Summer 2016 - Society of Correctional Physicians
Transcription
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 ALLABMS-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 [email protected] ACCP operations [email protected] Advertising [email protected] Letters to the Editor and prospective articles [email protected] 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 $5 million initial budget to fund the first year operations. New medical policies and procedures were written to meet standards and new nursing protocols implemented. Pharmaceutical services were transferred from a for-profit community pharmacy to the GMH pharmacy, which resulted in a significant cost savings. Renovating the clinic facilities was also necessary to meet infection control and sanitary conditions, let alone aesthetics. Fresh paint, new Continued on page 10 u Page 5 / HOW I PRACTICE — MANAGING OPIATE WITHDRAWAL By Todd Wilcox, MD, MBA, FACCP, CCHP-P O ver the course of my medical career, everything about opiate management and treatment has changed. This is particularly true for opiate withdrawal. Like most of us, I learned early in my career that opiate withdrawal could be treated cold turkey. In fact, a well-known correctional medical textbook instructs the following: “Opiate withdrawal is known to be very unpleasant for patients but is not generally associated with life-threatening complications.” Identification and Monitoring The first major step in redesigning our practices for opiate withdrawal involved the development of a targeted tool for opiate withdrawal that was customized to correctional health. We ultimately created the Wilcox Opiate Withdrawal Scale protocol that is attached to this article. The primary focus of WOWS is to identify clinical scenarios that cause dehydration and electrolyte abnormalities. These are the two main areas where patients can get in trouble, and an earlier intervention for vomiting and diarrhea and targeted assessment for clinically relevant dehydration became the focus of the WOWS protocol. While that may have been true when that was written, we live in a New World of opiates that presents far greater challenges clinically. As a result of multiple changes outside of our sphere of practice, we now have !"#$%&'()"*+,'!"+-./*0*#'1$*#,'2!(!1'3/%+%$%#4 more patients coming in 8(97 5*6,7 on opiates, the prescription 8*+,7 =%$*>%?7'' strength of opiates is @"6,7 substantially stronger, 1937 8937 illegal opiates are now of D;7EE 1ABC+*?$,7 much higher purity, and @,6)7 ;,C)F';*+,7 opiate withdrawal is more 1*(G7 clinically severe and can <'%I'J*+%/*.,'J"K,? 9:H7 frequently result in death if <'%I'L%6"+C'C"?$,'#*C+'$-,$MEE !!!'EE;N1@H5J'3O=1N';P@N!!"#$%&'()*%+'$,-.'$'/01%20+'34$+5-6! not managed appropriately. "!#!$%&'(!)""!*!+(&,-!!!!!!.!#!$%&'(!)")/)."!!!!!!!!!!!0!#!$%&'(!1)." 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. 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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 [email protected] 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: [email protected] 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