Monday, April 14, 2014
Inmate deaths raise questions about jail detox procedures
Posted: Monday, April 7, 2014
Did You Know?
In her third day of heroin detox in the Bucks County prison on March 22, Marlene Yarnall received the scheduled doses of medications to ease her withdrawal symptoms around 8:15 a.m., according to a prison administrator.
For the next three hours, correction officers and an assigned inmate watched over the 49-year-old Bensalem woman inside her cell in what should have been 15-minute rotations under the jail’s normal medical watch protocol, Director of Corrections William Plantier said.
But no one checked her vital signs, such as respiratory rate, body temperature or blood pressure, until the privately contracted prison medical staff arrived shortly before 11:30 a.m., Plantier said. By then, Yarnall was dead.
An autopsy found she had a fatal cardiac arrest during detox, making her the second inmate to die during opiate detoxification at the jail in less than six months.
In October, Philadelphia resident Valene Karaharisis, 29, was going through heroin detox when she was found dead in her cell. She had been incarcerated for about a month on credit card fraud charges, officials said.
Karaharisis was also under normal medical watch and last spoke with a prison staff member around 4 a.m. the day she died, officials said. She was running a fever, a typical withdrawal symptom among opiate addicts. It’s unknown if she had any pre-existing medical conditions. Her cause of death was ruled “undetermined,” Plantier said.
But Yarnall’s medical problems were known. She had a heart attack last year while undergoing detox at the county jail, the coroner said. She also had heart disease, an enlarged heart and high blood pressure, according to the coroner.
Those medical issues, combined with an opiate addiction, put an individual at a higher risk for dangerous complications during drug or alcohol detoxification, medical experts said.
Standard medical protocols, including federal prison guidelines, recommend that opiate-dependent inmates with chronic health conditions undergo medically supervised detoxification, a process typically offered in hospitals and drug rehab facilities. The process uses drugs designed to ease withdrawal symptoms and an opiate substitute that is gradually tapered.
Studies suggest that inadequately treated drug and alcohol withdrawal appears widespread in U.S. jails and has been shown to contribute to deaths among newly arrested individuals.
Is that what happened in the latest death at Bucks County prison?
No one is saying right now. The investigation is in the hands of county detectives.
PrimeCare Medical Inc., the prison’s private health care provider since July, said it has a detox protocol that includes the administration of drugs, including narcotics. Neither PrimeCare nor the prison would say if Yarnall received an opiate substitute, though, citing medical confidentiality.
Bucks County Commissioner Diane Marsaglia said after reviewing PrimeCare’s protocols and speaking to the county health department director she doesn’t feel she has a “full picture” of what kind of detox care is provided.
“It’s an issue we need to take a look at,” said Marseglia, a licensed social worker.
Bucks is in the minority when it comes to jailhouse detox. Opiate substitute taper protocols are unusual in county jails, where access to narcotics may be restricted, according to available national research.
The Federal Bureau of Prison estimates that only 32 percent of local jails provide detox programs. Among 245 U.S. jails that responded to a 2005 survey on access and management of opiate dependency among inmates more than half reported they routinely assessed individuals for opiate dependency, but many failed to use recommended opiate detox procedures.
The newspaper was unsuccessful in getting a copy of PrimeCare’s medical and detox protocols from either the company or the county. PrimeCare is also the health care provider for the Montgomery County jail. The newspaper has filed a right-to-know request for access to those documents, which may shed light on when an opiate substitute drug would be prescribed at the jail.
Bucks County Health Department Director Dr. David Damsker described PrimeCare’s detox protocols as “very comparable” to the protocols his department previously followed at the prison, including medical monitoring. However, before PrimeCare took over, narcotics weren’t provided to non-pregnant prisoners undergoing detox.
Even now, the jail does not “routinely” dispense narcotics, for security reasons, and opiate detox symptoms are typically managed through non-narcotic medications, Damsker added.
About one quarter of the 6,700 inmates who entered the Bucks County prison since PrimeCare took over, required detox, said Todd Haskins, vice president of operations for the Harrisburg-based correctional health care company. About 40 percent of those 1,703 inmates — about 685 — were detoxed from opiates or methadone only.
Haskins said some inmates may be on “multiple” detoxification regimes since many not only abuse opiates but other substances including alcohol. He couldn’t say what percentage of the 685 inmates detoxed since July received a narcotic as part of the detox.
PrimeCare’s detox protocols for alcohol and opiates can be deviated from, modified or, if necessary, include medications, Haskins said. An opiate taper drug or mental-health related medication also can be added as well as “comfort” medications. And certain vitamins and minerals are needed with some detoxifications, Haskins said.
Most medications are given in pill or liquid form and narcotics susceptible to abuse are crushed first, Haskins said. The taper drug is generally administered three times a day and gradually decreased over the next seven to 10 days or longer, he explained.
Medical staff perform vital-sign checks twice a day on detoxing inmates and examine inmates three times during the first 10 days of detox, Haskins said. Medical staff conduct daily checks to make sure inmates are taking prescribed medications; if not, staff is supposed to meet personally with the inmate to discuss the situation and perform additional wellness checks.
Inmates who cannot be medically managed or experience “extenuating complications” are transferred to a hospital for treatment, Haskins added.
Opiate withdrawal causes significant mental and physical stress on the body, a situation that can put more strain on a compromised organ functions and weakened blood vessels, said Dr. William Lorman, vice president of clinical services at the Livengrin Foundation, a nonprofit substance abuse rehabilitation center in Bensalem.
Other common opiate withdrawal symptoms, such as vomiting and diarrhea, can also create dangerous medical complications, such as aspiration (breathing in regurgitated food and liquids), dehydration and chemical imbalances in the body that can be life-threatening.
“The whole trick of detox is to tell the patient if you are feeling anxious or sick, come and see us right away,” Lorman added.
The frequency of medical monitoring for detox patients depends on an individual’s medical and psychiatric history and past withdrawal experiences, Lorman said. For some chronically ill people, a minimum of hourly vital sign checks may be necessary, he said, especially at the onset of withdrawal.
Inmates with cardiac disease are more sensitive to sympathetic hyperactivity. The syndrome causes episodes of increased activity of the sympathetic nervous system, which mobilizes the body’s fight-or-flight response. That means careful monitoring and control of symptoms is essential and a slower tapering off opiate-substitute medications is recommended under the Federal Bureau of Prison’s clinical practice guidelines, which were updated in February.
Many inmates with opiate dependence have experienced multiple episodes of withdrawal prior to incarceration, and are typically highly anxious during withdrawal, even when their symptoms are well-controlled, the federal guidelines added. The inmate’s mental health status should be monitored on an ongoing basis during withdrawal.
Yarnall was incarcerated at the Doylestown Township jail March 18 on a probation violation, according to the county. Plantier declined to name what medications Yarnall was prescribed in jail.
However, the watch entries showed nothing unusual and monitors noted it appeared that Yarnall was asleep in her bunk, Plantier said.
THEN AND NOW
When F.B. detoxed from heroin at Bucks County prison in 2010, he described the experience as night and day compared to his previous stints at private rehab centers. At the time, the county health department was responsible for medical care of prison inmates.
“I couldn’t forget it. It was terrible,” said F.B., who added that he has been drug-free for eight months.
At the prison, he said he received no medications to ease or prevent withdrawal symptoms, a detox commonly known as going cold turkey. He said he was placed on a medical watch, where fellow inmates checked his cell to see how he was doing.
“Pretty much, they just looked in to, literally, see if I was alive,” he said.
F.B. said he barely got out of bed and ate only when he was famished. The only time he could sleep was when his body gave out from pure exhaustion.
He didn’t shower for 15 days because he didn’t have the strength to leave his cell, he said. Around day 20, he said he finally started to feel better.
His brother, who F.B. said is also a heroin addict, was incarcerated more recently at the county jail and his detox experience was a lot different than his brother’s. He received Tylenol 3 and a benzodiazepine, a drug class used to treat insomnia, seizures, nausea and panic attacks, F.B. said.
“He said it wasn’t that great, but still, it’s medication,” F.B. added. “It’s something better than nothing.”
Pregnant women who suffer from opiate addictions are not detoxed in Bucks County and Montgomery County jails under PrimeCare Medical protocols. The reason is standard medical protocols believe the risk of danger to the woman and fetus is too great. Instead, they are placed in a methadone replacement program at an outside state-certified treatment center.