1. Prescribing to Drug Users Dr Iain Brew Medical Officer HMP Leeds November 2010

2. General Principles – drug users Entitled to same quality of healthcare as we are Characteristics / challenge stereotyping? Addiction – the defining criteria Morbidity and mortality Prescribing Prison specifics

3. Blimey Even I’m bored!

4. Drug users Social exclusion Abusive upbringing Children in care School exclusion - poor educational achievement Illiteracy Unemployment Low self-esteem Criminal justice system

5. Addiction Persistent use despite problems related to that use This may be drugs or behaviour (eg gambling / sex) Development of tolerance Withdrawal syndrome Craving and drug seeking behaviour Primarily a disorder of the brain’s reward system

7. Addiction - continued Relapsing – remitting pattern Treatment is dependent on patient’s motivation Avoid complicity in prescribing Avoid judgemental management Importance of therapeutic alliance (mutual trust) Psychosocial management – MI, Life mapping etc

8. Cycle of change DiClemente 1982

9. Morbidity and Mortality Approx 1,500 drug related deaths/yr 2001-2005 Overdose Hepatitis B and C; HIV; DVT; venous insufficiency; leg ulceration Endocarditis Septic arthritis

10. Prescribing analgesia to Drug Users Accurate assessment / diagnosis of pain causation Learned behaviour – eg “shooting pains, Doc!” Non-pharmacological pain management WHO Pain ladder Awareness/abuse of non-opioid popular among drug users Gabapentin, pregabalin, benzo’s, tricyclics, quetiapine Regular review of dosages / need for medication

11. Prescribing analgesia to Drug Users (cont) Encourage other coping strategies ?Need to co-prescribe substitute and analgesic Rx Eg Methadone and dihydrocodeine / tramadol Split dose methadone – all supervised Supervised slow release preparations - MXL Urine testing to monitor compliance Opiate hyperalgesia? Low pain tolerance levels

12. HMP Leeds – a listed building!

13. Prison specifics 83,000 in custody Increasing numbers of elderly patients Long sentences, sex offenders caught long after the crime eg using DNA Socio-economic factors – higher morbidity rate, smoking Cost of escorts and bed-watches

14. Palliative care in prison Gold standards framework (prison version pilot) Medication Syringe driver security MacMillan nurses Patient choices?? – place of death Dignity ROTL Public protection

15. Any questions?