shaap.org.uk · Web viewAcute Alcohol Withdrawal is the physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if

Delivering Quality Alcohol, Drugs and Tobacco Healthcare Services to People in Police Custody in Scotland

Guidance for Police Scotland and Healthcare Professionals

DRAFTVersion 0.7, 21st June 2016

1 | P a g e Delivering Quality Alcohol, Drugs and Tobacco Healthcare Services to People in Police Custody in Scotland - Guidance for Police Scotland and Healthcare Professionals

Version Control

Date Version Changes Author14/01/2016 0.1 Draft developed following discussion at

Substance Misuse Group 3/11/2015Hannah Cornish

19/02/2016 0.2 Changes made following comments from Duncan Stewart and Lesley Graham

Hannah Cornish

1 April 2016 0.3 Changes made following group meeting on 29/2/16 and comments from Group members by email

Hannah Cornish

14 and 22 April 2016 0.4 Changes made to formatting and proof read and comments from Lesley Graham, Barry Muirhead and Duncan Stewart

Laura McDonnell / Hannah Cornish

10 May 2016 0.5 Changes made following further comments from Lesley Graham and Duncan Stewart

Hannah Cornish

8 June 2016 0.6 Changes made following comments from Substance Misuse Group via email

Hannah Cornish

21 June 2016 0.7 Changes made following Substance Misuse Group meeting on 15th June 2016

Hannah Cornish


Contents

1. Introduction........................................................................................................................ 41.1 Measuring and Improving Quality............................................................................4

2. Development of the Guidance...........................................................................................53. Need for substance misuse services in police custody......................................................64. Optimal Model of Care.......................................................................................................7

4.1 High level pathways.....................................................................................................74.1.1 Police Pathway.............................................................................................74.1.2 Healthcare and Forensic Medical Pathway...................................................8

4.2 Police Scotland Custody Division - Identifying people in need of Healthcare and Forensic Medical Services......................................................................................9

4.3 Healthcare Professional Healthcare Assessment..................................................104.4 Alcohol..................................................................................................................12

4.4.1 Alcohol Patient Pathway..............................................................................124.4.3 Management of Acute Alcohol Withdrawal..................................................134.4.4 Screening for Alcohol Use Disorders..........................................................154.4.5 Alcohol Brief Interventions Delivery.............................................................16

4.5 Drugs.....................................................................................................................174.5.1 Drug Patient Pathway..................................................................................174.5.2 Assessment of Withdrawal..........................................................................184.5.3 Management of Drug Withdrawal................................................................194.5.4 Opioid Substitution Therapy (OST).............................................................214.5.5 Administration of Naloxone in an Emergency Situation...............................21

4.6 Tobacco................................................................................................................224.7 Ongoing Care whilst in custody.............................................................................23

4.7.1 Communication with Police Scotland..........................................................234.8 Throughcare – to other services and through the justice process.........................23

4.8.1 Naloxone Take Home Kits...........................................................................234.9 Links to Scottish Prison Service............................................................................244.10 People with multiple needs....................................................................................25

4.10.1Mental health and substance misuse..........................................................254.10.2Blood Borne Viruses...................................................................................254.10.3Pregnant women.........................................................................................254.10.4People under 18..........................................................................................25

Appendixes……………………........................................................................................................ 26Appendix A - Substance Misuse Membership.................................................................26Appendix B - Clinical Institute Withdrawal Assessment of Alcohol Scale........................27Appendix C - Alcohol Screening Tools............................................................................29Appendix D - Drug Screening Tools................................................................................31Appendix E - The Drugs Wheel.......................................................................................34Appendix F - Sample resources for the collection of Methadone / Buprenorphine from

community pharmacists.........................................................................................35Appendix G – Summary Care Plan..................................................................................37

Glossary……………………………………………………………………………………………………..39References…………....................................................................................................................... 40Bibliography…………………...........................................................................................................43


1. Introduction

This Alcohol, Drugs and Tobacco Guidance has been produced by the Substance Misuse Group of the National Coordinating Network for Healthcare and Forensic Medical Services for People in Police Care (Police Care Network). It sets out an evidence informed ‘Optimal Model of Care’ for people with alcohol, drug and tobacco problems who come into police custody in Scotland. It outlines best practice for the identification and management of individuals, as well as advising on harm reduction, health improvement interventions and the provision of ongoing support in the community.

Responsibility for the delivery of healthcare to people within police custody sits with NHS Boards. There are however different service delivery models across Scotland. Some are nurse led with nurses providing the initial triage, assessment and treatment, supported by Forensic Physicians, and others are primarily provided by contracted Forensic Physicians. In remote and rural areas services are generally provided by General Practitioners. This takes cognisance of the remote and rural geography as well as the infrequent requirement for expert forensic involvement. This guidance can be used by all healthcare professionals working in police custody regardless of the model of service delivery.

The Guidance can be used by NHS Boards and Police Scotland to inform the way in which services are delivered and structured locally. The Optimal Model of Care, as outlined in section 4, has been developed using the best available evidence and expert clinical views. It in no way constrains NHS Police, Scotland or associated partnerships should they wish to enhance the model with innovative elements of service delivery.

The Optimal Model of Care is intended to supplement but does not replace existing national guidance such as from Scottish Intercollegiate Guideline Network (SIGN) or National Institute of Clinical Excellence (NICE). The model of care presented here is designed with particular attention to the unique police custody environment.

1.1 Measuring and Improving Quality

This Guidance can be used in conjunction with the Police Care Network’s Quality Improvement and Outcome Framework (Graham, Cornish, Fletcher 2015). The Framework contains a suite of evidence informed indicators that can assess outcomes of healthcare delivery within police custody healthcare services and support service planning and quality improvement. Eight of the indicators within the Framework cover alcohol service delivery and ten cover drug service delivery. The indicators can help NHS Boards, Police Scotland and wider partners understand what impact the services are having for individuals and how they are contributing to common outcomes (short, medium and longer term) as identified in the logic models in the Framework.


http://www.policecare.scot.nhs.uk/wp-content/uploads/2015/03/Quality-Improvement-and-Outcome-Framework-v1.pdf

http://www.policecare.scot.nhs.uk/wp-content/uploads/2015/03/Quality-Improvement-and-Outcome-Framework-v1.pdf

2. Development of the Guidance

This Guidance has been developed by the Substance Misuse Group of the Police Care Network. It has been developed by experts working in the field for use by healthcare professionals and Police Scotland working within a police custody environment. The Guidance has been informed by seven key components:

A Literature Review of peer reviewed journal articles relating to the evidence of substance misuse in police custody along with relevant guidelines, policy and strategy documents (Fletcher, Cornish, Graham, 2015a). These provided information on the epidemiology of alcohol and drug problems of those in police custody and an evidence base for the clinical management of individuals in police custody.

A service mapping exercise was undertaken with NHS healthcare professionals working in police custody to determine the current service provision for people with substance misuse or mental health problems who come into police custody in Scotland. The mapping was used by the Group to inform recommendations for improvements to the provision of healthcare delivered to people in police custody (Fletcher, Cornish, Graham, 2015b).

A service mapping exercise was undertaken with Police Scotland Custody Division staff to seek their views on the provision of mental health and substance healthcare within police custody. This was used by the Group to inform recommendations for improvements to the provision of healthcare delivered to people in custody.

The Quality Improvement and Outcomes Framework was published by the Network in 2015. It provides logic models and evidence informed indicators for outcomes for healthcare delivery, including substance misuse services in police custody. The evidence base and expert input into the development of these indicators was used by the Group to inform best practice for service delivery (Graham, Cornish, Fletcher, 2015).

Expert views from members of the Substance Misuse Group - Membership of the Group can be found in Appendix A.

Expert views from the wider Network and associated stakeholders - The Guidance was issued for consultation with a wide range of stakeholders. All comments were considered and changes made as appropriate.

The National Guidance for the Delivery of Police Custody Healthcare and Forensic Medical Services which was initially developed by the Network to inform service delivery prior to transfer of responsibility (Police Care Network 2015a).

During the development of this guidance a number of operational and strategic recommendations were considered and these are contained in a separate document Delivering Quality Alcohol, Drugs and Tobacco Services to People in Police Custody in Scotland – Making it Happen (Police Care Network 2016) for consideration at local, regional and national level.


http://www.policecare.scot.nhs.uk/groups/quality-outcome-information-2/

3. Need for substance misuse services in police custody

Published Journal Articles have found that between 18% and 34% of people in police custody have a healthcare issue relating to alcohol (although there was significant variation between studies as to how this was identified). Substance use in this population group is high, with up to two thirds dependent on tobacco and up to a third dependent on heroin, crack cocaine or cannabis. Multiple substance use is common, a study by Ogloff et al. (2011) found that half of people in police custody reported abusing multiple substances. Of people who admitted using illicit drugs, Payne-James et al (2005) found that 50% reported injecting crack cocaine and heroin simultaneously. Carter and Jenkins (1996) noted that 70% use multiple substances. Gregory (2007) reported that 8% of 103 people in police custody referred to arrest referral services admitted taking a combination of three or more drugs. However a 2014 study by Bahl and Tormey in West Yorkshire, found no demonstrable relationship between alcohol dependence and concomitant drug abuse amongst people in police custody.

People in police custody are known to present with increased prevalence of injecting drug use. In one UK study, of those police detainees who reported drug dependency, 56% reported injecting drug use and 25% reported sharing needles, 6% knew they were Hepatitis B positive, Hepatitis C positive status was 20% and 4% were HIV positive (Payne-James et al 2005).


4. Optimal Model of Care

This section sets out an evidence informed ‘Optimal Model of Care’ for people with alcohol, drug and tobacco problems who come into police custody in Scotland. It outlines best practice for the identification and management of individuals as well as advising on harm reduction, health improvement interventions and the provision of ongoing support in the community. 4.1 High level pathways

4.1.1 Police Pathway The pathway below provide a high level overview of a person’s journey, from coming into a police custody suite, to release or their continued journey through the criminal justice system.


4.1.2 Healthcare and Forensic Medical Pathway The Healthcare and Forensic Medical pathway outlines a person in police custody’s interaction with the Healthcare and Forensic Medical Service and wider NHS.


4.2 Police Scotland Custody Division - Identifying people in need of Healthcare and Forensic Medical Services

The care and welfare of people in custody is the responsibility of Police Scotland. Diligence needs to be taken to identify people who may be in need of healthcare in order for Police Scotland to be able to carry out this duty.

Police Scotland use a number of approaches to establish acute clinical and welfare risk: Answers to the Risk Assessment Question Set Previous Police awareness of substance misuse concerns Previous history of drug offences / violent crime

All people in police custody should be asked about substance misuse, including alcohol and benzodiazepine use so that early intervention can be provided (Medical Working Group 2011). Based on the answers provided, police should refer to the Healthcare and Forensic Medical Service.

It is advisable that all people in police custody are managed in accordance with the Police Scotland’s Health and Welfare of Prisoners Standard Operating Procedures, which outlines processes for identifying people who require review by a healthcare professional or who require to be transferred to Accident and Emergency Departments.

People who are suspected of having concealed drugs internally should be managed according to the Management Guidelines for Persons Suspected of Having Drugs Concealed Internally, Version 2, June 2015 (Police Care Network 2015b).

People suspected of having taken new psychoactive substances should be managed according to The Standards for the pre-hospital clinical management of those suspected of being under the influence of new psychoactive substances developed by the National Prisoner Healthcare Network with input from wider partners (awaiting publication).


http://www.policecare.scot.nhs.uk/groups/healthcare-service-delivery-group/drug-banking/

http://www.policecare.scot.nhs.uk/groups/healthcare-service-delivery-group/drug-banking/

4.3 Healthcare Professional Healthcare Assessment

UK guidelines recommend that healthcare professionals should be involved in the management of people in police custody with substance misuse or dependence (Medical Working Group 2011). Substance misuse is known to be a contributory factor in a substantial proportion of deaths in police custody in UK and Europe (Heide et al 2009 and Best et al 2004). Early identification and management of people is therefore key to reducing such events.

Accurate assessment of morbidities associated with substance misuse, including the degree and severity of dependence and of the need for medical intervention is essential, because both intoxication and withdrawal can put people in custody at risk of medical, psychiatric and legal complications and can affect interviewing and therefore potentially the judicial process.

Furthermore identifying individuals with alcohol problems is a necessary step to address the links between alcohol and offending, by aiming to intervene in the often cyclical process of offending where alcohol plays a major part, thus potentially reducing re-offending and prison admissions (MacAskill et al 2011).

Following referral from Police Scotland, a general healthcare assessment will be conducted by a healthcare professional. The healthcare assessment should take place within a designated healthcare area unless the patient is physically incapable of being brought to this location. Health Facilities Scotland have issued Guidance on police custody medical services facility design and cleaning (2014).

The healthcare assessment could involve:

A detailed alcohol and drug history, including

Types of substance misused – it is important to know whether the patient misuses multiple substances, including legitimately prescribed medications, tobacco and alcohol. It is suggested that this is an active enquiry, as alcohol dependency is often not recognised or reported by users of other substances.Duration of substance misuse Quantity taken per day, on an average / typical day and / or amount spent on substances Frequency of useQuantity used in the past 24-48 hours Time of the last dose (Medical Working Group 2011 and NICE 2007) Route of administration. For those reporting an active history of intravenous drug misuse, clinical examination should include a “site check” to confirm the history and also look for abscesses, cellulitis, etc (Police Care Network 2015a)Biological testing can help guide treatment (NICE 2007). A urine sample for drug screening could also be collected to support clinical findings, particularly for individuals who report non-intravenous illicit use or who are prescribed unsupervised methadone.An alcometer for non-evidential breath alcohol measurement can be a useful tool to aid diagnosis and management in those where alcohol excess is suspected as a possible cause of a decreased conscious state.

Checking the Emergency Care Summary for information on previous episodes of alcohol/drug intoxication, treatment or withdrawalChecking other local patient management systems where possible Checking, where appropriate, whether the patient is on an opioid substitution therapy, usually with the Community Pharmacy or drug treatment services


If, following a healthcare assessment the patient is thought to be at risk of withdrawal, an assessment of withdrawal should be conducted (see section 4.4.2 and 4.5.2).

It is recommended that all consultations are recorded on Adastra, the national clinical IT system within police custody. In order to accurately record activity and develop a better understanding of the clinical needs of this population group, it is suggested that where ‘fitness to be charged / detained / interviewed etc…’ is recorded as the reason for referral, it would be beneficial to also record any healthcare reasons that might underpin that.


4.4 Alcohol

4.4.1 Alcohol Patient Pathway


4.4.2 Assessment of Acute Alcohol Withdrawal

Acute Alcohol Withdrawal is the physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time (NICE 2010). Alcohol withdrawal complicates other presenting symptoms and signs and carries a significant morbidity and mortality if untreated (Medical Working Group 2011). Alcohol-dependent people in custody may develop withdrawals as early as 6-8 hours after their last consumption of alcohol and before blood alcohol reaches zero. Common clinical features include tachycardia, sweating, tremor and agitation. Severe alcohol withdrawal can lead to delirium tremens and seizures.

It is recommended that the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) is used as the tool to assess withdrawal, as per NICE guidance, as an adjunct to clinical judgement. The CIWA-Ar, which is on Adastra, has well documented reliability, reproducibility and validity, based on comparison to ratings by expert clinicians. It is easy to use and has been shown to be feasible to use in a variety of clinical settings (Clinical Institute Withdrawal Assessment of Alcohol Scale).

4.4.3 Management of Acute Alcohol Withdrawal

For healthcare provision in police custody, early intervention for acute alcohol withdrawal is key. If possible intervention should be provided prior to patient’s exhibiting severe signs of withdrawal (based on clinical assessment and history) (Medical Working Group 2011).

All NHS Boards should consider having local protocols in place for the management of alcohol withdrawal which are suitable for use within a custody suite.

Although treatment to limit or prevent withdrawal may seem desirable, before such treatment is initiated, healthcare professionals should be satisfied that the patient is not under the influence of other substances that might significantly alter the action of the prescribed medication, thus making it unsafe. To treat symptoms of withdrawal from alcohol, benzodiazepines such as chlordiazepoxide or diazepam are recommended (Medical Working Group 2011). Local protocols should be followed for dosages.

In accordance with NICE (2010) Alcohol-use disorders: diagnosis and management of physical complications and SIGN Guideline 74 (2003) The management of harmful drinking and alcohol dependence in primary care1, thiamine should be offered to people with a chronic alcohol problem whose diet may be deficient and are therefore at high risk of developing Wernicke’s encephalopathy.

Thiamine should be given orally to harmful or dependent drinkers if they are malnourished/at risk of malnourishment, have decompensated liver disease or are in acute withdrawal. Parental thiamine followed by oral thiamine is recommended for harmful or dependent drinkers with these characteristics who attend an Emergency Department or are admitted to hospital with an acute illness or injury.

1 Note that although SIGN Guideline 74 has been withdrawn, in the absence of an updated version, the broad key principles of SIGN apply


https://www.nice.org.uk/Guidance/cg100

https://www.nice.org.uk/Guidance/cg100

http://wiki.hl7.org/images/2/25/Alcohol-Withdrawal-Assessment-Scale.pdf

National guidance notes that “there is some theoretical and trial evidence to suggest that parenteral replacement elevates blood levels more quickly than oral replacement, however it is not known if this is clinically significant, and there is no convincing clinical evidence to suggest which route and dose of thiamine is most effective at preventing Wernicke’s encephalopathy”. NICE reflects that this is important to consider given that parenteral dosing uses additional resources, is unpleasant for the patient and has a very small risk of anaphylaxis (NICE 2010). It is important to note that given the risk of anaphylaxis, appropriate responses would need to be in place.


4.4.4 Screening for Alcohol Use Disorders

For individuals who are not at immediate risk of withdrawal but who may have an Alcohol Use Disorder (AUD), screening is recommended. Effective identification is needed to signpost individuals to appropriate intervention, treatment and support options (MacAskill et al 2011). In most cases, a clinical history as outlined in section 4.3 would be sufficient information on which to determine the category of AUD, however services may wish to consider the use of validated screening tools to supplement this information.

NICE advocates the use of screening tools to identify people who may be at risk of harm from the amount of alcohol they drink, including in the criminal justice setting. AUDs are defined as where someone has hazardous, harmful or dependent drinking:

Hazardous drinking is a pattern of alcohol consumption that increases someone’s risk of harm (physical health, mental health, as well as social consequences)

Harmful drinking is a pattern of alcohol consumption that is causing mental or physical damage

Alcohol dependence is characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences (for example liver disease, or depression caused by drinking). Alcohol dependence is associated with increased criminal activity and an increased rate of significant mental and physical disorders (NICE 2010).

The Fast Alcohol Screening Test (FAST) is a 4-item initial screening test taken from the AUDIT screening tool. It was developed for busy clinical settings as a two-stage initial screening test that is quick to administer since >50% of patients are identified by using just the first question (Public Health England 2016).

If the individual scores 3 or more it is appropriate to carry on delivering an ABI (NHS Health Scotland 2015)2. If it is felt further questions are required to reach a more comprehensive result it may be appropriate to continue with the use of the full AUDIT tool. AUDIT is regarded as the ‘gold standard’ screening questionnaire for detecting hazardous and harmful drinking with 92% sensitivity and 93% specificity (NICE 2010). AUDIT has been shown to be feasible to use in prisons and community justice settings and can provide valuable information to detect and understand alcohol problems in people in police custody (Fletcher, Cornish, Graham 2015a). AUDIT can be found in Appendix 3.

Those drinking at hazardous or harmful levels can be offered an Alcohol Brief Intervention (ABI) (see section 4.4.5 below). Those who are identified as alcohol dependent can be signposted to / referred into specialist alcohol treatment services (see section 4.6.2).

2 The new UK CMO Alcohol Guidelines were published on in January 2016. The ABI screening tools are internationally validated and are designed to give clinicians a consistent way to screen for alcohol problems. In the main these screening tools ask about drinking behaviours with the number of units as the first question in FAST which can quickly identify those who would benefit from an ABI. These tools (FAST and AUDIT) remain appropriate and relevant and should continue to be used.


https://www.gov.uk/government/consultations/health-risks-from-alcohol-new-guidelines

4.4.5 Alcohol Brief Interventions Delivery

Alcohol Brief Interventions (ABI) are practices that aim to identify a real or potential alcohol problem and provide motivation for an individual to make a change. NICE guidance advocates the use of ABIs in the criminal justice system (NICE 2010).

Screening and ABIs targeted towards those in a criminal justice setting have the potential not only for health gain and reductions in reoffending and the associated economic costs, but also for reducing the wider societal impacts of offending (Coulton et al 2012 and Newbury-Birch et al. 2014). The frequent link between alcohol and crime, particularly violent crime highlights the value of such interventions (Scottish Government 2014 and Chariot et al 2013).

ABI delivery is an NHS Board Local Delivery Plan (LDP) standard, with NHS Boards able to deliver 20% of ABIs in ‘wider settings’ which includes police custody (Scottish Government 2016).

Through the use of FAST and / or AUDIT, those identified as having an Alcohol Use Disorder with hazardous and harmful patterns of alcohol consumption can receive an ABI. If this cannot be done immediately, NICE recommends an appointment should be offered as soon as possible thereafter. If a person in custody is a dependent drinker (AUDIT score 19 or more) then he/she should be referred for specialist treatment (NICE 2010).

A brief intervention is defined in ’Sign Guideline 743 as: Feedback: about personal risk or impairment Responsibility: emphasis on personal responsibility for change Advice: to cut down or abstain if indicated because of severe dependence or harm Menu: of alternative options for changing drinking pattern and, jointly with the patient,

setting a target. Intermediate goals of reduction can be a start Empathic interviewing: listening reflectively without cajoling or confronting; exploring

with patients the reasons for change as they see their situation Self efficacy: an interviewing style which enhances peoples’ belief in their ability to

change.

NHS Health Scotland provide guidance and training on ABI delivery, for further information visit their website:

ABI delivery for people in police custody should be reported to local Alcohol and Drug Partnerships (APD) in line with the Scottish Government’s Local Delivery Plan Standard: Alcohol Brief Interventions, National Guidance: 2015-16. NHS Boards and the Scottish Government monitor NHS Boards performance against the national LDP standards and progress is published on the Scottish Government Scotland Performs website and in the Information Services Division (ISD) ABI Annual Report (ISD 2015a).

3 Note that although SIGN Guideline 74 has been withdrawn, in the absence of an updated version, the broad key principles of SIGN apply.


https://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2015-06-30/2015-06-30-ABI2014-15-Report.pdf

http://www.show.scot.nhs.uk/wp-content/uploads/2015/06/Alcohol-Brief-Interventions-ABI-National-Guidance-2015-16.pdf%20%20%20%5D

http://www.show.scot.nhs.uk/wp-content/uploads/2015/06/Alcohol-Brief-Interventions-ABI-National-Guidance-2015-16.pdf%20%20%20%5D

http://www.healthscotland.com/topics/health/alcohol/local-delivery.aspx

4.5 Drugs 4.5.1 Drug Patient Pathway


4.5.2 Assessment of Withdrawal

The clinical history as outlined in section 4.3 is sufficient information with which to assess whether a patient is at risk of withdrawal. Services may wish to consider the use of validated screening tools to supplement this information, which are outlined below. However it should be noted that these have not been validated for use in a police custody setting.

The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed to be administered by a healthcare professional to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. The summed score for the complete scale can be used to help clinicians determine the stage or severity of opiate withdrawal and assess the level of physical dependence on opioids (National Institute on Drug Abuse 2003).

The Severity of Dependence Scale (SDS) is a 5-item questionnaire that provides a score indicating the severity of dependence on opioids. Each of the five items is scored on a 4-point scale (0-3). The total score is obtained through the addition of the 5-item ratings. The higher the score the higher the level of dependence. The SDS takes less than a minute to complete (World Health Organisation 2016).

The Drug Abuse Screening Test (DAST) is a screening tool whereby the extent of problem drug use can be quantified. Although used by researchers in police custody suites little comment has been made in the literature as to its reliability.

It should be remembered that the onset of signs of overdose with certain substances, for example, methadone or other substances swallowed immediately before arrest in order to escape detection, may not be immediately obvious and may occur later (Medical Working Group 2011).


4.5.3 Management of Drug Withdrawal

As with all healthcare provision in police custody, early intervention is key. If possible interventions should be provided prior to patient’s exhibiting signs of severe withdrawal (based on clinical assessment and history). Withdrawal can put a person in custody at risk of medical, psychiatric and even legal complications (Medical Working Group 2011).

All NHS Boards should have local protocols in place for the management of drug withdrawal which are suitable for use within a custody suite.

Although treatment to limit or prevent withdrawal may seem desirable before such treatment is initiated healthcare professionals should be satisfied that the patient is not under influence of other substances such as alcohol that might significantly alter the action of the prescribed medication, thus making it unsafe,

Multiple substance misuse is common in people in police custody (Ogloff et al 2011, Payne-James et al 2005).

People will react differently to different drugs, and indications of withdrawal will vary as outlined below.

The Drug Wheel The drugs wheel is a new model for substance awareness, which covers traditional drug categories and reflects new drug trends such as emergence of New Psychoactive Substances (NPS). Classifying drugs in this way allows for advice and harm reduction information to be given by category, meaning that workers do not need to know in-depth details of all the drugs currently on the market (The Drugs Wheel 2016). A larger version is included in Appendix E and can also be found on the Drugs Wheel website.


http://www.thedrugswheel.com/downloads/TheDrugsWheel_2_0_1_colour.pdf

BenzodiazepinesThe acute cessation of benzodiazepines can lead to a clinical picture of withdrawals similar to that seen with alcohol. The development of withdrawal symptoms is slower that that seen with alcohol, typically developing within two days, and the risk of withdrawal seizures within police custody is low

PsychostimulantsWithdrawal from psychostimulant drugs such as cocaine, ecstasy and amphetamine does not produce major physical withdrawals. Psychological dependency is common in habitual users with insomnia and depression being precipitated on withdrawal.

HallucinogensHallucinogenic drugs such as LSD have a relatively quick onset of symptoms (10-60 minutes) with recovery seen usually within twelve hours. No physical withdrawal syndrome is typical although anxiety may be precipitated.

Volatile substancesSolvent abuse leads to intoxication that can develop within one minute and persist for up to 45 minutes. Presentation can be similar to alcohol intoxication although perceptual disturbances and hallucinations are more common. There is no physical withdrawal syndrome and no specific management is required.

CannabisWithdrawal from cannabis in people in custody may precipitate mild symptoms including insomnia, agitation and irritability. No specific treatment is required.

New Psychoactive Substances New Psychoactive Substances are an emerging issue of concern to Police Scotland and to NHS Boards. There are challenges in responding to the emergence of NPS due to the limited available evidence. There are indications that NPS can cause a range of physical and psychological symptoms ranging from cardiovascular problems and seizures to psychological disorders such as anxiety, agitation, memory loss, depression and psychosis, however, the health risks vary depending on the manner and method of NPS consumer (National Prisoner Healthcare Network awaiting publication). The National Prisoner Healthcare Network has developed Standards for the Pre-Hospital Clinical Management of those suspected of being under the influence of New Psychoactive substances in a secure mental health setting, Police custody and Prisons. The Psychoactive Substances Act 2016 came in to effect on 6 April 2016. The Act makes it an offence to produce, supply, offer to supply, possess with intent to supply, possess on custodial premises, import or export psychoactive substances; that is, any substance intended for human consumption that is capable of producing a psychoactive effect.

Opioids and Opioid Substitution Therapy Many people in custody will use multiple opioids with differing half-lives resulting in a variation as to when withdrawal symptoms will develop. Opioid withdrawal can arise from both illicit and prescribed opioids. Typically withdrawals from heroin will commence approximately eight hours after last use. Clinical features include tachycardia, rhinorrhoea, pupillary dilation, sweating and gooseflesh.

Opioid withdrawals are influenced by psychological factors and subjectively people in custody may complain of numerous symptoms including tremors, nausea, feeling “hot and cold”, myalgia, anxiety and agitation. Greater weight should be given to objective clinical findings when assessing for opioid withdrawal.


4.5.4 Opioid Substitution Therapy (OST) “Not continuing a legal prescription of methadone is interfering in an unacceptable way with an individual’s medical treatment” (Stark and Gregory 2005 pg. 119). When detained in police custody there is a recognised risk that continuity of medication and healthcare support may be disrupted. As long as it is safe and appropriate to do so, people in custody should have prescribed medication continued including the consideration of opiate substitution therapy such as methadone. This is of particular importance to pregnant women for whom there could be potential complications to their foetus in the event of sudden cessation of opioid use (Medical Working Group 2011).

Opioid detoxification should not be routinely offered to people in police custody, consideration should be given to treating opioid withdrawal symptoms with opioid agonist medication (NICE 2007)

Patients in receipt of a community substitute prescription of Methadone or Buprenorphine can have the prescription confirmed by telephone contact with the dispensing chemist following detention. A sample algorithm for prescribed methadone or buprenorphine for people in police custody and an authorisation form for collecting patient’s own methadone / buprenorphine from community pharmacy can be found in Appendix F.

Some NHS Boards stock methadone which can be dispensed and administered once an individual’s prescription is confirmed. Where this is not the case, Police officers should collect this medication if possible from the community pharmacy. Healthcare professional can administer the OST on a supervised basis following clinical assessment if deemed appropriate.

4.5.5 Administration of Naloxone in an Emergency Situation Naloxone is an opioid antagonist; a drug which can temporarily reverse the effects of a potentially fatal overdose with opioid drugs such as heroin or morphine. Intramuscular injection of naloxone provides more time for emergency services to arrive and treatment to be given. (For information on Take Home Naloxone Kits see section 4.7.3)


4.6 Tobacco

The vast majority of smokers can refrain from smoking for a period, but it should be remembered that the effects of withdrawal from any substance, including nicotine, are likely to be exacerbated by the circumstances of acute enforced detention. Many of the features of nicotine withdrawal are indistinguishable from anxiety (FFLM 2014).

Smoking is not permitted in police custody. Whilst addiction to tobacco may not be the most significant healthcare need for people in police custody, there is an opportunity to provide support for this hard to reach population. Police custody therefore presents an opportunity for smoking cessation promotion by way of brief interventions where appropriate and signposting to local agencies.

NHS Health Scotland provide a number of resources in this area which are available on their website.


http://www.healthscotland.com/topics/health/tobacco/index.aspx

4.7 Ongoing Care whilst in custody

4.7.1 Communication with Police Scotland Healthcare professionals should provide Police custody officers with clear and detailed instructions about any medical supervision required including the frequency of visits needed.

After each consultation, a Summary Care Plan generated through Adastra should be provided to Police Scotland. A copy of the Summary Care Plan is provided in Appendix G.

4.8 Throughcare – to other services and through the justice process

In light of the well-established links between chaotic and or chronic substance/alcohol misuse and multiple re-offending the notion of integrating NHS care with custody brings with it certain prima facie advantages. A more direct form of integration between custody healthcare and the local NHS Board also brings the potential for joined-up access to critical service areas, such as mental health and substance misuse services (Elvins et al 2012).

A focus group undertaken by the Revolving Doors Agency in England with people who had been in police custody found that participants would like the community services to be described to them and made aware of what these can provide, so that they can give informed consent to the healthcare professionals in the police station to contact the services on their behalf (Revolving Doors Agency 2013).

It is recognised that making appointments for this patient group is problematic as the availability of people in custody to attend pre-arranged appointments can depend on court outcomes; and secondly, individuals are less likely to attend for appointments made for them by others as opposed to ones they have generated themselves.

It is therefore recommended that patients are referred or signposted to support services or that NHS Boards work with service providers to provide in reach services such as Arrest Referral Services.

Police Custody Healthcare Services should make strong links with specialist services and Alcohol and Drug Partnerships.

4.8.1 Naloxone Take Home KitsNaloxone is an opioid antagonist; a drug which can temporarily reverse the effects of a potentially fatal overdose with opioid drugs such as heroin or morphine. Intramuscular injection of naloxone provides more time for emergency services to arrive and treatment to be given. Following suitable training, ‘take home’ naloxone kits are issued to people at risk of opiate overdose in order to prevent overdose deaths.

While it is recognised that naloxone alone is not the solution to drug related deaths, it has been identified as an important intervention which can help reduce harm and support individuals towards recovery (ISD 2015b). Data from ISD’s National Drug-Related Deaths Database (Scotland) Report: Analysis of Deaths occurring in 2014 demonstrated that where known, 26% (128) had been in police custody in the six months prior to death (ISD 2016)4. In 2014, 41 individuals were reported to have been in police custody in the four weeks prior to death and 71 in the twelve weeks prior to death.

4 Police custody contact data was missing for 15% (86) of the cohort.


Should services wish to provide take home naloxone kits to people in police custody who are identified as at risk of opioid overdose, partnership working between NHS staff and Police Scotland is crucial. Healthcare professionals could provide training to the patient and the kit could be placed in the persons belongings for when they leave custody.

More information on the Take Home Naloxone Programme can be found on their website.

4.9 Links to Scottish Prison Service Arrangements should be made to ensure that details of healthcare delivered in police custody suites can be accessed by prison based NHS healthcare staff, such as by a suitable IT linkage, to inform continuity of care.

The British Medical Association (BMA) and FFLM (2009) note that, as with other areas of medical practice, it is important for healthcare professionals in police custody to share information with other providers of healthcare. This includes ensuring that the confidential record of any treatment provided or requested by the healthcare professional while the individual is in police custody, accompanies the individual when he / she is transferred elsewhere. Healthcare professionals in police custody and prison medical officers are encouraged to communicate with each other, with the patient’s consent, to obtain confirmation of the patient’s medical history.


http://www.naloxone.org.uk/

4.10 People with multiple needs

4.10.1 Mental health and substance misuse Mental health assessment is important for the general care of the people in custody. For example, there may be depression, psychosis or other psychiatric conditions requiring treatment. When undertaking an assessment for psychiatric conditions, the healthcare professional will need to decide whether to obtain the opinion of a psychiatrist and if so when. Examination of mental state is particularly important medico-legally because if a drug – for example new psychoactive substances amphetamines, cocaine, cannabis or alcohol use gives rise to a psychotic state, this may have implications for the offence or affect fitness for interview (Medical Working Group 2011).

Co-morbidity of severe mental illness and substance misuse is common (Scottish Executive 2003). For example a diagnosis of schizophrenia may coexist with a diagnosis of drug or alcohol dependence. Drug use can cause rapid worsening of mental state in a stable psychotic illness. Intoxication may mimic psychosis which may be triggered by stimulants. A psychotic state may arise that persists beyond the elimination of the drug. Withdrawal states such as those seen with alcohol or benzodiazepines may result in vivid hallucinations and clouding of consciousness (Medical Working Group 2011).

Substance misuse may also be associated with other psychiatric conditions including affective disorders such as depression that can result in acts of self harm, suicide and aggressive behaviour. This is a particular problem following stimulant withdrawal (Medical Working Group 2011). Drug and alcohol misuse can mask other underlying psychiatric disorders.

All people in custody who have a dependency on substances will feel emotionally bereft of their drug of choice when coming into custody. Patients in police custody are not expecting a therapeutic detoxification regime, and as such prevention of withdrawal from any substance is of paramount importance.

4.10.2 Blood Borne Viruses People in police custody are known to present with increased prevalence of injecting drug use and are therefore a high risk group for blood borne viruses.

Based on clinical history and assessment patients should be asked whether they know their status and if so whether they are actively in treatment and refer or signpost accordingly to appropriate services for testing or treatment. It may also be appropriate to signpost to harm reduction services, such as needle exchanges.

4.10.3 Pregnant women Sudden cessation of opioid use in a dependent pregnant woman may be life-threatening for the fetus (Medical Working Group 2011).

4.10.4 People under 18 Whilst young people may not present in police custody with alcohol withdrawal symptoms, NICE notes that the using a validated screening questionnaire as well as a providing an ABI for young people who are thought to be at risk from their use of alcohol is beneficial, particularly those involved in crime or antisocial behaviour (NICE 2010). However NICE recommends that when broaching the subject of alcohol and screening, ensure discussions are sensitive to the young people’s age and their ability to understand what is involved, their emotional maturity culture, faith and beliefs.


Appendixes

Appendix A - Substance Misuse Membership Dr Duncan Stewart, Consultant Addictions Psychiatrist, NHS Lothian (Chair) Ms Amanda Adam, Alcohol Team, Scottish Government Ms Carole Barker-Munro, Scottish Government Ms Hannah Cornish, Programme Manager, National Services Division (NSD), NHS National

Services Scotland (NSS)Mr Phil Eaglesham, Organisational Lead for Health Equity (Community Justice), NHS Health

Scotland Superintendent Andy Edmonston, Custody Division, Police Scotland (until September 2015)Dr Emma Fletcher, Specialty Registrar in Public Health, Information Services Division (ISD),

NSS (until November 2015)Dr Lesley Graham, Public Health Lead for Drugs, Alcohol and Health and Justice, ISD, NSSMs Elizabeth Hutchings, Specialist Pharmacist in Substance Misuse, NHS Fife Mr Sandy Kelman, Team Leader, Aberdeen City Alcohol & Drugs Partnership, NHS

GrampianMr Colin MacDonald, Service Manager Police Custody Health Care, NHS Greater Glasgow

& ClydeDr Richard Milburn, Forensic Physician, NHS Greater Glasgow and Clyde Mr Barry Muirhead, Senior Clinical Forensic Charge Nurse, Forensic Medical Examiner

Service, NHS Lothian Ms Laura McDonnell, Programme Support Officer, NSD, NSS (from February 2016)Mrs Pauline Mullen, Programme Support Officer, NSD, NSS (until February 2016)Ms Claire Ogilvie, Clinical Psychologist, Prisons & Addictions, NHS Forth Valley Mr Tim Parkinson, Professional Officer, Scottish Association of Social Workers (SASW)Mr Grant Scott, Professional Nurse Advisor for Prison & Police Custody Healthcare, NHS

Greater Glasgow & Clyde Ms Karan Simson, Team Leader, NHS Greater Glasgow & ClydeInspector Sandra Stewart, Police Custody Healthcare, Police Scotland Ms Susan Wynne, Service Improvement Facilitator, Scottish Ambulance Service


Appendix B – Clinical Institute Withdrawal Assessment of Alcohol Scale



SCORE

Appendix C – Alcohol Screening Tools

This is one unit of alcohol…

…and each of these is more than one unit

FAST Scoring system Your

score0 1 2 3 4How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

NeverLess than monthly

Monthly Weekly

Daily or almost daily

Only answer the following questions if the answer above is Never (0), Less than monthly (1) or Monthly (2). Stop here if the answer is Weekly (3) or Daily (4).

How often during the last year have you failed to do what was normally expected from you because of your drinking?


Monthly Weekly


How often during the last year have you been unable to remember what happened the night before because you had been drinking?


Monthly Weekly


Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?

No

Yes, but not in the last year

Yes, during the last year

Scoring:If score is 0, 1 or 2 on the first question continue with the next three questions

If score is 3 or 4 on the first question – stop here. An overall total score of 3 or more is FAST positive.

What to do next?


SCORE

TOTAL

If FAST positive, complete remaining AUDIT questions (this may include the three remaining questions above as well as the six questions on the second page) to obtain a full AUDIT score.

Score from FAST (other side)

Remaining AUDIT questions

QuestionsScoring system Your

score0 1 2 3 4

How often do you have a drink containing alcohol? Never Monthly

or less

2 - 4 times per month

2 - 3 times per week

4+ times per week

How many units of alcohol do you drink on a typical day when you are drinking?

1 -2 3 - 4 5 - 6 7 - 8 10+

How often during the last year have you found that you were not able to stop drinking once you had started?


Monthly Weekly


How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?


Monthly Weekly


How often during the last year have you had a feeling of guilt or remorse after drinking?


Monthly Weekly


Have you or somebody else been injured as a result of your drinking? No

Yes, but not in the last year

Yes, during the last year

TOTAL AUDIT Score (all 10 questions completed):0 – 7 Lower risk, 8 – 15 Increasing risk,16 – 19 Higher risk, 20+ Possible dependence


TOTAL

Appendix D – Drug Screening Tools

D1 Clinical Opiate Withdrawal Scale


D2 Drug Abuse Screening Test


D3 Severity of Dependence Scale


Appendix E – The Drugs Wheel


Appendix F – Sample resources for the collection of Methadone / Buprenorphine from community pharmacists

F1 Sample Algorithm for the Collection of Opioid Substitution Medication from Community Pharmacies for People in Police Custody (to be adapted for local use as required)


F2 Sample authorisation form for collecting patient’s own Methadone/Buprenorphine from Community Pharmacy

Healthcare and Forensic Medical Services [Address of Division] Tel:.................................

[name]

For the attention of the duty pharmacist at………………………………………………pharmacy

Re: [title, forename, surname][address of patient ]DOBCustody number:C/O [address and telephone number of police station]

Dear Pharmacist

Please supply the bearer of this note, [insert name of bearer and custody suite address], with my daily dose of methadone/buprenorphine (delete as applicable), which is due on: [insert date(s)]

Name of medicine Dose Number of doses

I will take this under the supervision of the healthcare professional while I am temporarily detained. I consent to relevant clinical information being shared between police custody healthcare professionals and the community pharmacy.

Signed (patient)……………………………………………………………….

Print name:………………………………………………………………………

Dated:……………………………………………………………………………

Authorised for collection by custody officer:

Name:……………………………………………………………………………

Signed:…………………………………………………………………………...

Dated:……………………………………………………………………………


Medication supplied by pharmacy? Y / N

Reason if not supplied……………………………………………………………………………………………

Pharmacist Name…………………………………………………………………………………………………

GPhC number……………………………………………………………………………………………………..

Appendix G – Summary Care Plan


Glossary

ABI Alcohol Brief Intervention BMA British Medical Association BBV Blood Borne Virus CIWA-AR Clinical Institute Withdrawal Assessment of Alcohol ScaleCOWS Clinical Opiate Withdrawal ScaleDAST Drug Abuse Screening Test ECS Emergency Care Summary FAST Fast Alcohol Screening Test FFLM Faculty of Forensic and Legal Medicine FP Forensic Physician FME Forensic Medical Examiner NRT Nicotine Replacement Therapy NPS New Psychoactive Substances OST Opioid Substitution Therapy PHE Public Health England ROSC Recovery Orientated Systems of CareWHO World Health Organisation


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