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.
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.
I am pleased to be joined on JailMedicine by my colleague Dr. Sharen Barboza! Dr. Barboza has been providing correctional mental health care for more than 20 years. Her complete bio can be found in the About The Authors tab (here). Besides her broad experience, intelligence and common sense, Dr. Barboza is simply the best speaker I have heard at any correctional medicine conference. I am honored to have her as my co-editor at JailMedicine! Jeffrey Keller
I am truly honored, grateful and humbled to join Dr. Keller on JailMedicine.com. I think that now, more than any other time in the past, we are all realizing the impact that our mental health has on our ability to function in the world. For so many of us, we take the “health” part of our “mental health” for granted. We trust our thoughts to be based in reality; we rely on our emotions to adequately and appropriately meet the moment; and we have confidence in our ability to cope with what comes our way. Most days.
When Covid-19 burst onto the scene three months ago, the jail administrators and the medical teams in my jails initiated several common sense practices to reduce the possibility of Covid infiltrating the jails. These included screening and quarantining new inmates before allowing them into the dorms, screening jail employees daily, doing lots of Covid tests and, perhaps most importantly, having deputies wear masks at work. The good news is that, so far, there have been no cases of Covid-19 in any of my jails (knock on wood here).
However, there seems to be growing evidence of “Covid
Fatigue” in my community. When I go out
in public, I am one of the very few still wearing a mask. And this is unfortunately spilling over to
the correctional facilities. I did a
clinic at one of my smaller jails this week and was surprised and dismayed to
see that the deputies were no longer wearing masks. In the meantime, Community Covid cases are
climbing, so the risk of transmitting Covid to the jail is actually greater
than it was, say, a month ago.
I am seeing a 52-year-old male in my jail medical clinic who
was booked yesterday on a felony DUI charge.
He says he drinks “a lot of beer” but denies having a drinking problem. He is cranky and not really cooperative. He does not want to be here. However, the deputies tell me that he did not
sleep much last night and did not eat breakfast. I note that he has a mild hand tremor and a
heart rate of 108. According to the
clinical Institute Withdrawal Assessment for Alcohol–revised version (the most
common tool used in the United States to assess the severity of alcohol
withdrawal since 1989) my patient needs no treatment for alcohol withdrawal. But this is wrong! In actuality, my patient is experiencing
moderate withdrawal and should be treated immediately and aggressively.
Using CIWA is like
using a wrench to pound in a nail. It
can be done, but it is not really efficient or accurate. A different tool (a hammer) could drive the nail
much more quickly and effectively. CIWA is simply not the right tool to assess
alcohol withdrawal. We should be using
I recently published the official position paper of the American College of Correctional Physicians (ACCP) on the treatment of Hepatitis C in incarcerated patients (found here). However, some state legislatures (and others who which authorize funds for inmate medical care), have been reluctant to fully fund Hepatitis C treatment. Because of this, ACCP has formally approved the following Position Paper to encourage full funding of HepC treatment among incarcerated inmates.
“We’ve got another one,” My nurse told me on the phone. “He
says he was exposed to Covid.”
Ever since Covid-19 came to my town, many people being
arrested have begun to say that they have Covid or have been exposed; the
thought being that “If I have Covid, they can’t put me in jail.” Of course, it doesn’t work that way. They go to jail anyway.
Unless you’ve been living under a rock, you have been hearing about the threat of a Corona virus pandemic. Every day, the evening news anchor breathlessly gives an update of the number of new cases, the number of new countries affected and the number of new deaths. You probably already know that this disease was originally found in China. What you may not know (but you should if you work in corrections) is that Chinese prisons were especially hard hit. This disease spreads most rapidly where people are enclosed together, like nursing homes, cruise ships and prisons. If this disease gets a foothold in the United States, correctional institutions are likely to suffer.
Patients are dying in correctional facilities from
benzodiazepine withdrawal! This is not
just a theoretical observation; this really is happening. This fact bothers me since
benzo withdrawal deaths are preventable.
Benzodiazepine withdrawal is easy to treat! It is certainly easier to treat benzo
withdrawal than the other two potentially deadly withdrawal states, alcohol and
opioids. By far, the most common cause of
benzodiazepine deaths is, of course, not treating it!
So, is your facility at risk to have a patient die of
benzodiazepine withdrawal? To find out, compare
your policies to the following Rules for the Treatment of Benzodiazepine Withdrawal.