Upholding confidentiality in the preparation and distribution of medication in prisons: implementing recommendations of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment

Confidentiality must be ensured even in the preparation and distribution of medications in detention settings. In this respect, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment found during recent prison visits several instances where prison staff, and at times detainees, dispensed prescribed treatments and supervised their intake. Such a practice compromises medical confidentiality requirements and the establishment of a trusting doctor-patient relationship. To respect medical confidentiality and ensure safety and quality of care, the authors argue that only qualified healthcare personnel should prepare and distribute prescribed medications, all of which require specialized training. They call for robust research that examines the operational barriers and facilitators as well as the respect of human rights related to various approaches to medication preparation, distribution, and intake so that people in detention can access their treatment with safety, confidentiality, autonomy, and dignity.


Background
The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) provides a non-judicial preventive mechanism to protect persons deprived of liberty against torture and other forms of ill-treatment 1 The CPT visits detention places in the 47 member states of the Council of Europe.The visits include the assessment of medical services in carceral settings to gain insights into the way individuals access healthcare prevention, treatment, and care.The access to healthcare services for individuals experiencing incarceration is essential as this priority population carries a high burden of physical and mental health conditions [2][3][4][5] .Operating such services in prison must be underpinned by the following guiding principles: timely access to competent medical staff who work independently from the criminal justice system 6 , equivalence of preventive and curative care services that are free-of-charge to patients (i.e., states bear all the healthcare costs), humanitarian assistance to individuals with increased vulnerabilities (e.g., mothers with children, adolescents), and patient's right to informed consent and confidentiality 7 .Failing to respect these principles can result in situations falling within the scope of inhumane and degrading treatment.The objective of this article is to underscore the paramountcy of upholding confidentiality in the preparation and distribution of medication, as highlighted by recent CPT visits.

Examples of violations
There is a paucity of published peer-reviewed literature on this subject and our sources stem from published CPT reports.Once prescribed, medications require coordinated preparation and distribution for individuals to have timely access to their treatment.In Scotland, the CPT delegation found that medical and prison staff shared the task of distributing medication and supervising its intake 8 .In Greece, prison staff and detained individuals were acting as orderlies (i.e., they were trained in first aid and selected clinical tasks), who dispensed medication under the supervision of nurses and had access to patient medical records 9 .In Norway, it was the duty of the custodial officers to distribute prescribed medications despite the daily presence of a nurse 10 .In Estonia, nurses prepared the medication, and custodial staff ensured its distribution except for psychotropic treatment, which was delivered by nurses 11 .In Cyprus, several prison officers worked as medical orderlies who distributed medication and accompanied doctors on their rounds, with a few assigned to medical duty during the day or at night 12 .In the Netherlands, external pharmacies prepared the medication and custodial staff carried out its distribution.For prescribed opioids and psychiatric medication, prison officers also had to check that recipients swallowed them properly (patients reported that they had occasionally received the wrong medication, for example that of their neighbor, due to a lack of attention by the prison officer) 13 .

CPT rules and recommendations
Cooperation between healthcare professionals and prison authorities is necessary if it is deemed reasonable and respects the guiding principles mentioned above.However, in the given examples, the distribution of medication, including psychotropic substances and methadone, by prison officers or by incarcerated persons compromised the respect of medical confidentiality-the medication name and its dosage were visible.Such a practice could compromise medical confidentiality requirements and the establishment of a proper doctor-patient relationship.
According to the 1992 CPT report, there should be appropriate supervision of the pharmacy and the distribution of medicines.Further, the preparation of medicines should always be entrusted to qualified staff (pharmacist/nurse, etc.) 7 In other words, to respect medical confidentiality and ensure safety and quality of care, individuals in prison and custodial staff should not be involved in performing healthcare tasks and only qualified healthcare personnel should prepare and distribute prescribed medications, all of which require specialized training.
We acknowledge the difficulty in following this recommendation, especially in smaller detention facilities, where healthcare professionals are not available 24h/7 when compared to larger and high security facilities.These facilities tend to have the most comprehensive healthcare services and staffing because the patient population is older and present for a longer period 14 .However, irrespective of the size of the detention centers, people experiencing incarceration use health services more often when compared with the community 15 .We also understand that ensuring access to medication while respecting confidentiality, complying with prison security requirements, and accounting for fears of theft, trafficking, and misuse, especially of psychoactive medication 16 , needs a balanced operational approach.

Recommendations for best practice
The best-case scenario, one that respects medical confidentiality and quality of care while empowering patients in their autonomy, would comprise the following steps: as blister medication increases adherence to treatment 17 , prescribed medications are left in their blisters (for tablets) and packaged individually for each patient by healthcare staff (such as in the detention facilities of Geneva, Switzerland) or an automated pharmacy preparation system (such as in larger facilities in France); to avoid the confusion of roles between healthcare and prison staff 18 and to respect patients' right to confidentiality 19 , healthcare professionals-not prison officers or incarcerated individuals-distribute the medications either in-hand (as privately and confidentially as possible) or in individual lockable medication boxes that each user can independently access (such as at La Brenaz facility in Geneva); and when supervised intake is not medically indicated, patients should have the option of taking their treatment in the privacy of their cells.
However, based on the CPT experience, there are limited examples that adhere to this best-case scenario.Therefore, we call for robust operational research that examines the operational barriers and facilitators as well as the respect of human rights related to various approaches to medication preparation, distribution, and intake.Identifying and disseminating best practices that are rights-based will allow people in detention to access their treatment with safety, confidentiality, autonomy, and dignity.For the same reason, the authors may consider also recommending for medically indicated supervised intake of medication that the supervison should be conducted by health care staff and not by custodial staff and, if presence of custodial staff is deemed necessary, they should stay outside of the room.

PubMed
Please correct in the text the year of the 3rd General Report of the CPT in accordance to ref 7, i.e., 1993 not 1992.

Are all factual statements correct and adequately supported by citations? Yes
Are arguments sufficiently supported by evidence from the published literature?Yes

Are the conclusions drawn balanced and justified on the basis of the presented arguments? Yes
Overall, this is a very well written commentary with some important implications.I do think there could be a few additional considerations incorporated in order to broaden the applicability of the perspective and recommendations.For example, in some parts of the world (e.g.US) correctional facilities contract medical services to a third-party vendor.As such, there needs to be additional coordination between corrections-based staff and non-corrections based medical staff, especially with respect to facilitating medical appointments and medication receipt.With respect to the recommendations for best practice, while the best-case scenario the authors outline is one that all facilities should strive to achieve, it would be nice to see some gradation of compliance with this best-practice in order to make it a bit more practical and/or feasible.For example, if facilities do not have the resources, especially in terms of medical staff to adequately supervise medication, what can be done to mitigate concerns re breaches in confidentiality?It would be good to see recommendations for facilities across a "spectrum" of compliance such that those facilities in poor resourced settings do not feel as though they must undertake an all or nothing approach.Again, if facilities can take measured steps toward achieving the stated best-case scenario, they should be strongly encouraged to do so.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Is
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com Abstract | Publisher Full Text | Free Full Text 7. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment: Health care services in prisons -3rd General Report of the CPT.Council of Europe, 1993.Reference Source 8. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment: Report to the Government of the United Kingdom on the visit to the United Kingdom carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 17 to 25 October 2018; Para 107.Strasbourg: CPT.2019.9. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment: Report to the Greek Government on the visit to Greece carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 14 to 23 April 2015; Para 80, 81, 85.Strasbourg: CPT.2016.Reference Source 10.European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment: Report to the Norwegian Government on the visit to Norway carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 28 May to 5 June 2018; Para 90.Strasbourg: CPT.2019.Reference Source 11.European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment: Report to the Estonian Government on the visit to Estonia carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 27 September to 5 October 2017; Para 60.Strasbourg: CPT.2019.Reference Source 12.European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment: Report to the Government of Cyprus on the visit to Cyprus carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 2 to 9 February 2017; Para 85-86.Strasbourg: CPT.2018.Reference Source 13.European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment: Report to the Government of the Netherlands on the visit to the Netherlands carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 2 to 13 May 2016; Para 60.Strasbourg: CPT.2017.
the topic of the opinion article discussed accurately in the context of the current literature?Yes Are all factual statements correct and adequately supported by citations?Yes Are arguments sufficiently supported by evidence from the published literature?Yes Are the conclusions drawn balanced and justified on the basis of the presented arguments?Yes Competing Interests: No competing interests were disclosed.