Opioids in prison: can we reduce their use?

J Velasco Montes1, S González Díez2

1 Faculty of penitentiary health
2 Primary attention Doctor. La Rioja


To the Editor of Revista Española de Sanidad Penitenciaria:

In March 2016, Centers for Disease Control and Prevention (CDC) in Atlanta published the CDC Guidelines for prescribing opioids for chronic pain1. They gather quite thoroughly relevant aspects in prescribing this relevant pharmacological group. It is compulsory to acknowledge that opioids have proved effective in improving pain and functionality in neuropathic and non-tumor-related nociceptive pain in clinical trials of less than 12 weeks duration2, 3.

However, using opioids entails some unquestionably important and serious risks, moreover in the penitentiary setting, among which we can consider overdose and opioid use disorder. This is characterized by specific criteria among which there is a persistent desire or unsuccessful efforts to cut down or control opioid use resulting in a failure to fulfill major role obligations at work, school, or home4. In the scientific literature, this diagnosis is referred to as «abuse or dependency» or «addiction» and it differs from tolerance (markedly diminished effect with continuous use) and physical dependency (appearance of withdrawal symptoms when discontinued). Both entities can be present without a specific diagnosis of opioid use disorder. Moreover, surreptitious use of these medications can contribute to greater conflict in penitentiary settings.

In view of the aforementioned, we believe that we should consider the need for a more restrictive use of opioids for chronic pain in the penitentiary setting (tramadol and codeine in particular). Therefore, once aware of the importance of controlling unjustified use of this pharmacological group, we can assess what are the most effective measures to achieve this goal. We believe that, among others, the following measures should be implemented. First, all opioid prescriptions should automatically stop at three months if prescribed for chronic pain. This way we would count upon a rather «compulsory» window period and unnoticed prolongation of some treatments would be avoided (especially for inmates who are admitted to different prisons without a specific assessment on the duration of opioid prescription). Second, seizing the opportunity that the implementation of electronic prescription in Spanish prisons entails, we could introduce an automatic alert in case of surpassing a previously established dose range (eg. 150 mg /day of tramadol or equivalent). Third, with regard to prison pharmacists (if available) other measures should be implemented to control opioid prescription (for example, prescription lists that automatically alert health providers responsible for prescribing opioids). In essence, in view of the potential risks implied by an abusive use of opioids, measures should be implemented aimed at a more rational prescription.



Javier Velasco Montes



1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49.

2. Furlan A, Chaparro LE, Irvin E, Mailis-Gagnon A. A comparison between enriched and nonenriched enrollment randomized withdrawal trials of opioids for chronic noncancer pain. Pain Res Manag. 2011;16:337-51.

3. Guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. American Pain Society, American Academy of Pain Medicine Opioids Guidelines Panel. Chicago, IL: American Pain Society; 2009.

4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.


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