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.

Thank you, he does only have a few days left which is good. We tried to get to visit him but struggled to book it but that's another story...

He's an alcoholic but I seriously doubt he's told anyone - is in denial and often stops cold turkey himself (even tho he's been told how dangerous this is) only to start drinking again.

I'm just hoping 2 weeks without a drink and the experience of prison may help him turn a corner.

Regina that is exactly the kind of situation that worries me

And what if the prison faxes the GP re the meds, the GP doesn't get the fax or is busy and forgets to reply... prison doesn't chase up.... then patient doesn't have essential meds (eg heart meds, blood pressure meds) and gets very sick or worse... so scary...

I just believe there are exceptions to every rule - maybe 9,999 out of 10,000 people who are in prison and take certain medication are addicts, but what about the one person who has been under a pain clinic and used the medication responsibly for 15 years... then is imprisoned for a minor offence and dies in horrible pain because their medication is stopped? Does anyone care about that one person who slips through the net, or is he/she just collateral damage? Does the system prefer to uphold the view that 100% of prisoners on medication must be addicts, full stop, no questions asked, ever?

No, like I said I'm a detox nurse so all prisoners coming to me have tested positive for illicit drugs in reception. If someone tests positive to opiates only but they are prescribed tramadol for example, they may come to me for monitoring if they appear to be in withdrawals and we switch them to 24 hour modified release tablets under strict supervision.

It's very common for addicts to come in prescribed methadone, pregabalin, tramadol, mirtazepine, diazepam and zopiclone. There is no way on earth I would administer all of that. We would increase the methadone and discontinue the tramadol to prevent severe withdrawals/rebound pain, discontinue the zopiclone and detox from diazepam and pregabalin. Methadone is a very effective pain killer and is harder to divert because it is liquid.

I've only had one patient that was an addict and under pain clinic, he was on sublingual buprenorphine and pregabalin so we switched him to liquid pregabalin and left him on the buprenorphine. We aren't cold hearted even though it may seem that way

We always hear about female prisoners having a lesbian relationship inside. Does this happen regularly in a male prison? The women tend to have stable relationships (ie until one is released) - does that happen in male prisons?

I'm sure it does but it is very much taboo and not spoken about EVER.

And what if the prison faxes the GP re the meds, the GP doesn't get the fax or is busy and forgets to reply... prison doesn't chase up.... then patient doesn't have essential meds (eg heart meds, blood pressure meds) and gets very sick or worse... so scary...

If it is essential medication eg for epilepsy, heart conditions etc we will chase it up. We have an administrator that works full time doing this.

This is fascinating. Thank you for sharing!

He's an alcoholic but I seriously doubt he's told anyone - is in denial and often stops cold turkey himself (even tho he's been told how dangerous this is) only to start drinking again.

I would be surprised if healthcare didn't pick this up at the secondary health screen - I can spot someone in withdrawals from a mile off!

What is your training and what drew you to this? I love these threads!

What is your training and what drew you to this? I love these threads!

My background is community recovery services and hostel support. I'm a RMN, trained because I wanted to work more clinically with addicts

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,

Thank you to banana and twotabby for replying to this before I had chance to, and saying everything I would have wanted to, you’ve saved me a lot of time and effort!

Fruit, you should be aware that it’s far from conclusive that long term management of chronic pain using opioids doesn’t work. See this very recent study:

www.painnewsnetwork.org/stories/2018/5/3/study-finds-opioid-medication-effective-for-chronic-pain

By the time many people are prescribed heavy duty opioids it’s not something that has been unthinkingly prescribed by a GP, it’s the result of a very long journey into and through a specialised Pain clinic, and is the last resort for my patients because the alternatives you mention simply have not worked.

I am a long term chronic pain patient under the pain clinic prescribed daily morphine, btw. It horrifies me to think that someone else in my position who has committed a crime (or perhaps not: don’t forget a remand prison is also used for people who are pre trial, have not been convicted and may be found innocent) may find that upon entry to prison, their essential medications (prescribed by Pain consultants) are refused to them. I simply can’t imagine the lack of control, coupled with immense pain, and how I would survive it.

There are so many misconceptions out there about the use of opioids for pain, sometimes coming from clinical staff who haven’t done any independent research into the topic. I’m really genuinely thankful to banana and twotabby for the work you’ve put into this thread in discussing this with OP and educating readers!

I’m so disturbed by the cavalier attitude of ‘no way on earth would I prescribe all of that’ about a patient whose own doctor (no offence intended, but doctors do have a much longer and more in depth training than nurses) saw it fit to prescribe this regimen of medications.

PS OP: I’m not trying to undermine you, and of course you’re the one clinically trained, not me! Just adding my thoughts to the debate, from my own perspective. Thanks for this thread, it’s a very interesting discussion.

I've got a few patients who are palliative and in prison. Getting them opioids and gabapentin etc involves a bit of hoop-jumping to make sure it is secure but they get their medication.

These patients are usually v keen to stress they don't want to hang out with the patients at the detox clinic - actually getting them to take pain relief can be a problem!

However even so, I've been had patients claiming to be in severe pain and then selling on vomited up opioids. Very tricky to re-establish a relationship with them when they were really ill and in pain when we both knew they'd sold prescribed meds before.

For those worried about patients who should be entitled to gabapentin etc for chronic pain - prisons seem full of an enormous amount of chronic pain patients, some of whom spend their whole time hanging round the gym bench-pressing mindblowing amounts of weights

Yes, meds might be prescribed by an outside pain specialist or GP, but if you aren't prison-savvy, it's v easy to be had.

For those worried about patients who should be entitled to gabapentin etc for chronic pain - prisons seem full of an enormous amount of chronic pain patients, some of whom spend their whole time hanging round the gym bench-pressing mindblowing amounts of weights hmm

That’s nasty and judgmental, I’m sad to say i’d have expected better from a doctor.

I’m sure, as a doctor, you’re aware that chronic pain comes in many forms, and not all of it is related to the back, or an area that would make exercise/weights difficult. Mine for example is pelvic pain, when it’s well controlled it doesn’t prevent me at all from doing weights or running. When it’s not controlled at all it stops me doing anything but more because I’m in too much pain to think straight rather than that exercise would specifically hurt my bladder if that makes sense.

It’s perfectly possible for someone to be receiving pain relief for a problem with their legs but be able to work on their arms, exercise and movement can be part of the management plan for chronic pain if it’s possible for the patient, as being too still/afraid to move the area can cause issues in itself through underuse/seizing up.

Even if a prison had a hundred patients prescribed gabapentin and 80 were diverting, does that justify harming the 20 who aren’t?

I really enjoyed your posts on the hospice thread and you came across as a caring, compassionate clinician. What you just said is sad, but aperfect example of how medics sometimes treat their patients in prison with more judgment/stigma/distaste than those in the community.

Forgot - there is a specific prison pain formulary and a training course run on treating chronic pain in prison run by an anaesthetist (who is amazing BTW).

Any prison GP going on her course knows more about treating chronic pain than a GP you would see on the outside.

The concern is not just that gabapentin/pregabalin have a high abuse potential but there have now been deaths associated with their use alone, without opioids alongside. So massive need to control their abuse in the prison setting, not to mention all the bullying etc that goes on to get them.

I’m so disturbed by the cavalier attitude of ‘no way on earth would I prescribe all of that’ about a patient whose own doctor (no offence intended, but doctors do have a much longer and more in depth training than nurses) saw it fit to prescribe this regimen of medications

If you saw some of the medicine regimes patients come in with you would be shocked. This is not responsible prescribing - Gp's simply give into demand from aggressive patients to get them out of the door. In a GP practice this kind of patient is maybe 1% of their caseload - in prison it's 3/4 and we are very used to the threats of violence when we "dare" detox people from medication that they don't need. At the end of the day I'm not in the business of putting my patients at risk of death, if their medication regime is dangerous they do not get it and that is that. I am expected to gatekeep in this manner and it's a very important aspect of my job.

That’s nasty and judgmental, I’m sad to say i’d have expected better from a doctor.

But they are spot on I'm afraid to say. As I said before, those that have a genuine history and are in pain will get off formulary medication such as pregabalin. But do you really expect me to believe that 90% of my patients have nerve damage and therefore need 300mg pregabalin BD and 400mg tramadol a day alongside 80ml methadone whilst they can spend all day exercising in their cell? I don't think so...

The concern is not just that gabapentin/pregabalin have a high abuse potential but there have now been deaths associated with their use alone, without opioids alongside. So massive need to control their abuse in the prison setting, not to mention all the bullying etc that goes on to get them

Exactly this. We cannot allow prisoners to die through misuse of gabapentinoids, it's completely unacceptable for any unnecessary deaths to happen in prison in this day and age.

But they are spot on I'm afraid to say.

I’m sure that technically they are spot on. There probably are plenty of patients exercising who have chronic pain. As I’ve explained why that could be possible.

It’s not surprising a huge number of patients come in on pregabalin for pain when your client base is lots of IV drug users, given that IV use with poor harm reduction techniques can cause a lot of nerve damage through poor injection and hygiene practices.

But my point wasn’t that Anna’s statement isn’t factual. It’s what she means by it. Basically disbelief, they’re liars, without qualification that it’s wrong to tar all with the same brush without taking each patient individually. That working out means they don’t need their prescribed pain relief. The hmm face shows that’s her point, not that lots of people on prescription painkillers use the gym!

Cross posted - I think you are being narrow in your reading of my post, when I clearly wasn't going to post working in the gym doing arms, back, leg, hand and foot exercises... But I have now and hopefully you can see my point.

Gabapentin and pregabalin are a serious problem for prisons. The prison I work at has gone for 'See to take' for all Gabapentin/pregabalin. Funnily enough, a lot of prisoners instantly decided they didn't need it anymore.
They are also reviewing everyone on gabapentin and pregabalin. For a lot of the prisoners this means they are actually getting better care than they were before - no lazy prescribing but proper diagnoses, physio reviews, referrals to secondary care, sorting out their mental health instead of just giving them something that let them feel spaced out all day and so on.

I really like my prison sessions and I am sorry you have taken this view of my posting, but I think your own experience of chronic pain is likely very different that that of the average prisoner on pregabalin.

If you saw some of the medicine regimes patients come in with you would be shocked.

I’m well aware, trust me. Reviewing a patient’s medication was a part of intake. I also worked in community drug services and understand a lot of patients have complex health needs necessitating various medications (often around the complications of long term drug use: antidepressants or anti anxiety medications, painkillers for either conditions resulting from IV drug use such as nerve damage or long term pain that was part of the reason they started taking drugs in the first place, substitute prescribing).

Are these decisions about which medications to continue and which to discontinue taken in conjunction with a specialist doctor, or down to nursing staff?

They are also reviewing everyone on gabapentin and pregabalin. For a lot of the prisoners this means they are actually getting better care than they were before - no lazy prescribing but proper diagnoses, physio reviews, referrals to secondary care, sorting out their mental health instead of just giving them something that let them feel spaced out all day and so on.

That is undoubtedly a good thing, if it’s a collaborative process that ensures the patient is receiving the care they need, as opposed to just being rapidly detoxed from a medication because ‘we’re a pregabalin free prison’ (not exactly in line with treating each patient as an individual!) and not being taken seriously about the needs that led to the pregabalin being prescribed in the first place.

I’m sure you can see why I read that paragraph as I did, surely? If I said:

“For those worried about claimants who should be entitled to benefits etc for chronic pain disabilities - the benefits office sees full of an enormous amount of people with chronic pain, some of whom spend their whole lives walking around, exercising, playing golf hmm”

You would understand the implication behind my words, right? That there’s no need to worry about people being denied essential benefits because lots of them are lying fakers pretending to have an illness their activities prove they don’t actually have?

Are these decisions about which medications to continue and which to discontinue taken in conjunction with a specialist doctor, or down to nursing staff?

We don't have specialist doctors, we have 1 GP to cover the entire prison (500+ prisoners) for 24 hours a week. Prison healthcare is nursing lead, we are autonomous clinicians. And even if the medication has been written up by a prison doctor, I'm perfectly within my rights to withhold it if I feel it is unsafe. When a patient comes in I'll assess them and guide the GP as to what I feel should be prescribed based on withdrawals and presentation. It's very rare for the GPs to disagree with my recommendations.

Thanks for the info!

Do you feel one GP is enough for a prison? And that nursing led healthcare is adequate? I found it astonishing when I worked in prisons that there would usually be just one doctor there eight hours per day to take care of a huge population of people with complex medical needs, who were unable to leave to access treatment of their own volition. I know it can’t be directly compared to numbers of doctors in a hospital as people specifically go there when they’re ill rather than live there, but the lack of doctors often made me feel that this was another way that offenders were treated as second class citizens. It’s a very demanding client group with so many mental and physical health problems that can’t do much about their own health needs, one doctor for a third of the day seemed wholly inadequate to me from my experience, not that nursing care wasn’t great for what it was capable of.

I am appalled anyone would advocate decriminalising drugs.

It would mean it would become socially acceptable!

My DC choose not to take drugs because they know it's a criminal offence, and they know how blighted the lives are for people who take them!

The system might be broken for those imprisoned but the situation would get far far worse and less safe for the rest of us who want to have drug free lives.

What happens to people who detox off of heroin or crack cocaine?

Why is it so horrendous (as I've heard).