Welcome to Palliative Equality!
There is a vast disparity of comfort and pain status across income groups. Medical patients in low income groups experience more unmanaged pain and symptoms. Among the poorest in the United States is the incarcerated population, living with debilitating levels of pain and discomfort associated with a lack of access to effective medical care.
We believe that people who are incarcerated must have access to the same health services available to their non-incarcerated counterparts for physical illness, mental health issues, and other services related to well-being. These services must include those aimed at alleviating pain and discomfort.
If current professional standards of care for medical treatment are not met within the incarcerated population, this falls under the Supreme Court’s description of Cruel & Unusual Punishment that is “severe and unnecessary” – Furman v. Georgia, 408 U.S. 238 (1972).
The California Health and Safety Code 11362.785 (a), (b), (c), provides that incarcerated persons may apply for a Medical Evaluation to obtain a Recommendation by a qualified medical professional. Developing a mechanism to exercise this provision is the first step.
WHAT IS PALLIATIVE CARE?
Palliative care is the heart of medical care because it addresses how a patient moves, breathes, feels, and is experiencing a disease throughout the course of an illness. If medical issues are treated, but a person remains unable to function due to pain or unmanaged symptoms, then what value is the treatment? For example, someone with HIV may be receiving antiretroviral therapy, but continue to have persistent and debilitating pain, nausea and vomiting , loss of appetite, itching, diarrhea, weakness, and fatigue, debilitating depression, and insomnia, among many other symptoms.
Everyone deserves the quality of life necessary to come to terms with life. Pain is a part of life, and it is impossible to eradicate. However, it often can be brought to tolerable levels, or at least reduced to the extent possible. If potential solutions exist, they should be offered.
THE PROBLEM: THE INCARCERATED POPULATION IS DENIED MEDICAL AND PALLIATIVE CARE BECAUSE POOR CONDITIONS ARE VIEWED AS AN EXPECTED PART OF INCARCERATION.
The first national study of health-status and health-access among inmates was completed by The Cambridge Health Alliance and Harvard Medical School in 2002 and 2004, and published by the American Journal of Public Health in 2009.
Not surprisingly, the study showed that inmates suffer worse courses of illness and have poorer access to health care than other Americans of the same age. Disparities exist throughout prisons and jails, with the worst disparities of both health-status and health-access found in local jails.
The study reports that many inmates with a serious medical condition fail to receive any evaluation or treatment while incarcerated. For example, 25 % of local jail inmates suffering a severe injury received no medical attention, and 13.9 % of inmates in federal prisons had received no evaluation by a physician or a nurse during their incarceration.
Forty percent of the incarcerated population, or 800,000 inmates, live with one or more serious, physical conditions. An even higher percentage is affected with mental health conditions. Many inmates have a blend of disease-related dementias, such as HIV associated neurocognitive disorder (HAND), and mental health diagnoses that are considered psychiatric in origin.
The most prevalent physical conditions among the incarcerated include HIV-infection, hepatitis C infection (HCV), HIV-HCV co-infection, and other forms of hepatitis. In addition to viral infections, this population suffers from the chronic conditions associated with aging, such as diabetes, cardiac disease, neurodegenerative conditions such as Alzheimer’s disease, and the chronic failure of organ systems such as renal and liver.
Although it may be obvious, it must be noted here that current management of the above conditions requires daily adherence to pharmaceutical treatments in order to prevent acute chronic flare-ups, potentially requiring hospitalization. We live in a different world than the early days of pharmaceuticals when acute infections posing public health risks could be cleared with “the magic bullet.”
Anyone designing the architecture of a health-care delivery system to incarcerated persons must understand the concepts of polypharmacy and adherence, if their goal is, in fact, the delivery of care.
Polypharmacy is an overwhelming health-systems obstacle that has been identified within the medical industry. This term refers to the shocking length of physician-required medication lists for nearly every patient with a chronic condition. The pill-burden is especially unreasonable for the HIV-infected patient, as this group experiences all the diseases of aging at an earlier age. Cardiac and renal disease, for example, is mainly treated with pharmaceuticals. Physicians often require prophylaxis for opportunistic infections that have occurred in the past, such as toxoplasmosis, translating into additional pharmaceuticals on the list. Antiretroviral therapy (ARV) is comprised of a cocktail most commonly containing three additional pharmaceuticals on the list. Pharmaceuticals are used to treat the various palliative goals such as control of pain, itching, nausea and many other symptoms.
It must be understood as well that most pharmaceuticals are not dosed as one pill per day, but more often require multiple doses per day to meet adherence-standards for just one of the physician-required pharmaceuticals.
Adherence to current physician-required medication lists for people with chronic illness is nearly impossible, if not impossible.
It is easy to see how polypharmacy gradually came about, but it is harder to know what to do about it, particularly within the incarcerated population. Once pharmaceutical treatment is initiated, adherence is required not only to achieve a positive treatment outcome for the individual, but also to minimize public health risks.
When a person with a chronic illness is taken into custody, the facility of incarceration is responsible for an inmate’s adherence to his or her current treatments since the inmate does not have access to his or her medicine. The interruption or stopping of pharmaceutical and other treatments frequently occurs when an inmate is taken into custody, or during a transfer from one facility to another.
The Cambridge Health Alliance study reports that 25 % of inmates in state facilities and 36.5 % of inmates in local jails with a serious condition, had critical medications stopped upon being taken into custody.
Interruption of on-going treatment places individual and public health at great risk due to viral resistance and life-threatening medical events associated with unmanaged disease, such as heart attack and organ-failure. This common scenario within facilities of incarceration also places those who will become infected with HIV in the future at risk for diminished pharmaceutical treatment options.
We have unprecedented levels of suffering currently within our facilities of incarceration. Much of this suffering is unnecessary.
We have tolerated and tolerated to the point of accepting unnecessary suffering as an expected condition of incarceration, or an insurmountable problem that is too big to address.
To be forced to live with unmanaged illness, pain, and symptoms is another punishment added on to the intended punishment of incarceration. In the case of Jackson v. Bishop, 404 F. 2d 571-Court of Appeals, 8th Circuit, 1968 found the Eighth Amendment’s basic concept to be nothing less than the dignity of man. Estelle vs. Gamble, 429 U.S. 97 (1976)- U.S. Supreme Court ruled that “willful indifference” with regard to medical needs of inmates violates an inmate’s Eighth Amendment rights.
Palliative Equality earnestly protects the right of an incarcerated person to refuse medical treatment as this is also protected by the Eighth Amendment. Required medical screenings, vaccines, and treatments must be similar in scope and intent to facilities in the community that are high-risk for communicable disease, such as a Residential Care Facility for the Chronically Ill (RCFCI), or a Skilled Nursing Facility (SNF).
The over-riding of an inmate’s choice to refuse a treatment must follow the current professional standard of legally establishing an inmate’s capacity to make medical decisions for themselves. Medical providers must follow current standards relative to informed consent and provide an inmate, or their legal representative, with an understandable presentation of risks and benefits prior to initiating all medical treatments including pharmaceuticals and injections.
Since the 1976 Estelle vs. Gamble decision, there has been a reverse trend toward decisions that deny inmates of private prisons the use of Eighth Amendment protection, leaving them with a state remedy only. An example of this trend is the 2012 Minneci v. Pollard decision.
THE SOLUTION: CANNABIDIOL (CBD) MADE AVAILABLE TO QUALIFIED MEDICAL CANNABIS PATIENTS IN JAILS AND PRISONS
Palliative Equality’s solution for the massive and complex public health challenges associated with the incarcerated population is the non-psychoactive compound, cannabidiol (CBD). CBD is found in all forms of cannabis, and is highly concentrated in the leaves of the industrial hemp plant.
The therapeutic profile of CBD found in the scientific literature is extremely well matched to the medical conditions that are plaguing the incarcerated population. CBD is a non-toxic, inexpensive option with an excellent profile of safety and predictability. CBD’s effectiveness in managing, and in some cases curing diseases, is its ability to control the inflammation underlying chronic conditions associated with aging, and chronic viral infections. Read our review of the scientific literature that suggests CBD is an appropriate antidote for this class of diseases.
We suggest a (smokeless) meltaway strip or non-psychoactive capsule made only from the leaves of Hemp be offered to medical cannabis patients within facilities of incarceration. The industrial hemp required to produce these capsules has potential to be easily produced on-site with a self-sustaining stream of funding.
We envision inmates being offered the opportunity to become partial owners of a worker-owned on-site cooperative aimed at farming organic, non-GMO hemp during incarceration. In this scenario, inmate-business owners would gain both business skills and practical agricultural skills that are greatly needed to produce many products in our current economy.
The medical literature relating to CBD strongly suggests its value as an anti-inflammatory, an immune modulator, and a neuroprotective anti-oxidant (Institute of Medicine 1999, Mechulum et al. 2007). The literature also suggests an anti-anxiety effect (Mechulum et al 2007), and an anti-psychotic effect (Zuardi et al 2006). CBD is a sophisticated molecule in that it is able to address problems by promoting the body’s own homeostatic control mechanisms.
CBD interacts with receptors that are mostly located outside the brain and central nervous system, explaining its non-psychoactive effect (Mechulum et al. 2007, Russo & Guy 2005). Additionally, no compound within cannabis interacts with the respiratory centers. This explains why cannabis will not slow the respiratory rate, causing “respiratory depression”, or the decreased drive to breathe that is associated with opiate overdose.
The LD-50 measures the lethal dose of a substance and indicates potential for toxicity by establishing the dose at which 50% of subjects die. The LD-50 of Cannabis sativa has been studied in monkeys, demonstrating a lethal dose that is far greater than one can realistically consume (Grotenhermen 2003), providing an excellent safety profile.
Some suffering cannot be avoided, but the levels of debilitating pain, anxiety, stress and illness among those in prison must now be recognized as inhumane.
Institute of Medicine. Marijuana and Medicine: Assessing the Science Base. Washington, D.C.: National Academy Press 1999.
Mechulum, R., Peters, M., Murillo-Rodriquez, E., Hanus, L.O. “Cannabidiol: Recent Advances.” Chemistry and Biodiversity. 4(2007): 1678-1692.
Russo, Ethan & Guy, Geoffrey. “A Tale of Two Cannabinoids: The Therapeutic Rationale for Combining Tetrahydrocannabinol and Cannbidiol.” Medical Hypotheses. 66(2006): 234-246.
Zuardi, A., Crippa, J., Hallak, J., Moreira., F., Guimaraes “Cannabidiol, a Cannabis Sativa Constituent, as an Anti-psychotic Drug.” Brazilian Journal of Medical and Biological Research. 39 (4) 2006: 421-429.