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 →
Today’s post is the first in a series of sample clinical guidelines. These will be placed under the “Guidelines” tab (above) as they are published. These guidelines are open access; you may use them in whole or in part as you see fit. I view these sample guidelines as a group effort! If you have a suggestion, critique or simply a better way to phrase some concept, say so in comments.
This particular clinical policy addresses a common problem in jails (less so in prisons). I addressed the issue of allowing personal shoes in jail previously in “A Quick-and-Easy Solution to those Pesky ‘Own Shoes’ Requests,” (found here). As a result of that post, I have had many email requests for a sample “Own Shoes” guideline.
Medical Approval of Personal Footwear in Jails
This clinical guideline is intended to be used as a template to help clinicians and administrators create their own policy on personal footwear. This sample guideline must be modified to make it applicable to each unique correctional facility. This guideline is not intended to apply to all patients. Practitioners should use their clinical judgement for individual patients.
Introduction. Inmates housed in county jails are provided footwear by security personnel. Occasionally, inmates will state that they have a medical condition that requires them to wear their own personal shoes. If an inmate asks medical personnel to authorize him to wear his own personal shoes, medical providers should re-frame the question as “does this patient have a legitimate medical need to wear his own personal shoes?” Inmates may desire to wear their own shoes for many non-medical reasons, such as convenience, as a sign of increased status among other inmates and as a way to smuggle contraband. This guideline addresses the question of when inmates have a medical need to wear their own personal shoes.Continue reading →
I have begun a new blog that is being published on MedPage Today entitled “Doing Time: Healthcare Behind Bars.” The difference between that blog and JailMedicine is the audience. JailMedicine is written for medical professionals already working in a jail or prison (bless us all!). The MedPage Today blog is written for medical professionals who have no idea what Correctional Medicine is all about. The first post of Doing Time follows:Continue reading →
You are seeing a newly booked patient in your jail medical clinic. He states he has been in jails before, many times, and is always given a second mattress and an extra pillow because he had surgery on his back many years ago. You note that the patient has not seen a doctor on the outside for many years, that the patient walks and moves normally and that he has a normal neurological examination. You tell the patient that medical does not give out passes for extra mattresses or pillows. The patient angrily erupts in a blaze of obscenities and threatens a lawsuit.
Manipulation happens when a patient wants something that they should not have (like an extra mattress and pillow) and will not accept “NO” for an answer. In my last JailMedicine post, I outlined the strategies patients employ in an attempt to entice or force practitioners to change a No to a Yes. This patient is employing the “threatening” strategy.
Verbal Jiu-Jitsu is the technique of deflecting and defusing manipulative confrontations. Notice that I did not use the word “defeating.” That is because the first and most important rule of Verbal Jiu-Jitsu is to remember that this is not a war or a contest! There should be no “battle of wills” between you and your patient. There is no winner or loser. Instead, you and your patient are having a conversation. The whole goal of Verbal Jiu-Jitsu is to avoid any kind of verbal battle.Continue reading →
One of the more common complaints that I hear from correctional practitioners (especially new practitioners) is “Manipulative patients are driving me crazy!” To be honest, I ran into a lot of manipulative patients when I worked in the ER, as well. ERs are the epicenter of narcotic drug seeking! But it is true that many of our patients in Corrections are especially skilled in manipulation. They have practiced this skill their whole lives and have become very proficient. Most people, including correctional professionals, are not naturally skilled at dealing with manipulation. This is often not a skill that we have needed before coming to work in a jail or prison. But once there, learning to manage manipulation is an essential skill if you want to be happy in correctional practice. I call the art of dealing with manipulation “Verbal Jiu-Jitsu.” In order to become a skilled practitioner of verbal jiu-jitsu, we must first start with an analysis of what “manipulation” actually is.
Manipulation in a medical encounter occurs when a patient wants something he shouldn’t have and won’t take “No” for an answer. If the patient wants something he should have-no problem! Or If the patient is told “No” and accepts that answer–also no problem!
So manipulation involves these two essential elements:
1. The patient wants something she should not have. This something could be an extra mattress, a special diet, gabapentin, an MRI, a referral off site–anything.
2. The patient does not accept “No” for the answer.
What comes after not accepting “No” for an answer is manipulation. Manipulation is the attempt to coerce the practitioner into changing a “No” into a “Yes.” Manipulation comes in many forms.Continue reading →
In the last JailMedicine post, I introduced the subject of Utilization Management (UM) in Corrections. To some, Utilization Management has earned the reputation of being too focused on money and not enough focused on patients. But after I had been doing UM for awhile, I had an important insight that changed the way I thought about Utilization Management and (I believe) made my own efforts at UM much more effective.
That key insight is this: That which is expensive in medical practice is bad medicine. The way to control costs in medicine is to reduce or eliminate bad medical practice. Cost containment is simply a happy byproduct of this endeavor. When UM physician advisors work with primary care practitioners, the conversation should center around best medical practice, not money.
It is this simple: Good medicine is cost effective. Bad medicine is expensive.Continue reading →
Consider two people standing outside of a grocery store.
Person one is told: “Here is $200.00 for groceries for one month. You may buy any food you wish—but you may not spend more than this $200.00. So, make your purchases wisely. We are going to watch carefully to make sure that you do not exceed $200.00.”
The second person is told: “There is no limit on how much you spend on groceries in the next month. You may spend as much as you wish! And you may come back as often as you like. There are no limits. In fact, no one is even going to pay attention to what you buy!”
Which person do you think is more likely to walk out of the store with the most expensive cut of steak?
Which person is more likely to pay attention to prices and sales?
Which one do you think is more likely to buy food that they will never eat?
This scenario is very like the difference in health care spending within your average state prison system and the medical community at large.Continue reading →
Dr. Keller – would you consider a discussion of balancing the autonomy of patient decision-making and the risk to the facility for not providing appropriate care.
1. Individual is on disability but wants to sign a ‘waiver’ of responsibility so he/she can work
2. Diabetic (NIDDM) individual that wants to refuse diet and be placed on insulin so he/she can eat what ever they wish
3. Individual with a comminuted jaw fracture – cut wires on episode of nausea – now wants regular food despite oral surgeon advising limited jaw movement
Documentation of appropriate exam and advice to the individual is, of course, the foundation of addressing the issue – but do you allow the 100% (physically) disabled person work; allow the diabetic to sign a refusal of the diet & prescribe insulin; give the individual with the broken jaw (who is asking for more hydrocodone) a regular diet?
I believe your expert ability to address these thorny issues will help us all
Thank you for the kind words, Al! The issue you highlight is indeed a thorny one—when a patient wants to refuse strongly recommended medical care. Sometimes these are true refusals, meaning the patient understands the medical intervention being offered and truly does not want it. More often, though, such refusals are a form of manipulation to get something else that the patient wants. I would like to address these two scenarios first and first and then discuss your three specific examples.Continue reading →
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 →
The analogue insulins were introduced into the United States in the late 1990s and early 2000s. They are called “analogue” insulins because their chemical structure is subtlety different than native human insulin, which gives them different, advantageous properties. Analogue insulins include the short acting insulins Humalog (insulin lispro) and Novolog (insulin aspart) and the long acting insulins Lantus (insulin glargine) and Levemir (insulin detemir).
Since their introduction, the insulin analogues have pretty much taken over the insulin market in the US. That is why I only mentioned human insulins in passing in the JailMedicine post “Insulin Dosing Made Simple.” It is unusual to see patients show up at the jail on any other insulin regimen than analogue insulins, usually Humalog and Lantus. And I have to admit; the analogue insulins are easier to use than human insulins. I like them.