Original communication
The clinical management of substance misusers in police custody – a survey of current practice

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Abstract

Large numbers of substance misusers are seen in police custody. Their management remains a significant part of a forensic physician’s workload. Substance misuse, including alcohol, is a factor in a substantial number of deaths in custody.

Guidelines have been produced on the acceptable minimum standards for assessment and treatment. The aims of this study were to determine the current attitudes and practice of forensic physicians to see whether there had been any change in practice since their publication. The results suggest that the majority of respondents had read the guidelines. However, there were still considerable variations in practice and circumstances where the minimum standards were not being achieved. Whilst 90% of respondents felt confident in dealing with substance misusers, many commented that further information on specific drugs and further training on management of substance misusers would be beneficial.

Introduction

Large numbers of substance misusers are detained in police custody. It has been found that on average 69% of arrestees gave positive urine samples for at least one illicit substance.1 In another study (post charge for certain ‘trigger offences’), 44% of detainees tested positive for opiates and 32% for cocaine.2

The management of substance misuse detainees in police custody has been the subject of great debate with particular focus on the extent of the problem and the difficulties of assessing fitness for interview.[3], [4], [5] Of particular concern, has been a perceived reluctance for forensic physicians (FPs) to prescribe or authorise the continued administration of prescribed opiate substitution treatment in police custody.6 It has been commented,7 that not continuing a legal prescription of methadone is interfering in an unacceptable way with an individual’s medical treatment. The quality of treatment provided to substance misusers has been described as being of a cursory nature providing only minimal standards of care.

Previously, it was found that there was no common practice for the assessment and treatment of substance misusers and there was an urgent need for specific guidelines to address the arbitrary nature of practice at that time.4 Guidelines for the clinical management of substance misusers in police custody were produced 1994 – the Blue Guidelines”.8 These were revised in 2000 giving clear recommendations and a proposed management pathway regarding assessment and treatment.9 These guidelines were intended to appropriately amplify but not replace the Department of Health’s publication Drug Misuse and Dependence – Guidelines on Clinical Management.10 All members of the Association of Forensic Physicians (AFP – formerly the Association of Police Surgeons) were sent a copy of the guidelines each time they were published.

The aims of this study were to determine the current attitudes and practice of forensic physicians to the management of substance misusers in police custody to see whether there had been any change in practice since the publication of the specific guidance to assist doctors in this area.

Section snippets

Methods

The exact number of doctors working as forensic physicians in Great Britain is still uncertain. Therefore, the only accessible database is that of members of the AFP. There were 937 members in September 2003 and each one was sent a postal questionnaire. Previously, police forces have been contacted through the auspices of the Home Office Advisory Forum on Forensic Physicians to try and obtain contact details of doctors who provide clinical forensic medical services to police but data protection

Results

Questionnaires were returned from 409 members representing a 44% response rate which included 7% (n = 65) of invalid questionnaires because of retirement of the respondent or because his or her sub speciality did not bring them into contact with drug misusers leaving 347 (37%) as the valid sample. The responders represented fifty two forces in the United Kingdom, Eire and the Channel Islands.

Discussion

The management of substance misuse detainees in custody remains a controversial, but highly significant part of a forensic physician’s workload. Substance misuse, including alcohol, is a factor in a substantial number of deaths in custody.[12], [13], [14] However, the patterns of drug consumption and the modes of ingestion are atypical of drug-related deaths in the UK with the most common drug identified at post-mortem being cocaine and the mode of ingestion oral.15

It is essential that forensic

Acknowledgments

This research was supported by a grant from the Department of Health. The research received support and advice from the Education and Research Committee of the Association of Forensic Physicians. We are grateful to Dr. Paul Jackson who provided the data entry and statistical analysis.

References (21)

  • G.A. Norfolk

    Deaths in police custody during 1994: a retrospective analysis

    J Clin Forensic Med

    (1998)
  • Bennett T, Holloway K. Drug use and offending: summary results of the first two years of the NEW-ADAM Programme....
  • Matrix MHA, Nacro. Evaluation of drug testing in the criminal justice system in nine pilot areas. Findings No.180....
  • R. Pearson et al.

    The identification and treatment of opiate users in police custody

    Med Sci Law

    (2000)
  • M.M. Stark

    Management of drug misusers in police custody

    J Roy Soc Med

    (1994)
  • S. Davison et al.

    The management of opiate addicts in police custody

    Med Sci Law

    (1999)
  • M.M. Stark

    The management and implications of drug abusers in custody

    Med Leg J

    (1998)
  • S.E. Davison et al.

    Retracted confessions through opiate withdrawal to a new conceptual framework

    Med Sci Law

    (1993)
  • Department of Health, Scottish Office Home and Health Department, Welsh Office. Substance misuse detainees in police...
  • Association of Police Surgeons & Royal College of Psychiatrists. Substance misuse detainees in police custody....
There are more references available in the full text version of this article.

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