Journal of Correctional Health Care - April 2023 - 111

EXPANDING CLOZAPINE USE IN STATE PRISONS
111
services for patients throughout the state. This partnership
led to the availability of psychiatric consultants who had
interest in clozapine management based on experience
working in state hospitals with treatment-refractory patients,
many of whom had dramatic improvements in psychosis
and SIB after treatment with clozapine.
In 2015, NC DPS sought to significantly expand clozapine
use within its network of 55 state prisons. At that
time, NC DPS housed approximately 35,000 individuals,
of whom 18% received some level of mental health services.
From July 2014 to June 2015, there were 21 individuals
within NC DPS who had received at least one
dose of clozapine.
Beginning in 2016, meetings were held with prison administrators,
nurses, pharmacists, and psychologists to revise
the NC DPS policy on clozapine use. This new
policy was based on the ''community standard''-
namely, those policies used at a local state psychiatric
hospital and within UNC. The policy discussed criteria
for consideration for treatment, prescriber registration,
informed consent, routine laboratory monitoring, dispensing,
discontinuation, and provision of prescriptions
at discharge and/or release from prison. In addition, a
standard informed consent form was developed that all
patients or their legal guardians were required to sign.
If a legal guardian signed the form, patients still had to
assent to treatment and blood draws.
The setup of the clozapine program required considerable
coordination among disciplines and professions-
psychiatry, internal medicine, pharmacy, laboratory,
nursing, and psychology services-as well as the buy-in
and support of administrative and custody staff. Prescribers
within NC DPS were initially able to start clozapine at any
prison that had 24-hour nursing coverage. However, some
prisons at times had difficulty with timely blood draws and
monitoring vital signs.
Therefore, NC DPS decided that all clozapine initiations
would take place at two prison-operated inpatient
mental health units (one male, the other female). This
streamlined the process of initiation, ensured that lab
test values and vital signs were monitored per protocol,
and allowed in-house consultants from UNC to assist
with initiations. Patients starting clozapine typically
spent at least 2 to 4 weeks in the inpatient unit titrating
clozapine slowly before transitioning back to their prior
correctional institution.
Clozapine initiations began in mid-2016 with the new
NC DPS clozapine policy and procedures in place. The
numbers of patients prescribed clozapine between July
2014 and June 2020 are presented in Figure 1. The total
number of patients who were prescribed clozapine increased
from 21 to 82 during this time period, a 390% increase.
In addition to the benefits for self-injury,
aggression, and time in solitary confinement discussed
above, costs of treatment were also estimated to be greatly
reduced (Zarzar et al., 2019). Patients who were consistently
difficult to manage became calmer and could engage
more readily in psychotherapeutic offerings.
Although many remained quite ill based on clinical assessments,
they could go for longer intervals without selfFig.
1. Patients taking > 1 dose of clozapine over time in the NC DPS system from July 2014 to June 2020. The ''*''
indicates the initiation of the new NC DPS clozapine prescribing policy and procedures.

Journal of Correctional Health Care - April 2023

Table of Contents for the Digital Edition of Journal of Correctional Health Care - April 2023