Journal of Correctional Health Care - April 2023 - 112

112
PRUETTE ET AL.
harm or aggression. Often patients on multiple psychotropic
medications could have their regimens simplified to
clozapine with or without an antidepressant. Although
clozapine can be dosed up to 900mg daily (Novartis
International AG, 2010), we used relatively low average
doses of 164 mg/day for patients with personality disorders
and 186 mg/day for patients with psychotic disorders,
to help mitigate side effects. Daytime sedation, a
side effect some incarcerated individuals want to avoid
to remain vigilant, or alternatively desire to sleep away
their sentence, was also minimized by the lower doses.
Despite these successes, one-third of patients who
started clozapine discontinued treatment before 3
months, while another subset stopped treatment and
asked to be restarted at a later time. We allowed patients
to restart clozapine if requested and indicated, though
typically not after two or three failed attempts.
Challenges of Clozapine Use in Corrections
Clozapine treatment in corrections is not without its pitfalls.
Because of its sedating qualities, clozapine can be
misused, abused, or bartered in jails and prisons. One patient
in NC DPS hoarded his clozapine and then overdosed,
requiring inpatient medical hospitalization.
There were also reports of some patients diverting the
medication. As a result, NC DPS instituted a crush and
float recommendation (requiring the medication be
crushed and put into water for the patient to drink) for
all patients taking clozapine with a history of medication
misuse, frequent SIB, or ongoing substance abuse issues.
When indicated, clozapine blood levels were also
reviewed to monitor adherence. With these checks in
place, providers could feel more comfortable prescribing
clozapine.
Initially, patients who started clozapine in the inpatient
mental health unit were discharged only to certain prisons
across the state, allowing prescribers, nurses, and pharmacists
at these sites to develop experience using clozapine
and to further encourage streamlining of processes.
However, this system led some patients to request clozapine
not for the betterment of their mental health symptoms
but rather to be moved to one of these specific
sites. Procedures were then changed to allow clozapine
patients to be discharged to any prison that had fulltime
nursing care available. The goal here was to treat patients
who receive clozapine the same as individuals on
other psychotropics.
Coordination among different prisons is another challenge.
In North Carolina, patients initiated clozapine in
centrally located inpatient mental health units. Upon discharge,
the majority went back to their assigned prison to
resume outpatient services, while others entered stepdown
residential programs within the prison system.
When moving to outpatient care, medications had to be
supplied and lab tests ordered and monitored by an
outpatient psychiatrist.
At times, the transition caused lab tests to be missed. It
also was not uncommon for patients to decline the tests
early in the morning, though in outpatient settings there
are no procedures to obtain these later in the day or the
next day. Frontline staff may feel frustrated and annoyed
with lab test refusals, which can be seen as a personalitydisordered
behavior, and if unfamiliar with clozapine
they may not adequately encourage patients to allow
the blood draw.
In some instances, custody staff move patients from
one prison to another without the knowledge of the treating
provider, and the ability to track these movements becomes
critical. Our regional pharmacies now track all
patients prescribed clozapine in the prison system
through the centralized electronic health record, in addition
to entering absolute neutrophil counts (ANCs) into
the Clozapine REMS database.
Ultimately, prescribing clozapine takes a significant
amount of effort from the treatment team. There are medical
risks, but those are generally rare and can be appropriately
managed when following monitoring protocols.
On account of long-term outcomes on psychotic symptoms
and mortality, the benefit-cost calculus in using clozapine
is best framed not as clinical benefits versus
clinical risks, but rather clinical benefits versus the time
and effort required to safely use the medication. The
coordination of various departments along with administrative
support is generally the rate-limiting step in
prescribing clozapine to more individuals in need.
Expanding Clozapine Use Nationally
Educating providers about clozapine's risks and benefits
is a necessary first step to increase prescribing, but alone
is not sufficient. Correctional institutions must also create
systems and processes to support prescribers with clozapine
initiation and monitoring. Specifically, criteria and
guidelines for clozapine initiation and protocols for monitoring
are important to have codified. Prison administrators
and clinicians must determine the logistics of
clozapine prescribing in a resource-limited environment.
In our experience, it is necessary to have at least one
person, preferably more, fully committed to facilitating
clozapine treatment. A clozapine ''champion'' does not
require specific training or qualifications; it simply requires
that the person promote, encourage, and monitor
clozapine prescribing in the prison system.
This role could also be fulfilled by a dedicated clozapine
team. These individuals would help assess whether
clozapine is an appropriate treatment, guide providers
during the initiation phase, and be available for as-needed
consultation during the maintenance phase of treatment.
A multidisciplinary approach is critical, with nurses
Journal of Correctional Health Care - April 2023

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