I had yet another patient recently who demonstrated what I call the “Compliance Trap” of corrections. The Compliance Trap is simply this—on the outside of jail, in the real world, most people do not take their medications perfectly. They miss doses. They forget sometimes. Many studies have demonstrated this. But when these same people come to jail, they get their medications passed to them every dose—they do not miss doses. They are compliant with their medication dosing in a way they weren’t on the outside. And this can sometimes get them into trouble.
Take for example, the patient who came to my jail with a prescription for Dilantin 600mg a day. This is a huge dose! But he had a legitimate prescription for it and so it was continued at the same dose in jail. However, two weeks late, he began to have nausea, vomiting and dizziness. We checked his dilantin level and it was 32–he was toxic! Dilantin 600mg a day was, indeed, too big of a dose for this patient. In fact, after we had adjusted his dose and checked levels a couple of times, we found that the proper dose of Dilantin in this patient was a more modest 400mg a day.
So how did this happen? I did not interrogate this patient’s outside doctor, but I think I know what happened. He kept returning to the outside clinic with subtherapeutic blood levels of Dilantin and the doctor kept increasing to dose. However, the reason the patient had subtherapeutic blood levels was NOT that he was a super-rapid metabolizer of Dilantin; rather he just hadn’t been taking it every day. He had been missing doses.
But when he came to jail, the jail nurses made sure he did not miss any doses and quickly, he was toxic.
So that is the Compliance Trap. Outside of jail, many patients do not take their medications regularly or at all. When they come to jail, they don’t miss doses. Outside–not compliant. In jail–compliant. And sometimes this can make them sick.
The Compliance Trap–Examples