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Prison Medicine

Fascilitated By Spectrum, Wakefield 12th July 2019

prison pic.png

Spectrum community health comprises of:- 

  • prison healthcare
  • Sexual health
  • Community substance misuse 

Spectrum background:- 

  • Previously run by PCT
  • Runs up to north Tyneside down to Barnsley
  • UK registered charity – spectrum people
  • multiple partnerships all across north west – 
  • Good values based culture

Prison categories:- 

  • Range from Cat A to Cat D 
  • Cat A is closed, high risk crimes
  • Cat D is open low risk
  • Others in between 

Constraints of Prison

  • operational (medication timing, differences)
  • Access (so many other priorities eg. Education /work (even though low pay))
  • Other priorities (eg. Legal visits can take priority for some patients in cat A particularly or visits from family and gym is very important)
  • Security 
  • Escorts (some prisoners may need 6 officers before even opening the door, and going to hospital appt)
  • Bed watches (need 2 officers, therefore need to keep prison safe- staffing) 
  • Transfers
  • Prescribing (more acute medicine in cat A eg. Pcm overdose/ drug seeking/ can even manipulate use of nicotine patches)
  • All prisons on system one now
  • Ethical dilemma with prescribing psychoactive substances 
  • Breaking confidentiality with patient to prison officers eg.illicit substances, not allowed on the wings. 
  • Important for MDT approach 

Opportunities 

  • Health promotion
  • Self esteem
  • Access to healthcare
  • Continuity
  • Healthy lifestyles

Ethical dilemmas

  • pressure to reduce hospital admission (due to the number of the staff it would require to do so) 
  • Confidentiality
  • Prescribing for pain vs substance misuse 
  • Every death in custody goes to coroner 
  • So many implications from actions 
  • Need good record keeping 
  • Some only have 7am-7pm health care cover 

Healthcare in prisons consist of:- 

  • Primary care providers
  • Substance misuse
  • Secondary care mental health eg. Psych ,palliative care
  • National Shortage of prison medicine drs
  • Can compromise services too 

Forensic psych beds

  • Difficult to issue
  • Hard to move those with severe psychosis for example to a forensic psych bed
  • Big pressure on the system and normally the pt is on a segregation unit not suitable

Access 

  • Morning urgent triage from 8am, then an evening triage 
  • Still have clinics and a waiting room, majority are consulted 1:1 (without police) 
  • 95% men 5% female in prison
    • women more smaller group and can be difficult behaviours 

Safeguarding in the secure environment 

Women 

  • Drug use in women is double the percentage of the number of female prisoners than the Male
  • This is most likely due to childhood traumas in women
  • Women are normally controlled with their drug use whereas men more likely to be independent and do drugs with their male peers
  • Also perinatal health/Street sex workers/pregnancy
  • Sometimes can keep baby on a mother and child unit 
  • Also mixed categories due to small number of women harder to keep all categories separate

Adult at risk vulnerable prisoner 

  • learning disabilities
  • Elderly/dementia/alcohol induced 
  • Poor access for wheelchair uses due to older facilities
  • Increasing age in prison due to historical crimes 
  • Elderly in prison >50 (as the prison process can add 10-15years)
  • Each year spent in prison can reduce the life expectancy by 2 years for every year spent

Learning disabilities

  • 7% of prisoners have learning disabilities compared to 2% of the general population
  • There’s no specialised provision in prisons 
  • 36% have a physical or mental disability
  • Literacy skills similar to 11 years old 

Other safeguarding:- 

  • Substance misuse
    • majority opiate use 
    • Spice use makes people more vulnerable 
    • High number of physical abuse/sexual abuse
  • Mate crime:- form of grooming 
  • Institutional abuse- just overall poor practices and behaviours of the team
  • important not to be judgemental
  • Unexplained injuries – just report through security systems 
  • Refer through safer custody department rather than adult social care
  • Complex cases can be sought from the local safeguarding board

Self harm

  • seen a lot in personality disorder
  • 87 suicides in 2018
  • Ingestion of batteries (problems as battery vapes) 

Concerns about children

  • Male a disclosure about children on the outside

Personality disorders

  • Around 50% prisoners/offenders 
  • Problematic/persistent/pervasive 
  • Normally onset’s in adolescence, with issues around attachment and security 
  • Borderline commonly seen with unstable relationships
  • Paranoid PD linked to offending, easily provoked into feeling unfairly treated and attacked
  • Obsessive compulsive struggle more in prison given lack of control 

Trade-able medications 

  • Understanding pain 
  • Use the acronym PADABIT for reviewing records 

Prescribing

  • Use prison formulary- can be slightly different mental health and pain medication
  • Try to give longer acting preps, need an ECG, don’t use liquids. 
  • Mirtazipine – Suicide risk 10x higher than ssri
    • the sedative effect wears off after a few weeks 
    • Buscopan- psychoactive if smoked 
  • Venlafaxine- give a high like amphetamine
  • Opiate- good to write morphine equivalent 
    • not effective for chronic pain 
    • Be objective eg. If hip pain stopping you from up the stairs, with the morphine now you should get up the stairs
    • Unlikely to respond to different opiates 

Managing intoxication

  • Alcohol, do breathalyse and can tell the level, can speak to hepatology if concerned, lactulose use
  • Spice, cannabinoid agonist, sprayed onto letters normally, normally smoked. Increases risk of serotonin syndrome , long term use can cause withdrawal.
  • Opiate overdose can affect 45% of opiate users 
  • Naloxone given to pt, being used a lot to reduce overdose. 
  • Methadone/buprenorphine/suboxone
  • Depot injection of buvidal- steady dose, not lots of information on polypharmacy, going into hospitals and needing further analgesia.
  • Espranor- dissolving wafers of buprenorphine, not easily removed after 15sec.

Preparing for Coroner’s court

  • Palliative care don’t need jury 
  • Good report, get indemnifier to read it
  • Full name, qualifications (bachelor of medicine not MB) status (GP for 1 year salaried)
  • Factual account, explain medical terminology, seen alone, nhs reason, report should be standalone, wrote in first person and be specific, don’t just quote what the pt said, interpretation of your examination into context, say what you found and what you failed to find. But explain why you didn’t do it. 
  • If you cannot recall the case, then state what your usual or normal practice will be. Specify what you can remember from memory.
  • Read the records prior, know your report, speak to mps, 
  • Remember confidentiality, confirmation
  • “I don’t recall this can I review?”
  • Can watch on YouTube cross examination 
  • Ask for clarification 
  • MDU website

Blog by Dr Saira Khan

By TrailblazerGPs

These blogs are from current and past Trailblazer GPs - newly qualified GPs working in areas of poverty supported by the fairhealth trailblazer scheme

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