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Personal View International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 363–365
Beyond equivalence of care in prison pharmacy Khurshid Choudhry and Nicola Evans HMP Highdown, Sutton, UK
Keywords clinical pharmacy; clinical practice; drug misuse; inappropriate prescribing; pharmaceutical care Correspondence Mr Khurshid Choudhry, HMP Highdown, Highdown Lane, Sutton SM2 5PJ, UK. E-mail: [email protected] Received May 8, 2013 Accepted November 18, 2013 doi: 10.1111/ijpp.12089
Abstract Prison healthcare has undergone a significant transformation over recent times. The main aim of these changes was to ensure prisoners received the same level of care as patients in the community. Prisons are a unique environment to provide healthcare within. Both the environment and the patient group provide a challenge to healthcare delivery. One of the biggest challenges currently being faced by healthcare providers is the misuse and abuse of prescription medication. It seems that the changes that have been made in prison healthcare, to ensure that prisoners receive the same level of care as patients in the community over recent times, have led to an increase in this problem. Prison pharmacy is ideally placed to help reduce the misuse and abuse of prescription medication. This can be achieved by using the skills and knowledge of the pharmacy department to ensure appropriate prescribing of medication liable to misuse and abuse.
Introduction Prison healthcare has undergone a significant transformation over the last two decades. These changes aimed to give prisoners the same level of care as patients in the community.[1] This ideology has been termed the ‘the Principle of Equivalence’. To achieve this equivalence of care, healthcare services were transferred from the prison service to the National Health Service (NHS). Though the overall consensus is that these changes amounted to success, an argument exists that this ‘equivalence of care’ is not only inappropriate for the prison environment but may not lead to the desired outcomes.[2,3] Key to this argument is the detrimental effect the prison environment can have on a prisoner’s health. The prison setting is an environment associated with negative health outcomes that occur from factors that arise specifically from being imprisoned, including overcrowding, emotional stress, violence and illicit drug abuse.[4,5] This undermines the assumption that a healthcare service designed for the community setting could achieve the same results in the more complex and challenging prison environment. Also, the health status of the general population and the prison population differs greatly.[6] For example, 66% of male prisoners have used drugs in the previous year, compared with 13% in the general population. This raises the issue of whether a healthcare service that is designed for community patients could also meet the needs of prisoners. © 2014 Royal Pharmaceutical Society
Therefore,it would seem unlikely that a model of healthcare for patients in the community can achieve the same results in the prison population.By failing to take into consideration the unique characteristics of the prison environment and population, it could be detrimental to the prisoner’s health. Charles and Draper[3] gave the prescribing of opiates and drugs liable to abuse as an example of where following a community-based model of care may lead to undesirable outcomes. These drugs are sought after in prison for misuse and as currency to trade. They stated that: [T]aking all prisoners’ accounts of pain at face value and prescribing strong painkillers in response may not therefore be in every prisoner’s best clinical interests, as it may facilitate addiction and expose him/her to unnecessary side effects. Consequently, application of equivalent prescribing policy within and outside prison may have poorer outcomes for prisoner patients, exacerbating health inequalities. Though this statement was given as an example of what could happen, it may have now become the reality.
Misuse and abuse of prescribed medication in prison Last year, Nick Hardwick, the chief inspector of prisons, told the Times newspapers that the misuse and abuse of prescripInternational Journal of Pharmacy Practice 2014, 22, pp. 363–365
364
tion medication had spiraled out of control throughout the prison service.[7] He went further stating that general practitioners (GPs) in prison were being tricked into prescribing painkilling medication that was not needed, and often, these medications were being misused by the patient or being diverted and traded. These comments came about because of the findings of recent prison inspections, which highlighted various areas of concern with the misuse and abuse of prescription medication. An inspection[8] at one establishment found that a third of the prison population was on medication liable to misuse, and around 9% of the prison population had developed a problem with diverted medication since they had been at the establishment. Similar findings were observed in an inspection at another establishment,[9] where around 10% of patients had reported developing a problem with diverted medication, with a large number of patients on Tramadol, Gabapentin and Pregabalin. More importantly, the prison inspectorate has blamed the transfer of GP service from prison service to the NHS as one of the main causes. This suggests that medical practitioners may be failing to take into account the unique characteristics of the prison environment when making prescribing decisions, thus supporting the predictions of Charles and Draper.[3] Though the government[10] advocates prisoners having their medication in their possession, the administration of medicines liable to misuse and abuse should be supervised where possible. The issue of prescription drug abuse in prison is not new. The issue and the complexity are discussed in the document[11] ‘Safer Prescribing in Prisons’. This document is intended as a guide to help clinicians working in prison and other secure environments. It recognizes the shortcomings of using an equivalence approach within prison while at the same time recognizing that the role of prison is to rehabilitate and that a healthier state can be achieved by reducing use of illicit and prescribed medication. Though the document recognizes that prison is a complex environment, in its purest form, it is a risk management document as it identifies problems with prescribing drugs liable to abuse in prison, as well as strategies to minimize this risk. This is not to say that risk management strategies discussed do not play a significant role in reducing abuse and diversion of medicines liable to abuse; rather, they do not tackle the issue of drug abuse and drug-seeking behaviour. It must be remembered there will be prisoners who genuinely require these medications for their clinical condition. It would be unethical to reduce the prescribing of these drugs to prisoners who need them solely for the reason that they may be misused and abused by other prisoners. It may be that pharmacists can play a role in helping to solve this problem. © 2014 Royal Pharmaceutical Society
Beyond equivalence of care in prison pharmacy
Opportunity and challenges for pharmacy The misuse and abuse of prescription medications are ideal opportunities for pharmacists to effectively intervene. A dedicated prison pharmacy team will have the knowledge, skills and opportunity required to tackle the problem of prescription medication abuse in prisons. Delivery of a pharmacy service specific for the prison population will help to reduce the problems of prescription drug abuse and contribute towards improving the health outcomes of those patients being managed in secure environments. Pharmacists will use their knowledge of drugs liable to abuse to ensure they are prescribed and used appropriately. An example of this would be the development of specific national pain ladders to encourage appropriate use of analgesic medication. This would ensure consistency of care and help medical practitioners to treat their patients appropriately while taking into account the prison environment. This is important because of the transitory nature of the prison population. This could be achieved through collaborative working between pharmacies from different prisons. Locally, pharmacists can use their knowledge to increase the awareness of the problem among staff and prisoners. This could be achieved through establishing regular training events for staff and health promotion events for prisoners. Pharmacists should be involved in the setting up and running of multidisciplinary pain review clinics where their skills and knowledge of drugs of abuse in prisons can be used to perform detailed medication histories in order that each individual will receive the most appropriate treatment for their needs. The pharmacy team should be involved in ensuring medicines liable to misuse or abuse are supplied and administered in the most appropriate manner, for example, sourcing liquid formulations of medicines at high risk of being diverted. As the prison pharmacy department supplies medicines to prisoners, it is ideally placed to monitor which medicines are being prescribed, for whom and for what conditions. This data can be used locally to identify any trend or pattern that may raise concerns. Also, by using the network of prison pharmacists, important intelligence information can be passed between establishments to identify trends and raise alarms about possible new concerns of abuse of drugs. One of the biggest barriers to achieving the above is the difference in the levels of pharmacy service at different prisons. Some prisons have more community-based models, with the main role of the pharmacy to supply medicines. While some have a pharmacy service which is more clinically orientated and able to meet the unique needs of the prison environment. To overcome this obstacle, pharmacists involved in the International Journal of Pharmacy Practice 2014, 22, pp. 363–365
Khurshid Choudhry and Nicola Evans
365
delivery of care within prison will need to ensure that healthcare commissioners are aware of the need to commission pharmacy services which meets the specific needs of the prison environment. The problem associated with the misuse of prescription medication provides a challenge for both the prison authorities and healthcare within prison. Prisoners should not be made to suffer and denied treatment just on the basis of fear of substance misuse. This dilemma provides an ideal opportunity for prison pharmacy to demonstrate its importance in prison healthcare. This can be achieved by utilizing the knowledge and skills of the pharmacy department to
References 1. Joint Prison Service and National Health Service Executive Working Group. The Future Organization of Prison Healthcare. London: Department of Health, 1999. 2. Birmingham L et al. Prison medicine: ethics and equivalence. Br J Psychiatry 2006; 188: 4–6. 3. Charles A, Draper H. ‘Equivalence of Care’ in prison medicine: is equivalence of process the right measure of equity? J Med Ethics 2012; 38: 215–218. 4. Her Majesty’s Inspectorate of Prisons. Unjust Deserts: A Thematic Review of the Treatment and Conditions of Unsentenced Prisoners in England and Wales. London: Home Office, 2000. 5. Viggiani N. Unhealthy prisons: exploring structural determinants of prison
© 2014 Royal Pharmaceutical Society
provide a model of healthcare beyond that of the equivalence of care.
Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Authors’ contributions All Authors state that they had complete access to the study data that support the publication.
health. Sociol Health Illn 2007; 29: 115– 135. 6. Social Exclusion Unit. Reducing Re-offending by Ex-prisoners. London: Crown, 2002. 7. HM Chief Inspector of Prisons in England and Wales. Annual report 2011–2012. http://www.justice.gov.uk/ downloads/publications/corporatereports/hmi-prisons/hm-inspectorateprisons-annual-report-2011-12.pdf (accessed 8 January 2013). 8. HM Chief Inspector of Prisons. Report on an announced full follow-up inspection of HMP Wolds 2012. http:// www.justice.gov.uk/downloads/ publications/inspectorate-reports/ hmipris/prison-and-yoi-inspections/ wolds/wolds-2012.pdf (accessed 8 January 2013).
9. HM Chief Inspector of Prisons. Report on an announced inspection of HMP Ranby 2012. http://www.justice.gov .uk/downloads/publications/ inspectorate-reports/hmpipris/prisonand-yoi-inspections/ranby/ranby2012.pdf (accessed 8 January 2013). 10. Department of Health. A pharmacy service for prisoners. http://webarchive .nationalarchives.gov.uk/2013010710 5354/http://www.dh.gov.uk/prod _consum_dh/groups/dh_digitalassets/ @dh/@en/documents/digitalasset/dh _4065707.pdf (accessed 1 July 2013). 11. Royal College of General Practitioners and Royal Pharmaceutical Society of Great Britain. Safer prescribing in prisons: guidance for clinicians. Nottinghamsire Healthcare. 2011.
International Journal of Pharmacy Practice 2014, 22, pp. 363–365
Personal View International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, 22, pp. 363–365
Beyond equivalence of care in prison pharmacy Khurshid Choudhry and Nicola Evans HMP Highdown, Sutton, UK
Keywords clinical pharmacy; clinical practice; drug misuse; inappropriate prescribing; pharmaceutical care Correspondence Mr Khurshid Choudhry, HMP Highdown, Highdown Lane, Sutton SM2 5PJ, UK. E-mail: [email protected] Received May 8, 2013 Accepted November 18, 2013 doi: 10.1111/ijpp.12089
Abstract Prison healthcare has undergone a significant transformation over recent times. The main aim of these changes was to ensure prisoners received the same level of care as patients in the community. Prisons are a unique environment to provide healthcare within. Both the environment and the patient group provide a challenge to healthcare delivery. One of the biggest challenges currently being faced by healthcare providers is the misuse and abuse of prescription medication. It seems that the changes that have been made in prison healthcare, to ensure that prisoners receive the same level of care as patients in the community over recent times, have led to an increase in this problem. Prison pharmacy is ideally placed to help reduce the misuse and abuse of prescription medication. This can be achieved by using the skills and knowledge of the pharmacy department to ensure appropriate prescribing of medication liable to misuse and abuse.
Introduction Prison healthcare has undergone a significant transformation over the last two decades. These changes aimed to give prisoners the same level of care as patients in the community.[1] This ideology has been termed the ‘the Principle of Equivalence’. To achieve this equivalence of care, healthcare services were transferred from the prison service to the National Health Service (NHS). Though the overall consensus is that these changes amounted to success, an argument exists that this ‘equivalence of care’ is not only inappropriate for the prison environment but may not lead to the desired outcomes.[2,3] Key to this argument is the detrimental effect the prison environment can have on a prisoner’s health. The prison setting is an environment associated with negative health outcomes that occur from factors that arise specifically from being imprisoned, including overcrowding, emotional stress, violence and illicit drug abuse.[4,5] This undermines the assumption that a healthcare service designed for the community setting could achieve the same results in the more complex and challenging prison environment. Also, the health status of the general population and the prison population differs greatly.[6] For example, 66% of male prisoners have used drugs in the previous year, compared with 13% in the general population. This raises the issue of whether a healthcare service that is designed for community patients could also meet the needs of prisoners. © 2014 Royal Pharmaceutical Society
Therefore,it would seem unlikely that a model of healthcare for patients in the community can achieve the same results in the prison population.By failing to take into consideration the unique characteristics of the prison environment and population, it could be detrimental to the prisoner’s health. Charles and Draper[3] gave the prescribing of opiates and drugs liable to abuse as an example of where following a community-based model of care may lead to undesirable outcomes. These drugs are sought after in prison for misuse and as currency to trade. They stated that: [T]aking all prisoners’ accounts of pain at face value and prescribing strong painkillers in response may not therefore be in every prisoner’s best clinical interests, as it may facilitate addiction and expose him/her to unnecessary side effects. Consequently, application of equivalent prescribing policy within and outside prison may have poorer outcomes for prisoner patients, exacerbating health inequalities. Though this statement was given as an example of what could happen, it may have now become the reality.
Misuse and abuse of prescribed medication in prison Last year, Nick Hardwick, the chief inspector of prisons, told the Times newspapers that the misuse and abuse of prescripInternational Journal of Pharmacy Practice 2014, 22, pp. 363–365
364
tion medication had spiraled out of control throughout the prison service.[7] He went further stating that general practitioners (GPs) in prison were being tricked into prescribing painkilling medication that was not needed, and often, these medications were being misused by the patient or being diverted and traded. These comments came about because of the findings of recent prison inspections, which highlighted various areas of concern with the misuse and abuse of prescription medication. An inspection[8] at one establishment found that a third of the prison population was on medication liable to misuse, and around 9% of the prison population had developed a problem with diverted medication since they had been at the establishment. Similar findings were observed in an inspection at another establishment,[9] where around 10% of patients had reported developing a problem with diverted medication, with a large number of patients on Tramadol, Gabapentin and Pregabalin. More importantly, the prison inspectorate has blamed the transfer of GP service from prison service to the NHS as one of the main causes. This suggests that medical practitioners may be failing to take into account the unique characteristics of the prison environment when making prescribing decisions, thus supporting the predictions of Charles and Draper.[3] Though the government[10] advocates prisoners having their medication in their possession, the administration of medicines liable to misuse and abuse should be supervised where possible. The issue of prescription drug abuse in prison is not new. The issue and the complexity are discussed in the document[11] ‘Safer Prescribing in Prisons’. This document is intended as a guide to help clinicians working in prison and other secure environments. It recognizes the shortcomings of using an equivalence approach within prison while at the same time recognizing that the role of prison is to rehabilitate and that a healthier state can be achieved by reducing use of illicit and prescribed medication. Though the document recognizes that prison is a complex environment, in its purest form, it is a risk management document as it identifies problems with prescribing drugs liable to abuse in prison, as well as strategies to minimize this risk. This is not to say that risk management strategies discussed do not play a significant role in reducing abuse and diversion of medicines liable to abuse; rather, they do not tackle the issue of drug abuse and drug-seeking behaviour. It must be remembered there will be prisoners who genuinely require these medications for their clinical condition. It would be unethical to reduce the prescribing of these drugs to prisoners who need them solely for the reason that they may be misused and abused by other prisoners. It may be that pharmacists can play a role in helping to solve this problem. © 2014 Royal Pharmaceutical Society
Beyond equivalence of care in prison pharmacy
Opportunity and challenges for pharmacy The misuse and abuse of prescription medications are ideal opportunities for pharmacists to effectively intervene. A dedicated prison pharmacy team will have the knowledge, skills and opportunity required to tackle the problem of prescription medication abuse in prisons. Delivery of a pharmacy service specific for the prison population will help to reduce the problems of prescription drug abuse and contribute towards improving the health outcomes of those patients being managed in secure environments. Pharmacists will use their knowledge of drugs liable to abuse to ensure they are prescribed and used appropriately. An example of this would be the development of specific national pain ladders to encourage appropriate use of analgesic medication. This would ensure consistency of care and help medical practitioners to treat their patients appropriately while taking into account the prison environment. This is important because of the transitory nature of the prison population. This could be achieved through collaborative working between pharmacies from different prisons. Locally, pharmacists can use their knowledge to increase the awareness of the problem among staff and prisoners. This could be achieved through establishing regular training events for staff and health promotion events for prisoners. Pharmacists should be involved in the setting up and running of multidisciplinary pain review clinics where their skills and knowledge of drugs of abuse in prisons can be used to perform detailed medication histories in order that each individual will receive the most appropriate treatment for their needs. The pharmacy team should be involved in ensuring medicines liable to misuse or abuse are supplied and administered in the most appropriate manner, for example, sourcing liquid formulations of medicines at high risk of being diverted. As the prison pharmacy department supplies medicines to prisoners, it is ideally placed to monitor which medicines are being prescribed, for whom and for what conditions. This data can be used locally to identify any trend or pattern that may raise concerns. Also, by using the network of prison pharmacists, important intelligence information can be passed between establishments to identify trends and raise alarms about possible new concerns of abuse of drugs. One of the biggest barriers to achieving the above is the difference in the levels of pharmacy service at different prisons. Some prisons have more community-based models, with the main role of the pharmacy to supply medicines. While some have a pharmacy service which is more clinically orientated and able to meet the unique needs of the prison environment. To overcome this obstacle, pharmacists involved in the International Journal of Pharmacy Practice 2014, 22, pp. 363–365
Khurshid Choudhry and Nicola Evans
365
delivery of care within prison will need to ensure that healthcare commissioners are aware of the need to commission pharmacy services which meets the specific needs of the prison environment. The problem associated with the misuse of prescription medication provides a challenge for both the prison authorities and healthcare within prison. Prisoners should not be made to suffer and denied treatment just on the basis of fear of substance misuse. This dilemma provides an ideal opportunity for prison pharmacy to demonstrate its importance in prison healthcare. This can be achieved by utilizing the knowledge and skills of the pharmacy department to
References 1. Joint Prison Service and National Health Service Executive Working Group. The Future Organization of Prison Healthcare. London: Department of Health, 1999. 2. Birmingham L et al. Prison medicine: ethics and equivalence. Br J Psychiatry 2006; 188: 4–6. 3. Charles A, Draper H. ‘Equivalence of Care’ in prison medicine: is equivalence of process the right measure of equity? J Med Ethics 2012; 38: 215–218. 4. Her Majesty’s Inspectorate of Prisons. Unjust Deserts: A Thematic Review of the Treatment and Conditions of Unsentenced Prisoners in England and Wales. London: Home Office, 2000. 5. Viggiani N. Unhealthy prisons: exploring structural determinants of prison
© 2014 Royal Pharmaceutical Society
provide a model of healthcare beyond that of the equivalence of care.
Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Authors’ contributions All Authors state that they had complete access to the study data that support the publication.
health. Sociol Health Illn 2007; 29: 115– 135. 6. Social Exclusion Unit. Reducing Re-offending by Ex-prisoners. London: Crown, 2002. 7. HM Chief Inspector of Prisons in England and Wales. Annual report 2011–2012. http://www.justice.gov.uk/ downloads/publications/corporatereports/hmi-prisons/hm-inspectorateprisons-annual-report-2011-12.pdf (accessed 8 January 2013). 8. HM Chief Inspector of Prisons. Report on an announced full follow-up inspection of HMP Wolds 2012. http:// www.justice.gov.uk/downloads/ publications/inspectorate-reports/ hmipris/prison-and-yoi-inspections/ wolds/wolds-2012.pdf (accessed 8 January 2013).
9. HM Chief Inspector of Prisons. Report on an announced inspection of HMP Ranby 2012. http://www.justice.gov .uk/downloads/publications/ inspectorate-reports/hmpipris/prisonand-yoi-inspections/ranby/ranby2012.pdf (accessed 8 January 2013). 10. Department of Health. A pharmacy service for prisoners. http://webarchive .nationalarchives.gov.uk/2013010710 5354/http://www.dh.gov.uk/prod _consum_dh/groups/dh_digitalassets/ @dh/@en/documents/digitalasset/dh _4065707.pdf (accessed 1 July 2013). 11. Royal College of General Practitioners and Royal Pharmaceutical Society of Great Britain. Safer prescribing in prisons: guidance for clinicians. Nottinghamsire Healthcare. 2011.
International Journal of Pharmacy Practice 2014, 22, pp. 363–365
