Category Archives: Drugs of Abuse

Reader Question: Xanax Withdrawal

I am looking for a withdrawal protocol for benzos. I have patients that have been on Xanax 2mg for 3-5 years and now I need to detox them. We all know how difficult this is with people in the community let alone in the correctional setting. PLEASE HELP !!!!
Thank You, Doris

Well, Doris, you have come to the right place! I, and many other JailMedicine readers, are happy to share our strategies for dealing with benzodiazepine withdrawal. And this is a common dilemma in county jails. Believe it or not, Xanax is the single most-prescribed psychiatric drug in the United States. My experience is that Xanax is highly addictive and yet handed out like candy by some community practitioners. Some community prescribers I have talked to do not even realize that Xanax is addictive!  Strange but true.GABA-Production Continue reading

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

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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Essential Pearls from Essentials

Essentials of Correctional Medicine was held last week in Salt Lake City, Utah and included some great talks.  Today’s post is a list of Pearls I gleaned from the conference speakers.

The definition of a “Pearl” is a bit of pithy and insightful information that can be communicated in one or two sentences. Hopefully, it is also something that you have not thought of yet and will change your practice for the better.

I ran into several Pearls at the Essentials conference. Here is a sampling (in no particular order): Continue reading

What’s That Skin Lesion? Plus updates.

Before we get to the cool skin lesion quiz, first a couple of updates!

Get your flu shot!

Robin, at the Ada County Jail in Boise, should get her flu shot!

Influenza shots are here.  Be sure to get yours.  I didn’t get my flu shot last year and subsequently came down with true influenza–NOT a fun experience.  I wrote about that experience here: Should the Flu Vaccine Be Mandatory?  Influenza is way worse than the shot. Continue reading

Methadone? In a Jail?

The question was raised recently about how to handle inmates who prior to jail,  were enrolled in a methadone or Suboxone program to treat narcotic addiction.  Should they continue the methadone or Suboxone in jail?  Or should they instead be enrolled in the jail opioid detoxification program (we use clonodine at my jails) and withdrawn? Continue reading

Interesting Study of the Week and Updates

Janelle, Excellent Ada County Jail nurse!

Set your TiVos!

For those interested in the Bath Salts phenomenon that I wrote about in “Bath Salts,” A Review and Bath Salts Update, CNBC is airing an hour-long program tonight about the “Bath Salts” and “Incense” phenomenon entitled Crime Inc.: A Deadly High.  The program promises to explore in detail this marketing phenomenon, as well as the designer drug analogue issue, in which chemists make minor changes to the chemical structure of an illicit chemical, thus making it legal.  Who knew that bath salts and incense generate an estimated  $5 billion per year!

Crime Inc.: A Deadly High airs tonight, August 2nd, at 8:00, 9:00 and midnight on CNBC.

Interesting Study of the Week

Moyer VA, for the U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2012;156:880-891.

This U.S. Preventative Services Task Force guideline replaces the one issued in 2003 and contains several important changes that will impact correctional facilities.

1.  Less than age 21.  No PAP smears before age 21.   No HPV (Human Papilloma Virus) screening.  Period.

2.  Age 21-30.  PAP smears every 3 years.  No HPV testing.

3.  Age 30-65.  PAP smears every 5 years.  HPV testing begins and is also done every five years.

4.  Age older than 65.  No PAP smears.

Implementing these official government guidelines will result in big changes in my facilities.  One of the facilities that I am the Medical Director for is the Idaho Juvenile Correctional Facility, which we call JCC and is the state juvenile prison.  Heretofore, we have done HPV testing and PAP smears on all of the girls entering the JCC.  According to these new guidelines, we should stop.  I need to discuss the matter with the medical administrator there (I’ll be calling, Mardi)!

The adult women in the state prison have been getting PAP smears as often as yearly and have come to expect them.  According to the new guidelines, we would only do them every 3 years from ages 21-30 and every five years thereafter until age 65.

On a personal note, a relative of mine (who prefers to not be identified) continues to dutifully report to her gynecologist for her annual “exam,” (including a PAP smear) even though she is well into her 80s.

The U.S. Preventative Services Task Force did not comment on the potential economic impact of this guideline, but it seems that it has the potential to save a lot of money in correctional facilities.  How much did your institution spend on PAP smears and HPV testing last year?  If you adopt these new guidelines, cut that in half.  At least.

Have you already implemented these guidelines at your facility?  How has it worked out?

Have you considered these new guidelines but have not implemented them?  Why not?

Please comment!

Essentials of Correctional Medicine is approved for CME credit!

Essentials of Correctional Medicine has been approved for 19.5 hours of Continuing Medical Education Credit by the American Academy of Family Physicians.  This conference should be a great learning experience as well as a good way to get Correctional Medicine specific CMEs!

 

“Bath Salts,” A Review.

It used to be that “Bath Salts” were, well, salts that you would use in a bath.  Not anymore!  Nowadays, “Bath Salts” refers to a designer drug of abuse that is marketed like traditional bath salts to give legitimacy to the transaction.  They are also marketed as computer screen cleaners, jewelry cleaners and bug spray.  They are, of course, not intended to be used for any of these purposes; they contain synthetic designer drugs used to get high. Continue reading