Because this chapter includes many classes of medication that are sedative and/or addictive and/or dangerous in overdose, particular care is required in prescribing.

 
A good protocol agreed and consistently applied by the clinical team will lead to improved patient care and improved patient safety. The clinical team will also have more time and resources to direct to the clinical needs of its patients by reducing inappropriate requests for medication.

4.1 HYPNOTICS

All hypnotics are highly sought and abused or traded in prisons because of their effects on GABA pathways.

The ability to ‘sleep away your sentence’ is highly prized.

Benzodiazepines are frequently abused/misused or traded and so are not suitable for prescribing within prisons, unless as part of a supervised benzodiazepine withdrawal programme.

The Z- drugs are also frequently traded/abused both as ‘street’ drugs or within prison and so are not suitable for prescribing unless as short-term emergency treatment.

It is possible to place someone on a ‘sleep watch’ to check how badly they are sleeping in the first instance, before instigating any therapy.

Suitable alternatives are non-drug therapy as first-line treatment in most cases and the introduction of sleep clinics may be useful to teach patients how to relax and learn ‘getting to sleep’ routines.

Links:

NICE guidelines on Z-drugs TA77 Insomnia 

4.2 ANTIPSYCHOTIC DRUGS

When treating the side effects of using antipsychotics, the treatment of extra-pyramidal symptoms needs particular care as the usual anti-muscarinic drugs are also frequently misused/traded or abused.

Points to note:

Procyclidine or Orphenadrine are the most frequently prescribed antimuscarinics to treat the antiparkinsonian extrapyramidal symptoms. Routine administration is not justified because regular use may unmask or worsen tardive dyskinesia and because of the problems with possible diversion, extra care is needed when prescribing.

Links:

NICE guidance of Schizophrenia

4.3 ANTIDEPRESSANT DRUGS

All tricyclic antidepressants have a high toxicity profile with regard to overdose. For this reason they are best avoided in prison environments, particularly as other antidepressants such as the SSRIs have a much lower toxicity profile.

Tricyclic Antidepressants, especially Amitriptyline are particularly popular and frequently traded/abused/misused because of their sedative properties.

• NICE guidance recommends non-drug therapies for mild depression
• SSRI therapy initiation for moderate to severe depression.
• Use of Amitriptyline may be justified in certain situations, such as prescribing of low dose treatment for neuropathic pain (unlicensed indication), but any prescribing must take into account the toxicity as part of the risk assessment for prescribing medication for that patient.
• The sedative effects of the tricyclics also make them a valuable tradable commodity within the prison community. Sedative drugs are highly prized to help ‘sleep away the sentence’.
• In addition, any patient who is prescribed these drugs is likely to be bullied or harassed to hand over their medication for use by others and so prescribing could be considered a high risk for suffering physical violence.

Consideration should be given to the above points when such medication is requested or sought.

Links:

• NICE guidance CG 23 Depression (amended May 2007)
  
• NICE guidance CG28 October 2005 Depression in Children and Young People
• Antidepressant use in adolescents JAMA 2007
• Prison Medication Audit Newsletter Winter 03/04  Issue 14 Gateway 2889

4.3.4 OTHER ANTIDEPRESSANTS

MIRTAZAPINE:

Highly prized in the prison setting as it’s sedative properties increase it’s popularity. It is highly tradable/ misused to a large extent across prisons.

VENLAFAXINE:

There have been concerns with toxicity in overdose and so it’s place in risk assessment for IP medication must be considered carefully.
Note problems with current heart disease and possible prolongation of QT interval (and possible interaction with other medication)

Links:

• NICE Guidelines
• MeReC
• Prison Audit Newsletter Winter 03/04  Issue 14 Gateway 2889

4.4 CNS STIMULANTS

The treatment of ADHD has an evidence base in treating adolescents but there is much less of a clinical evidence base in adults.

There is a need to emphasise confirmation of initial diagnosis (made by an appropriate consultant) and the treatment length and to link in with local psychiatric input/shared care to ensure best practice.

These medications are liable to abuse/trading and so this needs to be borne in  mind when prescribing in the prison environment.

Links:

ADHD NICE Guidance Sep 08  

4.7 ANALGESICS

Codeine-based or other opiate analgesia whether alone or in combination (‘Co-analgesics’) are highly tradable/abused/misused and so are best avoided in the prison environment. Treatment guidelines need to reflect these problems.

For information on use of various analgesics please see links below:

• Withdrawal of Co-Proxamol and Zuse of pain ladder
• Prodigy guidelines
  Back Pain
  Sprains & Strains
  Osteoarthritis
• MeReC bulletin -  2000 Vol 11, No 1; 2006 vol 16, No 4.

OPIATE ANALGESICS

Points to consider:

Any request by patients for ‘strong analgesia’ i.e. low dose opiates/opioids is likely to be made because of needs other than analgesia.

• Need to augment other illicit drugs traded on the wings
• Need to provide an alibi for failing a random drug test
• Need to provide ‘currency’ for bartering on the wings
• Need to pay back a debt on the wingsAs a result of bullying from other inmates

Other Points:

Prescribers may seek to limit diversion/misuse of opiate medication by prescribing the newer preparations which do not use the oral route e.g. various analgesic patches.

Unfortunately there have been several recent reports of these also being misused.

Some patches have drug reservoirs rather than a matrix formulation and so the drug can be extracted from the patch (and has been!) and so patches can still be traded and subject to the above drivers to request medication. 

TRAMADOL

Opioid analgesics are highly tradable and subject to abuse in prisons because illicit drugs are in short supply or to ensure that failed mandatory drug tests are legitimised by prescribed medication.

Tramadol has a dependence potential and psychiatric side effects have been noted.

Link:

Tramadol associated with withdrawal and increased risk of dependency

• Analgesics, especially opioid analgesics such as tramadol are liable to abuse in the prison setting.
• Those patients who persist in drug seeking behaviour to manage their addiction or who wish to trade in such drugs, will endeavour to persuade prescribers that their pain is unresponsive to all other medications. Other reasons for seeking prescribed tramadol in the prison setting also include the fact that abusing this opioid does not show up on the mandatory drug tests and so masks their illicit use and increases tradable value.

Prescribers will always be placed in this dilemma and the best advice is to follow the recognised pain ladder in the prison formulary.

Patients who are on a substance misuse maintenance or withdrawal programme can also suffer from physical conditions which require adequate analgesia. Such patients often have a low pain threshold but any prescribing of opiate analgesics in these patients requires a multidisciplinary approach and careful consideration of associated problems. For mild to moderate analgesia, non-opioid analgesia would be a suitable treatment (as used in general pain management guidelines). For severe pain, if opioid analgesia is clinically indicated, treatment will depend on whether the patient is taking an opioid agonist such as Methadone, a partial agonist such as Buprenorphine or an antagonist such as Naltrexone to ensure that respiratory depression, unintentional withdrawal or opioid intoxication is not precipitated. Any induction of opioid analgesia in this setting should be carefully titrated to obtain desired effect. Consideration of non-pharmacological treatment should also be considered. Specialist advice should be sought.

There have been several studies with opiates e.g. opiate use for chronic back pain – which fail to show any long-term gains and raise queries with dependency. 

Links:

• Prescribing guidelines in back pain
• Advice re opiate prescribing – NICE and other guidance re non opiate pain relief.
• BNF advice on not using ‘co’ drugs
• Prescribing audit Prison Health – Prison Health Newsletter article Issue 14 Winter 03/04 Gateway number 2889
• Drug Dependence links

4.7.3 NEUROPATHIC PAIN

GABAPENTIN / PREGABALIN

These drugs are currently in great demand for treating neuropathic pain, low back pain, and misuse / trading reports are frequent.

Important Points:

• Demand seems to stem from the fact that patients are aware that both of these drugs work via GABA pathways and so the side effects of drowsiness, and feeling ‘spaced out’ are highly prized.
• There have been examples of emptied capsules found and so gabapentin may be being used parenterally
• The few patients who genuinely need medication to ameliorate diabetic neuropathy or to treat epilepsy, may be subject to bullying or assault if gabapentin or pregabalin is prescribed.
• Some genuine patients, particularly if used for epilepsy, may not be compliant with therapy as they have the medication bullied off them, and so may be consequently given higher doses to treat their condition, causing even more bullying or assaults.

In the United States of America, Pregabalin is designated as a Schedule 5 Controlled Drug because of it’s potential for abuse and dependence. (See reference below)

South Derbyshire have a neuropathic pain algorithm which is very helpful 

Because of lack of robust evidence, most area medicine committees have Pregabalin as a ‘Traffic Light’ drug and it’s use is limited to where most other options for treatment have failed.

Links:

American Journal of Health – System Pharmacy, Vol 64, Issue 14, 1475 - 1482

4.10 DRUGS USED IN SUBSTANCE MISUSE

For further guidance and information please refer to:

Clinical Management of Drug Dependence in the Adult Prison Setting including psychosocial treatment as a core part.

The treatment of substance misuse in prisons has changed significantly recently. An Integrated Drug Treatment System is being introduced in prisons.

All medication for the treatment of substance misuse should be prescribed for supervised consumption i.e. Not In Possession and by prescribers who have suitable experience in treating substance misuse.

PSO Substance Misuse IDTS – to be published shortly

ALCOHOL DEPENDENCE

Assessment and management should begin in Reception. Recognised treatment is detoxification with Chlordiazepoxide on a gradually reducing regime over 7 to 14 days.

Thiamine 200mg daily (orally) for 28 days should also be prescribed concurrently for those patients undertaking an alcohol detoxification regime.

OPIOID DEPENDENCE

Assessment and management should begin in Reception. Recognised pharmacological treatment is stabilisation, followed by a period of maintenance or gradual withdrawal, following the clinical guidelines. There should also be a period of psychosocial involvement as specified in the clinical guidelines above.

NICOTINE REPLACEMENT THERAPY.

Smoking Cessation treatment is a Public Health initiative and so is very desirable in Prisons, particularly as, unlike in the general population, levels of smoking remain high.

Certain NRT products cannot be prescribed in the secure environment because of various security issues. 

NRT Gum is not prescribed due to the security problems of gum with regard to key and lock.

Universally acceptable NRT products are patches and lozenges. However care must be taken to ensure they are used appropriately as these products are highly tradable as so much in demand in the prison environment as a form of currency.

NRT patches have the greatest evidence base as an aid to smoking cessation and are the most used NRT product in prisons. Ensuring that the NRT patches are not traded and abused can be a problem. Robust clinic guidelines,  holding regular weekly support clinics and checking Carbon Monoxide readings each week may help solve some of these abuse problems and ensure that funding remains available for those who genuinely wish to stop smoking.