Running head: CORRECTIONS PAIN MANAGEMENT 1

Pain Management in Correctional Healthcare

Joshua K Rutledge

NUR460

DTCC
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Abstract

Pain management is a major medical issue in healthcare across the nation. Currently there is no

cure for chronic pain and is commonly managed by the collaboration of multiple different

treatment methods to achieve positive patient outcomes. One major problem found which I

decided to research a formulate a plan for is pain management in correctional healthcare settings.

Pain management in correctional healthcare settings poses the problem how do we manage pain

on a large-scale basis to a greatly restricted population with a high incidence of substance abuse?

Further reading depicts my proposal under the role of a nursing administrator to modify pain

management in the correctional healthcare setting, to provide preventative care, improve primary

care protocols, and extend specialized and alternative services offered to promote positive

outcomes for this affected population. The ideology behind this proposal is that promoting better

pain management services from correctional healthcare providers this will reduce healthcare

costs from third party consultation services and reduce the amount of pain analgesic medications

in this population.
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Pain Management in Correctional Healthcare

In correctional medicine, pain management is a high-volume issue for healthcare teams

caring for prisoners across the entire United states. Whether its osteoporosis complaints in the

aging geriatric populations or joint and nerve injuries from gunshot wounds conceived during

police apprehension, pain management cases stretch across a vast range of severities and

complexities requiring extensive healthcare management. March 2021, there were nearly 1.8

million individuals incarcerated in the United States each requiring state or federally funded

healthcare services (Kang-Brown et al, 2021). Across the United States of America for the year

of 2015 departments of corrections collectively spent $8.1 billion on prison health care services

for incarcerated individuals (Huh et al, 2017). With chronic and acute pain management as a

large portion of services requested in correctional healthcare, revision of the correctional pain

management protocols could yield in a great reduction of correctional healthcare expenditures.

Not only could it greatly reduce healthcare costs, but more effective pain management could

yield a higher efficiency in correctional healthcare systems such as chronic care, Nurse Sick-call

(NSC), and mid-level provider (NP, PA) services. My proposal is to restructure the correctional

healthcare pain management protocols and add more pain management services to reduce

healthcare costs and reimplement saved money into increasing patients pain management

satisfaction.

Medicine in Prison

Healthcare in prison differs greatly from healthcare an individual would receive on the

street. Due to the nature of the setting and the diverse populations incarcerated, healthcare is

given through very structured processes. Commonly the first process that a patient experiencing
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pain would encounter is nurse sick call in which a general assessment, vitals assessment would

be completed, and the patient would most commonly be treated by protocol interventions. One of

the major restrictions is seen in NSC, the protocol interventions for pain are muscle rub,

NSAID’s, ACE, Ice packs, Non-metal splints, etc. and are effective only in a small number of

cases. If protocol interventions are not effective patients are escalated to a mid-level provider. To

form a better understanding of the processes at the Mid-level, I surveyed on of my colleagues

William N. (F-NP). He described to me that pain is categorized to be either acute or chronic.

Acute pain is usually treated on a temporary basis with narcotics or NSAIDS and easier to treat

usually by removal of the causative factors. Chronic pain however is treated long term according

to level/loss of function. The first level of treatment, inmates are seen by the medical providers

and commonly prescribed. Keep-on-Person medications (KOP’s) of approved formulary

NSAID’s for pain management. Due to the high amounts of drug abuse in correctional settings

medications are largely restricted. If NSAID’s are not effective a second level of medications are

ordered by the mid-level provider to treat specific types of pain, medications such as Baclofen,

Elavil, or Neurontin. Diagnostic testing or consults are completed to diagnose any causative

factors and explore potential treatment recommendations. Staff referrals for physical therapy are

submitted to be seen by the onsite physical therapist for applicable patients. Once reaching this

point off site consultations are ordered by the mid-level provider and can either be approved or

declined by the site medical director. Most commonly once a patient reaches this level consults

are approved, and off-site consultations recommended interventions are commonly practiced.

Even after the conclusion of this long process chronic pain can still be present for some patients.

This protocol for pain management is extensive and not only overloads the corrections healthcare

systems but is costly and, in some cases, ineffective.

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Plan for Pain

My “Plan for Pain” in corrections consists of three tiers Preventative Care, Primary Care,

and Alternative/Specialized Services.

Preventative Care

Prison is a rough lifestyle and is not exactly accommodating to the prevention of pain for

the residents. I surveyed one of my bosses Susan C. (MSN) about pain prevention, she is one of

the supervisory employees of the Bureau of Correctional Healthcare Systems (BCHS). We tried

to solve potential causative factors at every level. Step one of preventative care is the

implementation of better, more supporting mattresses. Currently inmates are given a state issued
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twin mattress estimated three inches thick, at least at James T Vaughn in Smyrna these are used.

This is not advocating for societies convicted criminals to be lounging in luxury, but poor

mattresses have a strong correlation with negative effects to chronic pain. Medical research on

mattresses and chronic pain is limited but in a double-blind research trial of 313 adults with

chronic lower back pain it was found that individuals in the study that used medium-firm

mattresses statistically had greater pain outcomes in comparison to individuals with firm and soft

mattresses (Kovacs et al, 2003). This research supports the idea that chronic pain outcomes have

a correlation to sleeping conditions such as poor mattress quality. Step two is adding

supplemental commissary items currently offered for purchase from the state. Commissary

items such as NSAID’s, ACE wraps/non-metal supportive braces, glucosamine, lidocaine

patches/muscle rub etc. could greatly reduce incidences of pain management requiring medical

interventions. Step three is the proposal for department of corrections to provide better exercise

equipment and for the creation of a virtual medical library accessible through inmate GTL touch

screen tablets. This library would have information such as injury/chronic pain prevention and

treatment methods. Commonly a lot of chronic pain issues in prison can be from the overuse of

body weight exercises such as pushups, due to lack of proper exercise equipment. Inmates,

especially those in isolation have little resources to maintain fitness, a lot of the time this is

solved with bodyweight exercises. Although body weight exercises are great in moderation, they

are difficult to modify to progressively increase workload on muscles. Many times, the solution

for inmates is to increase volume of body weight exercises to increase the workload on muscles.

One of the results of this that can be seen is inmates doing 300 pushups a day submitting sick

calls for shoulder pain because they’ve totally wrecked their joints and tendons. “Osteoarthritis is

defined as a noninflammatory, degenerative joint disease characterized by loss of articular

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cartilage and marginal hypertrophy of bone accompanied by pain and stiffness that is aggravated

by prolonged activity” (Sandmeier et al, 2000). Implementing exercise equipment would allow

for better, more proper methods for exercise.

Primary Care

Tier two Primary Care pain management I collaborated with William NP and another

colleague Kim BSN, and we discussed a problem that NSC is overloaded with pain appointments

which offer Nursing protocols. We formulated Step one to forward all chronic pain sick calls to

the Mid-level provider as part of chronic pain protocols. This with the addition of preventative

commissary items (nursing protocol items/meds), would allow for chronic pain patients to

bypass the NSC process, and only acute pain cases would be seen in NSC. Next step would be

the designation of specific pain management providers directly responsible for seeing chronic

pain patients promoting continuity of care and the ability to establish care adherence protocols.

This is especially important in corrections due to the large drug seeking and manipulative nature

of the inmate populations. This allows for mid-level providers to have assigned chronic pain

patients in assigned buildings and collaborate with DOC staff to collect background information,

which is important for monitoring care adherence. One example of this is patients faking injuries

to get placed on medications such as Neurontin or baclofen and different housing

accommodations such as bottom bunk memos, but then are seen playing basketball in the

recreation yard, this is a common example seen in correctional settings. The last step to primary

care pain management is the promotion of alternative treatment methods for pain management.

Currently most chronic pain is treated with analgesic medications but recently at my facility

Cortisone injections were introduced which have greatly reduced the amount of chronic pain
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patients taking analgesic medications. “Research suggests that using nonpharmacologic therapies

to manage chronic pain may be effective not only in decreasing pain and improving function but

also in reducing longer-term adverse effects such as substance use disorders” (Devitt et al, 2020).

Some of the alternative treatment options correctional healthcare team would now be able to

offer is electrical nerve therapy, nerve block injections, and cognitive behavior therapy. I believe

that with the large drug epidemic plaguing this country and the prison systems,

alternative/nonpharmacological treatments expand treatment options that could be more effective

for the patient and more cost effective for the healthcare system.

Alternative/Specialized Services

The third tier for revision in my “Plan for Pain” is the promotion and advancement of

alternative and specialized services offered in the correctional healthcare system. Currently

James T. Vaughn Correctional Center houses 2600 inmates and is the largest maximum-security

prison in Delaware (Delaware et al, 2019). Vaughn has two physical therapists currently

employed one full time, and one part time that is split among other Delaware prisons. For such a

large prison one full time physical therapist to take care of such a large population is ineffective

and patients currently on the physical therapy roster are seen 1-2 times per month which differs

from physical therapy practices in the public sector. Common practice for physical therapy

prescriptions is for visits at a frequency of 2-3 times per week for optimal outcomes, degree of

injury or illness can vary the frequency according to patient needs (Rand et al, 2007). Part one of

my pain plan is to revise this current standard and propose that the state expand the amount of

physical therapist positions for each prison to effectively meet the populations care requirements.

I surveyed a physical therapist at Vaughn Mary PT to get a better understanding of the

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correlation between pain management and physical therapy and to explore ideas to improve pain

management services in prison. Pain management ideas we explored were alternative therapies

that would be able for integration in a correctional setting. Part two of the pain plan is for the

addition of chiropractic therapy to work in conjunction with physical therapy and the healthcare

team. One of the major problems with pain in correctional settings is insufficient treatment

resources and options to manage pain. “Chiropractic care has been shown to help in managing or

alleviating chronic pain without the use of drugs or surgery as well as being cost effective,

considered safe, and satisfactory to a high number of patients” (Mann et al, 2018). Another

alternative treatment option I discussed with Mary and adopted into my pain plan was the

implementation of pain support groups. Part 3 of the pain plan is the implementation of pain

support groups will allow for patients to discuss issues with their pain and to collectively learn

coping mechanisms from each other promote patient education for pain management. The

ideology behind this pain support group is for the expansion of resources available to the patient

both through the healthcare team and peer support, which could increase positive patient

outcomes, increase patient satisfaction, and provide a bridge for communication between the

affected population and the healthcare team.

Evaluation

In order for a plan to be effective and properly implemented into medical practice an

evaluation plan must be developed to examine the success and the failures of the implemented

changes. Evaluations for success can implemented into this pain plan by annually surveying the

NSC system for pain management sick call requests to statistically compare the number of

requests prior to implementation and post implementation. A successful outcome for this
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evaluation would consist of a large percentage reduction in pain management sick call requests

over one year. Another method to evaluate success would be to survey the percentage of

analgesic medications prescribed in relation to the population. A successful outcome for this

evaluation would see a large reduction of analgesic medications prescribed which could be

linked to a shift in population needs for pain management, from pharmacological treatments to

the alternative treatments offered with the pain plan. This method for evaluation can be further

extended by creating satisfaction-based surveys for chronic pain patients which would be

implemented as part of chronic care appointments. One complication of this style of surveying is

the lack of a current baseline for comparison but one of the major benefits to this style of

surveying is that it provides information that can be evaluated on a continuous basis. A

successful outcome for this evaluation method would be to see progressive yearly increases of

patient satisfaction for chronic pain patients. One of the large complications to this pain plan is

cost versus effectiveness, the addition of the numerous pain management services can be costly

and require an increased medical budget. For evaluation of plan effectiveness and success the

current healthcare costs for pain management would need to be examined to analyze against

healthcare costs for pain management with this new plan implemented. Successful outcomes for

pain management cost comparisons would be a decrease of medical costs of greater than 5%

along with increased patient satisfaction statistics greater than 5%. I chose 5% as the statistical

significance level to accommodate for fluctuations in healthcare spending and patient driven

surveying, any results above this threshold 95% confidence that results are significant to the Plan

for Pain. Minimal changes to healthcare costs along with increased patient satisfaction statistics

would indicate that resources are properly allocated and effective.

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Conclusion

“Plan for Pain” is a proposal to reduce pain management costs and restructure to a more

efficient system with an arsenal of pain management services. These changes would be

implemented using a three-tier plan revising the current pain management resources in

preventative care, primary care, and specialized/alternative care. This proposal if effectively

implemented allows for the redistribution of funds to improve pain management protocols,

improve patient satisfaction, and improve standards of care. This is important in nursing because

nurse administrators hold positions with power to implement ideas like the “Plan for Pain” and

the power to significantly increase standards of care in healthcare systems. Evolving healthcare

practices to best fit patient health needs is a major part of being a patient advocate as a nurse and

allows for improvement and elevation of nursing practice.

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References

Delaware, S. of. (2019, September). Government and services. Department of Correction.

Retrieved November 28, 2021, from https://doc.delaware.gov/views/jtvcc.blade.shtml.

Huh, K. (2017, December). Prison health care costs and quality. Prison Health Care Costs and

Quality. Retrieved November 28, 2021, from https://www.pewtrusts.org/en/research-and-

analysis/reports/2017/10/prison-health-care-costs-and-quality.

Kang-Brown, J. (2021, June). Summary of Incarcerated Populations. People in jail and prison in

spring 2021. Retrieved November 28, 2021, from

https://www.vera.org/downloads/publications/people-in-jail-and-prison-in-spring-

2021.pdf.

Devitt, M. (2020, January 15). Nonpharmacologic therapies can improve chronic pain outcomes.

AAFP Home. Retrieved November 28, 2021, from https://www.aafp.org/news/health-of-

the-public/20200115nonpharmtx.html.

Rand, S. E. (2007, December 1). The physical therapy prescription. American Family Physician

Journal. Retrieved November 28, 2021, from

https://www.aafp.org/afp/2007/1201/p1661.html.

Mann, D. J. (2018, June). Chiropractic management of a patient with chronic pain in a

Federally Qualified Health Center: A case report. Journal of chiropractic medicine.

Retrieved November 28, 2021, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112063/.