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 →
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 →
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 →
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.
As we all know from long experience, hypertension is the single most commonly seen and treated condition in primary care medicine. It is an important risk factor for strokes, heart attacks, kidney failure and overall death. It has been exhaustively studied. And yet there is still significant controversy over hypertension, including how to define it and what the best agents for treatment are.
Against this background, The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults was released last December in JAMA. It was written by the 8th Joint National Committee, and so, of course, is referred to as JNC 8.
JNC 8 has a couple of important and surprising changes from JNC 7. One of these, at least, is controversial enough that some members of the committee rebelled and released a dissenting “Minority Report” (apologies to Tom Cruise). Today’s JailMedicine post is a summary of JNC 8 recommendations and changes to JNC 7.Continue reading →
Today’s post is an opinion piece. 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.” Continue reading →
In response to my last post, one reader wrote to tell me that the jail where she works does not accept medications brought in by inmates or their families. They consider this a security risk. All medications are ordered and supplied by the jail. She asks if I will comment on this. Before I do, I need to define a couple of terms that come up over and over in any discussion of newly booked inmates’ medications.
The first term is “Verification.” Verification refers to the process of verifying what medications an inmate is currently prescribed and is taking. There are three ways to verify medications. The first is to call the prescribing doctor’s office to get a list of currently prescribed medications. The second is to call the dispensing pharmacy to get a list of all prescriptions they have recently filled for the patient. Finally, the inmate could bring the medications they are taking into the jail with them in the original pill bottles. On the label is everything we need to know—who prescribed the medication, when it was filled, dosages–everything.
One problem with calling the doctor’s office to verify medications is that the patient often is not taking all of the prescribed medications. If I remember right, studies show that only around half of all prescriptions are filled. So you will get a list of prescribed medications, but that may not be what the patient is actually taking. Another problem with calling the doctor’s office for a current medication list is that doctor’s offices are often closed. If a patient is booked Friday afternoon of a holiday weekend, you may not be able to get a current medication list until Tuesday. Finally, many inmates get medications from multiple prescribers. For example, the patient may have a family physician, but a psychiatrist prescribes their mental health medications and they also use a pain specialist. And get prescriptions also from ERs and “Doc-in-the-Box” clinics.
Calling the pharmacy may get you more information than calling the doctor’s office. After all, the pharmacy will only tell you about prescriptions that were filled and can also tell you when the prescription was filled. If you do call a pharmacy to verify meds, don’t just ask for an “active medication list!” The pharmacy considers any prescription that they would fill for the patient active, and refills are generally good for one year. So if a patient may not have taken a certain medication for many, many months, but the pharmacy still considers it “active.”
And like doctors’ offices, pharmacies may be closed when you want to call them. And inmates often use more than one pharmacy. Some inmates use mail order pharmacies that are hard to get any information out of. Or an inmate may not use a pharmacy at all—for example, their medications might be supplied by a psychosocial rehab group. Finally, it is not uncommon for an inmate not to remember what pharmacy they use, at all!
The second term to define is “Authorization.” I discussed medication authorization in my last post. Authorization refers to the process of reviewing and inmate’s (verified) medication list and deciding which of those medications will be dispensed at the jail—and which will not.
All incoming inmates taking medications should have their prescription list verified and authorized. These two processes take quite a lot of nursing time and effort at most jails.
So now we return to the original question. Which is better, to allow inmates to bring their outside medications into the jail with them or not to allow this and instead verify their medication list and re-prescribe the approved medications ourselves? The answer is that there is no “right” answer. Each system has its advantages and disadvantages. Which you choose to use at your jail depends on several factors, such as the size of your jail, your staffing levels and the sophistication and efficiency of your pharmacy system.
With that in mind, let’s compare each system as to its relative advantages and disadvantages with regard to some of our goals in jail.
Continuity of Care
We want medical care to continue seamlessly from the outside to the inside of the jail. We want there to be no lapses in ongoing medical care for newly booked inmates. This means that, ideally, there will be no missed doses of important medications. This is, of course, easiest to accomplish if inmates brings their medications to the jail in the original containers. This makes verification, authorization and dispensing to the inmate a simple process.
Contrast this with what usually happens if the inmate does not bring the meds with them. The current medication list must be verified with phone calls to the doctor’s office and pharmacy. Even if this goes well (no offices are closed), the medications then must be ordered from the jail’s pharmacy. Best-case scenario: the process takes 24 hours. More commonly, it takes 48-72 hours and the patient has been without medications for 2-3 days.
If the inmate does not bring meds into the jail with them, the only solution for timely administration of most medications is to have an extensive collection of “stock” meds on hand, so that most medications can be continued quickly from stock. In order to be able to fill the majority of outside medication prescriptions, there must be a lot of stock meds plus protocols for automatic “therapeutic substitution” (mentioned here). https://www.jailmedicine.com/the-f-word-formulary/ That is a pretty sophisticated system.
However, even then, no “stock” med collection is going to contain all of the various HIV meds, say. Or cancer chemotherapy agents. And these are precisely the medications that we most want to continue without missing a dose!
Clearly, from a “continuity of care” perspective, it is better to encourage inmates to bring in their own, outside medications.
Advantage: Allowing outside prescriptions.
There is no question that having the original pill bottles sometimes gives you medically important information. As one example, consider the patient who takes combination lisinopril/HCTZ for blood pressure. He brings in a bottle that was filled 45 days ago for a one month supply (30 pills). There are 29 left in the bottle. His blood pressure is 128/78. Would you continue the prescription? I probably would not. I would, instead, monitor his blood pressure to see if he really needed the medication.
Or say instead, his blood pressure is 180/120. If I know that he has not been taking his hypertension medication, I would simply restart it in the jail. But if he had been taking it faithfully, I might consider adding or changing the prescription.
I could give many more examples of similar situation. Knowing that the patient has (or has not) been taking their prescribed meds is often very helpful clinically.
Advantage: Allowing meds to be brought in to the jail.
The issue here is how long it takes nursing staff to verify and approve a newly booked inmate’s medications. If the inmate brought meds to the jail in the original pill bottles, verification consists of noting the information on the prescription label, verifying that the medications in the bottle match the label and counting them. Authorization is easy as a phone call to the provider. And then the medications can be immediately dispensed to the inmate.
If the inmate did not bring meds to the jail, verification will take much more time. It consists of interviewing the inmate (Who is your doctor? Which pharmacy do you use?), then calling the doctor’s office, the pharmacy or both (hopefully, there is only one of each!). If there is a discrepancy between what the inmate says they take and what the pharmacy says they filled, a second interview with the inmate may be required. Then, after the approval process, the medications must be ordered from the jail pharmacy, delivered, processed and then, finally, they can be dispensed.
Advantage: Allow meds to be brought in.
Consider the case of the inmate who is only going to be in jail for 30 days. He is willing to supply his own medications for the month long stay. Among other things, he takes Abilify, which costs approximately $25.00 a pill. If your jail will not allow him to bring in his own Abilify, then you must either supply it at a cost of many hundreds of dollars for that medication alone, or substitute something else. Even if patients are on inexpensive medications, these med costs and fill fees add up.
In addition, if your jail charges a fee to fill prescriptions, inmates will complain, because often they get their outside medications for “free” (meaning Medicaid, most often). I have even had inmates go so far as to call this extortion and refuse to take jail prescriptions because they do not want to pay any money for meds that they are willing to supply “for free.”
Advantage: Allowing meds to be brought in at booking.
The main medico-legal risk in these situations is disruption of the continuity of care, in this case, patients missing doses of important medications. If (Heaven forbid!) something bad happens after the patient has missed a dose of medication—like the patient has a heart attack or commits suicide—it will inevitably be blamed on the missed meds by the patient, his family and their attorney. I have seen this many, many times.
Advantage: allowing meds to be brought in.
This is the one aspect of the problem where there is a decided advantage not to allow outside medications into the facility. Anytime you allow stuff from the outside to come into the jail, there is a potential for a security breech.
One possibility is that inmates might adulterate capsules by pulling them apart, pouring out the real medication and then filling them with cocaine, heroin or whatever. However, this is not as easy to do as it sounds. Adulterated capsules don’t look right and, in my experience, are quickly suspected and discarded. Besides, if you want to smuggle illicit substances into a jail, there are easier methods than trying to pour powder into tiny capsules.
A more legitimate security concern is what to do with medications that were brought in to the jail but then were rejected during the authorization phase and so never dispensed to the patient. Non-controlled substances can be placed in the patients’ property, but things can go wrong. For example, the meds, somehow, are not there when the inmate is discharged from the jail six months later. Where did they go? The inmate, of course, may demand compensation for his lost property. Maybe there should be an investigation?
Controlled substances are even worse, especially DEA schedule 2 drugs like methadone and amphetamines. Like all schedule 2 controlled substances, these properly should be kept under double-lock (i.e., a locked box in a locked room) and should be counted every day with two people witnessing and signing off. That is a lot of work should the patient stay in jail for a significant amount of time. And when the inmate is released, you have this dilemma: should you return these addictive controlled substances to him? What if he overdoses? What is your risk exposure?
Advantage: not allowing out-of-jail medications in the facility.
In the end, which system you eventually put into place for incoming inmate medications depends on how important the security angle is to you and how well you can create and use a stock medication system. To some degree, this depends on jail size. The smaller the jail, the more important continuity of outside care becomes because the small jail’s medical staff may not be there all the time. Large jails are better able to develop sophisticated stock medication systems where most incoming prescriptions can be quickly and easily filled from stock. But even big jails should have exceptions in place for expensive specialty medicines, like chemotherapy agents, immune-modulators and HIV meds.
Does your jail allow incoming inmates to bring their medications to booking? Do you like the system your jail uses? Please comment!
Sometimes, good ideas just don’t turn out as we expect. This Interesting-Article-of-the-Week is one such case and is, perhaps, the death knell for fish oil capsules so long prescribed for heart disease.Continue reading →
Imagine that you are a healthcare provider in a jail medical clinic. One of the jail nurses comes to you and says “Will you call me in a prescription for my hypertension meds? I have no more refills and my doctor charges $100.00 for a visit just to get more!” Or perhaps it is a detention deputy who asks, “Can I get a few Ambien from you? This shift work kills me and I need them occasionally.” Or “Can I get some Augmentin? I have Bronchitis.”