Journal of Correctional Health Care - April 2023 - 113

EXPANDING CLOZAPINE USE IN STATE PRISONS
113
helping to assess for and monitor side effects and vital
signs, phlebotomists and laboratory technicians assisting
with routine blood monitoring, and pharmacists monitoring
ANCs and interfacing with the REMS system.
Similar innovations have been developed for other
medications (e.g., warfarin) with success (Mathis &
O'Reilly, 2010). With clozapine, medical providers (internists,
family physicians, or advanced practice providers)
assist with abnormal electrocardiograms or lab test results
at baseline and with medical management of patient side
effects. Once stabilized, psychology staff could then
work with the patients on dialectical behavior therapy
(DBT) skills to help reinforce and maintain the gains
they have achieved. Pertinent DBT skills include mindfulness,
interpersonal effectiveness, emotion regulation, and
distress tolerance (Lynch et al., 2007).
If a prison does not have an inpatient psychiatric unit, a
small number of prison clinics could be used to initiate
clozapine as it does not require inpatient hospitalization.
Reducing the number of outpatient initiation clinics
would allow for staff to become more familiar with routine
clozapine monitoring. The outpatient clinic would need to
have the resources to monitor vitals, lab test results and potential
side effects closely and consistently during the first
4 weeks of therapy. Providers would also need the flexibility
to see patients at least twice weekly during this period.
In North Carolina, we have allowed patients previously on
clozapine to restart the medication in an outpatient setting
if the first initiation was relatively uncomplicated.
Another potential solution to the shortage of real-time
clozapine expertise in correctional systems is a consultative
system similar to the Extension for Community Healthcare
Outcomes (ECHO) model (Arora et al., 2007). Originally
developed to harness the expertise of specialists to broaden
treatment of hepatitis C, ECHO relies on a central group of
experts who partner with regional providers to share
knowledge and expand specialty care.
Similarly, experts who routinely prescribe clozapine
and clinical pharmacists experienced with clozapine use
can consult with other psychiatrists, primary care providers,
and advanced practice providers to broaden use in
correctional systems. Clinical pharmacists would provide
key support and assist with safety and lab test monitoring
and tracking of patients. Specifically, the clinical pharmacist
would monitor ANCs, input the data into the REMS
website, monitor other medications and potential drug-
drug interactions, and keep a spreadsheet to help track patients
to ensure lab test results are obtained with movement
from one facility to another. Pharmacists can also
lead or assist in the evaluation of clozapine treatment programs
in prison systems.
A consultative system would allow correctional institutions
with fewer psychiatric resources to provide clozapine
for the many patients in whom it is indicated. Clozapine
initiation has historically been left to psychiatrists (Manuel
et al., 2012), but this does not have to be the case. In correctional
systems with fewer psychiatric resources, a consultative
system can leverage the expertise of a few
psychiatrists to provide support and training for internists,
family physicians, and advanced practice providers to treat
a greater number of patients (Fortney et al., 2015).
A prison-academic partnership, initiating clozapine in
specialized outpatient clinics, and using a consultative
model are only three possible solutions to clozapine
underuse in prisons. Each state and prison system will
present its own unique challenges to increasing clozapine
use. The common denominator for any solution is a dedicated
multidisciplinary team able to think creatively
about logistic challenges along with administrative backing
to provide necessary resources and support. The effort
it takes to establish teams and protocols to safely
prescribe clozapine will ultimately lead to less suffering,
fewer behavioral problems, and less time and money
spent on this population.
Conclusion
Clozapine is a unique evidence-based treatment with numerous
benefits for patients with treatment-refractory
schizophrenia and severe personality disorders but is underused
in correctional settings despite a high prevalence
of seriously ill patients. Prescribing in prisons is limited
by a time-consuming initiation process, more intensive
medical monitoring, high demands on frontline staff,
and limited provider expertise.
Clozapine can be used safely in prisons with administrative
support toward allocating resources to dedicated
multidisciplinary teams as demonstrated in the North
Carolina prison system. The benefits of increasing clozapine
prescribing, including the potential to reduce disruptive
behaviors, decrease costs, and improve staff and
patient satisfaction, far outweigh the increased time and
effort needed to safely use the medication. Additional research
is necessary to analyze what can be done to encourage
treatment adherence. Prison systems should
explore consultative models and allocate resources to increase
clozapine prescribing nationwide.
Authors' Contributions
T.R.Z. and M.E.P. wrote the article. T.R.Z. and B.B.S.
conceived of the presented idea. All authors contributed
to the editing of the final article.
Author Disclosure Statement
The authors disclosed no conflicts of interest with respect
to the research, authorship, or publication of this article.
Funding Information
The authors received no financial support for the research,
authorship, and/or publication of this article.
Journal of Correctional Health Care - April 2023

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