Even though chronic pain management in a correctional environment is challenging, standard of care in correctional practice is that chronic pain must be responsibly managed and treated. To do so requires the following components:
- Reasonable diagnosis
The physician has to take an appropriate history, perform an examination, order indicated diagnostic testing, and involve specialist consultation as needed to at least arrive at what is known as a working diagnosis that reasonably explains the patient’s chronic pain. Having a precise and exact diagnosis is not always needed (and not always possible), and this is acceptable so long as the physician has considered and excluded more worrisome longevity- or functionality-impacting diagnoses.
- Assessment
The physician also has to gauge the impact of the pain on the patient’s ability to remain functional at the facility. By functionality, what is meant is preserving the patient’s ability to bathe, dress, use the toilet, ambulate to the cafeteria and so forth. Occasionally, functionality is best determined by the physician making a “house call” and observing the incarcerated individual in their living unit or at another location in the facility.
- Treatment plan
A treatment plan might include medication, physical therapy, ambulatory aids (e.g., walking cane), referral for a procedure, or a combination of these. The goal of the treatment plan is focused more on maintaining and preserving functionality rather than a reduction in subjective complaints of pain. A pharmaceutical approach that stresses non-opioid options is best practice; however, upon due assessment and evaluation, there are some patients where the benefit of opioid medications outweighs the risk. For these patients, access to these medications must be preserved-with proper counter-diversion practices in place.
- Follow-up
There needs to be follow-up to reassess the patient’s pain and the impact of any treatment being provided.
Scenarios that do not follow accepted standard of care include:
- Physicians not addressing complaints of pain.
- Incarcerated individuals not having access to their physicians. This includes follow-up visits and reassessment of pain not taking place because of system design, e.g., relying on patients having to repeatedly kite or submit sick call slips to be seen for their chronic pain.
- Utilization review and managed care strategies and/or custody policies that have as their goal the restriction of prescribed medication. Such practices and policies function as barriers and are contrary to standard of care.
- Managed care strategies with the goal of assuring that a particular medication is indeed indicated is perfectly reasonable. It is also reasonable for security personnel to require that certain processes be followed to maintain safety and security as long as access ultimately is preserved. In addition, administrative prohibition of medications (such as fentanyl patches) that are clearly dangerous in a correctional setting is reasonable.
Ultimately, what a physician wants to be able to document in the medical record of a chronic pain patient is something like this:
I have seen and assessed Mr. X. His treatment plan is Y. He is functioning reasonably well with his current treatment plan which is Z. We will continue to follow and adjust as indicated.