Monthly Archives: January 2013

What Do You Think of The 10 Point Pain Scale?

20050824I was asked via email what I thought of the 10 Point Pain Scale.  I have never been a big fan of the 10 Point Pain Scale, but I think that it is a particularly poor fit for Correctional Medicine and I don’t use it in my jails.

Hospitals have to use the 10 Point Pain Scale because it is mandated by JCAHO, the hospital accreditation body.  But JCAHO has no authority over jails and prisons. We don’t have to use it and I personally think we practitioners of Correctional Medicine are better off without it.

I used the 10 Point Pain Scale quite a lot when I worked in a busy Emergency Department, both because I had to (it was a JCAHO mandate) and because it can be useful in an ER setting.  The 10 Point Pain Scale is not bad at evaluating acute pain, like the pain from appendicitis or a broken leg.  However, it is not as useful when evaluating chronic pain like what we see in corrections.

Even in an ER setting, I noticed problems with the 10-Point Pain Scale.  First, it is entirely subjective.  In other words, patients say a number and there is no objective way to know if they are being honest or not.  In the ER, I suspected that many patients inflated their numbers.  For example:

My pain is 13-out-of-10.”

My abdominal pain is 10-out-of-10 (said while the patient was eating Cheetos).”

The 10 Point Pain Scale is more useful evaluating responses to therapy via changes in the pain scale.  So if a patient tells me that he has 10-out-of-10 pain, I may not be exactly sure what that means.  But if he later tells me that his pain now is 8-out-of-10, I know that he has improved.  But even that did not happen all of the time.

I had cases where I would treat patients with IV Dilaudid, say, until they were asleep.  Yet when the nurse woke them to ask about their pain, the patient would say (with slurred words) “itsh shtill a ten.”  Should I have given more Dilaudid based on that report of 10-out-of-10 pain?  Of course not!

Let me give an example from the other end of the spectrum.  Tough, stoic cowboy-types would come to the ER with long bone fractures and would rate their pain a “2-out-of-10.”  Do I then use Tylenol instead of IV narcotics to treat the pain from this femur fracture?  Again, of course not.

Finally, what do I do with a patient who rates her pain high–say 9 out of 10–but refuses narcotic pain medication?  Don’t laugh, that actually happens!  Some people are tough and can handle pain better than others.  Others would rather have pain than be gorked by pain meds.

In the end, even using the 10 Point Pain Scale, ER doctors still have to rely on their clinical judgment.  Yet that means there will be discrepancies between what the patient says his pain is and how it is treated.  Let’s say the nurse dutifully records in the medical record that the patient says his pain is 10-out-of-10, but, based on my clinical judgment, I do not give pain medication.  Later, when the medical record is reviewed by JCAHO, a hospital committee or a plaintiff’s attorney, I look like an uncaring sadist:  “My client was crying out that his pain was as bad as pain could possibly be and you did nothing, Doctor?”

And those are just the problems when the 10-Point Pain Scale is used to evaluate acute pain in ERs.  It is even worse when used to evaluate chronic pain in Correctional Medicine clinics.  Chronic pain patients tend more than acute pain patients to rate their pain 10 out of 10 and to admit to little change.  There is also more discrepancy between what chronic patients say (The pain is 10 out of 10) and what they do.  For example, consider the patient I actually had in one of my jails who told me in clinic that his chronic back pain was 10/10 in intensity.  Later in the day, I looked into the recreation area just in time to see this patient perform a perfect basketball reverse layup.  This did not mean that this patient did not have back pain at all—he probably really did–but it did mean that he probably did not have true “10 out of 10” pain.  It also meant that I could not trust this patient’s subjective pain scale scores.

It seems to me that I have to use even more clinical judgment in a jail than I did in the ER.  I have to weigh the potential adverse effects that narcotics have on the safety and security of the facility.  I have more patients with addiction problems and have to try to sort out true chronic pain from addiction.

Plus, in a jail, I have more true objective evidence to base my clinical decision on than I did in the ER since I can observe patients away from the medical clinic.  I can watch them at recreation.  I can watch them walk and talk and eat in their dorm.  I know the legal circumstances that landed them in jail, like illicit drug use, that an outside doctor may not ever know about.

The subjective 10 Point Pain Scale in such a setting is more hindrance than help, I believe.

I still ask the patients about their pain. I even use a pain scale, though a simpler one consisting of just four points: none, mild, medium and severe.  I also ask about changes in  pain:  “Is your pain improved since yesterday?”  But more importantly, I ask patients how their pain affects them in everyday life.  Can you sit?  Stand?  Watch TV?  Walk during recreation?  I record the answer and then compare that (if necessary) to observation of those activities.

The 10-Point Pain Scale does have its uses.  In my opinion, it works best for monitoring responses to therapy of acute pain.  For example, when I used to give IV Dilaudid in the ER to a patient with a femur fracture, her responses to the 10-Point Pain question would help me to know that I was getting somewhere with pain relief and when to stop.  Whether it worked better than asking “Is your pain improved?” or “Do you want any more pain medication?” is a debatable point.

But the 10 Point Pain Scale is not as useful for rating chronic pain.  In my opinion, it is the wrong tool for this task.

Feel free to disagree with me, though!  I could be wrong in my opinions!

What is your experience with the 10 Point Pain System used in hospitals?  Do you use it in your correctional facility?  Please comment!

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Interesting Articles of the Week: Prescriber’s Letter and Medical Letter

20121128The saying goes that just half of what we were taught in medical school is wrong.   Also half of what we think we know about medicine now is wrong.  The problem is that we don’t know which half!  But this does mean that keeping up-to-date with the current medical literature is very important.  Why just yesterday I read that maybe leeches and purging aren’t such good treatments for headaches after all!

Two of my favorite sources of continuing medical education are the Prescriber’s Letter (found here) and the Medical Letter (found here).  Both provide evaluations of medications and changes in medical thinking that are unbiased by marketing from Big Pharma.  Both are subscriptions services (which they have to be since they don’t accept advertising) but both are well worth the money.

Recent editions of both publications have some really interesting information that I would like to share here.  Because I don’t want to infringe copyrights, I will summarize the information presented instead of “copy and paste.”  Those who are interested can look up the originals!

Prescriber’s Letter, January 2013

Beta Blockers for Hypertension?  Not for most patients!

Beta-blockers are no longer a preferred drug for uncomplicated hypertension.  Even though they do lower blood pressure, beta blockers are less effective in preventing long term bad outcomes like heart attacks and strokes than alternative medications like  diuretics, ACE inhibitors/angiotensin receptor blockers (ARBs) or calcium channel blockers. Atenolol appears to be the worst offender in this regard.  The one population in which beta-blockers should still be used are those patients who have had heart attacks or otherwise have known coronary artery disease.  So if your patient has had an MI, use metoprolol or carvedilol.  If not, use something else for hypertension.  Get rid of atenolol entirely.

The Medical Letter, Dec. 24, 2012

Can you use cephalosporins in patients with penicillin allergies?  Yes, in most patients.

I was taught in medical school that patients with a true penicillin allergy had a 10% risk of also being allergic to a cephalosporin.  It turns out that this is not true.  The true incidence of allergic reactions to cephalosporins in patients who relate a history of penicillin allergy is only 0.1%.

There are two reasons for this.  First of all, if you skin test all people who say that they are allergic to penicillin, only a small minority will be found to be truly allergic (I have heard less than 10%).  Second, even those patients who are proven to be allergic to penicillin by skin testing have only a 2% chance  (not 10%) of also being allergic to cephalosporins.

Chemically, penicillins and cephalosporins do share a common beta-lactam ring, but it is the side chains of the molecules, not the central ring, that cause allergic reactions.

So if a patient has almost died from a penicillin allergic reaction, i.e, Stevens Johnson Syndrome or toxic epidermal necrolysis or the like, I would not risk the 2% chance of repeating the event.  But if the patient gives a history of a vague rash thought to be due to penicillin, the risk of using a cephalosporin is very, very low.

Do you still use beta blockers for uncomplicated hypertension?  Why or why not?  Please comment.

Do you give cephalosporins to patients with a stated penicillin allergy?  We would like to hear your comments!

I have only listed two of my many favorite resources for Continuing Medical Education.  What are yours?  Please comment.




Reader Question: How Safe Is Correctional Medicine?

Ryan writes:

Hi Dr. Keller. I am a third year Physician Assistant student at the Rochester Institute of Technology. I am beginning to write a research paper, for which I have chosen to write about Correctional Medicine. Your blog appears to be an excellent resource, especially because there are so few publications on Jail Medicine. I was wondering if you or any of your colleagues would be willing to answer a few questions for my paper. If so, please contact me (contact information below), I would really appreciate it!

tcb-37079_resized1_325286Ryan’s questionnaire and contact information appears at the end of this blog post if anyone would like to help him with this very worthwhile project. If Ryan gives me permission, I will publish his paper here on JailMedicine!

It would take too long for me to answer all of Ryan’s questions here, but I would like to answer a couple of his questions that I found interesting. They are:

• What special training was required of you prior to starting the job? Self-defense?
• What are the security measures like while working?
• Are you accompanied by guards? Do you possess weapons? Are assaults common?

Ryan, there are several common misconceptions about medicine practiced in jails and prisons. One of these is that jails and prisons are dangerous places to work; that assaults by inmates on medical staff are common. Actually, this is not true.

In fact, I personally have found that my jail medical clinics are a much safer work environment than where I worked before. I started out as an Emergency Physician and worked in a busy ER for upwards of 25 years. During that time, I have been slapped, punched and kicked–several times! I was spat upon. I was peed upon. I was pooped upon (don’t ask).  I wrestled with out-of-control patients. I was threatened with violence many times. Though this never happened to me, one of my colleagues had a patient pull a knife on her in a small ER exam room. We found many guns in ER patient’s clothing. Guns were even found hidden in our ER waiting room! I’ve seen no shootings in my ERs, but gunfire in ERs elsewhere in the country are not uncommon. ER doctors and ER staff have been killed.

But none of these have ever happened to me in  the 15 years that I have been working in Correctional Medicine. My jail medical clinics have been much safer overall than emergency departments. The danger of assaults and violence are way less. There are several reasons for this.

1. Weapons are forbidden in correctional facilities. The Detention Deputies and Correctional Officers do not carry guns while on duty. Guns, and knives and other such weapons are not allowed in correctional facilities.
2. Inmates in jail and prison are, for the most part, sober when I see them. The most dangerous patients in the ER were those who were drunk or high. Inmates coming to scheduled “Sick-call” clinics are not.
3. Detention deputies are always nearby. We try to safeguard inmate privacy, but Safety and Security take precedence over privacy. This means that security staff are always nearby. In most clinical encounters, the detention deputy is just outside the room or down the hall, so that there is some privacy, but if something happens, the deputies can be there in an instant. In other cases, if an inmate has a high security level deputies may literally stand right by me. Especially dangerous inmates may even be shackled when I examine them.
4. Inmates are punished for acting badly in clinic. This punishment can take the shape of loss of privileges (like not being able to buy from the jail commissary or even the loss of visitation rights), transfer to maximum security status or even additional criminal charges.
5. I even can control profane language better in the jail than I could in the ER. In the jail, I can terminate a clinic visit if an inmate swears at me, knowing that I can see him again tomorrow. In the ER, I had to put up with bad language much more often because that visit was likely my one-and-only chance to make the diagnosis. If I sent the patient away, I probably would not see them again.

This does not mean that inmate on staff violence is non-existent; because it does happen. Detention deputies are assaulted by inmates. Medical personnel, on the other hand, are much, much safer than your typical Emergency Room.

How safe do you feel in your facility? Please comment!

Please Respond to Ryan’s Questionaire:

• What attracted you to working in Correctional Medicine?
-Did you have prior healthcare experience that influenced your decision?

• Could you tell me about the correctional facility you work at?
-Name, location, patient population, security level, For-profit or Public health organization, etc.

• What is your relationship like with the inmates?
-What approaches do you use to gain and maintain their respect?

• What special training was required of you prior to starting the job?
-Self-defense? Legal? Psychosocial?

• What is your daily schedule like?

• What are the security measures like while working?
-Are you accompanied by guards? Do you possess weapons? Are assaults common?

• How difficult is it to balance optimizing your patient outcomes and maintaining a good patient-provider relationship with the security guidelines of the facility?
-Ex: What happens if a patient needs services beyond what your facility can provide?
-How do you handle patients concealing personal information to you that is potentially dangerous to other inmates or out of line with the facilities rules?

• Do you have problems with patient compliance?
-Do patients administer their own pills? If not, how do you ensure compliance?
-Are special dietary requirements able to be accommodated? Are patients able to get enough exercise?
-How do you promote continuity of care upon inmate release?
-How much of your job is teaching your patients and other staff members?

• What are some of the more common or interesting presenting problems?

• Are you multilingual? Do you have interpreters at your facility?

• Do you find it hard to maintain professional objectivity while working with certain criminals?
-If you have treated patients facing execution, what has that dynamic been like?

• Do you have students rotate through your facility?
-If so what are some of the unique opportunities that a correctional medicine rotation offers?

• What has been the greatest thing you have learned from your job?

Please send responses to Ryan at

The F-Word. “Formulary!”

20021002Back when I worked in the Emergency Department of a large hospital, my medical staff assignment for many years was to the Pharmacy and Therapeutics Committee.  The P&T committee’s assignment was to develop a hospital Formulary and to establish guidelines and rules for medication use.   My hospital was not unusual.  In fact, every hospital has a drug formulary and a P&T committee to oversee it.

So when I got into correctional medicine, I was surprised to learn that “Formulary” is often considered to be a dirty word in corrections and many correctional facilities do not even have a formulary.

I have been told that one reason for this is that inmates, their attorneys and advocates (like the ACLU) sometimes define “Formulary” as a system that bans certain medications simply based on their cost without any consideration of the medical needs of the patient. “This is the best medication for my client and you denied it just because it cost too much.  As a result, my client suffered harm.”  So some facilities, I am told, are afraid to have a formulary because of its bad reputation.

But this is an incorrect definition of a formulary.  Formularies aren’t bad; to the contrary, a well-done formulary is good medical practice.  Every correctional facility should have a formulary and some mechanism for formulary oversight.  In fact, if you don’t have a formulary, you are practicing inferior medicine.

The first thing to understand about formularies is that having a drug formulary is the Standard of Care in your community.  Every hospital has a formulary. Nursing homes have formularies.  The VA has a formulary.  Your state’s Medicaid program has a formulary.  Why is this? Because formularies are good medicine.  Formularies have two basic functions.

Formularies and Drug Value

First, formularies do evaluate drug prices, but not to forbid medications based on cost alone but rather to evaluate drug Value.  “Value” in general is the benefit of a product, any product, divided by its cost.  The easiest way to assess value is by comparing prices of identical (or similar) items.  For example, if I want to purchase a new vacuum and the exact same model is sold at store A for  $50.00 less than store B, I usually will buy from store A because it is offering me a better deal, i.e. better value.

In pharmaceutical purchases, the value of a drug again is the benefit of that drug divided by its cost.  Since Value is easiest to assess when comparing similar drugs, my P&T committee spent a lot of time setting up lists of “Therapeutic Equivalents.”  This entailed reviewing the literature and making lists of drugs that had similar therapeutic properties.  A good example would be Proton Pump Inhibitors (PPIs).  The literature shows that the various Proton Pump Inhibitors are equivalent; there is no one PPI that is clearly better than any other.  So the preferred PPI for our hospital was the least expensive one.  This PPI was the best value.

Interestingly, the prices of similar models of vacuum cleaners don’t vary too much between stores.  The $50.00 cheaper price between store A and store B may represent only a 10% cost savings.  But the difference in pharmaceutical prices can often be mind-boggling.  For example, consider these two therapeutically equivalent PPIs:  as of January 2, 2013, the cost of Nexium was $6.15 per capsule.  But omeprazole costs 10 cents a capsule.  Is Nexium really 60 times better than omeprazole?  No!  They are therapeutically equivalent!

A formulary points these two facts out:  that the two drugs are therapeutically equivalent and that omeprazole is 60 times less expensive.  A formulary that absolutely forbids any physician to prescribe Nexium, ever, is called a “Closed Formulary.”  On the other hand, a formulary that allows Nexium to be prescribed in certain circumstances is called an “Open Formulary.”  In my hospital, if you wanted to prescribe Nexium rather than omeprazole, you would have to make a presentation to the P&T Committee as to why you thought Nexium (or any other non-formulary drug) was worth the extra cost.  Until then, the hospital pharmacy would not fill a Nexium prescription.  In fact, if you were to write an order for Nexium, the hospital pharmacy would automatically substitute omeprazole without even telling you—this is called “Automatic Substitution” and happens all the time in community hospitals.

Formularies Monitor Appropriate Drug Prescribing

The second main function of a formulary is to define and monitor appropriate prescribing within the facility.  As another example, we had one older physician who prescribed hydralazine as a first line agent for hypertension. The P&T Committee noted that this did not conform to any hypertension treatment guidelines (notably JCIS-7) and so did not permit the prescription to be filled until the physician explained himself.  Rather than come to a P&T Committee meeting, this physician chose, instead, to change his prescription to a standard agent. The reason, then, that hydralazine is non-formulary is not that it is expensive (hydralazine is, in fact, quite cheap); rather, it is because hydralazine has no indications as a first line antihypertensive.  There are other, better drugs that should be used yet before anyone thinks of using hydralazine.

Another way my P&T Committee’s formulary monitored prescribing was by making sure that specialty drugs were prescribed appropriately.  For example, the P&T Committee would not allow, say, an orthopedic surgeon to prescribe chemotherapy for leukemia without consulting an oncologist (don’t laugh, it really happens).  Some medications are so potentially toxic that their prescription should always be double-checked by someone:  a specialist, a P&T committee, or maybe just the facility medical director.  Thus, Peg-interferon for hepatitis C is non-formulary in my jails not because we do not want to use it, but because its prescription should be double-checked to make sure it is being used appropriately.

What’s in a Name?

The problem with the word “Formulary” is not with what a formulary does.  No one would object to monitoring appropriate drug usage within a facility or preferring the best value among equivalent drugs.  No, the problem with the word “Formulary” is that the word itself has taken on a negative connotation:  “Formulary” implies to some the denial of appropriate medical care based on cost alone.

One way to combat this notion is to use a different term for the processes of monitoring appropriate drug usage and preferentially using drugs with the best value.  This term should emphasize the “Open” nature of the process.  No drug is banned.  Any drug can be prescribed if the prescriber can justify the medical need for that particular drug over alternative therapies.  (That might be hard for a drug like hydralazine.  Or Nexium.  Or Ritalin in a county jail.  But it is not impossible!  In fact, I have allowed all three of those drugs to be dispensed in my jails in unusual but appropriate circumstances!)

“Pre-Approved” instead of “Formulary”

One term that works to convey this is “Preferred Drug List.”  My state’s Medicaid program uses that term.  But I think an even better term is this:  “Pre-approved Drug List.”  That term concisely conveys all of the important information:  the drugs on the list can be prescribed without obtaining outside approval.  Obviously, cancer chemotherapy is not going to be on that list.  Neither is Nexium.  But the term also implies that there is a mechanism to obtain approval for drugs not on that list.

Next:  A step-by-step guide on how to set up a “Pre-Approved Drug List.”

Has your facility had problems setting up a formulary?  Has your facility had particular success with your formulary program?  Please comment!