MEDICINE BEHIND BARS - Life as a prison GP

Report
LIFE AS A PRISON GP
Dr Ben Sinclair MRCGP
Lead GP HMP Lindholme High Security GP HMP Full Sutton
With Thanks to Dr Mark Pickering for contributing material to this presentation
York VTS
January 2015
WHAT DO WE HOPE TO COVER?
National and Local prison service
 Prison medicine – commissioning/provision
 Prescribing challenges – inside and outside
 Secure Environment Hazards and opportunities
 CASES
 Communication – how can GPs help each other?
 Resources and opportunities in prison medicine
 Questions – ask as we go along

THE PRISON POPULATION – ENGLAND/WALES

July 2014 – 85,600 prisoners


81,700 male & 3,900 female
127 prisons
Category A-D (male)
 Female (closed/open)
 Young Offender Institutions
 Immigration Removal Centres
 ‘Mains’ or ‘VPs’


Also secure psychiatric hospitals

High, Medium, Low Secure (nearest Stockton Hall)
LOCAL PRISONS IN SOUTH YORKSHIRE


HMP Doncaster ‘Marshgate’ SERCO Cat B
local/remand ~1,100 inmates
 High turnover – From courts, short sentences
 “off the Streets”
 Chaotic population
LOCAL PRISONS IN SOUTH YORKSHIRE

HMP Moorland near Doncaster
 Cat
C working ~ 1,000 inmates
 YOs, sex offenders, foreign nationals, mains
LOCAL PRISONS IN SOUTH YORKSHIRE

HMP Lindholme near Doncaster
 Cat
C working ~1,000 inmates
 Young drug crime population
 “Best Prison Gym in the UK”
LOCAL PRISONS IN SOUTH YORKSHIRE

HMP Hatfield near Doncaster
 Cat
D working ~260 inmates
 “Open” prison
HMP LEEDS “ARMLEY”
HMP FULL SUTTON NEAR STAMFORD BRIDGE
COMMON PROBLEMS IN PRISON
MEDICINE

Musculoskeletal (often neglected)
 Occupational
hazards – barbed wire, police dogs…
 Chronic Pain incl. neuropathic
Mental health – inc. forensic psychiatrists
 Addiction – opiates, alcohol, POMs, Benzos

 Consequences
– Hep C, DVT, liver disease
 Hep C inreach service – good treatment results
SECURE ENVIRONMENT PRESCRIBING
Population characterised by addiction/abuse
 Concentration of tradeable, abusable meds


‘chemical haze’ and pocket money
Balance of efficacy v security
 Risks – overdose, trading, addiction
 In Posession Medication Risk assessment
observed, weekly, monthly – patient v medication.
 Verifying with community GPs – false claims
 “You can’t stop my meds! I want mi pregabs!”

SECURE ENVIRONMENT HAZARDS PAY OFF
Threats of legal action / complaints = cpd
 Challenging consultations = new skills / SEAs
 Volatile situation = admin time no QOF no visits
 Low risk of physical harm but be on guard

WHATS IT LIKE? 1
Officers
 Locked waiting room
 Language
 Vulnerable vs manipulative patients
 Violence and gang culture
 Healthcare building protected
 Systm 1 “prison” sealed from outside
 Prison liasons

WHATS IT LIKE? 2
Disturbances
 Hospital transport issues re triage
 Small close team

PATIENT MR G
20yr old NFAW with URTI
 Reports dry skin dry scalp asks for e45 coal tar
 Has prison tattoos what issues?

CASES MR M

Age 82 Serving Life for murder
MR M
Elderly Bangladeshi, DM,COPD < BMI- issues?
 Brings another inmate to translate – issues?
 Begins to cough c/o sweats – Differential?
 Diagnosed with TB – what prison issues arise?
 Admitted for Rx; returns to prison frail: subdural
 Admitted bedbound non communicative…
 What issues surround his care now?
 Infective disease, compassionate release,
suitable location, death in custody, coroner.

MR J R HIGH SECURE VIOLENT PATIENT
Diagnosis shizotypal dissociative PD DSH
 Numerous assaults on Medical staff
 Epileptic but intermittent compliance- issues?
 Begins to breath hold to induce fits then
assault staff- expressed wish to die – issues?
 Transported to YDH in status from non
compliance – 16 police restrain him 2 NHS
staff injured
 Also claims transgender issues while in prison?

MR NM
MR NM PAIN MANAGEMENT
37 yr old in prison for burglary on Methadone
 Fall in another prison causes back injury?
 On gabapentin 800mg tds asking for increase?
 Seen in pain clinic who advise pregabalin?
 Threatens to sue you if no Px Pregab 300mg bd
 Spot audit shows no meds in possession?
 Where do we go from here?

THE CHALLENGE OF ‘NEUROPATHIC’ PAIN
Easy to claim, hard to evaluate eg “sciatica”
 Tenuous links to old injuries/ Scars
 Addictive, tradeable medications sought

 Gabapentin,
pregabalin, tramadol
Discrepancies of history and function
 Due diligence required to verify backstory
 Warning signs: pt asks for named drug declines
all other options and threatens legal action

MR K EPILEPTIC
34 year old epileptic
 On pregabalin and clonazepam for epliepsy?
 Lost to neurology FU had normal EMG + MRI?
 D+V on the day of neurology appt hence DNA
 Also claims chronic anxiety problems?

PREGABALIN AND GABAPENTIN – 1
•
•
Both potentiate the effects of opioids/alcohol
Anxiolytic, sedative, relaxant & euphoriant
•
•
•
•
•
•
‘ideal psychotropic drugs’
Not routinely tested by urine drug screens
Learned behaviour (“I got this Shooting pain”)
Easy to get from secondary care & some GPs
Requested by name in drug-using patients
Concern in those already on opiates
PREGABALIN AND GABAPENTIN – 2
Patients’ statements about pregabalin:-
• “If you get the dosing right then you only need to be
conscious for a few hours every day”
•“They are better than crack!”
•“I rattled for weeks when you took them off me last
time.”
Pregabalin = the new diazepam
We should have similar caution in prescribing it.
BMJ – Des Spence article 8 Nov 2013
Gabapentin is better if you feel it’s necessary – it’s less
euphoriant, less addictive.
SECURE ENVIRONMENT PRESCRIBING

NICE guidance generally unhelpful – CG96 (Neuropathic Pain)




RCGP Safer Prescribing in Prisons – www.rcgp.org.uk


Cost-effectiveness only, little awareness of addiction/abuse
Updated version makes only passing generic mention
Local prescribing guidelines now recognising the problems.
Imaginative combinations – often unlicensed but evidence-based
Neuropathic pain – amitriptyline/nortriptyline, carbamazepine,
duloxetine rather than gabapentin/pregabalin.


Pain clinics may not always realise the problem
Specify substance misuse when referring

TENS machines

Depression - SSRIs/venlafaxine rather than mirtazapine/trazodone


Widespread abuse as ‘sleepers’
Doncaster Prison GPs no longer initiate mirtazapine/trazodone.
COMMUNICATION - INCOMING

SystmOne Prison good between prisons but no
connection with community

May connect with NHS Spine 2016
Prison records often limited
 Faxed requests from prison to community GPs


Reception screening (HMP Doncaster) – basic info –
current meds (esp need to know if recently started)
 Do


admin or GPs deal with these?
Further info (all prisons) – specific info on a condition
– hospital letters, MRIs etc
We know you’re busy but any help appreciated!
COMMUNICATION – OUTGOING

Release process not connected with healthcare
 Court,
tagging, parole – can be unpredictable
 Difficult to do routine ‘discharge summary’
 Should always have a week’s meds and hosp appts

Not always back to previous GP
 May
be going to bail hostel
 May not want you to know what we’ve done!

We’d like to improve it - call the prison for info
OPPORTUNITIES IN PRISON MEDICINE
Make a huge difference to a vulnerable
population
 Neglected field – lots of opportunity
 Small pool – leadership opportunities

 Will
only stop being a dead-end job if we make it so!
Special interests – MSK, mental health,
men’s health, Hep C
 Sessional/salaried opportunities in GP

RESOURCES IN PRISON MEDICINE

RCGP Secure Environment Group
 Regional

peer educational meetings
RCGP Substance Misuse and Allied Health
 Certs
in drug/alcohol misuse, Hep B/C etc
BMJ article series – Stephen Ginn
http://www.bmj.com/content/345/bmj.e5921
 Email : [email protected]

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