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Dr. Appelbaum is Professor of Clinical Psychiatry, and Director, Correctional Mental Health Policy and Research, Center for Health Policy and Research, Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury, MA. Address correspondence to: Kenneth L. Appelbaum, MD, Center for Health Policy and Research, 13E779, University of Massachusetts Medical School, 333 South Street, Shrewsbury, MA 01545-2732. E-mail: kenneth.appelbaum{at}umassmed.edu
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Abstract |
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 Top Abstract Developing the ProtocolProvisions of the ProtocolReactions to the ProtocolConclusionReferences |
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Despite legitimate concerns about treating inmates with controlled substances, ADHD remains a significant disorder with potentially serious consequences that often persist into adulthood.3–7 Some data suggest that the rate of ADHD among prison inmates significantly exceeds the prevalence in community settings.8–14 Untreated inmates can experience functional impairments that interfere with their ability to participate in work, programming, and educational activities. In addition, impulsivity can contribute to behavioral problems and disciplinary infractions. Effective treatment, which often requires stimulant medications, improves functioning and relieves distress for many patients,5,6,15,16 including inmates.17 A complete prohibition of such treatment would deprive appropriate inmates of beneficial treatment and result in preventable individual dysfunction and institutional disruptions.
Unmonitored prescribing of controlled substances, however, creates its own problems. Inconsistent standards and prescriber variability in use of diagnostic and treatment criteria can result in disorganization and discord. Inmates may pressure conservative prescribers to behave more like their liberal colleagues, while security and nursing staff may pressure liberal prescribers to become more conservative. When inmates transfer between facilities, conservative practitioners might inherit patients who are already on stimulants and are resistant to coming off them. The lack of explicit guidelines for medication use or an independent approval process leaves the individual psychiatrist with little support for difficult decisions on whether to prescribe stimulants.
Unless stimulants are to be entirely restricted, correctional systems must develop approaches to their use that address the risks and concerns. In 2004, the University of Massachusetts Correctional Health (UMCH) program sought to do this by developing a protocol for the treatment of ADHD in the Massachusetts prison system. In addition to addressing the concerns already noted, the purpose of this initiative included two major goals. The first was to foster greater diagnostic and treatment consistency in a multi-prescriber environment. The second was to support reasonable and appropriate prescription practices by implementing more consistent standards and a prior approval process that could shield practitioners from excessive pressure about their treatment decisions. For example, a protocol with explicit diagnostic and treatment guidelines could support individual practitioners in their decisions not to prescribe stimulant medications when inmates file grievances, complaints, or litigation for failure to treat. Alternatively, the approval process could diffuse some of the pressures against practitioners who prescribe stimulants.
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Developing the Protocol |
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Considerable effort went into consultations with key stakeholders. At the start of the project, we reviewed the underlying concerns with all clinical and administrative staff; we informed them that a protocol would be developed; and we solicited their initial suggestions and comments. Special outreach was made to our psychiatry staff, prison site-based mental health clinical administrators, nursing administrators, nonpsychiatric physicians, and statewide DOC administrators. During the year that it took to complete the final draft, the developing policy was discussed at multiple meetings, especially with psychiatry staff and site-based mental health clinical administrators. These groups, along with nursing, medical, and DOC leadership, received early drafts of the protocol for their feedback. In addition to group meetings, we received written feedback and we met individually or in small groups with concerned stakeholders.
Although a broad spectrum of clinical and security staff had opportunities to comment on the development of the protocol, some potentially noteworthy groups of stakeholders did not. We did not solicit input from inmates or from community organizations or advocates. None of these groups typically plays a direct role in policy development within the DOC in general, and the ADHD protocol was no exception. Perhaps not surprisingly, many of the most vocal objections to the policy after its implementation came from these groups, as described later.
Reactions from stakeholders during the development of the protocol ranged from enthusiastic support to dismay and irritation. On one extreme, some individuals opined that controlled substances should simply have no place in a correctional setting and that a protocol that allowed and sanctioned their use was misguided at best. On the other end of the spectrum, some of the more liberal prescribers felt personally targeted by the development of the protocol and viewed it as an unjustified infringement on their clinical independence and discretion. The more common reaction, however, consisted of cautious optimism. Although some stakeholders indicated that they would reserve judgment until seeing the final product and its effects, many expressed hope that a protocol would have the desired results, including increased consistency of practice and decreased medication misuse.
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Provisions of the Protocol |
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As part of the diagnostic assessment, the inmate must provide evidence consistent with the diagnosis of ADHD before the age of 12. In general, this evidence should be more than just self-report. It can consist of written or oral documentation from parents, teachers, treatment providers, or other sources. Although current diagnostic criteria as specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)18 require evidence of symptoms causing impairment before age seven, we believed that this would set too high a threshold for documentation by adult inmates and that age 12 was more reasonable. This loosening of the age requirement seemed justified by findings that a significant number of children who likely have ADHD fail to show impairment before age seven,19 a finding that has led some commentators to call for raising the age of onset criterion to age 12.20 The difficulty that adults in general have in recalling or providing evidence of symptoms and impairments during childhood21 and the limited empirical support for using age seven as a threshold have also led some experts to call for setting evidence before age 12 or the onset of puberty as a more appropriate criterion when diagnosing ADHD in adults.22 The evidence and support for loosening the age criterion has continued to mount since the development of our protocol.23,24 After implementation of the protocol, we allowed this criterion to be met with a relatively low threshold of documentation and the most frequent use of the provision for exceptions by the program director because of the understandable difficulty that some inmates have in providing childhood data.
The protocol also requires psychological testing by a doctoral psychologist as part of the diagnostic work-up. Testing includes a diagnostic interview, a self-report instrument, assessment of cognition and attention, and assessment for malingering. We recognized that such tests might have limited diagnostic validity for ADHD, but they could still aid in the accuracy of the diagnosis and in delineating the extent of functional impairments. For these reasons, the test results must be reviewed by the treatment providers, but no threshold test findings are required before making the diagnosis or commencing treatment.
Along with establishing diagnostic requirements, the protocol emphasizes that an assessment of current functioning should generally precede the more labor-intensive interventions such as testing. To qualify for treatment, the inmate must have clinically significant impairment in areas such as ability to function in the general prison population, ability to participate in programming, or ability to perform work assignments. Data on functioning obtained from the diagnostic process and the inmate's self-report generally must be corroborated by collateral sources, such as corrections officers, administrators, teachers, work supervisors, program officers, and health care staff. The key to this part of the assessment is the focus on current environmental demands and activities rather than on past functional difficulties in other community or correctional settings.
Patients who meet the protocol's assessment requirements must cooperate on an ongoing basis with nonpharmacological treatment recommendations, such as individual or group therapies, to be eligible for pharmacologic interventions. Group interventions may focus on areas such as organizational skills, self-esteem, and education about the disorder.25,26 Meaningful participation can improve functioning and confirm the inmate's investment in the treatment process. Initial pharmacologic treatment is with nonstimulant medications (e.g., tricyclic antidepressants, bupropion, and venlafaxine), unless the inmate has clear contraindications or well-documented lack of response to adequate past trials of nonstimulants. When we developed the protocol, atomoxetine had not been added to the statewide formulary, which applied to all state agencies, largely because of questions about whether it had superior efficacy compared with other less costly nonstimulants.
Treatment with stimulants can occur only after a failure of a complete trial of one or more nonstimulant agents, or when such trials are contraindicated. The decision to treat with stimulants also requires a review of the patient's substance abuse history for potential contraindications to stimulants. The pharmacy must receive prior approval from a senior supervising psychiatrist and annual reapprovals before beginning or continuing to dispense stimulants. The approval process is initiated through submission, by the treating psychiatrist, of a one-page form that includes prompts for diagnostic, functional, past treatment, and nonpharmacologic treatment information.
Additional constraints on treatment with stimulant medications include use of crushable, immediate-release medications, which lessens the risk of medication diversion and misuse, unless there is documentation of the functional necessity for use of sustained-release medications. Ongoing treatment requires documentation of objective improvement in functioning, including corroborating information from collateral sources. Stimulant use also must be discontinued if the inmate diverts or otherwise misuses the medication.
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Reactions to the Protocol |
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The response from nursing and correctional staff was generally positive. Many appeared to view the protocol as responsive to their concerns, especially in that it limits stimulant use to inmates with demonstrable needs and provides effective mechanisms to discontinue medications if they are abused. Concerns expressed by these groups about unbridled or inappropriate medication use diminished significantly after implementation of the protocol. Nevertheless, some negative responses continued, often based on opposition to use of controlled substances in prison for any reason.
Responses from inmates included several formal grievances from some who did not meet treatment criteria under the protocol. Most of these grievances, and at least four cases of threatened or actual litigation, involved inmates who were denied stimulants due to confirmed misuse or abuse of their medications (e.g., hoarding) or contemporaneous misuse or abuse of other medications or illicit substances.
Responses by external reviewers from the community also were primarily critical. Their criticisms involved three main contentions: the diagnostic criteria, such as diagnostic data before age 12, were too restrictive; the protocol would exclude many inmates who would benefit from treatment resulting in unnecessary discomfort or behavioral problems; and several psychiatrists in the system told the reviewers that they objected to the protocol's restrictions and the manner in which it was implemented. Although we had chosen a less restrictive age threshold than the one specified in the DSM-IV, some reviewers argued that diagnostic criteria in general and testing do not necessarily predict who will benefit from treatment, and therefore they should not be used to restrict treatment. The repeated opportunities for feedback during the development of the protocol also apparently did not mollify some of the dissatisfaction with its final provisions or the fundamental objection by some psychiatrists to oversight of their practice.
The range of reactions from stakeholders persisted during the first two years of the protocol. Although some individuals remained dissatisfied for the reasons previously mentioned, much of the pre-protocol discord over the use of stimulants for inmates with ADHD disappeared. The new procedures appeared to address many of the prior concerns about treatment of inmates with ADHD.
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Conclusion |
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References |
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This article has been cited by other articles:
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  A. Ghanizadeh and S. Akhondzadeh J Am Acad Psychiatry Law, June 1, 2009; 37(2): 278 - 278. [Full Text] [PDF]
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K. A. Burns Commentary: The Top Ten Reasons to Limit Prescription of Controlled Substances in Prisons J Am Acad Psychiatry Law, March 1, 2009; 37(1): 50 - 52. [Abstract] [Full Text] [PDF]
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