Tag Archives: pharmacy practice

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

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

Taming the Beast—Gabapentin. Ban It or Regulate It?

In my last post, I began with a question from Christy.  Her facility was considering banning gabapentin from their facility due to rampant abuse and diversion problems.  My last post dealt with gabapentin’s interesting history and the evidence base for off-label gabapentin prescribing.  This JailMedicine post will deal with the pros and cons of banning gabapentin versus creating rules to regulate gabapentin use and hopefully minimize diversion and abuse. Continue reading

Taming the Beast: Gabapentin

A reader recently wrote

At our facility, one of the most abused drugs in Neurontin. I am the trying to formulate when this medication will be continued. My question is if the following is acceptable in your opinion:
Neurontin will not be given for any indication not approved by the FDA. The only indications approved by the FDA is for epilepsy and PHN after shingles. Now the question remains how can you tell what the indication of prescribing the Neurontin was? The therapeutic dose for the treatment of epilepsy is 900 to 1800mg a day divided into three times a day not to exceed 3600 mg per day. If you come to our facility on 300mg at night, this clearly indicates that the drug was not given for the two recommended doses so therefore, it can be assumed it was given for insomnia- which we do not treat at our facility. The Neurontin would be canceled and we would observe for signs and symptoms of withdrawal for the next 5 days.
Does this sound reasonable and do you know of a substitution for the treatment of diabetic neuropathy that is less abused in the jail setting?

Well, you’re not alone, Christy! Gabapentin is one of the most abused and diverted drugs at all correctional facilities that I know of! (I’m going to use the generic term “gabapentin” interchangeably with the brand name “Neurontin” in this article). In fact, I was recently in a meeting with the commissioner of a certain state’s Department of Corrections to give an update on medical services in his prisons and the very first question he asked was about gabapentin. Gabapentin! Think of all the things he could have been concerned about—Hepatitis C for example—and instead, he asked about the security problems caused by gabapentin diversion.

In my experience, gabapentin is one of the “Big Three” non-DEA regulated drugs with the potential for diversion and abuse in a prisons and jail. The other two are Seroquel and Trazodone. The important difference is that Seroquel and Trazodone both allow easy substitution of another, less abused, cousin. Gabapentin, not so much.  More on that later.

In order to get a handle on gabapentin, I think it is important to understand where it came from and why it has not approved by the FDA for most of the reasons it is prescribed nowadays. B_beuRNW8AEYOgn

Continue reading

Proton Pump Inhibitors: Dependency and Risk

I recently saw yet another patient come into the jail who was worried about one particular drug in a long list of medications he was taking—his Nexium. “I can’t miss a day of taking Nexium” he said, “It has to be refilled right away!” He was more concerned about Nexium than his blood pressure meds, his diabetes medications or his mental health medications. There was a lot of Nexium-anxiety on display.

And the funny thing is, this happens all the time! I have seen lots of jail patients wedded to their proton pump inhibitor, whether Nexium, Prilosec, Protonix or what ever. A prescription of a PPI often becomes a lifelong need.

I think it is important for all prescribers to understand why this is so. And why, despite this, it is not a good idea for most people to be on PPIs for long periods of time. Prescribers tend to under-estimate both the potential harms of long-term PPI use and the potential for patients to become dependent on them.

To this end, today’s Jail Medicine post presents two “Must Know” papers about Proton Pump Inhibitors. Continue reading

Book Review: Correctional Health Care Patient Safety Handbook

If you’ve ever gone looking for books, articles, or–well anything! written about correctional medicine, you will quickly notice that there really isn’t very much out there. The specialty of correctional medicine is in its infancy. You can count the number of published books about the subject on less than two hands.

So a day in which a new book about correctional medicine is published is always a good day. And if by chance that book also happens to be well written and truly useful, well, that’s a true bonus and time for celebration.

Lorry Schoenly has written such a book that I recommend for all of us who practice in jails and prisons. This is a book that has universal applicability, whether you are a nurse, a practitioner, a mental health provider or an administrator. The name of the book is Correctional Health Care Patient Safety Handbook. You should read this book!3DBook Continue reading

Price Check! Extended Release Antidepressants

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

Skeletal Muscle Relaxers Do Not Relax Skeletal Muscles!

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

Price Check! Genital Herpes. How Much is Nursing Time Worth?

It is worthwhile to check drug prices now and then (once a quarter seems about right) to see what is happening in the pharmaceutical world.  When you do this, you will find some drugs that have inexplicably shot up in price.  One recent example was doxycycline, which went from around ten cents a tablet to over two dollars a tablet in a couple of months.

On the other hand, drugs that we think of as expensive in the back of our minds sometimes are no longer expensive.  Olanzapine (Zyprexa) is now cheaper than haloperidol.  Risperidone is cheaper still.

And sometimes, a drug that is a bit more expensive than its alternative is still the most cost-effective treatment based on “the hassle factor,” meaning frequency of dosing, ease of administration, potential for diversion–that sort of thing. Drugs prescribed for outbreaks of genital herpes are like that, in my opinion.  Valacyclovir can be more cost-effective than acyclovir for the treatment of recurrent genital herpes.herpes1 Continue reading