1. Good Prescribing to support Criminal Justice Interventions
Lucy Cockayne
Consultant Psychiatrist
Lead Clinician
NHS Fife Addiction Service

2. Structure of the session
Introduction (5 minutes)
Overview of prescribing principles (20 minutes)
Small group scenarios (10 minutes)
Prisoner release planning
The doctor won’t prescribe diazepam
Continued use “on top”
Cocaine and methadone
A client smelling of alcohol
Feedback (5 minutes)

3. Introduction – What are the main issues?
Are there Common Principles to non forensic treatment?
Write down your top 3
Are there differences in practice?
Write down 3 differences
Why do these occur? Are these good differences or not?
Group discussion

4. What are the aims of good prescribing in a forensic setting?
Alleviate suffering
Reduce harm associated with drug use
Reduce criminal behaviour
Reduce complications of drug misuse
Reduce risk of BBV transmission
Complications of injecting
General health
Promote recovery

5. Specific Challenges 1. For Prison Prescribing
Continuity of prescription
from the community
Back into the community
Especially for short termers
Volume of potential clients and their speed of movement through the system
Tension of depth vs speed of assessment
Response to drug related death data
Issues around loss of tolerance
Cost and staffing

6. 2. Community criminal justice prescribing
Tensions within the team
Differing opinions
Expectations from court
Treatment as more than a prescription!
“First do no harm”
“More than methadone”

7. What forms of drug misuse have evidence based prescribing options?
Opiates
Methadone
Buprenorphine
Benzodiazepines?
Actually no licensed prescribing- controversy over structured detoxification
Alcohol
Detoxification
Acamprosate, naltrexone and antabuse as adjunct to abstinence

8. Alcohol Treatments Detoxification
Chlordiazepoxide (Librium)
Vitamin supplementation
Aids to maintaining abstinence or controlled drinking
Antabuse (abstinence only)
Acamprosate
Naltrexone

9. Treatments exist:- Average alcohol intake (drinks / week, TLFB) –but they’re not a “cure”* *

10. Opiate dependence Four treatment types:
Agonist eg methadone
Antagonist eg naltrexone
Partial agonist eg buprenorphine
Symptomatic eg lofexidine
Think lightbulbs! 100w vs 60w vs dead!

11. Lightbulbs… Agonists Heroin Methadone Partial agonist
Antagonist (Blocker)
Buprenorphine (Subutex, Suboxone)
Naltrexone

12. WHY NOT JUST METHADONE?
“If the only tool you own is a hammer, everything starts to look like a nail”
Choice increases retention in treatment
Choice increases patient “buy in”
Different patients need different treatment
Some want sedative effects
Some need to be clear minded
Some are at higher risk of overdose
Some need to avoid drug interaction or side effects

13. Prescribing for complications of substance misuse
Important to help progress through treatment and prevent relapse
Up to 40% have mental health needs that may benefit from prescribing
Physical health problems common

14. Current barriers to good quality treatment in forensic settings 1
Current barriers to good quality treatment in forensic settings 1. Organisation factors
Stigma
Unrealistic expectations and false beliefs…
Confusion between getting addicted and treating addiction and its consequences –ie cause and effect
Lack of flexibility

15. 2. Patient factors in prescribing
“Motivation”?
Compliance
Severe dependence
Complex issues
Memory problems

16. There is no single, one “best” treatment for ever and ever
the best treatment is the one that suits the client at that time

17. Where does medication fit in the treatment programme?
House theory of addiction
medication fills in the foundations.
Foundations come first
Foundations are only the start…
Foundations must be strong
Changes in foundations may have catastrophic effects.

18. “Drug addiction is a chronic, relapsing brain disease”

19. Benzos also cause more subtle problems:-

20. Why is it so hard to detoxify from benzodiazepines?
Not usually aware of mild intoxication
Amnesia
Physically hard
Behaviourally hard
We underestimate how much impact it has on the brain…

21. GABA BRAIN CIRCUITRY
% OF ALL BRAIN SYNAPSES ARE GABAERGIC

22. Treatment of benzodiazepine dependence
Gradual withdrawal –regimen will depend on pattern of dependence and length of dependence – can take years…
NO proven role for “substitute prescribing”
Possibly use of flumazanil in future to help withdrawal.

23. Small Groups and Feedback
Prisoner release planning
The doctor won’t prescribe diazepam
Continued use “on top”
Cocaine and methadone
A client smelling of alcohol
Please summarise the MAIN concern and give
ONE take home message from the group!

24. Some men see things as they are, and say “why
Some men see things as they are, and say “why?” I dream of things that have never been, and say “why not?” Robert F Kennedy