Evaluation of a Framework for Safe and Appropriate Prescribing of Psychoactive Medications in Prison

Abstract

Background: The widespread use of drugs in prisons leads to avoidable deaths and a poor living environment. The contribution of psychoactive prescription drugs to this problem has received little attention in prison policy and at individual prescriber level. To the best of our knowledge this is the first study to evaluate a framework for safe and appropriate prescribing of psychoactive prescription drugs in a prison setting. Methods: A medicines optimisation framework was developed based on principles of good prescribing. It was initiated on the opening of HMP Berwyn in February 2017. During the study period, all prisoners at HMP Berwyn were transferred from other prisons. The safety and appropriateness of psychoactive medications were evaluated de novo on reception at HMP Berwyn and during follow up, using the medicine optimisation framework. Data was collected retrospectively from the online prison database. Key outcomes were proportion of unsafe and inappropriate prescriptions. Findings: 1941 men arrived at HMP Berwyn between February 2017 and December 2018. 32·6% (634/1941) were on a prescribed psychoactive medication. Overall 75·2% (477/634) required a prescription change due to appropriateness or safety concerns. 46·5% (295/634) received changes at reception despite having already undergone medicines reconciliation at their previous prison. 43·7% (277/634) received changes at follow up, most commonly in those who had no prior risks identified at reception. Interpretation: Inappropriate and unsafe prescribing of psychoactive medications is occurring in prisons despite mandatory medication reviews. Ongoing monitoring is required to reduce the risk from these medications. A medicines optimisation framework such as this could be adopted across other prisons in England and Wales to help contribute to risk reduction from drug use in prisons. Appropriately modified, a similar framework might help reduce inappropriate and harmful prescribing in hospitals and in the community. Funding Statement: Betsi Cadwaldr University Health Board. Declaration of Interests: Dr. Bebbington reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Dr. Lawson reports I contributed to the design of the medicines optimisation framework, completed some of the drug reviews, and completed data collection. I am the Medical Director of Gables Medical (Offender Health) Ltd which is contracted to provide primary care services to HMP Berwyn. Dr. Nafees reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Prof. Robinson reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Prof. Poole reports grants from Betsi Cadwaladr University Health Board during the conduct of the study. Ethics Approval Statement: As this study uses an anonymised routinely collected dataset, the Betsi Cadwaldr University Health Board (BCUHB) (NHS) research and development department recommend that the project is exempt from ethics approval. This project is registered with the BCUHB Clinical Audit and Effectiveness office.