What is the most common mistake made when treating withdrawal in a correctional facility?
Consider these two patients:
- A jail patient booked yesterday is referred to medical because of a history of drinking. He has a mild hand tremor and “the look” of a heavy drinker. But he says he feels fine and has no complaints. His blood pressure is 158/96 and his heart rate is 94.
- A newly booked jail patient says that she is going to go through heroin withdrawal. She is nauseated but still eating and has no gooseflesh or rhinorrhea. Her heart rate mildly elevated.
In many jails, neither of these patients would be started on treatment for withdrawal at their first visit to medical. But this would be a mistake! Both patients should be started on treatment for withdrawal immediately.
The most common mistake made when treating withdrawal in a jail is not to treat the withdrawal at all!
Both of these patients have the potential to slide downhill rapidly. And in both cases, the potential benefits of starting treatment far, far outweigh any potential liability.
Let’s look at these cases in more detail.
It’s September, which is National Suicide Prevention Awareness Month. Let’s start with awareness. According to the Centers for Disease Control, rates of death by suicide have increased in this country by 35% from 1999 to 2018. More specifically, the rate has increased by 2% every year from 2006 to 2018. The overall rate of death by suicide in 2018 was 14.2 people per 100,000. For men, the rate is higher than the rate for women, with a suicide rate of 22.8 per 100,000 for men and 6.2 per 100,000 for women. The rate for women, however, increased by 55% between 1999 and 2018.
According to the most recent data released by the Bureau of Justice Statistics, the rate of death by suicide in state prisons was 21 per 100,000 up from 14 per 100,000 in 2001. In federal prisons the rate in 2016 was 12 per 100, 000 down from 13 per 100,000 in 2001. In local jails, the rate of death by suicide in 2016 was 46 per 100,000 down from 48 per 100,000 in 2000.
These rates tell us despite our efforts in training, education and suicide prevention within our jails and prisons, people are still choosing to take their own lives.
Suicide is the intentional ending of one’s own life. Think about that. Just sit and think about the fact that thousands of individual human beings, every year, decide that the life they have should end. Many of these individuals experienced emotional and cognitive distress beyond what they believed they could handle and saw death as the best possible choice in the moment. They likely felt alone, isolated, trapped and hopeless. Like there was nowhere to turn. We can change that.
The National Commission on Correctional Health Care (NCCHC) recently established the NCCHC Correctional Health Foundation. The mission of the Foundation is to champion the correctional health care field and serve the public by supporting research, professional education, scholarships, and patient reentry into the community. I am honored and proud to be part of the first Board of Directors of the Foundation.
Just this week, the Foundation announced that scholarships are available for the NCCHC Virtual National Conference in November. Deadline for applications is September 30, 2020. Students, staff new to corrections and individuals who have never attended an NCCHC conference are strongly encouraged to apply, but all are welcome.
Find out more about the Foundation and the scholarship by visiting: www.NCCHC.org/Foundation
It was a holiday weekend in the middle of the night. The booking area of the jail was a big, open, noisy pit with people sitting in plastic chairs, watching TV or on phones and the officers either behind desks or circling the perimeter. It was filling up. A staff member was completing initial mental health screenings in a corner of the open room, up on a platform and behind a computer. She had the electronic health record open to the mental health screening form and she was going through each “yes/no” question, reading from the computer screen and not looking at the recently arrested individual, a young man picked up on a possession charge.
“Are you currently taking any medications for mental health problems?” “No.”
“Have you ever been hospitalized for mental health reasons?” “No.”
“Are you currently thinking about hurting or killing yourself?” Pause. Swallow. “No.”
“Have you ever been treated for withdrawal from drugs or alcohol?” “No.”
She missed it. She missed the pause; she missed the swallow.
I learned about Bounce-Backs back in my Emergency Medicine days. A bounce-back is a patient who you saw in the ER and discharged but then returned within 48 hours with the same complaint. A lot of time is spent in emergency medicine education talking about how to handle bounce-backs. The basic message is “Beware! You may have missed an important diagnosis the first time!”
Bounce-backs happen in correctional medicine, too. Bounce-backs can happen in jails, where we often deal with patients we do not know well. But bounce-backs also happen in prisons, when patients we do know well have a new complaint. Just like in emergency medicine, a bounce-back in a jail or a prison is a patient who comes to the medical clinic with a new complaint, receives a diagnosis and treatment and then re-kites for the same complaint within a couple of days. Here are a couple of examples.