Understanding the impact of Covid-19 on the delivery and receipt of prison healthcare: an international scoping review.

BACKGROUND: People being held in prison are particularly vulnerable to Covid-19 infection, as places of detention are high-risk environments for spread of infection. Due to this risk, many prisons across the globe introduced measures to reduce the risk of Covid-19 transmission. The pandemic changed almost all aspects of prison life, including prison healthcare provision. We undertook a scoping review to understand what is known about the impact of the Covid-19 pandemic on the receipt and delivery of prison healthcare. This scoping review is part of a wider mixed-methods study focusing more specifically on the impact that Covid-19 had on prison healthcare delivery in England. METHODS: We conducted an international scoping review of peer-reviewed articles published between December 2019 and January 2022, across six electronic databases. We also conducted a hand search of key journals and the reference lists of included articles. RESULTS: Twelve articles met our inclusion criteria. The articles focused primarily on prisons in high-income countries and mostly explored the impact that the pandemic had on the provision of drug treatment services. Some aspects of drug treatment services were more impacted than others, with those delivered by external providers and preparations for release particularly hindered. Whilst prison mental health services were purportedly available, there were changes regarding how these were delivered, with group therapies suspended and most consultations taking place using telehealth. The articles reported both digital and non-digital adaptations or innovations to prison healthcare services to ensure continued delivery. Collaboration between different agencies, such as the prison itself, healthcare providers, and non-governmental organisations, was key to facilitating ongoing provision of healthcare to people in prison. CONCLUSIONS: Covid-19 impacted on prison healthcare internationally, but different treatment services were affected in disparate ways, both within and between countries. The published literature concentrates on the impact on drug treatment services. Prison healthcare providers rapidly adapted their processes to attempt to maintain service provision.

The quality of prison primary care: cross-sectional cluster-level analyses of prison healthcare data in the North of England.

Background: Prisoners have significant health needs, are relatively high users of healthcare, and often die prematurely. Strong primary care systems are associated with better population health outcomes. We investigated the quality of primary care delivered to prisoners. Methods: We assessed achievement against 30 quality indicators spanning different domains of care in 13 prisons in the North of England. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records over 2017-20. Multi-level mixed effects logistic regression models explored associations between indicator achievement and prison and prisoner characteristics. Findings: Achievement varied markedly between indicators, prisons and over time. Achieved processes of care ranged from 1% for annual epilepsy reviews to 94% for blood pressure checks in diabetes. Intermediate outcomes of care ranged from only 0.2% of people with epilepsy being seizure-free in the preceding year to 34% with diabetes having sufficient blood pressure control. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, e.g., 1.93-fold for gabapentinoid prescribing without coded neuropathic pain (odds ratio [OR] range 0.67-1.29) and 169-fold for dried blood spot testing (OR range 0.05-8.45). Shorter lengths of stay were frequently associated with lower achievement. Ethnicity was associated with some indicators achievement, although the associations differed (both positive and negative) with indicators. Interpretation: We found substantial scope for improvement and marked variations in quality, which were largely unaltered after adjustment for prison and prisoner characteristics. Funding: National Institute for Health and Care Research Health and Social Care and Delivery Research Programme: 17/05/26.

Evaluation of a complex intervention for prisoners with common mental health problems, near to and after release: the Engager randomised controlled trial.

BACKGROUND: Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse. AIMS: This study aims to evaluate whether the Engager intervention improves mental health outcomes following release. METHOD: The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3-5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT). RESULTS: In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI -1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact. CONCLUSIONS: Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.

Quality indicators and performance measures for prison healthcare: a scoping review.

BACKGROUND: Internationally, people in prison should receive a standard of healthcare provision equivalent to people living in the community. Yet efforts to assess the quality of healthcare through the use of quality indicators or performance measures have been much more widely reported in the community than in the prison setting. This review aims to provide an overview of research undertaken to develop quality indicators suitable for prison healthcare. METHODS: An international scoping review of articles published in English was conducted between 2004 and 2021. Searches of six electronic databases (MEDLINE, CINAHL, Scopus, Embase, PsycInfo and Criminal Justice Abstracts) were supplemented with journal searches, author searches and forwards and backwards citation tracking. RESULTS: Twelve articles were included in the review, all of which were from the United States. Quality indicator selection processes varied in rigour, and there was no evidence of patient involvement in consultation activities. Selected indicators predominantly measured healthcare processes rather than health outcomes or healthcare structure. Difficulties identified in developing performance measures for the prison setting included resource constraints, data system functionality, and the comparability of the prison population to the non-incarcerated population. CONCLUSIONS: Selecting performance measures for healthcare that are evidence-based, relevant to the population and feasible requires rigorous and transparent processes. Balanced sets of indicators for prison healthcare need to reflect prison population trends, be operable within data systems and be aligned with equivalence principles. More effort needs to be made to meaningfully engage people with lived experience in stakeholder consultations on prison healthcare quality. Monitoring healthcare structure, processes and outcomes in prison settings will provide evidence to improve care quality with the aim of reducing health inequalities experienced by people living in prison.

Using mixed methods to explore diabetes care in a medium-secure setting in England: A case study.

BACKGROUND AND AIMS: Diabetes is highly prevalent among individuals with serious mental illness. Managing diabetes in forensic mental health settings presents unique challenges which are under-reported and poorly understood. This study aimed to explore diabetes care in a medium-secure setting and identify key areas for improvement. METHODS: A single case study design used a retrospective chart review. Qualitative interviews and a focus group were analyzed using thematic analysis. RESULTS: Prevalence of diabetes was over twice that of the general population and highest in female service users. Evidence suggests limited understanding and lack of diabetes education for staff and service users, and difficulties in accessing external diabetes recourses. CONCLUSION: Constraints inherent to forensic mental health settings contribute to difficulties in accessing external resources and adequate diabetes education. Secure mental health services should adopt a collaborative approach to diabetes care and provide appropriate specialist training to both staff and service users.

Waiting list eradication in secondary care psychology: Addressing a National Health Service blind spot.

OBJECTIVES: Waiting times for secondary care psychological therapy remain a 'blind spot' in serious mental illness (SMI) provision, and their reduction is a priority within the National Health Service (NHS) Five Year Forward View. The paper describes the eradication of waiting times within a community-based NHS service and the effectiveness of strategies whilst examining help-seeking behaviour, compliance and therapeutic need. METHODS: Analyses are reported for treatment compliance and therapeutic outcomes for 208 waiting-list cohort individuals seen by the SMI psychology service over an 18-month period between October 2014 and March 2016. RESULTS: No significant clinical or demographic differentiation between individuals who successfully completed therapy compared to those who disengaged was observed. Despite an average 2.20-year waiting time, this alone did not significantly impact engagement with psychological treatment and all psychological therapies provided led to a significant clinical improvement and no individuals who completed therapy required re-referral at 12-month follow-up. CONCLUSIONS: If imposed appropriately over a suitable time frame evidence-based practice coupled with effective operationalization can result in efficient needs-led psychological provision within SMI and secondary care. Potentially debilitating waiting times for service users and other referring professionals can be avoided, whilst psychology provision retains a flexible, formulation-based and person-centred approach.

OUD Care Service Improvement with Prolonged-release Buprenorphine in Prisons: Cost Estimation Analysis.

BACKGROUND: In prisons in England, integrated treatment for opioid use disorder (OUD) is accessible and effective, commonly based on daily supervised consumption of methadone. Treatment limitations (inadequate dosing, nonengagement with care, stigma, diversion and bullying) are noted. Flexible dose, injectable prolonged-release buprenorphine (PRB) which removes the need for daily dispensing and supervision is suggested for prisoner care. This work aimed to predict the difference in costs of current standard of care vs partial introduction of PRB. METHODS: A predictive model of compared costs for the provision of OUD care in the prison setting in England evaluated current standard of care (all receive methadone) with a future situation of 30% of prisoners electing to use a monthly dose of PRB. Evidence describing costs to deliver OUD care for 150 prisoners (pharmacotherapy, direct service, indirect health care, indirect security costs) were collected, including assumptions describing how care would be delivered. Evidence sources include national data sources, scientific literature and from experience in the prison health care setting. RESULTS: For a representative standard prison population requiring OUD care of 150 prisoners in England PRB introduction is associated with a predicted reduction in direct and indirect costs of OUD care. Annual OUD care costs for current standard of care were £0.6M; with 30% PRB costs reduced by £8665, more than 3000 hours of staff time is saved. Sensitivity analyses showed greater adoption of PRB resulted in further cost reduction. CONCLUSION: PRB can address limitations of OUD care in prisons and improve outcomes. Introduction does not increase cost of care in this predictive analysis. PRB may lead the transformation of prisoner OUD care.

Problem-solving training: assessing the feasibility and acceptability of delivering and evaluating a problem-solving training model for front-line prison staff and prisoners who self-harm.

OBJECTIVES: Problem-solving skills training is adaptable, inexpensive and simple to deliver. However, its application with prisoners who self-harm is unknown. The study assessed the feasibility and acceptability of a problem-solving training (PST) intervention for prison staff and prisoners who self-harm, to inform the design of a large-scale study. DESIGN AND SETTING: A mixed-methods design used routinely collected data, individual outcome measures, an economic protocol and qualitative interviews at four prisons in Yorkshire and Humber, UK. PARTICIPANTS: (i) Front-line prison staff, (ii) male and female prisoners with an episode of self-harm in the previous 2 weeks. INTERVENTION: The intervention comprised a 1 hour staff training session and a 30 min prisoner session using adapted workbooks and case studies. OUTCOMES: We assessed the study processes-coverage of training; recruitment and retention rates and adequacy of intervention delivery-and available data (completeness of outcome data, integrity of routinely collected data and access to the National Health Service (NHS) resource information). Prisoner outcomes assessed incidence of self-harm, quality of life and depression at baseline and at follow-up. Qualitative findings are presented elsewhere. RESULTS: Recruitment was higher than anticipated for staff n=280, but lower for prisoners, n=48. Retention was good with 43/48 (89%) prisoners completing the intervention, at follow-up we collected individual outcome data for 34/48 (71%) of prisoners. Access to routinely collected data was inconsistent. Prisoners were frequent users of NHS healthcare. The additional cost of training and intervention delivery was deemed minimal in comparison to 'treatment as usual'. Outcome measures of self-harm, quality of life and depression were found to be acceptable. CONCLUSIONS: The intervention proved feasible to adapt. Staff training was delivered but on the whole it was not deemed feasible for staff to deliver the intervention. A large-scale study is warranted, but modifications to the implementation of the intervention are required.

Optimising opioid substitution therapy in the prison environment.

PURPOSE: The purpose of this paper is to examine the current provision of opioid substitution therapy (OST) during and immediately following release from detention in prisons in England and Wales. DESIGN/METHODOLOGY/APPROACH: A group of experts was convened to comment on current practices and to make recommendations for improving OST management in prison. Current practices were previously assessed using an online survey and a focus group with experience of OST in prison (Webster, 2017). FINDINGS: Disruption to the management of addiction and reduced treatment choice for OST adversely influences adequate provision of OST in prison. A key concern was the routine diversion of opiate substitutes to other prisoners. The new controlled drug formulations were considered a positive development to ensure streamlined and efficient OST administration. The following patient populations were identified as having concerns beyond their opioid use, and therefore require additional considerations in prison: older people with comorbidities and complex treatment needs; women who have experienced trauma and have childcare issues; and those with existing mental health needs requiring effective understanding and treatment in prison. ORIGINALITY/VALUE: Integration of clinical and psychosocial services would enable a joint care plan to be tailored for each individual with opioid dependence and include options for detoxification or maintenance treatment. This would better enable those struggling with opioid use to make informed choices concerning their care during incarceration and for the period immediately following their release. Improvements in coordination of OST would facilitate inclusion of strategies to further streamline this process for the benefit of prisoners and prison staff.

Prison primary care and non-communicable diseases: a data-linkage survey of prevalence and associated risk factors.

BACKGROUND: The size and mean age of the prison population has increased rapidly in recent years. Prisoners are a vulnerable group who, compared with the general population, experience poorer health outcomes. However, there is a dearth of research quantifying the prevalence of non-communicable diseases (NCDs) among prisoner populations. AIM: To explore both the prevalence of NCDs and their risk factors. DESIGN & SETTING: A cross-sectional survey was undertaken that was compared with clinical records in two male prisons in the north of England. METHOD: Self-report surveys were completed by 199 prisoners to assess sociodemographic characteristics, general health, NCD prevalence, and risk factor prevalence. Data were checked against that retrieved from prison clinical records. RESULTS: It was found that 46% reported at least one NCD and 26% reported at least one physical health NCD. The most common self-reported NCD was 'anxiety and depression' (34%), followed by 'respiratory disease' (17%), and 'hypertension' (10%). Having a physical health NCD was independently associated with increasing age or drug dependence.The level of agreement between clinical records and self-report ranged from 'fair' for alcohol dependence (kappa 0.38; P<0.001) to 'very good' for diabetes (kappa 0.86; P<0.001). CONCLUSION: Compared with mainstream populations and despite high prevalence of risk factors for NCDs physical illness NCDs, with the exception of respiratory disease, are less common. However, poor mental health is more common. These differences are possibly owing to the younger average age of prison populations, since prevalence of risk factors was reported as high.Secondary data analysis of clinical records is a more methodologically robust way of monitoring trends in prisoner population disease prevalence.

Deep Vein Thromboses in Injecting Drug Users: Meanings, Bodily Experiences, and Stigma.

Deep vein thromboses (DVTs) are common sequelae of injecting drugs into the groin. We explored meanings and experiences of DVTs in a group of 19 patients from the North East of England with a DVT and in treatment for opioid use. We report three themes: (a) DVT meaning making, (b) embodied experience, and (c) Stigma. Patients attributed DVTs to groin injecting, though thought other factors were also partially responsible. Medication performed both treatment and preventive functions. The most pertinent worry was amputation. Patients recognized stopping injecting as important, but it did not necessarily occur. Stigma resulted in delayed admission to hospital and feelings of isolation; support groups might alleviate the latter. Although groin injecting was undertaken partly to avoid the censure of being a drug user, ironically, a DVT led to long-standing stigmata that were discrediting signs of that exact status.

Assessing the predictability of self-harm in a high-risk adult prisoner population: a prospective cohort study.

BACKGROUND: Prisoners are at increased risk of self-harm and when either intent is expressed, or an act of self-harm carried out, prisoners in the UK are subject to self-harm/suicide monitoring (referred to as "open ACCT" monitoring). However, there is a paucity of validated instruments to identify risk of self-harm in prisoner populations. In response to the need to support prison staff to determine who is at increased risk of self-harm or repeat self-harm, the aim of this study was to determine whether any pre-existing, standardised instruments could usefully identify future self-harm events in prisoners undergoing ACCT monitoring. METHODS: A multi-stage prospective cohort study was conducted, where the Prison Screening Questionnaire (PriSnQuest), a modified Borderline Symptom List-23 (BSL-23), Self-Harm Inventory (SHI), Patient Health Questionnaire-9 (PHQ-9) and Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) instruments were administered to prisoners aged 18 and above, who were judged to be at an increased risk of self-harm (on open ACCT monitoring) during the recruitment phase. A 6-month follow-up determined self-harm occurrence since baseline, and Area-Under-the-Curve (AUC) analysis examined the ability of the instruments to predict future self-harm. RESULTS: Prison records established that 29.1% self-harmed during the follow up period, involving a total of 423 self-harm events reported from 126 individuals, followed up for 66,789 prisoner days (median 167 days; IQR 71-207.5 days). This translated to an 'event incidence' of 6.33 per 1000 prisoner days of those who had been placed upon an ACCT, or 'prisoner incidence' of 1.89 per 1000 days, with considerable variation for both gender and participating prisons. None of the summary scores derived from the selected instruments showed a meaningful ability to predict self-harm, however, exploratory logistic regression analysis of individual background and instrument items revealed gender-specific item sets which were statistically significant in predicting future self-harm. CONCLUSIONS: Prospective self-harm was not predicted by any of the pre-existing instruments that were under consideration. Exploratory logistic regression analysis did reveal gender-specific item sets, producing predictive algorithms which were statistically significant in predicting future self-harm; however, the operational functionality of these item sets may be limited.

Are we ready to treat hepatitis C virus in individuals with opioid use disorder: assessment of readiness in European countries on the basis of an expert-generated model.

Individuals with a history of injecting drugs have a high prevalence of chronic hepatitis C (HCV) infection. Many have a history of opioid use disorder (OUD). Despite novel treatments with improved efficacy and tolerability, treatment is limited in the group. A faculty of experts shared insights from clinical practice to develop an HCV care-readiness model. Evidence and expert knowledge was collected. Ten experts developed a model of three factors (with measures): 'healthcare engagement', 'guidance' and 'place'. Overall, 40-90% of individuals with OUD engage with drug treatment services. Ten of 12 HCV guidelines provided specific advice for the OUD population. Ten of 12 OUD care guidelines provided useful HCV care advice. In 11 of 12 cases, location of HCV/drug treatment care was in different places. This readiness assessment shows that there are important limitations to successful HCV care in OUD. Specific actions should be taken: maintain/increase access to OUD treatment services/opioid agonist therapy, updating HCV guidance, locate care in the same place and allow wider prescribing of anti HCV medicines.

Supporting research readiness in social enterprise health services.

Health-based social enterprises are spun out of the NHS, yet continue to provide NHS-funded services. With the spin-out, however, formal processes for research governance were lost. Patients have a right to take part in research, regardless of where they access healthcare. This paper discusses the barriers to social enterprises undertaking applied health research and makes recommendations to address the need for equivalence of governance processes with NHS trusts.

Research priorities to achieve universal access to hepatitis C prevention, management and direct-acting antiviral treatment among people who inject drugs.

Globally, it is estimated that 71.1 million people have chronic hepatitis C virus (HCV) infection, including an estimated 7.5 million people who have recently injected drugs (PWID). There is an additional large, but unquantified, burden among those PWID who have ceased injecting. The incidence of HCV infection among current PWID also remains high in many settings. Morbidity and mortality due to liver disease among PWID with HCV infection continues to increase, despite the advent of well-tolerated, simple interferon-free direct-acting antiviral (DAA) HCV regimens with cure rates >95%. As a result of this important clinical breakthrough, there is potential to reverse the rising burden of advanced liver disease with increased treatment and strive for HCV elimination among PWID. Unfortunately, there are many gaps in knowledge that represent barriers to effective prevention and management of HCV among PWID. The Kirby Institute, UNSW Sydney and the International Network on Hepatitis in Substance Users (INHSU) established an expert round table panel to assess current research gaps and establish future research priorities for the prevention and management of HCV among PWID. This round table consisted of a one-day workshop held on 6 September, 2016, in Oslo, Norway, prior to the International Symposium on Hepatitis in Substance Users (INHSU 2016). International experts in drug and alcohol, infectious diseases, and hepatology were brought together to discuss the available scientific evidence, gaps in research, and develop research priorities. Topics for discussion included the epidemiology of injecting drug use, HCV, and HIV among PWID, HCV prevention, HCV testing, linkage to HCV care and treatment, DAA treatment for HCV infection, and reinfection following successful treatment. This paper highlights the outcomes of the roundtable discussion focused on future research priorities for enhancing HCV prevention, testing, linkage to care and DAA treatment for PWID as we strive for global elimination of HCV infection.

Prescription opioid abuse in prison settings: A systematic review of prevalence, practice and treatment responses.

BACKGROUND: To systematically review the quantitative and qualitative evidence base pertaining to the prevalence, practice of, and treatment response to the diversion of prescribed opiates in the prison setting. METHODS: Medline, Embase, CINAHL, PsycINFO, Google Scholar, ASSIA and Science Direct databases were searched for papers from 1995 to the present relevant to the abuse of prescribed opiate medication. Identified journals and their reference lists were hand searched for other relevant articles. Of the abstracts identified as relevant, full text papers were retrieved and critiqued against the inclusion criteria for the review. RESULTS: Three hundred and fifty-five abstracts were identified, leading to 42 full-text articles being retrieved. Of those, 10 papers were included in the review. Significant differences in abuse behaviours between different countries were reported. However, a key theme emerged from the data regarding a culture of nasal administration of prescribed sublingual buprenorphine within some prisons due to both reduced prevalence of injection within prison and reduced supplies of illicit drugs within prison. The buprenorphine/naloxone preparation appears to be less amenable to abuse. The review highlighted a paucity of empirical research pertaining to both prevalence of the phenomenon and treatment responses. CLINICAL AND RESEARCH IMPLICATIONS: Healthcare providers within prisons need to prescribe opioids in the least abuseable preparation since the risk of abuse is significant, despite widespread processes of supervised dispensing. Prescription medication abuse is not limited to opioids and the predominant drug of abuse in an individual prison can rapidly change according to availability.

Buprenorphine dosing choices in specific populations: review of expert opinion.

INTRODUCTION: Treatment of opioid dependence with buprenorphine improves outcomes. Typical dosing ranges for all patients from clinical evidence and as defined in the product information are wide. For specific groups with complex clinical scenarios, there is no clear consensus on dosing choices to achieve best possible outcomes. AREAS COVERED: The doses of buprenorphine used in 6 European countries was reviewed. A review of published evidence supported rapid induction with buprenorphine and the benefits of higher doses but did not identify clearly useful guidance on dosing choices for groups with complex clinical scenarios. An expert group of physicians with experience in addiction care participated in a discussion meeting to share clinical practice experience and develop a consensus on dosing choices. EXPERT OPINION: There was general agreement that treatment outcomes can be improved by optimising buprenorphine doses in specific subgroups. Specific groups in whom buprenorphine doses may be too low and who could have better outcomes with optimised dosing were identified on the basis of clinical practice experience. These groups include people with severe addiction, high tolerance to opioids, and psychiatric comorbidities. In these groups it is recommended to review dosing choices to ensure buprenorphine dosing is sufficient.