I'm a prison detox nurse, ask me anything!

[fruitcider]

Jumping on the band wagon!

Obviously I cannot give out any info that breaches official secrets act or may put prison security at risk but I'll do my best to be as open as I can.

After seeing it from the inside do you think the system works? Do you see more people leave in a better place, having dealt with some of their issues or are there more that are angrier and therefore more aggressive as a result of being inside?

The system is completely broken. Until we stop punishing addicts for having fractured lives and putting them in cages nothing will change. The majority of addicts have been abused or neglected as children, how is putting them in prison going to help?

If you could do whatever you wanted, what changes would you make to make prisons the place you'd like them to be? (So changes in law, rules inside prison etc.)

1. decriminalise all drugs
2. stop short term license recall to cut a flow of drugs into prisons
3. sending people that carried out drug related crimes for drug treatment - 40% of all crime is related to drug use
4. utilise the Portuguese model
5. utilise the ACE study and design a service for young adults with high ACE scores to get them into work and education, reducing the risk of problematic substance abuse

Fascinating, thank you. Had a former friend who was a prison officer in fairly benign area, every issue seems so tough to crack! Much more complex world than we assume.

Do you think there's any kind of success in just sending someone for drug treatment? I thought it only worked if someone wanted to change.

This is very interesting fruitcider.
When you say decriminalise all drugs do you mean opiates and spice as well?

- Do you think there's any kind of success in just sending someone for drug treatment? I thought it only worked if someone wanted to change

I read a study a few years ago that suggested the drug treatment orders are just as successful as someone making a decision to go into treatment. Im not sure whether that's because the overall success rate is really low, or because willingness to change is not a factor in how effective treatment is.

When you say decriminalise all drugs do you mean opiates and spice as well?

Yes, decriminalise (but not legalise) the use and possession of small quantities of all drugs. Ideally I would like to see the Portuguese model here.

Following on from your interesting dialogue with Lovemyjob re pregabalin:

Is gabapentin acceptable in your prison? What happens if the patient is offered duloxetine instead of pregabalin but suffers terrible side effects? I tried it for several weeks and felt like I had flu - really sick and dizzy with chills - I could barely get out of bed. And I had uncontrollable shaking. (It was good for the pain though!)

What about patients who are prescribed opiates for pain? Do they just have to detox and put up with the pain? And what if they are prescribed benzos for anxiety (which I imagine would get worse in prison) or as muscle relaxants?

I am on quite a cocktail of prescribed medication including all the above (multiple chronic health issues) and the thought of having to live without them terrifies me. I'm pretty sure I would kill myself if I could find a way due to the level of pain I'd be in without them. If I couldn't kill myself I'd unintentionally be very disruptive because I'd be screaming in pain 24/7. I'm sure you appreciate that not all conditions can be controlled with paracetamol and anti-inflammatories.

I'm not planning on committing any crimes, but is it part of the prison regime that patients have to put up and shut up? Or in practice is it rare for patients with serious chronic pain to be in prison?

sending people that carried out drug related crimes for drug treatment - 40% of all crime is related to drug use

We are not able to send people on drug treatment orders unless they want to do it. It is very frustrating when we see people who could clearly benefit but say they don’t want to come off drugs. We are then stuck as to what to do with them.

I have long been an advocate of trying to treat people in the community whether that be through drug treatment orders, thinking skills programmes, domestic violence programmes etc but the person has to be willing to do these things. It is also difficult when the general public say someone should be locked up for doing x or y but actually we know a short prison sentence will not help at all whereas we stand a chance of rehabilitation with a structured community programme. But the public sees a community sentence as a criminal being ‘let off’.

From my experience I would be surprised if only 40% of crime is drug or alcohol related. I imagine it is far higher.

I'm quite naive, what is spice and how is it different from say, weed or benzos?

Thank you OP. I was thinking of cutting it out. For someone injecting regularly, digging under the skin to retrieve a supply of saleable opioids may be something they'd consider. Perhaps more in the community though where they're not under such close supervision.

Is gabapentin acceptable in your prison? What happens if the patient is offered duloxetine instead of pregabalin but suffers terrible side effects? I tried it for several weeks and felt like I had flu - really sick and dizzy with chills - I could barely get out of bed. And I had uncontrollable shaking. (It was good for the pain though!)

No we do not prescribe any gabapentinoids. We can also use amitryptaline and nortryptaline, or another SSRI.

What about patients who are prescribed opiates for pain? Do they just have to detox and put up with the pain? And what if they are prescribed benzos for anxiety (which I imagine would get worse in prison) or as muscle relaxants?

Well being as opiates are not indicated for chronic pain and benzos are not indicated for long term management of anxiety or muscle spasm then I would certainly want to detox prisoners from those. There are lots of other effective medications to manage those conditions which are not addictive, and actually it's really irresponsible of GPs to prescribe these medications long term.

i am on quite a cocktail of prescribed medication including all the above (multiple chronic health issues) and the thought of having to live without them terrifies me. I'm pretty sure I would kill myself if I could find a way due to the level of pain I'd be in without them. If I couldn't kill myself I'd unintentionally be very disruptive because I'd be screaming in pain 24/7. I'm sure you appreciate that not all conditions can be controlled with paracetamol and anti-inflammatories.

But you do understand that benzos and opiates become less effective over time and more difficult to stop? I would never advocate the use of opiates for non cancer pain for long term management, nor would I agree that leaving someone on benzos for more than 4 weeks is sensible. Pregabalin/gabapentin do have their uses but are less effective than the public are lead to believe. Baclofen for example is a great alternative for back spasms.

I'm not planning on committing any crimes, but is it part of the prison regime that patients have to put up and shut up? Or in practice is it rare for patients with serious chronic pain to be in prison?

We have people with chronic pain all the time, we manage to control their pain levels without benzos and opiates.

From my experience I would be surprised if only 40% of crime is drug or alcohol related. I imagine it is far higher

From my experience you are probably right!

I'm quite naive, what is spice and how is it different from say, weed or benzos?

Hi Lola, if you take a look at talk to frank website it outlines the effects, side effects and risks of all of these drugs.

Most interesting AMA I've seen.

Fruit you sound like you actually care, your patients are lucky to have you.

(Prison, one nurse in particular got my good friend off the drink, more then likely saved her life and she is 6 month sober)

Thank you OP. I was thinking of cutting it out. For someone injecting regularly, digging under the skin to retrieve a supply of saleable opioids may be something they'd consider. Perhaps more in the community though where they're not under such close supervision.

No they would definitely cut them out in prisons, and they wouldn't choose to do it themselves....

Why is all this money spent in the first place?? Why aren't they just not to expected to go cold turkey? It's supposed to be prison. Their addictions shouldn't be encouraged. I doubt alcoholics are given alcohol or supplementary alcohol when they are sent to prison.

Interesting thread

Are you seeing issues with crystal meth?

Yes seeing someone who has taken spice is really quite shocking and some of the legal highs (that I think were made illegal recently) are very concerning to (I work with ex offenders)

Is drugs or drink the worst for people arriving in prison? I'm assuming once you're in the bar facilities aren't so great so drugs reign inside.

How do you detox someone from alcohol and how long does it take?

If a corrupt member of staff was passing drugs what would you do?

Well being as opiates are not indicated for chronic pain and benzos are not indicated for long term management of anxiety or muscle spasm then I would certainly want to detox prisoners from those. There are lots of other effective medications to manage those conditions which are not addictive, and actually it's really irresponsible of GPs to prescribe these medications long term.

But you do understand that benzos and opiates become less effective over time and more difficult to stop? I would never advocate the use of opiates for non cancer pain for long term management,

I've been on long term opioid therapy for 19 years so far, for chronic pain due to a spinal injury, under the care of a pain clinic

I saw my pain consultant yesterday in fact - we agreed to my first dose increase of my modified release meds for a long time, which is of course due to the downregulation of opioid receptors that occurs over time as tolerance builds. I was taking my max dose of breakthrough oxycodone IR daily, so my GP referred me back to see my pain consultant to see if my MR oxycodone should be upped.

They are very, very effective for managing my pain

We have tried many different therapies with limited success

Interventional pain procedures: steroid injections and radiofrequency denervation

Anti inflammatories: both NSAIDS and COX-2

Neuropathic pain meds: pregabalin, gabapentin, amitrypitline, oxcarbazepine

Opioids: codeine, dihydrocodeine, tramadol, oxycodone MR and IR, morphine and fentanyl patches

The opioids allow me to have a very functional life - I work, pay my taxes, go to the gym, have a social life

I came off them completely whilst undergoing IVF and during my (sadly unsuccessful) pregnancies and the difference was stark - I couldn't work, I was sleeping about 2h a night, the pain preventer me from functioning. I didn't have any physical withdrawal (I've only ever had withdrawal once, when I came off fentanyl too quickly, which was horrible), but my uncontrolled pain was beyond awful

I have tolerance
I have limited dependence
I am not addicted

I have done pain management courses, practice meditation, undergo regular physiotherapy, and utilise a range of pain management strategies

The opioids are clearly not ideal but they make the difference between being able to function and not

My pain consultant is happy with my regimen and keeps me under regular review.

Opioids shouldn't be used unless necessary and clearly the prison population is a specific case in and of itself. But for certain people and certain types of pain (nociceptive, non neuropathic, non inflammatory(, they can be very effective.

My GP will only prescribe my pain meds under the direction of my pain consultant. They will not make any dose changes without his say so. So I don't personally believe they're irresponsible for following the advice of a consultant who's one of the country's leading pain specialists.

Yes, tolerance builds. Yes my dose has and will change over time. But as with anything, it has to be considered on a case by case basis.

whats the wierdest thing a prisoner has smuggled in and how did they do it?

Thanks for answering. Interesting that detoxing is prioritised over pain management. I think I had better stay home In case I inadvertently commit a crime!

Such a shame there is no real alternative to pregabalin - most anti-depressants are quite hit-and-miss for nerve pain. And a shame that those who abuse it have stolen the chance of effective nerve-pain relief from those who need it.

Sorry for the side-track but I feel I have to defend my doctors' position on pain relief... I'm in Europe (the continent, not the EU) so maybe the prescribing recommendations are different. I understand about dependence and the lessening of the effect of opiates over time. However this is not the case for everyone and I have managed to stay on the same dose for many years and it is still working. I am under a multi-disciplinary team of doctors at a pain clinic in a major European city and they are in agreement that my medication regime - honed over many years - is appropriate for my multiple serious conditions. I am not under some small-town GP who is a little too free with the prescription pad! I think it is hard to come up with a one-size-fits-all solution to chronic pain when there are a lot of different factors involved, and therefore it's a bit rash to decide that opiates can never ever be part of that regime. One of my consultants has actually said he would prefer to see me on a low dose of oxycodone rather than a high dose of Tramadol (a lower class of pain med), because Tramadol is a more complex drug with more chances of side effects and complications.

Would the opinion of the prisoner's doctors be taken into account when deciding to radically change a patient's medical regime?

Cross-posted with bananafish - sorry you are in this position but happy to see my defence of opiates for chronic pain backed up! I too tried many different approaches before ending up on the regime I have today. I too worked for many years on this regime though an extra issue has put me out of action in the last couple of years.

One of my consultants has actually said he would prefer to see me on a low dose of oxycodone rather than a high dose of Tramadol (a lower class of pain med), because Tramadol is a more complex drug with more chances of side effects and complications.

Same. Tramadol is a complicated drug because it's not a pure opioid, and works on the serotonergic and noradrenergic systems. Which means not compatible with SSRI, increased risk of serotonin syndrome and seizure risk if combined with amitrypitline, and increased risk of seizure threshold generally - which isn't ideal if you're epileptic like me. My consultant said a pure opioid like oxycodone is preferable to the US model where they're combined with paracetamol, as the long term impact on the liver is significantly higher.