Opioid Treatment in a Corrections Setting One Community’s Response

1. Opioid Treatment in a Corrections SettingOne Community’s Response Presented by: Babette Hankey Chief Operating Officer The Center For Drug-Free Living, Inc.

2. Background • Chairman’s Jail Oversight Commission • 2001 • Response to jail deaths • Review jail related programs/policies • Several Task Force • SA/MH/Medicaid • Personnel/hr. • Operations • Policy/procedure • Purpose to improve jail services and related programs for those with behavioral health issues

3. Mental Health Questions • What level of mental health services should be provided at the jail? • How should mental health services be provided? • What medications are dispensed? • What policy exists, if any, for forcing an inmate to take medication? • What alternative facilities for mental health treatment are there which could be operated by providers?

4. Substance Abuse Questions • Should the jail be a “defacto” detoxification center and how should violent inmates with substance abuse problems be detoxed? • How should nonviolent and violent inmates with substance abuse issues be treated as opposed to other inmates? • What is the cost of and funding source for inmates with substance abuse problems?

5. Medical Questions • What is the appropriate level of healthcare provided to inmates? • What relationship exists with Health Dept. for controlling infectious diseases? • Adequate on site staff/staffing ratio’s • Relationship between medical and management • Role and training to Correction Officers • Will formulary meet pharmaceutical needs • Internal vs. privatizing medical services

6. Overview of Jail Substance Abuse Treatment Orange County Jail Oversight Commission; Mental Health Substance Abuse and Medical Committee, November 15, 2001, Orlando, Florida Presentation by Roger Peters, Ph.D., University of South Florida, Louis De Parte Florida Mental Health Institute, Department of Mental Health Law and Policy

7. Scope of Substance Abuse Treatment in Jails • 25% of inmates ever received substance abuse treatment in custody settings • 4% received substance abuse treatment during current stay in jail • 1.4% received counseling services during current stay in jail (Bureau of Justice Statistics, 2000)

8. Scope of Substance Abuse Treatment in Jails • 43% of jails report substance abuse treatment programs • 74% of jails > 1,000 inmates • 34% of jails < 50 inmates • 64% of jails report self-help programs • Only 12% provide combination of SA treatment, self-help, and drug education (Bureau of Justice Statistics, 2000)

9. Type of Treatment Services Available in Jails • Individual counseling (77%) • Group counseling (64%) • Assessment (64%) • Self-help groups (AA/NA; 60%) Bureau of Justice Statistics, 2000

10. Type of Treatment Services Available in Jails • Drug education (43%) • Drug testing (42%) • Detoxification (28%) • Family counseling (19%) Bureau of Justice Statistics, 2000

11. Treatment Services Available in Metropolitan Jails • HIV education/prevention (100%) • Individual counseling )100%) • Relapse prevention services (100%) • Education/GED (94%) • Parenting skills (94%) • 12-step groups (94%) (Peters & Matthews, in press)

12. Treatment Services Available in Metropolitan Jails • Modifying criminal thinking (82%) • Domestic violence treatment (77%) • Vocational/job training (65%) • Dual diagnosis treatment (47%) (Peters & Matthews, in press)

13. Treatment Services Available in Metropolitan Jails • Acupuncture (18%) • Anger Management (18%) • Medically supervised detoxification (18%) • Family therapy (12%) • Sexual trauma treatment (12%) (Peters & Matthews, in press)

14. Legal Standards for Substance Abuse Treatment in Jails • No constitutional right to substance abuse treatment (Marshall v. U.S., 1974) • “Deliberate indifference” to serious medical needs is exception • Withdrawal or other life-threatening symptoms • Screening • Detox: critical issue

15. Legal Standards for Substance Abuse Treatment in Jails • Continuation on methadone is not required • AA/NA groups can’t be required as condition of favorable classification, release, or institutional privileges

16. Outcomes of Jail Substance Abuse Treatment • Lower rates of follow-up arrest vs. untreated comparisons and program dropouts (5-25% difference) • Longer duration to re-arrest, fewer arrests during follow-up • Reduced rates of relapse, lower levels of depression, fewer disciplinary infractions • Cost savings: $150k - $1.4 million per year (Peters & Matthews, in press)

17. Effects of Duration of Jail Treatment • Recidivism rates in TC’s inversely related to duration of treatment, up to a point • Optimal duration of TC treatment is 46-150 days • Some positive effects from short-term programs of moderate-high intensity (Peters & Matthew, in press)

18. Outcomes of Post-Custody Treatment Services • Aftercare recipients have 50% lower rates of follow-up arrest vs. non-recipients • Linkage with either residential or outpatient treatment leads to lower rates of follow-up arrest • Half of in-jail treatment participants are involved in follow-up treatment, vs. 6% of untreated inmates (Peters & Matthews, in press

19. Features of Jail Substance Abuse Treatment Programs • Therapeutic communities • Isolated treatment units • Assessment • Program phases

20. Phases of Jail Substance Abuse Treatment Programs • Assessment, intake, orientation, motivational enhancement, and medical detoxification • Skill-building, psychoeducational activities, 12-step groups • Relapse prevention, transition planning, and community linkage

21. Features of Jail Substance Abuse Treatment Programs • Restructuring ‘criminal thinking errors’ • Specialized mental health services • Transition and re-entry services

22. Community Linkage and Re-entry Services • Re-entry planning • Linkage with community services • Case management and use of “boundary spanners” • Post-booking diversion programs

23. Characteristics of Co-occurring Disorders (General) • Repeatedly cycle through treatment, probation, jail, and prison • More likely to re-offend or to receive sanctions when: Not taking medication, not in treatment, experiencing mental health symptoms, using alcohol or drugs • Use of even small amounts of alcohol or drugs may trigger recurrence of mental health symptoms

24. Characteristics of Co-occurring Disorders (Treatment-related) • More rapid progression from initial use to substance dependence • Poor adherence to medication • Decreased likelihood of treatment completion • Greater rates of hospitalization • More frequent suicidal behavior • Difficulties in social functioning • Shorter time in remission of symptoms

25. Characteristics of Co-occurring Disorders (Behavioral) • Difficulty comprehending or remembering important information (e.g., verbal memory) • Not recognize consequences of behavior (e.g., planning abilities) • Poor judgment • Disorganization • Limited attention span • Not respond well to confrontation

26. Treatment of Co-occurring Disorders in Custody Settings • Highly structured therapeutic approach • Destigmatize mental illness • Focus on symptom management vs. cure

27. Treatment of Co-occurring Disorders in Custody Settings • Education regarding individual diagnoses and interactive effects of disorders • Basic life management and problem-solving skills

28. Modifications to Treatment for Co-occurring Disorders • At least one year of treatment provided, with potential for ongoing treatment participation • More extensive assessment provided • Greater emphasis on psychoeducational and supportive approaches • Movement through program and tasks is more individualized

29. Modifications to Treatment for Co-occurring Disorders • Rewards delivered more frequently • Treatment groups and other activities are of shorter duration • More overlap in activities, pace of treatment activities is slower • Information provided gradually, and with significant repetition

30. Modifications to Treatment forCo-occurring Disorders • More individual counseling is provided • Deemphasize confrontative approach • Higher staff-to-client ratio, more mental health staff involved in treatment groups • More staff monitoring and coordination of treatment activities • Cross-training of all staff

31. Group Treatment Manual for Co-occurring Disorders • Adapted from Dartmouth/NH Psychiatric Research Center family educational handouts • Manualized group treatment approach, includes 8 sessions • Developed and refined through consensus process • Implemented in jail treatment and other community-based offender treatment settings

32. Group Treatment Manual for Co-occurring Disorders • Theme running throughout is that mental and substance use disorders are interactive and affect each other • Manual designed for implementation within substance abuse treatment settings • Focus on most severe Axis I mental disorders commonly found among offenders with co-occurring disorders: • Major Depression • Bipolar Disorder • Schizophrenia/Schizoaffective Disorder

33. Group Treatment Manual for Co-occurring Disorders • Module 1: Connection Between Substance Use and Mental Health Disorders • Module 2: What is Major Depression? • Module 3: What is Bipolar Disorder? • Module 4: What are Anxiety Disorders? • Module 5: What are Schizophrenia and Schizoaffective Disorder? • Module 6: Substance use: Motives and Consequences • Module 7: Principles of Integrated Treatment • Module 8: Relapse Prevention

34. Group Treatment Manual for Co-occurring Disorders • Overview • Symptoms • Connection between mental disorder and substance abuse • Case Story • Self-assessment exercise • Treatment approaches (medication, phychotherapy, support groups)

35. Value of OTP • Medical response to a medical problem • Reduces high-risk behavior by providing services in a controlled clinical and medical environment • Increases opportunity for healthier socio-economic climate for addict and community • Reduces the need to rely on public assistance

36. Objective To develop specific policies and procedures for dosing methadone patients who are incarcerated

37. Accomplish By: • Establishing the scope of the objective (e.g., identify target group, affected agencies, etc.) • Consulting with Federal and State authorities regarding options and associated requirements • Consulting with OTP providers regarding treatment issues and provider involvement

38. Accomplish By: • Consulting with officials at the local and county level regarding implementation issues and liability issues • Discussing known options and developing pros and cons to each option as follows: • Potential liabilities • Potential resources • Ability to operationalize • Applicable regulations to be followed

39. Accomplish By: • Identifying the most workable option • Establishing a local work group to begin drafting policies and procedures and local cooperative agreements where appropriate or required

40. Questions • How do we think this option would work if actually implemented (NOTE: Ease of implementation may not be a good criteria for selecting the best option)? • Based on how we think this option would work, could it operationalize successfully and continue so within the context of necessary policies and procedures? • What current and additional resources would be needed to implement this option within the context of • “How it would work” • Prospect of operational success • Can this option work within the context of current state and federal regulatory requirements and local codes and policies? • Cite the potential pros and cons of adopting this option within the context of 1-4 above

41. Option 1 • Certified Methadone Clinic can deliver a one week supply of Methadone to the jail for each inmate, or inmates may be transported to the clinic • Methadone administered by the nurse in individual doses daily

42. Option 1 • Jail transports to the clinic • Clinic doses at the jail • Clinic sends medication to the jail and the jail doses

43. PROS 1A/B/C. Continuity of Care optimized 1A/B/C. Harm reduction to inmate/patient 1A/B/C. Reduces the level of physical discomfort for those incarcerated 1A/B/C. Sets a state or national precedent for replication (Outcome) 1A/B/C. Response to a current public image problem requiring a solution CONS 1A. Security risks in transporting inmates 1A/B/C. Costs – personnel, transportation and supplies 1B/C. Transporting methadone by clinic nursing staff 1B/C. Additional charting responsibilities Option 1

44. PROS 1A/B/C. Potential for conformity with state and federal regulations 1A/B/C. When compared with other options, Option 1 easier to implement in short-term 1B. Prior experience – 1988-2000 1A. Current practice – Interim process CONS 1A. Security risks in transporting inmates 1A/B/C. Costs – personnel and transportation Option 1

45. Option 1 Questions • 1B/C – Clarification of physician (jail and clinic) responsibility • Criteria physicians have to follow under the F1. Administrative Codes • Professional opinions of efficacy of illicit drug maintenance therapy maintenance vs. detox • Treatment restricted to clinic clients • Length of time providers would provide methadone maintenance • Transporting of methadone to the jail and the jail’s nursing staff would dose clients – what is the liability of the jail’s nurses accepting methadone from a clinic nurse and would their license allow • Additional charting responsibility

46. Option 2 • A certified Methadone clinic could apply to the DEA and to CSAT to operate a medication unit in the jail • The jail would operate as an NTP under the parent clinic • The jail could order the Methadone from a wholesaler under the order of the jail’s medical director • Methadone could be in liquid or in diskette form and would be administered in individual doses daily by jail nursing staff

47. PROS Internal medical expertise by parent clinic Reduce risk management issues if administered in jail Reduced costs (transportation, staffing, liability) if administered in jail Quick response time and service Continuity of Care Reducing level of physical discomfort Improves ability to observe/evaluate clients CONS Not cost effective for the number of patients served in the short-term Clarification of complex procedural issues relative to Option 2 Cost associated with additional staff training Option 2

48. PROS Establishes a program in the jail for potential expansion into intervention Foundation for a stronger long-term solution Supports current addiction programs offered in jail – medication support CONS Option 2 (continued)

49. Option 2 Questions • Responsibilities of the jail’s physician and the clinic’s physician and the responsibilities of jail’s nursing staff and clinic’s nursing staff • Training issues at the jail for methadone distribution – specialized training • Potential conflict between medication treatment vs. drug free environment

50. Option 3 • The jail could receive the appropriate DEA registration as an NTP • In this case, it must also receive approval from CSAT through some exemption • The jail’s medical director could order Methadone directly from a wholesaler in liquid or diskette form • The Methadone would be administered in individual doses daily by jail nursing staff