Advanced Correctional Healthcare, Inc. (ACH), prides itself in not having a medication formulary.  What does this mean?  In short, it means that we do not limit the ability of site practitioners to prescribe what they feel is indicated for any given clinical situation.  When patients come into the jail setting, their medications are not compared against a list of approved medications to decide what will be continued, modified, or discontinued.  While this sounds great on the surface, there is an unseen power at work to prevent practitioners from truly practicing as they feel is indicated: the unwritten formulary of correctional medicine.  An unwritten formulary of what is “right” for patients to have has evolved through the years based on healthcare staff and jail staff biases and opinions, not on clinical reasoning.  This problem plagues the entirety of corrections and should be stopped before it leads to poor patient outcomes.  It starts with the Medication Verification phone call.

It is this phone call that falls prey to the unwritten formulary found in correctional medicine.  The phone call on the surface is innocent enough, nursing or security staff fills out the standardized form and calls the practitioner.  How can the lurking unwritten formulary affect this process?

First, practitioners can have in their minds that certain medications are not allowed in the jail setting, such as controlled substances or highly abused medications (think bupropion, quetiapine, mirtazapine, etc).  Each case should be evaluated independently and with an eye for indications for the given medications.  The complexity of this process should go beyond blurting out a “yes” or “no” before the nurse or officer is even done reading the name, dose, pill count, and date of the prescription.  Is an opioid indicated in a patient recovering from a surgery performed the day before incarceration? Yes, it likely is indicated.  Is a benzodiazepine indicated for generalized anxiety disorder?  Likely not, and it could even lead to unwanted consequences and dependence for the patient.

Second, nurses or officers may allow the unwritten formulary to affect the way they present the medication verification process.  Phrases like, “well, I know what you are going to say to this one,” or, “this isn’t allowed in our facility,” already start to sway the opinion of the prescriber on the other end of the phone call.  With ACH, there is no formulary to dictate what medications are allowed in the jail, and there should be no blanket policy on one class of medication for any jail.

Staff having worked for other companies in years past may be accustomed to the unwritten formulary of correctional healthcare, and they should actively work to stay objective as they present medications to the practitioner.

As we approach the important decision of what medications will be used during a patient’s time in the jail, we need to continue to honor the complexity that is each clinical presentation to our jail.  Practitioners should be able to exercise the freedom to decide what medications are appropriate and indicated for each given clinical scenario.  Further, practitioners should not rush the medication verification process or simply give a “no” based on the name of the medication.  If the medication is indicated, it should be continued.  If a medication is not indicated, it should be discontinued with a note as to why this decision was made and documentation of a discussion with the patient explaining the reason behind the change.  If an alternative medication would be more appropriate given the clinical situation, a therapeutic modification should be used.

At the end of the day, doing the right thing for the patient should be the goal.  ACH continues to support the thinking practitioner by avoiding the constraints of a medication formulary, and we will continue to work as a team to combat the lurking unwritten formulary in correctional medicine.

Key Points and Pearls of Wisdom:

  1. Don’t let the unwritten formulary affect you
  2. Do not have blanket policies
  3. Educate patients on the reason for change and document the conversation

 

All materials have been prepared for general information purposes only. The information presented is not intended to establish a standard of medical care. The information presented is not legal advice, is not to be acted on as such, may not be current, and is subject to change without notice.

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