Drugging Aggression Behind Bars

It is obvious, if not platitudinous, that men and women who are abnormally aggressive and impulsive are especially likely to get into trouble with the law, and many of them will end up behind bars. Some of them will obey prison rules and regulations and stay out of any more trouble, at least until they are released from the “joint.”

Light through prison bars

(Image: Prison bars via Shutterstock)

By James L Knoll IV and Robert Wilbur, Truthout

Others will prove to suffer from schizophrenia, intellectual disabilities or traumatic brain injury and – judging from prevailing standards in present-day, punitive America – will languish untreated in their cells until they have served their time. That leaves a substantial proportion of psychiatrically challenged inmates with aggressive impulses that make them dangerous to other inmates, to prison guards, to themselves and to society (once they are released).

Thanks to the psychotropic drug revolution, inmates of our “correctional” institutions are being corrected with a plethora of drugs – antidepressants, antipsychotics, anxiolytics, anticonvulsants, mood stabilizers, and other powerful mind-altering pharmaceuticals.

It is not the purpose of this article to deride the use of psychoactive drugs with prison inmates when there exists a psychiatrically or medically proper indication that such use will benefit the inmates or prevent harm to others. No one would deny that forensic psychopharmacology is a civilized alternative to the truncheon or the hole. Nevertheless, there is an important caveat, and that is the qualifier “proper.

Proper forensic psychopharmacology does not begin with a marginally trained prison employee popping a pill into an inmate’s mouth, although that is the rule rather than the exception in many if not most jurisdictions. American penology has largely given up on rehabilitation and cure in favor of retribution. That measure should be reserved for the very end of the process, except in situations where inmates become violently aggressive. Rather, the beginning of the process is – admittedly ideally in this world of budget-cutting – a thorough medical and psychiatric workup to identify conditions such as brain tumors, seizures, chronic schizophrenia and other disorders that might account for the main reason that prisoners are medicated: aggression. All too many prisoners with treatable illnesses languish untreated year after year because the state department of corrections did not budget for the most fundamental standard of humane care: a thorough workup.

Fortunately, solid case law has addressed the thorniest legal and ethical issues involved in medicating persons whose freedom is already circumscribed, i.e. the issue of informed consent and the right to say “no.” The Supreme Court set the “constitutional minimum” in the case of Washington v. Harper.  This case gave much deference (as usual) to corrections administrators based on the governmental interest in keeping prisons “safe” – and there was discussion about how prison is inherently a dangerous place, and would be more so if it was made too difficult to medicate inmates who are acutely psychotic.  The court held that due process was satisfied by conducting an intra-institutional hearing with a lawyer, psychiatrist and psychologist to make the decision.

States are able to enact more, but not less, stringent standards than the Supreme Court developed. One example of this is New York. The controlling case is Rivers v. Katz, which gives inmates the right to a full due process adversarial hearing if their psychiatrist wants to medicate over their objection. This can be a real protection: for example, in New York inmates get a Mental Hygiene Legal Services (MHLS) attorney who vigorously cross-examines the doctor, as, frequently, do the presiding judges. One author has been quite surprised over the seriousness with which the courts take medication over objection. In most Supreme Court of the State of New York cases dealing with the subject, the court does not use friendly language when considering antipsychotic medication.

These long-term, non-acute forms of involuntary medication must be distinguished from “emergency medications” – which can be given without legal oversight if the inmate suddenly becomes an acute danger to himself or others as a result of mental illness.

Consequently, once other causes have been ruled out, forensic psychopharmacology devolves around the management of aggression.

Acute aggression is a psychiatric emergency. One of us (JLK,IV) identifies two strategies. The first relies on antipsychotics, either the older first-generation (Haldol) drugs or the newer second-generation agents (Zyprexa, Geodon). The second alternates Haldol with Ativan, an anti-anxiety medication. The strategies work like this:

Haldol is administered in a dose of 5 to 10 milligrams and the patient is reassessed closely for the need for further dosing.

The second strategy alternates 5 mg of, typically, Haldol IM every 30 minutes with 1-2 mg of Ativan, also every 30 minutes, until the prisoner is calm.  In some situations, the medication Benadryl is added, both for its sedating property, as well as its ability to counteract any untoward muscle stiffness resulting from the rapid dosing of Haldol.

The various drugs for managing acute aggression differ not only in potency (Haldol is roughly 100 times more potent than Thorazine) but also in their pharmacological “profiles.” For example, Thorazine can cause side effects such as dry mouth or even temporary urinary retention; such side effects are much rarer with Haldol, but the downside is that Haldol causes a much higher incidence of neuromuscular side effects, among them akathisia, a state of muscular and mental restlessness. Among the second generation antipsychotics, Geodon can be toxic to the heart; specifically, it prolongs the QTc interval, a period on the electrocardiogram that corresponds to the repolarization or “recharging” of the lower two chambers of the heart, namely the ventricles; rarely, it causes a sometimes-fatal condition called ventricular fibrillation, or extremely rapid beating of the lower chambers of the heart, leading to a loss of cardiac pumping ability. Persons at risk for this condition can be identified before Geodon is ever given by means of a routine EKG – but, tragically, such EKGs are rarely if ever administered during an aggressive episode that calls for the drug. Zyprexa is a heavily sedating antipsychotic; its steepest downside is that long-term use can cause diabetes – which is not a consideration in taming the fury of acute aggression.

What about Ativan? It is not an antipsychotic, but it has powerful calming properties – most of the time. Benzodiazepines (including Ativan) are widely used in human and veterinary medicine to control aggression. Rarely, Ativan or other benzodiazepines can cause an opposite effect – a paradoxical reaction [Veterinary Psychopharmacology; Crowell-Davis SL, Murray T; 2006 chapter 2] Paradoxical reactions have also been reported in humans. On the plus side, combining Ativan with Haldol attenuates the discomfort of akathisia, not only because the dose of Haldol is lower but because benzodiazepines are widely used for treating akathisia.

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