Spotlight on the Standards

Problematic Medication Practices: The Top 10

[This is the first of a three-part article. Parts two and three appeared in the Winter and Spring 2007 issues of CorrectCare.]

After yesterday’s root canal, you call your dentist’s office to complain that the over-the-counter pain reliever he recommended is not working. His dental assistant tells you that your dentist never gives anything stronger for root canal work and ends the conversation with “Take two!”

For years you have heard voices that interfered with your ability to function on a daily basis. Last year, after many years of trying different psychotropic medications, side effects and all, a new drug has stopped the voices. But your new psychiatrist isn’t comfortable with this drug and decides to switch back to your last one. She did not tell you this; you found out when you picked up the refill from the pharmacy.

Your diabetes finally responded to a schedule and dose of a specific insulin after years of trial and error. You have learned when and how to eat, and can anticipate a need for additional insulin. Your boss just transferred you to the night shift. Since this will upset the balance between eating times and blood sugar levels, you ask to remain on the day shift. His reply: “Take it—or leave.”

Unacceptable? Indeed. Fortunately, as a member of the free world, you are free to change dentists or psychiatrists and to explore legal options for medical accommodations.

But inmates have almost no control over the health care they receive, and getting needed medications can be a central concern. Whether it is a long-standing order for chronic care meds or a time-limited prescription to treat an acute illness, a hassle-free system that delivers the right drug to the right person at the right time and in the right manner can make the difference between acceptable and intolerable conditions of confinement. When this system fails, inmates’ choices are limited and remedies difficult to obtain.

Laying the Groundwork
Like the NCCHC Standards for Health Services in general, essential standard D-02 Medication Services intends that practices be “commensurate with current community practice.” The standard lays out the basic requirements for correctional medication services: They must be “clinically appropriate and provided in a timely, safe, and sufficient manner.”

Using as a guide this and the other standards that relate to medications can help facilities avoid the top 10 problematic practices that we see with correctional medications. The practices listed here are cited most often when we assess facilities for compliance with the Standards. Part 2 will present solutions to consider.

Problematic Practices

1. Delay in continuing prescribed drugs at admission or transfer
This is probably the most common (and potentially lethal) medication error, especially in jails but also with prison transfers and short-term moves. Good medical practice, and compliance with the standard, requires that there be no interruption of life-sustaining medications or those needed to maintain therapeutic blood levels for serious health conditions.
   Reasons for this problem are many: experience with questionable inmate self-reporting, the need to maintain control of drugs coming into the facility, inability to stock or access certain drugs, timeliness of health staff review of incoming inmates’ health needs and different opinions as to which drugs are essential.

2. Running out of prescribed medication
Interruptions in medication lead to drops in therapeutic drug levels and reduced drug efficacy. There are myriad system-related causes for depleted drug stocks. If a facility is short-staffed, proactive initiatives may be set aside to grapple with the day’s emergencies. Or efforts to get inmates to take responsibility for self-care can backfire when unexpected events interrupt a “fail-proof” delivery system.

3. Altering the drug form for security reasons
In the desire to control hoarding or selling, or perhaps as a result of one bad outcome, the facility may turn to diluting, crushing or otherwise making it impossible for anyone besides the intended inmate to get the drug. Not all medications can be treated in this manner; in fact, the efficacy of time-release or specially coated drugs can be destroyed.

4. Changing medications or doses without discussing with inmate
Perfectly good clinical decisions become problematic when the patient does not know what is happening. Yes, it is time-consuming to call the inmate to the clinic just to tell him that lab results indicate the dosage needs to be increased. But if you don’t, you risk dealing with an irate inmate who thinks the medication nurse is “picking on me.” For an inmate with paranoia, a change in color of a regular pill is a threat.

5. Frequent medication changes by different prescribers
Medications require time to have an effect; some must be stopped for a period before a different formula is tried. Thus, it is clinical common sense not to change medications too frequently. When several part-time physicians, each with different backgrounds and professional biases, provide care, there is the tendency for medications to be changed more often than good practice would dictate.

6. Medication changes to stay on formulary
While the standards require use of a formulary, the caveat is that the clinician may order off formulary when it is clinically indicated for a given patient. Procedures for off-formulary ordering can be so complex that it takes multiple approvals and an inordinate amount of time, which unnecessarily delays treatment. Pressure to keep drug expenditures within projected limits can be strong when correctional health budgets are tight and getting tighter.

7. Inadequate pain medication
Inmates do suffer from terminal illnesses and painful chronic conditions, and they can experience acute and debilitating pain. Even in the best systems, adequate pain control is the exception for reasons such as the belief that all inmates are “druggies,” the decision that “we do not use narcotics here” and the fear of being seen as soft by coworkers.
   Scientific evidence that individuals experience pain differently and that pain is real even when proof is lacking seems to be interpreted as “except for inmates.” Clinicians may become jaded and respond accordingly, especially when overworked or undersupported. On the other hand, novice practitioners may be drawn into improper prescribing to avoid having to deal with dependency issues that sometimes arise.

8. Lack of informed consent regarding use of psychotropic medication
Written consent for the use of psychotropic medication (except in emergencies) is standard practice supported by legal requirements. It is good clinical practice, as well, given the significant side effects possible with many of these drugs. A general laxity when it comes to consent issues can be pervasive in correctional settings, especially when it comes to treatment for mental illnesses.

9. Inflexible drug distribution schedules
In the paramilitary correctional environment, schedule deviations are problematic. Exceptions may be required when a patient cannot take a certain medication on an empty stomach, or must wait a set interval between meds and meals or doses. Altering distribution procedures is often complex when security classifications make movement limited.

10. Lack of, or limited access to, opioid dependence treatment options
In the community, it is common and acceptable practice to use methadone or buprenorphine to aid withdrawal from opioid dependency. Although less common, it is also accepted practice to use these substances for maintenance therapy.
   However, very few jails offer therapeutic methadone-based withdrawal, and new detainees who participate in a community methadone program seldom can continue that treatment behind bars. “Cold turkey” is no longer an acceptable approach to withdrawal, and protocols that don’t use opioid agnostic agents are not as therapeutic as other alternatives.

Share Your Solutions
Besides discussing the standards’ expectations and requirements, it will outline solutions, many of them from facilities that have struggled with these issues as they worked toward accreditation.

(This article first appeared in the Fall 2006 issue of CorrectCare. For the follow-up articles, which discussed solutions to these challenges, see the Spotlight columns from Winter and Spring 2007.)

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