Editor:

We thank Kenneth Appelbaum for his interesting article, “Attention Deficit Hyperactivity Disorder in Prison: A Treatment Protocol”,¹ published in The Journal earlier this year.

One of the subjects discussed was the criteria for the treatment with stimulants of prison inmates with attention-deficit hyperactivity disorder (ADHD). At first, nonpharmacological treatment recommendations were provided. Appelbaum explained that atomoxetine had not been added to the statewide formulary when the protocol was developed. Then, he expressed his concerns about treating inmates with controlled substances such as stimulants. The protocol proposes that stimulants be recommended only after the failure of a complete trial of one or more nonstimulant medications, or when such trials are contraindicated, and after a review of the patient's substance abuse history. The protocol then recommends prescription of immediate-release medications that decrease the risk of misuse. It also requires documentation of objective improvement in functioning. In the case of stimulant misuse by an inmate, the medication is stopped.¹

Kathryn Burns’ interesting commentary reminded us of the limitations that should be placed on the prescription of controlled substances in prisons. She recommended that prescriptions be restricted because of the high prevalence of substance use disorders in prison populations, the potential for misuse, the barter and sale of controlled substances among inmates, challenges for nursing, direct and indirect costs, and available alternatives.²

Burns was correct in stating that there are some important concerns that should be discussed. However, it seems that at least some of them were included in Appelbaum's protocol. Moreover, if the prescribing of medication for inmates, in light of Appelbaum's criteria, is discouraged, the question should be raised as to whether, despite the need to control such medications, it is ethical to deprive inmates of well-known and effective treatment just because there are risks. It should be noted that ADHD may be a risk factor for the inmates’ imprisonment. Perhaps, future studies to investigate the possible risks, costs, and benefits of prescribing stimulants for inmates are needed.

• American Academy of Psychiatry and the Law