Category Archives: Drug Evaluations

Constipation Plus Sample Guideline

Today’s post is a repost of an article I wrote previously about Constipation. Concurrent with this article, I have added a Sample Guideline on Constipation to the Guideline Section of JailMedicine (found here).

I have decided after many years of dealing with complaints of constipation both in the ER and in correctional facilities that bowel health is the last taboo subject.  We all received “The Talk” (about sex and reproductive health) when we were adolescents.  But nobody seems to talk about how to have a proper bowel movement.  It is a subject that inevitably causes giggling and uncomfortable laughter.  It is not spoken of in polite society.  As a result, many people do not understand how their bowels work.  I have found this to be a big problem in the jails I work in.  Inmates complain of constipation when they are not really constipated.  They are bowel-fixated when there is no reason for them to be.  Often, they need education more than they need laxatives. To this end, I want to discuss several essential factors relating to understanding and treating constipation that may help make your correctional medicine practice a little easier.

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Skeletal Muscle Relaxant Guideline

Today’s post is a repost of an article I wrote previously about Skeletal Muscle Relaxants (SMRs). Concurrent with this article, I have added a Sample Guideline on prescribing Skeletal Muscle Relaxants to the Guideline Section of JailMedicine.

Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”

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Transforming Our Approach to Chronic Pain

One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic.  A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years.  Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective.  He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids.  In addition, Ralph has alcohol abuse issues.  The reason he is in jail is a felony DUI charge.  Now he is in my medical clinic, looking expectantly at me.  How am I going to fix his pain problem? 

The answer, of course, is that I am not.  I am not that smart.  He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem.  I’m not going to be able to, either.  In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain. 

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My Thoughts on MAT in Jails

I recently ran across this news article on NPR (found here) about the problem of treating the large number of opioid addicted patients who are coming to our jails. There is a growing movement that all opioid addicted patients should be offered Medication-Assisted Treatment (MAT) while in jail–meaning one or more of three drugs: methadone, Suboxone or Vivitrol. The article does a good job in pointing out that this is a complicated problem. Having been on the front lines of this problem for many years in my own jails (and so having that great teacher–experience), I would like today to present my own thoughts on using MAT in jails. (MAT in prisons is a separate subject that I will address later).

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Reader Question: How does a KOP Policy Work?

Hi Dr Keller,

I work in the prison system in the UK. I wanted to ask you if the prisoners have in-possession medication in America or is it all supervised? 
If you do have in-possession medication, have you seen or thought of a way for the inmates to keep the medication safe i.e. lock box in their room (this then highlights a security issues as can store contraband etc. in  lock boxes? Is there a feasible and reasonable way that inmates who want to keep their tradable medication to them self and not fear being bullied by peers for them? 
Any ideas would be greatly appreciated!

After doing research in my current jail. The percentage of people who actually pass random meds check is currently 18%. Now obviously not all those that failed had them “pinched” from their possession and most certainly commonly abused meds such as trazadone and mirtazapine have been sold as “sleepers” on the wings. But for those people who genuinely get bullied for their medication or do in fact get them stolen what is the alternative measure to help them apart from to put them not in-possession and supervise them daily? 

If you have any ideas I would greatly appreciate it.

Dez

Thanks for the questions Dez! In the United States, most medications are passed in a supervised setting. “In-possession” medications are referred to as “KOP,” which stands for “Keep on Person.”  I’m going to use this term despite the fact that not all KOP meds are kept on person. Different facilities handle KOP medications in different ways, which I’ll get into. Here are the basics of KOP medications:

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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

Price Check! Are analogue insulins worth their hefty price?

The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).

Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.

But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen) Continue reading

Effective Treatment of Heroin Withdrawal in Corrections

Imagine this: You’re practicing medicine and a patient comes to you with an illness. You make the diagnosis and then say to the patient, “I can see that you are very sick. And there is a highly effective treatment for your condition that would make you feel a lot better. It’s simple and it isn’t even expensive. But, you know what? I’m not going to give it to you! You’re not sick enough. Come back tomorrow. If you’re sicker tomorrow—well, if you’re sick enough—I will treat you then. But not right now.”

Crazy, right? We’d never do such a thing.

But . . . the problem is, we frequently do that exact thing with our heroin withdrawal patients. I’m not singling out correctional medicine practitioners here. I think that, in general, heroin withdrawal is treated better in correctional settings than it is in the community. Nevertheless, it is a fact that heroin withdrawal is often not properly treated in jails and prisons. I have seen it.

I believe that there are four main reasons that some facilities do not appropriately treat heroin (and other opioid) withdrawal. Continue reading

Medications at High Risk for Diversion and Abuse In Correctional Facilities

The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings.

Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, followed by Schedule II, and so on, all the way down to Schedule V, which are thought to have the least risk.

However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons.

The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch.

It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution–if we make them available. Continue reading

Correctional Medicine: The Principle of Fairness

I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.

But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!

This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness.Unknown-1 Continue reading