Summer 2016 - Society of Correctional Physicians

THE NEWSLETTER OF THE AMERICAN COLLEGE OF CORRECTIONAL PHYSICIANS
Volume 19 / Issue 2 / Summer 2016
ADDICTION MEDICINE: A NEW SUBSPECIALTY
AVAILABLE TO ALL​ABMS-CERTIFIED PHYSICIANS
By Dr. Lori Karan, FACP, FASAM
ACCP Board and
Administration
President
Todd Wilcox, MD, MBA,
FACCP, CCHP-A, CCHP-P
President-elect
Keith Ivens, MD, FACCP
Secretary
Cassandra Newkirk, MD, MBA
Treasurer
Keith Courtney, DO, CCHP
Immediate Past President
Rebecca Lubelczyk, MD, FACCP, CCHP-P
Director
Jennifer Clarke, MD, MPH
Director
Charles Lee, MD, JD, CCHP-P
Director
Thomas Lincoln, MD, CCHP
Director
Juan “Rudy” Nunez, MD, FACCP, CCHP-P
Director
Kelly O’Brien, MD, CCHP, FACP
Director
Olu Ogunsanwo, MD, FACCP, CCHP
Director
Joseph Penn, MD, CCHP
Executive Director
Christine Westbrook
Inquiries:
Board of Directors
trwilcox@wellcon.net
ACCP operations
christine@ACCPmed.org
Advertising
christine@ACCPmed.org
Letters to the Editor and
prospective articles
editor@corrdocs.org
CorrDocs
Copyright 2015, American College
of Correctional Physicians (ACCP)
CorrDocs is published as a benefit
to the members of ACCP
The appearance of advertising,
marketing, or commentary of any
kind in ACCP publications is not an
endorsement, unless indicated as
such, or guarantee of the product
or service being advertised or of the
claims made for the product or
service by the advertiser.
O
n March 14, 2016 the American Board of
Medical Specialties (ABMS) announced
its recognition of Addiction Medicine as
a multispecialty subspecialty, open to all ABMS
certified physicians. This key milestone is cause
for celebration.
The field of Correctional Medicine can look
to the course forged by the American Board of
Addiction Medicine (ABAM) to assist us in
gaining our own ABMS subspecialty recognition.
In addition, since the majority of patients treated
by correctional medicine physicians have a
history of addiction, correctional physicians may
wish to apply for subspecialty certification in
Addiction Medicine within the next five years
before a fellowship is required.
ABMS recognition of addiction medicine is
a pinnacle built on a rich history over several
decades. In 1954, Dr. Ruth Fox organized a
meeting of physicians at the New York Academy
of Medicine whose goal was to gain recognition
of alcoholism as a treatable disease. In 1971, the
National Institutes of Health created the Career
Teacher Program in the addictions and supported
63 medical schools with faculty development
grants. California, New York, and Georgia each had
activities fostering the field of addiction medicine,
and the leaders from these areas came together
at a unity meeting at the Kroc Ranch in 1983,
sanctioned by the American Medical Association,
IN THIS ISSUE
ADDICTION MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PRESIDENT’S COLUMN. . . . . . . . . . . . . . . . . . . . . . . . . . 2
WELCOME CHRISTINE WESTBROOK. . . . . . . . . . . . 2
THERE BUT FOR THE GRACE OF GOD GO I. . . . . . 3
PENITENTIARY GEESE. . . . . . . . . . . . . . . . . . . . . . . . . . 3
RUMINATIONS ON GENDER DYSPHORIA. . . . . . . . 4
GOVERNMENT HELPING GOVERNMENT. . . . . . . . . 5
HOW I PRACTICE —
MANAGING OPIATE WITHDRAWAL. . . . . . . . . . . . . . 6
to establish a “national society of physicians
concerned with the problems of psychoactive drug
use.” After accomplishing significant milestones
and growth, and several name changes, this
organization became known as the American
Society of Addiction Medicine (ASAM). One
goal was to provide expertise in the diagnosis
and treatment of addiction. Beginning in 1982, a
rigorous certificate examination was developed in
collaboration with the National Board of Medical
Examiners. In 1993, ASAM physicians coalesced a
core body of knowledge in the textbook, Principles
of Addiction Medicine. This textbook is now in its
5th edition and over 1700 pages in length.
While ASAM proposed that addiction medicine
be ABMS recognized several decades ago, it
was Kevin Kunz, MD, MPH who in 2006 had
the enthusiasm, energy and foresight to persuade
ASAM to give birth to the American Board of
Addiction Medicine (ABAM) and to avidly
pursue this goal. Leaders were recruited from all
primary care specialties, psychiatry, emergency
medicine, surgery, and ASAM to join the ABAM
board in 2007. ASAM transferred its certification
examination to ABAM in 2009. At the same time,
ABAM created the ABAM Foundation (now
known as The Addiction Medicine Foundation)
to establish and fund quality addiction medicine
fellowships. A critical mass of addiction medicine
Continued on Page 2...
SCREENING HEALTH PROBLEMS FOR
ADOLESCENT DETAINEES WHO REPORT
SUBSTANCE USE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
SELF-HARM FOLLOWING RELEASE
FROM PRISON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PROTECTING YOURSELF FROM THE NEGATIVE
IMPACT OF WORKING IN CORRECTIONS. . . . . . . 12
LIFE AND DEATH OF A MEDICAL DIRECTOR. . . . 13
THE NORTHUMBERLAND PRISON FIRE . . . . . . . . 14
9TH ANNUAL ACADEMIC & HEALTH POLICY
CONFERENCE ON CORRECTIONAL HEALTH. . . . 15
American College of Correctional Physicians 1145 W. Diversey Pkwy. | Chicago IL 60614 | Tel: 773-883-5375 | Fax: 773-880-2424 | Web: www.ACCPmed.org
Addiction Medicine from Page 1...
PRESIDENT’S COLUMN
NASHVILLE BEHIND,
BOSTON AND LAS VEGAS
HERE WE COME!
Todd Wilcox, MD, MBA, FACCP, CCHP-P
I
t was great to
see many of you
in Nashville for
the spring NCCHC
conference. The
conference was overall
a success due in large
part to the excellent
lectures presented by ACCP members. The social highlight
of the conference was the President’s Reception that was held
at BB King’s Blues Club in downtown Nashville. The band
was phenomenal, the food was excellent, and the dancing
was beguiling.
The board and the education committee are hard at work
at planning the events for the fall conference upcoming in
Las Vegas. The highlight of the fall conference is the ACCP
educational meeting that is held on the Sunday prior to the
start of the NCCHC conference. Mark your calendars now
for October 23, 2016, and stay tuned for program information
and registration details. ACCP will also be hosting another
Presidents Reception on Monday night October 24 at a local
nightclub in Las Vegas and it promises to be the best one yet.
Don’t forget about the Leadership Institute, a co-sponsored event
with NCCHC, which will be held in Boston, MA this summer.
Program will feature many of our ACCP colleagues as speakers.
A strong event for your new medical directors, July 15-16th.
I hope you all take time to get outside the walls and enjoy the
beauty around you.
Best regards,
Todd Wilcox, MD, FACCP, CCHP-P
President
American College of Correctional Physicians
physicians and trainees was needed in order for a successful
application to ABMS. Finally, the American Board of Preventive
Medicine (ABPM) agreed to sponsor the addiction medicine’s
application to ABMS as a multispecialty subspecialty.
While there has been discussion and collaboration between ASAM
and ABAM, and now ABAM and ABPM, each is an independent
organization. The ABAM Directors are working with ABPM to
plan a smooth transition for addiction medicine certification and
transitional maintenance of certification (Tmoc). There will not be
a certification examination in 2016, during this time of transition.
Thereafter, it is anticipated that there will be a Practice Pathway
for 5 years (2022 or later) where ABMS member Board diplomats
will be eligible for certification without a fellowship in Addiction
Medicine. ABAM diplomats will have to take another certification
examination to become ABMS credentialed, but those who remain
with active ABAM certificates and current MOC will have an
expedited review process to become ABMS eligible in Addiction
Medicine. Further information can be found at the ABAM website:
http://www.abam.net and later through the American Board of
Preventive Medicine.
ABMS is the gold standard for board certification and maintenance
of certification (MOC). ABMS recognition enables addiction
medicine physicians to be mainstreamed as specialists in the
medical community and to be recognized and compensated for
their expertise. ABMS Certification advances the training and
credentialing of the next generation of physician experts working
hand-in-hand with Accreditation Council for Graduate Medical
Education (ACGME) accredited fellowships. While Addiction
Psychiatry has been previously recognized by the ABMS, the
workforce can now be expanded across 24 ABMS specialties.
No longer is addiction a stepchild of healthcare and an orphan
of medicine. ABMS recognition empowers advocacy for the
improved prevention, diagnosis, and treatment of unhealthy
substance use and addiction across populations and communities,
replacing stigma-based ideas of addiction as a moral shortcoming
with bio-psycho-social constructs and evidence-based practice.
ABMS acknowledgement will enable increased access to and
reimbursement of addiction-related services including supporting
legislative mandates for parity, so that addiction treatment is
covered equally with treatments for other chronic medical illnesses,
as well as fostering reimbursement incentives from the Centers
for Medicare and Medicaid Services (CMS) and other payers to
integrate addiction services with mental health and primary care. n
ANNOUNCING ACCP’S NEW EXECUTIVE DIRECTOR
P
lease welcome Christine Westbrook,
our new Executive Director.
Christine works with several other
small medical societies in a similar
capacity. She has an Associate Degree in
Accounting and an Associate Degree in
Business Management and has worked in
Accounting/Business for 31 years and has
managed non-profit medical organizations for 17 years.
Page 2 /
Christine has worked for the ACCP for 5 years as the Sales
& Marketing Manager. Christine worked with the NCCHC to
obtain exhibitors for the October SCP Meeting. She has worked
with many of our members at meetings, the ACCP booth and
on committees.
Christine lives and works from her home in Littleton, Colorado.
She and her husband have five children ages 19 to 26, along
with a 14 month-old grandson. n
Volume 19 / Issue 2 / Summer 2016
THERE BUT FOR THE
GRACE OF GOD GO I
PENITENTIARY GEESE
By Luis Perez
By Rebecca Lubelczyk, MD, FACCP, CCHP-P
“
There but for the grace of God go I.” Dr. Armand Start would
often say that, I’ve been told. I’ve heard Dr. Lynn Sander and
other SCP founding members reflect often on those words as
we shared our professional struggles with each other. I’ve heard
it uttered so many times by my colleagues now and I think I even
said it to some of you once or twice.
Confession time. I never really understood what it meant. Well,
actually – I had no idea what I meant. It sounded good though.
Something wise, a bit profound, a little semantically backwards.
Like something Yoda would say. Except, then it would be “There
but for the Force go I,” of course. I digress.
After hearing it a few times, a meaning started to form that
seemed to make the most sense. I work in a prison. Prisons can be
dangerous places. It is because of God’s Grace I am able to go in
and out of work safely (There but for the Grace of God go I). For
that I’m very thankful as we all are I’m sure for any day when we
leave our facilities and rejoin our families.
After a while, my interpretation
seemed TOO literal. The short
phrase had more to it buried in
those simple, monosyllabic words.
And I noticed other physicians
said it talking when about their
professions, and they weren’t even
in corrections.
Ahhh... maybe due to God’s Grace,
I can go and fulfill the work I was
meant to do. Not everyone can do
what they love, get paid for it, and
be able to continue doing it. Some
people never figure out what they
were meant to do, or if they do – obstacles prevent them from doing
it. Also, maybe what they are meant to do doesn’t let them provide
for themselves and their families so they have to do something else
(There but for the Grace of God go I).
It wasn’t until recently that I had another epiphany. Doing intake
physicals at the women’s prison, it finally happened (I always knew
it would but I didn’t know how long it would take). There sitting in
front of me was a woman with the same birthdate as me. Same day,
same month, same year. But there the similarity stopped. I looked
at her trying to see if it was like a mirror but the face looking back
at me was much older in appearance, more tired, more pained. The
bruises and the track marks were unique to her, but what if our
lives were swapped? What if on that same day, I was born in her
place to her parents and in her living conditions, and she were born
into mine? How would I have fared, facing the challenges that she
faced all these years. How would I have coped? Would I have done
better? Would I have done worse?
W
hy we say they fly south?
As they beat their wings of freedom,
and into this prison they fly with
joy and wander about.
The contrast of a prisoner, the fences,
destitution and gates of iron,
all seem to vanish, if only for a moment,
when we see the birds of freedom.
It is an expression of nature when
these geese and birds enter the prison,
I feel the caress of peace when I see them,
It’s like exchanging thorns for flowers,
It’s a reflection of love that can only
Be felt within one’s own family.
I view them with admiration and respect,
they give me a sense of something that
perhaps does not exist and I don’t have,
but only for an instant the burdens of life
seem to vanish with peace and tranquility.
I cannot touch them or feed them,
Nor can I freely stroll about with them,
but as I see them beat their wings of freedom,
they give me hope and a longing to have
that freedom of flying high.
The beauties of nature, how much I’ve truly lost
I am able to see the birds in prison as they fly by,
On their wings of freedom. Why say they fly south?
They are penitentiary birds who are carrying the
wings of freedom.
Maybe I am looking in a mirror every time I see a patient.
There but for the Grace of God go I.
n
From Abnormal Footprints by Luis Perez,
AuthorHouse, Bloomington, ID. 2004
Reprinted with permission from the author.
n
Page 3 /
RUMINATIONS ON GENDER DYSPHORIA (A SERIES):
APPROACHING THE TRANSGENDERED INMATE
By Dean Reiger, MD, MPH
G
ender dysphoria was defined in the fifth edition of the
psychiatric Diagnostic and Statistical Manual, DSM-5. It
replaced the DSM-4 diagnosis “gender identity disorder.”
Described briefly, gender dysphoria is present when significant
distress is caused by long-standing gender incongruence.
(I encourage the readers to read the diagnostic criteria for
themselves.) During the past two decades many inmate patients
have presented to federal courts requesting accommodation or
other treatment for concerns related to gender identity and as
of 2016 we must accept as settled that, in the eyes of the federal
courts, gender dysphoria is a serious medical condition. Because
it has that status, we who provide care within corrections are
expected to include gender dysphoria among the conditions
that we treat. To do otherwise is a violation of our patients’
Constitutional rights.
The World Professional Association for Transgender Health
published its original “Standards of Care” in 1979. It has been
revised six times since then, and the most recent revision
(published in the International Journal of Transgenderism in
2011) contains much that is helpful to us in understanding how
to provide care for this group of patients. Transgendered persons
are more likely than ever to be “out of the closet” since societal
acceptance has increased. Famous publicly transgendered
persons include a sports star who has transitioned male-tofemale (MtF) and television stars.
There has been a steady drift away from considering gender
incongruence a disorder towards considering a variant of
normal. This is similar to what happened decades earlier
when the psychiatric community realized that homosexuality
was not a disorder, and homosexuality was removed from
the diagnostic lexicon. The WPATH goes farther than the
American Psychiatric Association and instead of using the
word incongruent to identify the difference between one’s
biologically assigned birth gender and one’s self-identified
gender, uses the word nonconforming. The difference is one of
connotation. WPTH never considered gender nonconformance
an illness and now the APA has come around to that position,
although the APA uses the term gender incongruence. Clearly
the WPATH embraces the entire LGBTI spectrum, going far
beyond that of the APA. (From here on out I will use the term
gender incongruence unless I am referring specifically to the
WPATH construct, because it better reflects our concern not
with whether or not a patient conforms to society norms, but
because of the potential internal conflict that incongruence
implies.)
to treat, especially when treatment has previously relieved
distress, is likely to result in a return of distress. First do no
harm. Stopping treatment which has previously successfully
resulted in relief of gender-related distress is likely to cause
harm.
WPATH supports interventions that support transgendered
lifestyles whether or not the interventions are necessary
to relieve distress. We do not need to do that to meet
Constitutional requirements. I would use as a metaphor our
responsibilities in addressing behavioral health disorders.
We need to relieve distress and would like to provide support
such that our behaviorally health disordered patients can first
adjust to confinement and second have some chance of success
upon release, but we do not identify self-actualization as an
appropriate goal for behavioral health treatment in detention
settings. This can also be thought of as the distinction between
what is necessary and what is desirable.
So what does this mean to us as we care for our patients?
Clearly we must not turn a blind eye to these issues; they are
with us in facilities large and small, urban and rural. Pretending
that these patients are not confined would be an indifference
that is below our standards as we provide a high quality of
care to our patients. We must plan for these patients, including
behavioral health, somatic health, and our custodial partners in
the process. We must learn to provide what they need to manage
gender-associated distress, and to relieve it to a reasonable
level. This may require interventions or a combination of
interventions from health care and custodial personnel. And
the interventions ought to be made in a respectful and sensitive
manner. For example, since the gender incongruence itself is not
an illness, placement of this group of patients in mental health
units may be inappropriately stigmatizing.
We already have a paradigm for treating patients with illnesses;
we take a history (including obtaining histories from outside
parties), we interview and examine the patient, we make an
assessment that usually includes some sort of differential
diagnosis, and we formulate a treatment plan. This is the same
process we need to follow what providing care for our gender
incongruent patients. We need to provide them with what they
need, and not necessarily with what they want.
Stay tuned next quarter when the next part in this series
will discuss the use of hormones and other interventions in
correctional settings. n
Many gender incongruent inmates do not exhibit any distress.
Perhaps they never did, or perhaps they were very distressed
and obtained treatment or modified their lifestyles to relieve that
distress. Both APA and WPATH are now in agreement that not
all gender incongruence or nonconformance means that gender
dysphoria is present. The diagnosis requires both the gender
incongruence and distress, and without distress we do not have
a constitutional obligation to treat. But be cautious here; failing
Page 4 /
Volume 19 / Issue 2 / Summer 2016
GOVERNMENT HELPING GOVERNMENT
IMPROVING HEALTHCARE IN GUAM’S PRISON
By Raymond S. Tenorio, Lt. Governor of Guam
T
he island of Guam has been a territory of the United
States since its annexation in 1898 after the SpanishAmerican War along with the Philippines and Puerto
Rico. Our system of justice and rule of law is founded on the
Constitution of the United States. Today Guam’s prison system
struggles with the same healthcare and mental health issues as
the rest of the nation.
In the early nineties the United States sued the Government
of Guam for substandard medical care and security issues
affecting the civil rights of inmates
within the island’s only prison
institution. The Government
of Guam and the United States
entered into a stipulated agreement
regarding these issue in 1991
(District Court Civil Case #9100020, United States v. Territory
of Guam, et al.). Over the next
decades, progress was nominally
made. For the most part, however, real
improvement in healthcare was topical
and inconsistent. Twentyfour
years after the first stipulated
order was signed, a new
Order was issued by the
District Court of Guam,
Judge Alex Munson, ordering
the Government of Guam
to complete the case within
one year that included a
comprehensive timeline for
corrective action.
Through the joint leadership
of Lt. Governor Ray S.
Tenorio and Elizabeth
Barrett-Anderson, Guam’s
newly elected Attorney
General, it was deduced
that receivership was an
inevitable consequence if the
During Construction
Government of Guam failed
to meet the court ordered
timelines. Governor of Guam, Eddie B. Calvo, cognizant of this
likelihood, requested that the Lt. Governor and the Attorney
General work cooperatively with all government of Guam
entities to assure every effort was made to prevent the territory
from falling into an unwanted federal receivership.
Instrumental in this effort was a search for experts in the
field of correctional healthcare. Attorney General BarrettAnderson solicited the University of Connecticut’s Director of
Medical Services, Dr. Johnny Wu. The model of correctional
healthcare in the State of Connecticut was looked at as doable
for Guam based on our community population. The UConn
model along with the Lt. Governor Tenorio’s application of
public administration principles, led the working group to
embrace a ‘government helping government’ approach. In
essence, government agencies with core competencies in
areas where another agency is deficient can leverage resources
through interagency cooperation to meet outcome goals,
with potential for savings by increasing economies of scale,
improving efficiencies, and benefiting the recipient agency with
expertise and heightened confidence
to meet standards. This has been a
practical and sustainable approach to
our island community, made up of an
approximately 185,000 residents, with
a single system of government based
on a limited resources and revenues.
The Guam Memorial Hospital
(GMH), the islands only public
hospital, assumed the role of a
service vendor, agreeing to provide
medical services through healthcare
professionals that the hospital was
responsible for employing
and assigning to the
Department of Corrections
(DOC). This is the model
of correctional health that
is adopted in many other
jurisdictions today. The
familiarity of GMH with
DOC’s inmate and detainee
health needs made the
partnership workable.
Key to the success of the
Governor’s Blue Ribbon
Team were weekly working
group meetings over the
course of a year focused
on establishing a plan for
facilitating, financing and
operating a clinic, support
Dr. Wu After Construction
systems as well as policies to
deliver medical, behavioral,
and dental care for inmates and detainees. Budgeting exercises
considered all costs for renovations, personnel, pharmaceuticals,
vehicles, equipment, and supplies. Governor Calvo answered
these concerns with a $5 million initial budget to fund the
first year operations. New medical policies and procedures
were written to meet standards and new nursing protocols
implemented. Pharmaceutical services were transferred from
a for-profit community pharmacy to the GMH pharmacy,
which resulted in a significant cost savings. Renovating the
clinic facilities was also necessary to meet infection control
and sanitary conditions, let alone aesthetics. Fresh paint, new
Continued on page 10 u
Page 5 /
HOW I PRACTICE —
MANAGING OPIATE WITHDRAWAL
By Todd Wilcox, MD, MBA, FACCP, CCHP-P
O
ver the course of my medical career, everything about
opiate management and treatment has changed. This
is particularly true for opiate withdrawal. Like most of
us, I learned early in my career that opiate withdrawal could be
treated cold turkey. In fact, a well-known correctional medical
textbook instructs the following: “Opiate withdrawal is known
to be very unpleasant for patients but is not generally associated
with life-threatening complications.”
Identification and Monitoring
The first major step in redesigning our practices for opiate
withdrawal involved the development of a targeted tool for
opiate withdrawal that was customized to correctional health.
We ultimately created the Wilcox Opiate Withdrawal Scale
protocol that is attached to this article. The primary focus of
WOWS is to identify clinical scenarios that cause dehydration
and electrolyte abnormalities. These are the two main areas
where patients can get in trouble, and an earlier intervention for
vomiting and diarrhea and targeted assessment for clinically
relevant dehydration became the focus of the WOWS protocol.
While that may have been true when that was written, we live
in a New World of opiates that presents far greater challenges
clinically. As a result of multiple changes outside of our sphere
of practice, we now have
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As a result of all these
influences, the Salt Lake
County Jail practice
group felt that it was
imperative to redesign
how we managed opiate
withdrawal to minimize
morbidity and mortality.
Accordingly, we undertook
a comprehensive review of
the literature and we found
that the medical literature
really did not address the
issues that we were facing
in a correctional setting.
Consequently, we were
left with the only option of
designing our own program
using the literature as a
guideline but customizing
the program for what
could be accomplished
and what the priorities are
in a correctional setting.
I was asked to write up
this program by several
clinicians at the last
NCCHC conference and to
disseminate it as quickly as
possible to try to improve
the care for this serious
condition nationally.
Page 6 /
In my facility, any
patient undergoing opiate
withdrawal is assessed
twice per day for a
minimum of five days
by nurses who have been
trained in the WOWS
protocol. The assessment
includes a full set of vital
signs, serial tracking of the
patient’s clinical progress,
and interventions as
necessary based on clinical
presentation. We have used
the WOWS protocol for
approximately two years
and have found it to be a
much more sensitive tool
for identifying patients
who need additional
medical assistance early
enough in the withdrawal
process to intervene
effectively without having
to send out patients in
crisis.
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In running this program,
we have found that many
of our opiate withdrawal
patients are physiologically
fragile and require medical
support to withdraw from
opiates safely. Patients with
an abnormally low body
mass index are common
and they frequently
experience extreme
distress during opiate
withdrawal. One of the
changes we made with this
program was to implement
a mandatory height and
u
weight measurement
Volume 19 / Issue 2 / Summer 2016
in the intake process using a standardized industrial scale.
Patients with a body mass index less than 18 receive heightened
scrutiny during their opiate withdrawal.
We have also found that young patients present a serious
diagnostic challenge in the opiate withdrawal syndrome
because they have tremendous physiologic reserve and they
are able to maintain their vital signs in a normal range right
up to the point in which they are in crisis. Thus, we have
a high level of suspicion for young opiate addicts and we
emphasize relying upon laboratory results as opposed to vital
signs in these patients to determine their need for additional
medical care.
Self-Harm
Severe opiate withdrawal puts patients in such physical distress
that self-harm and suicide are extremely frequent in this patient
population. Indeed, many patients who die of opiate withdrawal
die as a result of suicide. Therefore, when the nurses assess
patients using the WOWS protocol, we found it necessary for
them to do an assessment for self-harm.
In this scenario, it is common to encounter patients who
are thinking about self-harm and merely treating their
opiate withdrawal adequately resolves the issue for them.
Consequently, we view adequate opiate withdrawal treatment
to be a critical component of our suicide prevention plan.
Since implementation of this protocol, we have seen significant
decreases in suicide attempts and suicide completions within
our patient population.
Targeted Outpatient Treatment
In the general population setting, this program prompts
aggressive targeted treatment for diarrhea, vomiting, and
hydration. For diarrhea we typically use loperamide, and for
vomiting the first drug of choice is promethazine followed
by ondansetron if the patient has clinical issues with the
promethazine.
We also place a significant emphasis on oral hydration. All
nurses are supplied with bottles of Gatorade that they hand out
freely to any patient on the withdrawal protocol. In addition,
custody staff has created “hydration stations” that consist of
large coolers of Gatorade that offer open and unlimited access
to patients who are withdrawing. This program has proven to
be invaluable in minimizing complications from withdrawal
syndrome. Say what you want, the water in correctional
facilities is disgusting. The pipes are old, the water tastes bad,
the water is not cold, and inmates will not drink it, especially
when they are sick. Believing that your inmates have adequate
access to water, that it is sufficient to meet their hydration
needs, and that they will actually drink it is a deviation from
rational clinical thought.
Targeted Inpatient Treatment
For patients who do not respond to the early outpatient
interventions, more aggressive surveillance and treatment
are necessary. We estimate that between 5% and 10% of our
patients undergoing opiate withdrawal need care at this level.
The first step in caring for these patients is to obtain basic
laboratory assessment including a CBC and a CMP to assess
their electrolytes, renal function, and critical blood components.
It is common to identify abnormalities that require correction
or additional workup in these patients. These individuals are
typically admitted to an inpatient setting where they can be
monitored much more closely and appropriate interventions,
including IV fluids and electrolyte replacement, can occur.
Treatment in the inpatient setting also allows for much more
aggressive medical management. When clinically appropriate, a
primary therapy used to manage these serious opiate withdrawal
patients is the initiation of a buprenorphine/naloxone
(Suboxone) taper. We have found incredible, almost magical,
success with this medication. We typically start at 16 mg
buprenorphine / 4 mg naloxone and cut that dose in half every
two to three days. The clinical turnarounds you can see in these
patients is nothing short of miraculous.
Summary
+ In the modern world, opiate withdrawal is a life-threatening
medical condition.
+ In large institutional settings, a targeted serial screen
tool like WOWS is extremely effective at standardizing
treatment.
+ Assessment should be done twice per day for five days
minimum including vital signs and self-harm assessment.
+ Assess for dehydration.
+ Assess for comorbidities including advanced age,
underlying chronic diseases, and malnourishment.
+ Begin targeted treatment for diarrhea and vomiting early in
the withdrawal process.
+ Hydrate, hydrate, hydrate using something that the patients
will actually drink.
+ Obtain lab work on any patients not responding to the basic
protocol.
+ Admit to an inpatient setting if the patients’ clinical
presentation or laboratory results dictate.
+ Become buprenorphine certified and use it to treat severe
opiate withdrawal. n
Additionally, patients with a low body mass index are
immediately started on double portion diets as well
as nutritional supplementation like Ensure and that
supplementation is continued while they are on the
withdrawal protocol.
Page 7 /
SCREENING HEALTH PROBLEMS FOR ADOLESCENT
DETAINEES WHO REPORT SUBSTANCE USE
By Michelle Staples-Horne, MD, MPH, MS & Madison L Gates, PhD
A
dolescence is often a time when many youths experiment
or initiate substance use, particularly tobacco, alcohol
and cannabis 1-8, in which persistent and long-term use
may have lasting cognitive and physical health effects. Substance
use among detained adolescents, who are more likely to initiate
drugs and alcohol consumption compared to non-detained peers
9-12
, is a significant health issue for departments of juvenile justice
and primary care providers in these settings. Several studies,
investigating the effects of adolescent substance use, have found
a strong relationship to cognitive impairments and the need for
mental and behavioral health services 1,5,7,8. Further, adolescent
substance use, especially among justice involved adolescents, has
been linked to underlying experiences of and exposure to trauma
(i.e., some youths are self-medicating as a coping mechanism) 13-15.
However, there are few studies that have investigated the
relationship between different types of substance use and
adolescent physical health 4,6. The number of studies in vestigating
adolescent substance use and physical health largely have been
limited to physical functioning 13. Thus, there is a significant gap
regarding types of substance use and physical health problems
reported by adolescents, especially the population involved with
the juvenile justice system. The goal of this study was to provide
evidence to enhance substance use related screenings during
intake. This study primarily aimed to understand the association
between self-reported substance use and health problems among
detained adolescents. Secondarily, we investigated health
problems in regard to potential race/ethnicity and/or gender
disparities.
females reported substance use in greater proportions than their
statewide juvenile justice distribution.
Table 1. Study and Statewide Population
Study
RACE
Statewide
n (%)
Mean Age
n (%)
313 (64.3)
15.9
219 (72.7)
Hispanic
47 (9.7)
16.1
72.7 (6.0)
Other
16 (3.3)
16.0
41 (3.3)
White
111 (22.8)
15.4
74 (6.0)
Female
61 (12.5)
15.6
124 (10.0)
Male
426 (87.5)
15.8
1100 (90.0)
African American
GENDER
TOTAL
487
1224
Methods
The five most frequently reported health problems among
detainees reporting substance use pertained to either
neurological (e.g., insomnia, headaches and previous head
injury), eyes (e.g., blurred vision), or dental problems (e.g.,
cavities). Detained adolescent reported marijuana (60.2%) and
alcohol use (30.8%) more often than other substances. Crack/
cocaine and methamphetamine were reported by 2.7% and 2.5%
of the study population.
This cross-sectional investigation was approved by a department
of juvenile justice in the southeast United States. All data (e.g.,
self-reported health problems, substance use, race/ethnicity,
gender and age) were extracted from the department’s electronic
health record. The population was sampled from current detainees
(2016) who reported substance use prior to their detention. SAS®
9.4 (SAS Institute, Cary, NC) was used to perform all statistical
analyses (nonparametric statistics). We used p ≤ .05 as the cutoff
point for significant findings; analyses were based on two-sided
tests. Race comparisons were limited to African Americans and
Whites, since the distribution of Hispanics and Others were not
large enough for meaningful analyses.
There were significant differences between reported substance
abuse and health problems. Dental and neurological problems
were the only health conditions significantly associated with
substance use. Adolescents who used methamphetamine/
amphetamine had 2.6 times greater odds ( p = .05) of reporting
at least one dental condition (bloody gums or cavities)
compared to the population that used other types of substances.
The relationship between methamphetamine/amphetamine
and cavities also was significant ( p = .03) where users of
these substances had 3.0 times greater odds of reporting this
particular dental problem compared to adolescents reporting
other types of substance use.
Results
We sampled 487 records out of a statewide population of 1224,
a sampling rate of 39.8%. The sample also indicated that a large
percent of the population reported a history of substance use.
Further, the sample was majority male and African American,
which reflected the statewide population (See Table 1). However,
a comparison between the two populations indicated that the
distribution of African Americans reporting substance use was
less than their statewide representation. Conversely, Whites and
Page 8 /
Crack/cocaine was significantly associated with reports of
headache, in which adolescents who used this substance had 2.9
times greater odds (p = .05) of reporting the problem compared
to the population that used other types of substances. Adolescents
who reported cannabis use had 1.4 times greater odds (p =
.06) of also having issues sleeping in comparison to those who
did not use marijuana, which was close to the cutoff point for
significance. Although previous head injuries were not directly
associated with substance use, the problem was significantly
related to insomnia (p < .01); the population tended to present
both problems. u
!1
Volume 19 / Issue 2 / Summer
2016
Interestingly, there were few significant race or gender
differences in regard to substance use and health problems. White
adolescents compare to African Americans had 2.8 times greater
odds (p < .01) of reporting insomnia and were 6.8 times more
likely to report methamphetamine or amphetamine use (p < .01).
However, African Americans were 3 times (p < .01) more likely
to report cannabis use than Whites (See Figure 1).
Figure 1. Health & Substance Use Differences by Race
Figure 1. Health & Substance Use Differences by Race
Conclusion
Results that emerged from this study indicated there is a
relationship between type of substances and health problems
that detained adolescent report, as well as the most prevalently
used substances (e.g., cannabis and alcohol). Methamphetamine
and amphetamine were strongly associated with dental
problems, especially cavities, while crack/cocaine and cannabis
were related with neurological issues, headaches and insomnia,
respectively. These findings may provide guidance for
enhanced health screenings for adolescents who have used these
substances.
The methamphetamine finding in regard to dental problems
and the crack/cocaine link to headaches were consistent
with expected health effects from using these substances 16.
However, the association between cannabis and insomnia
may indicate that some adolescents were self-medicating with
marijuana, which typically results in drowsiness or relaxation
after an initial feeling of euphoria or heightened sensory
perception 16. Further, the limited number of race and gender
differences was unexpected, especially since other investigators
have focused on minorities, substance use and adverse health
outcomes 17-19.
Substance use and its effect on health that emerged from this
study is a starting point for understanding the population
referred to departments of juvenile justice. While detained,
most adolescents are provided services in regard to their
physical, behavioral and mental health issues, but often return
to communities where they initially became involved with
the justice system. Along with improved understanding of the
health effects of substance use among adolescents, there also is
a need to investigate generational trends and drug preferences
with the aim of developing and delivering more effective risk
reduction interventions for adolescents who are returning to
their communities (i.e., reentry).
!
!
In regard to gender, males were 5.5 times (p < .01) more like to
report cavities compared to females (See Figure 2).
Figure 2. Health Differences by Gender
Figure 2. Health Differences by Gender
Expanding upon this investigation and developing efficacious
and evidence-based interventions, future studies will have a
significant role in exploring the relationship between adolescent
substance use and parental experience or exposure. In other
words, why do detained adolescents select the drugs they
do (e.g., availability, physiologic effect)? There is emerging
evidence that adolescents are shifting their perception of what
they consider substance use. For example, some adolescents
do not classify alcohol and cannabis as drugs in the same way
they would cocaine. These proposed investigations are likely
important factors for treating adolescents who use substances,
as well as developing preventive interventions. n
References
1. Baggio S, N’Goran AA, Deline S, et al. Patterns of cannabis use and prospective associations with health issues among young males. Addiction (Abingdon, England). 2014;109(6):937-945.
2. de la Haye K, D’Amico EJ, Miles JN, Ewing B, Tucker JS. Covariance among multiple health risk behaviors in adolescents. PloS one. 2014;9(5):e98141.
!2
3. Degenhardt L, Stockings E, Patton G, Hall WD, Lynskey M. The increasing global health priority of substance use in young people. The lancet. Psychiatry. 2016;3(3):251-264.
4. Hall WD, Patton G, Stockings E, et al. Why young people’s substance use matters for global health. The lancet. Psychiatry. 2016;3(3):265-279.
!
!
5. Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences. 2012;109(40):E2657–E2664.
!2
Continued on page 10 u
Page 9 /
Government Helping Government from Page 5...
Screening Health Problems from Page 9...
ceiling and floor tiles, and sinks were installed among many
other necessities. Furthermore, infection control methods such
as hand soap and paper towel dispensers were added. Equipment
was repaired, upgraded or replaced and airflow systems were
installed for isolation for contagion control.
6. Murphy K, Sahm L, McCarthy S, Lambert S, Byrne S. Substance use in young persons in Ireland, a systematic review. Addictive behaviors. 2013;38(8):2392-2401.
DOC ensured correctional and security staff was educated
and embraced the goals as fully vested team members with the
medical staff to achieve the care necessary. The operational
and procedural changes necessitated everyone to work together,
creating a seamless and cordial interchange between corrections
and medical staff to operate effectively and meet the new
standard of care. Additional training was provided, with
corrections officers trained in first aid and suicide prevention,
and medical staff trained on security processes and protocols of
providing health care in a correctional setting.
7. Phillips NL, Milne B, Silsbury C, et al. Addressing adolescent substance use in a paediatric health-care setting. Journal of paediatrics and child health. 2014;50(9):726-731.
8. Pitts S, Shrier LA. Substance abuse screening and brief intervention for adolescents in primary care. Pediatric annals. 2014;43(10):412.
9. Martin RA, Stein LAR, Clair M, Cancilliere MK, Hurlbut W, Rohsenow DJ. Adolescent Substance Treatment Engagement Questionnaire for Incarcerated Teens. Journal of Substance Abuse Treatment. 2015;57:49-56.
10.Ramaswamy M, Faseru B, Cropsey KL, Jones M, Deculus K, Freudenberg N. Factors associated with smoking among adolescent males prior to incarceration and after release from jail: a longitudinal study. Substance Abuse Treatment, Prevention, and Policy. 2013;8:37-37.
11.Snyder SM, Howard MO. Patterns of Inhalant Use among Incarcerated Youth. PloS one. 2015;10(9):e0135303.
12.Stein LAR, Lebeau R, Clair M, Rossi JS, Martin RM, Golembeske C. Validation of a Measure to Assess Alcohol- and Marijuana-Related Risks and Consequences Among Incarcerated Adolescents. Drug and alcohol dependence. 2010;109(1-3):104-113.
13.N’Goran AA, Deline S, Henchoz Y, et al. Association between nonmedical prescription drug use and health status among young Swiss men. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2014;55(4):549-555.
14.Woodson KM, Hives C, Sanders-Phillips K. Violence exposure and health related risk among African American adolescent female detainees: A strategy for reducing recidivism. Journal of offender rehabilitation. 2010;49(8):571-584.
15.Lopez V, Kopak A, Robillard A, Gillmore MR, Holliday RC, Braithwaite RL. Pathways to Sexual Risk Taking Among Female Adolescent Detainees. Journal of youth and adolescence. 2011;40(8):945-957.
16.Drug Facts. National Institute on Drug Abuse. 2016. https://www.drugabuse.gov/publications/
finder/t/160/DrugFacts. Accessed February 16, 2016.
17.Champion JD, Young C, Rew L. Substantiating the need for primary care-based sexual health promotion interventions for ethnic minority adolescent women experiencing health disparities. Journal of the American Association of Nurse Practitioners. 2016.
18.Chatterjee A, Gillman MW, Wong MD. Chaos, Hubbub, and Order Scale and Health Risk Behaviors in Adolescents in Los Angeles. The Journal of pediatrics. 2015;167(6):1415-1421.
19.Green KM, Musci RJ, Johnson RM, Matson PA, Reboussin BA, Ialongo NS. Outcomes associated with adolescent marijuana and alcohol use among urban young adults: A prospective study. Addictive behaviors. 2016;53:155-160.
Guam Working Group
New inmate and detainee receiving and screening policies were
modified to enable nursing staff to evaluate an inmate’s health
prior to housing. Inmates were given identification cards so
nursing staff could verify medication goes to the right inmate.
Nurses received and triaged sick call requests within 24 hours to
alleviate clinic backlog, a stark improvement over the previous
timeline.
The Government of Guam hopes to close the generation-old
case, finally living up to the stipulated agreement by achieving
care and locking systems requirements in accordance with
the district court’s timelines. DOC plans to move forward
in obtaining accreditation by the NCCHC as an accredited
institution that meets the national standards on correctional
health care. In reflection, when government helps government,
when you build a one-team approach with good leadership,
government rises to the challenge. For Guam, we have what is
called the “Inafa maolek” spirit... translated means “to make
better.” This is our goal. n
CALL FOR ARTICLES
CorrDocs is always interested in publishing original research,
innovative practices used in correctional medicine, news that
may affect our patients and us, and human interest stories.
Send your submissions or questions about submissions
to editor@corrdocs.org
LETTERS TO THE EDITOR
Did an article, opinion, or statement in CorrDocs inspire
you, impact your work, sound too good to be true? Express
your opinions in a letter to the editor. The editor relies
on your feedback to continually improve the quality of
information in CorrDocs. Articles from our members are
always welcome.
Direct all Submissions to: editor@corrdocs.org
Page 10 /
Volume 19 / Issue 2 / Summer 2016
SELF-HARM FOLLOWING RELEASE FROM PRISON:
A PROSPECTIVE DATA LINKAGE STUDY IN
QUEENSLAND, AUSTRALIA
By Dr. Rohan Borschmann, Emma Thomas, Dr. Paul Moran, A/Prof. Matthew J. Spittal, Megan Carroll, Jesse Young, A/Prof.
Ed Heffernan, Prof. Rosa Alati, Dr. Georgina Sutherland, Prof. Stuart A. Kinner
P
risoners are at increased risk for both self-harm and
suicide compared with the general population and the
risk of suicide after release from prison is three times
greater than for those still incarcerated. However, surprisingly
little is known about the incidence of self-harm following
release from prison. We aimed to determine the incidence of,
identify risk factors for, and characterise emergency department
presentations resulting from self-harm in adults after release
from prison.
Method
proportion was more than 10 times greater than that reported
in the general population. The high prevalence of psychiatric
and substance use disorders in this population suggests that
these issues should be considered during emergency department
presentations and subsequent referrals. However, in our study,
fewer than three in ten participants (29%) who presented to
the emergency department due to self-harm received a mental
health assessment.
Clinical Implications
We conducted a cohort study of 1325 adults who were
interviewed prior to release from prison, linking these
interview data prospectively with State correctional and
emergency department records. Data from all emergency
department presentations resulting from self-harm were
secondarily coded to further characterise these presentations.
We used negative binomial regression to identify independent
predictors of such presentations.
The incidence rate of emergency department presentations
for any reason in our sample was more than five times higher
than that of the general population in Queensland during
the study period, a finding which is in line with previous
research indicating that ex-prisoners represent a group with
disproportionately high emergency department use. Given
this high presentation rate, it might be feasible to initiate a
critical time intervention for self-harm in ex-prisoners in the
emergency department.
Results
Conclusions
During a total of 3192 person-years of follow-up (median 2.6
years per participant) there were 3755 emergency department
presentations. Eighty-three participants (6.4% of the total
sample) presented due to self-harm, accounting for a total of 165
(4.4%) presentations. The crude incidence rates of self-harm
for males and females were 49.2 and 60.5 per 1000 person-years
respectively. Presenting to the emergency department due to
self-harm was independently associated with being Indigenous,
having a lifetime history of a mental disorder, having previously
been hospitalised for psychiatric treatment and having
previously presented to the emergency department due to selfharm. Most presentations were between the hours of 7:00am
and 5:00pm and one in every eleven ex-prisoners left the
emergency department before receiving treatment, a proportion
which was almost double that recorded in Australia in 2011-12
(9% vs. 5%). In 41 (24.9%) cases, ex-prisoners were admitted
to hospital for psychiatric treatment within 48hrs of presenting
to the emergency department. In 48 (29.1%) cases, ex-prisoners
accessed mental health services during their time in the
emergency department and in 100 (60.6%) cases participants
had contact with public mental health services either during
their visit or within 30 days afterwards.
Demographic and mental health variables help to identify
prisoners at-risk of presenting to the emergency department due
to self-harm and such presentations could provide opportunities
for suicide prevention in this population. The transition from
prison to the community is challenging, particularly for those
with a history of mental disorder. In light of this mental health
support during and after release may reduce the risk of adverse
outcomes, including self-harm. n
BIG THANKS
to Wexford Health Services for our night out
at B.B. King’s in Nashville! ACCP members
thoroughly enjoyed the music, food, and genuine
comradery that went on and on and on...!
Discussion
Following release from prison, approximately one in 15 exprisoners presented to an emergency department due to selfharm in the first 2.6 years. Although self-harm was responsible
for less than 5% of all emergency department presentations, this
Page 11 /
RISK REDUCTION: PROTECTING YOURSELF FROM THE
NEGATIVE IMPACT OF WORKING IN CORRECTIONS
By Sharen Barboza, PhD, CCHP-MH
W
orking in correctional facilities exposes healthcare
staff to a set of stressors often not experienced in other
settings. For most of us, we can easily list the physical
safety threats of a correctional environment, the liability risks of
the work, and the stress associated with the litigious nature of our
patient population. We also may experience stigma and isolation
from our community colleagues. Other healthcare providers may
not understand the complexities of the work that we do, including
the co-morbid conditions we treat, the challenging cases where
illness and chronic conditions have gone untreated for years, and
the limited funding and resources available. Instead, we can be
criticized for the
work. Others may
focus on how we
care for “criminals”
or how correctional
healthcare staff are
believed to be subpar and unable to find
employment in the
community.
Let’s not forget the
noise, the smells,
the poor visibility,
the waiting, the dehumanizing culture
and the “code of
silence” that can exist
all around us in corrections. Additionally, the work that we do can
isolate us from our families and friends. We cannot have our cell
phones at work. We cannot meet friends for lunch. The traumatic
nature of our work does not lend itself to dinner conversation.
The work of delivering healthcare in correctional facilities can
expose staff to chronic stress. Chronic stress puts us at increased
risk for diabetes due to changes in blood glucose and increased risk
of cardiovascular disease due to increases in blood pressure. We
can experience back and neck pain due to increased muscle tension,
memory problems secondary to decreased hippocampal volume,
and we can be more susceptible to illness and infection.
Chronic stress can lead to poor judgment, negative cognitive
interpretations of life events, and a reduction in our perception
of the meaning in our lives. Emotionally we can become more
anxious, more irritable, and/or more angry. We may display
increased moodiness and decreased frustration tolerance. Much
like a callous can develop when the same place on our foot gets
rubbed by an ill-fitting shoe, we can develop emotional callousness
when the same feelings get triggered again and again. Callouses
are protective again pain. They are adaptive. Emotional callousness
and numbness can be our psyche’s way of protecting us again
continuous distress. But these callouses can carry over into our
“real lives” and impact our relationships outside of work. Many of
us just simply want to be alone when we get home. We do not want
to talk about our day, we do not want to engage socially, and we do
not want to hear about other people’s problems.
Page 12 /
Fortunately, there are some things we can do to help ourselves.
First, acknowledge what is happening. The issues described
above are common reactions experienced by most of us who work
in corrections. They are not a reflection of professional inadequacy,
personal weakness, or a failure on our part. Our reactions are
normal responses to abnormal situations. Given the environment,
these reactions are predictable and common. Take a minute to
do an internal inventory and admit to yourself that you may be
experiencing some of the issues described above.
Second, adjust your work to better support your professional
functioning and your health. Recommendations for protective
factors against chronic stress include the following:
1 Take short breaks during the day – even if this means heading
to the restroom for 2 minutes of deep breathing. Make sure
you take a break every few hours
2 Diversify your work – do not engage in direct care only.
Provide training when you can, offer time to provide
supervision, ask about committees you can join, etc.
3 Seek supervision from peers and supervisors to process
difficult cases and clinical challenges
4 Debrief after crises – talk through traumatic events with your
colleagues as soon as possible following an event
Third, focus on creating a more balanced lifestyle, across all
health domains.
+ Cognitive – Keep your brain active by doing puzzles like
crosswords and Sudoku; chose positive interpretations of
events (find that silver lining); remind yourself of the good
you do every day
+ Emotional – Engage in relaxation activities, including
mindfulness and meditation; laugh more; acknowledge your
limits; internally praise yourself for the help you give to others
+ Physical/Behavioral – Exercise, eat right, watch your
substance use, get enough sleep, engage in a hobby that does
not include human services
+ Social – Engage with friends and family; stop saying “no” to
social events; share your feelings with family and friends, they
love you and want to help you deal with your stress. When we
choose to keep our problems to ourselves, we create distance
from others and they feel untrusted and rejected. They see us
suffering and cannot help. They want to help, let them.
Working in corrections can be very rewarding. We serve the
underserved and we care for those who have been rejected. We
improve the overall public health by reducing chronic disease and
helping our patients return to the community healthier than they
were when they entered the correctional system. But we need
to keep ourselves healthy too. Please take some time to look at
yourself, see how you’re coping, and address concerns that may
be present. As healthcare providers, we should “return to the
community” each day at least as healthy as we were when we
entered the correctional facility. n
Volume 19 / Issue 2 / Summer 2016
THE LIFE AND DEATH
OF A MEDICAL DIRECTOR
By Juan Rudy Nunez MD, CCHP-P, Associate Chief Medical Officer, Armor Correctional Health Services, Inc.
I
often wonder what path my medical profession would have
taken me had I not decided to accept the role of medical
director in a correctional facility 21 years ago. Back in the
day, a medical director was more of an administrator than a
clinician. Times have changed. These days a medical director
of a correctional facility, jail or prison, wears many hats. The
medical directors play important roles in ensuring the delivery
of quality long-term health care to the offenders which I prefer
to call “patients” are adequate. The tile of “medical director”
sounds important but does come with a price. The medical
director must learn the art of multi-tasking in order to be
efficient.
So your typical day starts out like this: Do daily infirmary
rounds, sign off on all lab results and review all outside
hospital charts or x-ray reports and don’t forget to document
that you have reviewed them. In the afternoon, see your share
of patients to help your providers with the load of patients they
see on a daily basis. Other functions are the offsite consults
reviews for approval, attend staff meetings with the nurses
or security staff meetings, review and present all mortalities
to the Mortality Review committee and if that’s not enough:
demonstrating accountability, that is supervising or in some
cases micro-managing those providers that are not providing
proper medical care. Oh, don’t forget the conference calls you
must have with your superiors to reassure them that everything
is running smoothly.
Yes indeed, the life of a medical director is never boring. On
the contrary, you don’t need to drink four cups of coffee or
consume your favorite energy drink on daily basis. Once you
step inside the facility you are suddenly wide awake and feel
that adrenaline surge rushing all through your body as the jail
commander is waiting to ask you why there are 8 patients in the
hospital? Or that two of your health care providers called out
sick or even better yet you might have to be 2 weeks “on call”
back to back because there is no one who wants to be on call for
2 consecutive weeks.
Another key component is that medical directors must remain
open to emerging technologies that make correctional health
care simultaneously more beneficial to patients and cost
effective for the employer. Medical directors must be receptive
and supportive of all staff. This includes nursing staff,
health services administrator and especially (yes, and I mean
“especially”) the Director of Nursing.
As the years passed, I have somewhat improved the art of
multi-tasking and am still working on it. I feel more confident
and better prepared to tackle the daily challenges that I still
felt reluctant at times to accept. It seems like yesterday I began
my duties as medical director. Just like all US Presidents when
they begin to fulfill their duties as Commander in Chief, you
see them age in front of your eyes in such a short time span. I
recently took a look at my wedding picture and saw myself in
the mirror. It was quite obvious that in such a short amount of
time, my head was covered in gray and I looked worn out. In
fact some of my friends including my relatives commented at
a family reunion, that I had taken this job too personal and as
a result, the job had taken its toll on me. I actually took that as
compliment and preferred to call it “dedication”.
It’s been 4 years and 2 promotions later since I left the medical
director’s position. I can honestly say that, at times, it was
difficult coming into a facility and hear all the negatives instead
of the positives. Of course not everything was negative, but
some of it was really pure every day nonsense. There was one
main factor that made my day. It was the satisfaction I received
in providing the best medical care that I could provide to the
patients. At the end of the day that was all that mattered.
In my present role when I do site visits once in a while, I get a
patient in the medical area who remembers my name and thanks
me for helping him when I was medical director. Believe me,
it feels good. If it’s one thing I learned as medical director is
the meaning of “compassion”/ So Is it worth being a medical
director? I’ll let you be the judge of that. As for me, it was worth
every moment of it. n
SAVE THE DATE/S:
UPCOMING CONFERENCES
JULY 15-16, 2016
NCCHC CORRECTIONAL HEALTH
CARE LEADERSHIP INSTITUTES
(FORMERLY SCP BOOT CAMP)
BOSTON MA
JULY 17-18, 2016
NCCHC CORRECTIONAL MENTAL
HEALTH CARE CONFERENCE
BOSTON MA
OCTOBER 23, 2016
ACCP ANNUAL EDUCATIONAL CONFERENCE
LAS VEGAS NV
OCTOBER 22-25, 2016
NCCHC NATIONAL CONFERENCE
ON CORRECTIONAL HEALTH CARE
LAS VEGAS NV
Page 13 /
THE NORTHUMBERLAND PRISON FIRE
By Jamie Hess, RN, and William Young, MD
A
six alarm fire broke out in the left wing of the 139
year old Northumberland County Prison in Sunbury,
Pennsylvania on January 14, 2015.
The assist alarm went off during the afternoon shift change
when the inmates were locked down. A lieutenant grabbed a
fire extinguisher and ran down the left wing, but came right
Several factors account for the fortunate outcome:
+ First, the fire occurred during lockdown and change of
shift. So the inmates were in their cells rather than scattered
throughout the prison, and enough officers were present to
evacuate the facility.
+ Second, the staff did everything right. There was confusion
but cell keys were available, the call to 911 occurred quickly,
the staff followed their plan and there was no panic.
+ Third, the inmates could be taken out safely through the
basement. This allowed their movement to be easily controlled.
+ Fourth, the church that served as a holding area for the
inmates was conveniently located across the street. The
weather was cold but the inmates were kept warm, dry and
secure.
+ Fifth, the inmates could be evacuated to nearby state prisons.
Similar evacuation arrangements had been made at other
times, most recently during the flooding from Tropical Storm
Lee in 2011 although it proved unnecessary. And the state
prison staff was quite helpful.
The Northumberland County Prison Fire
back to call 911. A group of officers went down the first floor
left wing with cell keys and released those inmates into the
yard. Then they released inmates from the first floor right wing
into the yard. Female inmates were released from the basement
into the female yard. When the smoke in the yard became too
thick the inmates were bound in pairs by zip ties. They were
evacuated back into the jail building through the jail basement
and out the front of the jail. The nursing staff was at the front
entrance where they triaged the inmates for burns and injuries
and dyspnea. Male inmates were taken across the street into the
church basement social hall; the female inmates were taken up
to the second floor of the church. The nursing staff continued
monitoring and reassuring the inmates. Both inmate holding
areas remained calm probably because of the canine patrols. In
addition 150 local law enforcement personnel maintained an
inner and an outer perimeter around the entire area. Injuries
were limited to one inmate taken to the hospital for vasovagal
syncope and one officer who slipped and broke his foot.
After the jail was evacuated and the firemen were working
to control the fire, arrangements were made to transport the
inmates to other sites. Buses took the male inmates to the
nearby State Correctional Facility at Coal Township and the
female inmates to the State Correctional Facility at Muncy.
The nursing staff gave reports on the inmates to the state staff
during the transfer.
The SCI Coal Township staff processed 171 male county
inmates into the state prison that evening, and the next day the
overcrowding was relieved by transferring 240 state inmates out
to SCI Gratersford outside Philadelphia. Thirty seven female
inmates were taken to SCI Muncy, the female state prison.
Page 14 /
+ Sixth, they were lucky.
Star – Jail Building
Blue Arrows/Lines – Male Inmates
Pink Arrows/Lines – Female Inmates
Concentric Circles – Yard
ZigZag Lines – Stairs/Basement
Cross – Church
The State Fire Marshall could not determine the cause of the
fire. The inmates are still housed in the two state prisons as well
as several nearby jails.
The county had planned to construct a new jail, courthouse and
police station on 22 acres a half mile from the center of Sunbury.
Their current plans are to convert the 168 acre site of the
Northwestern Academy, twenty miles away, into the new jail.
Once a warden told me after a case of meningitis that its better
to be lucky instead of good. I don’t disagree, but if you’re
prepared, then you’ll be even luckier. There are several sources
that can be used: the Emergency Management Institute on
the FEMA website, training.fema.gov. Another is A Guide to
Preparing for and Responding to Jail Emergencies published
by the US Department of Justice and available at nicic.gov/
Library/Files/020293.pdf. In addition, online bookstores sell the
FEMA EMI Independent Study Course material. n
Volume 19 / Issue 2 / Summer 2016
9TH ANNUAL ACADEMIC & HEALTH POLICY CONFERENCE
ON CORRECTIONAL HEALTH: ADVANCING THE FIELD OF
ACADEMIC CRIMINAL JUSTICE HEALTH
T
he 9th Annual Academic & Health Policy Conference on
Correctional Health in Baltimore, Maryland highlighted
the positive impact of criminal justice and public health
collaborations, successful community transition programs post
release and how implementation science can improve inmate
health care. The March 16-18 conference at the Grand - Embassy
Suites Baltimore Inner Harbor was hosted by the Academic
Consortium on Criminal Justice Health (ACCJH), which is
supported by UMass Medical School, and co-hosted this year by
George Mason University.
ACCJH is a pioneering membership organization comprised of key
leaders engaged in criminal
justice health research, health
career training and clinical
care systems. Its mission is to
improve the care and outcomes
of justice-involved individuals.
Several ACCP members
are on the board and ACCP
contributes greatly to ACCJH
either through participation,
speakers, or exhibits.
Dr. Steven Belenko, PhD,
kicked off this year’s
conference with his keynote address, “Creating and Sustaining
Effective Corrections and Public Health Collaborations: Teaming
Up to Improve Health Outcomes.” Dr. Belenko, a professor in the
Temple University Department of Criminal Justice and adjunct
professor of Psychology in the Department of Psychiatry at the
University of Pennsylvania’s School of Medicine, is a nationally
recognized health researcher, with funded research and published
works in the field of criminal justice health.
MSW, program chief, Division of Services and Intervention
Research, National Institute of Mental Health; Ruby Qazilbash,
associate deputy directo, Bureau of Justice Assistance, DOJ; and
Tisha R. A. Wiley, PhD, Health Sciences administrator, Services
Research Branch, NIDA. The panelists discussed the new
initiatives and strategic directions of organizations that provide
grants in criminal justice health.
The conference expanded this year to include a track on
Implementation Science. Conference founder and co-chair
Warren Ferguson, MD, a professor in Family Medicine and
Community Health at UMass Medical School, was awarded a
four-year grant from NIDA
and a three-year grant from
the Agency for Health Care
Research and Quality in
2016 to study treatments for
substance abuse disorder and
hepatitis C in four prison and
jail systems in the United
States. As the principal
investigator, he helped to
enlist correctional systems
from across New England to
participate in the conference’s
first Implementation Science
Track, which focused on medication-assisted substance abuse
treatment for incarcerated individuals before and during the
transition to release. Each correctional system sent a team of
five participants to the conference who worked collaboratively
throughout the three days, using the interdisciplinary team
science approach while aiming to adopt evidence-based
approaches.
Dr. Shira Shavit and Dr. Emily Wang co-presented an
inspirational plenary session, “Transitions Clinic Network:
Transforming the Health System in Partnership with Justice
Involved Individuals.” Shira Shavit, MD, is executive director of
the Transitions Clinic Network in San Francisco and associate
clinical professor of Family and Community Medicine at the
University of California in San Francisco; Emily Wang, MD,
MAS, is the evaluation director and co-founder of the Transitions
Clinic program and an associate professor of medicine at Yale
University. Together, they co-founded the Transitions Clinic
Network (TCN) which is now a national network of medical
homes to transition care for individuals with chronic diseases
recently released from prison and jail. Each clinic employs a
community health worker with a history of incarceration and is
located in communities most impacted by incarceration.
“Delivering health care to justice-involved individuals, who often
have complex medical and behavioral health conditions, can be a
challenge for correctional administrators struggling under limited
budgets and the rising costs of health care and prescriptions,”
Ferguson said. “Implementation science is a key method to
adapting and adopting evidence-based treatments behind bars.”
This year, co-host Faye Taxman, PhD, of George Mason
University organized a special session featuring representatives
from the National Institute of Drug Abuse (NIDA) and the U.S.
Department of Justice (DOJ), “Panel on Federal Initiatives
and Future Issues in Grants.” The speakers included Erin
Iturriaga, BS, MSN, program officer/clinical trials specialist,
National Heart, Blood and Lung Institute; Denise Juliano-Bult,
The 2017 conference will celebrate the 10th anniversary of
the Academic and Health Policy Conference on Correctional
Health and will take place on March 15-17 at the Atlanta Airport
Marriott in Atlanta, Georgia. The Call for Papers is expected
to open on June 15th and ACCJH is looking forward to a more
formal collaboration with the ACCP over the coming year. n
More than 230 people attended the conference, with 125
organizations, 31 states, the District of Columbia, Puerto Rico
and three countries represented. The annual conference plays an
important role in advancing the field of academic criminal justice
health by bringing together researchers, clinicians, policymakers
and trainees to network and learn from each other.
Through grants from NIDA and the Jacob and Valerie Langeloth
Foundation, ACCJH supported tuition and housing for eight
junior investigators and 10 student scholarship recipients.
Page 15 /
1145 West Diversey Parkway
Chicago, Il 60614
IN THIS ISSUE
Addiction Medicine
President’s Column
There But For the Grace of God Go I
Ruminations on Gender Dysphoria
Welcome Christine Westbrook
Penitentiary Geese
Government Helping Government
How I Practice — Managing Opiate Withdrawal
Screening Health
Problems for Adolescent Detainees Who Report Substance Use
Self-harm Following Release From Prison
Protecting Yourself from the
Negative Impact of Working in Corrections
Life and Death of a Medical
Director
The Northumberland Prison Fire
9th Annual Academic &
Health Policy Conference on Correctional Health