Baby on Board: Substance Withdrawal and Pregnancy

Baby on Board: Substance Withdrawal and Pregnancy

With the majority of female inmates of childbearing age, drug and alcohol withdrawal during pregnancy is a fact of life in most jails and prisons. This is definitely a risky business as many substances affect fetal growth and development. Therefore, correctional nurses need to know the pregnancy status of female inmate starting at booking and have a clear understanding of the potential for drug or alcohol withdrawal while in custody.

Finding the Baby

Pregnancy evaluation at intake is recommended by the American College of Obstetricians and Gynecologists (ACOG) as well as the National Commission on Correctional Health Care (NCCHC E-02, G-09). Pregnancy risk can be assessed through screening questions about:

  • Menstrual history
  • Sexual activity
  • Contraceptive Use

Urine pregnancy testing is inexpensive and some settings opt to perform pregnancy testing on all females of childbearing age. Once identified, pregnancy should initiate various activities such as evaluation of gestational age and enrollment in an obstetric program.

Finding the Substance

Many pregnancies in this patient population are high risk due poor lifestyle habits of the mother and lack of medical services.  Female inmates have higher rates of smoking, alcohol use, and illegal drug use than the general population. All of these substances have detrimental effects on an unborn child. Identifying substance use at booking will determine any special considerations and interventions for a pregnant patient.

If a female inmate is found to be pregnant or likely to be pregnant, special attention should be given to determining the level of drug or alcohol use. Several screening tools are advocated for this purpose such as AUDIT, CAGE-AD, or SSISA. The important point is to screen for substances so that proper withdrawal intervention can be initiated.

Planning for Two

Substance withdrawal for the pregnant inmate means thinking about both the mother and the child. In fact, some withdrawals, like opiates, are too risky for the unborn child. Here is a quick breakdown on what to do for key substance withdrawals. The recommendations below come from the Principles of Addiction Medicine, Chapter 81: Alcohol and Other Drug Use During Pregnancy  unless otherwise indicated.

Alcohol: The Federal Bureau of Prisons recommends that alcohol withdrawal of pregnant women be managed in an inpatient setting. This may be the safest route to take but is not always possible. The NYS Office of Alcoholism and Substance Abuse Services recommends the use of a benzodiazepine taper and careful, frequent evaluation of withdrawal symptoms for pregnant alcohol-involved patients.

Benzodiazepines: Benzodiazepines and other sedatives/hypnotics can be withdrawn during pregnancy with careful management as abrupt withdrawal can lead to spontaneous abortion or premature labor. The second trimester is the optimum time for this withdrawal to reduce either of these outcomes.

Opiates: Opiate withdrawal has a high likelihood of miscarriage and premature labor. Therefore, pregnant opiate users (including those using methadone and buprenorphine) should be carefully managed by a specialist and may be maintained on the drug through pregnancy.

Stimulants: Stimulant use, such as cocaine and methamphetamine, during pregnancy can lead to preterm labor, placental abruption and intrauterine growth restriction. However, stimulant withdrawal does not cause significant physiologic consequence to the unborn and can be managed according to protocol with careful management.

In all cases, a pregnant substance-involved patient needs specialized obstetric medical care and close observation during the withdrawal period to have a healthy outcome.

How are you managing alcohol and drug withdrawal for your pregnant patients? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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Stimulant Withdrawal: All Wound Up!

Stimulant WithdrawalPrimary concerns in substance withdrawal are alcohol and opiates; and rightly so. Withdrawal of these two drugs of abuse can cause serious health concern. Stimulants such as cocaine, methamphetamine, crack, and amphetamines are also popular among the inmate patient population and can cause significant effects when abruptly withdrawn upon incarceration. Fortunately, stimulant withdrawal, while uncomfortable, is rarely life threatening.

Case of the Jitters

Stimulant intoxication may well be the initiating circumstance landing your patient in booking. Cocaine and meth are used  for a heightened sense of well-being and euphoria. However, they can also lead to aggressive and violent behaviors. Here is a list of common negative effects of stimulant over-use:

  • Emotional instability
  • Agitation, restlessness, irritability
  • Impaired judgment
  • Poor impulse control
  • Aggression

Charges for domestic violence, aggressive driving, or property destruction may result when things get out of hand. Besides the above behavioral observations, other signs of stimulant intoxication that might be noted on booking include:

  • Rapid heart rate
  • Elevated blood pressure
  • Dilated pupils
  • Increased temperature

If a patient presents with these indications of stimulant over-use, probe further into their drug-taking behaviors and usual withdrawal symptoms.  This information will help in developing a plan to manage their withdrawal while incarcerated.

Stimulant Withdrawal Effects

Coming off stimulant use results in irritating then depressing the nervous system. The patient can expect to first experience agitation, intense drug cravings, and insomnia. Farther into withdrawal this changes to lethargy, fatigue, and dulled senses causing excessive sleepiness.

Stimulant Withdrawal Management

Stimulant withdrawal usually doesn’t require medical management and protocols rarely include medications. For example the Federal Bureau of Prisons Withdrawal Protocols recommends symptom management only. However, cardiac complications can be seen, especially in compromised individuals like the elderly or those with cardiac or respiratory disease. A baseline EKG and follow-up may be warrented.

Stimulant withdrawal behind bars is basically a self-managed event requiring the inmate to initiate health care contact for symptom relief. Therefore, it is important to provide instruction on how to access the medical unit and when to seek out treatment. Explore ways the person has managed periods without the drug in the past and provide options within available processes during incarceration.

Stimulant Withdrawal and Self-harm

Although stimulant withdrawal may not be life-threatening, coming down off uppers can lead to severe depression and suicide ideation. This ‘crash’ may happen quickly with rapidly metabolizing drugs like cocaine or more slowly with longer-acting stimulants like methamphetamine.  Conclusion of withdrawal symptoms follows the same progression with acute cocaine withdrawal lasting from 3-4 days while methamphetamine can last 1-2 weeks. Unfortunately, drug craving can last much, much longer.

Engage available mental health treatment for this patient. Suicide evaluation, drug treatment programs, and group therapy are all beneficial.

Mixed Withdrawal Alert

Like so many of our patients, stimulant users will self-medicate with other substances to smooth out uncomfortable symptoms of their drug of choice. So, be aware that cocaine and methamphetamine users are likely to also use alcohol, benzodiazepines, or opiates to mellow out between fixes or after binges. Specifically ask about what your patient uses to even out their stimulant highs and be prepared to manage possible withdrawal from these substances, as well.

Are stimulants like cocaine, methamphetamine, crack, or amphetamines popular with your patient population? Share your withdrawal tips in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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Benzodiazepine Withdrawal: Monitoring and Treatment

Benzodiazepines are frequently prescribed for anxiety and sleep disorders. They are also popular for self-medicating or abuse purposes; providing peace and euphoria for troubled individuals. They are rarely abused alone and often combined with alcohol or opiates. Those who abuse cocaine or methamphetamines may use benzodiazepines to ‘level off’ a high.  An earlier post discusses the hidden nature of benzodiazepine misuse and the high potential for late withdrawal in many of our patients, especially women. Once identified, successful benzodiazepine withdrawal requires monitoring and management.

Signs of Impending Troubles

The symptoms and duration of withdrawal can be hard to nail down and are based on length of use, type (short-acting vs. long-acting), and underlying psychopathology. Symptoms can be as mild as some irritability and insomnia to as intense as seizures, panic attacks, and hallucinations. General body discomforts such as bloating, muscle aches, and restlessness are also common. The Federal Bureau of Prisons Detoxification Guidelines provide a helpful staging guide:

  • Early Withdrawal: Increased pulse and blood pressure, anxiety, panic attacks, restlessness, and gastrointestinal upset.
  • Mid Withdrawal: Progressing to include tremor, fever, diaphoresis, insomnia, anorexia, and diarrhea.
  • Late Withdrawal: If left untreated, a delirium may develop with hallucinations, changes in consciousness, profound agitation, autonomic instability, seizures, and death

Monitoring and Protocols

Unfortunately, an extensively evaluated monitoring scale does not yet exist for benzodiazepine withdrawal. A scale modeled after the well-validated CIWA-Ar (for alcohol withdrawal) is currently being tested for widespread use. The CIWA-B is a 22-item instrument that monitors type and severity of benzodiazepine withdrawal symptoms such as irritability, fatigue, appetite, and sleeplessness. Objective assessment of sweating, restlessness (pacing), and tremor are also documented. A tally of points based on responses and observation can be used to determine treatment.

Another withdrawal monitoring option with some validation is the Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ). This tool is a 20-item self-report questionnaire that does not include scoring categories for level of treatment.

Because tools like the CIWA-B and BWSQ have had little validation, as yet, the FBOP recommends general evaluation of symptoms based on the withdrawal table above with vital signs at least every 8 hours for the first three days of therapy.

Medical Treatment

A tapered schedule of long-acting benzodiazepines to ease withdrawal is advocated. Under medical supervision, detoxification can be accomplished using clonazepam (Klonopin) or chlordiazepoxide (Librium). Some experts prefer the long-acting barbiturate phenobarbital for safe benzodiazepine withdrawal.

Unfortunately, benzodiazepine withdrawal is complicated by symptom reemergence and rebound. The anxiety and insomnia that caused the original drug use can return with greater intensity. Withdrawal can take many weeks or months to successfully accomplish and requires continued monitoring and attention.

What tools are you using to monitor and treat barbiturate withdrawal? Share your practices in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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Benzodiazepine Withdrawal: Hidden Troubles

Officers in the women’s wing of a large urban jail call down to medical asking for assistance with an out-of-control inmate. The 22-year-old woman was booked in 10 days ago and was successfully withdrawn from alcohol during the first week. Now the officers describe her as totally out of control, hearing voices, and bouncing off the walls. As preparations are underway to do a cell-side evaluation, a Man-Down is called for the same wing. The emergency bag is pulled and the designated emergency nurse asks a second nurse to accompany her to the floor. They find the woman unconscious on the floor of her cell. The officers state that just after they phoned medical, the woman began to shake, her eyes rolled back, and she collapsed on the floor.

Delayed Benzodiazepine Withdrawal

Health care staff at this jail did a good job of withdrawing this woman from alcohol. They used a standard withdrawal protocol based on the Federal Bureau of Prisons Guidelines that included scheduled evaluations using the CIWA-Ar and administration of lorazepam (Ativan) based on scoring. Within 4 days she was symptom free and CIWA evaluations ended on Day 7.

However, intake screening questions missed this patient’s heavy dependence on diazepam (Valium) along with her alcohol intake. The benzodiazepine treatment for alcohol withdrawal held off drug withdrawal symptoms until later in her stay. Benzodiazepines are rarely misused alone. As in this case, they can be combined with alcohol abuse. In other situations they may be used in conjunction with opiates or cocaine. Women are twice as likely to misuse benzodiazepines as men.

Long-acting sedatives like diazepam may take longer for withdrawal symptoms to emerge, as indicated by this graph.

benzo

What’s in a Name?

Depending on your geographic region, you will hear many names for street drugs. Keeping up with the lingo is an important part of assessing for benzodiazepine dependence or misuse. Here are some common street terms for this drug class. Do any of these sound familiar?

  • Benzos
  • BZDs
  • Stupefy
  • Tranx
  • Qual
  • Heavenly Blues
  • Valley Girl
  • Goofballs
  • Moggies
  • Candy
  • Z Bars
  • Sleepers
  • School Bus
  • Dead Flower Powers

Seeing the Big Picture

Benzodiazepines have a calming effect and are often taken to reduce anxiety or to help sleep. The correctional patient population is less likely to frequent the health care system for these conditions and may obtain relief by self-medicating using street drugs. Asking questions about treatments used for anxiety or insomnia may reveal a need for benzodiazepine withdrawal monitoring. If regular use of a benzodiazepine is identified during intake, answers to the following questions will determine withdrawal treatment options:

  • Type of medication
  • Length of time used
  • Amount used
  • Reasons for use
  • Symptoms that occur when doses are missed
  • Date and amount of last dose

Benzodiazepine withdrawal is a hidden trouble that is often mixed with other drug and alcohol withdrawal issues. Be particularly alert for this potential with female patients in combination with other primary concerns such as alcohol and opiates.

What are you using to screen and assess for benzodiazepine dependence? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing.

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What would you do in this situation? Comparing clinical judgement.

Last week’s post was an opportunity to exercise your skill in making clinical judgments about patients who present with possible mental health issues. This week the best clinical option in each case is described along with the rationale. Compare each answer to the conclusion you drew about what to do next with the patient. If your answer is different it is important to reflect on the reasons; it may be that you perceived the symptoms differently or that you had a past experience that influenced your decision. If your answer is the same did you have the same rationale or another?

Case # 1. Willie is a 46 year old man with a history of seizures, suicide attempts and has a mental health diagnosis of “psychotic disorder, not otherwise specified”. He is followed regularly in chronic care clinics for both the seizure disorder and mental health. Dilantin and Haldol are prescribed for him to take twice daily and he is for the most part adherent in taking the medication. This evening while administering medication cell side he will not come to the door to take his medication. He is responsive to you but his conversation is making no sense. His cell is messy and there are cartons of partially eaten food strewn about on the cell floor. What action do you take?

  1. Document your observations in the medical record.
  2. Take his vital signs.
  3. Call the medical provider.
  4. Make a referral to mental health.
  5. All of the above.

Rationale: There are both medical and psychiatric concerns here. Always consider medical reasons for disordered behavior first. This is because if diagnosed and treated early the consequences of delayed treatment are avoided (permanent disability, death, adverse events and stigma). Both medical and mental health staff need to be notified so that care of the patient is coordinated. Taking vital signs and initiating periodic monitoring as well as the description of symptoms by way of observation contribute important information to the patient’s evaluation by medical and mental health staff.

Case #2. Norma is a 55 year old woman with a history of bipolar disorder. She was taken off the mental health caseload several months ago because she was doing well. Recently she displayed threatening behavior to several other inmates and as a result has been put into administrative segregation. It is early in the morning and the officers complain to you that she has been awake all night, singing and prancing about the cell. You should do all of the following except:

  1. Try to speak with her and make your own observations of her condition.
  2. Document your assessment in the medical record.
  3. Join in her song to initiate a therapeutic alliance.
  4. Make an urgent referral to Mental Health.
  5. Call the Mental Health Clinical Supervisor to report that you have made the referral.

Rationale: While Norma is not imminently a danger to self or others right now, it is unusual behavior that needs to be addressed promptly. By trying to speak with her you can assess her ability to respond to others and the extent to which she is able to communicate. Obviously you will document your assessment in the record because otherwise “it never took place”, right? Communicating directly with the mental health supervisor about the urgent referral is recommended so that he or she has an opportunity to clarify information about your observations of the patient and has the information to follow up and ensure the patient is seen timely. Joining the patient in her song may not be interpreted by the patient as therapeutic (it could be viewed as demeaning, threatening or confusing) and it serves no therapeutic purpose.

Case # 3. Geraldo is a 35 year old man with diabetes. He is followed regularly in the chronic care clinic and his diabetes has been in fair control the last six months. At today’s insulin line you notice that he appears to be upset and say something to him about it. He says that he just got an additional 20 months on another sentence. He thanks you for your concern. What should you do next?

  1. Immediately contact the on call mental health provider.
  2. Make a supportive comment and provide information about how to access mental health services.
  3. Place him on suicide watch.
  4. Give him the insulin he needs and move on to the next patient in line.
  5. Suggest that he order some Honey Buns, a favorite comfort food, from the commissary.

Rationale: The other choices range from too much to too little, to counter-therapeutic, don’t they? He isn’t expressing actively suicidal intention so there is no basis for contacting the on call mental health provider or placing him on suicide watch. But he did just get “bad news” and looks upset about it. Don’t assume that every inmate is going to know how to access mental health services; they may not remember because it wasn’t something that was important at the time of explanation. Providing information about access also indicates that it is normal to be upset about bad news and that people can benefit from “help” in coping with these challenges. Suggesting that he eat “comfort food” undermines the management of his diabetes and is counter-therapeutic.

Case # 4. Tammy is a 23 year old woman received at the jail for the first time 72 hours ago on a charge of reckless driving. The officers have contacted you this evening because “she is going crazy” and has not rested or eaten over the last 24 hours. You check her medical record and note that on intake she gave no history of mental health treatment and denied use of drugs or alcohol. On interview she doesn’t make any sense, does not respond to requests and seemed to get increasingly agitated. She also was picking at things in the air and rolling her fingers. What would you do next?

  1. Have a drug urinalysis done.
  2. Place her on medical observation.
  3. Complete a CIWA-Ar evaluation.
  4. Contact the provider for orders.
  5. Follow up with the officer later in the shift.

Rationale: Even though Tammy denied use of drugs at intake screening and gave no history of mental health treatment these certainly are possibilities now. An earlier post commented that we should expect patients to under-report at intake use of alcohol and drugs and include possibility of withdrawal in our differential diagnosis. While you most certainly will contact the provider and place her on observation, the next step is to do a more focused assessment for withdrawal. The CIWA-Ar is a standardized assessment tool that many correctional health care programs use to manage patients in withdrawal. The data collected from an assessment with this tool will provide the clinician with important information to use in determining treatment and follow up of this patient.

Case # 5. Jamie is a 17 year old brought to jail on a charge of burglary. He has a history of several other detentions as a juvenile. Currently he is in segregation for failure to follow orders. He has multiple complaints of chest pain and indigestion because of the food served with the religious diet. He is brought to the clinic because he has cut himself. He has four superficial lacerations on his left forearm. You treat each of the wounds and after a brief examination release him to return to his cell. This is his fourth cutting episode. What would you consider the best next step to be?

  1. Schedule him for a nursing visit the next day?
  2. Make a referral to the mental health staff.
  3. Ask the dietician to see him about the religious diet.
  4. Suggest an interdisciplinary meeting to discuss his care.
  5. Report the cutting episode to the next shift.

Rationale: Repeated cutting, even when not severe, is considered self-harm. Self-harm is a form of psychological distress, even in the absence of a diagnosed mental illness. Since this is his fourth episode, we can expect to see more episodes of cutting or other forms of self-harm with accidental or intentional suicide a real possibility. Since his maladaptive behavior effects everyone (security, medical, food service, religious services and mental health) an interdisciplinary plan of care is going to be the most effective. Nursing staff are in the key position to make this recommendation because we see the constellation of problems he presents (segregation, physical complaints about the diet, self-harm etc.).

Learning from case examples

Exercising good clinical judgement is one of the most essential features of correctional nursing. The right to a clinical judgment is one of the three constitutional rights that inmates have while incarcerated and nurses are most often the first health care professional to make a clinical judgement about an inmate in the correctional setting. Comparing decisions about cases is one way to increase information and build skill in making clinical judgments.

So how do your clinical judgments compare to these recommendations? In what way do they differ and why? For example if mental health services are limited only to those with the most severe symptoms you may not provide information to Geraldo in Case # 3 about accessing mental health for help coping with “bad news”. But what if he has trouble coping? Suicide is a risk resulting from “bad news” so what is an alternative clinical judgement? Schedule him for a nurse follow up visit? Are there other programs at your facility to help…such as the chaplain or a volunteer group? Examining your answers in this way may lead to identification of additional resources that you may want to use or develop further.

You may want to discuss each of these cases with other nurses at your facility to find out what others would do. If you do this as a group you may find that there are more resources than any one individual knew were available. These cases also would be great for an interdisciplinary discussion. If each member discusses what is their most important next step and why, other disciplines will know more about each program and its operation so that work with the inmate is coordinated rather than at cross purposes. These discussions will also identify opportunities to improve the management of inmates or eliminate gaps or barriers in service that are a liability risk.

We are interested in hearing your comments about what you think is the best clinical judgement in these cases. To do so please respond in the comments section of this post. To learn more about correctional nurses’ assessment of mental illness, response to suicide, self -harm and withdrawal, see our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

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Drug Withdrawal: Watch Out for Opiate Overdose!

Young african man lying on the floor with a syringe in her handJace had a difficult time withdrawing from heroin when he entered the jail 10 days ago on a burglary charge. He was stealing to meet the demands of his 5-bag a day heroin habit. A man-down emergency was just called for his housing unit where Jace was found unconscious and barely breathing. He may have hit his head falling from the upper bunk. His cellmate was out in the TV room at the time. The housing officer reports that Jace returned from a court hearing this morning and seemed in an upbeat mood. The nurse  registers Jace’s heart rate at 36 and respirations at 9 per minute. He is unresponsive and his pupils are equal and pinpoint. What is going on?

Opiate addiction is powerful. Even after a difficult withdrawal, individuals can be overcome with desire to return to drug use.  Jace had opportunity to obtain narcotics while out at his court hearing. In some facilities like these in California and Kentucky, contraband like narcotics can be obtained from the inmate black market and even from staff members.

Overdose Suspicion

Correctional nurses need to be suspicious of narcotic overdose any time a patient presents as unconscious with slowed vital signs and pinpoint equal pupils. Although this patient may have suffered a head injury or stroke, the presentation is suspicious for drug use. Another consideration is hypoglycemia and a fingerstick BS should be obtained if the patient is diabetic. The nurse in this situation should protect the patient’s C-spine in case of traumatic fall and follow emergency protocols for reversing the opiate effects.

Overdose Indications

Once the patient is determined to be breathing and with a regular heart rate, further evaluation for drug overdose can begin. Here is the classic triad of assessment findings in a narcotic overdose situation:

  • Respiratory depression – less than 12 inspirations per minute
  • Depressed level of consciousness
  • Equal pinpoint pupils (miosis)

Overdose Treatment

Many correctional settings have medical-approved nursing protocols to provide prompt treatment of narcotic overdose. Here is an example from Oregon. Treatment for Jace would include:

  • Maintaining C-spine protection while establishing an open airway
  • Providing ventilation support with oxygen and ambu-bag
  • Establishing IV access, if possible
  • Administering Naloxone (Narcan): Check protocol but dose range is 0.4 to 2 mg IV, IM, or SQ. Repeat doses, per protocol, may be given every 3-5 minutes until an adequate response is obtained (return to consciousness and improved vital signs).
  • Duration of action of Narcan is 45 minutes and repeat doses may be necessary until the narcotic leaves the system.
  • Prepare the patient for transport to the emergency unit for definitive evaluation and stabilization.

Note about Body Packing

In a situation like the above, consideration should be given to body packing (storing contraband drugs in body orifices or in the intestines (see this news item). If the overdose was due to a burst or leaking drug packet in the intestines or rectum, further effects may develop even after successful treatment.  A packing patient is unlikely to be a good historian or implicate themselves in the illegal activity. Alert emergency personal to the potential for retained drug packet. A simple fabdominal x-ray will reveal the truth.

Have you had to manage a narcotic overdose in your correctional facility? Share your experiences in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Alcohol Withdrawal: Special Issues

Danger signEven with an effective screening process, a solid treatment plan, and regular monitoring, patients withdrawing from alcohol can be in danger. Seizures and Delirium Tremens (DTs) can derail an otherwise effective withdrawal program. That is why it is also important to consider patient safety when making management decisions.

Safe Housing

Withdrawing patients are prone to falls and injury. Decreased liver functioning from long alcohol use causes increased bleeding tendencies that lead to hematoma formation, making head injury dangerous. Hallucinations and delirium can lead to erratic behavior and friction with officers and other inmates. Officers need to be aware of any inmates they are monitoring who are withdrawing. Those with potential for confusion, agitation, seizures, or delirium should be housed in the most protective manner possible.

Complicating Circumstances

Chronic conditions and past injuries can make alcohol withdrawal even more perilous than usual. According to Federal Bureau of Prison guidelines, withdrawing patients who have any of these additional conditions should have even close monitoring and additional safety precautions.

  • Cardiac Conditions: Sympathetic hyperactivity, common as high levels of alcohol are withdrawn, can agitate a weakened heart. A slower taper of benzodiazepine therapy is recommended for this group of patients.
  • Elderly: Older alcoholics may not show the usual signs of sympathetic hyperactivity so they may progress to severe withdrawal symptoms without any warning. Higher levels of chronic diseases and greater use of prescription drugs in this patient population increases chances of co-morbid complications and drug interactions. Aging causes decreased drug metabolism that can affect the adjustment of medications during the treatment tapering process.
  • History of Traumatic Brain Injury (TBI): Past brain injury increases the likelihood of seizures or DTs.
  • Liver or Kidney Disease: Chronic liver or kidney disease leads to poor metabolism of medication that requires closer monitoring as treatments are tapered.
  • Pre-existing Psychiatric Conditions: Alcohol can ameliorate psychiatric conditions. Mental illness symptoms may re-emerge once alcohol is no longer in the system. Severe depression, in particular, can lead to attempts at self-harm and suicide. Another reason for close monitoring.
  • Pregnant Inmates: Pregnancy complicates the withdrawal process by adding a second patient. Coordination of alcohol withdrawal with an obstetrical specialist is highly recommended, especially if there is also concern about drug use. Many correctional settings are not equipped or staffed to manage complex situations so transfer to an acute care facility is often the best option.
  • Seizure Disorders: A history of seizure disorders or already being under medical management for seizures increases the potential for withdrawal seizures. This history should be considered when tapering from benzodiazepine treatment. A slower taper is recommended for these patients.

How do you handle alcohol withdrawal for patients with these additional considerations? Share your tips in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Alcohol Withdrawal: Keeping Tabs

AlkoholsuchtWithdrawing from alcohol may be a common experience behind bars but it can never be taken lightly. Withdrawing patients need ongoing monitoring until they are through the risky period – at least the first three to five days. So, once you have screened for alcohol withdrawal and set a treatment plan in motion, you need to regularly check-in with withdrawing inmates to assess the progression of symptoms.

Know the Score

Both the Federal Bureau of Prisons Clinical Practice Guideline for Detoxification of Chemically Dependent Inmates and the NCCHC Alcohol Detoxification Guideline recommend the use of the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) for ongoing symptom monitoring and management during alcohol withdrawal (A copy of the CIWA-Ar can be found in the FBOP Guidelines).

This quick-to-use tool has been validated in many settings and assesses vital signs and withdrawal symptoms in 10 categories:

  • Nausea/Vomiting
  • Tremors
  • Anxiety
  • Agitation
  • Paroxysmal Sweats
  • Orientation and Clouding of Sensorium
  • Tactile Disturbances
  • Auditory Disturbances
  • Visual Disturbances
  • Headache

A score is calculated by summing the scale number for each of the 10 categories. The highest obtainable score is 67 and most protocols consider a score greater than 15 to need increased attention and medical treatment. For example, the NCCHC Alcohol Detoxification Guidelines recommends this categorization of patients based on a CIWA-Ar Score:

  • Low Risk: Asymptomatic or minimal symptoms (CIWA-Ar score less than 10)
  • Moderate Risk: A history of significant alcohol withdrawal syndrome and history of medical and psychiatric conditions (CIWA-Ar 10-15)
  • High Risk: History of severe alcohol withdrawal syndrome including seizures, delirum tremens, and suicidal ideations (CISA-Ar greater than 15)

Using the Data

Using risk categories can determine the level of attention given to withdrawing patients. For example, low risk patients may be evaluated every 8 hours while moderate and high risk patients may need hourly assessments and intervention until symptoms subside.

Regularly assessing withdrawing patients along a continuum of these ten symptoms provides objective data that can be used to guide treatment with benzodiazepines. The FBOP guidelines establish a treatment protocol based on the CIWA-Ar score:

CIWA Treatment

The Assessment Challenge of CIWA-Ar

Although the CIWA-Ar rating system is practical and can be completed in a few minutes, it requires practice and consistency among raters. Let’s take the scoring for agitation as an example. Here are the directions on the Scoring Tool:

Rate on a Scale of 0-7

  • 0 = No Activity
  • 1 = Somewhat Normal Activity
  • 4 = Moderately fidgety and restless
  • 7 = Constantly paces or thrashes about

The directions indicate that you can rate this category anywhere from 0-7 and provides low, middle, and high score examples. One nurse may determine that the patient is slightly more than moderately fidgety and restless; rating the patient as a 5. The next shift nurse may see the same restlessness as slightly under moderate and rate the patient a 4. In reality, the patient may be escalating in agitation and is really on the way to a 7. With a spread of scores in both the FBOP and NCCHC guidelines of less than 10 to over 15 encompassing risk ranges, a couple points difference in nurse evaluations can mean missing increased withdrawal symptoms or overmedicating receding symptoms.

Meeting the Challenge

In the high-stakes process of managing alcohol withdrawal, assessment variability using the CIWA-Ar tool must be minimized. This can be accomplished in several ways:

  • Orient every nurse specifically to the tool including the use of case presentations to be sure the directions can be correctly applied.
  • Use actual withdrawal situations to determine inter-rater reliability of the use of the tool. Have more than one nurse independently score a withdrawing patient and then have them compare their findings.
  • Consider only using the defined scores on the tool. For example, in the agitation category the only scores possible would be 0,1,4,7. This could eliminate some of the variability among raters.
  • Consider instructing assessors to err on the side of higher scores as the greater risk is in not treating withdrawal and closer monitoring is a safer outcome.

Successful alcohol withdrawal in the criminal justice system requires a thoughtful coordinated effort involving many team members. Ongoing monitoring of withdrawing patients is a major part of this effort. How are you monitoring your withdrawing patients? If you use the CIWA-Ar Tool, how do you confirm proper use? Share your thoughts in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Alcohol Withdrawal: What’s the Plan?

What is your plan ?Alcohol withdrawal is a fact of life in our patient population. You are likely screening for it on intake and hopefully using a standard evaluation tool like those described in a prior post. Once you see an incoming patient is at risk for withdrawal, what is your plan?

Location, Location, Location

Withdrawing patients need to be located where they will not get lost in the system. Some facilities have the capacity to keep potentially withdrawing patients in an Infirmary or Special Needs Unit where they are directly monitored. Other facilities only place symptomatic patients in the infirmary and keep potentially withdrawing patients in a specific housing unit. If they develop symptoms they are transferred to a higher level of observation or treatment. The key principle is to have a designated place for potentially withdrawing inmates where officers and other staff are aware of what signs and symptoms indicate alcohol withdrawal.

Get the Timing Down

If you know when your patient last had a drink or can estimate it based on entry into the facility, you can have some idea of when withdrawal symptoms will peak. Of course, timing is individualized based on many factors such as the patient’s liver health and long-term nature of the alcoholism. However, generally, withdrawal from alcohol progresses to completion over 5 days with the greatest degree of symptoms in the first 24-36 hours. Without intervention, though, withdrawal can lead to delirium tremens at about 3-5 days from the last drink. This condition is serious and can lead to hallucinations, electrolyte imbalances, unconsciousness, and death. Even ‘frequent-flyer’ alcoholics with a known history of uncomplicated withdrawals in your facility should be watched closely and treated for withdrawal. A phenomena called ‘alcohol withdrawal kindling’  can emerge where progressive withdrawal episodes increase in neurotoxic intensity. This means your ‘regular’ withdrawing patient may not progress as mildly this time around.

Maintain the Protocol

Alcohol withdrawal is both a common and risky medical condition for the inmate-patient population. Therefore, it is important to have a standard protocol for treatment. A standard protocol establishes consistent and appropriate practices for all staff members and provides a safeguard in those situations where practitioners may be unfamiliar with the standard of care. The Federal Bureau of Prisons Clinical Practice Guideline for Detoxification of Chemically Dependent Inmates is a good place to start in determining necessary elements of a plan of care. Here are some important management principles that should be a part of any correctional alcohol withdrawal protocol:

When to Seek Provider Orders: If a patient is deemed a medium or high risk of alcohol withdrawal at intake, most protocols stipulate a provider evaluation and prescriptive therapy. Low risk patients may be put on a monitoring protocol and advanced to provider oversight if symptoms emerge. Many of the protocol treatments described in this post require a provider order but can be part of a protocol list to speed treatment ordering and avoid omissions.

Patient Evaluation: Withdrawal protocols should spell out how often patient evaluations should take place, with increasing evaluation frequency if severity progresses. Low risk patients, for example, may require three-times-a-day evaluation while high risk patients may require every two hour evaluations for a specific time period.

Benzodiazepine Therapy: A cornerstone of alcohol withdrawal management is the use of benzodiazepines to reduce the excitability of the nervous system that has been shocked by the loss of alcohol. This tranquilizing effect can relieve withdrawal symptoms such as insomnia, muscle spasms, involuntary movement disorders, anxiety, and convulsions. While some correctional providers recommend long-acting options, such as Valium, as they have the ability to self-taper over time, the FBOP guidelines recommends Ativan, a shorter-acting option. The point is to have benzodiazepine therapy as part of the protocol with specific guidelines at to timing and dose. This may end up being based on the facility medical director’s preference and comfort level. Having a consistant program for benzodiazepine therapy spelled out in a protocol eliminates variability and helps both nurses and providers maintain the program.

Vitamin Therapy: Many who are alcohol dependent are poorly nourished and frequently thiamine deficient. Thiamine replacement therapy is recommended as a part of a withdrawal protocol along with a multivitamin.

Symptom Management: Common withdrawal symptoms should be addressed on the protocol with standard treatment options. Many symptoms of alcohol withdrawal are reduced through benzodiazepine administration but other common side effects such as headache, nausea, and vomiting may need additional comfort measures such as pain relievers or anti-emetics. Having these options addressed on a protocol and then prescribed by a provider at the time of protocol initiation is efficient.

Nutrition and Hydration:Don’t forget the need for quality food and water during withdrawal. This point, in itself, may indicate a need for a special housing assignment for withdrawing inmates. Most chronic alcoholics are undernourished and can become dehydrated during withdrawal. This can lead to eleyctrolyte abnormalities and hypoglycemia. Encouraging eating and drinking is important. Some settings even have electrolyte replacement drinks available for use by patients in withdrawal. Many protocols include checking fingerstick blood glucose daily on high risk patients.

Know When to Hold ‘Em – Know When to Ship Them

Many, if not most, of our patients withdrawing from alcohol can be treated safely behind the perimeter, but some can’t. Knowing when a patient needs to be moved to a higher level of care is crucial. Generally, seizures, hallucinations, or hemodynamic instability are all indications of a need for acute care monitoring and treatment. Be sure to have indications for emergency transport spelled out in your alcohol withdrawal protocol.

What is your plan for managing alcohol withdrawal in your setting? Share your tips in the comments section of this post.

Other Alcohol Withdrawal Resources

Drug and Alcohol Withdrawal Clinical Practice Guidelines – NSW

World Health Organization Management of Alcohol Withdrawal Recommendations

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Preventing diversion of prescription drugs in prison and jail

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Last week’s post described the epidemic of prescription drug abuse in the United States and the impact on the nation’s jails and prisons. This week we return to the same subject but focus on the problem of prescription drug diversion during incarceration. There are many more medications available and appropriate to be used in treatment today than when I started in nursing 40 years ago. Just to illustrate there were an average of 13 prescriptions written in 2011 for every person in the United States. At one of the jails I am familiar with an average of 24 prescriptions per inmate are filled each month.

Most correctional facilities allow some medications to be taken by inmates on their own as directed by the provider. This is usually called a “self-carry” or “keep on person” program. Virtually all facilities also require that certain medication be administered to inmates. These medications usually have potential for misuse (narcotics) or are medication regimes that require close monitoring (TB prophylaxis). The volume of medications handled daily in correctional facilities is substantial.

Nearly 85% of incarcerated adults in the United States have a substance use disorder and four out of five crimes committed by youth involve substance abuse (National Center on Addiction and Substance Abuse 2010, 2004). Some misuse of prescription drugs takes place simply because access to illegal drugs is so greatly limited during incarceration. Incarceration also brings other discomforts such as insomnia, pain, anxiety and boredom. Inmates may request medication from health care staff; they may also simply take or trade for someone else’s medication in an effort to alleviate problems like these. As correctional health care professionals we all have experience with patients who feign an illness or symptom to get a prescription for a preferred medication. Prescription medication has a value in prison or jail that is greater than in the general community (Phillips 2014).

Diversion and misuse of prescription medication is as much a clinical problem as a custodial one. If patients are bullied or coerced into giving up needed medication their condition may deteriorate. The provider may prescribe higher doses or additional intervention to treat a condition that appears unimproved when instead the patient was not treated effectively in the first place. In addition inmates who take someone else’s medication are not monitored clinically and expose themselves to potential for adverse reaction or other injury.

Methods to prevent or mitigate diversion

  1. Formulary controls: Often the first reaction to counter diversion is to ban prescription of the drug in the first place. The problem with this approach is that once a particular drug is banned another becomes the drug of choice for misuse. Secondly there are appropriate clinical indications for these medications and not allowing their use is to deny medically necessary care. It is possible to designate a particular drug as a non-formulary item that requires additional rationale and review before it can be issued. An example of this is that many facilities have made bupropion a non-formulary anti-depressant and thus limited its use (Phillips 2012). It is also possible to designate a certain housing location with greater supervision and control for patients receiving drugs at high risk for diversion. For example some facilities require patients to be admitted to the infirmary in order to receive treatment with an opiate analgesic.
  2. Choice of preparation: Another action is to administer the drug in a way that limits the possibility of diversion. Choices include ordering the drug in a liquid, aerosol or injectable preparation or that the tablet be “crushed and floated” (Bicknell et.al. 2011). Challenges are that these methods are either more expensive or time consuming to administer. A policy to “crush and float” an entire class of drugs (i.e. psychotropics) is not advised since the effectiveness and safety of some medications may be altered. Nurses expose themselves to liability if they “crush and float” medications against manufacturer advice (Phillips 2012).
  3. Increased multidisciplinary communication: Communication between providers, nurses and custody staff about prescription drug abuse generally and the importance of each method used to minimize diversion will reinforce the roles of each (Phillips 2014). Both correctional officers and nurses have responsibilities to ensure that inmates take medications as prescribed. These include maintaining orderliness during medication administration, monitoring ingestion, observing individual inmates for intended and unintended effects of medication. Correctional officers should be invited to provide information about behavior that suggests coercion by others or diversion. Providers and nurses may ask correctional officers about their observations of an inmate’s behavior to help with diagnosis or clinical monitoring. Random cell searches by correctional staff and periodic review of adherence by nursing staff are very helpful in identifying inmates who are diverting medication. Recently a facility changed their procedure for medication administration to include checking an inmate’s hands as well as their mouth before leaving the medication area. This change was made after discussion with an inmate who was found trading medication. The provider asked the inmate how he managed to get the medication and he gladly demonstrated his sleight of hand. It was an educational experience for all the staff and improved the methods used to control diversion at the facility.
  4. Caring for patients: Proactive identification and preventive treatment of inmates withdrawing from use of illicit drugs is an important first step in reducing diversion. This includes programming and targeted education to build alternative coping skills and recovery (Phillips 2012).Indications that a patient may be “at risk” of diverting prescribed medication include:
  • Requesting a particular drug by name before describing symptoms
  • Objective data about the patient’s condition is inconsistent with the description of symptoms
  • Refusal or non-adherence with other drugs prescribed for the condition
  • Claiming allergies or side effects to other possible drugs without being able to provide specific detail
  • Not remembering or being able to pronounce drugs other than the preferred drug
  • Threatening or other signs of excessive distress when the requested drug is not prescribed (Phillips 2012, 2014).

The nurse should be observant for these behaviors when seeing patients in sick call, nurse clinics or during medication administration, document the findings in the inmate’s health record and inform the patient’s prescribing provider. This information is more helpful to the treating provider when it is descriptive rather than judgmental. Nurses should also discuss with patients the potential for victimization when taking medication, the adverse outcomes of prescription drug abuse as well as steps to protect the inmate. This discussion is most effective if it is specific to the patient, the drug and their behavior rather than more general information.

Medications with high diversion value in the correctional setting

Click on this link to a table Common Prescription Medications- Use and Misuse which lists the prescription medications that are commonly misused or abused by inmates. The table also lists the purpose each drug is usually prescribed for as well as the reason for its misuse. During administration or when working with patients to self-administer these drugs nurses should be hyper-vigilant for possible diversion. Please remember though that any prescription medication can be misused if there is a belief that the drug will produce some desired effect.

Conclusion:

What have you learned about diversion of prescribed medications at your correctional facility that has not been discussed here? Are there methods to prevent diversion not discussed here that should be? Please share your opinions and experience by responding in the comments section of this post.

Anthony Tamburello, MD, FAPA, Statewide Associate Director of Psychiatry,  Rutgers University Correctional Health Care in New Jersey provided much of this information in a continuing education presentation for nurses and was willing to share it for use in this post. Also correctional physicians in the United Kingdom have published Safer Prescribing in Prisons: Guidance for Clinicians a thoughtful and well organized on-line resource. For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources:

Bicknell, M., Brew, I., Cooke, C., Duncall, H., Palmer, J., Robinson, J. (2011) Safer Prescribing in Prisons: Guidance for Clinicians. Royal College of General Practitioners, Secure Environments Group. Accessed at http://www.rpharms.com/news-story-downloads/prescribinginprison.pdf.

Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.

Kirschner, N., Ginsburg, J., Sulmasy, L. S., (2014) Prescription Drug Abuse: Executive Summary of a Policy Position from the American College of Physicians. Annals of Internal Medicine 160 (3).

Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC).

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Phillips, A. (2014) Prescribing in prison: complexities and considerations. Nursing Standard 28 (21): 46-50.

Phillips, D. (2012) Wellbutrin®: Misuse and abuse by incarcerated individuals. Journal of Addiction Nursing, 23: 65-69.

Tamburello, A. (n.d.) Prescription Medication Abuse. Presentation for University Correctional Health Care. Rutgers, The State University of New Jersey. Personal correspondence dated 6/17/2014.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Behind bars II: Substance abuse and America’s prison population. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-prison-system-2010.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-juvenile-justive-children-left-behind.

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at http://www.cdc.gov/HomeandRecreationalSafety/overdose/hhs_rx_abuse.html.

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