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Prison Health Best Practices: Developing a


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Title: Prison Health Best Practices: Developing a

Prison Health Best Practices Developing a tool
box 9th Nov FMF2013, Vancouver
  • Ruth Elwood Martin, MD, FCFP, MPH Prison Health
  • Pat Mousmanis, MD, CCFP, FCFP Child and
    Adolescent Health SIFP
  • Liz Grier, MD, CCFP Developmental Disabilities
  • Ruth Dubin, PhD, MD, CCFP, FCFP Chronic Pain
  • Niloofer Baria BSc, MD, CCFP Addiction Medicine
  • 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
  • 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
  • 830 Introduction to Prison Health SIFP
  • 835 Around the room/table introductions (RM)
  • 840 Review the case and initiate the
    discussion (RM)
  • 845 DD (PM) and FASD (LG), then Q/discussion
  • 910 Pain (RD), then Q/discussion
  • 920 Addictions response (JK, NB)

Pat Mousmanis, MD, CCFP, FCFP Child and
Adolescent Health SIFP
  • 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
  • F Do your FAMILY/FRIENDS ever tell you to cut
  • T Have you ever gotten into TROUBLE while using

  • Two or more yes responses indicate a potential
    problem with alcohol
  • Further assessment is advised

  • 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
  • Increased risk of spontaneous abortion and
  • Increased risk of FASD (fetal alcohol spectrum
    disorder) - umbrella term encompassing various
    effects of alcohol on the developing fetus

What substance causes the most damage to a
growing fetus?
  • a) Heroin
  • b) Alcohol
  • c) Marijuana
  • d) Cocaine

b) Alcohol
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
  • 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
  • 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
  • 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 cant 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
FASD Functioning
  • Normal Functioning FASD
  • Abstract thinking
    Concrete thinking
  • Able to analyze Cant analyze
  • Good problem solving Poor problem solving
  • Good judgement Lack common sense
  • Learns by example Learns by
  • Learns from experience Always in

Differential Diagnosis of FASD
  • Its 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
A Diagnosis for Two?
  • Pregnant women who have already given birth to
    babies with FASD may have FASD themselves

References for FASD
  • 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.
  • Malbin, Diane. Timelines and FAS/FAE, Adapted
    from research findings of Streissguth, Clarren et
    al., 1994
  • A Laymans 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

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 persons
    intellectual capacity, including the capacity to
    reason, organize, plan, make judgments and
    identify consequences.
  • adaptive functioning means a persons capacity
    to gain personal independence, based on the
    persons 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 cont
  • 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
  • Borderline IQ scores but impairments in adaptive
  • 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
  • Sullivan et al. Primary care of adults with
    developmental disabilities Canadian consensus
  • Canadian Family Physician May 2011 vol. 57 no. 5
  • Guidelines Overview
  • General Issues
  • Physical Health
  • Mental Health
  • Clinical Tools and CME opportunities/Clinical
  • FASD Health Watch Table in final stages of
  • 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

  • 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
  • OLeary et al. Prenatal Alcohol Exposure and
    Risk of Birth Defects Pediatrics 2010126e843
  • Scheyett et al. Are we there yet? Screening
    processes for intellectual and developmental
    disabilities in jail settings. Intellect Dev
    Disabil. 2009 Feb47(1)13-23
  • Sondenaa et al. The prevalence and nature of
    intellectual disability in Norwegian prisons. J
    Intellect Disabil Res. 2008 Dec52(12)1129-37
  • Sphor et al. Fetal Alcohol Spectrum Disorders in
    Young Adulthood J Pediatr 2007150175-9
  • Streissguth et al. Fetal Alcohol Syndrome in
    Adolescents and Adults JAMA 19912651961-1967

Ruth Dubin, PhD, MD, CCFP, FCFP Chronic Pain SIFP
Managing chronic pain in correctional settings
  • Joey says hes 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
  • How are you going to help my pain, doctor?

  • How would you approach this patient?
  • What additional information would you like to
    know on history?
  • What would you like to know on physical
  • What is your proposed treatment plan?

Elements of a Good Pain History (But you dont
have to do it all in one visit)
  • Current pain descriptions (including pain
  • Previous pain history (including treatments and
  • Current treatments, effectiveness and adverse
  • Other concurrent medical/psych problems
  • Social history (family, work, income,
  • Addiction screening
  • Current functioning and future goals

The 4 2 As 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
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  • Neuropathic? burning, stabbing, tingling,
    electric shocks
  • Myofascial? tearing , pressure can hurt first
    and then relieve, NOT responsive to
  • 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
  • His sleep is really disrupted by the pain
  • He feels anxious, and depressed if I didnt have
    so much pain I wouldnt be buying drugs on the
  • 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

MOVEMENT Physical / Rehabilitative
Sleep Matters!
MEDICINE Medications Interventions
MIND Psychological
(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
Normal activities Splinting / Taping Aquafitness Physio Passive Active Stretching Conditioning Weight training Massage TENS Transcranial Magnetic Stimulation Chiropractic Acupuncture Dolphin Hypnosis Stress Management Cognitive- Behavioural Family therapy Psychotherapy Mindfulness- Based 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
Butrans patch Tapentadol
Acetaminophen- Suggested Dose Ceilings
His pain will be worse if he has Hep C due
to general inflammation
  • 4 gm/day short-term use in healthy patients
  • (FDA Advisory Report 2009 lower the ceiling
  • 3.2 gm / day chronically in healthy patients (gt10
  • 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 20037351-67 Latta
, 2000 Garcia Rodriguez, Arthritis Res 2001
Curhan 2002 Watkins et al., 2006.
Pharmacologic Treatment of Neuropathic Pain
TCA Gabapentin or Pregabalin
Add additional agents sequentially if partial
but inadequate pain relief
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
Moulin DE et al. Pain Res Manag 200712(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
  • Addiction issues treated as a social or
    behavioural problem

Substance Use History
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Evidence-based Addiction Treatment
  • Treating addiction as a medical issue
  • Screening and making a diagnosis while
  • Thinking beyond the prison gates aftercare