Tag Archives: prisons

What is the most common mistake made when treating withdrawal?

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.

Let’s look at these cases in more detail.

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Suicide – Don’t Be Afraid to Ask

It’s September, which is National Suicide Prevention Awareness Month.  Let’s start with awareness. According to the Centers for Disease Control, rates of death by suicide have increased in this country by 35% from 1999 to 2018.  More specifically, the rate has increased by 2% every year from 2006 to 2018.  The overall rate of death by suicide in 2018 was 14.2 people per 100,000.  For men, the rate is higher than the rate for women, with a suicide rate of 22.8 per 100,000 for men and 6.2 per 100,000 for women.  The rate for women, however, increased by 55% between 1999 and 2018.

According to the most recent data released by the Bureau of Justice Statistics, the rate of death by suicide in state prisons was 21 per 100,000 up from 14 per 100,000 in 2001.  In federal prisons the rate in 2016 was 12 per 100, 000 down from 13 per 100,000 in 2001.  In local jails, the rate of death by suicide in 2016 was 46 per 100,000 down from 48 per 100,000 in 2000.

These rates tell us despite our efforts in training, education and suicide prevention within our jails and prisons, people are still choosing to take their own lives.

Suicide is the intentional ending of one’s own life. Think about that.  Just sit and think about the fact that thousands of individual human beings, every year, decide that the life they have should end.  Many of these individuals experienced emotional and cognitive distress beyond what they believed they could handle and saw death as the best possible choice in the moment.  They likely felt alone, isolated, trapped and hopeless.  Like there was nowhere to turn. We can change that.

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Scholarship Opportunity!

The National Commission on Correctional Health Care (NCCHC) recently established the NCCHC Correctional Health Foundation.  The mission of the Foundation is to champion the correctional health care field and serve the public by supporting research, professional education, scholarships, and patient reentry into the community. I am honored and proud to be part of the first Board of Directors of the Foundation.

Just this week, the Foundation announced that scholarships are available for the NCCHC Virtual National Conference in November.  Deadline for applications is September 30, 2020. Students, staff new to corrections and individuals who have never attended an NCCHC conference are strongly encouraged to apply, but all are welcome. 

Find out more about the Foundation and the scholarship by visiting: www.NCCHC.org/Foundation

Mental Health Screening – Set Up for Success

It was a holiday weekend in the middle of the night.  The booking area of the jail was a big, open, noisy pit with people sitting in plastic chairs, watching TV or on phones and the officers either behind desks or circling the perimeter. It was filling up.  A staff member was completing initial mental health screenings in a corner of the open room, up on a platform and behind a computer.  She had the electronic health record open to the mental health screening form and she was going through each “yes/no” question, reading from the computer screen and not looking at the recently arrested individual, a young man picked up on a possession charge.

“Are you currently taking any medications for mental health problems?”  “No.”

“Have you ever been hospitalized for mental health reasons?”  “No.”

“Are you currently thinking about hurting or killing yourself?”  Pause. Swallow.  “No.”

“Have you ever been treated for withdrawal from drugs or alcohol?” “No.”

She missed it.  She missed the pause; she missed the swallow.

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Beware the Bounce-Back!

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. 

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Introducing Sharen Barboza

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

Dr. Sharen Barboza

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. 

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Covid Fatigue and Leadership

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.

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Using a Wrench Instead of a Hammer for Alcohol Withdrawal

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 something better.

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ACCP Position Paper on the Funding of Hepatitis C Treatment

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.

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Keep Covid Out of the Jail!

“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. 

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