Hi Dr Keller,

I work in the prison system in the UK. I wanted to ask you if the prisoners have in-possession medication in America or is it all supervised? 
If you do have in-possession medication, have you seen or thought of a way for the inmates to keep the medication safe i.e. lock box in their room (this then highlights a security issues as can store contraband etc. in  lock boxes? Is there a feasible and reasonable way that inmates who want to keep their tradable medication to them self and not fear being bullied by peers for them? 
Any ideas would be greatly appreciated!

After doing research in my current jail. The percentage of people who actually pass random meds check is currently 18%. Now obviously not all those that failed had them “pinched” from their possession and most certainly commonly abused meds such as trazadone and mirtazapine have been sold as “sleepers” on the wings. But for those people who genuinely get bullied for their medication or do in fact get them stolen what is the alternative measure to help them apart from to put them not in-possession and supervise them daily? 

If you have any ideas I would greatly appreciate it.

Dez

Thanks for the questions Dez! In the United States, most medications are passed in a supervised setting. “In-possession” medications are referred to as “KOP,” which stands for “Keep on Person.”  I’m going to use this term despite the fact that not all KOP meds are kept on person. Different facilities handle KOP medications in different ways, which I’ll get into. Here are the basics of KOP medications:

1. The first question about setting up a KOP program is whether you even want to do so. As far as I can see, the only advantage to allowing inmates to have KOP meds is as a time saver. Since nurses don’t have to pass KOP drugs at med pass, it shortens the time they spend on this task. However, if your KOP program takes more time to set up and administer than the time it saves on med pass, there is no reason to have a KOP program. This means that KOP programs make more sense in general for prisons than jails and more sense for big jails than little jails.
2. What medications will you allow to be KOP? KOP medications should be those medications that have a low risk of abuse (such as being able to get high by crushing and snorting) or being diverted to other inmates through coercion or on the black market. Examples of appropriate KOP medications are many hypertension medications, such as lisinopril, diabetic meds like metformin and lipid meds like the statins. You can’t get high on them and no one will want to steal them or buy them. Problematic KOP meds program are meds that have high value as commodities such as trazodone, Seroquel or the infamous gabapentin. Such meds should be administered in a supervised setting.
3. What inmates will be allowed to have KOP privileges? This is a security issue that you will need to coordinate with your security staff. Usually, maximum security inmates do not get to keep KOP meds, minimum security inmates do have this privilege and medium security inmates are a maybe. You have to be able to trust your KOP patients.
4. How will you dispense KOP meds? KOP meds need to be able to be easily counted, so the most common packaging of KOP meds is in the same bubble cards that are typically used in most US facilities anyway. Another method I have seen is to package the KOP meds in one of those plastic containers with seven sections labeled with the days of the week.
5. Where will the KOP meds be kept? I have seen several solutions to this question in various facilities. If you allow inmates to have their KOP meds in their personal unsecured property boxes, invariably, some will be stolen or lost. However, many facilities do KOP this way. One facility I know of actually requires KOP meds to be kept physically on person, which means that such patients have to have their KOP meds with them at all times. This would make it hard to play basketball, I would think! The best system, by far, is to put KOP meds in a secure area, such as individual boxes in a “KOP Room” or even secure lockers in the commons area of the dorm that KOP inmates have access to only with supervision.
6. How will you monitor KOP usage? You need to know if patients with KOP meds are actually taking their medications. If the meds are kept in secure lockers in a KOP Room, a nurse or pharmacist with a master key can get into each locker say once a month to document medication compliance. If the patients keep their KOP meds in their own unsecured property, they usually have to hand in an empty pill card to get a new one. But you also have to keep track of who is late handing in their card! You also will need a policy on what to do if a patient is not taking her meds or if the tally is wrong, such as if all of the KOP meds are gone before they should be.

You can see that there is a lot of administrative time involved in operating a successful KOP program. For many jails, administering a KOP program would take more time and effort than just passing all prescription meds at a regular supervised med pass.

Now. Dez, for your second question: It sounds like in your facility, all meds are kept in personal unsecured inmate property, even drugs with a high value in the prison black market, like trazodone and mirtazepine. Such meds have high value and will inevitably either be sold or given up to a bully more often than they will be taken by the intended patient. The only way I know of to prevent this is to increase the supervision and security of patients taking these meds. You can do this by having nurses pass problematic meds–like is typically done in the US. Or you can set up secure lockers that patients have access to one at a time and under supervision. I can’t think of any other solution myself–but I welcome comments and suggestions from readers!

How do you do KOP in your facility? Please comment!

As always, what I have written here is my opinion, based on my training, research and experience. I could be wrong!