Like everyone in corrections, I have seen my share of cheeking. For those who may not know what this is, “cheeking” is the slang term for when inmates pretend to swallow their medications but really secrete the pills in their cheek (hence the name) or elsewhere in their mouth. Some cheekers are really good at sleight of hand, and palm the pills as they pretend to pop them in their mouth. Some spit the pills into the cup that holds their water. A good correctional nurse will usually catch such attempts.
Some inmates, however, will get really creative. We had one inmate who was missing a tooth and he would slide the white pill into the empty socket so that when he showed his mouth, the pill would look like a tooth in a row of teeth. Another inmate put denture adhesive on the roof of his mouth and then stuck his pills onto the Fix-o-dent, so they weren’t visible when the nurse would check his mouth. But I recently ran into a method of cheeking that was new to me.
This was discovered when a certain inmate had a dystonic reaction of the type that occurs sometimes with phenothiazines like Haldol. Only he was not taking Haldol and the only inmate who possibly could have cheeked the Haldol and given it to this inmate was his roommate, a guy I will call Fred.
Fred had a long history of cheeking medications. He had tried many creative methods and had been caught on numerous occasions. Most recently, Fred’s medications were being crushed on the assumption that that the powder could not be manipulated and hidden. However, Fred found a way around this. He would pretend to swallow the powder, but would leave it on the back of his tongue. Then, when the nurse had gone, he would scrape the powder off of his tongue and mix the powder with saliva to make a paste. He then would dry the saliva-wad and sell this concoction to other inmates. By the way, the spit wad pill contained all of Fred’s medications, not just Haldol. He was on several.
Apart from the initial aesthetic response to such a thing (Ewww!), there are some lessons to be learned from this. First, some inmates are so desperate for psychoactive drugs to substitute for their preferred drugs of abuse outside of jail, that they will do near anything to get them, including eating a spit wad with who knows what in it. This is especially true for medications with very high value in correctional sttings, such as Seroquel and Trazodone. But anything that will alter consciousness will work.
Second, the effort we put into preventing cheeking is part of “the good fight.” We cannot prevent all cheeking—inmates are too creative. But inmates who purchase and consume someone else’s medications may have serious adverse reactions. The inmate consumer in this case only had a nuisance reaction (dystonia) that we easily treated with Benadryl. But it was still quite unpleasant and could be worse next time. I believe that our efforts to prevent cheeking are part of our overall “due diligence” efforts to keep our patients safe.
I believe that even though the street value of the medication is a motivating factor, inmates have other reasons for cheeking. One of these reasons is control. Once they are in jail they have lost the freedom to leave of course, but also the freedom to make day to day decisions for themselves. Most decisions are made for them and cheeking medications gives them a sense of even the smallest morsel of control. In their minds anything that they can do to thwart the system gives them a sense of independence. Even cheeking medicine with no street value such as Tylenol or Ibuprofen is common. It is the game. Being successful gains them the feeling of accomplishment that is so alien to anyone in this setting. But as much or even more than that, they gain respect from other inmates.
Much like the story of Cool Hand Luke, a prison inmate during the days of chain gangs who received great respect from fellow inmates because he was able to frustrate the system and in some cases use the system against itself and to his advantage. In fact his prowess even made the law abiding audience respect and even cheer for him to succeed. The jail is full Luke wanna-bes. They want respect among their peers and they get that if they are successful cheeking, and sometimes a customer comes along with the deal.
I think the control issue is significant. It impacts many facets of day-to-day living in the correctional system.
Thanks Kim. I think you are right.
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Our inmates are informed at their initial medical screening that “Inmates found to be sharing, hoarding, or cheeking medications will have the medication discontinued until review by provider”. Providers may discontinue the medication completely (you didn’t take it then you must not have needed it), meds may be replaced with liquid or crushed. This appears to be an effective deterent. Word travels fast.
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We have implemented the use of crushing medications and adding them to about 1 oz of applesauce. This makes it much less likely the patient will cheek the medication. This diminishes irritation to the mouth caused by the medication. It also makes mixing easier.
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Can you be charged with negligent homicide if an inmate cheeks a med, that is supposed to be crushed but is not, and then overdoses and dies?