Prescribing to Drug UsersDr Iain Brew

Medical Officer HMP Leeds

November 2010

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

Blimey

Even I’m bored!

Drug users

• Social exclusion

• Abusive upbringing

• Children in care

• School exclusion - poor educational achievement

• Illiteracy

• Unemployment

• Low self-esteem

• Criminal justice system

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

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

Cycle of changeDiClemente 1982

• 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

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

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

HMP Leeds – a listed building!

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

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

Any questions?