NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Prescribing and addiction issues in prisons (PostScript 80)

Dr Grace Campbell, Lead Clinician in Prison Health highlights some recurring issues which face doctors in that setting.

 

Healthcare within prisons was a non-NHS service organised by the Scottish Prison Service until late 2011 when it became an NHS responsibility. Within NHSGGC boundaries there are currently three prisons; Greenock holds 255 prisoners, Lowmoss has 780 and Barlinnie has a population of around 1,300. There is high psychiatric morbidity, including addiction issues, within the prison population.

 

Case Study

A 35 year old man was admitted to a local prison on the following medicines:

  • tramadol 50mg 1-2 capsules 6 hourly,
  • gabapentin 600mg three times daily
  • zopiclone 7.5mg at night
  • methadone 1mg/mL

 

A urine test was positive for methadone, opiates and benzodiazepines. The patient stated the gabapentin and tramadol were for a fractured clavicle 12 months ago, and nerve damage to his hand. The prescribed dose of methadone wasn’t clear, and as this was supplied from the Community Addiction Team and not the patient’s GP, it was not included on the Emergency Care Summary. The patient was given a dihydrocodeine based detoxification until the methadone history was confirmed by the prescriber. He was also prescribed diazepam detoxification due to zopiclone and diazepam misuse.

 

The patient was given a supply of 56 tramadol 50mg capsules and 30 gabapentin 600mg tablets. On a routine medicines check the next day, he only had 12 tramadol capsules and 10 gabapentin tablets.

 

He was assessed by the prison’s on duty GP and a pain assessment completed which found no clinical evidence of neuropathic pain or of severe pain meriting tramadol. Tramadol and gabapentin were discontinued and replaced with ibuprofen which was the treatment prescribed when the patient was liberated. Eight weeks later, the patient was readmitted on remand. Despite the changes made to his medication during the stay in prison he was now back on tramadol, gabapentin and zopiclone; all confirmed by the emergency care summary.

 

Learning Points

  • Clear communication is vital when patients move from one care setting to another. This is as true for patients moving from prison to the community as it is for patient moving from hospital to community care.
  • Drugs such as tramadol and zopiclone are addictive. They are like currency in a secure environment and, most likely, in the community.
  • Gabapentin and pregabalin are also addictive and can potentiate opiate effects. There is strong evidence that they are subject to diversion, substitution and misuse amongst certain populations, particularly those in a secure environment.
  • Implementing any changes to medicines can be challenging and may result in difficult consultations, verbal and physical abuse of staff, a high level of complaints and pressure on the community GP to reinstate.
  • GPs receive NHS discharge summaries from the prison service with details of prescribed. Prison doctors can confirm any details for GPs concerned about re-prescribing problematic medication, or feeling under pressure to do so.
  • The likely reclassification of tramadol to become a schedule 3 CD has prompted identification of all patients prescribed this drug in a secure setting. All patients will be individually assessed using the Pain Assessment Tool and transferred to another medication.

Assessment of pain within substance misusing populations can be challenging. The prison pain assessment tool and algorithm can be shared with GPs on request.

 

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