrge but I'm in full-time education'
Unless of course we sell it in Asda and have the occasional buy one get one free offers.
It seems a lot of people are getting twitchy again about Cannabis and it could be argued it's for good reason. I do though see mass building of the prison estate and think taxes could be spent on better and cheaper things.

Perhaps it would be Off licences? I don't prescribe alcohol or cigarettes, do I? I think it needs regularly re-visiting and debating at least. Our present system doesn't seem to have much to commend it.

The Chief constable seemed pretty certain:

Mr Brunstrom says: "If policy on drugs is in the future to be pragmatic not moralistic, driven by ethics not dogma, then the current prohibitionist stance will have to be swept away as both unworkable and immoral. Such a strategy leads inevitably to the legalisation and regulation of all drugs.

* The chief constable asserts that current British drugs policy is based upon an unwinnable "war on drugs" enshrined in a flawed understanding of the underlying United Nations conventions, and arising from a wholly outdated and thoroughly repugnant moralistic stance.

http://news.independent.co.uk/uk/politics/article3061121.ece

[QUOTE]Originally posted by judith yates:
Perhaps it would be Off licences? I don't prescribe alcohol or cigarettes, do I? I think it needs regularly re-visiting and debating at least.

Judith,
I would agree this needs regularly revisiting and debating. I wonder what will be our vision for the next ten years.