Monthly Archives: July 2013

Interesting EKG. What is Your Interpretation?

Your patient is a 29-year old male who presents to the medical clinic stating that he has been having a feeling of a racing heart off-and-on for the last couple of months.  It comes and goes, maybe two or three episodes a week.  They only last a few minutes.  He feels odd when this happens but he does not have to stop his activities.  He has noticed no pattern to these; they have happened at work (he is an inmate worker), in the middle of the night and every time in between.

His physical exam is normal including blood pressure of 124/78, regular heart rate of 68 and normal heart sounds.

What do you think is going on?  Would you order any tests?Original EKG Continue reading

Should Inmates Bring Their Own Prescriptions to the Jail?

In response to my last post, one reader wrote to tell me that the jail where she works does not accept medications brought in by inmates or their families. They consider this a security risk.  All medications are ordered and supplied by the jail.  She asks if I will comment on this. Before I do, I need to define a couple of terms that come up over and over in any discussion of newly booked inmates’ medications.

Verification

UnknownThe first term is “Verification.”  Verification refers to the process of verifying what medications an inmate is currently prescribed and is taking.  There are three ways to verify medications.  The first is to call the prescribing doctor’s office to get a list of currently prescribed medications.  The second is to call the dispensing pharmacy to get a list of all prescriptions they have recently filled for the patient.  Finally, the inmate could bring the medications they are taking into the jail with them in the original pill bottles.  On the label is everything we need to know—who prescribed the medication, when it was filled, dosages–everything.

One problem with calling the doctor’s office to verify medications is that the patient often is not taking all of the prescribed medications.  If I remember right, studies show that only around half of all prescriptions are filled.  So you will get a list of prescribed medications, but that may not be what the patient is actually taking.  Another problem with calling the doctor’s office for a current medication list is that doctor’s offices are often closed.  If a patient is booked Friday afternoon of a holiday weekend, you may not be able to get a current medication list until Tuesday.  Finally, many inmates get medications from multiple prescribers.  For example, the patient may have a family physician, but a psychiatrist prescribes their mental health medications and they also use a pain specialist.  And get prescriptions also from ERs and “Doc-in-the-Box” clinics.

Calling the pharmacy may get you more information than calling the doctor’s office.  After all, the pharmacy will only tell you about prescriptions that were filled and can also tell you when the prescription was filled.  If you do call a pharmacy to verify meds, don’t just ask for an “active medication list!”  The pharmacy considers any prescription that they would fill for the patient active, and refills are generally good for one year.  So if a patient may not have taken a certain medication for many, many months, but the pharmacy still considers it “active.”

And like doctors’ offices, pharmacies may be closed when you want to call them.  And inmates often use more than one pharmacy.  Some inmates use mail order pharmacies that are hard to get any information out of.  Or an inmate may not use a pharmacy at all—for example, their medications might be supplied by a psychosocial rehab group.  Finally, it is not uncommon for an inmate not to remember what pharmacy they use, at all!

Authorization

The second term to define is “Authorization.”  I discussed medication authorization in my last post.  Authorization refers to the process of reviewing and inmate’s (verified) medication list and deciding which of those medications will be dispensed at the jail—and which will not.

All incoming inmates taking medications should have their prescription list verified and authorized.  These two processes take quite a lot of nursing time and effort at most jails.

So now we return to the original question.  Which is better, to allow inmates to bring their outside medications into the jail with them or not to allow this and instead verify their medication list and re-prescribe the approved medications ourselves?  The answer is that there is no “right” answer.  Each system has its advantages and disadvantages.  Which you choose to use at your jail depends on several factors, such as the size of your jail, your staffing levels and the sophistication and efficiency of your pharmacy system.

With that in mind, let’s compare each system as to its relative advantages and disadvantages with regard to some of our goals in jail.20130619

Continuity of Care

We want medical care to continue seamlessly from the outside to the inside of the jail.  We want there to be no lapses in ongoing medical care for newly booked inmates.  This means that, ideally, there will be no missed doses of important medications.  This is, of course, easiest to accomplish if inmates brings their medications to the jail in the original containers.  This makes verification, authorization and dispensing to the inmate a simple process.

Contrast this with what usually happens if the inmate does not bring the meds with them.  The current medication list must be verified with phone calls to the doctor’s office and pharmacy.  Even if this goes well (no offices are closed), the medications then must be ordered from the jail’s pharmacy.  Best-case scenario:  the process takes 24 hours.  More commonly, it takes 48-72 hours and the patient has been without medications for 2-3 days.

If the inmate does not bring meds into the jail with them, the only solution for timely administration of most medications is to have an extensive collection of “stock” meds on hand, so that most medications can be continued quickly from stock.  In order to be able to fill the majority of outside medication prescriptions, there must be a lot of stock meds plus protocols for automatic “therapeutic substitution”  (mentioned here).  http://www.jailmedicine.com/the-f-word-formulary/ That is a pretty sophisticated system.

However, even then, no “stock” med collection is going to contain all of the various HIV meds, say.  Or cancer chemotherapy agents.  And these are precisely the medications that we most want to continue without missing a dose!

Clearly, from a “continuity of care” perspective, it is better to encourage inmates to bring in their own, outside medications.

Advantage:  Allowing outside prescriptions.

Information Gathering

There is no question that having the original pill bottles sometimes gives you medically important information.  As one example, consider the patient who takes combination lisinopril/HCTZ for blood pressure.  He brings in a bottle that was filled 45 days ago for a one month supply (30 pills).  There are 29 left in the bottle.  His blood pressure is 128/78.  Would you continue the prescription?  I probably would not.  I would, instead, monitor his blood pressure to see if he really needed the medication.

Or say instead, his blood pressure is 180/120.  If I know that he has not been taking his hypertension medication, I would simply restart it in the jail.  But if he had been taking it faithfully, I might consider adding or changing the prescription.

I could give many more examples of similar situation.  Knowing that the patient has (or has not) been taking their prescribed meds is often very helpful clinically.

Advantage: Allowing meds to be brought in to the jail.

Time Management

The issue here is how long it takes nursing staff to verify and approve a newly booked inmate’s medications.  If the inmate brought meds to the jail in the original pill bottles, verification consists of noting the information on the prescription label, verifying that the medications in the bottle match the label and counting them.  Authorization is easy as a phone call to the provider.  And then the medications can be immediately dispensed to the inmate.

If the inmate did not bring meds to the jail, verification will take much more time.  It consists of interviewing the inmate (Who is your doctor?  Which pharmacy do you use?), then calling the doctor’s office, the pharmacy or both (hopefully, there is only one of each!).  If there is a discrepancy between what the inmate says they take and what the pharmacy says they filled, a second interview with the inmate may be required.  Then, after the approval process, the medications must be ordered from the jail pharmacy, delivered, processed and then, finally, they can be dispensed.

Advantage:  Allow meds to be brought in.

Cost Considerations

Consider the case of the inmate who is only going to be in jail for 30 days.  He is willing to supply his own medications for the month long stay.  Among other things, he takes Abilify, which costs approximately $25.00 a pill.  If your jail will not allow him to bring in his own Abilify, then you must either supply it at a cost of many hundreds of dollars for that medication alone, or substitute something else.  Even if patients are on inexpensive medications, these med costs and fill fees add up.

In addition, if your jail charges a fee to fill prescriptions, inmates will complain, because often they get their outside medications for “free” (meaning Medicaid, most often).  I have even had inmates go so far as to call this extortion and refuse to take jail prescriptions because they do not want to pay any money for meds that they are willing to supply “for free.”

Advantage:  Allowing meds to be brought in at booking.

Medico-Legal Considerations

The main medico-legal risk in these situations is disruption of the continuity of care, in this case, patients missing doses of important medications.  If (Heaven forbid!) something bad happens after the patient has missed a dose of medication—like the patient has a heart attack or commits suicide—it will inevitably be blamed on the missed meds by the patient, his family and their attorney.  I have seen this many, many times.

Advantage:  allowing meds to be brought in.

Security Considerations

This is the one aspect of the problem where there is a decided advantage not to allow outside medications into the facility.  Anytime you allow stuff from the outside to come into the jail, there is a potential for a security breech.

One possibility is that inmates might adulterate capsules by pulling them apart, pouring out the real medication and then filling them with cocaine, heroin or whatever.  However, this is not as easy to do as it sounds.  Adulterated capsules don’t look right and, in my experience, are quickly suspected and discarded.  Besides, if you want to smuggle illicit substances into a jail, there are easier methods than trying to pour powder into tiny capsules.

A more legitimate security concern is what to do with medications that were brought in to the jail but then were rejected during the authorization phase and so never dispensed to the patient.  Non-controlled substances can be placed in the patients’ property, but things can go wrong.  For example, the meds, somehow, are not there when the inmate is discharged from the jail six months later.  Where did they go?  The inmate, of course, may demand compensation for his lost property.  Maybe there should be an investigation?

Controlled substances are even worse, especially DEA schedule 2 drugs like methadone and amphetamines.  Like all schedule 2 controlled substances, these properly should be kept under double-lock (i.e., a locked box in a locked room) and should be counted every day with two people witnessing and signing off.  That is a lot of work should the patient stay in jail for a significant amount of time.   And when the inmate is released, you have this dilemma:  should you return these addictive controlled substances to him? What if he overdoses?  What is your risk exposure?

Advantage: not allowing out-of-jail medications in the facility.

In the end, which system you eventually put into place for incoming inmate medications depends on how important the security angle is to you and how well you can create and use a stock medication system.  To some degree, this depends on jail size.  The smaller the jail, the more important continuity of outside care becomes because the small jail’s medical staff may not be there all the time.  Large jails are better able to develop sophisticated stock medication systems where most incoming prescriptions can be quickly and easily filled from stock.  But even big jails should have exceptions in place for expensive specialty medicines, like chemotherapy agents, immune-modulators and HIV meds.

Does your jail allow incoming inmates to bring their medications to booking?  Do you like the system your jail uses?  Please comment!

Reader Question: Medication Approval

My friend Al Cichon recently asked the following questions:

UnknownWhat ‘authority’ does a jail provider have to change the prescription of an inmate coming into the jail?

I have been asked when I would not approve an existing prescription – non-compliance (over / under); diagnostic mismatch (extreme example anti-viral for bacterial infection); – can you think of others? Continue reading