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.
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
Patients are dying in correctional facilities from
benzodiazepine withdrawal! This is not
just a theoretical observation; this really is happening. This fact bothers me since
benzo withdrawal deaths are preventable.
Benzodiazepine withdrawal is easy to treat! It is certainly easier to treat benzo
withdrawal than the other two potentially deadly withdrawal states, alcohol and
opioids. By far, the most common cause of
benzodiazepine deaths is, of course, not treating it!
So, is your facility at risk to have a patient die of
benzodiazepine withdrawal? To find out, compare
your policies to the following Rules for the Treatment of Benzodiazepine Withdrawal.
At one of my recent jail medical clinics, three patients in a row requested prescriptions for gabapentin. One was a patient newly arrived from the Idaho Department of Corrections to be housed at my jail due to prison overcrowding. He had already been prescribed gabapentin at the prison for complaints of low back pain radiating to one leg and wanted me to continue it–forever. The second patient was prescribed gabapentin by his outside practitioner for a boxer’s fracture that had been surgically repaired years ago. The third was prescribed gabapentin at a previous jail due to “nerve damage” from an old gunshot wound to the upper arm (he had a large scar but no functional disability or decreased sensation).
Gabapentin prescriptions for nonspecific musculoskeletal pain have clearly become common in the community and in corrections. These three patients represent only a fraction of the similar cases I see in my jails! I suspect that this gabapentin-mania is being driven by a belief that gabapentin is preferable to prescribing narcotics (though I would not think any of the three patients above would be candidates for narcotics). Gabapentin, in fact, is often prescribed for musculoskeletal pain in my community first line—before NSAIDS and Tylenol, even—and many, like these three patients, subsequently believe that gabapentin is something they will need to take for the rest of their lives.
The problem is that prescribing gabapentin for
musculoskeletal pain is not evidence-based and (in my opinion) bad medicine.
Today’s post is a repost of an article I wrote previously about Skeletal Muscle Relaxants (SMRs). Concurrent with this article, I have added a Sample Guideline on prescribing Skeletal Muscle Relaxants to the Guideline Section of JailMedicine.
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.”
I recently ran across this news article on NPR (found here) about the problem of treating the large number of opioid addicted patients who are coming to our jails. There is a growing movement that all opioid addicted patients should be offered Medication-Assisted Treatment (MAT) while in jail–meaning one or more of three drugs: methadone, Suboxone or Vivitrol. The article does a good job in pointing out that this is a complicated problem. Having been on the front lines of this problem for many years in my own jails (and so having that great teacher–experience), I would like today to present my own thoughts on using MAT in jails. (MAT in prisons is a separate subject that I will address later).
I work in the prison system in the UK. I wanted to ask you if the prisoners have in-possession medication in America or is it all supervised? If you do have in-possession medication, have you seen or thought of a way for the inmates to keep the medication safe i.e. lock box in their room (this then highlights a security issues as can store contraband etc. in lock boxes? Is there a feasible and reasonable way that inmates who want to keep their tradable medication to them self and not fear being bullied by peers for them? Any ideas would be greatly appreciated!
After doing research in my current jail. The percentage of people who actually pass random meds check is currently 18%. Now obviously not all those that failed had them “pinched” from their possession and most certainly commonly abused meds such as trazadone and mirtazapine have been sold as “sleepers” on the wings. But for those people who genuinely get bullied for their medication or do in fact get them stolen what is the alternative measure to help them apart from to put them not in-possession and supervise them daily?
If you have any ideas I would greatly appreciate it.
Thanks for the questions Dez! In the United States, most medications are passed in a supervised setting. “In-possession” medications are referred to as “KOP,” which stands for “Keep on Person.” I’m going to use this term despite the fact that not all KOP meds are kept on person. Different facilities handle KOP medications in different ways, which I’ll get into. Here are the basics of KOP medications:
2018 has been a remarkable year for news and research into gabapentin, and the year is not even over yet! That is great news for those of us (myself included) who puzzle over the proper role of gabapentin within correctional medicine. On the one hand, if gabapentin is a useful drug for chronic pain, neuropathy, or any other medical condition, I want to use it properly. On the other hand, gabapentin is a ferociously abused drug within jails and prisons. It is both a sedating and euphoric drug that also can be hallucinogenic at high doses. When it is available within a prison, there is inevitably abuse of gabapentin (like snorting it), diversion of gabapentin (because it has large value within the correctional black market and so can be sold to others), and finally, there is inevitably coercion of weaker inmates by stronger inmates to acquire gabapentin prescriptions and give those prescriptions up to the strong. Those of us in corrections have seen all of this and worse.
So any news of gabapentin, whether good or bad, can change the balance of this deliberation. If gabapentin is proven to be more effective medically, it may be worth tolerating the abuse. If it is found to be ineffective, there is no reason to introduce this stressor into the system. With this in mind, here is a sample of the 2018 news on gabapentin.Continue reading →
I had a lot to learn when I began practicing medicine in county jails. One of the most important of those lessons was how properly to assess and manage alcohol withdrawal. In my previous life as an ER physician, I had seen a few alcohol withdrawal patients and even one or two cases of DTs. I thought I knew what I was doing. Wrong-o! I was first unprepared for the sheer number of alcohol withdrawal patients I would see as a correctional physician. Alcohol withdrawal in jails is simply very common.
But I was also unprepared because much of what I had been taught about alcohol withdrawal was inaccurate or misleading. Nothing teaches like experience! After many years of treating a lot of alcohol withdrawal, I have gained some insights.Continue reading →
In my last JailMedicine post, I wrote that clonidine is an excellent drug for the treatment of opioid withdrawal. In response, several people have asked about methadone and Suboxone. Why not use one of those drugs instead of clonidine?
The short answer is that both methadone and Suboxone are excellent drugs for the treatment of withdrawal. However, both are much more complicated to use in jails due to DEA legal requirements and a much larger potential for diversion and abuse. If you are using Suboxone or methadone, great! I believe that clonidine is a better choice for most jails. Those interested in using methadone or Suboxone need to be fully aware of the DEA laws surrounding their use. Before you use one of these drugs, you must make sure that you are following the law. I know of two physicians in my hometown who were disciplined by the DEA for prescribing narcotics to treat addiction without registering. The DEA are not kidders!
By the way, Jail practitioners should also be aware that Tramadol has been used successfully to treat withdrawal, as well.Continue reading →