A brief account of the patient/client assessment
Drug misuse within state prisons has persistently been a major problem for the healthcare personnel. The treatment of misusers within these units is however a challenge for those concerned and this is attributed to a host of factors which dependently or independently leads to fragmented measures of managing this population. These challenges range from the vulnerability of the prisoners to self-harm and suicide cases while in prison; the occurrence of death upon serving their term due to intentional or accidental opiate overdose; the lacking measures of counseling as part of an integrated withdrawal system; the non-adherence to national and international good practices and the inability to articulate appropriate clinical interventions that harmonize the criminal justice system with practice at community level as well as prison regimes overheads on illicit use of drugs within prisons (Fagan, Cox, Helfand & Aufderheide, 2010).
Amidst these challenges, there has been increasing awareness in regard to understanding how drug withdrawals influence self-descriptive behaviors within these units. Prison services are expected and required to pay attention to the management of prisoners in a safe way especially in the early stages of their custody with focus on induction as well as detoxification measures. The focus of the prison nurse is to integrate the criminal justice system measures for behavioral and health modification with the nursing concept (NMC, 2015). Essentially, with prisoners, the incidences of self-harm, suicide, violent aggression and drug smuggling across the reception are all attributed to the lacking long term strategies that can help alleviate the issues of drug misuse within the prisons. These issues are however the effects of lacking mechanisms that can help facilitate withdrawal from drugs. Alcohol withdrawal is one of the pertinent issues that nurses and prison service systems have to contend with in prisons (Fagan, Cox, Helfand & Aufderheide, 2010).
The withdrawal symptoms are difficult to manage as they involve integrating pharmacological and non-pharmacological aspects to help sustain long term solutions. However, with the fragmented security systems that allow for continued access to drugs, these patients tend to take long before they accomplish any meaningful progress. Cases of relapse are rife and these even provide a greater challenge for the nurse because they not only imply that the current measures have failed significantly but also indicate that the patient’s morale at psychosocial level will decline to new lows (Bryan, 2016). Patients battling drug abuse within the prison settings have to contend with the use of opiates as the method for detoxification and these usually pose a bigger challenge because of the lack of monitoring mechanisms that would assure of effective management of the tolerance effects of these opiates.
An exploration of the relevant pathophysiology and pharmacology
For the prison nurse, the most important role to pay is to provide a thorough assessment of the patient because in most cases the inmates may underestimate, deny or provide a poor description of their substance abuse. In some instances, the inmates are likely to overstate their substance abuse experiences based on their hidden intentions (Messina, Grella, Cartier & Torres, 2010). On the other hand, some substances may present symptoms that are not clinically significant and this means that in the case of multiple substance abuses, the nurse may likely adopt a generalized management strategy that will ultimately ignore the specifics of care. Further, there are lacking mechanisms as to which the intensity of the withdrawal symptoms can be determined. The characteristics of a drug differ significantly and they actually determine the intensity of symptoms (Fagan, Cox, Helfand & Aufderheide, 2010). In the case of withdrawal plan, the intensity of the withdrawals will be equal to the intensity of that drug when the patient was under drug use.
The process is even more complex when the drug being used for detoxification has similar effects with the drug that the patient has been abusing. The role of the nurse even amidst the lacking specifics is to ensure close monitoring of the inmates and their specific responses to the drug being used for detoxification. The consistent monitoring helps determine the possibility of some symptoms subsiding or remaining static (Hoffman, Weinhouse, Traub & Grayzel, 2011). This information would significantly help review the medication and care plan and despite the whole process seemingly being a trial and error pattern, it could subsequently help unearth those aspects that the patient may have confined from the nurse. Alcohol withdrawal is regarded as one of the complex processes and this is attributed to the fact that alcohol is a depressant of the central nervous system. This implies that it simultaneously inhibits the excitatory tones and the inhibitory tone. The accomplishment of inhibitory tone occurs as a result of gamma-amminobutyric activity modulation while excitatory tone occurs as a result of excitatory amino-acid modulation activity (Messina, Grella, Cartier & Torres, 2010).
In the cessation processes, the patient cannot therefore implement an abrupt quit process due to the association between the central nervous system and the homeostatic process. In that particular case, the patient cannot manage such an abrupt change and thus the continuous presence of ethanol within the body system has to be maintained and lowered gradually so that at least the patient can easily manage the change in intensity of the symptoms with time. The key aspect in such a gradual process is to help the patient build adaptive responses that are not characteristic to abrupt cessation which would cause an over-activity of the CNS. The use of Librium (chlordiazepoxide) within the prison service is thus informed by the need to facilitate the ethanol levels in the body to remain within a state where they would not significantly affect the activity rate of the CNS and subsequently the homeostatic process (Fagan, Cox, Helfand & Aufderheide, 2010). For patients within the prison units, the level of monitoring is limited by the strict code of segregation that these inmates are subjected to and the lack of internal systems that can actualize effective monitoring which require the presence of a professional care provider.
The prison nurse is provided a basic role that separates them from the patient group that they are supposed to serve. This is even within the recognition that the withdrawal mechanism is significantly influenced by pharmacological features of the drug and even so the patient characteristics. At the patient characteristic level, the patient’s personality, diagnosis, medical and physical cormobidities as well as concurrent drug or alcohol use will determine the impact of the symptoms upon withdrawal (Hoffman, Weinhouse, Traub & Grayzel, 2011). On the other hand, these same factors will determine how the nurse will reduce the treatment dosage say for instance in the use of Librium up to a point when the medication can be discontinued to ensure voluntary management of symptoms that is not mediated by medication (Hoffman, Weinhouse, Traub & Grayzel, 2011).
The major problem within the prisons is that the rate of abuse of the drugs used as treatment is equally high and the treatment formulas tend to be a formality. The colluding between staff and the inmates and the continued sidelining of the prison nurse away from the actual monitoring process all imply that these groups will have some illegal access to substances that help them sustain their dependency on drugs. These mishaps and the uncontrolled association of inmates within the prisons even at a time when the illegal trading of drugs in the prison is noted as being at an all time high means that even for the willing inmates, the continued availability of the drugs hinders the process of cessation (Fagan, Cox, Helfand & Aufderheide, 2010). Further, even for those inmates that are in the cessation process, the withdrawal monitoring is limited thus predisposing them to the risks of unmanaged symptoms of withdrawal. Further, the accessibility to drugs illegally predisposes the inmates to the risk of overdose which is further predisposes the inmates to the risk of cerebrovascular and cardiac events.
On the other hand, the lacking mechanism to monitor appropriate use of the medication and minimize sharing of the treatment drugs such as Librium also poses a serious problem to the inmate population. In most cases, the nurse is tasked with providing the dosage as required without following up on whether the patient actually uses the Librium (Bryan, 2016). In that case, there are gaps that open up to a case where the Librium even being a controlled substance is misused rather than used for purposes of treatment of the primary condition; withdrawal. Such instances are propelled by misidentification of the actual patients specifically due to the distance of separation between the nurse and the inmate patient population.
On the other hand, the drug administration duplication partially influenced by the inefficiency of collaboration between the prisons service and the much independent healthcare unit within these facilities is also another gap along which Librium has been misused within these units. The lack of a system that can track and keep these records all but underlines the systemic failure of the health unit within the prisons service which is a problem at the legal and administration unit (Messina, Grella, Cartier & Torres, 2010).
The legal and ethical framework underpinning your practice
Within the prison units, nurses are designed to deliver all forms of care irrespective of their specialty areas. Health units within the correction units have minimal regard for quality of care as compared to the units in the community settings. This in itself poses a significant challenge ethically especially in the dissemination of care that is holistic and patient centric. On one hand, the major health issue within the correctional facilities is drug abuse. Management of drug abuse is an interdisciplinary role that encompasses the social, behavioral and cognitive care for the patients. However, within the specific nature of the correctional units, nurses are expected to provide all forms of care that the interdisciplinary team would have otherwise found it difficult to accomplish (National Treatment Agency for Substance Misuse, 2015). The quality of care afforded is essentially affected and the outcomes in their totality may not be anything close to the expectations.
Even within this issue lies the limited regulation of prescription of controlled substances which form a significant component of the management of drug abuse in any patient population. Prison nurses who can either be an RN or an LPN has the ability to administer Librium as an alcohol withdrawal treatment drug (RCPG, 2015). This is a role that an LPN or RN cannot accomplish at the community level without the correction of the physician. However, within the correctional unit, the nurse is also expected to observe Direct Observation Therapy (DOT) policy which implies that they have to issue a single dose to the patient. The aspect of self-administration is minimally utilized in correctional units save for those on home leave or work release (NMC, 2015). In the case where the inmate patient is in custody supervision, the officer in charge of the custody is tasked with the role of prescription and administration even in the absence of the nurse.
Apparently, the entire process of prescription of Librium and other controlled substances that are utilized in drug abuse treatment is fragmented and unregulated thus allowing for gaps where the officers who have such authority to collude with the inmates and other staff to supply these medications for misuse. While the Drug Enforcement Administration (DEA) is mandated to dictate and determine the people who are eligible to prescribe controlled substances, this role in most cases is limited to the physicians and some APRN roles (NMC, 2015). However, the Bureau of Prisons is also mandated by the DEA to determine a member of their staff who can prescribe in thee course of the official duty.
Beyond this provision, there is no law or regulation that determines how stock taking is done especially due to misrepresentation of figures on number of patients in need of those services within the units. This is actually the major loophole align which the controlled substances such as Librium find their way to the inmates illegally and where they are abused rather than utilized for intended purposes. The nurse’s role in these units is limited by the very conservative nature of correctional units that limits the time that other personnel can spend and interact with the inmates including during the care process (RCPG, 2015).
References
Bryan, J. (2016). Landmark drugs: The discovery of benzodiazepines and the adverse publicity that followed. Dementia. 14(53), 583m
Fagan, T. J., Cox, J., Helfand, S. J., and Aufderheide, D. (2010). Self-injurious behavior in correctional settings. Journal of Correctional Health Care. 16(1), 48-66.
Hoffman, R. S., Weinhouse, G., Traub, S. J., & Grayzel, J. (2011). Management of moderate and severe alcohol withdrawal syndromes.UpToDate, Waltham (MA): UpToDate.
Messina, N., Grella, C. E., Cartier, J., & Torres, S. (2010). A randomized experimental study of gender-responsive substance abuse treatment for women in prison. Journal of substance abuse treatment, 38(2), 97-107
National Treatment Agency for Substance Misuse. (2015). Drugs and Alcohol Ireland - Clinical management of drug dependence in the adult prison setting including psychosocial treatment as a core part. - Drugs and Alcohol, Retrieved from http://www.drugsandalcohol.ie/11496/
NMC, (2015). NMC revised code unveils 25 standards for good practice. (2015). Cancer Nursing Practice, 14(2), 7-7. doi:10.7748/cnp.14.2.7.s6
RCPG, (2015). General Practice Advanced Nurse Practitioner Competencies. Retrieved from http://www.rcgp.org.uk/membership/practice-team-resources/~/media/16411E76AC5B4E818547E331F9D3CA97.ashx
