Safer Prescribing in Prisons – 2^nd Edition January 2019

The second edition of Safer Prescribing in Prisons has drawn on emerging evidence and responded to feedback from the first edition. A chapter on wider prescribing issues has been added and several chapters have been expanded, including those on substance use and misuse and palliative care. It has followed National Institute for Health and Care Excellence (NICE) guidance where possible and adapted some recommendations to reflect the safety and security issues that affect the prison environment, in order to improve care, while aiming to embrace equivalence of effect, practice and outcome, where possible.

The publication is an in-depth and comprehensive evidence-based resource, designed to promote and support good clinical practice within a robust medicines governance framework. It highlights important considerations for clinicians working in secure settings and offers a rational, safe approach to appropriate prescribing for specific patient groups. It recognises developments in the role of the on-site pharmacy team that contribute to safer prescribing practices, particularly in the areas of polypharmacy and in the timely transfer of information and medications at the interfaces between prison and the community.  Safer Prescribing in Prisons should be regarded as guidance; prescribers should always refer to the British National Formulary for definitive prescribing decisions.

Key messages of the second edition are summarised at the start of each chapter and a traffic light system has been used to evaluate medicines with regard to the risks associated with prescribing them in prison. In the chapter on insomnia, the emphasis is on assessment and a non-pharmacological approach for all but short periods of acute distress, when sedating antihistamines are recommended. The importance of screening for depression and a whole prison approach to assessing and managing risk of deliberate self harm and suicide is recommended in the chapter on depression. The importance of using the stepped care model in depression and anxiety is covered, together with guidance on first line SSRI prescribing, risks to the under 30s, and the need for supervised consumption of medication at risk of abuse and diversion due to its sedating or euphoric effects.

While the extended chapter on substance use and misuse in prisons does not offer a comprehensive alternative to the Clinical Guidelines on Drug Misuse and Dependence Update 2017, it highlights the importance of good communication within and between teams particularly at the interface between community and prison and offers guidance about managing withdrawal from alcohol, opiates and benzodiazepines in prison, as well as covering the problems of NPS, IPEDs and dependence on prescribed medications.

The Epilepsy chapter identifies the need for continuation of medication on coming into custody, while seeking neurological opinion where necessary and raising awareness of the risk of abuse and diversion of AEDs with sedating, anxiolytic or euphoric effects. Prescribing guidance for women of child-bearing age identifies the risk of sodium valproate to the foetus. The importance of psychiatrist involvement in diagnosing and prescribing for psychoses, neurodevelopmental disorders and narcolepsy is also covered in the publication.

Recommendations for the management of acute, persistent and neuropathic pain align with those in the Opioids Aware resource and the NHS England Prison Pain Management Formulary. The importance of non-pharmacological multi-modal approaches, the use of simple analgesia and the limited efficacy of opioids in managing persistent pain are discussed together with guidance on prescribing of gabapentinoids. Multidisciplinary collaboration is regarded as essential for complex cases, particularly in those people with substance misuse or mental health problems.

The chapter on palliative care identifies the need for a compassionate holistic approach, involving additional specialist community and third-sector resources. It also identifies the importance of good medicines governance to ensure safe effective prescribing of potent medicines at risk of abuse. Safer Prescribing in Prisons – Second Edition concludes with a chapter covering additional issues in the complex arena of prescribing in the secure setting.