At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin. One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding. He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it--forever. The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago. The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).
Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections. These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics). Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives.
The problem is that prescribing gabapentin for musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.
Penicillin is miraculous. It was discovered in 1928 by Alexander Fleming (founding the modern era of antibiotic medicine) and is still the most common antibiotic prescribed in my jails. The dentist and I use Penicillin VK as our preferred initial agent for dental infections. I prescribe PCN VK, as well, for strep throats. I use amoxicillin occasionally for sinus infections and UTIs and even amoxicillin/clavulanate (Augmentin) occasionally.
Because penicillin is so useful (and inexpensive), I hate to hear the words “I’m allergic to penicillin.” If a patient with a dental infection can’t take penicillin, for example, the dentist commonly prescribes clindamycin, which is expensive, a pain to administer three times a day and has potentially bad side effects. I have seen more than one patient who developed C. difficile after getting a broad-spectrum antibiotic because of a reported penicillin allergy--probably unnecessarily!
This problem is pretty common since about 10% of the adult population will report a penicillin allergy. However, research has shown that, when tested, more than 90-95% of patients who state that they have a penicillin allergy really do not. These patients can be harmed by giving them an inferior antibiotic more likely to cause them harm than plain old penicillin.
The test most commonly used to gauge true allergic status is Penicillin Skin Testing (PST). No jail or prison that I know of does skin prick tests. We also don’t refer patients reporting penicillin allergy to an allergist for testing. We just groan and prescribe an inferior antibiotic.
However, this could potentially change based on research published this year on the safety and efficacy of “Direct Challenge” penicillin allergy testing. Direct challenge means giving a low-risk (this is important) patient an oral dose of whatever penicillin you want to prescribe and observing them for an hour for an allergic reaction. This has been done in studies and has been reported to be safe and effective.
Through many years of experience in correctional medicine, I occasionally have come up with a speech or dialogue that works especially well with patients; a speech which I then use over and over again. One of these speeches is one I use to get patients to take fewer NSAIDs.
The State Board of Medicine in my home state recently sent out a bulletin about the practice of "friendly prescribing" to people who the practitioner has not examined. For example, a friend might call me and say something like “I have a sore throat. Will you call me in a prescription for antibiotics?” I’m sure that almost everyone who has practiced medicine has received such phone calls! The Board of Medicine was concerned about this. They went so far as to to condemn as unethical the practice of issuing such prescriptions without ever examining the patient or documenting the encounter.
In my opinion, this applies to correctional physicians prescribing to new inmates they have never seen, as well.
When arresting officers arrive with their charges at a certain large urban jail, the first person they see when they come through the doors is a nurse. The nurse quickly evaluates the arrested person to determine whether a medical clearance is needed before the person can be booked. If a clearance is needed, the arresting officer has to transport the prisoner to a local ER and then return with the medical clearance in hand.
One evening (so the story goes), an arresting officer arrives at the jail bodily dragging a prisoner through the pre-book door by the backseat of his pants and coat. "This guy's an a**hole," the officer says. "He won't do anything I ask. He just ignores me." He then dumps the prisoner on the floor. The nurse kneels down by the prisoner briefly, looks up and says, "That's because he's dead!"
Medical clearances are a hugely important and often neglected part of the jail medical process.