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Pregabalin: Assisted withdrawal with the support of a multidisciplinary team

  • HMP Norwich implemented a structured approach that reduced pregabalin prescribing in prisons below regional average of 5% (from 10% to 4% = 6% reduction) leading to improved patient health outcomes
  • Better patient outcomes, reduced death as a result of respiratory depression when pregabalin is misused with opioids.
  • Structured team approach to safely managing pregabalin polypharmacy. Concealment (diversion) of pregabalin during supervised administration reduced with the number of patients on this medication is making the medication administration process smoother.
  • The reduction target was achieved, with the number of prisoners halved in just after 5 months
Virgin Care
Virgin Care

The Challenge

Pregabalin is known to be abused due to increasing the potency and effects of opiates. It is traded within the secure environment and in the community. There is evidence that the addition of a prescription of gabapentinoids (including pregabalin) to those receiving opioids is associated with a 50% increase in the risk of opioid-related death. With pregabalin prescriptions increasing by nine times from 2004 to 2014, it has been found that deaths have increased too - with 4 deaths in 2012 soaring to 111 deaths in 2016. New evidence shows 89% of the pregabalin-prescribed deceased were found to have used an opiate too.

Pregabalin is licenced to be used in treatment of:
• Generalised Anxiety Disorder (GAD)
• Panic disorder in adults as a third line choice
• Focal epilepsy as a third line choice (Pregabalin is contraindicated in generalised, tonic-clonic, tonic, atonic, absence seizures and myoclonic seizures)
• Neuropathic pain (diabetic neuropathy and herpetic neuralgia only)

Pregabalin increases dopamine and may influence the dopamine reward system which is implicated in some addictive behaviours. Pregabalin acts as a central nervous system depressant so can cause drowsiness, sedation, respiratory depression and, in the extreme cases, death.

Based on an audit completed as part of 2018/19 Health and Justice East Medicines QiPP, it was identified that HMP Norwich had the third highest number of prisoners on pregabalin compared to other prisons in the east region. NHS Health and Justice data showed that in 2012, the average gabapentinoids (pregabalin) prescribing in the east region was 2.82%, with HMP Norwich having 5.6% population on gabapentinoids/pregabalin. By March 2019, the population of HMP Norwich on pregabalin had risen to 10%, exceeding the regional average of 5%.

Early challenges included:
• Contracted prison GPs were not willing to take the responsibility to detox patients without multidisciplinary input
• Unlicensed prescribing in the community
• Patients were aggressive when detox for unlicensed use of pregabalin was started - officer’s support was needed
• Pregabalin scripts were reissued in the community (following a successful detox in prisons) due to poor transfer of care
• Poor medication reconciliation on reception

The Solution

In 2019, a dedicated project team made up of Virgin Care leadership, medicine management and pharmacists from HMP Norwich came together with a clear focus on reducing drug-related deaths. Clear objectives were established, to:

  • Ensure safe prescribing for multi-drug users
  • Ensure the need for pregabalin is clinically justified if needed
  • Detox patients safely
  • Educate other healthcare professionals about prescribing pregabalin inappropriately
  • Work closely with GP surgeries to ensure continuity of care

Initial actions taken:

  • Posters were displayed on all prison wings to raise awareness amongst prisoners.
  • Monthly pregabalin audits were completed to track progress.
  • All pregabalin patients were booked for reviews with GPs
  • Prescribing Review Group was set up to manage complex patients

This achievement was testament to being trusted partners in wider systems as it took all the HMP Norwich team to work in partnership, without walls. Collaborating teams included the Substance misuse team, Consultant Psychiatrists and wider mental health team and psychologists, Clinical Pharmacists, Wellbeing service, Physiotherapy and local GP surgeries.

The Difference

The project started in Q1 2019/2020, and after 5 months of a structured-team approach, the number of prisoners being prescribed pregabalin was halved and positive progress is ongoing. Quarterly audits are now undertaken into pregabalin prescribing and metrics are recorded on clinical systems.

Since the reduction level was achieved, the service has maintained low level of pregabalin prescribing to just 4% of the prison population.

The outcomes of this project have been shared with the wider system we partner with by our Lead Pharmacist, including to Medicine Safety Officers, to the Eastern Medication Safety Network and with the Controlled Drug Local Intelligence Network for East of England.

Positive feedback from prisoners has also highlighted the positive outcomes this project has achieved, including: “I am able to control my irritation and anger”, “I can express myself better as I think more clearly” and “I no longer have suicidal thoughts”.

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