MEDICINE BEHIND BARS - Life as a prison GP

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)

Cost-effectiveness only, little awareness of addiction/abuse

Updated version makes only passing generic mention

Local prescribing guidelines now recognising the problems.

RCGP

Safer Prescribing in Prisons –

www.rcgp.org.uk

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]