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
My good friend Dr. Bill Wright guest-wrote this post about dizziness. He is the author of Maximum Insecurity: A Doctor in the Supermax, which you should read if you have not! Thanks, Dr. Wright! –Jeff Keller
“Can’t you understand? I’m just dizzy!”
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
I have been doing yearly wellness exams for the local fire fighters for many years now. I quite enjoy it. Many of them are in such good physical shape that I pronounce them to be “Mary Poppins” fire fighters, meaning “Practically Perfect in Every Way!” Many, however, succumb as they get older to the “weight creep” that is common in the US today. I saw one such firefighter this very week who had gained 8 pounds since I saw him last year. In such cases, I have to educate the patient about the Medical Consequences of Excess Weight. There is even a medical term for this phenomenon: “Metabolic Syndrome.” I think that just about everyone, whether a firefighter, an inmate in a prison or jail, or the medical staff that takes care of them, should understand Metabolic Syndrome. Continue reading
I ran across a couple of interesting articles about antibiotics recently.
In the first article, entitled We Will Soon Be in a Post-Antibiotic Era, CDC researchers predict that the end of the antibiotic era is coming quickly. Antibiotic resistance is developing so rapidly now, that it is only a matter of time until antibiotics just don’t work anymore. This actually is not surprising when you think about it. If we kill all of the microbes that can be killed by our antibiotics, then of course the only ones left will be those that cannot be killed by antibiotics, in other words, that are resistant. The fact that this will happen eventually is a no-brainer. Continue reading
My good friend Al Cichon in Maine writes:
As health care providers we are trained to be tolerant when patients are less than pleasant – excusing their behavior as a result of their illness / injury. Certainly there are occasions when this is appropriate. However, that tolerance can be abused in the correctional setting. Continue reading
I ran across a quite good article the other day entitled A Powerful Tool in the Doctor’s Toolkit written by Dr. Danielle Ofri. It was about how the placebo effect is underappreciated in medicine. Far from being an esoteric “Gee-Whiz!” phenomenon, the placebo effect and its counterpart, the nocebo effect, are things we can use to our advantage in almost every clinical encounter. Continue reading