Changing how prisoners access ‘over the counter’ (OTC) medications of paracetamol and ibuprofen
The Project
This project assesses the impact of a recent trial at one Queensland Correctional Centre which has changed how prisoners access paracetamol and ibuprofen, unscheduled ‘over the counter’ (OTC) medications which generally do not require a prescription. Current practice in most Australian prisons is access via the prison health centre: that is, prisoners need to have a consultation with a doctor or nurse to access paracetamol or ibuprofen.
The OTC trial changed access, so a small group of prisoners may also purchase paracetamol and ibuprofen through “prisoner buy-up”. This is where, typically on a weekly basis, prisoners can buy a fixed range of consumer items (e.g., groceries, stationary, small gifts etc) up to a set monetary limit. Our project is an independent assessment of this trial, driven by one central research question: what are the benefits and challenges of changing how prisoners access unscheduled ‘over the counter’ medications of paracetamol and ibuprofen from the perspective of prisoners, health (nursing, pharmaceutical, medical) and correctional centre staff (management and operational)?
As well as surveying these key stakeholders, the project team is conducting in-person focus groups to assess the efficacy of the program, any operational challenges, learnings, and processes, designed to inform a potential state-wide roll-out of these two OTC pain medications.
The Rationale for Change
The public policy rationale for changing how prisoners access unscheduled ‘over the counter’ (OTC) medications is three-fold. Firstly, this change responds to international and domestic human rights obligations. The Nelson Mandela Rules require that prisoners have access to healthcare commensurate with that available in the community, while the Human Rights Act 2019 section 37(1) states ‘every person has the right to access health services without discrimination’. As adults can easily purchase and consume paracetamol and ibuprofen from supermarkets in the community, allowing access to these medications during ‘prisoner buy-up’ better aligns with the Nelson Mandela Rules and the Human Rights Act 2019.
Secondly, international best practice: prisoners in many countries across the globe access many medications, such as paracetamol and ibuprofen ‘over the counter’ (since 2003 in the United States of America, 2014 in Canada and 2015 in the United Kingdom). The argument is that: just as people in the community, prisoners should be encouraged to self-manage their health for minor ailments (including mild pain symptoms) – this promotes patient self-reliance and participation in their own health care – often termed health literacy. Thirdly, a recent local consultation led by Health Consumers Queensland noted that many prisoners ‘spoke about the difficulty in getting Panadol or Ibuprofen to deal with their pain”, especially at night and desired easier access via ‘buy-up’. Our project responds to such issues, assessing the experience of changing how prisoners access OTC pain medications.
The Conceptual Framework
In exploring the impact of this policy change, we are guided by Carl May’s (2007) Normalisation Process Theory. NPT helps identifies factors that promote and inhibit the routine incorporation of complex healthcare interventions into everyday practice. NPT focuses on how adoption, integration and implementation is operationalised, in four key areas: Sense-making/coherence (i.e., is the intervention easy to describe?; Do participants have a shared sense of its purpose?); Participation (i.e., do target user groups think it is a good idea?); Collective Action (i.e., is the intervention affecting the work of user groups?; how compatible is it with existing work practices; how is it impacting resources, power, and responsibility between different groups?); and Reflexive Monitoring (i.e., how are users likely to perceive the intervention once it has been in use for a while?; is it be clear what effects the intervention has had?). May’s NPT is a commonly accepted approach for exploring healthcare implementation, which supports a process of collective, self-reflective inquiry, in which stakeholders seek to understand how interventions are embedded (or not) into routine practice.
Outcomes
Evaluation
From March to May 2022, Townsville Correctional Complex (TCC) conducted a trial allowing prisoners in two units to access these OTC medications through ‘prisoner buy-up’. In May 2022, they expanded it to the whole prison – all prisoners were able to buy up to 10 paracetamol and 12 ibuprofen per buy-up, and keep twice that amount in their cell A team of independent researchers led by the QUT Design Lab conducted seven in-person focus groups at TCC in May 2023, speaking to 61 stakeholders – 37 prisoners, 13 clinicians and 11 officers across the Men’s and Women’s Prisons, with 11 staff completing an online survey, and 78 prisoners a paper survey.
Results
Over the last year, all prisoners (~800 male, ~200 female) have been able to buy up to 10 paracetamol and 12 ibuprofen per week (and to keep twice that amount in their cells), priced at paracetamol (85c/ packet) and ibuprofen ($1.37/packet) via buy-up – with a total of 9372 packets purchased – with no adverse events reported. Free pain medications remain available through the prison health centre, as prescribed. No significant problems or adverse events have been reported. While some officers and clinicians were initially concerned about misuse, these fears have not been substantiated. Being trusted to manage their pain relief gave agency/ decision-making ability to prisoners, helping to restore self-worth and health literacy, with clinicians and officers noting that this change helped to stop“prisoners repeatedly asking for pain relief”. Officers have been “pleasantly surprised” that this significant policy change just “happened” without negative impacts, while clinicians felt it was “more positive than negative”.
Prisoners were overwhelming positive about the change, valuing the opportunity to be trusted to manage their own pain relief, appreciating the restored sense of self-reliance, control, and empowerment. Female prisoners were “so grateful for it”, while the male prisoners felt it took the “unnecessary aggravation out of the system, improving prisoner dynamics because pain was better managed”. Being able to self-manage access to pain relief meant prisoners did not need to continually contact officers/the prison healthcare centre seeking treatment for common ailments (toothaches, headaches, sore muscles, period pains) – which was positively transformative:
With a headache, you are more grumpy, more likely to crack or be anti- social, to go against the grain … all you can do is think about this pain… this stops the pain and takes the edge of the hostility – (Male Prisoner)
You feel like kids getting Panadol brought to you by the nurse… we are paying for what we have done wrong… but we are adults, and should be able to take a Panadol when in pain… They [QCS] need to give inmates more trust… treat us like human beings. We are not children. We are adults… jail needs to help us help ourselves – (Male Prisoner)
If you are old enough to go to jail, I think you are old enough to take Panadol – and while you will always get the odd idiot, they really cannot hoard it, because the screws (guards) search your room – (Male Prisoner)
No one is misusing it. I know it is a medicine, but giving someone the opportunity to take Panadol … it’s a good idea. A high proportion of people inside have dental pain… that is why ibuprofen helps – (Male Prisoner)
Key Messages
- There have been no adverse events reported, after a year of operation in the Women’s and Men’s Prison at Townsville Correctional Complex.
- As prisoners have complex health needs and high rates of physical and mental illnesses (especially dental and osteoarthritic pain, many women experience menstrual-related pain), they greatly valued access to immediate pain relief, especially overnight.
- Female prisoners were “so grateful for it”. Male prisoners felt better pain management took “unnecessary aggravation out of the system, improving prisoner dynamics”.
- Officers were initially hesitant, anticipating challenges. Most were “pleasantly surprised”, with the Women’s Prison perceiving “dramatic reductions” in overnight hospital transfers as the ability to self-manage pain helped to alleviate issues from escalating.
- Clinicians felt it was “more positive than negative”, giving agency/decision-making ability to prisoners and “stopping prisoners repeatedly asking for pain relief ”.
- There was a desire for more information, communication, engagement, and educational resources, for all stakeholders, but especially for prisoners with cognitive impairment, low levels of health literacy, and culturally appropriate information for the high proportion of incarcerated First Nations people (e.g., videos on prisoner television, posters for all).
- There have been no reported adverse events, with all three key stakeholders (i.e., prisoners, officers, clinicians) generally agreeing that the benefits outweighed the perceived risks.
Awards
The HEAL Prison Pain Medication Project Team won the External Partnerships and Social Impact Award from the 2023 Faculty of Creative Industries, Education and Social Justice awards.
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Funding
Queensland Health’s Office for Prisoner Health and Wellbeing.
Team Members
- Prof Evonne Miller – QUT, Director, QUT Design Lab
- Prof Lisa Scharoun – QUT, Head, School of Design
- Prof Melissa Bull, QUT – Director, QUT Centre for Justice
- Prof Jane Phillips – QUT, Head of the School of Nursing
- Prof Lisa Nissen, UQ
- Dr Jane Hwang, UNSW
- Dr Abbe Winter, QUT.
- Dr Sarah Johnstone, QUT.