Safer prescribing for prisoners

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e447 (Published 26 January 2012) Cite this as: BMJ 2012;344:e447
  1. Michael Levy, professor
  1. 1Medical School, College of Medicine, Biology and Environment, Australian National University, ACT 0200, Australia
  1. michael.levy{at}act.gov.au

New guidance fails to deal properly with this complex area of practice

Most prisoner health services in developed countries are modelled on primary care, with nurse led health services. Prescribed drugs are a major component of clinical practice within prisons and usually form the central point of contact between the patient and prescribing medical staff; however, little information is available on how much care centres around prescribed drugs and the nuances of patient care in prisons. Much that supports the care of prisoners is excluded from public scrutiny because of generalised fears of disclosure of “in confidence” information. This impedes peer review and leaves a substantial void in an important area of primary care.

The Australian Institute of Health and Welfare is developing a surveillance system for prisoners in that country.1 A survey conducted in 2010 showed that 40% of prisoners were prescribed drugs—on average 2.3 drugs per person—and that women were more likely to be medicated than men (47% v 39%). Antidepressants and mood stabilisers accounted for 18% of repeat prescriptions and anti-inflammatory drugs for 12%.

Drug seeking behaviours in prison populations are underpinned to a large extent by psychological trauma, neuropathic pain, dependence on pain relief drugs, dependence on illicit drugs, mental illness, and oral (dental and gingival) disease, all of which are prevalent in prisoner populations.

The main message of the recently published guideline on prescribing in prisons from the Royal College of General Practitioners and the Royal Pharmaceutical Society is that there is a standard of safe prescribing, guided by community norms, that should be deviated from only in certain circumstances.2 Particular environmental issues and administrative concerns for custodial practices, as well as generalised attributes of the prisoner population, may need to be taken into account. For example, “The acquisition, misuse and onward trading of prescribed medication cannot be supported and should be discouraged as it presents risks in many ways.” The guidance offers a traffic light framework (red: do not prescribe; orange: proceed with caution; green: safe to prescribe) to assess levels of acceptability of prescribing in the custodial environment.

The implications of these guidelines are clear for clinicians who practise in prison. The guidelines also contain useful information for primary care clinicians who provide care for patients in contact with the criminal justice system. For example, prescription for patients who will return to the custodial setting, where some drug classes are more strictly controlled, will need to be tailored. Opiate analgesia should be prescribed for as short a period as possible because the administration of opiates needs to be intensively supervised and this might disrupt the patient’s reintegration into prison routine.

The guidelines advise that “Clinicians who choose to work within prison should . . . be familiar with the requirement of mandatory testing of prisoners for drugs and they should consider whether their prescriptions could mask illicit drug use, particularly with regard to the prescribing of opiates.” The adverse health effects of mandatory testing in prison have been highlighted elsewhere.3 Although the existence of a drug market (for both legal and illicit drugs) is widely acknowledged, the guidelines do not recognise the nature of such a market, which is opportunistic and variable. Prisoners can experience acute withdrawal when the supply of illicit drugs wanes, and healthcare practitioners should deal with such scenarios in a compassionate and non-judgmental way, without disclosing particular circumstances to custodial authorities. A recent report highlighted that responsible prescribing in prison reduced criminal recidivism.4

The guidelines recommend that pharmacists with experience in practising in secure environments are involved to optimise the use of the most appropriate drugs. This simple message deserves greater attention and a stronger evidence base.5 6

Health services on both sides of the prison gate must confirm that drugs dispensed to patients on one side are received or accounted for on the other side. It is currently unusual for a prisoner to enter custody with a letter from a community prescriber that details drugs prescribed, although it is more common for an ex-prisoner returning to society to have a letter detailing care received while in custody.

What impact might the recently published guidelines have on prison health services in the United Kingdom? Risk mitigation is the overarching principle of the guidelines, which seek to promote the creation of safe environments, to protect some prisoners from misguided attempts to overtreat existing or factitious health conditions, and to protect the prescriber. However, if not thoughtfully applied, the guidance may lead to a worrying degree of complicity between healthcare practitioners and the prison authorities.

Fishman acknowledged in 2006 that “drug abuse and undertreated pain are both public health crises,” but he went on to say that “the solution to one need not undermine the other” and warned against “impos[ing] solutions that are insensitive to their collateral damages” and against “displac[ing] the regulation of medicine from . . . agencies responsible for health to those focusing on law enforcement.”7 The controversy regarding the best form of analgesia to use in people who have had a dependency on opiates will not be resolved by the current concise guidelines.8

The guidelines offer no advice on palliative care, saying merely, “The security implications of administering powerful opiates and benzodiazepines in the prison must be carefully evaluated.” It is a shame that this is the final statement in a very useful document. Flexibility is needed—custodial authorities and health service providers must be able to offer a range of therapeutic options for intractable pain and end of life care. It is unconscionable that a person should not receive proper palliative care because he or she is in prison.


Cite this as: BMJ 2012;344:e447


  • Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.