Every once in a while, because of changing drug prices, I discover that my formulary has become outdated. More expensive medications are on my formulary and less expensive equivalents are non-formulary. Depending on how long the price change occurred before I noticed it, I may have overpaid hundreds of dollars unnecessarily. Oops!
This situation arises more frequently than you might expect. Drug prices can change rapidly. And formularies do not get updated often enough. I try to go through mine quarterly, but, to be honest, it probably happens only once or twice a year. As a result, I miss opportunities to save my jails some money.
Today’s example is extended release antidepressants. For many years, I never even looked at extended release drug prices. I just “knew” that ERs were much more expensive than their immediate release cousins. But wait long enough, and everything goes generic, including extended release.
If you have not yet noticed, you can save quite a bit of money (and time!) by switching to extended release venlafaxine (Effexor) and bupropion (Wellbutrin). Continue reading →
As we all know from long experience, hypertension is the single most commonly seen and treated condition in primary care medicine. It is an important risk factor for strokes, heart attacks, kidney failure and overall death. It has been exhaustively studied. And yet there is still significant controversy over hypertension, including how to define it and what the best agents for treatment are.
Against this background, The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults was released last December in JAMA. It was written by the 8th Joint National Committee, and so, of course, is referred to as JNC 8.
JNC 8 has a couple of important and surprising changes from JNC 7. One of these, at least, is controversial enough that some members of the committee rebelled and released a dissenting “Minority Report” (apologies to Tom Cruise). Today’s JailMedicine post is a summary of JNC 8 recommendations and changes to JNC 7.Continue reading →
Today on JailMedicine, I am happy to present a guest post by Dr. Bill Wright.As you may remember, Dr. Wright is the author ofMaximum Insecurity: A Doctor in the Supermax, which I reviewed hereand which you canpurchase here.
Correctional medicine attracts more than its share of argumentative and demanding patients. We all feel the tightening in our stomachs when finding certain names on the clinic schedule, anticipating the disputes that are almost certain to follow. It doesn’t need to be that way. Continue reading →
Today, I am adding more sites to the CFOAM page found at the top of the blog. Remember that FOAM stands for Free Online Access to Medicine and is a movement that seeks to utilize the full potential of the internet for medical education. In order to make it as FOAM, a web site must be free, provide useful education on a medical topic, and be easily accessible online. This can (and does) include audio podcasts, video lectures, and written articles and blogs. If the content is relevant to correctional medicine, well, that’s CFOAM: Correctional Free Online Access to Medicine. Today, I am adding three more CFAOM websites to the list. Continue reading →
Today’s post is an opinion piece. Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.” Continue reading →
As you probably know, Sovaldi (sofosbuvir) is an important new treatment for Hepatitis C infection that was released this last December and has been aggressively marketed by its maker, Gilead, ever since. The problem is that Gilead is charging an unheard of, jaw-dropping, $1,000.00 per pill for Sovaldi. This translates into a MINIMUM of $84,000.00 for Sovaldi alone for the simplest course of Hep C treatment. Add on the other necessary drugs and take into consideration more complicated cases, and a single course of therapy for Hepatitis C will cost between $100,000.00 and $250,000.00.
This price has placed prison systems in a no-win situation–and not just prisons, but also Medicaid, insurance companies, and HMOs. On one hand, Sovaldi is a good drug that, in fact, represents a significant advance in Hepatitis C treatment. Lots of Hepatitis C patients could potentially benefit from Sovaldi. On the other hand, no one can afford Sovaldi. Treating every potential Hep C patient using Sovaldi would bankrupt everyone. There is no good way out of this dilemma. Continue reading →
Do these words make you want to head for the clinic exit? If so, you’ll find a lot of company trying to get through the door. Many physicians hate to see dizzy patients because they can’t easily get their heads around the complaint. They can’t see, hear, feel, smell, or touch it, so it’s hard to know where to start. Help is on the way. Continue reading →
It is June, 2012 at a pub in Dublin, Ireland. During a break in an international Emergency Medicine conference, and over a pint of Guinness stout (what else?), several doctors were discussing how much medical information was freely available online. Everyone in attendance agreed that the way that medical information is shared has changed radically in the last 30 years—from a few choice textbooks on the office bookshelf and subscriptions to a few medical journals to the availability of most textbooks and journals instantly, online. Not only that, but instant messaging services like Twitter make it possible to get medical help from experts almost instantly—even if the expert is on the other side of the world! In fact, the main problem now is harnessing the incredible potential of the internet to improve medical knowledge and decision-making. Where are the really good reservoirs of medical information online? How can we more easily communicate with our colleagues and friends when we need help with a vexing case?Continue reading →
I am looking for a withdrawal protocol for benzos. I have patients that have been on Xanax 2mg for 3-5 years and now I need to detox them. We all know how difficult this is with people in the community let alone in the correctional setting. PLEASE HELP !!!! Thank You, Doris
Well, Doris, you have come to the right place! I, and many other JailMedicine readers, are happy to share our strategies for dealing with benzodiazepine withdrawal. And this is a common dilemma in county jails. Believe it or not, Xanax is the single most-prescribed psychiatric drug in the United States. My experience is that Xanax is highly addictive and yet handed out like candy by some community practitioners. Some community prescribers I have talked to do not even realize that Xanax is addictive! Strange but true.Continue reading →
We correctional practitioners get to see a wide range of medical practice as we review the medical histories of inmates arriving at our facilities. I myself have seen many prescribing practices that make me scratch my head. One example I have run into repeatedly is the practice at many jails of using hydroxyzine to treat alcohol withdrawal. It turns out that many jails do this. I am not talking about hydroxyzine as an adjunct or an add-on to the primary agent. I am talking about hydroxyzine being used as the primary treatment agent itself.
In my opinion, this is a mistake, and should be stopped.
Now I admit that there is room for dissention in medicine. Not all practitioners practice in the same way and there are many, many areas of medicine where there is no right answer. And it is true that hydroxyzine was used in the 1960’s to treat alcohol withdrawal. However, since then, medicine has discovered superior agents to treat this condition: the benzodiazepines. Today, hydroxyzine is the wrong agent for alcohol withdrawal. If your facility uses hydroxyzine as the primary treatment for alcohol withdrawal, you should change your protocol. There is no legitimate basis for this practice.Continue reading →