All medications have side effects and potential complications. Of course we all know this. Whether to prescribe and what to prescribe should involve a careful weighing of the expected benefits vs. the potential harm for each individual patient.  This math—risks vs. benefits—can change for many reasons.  For example, drug X may be great for most people but this patient has kidney disease and should not take drug X.  This patient does well on drug Y but that patient has no health insurance and cannot afford drug Y.

Being incarcerated changes the risk-benefit equation for many drugs.  This is especially true for drugs that are addictive or have the potential to be abused.  Some medications may be inappropriately used by inmates to continue or maintain their drug addiction while incarcerated. Such medications have value in the jail system and are commonly shared and sold.  Individuals taking these medications may be at risk from other inmates, who may coerce patients to “cheek” and share.  This additional extraordinary risk must be considered when prescribing medications in a correctional setting and for many drugs, the risks always (or almost always) outweigh any benefit a patient may derive from them.

Here, I begin by presenting three drugs (and alluding to others) which, in my opinion, should not be allowed in correctional settings.  This is an opinion piece.  Feel free to disagree!  For each medication, I will summarize the potential benefits of the medications, the potential for harm and the availability of substitute medications that do not carry this risk.  While all of these medications are commonly prescribed on the outside, in a jail or prison setting, their risks far outweigh any potential benefit patients may derive from them.

1.  Dextromethorphan (DM).  Dextromethorphan is a common ingredient in over-the-counter cough medications.   OTC cough medications, including DM, probably do not work well.  Multiple studies have failed to find any meaningful difference between DM and placebo in the treatment of cough. If there is a benefit, it is slight. On the other hand, DM has a significant abuse potential.  When taken in high enough doses (which are only 5-10 times the normal dose), DM blocks the excitatory brain receptor NMDA (N-methyl-D-aspartate) producing a “high” similar to that of PCP.  It is commonly abused on the outside.  6.9% of high school seniors reported ingesting DM to get high in a recent survey.  Are there substitutes?  Yes, there are other cough medications; though no OTC cough suppressant has ever been shown to be very effective, including antihistamines, decongestants, and guaifenesin.  The evidence based guidelines issued by the American Academy of Chest Physicians recommend NSAIDS for coughs due to viral URI and albuterol inhalers for wheezy coughs due to bronchitis.  No treatment is absolutely necessary in most cases.  If you feel like you must have a cough medicine available, I would recommend putting something  like menthol cough drops on the commissary.  It doesn’t work either but at least it is cheap and benign.
2. Tramadol.  Tramadol is a particularly ineffective pain reliever. Many studies have shown it to work no better than placebo and much worse than other narcotics.  It simply does not work well.  And although there seems to be a widely held misconception that Tramadol is not addictive and has few side effects, in fact, it has a fairly high adverse effect profile (nausea, drowsiness, etc) and is dangerous in overdose (seizures, serotonin syndrome).  And as any of us who have practiced in correctional medicine know, Tramadol, is, in fact, quite addictive.  In my experience, Tramadol addicts go through a particularly painful withdrawal process.  The bottom line is that Tramadol is less effective and just as addictive as is hydrocodone.  The misconception that Tramadol is not a narcotic and is not addictive is dangerous.  When narcotic treatment for acute pain is indicated, hydrocodone is a superior drug all the way around.  By the way, codeine also is inferior to hydrocodone as a pain reliever and has a worse side effect profile, so I personally would not ever use codeine in correctional settings either.
3. Pseudoephedrine and ephedrine.  These decongestants are able to dry up runny noses to a degree.  However, they are the precursor drugs to methamphetamine production and inmates know this.  They also can cause a high when large amounts are ingested.  Alternatives include antihistamines, which probably dry mucous membranes even better than decongestants.  I prefer topical therapy like nasal sprays or, if I truly think an oral agent is needed, I would use the second generation antihistamines like loratadine (Claritin).  Since nasal sprays and loratadine are OTC, I recommend putting them on the commissary.

I have only begun my discussion of inappropriate drugs with these three medications.   There are several other drugs I will discuss in future issues due to their high “value” in the jail and prison economies and the ready availability of less risky alternatives.  The risk-benefit math may not be quite as lopsided as with the three drugs here, but many other drugs can cause big problems in correctional facilities as well and this fact must be taken into consideration when prescribing them.

What medications have caused problems in your facility?

What would you nominate to be on this list?

Are there any drugs that are officially or unofficially banned at your facility right now due to abuse?

Sources:

1.    Systemic review of randomized controlled trials of over the counter cough medicines for acute cough in adults. Schroeder, K et al, Br Med J 324:1, February 9, 2002.

2.   Cough and the common cold: ACCP evidence based clinical practice guidelines. Pratter MR, Chest. 129(1 Suppl):72S74S, Jan 2006.

3.   Dextromethorphan abuse. Prescriber’s Letter 2007;23(2):230208.

4.   Tramadol:  Does it have a role in emergency medicine? Close MR. Emerg Med Australia 17:73, 2005.