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?

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.

20130529This 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

ADMINISTRATIVE POLICY – Medication Approval-Disapproval

How do you review and reconcile incoming medications at your facility?  Please comment!

17 thoughts on “Reader Question: Medication Approval

  1. Mark C.

    Excellent post. I was unaware Wellbutrin had abuse potential. Same with Topamax.
    I have recently gone to Claritan for all “wool allergies” and non-specific rashes. Everyone was triaging for Benadryl for sleep.
    High demand for neurontin for reasons I don’t understand. Neurontin has no effect on musculoskeletal low back pain (and little effect on neuropathic pain, in my estimation).
    If an inmate insists their trazodone is for depression, I give it in the morning. No one seems to want it then.
    My main concern is Xanax withdrawal. When and how do you taper?
    If the inmate is taking 0.5 mg. BID “PRN”, would you taper?

    Reply
    1. Jeffrey Keller MD Post author

      Many of the drugs with abuse potential are not abused at every facility. I was amazed when I learned that Wellbutrin was a banned drug at the Maricopa County Jail in Phoenix because I had never had a problem with it. But sure enough, a couple of years later, inmates at my facilities began to abuse it (preferred way is to crush and snort to get high). Some facilities have a problem with Topamax, others not. I agree with you that its benefits never (or rarely) exceed its liabilities in a correctional setting. But Neurontin is a special problem because it is so commonly prescribed in the community.
      Benzo withdrawal, in particular Xanax, is an interesting subject. The issue is not how it is prescribed (0.5mg BID prn) but rather how often it is taken. A variation is the person who has no prescription but says they buy it on the streets. Should you withdraw them? But back to the 0.5 prn person, if the prescription was filled 3 months ago and is still half full, I could reasonably assume that the inmate had not been taking too much, so I probably would not do a withdrawal protocol. If the prescription was filled 2 weeks ago and was gone, I would assume that the person was taking more than 0.5mg BID and was at risk for withdrawal (although they could be selling it, as well). If there is any question, I do a withdrawal taper. I would rather give out too much benzos than have an untreated withdrawal disaster.
      I never use Xanax for withdrawal. I use Valium. A quick and easy way to do this is to use a benzo equivalency chart to estimate the equivalent dose of Valium to their Xanax dose, then taper like this: Cut the dose in half and give for 5 days, cut in half again for five days. You might be done then, but if the patient is on a really high initial dose, you may need to cut in half again for another five days. Then you monitor.

      Reply
      1. Doris Brown

        This has always been a confusing issue in my jail. The psychiatrist will d/c the benzo and then it is up to me to deal with the patient and the withdrawal complications that occur. The psych does not want me to use another benzo but cold turkey the inmate even though this patient may have been on prescription meds for 20 plues years. I started using Librium as a taper. What are your thoughts on this matter ?

        Thank you so much for your time
        Doris Brown, FNP

        Reply
        1. Tamara, PA-C

          NP Doris,

          We also do a Librium taper for benzo withdrawal in our facility … Probably because it is cheaper than Valium. But Librium is also a benzo… As far as mental health suggesting a cold-turkey taper .. I have not run into an issue with that where I work; they are usually happy if we detox the patients, so they will hear less complaints from the patients coming in. Maybe suggest the implications and possible seizures a person could have from benzo withdrawal to them?

          Tamara, PA-C

          Reply
  2. Pingback: Should Inmates Bring Their Own Prescriptions to the Jail? | Jail Medicine

  3. Jon, D.O.

    We generally use a Valium taper in our facility. But if a benzo is contraindicated or needs to be avoided for some reason, there is literature which supports using Tegretol as an alternative for benzodiazepine detox. I have sometimes employed this as an adjunct for difficult cases as well in an effort to minimize the dose/duration of benzo therapy.

    Reply
    1. Jeffrey Keller MD Post author

      Hi Jon! I have seen literature supporting the use of Tegretol for alcohol withdrawal, but not benzos. I personally have not had a problem using Valium in a tapering dose.

      Reply
  4. Chris Huber

    We use a Tranxene taper for benzo withdrawal. I struggle with the meds patients are prescribed on the outside. Our policy is we don’t treat sleep or anxiety with medications. I am fine with this. I set inmates up with the mental health practitioner for these issues. It’s not that I don’t have compassion, as I have had issues with anxiety. I learned to meditate, do yoga, breathing exercises, relaxation techniques. The NP from the contracted mental health agency continues to recommend certain meds, even though we have told her we don’t use them in jail. Gabapentin for anxiety, Vistaril for anxiety, trazadone for sleep. I just have to believe there is something better than Gabapentin for mood disorders. We use vistaril with alcohol withdrawal, but not for ongoing anxiety. I feel like I , as the nurse, am put in the middle of our company medical director, our PA, and the NP.

    Reply
  5. Donna

    How does one obtain a list of approved medications to be dispensed while in the Jail. This Jail has a contract agency for health care.

    Reply
  6. Miller

    Do you by chance have a list of commonly diverted medications within Corrections?
    I have also heard prisoners can make buck or alcohol with antibiotics is this true?

    Reply
    1. Jeffrey Keller MD Post author

      I have plans to develop a list of commonly abused/diverted medications. it will be coming sometime soon. I have never heard about using antibiotics in the creation of inmate illicit alcohol. All you need as water, a source of yeast (bread) sugar (fruit or sugar packets) and time. But nothing surprises me anymore!

      Reply
  7. Miller

    Also does anyone have readily available medication of high risk for diverting and does anyone know of an established protocol for noncompliance documentation and non motivation for medication management federal system…

    Reply
    1. Jeffrey Keller MD Post author

      I assume you mean monitoring for over diagnosis and overprescribing of desirable psych meds? I don’t have such a policy. Pharmacists can be very helpful in this regard–monitoring for overprescribing and prescribing outside of acceptable parameters. Do you have access to a friendly pharmacists?

      Reply
  8. KPS ohio

    Hello,

    I’m new to your blog and am enjoying reading your posts, as I do not work in correction medicine. Regarding your general policies in regards to stimulants, how do you manage conditions such as narcolepsy or idiopathic hypersomnia (but not including fibromyagia, CFS, depression, mood disorders, etc)? Do you continue amphetamine or Ritalin or try newer meds such as Provigil or Nuvigil if they have objective documentation from MSLT and clean UDS? Thanks!

    Reply
  9. cfrazier

    At our facility, one of the most abused drugs in Neurontin. I am the trying to formulate when this medication will be continued. My question is if the following is acceptable in your opnion:

    Neurontin will not be given for any indication not approved by the FDA. The only indications approved by the FDA is for epilepsy and PHN after shingles. Now the question remains how can you tell what the indication of prescribing the Neurontin was? The therapeutic dose for the treatment of epilepsy is 900 to 1800mg a day divided into three times a day not to exceed 3600 mg per day. If you come to our facility on 300mg at night, this clearly indicates that the drug was not given for the two recommended doses so therefore, it can be assumed it was given for insomnia- which we do not treat at our facility. The Neurontin would be canceled and we would observe for signs and symptoms of withdrawal for the next 5 days.

    Does this sound reasonable and do you know of a substitution for the treatment of diabetic neuropathy that is less abused in the jail setting?

    Reply

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