Random Thoughts on Alcohol Withdrawal

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

Treating Heroin Withdrawal: Methadone, Suboxone and . . . Tramadol?

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

Effective Treatment of Heroin Withdrawal in Corrections

Imagine this: You’re practicing medicine and a patient comes to you with an illness. You make the diagnosis and then say to the patient, “I can see that you are very sick. And there is a highly effective treatment for your condition that would make you feel a lot better. It’s simple and it isn’t even expensive. But, you know what? I’m not going to give it to you! You’re not sick enough. Come back tomorrow. If you’re sicker tomorrow—well, if you’re sick enough—I will treat you then. But not right now.”

Crazy, right? We’d never do such a thing.

But . . . the problem is, we frequently do that exact thing with our heroin withdrawal patients. I’m not singling out correctional medicine practitioners here. I think that, in general, heroin withdrawal is treated better in correctional settings than it is in the community. Nevertheless, it is a fact that heroin withdrawal is often not properly treated in jails and prisons. I have seen it.

I believe that there are four main reasons that some facilities do not appropriately treat heroin (and other opioid) withdrawal. Continue reading

Medications at High Risk for Diversion and Abuse In Correctional Facilities

The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings.

Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, followed by Schedule II, and so on, all the way down to Schedule V, which are thought to have the least risk.

However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons.

The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch.

It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution–if we make them available. Continue reading

Taming the Beast—Gabapentin. Ban It or Regulate It?

In my last post, I began with a question from Christy.  Her facility was considering banning gabapentin from their facility due to rampant abuse and diversion problems.  My last post dealt with gabapentin’s interesting history and the evidence base for off-label gabapentin prescribing.  This JailMedicine post will deal with the pros and cons of banning gabapentin versus creating rules to regulate gabapentin use and hopefully minimize diversion and abuse. Continue reading

Taming the Beast: Gabapentin

A reader recently wrote

At our facility, one of the most abused drugs in Neurontin. I am the trying to formulate when this medication will be continued. My question is if the following is acceptable in your opinion:
Neurontin will not be given for any indication not approved by the FDA. The only indications approved by the FDA is for epilepsy and PHN after shingles. Now the question remains how can you tell what the indication of prescribing the Neurontin was? The therapeutic dose for the treatment of epilepsy is 900 to 1800mg a day divided into three times a day not to exceed 3600 mg per day. If you come to our facility on 300mg at night, this clearly indicates that the drug was not given for the two recommended doses so therefore, it can be assumed it was given for insomnia- which we do not treat at our facility. The Neurontin would be canceled and we would observe for signs and symptoms of withdrawal for the next 5 days.
Does this sound reasonable and do you know of a substitution for the treatment of diabetic neuropathy that is less abused in the jail setting?

Well, you’re not alone, Christy! Gabapentin is one of the most abused and diverted drugs at all correctional facilities that I know of! (I’m going to use the generic term “gabapentin” interchangeably with the brand name “Neurontin” in this article). In fact, I was recently in a meeting with the commissioner of a certain state’s Department of Corrections to give an update on medical services in his prisons and the very first question he asked was about gabapentin. Gabapentin! Think of all the things he could have been concerned about—Hepatitis C for example—and instead, he asked about the security problems caused by gabapentin diversion.

In my experience, gabapentin is one of the “Big Three” non-DEA regulated drugs with the potential for diversion and abuse in a prisons and jail. The other two are Seroquel and Trazodone. The important difference is that Seroquel and Trazodone both allow easy substitution of another, less abused, cousin. Gabapentin, not so much.  More on that later.

In order to get a handle on gabapentin, I think it is important to understand where it came from and why it has not approved by the FDA for most of the reasons it is prescribed nowadays. B_beuRNW8AEYOgn

Continue reading

Reader Question: Xanax Withdrawal

I am looking for a withdrawal protocol for benzos. I have patients that have been on Xanax 2mg for 3-5 years and now I need to detox them. We all know how difficult this is with people in the community let alone in the correctional setting. PLEASE HELP !!!!
Thank You, Doris

Well, Doris, you have come to the right place! I, and many other JailMedicine readers, are happy to share our strategies for dealing with benzodiazepine withdrawal. And this is a common dilemma in county jails. Believe it or not, Xanax is the single most-prescribed psychiatric drug in the United States. My experience is that Xanax is highly addictive and yet handed out like candy by some community practitioners. Some community prescribers I have talked to do not even realize that Xanax is addictive!  Strange but true.GABA-Production Continue reading

Reader Question: Medication Approval

My friend Al Cichon recently asked the following questions:

UnknownWhat ‘authority’ does a jail provider have to change the prescription of an inmate coming into the jail?

I have been asked when I would not approve an existing prescription – non-compliance (over / under); diagnostic mismatch (extreme example anti-viral for bacterial infection); – can you think of others? Continue reading

What Do You Think of The 10 Point Pain Scale?

20050824I was asked via email what I thought of the 10 Point Pain Scale.  I have never been a big fan of the 10 Point Pain Scale, but I think that it is a particularly poor fit for Correctional Medicine and I don’t use it in my jails.

Hospitals have to use the 10 Point Pain Scale because it is mandated by JCAHO, the hospital accreditation body.  But JCAHO has no authority over jails and prisons. We don’t have to use it and I personally think we practitioners of Correctional Medicine are better off without it.

I used the 10 Point Pain Scale quite a lot when I worked in a busy Emergency Department, both because I had to (it was a JCAHO mandate) and because it can be useful in an ER setting.  The 10 Point Pain Scale is not bad at evaluating acute pain, like the pain from appendicitis or a broken leg.  However, it is not as useful when evaluating chronic pain like what we see in corrections.

Even in an ER setting, I noticed problems with the 10-Point Pain Scale.  First, it is entirely subjective.  In other words, patients say a number and there is no objective way to know if they are being honest or not.  In the ER, I suspected that many patients inflated their numbers.  For example:

My pain is 13-out-of-10.”

My abdominal pain is 10-out-of-10 (said while the patient was eating Cheetos).”

The 10 Point Pain Scale is more useful evaluating responses to therapy via changes in the pain scale.  So if a patient tells me that he has 10-out-of-10 pain, I may not be exactly sure what that means.  But if he later tells me that his pain now is 8-out-of-10, I know that he has improved.  But even that did not happen all of the time.

I had cases where I would treat patients with IV Dilaudid, say, until they were asleep.  Yet when the nurse woke them to ask about their pain, the patient would say (with slurred words) “itsh shtill a ten.”  Should I have given more Dilaudid based on that report of 10-out-of-10 pain?  Of course not!

Let me give an example from the other end of the spectrum.  Tough, stoic cowboy-types would come to the ER with long bone fractures and would rate their pain a “2-out-of-10.”  Do I then use Tylenol instead of IV narcotics to treat the pain from this femur fracture?  Again, of course not.

Finally, what do I do with a patient who rates her pain high–say 9 out of 10–but refuses narcotic pain medication?  Don’t laugh, that actually happens!  Some people are tough and can handle pain better than others.  Others would rather have pain than be gorked by pain meds.

In the end, even using the 10 Point Pain Scale, ER doctors still have to rely on their clinical judgment.  Yet that means there will be discrepancies between what the patient says his pain is and how it is treated.  Let’s say the nurse dutifully records in the medical record that the patient says his pain is 10-out-of-10, but, based on my clinical judgment, I do not give pain medication.  Later, when the medical record is reviewed by JCAHO, a hospital committee or a plaintiff’s attorney, I look like an uncaring sadist:  “My client was crying out that his pain was as bad as pain could possibly be and you did nothing, Doctor?”

And those are just the problems when the 10-Point Pain Scale is used to evaluate acute pain in ERs.  It is even worse when used to evaluate chronic pain in Correctional Medicine clinics.  Chronic pain patients tend more than acute pain patients to rate their pain 10 out of 10 and to admit to little change.  There is also more discrepancy between what chronic patients say (The pain is 10 out of 10) and what they do.  For example, consider the patient I actually had in one of my jails who told me in clinic that his chronic back pain was 10/10 in intensity.  Later in the day, I looked into the recreation area just in time to see this patient perform a perfect basketball reverse layup.  This did not mean that this patient did not have back pain at all—he probably really did–but it did mean that he probably did not have true “10 out of 10” pain.  It also meant that I could not trust this patient’s subjective pain scale scores.

It seems to me that I have to use even more clinical judgment in a jail than I did in the ER.  I have to weigh the potential adverse effects that narcotics have on the safety and security of the facility.  I have more patients with addiction problems and have to try to sort out true chronic pain from addiction.

Plus, in a jail, I have more true objective evidence to base my clinical decision on than I did in the ER since I can observe patients away from the medical clinic.  I can watch them at recreation.  I can watch them walk and talk and eat in their dorm.  I know the legal circumstances that landed them in jail, like illicit drug use, that an outside doctor may not ever know about.

The subjective 10 Point Pain Scale in such a setting is more hindrance than help, I believe.

I still ask the patients about their pain. I even use a pain scale, though a simpler one consisting of just four points: none, mild, medium and severe.  I also ask about changes in  pain:  “Is your pain improved since yesterday?”  But more importantly, I ask patients how their pain affects them in everyday life.  Can you sit?  Stand?  Watch TV?  Walk during recreation?  I record the answer and then compare that (if necessary) to observation of those activities.

The 10-Point Pain Scale does have its uses.  In my opinion, it works best for monitoring responses to therapy of acute pain.  For example, when I used to give IV Dilaudid in the ER to a patient with a femur fracture, her responses to the 10-Point Pain question would help me to know that I was getting somewhere with pain relief and when to stop.  Whether it worked better than asking “Is your pain improved?” or “Do you want any more pain medication?” is a debatable point.

But the 10 Point Pain Scale is not as useful for rating chronic pain.  In my opinion, it is the wrong tool for this task.

Feel free to disagree with me, though!  I could be wrong in my opinions!

What is your experience with the 10 Point Pain System used in hospitals?  Do you use it in your correctional facility?  Please comment!

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Essential Pearls from Essentials

Essentials of Correctional Medicine was held last week in Salt Lake City, Utah and included some great talks.  Today’s post is a list of Pearls I gleaned from the conference speakers.

The definition of a “Pearl” is a bit of pithy and insightful information that can be communicated in one or two sentences. Hopefully, it is also something that you have not thought of yet and will change your practice for the better.

I ran into several Pearls at the Essentials conference. Here is a sampling (in no particular order): Continue reading