You Need a Medical Commissary in Your Facility!

When I was an undergraduate, before I switched to pre-med, I was an economics major.  Maybe because of that training, when I look at jail medical practices, I tend to look at all of the costs of medical practice, not just the monetary costs.  For example, the total cost of providing a medication to a patient in the jail includes the cost of the medication (of course), but it also includes the cost of the various people, like nurses, pharmacists, deputies and practitioners, who spend time creating the prescription.  Thinking of costs in this way can change our perspective of what something “costs.”

Consider the case of the man with heartburn.  We’ll call him “Jeffrey.”  He doesn’t know it, but he is about to go to jail.  Before Jeffrey goes to jail, if he wants to purchase something like ranitidine (Zantac) for his heartburn, he would go to a store and buy it.  He doesn’t need to see a medical professional.  He doesn’t need a prescription.  In most places, he doesn’t even need to wait—convenience stores sell ranitidine 24/7.  The monetary price Jeffrey will pay for 50 tablets of ranitidine at the store is around $7.00.  The cost in terms of time is how long it takes him to run to the store.  The total cost in time to the store to provide the ranitidine to Jeffrey is 30 seconds—how long it took the store clerk to ring up the sale.

Now think of the same guy in jail.  Jeffrey still has heartburn.  Let’s say he still has money—now in his commissary account.  He is still willing to buy ranitidine.  But ranitidine is not on the jail commissary list.  He can buy Ramen noodles or a Snickers bar, but not ranitidine.  In order to get ranitidine, he has to put in a “Request for Medical Care” form.  What happens now varies from jail to jail and prison to prison.  I am going to present a typical jail scenario.

The act of requesting non-emergent medical care costs Jeffrey $10.00.  The form is then triaged by a nurse and Jeffrey is scheduled to see a practitioner.  Since the clinics are crowded, the appointment is made for five days hence.  In the meantime, he continues to have heartburn.  On the scheduled day, he comes to the medical clinic.  He waits, say, an hour in the waiting area.  He then has vitals taken by a nurse.  The practitioner, unsurprisingly, orders a prescription of ranitidine from the pharmacy for Jeffrey.  The order is sent to the pharmacy and is delivered the next day.  It is paid for from the jail medical budget.

Total monetary cost to Jeffrey is $10.00.  Total monetary cost of the prescription to the jail is around $6.00.  Total price to everybody in time is, well . . . a lot.  Jeffrey had to wait five days.  The jail medical staff had to process and triage the Request for Medical Services (10 minutes total?).  A nurse and a practitioner had to see the patient in clinic (another 15 minutes total between the two?).  A chart is generated, which then has to be filed (30minutes?).  Deputies spent some time getting the patient to the clinic and back.  The pharmacist spent time filling the prescription.  The UPS/Fedex delivery service . . . well, you get the drift.

It doesn’t matter if I am over-estimating the time.  Just remember that we have to multiply whatever time figure we come up with by every request for an OTC product that is handled this way.  Not just ranitidine, but also foot fungus cream, cough drops, rash cream, ibuprofen,  acne cream, nasal spray and on and on.

Why not put OTC medical items on the commissary and let inmates purchase them without having to go through the medical service?

This actually seems to me like a no-brainer all the way around.  Put the ranitidine on the jail medical commissary so that Jeffrey can purchase it without having to involve the medical staff.  Jeffrey benefits by having much easier access to OTC products at a cheaper price.  The medical staff benefits by not having to deal with requests for OTC products and having that much more time to spend with truly sick patients.

I can hear you objecting!  “We don’t charge inmates a fee to access medical clinic.”  “Nurses can give inmates a week’s supply of OTCs; the inmate does not have to see the practitioner.”  These questions miss the point that the main cost of making inmates go through “the system” to get OTC medications is time!   The savings in time to nurses, for example, allows them to spend more time with truly sick and needy patients.

If you do decide to set up a medical commissary system, here are a couple of items to consider.

Indigency.  What happens if Jeffrey has no money on his books?  One way to deal with this is to allow indigent inmates to buy certain medical commissary items on credit (meaning that they “go into the hole” with their books—and if they ever get funds, the money is paid back).  Another is for the jail just to absorb the cost of certain medical OTC products for indigent inmates—that is still cheaper than making them kite and go to clinic.  The jail pays for the medication either way!

Inappropriate OTC items.  There are certain items that are available OTC at your local store that, in my opinion at least, should not be offered on a jail commissary.  This includes any item that can be abused or that can cause serious harm when taken in overdose.  I would include the following:  dextromethorphan cough medicine, Benadryl and other first generation anti-histamines (though I would allow purchase of second generation OTC antihistamines, like Claritin), and Pseudoephedrine (used in meth production).  No Ex-lax, of course!  Too tempting to play practical jokes on your neighbors!

Sometimes, inmates don’t like purchasing medical items off of commissary.  They get it free if they go through the medical clinic. Time is not as important to them as it is for us.  The answer to this question is to make purchasing OTC items off of commissary cheaper than going through medical.  One way to do this is this:  when an inmate comes through the medical clinic requesting, say, ranitidine; rather than order the item through the pharmacy, pull the item off of commissary and charge the inmate a small “urgent access fee.”  The idea is that you want it to be cheaper and easier for inmates to purchase commissary items without bothering you.

What items can be offered on a medical commissary?  Remember that any OTC medical item you do not make available on the commissary can only be obtained by an inmate by going through the medical process.  Here is one possible list:

  1. Rash medications
    1. Antifungal foot cream
    2. Hydrocortisone cream
    3. Benadryl cream
  2. Acne medications
    1. Stridex pads
    2. Benzoyl peroxide
  3. Stomach medications
    1. Antacids (Rolaids)
    2. Ranitidine
    3. Omeprazole
    4. Gas-X
    5. Beano
  4. Diarrhea medications
    1. Fiber tablets or Metamucil
    2. Pepto-bismol
    3. Imodium
    4. Kaopectate
  5. Constipation medications
    1. Fiber tablets or Metamucil
    2. Stool softeners (Colace)
  6. Diet supplements
    1. Vitamins
    2. Calcium
    3. Lactaid (for lactose intolerance)
  7. Cold and flu medications
    1. Saline nasal spray
    2. Afrin nasal spray
    3. Cough drops
    4. Sore throat lozenges
    5. loratidine (NOT other antihistamines or decongestants)
    6. Ibuprofen
  8. Muscle ache remedies
    1. Muscle rub
    2. Ibuprofen
  9. Psoriasis and dandruff medications
    1. Dandruff shampoo
    2. Coal tar shampoo
    3. Coal tar lotion


12 thoughts on “You Need a Medical Commissary in Your Facility!

  1. Pingback: Obstacles to a Medical Commissary Program | We discuss all aspects of medicine practiced in jails, prisons and juvenile facilities

  2. Brenda

    We removed Imodium off our OTC list as we were finding inmates crushing and snorting it! It apparently gives them an opioid-like high! We replaced it with kaopectate liquid.

    Reply
      1. Theo

        It needs to be in mega doses, like 50 to 100s of pills, along with a PP-inhibitor like tagamet in order for there to be any kind of opiates like high.
        They crush it because of the urban legend that if you snort it, it’ll cross the blood brain barrier.

        Reply
  3. Cheralee

    Recently searches resulted in a large amount of OTC ibuprofen bought from commissary. There was concern of the inmate consuming all the ibuprofen in an attempt to OD. The only things offered on our commissary for medical purposes are acne cream, antifungal cream, ibuprofen, Tylenol, and Rolaids. Any ideas?

    Reply
    1. Jeffrey Keller Post author

      Hi Cheralee,

      Ibuprofen is relatively benign. It would be hard to harm yourself with ibuprofen by overdosing. However, Tylenol can be deadly in only moderate amounts. For the average sized person,10,000mg could be a toxic dose. If you use 325mg tablets, that is only 30 pills. So it would be wise to have a mechanism to check on how much a person is ordering and periodically check their stash, as you are doing. However, this stuff is sold OTC on bootless much larger than 30 pills in the community. Having it on commissary is consistent with the community standard. Also, even if you take it off the commissary and inmates can only get it by prescription, they can still cheek and save, get extra from other inmates etc, and still overdose.

      Reply
  4. Pingback: Nursing Clinics and Scope of Practice. What Do You Think? | Jail Medicine

  5. AlanB

    Great article that was of significant help in setting up our facility’s OTC commissary system.
    Thanks

    Reply
  6. Mary Page Platerink

    How would you feel about a single dose of Dex and Phenylephrine in a liquid 35ml shot combined with menthol and pectin (i.e., ingredients in a typical cough drop)? It is powerful to stop coughs, but significantly more difficult to abuse than a multi dose of such products. It would be difficult to stockpile because it is relatively bulky. Thoughts?

    Reply
  7. Pingback: Obstacles to a Medical Commissary Program | Jail Medicine

  8. Nolan Brooksby

    You list Metamucil but in another article about abused medication you suggest no Psyllium due to the ability to make a weapon.

    Reply
    1. Jeffrey Keller MD Post author

      Good point! I listed metamucil before I learned of the possibility that psyllium could be made into a weapon . . .

      Reply

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