Matt, Correctional Pharmacist. Everyone Needs One!
In my last post on this subject (found here), I mentioned three medications that I think should rarely, if ever, be allowed in correctional institutions. I would like to expand this list today.
In my personal protocol on this subject, I break problem medications into four categories, depending on three criteria:
1. The risk of abuse the medication has in a correctional setting.
2. How much potential benefit the medication has.
3. Whether there is ready availability of other, less problematic, substitute medications.
“Category One” medications are those that have high abuse potential, little objective efficacy and/or the ready availability of substitutes. This means I basically do not allow Category One medications into my jails. I would have to have an extraordinary reason to approve these medications. Take Tramadol, for example, which I mentioned in my last post. It has poor efficacy, a high risk profile, and the ready availability of other, better, pain medications ranging from hydrocodone to Tylenol. So even if a patient comes into my jail with a legitimate prescription from an outside doctor for Tramadol, I usually will disapprove it–but will usually substitute something better and less risky.
Today, I would like to round out the list of “Category One” medications. The first three medications I discussed (dextromethorphan, Tramadol and pseudoephedrine) I have seen used in some correctional facilities, though I do not think they should be (obviously). The remaining medications on my list of “Category One” problem medications are perhaps less controversial.
- Amphetamines. Amphetamines like methylphenidate (Ritalin) are commonly prescribed for juveniles diagnosed with ADHD. I will not comment on amphetamine use in juvenile correctional facilities. However, in my opinion, the risk of amphetamine use in adult correctional facilities far outweighs the benefits adults may get from it. First of all, only 10% of children with ADHD carry this diagnosis into adulthood. In adults, amphetamines, atomoxipine, bupropion and desipramine and behavior modification have similar efficacy. The risk of using amphetamines in correctional facilities is extraordinarily large. Inmates may use prescribed amphetamines to maintain their addictions, to sell to other inmates and other inmates may coerce patients into sharing. In my experience sending a patient on amphetamines into a dorm filled with methamphetamine addicts never turns out well!
- Carisoprodol (Soma). Soma is an interesting drug. It itself is not an FDA-controlled substance, but its major metabolite, meprobamate, is. Also, Soma is marketed as a “muscle relaxant,” but its active metabolite, mebrobamate, is considered a sedative—and addictive. That is why mebrobamate is a schedule IV drug. Soma is commonly used in the drug community to enhance the effect of narcotics—or just on its own as a sedative to get high. Patients absolutely do get addicted to Soma, in my experience. There are several other muscle relaxers that can be substituted for Soma, such as cyclobenzaprine (Flexeril). However, all so-called muscle relaxers probably work via sedation; not because they directly relax muscles. And all have some degree of abuse potential. In my opinion all muscle relaxers should be used sparingly in correctional facilities, if at all. But Soma?—never.
Xanax. I talked about Xanax already in a previous post (found here). It is amazing to me that Xanax is the most prescribed psychotropic medication in the Untied States. Or maybe I shouldn’t be surprised. Its short acting effects produces quite a nice high–and so patients really like it. The livelihood of doctors outside of jails depends on keeping their patients happy, so they tend to prescribe what patients like, whether it be Xanax or the latest wonder drug advertised on TV. (As an aside, did you know that only two nations in the world allow direct-to-consumer advertising by drug companies? The US and New Zealand). There is a place for benzodiazepines in correctional settings–what would we do with our alcohol withdrawal patients without them? But Xanax is an inferior benzodiazepine for a couple of reasons. It is too short acting and is too subject to side effects, dependency and abuse. There are several better and safer benzos. When I need a benzo, I use Valium in my facilities.- Oxycontin. Hillbilly heroin. Need I say more? We do need narcotics in correctional settings. We need a short acting narcotic for acute pain, like for the inmate who just had surgery. Hydrocodone is a good choice. We also need a long acting narcotic for legitimate chronic pain syndromes like the patient I had who was dying from pancreatic cancer. I use methadone in my facilities in this situation.
- Ambien and the other sleeping aids. Now I know that inmates often have trouble sleeping in a jail setting. If I were to be (heaven forbid) arrested and thrown into a dorm of 60 guys, I am sure I would not sleep well. However, Ambien is an FDA scheduled drug and absolutely is used to get high. Also, The Principle of Fairness says that if you allow one inmate to use Ambien for insomnia, you are obligated to allow all inmates who claim insomnia to use Ambien. It is far better and safer in the long run to teach inmates sleep hygiene.
- Viagra, Cialis and Levitra. Remember the Viagra ad with the guy sporting little devil’s horns? I don’t want that guy in my facility.
- Marinol and marijuana. Thank goodness I live in a state that has not yet legalized medical marijuana! I am told that medical marijuana can be a thorny problem in those states that allow it. Marinol, of course, is tetrahydrocannabinol (THC–the active ingredient in marijuana) in pill form.
I could not agree more with your comments!!!
How would you classify testosterone in your problem list of medications? We’ve seen several inmates bring in testosterone either prescribed by their psychiatrist or primary care physician. Rarely is it ever continued, I can think of one case where the psychiatrist thought it medically necessary to continue, and we did.
In my protocol, “Category 2” medications are DEA controlled medications, like hydrocodone and Valium. “Category 3” medications are those with legimate medical indications iin some patients but that also have potential for abuse in correctional settings. Testosterone would go in this category along with bupropion, gabapentin, quetiapine, trazodone, etc. These are legitimate medications for some patients. In others, the indications are hazy, like the guy with a genuine prescription for testosterone due to “low testosterone levels,” but who is suspiciously muscular. In some facilities, the abuse of certain medications becomes so rampant that the facility elevates that medication to “Category 1” status and thereby basically bans the medication outright. I understand that the Idaho Prison system recently did this with Wellbutrin. I know some facilities ban Seroquel.
Finally, in my protocol, “Category 4” medications are those found in health food stores, like ginseng, saw palmetto and St. John’s Wort. I usually don’t allow those in my facilities.
Great article!
Regarding the use of narcotics, when I do utilize them (which is very rarely) I prefer to use an elixer, such as Lortab elixer, which makes it a whole lot tougher to traffic.
And, as an aside, I wonder if anyone uses Percogesic (which is acetaminophen and an antihistamine combo)? We used to use it in the ER when we had a drug-seeking type of patient. (sounds like percocet or duragesic)
Thanks Bryan! The only knock I have against hydrocodone elixer is that it is six times more expensive than tablets. A dose of 10mg of hydrocodone via tablet costs around 5 cents a dose whereas the syrup costs around 30 cents a dose. (You can look up pharmacy acquisition costs here). Of course, that is not a big difference, especially when we use hydrocodone so rarely.
I personally dislike Percogesic and do not use it in my jails, mainly due to the antihistamine. It is sedating (that is why it is in the pill) and I have found it has pretty big demand when it is available. What do others think?
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I was a paralegal for years and had a discussion with the local jail administrator regarding pain patients in the jail. I was told that they withhold ALL narcotics no matter what condition the person arrested has or what they have been charged with. They have 72 hours to bring formal charges against someone. That is three days of withdrawal hell for someone who could have spinal cord damage, cancer, MS or other serious and painful conditions. I was told they would be put in a special unit and “detox” just like the people who take medication for fun. I realize the number one rule would be don’t get arrested, but believe it or not there are some folks that wind up arrested that are not guilty. I mean whatever happened to innocent until proven guilty? I understand that it must be controlled, but I do not understand why they can not make sure someone like that has their pain medication rather than go through withdrawals! That to me seems cruel and it should be illegal.
I’m so glad someone else feels this way. Forcing a legitimate pain patient into withdrawal in a correctional environment (which with the uncomfortable beds and chairs). Is wrong. First, as mentioned inmates are innocent until proven guilty. The wrongfully accused pain patient pays a much higher price than a non-addicted / dependent inmate or even the physically dependent addict by virtue of the fact withdrawal exacerbates their condition, Yes, it does create more work for medical and nursing staff but the patients regular provider who most like knows the patient very well prescribed this medication for a reason. Saying that an NSAID or anti-convulsant alone is routinely acceptable is just wrong. It’s a ssimilar issue when psych meds are substituted for cost or abuse liability. The jail provider isn’t put in seg when the schizophrenia patient gets out of control after a med change. Only the patient is punished – both as a result of experiencing psychological distress and being placed in discipline segregation. This is not at all times therapeutic. Innocent or guilty, ones medical needs shouldn’t suffer as a result of incarceration. I DO realize cost and abuse liability are major issues. The patient shouldn’t be punished due to this. Local governments need to make better policies that promote education, treatment, and job training over incarceration. Patients with chronic illnesses prescribed daily opioid or benzodiazepine therapy require special consideration that they rarely receive from correctional and medical staff due to the strong addiction bias that exists so commonly. I can’t blame them in a sense because they see so much of it, but these beliefs shouldn’t negatively impact the care of a patient with a legitimate need for controlled substances. Though it m referring to medical patients here, I believe this should apply to patients receiving buprenorphine or methadone as well. Forcing them into withdrawal imposes suffering and promotes relapse. Corrections is meant to protect the public and help people to change their lives. The punishment aspect of a sentence does exist but as medical personnel we should promote the welfare of each individual. WE are not there to punish anyone.
People are not thrown in jail to detox without medical assistance, first myth. Obviously comments made that are pro-narcotic and continue with “prescriptions as ordered” on the outside, have never worked inside a prison. The bartering and abuse of medications in the department of corrections is tremendous. Seroquel is commonly known as “chain gang cocaine” and it seems that those without a mental illness all of the sudden need a an antipsychotic. Lets remember too, that a large majority of offenders are in prison for drug related crimes so yes it sucks that they might have to detox but I’m sure the victims have little pity that they are not capable of getting high.
We used to charge .25 for two tyl 500’s, but it became a burden to look up the inmate and take off a lousy 25 cents from their books. Our solution “give it out for free!” So on medical pill rounds in one cell block where we have only two patients on prescription medications I’ll get ever other mother’s son, some 35 inmates down to the cart to ask for 1000 mg of tylenol. (great ratio 2:35 that actually have prescriptions). This happens every day, potentially twice a day. The inmates are just taking it because it is there and it is free, or “maybe I’ll get a headache later, better take it just in case” or they just love to take pills. Two huge problems are that one, the deputies frequently don’t check the mouth of inmates just taking tylenol, greatly increasing the risk of cheeking and hoarding leading to potential overdose. Two, long term use of tylenol is found to have ill effects, namely kidney failure as stated in a study in the NEJM.
“*The risk of kidney failure increased about 40 percent in those who took acetaminophen from twice a week to once a day for at least a year, compared with those who used the drug less often.
*The risk was double in people who used it an average of once or more a day for at least a year.”
N Engl J Med 1994; 331:1675-1679December 22,
Another study states:
They found that participants who took acetaminophen at least four days a week over the course of four years were twice as likely to develop certain blood cancers compared to people who took less or none of the drug.
“We found that high use of acetaminophen, one of the most frequently used medications worldwide, was associated with an almost twofold increased risk of incident hematologic malignancies,” said Walter, referring to non-Hodgkin lymphomas, plasma cell disorders, and myeloid neoplasms. “Acetaminophen use on the majority of the days over many years appears to be associated with this new adverse effect.”
American Journal of Epidemiology in 2004.
Furthermore we don’t have any baseline data on their current liver function. And because it is free, those already on anti inflammatories take a thousand milligrams of tyl too. ‘More is better’ in the minds of the inmates. Also those taking it habitually have no medical record of how often they are taking it.
Any suggestions?
Thanks for the comments, David. You are right that many, if not most, of the inmates who request Tylenol off of the cart are doing it just because it is free and available. The exact same thing would happen for anything you hand out free from the med cart, whether it be Tums or floss or lip balm or whatever. The main issue is to get it off of the med cart. Passing out freebies off the med cart is a waste of nursing time. The med cart is for dispensing prescription medications. Here are possibilities:
1. Put the Tylenol on the commissary. People on the outside do not have to see a doctor or nurse to get Tylenol. They just go to the store and buy it. That is “the community standard.”
2. Start charging again but charge more–like $1.00 or more per dose. That is what you would pay for an individual dose at, say, a gas station.
2. Make the inmates request the Tylenol in writing, each and every time. Otherwise they don’t get Tylenol. Tylenol is not passed out from the med cart, there is a separate trip to see those who filled out a written request.
3. If you really have to dispense Tylenol from the med cart, treat Tylenol like a prescription drug and require inmates to go to clinic and have it prescribed.
Thanks Dr. Keller I’ll forward this on to the administrator I can’t seem to get any traction with it on my own.
In the jail system inmate they crush Tylenol and mix with tooth paste with mentol and smoke They go high I agree we need to make tylenol prescription med
No they don’t your a moron…. no one smokes Tylenol you fools
Most children with AD/HD do not outgrow it in adulthood, though their hyperactivity often subsides. According to the consensus statement from the United Kingdom’s Adult AD/HD Network (UKAAN), that was the result of a Forensic Meeting held in Nov., 2009, international studies from the USA, Canada, Sweden, Germany, Norway, and Finland, up to 2/3 of young offenders and half of the adult prison population screen positively for a childhood history of AD/HD. Those whose symptoms persisted into adulthood accounted for 8 times more aggressive incidents than other prisoners, and 6 times more aggressive incidents than prisoners with Antisocial Personality Disorder. Individuals with AD/HD had a younger onset of offending, 16 years vs. 19.5 years, and had significantly higher rates of recidivism. AD/HD was the most important predictor of violent reoffending, even above substance abuse. According to researchers at the Karolinska Institutet in Sweden, in a four year longitudinal study involving 25,000 people, (published in the New England Journal of Medicine, 2012), men with AD/HD were 37% more likely to commit a crime, women were 15% more likely, and rates of being convicted of a crime were reduced by 32-41%, when treated, compared to when they were off of their medication for 6 months or more. Professor Paul Lichtenstein said, If 30-40% of longstanding criminals have AD/HD, and recidivism can be reduced by 30%, it would clearly affect total crime in many societies. In the consensus statement, UKAAN says that the abuse potential of stimulants is often overstated, because follow up studies show that in individuals with AD/HD, it is not associated with an increase in drug abuse, but a decrease. They say the overall potential benefit of medical treatment, greatly outweighs the risks. They mention using Concerta, skin patches, and long acting forms of stimulants. In the US, atomoxetine (Strattera), is not a stimulant but also not considered as effective. It is also still too expensive, but have not had problems with diversion when using liquid forms of stimulants that must be swallowed (so cannot be “cheeked”).
It’s pretty disgusting the amount of Pharm Advertisement that goes on in our country. You especially realize it when you travel for a few months abroad, and come back. We don’t need all these drugs (and if we do, it’s probably because of a side-effect of the drug they were advertising to me last year).
Will D: I realize medications can cause more harm than benefit, in certain individuals, but we also need to weigh the potential risks against potential benefits. (FYI: I do not work in the pharmaceutical industry. I have no conflicts of interests to disclose and nothing to gain.) Medications need to be used appropriately, with follow-up and patient education, including educating those who take them, about the consequences of diversion, misuse, and abuse. When you say we don’t need all these drugs, based on having recently traveled abroad, I don’t know where you traveled, but the consensus paper that was released as the result of an international forensic meeting in the UK, was based on research from the US, Canada, Sweden, Germany, Norway, Scotland, Iceland, and Finland. Sweden is even closing 4 prisons, this year, due to a 6% drop in the rate of crime, though I am not sure to what they would attribute that to. As I mentioned in my earlier post, after Lancashire County’s success, now the UK screens for AD/HD.
Overall, the research in the consensus paper found that 2/3 of young offenders and half of the adult prison population screened positively for having had AD/HD in childhood. Another found that prisoners with AD/HD were 8 times more likely to be involved in critical incidents, than prisoners without AD/HD, and 6 times more likely to also develop Anti-Social Personality Disorder. Salvatore Mannuzza found AD/HD to be the most important predictor of violent reoffending, even more than Substance Abuse. Stephen Faraone, Ph. D., says its important to break the chain of events, before youth develop Antisocial Personality Disorder.
From my own experience, one of my own family members has been on stimulant medication for 30 years. He got in legal trouble, for the first time, two weeks after no longer being on stimulant medication, after having aged out of our health insurance plan. Trying to access stimulants as an adult in local public systems was futile and humiliating.
We can’t take away the very tools that helped children be successful all through school, at the very time they are taking on adult responsibilities with adult consequences, and can no longer have their parent advocate for them because they have reached the age of majority. There is a fine line between what allows someone to qualify for mental health services, due to being a danger to themselves or others, and what gets someone put in jail.
Stimulants help AD/HD brains work more efficiently, so they can connect cause and effect, keep track, anticipate consequences, understand someone else’s perspective, I wouldn’t have believed the difference, myself, if I hadn’t witnessed a miracle 3 times a day, 40 minutes after my son took stimulants. He would suddenly become thoughtful, reasonable, patient, mature, attentive, motivated, and calm.
He never reminded me when it was time for his next dose, as someone would if they were addicted. His meds helped him be the person he was choosing to be.
Stimulants for AD/HD have been the most studied, safe and effective medications of all time,– and a liquid form can’t be cheeked! The cost of crime, to victims and society in the U.S., due to AD/HD, in 2000-2001, was estimated to be: $4,320, 596 996.00, (according to Jason Fletcher and Barbara Wolfe, Ph.D., September 13, 2009). It would seem that treatment for AD/HD would be a wise investment!
I am in my third year of correctional medicine – and still learning every day.. fascinating, actually. I love your website, so much relevant information, thanks so much!! Quick question – just curious about the crushed tylenol and toothpaste thing? I have not heard of this, can anyone give me detail on this?? I get the menthol thing in toothpaste, but I am lost on effect of crushed tylenol.. Thanks!
Thanks for the comment, Melanie! I have not heard of the crushed Tylenol and toothpaste thing. You’ll have to fill me in!
Dr Keller – on a previous note you mentioned that you had a spreadsheet of meds that are abused for other reasons in prison. I asked if you would send details to me, but I have not received the information.
I am researching the ‘alternative’ use – and method – of common drugs and hope to pass the info on to my colleagues. I am also registered with my work email (@utmb.edu) .
Re the abuse of albuterol – If I have a pt that comes in early for the first time -( eg in 30 days instead of 90 ) for his refill because “his allergies and asthma have really been acting up, lately., I tell him that I plan to make his albuterol non KOP the next time it happens. The second time he comes in early (and it is not because he would benefit from q-var) I do 2 things. (after noting peak flows are 350 + – we do not have spirometry and checking his asthma history)
First I goad him into an argument with me and we have a shouting match. If he can keep this up for an extended time; If he can get emotionally upset and hoot and holler for an extended length of time with out any sx of dyspnea and no wheezing noted, yell in clear long sentences, etc., then I know that his respiratory effort is uncompromised. Then I make his albuterol non kop. Our unit has no medical personnel from 6 pm to 6 am. He would have to convince an RN on telehealth that he was actually having difficulty before he would be sent to an ER. I explain to him that I would rather he go to the ER with difficulty breathing than have him die. I also explain that there are others in his 50 person dorm that have a puffer if he needs it, and If he did go to the ER, he would be seeing Me in the morning. I have only had to do this on 2 or 3 times in the past 5 years and not once have they had to go to the ER. Interestingly, they don’t come in for a treatment, either.
sorry – forgot to ask – could you please send me the information and spreadsheet you have regarding the alternate uses of common drugs, I would appreciate it. thanks
Within correctional settings in the United States, the use of MOUD is a relatively recent phenomenon, with just a few exceptions.
It is with no small amount of trepidation that these comments are made.
The process of prescribing medication is, of itself, proof positive that ‘familiarity breeds contempt’. There are ‘conservative’ and ‘liberal’ prescribers – though remaining within the bounds of acceptable practice. Those who are incarcerated bring with them existing medication profiles from both types of prescribers.
The process of ‘medication reconciliation, is standard when entering a new practice – as the incarcerated do when arriving at a correctional facility.
Previous comments listing the many problematic issues with certain medications – notwithstanding – it is problematic when any medication is categorically banned from a facility. Particularly if that decision is made / enforced by non-medical staff. Certainly there are medications that are ineffective, some duplicative, and others that may be misused in one way or another – as our patients are not well known for following ‘the rules’.
No correctional health care provider would cause an unmonitored / untreated withdrawal if they could prevent it – usually the result of information withheld.
It is interesting – one of the medications most commonly banned (in the past) has been those used for Opiate Use Disorder. Currently these medications are (generally) not banned – and continued treatment is encouraged. Some have, despite the ‘sensibility of the times’, made efforts to continue these medications in a reasonable way – preventing unnecessary withdrawal. The evolution of thought in this area is appropriate.
Consider this when entertaining the idea of ‘banning’ a particular medication / category.
Proper medication and prescriptions should be given to those inmates. Thanks for sharing.
This is great content. Reading this over again is worth the time.