Spotlight on the Standards

Standing Up to Medication Practice Challenges (Part 2)

I will conclude what has grown into a three-part article with solutions to the final five problematic medication practices from my original list of 10 (see issues Fall 2006 and Winter 2007).

Solutions for Problematic Practices

6. Formulary as tool

Medication formularies are used both to facilitate initiation of drug therapies and to help control ever-rising drug costs. However, when patients are switched to formulary drugs without regard for their history of efficacy with those drugs, the tool becomes the tail that wags the dog.
   Protocols must provide for timely ordering of medications off-formulary when clinically indicated. The physician on-site should have ready access to any necessary forms, which should be well-designed to collect all of the information the clinical reviewer needs to evaluate the request. The procedures also must make provisions for urgent needs.
   When a nonformulary drug order is denied, the pharmacist can assist by suggesting alternative formulary drugs, or by helping the physician to justify the requested drug in a timely manner. In good professional working relationships, the physician will initiate such discussion with the pharmacist, who is seen as a partner in providing patient care.

7. Effective pain control

It is distressing to be honest about this, but inadequate pain control is often a result of poor attitude and stereotyping. Correctional staff’s negative experiences with drug-dependent persons, health staff memories of being “burned” by inmate-patients, the additional safeguards for use of strong pain medication—all contribute to a reluctance to prescribe for pain relief as would be done in community practice. Even with highly professional providers there may lurk unconscious motivation such as, “Well, this is an inmate who has done wrong and deserves to suffer.”
   Perhaps the best way to deal with personal biases is to forget for the moment that the patient is an inmate and ask, What is the appropriate professional response to the clinical distress? What ordinarily would be done in community practice? Offering over-the-counter meds for pain from end-stage-cancer, root canal, acute injury or surgery is not the current standard of care. Even if the patient is drug dependent, alternative pain medications are available and should be tried.
   In some cases, it may be necessary to obtain specialty consultation to get at the root of the distress, or to house the inmate-patient in a sheltered setting, or even to transfer the patient to a different facility.
   Palliative care specialists are expert in the use of various forms and dosages of pain-relieving drugs, and clinical pharmacists also have expertise to share. Both should be available to consult as needed.
   While other therapies—both traditional (e.g., physical therapy, antidepressants) and nontraditional (yoga, stress reduction, massage)—can help control pain, they require consistent work with specialists who are seldom available in correctional settings. Also, they often don’t help until the pain is at a manageable threshold, which differs for each patient.

8. Informed consent for psychotropics

The mental health care field recognizes that psychotropic medications may produce serious side effects. While these drugs often are highly effective in controlling clinical symptoms, that same potency can lead to undesirable health consequences.
   The clinician must involve the patient in weighing the pros and cons of the various drugs (except when the patient is not competent to make decisions about mental health care, or in emergency situations to protect life and prevent harm to self or others). Just as invasive medical procedures (surgery, dental extractions, use of experimental medication) require signed patient consent, so too should consent for the use of psychotropics be the norm, reflecting community practice.
   Again, the clinician should have ready access to the appropriate forms during patient examination to facilitate the consent process. Also, if the patient refuses treatment, this  documentation may be needed for future court proceedings.

9. Accommodating medication schedules

In the paramilitary correctional setting, anything out of the ordinary  may be seen as a threat to the smooth operation of the facility. When patient accommodations must be made, keeping the changes to a minimum and giving the rationale for them will likely meet with cooperation from correctional authorities. The pharmacist can help explain and document why a specific accommodation is needed.
   The less often a medication must be taken, the greater the chance the patient will receive it. Without compromising the therapeutic parameters of a drug, the physician should keep in mind that less is better when choosing frequency.
   A consulting pharmacist can assist in adapting a patient’s medication regimen to the facility’s schedule. If this is not possible, a self-medication program (with or without supervision) may be considered for at least some of the doses. Another possibility is to designate certain housing areas for patients with complex or frequent medication needs.
   Officer in-service training on how various medications work and the need to follow instructions for how to take the meds (e.g., with or without food) can help change negative attitudes about meeting inmates’ needs for medication.

10. Opioid dependence treatment options

The use of methadone, and to a lesser extent buprenorphine, to treat opioid dependence, by either withdrawal or maintenance programs, is generally considered standard community practice. Alternative protocols for withdrawal are not as effective.
   In correctional settings, opioid treatment programs may take different forms. For an independent, on-site OTP, federal law requires that the facility be accredited by one of five authorized accrediting bodies (NCCHC is one) and then certified by the Substance Abuse and Mental Health Services Administration. Another option is to partner with a certified community OTP.
   Clinically speaking, buprenorphine is viewed as a better treatment than methadone. Another benefit is that federal certification of the facility is not necessary; the only requirement is that the prescribing physician be trained in its use. However, this drug is more expensive than methadone.
   It is NCCHC’s understanding that OTP certification regulations do not apply when correctional facilities use either of these drugs for health conditions unrelated to opioid dependence (e.g., to protect the fetus in an opioid-dependent pregnant inmate or for pain control).

Sparking Ideas
Remember, the solutions I’ve shared are not meant to be exhaustive but rather to spark new ideas to help you meet your patients’ medication needs.

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* The standards mentioned in the boxed section above are A-01 Access to Care, A-03 Medical Autonomy, A-06 Continuous Quality Improvement Program, E-02 receiving Screening, E-07 Nonemergency Health Care Requests and Services, E-12 Continuity of Care During Incarceration, G-01 Special Needs Treatment Plans, G-02 Management of Chronic Disease, G-04 Mental Health Services, G-06 Intoxication and Withdrawal, I-02 Emergency Psychotropic Medication, I-05 Informed Consent.

(This article first appeared in the Spring 2007 issue of CorrectCare. Thanks to Syd Mulder, PharmD, CCHP, for his contributions to this article. Mulder is a cofounder of Clinical Solutions LLC, Nashville, TN.)

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