[QUOTE=diggleblop]
Understandable, but what would you do so the patient doesn’t have withdrawl? Because going from taking say… four 40mg Oxycontin a day to nothing is pretty rough on that patient. Would you slowly decrease his dose or just give him something like 10 mg Percocet, then go down to something even lighter after a few weeks?
[/QUOTE]
I’m wondering if they’d be given methadone. For that matter, can an addict (to illegal narcotics) get methadone in prison?
In 1991 (and maybe still in 2006) AZT was considered an experimental treatment for AIDS and one which was known to have serious side-effects. Many prison systems prohibit the use of inmates in experimatental medical tests.
Your second example is so vague I can’t really address it except to note that data is not the plural of anecdote.
[QUOTE=WhyNot]
none of us can swear for sure that **Qadop **is an actual prison doc
[/QUOTE]
I can! 
[QUOTE=overeasy4]
I also knew a woman who was locked up for 2 months in the same place and denied her prescription medication. I’m not making these up.
[/QUOTE]
Sure, but… when? Where? What drug?
It’s not that everybody thinks you’re making it up, it’s just that we need more context for it to be at all useful.
She was in June to August. I will call and ask her what drug she hadn’t received.
QtM- I have the utmost respect for you, and I know you have issues with prescribing strong painkillers for non-malignant pain.
My question is, if the only thing that makes you suspect dependence issues are high doses of pain medication (rather than, say, a history of showing up at multiple hospitals seeking opiates for fictitious ailments, or a conviction for buying opiates illegally), and the patient appears to function normally on their current regime, is it always appropriate to change it, just because you don’t like prescribing narcotics?
Considering, especially that other pain medications have their own side effects (GI bleeding with NSAIDS, Cardio-vascular complications with COX-2), it is estimated in the UK alone that several hundred people die every year from GI bleeding directly related to NSAID use, while there are very few deaths directly linked to prescription opiate dependence.
[QUOTE=elfbabe]
I can!
[/QUOTE]
I was going to mention you as the only one on the board who could absolutely, without a doubt vouch for QtM, being his daughter and all, but I thought I might be hauled away by the parenthetical police for overuse of punctuation marks!
'Sides, there is always the very very slim chance that you’re a sock or just part of the Matrix or Doc Merc’s stalker or my grandmother…then again, I could be Weird Al, and you’d never know!
[QUOTE=irishgirl]
If prisoners are being forced to regurgitate pills, or are “fake taking” in order to stockpile narcotics, there are simple steps that could be taken to overcome that. A nurse/doctor/health care worker could administer their medication by subcutaneous, IM or IV injection rather than an oral tablet, for example…
[/QUOTE]
What makes you think that injections, with all the paraphernalia and personnel they require, are a “simple” alternative to pills? Manpower issues aside, having a sharp object anywhere near an uncooperative and possibly violent inmate seems to be inviting many more problems than it would solve.
[QUOTE=Qadgop the Mercotan]
I
On the prisoner units, the “controlled” medicines are distributed at set times by officers. The officers do not dispense the medication, they just make it available to the inmate for them to take at the times and dosages prescribed. The officers report it to us if an inmate refuses to take controlled meds as ordered.
<snip>
If a drug is not controlled (like HCTZ for high blood pressure, indocin for pain), the inmate keeps these meds in his cell, and is expected to take them appropriately.
[/QUOTE]
Things in your institution are run very differently from the one in which my husband works. In his prison (medium security), all meds are dispensed by medical personel and inmates are not allowed to have any kind of medication in their posession. It was the same when he worked at SuperMax. Staff aren’t even allowed to have their own medications on the premisis. (One of my husband’s diabetic co-workers has to keep his insulin in a cooler in his car and give himself his shots in the parking lot.)
It’s not always that simple. At least in my state, prison medical services are run sort of like an HMO. There are medications which are approved and medications which aren’t. It’s possible that some medications might be approved in pill form but not in IV form and vice-versa. A doctor wanting to use a non-approved form of a medication would have to go before the board which supervises it and plead his case. If the reason was medically sound and justified the expense or change in policy, they might do it, but they generally don’t change things because of nebulous reasons like a pill might be puked up.
If an inmate was concerned he would be forced to vomit, all he would have to do is ask to wait in the medical area until the pill had dissolved. Most prison staff would have no problem with letting an inmate sit in a chair outside their office for a little while.
An IV comes with its own set of problems. Infection is a big problem in some institutions, and you also have to worry about collapsed veins and the like. And who wants the pain of getting an IV every day? It’d also be more expensive because of the supplies needed and staff time to monitor the IV drip.
[QUOTE=diggleblop]
Understandable, but what would you do so the patient doesn’t have withdrawl? Because going from taking say… four 40mg Oxycontin a day to nothing is pretty rough on that patient. Would you slowly decrease his dose or just give him something like 10 mg Percocet, then go down to something even lighter after a few weeks?
[/QUOTE]
I’ve got no problems with tapering meds given for pain. I do it all the time.
[QUOTE=betenoir]
I’m wondering if they’d be given methadone. For that matter, can an addict (to illegal narcotics) get methadone in prison?
[/QUOTE]
Methadone is an excellent long-acting narcotic to prescribe for pain. I prescribe it fairly often.
Neither I nor my establishment are licensed to prescribe methadone to maintain an opiate addiction nor detox someone from opiates. That’s a whole 'nother certification.
Tell me about it. I once wrote a manual for the procedures of inventorying, using, and disposing of syringes.
We’re in between. All medications are handed out by medical personnel (although I can remember dispensing medications as an officer twenty years ago). But we do issue some medications to inmates for them to keep and take themselves.
Okay. But keep in mind that during those same three months I witnessed about 6000 inmates get their medications.
[QUOTE=irishgirl]
QtM- I have the utmost respect for you, and I know you have issues with prescribing strong painkillers for non-malignant pain.
My question is, if the only thing that makes you suspect dependence issues are high doses of pain medication (rather than, say, a history of showing up at multiple hospitals seeking opiates for fictitious ailments, or a conviction for buying opiates illegally), and the patient appears to function normally on their current regime, is it always appropriate to change it, just because you don’t like prescribing narcotics?
Considering, especially that other pain medications have their own side effects (GI bleeding with NSAIDS, Cardio-vascular complications with COX-2), it is estimated in the UK alone that several hundred people die every year from GI bleeding directly related to NSAID use, while there are very few deaths directly linked to prescription opiate dependence.
[/QUOTE]
I believe that narcotics are never the first tool in my chronic non-malignant pain treatment toolbox, even if the patient has no history of addiction. I also believe that narcotics are relatively contra-indicated for the treatment of chronic non-malignant pain if the patient has a history of chemical dependency (drug addiction, alcoholism). Some folks feel that they’re absolutely contra-indicated in those circumstances. I’m not willing to go that far.
In the ordinary population, this means about 10% of patients will have a history of chemical dependency. In my population that number rises to about 70% by many estimates. So I really, really really defer using narcotics for chronic pain.
That doesn’t mean I never use them. But before doing so, I need to have a thorough documentation of the patient’s history and physical findings, study results, experiences with other treatment modalities, along with an idea of what the goal of treatment is, whether narcotics are utilized or not. And my goal is to improve function, not to eliminate pain, because frankly I’ll never be able to do that for the vast majority of my patients.
So if I can get the patient able to ambulate better, function longer, rest better, participate more in ADLs with my treatment program, then I’m making progress. If I find that adding a narcotic at some point helps me accomplish those goals, I’ll use them. But if the narcotic does not help me attain those goals then they’ll be taken out of the mix. And if the patient violates our agreement and uses the narcotics inappropriately, they are unlikely to be continued.
As for patients who come in on narcotics, the only way to really assess them is to find out what their baseline is like off narcotics. Sometimes that can be done with old records, but oftentimes it can’t. And frankly, I generally don’t see folks functioning ‘fine’ on high dose narcotics for failed back surgery pain. They come in groggy, constipated, unable to function well, yet complaining they need more narcotics. Frankly, they function better when they’re off the narcs in most cases.
And any treatment modality has risks and benefits. The NSAIDs can cause GI bleeding, APAP may lead to liver trouble, amitriptylene may aggravate certain cardiac problems, gabapentin may cause coordination trouble, tegretal may cause blood abnormalities, and so forth. So each must be weighed on the scale of risk vs. benefit.
It is difficult territory to navigate. And one battles a certain school of pain management thought that says any pain is the result of inadequate opiates. But my principles of pain management were learned from some top notch physiatrists, pain specialists, addictionists, internists, and anesthesiologists from across the country. And for the tough cases, I’ll send the patient out to a pain specialist for their input. What I often get is “yeah, that’s a tough case. You’ve already tried most things. Much of his behavior does seem to represent a drug-seeking attitude. Avoid short-acting narcotics like the plague, try some long-acting narcotics like methadone to a max dose of 100 mg a day, and if he doesn’t get benefit from that, taper him off of it, and go with continued exercise, weight loss, and physical therapy. Good luck. I don’t need to see him again”.
As you can tell, I’ve given this topic a bit of thought in the past. In fact I have put together two powerpoint presentations that I give to physicians about chronic pain management in general and about the use of opiates in chronic pain treatment.
And now I’m newly certified and licensed to prescribe buprenorphine to maintain or detox an opiate addiction. I doubt I’ll be maintaining many addictions (unless they’ve a short prison stay and came in on maintenance therapy) but it will be useful for helping me get some folks off their methadone maintenance.
That’s just the tip of the iceberg for what I’ve learned about treating chronic pain. It is a specialty unto itself. But now since most insurance companies no longer pay much for chronic pain referrals, a lot of folks are getting out of the business. However, that’s a whole 'nuther story.
I’ve rambled enough.
[QUOTE=WhyNot]
I was going to mention you as the only one on the board who could absolutely, without a doubt vouch for QtM, being his daughter and all,
[/QUOTE]
Fine. Who’s gonna vouch for her? Or you, for that matter? For all I know you’re the bastard child of Jerry Falwell and Phyllis Schaffley! 
[QUOTE=Little Nemo]
In 1991 (and maybe still in 2006) AZT was considered an experimental treatment for AIDS and one which was known to have serious side-effects. Many prison systems prohibit the use of inmates in experimatental medical tests.
[/QUOTE]
On the contrary, not only was AZT FDA-approved in 1987 for treatment of HIV, it was also the first drug approved for this purpose. I’d be exceedingly surprised if GSK was still spending money to test AZT for FDA approval over 2 decades after development. I can think of over 20 meds (some of which are combinations of other meds, mind you) that are FDA-approved for HIV treatment.
[QUOTE=overeasy4]
In 1991, in Cleveland Ohio’s county jail, at least 10 aids inmates who were on azt and other drugs were not given them at all over a period of a month. They brought a joint lawsuit and lost. I don’t know if I could find it online or search for it, but I will try.
I also knew a woman who was locked up for 2 months in the same place and denied her prescription medication. I’m not making these up.
[/QUOTE]
County jail policy varies from one county to the next. I’m no expert on what goes on in jails, but I do see a lot of different practices from different sites.
Some jails will allow a patient to take whatever medications his own doctors are prescribing, if the prescriptions are verified, and a friend or family member brings it in. Some don’t allow any outside meds, but turn over the medical care to the jail doctor, who may or may not work off of a formulary. Some jails frankly seem to not allow anything.
[QUOTE=WhyNot]
I was going to mention you as the only one on the board who could absolutely, without a doubt vouch for QtM, being his daughter and all, but I thought I might be hauled away by the parenthetical police for overuse of punctuation marks!
'Sides, there is always the very very slim chance that you’re a sock or just part of the Matrix or Doc Merc’s stalker or my grandmother…then again, I could be Weird Al, and you’d never know!
[/QUOTE]
I believe her sister posts here as well-or at least, she used to.
QtM- you’re the best. Thank you.
I spend my days doling out morphine, oxynorm, oxycontin, tramadol, co-codamol 30/500 and fentanyl to cardiothoracic patients, who all end up being sent home on just paracetamol (acetominophen). The only people I see complaining of pain are either having a heart attack, have just had their chest opened, or have malignant pain from their oesophageal or lung cancer.
I bow to your expertise in the field of drug-seeking junkie cons with non-malignant chronic pain. 
To add a little to the mix, at my county’s jail you can bring in your prescriptions and if they are non-narcotic you will get them at appropriate times. If you have narcotics with you or a prescription for them, you will be seeing the doctor to determine if you should be given them while in the jail.
If you are in jail for prescription fraud or something like that, you can pretty much forget about getting any narcotics. You will be prescribed a non-narcotic painkiller. Likewise, people with cocaine charges are unlikely to be continued on any narcotics or Adderal or anything like that.
QtM, can you explain the difference between malignant and non-malignant pain?