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Treating drug users in prison

Providing methadone maintenance helps addicted prisoners, writes Dr Nat Wright Three years ago I was approached by the prison healthcare department at Her Majesty’s Prison (HMP) Leeds to see if I would be involved in developing services for drug users in prison.

This was in response to successful legal action taken by a number of users against prisons across the country for substandard care they had received.

In particular, users coming in on maintenance methadone medication were put on detoxification programmes that only lasted a number of days, putting them at risk of self-harm and suicide. My remit was to work with clinicians and managers in setting up a methadone maintenance programme.

Over 6,000 prisoners enter HMP Leeds each year and we provide opiate maintenance for just over 2,000.

Earlier this year I was informed by the local drug-related death investigator that the number of deaths related to post-prison release had dropped by 85 per cent since starting the methadone maintenance programme.

Such health gain has not always been straightforward. Some drug users in prison also have a diagnosed personality disorder. The GP treating them needs to avoid being drawn into emotional confrontations and must stick to evidence-based consulting styles for the management of personality disorder.

My view has always been that applying the principles of good general practice consulting to even the most demanding of patients tends to lead over time to an improvement in the doctor–patient relationship.

Another challenge was the relationship with security staff as we gained a greater understanding of each others’ agendas and working practices.

Opiate maintenance
Often a prison officer would approach me and ask why we were providing opiate maintenance to prisoners.

Either explicit or implicit in the question was the view that drug dependence was self-inflicted and that the user would be able to control.

There was a feeling that users should be given one chance to ‘get off’ drugs.

We have worked hard on raising awareness that drug dependence is a state of ill health for which there is now a strong evidence base for opiate maintenance therapy.

The WHO’s action some years ago in adding the drugs methadone and buprenorphine to its international list of essential drugs has been helpful in promoting this awareness.

The listing of methadone and buprenorphine alongside recommendations for drugs to treat, for example, TB and other life-threatening conditions, was an acknowledgement that drug dependence is a state of ill health, which is over-represented in areas of poverty and for which there are scientifically proven effective treatments.

Prescribing in prison is not just about opiate maintenance treatment. We undertake well in excess of 1,000 detoxifications per year and are running possibly one of the world’s largest prison-based detoxification randomised controlled trials.

Other areas where a GP working in the prison can significantly address health needs is in the management of blood- borne viruses.

For those prisoners diagnosed as hepatitis C positive and who are serving long sentences, prison can be a time when they move away from injecting drugs and undertake treatment for antiviral therapy. GPs can also significantly contribute to addressing mental health needs with the support of the extended multidisciplinary team in the prison.

Dr Wright is a GP and clinical director for substance misuse at HMP Leeds. Contact him at n.wright@leeds.ac.uk

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