Rapid Responses to:

LETTERS: Bobby P Smyth, Herbert Langkamp, Matthias L Schmid, Stephen T Green, Michael W McKendrick, and Noel McCarthy Health effects of prisons BMJ 2000; 321: 1406a [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Something must be done & we should do it!

Andrew John Ashworth   (3 December 2000)

legitimacy of punishment regimes

Patrick Beauchamp   (9 January 2001)

Something must be done & we should do it! 3 December 2000
Andrew John Ashworth, Clinical Research Fellow Forth Valley Community Drug & Alcohol Service Send response to journal: Re: Something must be done & we should do it!	Editor, The medical profession should be embarrassed that the responses to Allwright et al's study (1) of blood-borne viral infection in Irish prisons give an impression that a) nothing can be done and b) politicians, not doctors are responsible. Smyth(2) points out that community interventions may not be relevant in prisons where some may find that prison stops them using drugs (and presumably increases their risk of post-liberation overdose death through reduction of opiate tolerance) but he ignores evidence that 10% of all prisoners (including non-drug users) in a Scottish Prison(3) and a fifth of drug injectors in Irish prisons(1) reported having injected for the first time in prison. Langkamp(4) argues that needle exchange may be harmful in prison where most new inmates may have already caught the viruses we are currently aware of. McCarthy(5) goes so far as to challenge the political legitimacy of incarceration in prisons where safety cannot be assured, presumably opting for the alternative of letting dangerous criminals walk the streets for their own safety! Previously Crofts et al(6) pointed out that needle exchange may be inadequate to prevent the spread of Hepatitis C even in community settings. When employed as a prison doctor I was demonstrated the efficacy of Buprenorphine for preventing injecting behaviour in single case (an HIV positive injector who ceased injecting with the treatment). To address the issue of diversion the sublingual tablets were contained in a porous "Tbag" throughout sublingual administration. The Buprenorphine was administered within a strict behavioural routine where the presence of new injecting sites led to withdrawal of a dose of medication. I have termed this technique SHaRP (Secure Harm Reduction prescribing). Unfortunately, the Scottish Prison Service, despite clear advice from BMA Council, has further reduced the clinical freedom of its prison doctors and thereby prevented further development of this technique in state prisons. While McCarthy(5) rightly praises this journal for its robust stand on the health needs of prisoners in general, it found this new Harm Reduction intervention technique unworthy of publication. It would be possible to carry out a controlled trial of SHaRP (perhaps against Methadone prescribing, needle exchange and a control) in UK prisons with the objective of reducing the transfer of injecting skills to injecting naïve drug users on remand but this would need the political will, not of the major political parties, but of our colleagues who advise them. We may have to rely on profit motivated private sector prisons to carry out this basic scientific work for commercial advantage: publication is likely to be impeded by "a lack of general interest". Safe alternatives to community interventions for drug using prisoners could be developed but, until doctors in Her Majesty’s Prisons are guaranteed the clinical autonomy enshrined in Statute but ignored in practice by civil servants with the complicity of responsible Ministers, prison will remain a testament both to the State’s failure to protect the victims of the International drugs trade and the indifference of the medical profession (including this journal) to this vulnerable group. A J Ashworth MRCGP Former Head of Medical Practice HMP Perth, Past Chairman BMA Civil Service Committee, Clinical Research Fellow (Addictions), Forth Valley Community Alcohol & Drug Service, Bannockburn Hospital, Stirling, 1Allwright S, Bradley F, Long J, Barry J Thornton L, Parry JV. Prevelance of antibodies to Hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. BMJ 2000;321:78-82. (8 July) 2Smyth BP. Many Injectors stop injecting while imprisoned BMJ 2000;321:1406 (2 Dec) 3 Gore S M, Bird A G, Burns S, Ross, Goldberg D Anonymous HIV surveillance with risk factor elicitation: at Perth (for men) and Cornton Vale (for women) Prisons in Scotland. International Journal of AIDS and STD;1997 8(3):166-75 4 Langkamp H. Risks of Syringe exchange programmes in prisons prevail BMJ 2000;321:1406 -1407(2 Dec) 5 McCarthy N Legitimacy of punishment systems should be addressed BMJ 2000;321:1407 (2 Dec) 6 Crofts N, Caruana S, Bowden S, Kerger M, BMJ 2000;321:899 (7 Oct) Competing Interests The Author holds world Patents for the Tbag device, The Author is approved as a parliamentary candidate by the Conservative Party
legitimacy of punishment regimes 9 January 2001
Patrick Beauchamp Send response to journal: Re: legitimacy of punishment regimes	EDITOR- I was astonished at Dr McCarthy's letter on this subject. The difference between judicial amputation and the risk of infection from shared needles in prison is that the amputations are not voluntary. I go into a prison on a regular basis. The inmates, apart from those who have committed serious offences as a first offence, have been through all the non-custodial regimes before ending up where they now are. To make comparison between this situation and amputation for theft, for example, is not sensible. Patrick Beauchamp, Retired G.P.