Clinical guidelines for alcohol treatment

17. Alcohol treatment in the criminal justice system

How to deliver alcohol treatment interventions in police custody suites, prisons and other secure settings and for people with community sentences or on licence.

17.1 Main points

People with alcohol use disorders in the criminal justice system are entitled to care that is safe and effective at a standard that is equivalent to care in the community. Care should be delivered by staff with appropriate competencies.

To address the needs of people with alcohol use disorders, healthcare staff should take opportunities at all points in the criminal justice system to identify, assess and treat people, as well as make appropriate referrals.

Healthcare staff should be competent to manage:

• alcohol use disorders
• drug use disorders
• complex co-occurring physical and mental health disorders
• risks in custody suites and secure settings

Effective communication and co-ordination between alcohol treatment staff, other healthcare services and criminal justice services is essential to provide integrated and continuous care for people throughout the criminal justice system.

Healthcare staff should re-assess, plan support and share clinical information when people move from one criminal justice setting (including court) to another so there is no interruption in medication and treatment can continue.

Alcohol intoxication and withdrawal:

• put the person at risk of medical or mental health complications
• are associated with deaths in police custody and in prison

The clinical safety of people in those settings is the highest priority.

A suitably competent clinician should comprehensively assess anyone identified as potentially alcohol dependent or intoxicated on arrival in a police custody suite or prison, and start medically assisted withdrawal where needed.

Where the clinician assesses that clinical risks (severity of dependence and complexity of co-occurring conditions) are too high for a person to be treated for alcohol withdrawal in the custody suite or prison, they should be transferred and admitted to an acute hospital.

It is essential to monitor anyone who is intoxicated or in withdrawal in police custody suites or in prison. Healthcare staff may also need to monitor other clinical risks.

Healthcare staff with appropriate competencies in alcohol and drug dependence are responsible for clinical monitoring, and people should be placed where healthcare staff can access them to provide this.

Non-clinical custodial staff in police custody and in some prisons carry out welfare observations. There should be standard protocols and staff training for carrying out these observations.

Healthcare staff and non-clinical custodial staff both have a role in managing risk. Communication between healthcare staff and non-clinical custodial staff about the person’s condition and any change in risk levels should be accurate and up to date because risks can change quite rapidly.

People should be offered care-planned and evidence-based psychosocial interventions and recovery support from when they enter prison and throughout their stay (see chapter 5 on psychosocial interventions).

Prison-based services and community services should have systems for sharing clinical information and arranging a smooth transition to community alcohol treatment following release to support continuity of care.

Probation (criminal justice social work in Scotland) and community alcohol treatment services should have clear partnership arrangements and information sharing agreements to support people to engage in alcohol treatment as part of a community sentence or licence condition.

17.2 Introduction

This chapter provides guidance on safe and effective alcohol treatment and care for people in contact with the criminal justice system in the community and in secure settings.

Criminal justice systems vary across England and Wales, Scotland and Northern Ireland. This chapter summarises important principles for people working in those systems to consider.

Commissioners and managers of health and criminal justice systems should have local protocols and operating procedures for delivering alcohol treatment in criminal justice community and secure settings. These protocols and procedures should be based on the most recent evidence and national guidelines, including these guidelines.

17.3 Providing healthcare in criminal justice settings

There is a high proportion of people with alcohol and drug use disorders among those in contact with the criminal justice system (Bebbington and others, 2017; Perkins and others, 2022). So, healthcare providers can intervene at several points in the system, in different settings, to address their needs. These settings include:

• police custody suites
• diversion to mental health services where this is available
• courts
• prisons
• probation services
• community alcohol treatment services

Effective communication and co-ordination between healthcare providers in these settings, and with non-clinical justice staff, is essential to ensure integrated and continuous care for people throughout the system and after they return to the community.

Treatment in the criminal justice system should be based on the principles of care in chapter 2 including taking a trauma-informed and a non-stigmatising approach. See the Working definition of trauma-informed practice for more information.

17.4 Alcohol treatment in police custody suites

Guidance in section 17.4 is for:

• clinicians working in police custody suites
• non-clinical police custody staff
• liaison and diversion workers
• drug arrest referrals workers

17.4.1 Overview

In this section, we summarise the main considerations for working with people with alcohol use disorders in police custody. The Faculty of Forensic and Legal Medicine of the Royal College of Psychiatrists’ clinical guidelines Detainees with substance use disorders in police custody (also known as ‘the blue guidelines’) provide detailed guidance for healthcare professionals and custodial staff across the UK.

People who have been arrested are normally detained in police custody suites while police decide whether to charge them with a crime. Police custody suites are usually based in large police stations. The person detained will have contact with staff including:

• custody sergeants who manage the custody suite, including the care and welfare of detained people
• custody detention officers whose main role is to ensure the dignity and welfare of the people detained in custody suites
• healthcare professionals with clinical and forensic competencies to work in a custodial environment
• liaison and diversion workers or drug arrest referral workers who assess and refer detainees with mental health or alcohol or drug use disorders (liaison and diversion services are available in all custody suites in England but not in all areas of the UK)

A review of deaths in police custody in England and Wales between 2004 to 2005 and 2014 to 2015 found that alcohol or drugs featured as causes in nearly half of deaths (49%) and as associated factors in 82% of deaths (Home Office, 2017). Managing intoxication and treating alcohol withdrawal in police custody is essential to prevent physical and mental health complications and deaths (Independent Police Complaints Commission, 2011).

17.4.2 Competencies for clinicians working in police custody

Several different healthcare professionals work in criminal justice settings and there are multidisciplinary teams in many large police custody suites. It is essential that all clinicians working in police custody have specific training, competencies and clinical support to assess and manage people with alcohol use and drug use disorders. These professionals also need to be able to manage complicated co-occurring physical and mental health conditions in the police custody setting.

You can find the necessary competencies for clinicians working in police custody in appendix A of the blue guidelines.

17.4.3 Considerations for working in police custody suites

The clinical safety needs of people detained in police custody suites is the highest priority, given the distress experienced by them and the need for urgent assessments.

Alcohol intoxication and withdrawal both put the person at risk of medical or mental health complications and are associated with deaths in police custody. Clinical staff must be competent to assess and manage alcohol intoxication and withdrawal.

Healthcare staff should be competent to screen, assess and manage all urgent needs and risks in police custody, including the risks of self-harm and suicide and any urgent physical and mental health conditions.

Healthcare staff should be able and competent to arrange urgent transfers to hospital if required. For example, if the person is experiencing severe complications of alcohol withdrawal.

Where it is indicated in the assessment, healthcare staff should arrange for people with co-occurring mental health conditions to be assessed for compulsory admission to hospital by suitably qualified mental health professionals under the:

• Mental Health Act 1983 (England and Wales)
• Mental Health (Care and Treatment) (Scotland) Act 2003
• Mental Health (Northern Ireland) Order 1986

In appropriate cases, healthcare staff should be able to assess whether the person has mental capacity to make the decision in question (see glossary), including consenting to their medical treatment. Healthcare staff are responsible for clinical monitoring and should be able to access the person to monitor their condition.

Non-clinical custodial staff carry out observations to help manage risk. There should be standard protocols and staff training for carrying out these observations.

Communication between healthcare staff and non-clinical custodial staff about the person’s health and current risks should be accurate and continuous because the person’s condition may change rapidly. Information should be recorded in line with local protocols.

All healthcare staff and non-clinical custodial staff should be trained to make simple assessments of whether a person can be roused and what actions to take if there are any difficulties in rousing them.

Healthcare staff should:

• be aware of the person’s right to:

  • equivalent standard of care to any member of public
  • have prescribed medication continued while in custody, as long as it is clinically safe to do so
  • be informed of the outcome of an assessment and the consequent clinical decisions
• pay close attention to the issue of informed consent by a person to any examination
• understand their role in providing an opinion on the person’s fitness to be interviewed if custodial staff request this

17.4.4 Assessment in police custody

Comprehensive assessment

In police custody suites, a comprehensive assessment, appropriate monitoring and re-assessments are crucial.

In addition to a full assessment of alcohol intoxication and dependence, clinicians should:

• assess the person for intoxication and dependence on drugs in addition to alcohol
• assess the person for co-occurring physical or mental health conditions
• assess the person for any urgent social care and safeguarding needs
• make a comprehensive risk assessment including for risks of self-harm and suicide

Following an initial comprehensive assessment, clinicians or healthcare staff trained and competent in monitoring people who are intoxicated or in withdrawal should continue to monitor and re-assess people who are detained. This is essential to manage alcohol intoxication and withdrawal and to monitor any other risks, since a person’s condition can change quite rapidly. There should be a place in the custody suite where varied levels of monitoring and re-assessment can take place.

There is guidance on comprehensive assessment, including risk assessment, in chapter 4 on assessment and treatment and recovery planning.

Information gathering

Clinicians should consult custody staff at an early stage in assessment because they can provide information on when the person was arrested. This can help the clinician assess when someone last used alcohol. Information about the person’s presentation and behaviour from custody staff and the police risk assessment can also support the clinicians’ risk assessment.

Clinicians should gather as much clinical information as possible about the person from primary or secondary health services, or community alcohol treatment services. However, they may not always be able to obtain this information within the required timescale.

Mental capacity and fitness for interview

If there is a proper reason to believe that the person may lack capacity to make the decision in question, a capacity assessment should be carried out. For example, the clinician may need to assess the person’s mental capacity to consent to their medical treatment. For the purposes of the Mental Capacity Act 2005, an inability to make the decision in question can arise - for example, because of severe intoxication. There is information on legislation and guidance on mental capacity in annex 1.

Clinicians may also be asked by custody staff for their opinion on whether the person is fit to be interviewed by the police. There is guidance on fitness for interview in chapter 4 of the blue guidelines.

Sharing assessments and plans with custody staff

Clinicians should communicate relevant information about a person’s assessed alcohol use disorder and health needs and their risk assessment with custody staff. They should share the risk management plan so custody staff are aware of the person’s needs. Sharing information also enables custody staff to make better decisions about charging and disposals, and to pass on information to courts to inform sentencing.

Referral for further alcohol treatment and other health and social needs

Even if people do not need medically assisted withdrawal, they may still benefit from psychosocial alcohol treatment in the community or in prison. By accurately assessing a person and referring them to treatment and further support, clinicians can effectively address healthcare problems to improve their health outcomes and reduce re-offending.

Police custody healthcare services are responsible for responding to people in need of immediate clinical intervention. Where liaison and diversion services are available, it is their role to provide supported referrals into local treatment services for those not in immediate need of intervention.

Dedicated liaison and diversion practitioners identify people who have vulnerabilities, including alcohol and drug use disorders, when they first come into contact with the criminal justice system in police custody suites or courts. They can then:

• support them through the early stages of the criminal justice system pathway
• refer them to appropriate health or social care services
• enable them to be diverted away from the criminal justice system into a more appropriate setting, such as a mental health setting if required

17.4.5 Intoxication in police custody

Managing intoxication in police custody is vital to reduce risks to the person, including risk of death.

Assessing and managing a person who is intoxicated

Clinicians assessing the person should note their symptoms and signs of intoxication.

For clinicians to diagnose alcohol intoxication, the person should have:

• recently drunk alcohol
• behavioural or psychological changes associated with drinking alcohol
• the necessary physical signs of being intoxicated
• no other medical conditions that explain the symptoms

There is a full list of signs of intoxication and of severe intoxication (which can be fatal) in section 3.3 of the blue guidelines - Detainees with substance use disorders in police custody.

The clinician should take baseline observations of the (potentially) intoxicated person’s:

• pulse
• blood pressure
• temperature
• respiratory rate
• oxygen saturation
• pupils, which should be checked for response to light and symmetry
• blood glucose level as low blood sugar mimics alcohol intoxication (potentially fatal)
• consciousness levels

Clinicians should not manage people who are severely intoxicated in custody suites, in particular those who are unable to walk unaided or speak to provide a coherent history. The person should be transferred to hospital for observation and treatment.

Symptoms of intoxication and alcohol poisoning can continue to worsen for a while after the person has stopped drinking. Alcohol poisoning (overdose) can lead to coma and death.

Clinicians should consider the possibility of illnesses, injury or mental conditions other than intoxication. A person who is drowsy and smells of alcohol may also have concurrent medical problems, including but not limited to:

• drug intoxication or overdose
• epilepsy or seizures
• head injuries
• hypoglycaemia (low blood sugar)
• infections
• metabolic causes (for example, diabetes mellitus)
• encephalopathy (either Wernicke’s encephalopathy or caused by infections), which causes damage or disease to the brain

There is detailed guidance on making a differential diagnosis in section 3.3 of the blue guidelines.

A breath test may be useful to confirm alcohol use, but this should never be a substitute for a full assessment. Clinicians and non-clinical staff should be aware that, even when a person has a breath test reading of a low blood alcohol level, they can still be alcohol dependent or at risk. They should not assume that certain breath test levels can be defined as safe without further assessment.

Monitoring and observing a person who is intoxicated in police custody

A person who is intoxicated in police custody is at risk of experiencing health complications and, in some cases, their behaviour can pose a risk to others. The person should be monitored regularly because their condition can change quite rapidly.

The clinician and healthcare staff who are trained and competent in monitoring intoxication and alcohol dependence are responsible for carrying out all clinical monitoring in line with local protocols.

In addition, custody staff are usually responsible for carrying out regular observations in line with the guidance on observation levels in appendix C of the blue guidelines. Staff carrying out observations should be trained to do so.

The clinician or healthcare practitioner should inform the custody sergeant of the risk management plan and can advise on observation levels.

All clinical monitoring by healthcare staff and regular observations by non-clinical custodial staff should be documented, so any changes in the person’s condition can be detected.

Urgent medical attention when a person cannot be easily roused

Intoxication can lead to over-sedation, which in some cases can lead to fatal respiratory depression.

All healthcare and custodial staff involved with people detained in custody should be trained to carry out simple assessments of whether someone can be roused.

They should also remember that a person who smells of alcohol and seems drowsy may have other serious and urgent physical problems that are making it difficult to rouse them.

You can find guidance on actions to rouse people and how to respond in appendix B of the blue guidelines - Detainees with substance use disorders in police custody.

Non-clinical custodial staff should immediately inform a healthcare professional or urgently call an ambulance if they have difficulty rousing a person or there is significant deterioration of the person’s condition.

A healthcare professional undertaking an assessment when a person cannot be roused should be trained to undertake these assessments through a suitably accredited course. In Northern Ireland, clinicians should know the Northern Ireland alcohol use disorders care pathway – management in the acute hospital setting.

Clinical staff should use a standardised system to monitor for early warning signs of deterioration in condition or loss of consciousness. For example, they can use the Royal College of Physicians’ National early warning score (NEWS) 2 guidance.

The clinician or healthcare professional should arrange for the person to be transferred to an external hospital if there are concerns about their level of consciousness or their condition following their assessment.

17.4.6 Managing alcohol withdrawal in police custody

Withdrawal symptoms and severe withdrawal complications

People with alcohol dependence might only be in police custody a short while, but they may begin to experience alcohol withdrawal, which puts them at risk. It is essential that:

• clinicians assess and diagnose alcohol dependence and its severity
• start early treatment to manage withdrawal symptoms and avoid the severe complications that can occur in withdrawal - which, in some cases, can be fatal

You can find a list of withdrawal symptoms and severe withdrawal complications in annex 3.

Severe withdrawal complications include:

• seizures (fits)
• auditory and visual hallucinations
• delirium tremens (severe shaking, agitation, fever, tachycardia, profound confusion, delusions and hallucinations)
• Wernicke-Korsakoff syndrome (confusion, impaired eye movements or unsteady walking)
• course tremor (very severe shaking)

Anyone experiencing these complications should be transferred to hospital immediately.

All healthcare staff and non-clinical custodial staff should be aware of the signs of severe withdrawal complications and understand that they are a medical emergency.

For guidance on preventing and managing severe withdrawal complications, see section 10.4 of chapter 10 on pharmacological interventions.

Treating alcohol withdrawal

There is guidance in section 17.5.5 on treating alcohol withdrawal in prisons, which is also relevant for treating withdrawal in police custody suites, and the clinician and healthcare staff should follow this.

The clinician should assess whether it is safe for a medically assisted withdrawal to be managed in the custody suite. People with a history of severe complications in withdrawal should be transferred to hospital. The clinician should review any past records for the person that show complications in withdrawal in police custody suites. People with severe dependence and complex co-occurring physical and mental health conditions, co-occurring drug dependence, or other vulnerabilities such as pregnancy may also need to be transferred to hospital.

When the clinician provides a person with medically assisted alcohol withdrawal in police custody, they should provide clinical monitoring of the person’s symptoms and overall condition. All clinical monitoring should be carried out by a specialist clinician or healthcare staff trained and competent in monitoring alcohol and drug withdrawal.

They should use a validated tool such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) scale or a similar validated tool. Frequency of monitoring should be based on individual assessment and in line with their local protocol on alcohol withdrawal.

Monitoring after providing treatment for alcohol withdrawal is particularly important for people with co-occurring medical conditions or drug dependence. If a person does not respond to treatment as expected, the clinician should reassess the person and consider other clinical conditions that can mimic alcohol withdrawal as a possible cause.

In addition to clinical monitoring, the person should be observed regularly. Non- clinical custodial staff should follow guidance on structured observation levels in appendix C of the blue guidelines. The clinician can advise the custody sergeant on the level of observation based on their clinical assessment.

People being treated for alcohol withdrawal can become over-sedated or have other urgent health complications. The guidance in section 17.4.5 on urgent medical attention when a person cannot be roused should be followed.

If a person being treated for alcohol withdrawal is transferred to court, the clinician should consider providing a limited supply of medicine used for this treatment to avoid the person experiencing withdrawal while at court. See section 17.5.5 on medicines continuity for more information.

With the person’s consent, the clinician should share information from the patient record, including full and accurate information on medicines, with the person’s GP and, where the person has agreed to a referral, with the community alcohol treatment service. Wherever possible, the person should be seen by a clinician in the community on release.

17.5 Alcohol treatment in prisons

Guidance in sections 17.5 and 17.6 is for clinicians that provide alcohol treatment interventions in prisons, and for other healthcare staff and non-clinical prison staff who have a role in supporting people with alcohol use disorders in prisons.

Guidance in these sections focuses on alcohol treatment in prisons, but much of it can be applied to other secure settings, including immigration removal centres (IRCs) (see section 17.7) and secure hospitals.

This guidance provides a summary of healthcare for people with alcohol use disorders in prison. Clinicians and practitioners should also follow national guidelines on care for people in prison including:

• National Institute for Health and Care Excellence (NICE) guideline Physical health of people in prison (NG57)
• NICE guideline Mental health of adults in contact with the criminal justice system (NG66)
• Royal Pharmaceutical Society (RPS) guidance Professional standards for optimising medicines for people in secure environments
• Royal College of General Practitioners (RCGP) guidance Safer prescribing in prisons

17.5.1 The prison population

As of March 2024, UK prison population statistics reported a total prison population of about 97,700 people, comprising:

• 87,900 in England and Wales
• 8,000 in Scotland
• 1,900 in Northern Ireland

Many more people than this pass through prison in a year. Some people have short stays in prison while others are there for many years.

Evidence (Bebbington and others, 2017; Wright and others, 2019) shows that compared with the general population, people in prison experience high levels of:

• alcohol and drug use and dependence
• mental health conditions
• some physical health conditions
• social support needs

Many people have a history of trauma. There are also very low levels of literacy and some prisoners do not speak English.

Healthcare teams often need to work with prisoners moving through a system where there is pressure on availability of prison places. Prison systems need access to healthcare staff who can competently assess, treat and monitor people with alcohol dependence, especially during the early days in prison and, increasingly, across all categories of prison.

17.5.2 Equivalence of treatment and care in secure settings

The principle of equivalence of care - as set out in RCGP Secure Environments Group position statement Equivalence of care in secure environments in the UK - is particularly important for people in prisons and similar secure settings.

Equivalent care does not mean that care is exactly the same in community and secure settings, and some interventions recommended in part 1 of these guidelines may need to be adapted for secure settings. There are situations where healthcare provision affects security decision making (for example, the need for frequent access to monitor a patient). Healthcare providers need to understand the potential impact of their actions and work with their non-clinical prison colleagues to find appropriate solutions so people can receive the care to which they are entitled.

17.5.3 Governance for alcohol treatment in prisons

Commissioners and providers of health and justice services should develop a clinical and quality governance strategy to ensure safe and effective treatment and care for people with alcohol and drug disorders in secure settings.

Local protocols should be in place that adequately reflect:

• the current evidence base
• these clinical guidelines
• any other authoritative guidance on implementing alcohol treatment and care in secure settings, for example Drug misuse and dependence: UK guidelines on clinical management
• national guidelines (as listed in section 17.5 above)

Protocols should include guidance on collaborative working between healthcare and non-clinical prison staff to manage risk.

RPS guidance ‘Professional standards for optimising medicines for people in secure environments’ provides a framework to support the commissioning and provision of safe, high-quality services in secure settings, including prisons, IRCs and other places of residential detention. These standards are for anyone working in or with secure settings in England, but they may also be useful in Wales and Scotland.

Each prison should have a HM Prison and Probation Service site-specific drugs (or substance use) strategy, or an equivalent strategy in each UK administration. This strategy should include the management of people with alcohol dependence or problem alcohol use.

It is the responsibility of any commissioners and managers to ensure healthcare staff in prisons are adequately resourced and supported in their roles to meet service demand.

Commissioners and managers of health and justice services should make sure there are sufficient competent staff and medical facilities to provide appropriate treatment and care for people with alcohol dependence.

17.5.4 Staff competencies

Competencies needed by staff for working in prisons include the following.

Competencies for doctors working with alcohol and drug use

The Royal College of Psychiatrists and RCGP report Delivering quality care for drug and alcohol users: the roles and competencies of doctors (PDF, 404KB) lists competencies for doctors. These are not specific to secure settings but identify competencies for working with alcohol and drug use at generalist, intermediate and specialist levels.

Providing safe and effective care

Providing safe and effective alcohol treatment and care in a prison setting is complex and skilled work due to the high levels of need and risk in the prison population, and the operational constraints of the setting.

Care should be delivered by clinicians and allied staff who are:

• suitably competent
• well led
• properly supervised
• operating within a clear quality and clinical governance framework that supports safe and effective service delivery

Healthcare staff, including alcohol treatment staff, should have a thorough understanding of the needs and risks of the prison population and should be able to confidently assess and manage individual clinical risk in the prison environment. This will involve regular re-assessments as risk can change quite rapidly for people in a prison setting.

Clinicians responsible for assessing and managing medically assisted alcohol withdrawal should be competent in the diagnosis and assessment of alcohol dependence and withdrawal symptoms, and in using recommended drug regimens appropriate to the prison setting.

As people with alcohol dependence often have complex co-occurring needs, clinicians should be competent in procedures for clinical monitoring for both alcohol and drug withdrawal or stabilisation, and other systems for monitoring clinical risk. For example, this could include NEWS 2 for assessing and responding to acute illness and risk management systems for preventing suicide such as Assessment, Care in Custody and Teamwork (ACCT) assessments.

Training and supervision

Commissioners and providers of health and justice services should make sure that healthcare staff and prison officers are appropriately trained and supervised, and are competent to carry out their roles when working with people with alcohol dependence.

Healthcare staff providing psychosocial interventions to people with alcohol dependence should be trained and supervised by a supervisor with experience of working in secure environments.

All healthcare staff and prison officers in contact with prisoners should have essential first aid training, including training for the person first on the scene in an emergency.

Working together

Clinical and healthcare staff and prison officers should be competent in working together to provide integrated care and manage risk.

Healthcare staff responsible for alcohol treatment should be competent to work collaboratively with other healthcare teams in the prison, including the mental health care team and with community alcohol treatment services, to provide integrated care.

17.5.5 Considerations for delivering alcohol treatment and care in prisons

Opportunities to access treatment and recovery support

Prison is an opportunity for people with alcohol dependence who have not effectively engaged with community services to access:

• alcohol treatment and support for longer-term recovery
• treatment and care for co-occurring drug use disorders, and mental health and physical health conditions
• health promotion and related social prescribing
• peer networks and peer mentoring

Alcohol withdrawal or intoxication

When a person is admitted to prison and identified as intoxicated or potentially alcohol dependent, a suitably trained and competent clinician should provide a comprehensive assessment and manage the risks of alcohol intoxication and withdrawal at reception.

The clinician should treat alcohol withdrawal in line with:

• local evidence-based protocols or operating procedures
• these clinical guidelines for alcohol treatment
• other relevant national guidelines as set out in section 17.5

Consumption of medication for alcohol withdrawal should always be supervised in prison.

People who are intoxicated or at risk of acute alcohol withdrawal should only be placed in a prison:

• with 24-hour healthcare provision
• where appropriately trained staff can carry out clinical monitoring and enhanced, regular observations based on local protocols

If a person being treated for alcohol withdrawal is transferred to court or another part of the prison system, a clinician should provide them with a limited supply of medicines being used for this treatment. This will help to prevent withdrawal symptoms from recurring and the risk of complications in withdrawal while they are in court or, if they are moving to another prison, until a clinician in the receiving prison can take over the person’s care. See the guidance on medicines continuity in section 17.5.5.

Managing self-harm and suicide risks

All staff (healthcare and prison officers) should understand the increased risks of self-harm and suicide for people on their first night in prison and the early weeks after. They should also understand that people with alcohol dependence or who are intoxicated are at particularly high risk of suicide.

Local risk management protocols and procedures should support an integrated approach to providing safe care for people with alcohol dependence. Clinicians and healthcare staff and non-clinical prison staff should work together to reduce harm and manage risk, particularly the risk of fatalities.

Prescribing decisions

Clinicians need to make prescribing decisions, including about polypharmacy (where the patient has been prescribed several different medicines for different conditions), in line with national guidance that identifies factors for safer prescribing. This includes all those listed in section 17.5 above.

Care planning and integrated care

The clinician or alcohol treatment staff should develop a care plan with the person and with staff from other relevant teams (for example, mental health) that:

• links initial treatment with ongoing treatment and recovery support in prison
• when they are released, links them to community treatment

Staff from different teams should work together to provide integrated care.

Continuity of care

The alcohol treatment or healthcare team should work with colleagues to plan and manage continuity of care from prison entry, through to court appearances, changes in prison setting and preparing for prison release. They should share clinical information (with the person’s consent) to minimise interruption in treatment and reduce risks.

All staff should understand the increased risks the person faces after release, including the risk of relapse and death from alcohol poisoning or drug overdose. Pre-release planning should take these risks into account.

Medicines continuity

RPS guidance ‘Professional standards for optimising medicines for people in secure environments’ describes how people should continue to access their medicines safely and promptly as they move within (including during transit for critical doses of medicines) or leave different criminal justice settings.

Partnership working is essential to provide a seamless and safe transition of medicines optimisation. This includes partnership working between:

• clinicians in sending and receiving care settings
• custodial teams
• healthcare teams
• pharmacy teams

Relevant patient information and full and accurate information on all medications should be provided.

Where people undergoing treatment for alcohol withdrawal are transferred to court or another part of the prison system, a clinician should arrange for a supply of the medicines used for this treatment for the person. This is to prevent withdrawal symptoms from recurring and the risk of complications in withdrawal.

The member of staff escorting the person to the next setting should hold the medication and hand it to a member of the healthcare or court staff in the receiving setting. The management of the medicines and access to the next and following doses will follow the usual arrangements and standards for the specific type of setting.

All staff involved in prescribing and handling medicines for people being transferred from one part of the criminal justice system to another should follow national guidelines on continuity of medicines as set out in NICE NG57 and RPS’s ‘Professional standards for optimising medicines for people in secure environments’.

17.5.6 The patient pathway in prisons

Screening

Screening for patterns of harmful drinking and alcohol dependence should take place at the first-stage health assessment on the day the person is admitted to the prison, at reception, before they go to a cell.

NICE NG57 provides guidance and a template for first-stage assessment which includes questions on alcohol use.

The screening assessment should include questions and actions on:

• alcohol use
• substance use
• physical health
• mental health
• self-harm and suicide risk

There are high levels of domestic abuse, assault and sexual violence among women who enter the prison system, and men also experience this. Screening should include sensitive questions on these topics in a private setting. There is guidance on routine questions on domestic abuse in chapter 22.

If screening identifies harmful drinking or alcohol dependence, or other substance use or dependence, the person should be referred to the substance misuse team or to a clinician with competencies in assessing and treating alcohol dependence and alcohol withdrawal and drug dependence and withdrawal. The clinician should then carry out a specialist assessment in reception before the person goes to the cell.

Comprehensive assessment

The clinician should comprehensively assess the person’s needs and risks. They should use validated tools to identify dependence and severity of dependence, but these tools should be used to support a clinical interview with the person, not to replace it.

You should read guidance on initial and comprehensive assessment in chapter 4 on assessment and treatment and recovery planning.

The increased isolation people experience from being in custody can amplify feelings of hopelessness and make mental and physical health symptoms worse. So, clinicians should take care to treat patients holistically by involving other appropriate services in assessment and care planning.

Many people with alcohol dependence or who drink at harmful levels have co-occurring mental health conditions. If the person appears to have possible symptoms of a mental health disorder, the prison mental health team should assess their mental health and contribute to the comprehensive assessment.

In line with NICE NG57, at screening assessment, healthcare staff should refer people for a mental health assessment if they have:

• previously seen a mental health professional in any service setting
• ever been admitted to a psychiatric hospital
• taken medicine for mental health problems

If the clinician identifies drug dependence (including dependence on prescribed or over-the-counter medication) in addition to alcohol dependence, the person will need concurrent treatment for their drug dependence. Medically assisted alcohol withdrawal will be more complex and requires specialist skills. See section 17.5.7 on co-occurring dependence on alcohol, illicit drugs or prescribed medication below.

Continuity of care on entry into prison

The clinician carrying out the assessment should obtain information from other services on the person’s:

• health (including any allergies)
• prescribed medication
• planned medical appointments
• community alcohol treatment

There are a range of other services and staff that could have important clinical information about the person, including:

• primary care
• community pharmacists
• secondary care physical and mental health services
• criminal justice healthcare services inside and outside the prison
• prison staff records and observation
• community alcohol treatment services
• adult social care

The clinician might not be able to contact all relevant services immediately (for example, if the person enters prison in the late evening), but they should try to make contact as soon as possible so they can make a full assessment.

It is vital that there are agreed partnership arrangements between community alcohol treatment services and prison substance misuse teams or healthcare services. Community alcohol treatment services that have been working with a person can support continuity of care by getting their consent to share their clinical information with a prison substance misuse team if the person is due to attend court and could be sentenced to prison. The community service should share information quickly to help prison substance misuse treatment services with their first assessment of need and risk.

Individual support

The first night and weeks in prison can be extremely stressful for people who are often already vulnerable. Assessment is a chance for the person to speak to someone on an individual basis.

The principles of care set out in chapter 2 apply in secure settings as well as the community.

People with alcohol use disorders in the prison population have often experienced high levels of trauma and disadvantage. A trauma-informed approach and a non-stigmatising attitude from staff can help the person to feel less isolated and distressed on entry into prison and help them go on to engage in alcohol treatment.

17.5.7 Managing urgent clinical needs and risks

Starting treatment and agreeing a plan

In reception, the clinician should start treatment to address all immediate clinical needs, including alcohol intoxication or withdrawal, and agree a risk management plan for all risks.

The clinician should make sure there is a clear, recorded plan for managing clinical needs and risks. The plan should be based on the person’s individual needs and include information from other healthcare teams and actions for these teams. This might include the mental health team and any relevant community services. The plan should take into account the person’s sentence and sentence planning.

The clinician should arrange for risk management plans to be regularly reviewed, particularly in the early days, as risks can change quite rapidly. Plans should also be reviewed when a person’s condition changes and at transition points during their stay in prison when they may need increased monitoring or observation.

The clinician should follow local protocols for recording and sharing information on risk with healthcare colleagues and non-clinical prison staff. Keeping a person’s record up to date and accurate is essential.

Staff from different teams should work together to provide integrated care in line with the care plan. Healthcare staff and prison officers should contribute to multidisciplinary prison risk management systems - for example, the ACCT process used in prisons in England and Wales.

Assessing and managing alcohol intoxication in prison

Clinicians should assess people in prison for symptoms and signs of alcohol intoxication. It is a vital step in the primary and secondary assessment for people who are received into a reception prison and on transfer between prison sites in the early days in custody.

While people cannot access alcohol in prison, it can be illicitly brewed from a variety of sources, such as fruit and bread, and is known as ‘hooch’. There are reports of prisoners becoming acutely intoxicated as a result of drinking illicit ‘hooch’.

Section 17.4.5 provides guidance on assessing and managing intoxication in police custody and clinicians can apply this to the prison setting. Alcohol intoxication can also be complicated by polydrug use or prescribed medications.

People who are intoxicated at reception or at another time during their prison stay need to be in an area of the prison where competent healthcare staff can monitor their condition. Clinicians should agree arrangements with prison officers so that healthcare staff can access the person to monitor their condition and make repeated observations at a sufficient level to manage risks to the person.

The clinician, in discussion with a multidisciplinary team when appropriate, should decide on the frequency of observation based on personalised risk assessment. Risk assessment should include intoxication and other risks, such as self-harm. In cases of self-harm or suicidal thoughts and behaviour, the clinician should begin their integrated risk management procedure if it has not already been started. For example, in England and Wales, an ACCT document should be opened. The clinician should be guided by local protocols that specify standard minimum observation levels related to level of risk, including in reception and overnight. They should also have the option to increase the level of observation if there are changes in the person’s condition that indicate increased risk.

All clinical monitoring should be carried out by clinicians and healthcare practitioners skilled in monitoring harmful and dependent alcohol and drug use and intoxication.

In addition, non-clinical prison officers may carry out welfare observations in some circumstances. There are variations in prison systems across the UK in the role of non-clinical prison staff in carrying out observations. Each prison should have a standardised protocol or local operating procedure that sets out guidance on standard minimum observation levels in relation to:

• levels of risk
• respective roles of healthcare staff and non-clinical staff

Clinicians should advise on level of observation based on the protocol and on their clinical assessment of the person. All staff carrying out observations should be trained to do so.

As an example of a standardised protocol for observation levels, prisons could consider the guidance set out in appendix C of the blue guidelines.

Clinicians, healthcare staff and non-clinical prison officers should work closely together, and clinicians should make sure prison officers are clear about when and how they should escalate any concerns about the person’s condition.

Assessing and managing medically assisted withdrawal

This section provides guidance specific to assessing and managing medically assisted withdrawal in prisons or other secure settings.

You should read it alongside the detailed guidance on assessment and pharmacological interventions for medically assisted withdrawal in chapter 10 on pharmacological interventions.

You should also read chapter 11 on community-based medically assisted withdrawal. Although this chapter provides guidance on community-based withdrawal, it describes the appropriate context of care when providing medically assisted withdrawal and much of this is relevant to secure settings.

Chapter 12 provides guidance on specialist inpatient medically assisted withdrawal.

The importance of effectively managing medically assisted withdrawal

Alcohol withdrawal is associated with significant mortality if it is undiagnosed or undertreated. About 15% of people entering custody report a history of alcohol withdrawal, although this figure is possibly an over-estimate due to an exaggeration of symptoms (Wright and others, 2019).

There should be local evidence-based protocols for carrying out medically assisted alcohol withdrawal drawn up on the advice of a specialist clinician and in line with national guidance.

It is essential that appropriately competent clinicians assess and diagnose alcohol dependence including severity of dependence. Once dependence has been confirmed, the clinician should start early treatment in reception to manage withdrawal symptoms and avoid the severe complications that can occur in withdrawal.

Severe complications include:

• seizures (fits)
• auditory and visual hallucinations
• delirium tremens (severe shaking, agitation, fever, tachycardia, profound confusion, delusions and hallucinations)
• Wernicke-Korsakoff syndrome (confusion, impaired eye movements or unsteady walking)

Clinicians should remember that not everyone will disclose their alcohol dependence and that alcohol withdrawal symptoms can look like or complicate symptoms of withdrawal from other substances. Alcohol withdrawal can also complicate agitated mental health presentations, because the 2 conditions together can cause distress and it can be difficult to know which condition is causing the symptoms.

If the person has been treated for alcohol withdrawal in a police custody suite before entry into prison, treatment for alcohol withdrawal should be continued (see section 17.5.5 on medicines continuity).

Preventing and managing severe complications

Severe complications of alcohol withdrawal can pose a serious threat to a person’s health. Both treated and untreated delirium tremens are related to increased mortality. There is also risk of alcohol related brain damage if Wernicke’s encephalopathy develops. A patient’s history of severe complications is a factor in deciding how and where the medically assisted withdrawal should be managed in the prison setting.

If there are signs of delirium tremens, Wernicke’s encephalopathy, auditory or visual hallucinations or withdrawal related seizures, the person should be immediately transferred to an external hospital with 24-hour medical and nursing care so they can receive parenteral treatment, constant observations or intensive care management if required.

See section 10.4 in chapter 10 on pharmacological interventions for more guidance on preventing and managing severe complications.

If a person’s alcohol dependence has not been identified at reception, they might present to healthcare staff or prison officers with acute withdrawal symptoms. All healthcare staff and prison officers involved in the care of people undergoing medically assisted withdrawal should be trained to recognise signs and symptoms of severe withdrawal complications as a medical emergency.

Deciding on the appropriate setting for medically assisted withdrawal

The clinician, and where appropriate the multidisciplinary team, will need to assess how and whether the medically assisted withdrawal can be managed in prison. This will be based on an individual assessment of:

• severity of dependence
• co-occurring drug use or dependence
• history and current risk of severe withdrawals
• complexity of co-occurring physical and mental health conditions

There is more detailed guidance on deciding on setting in section 10.2.4 in chapter 10 on pharmacological interventions. Although that section refers to community medically assisted withdrawal, it provides some guidance on criteria used to determine levels of monitoring and care required.

People undergoing medically assisted withdrawal should be placed in a prison (or held at reception) where 24-hour healthcare is available and in an area where competent healthcare staff can monitor and observe them to manage risk. Healthcare staff should work with prison officers to arrange appropriate access to the person.

People with the highest level of need, including severe alcohol dependence or complex co-occurring conditions, can require 24-hour monitoring from a healthcare team during the medically assisted withdrawal. These people will need constant monitoring from a healthcare team and should be treated in a prison hospital (or enhanced healthcare) unit which can offer nursing and clinical support and intensive clinical monitoring.

Local procedures for managing medically assisted withdrawal should set out the need for repeated risk assessment and monitoring, so that if the person’s clinical risk increases, they can be transferred to a setting with increased clinical care and monitoring. This should be a specific part of any local protocol or operating procedure for managing alcohol withdrawal in a prison setting.

In the most complex cases with the highest risks, or rapidly deteriorating conditions, patients may need to be transferred to an external acute hospital.

Clinical monitoring and observation during medically assisted withdrawal

People who are treated for withdrawal should be monitored regularly to check for:

• withdrawal symptoms
• any signs of severe complications
• over-sedation

Over-sedation can lead to respiratory depression. Depending on the complexity of the person’s needs, they may have other monitoring requirements, for example for drug withdrawals or for mental health symptoms or self-harm.

Clinicians should have access to their patients so they can carry out monitoring as often as required for safe care.

The quality, level and skill of clinical monitoring is an important factor in successfully managing medically assisted alcohol withdrawal. Clinical monitoring should include:

• assessing withdrawal symptoms using a validated measure of withdrawal symptoms, such as the Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) or a similar validated tool
• monitoring the effects of medication

The level of monitoring required will depend on several factors including:

• severity of alcohol dependence (assessed with a validated tool)
• risks of severe withdrawal complications
• co-occurring substance use or dependence
• co-occurring physical health and mental health conditions
• risk of self-harm or suicide

The clinician, in discussion with the multidisciplinary team where appropriate, should determine how often the person should be clinically monitored and observed, based on individual assessment guided by local protocols for medically assisted withdrawal. Local protocols should specify minimum levels of monitoring and observation required in relation to level of risk, with an option to increase these according to individual need. All staff carrying out observations should be trained to do so.

Care and support levels can be increased based on outcomes of clinical monitoring and ongoing repeated assessment of other risks.

Clinicians are responsible for carrying out all clinical monitoring during medically assisted withdrawal. In addition, non-clinical prison officers may carry out welfare observations in some circumstances. There are variations in prison systems across the UK in the role of non-clinical prison staff in carrying out observations. Clinicians should advise on level of observation based on their local protocol and their clinical assessment of the person’s risk. Local protocols should set out the respective roles of healthcare staff and non-clinical prison staff.

Prescribing for medically assisted withdrawal

When clinicians prescribe for medically assisted withdrawal in the community, they should normally arrange for blood tests to be carried out before starting the intervention to help identify any clinical issues. In prison, it is not necessary to wait for blood tests to be carried out before prescribing but blood tests should be carried out as soon as it is feasible. If the patient is very unwell, they may need to go to an external hospital for medically assisted withdrawal.

Blood tests usually include (but do not have to be limited to):

• full blood count (FBC)
• liver function test (LFT)
• urea, creatinine and electrolytes (U&E)
• international normalised ratio (INR)
• total protein and albumin

Medicines to treat alcohol and drug withdrawal and dependence are usually controlled drugs covered by The Misuse of Drugs Regulations 2001. Due to the risks of abuse and diversion (being used by other people) of these medicines, there are national standards in secure environments including in:

• NICE NG57
• RPS guidance ‘Professional standards for optimising medicines for people in secure environments’
• Royal College of GPs’ guidance Safer prescribing in prisons (PDF, 769KB)

The consumption of medication for alcohol misuse and drug misuse should always be directly supervised in prison and this should be done in line with local protocols. Clinicians should work with non-clinical prison staff to arrange timings of medicine doses, so they are in line with the prescribed dose regimen to manage the withdrawal safely.

Benzodiazepines (for example, chlordiazepoxide or diazepam) are the recommended pharmacological treatments for alcohol withdrawal. In the rare situation where the person cannot take oral medication, the clinician should arrange for them to be transferred to a general hospital where they can receive parenteral treatment.

The clinician should be aware that prisoners might falsely claim to be alcohol dependent to obtain benzodiazepines. If there is no clinical information to confirm the person is alcohol dependent, the clinician should immediately start to observe the person regularly. Then they should normally only prescribe benzodiazepines if they observe withdrawal symptoms beginning to develop.

A fixed and adequate dose regimen of a long-acting benzodiazepine is likely to be the most suitable regimen for medically assisted alcohol withdrawal in prison. A symptom triggered regimen will not normally be suitable because this requires a team trained in the approach and enough clinical staff to carry out careful hourly monitoring. You can read guidance on fixed dose and symptom triggered regimens in section 10.3.4 in chapter 10 on pharmacological interventions.

You can read guidance on benzodiazepine regimens in section 10.3 in chapter 10 on pharmacological interventions.

In line with local protocols, arrangements should be in place so that the clinician can adjust the dose of benzodiazepines promptly if they find the fixed dose has led to over-sedation or has not been enough to manage withdrawal symptoms adequately. If necessary, this could include providing an extra dose of medication under supervision.

For people being transferred to court or another part of the prison system medicines while they are being treated for alcohol withdrawal continuity isa priority. See section 17.5.5 on medicines continuity.

Polypharmacy

People in the prison population often have several long-term health conditions and the clinician should consider the risks of polypharmacy (prescribing several medicines for several different conditions at the same time). The person may also have been using illicit drugs or abusing prescribed or over-the-counter medication.

The person may have already been prescribed benzodiazepines (a sedative) for alcohol withdrawal (for example, in the police custody suite). NICE NG57 recommends that medication for alcohol withdrawal should not be stopped until medically assisted withdrawal has been completed.

Clinicians should consider contraindications for prescribing other medicines when prescribing benzodiazepines for medically assisted withdrawal.

National guidance recommends that clinicians should carry out a reconciliation of medicines so there is a complete and accurate list of the person’s medicines recorded. This includes:

• identifying an accurate list of the person’s current medicines
• noting any discrepancies with current medicines in use
• documenting any changes

It may not always be possible to obtain information on the person’s health or medication on the first day. RPS guidance ‘Professional standards for optimising medicines for people in secure environments’ is that a clinician should carry out a medicines reconciliation within 72 hours of the person being received in prison. The clinician needs to be aware that the person may be falsely claiming that they are prescribed medicines or high doses of medicines.

Polypharmacy in people with alcohol or drug dependence can be problematic, particularly other medications with sedative potential. The clinician needs to decide whether to continue some or all of the medications, taking into account the risks of stopping any medication and the risk of diversion. These are complex prescribing decisions requiring a high level of skill. When making decisions, the clinician should consult other healthcare teams where relevant - for example, the mental health team or pharmacists. The clinician should aim to simplify the prescription and make it as safe as possible. They need to be particularly careful in managing medicines in the first few days when risks of suicide are high and they might not have all the relevant information about a person.

Co-occurring dependence on alcohol, illicit drugs or sedating prescribed medication

The process is more complex if the person who needs medically assisted alcohol withdrawal has a co-occurring dependence on illicit drugs or prescribed medication that causes sedation. It will require more care and increased monitoring from a multidisciplinary team with specialist input.

Concurrent alcohol dependence and opioid dependence

There is guidance on treatment in prison for misuse or dependence on several illicit substances and on benzodiazepines in chapter 5 of ‘Drug misuse and dependence: UK guidelines on clinical management’. It includes guidance that clinicians should follow on opiate substitute prescribing, including guidance on concurrent alcohol and opioid dependence.

Clinicians need to take particular care when they are assessing and prescribing for people with concurrent opioid use (or other analgesics with habit-forming potential) and alcohol dependence. This is because there is a high risk of over-sedation and fatal respiratory depression when benzodiazepines and opioids are taken together. See important safety information from the Medicines and Healthcare products Regulatory Agency on Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression. Clinicians should also consider the risk of over-sedation in patients who have been prescribed anti-depressants.

Concurrent benzodiazepine dependence

If the patient has concurrent alcohol and benzodiazepine dependence, the clinician should treat the alcohol withdrawal before any withdrawal from benzodiazepines, as benzodiazepines are used to manage alcohol withdrawal. You should follow guidance in section 10.6.1 on medically assisted alcohol withdrawal when a person is also dependent on benzodiazepines in chapter 10 on pharmacological interventions.

Close observation and clinical monitoring are required when a patient with concurrent alcohol and benzodiazepine dependence is undergoing medically assisted alcohol withdrawal. They may need to be treated in the hospital (enhanced care) unit in the prison or, where clinical risks are very high, in an external hospital.

There is further guidance on benzodiazepine withdrawal, including where there is concurrent alcohol dependence, in section 5.4.6.7 in chapter 5 of ‘Drug misuse and dependence: UK guidelines on clinical management’.

Concurrent alcohol, opioid and benzodiazepine dependence

The management of polydrug and alcohol dependence requires specialist skills. Clinicians should take great care if the person has concurrent dependence on alcohol, opiates and benzodiazepines, and treatment will require input from a specialist clinician and a multidisciplinary team.

Chapter 5 of ‘Drug misuse and dependence: UK guidelines on clinical management’ includes guidance on managing medications in prison. It recommends that clinicians avoid prescribing people more than 2 drugs with sedative potential on the first night or for the first few days unless they confirm that:

• a clear medicines reconciliation has been carried out
• the person has fully adhered to their current prescriptions

Clinicians must use careful clinical judgement on what prescribed medications with sedative potential should be withheld from people in the early days in prison, before a full medicines reconciliation process led by pharmacists has taken place.

Concurrent alcohol dependence and cocaine use

Healthcare staff should intensively monitor a patient with alcohol dependence who has been using or is also dependent on cocaine. Normally, they should be in the prison hospital (enhanced healthcare) unit where there is 24-hour healthcare. There are risks of problematic increases in blood pressure and increased heart rate during alcohol withdrawal and there can be a risk of sudden death.

Management of stimulant withdrawal is associated with several risks and requires input from specialist addiction clinicians and often mental health teams.

You should read the guidance on managing stimulant withdrawal in the first week in section 5.4.6.8 in chapter 5 of ‘Drug misuse and dependence: UK guidelines on clinical management’.

Monitoring when there is concurrent alcohol dependence and drug dependence

When carrying out medically assisted withdrawal from alcohol in people with a concurrent drug dependence, close clinical monitoring and regular observation is required for the safety of the patient. This is because, in some cases (as outlined above), there is a risk of death.

The clinician, in discussion with the multidisciplinary team, should carry out a careful assessment and decide on the appropriate setting for medically assisted withdrawal.

Medically assisted withdrawal for people with concurrent alcohol and drug dependence will usually require monitoring in the prison hospital (enhanced care) unit where there is 24-hour care. In the most complex cases, patients may need to be admitted to an external hospital.

Assessing and monitoring for risk of self-harm and suicide

There is an increased risk of self-harm and suicide on the first night and weeks in prison among the prison population. Both alcohol intoxication and alcohol dependence are associated with increased risk of suicide (Kaplan and others, 2013; Ledden and others, 2022). A systematic review shows that alcohol misuse in the year before entry into prison is a risk factor for suicide in prison (Zhong and others, 2021).

Evidence suggests that the distress caused by withdrawal in an already highly stressful situation may be a factor in the high levels of suicide among people with alcohol dependence entering prison (Backet, 1987).

It is essential that the clinician assesses the risk of self-harm and suicide, and involves the mental health team if there are signs that the person is at current risk or specialist assessment is needed.

Where a patient is assessed as at risk of self-harm or suicide with suicidal ideation and intent, the clinician, healthcare staff and prison officers should follow the local prison suicide prevention protocol. They should observe the patient based on this protocol until the mental health team can assess the patient. Close clinical monitoring and intensive observation is required for the safety of the patient.

If a patient is assessed as at risk of self-harm or suicide, this should trigger the prison’s multidisciplinary risk management process - for example, the ACCT process in England and Wales. Clinicians and allied healthcare staff should make sure risks are recorded clearly and promptly in the patient’s record. They should also make sure that all relevant staff, including prison officers, are:

• informed of the risks and the risk management plan
• understand the rationale for the plan
• understand the agreed level of observation and clinical monitoring

Managing deteriorating health and emergencies

Prisons should have local protocols that set out how healthcare staff and prison officers should respond to situations in which a person’s health quickly deteriorates or is in a health emergency.

NICE NG57 provides guidance on what these protocols should include.

All secure environments need close working relationships between prison officers and healthcare providers, including mental health teams, and local hospital emergency departments to manage emergencies.

With the patient’s consent, clinicians should tell all healthcare staff and prison officers if someone has a chronic health condition that could deteriorate or has allergies. In emergencies, healthcare staff should share relevant confidential clinical information in line with their duty to do so.

If there is a concern about the patient’s condition, the clinician or multidisciplinary team should develop a clear plan for managing their condition that is shared with all relevant healthcare and prison staff. The clinician should carry out regular clinical assessments to identify signs that the person’s condition is deteriorating or there is an emergency, using a standardised early warning system, such as NEWS 2. They should escalate the patient’s care to include increased monitoring or transfer them to an external hospital, where this is indicated.

Staff need to know how to respond if they are concerned that someone may not be conscious. Prisons should have local protocols for checking if a person can be roused. As an example, appendix B in the blue guidelines provides guidance on these checks - see Detainees with substance use disorders in police custody.

All healthcare staff and prison officers should know how to carry out simple checks to see if a person can be roused.

If an officer finds that they cannot wake up a prisoner by either speech or light touch, they should follow their local protocol and immediately inform the on-call clinical staff member or call an ambulance.

All healthcare staff and prison officers in contact with prisoners should have essential first aid training, including training for the person first on the scene in an emergency.

17.5.8 Care planning

Developing the care plan

The clinician or a member of the substance misuse team should develop a care plan (also called a treatment and recovery plan) for anyone needing alcohol treatment in prison or another secure setting. To meet the principle of equivalent care to the community, they should offer personalised care-planned treatment and recovery support to people:

• with alcohol dependence
• who drink at harmful levels and have co-occurring physical health or mental health conditions

Where more than one clinician is providing care for the person, the clinicians should agree who is the lead professional who will be responsible for developing and reviewing the care plan. Even where the alcohol treatment clinician is not the lead professional, they should contribute to the care plan and care plan reviews.

The care plan should:

• be started at reception
• be linked with plans for further assessments and care planning throughout the person’s time in prison and at pre-release
• extend to treatment and support in the community

The plan should take account of the person’s sentence and sentence planning and be reviewed regularly and when there is a change in the person’s circumstances.

There is guidance on care planning (referred to as treatment and recovery planning) in section 4.10 in chapter 4 on assessment and treatment and recovery planning.

Planning for continuity of care

Plans should include actions to provide continuity of care if the person attends court appearances or moves to a different setting. Alcohol treatment staff (or the lead professional where people have complex needs) should make sure all relevant clinical information is passed on to the next setting with the person’s consent. This should include information about:

• their alcohol problem
• current alcohol treatment they are receiving
• any medication they are taking
• co-occurring drug use or dependence
• co-occurring physical health and mental health conditions
• any allergies

Medications, including for alcohol withdrawal and ongoing management of alcohol dependence, should also be transferred to the next setting including to courts. For more information on continuity of care leading up to release see section 17.6 below.

Multidisciplinary integrated care

It is likely that several teams will be involved in the care of prisoners with alcohol dependence, including from:

• healthcare (for example, mental health or substance misuse teams)
• prison officers
• community services

Assessment, care planning and risk management needs to be multidisciplinary and integrated. Good communication between community alcohol treatment services, prison healthcare teams and prison officers is essential from when the person enters prison through to transfer or release back into the community.

For people with the most complex needs, a multidisciplinary team should be involved in developing and monitoring their care plan and there should be an identified lead professional.

Psychosocial interventions and recovery support

Everyone requiring alcohol treatment should be offered psychosocial interventions. Chapter 5 provides guidance on psychosocial interventions.

Staff providing psychosocial interventions should be trained in the interventions they offer and have the appropriate competencies. They should also receive supervision from a qualified clinical supervisor. Providing psychosocial interventions in a prison setting requires advanced skills. Mental health symptoms can be intensified and there are heightened risks of:

• self-harm
• suicide
• violence

NICE NG66 provides guidance on considerations when offering mental health interventions in prisons.

Prison provides an opportunity for alcohol treatment practitioners to support the person with alcohol dependence to identify and work toward their recovery goals and help them to build recovery resources. There is guidance on structured support, which includes building recovery resources, in section 5.5 in chapter 5 on psychosocial interventions and chapter 6 on recovery support services.

There may be opportunities for the person to develop skills and activities that can help them towards employment or education on their release. These may include:

• literacy skills
• education classes
• occupational skills
• physical exercise

There may also be opportunities for them to join mutual aid groups, for example Alcoholics Anonymous, or meet with peer support workers, and so begin to build recovery-oriented support networks. Alcohol treatment staff should help people to engage with these groups.

Harm reduction and health promotion

People with alcohol dependence are often not aware of the health risks of harmful drinking and alcohol dependence. Alcohol treatment practitioners should provide them with information on health risks and offer harm reduction information and advice. There is guidance on harm reduction information and advice in chapter 8.

Information specific to the prison setting includes the health risks of alcohol brewed in prison (‘hooch’) and increased vulnerability caused by intoxication within in a prison setting.

Care plans should also include relevant health promotion interventions. For example, these could include interventions to:

• stop smoking
• lose weight
• increase exercise levels

Prison is also an opportunity to help people access routine vaccinations and scans they have missed. You can find guidance on physical health assessment in section 4.9.11 in chapter 4 on assessment and treatment and recovery planning.

17.6 Continuity of care: release, resettlement and recovery

Section 17.6 provides guidance on continuity of care on release from prison. This guidance is for staff in:

• prison substance misuse teams
• prison healthcare teams
• community alcohol treatment services

17.6.1 The importance of continuity of care

A significant proportion of people in prison serve short sentences, often a few months or less. This means people with problem alcohol use have less time to develop a stable recovery and any progress they make in prison can be difficult to maintain when they are released.

People who have served long sentences will be making a significant transition when they leave prison. This is likely to be a stressful experience for them and it can increase their risk of relapse, even if they have been abstinent for a long time.

Prison substance misuse services, wider prison healthcare services and community treatment providers are all responsible for making sure that people transferring from prison to the community have good continuity of care. There should be effective communication systems and pathways between substance misuse teams in prisons and community alcohol treatment services.

Joint planning between prison healthcare and community services should aim to:

• help the person engage in community alcohol treatment and recovery support services after release
• ensure the person is referred to relevant support for health and social needs
• reduce re-offending
• reduce homelessness
• reduce alcohol related harm
• make sure prescribing arrangements are in place for medication

If a prisoner on remand has a planned court date, it’s best practice for the prison-based alcohol treatment provider to:

• inform community alcohol treatment services about the date
• tell them the outcome of the court appearance

If this has not happened, the prison treatment service providers may need to check that anybody released in an unplanned way from court has information about and a referral to specialist alcohol treatment in the community.

17.6.2 Pre-release care planning

Care planning for release is essential and should begin about 6 weeks before release. For prisoners with very short sentences, planning for release should begin at the comprehensive assessment in the first week in prison.

A clinician should carry out a health assessment with the person and summarise information on their health and treatment needs and the risks to the person and others. If a multidisciplinary team has been involved with the person’s care, they should be involved in the pre-release health assessment and care plan.

NICE NG57 provides guidance on pre-release health assessments. The assessment should include information on:

• the person’s alcohol dependence
• the alcohol treatment and recovery support they received in prison
• any relapse prevention medication they have been prescribed before release

The pre-release care plan should be based on this assessment and the substance misuse team’s assessment of the person’s ongoing needs for alcohol treatment and recovery support.

The pre-release care plan should be written and should include:

• prison-based pharmacological, psychosocial and recovery support interventions, and ongoing treatment requirements from community alcohol treatment services
• details of planned appointments with community alcohol treatment services and recovery support networks
• details of planned appointments with relevant health, social care and prisoner resettlement services
• ongoing health and social support needs as outlined in the pre-release health assessment
• planned actions to reduce or manage risks to the person or to others
• details on provision of harm reduction advice (alcohol and drugs)
• details of any medication, including relapse prevention medication prescribed before release

If the person has problem with opioids or might possibly take opioids on release, the pre-release care plan should also include plans for provision of naloxone and harm reduction advice from appropriately trained staff in line with protocols.

When a person leaves prison, they should receive a copy of their pre-release assessment and care plan.

If the person is not registered with a GP, prison healthcare services should help them to register before release.

17.6.3 Information sharing between prison and community alcohol treatment services

There needs to be effective communication and information sharing between substance misuse services in the prison and the local alcohol treatment service before the person is released.

With the person’s consent, prison substance misuse services should share appropriate information, using a standard referral form, with community alcohol treatment services. This should include the information in the pre-release assessment and care plan.

Community alcohol treatment services should continue the specific treatment interventions offered in prison.

17.6.4 Arranging an appointment with community alcohol treatment services

People being released from prison normally have complex health and social care needs. They should receive a rapid assessment from the community alcohol treatment service to avoid their situation deteriorating.

The community alcohol treatment service should offer an assessment appointment before or immediately after release. Where alcohol treatment services can provide in-reach into prisons, this can help to engage people and strengthen continuity of care. Where in-reach is not an option, video appointments (telemedicine) is an alternative way for prisoners to engage with community treatment providers.

17.6.5 Medicines continuity and release into the community after a brief period on remand

Some people are on remand for a few days only. It is possible that they start treatment for alcohol withdrawal in police custody or on entry into prison and the course of treatment has not been completed when they are released into the community.

If a person being treated for alcohol withdrawal is released into the community, the clinician can consider providing them with a short-term supply of the medicine being used for their treatment. This will help to prevent withdrawal symptoms from recurring and the risk of complications from withdrawal. The clinician should carry out an individual assessment of the risks and benefits to the person of continuing and discontinuing the medication.

With the person’s consent, the clinician should share information from the patient record with the person’s GP and community alcohol treatment service (where the person has agreed to a referral) as soon as possible. This includes full and accurate information on medicine. Wherever possible, the person should be seen by a clinician in the community when they are released, so they can monitor the person if they complete the treatment for alcohol withdrawal.

17.6.6 Prescribing to prevent relapse

You should read section 10.5 on relapse prevention and section 10.6 on the needs of specific groups in chapter 10 on pharmacological interventions.

Some patients can remain abstinent from alcohol in prison without difficulty. But some may ask to start relapse prevention medication before being released from prison due to the risk of relapsing after release.

Clinicians should consider prescribing medication that supports relapse prevention. They will need to take account of the unique clinical risks in a prison setting when making decisions about prescribing before release.

Clinicians should not prescribe naltrexone (or nalmefene) for people using or possibly using prescribed or unprescribed opioid drugs, because these medications are opioid antagonists.

17.6.7 Pre-release harm reduction advice and interventions

When a person is released from prison, clinical staff should give them harm reduction advice to ensure that they keep themselves as safe as possible when they are released.

A person should receive harm reduction advice before release, including information on:

• how ending the sentence and a wish to celebrate can represent a risky situation for relapse
• their decreased tolerance to alcohol after a period of abstinence, including the risk of alcohol poisoning
• the increased risk of overdose and death if they use alcohol with illicit drugs or prescribed or over the counter medications, particularly those with sedative potential
• the medication they are currently taking and risks of using it with alcohol
• the risk of acute reactions and death from combining alcohol with specific substances, such as the increased toxicity of combined alcohol and cocaine

Appropriately trained prison substance misuse services staff should make sure naloxone is available to people who they think might also use opioids, in line with local protocols.

For people who have been exploited (for example, through county lines or sex work), all services should take extra care to ensure they have safe transport and somewhere safe to go, and are not being picked up by people who are likely to abuse them.

Staff should make sure there is a safety plan in place for people who are at risk of domestic abuse on their release. There is guidance on domestic abuse in chapter 22.

17.6.8 Improving continuity of care at a system level

Systems vary across the UK. Work to strengthen joint working between healthcare and substance misuse teams in prison and community alcohol and drug treatment providers at a system level can help to improve continuity of care. This is vital for people with problem alcohol use who often have co-occurring physical and mental health conditions.

Specialist services to support continuity of care

In England, the RECONNECT service aims to improve the continuity of care of people leaving prison or an IRC with an identified health need. This involves working with them before they leave to support their transition to community-based services, and so safeguarding the health gains they made while in prison or an IRC. People can also be referred to the service up to 28 days after their release.

Guidance on continuity of care

Continuity of care for prisoners who need substance misuse treatment is an audit toolkit and guidance on data recording for prison and community treatment providers and commissioners, to help improve continuity of care between prison and the community.

The main recommendations are as follows.

Prison healthcare services should consider developing a standard referral form to community treatment services.

Local alcohol and drug treatment systems should agree a referral protocol with their main feeder prisons.

Local commissioners and providers should consider establishing or expanding in-reach provision in prisons from community alcohol and drug treatment services.

Community alcohol treatment providers should review what they offer to people leaving prison to make sure it meets their needs and communicate this offer to their main feeder prisons.

Prison treatment services should review their links with resettlement services and jointly co-ordinate appointments and referrals arranged for the community (for example, to avoid appointments clashing).

Local community alcohol and drug treatment and recovery support services in England and Wales should ensure that their main feeder prisons are aware of the community single point of contact (SPOC).

Prison healthcare services and community alcohol treatment services should only communicate personal information through a secure method, such as secure email.

Treatment providers in prisons should record their data in line with data guidelines so that their post-release engagement rates accurately reflect the true picture of continuity of care.

There is more detail on all of these recommendations in the guidance.

To help effective referral and communication, the Office for Health Improvement and Disparities (OHID) SPOC criminal justice directory (England and Wales) lists the contact details of all:

• prison healthcare teams
• community-based treatment providers
• probation teams

If you want to be included on the distribution list for updates, email spoc-ohid@dhsc.gov.uk.

17.7 Immigration removal centres

The guidance on alcohol treatment in prisons is relevant to IRCs. There are also some specific considerations when working in this context.

Migrants may have been exposed to trauma, before, during and after their migration journey, and prevalence of mental health conditions, such as post-traumatic stress disorder (PTSD), is high among people in IRCs. The Royal College of Psychiatrists’ report Detention of people with mental disorders in immigration removal centres (PDF, 338KB) suggests that a high proportion of immigration detainees show clinically significant levels of depression, PTSD and anxiety. They also show intense fear, sleep disturbances, profound hopelessness, self-harm and suicidal ideation.

Services should follow trauma-informed principles and practice to help remove the barriers to access that people affected by trauma can experience.

Staff should routinely provide interpretation services to make sure they do not miss signs and symptoms of dependence and withdrawal when people do not speak English. OHID’s migrant health guide has guidance on language interpreting and translation.

The IRC treatment service should share appropriate information about the pharmacological and psychological treatment that the person has received, as well as suicide and self-harm risks and any other risks with community alcohol treatment services. This will help reduce risks as people transfer from custody.

Healthcare staff in IRCs should carefully consider people’s language and cultural needs to make sure that their alcohol treatment and support does not suffer.

17.8 Probation services and criminal justice social work

Section 17.8 provides guidance for probation services (criminal justice social work in Scotland) and community alcohol treatment services.

There are several ways in which probation services (criminal justice social work services in Scotland) and alcohol treatment services work together to help people on community sentences to engage in alcohol treatment. Arrangements vary in different UK nations, and even within nations, because some initiatives operate in a limited number of areas.

17.8.1 Community treatment requirements

In general, initiatives aim to reduce re-offending and divert people from short-term custodial sentences by addressing people’s alcohol dependence through community treatment requirements. If an area has good working between agencies, it’s more likely that courts will use treatment requirements. Community alcohol treatment services can contribute important information about the person’s alcohol problem and their treatment needs that can be included in the pre-sentencing report.

Examples of community treatment requirements include:

• alcohol treatment requirements as part of community orders or suspended sentence orders in England and Wales
• alcohol treatment requirements that can run jointly with mental health treatment requirements where the person also has mental health needs
• alcohol treatment as part of community payback orders mandated through problem-solving courts in Scotland
• access to alcohol treatment before sentencing, with levels of engagement acknowledged in subsequent sentencing in substance misuse problem-solving courts in Northern Ireland

17.8.2 Licence conditions

People can also be mandated to engage in alcohol treatment as part of a licence condition. Licence conditions are the rules that people must abide by when they are released from prison, if there is still part of their sentence to serve in the community.

Probation officers (social workers in Scotland) should discuss treatment plans with the community treatment provider before licence conditions are proposed. They should also discuss the plan with the person concerned.

Effective partnership working between alcohol treatment services and probation and other criminal justice services is essential to help people engage in treatment and recovery support and stay engaged.

17.8.3 Working relationships

Alcohol treatment services and criminal justice services should have working agreements that specify the responsibilities of each service:

• in relation to treatment requirements imposed through courts
• as part of licence conditions

Arrangements should include details of the information that each service is required to share with the other and the system for sharing this confidential information. The services should clearly explain these arrangements to the person.

Alcohol treatment and probation staff need to work to form positive, trusting relationships with people who are supervised so they feel they have an active role in their own treatment. The principles of care set out in chapter 2 are vital to engaging people who may be ambivalent or anxious about treatment.

17.8.4 Alcohol abstinence monitoring requirements

In England and Wales, the alcohol abstinence and monitoring requirement (AAMR) can be used as part of a community order or suspended sentence order for alcohol-related criminal behaviour. The AAMR imposes a total ban on drinking alcohol for up to 120 days.

A person’s compliance with the AAMR is monitored electronically using a tag that continuously monitors their sweat for the presence of alcohol. A 2021 Ministry of Justice alcohol monitoring statistics report shows evidence of high levels of compliance during the AAMR period. But there is currently no evidence of how AAMRs affect abstinence or controlled drinking outcomes when they are no longer in place.

Courts cannot impose an AAMR on someone who is alcohol dependent or has an alcohol treatment requirement imposed or recommended as part of a community sentence.

Given the significant health risks of rapid alcohol withdrawal, sentencers should carefully consider self-reported alcohol use (which is often under-reported) before imposing an AAMR. Any decision to impose an AAMR should be supported by a thorough alcohol assessment, conducted by staff with alcohol treatment competencies, at the pre-sentence stage.

Through their normal contact with offenders, probation staff must be alert to physical signs of worsening health and be aware of what action to take and where to refer the person.

17.9 References

Backet SA. Suicide in Scottish prisons. British Journal of Psychiatry 1987: volume 151, issue 2, pages 218 to 221 (registration and subscription required for full article).

Bebbington P, Jakobowitz S, McKenzie N, Killaspy H, Iveson R, Duffield G and Kerr M. Assessing needs for psychiatric treatment in prisoners: prevalence of disorder. Social Psychiatry and Epidemiology 2017: volume 52, pages 221 to 222.

Home Office. Deaths in police custody: a review of the international evidence, 2017.

Independent Police Complaints Commission. Learning the lessons: bulletin 12 (National Archives), 2011.

Kaplan M, McFarland B, Huguet N, Conner K, Caetano R, Giesbrecht N and Nolte K. Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System. Injury Prevention 2013: volume 19, issue 1, pages 38 to 43 (registration and subscription required for full article).

Ledden S, Moran P, Osburn D and Pitman A. Alcohol use and its association with suicide attempt, suicidal thoughts and non-suicidal self-harm in two successive, nationally representative English household samples. British Journal of Psychiatry Open 2022: volume 8, issue 6, article e192.

Perkins A, Livingston W, Cairns B, Dumbrell J, Gardiner K, Little S and Madoc-Jones I. Prison population: substance use and wider support needs. Scottish Government, 2022.

Wright NMJ, Hearty P and Allgar V. Prisons and non-communicable diseases: a data-linkage survey of prevalence and associated risk-factors. British Journal of General Practice Open 2019: volume 3, issue 2.

Zhong S, Senior M, Yu R, Perry A, Hawton K, Shaw J and Fazel S. Risk factors for suicide in prisons: a systematic review and meta-analysis. Lancet 2021: volume 6, issue 3, pages e164 to e174.