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Beware the Compliance Trap. It will catch the unwary . . .
By Jeffrey E. Keller MD
Published: 11/14/2016

Pharmacy I had yet another patient recently who demonstrated what I call the “Compliance Trap” of corrections. The Compliance Trap is simply this—on the outside of jail, in the real world, most people do not take their medications perfectly. They miss doses. They forget sometimes. Many studies have demonstrated this. But when these same people come to jail, they get their medications passed to them every dose—they do not miss doses. They are compliant with their medication dosing in a way they weren’t on the outside. And this can sometimes get them into trouble.

Take for example, the patient who came to my jail with a prescription for Dilantin 600mg a day. This is a huge dose! But he had a legitimate prescription for it and so it was continued at the same dose in jail. However, two weeks late, he began to have nausea, vomiting and dizziness. We checked his dilantin level and it was 32–he was toxic! Dilantin 600mg a day was, indeed, too big of a dose for this patient. In fact, after we had adjusted his dose and checked levels a couple of times, we found that the proper dose of Dilantin in this patient was a more modest 400mg a day.

So how did this happen? I did not interrogate this patient’s outside doctor, but I think I know what happened. He kept returning to the outside clinic with subtherapeutic blood levels of Dilantin and the doctor kept increasing to dose. However, the reason the patient had subtherapeutic blood levels was NOT that he was a super-rapid metabolizer of Dilantin; rather he just hadn’t been taking it every day. He had been missing doses.

But when he came to jail, the jail nurses made sure he did not miss any doses and quickly, he was toxic.

So that is the Compliance Trap. Outside of jail, many patients do not take their medications regularly or at all. When they come to jail, they don’t miss doses. Outside–not compliant. In jail–compliant. And sometimes this can make them sick.

The Compliance Trap–Examples

Dilantin is one example, but there are several more. All of these are real examples from my jails. Do any sound familiar?

A small (110 pound) woman takes six Lithium 300mg tablets a day.

A man with Deep Vein Thrombosis takes 15mg of Coumadin a day.

A woman with Bipolar Disorder takes Depakote 1500 mg a day.


Now, perhaps all of these are legitimate doses, carefully titrated based on perfectly compliant patients. However, you could also easily fall into the Compliance Trap and end up with a toxic patient. The only way to know is to check appropriate monitoring levels a week, say, after they arrive in the jail.

(By the way, one of the three examples above turned out to be a proper legitimate prescription based on blood levels. I’ll leave it to you to guess which one!)

The Compliance Trap–Insulin

An interesting variation of the Compliance Trap has to do with insulin doses. Believe it or not, some patients with diabetes are not compliant with their diabetic diets outside of jail. They eat at BurgerKing, McDonald’s, and Pizza Hut–all in the same day! They raid their refrigerator for chocolate ice cream at 2:00 AM. The amount of insulin they use is dosed accordingly.

Once they come to jail and the only thing they get to eat is a real diabetic diet, their outside insulin dose is suddenly way too much, and they get hypoglycemic.

The Compliance Trap–Sedatives

Another interesting variation of the Compliance Trap are methamphetamine abusers. Many of them are also psychiatric patients and are being prescribed sedating psych meds like Seroquel, Trazodone and Ambien by their psychiatry providers (who, of course, do not know that they are doing meth). When they come to jail and no longer have access to meth, their sedating medications are now no longer “counter-balanced” by amphetamines, and they become overly sedated.

Keep the Compliance Trap in mind, especially when inmates present with BIG doses of meds. It may save you a lot of grief!

Have you (like me) been burned by the Compliance Trap? Please tell us in comments!

Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Chief Medical Officer of Centurion. He is also the author of the "Jail Medicine" blog

Other articles by Keller


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