by Tom Cox MRPharmS, Lead Prison Pharmacist.
Medicines optimisation in prison – the challenge
It’s long been recognised within prison populations that there’s a high prevalence of substance use disorder in connection with prescription medicines. This is often found alongside problematic polypharmacy situations.[i] My main objective as a Lead Prison Pharmacist is to optimise medicines and resolve problematic polypharmacy, to try and rehabilitate people held in custody.
Medicines optimisation within a prison takes many forms, just as it does in other areas of health care. It starts with comprehensive medicines reconciliation when people arrive at the prison. Compared with the general population, people in custody have often lived chaotic lifestyles, either on the outside of prison, or perhaps in other prisons, so the first step is to understand what they have been taking, and how they have or have not been managing their medicines.
A particular problem we encounter during medicines reconciliation is that when a person arrives in prison, they often have other people’s prescription medicines in their possession, as well as their own. This forms important evidence for any resulting medicines optimisation.
Aiming for rehabilitation
As we’re aiming to rehabilitate people and reduce their likelihood of reoffending, pharmacy in prison is a collaborative effort, perhaps even more so than in other health care environments. An example of this is the need for joint medication reviews. Because of the challenges associated with manipulative and intimidating behaviours often expressed by people in prison, having a multidisciplinary medication review conducted between the prison GP, the prison pharmacist and the person is incredibly beneficial. This helps us to formulate the most appropriate way forward with a person’s prescribed medicines. Communicating the plan to their residential Prison Officers, within boundaries of confidentiality, also helps to seal the collaborative effort.
Within prison, people were traditionally restricted from holding any medicines in their possession. However, such institutional care culture is not conducive to rehabilitation and self-care. The pharmacy team therefore actively helps with the safe management of medicines in-possession, while liaising with prescribing colleagues ensures this is correctly risk assessed and monitoring is put in place.
Part of this monitoring is seeing people in their rooms to discuss and visualise how they are managing their medicines. A community pharmacy equivalent of this would be a domiciliary medicines use review, which shows that while the prison setting may be slightly removed from normality, the care we give has many similarities to that given in the community. Trying to keep care as ‘normal’ as possible is essential for improving the chance of positive outcomes and rehabilitation.
Playing a vital part in the multi disciplinary team
In the multidisciplinary team of prison healthcare, the pharmacy team collaborates with all the other healthcare teams. For example, a pharmacist attends the clinical decision meeting for people with a substance use disorder, and their presence helps balance the risks of prescribed medicines alongside the risks presented from their substance use disorder. For people who are being cared for within the mental health and learning disabilities team, as with everyone, it’s essential for them to have good understanding behind the reasons for their medicines. This takes active involvement of pharmacists and pharmacy technicians, especially in providing easy to understand education. Pharmacists working alongside members of the physiotherapy team mean that people are not inappropriately prescribed long-term opiate analgesics, when work with a physiotherapist can resolve the pain being experienced.
The importance of long-term conditions treatment and palliative care in prison
The prison population has a higher burden of disease than the general population[i], and thus it’s important for the pharmacy team to contribute towards the care of people with long-term conditions. With lower levels of literacy and polypharmacy, pharmacy staff can help people understand the importance of life-long medicines to get the best possible health outcomes. This is on top of the clinical pharmacist contribution to the physiological monitoring and safe-prescribing of treatment.
With an ageing prison population, the reality is that more and more people are dying while in custody.[ii] This presents specific challenges around the delivery and administration of end-of-life medicines within a secure setting, where controlled drugs have to be carefully managed, even more so than other settings. My role as a pharmacist is to ensure these challenges are overcome, so that we can give people who are dying in prison the dignity and quality of care that everyone deserves. As an expert in medicines and associated patient safety, while often difficult to deliver, I’m there to make sure that people can, where appropriate, hold controlled drugs in their possession to appropriately manage their pain. This involves complex working partnerships with prison service colleagues both on the person’s community and also the prison security department, in order to ensure the risk is managed and other people are not harmed by the potential diversion.
Delivering lifesaving care
An unfortunate aspect of current prison life is the availability of illicit substances, particularly synthetic cannabinoids. Alongside my wider health professional colleagues, we all have a duty to respond to instances of acutely unwell people from the effects of these substances. This includes the administration of intermediate life support skills, and regular use of resuscitation and airway management. This may be where prison pharmacy varies most from a typical pharmacist’s job, as any healthcare professional with clinical training and appropriate experience can be involved in this lifesaving care, especially in simultaneous casualty situations.
Uniquely challenging, uniquely rewarding
Working as part of a collaborative multidisciplinary team is a rewarding part of the job, and there is never a dull day with the unique challenges to overcome. As lead pharmacist, my wider leadership responsibility in the prison and daily collaboration with prison governors means my knowledge can be used to reduce the negative impact medicines can have on the wider running of a prison.
On a more personal level, it is incredibly rewarding to speak to peoples’ families, particularly when their loved ones in prison have for years been sedated by inappropriately prescribed medicines and in a ‘zombie’-like state. Following medicines optimisation, the families feel like they have got their loved one back, and the person is making more of their life, even actively taking part in the same prison running club that I attend! That knowledge that someone’s life has been, to an extent, rehabilitated through medicines optimisation is what we are here for.