A whole-prison approach to health and wellbeing: Developing education resources with prison residents for prison residents

Dr Caroline IJ Watson, RCGP Clinical Champion for Healthcare in Secure Environments, Lead GP HMP Bedford; Hayley Smith, PeoplePlus, Education HMP Bedford

Acknowledgements Healthcare at HMP Bristol; PHE SW England; Residents, HMP Bedford; PeoplePlus, Education HMP Bedford; Governor and prison staff, HMP Bedford; Healthcare Team HMP Bedford

Background• Pregabalin and gabapentin are

dependence-forming medicines and there has been increasing evidence of abuse of both drugs, particularly in people who misuse opioids and in prison populations.1 On 1 April 2019, they were classified as Schedule 3 (Class C) Controlled Drugs.2

• Both drugs can contribute to drug-related deaths3 and a number of prisons across the UK have introduced assisted withdrawal from pregabalin and gabapentin, for those at risk.

• In March 2019, it was decided to introduce pregabalin and gabapentin assisted withdrawal across all Northamptonshire NHS Foundation Trust secured environments, including HMP Bedford.

• A third of adults in prison report having learning disabilities or difficulties, four-fifths of whom have difficulties reading prison information.4 Co-production of information about the prescribing changes was therefore important to ensure material was accessible. It was also taken as an opportunity to engage residents and to develop collaborative working across prison departments.

Aims• To effectively communicate

prescribing changes to people affected by them.

• To co-produce information with prison residents that would be engaging and easily understood by those going through the assisted withdrawal programme.

Method• We worked in collaboration with

the Education Department who used posters and postcards from an assisted withdrawal programme in South West England as a source for an English class. Learners were required to demonstrate skills in evaluation by answering a survey about the educational material.

• The responses from the survey were used together with illustrations produced in an Art class to develop new posters and postcards. These were evaluated by English classes in a second survey.

PREGABALIN & GABAPENTINASSISTED WITHDRAWAL PROJECT

What’s happening nextDo you know…• In the last 5 years deaths involving

pregabalin or gabapentin when used with opiates are up 89%.

• The use of pregabalin and gabapentin with an opioid can cause death by slowing down your breathing and potentially stopping it completely.

• Naloxone cannot reverse life threatening breathing problems caused by pregabalin or gabapentin.

• All patients who are receiving a pregabalin or gabapentin prescription alongside opiate treatment therapy Methadone/ buprenorphine or opiate based pain killers will be called for a review and reduction of your medication.

• The healthcare team will talk to you about the best way of managing your problem without pregabalin or gabapentin.

• Our main concern is to prescribe safely and to avoid harm.

• Support will be provided by healthcare and the substance misuse team, so please talk with your keyworker.

• If you do not attend your GP appointment, then your medication will be reviewed in your absence and could be stopped.

Go live date Monday 4th December 2017

• Life threatening breathing problems

• Irritability• Aggression • Anxious and on edge

• Loss of sex drive• Blurred vision• Increased appetite • Addiction• Demanding

• Erectile dysfunction• Difficulty going to the toilet • Confusion• Loss of memory• Headache

Just a few of the unpleasant side effects and feelings that pregabalin and gabapentin may give you:

remember S.M. ServiceS ARE here to help YOUDeveloped by Public Health England

Method (contd)• Senior prison and healthcare

staff were asked to approve the resources and raised concerns about the artwork.

• The material was taken back to Art classes and new illustrations were produced. Further drafts were shown to residents and staff who gave feedback. The final version was then chosen.

Outcomes• Feedback from residents

indicated a preference for bright and bold colours with small amounts of simple text.

• Two illustrations caused staff concern as they did not support the values promoted by the prison or the healthcare department.

Discussion• Our feedback showed the need

to tailor health information to its audience, both in style and content. We further adapted it for prison officers with feedback from prison staff of all grades, to enable them to support residents. We also produced more detailed information which was shown on the prison television and displayed on wings and in visiting areas.

• We currently involve residents in shaping services through health forums. Co-production of health information has helped to engage others.

• Better integrated working relationships were established between departments across the prison through this project and further collaboration has been planned.

• HMP Bedford is a Category B prison with a remand function and a high turnover of residents. Challenges we faced included residents being transferred before completing their artwork and disruption due to volatility of the environment.

References1. Advisory Council on the Misuse of Drugs

(ACMD) Pregabalin and gabapentin advice (January 2016). www.gov.uk/government/uploads/system/uploads/attachment_data/file/491854/ACMD_Advice_-_Pregabalin_and_gabapentin.pdf

2. NHSE Rescheduling of Gabapentin and Pregabalin as Schedule 3 Controlled Drugs Guidance (March 2019). www.england.nhs.uk/wp-content/uploads/2019/03/pregabalin-and-gabapentin-guidance-v1.pdf

3. Henderson G, Audrey S. The role of pregabalin and gabapentin in drug related deaths. www.sdf.org.uk/wp-content/uploads/2017/ 03/Role-of-pregabalin-and-gabapentin-in-drug-related-deaths-Graeme-Henderson-University-of-Bristol.pdf

4. Prison Reform Trust. Bromley Briefing Summer 2019.

Pregabalin and Gabapentin - the facts

remember the S.M. Service is here to helpDeveloped by Public Health England

What users are saying:

“There is more chance for overdose if you take heroin and Pregabalin together because Pregabalin takes, like, two/three hours to kick in. So, like, and then we think ‘argh it hasn’t kicked in, oh I’ll have a dig’, so we have a dig and then that kicks in, and then there’s more chance of you going over.”

“They’re like zombies; they don’t know what they’re doing… Pregabalin does make people feel like a zombie.”

“Don’t like ’em… I woke up just feeling like jelly, didn’t know what happened.”

“That’s one of my last overdoses. I knew the heroin was strong and I didn’t know, I was naïve.”

What are Pregabalin and Gabapentin? They were originally used to treat epilepsy. They are also licenced to treat nerve pain and some types of anxiety.

Why do we worry about it?• Use of these drugs can lead to dependence. • Pregabalin and Gabapentin can cause

drowsiness, sedation, slow down breathing, and in extreme cases death.

• There are particular issues in secure settings where deaths have been found to involve illicit and/or diverted medication.

What to be aware of…• Deaths involving Pregabalin or Gabapentin have

increased drastically in the last 5 years, 89% of these are associated with opiate use.

• Opiates & Pregabalin together slow down breathing further.

Naloxone does not reverse respiratory depression caused by Pregabalin/Gabapentin.

Key findings

Loads of writing. I wouldn’t stop and read it.

Too much small print.No, it doesn’t grab you – needs more colour and it’s not bold enough.

Very long worded with words we don’t understand.

17

13

3

12

0

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14

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0

2

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18

Can you read allof the writing?

Is the writingclear?

Do you like thedesign?

Do youunderstand whatthe posters andpostcards are

saying?

Yes No

Survey 1: Evaluation of South West England Prisons poster and postcard material

Pregabalin and gabapentin prescriptions are changing . . .

. . . to reduce drug-related deaths and help make prison safer for everyone.

For more information, please ask the healthcare team. We are here to listen and help you cope with changes to your medicine.

• Pregabalin and gabapentin can cause severe breathing problems. They are even more dangerous when taken with opiates.

• Assisted withdrawal from pregabalin or gabapentin will help protect anyone who is also taking opiates, or who has a history of drug misuse.

• We will look at safer ways of managing symptoms for anyone prescribed pregabalin or gabapentin.

We are changing our pregabalin and gabapentin prescribing to reduce the risk of drug-related deaths and improve safety. Assisted Withdrawal is being introduced for people at increased risk of serious problems including breathing difficulties and death.

Pregabalin & Gabapentin Assisted Withdrawal

at HMP Bedford

Pregabalin and gabapentin can cause serious problems including breathing difficulties and death.

Assisted Withdrawal from pregabalin and gabapentin is being introduced to reduce drug-related deaths and help make prison safer for everyone.

If you are prescribed pregabalin or gabapentin you will be given more information about the changes and how we will support you.

There are information displays and people to help answer your questions and concerns.

Pregabalin & Gabapentin Assisted Withdrawal

at HMP Bedford

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!

Safer Prescribing Programme P

Pregabalin & Gabapentin Assisted Withdrawal

at HMP Bedford

We are changing our pregabalin and gabapentin prescribing to reduce the risk of drug-related deaths and improve safety. Assisted Withdrawal is being introduced for people at increased risk of serious problems including breathing difficulties and death.

It’s easy to read and good font. Yes I can read it all clearly.

Yes, I understand it all.

Not too long, so you’d stop and read it .

For me personally, I think the head exploding doesn’t really promote a supportive feeling. (staff)

Survey 2: Evaluation of redesigned poster and postcard material (Draft 1)

15 15

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0 0

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0

2

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Can you read all ofthe writing?

Is the writingclear?

Do you like thedesign?

Do you understandwhat the postersand postcards are

saying?

Yes No

Pregabalin & Gabapentin Assisted Withdrawal

We are changing our pregabalin and gabapentin prescribing to reduce the risk of drug-related deaths and improve safety. Assisted withdrawal is being introduced for people at increased risk of serious problems including breathing difficulties and death.

�

Safer Prescribing Programme P

Will everyone have their pregabalin or gabapentin reduced and stopped? On a case-by-case basis we will look at:• why pregabalin/gabapentin was started in the first place • any drug misuse, now or in the past• alternative safer medicines and different ways to treat your

problem• all other medicines, to see if they are still needed, safe and

suitable for prescribing in prison.How will I cope with these changes?During the assisted withdrawal period, we will offer: • Individual appointments and group support. • Safer alternative ways to manage ongoing symptoms.• We will listen and we will slow the reduction if someone is

struggling with it.What now?If you are taking pregabalin, your daily dose will be reduced by 75mg once a week to begin with, or 100mg if you are also prescribed high dose methadone, other high dose opiate medicines, or if you use illicit drugs while you are in HMP Bedford.If you are taking gabapentin, your daily dose will be reduced by 300mg every 4 days.If you are found trying to conceal or divert your pregabalin or gabapentin, it will be changed to liquid and the dose will be reduced rapidly: daily by 50mg pregabalin or daily by 300mg gabapentin. What if I have other questions?There will be poster displays around the prison and staff who can help you with any concerns. We understand that this may be a difficult time for you. Please remember, we are here to listen and to help you through. The Healthcare Team

I liked the yellow one more. It was less babyish.

I liked the yellow one more. It was less typical.I prefer the yellow background

of the poster but with the other picture of the men climbing the hill.

It’s laid out easy to understand.

I I like the uphill design more so than the chains, as chains are… associated with old fashioned… incarceration…we want Bedford to be viewed as a progressive establishment. (staff)

Survey 3: Evaluation of redesigned poster and postcard material (Draft 2) Two non-readers

10 10

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10

2 2

0

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0

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Can you read all ofthe writing?

Is the writingclear?

Do you like thedesign?

Do you understandwhat the posters

are saying?

Yes No

Original poster and postcard from HMP Bristol

Redesigned poster: Draft 1

Pregabalin and gabapentin can cause serious problems including breathing difficulties and death.

Assisted withdrawal from pregabalin and gabapentin is being introduced to reduce drug-related deaths and help make prison safer for everyone.

If you are prescribed pregabalin or gabapentin you will be given more information about the changes and how we will support you.

There are information displays and people to help answer your questions and concerns.

Pregabalin & Gabapentin Assisted Withdrawal

�

!

Safer Prescribing Programme P

Final version poster and postcard

Redesigned poster: Draft 2 – new images and choice of colour schemes

Let’s go with users’ preference. They are the people who matter and their opinion must be respected, and I want them to be able to influence outcomes rather than being simply told things will happen to them. (staff)