How the Prison Healthcare Service Currently Manages Mental Health, BBV and Drug Treatment

Nat Wright Clinical Director Leeds Cluster of Prisons

Hepatitis C, substance misuse and health inequalities conference London 19 th October 2010

Scale of the Problem

• Cross-sectional survey of England and Wales - 38% of male remand prisoners, 48% of male sentenced prisoners, 25% of female remand, and 34% of female sentenced prisoners had used drugs during their current prison term. The most commonly used drugs - cannabis and heroin. (Singleton

et al

, 1998). • Systematic review of the international prevalence studies of prison populations for drug dependence (13 studies total of 7563 prisoners). Prevalence rates 10-48% in male prisoners and 30-60% in female prisoners (Fazel

et al

, 2006).

• Prevalence of injecting reduces in prison BUT injecting practices more risky and prison is a site of initiation into drugs (Bellis

et al

, 1997; Boys

et al

, 2002) • 7% prison population HCV positive. Number of times in prison an association with antibodies to HCV and HBV (Weild

et al

, 2000)

Criminal Justice and Health: a sometimes uneasy alliance…….

In the days before contraception……

Victorian unmarried mothers, especially working class ones faced an impossible dilemma during the nineteenth century. Most employers would turn them out as soon as their condition [pregnancy] became obvious and then it was the workhouse or often unsympathetic relatives. After they gave birth few would employ a mother and child and lodging your child with a nurse cost money.

The saddest aspect of Emma's desperate act [charged for murdering her child at birth] was that it wasn't unusual her twin daughters.

– that same year Ann Noakes of Reigate was charged with murdering her baby son. In 1894 Minnie Wells was tried for killing

Jen Newby. Unmarried, Pregnant and Victorian. Writing Women’s History, 2010.

Barriers to Health

• • • • •

Social isolation

- many prisoners held a long way from their homes - despite a rise of more than 20% in the prison population, the number of prison visits has fallen by more than a third over a five year period (women and young offenders worst affected) (Home Office, 2002)

Parenting Issues

- Over 33% of women prisoners have child under age five when imprisoned though, though only 5% of these children remain in their homes

Large throughput

- on short sentences presents problems for screening programmes and management of chronic diseases

Punitive culture

- sense of distrust, lack of empathy and fear of being diagnosed with a mental illness (Howerton

et al

, 2007)

Budgetary Constraints limiting rehabilitation opportunities

high level of purposeful activity protects against suicide risk (Leese et al, 2006).

Treatment Responses to Hepatitis C

• Raise awareness of hep C – role for interactive media • Encourage testing wherever possible • Develop systems to communicate results (?telephone answering, ?written confirmation) to community service • “Shared care” arrangement with hepatology services for antiviral treatment • Deliver alongside opiate maintenance treatment in prisons (in Leeds >3000 per year discharged on opiate maintenance) • Remember Hep B vaccination

Management of Substance Misuse

• Marked increase in provision of prison based opiate maintenance, but under threat for political reasons • Many voices want to see “recovery” (Trojan horse for abstinence) and therefore time limited opiate maintenance • However, less than 20% of prisoners successfully undergo detoxification (Wright unpublished data) • Psychosocial support “patchy” – despite good evidence base for individual, group based and therapeutic community interventions (Wright, 2010)

Management of Dual Diagnosis

• A challenge - much of prison healthcare is still in professional silos (Sainsbury Centre for Mental Health, 2007) • Need to take greater account of co-morbidity • Co-training – substance misuse and personality disorder is everyone’s business • •Need to consider prison diversion schemes for those whose offences are not serious yet related to mental ill health (Draine and Solomon, 1999) • Prison based offender behaviour programmes can reduce the risk of re-offending (Sainsbury Centre for Mental Health, 2008)

In Conclusion

Much is being done to address the quality of care offered in prisons but significant cultural, logistical and political barriers remain [email protected]

References

• • • • • • • • • • • • •

Bellis MA, Weild AR, Beeching NJ, Mutton KJ and , Syed Q. Prevalence of HIV and injecting drug use in men entering Liverpool prison. British Medical Journal 1997; 315: 30-31 Boys A, Farrell M, Bebbington BT, Coid J, Jenkins R, Lewis G, Marsden J, Meltzer H, Singleton N and Taylor, C. Drug use and initiation in prison: results from a national prison study in England and Wales. Addiction 2002; 97: 1551-1560 Draine J and Solomon P. Describing and evaluating jail diversion services for persons with serious mental illness. Psychiatric Services 1999; 50: 56 –61 Fazel S, Bains P and Doll H. Substance abuse and dependence in prisoners: a systematic review. Addiction 2006; 101(2): 181-191 Fazel S, Benning R and Danesh J. Suicides in male prisoners in England and Wales, 1978-2003. Lancet 2005; 366(9493): 1301-2 Home Office. Prison Statistics England and Wales 2001. London: The Stationery Office, 2002 Howerton A, Byng R, Campbell J, Hess D, Owens C and Aitken P. Understanding help seeking behaviour among male offenders: a qualitative study. British Medical Journal 2007; 334: 303-306 Leese M, Thomas S and Snow L. An ecological study of factors associated with rates of self-inflicted death in prisons in England and Wales. International Journal of Law and Psychiatry 2006; 29(5): 355-360 Sainsbury Centre for Mental Health. A review of the use of offending behaviour programmes for people with mental health problems. Sainsbury Centre for Mental Health: London, 2008 Sainsbury Centre for Mental Health. Getting the basics right: Developing a primary care mental health service in prisons. London: Sainsbury Centre for Mental Health, 2007 Singleton N, Farrell M and Meltzer H. Substance misuse among prisoners in England and Wales: Further

analysis of data from the ONS survey of psychiatric morbidity among prisoners in England and Wales

carried out in 1997 on behalf of the Department of Health. London: Office for National Statistics, 1998 Weild AR, Gill ON, Bennett D, Livingstone SJM, Parry JV and Curran L. Prevalence of HIV, hepatitis B and hepatitis C antibodies in prisoners in England and Wales: a national survey. Communicable Disease and Public Health 2000;

3(2):

121-126 Wright N with Marteau D and Palmer J. The Offender and Drug Treatment: making it work across prisons and wider secure environments. Leeds: Wrighthealth publishing, 2010