- Email: [email protected]
Prisoners’ access to psychoactive medications: The need for research and improved policy
International Journal of Drug Policy 29 (2016) 98–99
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Viewpoint
Prisoners’ access to psychoactive medications: The need for research and improved policy Tara Marie Watson * Social and Epidemiological Research Department, Centre for Addiction and Mental Health, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada M5S 2S1
Access to psychoactive medications in prison does not garner as much research and policy attention as the use and trade of illicit drugs in these settings. Indeed, there is little published literature regarding how psychoactive medications are prescribed to prisoners, including studies of common practices and barriers (a few exceptions include Bowen, Rogers, & Shaw, 2009; Griffiths, Willis, & Spark, 2012; Nunn et al., 2009; see also Fazel, Zetterqvist, Larsson, La˚ngstro¨m, & Lichtenstein, 2014 for some references about prescribing antipsychotic drugs and mood stabilizers to people with histories of criminal justice involvement). As in-prison access to pharmaceuticals has direct and important impacts on prisoner health and well-being, there is a pressing need for improved understanding and policy in this area. Compared to general populations, prisoners have worse physical and mental health, exhibit higher levels of substance use, and have had little contact with health service providers prior to entering prison (WHO, 2014). Among prisoners, certain subpopulations are~more likely to have been prescribed and/or taking psychoactive medications (often self-medicating to help cope with, for example, histories of trauma and abuse). These groups include: prisoners with mental health needs; prisoners who use drugs; women prisoners; Indigenous prisoners; people living with chronic pain, including some who are living with HIV; and elderly prisoners (e.g., Bowen et al., 2009; Office of the Correctional Investigator [OCI], 2014; WHO, 2014). There are international standards and recommendations that clearly state prisoners are entitled to a level of health care equivalent to that provided in the community (WHO, 2014). In practice, however, prisoners do not have equivalent access to psychoactive medications that may help alleviate or treat varieties of pain, mental health symptoms, and substance dependence. The subpopulations noted above are thus disproportionately vulnerable when it comes to interrupted access to medication. A notable example of unequal access, while clinically-supervised provision of methadone is an efficacious pharmacological treatment for opioid dependence, only just over half of prisons in the United States offer methadone maintenance (Ludwig & Peters, 2014; Nunn et al., 2009). In addition, many other psychoactive
* Tel.: +1 416 535 8501x30943. E-mail address: [email protected] http://dx.doi.org/10.1016/j.drugpo.2015.12.007 0955-3959/ß 2015 Elsevier B.V. All rights reserved.
medications available in the community are much more strictly controlled or entirely excluded from prisons, especially drugs deemed to have high potential for misuse or diversion (e.g., see definitions of ‘‘red’’, ‘‘amber’’, and ‘‘green’’ medications in Bicknell et al., 2011). Prison systems across jurisdictions often have their own drug formularies that outline permissible medications and corresponding dispensing restrictions for physicians, pharmacists, and nurses who are working in correctional settings. In Canada, for instance, all federal prisons must follow a National Formulary – plus other applicable regulations and standards of practice – that specifies the types of drugs that can be prescribed including details about when (e.g., for certain medical conditions) and how (e.g., under direct observation by nursing staff) the drugs can be administered (Correctional Service of Canada [CSC], 2012). Despite these existing rules and policies that should ensure that prisoners are adequately provided with medication, the ombudsman for federally sentenced prisoners in Canada receives a significant number of health care complaints regarding medication access (OCI, 2014). Many people are destabilized as soon as they are incarcerated; they may have to be taken off or tapered off psychoactive medication(s) they were taking in the community and/or required to switch to different medication, according to what can be prescribed by the applicable drug formulary, regardless of how long (in some cases, years) they may have been on the previous medication(s). Concerns regarding adherence and changes to prescribing guidelines, as well as documentation and monitoring issues, have been reported (Griffiths et al., 2012; see also audit by CSC, 2012). Such issues can result in lengthy delays before prisoners can initiate or return to an appropriate medication schedule. There are also major issues with trust. Prisons are supposed to be ‘‘drug-free’’ environments, where security staff will enforce, often in a disciplinary or punitive manner, policies designed to deter or reduce drug use. Although health care staff should have therapeutic roles, they are strongly advised to be cautious of ‘‘drug-seeking’’ prisoners, and guidelines may even contain such built-in mistrust. For example, the introduction to safer prison prescribing guidance from the United Kingdom notes that ‘‘a significant proportion of patients will seek prescribed medication for the psychotropic effect rather than its therapeutic or licensed use’’ (Bicknell et al., 2011, p. 6). While every prison
T.M. Watson / International Journal of Drug Policy 29 (2016) 98–99
likely sees such cases, the process of investigating the so-called legitimacy of individual requests and/or claims of having previously been treated with psychoactive medication can further contribute to delays, as well as promote prisoner distrust and avoidance of health care staff. The potential consequences for prisoner health and safety are numerous. Poor monitoring and prescribing of medication to prisoners can lead to health-related harms, particularly distress and deterioration of mental health (Bowen et al., 2009) and exacerbated or prolonged experiences of physical and emotional pain (Walsh et al., 2014). Delays and interruptions to medication access may also lead some prisoners to seek out and use other substances, including diverted pharmaceuticals (e.g., Tompkins, Wright, Waterman, & Sheard, 2009) that are available in the unauthorized in-prison drug market and may carry potential health risks. Although prison staff are on guard to detect and prevent diversion, it is possible that lack of timely access to medication may, in part, promote more strategic tactics by prisoners to obtain scarce drugs, including ‘‘muscling’’ (e.g., making threats to) vulnerable prisoners for their prescribed medications. Ensuring that prisoners receive the essential health care to which they are entitled, including timely access to psychoactive medications, especially when responding to mental health symptoms and pain, requires up-to-date, evidence-informed policy and removal of institutional and practice barriers. Questions that researchers could pursue include how to: improve in-prison prescribing practices, wait times for medication, and reporting of medication-related events; design education, training, and other supports for prisoners and staff regarding safer use of psychoactive medications in prisons, as well as overdose prevention and intervention; and promote therapeutic, non-punitive attitudes towards prisoners who use drugs among correctional and health care staff. The issues briefly outlined here are long overdue for in-depth empirical investigation.
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Acknowledgement Dr. Tara Marie Watson is funded by a Canadian Institutes of Health Research Postdoctoral Fellowship. Conflict of interest statement None declared. References Bicknell, M., Brew, I., Cooke, C., Duncalf, H., Palmer, J., & Robinson, J. (2011). Safer prescribing in prisons: Guidance for clinicians. London: Royal College of General Practitioners and Royal Pharmaceutical Society. Bowen, R. A., Rogers, A., & Shaw, J. (2009). Medication management and practices in prison for people with mental health problems: A qualitative study. International Journal of Mental Health Systems, 3, 24. Correctional Service of Canada (2012). Audit of medication management. Ottawa: Correctional Service of Canada Retrieved from: http://www.csc-scc.gc.ca/ publications/005007-2520-eng.shtml Fazel, S., Zetterqvist, J., Larsson, H., La˚ngstro¨m, N., & Lichtenstein, P. (2014). Antipsychotics, mood stabilisers, and risk of violent crime. Lancet, 384(9949), 1206–1214. Griffiths, E. V., Willis, J., & Spark, M. J. (2012). A systematic review of psychotropic drug prescribing for prisoners. Australian and New Zealand Journal of Psychiatry, 46(5), 407–421. Ludwig, A. S., & Peters, R. H. (2014). Medication-assisted treatment for opioid use disorders in correctional settings: An ethics review. International Journal of Drug Policy, 25(6), 1041–1046. Nunn, A., Zaller, N., Dickman, S., Trimbur, C., Nijhawan, A., & Rich, J. D. (2009). Methadone and buprenorphine prescribing and referral practices in US prison systems: Results from a nationwide survey. Drug and Alcohol Dependence, 105 (1–2), 83–88. Office of the Correctional Investigator (2014). Annual report of the Office of the Correctional Investigator 2013–2014. Ottawa: The Correctional Investigator Canada. Tompkins, C. N. E., Wright, N. M. J., Waterman, M. G., & Sheard, L. (2009). Exploring prison buprenorphine misuse in the United Kingdom: A qualitative study of former prisoners. International Journal of Prisoner Health, 5(2), 71–87. Walsh, E., Butt, C., Freshwater, D., Dobson, R., Wright, N., Cahill, J., . . . Alldred, D. (2014). Managing pain in prison: Staff perspectives. International Journal of Prisoner Health, 10(3), 198–208. World Health Organization (2014). Prisons and health. Copenhagen: World Health Organization.
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Viewpoint
Prisoners’ access to psychoactive medications: The need for research and improved policy Tara Marie Watson * Social and Epidemiological Research Department, Centre for Addiction and Mental Health, 33 Russell Street, 3rd Floor Tower, Toronto, Ontario, Canada M5S 2S1
Access to psychoactive medications in prison does not garner as much research and policy attention as the use and trade of illicit drugs in these settings. Indeed, there is little published literature regarding how psychoactive medications are prescribed to prisoners, including studies of common practices and barriers (a few exceptions include Bowen, Rogers, & Shaw, 2009; Griffiths, Willis, & Spark, 2012; Nunn et al., 2009; see also Fazel, Zetterqvist, Larsson, La˚ngstro¨m, & Lichtenstein, 2014 for some references about prescribing antipsychotic drugs and mood stabilizers to people with histories of criminal justice involvement). As in-prison access to pharmaceuticals has direct and important impacts on prisoner health and well-being, there is a pressing need for improved understanding and policy in this area. Compared to general populations, prisoners have worse physical and mental health, exhibit higher levels of substance use, and have had little contact with health service providers prior to entering prison (WHO, 2014). Among prisoners, certain subpopulations are~more likely to have been prescribed and/or taking psychoactive medications (often self-medicating to help cope with, for example, histories of trauma and abuse). These groups include: prisoners with mental health needs; prisoners who use drugs; women prisoners; Indigenous prisoners; people living with chronic pain, including some who are living with HIV; and elderly prisoners (e.g., Bowen et al., 2009; Office of the Correctional Investigator [OCI], 2014; WHO, 2014). There are international standards and recommendations that clearly state prisoners are entitled to a level of health care equivalent to that provided in the community (WHO, 2014). In practice, however, prisoners do not have equivalent access to psychoactive medications that may help alleviate or treat varieties of pain, mental health symptoms, and substance dependence. The subpopulations noted above are thus disproportionately vulnerable when it comes to interrupted access to medication. A notable example of unequal access, while clinically-supervised provision of methadone is an efficacious pharmacological treatment for opioid dependence, only just over half of prisons in the United States offer methadone maintenance (Ludwig & Peters, 2014; Nunn et al., 2009). In addition, many other psychoactive
* Tel.: +1 416 535 8501x30943. E-mail address: [email protected] http://dx.doi.org/10.1016/j.drugpo.2015.12.007 0955-3959/ß 2015 Elsevier B.V. All rights reserved.
medications available in the community are much more strictly controlled or entirely excluded from prisons, especially drugs deemed to have high potential for misuse or diversion (e.g., see definitions of ‘‘red’’, ‘‘amber’’, and ‘‘green’’ medications in Bicknell et al., 2011). Prison systems across jurisdictions often have their own drug formularies that outline permissible medications and corresponding dispensing restrictions for physicians, pharmacists, and nurses who are working in correctional settings. In Canada, for instance, all federal prisons must follow a National Formulary – plus other applicable regulations and standards of practice – that specifies the types of drugs that can be prescribed including details about when (e.g., for certain medical conditions) and how (e.g., under direct observation by nursing staff) the drugs can be administered (Correctional Service of Canada [CSC], 2012). Despite these existing rules and policies that should ensure that prisoners are adequately provided with medication, the ombudsman for federally sentenced prisoners in Canada receives a significant number of health care complaints regarding medication access (OCI, 2014). Many people are destabilized as soon as they are incarcerated; they may have to be taken off or tapered off psychoactive medication(s) they were taking in the community and/or required to switch to different medication, according to what can be prescribed by the applicable drug formulary, regardless of how long (in some cases, years) they may have been on the previous medication(s). Concerns regarding adherence and changes to prescribing guidelines, as well as documentation and monitoring issues, have been reported (Griffiths et al., 2012; see also audit by CSC, 2012). Such issues can result in lengthy delays before prisoners can initiate or return to an appropriate medication schedule. There are also major issues with trust. Prisons are supposed to be ‘‘drug-free’’ environments, where security staff will enforce, often in a disciplinary or punitive manner, policies designed to deter or reduce drug use. Although health care staff should have therapeutic roles, they are strongly advised to be cautious of ‘‘drug-seeking’’ prisoners, and guidelines may even contain such built-in mistrust. For example, the introduction to safer prison prescribing guidance from the United Kingdom notes that ‘‘a significant proportion of patients will seek prescribed medication for the psychotropic effect rather than its therapeutic or licensed use’’ (Bicknell et al., 2011, p. 6). While every prison
T.M. Watson / International Journal of Drug Policy 29 (2016) 98–99
likely sees such cases, the process of investigating the so-called legitimacy of individual requests and/or claims of having previously been treated with psychoactive medication can further contribute to delays, as well as promote prisoner distrust and avoidance of health care staff. The potential consequences for prisoner health and safety are numerous. Poor monitoring and prescribing of medication to prisoners can lead to health-related harms, particularly distress and deterioration of mental health (Bowen et al., 2009) and exacerbated or prolonged experiences of physical and emotional pain (Walsh et al., 2014). Delays and interruptions to medication access may also lead some prisoners to seek out and use other substances, including diverted pharmaceuticals (e.g., Tompkins, Wright, Waterman, & Sheard, 2009) that are available in the unauthorized in-prison drug market and may carry potential health risks. Although prison staff are on guard to detect and prevent diversion, it is possible that lack of timely access to medication may, in part, promote more strategic tactics by prisoners to obtain scarce drugs, including ‘‘muscling’’ (e.g., making threats to) vulnerable prisoners for their prescribed medications. Ensuring that prisoners receive the essential health care to which they are entitled, including timely access to psychoactive medications, especially when responding to mental health symptoms and pain, requires up-to-date, evidence-informed policy and removal of institutional and practice barriers. Questions that researchers could pursue include how to: improve in-prison prescribing practices, wait times for medication, and reporting of medication-related events; design education, training, and other supports for prisoners and staff regarding safer use of psychoactive medications in prisons, as well as overdose prevention and intervention; and promote therapeutic, non-punitive attitudes towards prisoners who use drugs among correctional and health care staff. The issues briefly outlined here are long overdue for in-depth empirical investigation.
99
Acknowledgement Dr. Tara Marie Watson is funded by a Canadian Institutes of Health Research Postdoctoral Fellowship. Conflict of interest statement None declared. References Bicknell, M., Brew, I., Cooke, C., Duncalf, H., Palmer, J., & Robinson, J. (2011). Safer prescribing in prisons: Guidance for clinicians. London: Royal College of General Practitioners and Royal Pharmaceutical Society. Bowen, R. A., Rogers, A., & Shaw, J. (2009). Medication management and practices in prison for people with mental health problems: A qualitative study. International Journal of Mental Health Systems, 3, 24. Correctional Service of Canada (2012). Audit of medication management. Ottawa: Correctional Service of Canada Retrieved from: http://www.csc-scc.gc.ca/ publications/005007-2520-eng.shtml Fazel, S., Zetterqvist, J., Larsson, H., La˚ngstro¨m, N., & Lichtenstein, P. (2014). Antipsychotics, mood stabilisers, and risk of violent crime. Lancet, 384(9949), 1206–1214. Griffiths, E. V., Willis, J., & Spark, M. J. (2012). A systematic review of psychotropic drug prescribing for prisoners. Australian and New Zealand Journal of Psychiatry, 46(5), 407–421. Ludwig, A. S., & Peters, R. H. (2014). Medication-assisted treatment for opioid use disorders in correctional settings: An ethics review. International Journal of Drug Policy, 25(6), 1041–1046. Nunn, A., Zaller, N., Dickman, S., Trimbur, C., Nijhawan, A., & Rich, J. D. (2009). Methadone and buprenorphine prescribing and referral practices in US prison systems: Results from a nationwide survey. Drug and Alcohol Dependence, 105 (1–2), 83–88. Office of the Correctional Investigator (2014). Annual report of the Office of the Correctional Investigator 2013–2014. Ottawa: The Correctional Investigator Canada. Tompkins, C. N. E., Wright, N. M. J., Waterman, M. G., & Sheard, L. (2009). Exploring prison buprenorphine misuse in the United Kingdom: A qualitative study of former prisoners. International Journal of Prisoner Health, 5(2), 71–87. Walsh, E., Butt, C., Freshwater, D., Dobson, R., Wright, N., Cahill, J., . . . Alldred, D. (2014). Managing pain in prison: Staff perspectives. International Journal of Prisoner Health, 10(3), 198–208. World Health Organization (2014). Prisons and health. Copenhagen: World Health Organization.