Frequently asked questions (FAQ) regarding medication use and abuse in correctional healthcare settings

What are alternatives to medications considered appropriate in the correctional setting and what is recommended for a benzodiazepine withdrawal protocol? Dr. McKee discusses this and many more related questions from this list of FAQs he compiled when employed with the Travis County Correctional Center in Texas. Resources for further information are also included.

IS THERE A RECOMMENDATION FOR A STANDARD BENZODIAZEPINE WITHDRAWAL PROTOCOL – TAKING INTO CONSIDERATION THE UNIQUE CHALLENGES OFFERED IN A CORRECTIONAL SETTING?

Correctional formularies typically do not include benzodiazepines for use as anxiolytics or as sedative hypnotics due to abuse potential. One large correctional managed care system allows diazepam only for use in certain neurologic diseases via a prior authorization process. Others limit benzodiazepines to certain clinical situations or specific specialty providers due to the abuse potential. Lorazepam is available only as an injection in clinics to be used in seizures or psychiatric emergencies.

IN CONSIDERATION OF “CONTINUITY OF CARE” WHAT KIND OF TIME FRAME SHOULD BE ALLOWED BEFORE PSYCHIATRIC MEDICATIONS (CONFIRMED VIA INTAKE ASSESSMENT) ARE GIVEN TO A COMPLIANT PATIENT ONCE THEY HAVE BEEN BOOKED INTO OUR FACILITY?

There is not a hard and fast rule here; however, it should be as seamless as possible- as there is a great likelihood that medications prescribed in the community have not been administered just before admission to jail. Clearly as the period of nonadherence increases, so does the risk of decompensation.

SHOULD TRICYCLIC ANTIDEPRESSANTS BE GIVEN TO A PATIENT WITH BIPOLAR DISORDER? IF SO, WHAT IS THE MAXIMUM DOSE?

In general, most treatment guidelines do not recommend that antidepressants be given to a patient with bipolar disorder unless they are receiving a mood stabilizing agent. There is a clinical controversy regarding the use of antidepressants in bipolar disorder at all. But specifically, the TCAs are more commonly associated with the manic switch than SSRIs. However, unique to corrections, tricyclic antidepressants are frequent targets of abuse due to sedative and anticholinergic properties. Within many correctional systems, as tricyclic antidepressants may be lethal in relatively small quantities, they are typically not recommended as first line antidepressant therapy and access is limited to direct administration by nursing or a medication aide.

ARE THERE PARTICULAR PSYCHIATRIC MEDICATIONS THAT SHOULD BE CONSIDERED INAPPROPRIATE FOR A CORRECTIONAL SETTING? IF SO, WHICH ONES AND WHAT ARE RECOMMENDED ALTERNATIVES?

Correctional formularies typically do not include benzodiazepines for use as anxiolytics or as sedative hypnotics due to abuse potential. Amphetamines and psychostimulants in adult corrections populations are typically not available for the reasons similar to those noted for the benzodiazepines. Quetiapine and bupropion are the most frequently cited targets of abuse in corrections based upon reports in the peer reviewed literature. Quetiapine is generally felt to be sought for its sedative and cognitive blunting properties, while bupropion is crushed and snorted as a stimulant, referred to as “poor man's cocaine”. Tricyclic antidepressants are frequent targets of abuse due to sedative and anticholinergic properties. It is well known in correctional healthcare that offenders are creative in their choice of substances to abuse. For that reason, gabapentin, carbamazepine, and anticholinergics have been reported as potential targets of abuse in correctional settings.

IS THERE A RECOMMENDATION FOR TREATING “UNABLE TO SLEEP” COMPLAINTS?

Typically, education regarding sleep hygiene measures is recommended as a beginning point, just as in the community. As many medications used in the community to address sleep disturbance are prone to abuse, these are not recommended for use in correctional settings.

ARE THERE ANY RECOMMENDATIONS FOR USING ANTABUSE/DISULFIRAM IN A CORRECTIONAL SETTING?

This is not necessary nor indicated in this setting as in theory; the setting is closed to alcohol and illicit substances. However, many correctional healthcare settings use random urine drug testing to identify potential areas where contraband agents have been introduced into the correctional environment.

IS THERE AN OPINION REGARDING THE USE OF A LONG ACTING INJECTABLE (I.E. INVEGA SUSTENNA) FOR THOSE WHO WILL NOT FOLLOW-UP WITH TREATMENT UPON RELEASE?

Ideally, the long acting antipsychotic injections may bridge the adherence gap and at some point, allow the patient to achieve insight into the disease, or enable case management to become effective to the point that they will be adherent with treatment on the outside, when supervision is not as intensive as in the correctional setting. Even while in a closely supervised setting, the ongoing struggle to maintain daily adherence with an oral antipsychotic regimen in a patient with paranoia related to severe and persistent mental illness can often be bridged with the use of long acting antipsychotic injections. These agents, in particular fluphenazine decanoate and haloperidol decanoate, are used extensively in the many correctional settings for this reason.

ARE THERE OTHER MEDICATION RISKS WITH PSYCHIATRIC MEDICATIONS THAT CLINICIANS SHOULD BE AWARE OF?

One additional factor to keep in mind is that many correctional settings are not air conditioned in the summer and/or the offenders may have jobs that take them in hot/humid settings (landscaping or working in the laundry for example). Many psychoactive medications are highly anticholinergic and thus impair the body's ability to regulate heat. This should be factored when medication selection and job performance restrictions are considered. Due to the anticholinergic properties and/or direct inhibitory effects on the central nervous system's thermoregulatory function of many psychoactive (and other) medications, it is imperative that this potential impact on the offender's ability to dissipate heat be considered.