Medical Guidelines
Region: Jails

Wexford Health Sources, Inc.
501 Holiday Drive
Sulte300
Pittsburgh, PA 15220
Phone: 412-937-8590

Medical Guidelines
Region: Jails

Corporate Authorization
This Medical Guidelines has been reviewed and approved by the following individual(s):

Chief Medical Officer, Wexford Health Sources, Inc.

Regional or State Medical Director

Facility Medical Director

Site Administrator /Site Manager (If applicable)

Date of Effectiveness: February 1, 2021

The Medical Guidelines are reviewed annually but may not require revision. If a change is made, a revision
date will be added and updated accordingly.

The contents of this manual are proprietary and confidential. This manual must be returned to the corporate office of
WeKford Health Sources, Inc. {Wexford Health) upon employee termination or end of contract.

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/112021 Wexford Heatth Sources Inc., PROPRIETARY and CONFIDENTIAL

Medical Guidelines
Region: Jails

Preface
This manual is intended to serve as a reference tool for clinicians practicing medicine in the jails and
prisons served by Wexford Health Sources, Inc. (Wexford Health). The manual contains clinical pathways,
treatment protocols, and algorithms designed to promote a standard level of quality and care at Wexford
Health sites. The goal of each clinical pathway is to assist the clinician in reaching the best possible
outcome for each patient, while reducing opportunities for errors or inefficiencies. Wexford Health's
clinicians should incorporate the tools in this manual into daily practice.
The manual has been developed, and is maintained, by the Medical Advisory Committee of Wexford
Health. This committee is composed of clinical and administrative peers charged with developing
consensus on clinical issues utilizing the most recent professional standards, evidence-based studies,
and accepted practices.
Clinical pathways do not replace sound clinical judgment, nor are they intended to strictly apply to all
patients. The specific strategies and pathways presented in this manual provide a clinical management
approach, but their application is a decision made by the practitioner accounting for individual
circumstances.
Medical management and information is continually changing as better treatments, testing, or approaches
are learned. Consequently, some items in this manual may become obsolete and, as a result, this manual
will continually evolve. Clinicians practicing at Wexford Health sites are encouraged to assist in
keeping this manual updated and useful by presenting new information, sharing successful clinical
approaches, and informing of adverse or suboptimal outcomes.
As always, Wexford Health encourages its practitioners to utilize all accepted resources in providing care,
as well as the leadership and advisement of its varied staff of medical directors and administrators. The
"Quest for Excellence" is never complete.

If there are any conflicts between these guidelines and client-specific policies, administrative directives or
institutional directives, then the respective client-specific policies, administrative directives or
institutional directives language is controlling to resolve such conflict. In cases where state and local laws
differ from these guidelines, Wexford Health will comply with the applicable local or state law.
Revised: 8/26/2015

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medic-al Guidelines
Reg on: Jails

Table of Contents
Medical Advisory Committee: Mission Statement and GuideJines ..... ....... ..... .................................. .... 9
M-002: Pre-Booking Medical Screening (JAlLS ONLY) ......... ...... ........... .. ....... ............... ................... 11

M-003: Drug [ntoxication/ Withdrawal OuideJ lnes ..... ........ .. ................ ... ,.......... .... ... ....... .......•.•..•... 13
M &003: FORM : Physidan Detox Orders on Admission .......... ............................. ...... ........ ............... . 20
M-003 : FORM : Clinical Opioid Withdrawal Scale (COWS) .... ............. .................... ............ ........... ... 2 4
M -003 : FORM: ClWA - Aloohol/Drug Withdrawal Assessment and Treatment Flowshe ................. 25
M-003 : CfWA-B Clinical Evalua lon Record Guidelines ... .......... ... ... .............. ............ ......... ............. 26
M--003: CIWA-B Clinka Evaluation R cord ..... ......... ............... .... ............ ............... ..... ............. ...... 27
M-003A: Pregnancy and Opioid Use ... ....... •.•...•.•.•...•.....•.•............... ..... ... ............... .................. .. ...• 28
M-003A.01 Opioid Use Screening Form lSAMPLE) ... ...... ..................... ....... ..... .... ... .. ......... ...... ......... 40
M-003A.02 Consent to Participate in Medication Assisted Treatment (MAT) (SAMPLE) .... ... .... ..... .. .... 41
M-003A.02 Consent to Participate in Medication Assisted Treatmen (MATI (SAMPLE) ....... ........... .... 42
M -003A.03 Refusal to Participate in Med ication Assisted Treatm n (MAT) {SAMPLE) .............. .. ....... 43
M -003A.04 DSM-5 Opio.id Use Disorder (OUD) Diagnostic Clit ria (SAMPLE) ................ ................... 44
M -003A.05 Clinical Opioid Withdrawal ScaJe (COWS) (SAMPLE) .................. .................................... 45
l\.1-004: Primary Ce.re ·G uidelines ..... .... ................................................... ....... ............................... ... 46

M-006: Therap uti Shoe·s ............ ................. ........ ........ .. ·•·•·•·•·•·•·•· ........... .................... ................ ... 4 7
Hearing Aids............... .. ............. ................ .... ......................... ..... ..... .. .. .. ......... .. ....... ........... s.o
Blood Administration ................ ... .......... ...... .......... .. .. .................... ........... .......................... S.3
8-nteral Nutrition and Nutritional Supplementation .................. ..... ........................... ......... . 59
FORM: Nutritional Supplement Request Form ............... .. .. ....... ... .......................... ............. 61
Morbidi y Suivey Report Form (SAMPLE) ......... .......................... .. .. ....... ..... ......... ................... ......... 62
Mortality Review Worksheet (SAMPLE} ......................... ................................ ........... ........................ 63
M -018 : Naloxon 4 arcan}: Guidance for Use in Opioid Suspected Ingestion/Overdose .................... 65
M -019 : Medical Managem nt of Inmate Exposure to BJoodborne Pathogens ......... ........... ................ 68
M~020: Air Ambulance Guidelines .. . .............. .... ................................... ..... ................................... ... 78
M-007:
l\,l-008:
M•OI 0:
M-010:

Chronic Stable Angina: Clinica] Assessment ..................... .............................. ......................... ... ..... 82
Chronic Stable Angina; Stress Testing/ Angiography ........... ............. .............. ........... ....................... 83
·C hroni.c Stag Angina: Treatment ..... ............................. ........ ................. ....... .................................. 84
nstable Angina-Practical, E idence-Based ........................ .................... .... ........ ............................ 85
Calculating th Risk of oronary Artery Disease fCAD) ......... ......... ......................... .... ................ ..... 86
NYHA Functi•o naJ CJ.a sification .. ................... ............. .. .................... .............. ............................ .... 8 7
Diagnostic Tests .................. ....... ................................. ............ ........................... ...... ....................... 90
Treatment Plan .............. ,.......... ...... ................................... .................................................. ........... 9 1
Treatmen Pla.n ....... ..... ,........ ............ ........... .... ............................... ............ ...... ..... ........... ............... 92

Treatment Plan: Referral GuideHn.es ................... .. .... .. .... .. .. .... ................ .............................. .. ......... 93
YHA Functional Classification & Treatment Guidelines · • .... ................. .......................................... 94
Drug Therapy Selection ............ ........... .............. ................ ............ ....... ..... ........... ......................... . 95
NYHA Functional Classification & Guidelines ... ........................ .................................. .. ................... 96

Syncope ................. .. .................................. ..... .... ,............... ............... ....................... ..................... 97
When to Hospitalize a Patient with Syncop ..................... .............. .... .... ........ .... ....... ......... .. ........... 98
Algorithm for the Evaluation and Management of Pati nts Suspected of Having Acute Coronary
Syndrome (ACS) ....... ..... ......... ................. .. .. .. ................ ............................. ................. . ................... 99
Acute Ischemia Pathway ................. .. ........ ............. .................... ......... ... .... ....... ....... ............ ......... 100
Con stiv H. art Failu.r · : An Approach to Treatment .. ..................................... ........ ...................... 01
'Each tlal11fu9ion ma.y ltav-1 individual varia~s, ind I copy of thost v.aria.noes slloilld lie dadled to tllrs. guidellnt.
~. 21112&2:1 Wmotd Healttt Sourees me., flR()PRlEJARY .amil CONFlOENTIAL

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Medical Guidelines
Region: Jails

Highlights of Optimal CHF Management ....................................................................................... 102
Deep Vein Thrombosis Guldellne ...........................................................................................................................104

Approach to the Patient with an Acutely Swollen Leg ..................................................................... 105
Dental GuJdellnes ...................................................................................................................................................113

D-001: Oral Care ....... ... .............. ................................................................................................. 115
D-002: Generalized Procedure Guidelines ........... ... ............................................................ ....... ... 119
D-003: Dental Sick Call Requests ................................................................................................ 121
Dermatology, Guidelines ........................................................................................................................................123

Dermatology ....................... ......... .. ......... ............................................... ... .................. ......... ......... 124

Durable Medical Equipment Guldellnes ....................................................................................................................125
Ankle-Foot Orthotics .................................................................................................................... 126
M-012: Knee Orthotics ................................................................................................................. 127
M-013: Prosthesis ............................ ............................................................................................ 129

Endocrine/Metabolic Dlsorders .......................................................................................................................... 131
Type I Diabetes Mellitus ................................................................................................................ 132
Type II Diabetes Mellitus ............................................................................................................... 133

GastroenteroloO ................................................................................................................................................................134
Management of Ulcerative Colitis ............................................................. ................ ...... ...............
Medications Used to Treat Ulcerative Colitis ..................................................................................
Management of Crohn's Disease ..... ....... ..... ............ ............................ ........... ...... .. ... ....... .............
Medications Used to Treat Crohn's Disease ...... ....... ........ .. .. .. .............. ... .. ..... .......... .......... ............

135
136
137
138

Treatment of Gastroesophageal Reflux Disease (GERD) .........................................................................................139
Management of Gastroesophageal Reflux Disease (GERO) Including Proton Pump Inhibitor (PPI) Taper
···················································································································································· 140
GERO: Patient Algorithm and PPI Taper ........................................................................................ 144
Medications Use to Treat Uncomplicated Gastroesophageal Reflux Disease/Dyspepsia ......... .......... 145
Management of Suspected of Recurrent Gastric or Duodenal Ulcer ................................................ 146
Medications Used to Treat Suspected or Recurrent Gastric or Duodenal Ulcer .............................. . 147

General Surgery ...................................................................................................................................................148
General Surgery Guidelines ............ ... ................................................... ... ................... ... ............... 149
The Repair of Abdominal Wall/Inguinal Hernias .. .. .......... .. ...................................... ... ...... ...... .. ..... 150

Hematology Guldellnes ..................................................................................................................................................................152
Hematology Guidelines ................................................................................................................. 153

Hyperbarlc Oxygen Therapy (HBO) Treatment Guldellnes........................................................................................ 155
Hyperbaric Oxygen Therapy (HBO) Treatment Guidelines .............................................................. 156

Infectious Diseases ............................................................................................................................................... 158
Hepatitis B Guidelines ....................... ........... ....... ... .... ..... ............ ............................ .............. ....... 159
•each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

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u~W8dordleallh~
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MecUcaJ Guldelines
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Hepatitis C Virus Tr atrnent Guideline ............. ................... ........... .. .................... ..... ........... ......... 164
l'n itial H,e patitis \Vork Sheet .............. .. ........ ...... ...... .......... ... .......... ......... .... ......... .... ....... ....... ....... 168
Facts About Hepatitis B, and ·C ........................ .................................. ........ .... ............. .... ....... ....... . , 169
Intectious Disease: HIV Guid elines ................... .. ............ .............. ................... ... .... .. .. .. ......... .... ... 171
MRSA Control Guidelines ........... ...... ........ .......... ................. , ., .....•.•......•... ,....... ............................ 172
Append ix l : Lln n and Laundry Services ............ .... ....... ....... ..... ........................ ......... ,........ ........... t 80
Appendix 2: MRSA Q&A fCorrec ions Proressionals) ... .. .... ..... ...... ... ...... ...................... ............. ...... 18 1
Appendix 3.: MRSA Q&A ([nmates) ....................................... ........... .......... .................................... 184
Appendix 4: MRSA Reporting Template ....................................... .................................... ........... ... 186
I-llV Pr-ophyladic Post Exposure Medications .. ............................ .. ............ .......... ........................ .... 187
S xually Transmitted Diseases Treatment Recommendations .... , ., ....... ....... .. ......... .. .................. .... 191

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App ndix '; R comm nd ations for Who Can Be Housed in an l n fi rmary . ,..•.•.•... ., ,•.•.•. ,•.. .•.•.•........ 202
Appendix 2; Recornm nd.ations for Who Should NOT Be Housed in an Infirmary ........ ................... 203

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lnfl:uenza OutlJr-eak GuldeUnes. ln Corrections ............... _....,...,............................,......,.....................................................................:294,
JnOuenza Virus Management during a Confirmed Outbreak Correctional Institutions ..................... 205

Medlcallon Consent 1
Fotlns (EngJis and Spa.:nlsh) ........ ,... .. ,.... .,..u ......

HHHHliliil'IHH•H•• ....... H ........ ,.,.,.H,,, ......................... "" .................

210

MEDlCATION: BE ADRYL (Diphenhyd ra mine HC4 .................................. .................................... 21 l
MEDICATION: COGENTIN (Benztropine Mesylatej, , .................................... .. ..... ......... ............. .... .. 213
MEDICATION : EFF.E XOR (Venlafox.ine HCL), EFFEXOR XR (V nlafaxine HCL Extended ReJease
Capsules) ..... ................. .. ... ...... ....... ............ .. ........ ...................... ................................ .................. 215
INFORMED CO SENT FOR ANTlPSYCHOTIC MEDJCATlON- FORM A ........... ....... .... .................... 217
Informed Cons nt for Psychotropic Medication - FORM B .. .... .. ... ...... ....... ............. .. . ........ .............. 219
MEDlCATlON: GEODON (Zip rasidone) ................. .............. ........................ ; ........................... ........ 221
MEDICATION: HALDOL (HaloperidoJ} . HALDOL DE A OATE iHaloperidol Decanoate) ........ .. ... . , .•. 223
MEDICATION: LITHIUM ..... . ........ ... ........ .. . , ...... .. ... , .... .... ........ ..... .. .. .. ....... . ....... . ......... .. .... .......... •. 225
MEDICATION: PAXIL (Paroxetine HCI,j ........•. , .................. ................. .. ............ ....... .... .................. 227
MEDICATION: PROLIXIN (Fluphenaz.ine 'HCL), PROLJXIN DECANOATE (Fluphenazine Decanoate) 229
MEDICATION.: PROZAC (Fluoxetine HCLJ . ........ .. .......... .............. ..... ................ .. ....... .. ........ .. .. ...... 231
MED[CATIO : REMERON (Mirtazap ine) ..... ........ ............................................ ..... ......................... 233
M D[CATION; RISPERDAL (Risperidone) .... .... ............................................... .................... .......... 234
MEDICAT[ON; SEROQUEL (Quetiap ine Fumarate) ............ ..... ............... ........... ........................ .... 236
MEDI CAT.ION: TE-ORE-'fOL (Carb amazepine) .......... ..........., .•.•.•.,. .... ......... .............. ....... ........ ....... ,. 238
MEDICATION: THORAZINE (Chlorpromazine HCL} .......... ......... , .. ..... ................................... ... ...... 240
MEDICATION : TRILAFO (Perp henazrne) .......... ............ . , .... .. .. .. .. ... .. .. .. ..... .. ........... ... ......... ........ . ,. 242
MEDICATION; VALPR.OIC ACID ..... . .. .................................... .. .. .. . .. .. .. .. . ...... .. ..... .... ... ........ ... .. .. .... 244
MEDICATION: VlSTARIL (Hydroxyzine Pamoate) .... .................. .................. ........................... ........ 246
MEDJCATJON: WELLBUTRIN (Bupropion HCL), WELLBUTRIN SR (Bupropion HCL Extended Release

MEDICATION: ZOLOF'T (Ser raline HCL) ......... .... ................................. ................................... ..... 250

Neurelo.gy Guldellnes .............................,.,•••••••......................................,.................................................. .... ,-..............................................

11 • ., . . . . . . . . , . , . , . . . .

252

eurology Guidelines ........... ................. ..... ...... .. ................. . .......... . ............. ...... ... ....... ......... .. .. .... .. 253

Ol>stet.rlcs/Gynecolo,o ............................,................................................................................

Iii, . . . . . . . . . . . ,.~ • • • j< . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .

'Each state!l'Clgton ·ay twe indMduaf w1riancu, and • oopy o411wse varianc:411 mould bt altathed to tlll:& tuiclelme.
ReY.2'112021 Wmord H,.allh SOlfl'Ces Inc., PROPRETARY andCONFIOEttllAL

l!lll!■■ .. ••··· .... ...............254

6

Medical Guidelines
Region: Jails

Management of Cervical Cytology Interpretation ............................................................................ 255
Management of Cervical Cytology Interpretation ............................................................................ 256
Ophthalmology, Guldelines ..........................................................................................................................................257

Ophthalmology Guidelines ............. ....... ................ .... ................................................. ................... 258
The Management of Cataracts ............................................. ... ....................................................... 2 59
The Management of Glaucoma ...................................................................................................... 261
A. Tonometry: Recommended Screening Intervals ...................................................................... 262
Optometry' ...........................................................................................................................................................263

Optometry /Ophthalmology Protocols and Procedures .................................................................... 264
Eyeglasses and Contact Lens Protocols ......................................................................................... 266
Oral and Maxillofaclal Surgery Guidelines ............................................................................................................268

Oral and Maxillofacial Surgery ...................................................................................... ................ 269
Orthopedic Surgery Guldellnes ..............................................................................................................................271

Orthopedic Surgery Guidelines ..................................................................................................... 272

Otolaayngolol)' Guldellnes ........................................................................................ t1••················································27s
Otolaryngology ............................................................................................................................. 279
Pain Management ..........................................................................................................................................................283

Treatment of Mild to Moderate Pain .............................................................................................. 284
Treatment of Low Back Pain ........................................................................................ ................. 285
Pharmacologic Treatment of Chronic Pain ..................................................................................... 286
Pharmacologic Treatment of Migraine Headaches ................... ... .................................................... 292
Peer Review .................................................................................................................................................................296

M-001: Peer Review Activities ........................... ... .... ........... ....... ................................................... 297
Plastic Surgery Guldellnes ......................................................................................................................................307

Plastic Surgery ............................................................................................................................. 308
Prison Rape Elimination Act ........................................................................................................................................309

Prison Rape Elimination Act Guideline .......................................................................................... 31 O
Pulmona11 Guidelines ............................................................................................................................................313

Pulmonary Guidelines .................................................................................................................. 314
Respiratory Dlsorders .............................................................................................................................................317

Acute Asthma ............................................................................................................................... 318
Severity of Asthma Exacerbation ...................... .... ......................................................................... 319
Chronic Asthma Severity Classification/Management .................................................................... 320
Chronic Asthma ........................................................................................................................... 321
Asthma Control: Achieving the Best Outcomes with Medication Use and Targeted Patient Education
········································································ ·········································· ··································322
*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medical Guidelines
Region: Jails

Summary of Guideline Recommendations for Periodic Health Examinations ............................................................326
Summary of Guideline Recommendations for Periodic Health Examinations .................................. 327
Summary of Guideline Recommendations for Periodic Health Examinations, Table 1: Wexford Health
······························································································ ······················································ 329
Summary of Guideline Recommendations for Periodic Health Examinations, Table 2: Wexford HealthPregnant Females ......................................................................................................................... 334
Transgender Guldellnes.........................................................................................................................................336
Medical Management of Trans gender Inmate Guideline .................................... ............................. 337

Urolo§ Guldelfnes.................................................................................................................................................335
Urology Guidelines ........................................ ........... ......... ........................................................... 336
Vascular Disorders ••...........................•.........•••.....................•..••...••..........••.............••.....••••..................•.............338
JNC8 Hypertension Management Algorithm .............................. .................................................... 339
Vascular Surgery Guidelines ...................................... ................................................................... 344
Table 1: Classification of Blood Pressure for Adults ....................................................................... 348
Table 2: Causes for Lack of Responsiveness to Th rapy ...................................................... ........... 349
JNC 8 GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION IN ADULTS ............................ 350
Table 3: Risk Stratification Factors .............................................................................................. 352
Medications on the Wexford Health Corporate Formulary Used to Treat Hypertension .................... 353

Warfarln Management .......................•........•.........................................................•.............................•..............354
Warfarin Management ............................................................ ...................................................... 355
Warfarin Drug Monograph ............................................................................................................ 357
Non-Vitamin K Oral Anticoagulant (NOAC) Guidelines for Utilization ............................................. 363

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medical Guidelines
Region: Jails

M-003: Drug Intoxication/Withdrawal Guidelines
Reference: ACA: 5-ACl-6A-41; 5-ACl-6A-42; NCCHC: F-04

I.

DEFINITION
A group of symptoms brought about by abrupt discontinuance of heavy prolonged use of a specific
class of drugs. The drugs may or not cause dependence, but all have a potential detrimental effect
on the body. The goal is to preempt problems before they become life threatening. Drugs of high
abuse and/or concern in the intoxication/withdrawal process include: alcohol, amphetamines,
barbiturates, benzodiazepines, beta-adrenergic blockers, cocaine, hallucinogenics, and opiates.
The appearance of symptoms will vary by the amount of time the drug was used, the actual drug
used, i.e., half-life, the status of the liver, and the concomitant use of other agents. The basic
principle of pharmacodynamics is that it will take five (5) half-lives for the drug to be cleared and
therefore, at least that long for symptoms to occur. That is to say that a short half-life drug like
alcohol may exhibit the first signs of withdrawal in 12 to 24 hours after the last ingestion, whereas
a long half-life drug like methadone may require 5 to 7 days after the last ingestion to exhibit
withdrawal symptoms.
The goal is to prevent full-blown withdrawal, with all its accompanying physiologic aberrations from
manifesting itself.

II.

INFORMATION
Substance use disorders are highly prevalent among inmate populations, affecting an estimated 3060% of inmates. Drug intoxication and withdrawal may be particularly evident at the time of
incarceration. The Bureau of Justice Statistics reports that an estimated 70% of all inmates in local
jail facilities in the U.S. had committed a drug offense or used drugs regularly, and an estimated
35% were under the influence of drugs at the time of the offense.
Any substance that alters perception, mood, or cognition can be abused. Commonly identified
substances of abuse include illicit drugs, alcohol, and certain prescription drugs, which act through
their hallucinogenic, stimulant, sedative, hypnotic, anxiolytic, or narcotic effects. Other less
commonly recognized substances of abuse include medications with anticholinergic, antihistaminic,
or stimulant effects, e.g., tricyclic antidepressants, antiparkinsonian agents, low potency
antipsychotics, anti-emetics, and cold and allergy preparations.
Substances that produce dangerous withdrawal syndromes for individuals with physiological
dependence include alcohol, sedative/hypnotics, and anxiolytics. Withdrawal from narcotics is not
generally considered dangerous, except in pregnant women and the medically debilitated; however,
narcotic withdrawal does result in significant symptomatology, which can be markedly reduced with
targeted therapies.
Not all substances of abuse produce clinically significant withdrawal syndromes. However,
discontinuing substances on which an individual is dependent will likely produce some
psychological symptoms. Withdrawal from substances such as stimulants, cocaine, hallucinogens,
and inhalants can be accomplished with psychological support and symptomatic treatment alone,
along with periodic reassessment by a health care provider.

Ill.

GUIDELINE
A.

Function: This procedure is to facilitate and guide in the evaluation and treatment of
alcohol/ drug withdrawal. Detoxification is done by coordinating staff members but only under
medical supervision of a physician in accordance with local, state, and federal laws when
performed at the facility.

B.

Inmates experiencing severe, life-threatening intoxication or withdrawal as described in this
guideline should be transferred to a facility where specialized care is available.

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Medical Guidelines
Region: Jails
C.

IV.

Circumstances under which the licensed nurse may perform the function:
1.

Setting: Wexford Health contracted sites.

2.

Supervision: No direct supervision is required at the time of identifying and initiating
care. Overall the Supervising Nurse, Medical Director, and/or clinic physicians,
including contract and on-call physician as appropriate, provide supervision.

3.

Patient conditions: Nurses shall routinely reevaluate and care for inmate health
complaints following written procedures and order(s) by the responsible physician{s).

PROTOCOL
Withdrawal can be a life-threatening situation. During intake screening an inmate should be
questioned on alcohol and drug use using the intake screening tool. It is incumbent upon the staff
to initiate withdrawal, detoxification protocols as soon as it is identified that the inmate has been
actively using drugs that cause withdrawal symptoms or significant amounts of alcohol. (See
attached Physician Detox Orders on Admission.)
A urine drug screen (UDS) is a cost-effective tool that may be used to determine an accurate listing
of the substances of abuse instead of relying fully on the patient's history. Remember that claims
of drug use/ abuse may be exaggerated and/ or diminished by the patient. Based on the clinical
evaluation of the inmate, the staff member may contact the provider for orders for a UDS.

Do not wait until symptoms of withdrawal are evident to begin monitoring and/or therapy.
Evaluation and monitoring of the inmate with potential withdrawal should begin at intake with the
completion of the appropriate clinical monitoring tool.
Once the drug has washed out of the body (typically 5 half-lives), the withdrawal protocols can
usually be terminated. Every case will be different, but it is important to begin therapy early. Signs
and symptoms will vary but generally fall into the listed categories.

Opioids in Pregnancy. A urine drug screen should be completed on all pregnant female
inmates at intake. Staff should noj; rely only on the inmate's reported drug use. Abrupt
withdrawal of opiates in pregnancy may result in miscarriage, stillbirth or pre-term labor so
substitution of alternative opioid narcotics like Methadone or Subutex is recommended.

V.

NURSING MEASURES
A.

Alcohol Withdrawal
1.

General information:
a.

The alcohol withdrawal syndrome can develop in any individual who has a history
of regular, heavy use of alcohol, has a known dependence on alcohol, or has
clinical signs of intoxication.

b.

Alcohol withdrawal syndromes can be mild, moderate, or life-threatening. The
severity of an individual's alcohol withdrawal syndrome is difficult to predict,
although a history of problems with withdrawal makes it likely that a similarly
severe withdrawal syndrome will occur again.

c.

Individuals with a high blood alcohol level( > 100 mg/dL) and concurrent signs of
withdrawal are at particularly high risk for a severe withdrawal syndrome.

d.

Uncomplicated alcohol withdrawal is generally completed within four to five days.
Alcohol withdrawal symptoms can develop within a few hours of decreasing or
discontinuing use. Symptoms generally peak within 24-36 hours after abstinence
begins.

e.

Early signs and symptoms of withdrawal include gastrointestinal distress,
anxiety, irritability, increased blood pressure, and increased heart rate. Later,

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

14

Medical Guidelines
Region: Jails

symptoms of moderate intensity develop, including insomnia, tremor, fever,
anorexia, and diaphoresis.
f.

2.

CIWA. The inmate's status should be scored using the Clinical Institute
Withdrawal Assessment of Alcohol, (CIWA). The CIWA is an evidence-based
scoring system that should be used over time to objectively assess the severity
and progression of alcohol withdrawal symptoms.

Guidelines for using the Alcohol/ Drug Withdrawal Assessment and Treatment
Flowsheet

a.

The CIWA scale is the most sensitive tool for assessing a patient who is
experiencing alcohol withdrawal.

b.

Early intervention for a CIWA score of 8 or greater provides the best means of
preventing the progression of withdrawal.

c.

Use the attached Alcohol/ Drug Withdrawal Assessment and Treatment Flowsheet
to document the patient's vitals and CIWA scores, as well as the administration
of PRN medications.

d.

Follow the Assessment Protocol shown at the top of the flowsheet. Record the date,
time, vitals, and the CIWA ratings and Total Score each time the patient is
assessed.

e.

To calculate the total CIWA score, rate the patient according to each of the IO
CIWA criteria, and then add together the 10 ratings. Each criterion is rated on a
scale from O to 7 (except for "Orientation and Clouding of Sensorium," which is
rated on a scale from O to 4). The health care professional can select any rating
from O to 7 (or O to 4, in the case of "Orientation"), even for criteria where not
every number on the rating scale is defined.

3.

Complete the CIWA form at each assessment.

4.

Do record in the medical record any signs of trauma, intoxication: odor of alcohol, or
unsteady gait.

5.

Record in the medical record any signs of liver disease: jaundice, or ascites.

6.

Place on Detox protocol after contacting Clinician for approval. (See attached Physician
Detox Orders on Admission.)

NOTE: While breathalyzers are not routinely performed onsite, if there is any report of a

detainee who registers a 0.300 or above on a breathalyzer the detainee is to be sent to the
Emergency Room unless previously medically cleared by the hospital.
If the detainee that blows a 0.300 or above on a breathalyzer has been medically cleared to
return to the facility, he/she must be placed in the infirmary for observation.
B.

Amphetamine withdrawal: (Methamphetamines, uppers, stimulants, Dexedrine,
Benzedrine, Adderall, speed etc.) Symptoms include: hyperactivity, irritability, delirium,
hallucinations, psychosis, mydriasis, hyperpyrexia, hypertension, arrhythmias, vomiting, and
diarrhea.
1.

Record the type, amount, route of ingestion, and duration of habit.

2.

Note and record vital signs daily for three days, if needed

3.

Evaluate patient for:
a.

Nutritional status

b.

Mental alertness

c.

Neurological dysfunction

d.

Restlessness

•each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/112021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

15

Medical Guidelines
Region: Jails

C.

e.

Abnormal or variable pulse and blood pressure

f.

Place on detox protocol after contacting clinician for approval.

g.

Document in patient's file

Barbiturate withdrawal ("downers", sedatives, Amytal, Donnatol, Seconal, Quaaludes, etc.).
Symptoms depend on which stage of withdrawal and may include:
1.

Early Withdrawal
a.

2.

Mid Withdrawal
a.

3.

D.

Increased pulse and blood pressure, anxiety, panic attacks, restlessness, and
gastrointestinal upset.

In addition to the above early withdrawal symptoms, may progress to include
tremor, fever, diaphoresis, insomnia, anorexia, and diarrhea.

Late Withdrawal
a.

If left untreated, a delirium may develop with hallucinations, changes in
consciousness, profound agitation, autonomic instability, seizures, and death.

b.

Patients showing signs of late (severe) withdrawal may need to be hospitalized if
treatment cannot be given .

4.

Inmates experiencing barbiturate withdrawal should generally be actively medicated.

5.

Phenobarbital. Substitute phenobarbital for the drug of abuse in equivalent doses Equivalent doses can be found in the Federal Bureau of Prisons Clinical Practice
Guideline
for
Chemically
Dependent
Inmates
which
is
available
at:
http://www.bop.gov/resources/pdfs/detoxification.pdf

6.

Specific treatment strategies for barbiturate withdrawal should be determined by the
condition of the individual inmate, and should be reviewed and approved by a clinician.

7.

Record the type, amount, and frequency of ingestion and duration of habit.

8.

Place on detox protocol after contacting clinician for approval.

9.

Utilizing the CIWA flowsheet record vital signs and assessments.

10.

Should convulsions start, call clinician immediately.

11.

Contact clinician for orders for disorientation, severe agitation, severe tremors,
diaphoresis, pulse greater than 120, blood pressure greater than 150/ 100, temperature
> 101 °F.

12.

Should psychosis or hallucinations be present contact the clinician/psychiatrist for
further orders.

Benzodiazepine withdrawal (e.g., Valium, Xanax, Dalmane). Symptoms depend on which
stage of withdrawal and include:
1.

Early Withdrawal
a.

2.

Mid Withdrawal
a.

3.

Increased pulse and blood pressure, anxiety, panic attacks, restlessness, and
gastrointestinal upset.

In addition to the above early withdrawal symptoms, may progress to include
tremor, fever, diaphoresis, insomnia, anorexia, and diarrhea.

Late Withdrawal
a.

If left untreated, a delirium may develop with hallucinations, changes in
consciousness, profound agitation, autonomic instability, seizures, and death.

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/112021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

16

Medical Guidelines
Region: Jails

b.

E.

F.

Patients showing signs of late (severe) withdrawal may need to be hospitalized if
treatment cannot be given.

4.

Record type, amount, and frequency of ingestion and duration of habit.

5.

Record level of consciousness, general appearance, orientation, character of speech,
pupil size and symmetry, and presence or absence of hallucinations.

6.

Record vital signs.

7.

Place on detox protocol after contacting clinician for approval.

Beta blockade withdrawal (Tenormin, Inderal, etc.).
urgency, arrhythmias, angina, tremor, migraine, etc.

Symptoms include: hypertensive

1.

Record type, amount, and frequency of ingestion and duration of drug use. This class
of drugs causes an acute exaggeration of sympathetic outflow upon abrupt cessation,
i.e., if used for hypertension when stopped may cause blood pressure to soar.

2.

Record level of consciousness, general appearance, and orientation.

3.

Place on beta~blocker protocol, until verification of inmate's prescriptions, after
contacting clinician for approval.

4.

Record vital signs.

Cocaine withdrawal. Symptoms may include: depression, hypersomnia or insomnia, fatigue,
anxiety, irritability, paranoia and decreased concentration.
1.

Most cases of cocaine withdrawal do not require medical therapy.

2.

Record the amount, route, and duration of habit/use.

3.

If warranted, record vitals 4 times daily.

4.

Place on detox protocol after contacting clinician for approval.

NOTE: Cocaine intoxication as demonstrated by sympathetic stimulation including
advanced hypertension, tachycardia and tachypnea need heart protection and therefore
requires immediate clinician notification.
Any detainee suspected of ingesting cocaine (balloon, etc.) is not to be accepted into
the jail (medically) until cleared by an E.R. physician.
G.

Hallucinogen intoxication/withdrawal (LSD, PCP, mescaline, psilocybin, THC, etc.).
Symptoms of acute intoxication include: agitation, violent behavior, hypertension,
tachycardia, nystagmus, impervious to pain, self-destructive, etc.
1.

Symptoms of intoxication following ingestion of hallucinogenic substances may result
in a state that produces a heightened "awareness of one's environment," distorted
responses to sensory stimuli, and psychotic behavioral patterns.

2.

Record the type, amount, and route of ingestion if possible.

3.

Note and record vital signs .

4.

Note and record presence or absence of:

5.

a.

Hallucinations

b.

Distorted sensory perception

c.

Fever

d.

Coma

e.

Bizarre behavior patterns

While a typical withdrawal syndrome from hallucinogens has not been reported, it may
be necessary to manage an acute intoxication.

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

17

Medical Guidelines
Region: Jails

H.

6.

Place patient in infirmary /medical housing and assign a calm, sympathetic person to
frequently reassure patient during his period of intoxication/withdrawal.

7.

Orient patient to reality frequently and protect him from obeying distracting or
dangerous hallucinatory suggestions.

8.

If restraints are considered, refer to treatment protocol for "Restraints."

9.

Encourage fluids.

10.

Place on detox protocol after contacting clinician for approval.

11.

Contact clinician if vital signs become unstable or if patient is extremely agitated or
appears to pose a threat to others or themselves.

Opiate intoxication/withdrawal (Heroin, codeine morphine, OxyContin, hydromorphone,
Methadone, etc.). Symptoms include:
depressed consciousness, miosis, respiratory
depression, etc.
1.

Record amount, route, and duration of habit/ use. Taking into account the possibility
of exaggerated dosages.

2.

Keep patient on bed rest.

3.

Place on detox protocol after contacting clinician for approval.

4.

Record on the Clinical Opioid Withdrawal Scale (COWS) the presence or absence of signs
and symptoms and calculate the severity score of the withdrawal:

5.

Record vital signs.

6.

Call clinician immediately for any patient suspected of having a severe narcotic
withdrawal by either symptoms or through the COWS assessment.

7.

DO NOT STOP OPIATES IN PREGNANT FEMALES.

8.
I.

a.

Obtain a urine drug screen.

b.

Immediate notification of the responsible provider is needed.

c.

Methadone induction in a licensed methadone program needs to be arranged
ASAP and may in some cases require hospitalization for induction of Methadone
or the substitution of prescription narcotics to prevent withdrawal.

Remember that claims of past substance abuse are often exaggerated.

Polysubstance withdrawal
1.

It is generally best practice to prioritize the substances an individual has been
dependent on and treat them according to the severity of the withdrawal produced by
the substance.

2.

The substances with the most serious withdrawal syndromes, those where the
withdrawal syndrome can be fatal, are alcohol and sedative-hypnotics which includes
barbiturates and benzodiazepines.

3.

It is acceptable to order additional protocols to address multiple withdrawals while
avoiding duplication within a medication class (not duplicating Ativan (lorazepam)
orders).

4.

When treating patients detoxifying from substances other than barbiturates,
benzodiazepines and/or alcohol, the management of opioid detoxification should be the
next priority.

5.

Generally, other substances of abuse, including stimulants, marijuana, hallucinogenics
(LSD and similar drugs), and inhalants, will not require specific treatment in patients
who are being detoxified from barbiturates, benzodiazepines, alcohol and/or opioids.

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

18

Medical Guidelines
Region: Jails

6.

VI.

If the patient has been abusing multiple sedative-hypnotic substances or a sedativehypnotic and alcohol, withdrawal should be handled in the same way as withdrawal
from one such substance.

ATI'ACHMENTS
M-003: Physician Detox Orders on Admission
M-003: Clinical Opioid Withdrawal Scale (COWS)
M -003: CIWA - Alcohol/ Drug Withdrawal Assessment and Treatment Flowsheet
M-003 CIWA-B Clinical Evaluation Record Guideline
M-003 CIWA-B Clinical Evaluation Record

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/112021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

19

Medical Guidelines
Region: Jails

M-003: FORM: Physician Detox Orders on Admission
Medical Policies and Procedures
PHYSICIAN DETOX ORDERS ON ADMISSION

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ID#: _ _ _ _ _ _ _ _ _ __
DOB: _ _ _ _ _ _ _ _ _ _ Drug Allergies:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I

I.

ADMJSSION ORDERS -All DETOX PATIENT(S) -(VALID ONLY I/MEN SIGNED AND DATED)
1.

House at Health Service Unitllnfinnary

2.

House diet (If vomiting. <larrhea, or signs d dehydration, give fu~ liquid diet x 48 hours and infonn clinician if
symptoms persis~ .

3.

Vital signs once per shift unless othefv,;se specified by dinician and/or unti cleared fran detox.

4.

Multivitamin 1 tablet p.o. daily lM'llle in health services housing or infinnary

5.

Folic add 1 11'9 1 tablet po. daily whl e in health setVices housing or infirrrery.

6.

lnaease oral ftur:ls..

DiagnOSis:

DATE

CLINICIAN SIGNATURE

I

11

TIME

ALCOHOL DETOX FOR MOST INMATES-(VAUD ONLY WHEN SIGNED AND DATED)
1.

Draw labs for CBC , CMP and Mg

2.

Obtain and send out urine drug saeert

3.

Seizure precautions x 72 hours.

4.

Thiamine 100 mg 1 tablet p.o. x 10 days.

5.

Maalox 30 cc p.o. tl.d. p r.n. x 72 hours,

6.

MOM 60 cc p.o. p.r.n. at hs. for constipation ~ 72 hOUrs.

Recommended L
7.

Mild Withdrawal (ctWA 8-91
Repeat CIWA f!Nety 4-6 hours
until C!WA has rema ned <10 for
24 hours without medication

1.

2.

Treatment Schedule Based on ctWA Score
severe Withdrawal
Moderate Withdrawal
(CIWA>15)
(ctWA 10-151
Discuss with clinician:
Administer torazepam 2 mg
p.o. or IM q 1 hour
Hospitalization for Inpatient
Repeat CIWA in 1 hour (90
detoxification and moni1oring is
minutes if giving lorazepam
strongly suggested.
PO)
~orazepam is adminlstered
acx:crding to the same sdledule as
Repeat lorazepam 2 11'9
desoi)ed unijer Moderate
q 60-90 minutes until CIWA
~aawaf. H<Nlew!r, an · ncrease in
score< 10 then disrontinue
lorazepam.
frequency Of boltl IOraZef)am and
CrNA may be indicated.
Repeat CIWA q 4-8 hours Until

.
.

3.

4.

the score has remained
< 10 for 24 hours. If the srore
rises again \Whin this 24-hour
period, repeat steps 1...J
above.
CLINICIAN SIGNATURE

. Lorazepam can be given up to

2-1 mg IV as frequently as q 15-20
minutes. This would require a
patient-specific order.

DATE

Rev. 412012020

•each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

TIME

Page 1 of/4

20

Medical Guidelines
Region: Jails

Medical Policies and Procedures
PHYSICIAN DErOX ORDERS ON ADMISSION

Im.

Alcohol Detox for INMATES WJTH HISTORY OF ALCOHOL WITHDRAWAL SBZURES OR CO-MORBID
CARDIOVASCULAR CONDITIONS - (VALID ONl Y WHEN SIGNED AND OAlEO)
CV cornfllions include: Hypertens()fl. an~ina, CHF, History of Ml or CVA. {Consider lorazepam treatment even if
1.
only mild wthdrawal symptoms are present.)

2

Patients will'I a hismry of alcohol withdrawal seizures Y.rill generally present vmh ~ ns and symptoms or moderate to
severe withdrawal DO NOT GIVE AKTI-SEtzURE MEDICATIONS unless the inmate also has an underlying
seizure disorder. carbamazepine may be useful in lreating patient with a history of alcol'ld withdrawal seizures.

3.

Draw labs for CBC, CMP and Mg.

4.

Obtain and send out unne drug screen .

5.

Seizure precautions x 72 hours.

6.

Thiamine 100 mg 1tablet p.o. daily x to days.

7.

Maalox 30 cc p.o. t1.d. p.r.n. JI

8.

MOM 60 cc p.o. p.r.n. at h.s. for constipation x

n l'IOurs.
n hours.

Recommended Lorazepam Treattnent Schedule Based on CIWA Score

9.

Suggested Initial Regimen~

D.ays 1-2: Lorazepam 2 mg Ud.
Days 3-4: Lorazepam 2 mg b.i.d

Day 5:

Lorazepam 2 mg single
dose (AM or HS)

Days 1-6: Monitor C~A t.i.d."

Moderate Withdrawal
!CIWA 10-15)
Administer lorazepam 2 mg p.o.
orlMq 1 hour
2 Repeat CiWA jn 1 hour (90

Severe Withdrawal
(CIWA>15)
DisaJss wi1h clinician:

•

Hospitalization for inpatient
detoxification and monitoring is
strongly suggested.

•

Lorazepam is administered
accordi~ to the same schecllle
as desaibed under Mocterate
'Mthdrawal. However, an
increase in fre-quency of both
lorazepam and CIWA may be
irdcated.

•

Lorazepam can be Qiven up to
2-4 mg IV as frequenuy as
q 1~20 minutes. lhis woutd

minutes if giving lorazepam p.o.)
3. Repeat lorazepam 2 mA

q 60-90 minutes until Cl.WA
sco,e <10 then discontinue

lorazepam.
4. Repeat CIWA q 4-8 hrs. until the

score has remained < IO for 24
hours If the score rises ~ain
withfn this 24-hour period, repeat
steps 1-3 above.

require a patient-specific order.
• In tllese c-ases. the dooe of lorazepam may need to be decreased if tt!e · mate experiences somndenee. atuic gait, slurred
Eaeech or other sians al medication intoxic.atio:)
.. If Ille CIWA score ii,?: 10 at any lime, rnnow the steps fol' Moderare Wilhdrawator Severe IWhrtawal

CLINICIAN SIONATURE

DATE

Rev. 412Q.12020

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/112021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

TIPIE

Page2of/4

2t

Medical Guidelines
Region: Jails

Medical Policies and Procedures
PHYSICIAN DEl'OX ORDERS ON ADMISSION

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ IOif: _ _ _ _ _ _ _ _ _ _ __
DOB: _ _ _ _ _ _ _ _ _ _ Drug Allergies:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I

IV.

DELIRIUM TREMENS ORDER ONlY-(VALID ONLY WHEN SIGNED AND DATED}
INSTJruTE DELIRIUM TREMORS SYMPTOM FLOW SHEET
Admit to infinnary.
1.

3.

lhiamine 100 mg 1tablet p.o. da~y for 30days.

4.

If unable to admlnlster Lorazepam p.o. to patient proceed as follows:
torazepam (Ativan} 2 mg JMq 4 hours PRN agitation x n hours.
If at>ove Lorazepam •Inadequate to treat agitation_contact dlrncian.

5.

If psychosis or ongoing severe agitaoon contact clnician for possibte order for haloperidol 5 mg p.o. p.r.n. q 4 hours
or haloperidol 2.5 mg JM q 2 hoors p.r.n . agitation/confusion/psychosis.

6.

Draw blood and obtain urine and send out Urine Drug Saeen. CBC, CMP, and Mg.

CLINICIAN SIGNATURE
V.

1.

Obtain urine and send out for Urine Drug Saeen.

2

Metoprolol 25 mg p.o. b.i.d. x 72 hours p.r.n. lachycardia (pulse> 100).

3.

Lorazepam (Ativan~0.5 mg p.o. Bto x 72 hours p,r.n. agitation.

4.

Hakfol 0.5 mg p.o. b.Ld. x 72 hours p.r.n. hallucinations.

DATE

TIME

BARBITURATE DETOX ORDER ONLY -(VALID ONLY 1M-IEN SIGNED AND DATED)
INSTJruTE ALCOHOI.JDRUG WITHDRAWAL SYMPTOM FLOW SHEET
1

Obtain urine and send out for Urine Drug Saeen.

2.

100 meq IV sodium bicarbonate ASAP, then 150 meq sodium bicarbonate in 1000 cc D5W IV@ 10 rnllkWJlr. until
adequate urine output then reduce to 3 ml/kg/hr x 72 hours

3.

Serum potassium each day x 96 hours. If< 3.5 meq add 20 meq KCL to each 1000 cc's fluid.

CLINICIAN SIGNATURE
VU.

TIME

AMPHETAMINE DETOX- (VALID ONLY W'HEN SIGNED AND DATED)
INSTJruTE ALCOHOUDRUG WITHDRAWAL SYMPTOM FLOW SHEET

CLINICIAN SIGNATURE
VI.

DATE

DATE

TIME

BOOODIAZEPINE DETOX ORDER ONLY -(VAL D ONLY WHEN SIGNED AND DATED)
INSTJruTE ALCOHOUDRUG WITHDRAWAL SYMPTOM Fl.OW SHEET
1.

Obtain urine and send out for Urine Drug Screen.

2.

orazeparn (Alivan) 1.0 mg p.o. tld. x 48 hours start now, then
Lorazepam (Ativan) 0.5 mg p.o. t.Ld. x 72 hours, then
Lorazepam (Ativan) 0.5 mg p.o. b.i.d. x 72 hours, then
orazeparn (Ativan) 0,5 mg qh .S, x 48 l'IOurs, then DC,

CLINICIAN SIGNATURE

DATE

Rev, 4/2012020

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

TIME
Page J of/4

22

Medical Guidelines
Region: Jails

Medical Policies and Procedures
PHYSICIAN DEl'OX ORDERS ON ADMISSION
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ID#: _ _ _ _ _ _ _ _ _ _ __

DOB: _ _ _ _ _ _ _ _ _ _ OrugAllergies:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
VIII.

BETA BLOCKER WITHDRAWAL ORDER ONLY -(VALID ONLY WHEN SIGNED AND DATED)
INSTITUTE ALCOHOLJDRUG WITHDRAWAL SYMPTOM FLOW SHEET

1.

Metoprolol 25 mg p.o. b.i.d. unlit adual agent and dosage can be verified.

CLINICIAN SIGNATURE

IX.

Obtain urine and send out for Urine Drug sereen.

CLINICIAN SIGNATURE

DATE

TIME

HALLUCtNOOENIC DETOX ORDER ONLY -(VALID ONLY WHEN SIGNED AND DATED)
1-

Obtain urine and send out for Urine Drug Saeen.

2.

Haldd 0.5 mg p.o. q.i.d. x n hours p.r.n. tor acute agitation.

CLINICIAN SIGNATURE

XI.

TIME

COCAINE DETOX- (VAUD ONLY WHEN SIGNED ANO DATB>)
INSTITUTE ALCOHOUDRUG WITHDRAWAL SYMPTOM FLOW SHEET
1.

X.

DATE

DATE

TIME

OPIATE DETOX ORDER ONLY -(VALID ONLY WHEN SIGNED AND DATED)
INSTITUTE ALCOHOUDRUG WITHDRAWAL SYMPTOM FLOW SHEET
1.

Obtain urine and send out for Urine Drug Screen.

2.

Clonidine0.1 mg p.o. bJ.d. :x 24 hours
Clonidine O.t mg p.o. q.i.d. x 48 hours
Clonidine 0.2 mg p.o. q.i.d x 48 hours
Clonidine 0.1 mg p.o. q.i.d. x 48 hours
Clonidine 0.1 mg p.o b.i.d. x 24 hours
Hold if blood pressure < 85/70.

3.

COWS assessment t.l.d wtule on opiate detox protocol.

4.

Ibuprofen, 6'00 mg p.o. U d. x 72 hours p.r.n. for muscle aches.

5.

Pepto-Bismol (bismuth subsalicylate). 30 m! p.o. q.i.d. x 72 hours pr n for diarrhea.

6.

Benty! (dicydomine), 20 mg po. q.Ld x 72 hours p.r.n. for abdominal cramping .

7.

Phenergan (promethazine}, 25 mg IM q 6 hour.; x 72 hours p.r.n. for vomiting.

CLINICIAN SIGNATURE

DATE

Rev. 4/2Q/2020

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

TIME

Page 4 of !4

23

Medical Guidelines
Region: Jails

M-OO3: FORM: Cllnlcal Opioid Withdrawal Scale (COWS)
Clinical O 1a1e Withdrawal Scale COWS)
For each Item, arde 1ha number that best describes the patienfs signs or symptoms. Rate on just the relationstvp to opiate wilhmawal
For example, if heart rate Is increased because the patient was jogging just prior to assessment. the lncreese pulse rate would not add
to the score.
Patient's Name: _ _ _ _ _ _ _ _ _ _ _ _ Date and Time _ i _ j_ _ _ _ _ _ __
Reason for this assessment _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Resting Pulse Rate~_ _ _beats/minute
Measured :rfter palit~nt ,., -.l"ing tl1 lyir,g tm 1ttkJ rn/r'Nllt~

o

pulse rate 80 or below

pulse rate 81- 100
pulse rate 101 -120
pu1se rate greater than 120
SWeatlng: OW!r pasl ½ hour nor aa:mmted fat by room
temperature or ~lim acfivtly
0
report of chills or flushing
1 subjective report or chills or flushing
2 Hushed o, observab e moistness on face
3 beads of sweat on brow or face
4 sweat streaming off face
Restlessness: Obsentaticn drJring assessment
0 able lo stt sM
1 repotts difficulty sit11ng sbl. but 1s ab!e to do so
3 frequent shifting or extraneous movements of tegsiarms
5 unable to sit s~II tor more than a few seconds
1

2
4

"°

GI Upset Over la'il YI 1101/T
o no Gi,symptoms
1 stomach cramps
2
3
5

nausea or loose stool
vorn1tng or diarrhea
mulh pie episodes of dl8Jltiea or vorrutlng

Tremor 01&¥Vittivn uf outstrcJdu.vl hands
0
1
2
4

notremor

tremor can be felt. but not observed
slight tremor observable
gross tremor or muscle twitchmg

Yawning Ottswnrinn dunng ;,sses.r;ment
0

no )'8Wntng
yawning onoo or twice during assessment

2 yawning tllree or more limes during assessment
4 yawning several t1mes1mmute
Anxiety or irritability
Pupflsl1e
0 pupils pinned or normal s12e for room light
0 none
1 pupils possibly larger than normal for room light
1 patient reports IncreasIn,g nrilab1lity or anxiousness
2 patient obviously 1rntable I amaous
2 pupils moderately dJated
5 pupils so dilated that only the ,im of the ms is isibte
4 patient so nritable or anxious that partic1palion in
assessrnenl is d1ff,cult
Bone or joint aches If patient was llavinq pain previously. ootv the GooseRash skin
atltlitinnal component attnbutP.d lo opmtes 1wt11dra !Wit~ scorP.11
O not present
0 skin is smooth
1 mild diffuse discomfort
3 pitoerection of skin can be felt or hairs standing up on e,ms
5 prominent pdoerect1on
2 pabent reports severe diffuse aching of 101nts1muscles
4
pallent 1s rubbmg Joints or muscles and IS unable to sit still
becall5& of disoomfort
Runny nose or tearing NOi accounted fOl by cold symptoms u,
Total Score: _ _ _ _ _ __

alte,ges
0 not piesent
nesal stuffiness or unusually moist eyes
2 nose running or tearing
4

r/J('/0{:Ji -.COff! 1,; lhi'! 'ill/II()( ,11/

11 !/1'1/l'i

Initials of person completing assessment: _ _ _ __

nose conslanUy runmng or tears streammg down cheeks

SCORE'. 5 -U . mild; 13 -14; moderate; 25 -36::: moderately se11ere; more than 36; severe withdrawal
Sourr;e: w,sson ond ting 1003

•each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 211/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

Medical Guidelines
Region: Jails

M-003: FORM: CIWA -Alcohol/Drug Withdrawal Assessment and Treatment Flowsheet

I iQl::illDD!!IIS fml~I
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)OU MO'I/ isn l lfrete?' RlllHllP !!Ci!/e 0-1.

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n~l~"'8IDnt: 1- oonnrwu, t.alu<i,ij~
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b.JooJJrlJUlld ~ hfWf?' Ra:P. 011."C,'l!e 0-1 lluw ,,1tf! ti,me~~ o.• i!Ji,m11t•rn-t<1
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Tlllll CMA Sean!:
IM; mllol dl:riral 10.. f!'i """""""-WJIY!ldW-'11.1> ~t; : ~will.Jr!IWMI
Indications fllf PRN M~h;arlon: Fleaso ~low 1h11 pro!Orol ,~ {'lrrox,/if.•,11,1111 ,11 ('/lm1JG1,1iy /};J,•)(~lx/Pttf 11111fille,i for USC or loraz~rn and otr-ermedlcaliois lot
•1,dld'awal.

Meditlllian administered? ,~i:l" l,lf.(J~~••l Acll\!11!~,lbif, q,:.·r,,<11 V~ltl
ltn11H1I PRN mrdu::1oon ~dmn1i-.uo11oon:
l't.!a51!SY111!nl al respoo!ie:
l•~IWA 5w~ ~l:.-:,) 11',rulH e'l,Mflll<lUbtn ad111n~e•Edl

PalienlNan: _ _ _ _ _ _ __
IDNQ. _ _ _ _ _ _ _ _ _ __

l""'Sc.lgn,a~.aatu""re/Ti""""'itl""e_ _ _ _ _ _ _ _ _-f_lc.:m1c.:·ia:=;I=-~__Siiln.:.;.alllre/Ttlle

Oace ol Rilth: _ _1__1 _

IIMIJt~----------

•each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

-

l

--t

Medical Guidelines
Region: Jails

M-003: CIWA-B Clinical Evaluation Record Guidelines
In order to streamline the assessment of the inmate-patient experiencing benzodiazepine withdrawal and
to be able to quickly see improvement or worsening of symptoms, a CIWA - B Clinical Evaluation Record
tool has been developed.
The multi-use tool is designed to be inmate-patient specific while allowing health care providers the ability
to see improvement or worsening of symptoms at a quick glance.
The health care clinician/nurse begins by completing the inmate-patient's name and inmate number at
the top of the form. The documentation of each assessment will start with a date and time at the top of
the column. From there the form is divided into a subjective section and a clinical observations section.
To complete the subjective portion, the health care clinician/nurse will ask the inmate-patient a series of
questions with the inmate-patient giving a numerical answer from O - 4. The scores from this section are
totaled and the clinician/nurse begins the clinical observation portion of the evaluation.
The clinical observation piece is broken into three questions - agitation/restlessness, tremor, and
sweating. The clinician/nurse scores each of these on a O - 4 scale and totals up this section.
The scores for the subjective and clinical observations sections are then totaled and the clinician/nurse
completing the evaluation initials the bottom of the column. Each clinician/nurse completing an
evaluation must include a signature corresponding to their initials at the bottom of the page.
In accordance with the Wexford Health Detox Guidelines, the benzodiazepine withdrawal protocol is to be
followed. Unlike the alcohol withdrawal protocol, the benzodiazepine withdrawal protocol does NOT
include PRN medications to be given based on the CIWA - B score. The CIWA - B Evaluation Record is
designed to be an evaluation tool only, ensuring consistent evaluations and scoring of the inmate-patient
experiencing benzodiazepine withdrawal.

The physician will need to be contacted for orders to initiate the Benzodiazepine Withdrawal
Protocol.

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

26

Medical Guidelines
Region: Jails

M-003: CIWA-B Clinical Evaluation Record

CIWA-B Clinical Evaluation Record
For flte ~vahlafioR of beRzodiazepine wifl,drawalsymptoms

l1111a1e Name:___________________

Nc.mber:._____________

Date

llme
SUBJECTIVE FINDINGS
Askf1e nahntto re!e each of 1hefollowi (I on ueale of Ofnot II a!Oto 4 Mn n.ich sol
Feeing lrrlable?
FeeingfaliQUed?
Feeti~tanse? ·
Drficulty cone entralng?
t,ny ~s d appetite?
Numbne11$ qr IJt.ming in face, hands, or feet?

Palpitations?
Head feels full or achy?
lillscte aches/stiffness?
.Aro<IOUs, nerwus, or jittery?
Feelina upset?
Feefing weak?
How restful was vour sleep last nigtt?·
Do you lhlhk ~u had enough sleep last night?
vtsual disturbances? tbluff'ed 1nsion, photopobia)
Ne vou fearful?
Have yw beien twrr'yinft abOtJ possible mlsfortunes
latelv?

·SUB-TOTAL SUBJECTIVE FINDINGS
.CLINI.CAL OBSERVATIONS
AAl1atiomRestlesaness
Score· 0-4
0- Nme,nom,ahchily

2- Redleis
4- Padnn unabletodstil

Tremor'

0- ~ tremor

1- N1t-.isibie,can be felt mfingm
2-

\hmie bit mild

3- Mlderate Mb arms e:dended
4 - Se.1ere Nlhout arms eldended

Sweating
0- N, llisible sweating
1- Barelypereeplible mealing, palms moist
2- Palms and forehead moist, reports a~lary.swnting
3- BeadsohweatonforehMd
4- Se'ie~ drenchinuweals

SUB-TOTAL CLINICAL OBSERVATIONS
. · + -a;wmc.ia ~ l

TDJ'AL SCORE.-··
l~tials d Evaluator

Total Seen: 1-21t mild wltidrawal 21 -40: modentu.tthdnwal 41-111: .evue withdrawal 61 - llt nrueven wlhdrawal
..

lrilttalslSJa•ture• of Evalmtors-

~

Rev. 2.07/2019 Wexford Health SourC!:5, Inc PROPRIETARY and CONFIDENT L

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

21

Medical Guidelines
Region: Jails

M-003A: Pregnancy and Opioid Use
References: ACOG, ASAM, SAMSHA, ACA: 5-ACI-GA-41, 5-ACI-SE-11, 5-ACl-6A-10; NCCHC: P-F-05, MH-G-07,
J-F-05

I.

GUIDELINE
For the management of opioid use in pregnant inmate-patients Wexford Health's guidance is based
on the guidelines set forth by SAMSHA, American Society of Addiction Medicine (ASAM) and The
American College of Obstetricians and Gynecologists (ACOG).
Pregnant inmate-patients with opioid use disorder should not undergo withdrawal from opioids.
Medication Assisted Treatment (MAT) is the standard of care for pregnant women with opioid use
disorder and will be provided for the duration of the pregnancy.
Coordination of care between with the O8/GYN and onsite medical/behavioral health is important
for pregnant women with opioid use disorder.
Decisions on MAT during the postpartum period will be based on client guidance and policy.

11.

BACKGROUND INFORMATION
The National Institute on Drug Abuse (NIDA) defines addiction as a chronic disease that can be
managed and treated successfully. Like other chronic disease processes (e.g. diabetes,
hypertension), the successful treatment of substance use disorders depends on social support,
inmate-patients- provider rapport, as well as treatment availability.
Approximately 40- 60% of inmate-patients relapse and resume illicit drug use in the first year after
discharge from substance abuse treatment programs, which is similar to a 60% relapse rate for
adults undergoing treatment for hypertension or asthma.
Barriers to treatment in pregnancy created by misguided policy approaches result from a
fundamental misunderstanding of the chronicity of addiction and the need to provide ongoing
treatment for addiction disorders with both medical and psychosocial interventions.
Opioid use disorder (OUD) may involve illicit or prescription medications, as well as heroin,
methadone, buprenorphine diverted or misused prescription opioids, or other morphine-like drugs.
Opioid addiction is a chronic, relapsing disease.
Acute opioid withdrawal is physiologically stressful, characterized by profound activation of the
sympathetic nervous system with hypertension, tachycardia, and gastrointestinal symptoms. MAT
during pregnancy improves prenatal care, reduces illicit drug use, and minimizes the risk of fetal
in utero withdrawal.
Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic
observed in the general population. The number of women with opioid use disorder in labor and
delivery has recently more than quadrupled.
Opioid use during pregnancy is associated with substantial maternal, fetal, and neonatal risks.
These risks are related to repeated opioid exposure (e.g., risk of overdose) as well as factors
associated with opioid use (e.g., smoking, poor nutrition, needle sharing, unstable lifestyle).
Opioid exposure during pregnancy has been linked to negative health effects for both mothers and
their babies. These include maternal death and poor fetal growth, preterrn birth, stillbirth, possible
specific birth defects, and neonatal abstinence syndrome. The effects of prenatal opioid exposure
on these children over time are largely unknown. However, using prescribed opioids for treatment
of opioid use disorder during pregnancy may be necessary and outweigh the risks of these potential
negative health outcomes.
Opiate use or misuse may include heroin, codeine, morphine, OxyContin, Tylenol #3,
hydromorphone, buprenorphine (Suboxone or Subutex), Tramadol, Fentanyl, etc. regardless of the
route of transmission.

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

28

Medical Guidelines
Region: Jails

Ill.

INTERVENTION
Medication Assisted Treatment (MAT) is defined as the use of FDA-approved medications, in
combination with counseling, and behavioral interventions to provide individualized whole patient
approach to treat opioid use disorders. This treatment combination can lead to more favorable
outcomes.
Medication Assisted Treatment (pharmacotherapy) of opioid use disorder (OUD) is recommended for
pregnant women with OUD and should be accompanied by close supportive clinical follow-up. The
goal is to prevent obstetric and neonatal complications associated with OUD as well as detox,
facilitate prenatal care, and help women avoid the myriad risks from the unstable lifestyle
associated with the drug culture (e.g., drug-related criminal activity, homelessness, domestic
violence, and infectious diseases).
The Substance Abuse and Mental Health Services Administration (SAMHSA) the American Society
of Addiction Medicine (ASAM) and the American College of Obstetricians and Gynecologists. (ACOG)
recommend MAT with either methadone or buprenorphine (without naltrexone which is Subutex)
for pregnant women with opioid use disorder.

IV.

MEDICATIONS USED FOR MAT
A.

8.

C.

D.

Buprenorphine - Subutex vs. Suboxone
1.

Buprenorphine belongs to a class of drugs called partial opioid agonist.

2.

The primary difference between Suboxone and Subutex is that Suboxone also contains
a substance called "naloxone" while Subutex does not:

Subutex contains a single active ingredient: buprenorphine.

b.

Suboxone contains two active ingredients: buprenorphine and naloxone.

Methadone
1.

Methadone is a long-acting full opioid agonist.

2.

Understanding the signs and symptoms of intoxication verses withdrawal is imperative
when providing MAT intervention. If an inmate-patient is currently "intoxicated,"
adding medication could, in fact, cause an overdose. Clinical judgment is crucial during
this process since methadone is a Schedule II controlled medication.

Methadone or Buprenorphine
1.

While methadone has been the standard choice for pharmacotherapy of OUD during
pregnancy since the 1970s, buprenorphine is increasingly used because neonatal
withdrawal (also known as neonatal abstinence syndrome) appears to be less severe
when the mother is treated with buprenorphine as opposed to methadone.

2.

When determining the appropriate course of treatment, multiple factors must be
evaluated including medication availability, during and after incarceration.

Pregnant individuals already established on MAT (methadone or buprenorphine) should
continue the established medication.
1.

V.

a.

Switching/ changing from methadone to buprenorphine or from buprenorphine to
methadone is not recommended and may lead to withdrawal.

Recognizing Signs and Symptoms of Opioid Intoxication and Withdrawal
The table below lists signs and symptoms of opioid intoxication and withdrawal.
·t..:·

Signs

Opioid Intoxication

'

Opioid Withdrawal

-

.

Signs

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/t/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

29

Medical Guidelines
Region: Jails

Opioid Intoxication

·~

Opioid Withdrawal

., ___.. ·-

•
•

Bradycardia (slow pulse)

•

Tachycardia (fast pulse)

Hypotension {low blood pressure)

•

Hypertension (high blood pressure)

•

Hypothermia (low body temperature)

•

Hyperthermia {high body temperature)

•

Sedation

•

Insomnia

•
•

Miosis (pinpoint pupils)

•

Mydriasis (enlarged pupils)

Hypokinesis (slowed movement)

Hyperreflexia (abnormally heightened reflexes)

•

Slurred speech

•

Head nodding

•
•
•

Diaphoresis {sweating)
Piloerection (gooseflesh)

•
•
•

Rhinorrhea (runny nose)

•

Muscle spasms

Increased respiratory rate
Lacrimation (tearing), yawning

Symptoms

Symptoms

•

Euphoria

•

Abdominal cramps, nausea, vomiting, diarrhea

•

Analgesia (pain-killing effects)

•

Bone and muscle pain

•

Calmness

•

Anxiety

Source: Consensus Panelist Charles Dackis, M.D.

VI.

MAT OF INCARCERATED PREGNANT INMATE-PATIENTS - GENERAL GUIDANCE
A.

DO NOT STOP OPIOIDS IN PREGNANT INMATE-PATIENTS.

B.

Contact the clinician as soon as possible for any pregnant inmate-patients suspected of being
severely intoxicated.

C.

For MAT, the inmate-patient should have clinical evidence of opioid dependency as well as a
positive pregnancy test.

D.

Screening will be provided by staff upon discovery of opioid use to determine frequency and
severity of use. (See attached MT003A.01 Opioid Use Screening form.)

E.

Record amount, route, and duration of habit/use considering the possibility of exaggerated
dosages.

F.

All female inmate-patients assessed for opioid use will be tested for pregnancy prior to
beginning an opioid detox protocol. If pregnant, do not detox.

G.

If available, an onsite urine drug test should be performed to confirm opioid use.

H.

A Clinical Opiate Withdrawal Scale (COWS) assessment should be conducted as soon as
possible to track and monitor the pregnant inmate-patient. {See attached
M-003A.05 Clinical Opiate Withdrawal Scale.)

I.

Call the clinician as soon as possible for any inmate-patients suspected of having a severe
narcotic withdrawal if determined by either signs/symptoms or through the COWS
assessment.

J.

Frequency of the COWS is typically directed by a clinician.

---------------

•Each stale/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

30

Medical Guidelines
Region: Jails

1.

K.

L.

The recommended frequency for a pregnant inmate-patient with a confirmed opioid use
disorder is typically between 4 to 8 hours until stable and the provider requests that
COWS is discontinued.

The clinician will be notified as soon as possible to ensure appropriate course of action is
taken to ensure the safety of the mother and her fetus.
1.

The provider should review both the Opioid Use Screening form and the COWS to
determine the course of action needed to determine the time frame to start MAT.

2.

The planned course of action will depend on the source of the opioids as described in
later sections.

An additional form called DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria has been
attached to this guideline to provide additional guidance when diagnosing OUD. (See attached
M-003A.04 DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria.)

VII.

PREGNANT INMATE-PATIENTS ENTERING THE FACILITY ESTABLISHED ON METHADONE THROUGH AN OTP
A.

A Release of Information (ROI) should be obtained to discuss protected health information
with the OTP.

B.

Confirmation of established methadone dose should be obtained as soon as possible.

C.

A pregnant inmate-patient should NOT DETOX.

D.

A clinician needs to be involved / contacted as soon as possible to ensure detoxing does not
occur.

E.

If a pregnant inmate-patient arrives at the facility already established on methadone the onsite
provider will BRIDGE the prescription of methadone to ensure no harm comes to the inmatepatient as well as the fetus.
1.

The DEA has clearly stated BRIDGING methadone in a PREGNANT INNMATEPATIENT is considered a MEDICAL intervention for the safety of the fetus, NOT
an opioid treatment intervention. Therefore, any clinician with a DEA license can
BRIDGE methadone.
a.

In bridging methadone, the primary purpose is not to provide drug treatment;
rather, it is to provide medical intervention to the fetus and to ensure no harm
comes to the fetus and mother until the inmate-patient can be taken to an opioid
treatment program OR services are continued by the current OTP provider.

b.

"Bridging'' methadone is considered the period 72 hours following the first dose
administered.

c.

Contacting the inmate-patient's current methadone provider and/or referring
the inmate-patient to the methadone clinic that manages your site's methadone
patients must certainly be a priority to ensure continuity of care within the time
frame expected. This can be accomplished by the following steps:

d.

2.

i.

Contact the inmate-patient's current OTP provider and have them provide
an order (prescription) to your site to continue methadone. The 72-hour
clock stops when the methadone order from the OTP is received.

ii.

Contact your site's OTP and set up the next available appointment for the
inmate-patient to be enrolled in their OTP (if the inmate-patient's current
OTP is outside the geographic boundaries of your site) .

Linking the inmate-patient to an OTP provider that can continue their current
methadone prescription will ensure that they receive needed treatment while
incarcerated.

The site's contracted pharmacy will supply the methadone once the site's DEA licensed
provider has written the patient-specific order.

•each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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a.
3.

The bridged order MUST include the verbiage "PREGNANT FEMALE."

The site clinician should continue the current dose the pregnant inmate-patient is
established on UNLESS detox symptomatology becomes present.
a.

In this event the OTP clinician should be contacted for additional guidance.

F.

Coordination with an OTP must be established for ongoing treatment of the pregnant inmatepatient.

G.

Transportation must be arranged for a pregnant inmate-patient for transport to the OTP as
determined by the OTP physician and the onsite medical provider if deemed appropriate.

VIII. PREGNANT INMATE-PATIENTS ENTERING THE FACILITY ESTABLISHED ON SUBUTEX THROUGH AN OTP
A.

A release of information (ROI) should be obtained to discuss protected health information with
the OTP.

B.

Confirmation of established Subutex dose should be obtained as soon as possible from the
OTP.
1.

C.

A pregnant inmate-patient should NOT DETOX.

D.

A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.

E.

If a pregnant inmate-patient arrives at the facility already established on Subutex, a provider
with a DEA-X should order the Subutex to ensure no harm comes to the inmate-patient as
well as the fetus.

F.

1.

The new prescriber will typically assume the care of the opioid use disorder while the
inmate-patient is pregnant and incarcerated.

2.

If there is no available clinician with a DEA-X waiver then the inmate-patient will need
to continue care at the OTP.

The site clinician should continue the pregnant inmate-patient's current established dose
UNLESS detox symptomatology becomes present.
1.

G.

IX.

A copy of the prescription is to be faxed from the current supervising OTP clinician.

In this event the OTP clinician should be contacted for additional guidance.

Coordination with 0B/GYN should be established for ongoing treatment of the pregnant
inmate-patient.

PREGNANT INMATE-PATIENTS ENTERING THE FACILllY ON PRESCRIBED OPIOIDS
A.

A release of information (ROI) should be obtained to discuss protected health information with
the inmate-patient's clinician.

B.

A pregnant inmate-patient should NOT DETOX.

C.

A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.

D.

If a pregnant inmate-patient arrives at the facility already established on ongoing prescribed
opioids, a clinician should order the prescribed opioids to ensure no harm comes to the
inmate-patient as well as the fetus.
1.

E.

The continuing of opioids does not automatically apply to opioids prescribed for an
acute condition.

The site clinician should continue the pregnant inmate-patient's current established
medication/ dose UNLESS detox symptomatology becomes present.
1.

In this event the OB clinician should be contacted for additional guidance.

*Each stale/region may have individual variances, and a copy of those variances should be attached to this guideline.
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F.

X.

Coordination with OB/GYN should be established for ongoing treatment of the pregnant
patient on opioids.

PREGNANT INMATE-PATIENTS ENTERING THE FACILITY ON OPIOJDS THAT WERE NOT PRESCRIBED AND
AVAILABILITY OF A PRESCRIBER WITH A DEA-X WAIVER TO PRESCRIBE SUBUTEX
A.

Opiate use may include heroin, codeine, morphine, OxyContin, hydromorphone,
buprenorphine (Suboxone or Subutex), Tramadol, Fentanyl, etc. regardless of the route of
transmission.

B.

A pregnant inmate-patient should NOT DETOX.

C.

A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.

D.

If a pregnant inmate-patient arrives at the facility on opioids that were not prescribed for the

patient, then a designated provider with a DEA-X license should be contacted for
consideration of a Subutex induction protocol.
E.

XI.

Coordination with OB/GYN should be established for ongoing treatment of the pregnant
patient on opioids.

SUBUTEX (BUPRENORPHINE WITHOUT NALOXONE) INDUCTION PROTOCOL
A.

Because Suboxone (buprenorphine with naloxone) can precipitate withdrawal, pregnant
inmate-patients should not typically receive Suboxone.

B.

Induction to Subutex typically involves considering the type of opioid - i.e., short-acting
opioids or long-acting opioids - that an inmate-patient is using.

C.

If an inmate-patient is using short-acting opioids, there should be a minimum of 12 to 24

hours between opioid use and buprenorphine administration, and, as a result, the inmatepatient should exhibit mild to moderate withdrawal symptoms (as assessed by the COWS).
D.

E.

Induction can take place in one day or over a week.
l.

A typical induction takes place over a three-day to one-week period.

2.

The induction period is a time frame where constant monitoring is needed as well as
possible dosage adjustment - to ensure the individual is on an appropriate dose.

3.

It is important to ensure that the individual remains stable on that dose.

The following are general recommendations on Subutex induction:
1.

Recognizing that each inmate-patient is unique the following guidance is meant to be
a guidance not a prescribed plan of care.

2.

Providers should consider an inmate-patient's recent drug history when determining a
therapeutic dose.

3.

Most inmate-patients can stay in outpatient status through induction.

4.

Initial dose may begin with 2 mg or 4 mg of Subutex and monitored for 2 to 4 hours.

5.

If withdrawal symptoms are not relieved, then additional Subutex can be administered,

followed by ongoing monitoring.
6.

If withdrawal symptoms persist, manage symptomatically with a suggested maximum
first day dose of Subutex of 8 mg.

7.

Inmate-patients who require an initial dose greater than 8 mg should be under direct
observation.

8.

If an inmate-patient is still exhibiting withdrawal on subsequent days, follow the same

procedure with a first dose equal to the total amount administered on the previous day
plus 4 mg until the inmate-patient has no withdrawal symptoms since the last dose.
•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XII.

9.

Typical recommendations are 8 mg - 16 mg per day until withdrawal no longer occurs.

10.

The typical dose for most inmate-patients is 8 mg - 16 mg per day by the end of the first
week.

11.

Doses greater than 24 mg per day are not believed to offer any clinical advantage in
treatment.

SUBUTEX MAINTENANCE
A.

The dose of Subutex must be adequate to be therapeutic for the individual.

B.

Pregnant women may develop symptoms of withdrawal as pregnancy progresses and may
require dose increases in order to maintain the same plasma level.

C.

The maternal dose should not generally be reduced during pregnancy to minimize neonatal
abstinence syndrome (NAS).

D.

Buprenorphine (Subutex) dose reduction during pregnancy does not improve fetal outcomes
and may increase the risk of recurrent substance use disorder in the mother.

XIII. PREGNANT INMATE-PATIENTS ENTERING THE FACILllY ON OPIOIDS THAT WERE NOT PRESCRIBED AND
WITHOUT THE AVAILABILITY OF A PRESCRIBER TO PRESCRIBE SUBUTEX
A.

Opiate use may include heroin, codeine, morphine, OxyContin, Tylenol #3, hydromorphone,
buprenorphine (Suboxone or Subutex), Tramadol, Fentanyl, etc. regardless of the route of
transmission. A pregnant inmate-patient should NOT DETOX.

B.

A clinician needs to be contacted as soon as possible to ensure detoxing does not occur.

C.

If a pregnant inmate-patient arrives at the facility on opioids that were not prescribed for the
patient the clinician should be contacted for consideration of an OTP.

D.

Coordination with the accepting OTP needs to occur ASAP.

E.

If the inmate-patient starts to exhibit significant withdrawal symptoms prior to being
evaluated by the OTP, then the inmate-patient should be sent to the ER for evaluation.

1.
F.

XIV.

The plan of care will follow the ER's/hospital's plan of care until follow-up with an OTP
can be arranged.

Coordination with OB/GYN should be established for ongoing treatment of the pregnant
patient on opioids.

INMATE-PATIENTS ON MAT POSTPARTUM TREATMENT
A.

Subutex/Buprenorphrine - Postpartum
1.

Wexford Health recognizes that each client may have different guidelines or policies
related to MAT in the postpartum period. Wexford Health will work cooperatively with
their client's policies and guidelines related to this subject.

2.

Following birth, most inmate-patients will be tapered off the MAT, unless the site has
an existing MAT program for non-pregnant patients.

3.

Tapering the inmate-patient off the MAT after birth should typically be done at a
comfortable rate and without inducing severe withdrawal symptoms.
a.

Tapering an inmate-patient off the MAT varies depending on the patient's current
dosage of Subutex as well as the providers medical determination of the taper
schedule.

b.

Tapering schedules should consider postpartum pain management for the
individual.

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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c.

B.

Start nursing assessments
symptomatology.

with

the

COWS

to

monitor

withdrawal

i.

When Subutex leaves the body, the inmate-patient will experience not only
physical but emotional withdrawal.

ii.

With the risk of postpartum depression, the possibility of mother-child
separation following birth which could cause depression, as well as the
withdrawal from Subutex inducing depression, it is recommended that the
patient is referred to mental health services if available; if not available,
monitor the patient's emotional status and follow up as needed.

d.

Gradually reduce the dose.

e.

Quitting or stopping Subutex abruptly is NOT recommended.

f.

Buprenorphrine half-life is 37 hours for a single dose.

g.

Create a taper schedule reducing the amount of Subutex given in increments.

h.

When monitoring withdrawal symptoms, if symptomatology is too prevalent and
causing extreme discomfort, return to the previous dose for a few days then
decrease again.

Methadone - Postpartum
1.

Wexford Health recognizes that each client may have different guidelines or policies
related to MAT in the postpartum period. Wexford Health will work cooperatively with
their client's policies and guidelines related to this subject.

2.

Following birth, most patients will be tapered off the MAT, unless the site has an existing
MAT program for non-pregnant patients.

3.

Tapering the patient after birth should typically be done at a comfortable rate and
without inducing severe withdrawal symptoms.
a.

Tapering a patient varies depending on the patient's current dosage of methadone
and should be determined by the off-site OTP medical provider (if applicable).

b.

Tapering schedules should consider postpartum pain management.

c.

Postpartum patients should be monitored for over sedation as therapeutic dosing
requirements may change.

d.

Frequent clinical assessments need to occur in monitoring methadone dosing
delivery to ensure over-sedation doesn't occur.

e.

Start nursing assessments
symptomatology.

with

the

COWS

to

monitor

withdrawal

i.

When methadone leaves the body, the patient will experience not only
physical but emotional withdrawal.

ii.

With the risk of postpartum depression, the possibility of mother-child
separation following birth which could cause depression, as well as the
withdrawal from methadone inducing depression, it is recommended that
the patient is referred to mental health services if available, if not available
monitor the patient's emotional status and follow up as needed.

f.

Quitting or stopping methadone abruptly is NOT recommended.

g.

A gradual reduction in dosing is recommended.

h.

Methadone half-life is 24 to 36 hours for a single dose.
i.

This can vary person to person, there are several mitigating factors that can
influence half-life.

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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XV.

i.

Reduce the amount of methadone given in increments as instructed by the OTP
provider.

j.

When monitoring withdrawal symptoms, if symptomatology is too prevalent and
causing extreme discomfort, return to the previous dose for a few days then
decrease again or contact the OTP provider as soon as possible to discuss.

REFUSAL OF MAT- HOW TO MANAGE PREGNANT INMATE-PATIENTS WITH OUD WHO REFUSE MAT
A.

ALL individuals have a right to refuse treatment, if a pregnant female chooses to exercise
these rights, and refuse medical intervention, the following should occur:
1.

An urgent consultation with the OB/GYN specialist for your facility should occur within
48 hours.

2.

The OB/GYN specialist will determine the appropriate treatment for the pregnant
inmate-patient.

3.

This consultation can occur the following ways.

4.

B.

a.

The OB/GYN clinician can be consulted via conference call for a peer-to- peer
review with the onsite provider.

b.

A face-to-face consultation occurs.

c.

Ifno OB/GYN is available for consultation within 48 hours, the pregnant inmatepatient can be taken to the nearest emergency room to receive clearance as well
as a treatment plan.

Informed consent: the pregnant inmate-patient will be informed of ALL risks associated
with detoxification during pregnancy and a refusal of medical treatment form should
be signed and witnessed by staff.

The inmate-patient should be supervised throughout the duration of the detoxification
process; follow the OB/GYN clinician's guidance as well as the following:
1.

Document signs and symptoms with the COWS assessment.
a.

2.

If symptoms begin, suggesting a miscarriage may be occurring, inform the OB/GYN
clinician and follow their instructions, as well as:

a.
3.
C.

D.

A COWS assessment should generally occur at minimum every 8 hours. The
frequency should be ordered by the onsite clinician.

Transport the pregnant inmate-patient to the hospital when medically indicated.

Communication and monitoring the inmate-patient in collaboration with the OB/GYN
specialist is crucial throughout this process.

A referral to behavioral health services and/or a mental health screening should occur. This
will be determined by what is available at your facility, follow your facility's protocol.
1.

Individuals withdrawing/detoxing from opioids will exhibit several behaviors and
emotions throughout the detox process as the opiates leave their system.

2.

An individual may change their mind during the actual detox process. It is important
to "check with the individual" to ensure they want to continue detoxification without
MAT.

If the OB/GYN clinician agrees with managing the inmate-patient's detox symptomatology,
consider other options to increase the individual's comfort level throughout the detox process.
If the inmate-patient consents, additional support can be provided in the following ways:
1.

Mild withdrawal can be treated with acetaminophen (Tylenol), aspirin, or nonsteroidal
anti-inflammatory drugs (NSAIDs) such as ibuprofen.

2.

Plenty of fluids and rest are important.

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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3.

Medications such as loperamide (Imodium) can help with diarrhea and hydroxyzine
(Vistaril, Atarax) may ease nausea. (Please refer to M-003: Drug Intoxication/ Withdrawal
Guidelines for additional information.)

XVI. ATTACHMENTS
Provider Resources
References
M-003A.01 Opioid Use Screening Form
M-003A. 02 Consent to Participate in Medication Assisted Treatment (MAT)
M-003A.03 Refusal to Participate in Medication Assisted Treatment (MAT)
M-003A. 04 DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria
M-003A.05 Clinical Opioid Withdrawal Scale (COWS)

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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Provider Resources
Wexford Health supports all providers seeking additional experience as well as obtaining their waiver to
provide treatment with Buprenorphine. The following is a list of resources available to providers.

I.

SUBSTANCE ABUSE MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)
The
Substance
Abuse
and
Mental
Health
Services
Administration
(SAMHSA)
(https: //www.samhsa.gov) is the agency within the U.S. Department of Health and Human Services
(HHS) that leads public health efforts to advance the behavioral health of the nation and to improve
the lives of individuals living with mental and substance use disorders, and their families.

II.

PROVIDER CLINICAL SUPPORT SYSTEM (PCSS)
The Provider Clinical Support System (PCSS) (https : //pcssnow.org/ medication-assistedtreatment /) is a program funded by the Substance Abuse and Mental Health Services
Administration (SAMHSA) created in response to the opioid overdose epidemic to train primary care
providers in the evidence-based prevention and treatment of opioid use disorders (OUD) and
treatment of chronic pain.
The project is geared toward primary care providers who wish to treat OUD. PCSS is made up of a
coalition, led by American Academy of Addiction Psychiatry (AAAP), of major healthcare
organizations all dedicated to addressing this healthcare crisis. Through a variety of trainings and
a clinical mentoring program, PCSS's mission is to increase healthcare providers' knowledge and
skills in the prevention, identification, and treatment of substance use disorders with a focus on
opioid use disorders.

111.

AMERICAN SOCIElY OF ADDICTION MEDICINE (ASAM)
The American Society of Addiction Medicine (ASAM) (https://www.asam.org/asam-home-page)
founded in 1954, is a professional medical society representing over 6,000 physicians, clinicians
and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing
access and improving the quality of addiction treatment, educating physicians and the public,
supporting research and prevention, and promoting the appropriate role of physicians in the care
of patients with addiction.

IV.

NATIONAL INSTITUTE ON DRUG ABUSE (NIDA)
The mission of the National Institute on Drug Abuse (NIDA) (https://www.drugabuse.gov/l is to
advance science on the causes and consequences of drug use and addiction and to apply that
knowledge to improve individual and public health. This involves:
•

•

Strategically supporting and conducting basic and clinical research on drug use (including
nicotine), its consequences, and the underlying neurobiological, behavioral, and social
mechanisms involved.
Ensuring the effective translation, implementation, and dissemination of scientific research
findings to improve the prevention and treatment of substance use disorders and enhance
public awareness of addiction as a brain disorder.

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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References
The following is a list of references consulted, reviewed and/or utilized in the development of this policy:
The American College of Obstetricians and Gynecologists (ACOG), Women's Health Care Physicians & The American Society of Addiction
Medicine (ASAM); AGOG Committee Opinion. Number 711, August 2017.
Substance Abuse and Mental Health Services Administration. Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP)
Series 63, Part 3. HHS Publication No. (SMA) 18-5063 Rockville, 2018.
Prescribing guidelines for Pennsylvania, Use of Addiction Treatment Medications in the Treatment of Pregnant Patients with Opioid Use
Disorder. The Commonwealth Pennsylvania 2016.
Center for Substance Abuse Treatment. Medication-Assisted Treatment tor Opioid Addiction in Opioid Treatment Programs. Treatment
Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 12-4214. Rockville, MD: Substance Abuse and Mental Health Services
Administration. 2005.

Peeler M, Fiscella K, Terplan M. Sufrin C. Best Practices for Pregnant Incarcerated Women with Opioid Use Disorder. J Correct Health Care.
2019;25(1):4-14. doi:10.1177/1078345818819855.
ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use; 2015.
Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use
Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016.
Substance Abuse and Mental Health Services Administration. Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use
Disorder and Their Infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration,
2018.Substance Abuse and Mental Health Services Administration (SAMHSA) by the Knowledge Application Program (KAP), a Joint Venture
of The COM Group, Inc., and JBS International, Inc., under contract number 270-04-7049, with SAMHSA, U.S. Department of Health and
Human Services (HHS). Christina Currier served as the Government Project Officer, 2014.

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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M-003A.01 Opioid Use Screening Form (SAMPLE)

Opioid Use Screening
Patient Name:

--------------

Date:

-------------

QUESTION

YES

1

Do you use opioids for larger amounts or over a longer period of time than intended?

2

Have you tried to cut down or control your opioid use?

3

Are you taking a lot of time finding opioids, using opioids, or recovering from opioids?

4

Do you have cravings or a strong desire to use opioids?

5

Have opioids interfered with your roles at work, school, or home?

6

Have you continued to use opioids despite people telling you that you need help?

7

Have you given up social, occupational or recreational activities due to opioids?

8

Have you continued to use opioids in situations where it is physically hazardous?

9

Do you continue using opioids despite knowing it is hurting you physically and mentally?

10

Have you noticed you needing more opioids to get the desired effect you want?

11

Have you gotten ill when trying to quit opioids or do you keep using to avoid withdrawal symptoms?

12

How many times have you been in treatment for opioid addiction?

13

Are you currently in an opioid treatment program?

NO

If Yes to 13 - Which one?

14

Are you currently on methadone under the supervision of a provider?

15

Are you currently on buprenorphine under the supervision of a provider?

This section is to be completed by staff.
Contact information of opioid treatment program:________________________

Was contact made with OTP?

--------------------------

Was methadone/or buprenorphine RX confirmation received from OTP?_ _ _ _ _ _ _ _ _ _ _ _ __

Signature:________________

Date:

Title: ____________

------------------

•each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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M-003A.02 Consent to Participate in Medication Assisted Treatment (MAT) (SAMPLE)

Consent to Participate in Medication Assisted Treatment (MAT)

D
D

Methadone
Pregnant

Patient's Name:

D
D

Buprenorphine Treatment
Not Pregnant

--------------

ID:_ _ _ _ _ _ _ _ _ _ __

I authorize and give voluntary consent to Wexford Health Sources Inc. to dispense and administer Medication Assisted Treatment
medications-including methadone or buprenorphine-to treat my opioid use disorder. Treatment procedures have been
explained to me, and I understand that I should take my medication at the scheduled time determined by the program physician,
or his/her designee, in accordance with federal and state regulations.
I understand that, like all other medications, methadone or buprenorphine can be harmful if not taken as prescribed. It has been
explained to me that I must follow the medication protocol of the program and safeguard these medications and not attempt to
"cheek" them nor share with anyone because they can be fatal to children and adults if taken without medical supervision. I also
understand that methadone and buprenorphine produce physical opioid dependence. Like all medications, they may have side
effects. Possible side effects, as well as alternative treatments and their risks and benefits, have been explained to me.
I understand that it is important for me to inform any medical provider who may treat me that I am currently in MAT. In this way,
the provider wrll be aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing
medications that might affect my treatment as well as my fetus.
I understand that I may withdraw voluntarily from this treatment program and discontinue the use of these medications at any
time. If I choose this option, I understand I will be offered medically supervised withdrawal as well as a need to sign a refusal of
treatment, and this may affect my unborn fetus and could possibly cause a miscarriage.
I understand that pregnant women treated with methadone or sublingual buprenorphine (SUBUTEX) have better outcomes than
pregnant women not in treatment who continue to use opioid drugs. Newborns of mothers who are receiving methadone or
buprenorphine treatment may have opioid withdrawal symptoms (i.e., neonatal abstinence syndrome}. The delivery hospital may
require babies who are exposed to opioids before birth to spend a number of days in the hospital for monitoring of withdrawal
symptoms. Some babies may also need medication to stop withdrawal.
If I am or become pregnant, I understand that I should tell the medical staff right away so that I can receive or be referred to
prenatal care. I understand that there are ways to maximize the healthy course of my pregnancy while I am taking methadone or
buprenorphine.

Patient Name (Print): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Patient Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Date: - - - - - - - Page 1 of 2

*Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
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M-003A.02 Consent to Participate In Medication Assisted Treatment (MAT) (SAMPLE)

Treatment Agreement
I agree to accept the followlng treatment contract for buprenorphine office-based opioid addiction treatment:
1. The risks and benefits of buprenorphine treatment have been explained to me.
2. The risks and benefits of other treatment for opioid use disorder (including methadone, naltrexone, and nonmedication
treatments) have been explained to me.
3. I will keep following my medication schedule that has been explained to me by the medical staff.
4. I will show up to medication time (as indicated by the facility) to receive my dosing on time as prescribed by the provider, and
I understand if I no-show to the medication time that I could possibly begin "withdrawal" which could be harmful to my baby.
5. Medication times:
6. I will take the medication exactly as my healthcare provider prescribes. If I want to change my medication dose,
I will speak with my healthcare provider first.
7. Taking the medication by snorting or by injection is also medication misuse and may result in supervised dosing at the clinic,
referral to a higher level of care, or change in medication based on my healthcare provider's evaluation.
8. If I am go·ng to have a medical procedure that will cause pain, I will let my healthcare provider know in advance so that my
pain will be adequately treated.
9. I understand that random urine drug testing is a treatment requirement. If I do not provide a urine sample, it will count as a
positive drug test.
10. I understand that people have died by mixing buprenorphine with alcohol and other drugs like benzodiazepines
(drugs like Valium, Klonopin, and Xanax).
11. I understand that treatment of opioid use disorder involves more than just taking medication. I agree to comply with my
healthcare provider's recommendations for additional counseling and/or for help with other problems.
12. I understand that I may experience opioid withdrawal symptoms when I stop taking buprenorphine.
13. I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting
buprenorphine treatment and been informed about methods for preventing pregnancy.

-----

Patient Name (Print): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Patient Signature: _________________

Date: - - - - - - - -

This form is adapted from the American Society of Addiction Medicine's Sample Treatment Agreement, which is updated
periodically; the most current version of the agreement is available online at: (https://www.asam.org/docs/defaultsource/advocacy/sample treatmentagreement30fa 159472bc604ca5b 7ff000030b21 a.pdf?sfvrsn}.
Page 2 of 2

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M-003A.03 Refusal to Participate In Medication Assisted Treatment (MAT) (SAMPLE)

Refusal to Participate in Medication Assisted Treatment (MAT}

D

Refusal of MAT Intervention

D

Pregnant

Patient's Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Patient ID:

------

I REFUSE TO give voluntary consent to Wexford Health Sources Inc. to dispense and administer Medication Assisted Treatment
medications-including methadone or buprenorphine- to treat my opioid use disorder. Treatment procedures have been
explained to me, and I understand that, should I REFUSE medication INTERVENTION WHILE PREGNANT, that this puts me at
risk for miscarriage.
I understand that, I CAN REVOKE THIS REFUSAL AT ANY TIME. If I decide to change my mind, I will immediately notify medical
personnel.
I understand I will be offered medically supervised withdrawal as well as a need to sign a refusal of treatment, and this may affect
my unborn fetus and could possibly cause a miscarriage.
I understand that pregnant women treated with methadone or sublingual buprenorphine (SUBUTEX) have better outcomes than
pregnant women not in treatment who continue to use op'oid drugs. Newborns of mothers who are receiving methadone or
buprenorphine treatment may have opioid withdrawal symptoms (i.e., neonatal abstinence syndrome). The delivery hospital may
require babies who are exposed to opioids before birth to spend a number of days in the hospital for monitoring of withdrawal
symptoms. Some babies may also need medication to stop withdrawal.

Signature of Patient: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date:

--------------------------------

Witness:· - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Name & Title (print):._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Witness: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Name & Title (print):._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Date: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

'Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

Medical Guidelines
Region: Jails

M-003A.04 DSM-5 Opioid Use Disorder (OUD) Diagnostic Criteria (SAMPLE)

DSM-5 Opioid Use Disorder {OUD) Diagnostic Criteria
Patient Name:

-------------------ID:----------

This form is to provide assistance as well as documentation to diagnose individuals with OUD. Reviewing the Opioid Use
Screening tool, the COWS, as well as discussing the individual's presentation with staff, should allow all providers to appropriately
diagnose individuals with an OUD to start MAT intervention or withdrawal management. Please refer to M-003 and M-003A for
additional guidance.
This tool is intended for guidance purposes only. Each provider has individual experience with OUD, and this tool is to assist when
certainty is questionable.
A problematic pattern of opioid use leading to clinically significant impairment or distress is manifested by at least two of the
following, occurring within a 12-month period:
1.
2.
3.
4.
5.
6.

Opioids are often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
A great deal of time is spent in activities necessary to obtain the opioid. use the opioid, or recover from its effects.
Craving, or a strong desire or urge to use opioids.
Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued opioid use despite having persistent or recurrent social or ·nterpersonal problems caused or exacerbated by the
effects of opioids.
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8. Recurrent opioid use in situations in which it is physical y hazardous.
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely
to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of the same amount of an opioid.
11. Withdrawal, as manifested by either of the following:
a. The characteristic opioid withdrawal syndrome.
b. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.
Note: The last two criteria are not considered to be met for those individuals taking opioids solely under appropriate medical
supervision.

Number of criteria:

0-1

2-3

4-5

6+__

Interpretation:

No CUD

Mild CUD

Moderate CUD

Severe CUD

Comments/TX plan: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Provider's Signature

Title

•Each stale/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

Date

Medical Guidelines
Region: Jails

M-OO3A.O5 Clinlcal Opioid Wlthdrawal Scale (COWS) (SAMPLE)

Clinical Opl• Wllhdrawal Scale (COWS)
Clinical O 1iatc \,Jithdrawal Scale (CO\'/S

For each Item, ci.rde !he rorwer !hat best desclibes the patienfs sign; or sy~cms. Raia on ,isl the relationsh~ lo opial e wilhdicWcil

For exari1!1e; l heart rate is increased because the patientwas io1111inq ~I prior lo assessment, the increase p!Ase rate would nd add
tothesan.

Patient's Name: _ _ _ _ _ _ _ _ _ _ _ __ Dateandlme:___J_______._ _ _ _ _ __
Reasonforthis assessment _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Reetlhg ~ •-~ : _ __..;beats/mnute
Measixed after patient IS sillirg 01 !jing for ens minute
0
puse rale 00 or below
1 puse rate 81 -100
2 pulse rate 101 - 120
4 puse rate grealerlhan 120

GI Upset: 0 ver last½ hoUI

Sweating: Or/erpas# ½./101.Jr mt accoonted for bv ~
~rl11e or patient a-;fNly
0
no report d ch~ls or flushilg

Tremor Observation of ool$f1elohg/ hards

1
2
3
4

subjective report ol chUls or flushing
flushed or obseiv able moistness on lace
beads of SV18al on brow or lace
sweal streamng_oft face

4

able to sit still

1

reports difficulty siting slll, but is able lo do so
frequent shifting or extraneous movements of legs/arm;
unable to sitsr I for more than a fewseconds

Pl,ipD !lilt
0 pupils pinned or normal si?e for room li!tit
1

5

pupils possib~ largerlhan normal for room light
pup11s moderatet, d~aled
pupils so dilated that on~ the rrn of the 1rs s vsible

Bane-or Jo.hi aches JI paliml W8$ hamg pein p,evoost a,/y th:i
8liJilia:)a1 CO(TW~ tifriblied to cpli9S withdrawal is sco,ed
0 not present
1

mid diffuse discomfort
2 patient reports severe dilluse aching of jointsJmus cles
4 patient s n.i>bing joints or rm£ cles and is unable to sit stil
because ot discomfort
Runny nose or.tearing Not acoounled for by cold symfioms or

aletges
0
1

2
4

'

not present
nasal stuffiness or unusuallf moist 8'jes
nose ruming ortearirg
nose constanttv runnin Cl or tears slreamina down cheeks

SCORE:6 •12 = mid; 13 -14 =moderate; 25 -3&

no GI symptom,
stomach cramps
nausea or loose stool
vomiting or diarrhea
rrulliple episodes of diarrhea orvomiting

no tremor
tremor can be tell, but not obseived
slight tremor obseivable
gross tremor or rruscle twtching

Yawn Ina Obs81Variai .durr,g assessment

0

2

0
2

RestltHntsa: ()~sf611~ d.mng &sessmert

3
5

0
1
2
3
5

0
1
2

no yav.ning
yawning once or twee during assessment
yawnmg three or more times during assessrrent
4 yawning several timesJminute
Anxiety or in-labDlty
0 none
patient reports increasing irritability or anx10usness
2 patient obviously irritable I anxious
4
patient so irntable or anxious that partie1pabon m
assessment s difficaJt

Gooseflesh sh.,
0
3
5

skin is smooth
piloereclion of ski1 can be felt or hairs standing up on arm;
prominert pfaereclion

Total Score: _ _ _ _ _ _ __
The total score ,s the sum cl all 11 items

Initials af person omnplellngassessment: _ _ _ __

=moderately severe; more than 38 =se.r ere withdrawal

Srurce: Weffl>n and Ung 2003
Rev.6l17/2020WeXlord Healh SOlJ'Ces, ric. PROPRIETARY and CONFIDENTIAL

M-003A.05

*Each slate/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sources Inc., PROPRIETARY and CONFIDENTIAL

Medical Guidelines
Region: Jails

M-004: Primary Care Guldellnes
Reference:

I.

ACA: 5-ACl-6D-10; NCCHC: A-05

GUIDELINE
Wexford Health's primary care guidelines are intended to assist the health care staff in clinical
decision-making by describing a range of generally acceptable approaches for the diagnosis and
management of specific diseases or conditions. Although these guidelines are based on evidencebased research, they should not preclude the use of other methods directed at obtaining the same
results.

II.

PROCEDURE
A.

The guidelines are continually updated and reviewed by the Medical Advisory Committee for
their suitability to the inmate health care setting.

B.

The guidelines do not supersede established state/county guidelines and/or facility
contractual obligations nor are they mandated for sites which have limited facility equipment
and resources.

C.

All medical decisions regarding the care of inmates should be made with consideration given
to the individual circumstances presented by the patient.

•Each state/region may have individual variances, and a copy of those variances should be attached to this guideline.
Rev. 2/1/2021 Wexford Health Sourc:es Inc., PROPRIETARY and CONFIDENTIAL