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Substance misuse detainees in police custody. Guidelines for clinical management
JournalofClinicalForensieMedicine(1995)2, 173 174 © APS/Pearson Professional Ltd 1995
~
_J2U_R_N_AkO_F~ CLINICAL FORENSIC
II I!
BOOK REVIEWS
prescriber! The now unfashionable Hippocratic approach has dearly been discarded by some, but to my mind it should never be forgotten, whatever modern clinicians may say. Doing precisely what the addict demands is usually fraught with danger. In Chapter 2 (section 2.2.1) a passage reads: 'substance misusers who are involved in maintenance programmes generally are honest when reporting recent drug use'. However, in police custody (section 2.2.2), there is an admission that frankness appears less common! I have never found frankness to be a hallmark of any substance misuser. In my view, every prisoner (irrespective of his or her alleged offence, intoxicated or sober) is entitled to a sympathetic hearing but every case must be given the most careful and thorough consideration before any medication is prescribed. Frequently, I have discovered the withholding of a controlled drug or its substitute has had the most beneficial effect, especially after the ingestion of food and comfort. So many misusers suffer from the effects of multiple addictions which include tobacco, alcohol, solvents, aerosols and hard drugs. Much good advice is contained in Chapter 3: 'The overriding consideration of the attending forensic physician is the clinical safety and well-being of the detainee' (3.1.2). Nonetheless, the practical police surgeon faced by a known violent recidivist misuser will have to consider the welfare of the family, the safety of the public and the urgent needs of the police service. Any individual incarcerated in a police cell is entitled to the same standard of care as any other member of the public, but this standard is extremely difficult to achieve with a hostile, inconsiderate patient/prisoner. Busy police doctors - often working in several different police stations are unlikely to develop strategies for future management, as the document seems to suggest is necessary. There has been a dangerous tendency in medical practice to prescribe 'a pill for every ill' and this has been sustained largely by the National Health Service ethos of free-at-the-time medicine for the majority of patients in the scheme. I have never understood the need for the most generous prescribing of methadone to known criminals who promiscuously take street-drugs to supplement their addiction. The correct supervision of drugs taken in custody is of great importance. Fortunately, the advice in the booklet is sound: 'good practice dictates that the forensic physician will have previously examined the detainee' before prescribing. The Codes of Practice in PACE (1984) require that 'a person may administer any such drug to him/herself only under the personal supervision of a police surgeon'. The booklet deals adequately with confessions, fitness for interviews and the need for notification and reporting. It reminds doctors in England and Wales of their statutory duty to notify in writing the Chief Medical Officer at the Home Office of any contact with a known or suspect addict detainee. The controlled drugs requiring notification are listed in the booklet. The fourth and final chapter concentrates on the management of specific drug problems. The symptoms and signs of opiate withdrawal are tabled as are the opiate equivalents for withdrawal. In the same manner, benzodiazepine withdrawal and dosage is considered. I have never found this structured method of advice of any great assistance in practice although it has many adherents. Clearly naloxone cannot be used in a police station, but I agree completely that when assessing the severity of withdrawal more weight should be given to observable signs than to subjective symptoms. The authors say paracetamol is 'useful for minor aches and pains'. I have found it useful and safe in addicted patients. No dosage has been given for this drug or for the
The Extent and Nature of Organised and Ritual Abuse. Research Findings. By Professor J. S. L a F o n t a i n e . H M S O : L o n d o n . £3.50. I S B N 0-112-21797-8. This study considered 211 cases where organised ritual or satanic abuse of children had been alleged. It was commissioned by the Department of Health and received co-operation from Courts, the Association of Directors of Social Services and the Association of Chief Police Officers. No evidence of satanic abuse was found in the cases studied, though there were cases of a paedophile using so called magic powers to control and abuse children. It was possible to trace the influence of a proselytising campaigner in causing social workers and foster carers in particular to believe that ritual abuse would provide an explanation for the behaviour of very disturbed damaged children. There was concern that children's evidence could be manufactured to suit the preconception of the adults, and it was common to find errors in the manuscripts and selective editing of video recorded interviews. Though no evidence of satanic abuse was found, the researchers do not say they have proved conclusively that it never occurs. They have however, by careful inquiry, altered the balance of probability as to whether it does occur. It is most unfortunate that an obsession with the possibility of satanic abuse, fostered by 'empire builders' in the US and Europe promoting their beliefs which are accepted uncritically by journalists and others, have focused attention on this theory and caused some of those caring for children to lose sight of the real needs and well-being of the children and their families. It is a short monograph of only 36 pages which should be read by everyone who is involved in the very difficult field of child abuse. RAINE E. I. ROBERTS Manchester, UK
Substance Misuse Detainees in Police Custody. Guidelines for Clinical M a n a g e m e n t . H M S O : D e p a r t m e n t o f Health, Scottish Office H o m e a n d H e a l t h D e p a r t m e n t , Welsh Office, 1994. £4.25. This useful booklet is a report of a medical working group chaired by Hamish Ghodse (Professor of the psychiatry of addictive behaviour at St George's Hospital Medical School, London, UK). Three members of the group are active forensic physicians. The development of the document was initiated by the Association of Police Surgeons, ably supported by the Royal College of Psychiatrists and approved by other bodies including the Royal College of General Practitioners. The subtitle implies the contents are guidelines (not rules) and it endorses principles which indicate good standards of care in the police cell population. Good practice is not universal. In some well-publicised cases in the U K it has been possible to identify, very clearly, bad practice. A wholly liberal approach to management of the drug misuser has produced disastrous results because of some ill-trained, inexperienced doctors doing part-time forensic medical work. Substance misusers in custody present a stiff challenge to the wiliest physicians. Shrewd practitioners will always be alert to the twin dangers of prescribing or not prescribing controlled drugs; always bearing in mind a need to justify their actions in a court setting, perhaps many months away. In this context I make claim to be a minimalist, verging on a non173
174 Journal of Clinical Forensic Medicine non-steroidal inflammatories in this section. Stimulant drugs and volatile substances are shunned as are injectable controlled drugs. This must be right. There is a vast amount of useful advice compacted into this small volume. It is succinct and sensible and it will be invaluable as a handbook for the clinician starting out on a career in clinical forensic medicine. It is a pity the covering letter from Kenneth Calman is riddled with minor inaccuracies. I found four mistakes including an incorrect subtitle. Perhaps the Department of Health was testing us, and they were all deliberate? I think we should be told: but we cannot expect perfection at the price of £4.25! ROBIN MOFFAT Senior Forensic Medical Examiner Metropolitan Police Service London, UK
Police Health. A Physician's Guide to the Assessment of Police Officers. By A. Trottier and J. Brown. 1994. C a n a d a C o m m u n i c a t i o n Group: Ottawa, Canada. ISBN 0-660-15391-2 As part of a larger exercise in collating their occupational health practices across the country, medical advisers to the various police forces in the U K are engaged on a comprehensive review of standards for police recruits. Quite properly, traditional ideas of who is or is not fit to be a police officer are changing, for each cavalier or quixotic notion must be justified, a point made very ably by Trottier and Brown. 'Occupational health deals with the member's ability to do police work in a manner that does not threaten public safety. It also deals with the effect of police work on the member.' It is, perhaps, inevitable that public safety come first in a culture where a handgun is one of the normal impedimenta of the patrolling officer, but we in the U K can no longer be complacent on that score. As police training becomes more and more related to the tasks that an officer engages in, so should the standards demanded before and during service be relevant. That has not always been the case. Examples from Canada that do not apply here are the geographical features of so vast a country; much emphasis in the book centres on the distance an officer might have to be transported for medical help. In terms of occupational factors, the Canadian system grades members of the force according to the degree of physical, psychological and operational stresses likely to apply. In this country, it becomes ever more difficult to accommodate those who are unfit for operational duties. The °bottom line' philosophy takes no account of the consequential loss of operational experience which, although confined to an office, could be put to good use. On the other hand, it is not always a kindness to tuck away in a safe berth an officer who may profit from the opportunities to be found away from the job. A most useful task analysis of the work of general duty constables is set out, including much that is not measurable by the doctor, yet helpful to any medical adviser not familiar with the range of activities expected of officers. The lists of diseases, with comments designed to show why these may (or may not) exclude admission or influence deployment, seem a bit on the elementary side. The comprehensive nature of the care expended at routine, biennial assessments is shown by the suggestion that a female have her breasts, pelvis and rectum examined (including an annual smear) and flexible
sigmoidoscopy and mammography as appropriate; males are recommended to have the equivalent examinations, including prostate specific antigen. Measurement of hearing, urinalysis, blood cholesterol and gamma glutamyl transferase assays are requirements. This book is designed not to teach medicine, but to assist physicians who are designated to examine members of the Royal Canadian Mounted Police. In its present form, it is likely to be little used elsewhere. W. D. S. MCLAY Chief Medical Officer, Strathclyde Police, Strathclyde, UK
Practical Forensic Psychiatry. Derek Chiswick a n d Rosemarie C o p e (Eds). 1995. Gaskell/The Royal College o f Psychiatrists. £17.50. 359 pp. I S B N 0-902241-78-8. With this book, the Royal College of Psychiatrists continues its series of seminars which contain much material of interest to those who work in other disciplines. What is in it for forensic clinicians? A major component of the medical work in police stations concerns care of those in custody. The great bulk of these are untried, but police surgeons need no reminder of the aftermath when prisoners are decanted into the reluctant arms of the police. Simple overcrowding has been one cause, unrest among staff another, but who will forget a series of riots, most spectacularly the one leading to the destruction of Strangeways Prison in Manchester, UK. Chiswick and Dooley, writing on psychiatry in prisons, remind us that this riot started on All Fools' Day (April 1) in 1990. If medical or psychiatric care is difficult to achieve in prison, how much more difficult is it going to be in a police station with no trained staff and visits only from the police surgeon. Chiswick and Dooley make the observation that remand in custody for the purpose of securing treatment of psychiatric conditions is doomed to failure, but the attempt may well inflate the prevalence of psychiatric disorder in the prison population. The publication states: 'substance abuse and personality disorder are the other areas of unmet need, although it may be unrealistic to expect prisons to achieve therapeutic gains that have eluded psychiatry'. Does this not suggest that it is somewhat arrogant to believe that we can have any influence on the lives or behaviour of prisoners with drug abuse problems while they remain in police custody? A brief but clear account is given of mental health legislation in the UK, and a chapter devoted to the practice of psychiatry within the criminal justice systems. These systems are themselves described in a succinct way which could serve as a handy introduction for any tyro police surgeon. The writing style reflects the multiple authorship, but the book must have been tightly edited, for it is very readable. Although writing from a somewhat different perspective, the editors end with a chapter on ethical issues from which all who practice clinical forensic medicine could profit. W. D. S. MCLAY Chief Medical Officer, Strathclyde Police, Strathclyde, UK
~
_J2U_R_N_AkO_F~ CLINICAL FORENSIC
II I!
BOOK REVIEWS
prescriber! The now unfashionable Hippocratic approach has dearly been discarded by some, but to my mind it should never be forgotten, whatever modern clinicians may say. Doing precisely what the addict demands is usually fraught with danger. In Chapter 2 (section 2.2.1) a passage reads: 'substance misusers who are involved in maintenance programmes generally are honest when reporting recent drug use'. However, in police custody (section 2.2.2), there is an admission that frankness appears less common! I have never found frankness to be a hallmark of any substance misuser. In my view, every prisoner (irrespective of his or her alleged offence, intoxicated or sober) is entitled to a sympathetic hearing but every case must be given the most careful and thorough consideration before any medication is prescribed. Frequently, I have discovered the withholding of a controlled drug or its substitute has had the most beneficial effect, especially after the ingestion of food and comfort. So many misusers suffer from the effects of multiple addictions which include tobacco, alcohol, solvents, aerosols and hard drugs. Much good advice is contained in Chapter 3: 'The overriding consideration of the attending forensic physician is the clinical safety and well-being of the detainee' (3.1.2). Nonetheless, the practical police surgeon faced by a known violent recidivist misuser will have to consider the welfare of the family, the safety of the public and the urgent needs of the police service. Any individual incarcerated in a police cell is entitled to the same standard of care as any other member of the public, but this standard is extremely difficult to achieve with a hostile, inconsiderate patient/prisoner. Busy police doctors - often working in several different police stations are unlikely to develop strategies for future management, as the document seems to suggest is necessary. There has been a dangerous tendency in medical practice to prescribe 'a pill for every ill' and this has been sustained largely by the National Health Service ethos of free-at-the-time medicine for the majority of patients in the scheme. I have never understood the need for the most generous prescribing of methadone to known criminals who promiscuously take street-drugs to supplement their addiction. The correct supervision of drugs taken in custody is of great importance. Fortunately, the advice in the booklet is sound: 'good practice dictates that the forensic physician will have previously examined the detainee' before prescribing. The Codes of Practice in PACE (1984) require that 'a person may administer any such drug to him/herself only under the personal supervision of a police surgeon'. The booklet deals adequately with confessions, fitness for interviews and the need for notification and reporting. It reminds doctors in England and Wales of their statutory duty to notify in writing the Chief Medical Officer at the Home Office of any contact with a known or suspect addict detainee. The controlled drugs requiring notification are listed in the booklet. The fourth and final chapter concentrates on the management of specific drug problems. The symptoms and signs of opiate withdrawal are tabled as are the opiate equivalents for withdrawal. In the same manner, benzodiazepine withdrawal and dosage is considered. I have never found this structured method of advice of any great assistance in practice although it has many adherents. Clearly naloxone cannot be used in a police station, but I agree completely that when assessing the severity of withdrawal more weight should be given to observable signs than to subjective symptoms. The authors say paracetamol is 'useful for minor aches and pains'. I have found it useful and safe in addicted patients. No dosage has been given for this drug or for the
The Extent and Nature of Organised and Ritual Abuse. Research Findings. By Professor J. S. L a F o n t a i n e . H M S O : L o n d o n . £3.50. I S B N 0-112-21797-8. This study considered 211 cases where organised ritual or satanic abuse of children had been alleged. It was commissioned by the Department of Health and received co-operation from Courts, the Association of Directors of Social Services and the Association of Chief Police Officers. No evidence of satanic abuse was found in the cases studied, though there were cases of a paedophile using so called magic powers to control and abuse children. It was possible to trace the influence of a proselytising campaigner in causing social workers and foster carers in particular to believe that ritual abuse would provide an explanation for the behaviour of very disturbed damaged children. There was concern that children's evidence could be manufactured to suit the preconception of the adults, and it was common to find errors in the manuscripts and selective editing of video recorded interviews. Though no evidence of satanic abuse was found, the researchers do not say they have proved conclusively that it never occurs. They have however, by careful inquiry, altered the balance of probability as to whether it does occur. It is most unfortunate that an obsession with the possibility of satanic abuse, fostered by 'empire builders' in the US and Europe promoting their beliefs which are accepted uncritically by journalists and others, have focused attention on this theory and caused some of those caring for children to lose sight of the real needs and well-being of the children and their families. It is a short monograph of only 36 pages which should be read by everyone who is involved in the very difficult field of child abuse. RAINE E. I. ROBERTS Manchester, UK
Substance Misuse Detainees in Police Custody. Guidelines for Clinical M a n a g e m e n t . H M S O : D e p a r t m e n t o f Health, Scottish Office H o m e a n d H e a l t h D e p a r t m e n t , Welsh Office, 1994. £4.25. This useful booklet is a report of a medical working group chaired by Hamish Ghodse (Professor of the psychiatry of addictive behaviour at St George's Hospital Medical School, London, UK). Three members of the group are active forensic physicians. The development of the document was initiated by the Association of Police Surgeons, ably supported by the Royal College of Psychiatrists and approved by other bodies including the Royal College of General Practitioners. The subtitle implies the contents are guidelines (not rules) and it endorses principles which indicate good standards of care in the police cell population. Good practice is not universal. In some well-publicised cases in the U K it has been possible to identify, very clearly, bad practice. A wholly liberal approach to management of the drug misuser has produced disastrous results because of some ill-trained, inexperienced doctors doing part-time forensic medical work. Substance misusers in custody present a stiff challenge to the wiliest physicians. Shrewd practitioners will always be alert to the twin dangers of prescribing or not prescribing controlled drugs; always bearing in mind a need to justify their actions in a court setting, perhaps many months away. In this context I make claim to be a minimalist, verging on a non173
174 Journal of Clinical Forensic Medicine non-steroidal inflammatories in this section. Stimulant drugs and volatile substances are shunned as are injectable controlled drugs. This must be right. There is a vast amount of useful advice compacted into this small volume. It is succinct and sensible and it will be invaluable as a handbook for the clinician starting out on a career in clinical forensic medicine. It is a pity the covering letter from Kenneth Calman is riddled with minor inaccuracies. I found four mistakes including an incorrect subtitle. Perhaps the Department of Health was testing us, and they were all deliberate? I think we should be told: but we cannot expect perfection at the price of £4.25! ROBIN MOFFAT Senior Forensic Medical Examiner Metropolitan Police Service London, UK
Police Health. A Physician's Guide to the Assessment of Police Officers. By A. Trottier and J. Brown. 1994. C a n a d a C o m m u n i c a t i o n Group: Ottawa, Canada. ISBN 0-660-15391-2 As part of a larger exercise in collating their occupational health practices across the country, medical advisers to the various police forces in the U K are engaged on a comprehensive review of standards for police recruits. Quite properly, traditional ideas of who is or is not fit to be a police officer are changing, for each cavalier or quixotic notion must be justified, a point made very ably by Trottier and Brown. 'Occupational health deals with the member's ability to do police work in a manner that does not threaten public safety. It also deals with the effect of police work on the member.' It is, perhaps, inevitable that public safety come first in a culture where a handgun is one of the normal impedimenta of the patrolling officer, but we in the U K can no longer be complacent on that score. As police training becomes more and more related to the tasks that an officer engages in, so should the standards demanded before and during service be relevant. That has not always been the case. Examples from Canada that do not apply here are the geographical features of so vast a country; much emphasis in the book centres on the distance an officer might have to be transported for medical help. In terms of occupational factors, the Canadian system grades members of the force according to the degree of physical, psychological and operational stresses likely to apply. In this country, it becomes ever more difficult to accommodate those who are unfit for operational duties. The °bottom line' philosophy takes no account of the consequential loss of operational experience which, although confined to an office, could be put to good use. On the other hand, it is not always a kindness to tuck away in a safe berth an officer who may profit from the opportunities to be found away from the job. A most useful task analysis of the work of general duty constables is set out, including much that is not measurable by the doctor, yet helpful to any medical adviser not familiar with the range of activities expected of officers. The lists of diseases, with comments designed to show why these may (or may not) exclude admission or influence deployment, seem a bit on the elementary side. The comprehensive nature of the care expended at routine, biennial assessments is shown by the suggestion that a female have her breasts, pelvis and rectum examined (including an annual smear) and flexible
sigmoidoscopy and mammography as appropriate; males are recommended to have the equivalent examinations, including prostate specific antigen. Measurement of hearing, urinalysis, blood cholesterol and gamma glutamyl transferase assays are requirements. This book is designed not to teach medicine, but to assist physicians who are designated to examine members of the Royal Canadian Mounted Police. In its present form, it is likely to be little used elsewhere. W. D. S. MCLAY Chief Medical Officer, Strathclyde Police, Strathclyde, UK
Practical Forensic Psychiatry. Derek Chiswick a n d Rosemarie C o p e (Eds). 1995. Gaskell/The Royal College o f Psychiatrists. £17.50. 359 pp. I S B N 0-902241-78-8. With this book, the Royal College of Psychiatrists continues its series of seminars which contain much material of interest to those who work in other disciplines. What is in it for forensic clinicians? A major component of the medical work in police stations concerns care of those in custody. The great bulk of these are untried, but police surgeons need no reminder of the aftermath when prisoners are decanted into the reluctant arms of the police. Simple overcrowding has been one cause, unrest among staff another, but who will forget a series of riots, most spectacularly the one leading to the destruction of Strangeways Prison in Manchester, UK. Chiswick and Dooley, writing on psychiatry in prisons, remind us that this riot started on All Fools' Day (April 1) in 1990. If medical or psychiatric care is difficult to achieve in prison, how much more difficult is it going to be in a police station with no trained staff and visits only from the police surgeon. Chiswick and Dooley make the observation that remand in custody for the purpose of securing treatment of psychiatric conditions is doomed to failure, but the attempt may well inflate the prevalence of psychiatric disorder in the prison population. The publication states: 'substance abuse and personality disorder are the other areas of unmet need, although it may be unrealistic to expect prisons to achieve therapeutic gains that have eluded psychiatry'. Does this not suggest that it is somewhat arrogant to believe that we can have any influence on the lives or behaviour of prisoners with drug abuse problems while they remain in police custody? A brief but clear account is given of mental health legislation in the UK, and a chapter devoted to the practice of psychiatry within the criminal justice systems. These systems are themselves described in a succinct way which could serve as a handy introduction for any tyro police surgeon. The writing style reflects the multiple authorship, but the book must have been tightly edited, for it is very readable. Although writing from a somewhat different perspective, the editors end with a chapter on ethical issues from which all who practice clinical forensic medicine could profit. W. D. S. MCLAY Chief Medical Officer, Strathclyde Police, Strathclyde, UK