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Life as a prison GP Life as a prison GP

Life as a prison GP - PowerPoint Presentation

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Life as a prison GP - PPT Presentation

Dr Ben Sinclair MRCGP Lead GP HMP Lindholme High Security GP HMP Full Sutton York VTS January 2015 With Thanks to Dr Mark Pickering for contributing material to this presentation What do we hope to cover ID: 511652

issues prison secure hmp prison issues hmp secure pregabalin local prisons pain gabapentin gps prescribing drug environment medicine opportunities

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Slide1

Life as a prison GP

Dr Ben Sinclair MRCGPLead GP HMP Lindholme High Security GP HMP Full Sutton

York VTS January 2015

With Thanks to

Dr

Mark Pickering for contributing material to this presentationSlide2

What do we hope to cover?

National and Local prison servicePrison medicine – commissioning/provisionPrescribing challenges – inside and outsideSecure Environment Hazards and opportunities

CASESCommunication – how can GPs help each other?Resources and opportunities in prison medicine

Questions – ask as we go alongSlide3

the prison population – england/wales

July 2014 – 85,600 prisoners81,700 male & 3,900 female127 prisons

Category A-D (male)Female (closed/open)Young Offender InstitutionsImmigration Removal Centres‘Mains’ or ‘VPs’

Also secure psychiatric hospitalsHigh, Medium, Low Secure (nearest Stockton Hall)Slide4

Local prisons IN South Yorkshire

HMP Doncaster ‘Marshgate’ SERCO Cat B local/remand ~1,100 inmates

High turnover – From courts, short sentences“off the Streets”Chaotic population Slide5

Local prisons IN South Yorkshire

HMP Moorland near DoncasterCat C working ~ 1,000 inmatesYOs, sex offenders, foreign nationals, mainsSlide6

Local prisons IN South Yorkshire

HMP Lindholme near DoncasterCat C working ~1,000 inmatesYoung drug crime population“Best Prison Gym in the UK”Slide7

Local prisons IN South Yorkshire

HMP Hatfield near DoncasterCat D working ~260 inmates“Open” prisonSlide8

HMP Leeds “

Armley”Slide9

HMP Full Sutton near Stamford BridgeSlide10

Common Problems in prison medicine

Musculoskeletal (often neglected)Occupational hazards – barbed wire, police dogs…Chronic Pain incl. neuropathicMental health – inc. forensic psychiatristsAddiction – opiates, alcohol, POMs, BenzosConsequences – Hep C, DVT, liver disease

Hep C inreach service – good treatment resultsSlide11

Secure environment prescribing

Population characterised by addiction/abuseConcentration of tradeable, abusable meds‘chemical haze’ and pocket money

Balance of efficacy v securityRisks – overdose, trading, addictionIn Posession Medication Risk assessment observed, weekly, monthly – patient v medication.

Verifying with community GPs – false claims“You can’t stop my meds! I want mi pregabs

!”Slide12

Secure Environment Hazards pay offThreats of legal action / complaints =

cpd Challenging consultations = new skills / SEAsVolatile situation = admin time no QOF no visitsLow risk of physical harm but be on guardSlide13

Whats It like? 1Officers

Locked waiting roomLanguageVulnerable vs manipulative patientsViolence and gang cultureHealthcare building protectedSystm 1 “prison” sealed from outsidePrison liasonsSlide14

Whats It like? 2

DisturbancesHospital transport issues re triageSmall close teamSlide15

Patient MR G20yr old NFAW with URTIReports dry skin dry scalp asks for e45 coal tar

Has prison tattoos what issues?Slide16

Cases Mr M

Age 82 Serving Life for murderSlide17

Mr MElderly Bangladeshi, DM,COPD < BMI- issues?

Brings another inmate to translate – issues?Begins to cough c/o sweats – Differential?Diagnosed with TB – what prison issues arise?Admitted for Rx; returns to prison frail: subduralAdmitted bedbound non communicative…What issues surround his care now?

Infective disease, compassionate release, suitable location, death in custody, coroner.Slide18

Mr J R High Secure violent patientDiagnosis

shizotypal dissociative PD DSHNumerous assaults on Medical staffEpileptic but intermittent compliance- issues?Begins to breath hold to induce fits then assault staff- expressed wish to die – issues?Transported to YDH in status from non compliance – 16 police restrain him 2 NHS staff injuredAlso claims transgender issues while in prison?Slide19

Mr NMSlide20

MR NM Pain management37 yr

old in prison for burglary on MethadoneFall in another prison causes back injury?On gabapentin 800mg tds asking for increase?Seen in pain clinic who advise pregabalin?Threatens to sue you if no Px Pregab 300mg bd

Spot audit shows no meds in possession?Where do we go from here?Slide21

The challenge of ‘neuropathic’ painEasy to claim, hard to

evaluate eg “sciatica”Tenuous links to old injuries/ ScarsAddictive, tradeable medications sought

Gabapentin, pregabalin, tramadolDiscrepancies of history and functionDue diligence required to verify backstoryWarning signs: pt asks for named drug declines all other options and threatens legal actionSlide22

Mr K epileptic34 year old epileptic

On pregabalin and clonazepam for epliepsy?Lost to neurology FU had normal EMG + MRI?D+V on the day of neurology appt hence DNAAlso claims chronic anxiety problems?Slide23

pregabalin and gabapentin – 1

Both potentiate the effects of opioids/alcoholAnxiolytic, sedative, relaxant

& euphoriant‘ideal psychotropic drugs’ Not routinely tested by urine drug screensLearned behaviour (

“I got this Shooting pain”)Easy to get from secondary care & some GPs

Requested

by name

in

drug-using

patients

Concern in those already on opiatesSlide24

Pregabalin and gabapentin – 2

Patients’ statements about pregabalin:-

“If you get the dosing right then you only need to be conscious for a few hours every day”“They are better than crack!”

“I rattled for weeks when you took them off me last time.”Pregabalin

= the new diazepam

We should have similar caution in prescribing it.

BMJ –

Des Spence article 8

Nov 2013

Gabapentin

is better if you feel it’s necessary – it’s less

euphoriant

, less addictive.Slide25

Secure Environment Prescribing

NICE guidance generally unhelpful – CG96 (Neuropathic Pain)Cost-effectiveness only, little awareness of addiction/abuseUpdated version makes only passing generic mention

Local prescribing guidelines now recognising the problems.RCGP Safer Prescribing in Prisons – www.rcgp.org.uk

Imaginative combinations – often unlicensed but evidence-basedNeuropathic pain – amitriptyline

/

nortriptyline

,

carbamazepine

,

duloxetine

rather than

gabapentin

/

pregabalin

.

Pain clinics may not always realise the problem

Specify substance misuse when referring

TENS machines

Depression - SSRIs/venlafaxine rather than

mirtazapine

/

trazodone

Widespread abuse as ‘sleepers’

Doncaster Prison GPs no longer initiate

mirtazapine

/

trazodone

.Slide26

Communication - incoming

SystmOne Prison good between prisons but no connection with communityMay connect with NHS Spine 2016Prison records often limited

Faxed requests from prison to community GPsReception screening (HMP Doncaster) – basic info – current meds (esp need to know if recently started)Do admin or GPs deal with these?

Further info (all prisons) – specific info on a condition – hospital letters, MRIs etcWe know you’re busy but any help appreciated!Slide27

Communication – outgoing

Release process not connected with healthcareCourt, tagging, parole – can be unpredictableDifficult to do routine ‘discharge summary’Should always have a week’s meds and hosp appts

Not always back to previous GPMay be going to bail hostelMay not want you to know what we’ve done!We’d like to improve it - call the prison for infoSlide28

Opportunities in prison medicine

Make a huge difference to a vulnerable populationNeglected field – lots of opportunitySmall pool – leadership opportunitiesWill only stop being a dead-end job if we make it so!

Special interests – MSK, mental health, men’s health, Hep C Sessional/salaried opportunities in GPSlide29

Resources in prison medicine RCGP Secure Environment Group

Regional peer educational meetingsRCGP Substance Misuse and Allied HealthCerts in drug/alcohol misuse, Hep B/C etcBMJ article series – Stephen Ginn http://www.bmj.com/content/345/bmj.e5921

Email : drben@sinclairhealth.co.uk