Where Should the Hydrocodone Go?

Do these go into property?

My friend Sherry Stoutin, Medical Director of the Nez Perce County Jail in Lewiston, Idaho, shared an interesting case.

She sent a patient in her jail to the Emergency Department to be evaluated for chest pain.  He was cleared in the ER but was sent back to the jail with six hydrocodone tablets to be used PRN for chest pain as well as a prescription for 20 more.  The patient actually had no further complaints of chest pain when he returned to the jail, so whether to give the six tablets to him was a moot point.

The real question is what to do now with the six hydrocodone tablets and the prescription for 20 more.  Should they be placed in his property and given to him when he is released from jail?

What would you do?  Read on for my thoughts, such as they are:

In my opinion, the medication tablets and prescription do NOT have to be placed in the inmate’s property and given to him when he is released from jail; they may be destroyed.  My justification for this follows:

1.  Dr. Stoutin is the Medical Director of the Jail and directly responsible for the care of the patient.  It is her job to weigh the long-term risks and benefits of a particular therapy for individual patients under her care.  And she has a better understanding of this patient than the ER Doc does.  She is ultimately responsible for him.  As an example, let’s say that this patient has an allergy to sulfa and the ER Doc, not knowing this, sends him back to jail with six Bactrim tablets.  Should Bactrim tablets be put into his property and given to him when he leaves the jail?  Of course not–knowing the danger that Bactrim could be to a sulfa-allergic patient, it is, in fact, the duty and obligation of the jail doctor NOT to give the patient these tablets.  It is the same thing with the hydrocodone tablets for a patient with a drug abuse history.

2.  Dr. Stoutin sent this patient to the ER with a specific question–is this patient’s chest pain being caused by coronary artery disease?  The ER doctor did an appropriate work up and answered that question “No.”  However, Dr. Stoutin did not ask the ER doctor for advice on how to mange the patient’s non-cardiac pain.  She did not need or even want his assistance with pain management.

3.  I don’t think that the hydrocodone tablets belong to the patient, they belong to the county as a result of his custodial status in the jail.  Do any attorneys want to comment on this one?

4.  Keeping the six tablets would have been quite a hassle for the jail medical staff because , as controlled substances, they would have to be counted and accounted for every day.  This adversely impacts the safety and security of the facility (to a small degree admittedly).

I don’t know for sure what Dr. Stoutin did in this case, but in my opinion, the hydrocodone and the prescription should be destroyed.

But I could be wrong!  What would you do?

 

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30 thoughts on “Where Should the Hydrocodone Go?

  1. Sherry Stoutin

    Hydrocodone have been destroyed, prescription has been shredded.
    Thanks for your wisdom.
    A letter of communication to the local ER is being sent with a request to abstain from sending narcotics or benzodiazepines back to jail with an inmate, as this was our second similar incident in the past month.

    Reply
  2. Courtney Adam

    I would not give the pt the remaining tablets or prescription. I would say these are property of the county, assuming the pt didn’t pay for his ER visit, any diagnostics, and any medications that he received while in the ER. It seems too often pts come back from trips to the ER and think they are entitled to what they came back with, regardless of pay source. Their rationale? “I was prescribed that in the hospital!”

    Reply
  3. Donna Schroeder,RN

    It is easier for you who have an MD on staff but our county jail has a nurse 2x/wk for 8hr. The hydrocodone is the property of the inmate but personally I feel we are promoting adictive behavior. What is the legal answer.

    Reply
    1. Jeffrey Keller Post author

      Thanks for the comment Donna. Do you not have an on-call practitioner who you can call when such questions come up? You are right that those of us in corrections, especially, need to not be enablers for addictive behaviors. I will see if I can get a legal opinion on this question.

      Reply
  4. Alfred Cichon

    Absolutely Agree!
    We generally destroy controlled medication when the pharmacist comes for monthly audit. Although, we could just do it with two licensed staff (Exception – things like methadone which actually require a pharmacist)
    Our approach to the ‘When the inmate leaves’ is this: posession of prescription medication of any kind requires two components – prescription and payment. Often we get ‘they are mine I paisd for them’ – which may be true…
    However, prescriptiions are authorized for a certain period of time (not getting into abuse / misuse). When that time is up – it is up. So if you come to jail with a prescription for medication that is not approved – and leave when it should normally be expended – they don’t go with you. More community providers should call the jails for medical records…

    Reply
    1. Jeffrey Keller Post author

      Thanks, Al. When I wrote the case, I had not thought of the payment aspect that both you and Megan Tumulty pointed out. I think it is very important. If the County, acting as the inmate’s custodial guardian, paid for the ER visit and for the medication, the medication then should belong to the county.
      That is a good point about expired medications that I also had not thought of. Should an inmate be given expired personal medications when released?

      Reply
  5. Christina

    I agree they should be wasted. And I think of it this way, the initial reason they were prescribed hyrdocodone for probably has resolved by the time they get released so what is the purpose of giving them the pills and script when they leave…. other than aiding a possible addiction or to sell. If they have the same issue arise again then they should follow up with their regular doctor for further evaluation and they can get their own new script for hydro if the physician deems it appropriate 🙂

    Reply
  6. megtumulty

    Sounds like county property, or did he pay for the RX? Doubt it. Waste the tablets, no clinical indication for its use at this point.

    Reply
  7. Bernice

    I just ran into a similar predictament. We had sent an inmate to an outside specialist and he ended up with surgery and D/C with a narcotic perscription. Upon release from–jail three months later–he wanted that script.

    I agree with the above, the time was beyond his NEED for the narcotic and most likely would of ended up on the street or abused by the inmate. I chose to keep the script as part of his medical record.

    Two weeks has gone by and I have not received a phone call from the released inmate asking for the script yet!

    As far as narcotics that are brought in by an inmate being left behind upon release, it is our policy that they have 30 days to come and sign a release to repossess them or be destroyed!

    It is ultimately up to the doctor of the jail as to what medications will be prescribed to an inmate. As long as there is an alternative offered you will not be nailed for Medical Indifference.

    In summary, our facility does not order narcotics except in acute situations, ie. benzo withdrawal, etc.

    Reply
    1. Jeffrey Keller Post author

      I agree with your solution for the inmate prescription three months later. Besides, I’l bet you did give that inmate narcotics after his surgery and so you had “filled” the prescription.

      Reply
      1. Bernice

        Actually, we did not give what the surgeon recommended…I believe we gave the inmate a few days of ultram. Continued to monitor him and obtained reports from security as to what the inmates behavior was on the unit. etc.

        We depend upon our officers often, when requested, to watch some of the inmates to help assist in determining the extent of pain, etc. Watch them walk the hallways, if they are exercising in the units, sleeping, etc., Security can be VERY informative …. and bias.

        Our providers are very conscious of spending “County” money and what they order but also VERY caring and compassionate and provide GREAT medical care. If an inmate needs a medication they will order it. The Providers are the ones whom ultimately have to answer to the Sheriff and the County Board.

        We have and continue to work with our Pharmacy, came up with a formulary to try to contain costs, (which has decresased our pharmacy bill tremendously) and we often rely on them for comparable alternatives when a medication that is prescribed is more then expected.

        As mentioned above it helps to have a relationship with the ER Medical Director. Express your concerns with him or her and build a working relationship with them. Also, ask what your jail nurses/Security can do to help facilitate any ER visits. The relationship can only benefit both of you.

        Sorry for the extra input. Just sharing my experiences.

        Sorry for the extra information.

        Reply
        1. Jeffrey Keller Post author

          No need to be sorry, Bernice. We like your comments and descriptions of your services! I think most jail and prison medical staffs do their best to provide excellent, cost-effective, medical care. You should rightly be proud of what you do! Keep fighting the good fight!

          Reply
  8. DE Sanders

    We only stock one narcotic grade medication which is rarely used. Our local hospitals (ER’s and specialty clinics) as well as allied community providers are provided with a copy of our medication formulary. The standardization is not intended to impede or restrict physician judgement, but maintaining continuity within our formulary helps to ensure no delays in the inmate patient recieving necessary medication; whether for pain or otherwise.

    Reply
  9. Sarah Schaefer

    I would be very interested in knowing what to do with expired medications, loose pills or even Rxs that are not the inmate’s that the inmate brings in upon booking. We have historically documented everything and then return everything as is upon their release. It is difficult to reconcile in my mind sending out expired and/or loose pills. Frequently our patients will say they consolidated their recently refilled meds into the old bottle. Of course we are confirming with pharmacies the last refill date but trying to track everything down can be quite difficult at times. Any thoughts or suggestions?

    Reply
    1. Jeffrey Keller Post author

      Well, Sarah, I personally think that this is a legal issue rather than a medical issue. I can see taking personal medications away from an inmate if possession of them is illegal, for example, Scheduled II narcotics in a bottle with someone else’s name on it. But the deputies should be performing this property seizure, not medical. If possession of the expired medications is not illegal, then I don’t see how we can destroy them or withhold them unless we have the OK and backing from our legal representatives, like the county attorney. It may be different in prisons, where the inmate is sentenced and is a ward of the state. The prison, as a guardian, maybe can then destroy personal property like this. It is a good question! I think I will ask my legal consultants and maybe do a post on this in the future!

      Reply
      1. Carol Young RN

        I aagree that the deputies should be seizing illegal medications. However, if the medication is left at the jail and the inmate does not have a valid RX they are obviously not his property so are destroyed in conjunction with the Rph as as directed by the Board of Pharmacy. If the inmate receives a narcotic script at the ED and it is not utilized at the jail it is voided and entered into the medical record with a entry regarding why an alternative treatment modality was chosen. If an inmate has a valid script for narcotics on entry to the jail and the narcotics are discontinued at the jail the community prescribing clinician is contacted prior to release. If the provider wishes to continue the narcotics the medication is returned to the inmate on release. If the clinician does not want to continue the RX the script is no longer valid and the patient is not allowed to possess a medication for which there is not a valid script. The medication is destroyed with the consulting facility Rph.

        Reply
        1. Jeffrey Keller Post author

          This is all good policy, Carol. Calling the outside physician prior to release each time would not work well at my jails–there is often too much uncertainty about when exactly they will be released. But if you can, coordinating care with the outside medical provider is almost always the best way to go!

          Reply
  10. James Ondricek

    Here at Davis County Jail, if an inmate returned from the hospital with a script for a controlled substance we would first house the inmate in our medical unit and give as prescribed until the next available sick call with our doctor. Our doctor would review the hospital orders and determine whether or not to continue the medication. If he wrote an order to discontinue the Hydrocodone, we would immediately destroy the remaining tabs as it is no longer a valid prescription because our doctor had D/C’d it. Thus the refill would not be valid either as our doctor is the Jail Health Authority and his orders supersede the outside physician while the inmate is in the custody of our facility.
    This still applies with personal outside medications that an inmate may have had on his person when arrested or transferred from another facility on. Even though the inmate may have paid for the prescription before coming to jail and the prescription may be valid not abused or tampered with prior to coming into this jail, as soon as our doctor D/C’s that medication it is no longer a valid prescription. In that case we would simply hold onto the outside controlled medication and lock it up in the narcotic lock box in the nurse’ station and do a count log. If that inmate remains in jail custody for greater than 30 days we would at that point destroy that personal medication (it is no longer a valid prescription). If the inmate bailed out of jail or was released prior to the 30 days he could take his personal meds with him. We will not put CONTROLLED medications in his property locker as it is no longer being counted or closely monitored in the property room and we all know that no matter how careful property is handled, items do turn up missing from time to time from inmates Property. We will allow non-controlled meds to be locked up in property. We do not allow personal outside meds to be brought into the jail nor will we allow family members come into the jail to pick up an inmate’s meds that he was arrested with. It is illegal to release those controlled meds to a family member that they are not prescribed for. So now if I have confused you all with this long description just realize that we reserve the right to destroy even personal medications that are controlled substances, even if the inmate has paid for them on the outside, if they have been off that medication for over 30 days and returning it to the inmate may cause bodily harm or possible death by giving it back to them.

    Reply
    1. Jeffrey Keller Post author

      Excellent, James. I agree with everything you have outlined. I wonder if any inmates have ever sued because their “stash” was destroyed in this way? I have not heard of such a suit–but maybe it has happened somewhere.

      Reply
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  13. Theo

    Former cop & prosecutor speaking. The state has full custody of felonious prisoners, but things can get a little murkey in a jail with inmates who are waiting for trial. Convicted misdomeanor custody varies from state to state and if there’s any third party contracts, ie the shit show that is private prisons. But that’s all more CO job function related, more of.

    I’d imagine your consideration on the right action more so is derived from the State Medical Board, and the policy on when it’s acceptable to change another’s rx. Not so much worrying about destroying property, as inmates have no expectations to have property. Actually, most of the jails here in Oklahoma will destroy any narcotics that are brought into the jail even if they were prescribed legitimately and the person is bonding out an hour later, the COs destroy them. Ran into a lot of women with prescribed benzos in their purses, get arrested for something not substance abuse related, get their rx destroyed, end up in the hospital begging for another rx because their prescriber refused to rewrite, and then the hospital calls the police saying she’s doctor shopping and she’s off to do a jail house detox off benzos, because she’s now been charged with a controlled substance crime.
    I don’t think the general public realize how much of a real revolving door the justice system is right now.

    Reply

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