Recent Entries

Price Check! Are analogue insulins worth their hefty price?

2017-09-14 15:44:45 jeffk2996
The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir). Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them. But here is the problem: the analogue insulins have become insanely expensive! When they were first introduced, the price of Humalog and Lantus was around $20.00 per vial of 100 units. That compared to the price of human insulins like Humulin R and NPH of around $5.00 per vial. So the analogues were expensive, but doable. However, since around 2006, analogue insulins have dramatically increased in price—whereas the price for most other diabetic therapies has actually decreased over time. (You can read more about this price increase here)(In the graph above, notice the huge increase in insulin prices since 2006, while every other diabetic therapy price has actually fallen)
Posted in: DiabetesDrug EvaluationsMedical PracticePractice ManagementStudiesUncategorizedTagged in: correctional medicinediabetesevidence based medicineinmatesInsulinjail medicinejailspharmacy practiceprisons Read more... 3 comments

Inmates cannot go out to find good doctors in the community. Good doctors have to choose to go to them!

2017-08-07 11:00:18 jeffk2996
I remember the first time someone told me that I was “wasting my talents” by working in a jail. At that time, I had no ready witty rebuttal. I love my job and I especially appreciate working with a patient population that is disadvantaged and underserved. Of course, the idea that incarcerated inmates are worthy recipients of medical care is, well--controversial. Inmates are not as politically correct as other medically disadvantaged populations. As an example, if you were to tell your family and friends that you were going to work with at a medical clinic for the homeless in an inner city, or to provide medical care in a needy third world country, the reaction probably would be something along the lines of “Good for you! I admire your selflessness and dedication!” Yet when you tell these same people instead that you are going to work in a prison, you are much more likely to get this reaction: “What’re ya, nuts? Why would you waste your talents working with them?” I personally have heard the “you’re wasting your talents” line more than once.
Posted in: Inmate issuesJail culturePractice ManagementUncategorizedTagged in: correctional medicinedisadvantagedinmatesjail medicinejailsprisonsunderserved Read more... 7 comments

Treating Heroin Withdrawal: Methadone, Suboxone and . . . Tramadol?

2017-07-16 09:52:47 jeffk2996
In my last JailMedicine post, I wrote that clonidine is an excellent drug for the treatment of opioid withdrawal. In response, several people have asked about methadone and Suboxone. Why not use one of those drugs instead of clonidine? The short answer is that both methadone and Suboxone are excellent drugs for the treatment of withdrawal. However, both are much more complicated to use in jails due to DEA legal requirements and a much larger potential for diversion and abuse. If you are using Suboxone or methadone, great! I believe that clonidine is a better choice for most jails. Those interested in using methadone or Suboxone need to be fully aware of the DEA laws surrounding their use. Before you use one of these drugs, you must make sure that you are following the law. I know of two physicians in my hometown who were disciplined by the DEA for prescribing narcotics to treat addiction without registering. The DEA are not kidders! By the way, Jail practitioners should also be aware that Tramadol has been used successfully to treat withdrawal, as well.
Posted in: Drugs of AbuseMedical PracticeUncategorizedWithdrawalWithdrawal SyndromesTagged in: correctional medicineevidence based medicineheroinjailsprisonswithdrawal Read more... 11 comments

Effective Treatment of Heroin Withdrawal in Corrections

2017-05-26 15:25:13 jeffk2996
Imagine this: You’re practicing medicine and a patient comes to you with an illness. You make the diagnosis and then say to the patient, “I can see that you are very sick. And there is a highly effective treatment for your condition that would make you feel a lot better. It’s simple and it isn’t even expensive. But, you know what? I’m not going to give it to you! You’re not sick enough. Come back tomorrow. If you’re sicker tomorrow—well, if you’re sick enough—I will treat you then. But not right now.” Crazy, right? We’d never do such a thing. But . . . the problem is, we frequently do that exact thing with our heroin withdrawal patients. I’m not singling out correctional medicine practitioners here. I think that, in general, heroin withdrawal is treated better in correctional settings than it is in the community. Nevertheless, it is a fact that heroin withdrawal is often not properly treated in jails and prisons. I have seen it. I believe that there are four main reasons that some facilities do not appropriately treat heroin (and other opioid) withdrawal.
Posted in: Drug EvaluationsDrugs of AbuseUncategorizedWithdrawalWithdrawal SyndromesTagged in: correctional medicineevidence based medicineheroin withdrawalinmatesjail medicinepharmacy practiceprisons Read more... 18 comments

Medications at High Risk for Diversion and Abuse In Correctional Facilities

2017-04-14 16:13:21 jeffk2996
The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings. Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, followed by Schedule II, and so on, all the way down to Schedule V, which are thought to have the least risk. However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons. The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch. It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution--if we make them available.
Posted in: Drug EvaluationsDrugs of AbuseInmate issuesJail culturePharmacyUncategorizedTagged in: AbuseAntidepressantcorrectional medicinedrugsevidence based medicineinmatesjail medicinepharmacy practiceprisons Read more... 24 comments

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