Presentation on theme: "Lead GP HMP Lindholme High Security GP HMP Full Sutton"— Presentation transcript:
1Lead GP HMP Lindholme High Security GP HMP Full Sutton Life as a prison GPDr Ben Sinclair MRCGPLead GP HMP Lindholme High Security GP HMP Full SuttonWith Thanks to Dr Mark Pickering for contributing material to this presentationYork VTSJanuary 2015
2What do we hope to cover? National and Local prison service Prison medicine – commissioning/provisionPrescribing challenges – inside and outsideSecure Environment Hazards and opportunitiesCASESCommunication – how can GPs help each other?Resources and opportunities in prison medicineQuestions – ask as we go along
3the prison population – england/wales July 2014 – 85,600 prisoners81,700 male & 3,900 female127 prisonsCategory A-D (male)Female (closed/open)Young Offender InstitutionsImmigration Removal Centres‘Mains’ or ‘VPs’Also secure psychiatric hospitalsHigh, Medium, Low Secure (nearest Stockton Hall)
4Local prisons IN South Yorkshire HMP Doncaster ‘Marshgate’ SERCO Cat Blocal/remand ~1,100 inmatesHigh turnover – From courts, short sentences“off the Streets”Chaotic population
5Local prisons IN South Yorkshire HMP Moorland near DoncasterCat C working ~ 1,000 inmatesYOs, sex offenders, foreign nationals, mains
6Local prisons IN South Yorkshire HMP Lindholme near DoncasterCat C working ~1,000 inmatesYoung drug crime population“Best Prison Gym in the UK”
7Local prisons IN South Yorkshire HMP Hatfield near DoncasterCat D working ~260 inmates“Open” prison
10Common Problems in prison medicine Musculoskeletal (often neglected)Occupational hazards – barbed wire, police dogs…Chronic Pain incl. neuropathicMental health – inc. forensic psychiatristsAddiction – opiates, alcohol, POMs, BenzosConsequences – Hep C, DVT, liver diseaseHep C inreach service – good treatment results
11Secure environment prescribing Population characterised by addiction/abuseConcentration of tradeable, abusable meds‘chemical haze’ and pocket moneyBalance of efficacy v securityRisks – overdose, trading, addictionIn 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!”
12Secure Environment Hazards pay off Threats of legal action / complaints = cpdChallenging consultations = new skills / SEAsVolatile situation = admin time no QOF no visitsLow risk of physical harm but be on guard
13Whats It like? 1 Officers Locked waiting room Language Vulnerable vs manipulative patientsViolence and gang cultureHealthcare building protectedSystm 1 “prison” sealed from outsidePrison liasons
14Whats It like? 2 Disturbances Hospital transport issues re triage Small close team
15Patient MR G 20yr old NFAW with URTI Reports dry skin dry scalp asks for e45 coal tarHas prison tattoos what issues?
17Mr 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: subduralAdmitted bedbound non communicative…What issues surround his care now?Infective disease, compassionate release, suitable location, death in custody, coroner.
18Mr J R High Secure violent patient Diagnosis shizotypal dissociative PD DSHNumerous assaults on Medical staffEpileptic 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 injuredAlso claims transgender issues while in prison?
20MR 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 bdSpot audit shows no meds in possession?Where do we go from here?
21The challenge of ‘neuropathic’ pain Easy to claim, hard to evaluate eg “sciatica”Tenuous links to old injuries/ ScarsAddictive, tradeable medications soughtGabapentin, pregabalin, tramadolDiscrepancies of history and functionDue diligence required to verify backstoryWarning signs: pt asks for named drug declines all other options and threatens legal action
22Mr 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 DNAAlso claims chronic anxiety problems?
23pregabalin and gabapentin – 1 Both potentiate the effects of opioids/alcoholAnxiolytic, sedative, relaxant & euphoriant‘ideal psychotropic drugs’Not routinely tested by urine drug screensLearned behaviour (“I got this Shooting pain”)Easy to get from secondary care & some GPsRequested by name in drug-using patientsConcern in those already on opiates
24Pregabalin 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 diazepamWe should have similar caution in prescribing it.BMJ – Des Spence article 8 Nov 2013Gabapentin is better if you feel it’s necessary – it’s less euphoriant, less addictive.
25Secure Environment Prescribing NICE guidance generally unhelpful – CG96 (Neuropathic Pain)Cost-effectiveness only, little awareness of addiction/abuseUpdated version makes only passing generic mentionLocal prescribing guidelines now recognising the problems.RCGP Safer Prescribing in Prisons –Imaginative combinations – often unlicensed but evidence-basedNeuropathic pain – amitriptyline/nortriptyline, carbamazepine, duloxetine rather than gabapentin/pregabalin.Pain clinics may not always realise the problemSpecify substance misuse when referringTENS machinesDepression - SSRIs/venlafaxine rather than mirtazapine/trazodoneWidespread abuse as ‘sleepers’Doncaster Prison GPs no longer initiate mirtazapine/trazodone.
26Communication - incoming SystmOne Prison good between prisons but no connection with communityMay connect with NHS Spine 2016Prison records often limitedFaxed requests from prison to community GPsReception 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 etcWe know you’re busy but any help appreciated!
27Communication – outgoing Release process not connected with healthcareCourt, tagging, parole – can be unpredictableDifficult to do routine ‘discharge summary’Should always have a week’s meds and hosp apptsNot always back to previous GPMay be going to bail hostelMay not want you to know what we’ve done!We’d like to improve it - call the prison for info
28Opportunities in prison medicine Make a huge difference to a vulnerable populationNeglected field – lots of opportunitySmall pool – leadership opportunitiesWill only stop being a dead-end job if we make it so!Special interests – MSK, mental health, men’s health, Hep CSessional/salaried opportunities in GP
29Resources in prison medicine RCGP Secure Environment GroupRegional peer educational meetingsRCGP Substance Misuse and Allied HealthCerts in drug/alcohol misuse, Hep B/C etcBMJ article series – Stephen Ginn