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Dr Ben Sinclair MRCGP Lead GP HMP Lindholme High Security GP HMP Full Sutton York VTS January 2015 With Thanks to Dr Mark Pickering for contributing material.

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Presentation on theme: "Dr Ben Sinclair MRCGP Lead GP HMP Lindholme High Security GP HMP Full Sutton York VTS January 2015 With Thanks to Dr Mark Pickering for contributing material."— Presentation transcript:

1 Dr Ben Sinclair MRCGP Lead GP HMP Lindholme High Security GP HMP Full Sutton York VTS January 2015 With Thanks to Dr Mark Pickering for contributing material to this presentation

2  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  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  HMP Doncaster ‘Marshgate’ SERCO Cat B  local/remand ~1,100 inmates  High turnover – From courts, short sentences  “off the Streets”  Chaotic population

5  HMP Moorland near Doncaster  Cat C working ~ 1,000 inmates  YOs, sex offenders, foreign nationals, mains

6  HMP Lindholme near Doncaster  Cat C working ~1,000 inmates  Young drug crime population  “Best Prison Gym in the UK”

7  HMP Hatfield near Doncaster  Cat D working ~260 inmates  “Open” prison

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9 HMP FULL SUTTON NEAR STAMFORD BRIDGE

10  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  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  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  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  Disturbances  Hospital transport issues re triage  Small close team

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

16  Age 82 Serving Life for murder

17  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  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?

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20  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  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  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 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 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  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  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  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  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  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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