I have found that many correctional practitioners, especially in jails, do not understand the license requirements of the federal Drug Enforcement Agency (DEA) and, as a result, do not have all of the DEA licenses that they are legally obligated to obtain.
Take, for example, a correctional
physician that we will call Dr. K who is employed full time a a large urban
jail and has had a DEA license for that jail for many years. On the side, she also provides medical
services to three other smaller jails, where she does clinics once a week. The
question is whether her one DEA license covers her activities at the other
jails. Dr. K has always thought that she
only needs one DEA license—just like she only needs one Driver’s License—and it
will cover all of her activities.
But the real answer is, “No,” Dr. K is
not in compliance with DEA regulations.
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.
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.”
The recent suicide of Jeffrey Epstein while in custody at a Manhattan
detention facility has focused intense media scrutiny into jail suicide
prevention procedures. Suicide is the biggest cause of death in jails in the
United States—by far. Because of this,
all jails (including the facility where Mr. Epstein was housed) have a suicide
prevention policy. Since the suicide prevention process was an
epic failure at the facility where Mr. Epstein was housed, it might be useful
to discuss how a jail suicide prevention program is supposed to work.
Perhaps the strangest aspect of practicing medicine in a jail or prison is “comfort requests.” This is when an inmate comes to the medical practitioner asking for something like a second mattress, the right to wear their own shoes, a second pillow, a second blanket, etc. This, of course, never happens in an outside medical practice. When was the last time you heard of a patient asking for a prescription for a pillow? Yet such requests are extremely common in correctional medicine. You might think, “Well, just give them the second pillow—what harm can it cause?” But it is not that simple. Like every medical issue, there is a right way and a wrong way to handle these requests. To understand why, let’s consider the single most commonly requested comfort item in a correctional medical clinic: a second mattress.
I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!” . . . Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR
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.
One thing I look forward to each day is looking through my
medical feeds that keep me up to date with medical research. Most of this content ranges from bogus to
unhelpful (in my opinion), but every once in a while, a truly game-changing
article appears. Over the years, I have
noticed that most of the game changing articles are debunking articles. They show that something that is commonly
done in medicine actually has no value.
I love these! Not only do they
improve the medical care of my patients, they also make me more
cost-effective. As I have said before,
the main way to save money in Correctional Medicine is to eliminate (and stop
paying for) medical practices that have no value—or even worse, are harmful to
My last post about MAT in jails generated a lot of excellent responses–so many, in fact, that I realized that my discussion of MAT in jails was incomplete. I would like to enlarge the discussion about the proper role of MAT in jails by responding to these comments. Before I do, I want to make sure that we are all looking at the issue from the same perspective. Please consider how MAT should be used in three different 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).