Access to treatment in prison: an inventory of medication preparation and distribution approaches

Background

Individuals experiencing incarceration carry a high burden of physical and mental health conditions^1–4. Clinical services operating in prisons and jails are vital in offering non-pharmacological and pharmacological interventions to treat, care for, and support incarcerated persons. Once prescribed, medications require coordinated preparation and delivery for individuals to access their treatment on time. The report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) published in 1992 recommended that there should be appropriate supervision of the pharmacy and the distribution of medicines. Further, the preparation of medicines should always be entrusted to qualified staff (pharmacist/nurse, etc.)⁵. Therefore, medication preparation and distribution should only engage qualified healthcare professionals. This process is notably intensive and can take away resources from other clinically meaningful activities, such as individual patient visits and health promotion and prevention activities. In smaller detention facilities (less than 100 occupants), which usually have limited healthcare staff, prison officers or even prisoners can be involved in medication preparation and distribution⁶. Such practices violate the principles of confidentiality, autonomy, respect, dignity, and quality of care. CPT experts raised such concerns during recent visits in different European countries, where they observed a lack of respect for the 1992 recommendations of the CPT⁷. For instance, prison officers and incarcerated individuals were found in Greece to work as orderlies (i.e., persons trained in first aid and selected healthcare tasks, such as the delivery of medications, under the supervision of nurses)⁸. In Norway, although nurses were present daily, custodial officers had the duty to distribute prescribed medications⁹.

Best practices related to medication preparation and distribution in prison, and in particular in smaller facilities, could help inform the organization of healthcare service delivery that complies with quality of care, confidentiality, and other human rights principles. There is, however, a paucity of publication on the subject. The objective of this paper is to present a live inventory of different approaches to medication preparation and delivery in prisons.

Methods

First, we looked for published literature on different modalities of medication preparation and distribution. On 15 August 2019, we searched PubMed and Google Scholar for publications studying different approaches using search strings combining medical subject headings (MeSH) terms related to medication preparation, dispensing, and prison with terms related to best practices (i.e., pharmaceutical preparations AND prisons AND practice guidelines as topic). The review of titles and abstracts yielded no relevant articles, prompting us to extend our search to the grey literature by using Google Search, to no avail. Though our choice of keywords were limited, the lack of relevant publications yielded by our search suggests there may be paucity of research on this specific yet important operational aspect of health services management in prisons.

Second, we conducted a focus group discussion among our clinical staff from the Division of Health in Prison, which operates at the post-trial detention facility of La Brenaz in Geneva, Switzerland. On 22 August 2019, the Head of the unit facilitated a focus group discussion, which involved four female nurses, two male nurses, two internal medicine specialists (one female, one male), and a female psychiatrist. The discussion was guided by the care continuum of medication preparation, distribution, and self-administration and the “4Ws + H” lens (what, where, when, who, and how). We did not record the discussion but directly captured participants’ inputs on a whiteboard to help visualize the emerging mapping and catalyze additional contributions. Photographs of the whiteboard were taken and used to transcribe and further categorize the information in a Word document table (Table 1). We consolidated the initial results with inputs from healthcare colleagues who could not attend the focus group discussion and validated the content of the table with participants of the focus group discussion and the Division Chief. The mapping drew from our work experience in prisons and visit to other facilities in Switzerland and various countries in Europe and North America. It was also informed by quality of care and operational considerations with a focus on reducing errors¹⁰ and promoting key human rights principles, such as autonomy, confidentiality, respect, and dignity¹¹.

The Cantonal Ethical Review Board of Geneva granted ethical approval for the study (2017-01379). All participants consented to participate in the study and have the data published.

All the available data is presented in this paper.

Results

Table 1 summarizes different models of medication preparation and delivery with the right column giving comments on the quality of care and operational considerations as well as human rights principles. Within the same facility, various modalities may coexist, depending on staff availability and medication type. Medication can be prepared manually or via an automated and computerized system by a range of health cadres at different locations, including clinics within the facility, pharmacies inside or outside the facility, or prison officers’ quarters if officers carry such a duty. Medication tablets can be given within blister packs or deblistered (intact or crushed), while liquids or creams remain in their original tubes or bottles or are transferred into plastic containers. The distribution can be the responsibility of clinical staff, prison officers, fellow incarcerated individuals, educators, or teachers. Medication can be given in hand or left inside the cell, a personal locked medication boxes, or a cupboard for self-service. Finally, patients can take their medication under direct supervision or unsupervised.

Discussion

This report aimed to present an inventory of different medication preparation and delivery models in carceral settings with a focus on whether they respect quality of care and key human rights principles. Ensuring access to medication while conforming to prison security requirements and taking into account concerns about trafficking, theft, and misuse, particularly of prescribed psychoactive substances¹², needs a pragmatic and well-adjusted operational approach. We acknowledge the fact that our inventory is not exhaustive – this was the beginning of an effort to bridge the gap in published best practices on the topic. Therefore, we call upon prison health services managers, providers, and researchers to enrich this live document with their own experience and observations by adding their contributions directly in the section entitled “Comments on this article” located at the bottom of the online page of the article (an updated version will be uploaded once information saturation is reached). Additionally, individuals experiencing incarceration should be engaged in programmatic and research discussions to provide their perspectives on the topic so that guidance and practices reflect their needs. This continuously enriched inventory can provide a foundation for further operational research and cost-effectiveness studies. The emerging best practices can help inform the design of new medication delivery systems that can contribute to improve the efficiency of healthcare services in prisons as well as empower individuals to safely, timely, and confidentially access and manage their prescribed treatment.

Data availability