Prison Health Best Practices:Developing a ‘tool box’

9th Nov – FMF2013, Vancouver

Ruth Elwood Martin, MD, FCFP, MPH – Prison Health SIFPPat Mousmanis, MD, CCFP, FCFP – Child and Adolescent Health SIFP

Liz Grier, MD, CCFP – Developmental Disabilities SIFPRuth Dubin, PhD, MD, CCFP, FCFP – Chronic Pain SIFP

Niloofer Baria BSc, MD, CCFP – Addiction Medicine SIFPJohn Koehn, MD, CCFP – R3, Addiction Medicine

Learning Objectives

• Discuss some prison clinical scenarios, based on real situations that commonly present in prison health and focusing on addiction, chronic pain, child and adolescent health, and developmental disabilities

• Listen to evidence-based ‘best practice’ responses recommended for health care providers in the community and explore their feasibility for prison health care providers within a custodial setting

• Contribute to the development of a ‘tool box’ of prison health best practices, as participants network with other physicians, medical students and residents who wish to foster prison health best practices in Canada.

Workshop Agenda

8:30 – Introduction to Prison Health SIFP8:35 – Around the room/table introductions (RM)8:40 – Review the case and initiate the discussion (RM)8:45 – DD (PM) and FASD (LG), then Q/discussion9:10 – Pain (RD), then Q/discussion9:20 – Addictions response (JK, NB)

Pat Mousmanis, MD, CCFP, FCFPChild and Adolescent Health SIFP

SCREENING: CRAFFT(teens) • C: Have you ever ridden in a CAR driven by someone (including

yourself) who was “high” or using alcohol or drugs?

• R: Do you ever use alcohol to RELAX? Feel better about yourself?

• A: Do you ever use alcohol while ALONE?

• F: Do you ever FORGET things you did while using alcohol?

• F: Do your FAMILY/FRIENDS ever tell you to cut down?

• T: Have you ever gotten into TROUBLE while using alcohol?

CRAFFT: SCORING

• Two or more yes responses indicate a potential problem with alcohol

• Further assessment is advised

RISKS OF HEAVY PRENATAL ALCOHOL USE

• Alcohol passes through placenta & fetus has limited ability to metabolize alcohol

• Alcohol is known teratogen can damage developing fetal cells, umbilical cord & placenta

• Prenatal exposure to alcohol results in:1. Increased risk of spontaneous abortion and

stillbirth2. Increased risk of FASD (fetal alcohol spectrum

disorder) - umbrella term encompassing various effects of alcohol on the developing fetus

Most children with an FASD:

a) Show no external physical characteristics

b) Have low-set ears and small eye openings

c) Have a flat groove between the nose and upper lip

d) Have a wide nose bridge

a) Show no external physical characteristics

What percentage of children with FASD end up in the care of people other than their

parents?

a) 20%

b) 40%

c) 60%

d) 80%

d) 80%

How many children in foster care may have an FASD?

a) 20%

b) 30%

c) 50%

d) 80%

c) 50%

What percentage of prisoners were likely affected by alcohol in utero?

a) 20%

b) 40%

c) 60%

d) 80%

c) 60%

Children with so-called “mild” effects are at a higher risk than those with severe

forms because:

a) Doctors treat the most severe cases first

b) They look normal and are expected to perform normally

c) They are not diagnosed correctly and do not receive appropriate services

d) b and c

d) b and c

Children and youth with an FASD have trouble with:

a) Understanding consequences

b) Speaking

c) Trusting people

d) Being kind to animals

a) Understanding consequences

An 18-year-old with an FASD functions at the level of a child who is:

a) 6 years old

b) 9 years old

c) 12 years old

d) 15 years old

b) 9 years old

Behaviours Associated with an FASD

School-Aged Children

• Require constant reminders for basic activities at home and school

• “Flow-through” Learning: information is learned, retained for a while and then lost

• Very concrete thinker, will fall farther behind peers as the world becomes increasingly abstract and concept-based

Behaviours Associated with an FASD

Adolescents and Adults• Increased truancy• Increased problems linking cause and

effect• Problems managing time and money• Difficulty showing remorse or taking

responsibility for their actions• Say they understand instructions but can’t

carry them out

FASD Timelines8

A study of 18-year-old youth with an FASD revealed that they were functioning at the following developmental levels:

Organization (self-care hygiene, etc.) like an 11-year-old

Social skill development like a 7-year-old

Word recognition like a 16-year-old

Physical maturity of an 18-year-old

Emotional maturity of a 6-year-old

Understand time and money like an 8-year-old

Think and process like a 6-year-old

Sound verbally like a 20-year-old

0 10 20 30

11

7

16

18

6

8

6

20

FASD Functioning

Normal Functioning FASD Functioning

Abstract thinking Concrete thinking

Able to analyze Can’t analyze

Good problem solving Poor problem solving

Good judgement Lack common sense

Learns by example Learns by repetition

Learns from experience Always in trouble

Differential Diagnosis of FASD

It’s easy to misdiagnose a person as having a more well-known disorder when the person exhibits symptoms common to both disorders

Conduct Disorder (CD) Attention Deficit Hyperactivity (ADHD) Oppositional Defiance Disorder (ODD) Autism

While each of these is a legitimate separate diagnosis in itself, they may also be diagnostic of a symptom of FASD and thus give only a partial explanation for the constellation of problems experienced by people with FASD8

Cognitive Implications

Most people with FASD have no physical features so their “invisible” disability may go undetected

Some people have average levels of IQ and appear to understand, so people expect them to perform beyond actual capabilities

Psychometric IQ may be too high to qualify a child for special education, however functional IQ may be very low

IQ versus Adaptive Functioning

• 1996 study of 473 people with FASD9

• IQ ranged from 29 to 142

• 86% had IQ in the “normal” range

• Academic skills were below IQ

• Living skills, communication skills and

adaptive behavior levels were below

academic skills

FASD Assessments

A comprehensive assessment includes input from a multi-disciplinary team including:

• Physician

• Psychologist

• Speech-Language Pathologist

• Occupational Therapist

AAAIIIEEEEEEE! How to minimize screaming (yours, not theirs):

Structure with daily routine, with simple concrete rules

Cues (again and again and again), can be verbal, audio, visual, whatever works

Role models, show them the proper way to act

Environment with low sensory stimulation (small classrooms, not too much clutter)

Attitude of others, understanding that behaviour is neurological, not willful misconduct

Medications, vitamin supplements and healthy diet are quite helpful

Supervision - 24/7 (lack of impulse control and poor judgment at all ages)

S.C.R.E.A.M.S Seven Secrets to

Success

1998 -2002 Tersa Kellerman www.fasstar.com

A Diagnosis for Two?

Pregnant women who have already given birth to babies with FASD may have FASD themselves

References for FASD1. Fetal Alcohol Spectrum Disorder (FASD). Public Health Agency of Canada 2005, Cat. No.: H124-4/4004,

ISGN: 0-662-68619-5, Publication No.: 42002. Robinson, GC, Conry, JL, Conry, RF. Clinical profile and prevalence of fetal alcohol syndrome in an

isolated community in British Columbia. CMAJ 1087; 137(3); 203-7.3. Williams, RJ, Odaibo FS, McGee JM. Incidence of fetal alcohol syndrome in northeastern Manitoba.

Can J Public Health 1999; 90(3): 192-4.4. Square, D. Fetal alcohol syndrome epidemic on Manitoba reserve. CMAJ 1997; 157(1): 59-60.5. Habbick, BF, Nanson, JL, Snyder, RE, Casey, RE, Schulman, AL. Foetal Alcohol Syndrome in

Saskatchewan: Unchanged incidence in a 20-year period. Can J Pub Health 1996; 87(3): 204-207.6. Asant, KO, Nelms-Maztke, J. Report on the survey of children with chronic handicaps and Fetal Alcohol

Syndrome in the Yukon and Northwest British Columbia. Council for Yukon Indians 1985; Whitehorse, YT.

7. Mueller, Daniel P., Wilder Research Center, Amherst H. Wilder Foundation. Alcohol, Tobacco and Pregnancy: The Beliefs and Practices of Minnesota Women. Minneapolis, MN: Minnesota Department of Public Health, March, 1994, pg. 25-29.

8. Malbin, Diane. Timelines and FAS/FAE, Adapted from research findings of Streissguth, Clarren et al., 1994

9. A Layman’s Guide to Fetal Alcohol Syndrome and Possible Fetal Alcohol Effects, FAS/E Support Network of B.C. 1997 pg. 43-44

SIFP Prison Health Best practices workshop

FMF - 2013

Dr. Liz Grier, MD, CCFPChair – Developmental Disabilities

Program Committee

FASD and Adulthood

Physical Health Issues – congenital heart disease, renal defects, congenital vision and hearing deficits

• if childhood health unknown may wish to consider: echo, renal US, vision/hearing Ax

Dysmorphic features of FAS/FAE diminish over time (microcephaly, long philtrum, thin vermillion border, even short stature and underweight)

Mental handicaps persist including intellectual disability (avg IQ 68, academic fn 2nd-4th grade), limited occupational options and ability for independent living including navigating health, social and educational/vocational systems

Maladaptive Behavioural Problems are significantly increased including poor judgement, distractibility, impulsivity and difficulty perceiving social cues

Family Environments remarkably unstable

Importance of considering both Cognitive and Adaptive Functioning

Definitions:• “cognitive functioning” means a person’s intellectual capacity,

including the capacity to reason, organize, plan, make judgments and identify consequences.

• “adaptive functioning” means a person’s capacity to gain personal independence, based on the person’s ability to learn and apply conceptual, social and practical skills in his or her everyday life Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, Ontario, 2008, c.14, s.3 (2).

• Genetic and Environmental factors influence intellectual and adaptive functioning

Intellectual vs. Adaptive Functioning con’t

• Discrepancies are important to identify:–Low IQ scores but strong adaptive skills

• Ex. 21 year old man with IQ of 70 with strong interpersonal skills and family support network attends an adapted college program, lives in a supported independent living, can manage many IADLs

–Borderline IQ scores but impairments in adaptive functioning

• Ex. 21 year old man with IQ of 80 with co-morbid FASD and chaotic home environment. Moved frequently as a child, attending many different schools, IEPs not put in place, poor literacy skills and difficulties with attention, impulsivity and difficulties perceiving social cues make it very difficult for him to work and manage independent living

Developmental Disabilities Program Committee Resources

• Sullivan et al. Primary care of adults with developmental disabilities: Canadian consensus guidelines. Canadian Family Physician May 2011 vol. 57 no. 5 541-553

• Guidelines Overview:– General Issues – Physical Health– Mental Health

• Clinical Tools and CME opportunities/Clinical Support• FASD Health Watch Table – in final stages of publication

LINK to DDPC Website

Importance of Identification of Developmental Disability in the Criminal Justice System

Highly Vulnerable in community – limited understanding of legal terminology, court proceedings, their rights and cooperating with attorney, confessing during interrogation

-anxious to fit in – ‘cloak of competence’, ‘cheating to lose’, ‘halo effect’

-rates of ID are high in inmates: studies show 4-10% with mild ID (up to 5 fold of the rates in the general population), and an additional 10% with borderline ID

-many of these individuals are not diagnosed

-difficulties following rules or recommendations (including health related), highly vulnerable to victimization by other inmates, receive little in the way of services on release

Hayes Ability Screening Index (HASI) -validated instrument to screen for ID in prison system (Sens 82%, Spec 72%)-can be administered by non psychologists, 5-10 min to administer, culture and gender fair, available in Canadian French

ReferencesHayes S. et al Early Intervention or early incarceration? Using a screening test for

intellectual disability in the criminal justice system. Journal of Applied Research in Intellectual Disabilities, 2002(15):120-128

Hayes Ability Screening Index (HASI) 2002-2013 University of Sydney, Department of Behavioural Sciences in Medicine

Herrington, V. Assessing the prevalence of intellectual disability among young male prisoners. J Intellect Disabil Res 2009 May;53(5):397-410

O’Leary et al. Prenatal Alcohol Exposure and Risk of Birth Defects Pediatrics 2010;126;e843

Scheyett et al. Are we there yet? Screening processes for intellectual and developmental disabilities in jail settings. Intellect Dev Disabil. 2009 Feb;47(1)13-23

Sondenaa et al. The prevalence and nature of intellectual disability in Norwegian prisons. J Intellect Disabil Res. 2008 Dec;52(12):1129-37

Sphor et al. Fetal Alcohol Spectrum Disorders in Young Adulthood J Pediatr 2007;150:175-9

Streissguth et al. Fetal Alcohol Syndrome in Adolescents and Adults JAMA 1991;265:1961-1967

Ruth Dubin, PhD, MD, CCFP, FCFPChronic Pain SIFP

Managing chronic pain in correctional settings

• Joey says he’s had pain ever since an accident at age 19, when he jumped through a 3rd story window during a police chase. At that time he suffered a “broken back in 3 places” (you assume compression vertebral fractures to 3 lumbar vertebrae), “both ankles broken and I still have metal pins in both ankles”, 6 broken ribs and lacerations of upper body from the glass (he has ++ scars).

• • “How are you going to help my pain, doctor?”

Questions:

• How would you approach this patient?• What additional information would you like to

know on history?• What would you like to know on physical

examination?• What is your proposed treatment plan?

1. Current pain descriptions (including pain scoring)

2. Previous pain history (including treatments and results)

3. Current treatments, effectiveness and adverse effects

4. Other concurrent medical/psych problems5. Social history (family, work, income,

relationships)6. Addiction screening7. Current functioning and future goals8. GOOD DOCUMENTATION

Elements of a Good Pain History(But you don’t have to do it all in one visit)

The 4 + 2 A’s of pain assessment

• Analgesia (BPI)

• Adverse reactions• Activities of daily living (BPI)

• Aberrant behaviour (Addicts have pain too)• Affect (include sleep) (BPI)

• Accurate Medication log, accurate records

BPI InterferenceScore is 63/70

Brief Pain Inventory

JOEY’S PAINDIAGRAM

WHY DO WE ASK ABOUT PAIN QUALITY?

Neuropathic? – burning, stabbing, tingling, electric shocks

Myofascial? – tearing , pressure can hurt first and then relieve, NOT responsive to medications

Nociceptive – worse with motion: symptoms correspond to ‘observable’ tissue damage

Inflammatory – AM stiffness, red/swollen/tender, though CNS inflammation increasingly

researched in all chronic pain“Other” – fibromyalgia (Chronic widespread pain) –

central sensitization, deficient DNIC (Descending neurogenic inhibitory control)

Visceral – Irritable bowel, interstitial cystitis: common in fibromyalgia

Mixed - osteoarthritis, low back pain

GREAT Myofascial Pain APP“Real Bodywork (itunes)”

Myofascial Pain Does Not Respond to OPIATES!You can use trigger point injections, acupuncture, TENS, stretching, Yoga,

And other Manual Therapies

Hx and Pe

• Joey describes his pain as burning, like ants running on his legs and he hates wearing tight clothing

• His sleep is really disrupted by the pain• He feels anxious, and depressed “if I didn’t have so

much pain I wouldn’t be buying drugs on the street”• When you lightly touch his legs and his back he winces.

A safety pin in these areas feels “worse than the time I was stabbed”.

• There are no temperature, hair growth or skin colour changes on his legs

MEDICINEMedications &

Interventions

MOVEMENTPhysical / Rehabilitative

MINDPsychological

SELF MANAGEMENTSELF MANAGEMENT

*(R Jovey, Canadian Pain Society,2009-with input from R.Dubin)*(R Jovey, Canadian Pain Society,2009-with input from R.Dubin)Also see: Action Plan for the organization and delivery of chronic pain services in Nova Scotia, 2006Also see: Action Plan for the organization and delivery of chronic pain services in Nova Scotia, 2006

The ideal treatment of Chronic Pain*

Sleep Matters!

Treatment Options for PainPHYSICALPHYSICAL PSYCHOLOGICPSYCHOLOGIC PHARMACOLOGICPHARMACOLOGIC INTERVENTIONALINTERVENTIONAL

Normal activitiesSplinting / Taping AquafitnessPhysio• Passive• ActiveStretchingConditioningWeight trainingMassageTENSTranscranial Magnetic StimulationChiropracticAcupunctureDolphin

HypnosisStress ManagementCognitive-BehaviouralFamily therapyPsychotherapyMindfulness- Based Stress ReductionMirror Visual Reprogramming

OTC medicationAlternative therapiesTopical medicationsNSAIDs / COXIBsDMARDsImmune modulatorsTricyclicsAnti-epileptic drugsOpioidsLocal anestheticcongenersMuscle relaxantsSympathetic agentsNMDA blockersCGRP blockers

I.A. steroidsI.A. hyaluronanTrigger pt. therapyIntraMuscular stim.ProlotherapyNerve blocks EpiduralsOrthopedic surgeryRadio frequency facet neurotomyNeurectomyImplantable stimulatorsImplantable pain pumps

34

AcetaminophenASA / NSAIDs

Tramadol(+/- adjuvants)

HydromorphoneMorphine

OxycodoneFentanyl

Methadone(+/- adjuvants)

Codeine +/-Tramadol +/-

Oxycodone +/-acetaminophen(+/- adjuvants)

Modified “WHO Analgesic Ladder”

Adapted from The WHO 3 Step Analgesic Ladder, Cancer Pain Relief, 2nd Edition, World Health Organization

MildPain

ModeratePain

SeverePain

Butrans patchTapentadol

Acetaminophen*- Suggested Dose Ceilings

• 4 gm/day – short-term use in healthy patients

(FDA Advisory Report 2009 – lower the ceiling dose)

• 3.2 gm / day chronically in healthy patients (>10 d)

• 2.6 gm / day chronically in at risk patients**Daily alcohol consumption, warfarin, fasting, a low protein diet, cardiac or renal disease increase the risk of hepatotoxicity

Zimmerman & Maddry, 1995Seeff et al., 1986

Swarm et al., 2001Bromer MQ, Black M. Acetaminophen hepatotoxicity. Clin Liver Dis 2003;7:351-67

Latta, 2000Garcia Rodriguez, Arthritis Res 2001; Curhan 2002

Watkins et al., 2006.

His pain willbe worse if he

has Hep C due togeneral inflammation

Pharmacologic Treatment of Neuropathic Pain

Pharmacologic Treatment of Neuropathic Pain

TCA Gabapentin or Pregabalin

SNRI Topical Lidocaine*

Tramadol or CR Opioid Analgesic

Fourth Line Agents *

* e.g., carbamazepine, cannabinoids, methadone, lamotrigine, topiramate ** In using multiple agents, be aware of synergistic or additive adverse effects

Add additional

agents

sequentially if

partial but

inadequate

pain relief**

Moulin DE et al. Pain Res Manag 2007;12(1):13-21.

You diagnose Neuropathic Painpossible Pseudo-addiction*

or maybe Addiction

• Given his sleep disorder and symptoms what medications might you recommend?

• How will your management here differ from treating someone in the community?

• What might be effective treatments for him given his drug misuse and pain issues?

*Pseudo-addiction occurs when patients seek drugs to manage their pain. The drug-seekingbehaviour disappears when the pain is properly managed.

Prison Health Best Practices: Developing a “Tool Box” Addiction Medicine

FMF 2013

John Koehn, MD, CCFP.

Addiction in the Prison Setting

• Diagnosis of substance use disorder often assumed

• No documented substance history

• Prescribing decisions made on an institution-wide basis

• Addiction issues treated as a social or behavioural problem

Substance Use History

Evidence-basedAddiction Treatment

• Treating addiction as a medical issue

• Screening and making a diagnosis while incarcerated

• Thinking beyond the prison gates: aftercare planning