Retox: What does it involve

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Retox What does it involve?

• Dr Craig Sayers
• Medical Officer HMP Cornton Vale

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HMP Cornton Vale

• Scotlands only all female prison
• All categories of prisoner
• Capacity 230 prisoners
• Increasing numbers
• Sept 2000 - total prisoners 201
• Sept 2002 - total prisoners 293

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HMP Cornton Vale

• Background to patients
• 94 to 98 drug misuse
• 82 some form of abuse
• 47 sexual abuse
• 38 history of DSH, OD, Attempted suicide

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HMP Cornton Vale

• Jan 2001 Addictions Policy
• Maintain methadone if stable on admission
  however, if sentence gt6months detox.
• Otherwise detox with DHC and Diazepam

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HMP Cornton Vale

• Concerns
• Lack of interventions within prison
• High numbers of drug related deaths post
  liberation
• High numbers of repeat offenders with drug
  related crime - revolving door

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My Education!!

• Literature
• Dr Kidd (FVHB)
• Dr Roberts (Homeless Team GDPS)
• Needs assessment of HMP Cornton Vale

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Needs assessment results

• Key Outcomes of prisoner needs
• Substitute prescribing (77)
• Throughcare to community services (47)
• Key worker within establishment (37)

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Patient Groups

• 1) Patients admitted on a remand basis or
  convicted (sentence under 6 months) on a stable
  methadone prescription
• Plan
• Maintain methadone
• Vaccinations
• Brief Interventions

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Patient Groups

• 2) Patients admitted on remand with ongoing drug
  misuse or convicted (sentence under 6 months)
• Plan
• Extended detox based on accurate urinalysis of
  drugs of misuse
• Vaccinations
• Brief Interventions

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Patient Groups

• 3) Patients admitted on a convicted basis on a
  stable methadone prescription (sentence 6 months
  or over)
• Plan
• Education, programmes, key worker
• Encourage reduction at agreed rate with
  individual at appropriate time

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Patient Groups

• 4) Patients admitted on a convicted basis with
  ongoing substance misuse (sentence 6 months or
  over
• Plan
• Safe detox initially
• Proactively offer Education, Programs, SWD input,
  key worker
• Chemical intervention to be available during
  sentence if appropriate

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HMP Cornton Vale - Gaps

• Identified Gaps in Service
• No Fixed Addictions Specialist Nurse
• Inaccurate admission analysis (dipsticks)
• No Key workers
• No Programmes (DRP, DA, Harm Reduction)
• Poor throughcare

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HMP Cornton Vale - Review

• Addictions nurse - full time with no other duties
  within establishment
• Axiom urinalysis machine purchased
• 2 Addictions Officers appointed
• Programmes set up to deliver DRP, DA, BBV
  education, HR

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HMP Cornton Vale

• Remand or Convicted under 6 months
• Detox or Maintain as indicated
• Vaccinations
• Brief Interventions to all

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HMP Cornton Vale

• Convicted (over 6 months)
• Programs, key workers, education
• Vaccinations
• Maintain stable prescriptions (individual Tx)
• Initiate substitute prescribing in those who are
  well motivated but failing to manage to stay drug
  free (community model)

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Difficult Group (large group!!)

• Not adequately covered by above groups
• Repeat drug-related offender
• Using every admission
• Remains drug free in prison after detox
• Well motivated but aware will return to drug
  misuse on lib
• Well established record showing this revolving
  door pattern

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Difficult Group (large group!!)

• Concerns
• Greatest risk of OD
• No access to community services
• Missed Opportunity????

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Retox - The Idea

• Consideration should be given to commencing these
  prisoners on methadone to try and achieve the
  following
• Engagement in community services after liberation
• Remain stable after release
• Reduce fatal/non-fatal overdoses

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Retox - how do we do it?

• Identify patient meeting appropriate criteria
• Contact community prescriber to arrange
  throughcare of prescription and key worker
• Commence methadone
• 10ml first week
• 15ml second week
• 20ml thereafter

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Retox - early history

• Began retoxing identified prisoners from July
  2001 in FVHB and with GDPS
• No formal audit but all involved parties had a
  good gut feeling about it

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Sunday Times July 7th 2002
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Retox - Main Problem

• Inconsistency as patients from differing
  geographical areas were receiving different
  treatment options

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Retox - Problem resolved?

• October 2002 - met with SDSC with representatives
  from all areas of Scotland who agreed to give
  priority to our prisoners on release for
  provision of key workers and continuation of
  prescriptions

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Retox - The Future

• Now in a position to undertake a 2 year audit
  looking at
• Attendance first appointment
• Attendance at 1 month and 6 months
• Re-offending rates
• Overdose (fatal and non-fatal)

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Food for thought!!

• There are a large number of individuals who have
  remained drug free in prison but show no
  motivation to remain drug free on liberation, and
  are clear that they will return to substance
  misuse on release.
• Should DHC be used to retox to provide
  tolerance for liberation??