Tag Archives: formulary

Should Inmates Bring Their Own Prescriptions to the Jail?

In response to my last post, one reader wrote to tell me that the jail where she works does not accept medications brought in by inmates or their families. They consider this a security risk.  All medications are ordered and supplied by the jail.  She asks if I will comment on this. Before I do, I need to define a couple of terms that come up over and over in any discussion of newly booked inmates’ medications.

Verification

UnknownThe first term is “Verification.”  Verification refers to the process of verifying what medications an inmate is currently prescribed and is taking.  There are three ways to verify medications.  The first is to call the prescribing doctor’s office to get a list of currently prescribed medications.  The second is to call the dispensing pharmacy to get a list of all prescriptions they have recently filled for the patient.  Finally, the inmate could bring the medications they are taking into the jail with them in the original pill bottles.  On the label is everything we need to know—who prescribed the medication, when it was filled, dosages–everything.

One problem with calling the doctor’s office to verify medications is that the patient often is not taking all of the prescribed medications.  If I remember right, studies show that only around half of all prescriptions are filled.  So you will get a list of prescribed medications, but that may not be what the patient is actually taking.  Another problem with calling the doctor’s office for a current medication list is that doctor’s offices are often closed.  If a patient is booked Friday afternoon of a holiday weekend, you may not be able to get a current medication list until Tuesday.  Finally, many inmates get medications from multiple prescribers.  For example, the patient may have a family physician, but a psychiatrist prescribes their mental health medications and they also use a pain specialist.  And get prescriptions also from ERs and “Doc-in-the-Box” clinics.

Calling the pharmacy may get you more information than calling the doctor’s office.  After all, the pharmacy will only tell you about prescriptions that were filled and can also tell you when the prescription was filled.  If you do call a pharmacy to verify meds, don’t just ask for an “active medication list!”  The pharmacy considers any prescription that they would fill for the patient active, and refills are generally good for one year.  So if a patient may not have taken a certain medication for many, many months, but the pharmacy still considers it “active.”

And like doctors’ offices, pharmacies may be closed when you want to call them.  And inmates often use more than one pharmacy.  Some inmates use mail order pharmacies that are hard to get any information out of.  Or an inmate may not use a pharmacy at all—for example, their medications might be supplied by a psychosocial rehab group.  Finally, it is not uncommon for an inmate not to remember what pharmacy they use, at all!

Authorization

The second term to define is “Authorization.”  I discussed medication authorization in my last post.  Authorization refers to the process of reviewing and inmate’s (verified) medication list and deciding which of those medications will be dispensed at the jail—and which will not.

All incoming inmates taking medications should have their prescription list verified and authorized.  These two processes take quite a lot of nursing time and effort at most jails.

So now we return to the original question.  Which is better, to allow inmates to bring their outside medications into the jail with them or not to allow this and instead verify their medication list and re-prescribe the approved medications ourselves?  The answer is that there is no “right” answer.  Each system has its advantages and disadvantages.  Which you choose to use at your jail depends on several factors, such as the size of your jail, your staffing levels and the sophistication and efficiency of your pharmacy system.

With that in mind, let’s compare each system as to its relative advantages and disadvantages with regard to some of our goals in jail.20130619

Continuity of Care

We want medical care to continue seamlessly from the outside to the inside of the jail.  We want there to be no lapses in ongoing medical care for newly booked inmates.  This means that, ideally, there will be no missed doses of important medications.  This is, of course, easiest to accomplish if inmates brings their medications to the jail in the original containers.  This makes verification, authorization and dispensing to the inmate a simple process.

Contrast this with what usually happens if the inmate does not bring the meds with them.  The current medication list must be verified with phone calls to the doctor’s office and pharmacy.  Even if this goes well (no offices are closed), the medications then must be ordered from the jail’s pharmacy.  Best-case scenario:  the process takes 24 hours.  More commonly, it takes 48-72 hours and the patient has been without medications for 2-3 days.

If the inmate does not bring meds into the jail with them, the only solution for timely administration of most medications is to have an extensive collection of “stock” meds on hand, so that most medications can be continued quickly from stock.  In order to be able to fill the majority of outside medication prescriptions, there must be a lot of stock meds plus protocols for automatic “therapeutic substitution”  (mentioned here).  http://www.jailmedicine.com/the-f-word-formulary/ That is a pretty sophisticated system.

However, even then, no “stock” med collection is going to contain all of the various HIV meds, say.  Or cancer chemotherapy agents.  And these are precisely the medications that we most want to continue without missing a dose!

Clearly, from a “continuity of care” perspective, it is better to encourage inmates to bring in their own, outside medications.

Advantage:  Allowing outside prescriptions.

Information Gathering

There is no question that having the original pill bottles sometimes gives you medically important information.  As one example, consider the patient who takes combination lisinopril/HCTZ for blood pressure.  He brings in a bottle that was filled 45 days ago for a one month supply (30 pills).  There are 29 left in the bottle.  His blood pressure is 128/78.  Would you continue the prescription?  I probably would not.  I would, instead, monitor his blood pressure to see if he really needed the medication.

Or say instead, his blood pressure is 180/120.  If I know that he has not been taking his hypertension medication, I would simply restart it in the jail.  But if he had been taking it faithfully, I might consider adding or changing the prescription.

I could give many more examples of similar situation.  Knowing that the patient has (or has not) been taking their prescribed meds is often very helpful clinically.

Advantage: Allowing meds to be brought in to the jail.

Time Management

The issue here is how long it takes nursing staff to verify and approve a newly booked inmate’s medications.  If the inmate brought meds to the jail in the original pill bottles, verification consists of noting the information on the prescription label, verifying that the medications in the bottle match the label and counting them.  Authorization is easy as a phone call to the provider.  And then the medications can be immediately dispensed to the inmate.

If the inmate did not bring meds to the jail, verification will take much more time.  It consists of interviewing the inmate (Who is your doctor?  Which pharmacy do you use?), then calling the doctor’s office, the pharmacy or both (hopefully, there is only one of each!).  If there is a discrepancy between what the inmate says they take and what the pharmacy says they filled, a second interview with the inmate may be required.  Then, after the approval process, the medications must be ordered from the jail pharmacy, delivered, processed and then, finally, they can be dispensed.

Advantage:  Allow meds to be brought in.

Cost Considerations

Consider the case of the inmate who is only going to be in jail for 30 days.  He is willing to supply his own medications for the month long stay.  Among other things, he takes Abilify, which costs approximately $25.00 a pill.  If your jail will not allow him to bring in his own Abilify, then you must either supply it at a cost of many hundreds of dollars for that medication alone, or substitute something else.  Even if patients are on inexpensive medications, these med costs and fill fees add up.

In addition, if your jail charges a fee to fill prescriptions, inmates will complain, because often they get their outside medications for “free” (meaning Medicaid, most often).  I have even had inmates go so far as to call this extortion and refuse to take jail prescriptions because they do not want to pay any money for meds that they are willing to supply “for free.”

Advantage:  Allowing meds to be brought in at booking.

Medico-Legal Considerations

The main medico-legal risk in these situations is disruption of the continuity of care, in this case, patients missing doses of important medications.  If (Heaven forbid!) something bad happens after the patient has missed a dose of medication—like the patient has a heart attack or commits suicide—it will inevitably be blamed on the missed meds by the patient, his family and their attorney.  I have seen this many, many times.

Advantage:  allowing meds to be brought in.

Security Considerations

This is the one aspect of the problem where there is a decided advantage not to allow outside medications into the facility.  Anytime you allow stuff from the outside to come into the jail, there is a potential for a security breech.

One possibility is that inmates might adulterate capsules by pulling them apart, pouring out the real medication and then filling them with cocaine, heroin or whatever.  However, this is not as easy to do as it sounds.  Adulterated capsules don’t look right and, in my experience, are quickly suspected and discarded.  Besides, if you want to smuggle illicit substances into a jail, there are easier methods than trying to pour powder into tiny capsules.

A more legitimate security concern is what to do with medications that were brought in to the jail but then were rejected during the authorization phase and so never dispensed to the patient.  Non-controlled substances can be placed in the patients’ property, but things can go wrong.  For example, the meds, somehow, are not there when the inmate is discharged from the jail six months later.  Where did they go?  The inmate, of course, may demand compensation for his lost property.  Maybe there should be an investigation?

Controlled substances are even worse, especially DEA schedule 2 drugs like methadone and amphetamines.  Like all schedule 2 controlled substances, these properly should be kept under double-lock (i.e., a locked box in a locked room) and should be counted every day with two people witnessing and signing off.  That is a lot of work should the patient stay in jail for a significant amount of time.   And when the inmate is released, you have this dilemma:  should you return these addictive controlled substances to him? What if he overdoses?  What is your risk exposure?

Advantage: not allowing out-of-jail medications in the facility.

In the end, which system you eventually put into place for incoming inmate medications depends on how important the security angle is to you and how well you can create and use a stock medication system.  To some degree, this depends on jail size.  The smaller the jail, the more important continuity of outside care becomes because the small jail’s medical staff may not be there all the time.  Large jails are better able to develop sophisticated stock medication systems where most incoming prescriptions can be quickly and easily filled from stock.  But even big jails should have exceptions in place for expensive specialty medicines, like chemotherapy agents, immune-modulators and HIV meds.

Does your jail allow incoming inmates to bring their medications to booking?  Do you like the system your jail uses?  Please comment!

The F-Word. “Formulary!”

20021002Back when I worked in the Emergency Department of a large hospital, my medical staff assignment for many years was to the Pharmacy and Therapeutics Committee.  The P&T committee’s assignment was to develop a hospital Formulary and to establish guidelines and rules for medication use.   My hospital was not unusual.  In fact, every hospital has a drug formulary and a P&T committee to oversee it.

So when I got into correctional medicine, I was surprised to learn that “Formulary” is often considered to be a dirty word in corrections and many correctional facilities do not even have a formulary.

I have been told that one reason for this is that inmates, their attorneys and advocates (like the ACLU) sometimes define “Formulary” as a system that bans certain medications simply based on their cost without any consideration of the medical needs of the patient. “This is the best medication for my client and you denied it just because it cost too much.  As a result, my client suffered harm.”  So some facilities, I am told, are afraid to have a formulary because of its bad reputation.

But this is an incorrect definition of a formulary.  Formularies aren’t bad; to the contrary, a well-done formulary is good medical practice.  Every correctional facility should have a formulary and some mechanism for formulary oversight.  In fact, if you don’t have a formulary, you are practicing inferior medicine.

The first thing to understand about formularies is that having a drug formulary is the Standard of Care in your community.  Every hospital has a formulary. Nursing homes have formularies.  The VA has a formulary.  Your state’s Medicaid program has a formulary.  Why is this? Because formularies are good medicine.  Formularies have two basic functions.

Formularies and Drug Value

First, formularies do evaluate drug prices, but not to forbid medications based on cost alone but rather to evaluate drug Value.  “Value” in general is the benefit of a product, any product, divided by its cost.  The easiest way to assess value is by comparing prices of identical (or similar) items.  For example, if I want to purchase a new vacuum and the exact same model is sold at store A for  $50.00 less than store B, I usually will buy from store A because it is offering me a better deal, i.e. better value.

In pharmaceutical purchases, the value of a drug again is the benefit of that drug divided by its cost.  Since Value is easiest to assess when comparing similar drugs, my P&T committee spent a lot of time setting up lists of “Therapeutic Equivalents.”  This entailed reviewing the literature and making lists of drugs that had similar therapeutic properties.  A good example would be Proton Pump Inhibitors (PPIs).  The literature shows that the various Proton Pump Inhibitors are equivalent; there is no one PPI that is clearly better than any other.  So the preferred PPI for our hospital was the least expensive one.  This PPI was the best value.

Interestingly, the prices of similar models of vacuum cleaners don’t vary too much between stores.  The $50.00 cheaper price between store A and store B may represent only a 10% cost savings.  But the difference in pharmaceutical prices can often be mind-boggling.  For example, consider these two therapeutically equivalent PPIs:  as of January 2, 2013, the cost of Nexium was $6.15 per capsule.  But omeprazole costs 10 cents a capsule.  Is Nexium really 60 times better than omeprazole?  No!  They are therapeutically equivalent!

A formulary points these two facts out:  that the two drugs are therapeutically equivalent and that omeprazole is 60 times less expensive.  A formulary that absolutely forbids any physician to prescribe Nexium, ever, is called a “Closed Formulary.”  On the other hand, a formulary that allows Nexium to be prescribed in certain circumstances is called an “Open Formulary.”  In my hospital, if you wanted to prescribe Nexium rather than omeprazole, you would have to make a presentation to the P&T Committee as to why you thought Nexium (or any other non-formulary drug) was worth the extra cost.  Until then, the hospital pharmacy would not fill a Nexium prescription.  In fact, if you were to write an order for Nexium, the hospital pharmacy would automatically substitute omeprazole without even telling you—this is called “Automatic Substitution” and happens all the time in community hospitals.

Formularies Monitor Appropriate Drug Prescribing

The second main function of a formulary is to define and monitor appropriate prescribing within the facility.  As another example, we had one older physician who prescribed hydralazine as a first line agent for hypertension. The P&T Committee noted that this did not conform to any hypertension treatment guidelines (notably JCIS-7) and so did not permit the prescription to be filled until the physician explained himself.  Rather than come to a P&T Committee meeting, this physician chose, instead, to change his prescription to a standard agent. The reason, then, that hydralazine is non-formulary is not that it is expensive (hydralazine is, in fact, quite cheap); rather, it is because hydralazine has no indications as a first line antihypertensive.  There are other, better drugs that should be used yet before anyone thinks of using hydralazine.

Another way my P&T Committee’s formulary monitored prescribing was by making sure that specialty drugs were prescribed appropriately.  For example, the P&T Committee would not allow, say, an orthopedic surgeon to prescribe chemotherapy for leukemia without consulting an oncologist (don’t laugh, it really happens).  Some medications are so potentially toxic that their prescription should always be double-checked by someone:  a specialist, a P&T committee, or maybe just the facility medical director.  Thus, Peg-interferon for hepatitis C is non-formulary in my jails not because we do not want to use it, but because its prescription should be double-checked to make sure it is being used appropriately.

What’s in a Name?

The problem with the word “Formulary” is not with what a formulary does.  No one would object to monitoring appropriate drug usage within a facility or preferring the best value among equivalent drugs.  No, the problem with the word “Formulary” is that the word itself has taken on a negative connotation:  “Formulary” implies to some the denial of appropriate medical care based on cost alone.

One way to combat this notion is to use a different term for the processes of monitoring appropriate drug usage and preferentially using drugs with the best value.  This term should emphasize the “Open” nature of the process.  No drug is banned.  Any drug can be prescribed if the prescriber can justify the medical need for that particular drug over alternative therapies.  (That might be hard for a drug like hydralazine.  Or Nexium.  Or Ritalin in a county jail.  But it is not impossible!  In fact, I have allowed all three of those drugs to be dispensed in my jails in unusual but appropriate circumstances!)

“Pre-Approved” instead of “Formulary”

One term that works to convey this is “Preferred Drug List.”  My state’s Medicaid program uses that term.  But I think an even better term is this:  “Pre-approved Drug List.”  That term concisely conveys all of the important information:  the drugs on the list can be prescribed without obtaining outside approval.  Obviously, cancer chemotherapy is not going to be on that list.  Neither is Nexium.  But the term also implies that there is a mechanism to obtain approval for drugs not on that list.

Next:  A step-by-step guide on how to set up a “Pre-Approved Drug List.”

Has your facility had problems setting up a formulary?  Has your facility had particular success with your formulary program?  Please comment!

Pop Quiz: Medication and Lab Prices

One thing that has long bugged me about how medicine is practiced in the United States is that medical professionals for the most part have no idea how much stuff costs.   Doctors prescribe medications that their patients cannot afford to buy—even when cheaper alternatives are available.  We order tests not knowing what the patient is going to be charged.

This phenomenon occurs nowhere else in American culture.  It is kind of odd when you think about it.  It would be like going to the grocery store and having no prices on any of the food.  You could only get the meat that the butcher recommended, but he wouldn’t know the price of anything, either.   The first inkling you would have about costs would be when you got your bill in the mail a month later:  “Wow—that chuck roast was $200.00 a pound!” Continue reading