Management of attention deficit/hyperactivity disorder and the use of stimulants in prison. Evaluation of the risks and benefits Translated title: Manejo del trastorno por déficit de atención con o sin hiperactividad y empleo de fármacos psicoestimulantes en el medio penitenciario. Evaluación de riesgo y beneficios

Abstract

Attention deficit/hyperactivity disorder (ADHD) is a major focus of interest for prison psychiatry, given its high prevalence in prisons. Most authors conclude that the risk of presenting this disorder may up to ten times higher amongst inmates than among the general public 1 , 2 . Many studies state that there is a higher risk of offences and violent crimes being committed by people suffering from this disorder. Therefore, ADHD is very closely linked to an increase of high risk behaviours, court summonses and prison sentences 3 , 4 . Adequate management of ADHD could improve participation in social rehabilitation and/or educational programs, and reduce the frequency of violent behaviour. This in turn would improve general security for the inmates themselves and for prison staff 5 . Most experts agree on the clear benefits to be had from pharmacological therapy applied to this type of patient in the community. However research and guidance about the identification and management of ADHD among prison inmates are relatively scarce 6 . One of the most effective therapeutic options for treating ADHD is stimulants, which entail a major risk of abuse or trafficking in prison 7 . These drugs are generally well tolerated and present few side effects. However, any prescription should be accompanied by a rigorous diagnosis of the disorder, given the potential risks of abuse presented by some of them 8 . Despite their proven effectiveness, there is considerable resistance to the use of such drugs in prisons worldwide. Given that these drugs stimulate the reward circuits, there is a potential risk of abuse and dependence. This concern is increased because of the high percentage of substance addicts amongst prisoners in general, and among those with a diagnosis of ADHD in particular 9 , 10 . Another factor to be borne in mind is the potential for their use outside the field of prescribed medicines. In most prisons, psychoactive medication is seen as a product that can be sold, bought and exchanged, and the existence of any medication with the potential for abuse in prisons can increase the risk of intimidation, conflict and violence, both for inmates and for healthcare personnel and prison staff 11 . On the other hand, the administration of these drugs often involves treatment directly observed by the team (doctors, nurses, prison staff), which increases costs and reduces the inmate’s autonomy. Therefore, the potential for abuse of these drugs in the prison environment is a challenge and a cause for particular concern for doctors who prescribe them 12 . The experience acquired after work carried out at a number of prisons in Spain and abroad shows that use of stimulants is in most cases a cause for controversy. In my opinion, this is due to the complex nature of such a specific psychiatric diagnosis and the lack of familiarity on the primary care doctor’s part on how to manage this disorder, despite its high prevalence in prisons (over 25% according to the latest literature) 13 . We professionals should be able to correctly diagnose and treat inmates who present this disorder, avoiding the violence, trafficking and abuse of such drugs, which are regarded as narcotics in many countries and much sought after by prisoners 14 . Maybe now is the time to consider the implementation of alternative approaches, such as psychotherapeutic or socio-educational interventions, or the use of drugs with a reduced potential for addiction. In any case, I believe that it is imperative to re-launch a debate on the importance of prescribing these drugs in the prison setting. As prison doctors, we should encourage the exchange of experiences between professionals from different prisons, increase awareness of certain psychiatric disorders and of the challenges posed by some types of prescriptions. Deeper reflection about the risks and benefits offered by stimulants in prison should be the basis for adequate, safe and decisive practices that can establish risk-free guidelines for prescriptions.