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
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Both potentiate the effects of opioids/alcohol
Anxiolytic, sedative, relaxant & euphoriant
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‘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 : drben@sinclairhealth.co.uk
