Art & science prison nursing

Prescribing in prison: complexities and considerations Phillips A (2014) Prescribing in prison: complexities and considerations. Nursing Standard. 28, 21, 46-50. Date of submission: October 14 2013; date of acceptance: October 28 2013.

Abstract Prescribing in prison is challenging because of environmental constraints, drug-seeking behaviour and the potential for drug trafficking. Risk management is, therefore, a fundamental part of the non-medical prescriber’s role as he or she attempts to balance health needs with security requirements. This article highlights the need for an insightful, yet impartial, approach to prescribing for offenders.

Author Amanda Phillips Lead nurse, Isle of Man Prison Healthcare, Isle of Man. Correspondence to: [email protected]

Keywords Drug misuse, offender health, prescribing, prescription drugs, prison nursing, risk-taking behaviour, vulnerable people

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.

PRISON IS A HARSH environment where, because of limited supplies, everyday commodities acquire a value markedly greater than they have in the community. Prescription drugs are not exempt from this and the pressure to obtain saleable medication while in custody often results in bullying, feigned illness and deceit. A crucial role of the healthcare professional is to protect patients from this internal drug culture, for which they require the skills to differentiate between individuals with genuine needs and those engaging in drug-seeking behaviour. A high proportion of offenders have a history of prescription and/or illicit drug misuse. Her Majesty’s Inspectorate of Prisons (HMIP) (2011) revealed that 50% of offenders in the Isle of Man had drug problems on entry to prison and 20% of offenders

developed a drug problem while in custody (Box 1). More vulnerable offenders, such as those imprisoned for the first time or individuals with mental health problems, may use drugs to find a way of being accepted by their peers or escaping the difficult conditions experienced in prison (Stewart 2007). Any form of substance misuse has associated risks and increased mortality rates, and government statistics attributed a total of 1,496 deaths to drug misuse in England and Wales in 2012 (Office for National Statistics 2013). Hence, the dangers of drug use along with addicts’ known propensity for risk-taking behaviour should be at the forefront of the healthcare professional’s mind when prescribing in the prison environment. Offenders need safeguarding from their own actions and the actions of their peers. Bullying is endemic in prison, and vulnerable detainees often succumb to other, more forceful offenders. Ireland (2002) links a high proportion of victimisation to prison-enforced material deprivation, citing it as promoting a capitalist economic structure, which in turn increases predatory behaviour. Her Majesty’s Prison Service does not condone any form of victimisation and strives to provide an environment where all offenders are safe and where ‘detainees at risk or subject to victimisation are protected through active and fair systems known to staff and detainees’ (HMIP 2012). However, HMIP (2013a, 2013b, 2013c, 2013d) press releases for September 2013, for example, highlight varying degrees of bullying at four of five establishments recently inspected, inferring that although there is departmental commitment to addressing the behaviour, victimisation remains a significant problem in prisons. Detainees new to the prison environment are often targeted for their medication by veteran peers. New detainees who do not take medication may be coerced into feigning illness to obtain specific drugs, which can then be given to those responsible for the coercion. It is important that healthcare professionals pay attention to any prison intelligence that may suggest that an individual has been coerced into lying. Prescribing practitioners must, therefore, be aware of the signs which can indicate this type of bullying, such as:

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A patient requesting a drug by name before describing his or her symptoms to the doctor or nurse. A patient’s demeanour and clinical observations not substantiating his or her alleged symptoms. A patient’s excessive distress at not being prescribed a specific drug, possibly resulting in threats and/or requests for an appointment with a different healthcare professional. Improved prison security measures are designed to reduce the likelihood of illicit substances being brought into the custodial environment. Although this has probably reduced the amount of illegal drug importation, the desire for the psychotropic effects of drugs has not diminished and has resulted in increased demand for prescription medication (Kirwan-Taylor 2013). Trading of legal drugs is no less perilous than trading of illegal drugs, and may be associated with the risk of individuals accumulating debts that might result in significant risk to personal safety as well as to the patient’s physical and mental wellbeing (Royal College of General Practitioners (RCGP) 2011).

Prescribing in the prison environment To determine legitimate from feigned illness, the nurse practitioner should remain impartial and treat each case individually. A considerable section of the V300 Non-Medical Prescribing course aims to provide healthcare professionals with the necessary skills to establish whether an illness or condition warrants prescription medication (University of Chester 2013). The World Health Organization (1994) states that inappropriate prescribing leads to ineffective and unsafe treatment, often exacerbating or prolonging illness, and resulting in unnecessary distress to the patient. Indiscriminate prescribing also has a negative effect on the UK’s spending on drugs, which was £8.81 billion in England alone in 2011 (Taylor 2012). There are several factors that influence prescribing in any clinical setting, and patient adherence is significant. Studies reveal a high prevalence of medicine non-adherence, with 30-50% of all prescribed drugs not taken as recommended by the nurse or doctor (Felzmann 2012). Intentional non-adherence in prison may be as a result of the patient not being prescribed what he or she was hoping for, for example being prescribed beta blockers for anxiety instead of benzodiazepines. Conversely, unintentional non-adherence may occur as a result of misunderstanding if the nurse or doctor fails to adequately explain the patient’s treatment. Expecting offenders to follow written

instructions or read up on a particular drug may prove problematic given that 60% of the prison population has problems with basic literacy skills (Clark and Dugdale 2008). This should be acknowledged throughout the consultation, with the directions, effects and side effects of each prescribed drug being explained to the patient. There are additional factors that must be taken into consideration when prescribing in a prison environment, such as the misuse potential of the drug, its excipients and its pharmaceutical form.

Medication supplied in glass bottles

Shards of broken glass may be used as weapons. Medication supplied in bottles should, therefore, be avoided in prison. Often, a similar product is available in more appropriate packaging, such as plastic. Alternatively, if a specific drug is required that is only supplied in glass bottles, the medication must be retained by healthcare professionals and the patient must attend the healthcare department for administration of the drug.

Aerosol sprays

With the exception of respiratory inhalers, aerosol sprays are not allowed in prison settings because of their potential to be used as a fire accelerant or an incapacitant, for example if sprayed in the eyes.

Rubefacients

Rubefacients, such as capsaicin, are thought to relieve musculoskeletal pain by increasing blood flow to the affected area. They are also capable of causing transient irritation of

BOX 1 Isle of Man Prison Isle of Man Prison holds up to 138 remand and convicted offenders, of both sexes, aged 18 and older. It roughly equates to a category B establishment, housing individuals charged with crimes of varying degrees of severity for whom the highest levels of security are not necessary but escape must be made difficult. Responsibility for prison healthcare provision was transferred to the Department of Health’s primary care sector in 2007, having previously been under the remit of the prison. Patients have access to visiting GPs for six hours per week and access to psychiatric, dental, and drug and alcohol team services once per week. The healthcare team consists of five nurses and one paramedic and provides both a generic and a specialised role. Although the work can be demanding, support and advice is provided by colleagues in primary care as well as prison management. The author, a nurse prescriber, also receives guidance from the island’s lead nurse for non-medical prescribing, who was responsible for introducing the role of the non-medical prescriber to the Isle of Man and now takes responsibility for the recruitment and monitoring of non-medical prescribers. The ethos of the healthcare team is to ensure that patients, irrespective of their misconduct, have the same access to health opportunities and healthcare treatment in prison as they would in the community.

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Art & science prison nursing BOX 2 Objectives of mandatory drug testing in prison  To increase significantly the detection of those misusing drugs and to send a clear message to all offenders that if they misuse drugs they have a greater risk of being caught and punished.  To help offenders to resist the peer pressure often placed on them to become involved in drug taking, because of the increased possibility of detection.  To help to identify offenders who may need assistance to combat their drug problems, with assistance offered to those who want it.  To provide, by means of the random drug testing programme, more accurate and objective information on the scale, trends and patterns of drug misuse, allowing prisons to manage and target more effectively their resources for tackling drug problems.  To enable the proportion of offenders testing positive for different drug types on the random drug testing programme to be used as one performance indicator of drug misuse.

offenders to provide a urine sample for drug testing as part of an effort to combat prison drug use (Her Majesty’s Prison Service 2007) (Box 2). Therefore, healthcare professionals should be aware of the implications of prescribing medication that may influence the outcome of mandatory drug testing. Codeine is particularly problematic in this instance, and often offenders who have been using heroin will ask for codeine-based medication to mask their illicit drug use. Requests may be made for branded medication, such as Migraleve, or over-the-counter drugs known to contain traces of codeine.

Intimidation of healthcare professionals

Healthcare professionals in prison must consider the ingenuity of offenders when prescribing medicine containing alcohol. Detainees are renowned for their attempts at brewing alcohol and some might use any alcohol-based product to augment their concoction. Ethanol-based antibacterial hand gel issued to offenders in Dorset during the 2009 swine influenza outbreak was promptly withdrawn when it was discovered that prisoners were swallowing the gel rather than using it for its intended purpose (BBC News 2009). Caution should, therefore, be exercised when providing mouthwash following dental procedures or treatment for constipation (sodium picosulfate liquid contains 96% ethanol) (eMC 2013).

The healthcare professional’s ability to withstand coercion and refrain from prescribing medication under duress is very important. Some offenders will attempt to intimidate prescribers, hoping they will eventually capitulate and prescribe drugs to placate rather than for clinical necessity. Although any form of intimidation can prove disconcerting for the healthcare professional, he or she should only provide a prescription where there is a genuine clinical need and in accordance with Nursing and Midwifery Council (2006) guidelines. Substantial pressure may be placed on the healthcare professional to provide prescriptions for drugs popularly misused, such as diazepam, pregabalin and codeine because these have significant value in prison (RCGP 2011). All medication prone to misuse must be taken in front of healthcare staff. However, some patients still manage to secrete their tablets or capsules for distribution among fellow detainees. Any threats made to the healthcare professional should be reported to the prison security department and dealt with accordingly. This sends a message to other offenders that attempts to obtain drugs using menace will not be tolerated. Detainees new to the prison who have been engaging in illicit drug activity should have their urine tested before any drug replacement therapy is considered. Urine tests alone cannot provide definitive indication to prescribe, and drug replacement therapy in the form of dihydrocodeine or methadone should only be considered if a positive urine test is accompanied by objective signs of withdrawal such as diaphoresis, runny eyes and nose, gastrointestinal upset, and increased pulse and blood pressure (Knott 2012).

Mandatory drug testing

Trends in prescription drug misuse

Mandatory drug testing was introduced to prisons as part of the Criminal Justice and Public Order Act 1994. It gives penal institutions the power to require

Keeping abreast of emerging trends is of importance in safeguarding patients from the effects of prescription drug misuse. Information

(Her Majesty’s Prison Service 2007)

the mucous membranes if rubbed in the eyes (electronic Medicines Compendium (eMC) 2011). Rubefacients may be used to incapacitate officers or prisoners, and are best avoided in the prison setting.

Nicotine gum

The Isle of Man Prison is smoke-free, and patients are issued nicotine replacement therapy in the form of patches or lozenges. Gum is excluded from the nicotine replacement therapy formulary used in the prison because of the potential for aggrieved offenders to force the gum into keyholes, thus disabling the locks. This represents a serious security threat by creating a malfunctioning lock, and incurs considerable financial costs in replacing the locks.

Products containing alcohol

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on trends can be obtained from numerous sources, including police, probation staff, the drug and alcohol team, prison staff, and even detainees themselves. The local primary care prescribing committee also provides an excellent forum through which vital information can be disseminated and acted on. Prescription drug misuse and its associated dangers have resulted in prohibition being seen as the best means of controlling the problem in the past. One example of this is the hypnotic drug temazepam whose introduction in gelcap format in the early 1990s was to prove hazardous to individuals injecting drugs (Wilce 2004). Temazepam tablets have always been popular among intravenous drug users as a means of offsetting the stimulant effects of drugs such as amphetamines and cocaine (Wilce 2004). But then users discovered that the gelcap contents became liquefied on heating and were easier to inject. However, they were not aware that the gel re-solidified at body temperature, often resulting in occlusion of the vessels and necessitating distal limb amputation (Wilce 2004). In response to this danger, temazepam gelcaps were withdrawn from the UK pharmaceutical market in October 1995 (Parliament UK 1995).

adapted to ensure that the prescription of medication in prison remains appropriate and safe. This can be carried out by focusing on a series of environment-specific areas:

1. Consider the patient

Ask the following questions: Is the detainee likely to have been bullied into obtaining medication for others? Is there any intelligence to suggest the patient may be feigning illness to obtain drugs to misuse? Does the patient have a history of drug misuse or drug-seeking behaviour? Is the patient new to the prison environment? If the patient engages in risk-taking behaviour, have health promotional opportunities been exploited? For example, has the patient been offered blood tests or hepatitis B immunisation?

2. Which strategy?

Ask the following questions: Should the patient be referred to the prison GP or drug and alcohol doctor? Can the problem be addressed without the need for a prescription, for example by referral for relaxation therapy or consultation with a mental health practitioner?

3. Consider the choice of product

Guidance for the prescriber Safer Prescribing in Prisons (RCGP 2011) offers valuable advice for nurses and doctors working within the criminal justice system. A traffic-light system provides guidance and highlights common prescription drugs as being: Safe for use within the prison environment. Suitable for short-term use with caution. Unsuitable for use because of the potential for misuse, or known lethality in overdose. For example, known drugs of misuse such as dihydrocodeine and benzodiazepines as well as the antidepressant amitriptyline which is known to have cardiotoxic properties in overdose (RCGP 2011). The RCGP (2011) also provides practical advice to help prevent the medication being passed to others for whom the initial prescription was not intended. The advice covers prescribing drugs in liquid or orodispersible form or using modified-release medication to reduce the amount of tablets being issued. In addition, non-medical prescribers should not underestimate the importance of more fundamental guidance, such as the National Prescribing Centre’s (1999) prescribing pyramid, and associated seven principles (Figure 1). The prescribing pyramid can be

Ask the following questions: Is the medication suitable for prescription in prison? For example, is the medication on the list of prohibited substances? Is the product suitable for the prison setting? For example, is the medication in a plastic container as opposed to glass? Is the medication likely to cause dependence? This is especially important if the patient has a history of substance misuse.

FIGURE 1 National Prescribing Centre’s prescribing pyramid Reflect

7 6

Record keeping Review

5 4 3 2 1

Negotiate a contract Consider the choice of product Which strategy? Consider the patient

(National Prescribing Centre 1999)

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Art & science prison nursing 4. Negotiate a contract

Ask the following questions: If medication cannot be placed in the possession of the prisoner, is he or she aware of the importance of attending the drugs round on a regular basis? Does the patient understand fully the effects and side effects of the prescribed medication?

5. Review

Ask the following question: Have arrangements been made to ensure that the patient is available for a review, for example is he or she in court or expected to be released?

6. Record keeping

Ask the following questions: Have accurate entries of initial assessment and subsequent reviews been made on the patient’s electronic medical record? Have drugs with the potential for interfering with mandatory drug testing been appropriately highlighted? They may still be prescribed.

7. Reflect

Ask the following questions: Was prescribing influenced by mistrust? If so, was caution justified?

Was the patient treated with the same impartiality as an individual in the community? It can be beneficial to discuss the outcome of consultations with non-medical prescribers who do not work in a custodial environment. Reflective practice is encouraged in prisons because of the risk of the healthcare professional becoming overly suspicious or desensitised, and particularly when dealing with the needs of individuals renowned for their mendacity. Prejudice in any clinical environment is both unethical and deleterious, and increases the likelihood of misdiagnosis or suboptimal patient care.

Conclusion Prescribing in prison is not simply about treating illness, it is a complex approach to managing risk in an environment where there are altered values and needs. The role of the healthcare professional is pivotal in safeguarding patients’ wellbeing by determining and addressing their genuine needs, actively promoting good health and exercising caution when prescribing. It is a role that involves protecting vulnerable individuals from their peers, their surroundings and themselves NS

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National Prescribing Centre (1999) Signposts for Prescribing Nurses – General Principles of Good Prescribing. tinyurl.com/ 9ejoqw9 (Last accessed: December 31 2013.) Nursing and Midwifery Council (2006) Standards of Proficiency for Nurse and Midwife Prescribers. tinyurl.com/ojoj446 (Last accessed: December 31 2013.) Office for National Statistics (2013) Deaths Related to Drug Poisoning in England and Wales, 2012. www.ons. gov.uk/ons/dcp171778_320841.pdf (Last accessed: December 31 2013.) Parliament UK (1995) House of Lords: Column 663. Temazepam.

Taylor L (2012) NHS England Drugs Bill Falls as Patents Expire. tinyurl.com/d8qrub7 (Last accessed: December 31 2013.) University of Chester (2013) Programme Specifications. Non-Medical Prescribing (Level 7) 2011-2012. tinyurl.com/q9s8zsv (Last accessed: December 31 2013.) Wilce H (2004) Temazepam Capsules: What was the Problem? tinyurl.com/np2cbud (Last accessed: December 31 2013.) World Health Organization (1994) Guide to Good Prescribing – A Practical Manual. tinyurl.com/obel5va (Last accessed: December 31 2013.)

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Prescribing in prison: complexities and considerations.

Prescribing in prison is challenging because of environmental constraints, drug-seeking behaviour and the potential for drug trafficking. Risk managem...
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