I work at a prison and your blog has been such a resource for our unique niche of medicine. There’s nothing like practicing “behind the walls!" . . .
Recently I’ve been incorporating more conversations about functionality and short-term/long-term goals and visits are mostly positive. However, there are the difficult patients . . . wanting to bargain “well if you’re not going to do anything, can I have an extra mat?” Or “Can I have a bottom floor restriction?” “Transfer me then!” “Give me insoles.” …and other requests like this. How do you recommend I come to an agreement with these patients that are difficult to have conversations with? . . . If by the end of the appointment we do not come to some sort of agreement, they end up right back in sick call with the same complaint. Then the cycle repeats. KR
Imagine, if you will, a nurse who is assigned to take care of 50 patients on a medical floor—by herself. Clearly, this is an impossible task. There are just too many patients for one nurse to adequately monitor. But this nurse gamely does her best. Now let’s say that there is a bad outcome and an investigation. Even if the understaffing problem is recognized, it would be easy—and tempting--to scapegoat the nurse, especially if there was no intention of fixing the staffing problem (“We can’t afford to hire more nurses!”) Instead, the scapegoated nurse would be replaced by a new nurse, who, once again, would be expected to care for 50 patients.
Such were my thoughts when I read this article about the problems with the medical care for inmates in the Illinois prison system (found here): https://www.chicagotribune.com/news/local/breaking/ct-met-illinois-prison-health-lawsuit-20190103-story.html. The article says that there have been so many problems with medical care in the Illinois prison system that a class action lawsuit has successfully forced Illinois to make sweeping changes to the prison medical system. What is not mentioned in the article is that similar lawsuits have happened before in other states and will happen again.
One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic. A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years. Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective. He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids. In addition, Ralph has alcohol abuse issues. The reason he is in jail is a felony DUI charge. Now he is in my medical clinic, looking expectantly at me. How am I going to fix his pain problem?
The answer, of course, is that I am not. I am not that smart. He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem. I’m not going to be able to, either. In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain.
One thing I look forward to each day is looking through my medical feeds that keep me up to date with medical research. Most of this content ranges from bogus to unhelpful (in my opinion), but every once in a while, a truly game-changing article appears. Over the years, I have noticed that most of the game changing articles are debunking articles. They show that something that is commonly done in medicine actually has no value. I love these! Not only do they improve the medical care of my patients, they also make me more cost-effective. As I have said before, the main way to save money in Correctional Medicine is to eliminate (and stop paying for) medical practices that have no value—or even worse, are harmful to patients.
My last post about MAT in jails generated a lot of excellent responses–so many, in fact, that I realized that my discussion of MAT in jails was incomplete. I would like to enlarge the discussion about the proper role of MAT in jails by responding to these comments. Before I do, I want to make sure that we are all looking at the issue from the same perspective. Please consider how MAT should be used in three different jails.
Jail 1 is a 1000+ bed jail in a large city. Medical staff (mainly nurses) are on-site 24/7 and the practitioner(s) work at the jail full time. There are one or more Opioid Treatment Programs (OTP) in the community.
Jail 2 is a 250 bed jail in a smaller community. Nurses are at the jail daily, but not overnight. The doctor has a full time practice elsewhere (let’s say an ER) and does a jail medical clinic twice a week on the side. Since the county employs the practitioner as a part-time contractor, there is frequent practitioner turnover. There is no Opioid Treatment Program in the community.
Jail 3 is a 50 bed jail in a remote rural community. There is a nurse at the jail weekdays 8-4 but the deputies pass meds. A practitioner comes to the jail once a week to do sick call. There is, of course, no OTP within 200 miles.
Let’s keep in mind that there are even smaller jails (I am aware of several in Idaho with less than 20 beds) and in some of these very small jails, no medical professionals ever come to the jail. Any inmate needing medical care must be transported to a local clinic or ER. Let’s also keep in mind that there are many, many more small jails in the United States than there are big jails. In fact, if you were to add up all of the inmates incarcerated in jails with less than 100 beds, I suspect that the total number may well exceed the number of inmates incarcerated in big, urban jails.
And now to the responses and comments regarding MAT in jails. The first point was brought up independently by both Hsein Chiang and Jill NcNamara: even if MAT cannot be continued upon a patient’s release from jail, it still has the benefit of decreasing the risk of overdose post release because it prevents deterioration of tolerance that comes with other forms of treatment. This is an excellent point, and I believe that it is probably true. However, the evidence for this is limited and we don’t know how big this benefit is (more on this evidence later). It may be that in Jail 1 (a big jail in a big city), the benefit of MAT, including overdose risk reduction, may well outweigh the risks of using MAT–even if the jail has no community OTP to hand the patient off to upon release (importantly, Al Cichon points out that even when there is an OTP in a community, sometimes they are not willing to cooperate with the jail). There is no question in my mind that when it can be properly implemented, preferably in cooperation with an OTP, MAT is the best therapy for opioid abuse disorder. The question is using MAT with no integration with an OTP.
Consider MAT in Jail 3, the small jail with limited medical presence. MAT, whether methadone or Suboxone, simply cannot be legally done in jail 3. Jail 2 also would have a hard time using MAT without the support of an outside OTP. My point is that MAT is simply not going to be used at most small rural jails at the present point in time. However, even a small jail can properly treat patients for opioid withdrawal–using clonidine. There is a broad misconception that if a jail is not able or willing to use MAT, then there is no other treatment for opioid withdrawal out there, so “Let ’em go cold turkey!” I want all patients–every single one–going through opioid withdrawal to receive medical treatment. If a facility can’t or won’t use MAT, then, please, use an alpha-blocker, like clonidine!
Martin Krsak points out that one study done in Rhode Island showed that MAT prevents many post-release overdose deaths (this study can be found here). I was aware of this study and it was a great preliminary study! But it has limitations, as the study itself pointed out in the discussion section. First, the average length of incarceration among those studied was 23-40 months so this was essentially a prison study. Would the results hold up if the average length of incarceration was less than one month, like a typical jail? Second, the average length of time from release until the overdose death occurred was 4-6 months. How do we interpret that data if the way MAT works to prevent overdose deaths is by preventing tolerance deterioration while in jail? Third, this study took patients who were enrolled in an OTP before incarceration, continued their MAT “without tapering or discontinuing their medications” throughout their incarceration and then transitioned all of them back into an OTP after release from prison. What they did not do in this study is initiate MAT to treat opioid withdrawal for patients who had not been in opioid treatment before coming to prison. That is different from what Hsein and Jill were talking about, which is to use MAT to treat withdrawal even if MAT cannot be continued after discharge, in order to reduce the risk of post-release overdose. The Rhode Island study was also done in an urban area, in large facilities with dedicated medical staff, with OTP cooperation and with acceptance of all patients into an OTP guaranteed after release. How that translates to a rural jail where none of this is true is problematic. Bottom line, this was a great preliminary study. More studies need to be done, specifically in jails and specifically addressing the issue that we are talking about here–using MAT for opioid withdrawal in order to prevent tolerance deterioration.
Charles Lee points out that MAT is expensive and underfunded both in the community and in corrections. He is right! Besides being monetarily expensive, MAT in a jail is costly in many other ways, as well. It is time expensive–getting the appropriate certifications takes a lot of time as does administering the program. Also, MAT has substantial security concerns. Methadone and Suboxone are, to put it mildly, highly sought after whenever they are found in a jail facility. Preventing diversion and abuse of these drugs is not a small issue. Do the benefits of using MAT instead of clonidine to treat withdrawal outweigh the cost and risks of having these drugs loose in the facility? In my opinion, the answer is “Yes” for some jails (say Jail 1) and clearly “No” for other jails (jail 3 and many jails like jail 2).
As always, what I have written here is my opinion based on my training, research and experience. I could be wrong! I would like to hear your opinion in COMMENTS!