Prison Health Best Practices:
Developing a ‘tool box’
9th Nov – FMF2013, Vancouver
Ruth Elwood Martin, MD, FCFP, MPH – Prison Health SIFP
Pat Mousmanis, MD, CCFP, FCFP – Child and Adolescent Health SIFP
Liz Grier, MD, CCFP – Developmental Disabilities SIFP
Ruth Dubin, PhD, MD, CCFP, FCFP – Chronic Pain SIFP
Niloofer Baria BSc, MD, CCFP – Addiction Medicine SIFP
John 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 SIFP
8:35 – 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/discussion
9:10 – Pain (RD), then Q/discussion
9:20 – Addictions response (JK, NB)
Pat Mousmanis, MD, CCFP, FCFP
Child 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
stillbirth
2. 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)
b)
c)
d)
20%
40%
60%
80%
d) 80%
How many children in foster care
may have an FASD?
a)
b)
c)
d)
20%
30%
50%
80%
c) 50%
What percentage of prisoners were
likely affected by alcohol in utero?
a)
b)
c)
d)
20%
40%
60%
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)
b)
c)
d)
Understanding consequences
Speaking
Trusting people
Being kind to animals
a) Understanding consequences
An 18-year-old with an FASD functions at
the level of a child who is:
a)
b)
c)
d)
6 years old
9 years old
12 years old
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
11
Social skill development like a 7-year-old
7
Word recognition like a 16-year-old
16
Physical maturity of an 18-year-old
18
Emotional maturity of a 6-year-old
6
Understand time and money like an 8-year-old
8
Think and process like a 6-year-old
6
20
Sound verbally like a 20-year-old
0
10
20 30
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 from experience
Learns by repetition
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
S.C.R.E.A.M.S
Seven Secrets to Success
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)
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 FASD
1.
2.
3.
4.
5.
6.
7.
8.
9.
Fetal Alcohol Spectrum Disorder (FASD). Public Health Agency of Canada 2005, Cat. No.: H124-4/4004,
ISGN: 0-662-68619-5, Publication No.: 4200
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.
Williams, RJ, Odaibo FS, McGee JM. Incidence of fetal alcohol syndrome in northeastern Manitoba.
Can J Public Health 1999; 90(3): 192-4.
Square, D. Fetal alcohol syndrome epidemic on Manitoba reserve. CMAJ 1997; 157(1): 59-60.
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.
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.
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.
Malbin, Diane. Timelines and FAS/FAE, Adapted from research findings of Streissguth, Clarren et al.,
1994
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, CCFP
Chair – 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
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
References
Hayes 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, FCFP
Chronic 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?
Elements of a Good Pain History
(But you don’t have to do it all in one visit)
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 problems
5. Social history (family, work, income,
relationships)
6. Addiction screening
7. Current functioning and future goals
8. GOOD DOCUMENTATION
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
Brief Pain Inventory
BPI Interference
Score is 63/70
JOEY’S PAIN
DIAGRAM
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
The ideal treatment of Chronic Pain*
MOVEMENT
Physical / Rehabilitative
Sleep Matters!
SELF MANAGEMENT
MIND
Psychological
MEDICINE
Medications &
Interventions
*(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, 2006
Treatment Options for Pain
PHYSICAL
Normal activities
Splinting / Taping
Aquafitness
Physio
• Passive
• Active
Stretching
Conditioning
Weight training
Massage
TENS
Transcranial
Magnetic Stimulation
Chiropractic
Acupuncture
Dolphin
PSYCHOLOGIC
PHARMACOLOGIC
INTERVENTIONAL
Hypnosis
Stress
Management
CognitiveBehavioural
Family therapy
Psychotherapy
MindfulnessBased Stress
Reduction
Mirror Visual
Reprogramming
OTC medication
Alternative therapies
Topical medications
NSAIDs / COXIBs
DMARDs
Immune modulators
Tricyclics
Anti-epileptic drugs
Opioids
Local anesthetic
congeners
Muscle relaxants
Sympathetic agents
NMDA blockers
CGRP blockers
I.A. steroids
I.A. hyaluronan
Trigger pt. therapy
IntraMuscular stim.
Prolotherapy
Nerve blocks
Epidurals
Orthopedic surgery
Radio frequency
facet neurotomy
Neurectomy
Implantable
stimulators
Implantable pain
pumps
Modified “WHO Analgesic Ladder”
g
n
i
as
e
r
c
In
n
i
a
P
Moderate
Pain
Mild
Pain
Acetaminophen
ASA / NSAIDs
Tramadol
(+/- adjuvants)
Severe
Pain
Hydromorphone
Morphine
Codeine +/Tramadol +/Oxycodone +/acetaminophen
(+/- adjuvants)
Oxycodone
Fentanyl
Methadone
(+/- adjuvants)
Butrans patch
Tapentadol
Adapted from The WHO 3 Step Analgesic Ladder,
His pain will
be worse if he
has Hep C due to
general inflammation
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, 1995
Seeff et al., 1986
Swarm et al., 2001
Bromer MQ, Black M. Acetaminophen hepatotoxicity. Clin Liver Dis 2003;7:351-67
Latta, 2000
Garcia Rodriguez, Arthritis Res 2001; Curhan 2002
Watkins et al., 2006.
Pharmacologic Treatment
of Neuropathic Pain
TCA
Gabapentin or Pregabalin
Add additional
SNRI
Topical Lidocaine*
agents
sequentially if
partial but
Tramadol
or CR Opioid Analgesic
inadequate
pain relief**
Fourth Line Agents *
* e.g., carbamazepine, cannabinoids, methadone, lamotrigine, topiramate
** In using multiple agents, be aware of synergistic or additive adverse effects
Moulin DE et al. Pain Res Manag 2007;12(1):13-21.
You diagnose Neuropathic Pain
possible 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-seeking
behaviour disappears when the pain is properly managed.
Prison Health
Best Practices:
Developing a
“Tool Box”
Addiction
Medicine
John Koehn, MD, CCFP
.
FMF 2013
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-based
Addiction Treatment
• Treating addiction as a medical issue
• Screening and making a diagnosis while
incarcerated
• Thinking beyond the prison gates:
aftercare planning