I noted an alarming surge in the prescribing of quetiapine (Seroquel) in our County correctional facility, Santa Rita Jail, approximately five years ago. The number of quetiapine tablets dispensed surpassed all other antipsychotic medications combined, in the observed three-month period. This sudden four-fold increase in prescribing to inmates by our psychiatrists was extremely unusual and warranted further investigation.
Correctional settings have a convergence of factors that may predispose inmates in this setting to the abuse of available medications. As state hospitals have all but disappeared, a greater proportion of the chronically mentally ill now reside in our correctional facilities. This is often due to such laws as “Three strikes,” currently enacted in 24 states, and decreased funding for mental health services nationwide. As many as 20% of the 2.1 million Americans in county jails and state prisons are seriously mentally ill, far outnumbering the 80,000 who are in mental hospitals. A study by the Human Rights Watch concludes that these facilities “have become the nation's default mental health system” with the level of patient acuity growing more severe over the past few years.1
Although the number of inmates with psychiatric disabilities has been growing for the past decade, the available mental health services in these facilities have been slow to meet that need. Services are stretched and psychiatrists are overwhelmed by the sheer number of inmates requiring assessments and services. Often, an accurate psychiatric diagnosis may be complicated by personality disorders and malingered psychotic symptoms, which are left mainly unresolved.
In addition to both personality disorders and malingering, the high prevalence of substance abuse within this population complicates diagnosis. A recent study documented a lifetime prevalence of substance abuse disorders in 74% and alcohol use disorder in 72% of the mentally ill offenders.2 Furthermore, 51% had a documented personality disorder. Ultimately, only 25% of the subjects had neither a substance abuse disorder nor personality disorder.
Although misuse of anticholinergic agents (e.g. benztropine, trihexyphenidyl) by the seriously mentally ill has been long documented, until recently, the literature has been sparse regarding the abuse of other psychotropic medications in correctional settings.3 Luckily, some published case reports have begun to appear. Reccoppa et al. provided case reports of gabapentin (Neurontin) pulverized and intranasally snorted by inmates with a prior history of cocaine dependence in the Florida State Department of Corrections.4 These inmates described obtaining an altered mental state or high from snorting the gabapentin powder. This discovery eventually led to the removal of gabapentin from the formulary at these facilities.
Pierre et al. described widespread “abuse” of quetiapine (Seroquel) among inmates in the Los Angeles County Jail.5 In addition to oral administration, it was snorted in its pulverized powder form, and used intravenously for its potent sedative and anxiolytic properties. The authors concluded “while antipsychotic medications are not typically recognized as drugs with abuse potential, the use of intranasal quetiapine suggests otherwise, and underscores the importance of recognizing malingered psychosis in clinical settings.”
In correctional facilities across the U.S., inmates refer to quetiapine as “quell”, “Susie Q” or “baby heroin”.6,7 Hanley et al. describes the unforeseen use of antipsychotics as drugs of abuse by the correctional population through case reports. Furthermore, the literature documents inmates engaging in drug seeking and illegal behaviors to obtain quetiapine, even vowing threats of suicide when presented with its discontinuation.8 These factors led one set of authors to recommend that clinicians be extremely cautious when prescribing quetiapine for non-serious mental disorders (e.g. sleep and anxiety), and in all individuals with a history of substance abuse.9
In conversations with medical peers across the US, it was noted that psychotropic medication abuse has a widespread impact on inmate safety as well as larger economic repercussions. In addition to quetiapine, medications repeatedly named as carrying abuse potential include olanzapine (Zyprexa), gabapentin, trihexyphenidyl (Artane), buspirone (Buspar), bupropion SR (Wellbutrin SR), and the tricyclic antidepressants (amitriptyline, nortriptyline, desipramine etc.). These drugs are abused for their sedative properties, mind altering effects or for the potential to get a high. Reportedly, only the sustained release (SR) form of bupropion was crushed and snorted, most often as an adjuvant to gabapentin abuse. In addition to their sedative properties, tricyclic antidepressants (TCAs) are lethal when hoarded and taken as an overdose. In our facility we had one such case of suspected suicide, which alerted us to the need for a harm reduction model.
Since that initial observation, the widespread abuse of psychotropic medications has been reported throughout city, county, state and federal correctional facilities. It also became evident that a multitude of factors keep most facilities from restricting these abused medications: inmate grievances, ignorance on the practitioner's part, and until recently, the lack of any published information. One milestone in this area was the February 2008 memo from the California Department of Corrections and Rehabilitation, which changed quetiapine to non-formulary status due to abuse and misuse. Furthermore, criteria for its prescribing were established, effectively curtailing its prescribing.
In our Santa Rita facility, we also set about reversing this trend. A criminal justice-specific Therapeutics & Medication Use Committee was established, and began meeting every six weeks. A frank discussion with our MDs revealed that they were well aware of the burgeoning abuse problem: each had stories revealing inmate malingering and sociopathy. In addition, they described the targeting of chronically mentally ill inmates by other inmates based upon their prescribed psychotropic medication regimens. These inmates would be preyed upon, and their medications taken from them, resulting in wide-spread abuse and medication non-compliance.
Psychotropic medication abuse was presented, case studies reviewed and specific issues addressed at these meetings. In a two-part process, five drugs or drug classes of medications were removed from the jail formulary: quetiapine, gabapentin, bupropion SR, trihexyphenidyl and the TCAs. Furthermore, a clinical pharmacist was hired to both support and review medication prescribing using newly established psychotropic medication guidelines specifically in the county jail. As a result, medication abuse case reports, usage and costs dropped significantly within a 3-month period. Monthly monitoring, education and interventions have kept prescribing of these medications to inmates by our psychiatrists extremely low.
Interviews with correctional facilities nationally revealed psychoactive medications commonly bartered and abused in the jail setting. Through education and formulary changes, a harm reduction model was successfully implemented at Santa Rita Jail. Educational efforts using a clinical pharmacist and correctional psychotropic medication guidelines (e.g. restricted formulary status, detailed diagnostic criteria), directed at medical staff, can reduce the abuse potential of psychoactive medications in the correctional setting.