Author Archives: Jeffrey Keller MD

Gabapentin in the News!

2018 has been a remarkable year for news and research into gabapentin, and the year is not even over yet! That is great news for those of us (myself included) who puzzle over the proper role of gabapentin within correctional medicine. On the one hand, if gabapentin is a useful drug for chronic pain, neuropathy, or any other medical condition, I want to use it properly. On the other hand, gabapentin is a ferociously abused drug within jails and prisons. It is both a sedating and euphoric drug that also can be hallucinogenic at high doses. When it is available within a prison, there is inevitably abuse of gabapentin (like snorting it), diversion of gabapentin (because it has large value within the correctional black market and so can be sold to others), and finally, there is inevitably coercion of weaker inmates by stronger inmates to acquire gabapentin prescriptions and give those prescriptions up to the strong.  Those of us in corrections have seen all of this and worse.

So any news of gabapentin, whether good or bad, can change the balance of this deliberation. If gabapentin is proven to be more effective medically, it may be worth tolerating the abuse. If it is found to be ineffective, there is no reason to introduce this stressor into the system.  With this in mind, here is a sample of the 2018 news on gabapentin. Continue reading

My jail Is Safer Than Your ER! from MedPage Today

This article was first published here on MedPage Today.

How safe is correctional medicine?

People naturally assume that working in a jail or prison is dangerous. “Aren’t you nervous about working there?” they ask me. What people have seen of jails on TV looks pretty rough! After all, that’s where they put the violent criminals, right? The problem is, it just isn’t so!

Jails and prisons are not dangerous places to work; to assume so is just one of many misconceptions people have about correctional facilities. In fact, my jail medical clinics have been a much safer work environment than where I worked before.

Continue reading

Sample Clinical Guideline: Medical Approval of Personal Footwear

Today’s post is the first in a series of sample clinical guidelines.  These will be placed under the “Guidelines” tab (above) as they are published.  These guidelines are open access; you may use them in whole or in part as you see fit.  I view these sample guidelines as a group effort!  If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments.

This particular clinical policy addresses a common problem in jails (less so in prisons). I addressed the issue of allowing personal shoes in jail previously in “A Quick-and-Easy Solution to those Pesky ‘Own Shoes’ Requests,” (found here).  As a result of that post, I have had many email requests for a sample “Own Shoes” guideline.

Medical Approval of Personal Footwear in Jails

This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policy on personal footwear. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.

Introduction. Inmates housed in county jails are provided footwear by security personnel. Occasionally, inmates will state that they have a medical condition that requires them to wear their own personal shoes. If an inmate asks medical personnel to authorize him to wear his own personal shoes, medical providers should re-frame the question as “does this patient have a legitimate medical need to wear his own personal shoes?” Inmates may desire to wear their own shoes for many non-medical reasons, such as convenience, as a sign of increased status among other inmates and as a way to smuggle contraband. This guideline addresses the question of when inmates have a medical need to wear their own personal shoes. Continue reading

How Did I End Up in Jail? from MedPage Today

I have begun a new blog that is being published on MedPage Today entitled “Doing Time:  Healthcare Behind Bars.” The difference between that blog and JailMedicine is the audience.  JailMedicine is written for medical professionals already working in a jail or prison (bless us all!). The MedPage Today blog is written for medical professionals who have no idea what Correctional Medicine is all about.  The first post of Doing Time follows: Continue reading

NSAIDs Essentials of Prescribing for Inflammation

In the last JailMedicine post, I discussed the use of NSAIDS for pain. Pain management is probably accounts for 90+% of NSAID prescriptions in primary care. Oftentimes, though, we delude ourselves into thinking that we are also treating inflammation. Usually we are not and that is the subject of today’s post.

To show why, we have to delve into the NSAID inflammatory effect. How NSAIDS act to affect the inflammatory response is well known (unlike their pain effect, which is still a mystery). All practitioners should know the basics of how NSAIDS work. This is essential knowledge for rational prescribing. Continue reading

NSAIDs. The Essentials of Prescribing for Pain

After many years of reviewing prescribing practices of physicians both within correctional systems and outside of the walls, here is something that I strongly believe:

Non-Steroidal Anti-inflammatory Drugs (NSAIDS) just may be THE most misunderstood and overprescribed drugs in clinical medicine. It appears to me that, in general, we practitioners overestimate the benefit NSAIDS give. We underestimate the risks NSAIDS carry. And we prescribe NSAIDS in ways that are not evidence based and not in our patients’ best interest. Continue reading

The First Principles of Verbal Jiu-Jitsu

You are seeing a newly booked patient in your jail medical clinic. He states he has been in jails before, many times, and is always given a second mattress and an extra pillow because he had surgery on his back many years ago. You note that the patient has not seen a doctor on the outside for many years, that the patient walks and moves normally and that he has a normal neurological examination. You tell the patient that medical does not give out passes for extra mattresses or pillows. The patient angrily erupts in a blaze of obscenities and threatens a lawsuit.

Manipulation happens when a patient wants something that they should not have (like an extra mattress and pillow) and will not accept “NO” for an answer. In my last JailMedicine post, I outlined the strategies patients employ in an attempt to entice or force practitioners to change a No to a Yes. This patient is employing the “threatening” strategy.

Verbal Jiu-Jitsu is the technique of deflecting and defusing manipulative confrontations. Notice that I did not use the word “defeating.” That is because the first and most important rule of Verbal Jiu-Jitsu is to remember that this is not a war or a contest! There should be no “battle of wills” between you and your patient. There is no winner or loser. Instead, you and your patient are having a conversation. The whole goal of Verbal Jiu-Jitsu is to avoid any kind of verbal battle. Continue reading

Manipulation Defined

One of the more common complaints that I hear from correctional practitioners (especially new practitioners) is “Manipulative patients are driving me crazy!” To be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. ERs are the epicenter of narcotic drug seeking! But it is true that many of our patients in Corrections are especially skilled in manipulation. They have practiced this skill their whole lives and have become very proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation “Verbal Jiu-Jitsu.” In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what “manipulation” actually is.

Manipulation in a medical encounter occurs when a patient wants something he shouldn’t have and won’t take “No” for an answer. If the patient wants something he should have-no problem! Or If the patient is told “No” and accepts that answer–also no problem!

So manipulation involves these two essential elements:

1. The patient wants something she should not have. This something could be an extra mattress, a special diet, gabapentin, an MRI, a referral off site–anything.

2. The patient does not accept “No” for the answer.

What comes after not accepting “No” for an answer is manipulation. Manipulation is the attempt to coerce the practitioner into changing a “No” into a “Yes.” Manipulation comes in many forms. Continue reading

Bad Medicine is Expensive!

In the last JailMedicine post, I introduced the subject of Utilization Management (UM) in Corrections. To some, Utilization Management has earned the reputation of being too focused on money and not enough focused on patients. But after I had been doing UM for awhile, I had an important insight that changed the way I thought about Utilization Management and (I believe) made my own efforts at UM much more effective.

That key insight is this: That which is expensive in medical practice is bad medicine. The way to control costs in medicine is to reduce or eliminate bad medical practice. Cost containment is simply a happy byproduct of this endeavor. When UM physician advisors work with primary care practitioners, the conversation should center around best medical practice, not money.

It is this simple: Good medicine is cost effective. Bad medicine is expensive. Continue reading

Controlling Health Care Costs: Utilization Management

Consider two people standing outside of a grocery store.

Person one is told: “Here is $200.00 for groceries for one month. You may buy any food you wish—but you may not spend more than this $200.00. So, make your purchases wisely. We are going to watch carefully to make sure that you do not exceed $200.00.”

The second person is told: “There is no limit on how much you spend on groceries in the next month. You may spend as much as you wish! And you may come back as often as you like. There are no limits. In fact, no one is even going to pay attention to what you buy!”

Which person do you think is more likely to walk out of the store with the most expensive cut of steak?
Which person is more likely to pay attention to prices and sales?
Which one do you think is more likely to buy food that they will never eat?

This scenario is very like the difference in health care spending within your average state prison system and the medical community at large. Continue reading