Clinical management of substance misuse. Current situation in prisons in England & Wales
D Marteau1, JR Pallás Álvarez2
1 Department of Health. HM Prison Service. Section Head: Substance misuse.
2 Servicio Médico. C.P. El Dueso.
ABSTRACT
In this work the current situation relating to the clinical management of substance misuse is revised, due to the explosion in drug problems within the criminal justice population in England and Wales Prisons. Self-harm and suicides are the most serious effects that make modified the global healthcare planning. At the last years guidelines to opioid substitution regimes prescribing in prisons have provided. Although almost all prisons provide Naltrexone and psychological support programs, methadone treatment is still rarely available in prisons, Harm Minimisation programs, needle exchange specially, are still from evaluation.
Key words: Substance Misuse, Injecting Drug Users, Prison, Evaluation Studies.
Although there are no existent published studies regarding this subject, the differences among Spanish and England prisons are significant. Number and percentage of users of drugs in England and Wales prisons are greater, and the management of substance misuse is conditional on policy restricted in relation to Harm Minimisation1.
The past ten years or so have seen an explosion in drug problems within the criminal justice population in English and Welsh Prisons. This growth has been felt particularly sharply by staff working in the prison service. In 1993/94, a total of 2,300 clinical treatments for drug withdrawal (that is to say, detoxifications) were reported2. In 2003/04 the number of detoxifications reported was 57,891: a 25-fold increase in a decade.
A total of around 140,000 people are sent to the prisons of England and Wales each year, which means that a substantial minority (approximately 40%) of prisoners arrive in prison dependent on drugs. Among female prisoners, this ratio is even greater3. Many offenders will have been using a range of drugs, such as amphetamines, ecstasy, cocaine, crack cocaine and cannabis but none of these drugs causes marked physical dependence. The 57,000 treatments were therefore prescribed to offenders addicted to heroin, or benzodiazepines, or both of these.
The busier prisons such as HMP Leeds, HMP Pentonville and HMP Holloway each now provide clinical management to more than 2,500 patients per annum. Extended in-depth assessments may be wholly impractical in a prison healthcare department that has to screen, assess and initiate treatment plans for as many as 20 drug-dependent patients in a day. 40% of these patients will be regular injecting drug users, of whom many will have a complexity of physical, psychological and social needs. Some of these needs will be substantial (deep vein thromboses, type 1 diabetes, schizophrenia, special learning needs, histories of serious self-harm or withdrawal seizures). The range and severity of health problems experienced by drug users mean that the screening, assessment and referral processes must be extremely efficient, and prisons have developed systems that are both precise and brisk.
The great majority of clinical substance misuse work is carried out in the 50 or so ‘local’ prisons that take offenders directly from the court. Most other prisons operate as longer-stay secondary establishments, taking in prisoners by an internal transfer from a local prison where they have already been detoxified.
There is a frenetic pace to the clinical work in any local prison. A fast-moving conveyor belt of faces, files and urgent health problems makes the loss of vital clinical information or the confusing of identities a real risk, with potentially tragic implications.
So the clinical imperative to first do no harm is central to the method that each clinical team has evolved in their respective prison. This safety-first approach is most clear in the clinical use of methadone prescribing. Average doses tend to be lower than those prescribed in the community. Although all prisoners who declare a heroin problem are given a test to establish that they have opiates in their system, this is not categorical proof of physical dependence on heroin, so a cautious response is required, particularly as the opportunity to monitor any patient is severely limited by a locked cell door. Stabilisation is undertaken, therefore, at a conservatively paced dose induction, in increments of 10 mg, with at least 6 hours between each dose.
The Prison Health department recommended ceiling dose is 40 mg per day, an amount that would prove inadequate for the same patient in the community but, as a consequence of the diminished appetite for heroin many offenders experience in prisons, it is quite effective in this environment4.
The two largest challenges faced by clinicians in this area of prison work are:
- A growing rate of suicide in prison with an apparent correlation between suicidal intent and drug withdrawal.
- A high rate of fatal overdose in the first week of release from prison.
Both of these worrying problems present opportunities for beneficial clinical intervention.
SUICIDE AND DRUG WITHDRAWAL
The greatest risk to prisoner wellbeing occurs in the first few weeks of custody. This is a time of highest vulnerability to self-harm and suicide. It is also a period when many prisoners are withdrawing from a variety of street drugs. The experience of capture and incarceration can lead to profound regret and anxiety. When these uncomfortable emotions are coupled with the negative psychological effects of drug and alcohol withdrawal, the risk of impulsive regrettable action grows.
Evidence gained from a retrospective study carry out by the Department of Health carry out in 2003, of the 172 self-inflicted deaths in prisons in the years 1999-2000 revealed that a third of all these deaths occurred in the first week of imprisonment5. The most common clinical diagnosis of those who died was drug dependence. Perhaps as a consequence of the duress caused by withdrawal, drug-dependent prisoners were found to be at particular risk of suicide in the first week of imprisonment (figure I). Of the 172 deaths, forty-six (32%) had a secondary mental health problem (i.e. ‘dual diagnosis’). This figure indicates that prisoners with a combination of drug dependence and a serious mental health problem are particularly vulnerable to suicide and other self-inflicted harm.
A Prison Service internal review of prevention of suicide and self-harm in prisons published the previous year also identified drug withdrawal as a factor that contributes to risk of self-destructive actions6. The review included the recommendation that: "The Prison Service should pay special attention to the safe management of prisoners in the early stages of custody in a prison, with a focus on excellence of care for all prisoners in reception, first night, induction and detoxification units".
Experience gained from professional practice in individual prisons supports the notion that there is a correlation between drug withdrawal and suicide in the early days of custody. Stimulant withdrawal (often from crack cocaine) is a growing part of this problem.
To reduce these risks deeper and more co-ordinated services for offenders with a drug problem entering prison are being developed. These enhanced services include specialist first night centres, rapid assessment for drug problems and referral to residential clinical management units. These units provide active withdrawal management prescribing that accords with national and international good practice, and a varied range of harm minimisation and psychosocial interventions for up to and beyond 28 days. There are six prisons piloting this safer custody approach (Birmingham, Eastwood Park, Feltham, Leeds, Wandsworth and Winchester) and the results from an evaluation by Cambridge University will inform future developments in this critical area of drug treatment.
As a separate but related initiative, the Prison Health department has drafted a document that gives guidance on the management of patients with both substance misuse and serious mental health problems (‘dual diagnosis’). This dual diagnosis guidance will be issued as a companion to a new good practice guide to clinical substance misuse management in prisons7. These documents will make provision for extended opioid prescribing regimes for this vulnerable client group, in line with approaches recommended by the Department of Health for England and the Royal College of Psychiatrists8.
FATAL OVERDOSE
With regard to the risks of fatal overdose in the first few days of freedom, a Home Office study9, of 12,438 prisoners discharged in June and December 1999, 79 drug-related deaths were recorded in the study period up to 31 January 2001. Thirteen of these deaths happened in the first week after release, at a ratio 8 times greater than the annual mean average for this cohort, and 40 times greater than the mortality rate for the general population (figure II).
Loss of tolerance to opiates following withdrawal in prison appeared to be a major contributing factor. Put simply, this means that an injection of heroin that would barely make an addicted drug user feel sleepy, can kill that same drug user if he or she has not used any heroin for four days or more. The report’s authors recommended that methadone maintenance should be trialled in prisons as a means to preserving opiate tolerance and thereby lowering overdose risk during post-release celebration. Additionally, the option of the initiation of naltrexone treatment prior to discharge from prison represents a potential protection to those patients who have become heroin-free in prison and would like clinical assistance in remaining so as they face up to life on the outside.
Methadone or buprenorphine maintenance treatment is rarely available in prisons, although there is a greater provision of methadone maintenance in female prisons3. This situation is about to change, through a major programme that will make opioid substitution programmes available in all prisons.
For the majority of opiate dependent prisoners, however, detoxification is currently the standard clinical intervention. Recent evidence of the effectiveness of maintenance (i.e. longer term prescribing programmes using one of two heroin substitutes, methadone or buprenorphine) drawn from clinical prison research in Spain, Australia, Canada and France10-13, has led to the drafting of new clinical guidance that facilitates far greater access to extended substitution prescribing. International evidence suggests that this intervention can have a beneficial impact on both health and offending.
ASSESSMENT
To manage the risk of self-harm and suicide engendered by the combined negative impact on mood caused by incarceration and the physical and psychological discomfort of drug withdrawal, it is preferable to assess and begin treatment at the earliest opportunity.
Assessment begins in the first evening of arrival into prison, with the on-site clinical testing of oral fluid or urine for metabolites of the major street drugs. No prescribed management of opiate or benzodiazepine dependence is begun without a positive result unless there are overt signs of withdrawal from either substance.
DETOXIFICATION
Once an adequate assessment has been undertaken prescribed management begins. Prisons aim to initiate treatment at the earliest opportunity to restrict the development of withdrawal symptoms. This is a greater imperative in prisons as supply of heroin is generally less constant. As noted earlier, uncontained withdrawal symptoms are regarded as potentially contributing to risks of suicide and serious self-harm.
A standard opiate detoxification programme lasts for ten days, but this is set to be increased to a minimum of 14 days to accord with the English National Treatment Agency’s standard. Additional medication is prescribed to manage residual withdrawal symptoms.
LOCATION
Until recently patients undergoing clinical withdrawal management have ordinarily been accommodated in cells throughout the landings and wings of a remand prison. More recently there has been a move towards the opening of residential withdrawal management units. These are prison landings of between 10 and 100 cells that have been converted to assist the safer management of drug-dependent patients. Withdrawal management units have a blend of clinical and non-clinical drug workers and prison officers; many of these officers work in these extremely busy units as a matter of personal and professional preference. The staff builds up a core of expertise which has a beneficial effect on patient care.
PSYCHOSOCIAL PROGRAMMES
Offenders in all of the 138 prisons in England and Wales have access to the CARAT (Counselling, Assessment, Referral Advice and Throughcare) service, which acts as a case management service, providing entry to a range of structured treatment interventions14. These services can be summarised as:
• CARAT support – group work and individual counselling.
• Short-duration psycho-social treatment programmes for individuals who are only in prison for a brief time.
• Intensive rehabilitation programmes for those able to participate actively in longer-term abstinence-based treatment.
• Close co-ordination with any ongoing clinical treatment.
• Harm minimisation advice prior to release.
• Input to release planning, including through care to services on release, for clients who require it.
FURTHER CLINICAL WORK
Blood-borne virus testing is available in many prisons, either offered by the in-house staff or by visiting genitourinary clinicians. A Hepatitis B vaccination programme, which began in 2001, was expanded to include all prisons accepting prisoners directly from court15. Sixty-five prisons are currently participating in the programme with increasing success. Between April 2003 and May 2004, over 16,300 prisoners received one or more doses of hepatitis B vaccine and over 30,800 doses of vaccine were administered. 7684 prisoners completed the vaccination programme by receiving a 3rd dose of vaccine. The number of prisoners vaccinated continued to increase throughout the year. Each month, an average of 1892 prisoners received at least one dose of vaccine. This increased from 1369 prisoners in May 2003 to 2480 in March 2004.
Naltrexone is available in over a third of prisons in England and Wales. As many offenders take the opportunity to largely abstain from drugs while they are in prison, the approach of liberty can cause anxieties about a relapse to heroin dependence. Many prisoners regard naltrexone as a means to protection against this susceptibility. The drug cannot alone keep a client safe from further destructive use12, but when used as part of a supportive resettlement plan, involving specialist help, it represents a useful clinical option for the days or weeks that precede release. Urine or oral fluid drug screens and liver functioning tests are a prelude to any initiation of treatment.
Prisons present a unique opportunity for further clinical work with a hard-to-reach client group. The greatest health hazard to offenders in the middle months or years of their stay in prisons comes via the sharing of injecting equipment. It is commonly reported by injecting drug users that they reduce or discontinue drug use during their stay in prison, taking the opportunity to give their bodies and mind a break from the punishing effects of maintaining a serious drug habit. The reasons for this are unclear, but may be related to the more structured regime and greater scrutiny of prisons. This reduction in drug use goes some way to explaining the very low HIV rate (0.5%) among injecting drug users in our prisons16.
The Prison Health department has instigated a programme that will make sterilising tablets available across all prisons, the function of which will be to facilitate the cleansing by prisoners of illicit injecting equipment. Needle exchange is not currently available in any prison in England and Wales. In 1996 the Advisory Council on Drug Misuse concluded that needle exchange in prisons was not a practical proposition2. The Council subsequently adjusted its position by stating that17: ‘If studies currently underway demonstrate a high rate of hepatitis C transmission in prison, a fresh initiative may be needed in this area’.
In conclusion, today there are many opportunities into English prisons for the inclusion the policy designed to alleviate the problem, related to needle sharing. The inclusion of Harm Minimisation programs all English prisons could be an opportunity that at first will reduced the number of suicides and fatal overdoses, and indicate the accessibility to longterm (especially by methadone maintenance programs) to preventive programs (I.E. vaccination), such as has been in Spanish Prisons18.
REFERENCES
1. Pallás Álvarez, JR. Harm Minimisation in Spanish Prisons. In: First National Conference of the Clinical management of Substance Misuse in Prisons. London, 14TH October, 2004.
2. Home Office. Advisory Council on the Misuse of Drugs. Drug Misusers and the Prison Service – an Integrated Approach. Home Office, London, 1996.
3. Palmer J. Detoxification in prison. Nurse to Nurse 2002; 3:2.
4. Department of Health. PSO 3550, Standard for the clinical management of substance misuse. Health Management Prison Service, London, 2000.
5. Shaw J, Appleby L, Baker A. National Study of Prison Suicides 1999 –2000. Department of Health, London, 2003.
6. Health Management Prison Service. Prevention of suicide and self-harm in the Prison Service, an internal review. Department of Health, London, 2001.
7. Department of Health. Mental Health Policy Guide: Dual Diagnosis. Good Practice Guide. Department of Health, London, 2002.
8. Department of Health. Co-existing Problems of Mental Disorder and Substance Misuse (dual diagnosis): An Information Manual. Royal College of Psychiatry Research Unit. London, 2002.
9. Singleton N, Pendry E, Taylor C et al. Drug-related mortality among newly released offenders. Home Office Online Report Series, 2003. www.homeoffice.gov.uk/rds/pdfs2/r187.pdf
10. Pallás JR, López A (1998). Modificación de las prácticas de riesgo tras la inclusión en un programa de mantenimiento con metadona. II Congreso de Sanidad Penitenciaria. Barcelona, noviembre de 1998.
11. Dolan KA, Shearer J, MacDonald M, Mattick RP, et al. A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system. Drug & Alcohol Dependence 2003; 72: 59-65.
12. Tucker TK, Ritter AJ. Naltrexone in the treatment of heroin dependence: a literature review. Drug & Alcohol Review 2000; 19: 73-82.
13. Levasseur L, Marzo J-N, Ross N et al. Frequency of re-incarceration in the same detention center: role of substitution therapy. A preliminary retrospective analysis. Ann. Med. Interne 2002; 153: 14-19.
14. Health Management Prison Service. House of Commons Home Affairs Select Committee. Review of drug policy. The Stationery Office, London, 2002.
15. Department of Health. Annual report of the Unlinked Anonymous Prevalence Monitoring Programme. Prevalence of HIV and Hepatitis Infections in the United Kingdom. Department of Health, London, 2001.
16. Weild AR, Gill ON, Bennett D, et al. Prevalence of HIV, hepatitis B and hepatitis C antibodies in prisoners in England & Wales: a national survey, Commun. Dis. Public Health 2000; 3: 121-126.
17. Home Office. Advisory Council on the Misuse of Drugs. Reducing Drug-Related Deaths. Home Office, London, 2000.
18. Pallás Álvarez JR, López Sánchez A, Llorca J. Fourth Conference of hepatitis and AIDS in prison. Workshop 6: "Adherence to Prevention Programmes in a Spanish Prison among Methadone Users". Lisboa, March 2001.
CORRESPONDENCE
David Marteau
Prison Health. Section Head: Substance Misuse
Room 111 Wellington House
133-155 Waterloo Road
London SE1 8UG. England
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