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.