Medical plan for Forsyth jail ambiguous on opiate withdrawal

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Jen duplicateThe medical examiner who reviewed the death of my friend, Jen McCormack, following a heart attack in Forsyth County jail in September 2014 reflected in an interview that “it does seem a little odd that she would be found unresponsive just 15 minutes after being checked and found alert.”

Jen was 18 weeks pregnant and had recently completed treatment for dependence to the prescription painkiller hydrocodone when she died.

“Alert and mentation appropriate” is the characterization Dr. Patrick Lantz, the pathologist at Baptist Hospital used to describe Jen’s status during the check about 15 minutes before her heart attack, but in an interview later he speculated that jail staff might have thought she was sleeping.”

As previously reported by Triad City Beat, Dr. Robert Newman, a retired assistant commissioner for the New York City Health Department, said he found Lantz’s determination that Jen died as a result of lack of fluid intake to be “preposterous.”

“She was under constant supervision — every 15 minutes,” Newman wrote in an email after reviewing relevant records in the case. “At 10:15 she is said to be ‘alert and mentation appropriate.’ Eighteen minutes later she was ‘discolored’ and unresponsive and without a pulse.”

A lot remains unclear about Jen’s unexpected death after spending 16 days in jail awaiting trial for prescription drug fraud (reported in two previous installments), but documents recently obtained by Triad City Beat provide new insight into how Correct Care Solutions, the private company that provides contractual healthcare services to inmates at the jail, handles opiate withdrawal and pregnancy.

One possible explanation for the failure of Jen’s health might be withdrawal from benzodiazepine, an anti-anxiety medication, Dr. Jacquelyn Starer, a consulting physician with extensive experience in addiction treatment who is based in Massachusetts, told Triad City Beat after reviewing the case.

Janis McCormack, Jen’s mother, has said that Jen had been taking prescribed Xanax, a brand name for benzodiazepine, when she was admitted to the jail, but she was not allowed to bring the medication with her. Nine days before her heart attack, an internal report from the jail indicates that a corrections officer found Jen trapped between her bed and the wall with a large puddle of urine on the floor.

“If she was allowed to go into withdrawal, that could lead to a number of problems,” Dr. Starer told Triad City Beat. “Additionally, if she wasn’t allowed to take her Xanax, that would have caused a lot of problems — if she had been consistently taking Xanax prior to coming into the jail. The largest risk of Xanax withdrawal is seizures.

“If you see someone who has fallen down and become incontinent of urine and trapped against the bed, my first thought was that this person had a seizure,” she added.

Correct Care Solutions and Forsyth County have declined to respond to any questions about the medical care Jen received in jail, but the company’s 2009 proposal to provide health services to inmates at the jail — obtained through a public records request to the county — sheds some light on the company’s policy for administering benzodiazepine.

The proposal mentions benzodiazepine as treatment for severe detoxification without specifying the type of chemical withdrawal the medication is meant to treat. The proposal states, “A physician treatment plan should be established as soon as the potential for withdrawal is assessed. The treatment plan should include benzodiazepine during the acute withdrawal period and then tapered off if there are no other indications.”

Another red flag in Jen’s incarceration is the fact that she was arrested and booked in the jail the same day she was released from a drug treatment program at Forsyth Medical Center. Janis McCormack has said that Jen was treated with Suboxone, an opioid medication containing the drug buprenorphine. Janis said she turned Jen’s Suboxone over to the jail staff, but both Correct Care Solutions and the county have refused to say whether Jen continued to receive the medication during her incarceration.

“I would speculate that a lot of what should have happened, didn’t happen,” Dr. Starer told Triad City Beat. “The standard management for a pregnant woman with opioid dependence would be for her to be treated throughout the pregnancy with either methadone or buprenorphine.

“When she went into jail she would have been continued on that medication or transitioned to methadone if buprenorphine was unavailable, but if she had a prescription she should have been able to receive buprenorphine,” Starer added. “Unfortunately, a lot of jails and prisons don’t allow opioid agonist treatment.”

Clinical practice guidelines followed by the Federal Bureau of Prisons reflect Dr. Starer’s recommendation.

“Detoxification of Chemically Dependent Inmates,” a bureau document published in February 2014, states, “Medical detoxification is considered the standard of care for individuals with opiate dependence. Opiate withdrawal is rarely considered dangerous except in medically debilitated individuals and pregnant women. Pregnant women taking opiates should be treated with methadone or maintained on methadone, since detoxification increases the risk of miscarriage and premature labor.”

Correct Care Solutions’ policy on intoxication and withdrawal, part of a medical plan approved in March 2015 by Forsyth County Public Health Director Marlon Hunter in accordance with state law, addresses how staff should handle a pregnant inmate with a history of opiate use.

“If a pregnant inmate is admitted with a history of opiate use (including the partial agonist buprenorphine) a physician is contracted so that the opiate dependent can be assessed and treated,” the policy states.

The policy does not address whether buprenorphine should continue to be administered to an inmate with a prescription for the medication.

The policy goes on to say, “Inmates on methadone or similar substances receive appropriate treatment for methadone withdrawal syndrome. Pregnant inmates entering the facility on methadone treatment are continued on the treatment, when possible [emphasis mine].”

The US National Institutes of Health has recommended methadone maintenance as the standard of care for pregnant women addicted to opiates since 1998. Considering Correct Care Solutions’ refusal to answer questions about its services in the jail, it’s unclear why the company policy doesn’t call for continuing methadone treatment for pregnant inmates in all circumstances.

The company’s 2009 proposal to the county makes a somewhat contradictory pledge to provide “management of the chemically dependent pregnant inmate including a procedure for providing methadone maintenance and education.”

As previously reported by Triad City Beat, policies on medication-assisted treatment in local jails across North Carolina are spotty and inconsistent. The Durham County Detention Center — with inmate health services also contracted through Correct Care Solutions, incidentally — is a rare facility in this state with an explicit policy of maintaining methadone treatment for inmates who come in with a prescription for the medication.

“It is not seen by and large that county jails are not set up to provide substance abuse services,” Melissa Godwin, a clinical instructor at the UNC-Chapel Hill School of Social Work, previously told Triad City Beat. “The norm is to not have any medication-assisted treatment for opioid use disorder.”

John McCormack Jr., Jen’s brother, told Triad City Beat that he suspects his sister was denied access to her medication.

“I think it was straight cold turkey when they took her in jail,” he said. “From what my mom told me, she had nothing.”

Dr. Starer told Triad City Beat that based on jail incident reports referencing Jen’s condition during her incarceration she should have been transferred off site for a higher level of medical care long before her heart attack.

Considering the precipitous failure of Jen’s health in the Forsyth County jail and unanswered questions about whether she received appropriate care, it’s natural to ask whether Correct Care Solutions is cutting corners to try to contain costs.

The “business proposal & pricing detail” section of the company’s 2009 proposal to provide inmate healthcare in the jail references a “focused initiative” to “reduce off-site trips that add unnecessary medical care costs and security/transportation costs to the county budget.”

The heading above an itemized list of “cost containment & performance success stories” by detention facilities under contract with Correct Care Solutions hints at how the company balances cost against quality of care: “Every client will attest to our best value proposition!”

A summary of Correct Care Solutions’ track record at the Davidson County Sheriff’s Office in Nashville, Tenn., where the company is headquartered, boasts about reducing both methadone use among inmates and off-site medical care.

“CCS significantly reduced off-site trips for health services,” the company reported. “CCS expanded on-site dental and X-ray programs. Additionally, we decreased the use of methadone and expanded on-site pregnancy services. CCS reduced off-site trips by 50% in the first year of the contract while improving care!”

  • Michael Schiesser MD

    Buprenorphine withdrawal would tend to be delayed in onset for several days and intensify days 3-10.

    • Jordan Green

      Jen’s first episode of falling, getting trapped between her bed and the wall and experiencing urinary incontinence was on Day 9 of her jail stay, and she experienced similar symptoms on Day 15, just hours before her heart attack. So if she did not have access to buprenorphine or methadone in jail, the timing would tend to support the theory of buprenorphine withdrawal then, right?

      • Michael Schiesser MD

        The day 9 episode sounds like seizure but buprinorphine withdrawal should not directly result in a seizure. Benzodiazepine withdrawal should have occurred sooner unless for example she was for example tapered over week one, and too rapidly. Protracted buprinorphine withdrawal would have generated obvious signs and symptoms throughout her time there but the relationship to what occurred is difficult to glean without more detailed records and perhaps postmortem toxicology report.

  • Jiva Das

    Yes the half life for Buprenorphine averages at about 60 hours. In Washington state, where I live, Sonomish county will no longer admit persons who are going to experience withdrawal into the jail. Instead they are taken to the local hospital because due to numerous problems they’ve had with inmates detoxifying in the jail. The sheriff admitted they just aren’t equipped to give adequate care to inmates in withdrawal. I applaud Sonomish county for seeing those arrested as humans beings first and foremost and treating them as such.

  • robert newman

    The fact is that no one has a clue why Jen died – and they had no clue over a year ago when her death occurred. Under these circumstances,. it is simply incomprehensible that no autopsy – and no lab tests – were performed. If anyone thinks I’m being too harsh,. please advise – but to me the only explanation possible is either gross incompetence or gross malfeasance. robert newan