Tag Archives: evidence based medicine

Price Check! Are analogue insulins worth their hefty price?

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) Continue reading

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

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. Continue reading

Effective Treatment of Heroin Withdrawal in Corrections

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. Continue reading

Medications at High Risk for Diversion and Abuse In Correctional Facilities

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. Continue reading

A Better Way to Drain Abscesses: The Berlin Technique

One of the consequences of the heroin epidemic we all are experiencing is a marked increase in the number of skin abscesses presenting to the jail medical clinics.  Jails have always had to deal with skin abscesses.  In fact, the single most popular JailMedicine post has been the Photographic Tutorial on Abscess I&D (found here).  But since the heroin epidemic, the number of skin abscess we see has exploded.  It is not unusual nowadays to lance an abscess every day!

The reason for this big increase in skin infections, of course, is that heroin users tend to share needles to shoot up, and these dirty needles leave behind the bugs that cause abscesses.  And since shooting up causes the abscesses, they tend to be found where addicts commonly shoot up–like the inner elbow, the forearm and even overlying the jugular veins of the neck.

Fortunately, just in time for this onslaught of abscesses, my good friend Neelie Berlin PA taught me a new method of lancing simple abscesses that is quicker and easier—yet just as effective—as the method I had been using for my entire career. I’m going to call this new method of draining abscesses “The Berlin Method.”

Who says you can’t teach an old Doc new tricks?  I have wholeheartedly gone over to the Berlin procedure.  It is THE method I use now to drain simple abscesses.

Today’s JailMedicine post is a pictographic tutorial on how to do this new easier method of lancing simple abscesses. Continue reading

ACCP Conference!

The list of educational opportunities specifically geared towards correctional medicine is woefully short.  We correctional specialists need to take advantage of as many of our own conferences as we can.

One excellent resource for several years has been the one day conference put on by the American College of Correctional Physicians (formally known as the Society of Correctional Physicians).  Historically, this conference has always been held on the Sunday before the NCCHC National Conference held in October.  These ACCP conferences have always been excellent, but only held then.

This year, however, is different.  This year, the ACCP is also hosting a spring conference tied to yet another excellent educational opportunity in correctional medicine: the Academic Consortium on Criminal Justice Health.  The Academic Consortium conference will be held this year in Atlanta on March 16th and 17th.  ACCP’s one day conference will be held immediately afterwards, on March 18th, a Saturday. Continue reading

Correctional Medicine is Different: All Clinical Encounters are Discussed in the Dorm

On my last post, I began a series discussing how Correctional Medicine is different from medicine in the “outside world.”  The first (and arguably the most important difference) is that medicine inside corrections has to be fair, whereas the bigger world of US medicine is not fair.

The second big difference between Correctional Medicine and outside medicine is this:  Every clinical encounter in correctional medicine is discussed back in the housing dorm.  This does not occur in outside medicine and is critically important to understanding doctor-patient relationships in corrections.

For those not familiar with the housing situation in jails and prisons, most inmates are housed in large housing dorms or pods.  Depending on the size of the institution, these can house anywhere from 10 inmates to over a hundred.  As you might expect from this situation, inmates spend a lot of time talking with each other, especially since they generally have more free time than your average person in the outside world.  Inmates spend a lot of time talking to one another.

So when an inmate returns to the dorm from a visit to the medical clinic, it is natural for the encounter to be discussed.  If the encounter was unusual or noteworthy in any way, this quickly becomes known throughout the pod.  And since different housing pods also communicate with each other, information about clinical encounters quickly spreads throughout the entire institution.Dorm 1 Continue reading

Correctional Medicine: The Principle of Fairness

I am often asked by my non-correctional colleagues what it is like to work in a jail. I tell them that practicing correctional medicine is different in many ways than medicine in the “free” world. Many of them scoff at this. How could the practice of medicine be different in a jail than it is anywhere else? “Medicine is medicine,” they say.

But correctional medicine is different. In my experience, if you just throw a practitioner into a jail or prison clinic without any training, he likely will not do well. It took me two full years before I was comfortable in my sick call clinics and I am still learning things as I go. Experience matters in Corrections!

This is obvious to those of us who have experience working in jails and prisons. But how do you explain the intricacies of a jail medical clinic to an outside physician? I have thought about this a lot over the many years I have practiced correctional medicine and I have come up with several concrete examples of how correctional medicine is different from medicine “on the outs.” The first, and perhaps the most important, difference is the Principle of Fairness.Unknown-1 Continue reading

Do Uncomplicated Lacerations Need To Be Closed Within Six Hours?

Dr. Keller,
What do you think of the rule for lacerations that says a laceration has to be sutured within six hours or it cannot be sutured at all? At our facility, we send lots of inmates to the ER for simple cuts because the PA isn’t scheduled to be at the facility until the next day. If a cut is 10 hours old, why can’t it be fixed?  Where did this rule come from?
Kim A.

Thanks for the question, Kim. The short answer to this question is that that this belief is a myth. Uncomplicated lacerations can, indeed, wait more than 6 hours to be repaired.

“There is a common misconception that all wounds must be either sutured within a few hours or left open and relegated to slow healing and an unsightly scar.”  Roberts and Hedges’ Clinical Procedures in Emergency MedicineUnknown

Continue reading

The M-Word–Malingering

I went to the always excellent NCCHC spring convention in Nashville last month. One of the many outstanding presentations was done by frequent lecturer Deana Johnson. Deana talked about the risks of using the word “malingering.” Her basic message was to be very careful about saying that an inmate is malingering—in fact, perhaps we should never use that word.

I was surprised by the degree of spirited disagreement from several members of the audience. They pointed out that “malingering” has a specific medical meaning and sometimes—even often—it is an appropriate medical diagnosis. They pointed out that malingering is listed as an official diagnosis in DSM-5 and that outside medical agencies, like mental hospitals, use the term malingering. If we can’t say that an inmate who is clearly faking is malingering, what are we supposed to say?

Today in Jail Medicine, I am going to tackle the term malingering. It turns out that there is indeed a correct and proper way to use the term malingering in correctional medical practice—but it is tricky and most often (in my experience) done incorrectly, with resultant bad consequences.

There are three important reasons for this. First, most people have an inaccurate idea of what malingering actually means in a medical sense and so use the term inaccurately. Second, the use of the term “malingering” also carries with it an emotional definition that MUST be taken into account when it is used in a medical document. Finally, use of the term “malingering” has important consequences for patient relations, patient behavior and time management.

The bottom line, in my opinion, is that “malingering” is a term that should very rarely be used in correctional medicine. There are better and more precise ways to convey medical information. But if you do absolutely want to use the term “malingering,” you need to know how to use the term correctly. Continue reading