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Lead GP HMP Lindholme High Security GP HMP Full Sutton

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1 Lead GP HMP Lindholme High Security GP HMP Full Sutton
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

2 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

3 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)

4 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

5 Local prisons IN South Yorkshire
HMP Moorland near Doncaster Cat C working ~ 1,000 inmates YOs, sex offenders, foreign nationals, mains

6 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”

7 Local prisons IN South Yorkshire
HMP Hatfield near Doncaster Cat D working ~260 inmates “Open” prison

8 HMP Leeds “Armley”

9 HMP Full Sutton near Stamford Bridge

10 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

11 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!”

12 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

13 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

14 Whats It like? 2 Disturbances Hospital transport issues re triage
Small close team

15 Patient MR G 20yr old NFAW with URTI
Reports dry skin dry scalp asks for e45 coal tar Has prison tattoos what issues?

16 Cases Mr M Age 82 Serving Life for murder

17 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.

18 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?

19 Mr NM

20 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?

21 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

22 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?

23 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

24 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.

25 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 – 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.

26 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!

27 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

28 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

29 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

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