My friend Al Cichon recently asked the following questions:
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?
My thoughts – The inmate is a new patient to me and it is my professional obligation to review the medications (prescriptions) de novo. I am obliged to ensure that there is a diagnosis consistent with the medication / prescription and proceed from that point.
And should it matter – with those situations – that I’m a PA not a Physician?
Your feelings on prescribing controlled medication to known substance abuser in jail charged with substance misuse crime?
Good questions Al! To answer the first question, what authority does a jail practitioner have to discontinue or disallow a medication that has been lawfully prescribed before coming to jail? The answer to that question is that jail practitioners have this authority because it is the community standard. It is analogous to a patient being admitted to a hospital.
Consider the case of a regular “guy on the streets” (i.e, not in jail), who takes several medications prescribed by his family practitioner doctor. This guy then winds up being admitted to the hospital under the care of a hospitalist. The hospitalist is under no obligation to continue unchanged the medications prescribed by the outside family doctor. The hospitalist will look over the outside meds and decide, based on the new circumstances that led to the patient’s admission, what to continue and what to change. She might continue the patient’s previous medications, or she might not. In the end, it is this hospitalist who is ultimately responsible for the patient while in the hospital, not the outside family doctor. She must use her professional judgment based at least partly on the conditions that led to his admission to the facility.
This process of medical “reconciliation” of outside prescriptions is the community standard for admissions to all kinds of institutions, including hospitals, nursing homes, psych inpatient units . . . and jails. So you are well within your authority as medical provider to the jail to do these evaluations. In fact, not only are you authorized, it is your obligation and responsibility to evaluate the prescriptions of incoming inmates.
I also don’t think it matters whether the jail practitioner reviewing the medications is a PA, a NP or a physician. The important principle is responsibility. If you are responsible for the patient’s medical care while he is in the jail, you have the authority to make adjustments to incoming medications according to your professional judgment.
There are too many variations of incoming medications to consider every single instance in which I might refuse an incoming medication, but here are some examples:
- Past Due medications. An obvious example is the guy who brings to the jail a prescription filled in 2010. Another would be antibiotics prescribed a month ago that should have been all taken within ten days. It gets a little trickier if the patient is only a little off—for example, hypertension medication filled three months ago for a 30 day supply. Such a prescription would still be considered an “active prescription” by the pharmacy because they will honor refills for one full year. I may or may not approve this prescription depending on what the medication is. If it is a medication that I think the patient should have been taking all along, such as meds for heart disease, diabetes or schizophrenia, I would probably approve it. Out-of-date fish oil capsules—not so much.
- Medications that cannot be verified as truly having been prescribed to the patient. For example, inmates will come to the jail with many different kinds of pills jumbled up together in one pill bottle—or a garbage sack! Sometimes, they arrive with medications in a bottle that is labeled with someone else’s name. This category also includes sample medications, unless the sample medications have been appropriately labeled.
- Redundant medications. Let’s say an inmate brings in ibuprofen from one doctor, naproxen from a second and meloxicam from a third. They are all, of course, NSAIDS. They all do the same thing. There is no benefit from taking more than one so I will not approve more than one.
- Drugs with major drug interactions. I have written about this problem in more detail here. If a patient brings in two drugs with a major potential drug interaction, I may not approve them both. The most common example I run into is the SSRI/Trazodone or SSRI/Tricyclics. Almost always, the second medication is being used as a sleeper.
- Drugs with abuse potential. These drugs have the potential to disrupt the safety and security of the facility. This category includes obvious drugs such as amphetamines, but also drugs that I had no idea could be abused until I got into corrections—such as bupropion and gabapentin. Sleeping aids fall into this category, both because almost all of them are on the Drug Enforcement Agency’s Schedule of Controlled Drugs and also because they have high abuse potential.
It makes a difference with all of these drugs how long the person is going to be in jail. I commonly approve outside medications for a person serving two days in jail on a weekend that I would not approve if the person is going to be in jail for months.
It is clear that medication approval is an art rather than a science. I have been unable to come up with hard-and-fast rules as to what is allowed and what isn’t. Each case in a jail is unique. It depends on what the medication is, how compliant the patient has been taking the medication, how high the abuse potential for the medication is in a jail setting, what other medications the patient is taking, and how long the patient will be in jail.
The case of the known substance abuser charged with a substance abuse crime is a case in point. On the one hand, I do not want to be an “enabler” of a substance abuser. But on the other hand, these inmates are innocent until proven guilty. In the end, we try to do what is best for the patient medically. In many cases, this means stopping the drug and treating the patient for withdrawal. In other cases, as I have written about before (here), it makes more sense to continue the narcotic or benzodiazepine in some form (albeit perhaps in reduced dosages!) if the patient will only be in jail for a short time.
If you have not yet written an administrative policy about the medication approval process, here is one well written template provided by Al Cichon that you may download and modify for use at your facility.