Opioid Treatment in a Corrections Setting One Communitys Response

1
Opioid Treatment in a Corrections SettingOne
Communitys Response

• Presented by
• Babette Hankey
• Chief Operating Officer
• The Center For Drug-Free Living, Inc.

2
Background

• Chairmans 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 ratios
• 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 gt 1,000 inmates
• 34 of jails lt 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 cant 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 TCs 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
Option 1

• 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

44
Option 1

• 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

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
  jails nursing staff would dose clients what is
  the liability of the jails 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 jails medical
  director
• Methadone could be in liquid or in diskette form
  and would be administered in individual doses
  daily by jail nursing staff

47
Option 2

• 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

48
Option 2 (continued)

• 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

49
Option 2 Questions

• Responsibilities of the jails physician and the
  clinics physician and the responsibilities of
  jails nursing staff and clinics 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 jails 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

51
Option 3

• PROS
• Foundation for a stronger long-term solution
• Supports non-clinic based patients

• CONS
• Cost barriers for jail
• County carries liability risk
• Increase in specialized staffing
• Cost of meeting regulatory requirements
• Not cost effective based on limited number of
  inmates
• Lengthy startup time (18 months)
• Recurring costs and new costs to maintain
  regulatory requirements
• Complete comprehensive treatment center to
  include ancillary services
• Most costly option
• Toughest to implement

52
Option 3 Questions

• Communication between jail and providers for
  continuity of care
• Does the community want the jail to become a
  treatment center
• Sets the precedent for the jail becoming all
  things to all people
• Need increased community involvement and
  partnerships to divert clients from jail
• Does not deter people from entering the jail
  system to receive free services, i.e. Methadone

53
Other Options

• Privatize transportation
• Jail picks up Methadone
• High risk vs. Low risk inmates

54
Thank You.
55
OVERVIEW

• Profile of Orange County Jail
• Historical perspective
• Findings
• Solutions

Presented By George Ellis Medical
Director Health Family Services Dept. Health
Services Division
56
Orange County Corrections Department

• Orange County 1
  million citizens
• 14th Largest jail
• Average daily census 3600 inmates. Total annual
  bookings 56,000
• 7 Medical Clinics

57
Historical PerspectiveChallenges of Orange
County Corrections

• PRISONER DIED AS NURSES SAT BY FOR 12 DAYS, SHE
  DIDN'T EAT. SHE VOMITED UNCONTROLLABLY. STAFFERS
  AT THE ORANGE COUNTY JAIL DID LITTLE TO HELP
  HER. Orlando Sentinel. Orlando, Fla. Mar 22,
  1998.
• INMATES HELP FOR WOMAN TOO LATE. CELLMATES
  TOLD OF EVENTS AT THE ORANGE COUNTY JAIL THAT
  ENDED IN HER DEATH JUNE 7. Orlando
  Sentinel. Orlando, Fla. Jul 8, 2001

58
Historical Perspective

• As a result of tragic events, Orange County
  Government commissioned
• 1) Jail Oversight Commission
• 2) Change in Leadership and Health Management

59
Historical Perspective

• Health and Family Services Department
• Assumes management October 2001
• Integrated with Corrections Department
• Assessment of Mental Health Services

60
Historical Perspective

• Lacked
• medical/mental health integration
• consistent peer review
• multidisciplinary case conferences
• mental health data

61
Historical Perspective

• Changes and Challenges
• Jail Oversight Commission
• System Began to Change
• Study of Jail and Criminal Justice System
• Impacts on the Jail

62
ASSESSMENT OF RECOMMENDATIONS (JOC)
211 Recommendations
63

Historical Perspective

• SOLUTIONS
• Hired 2 FT MDs and a FT psychiatrist ( ARNPs)
• Integrated medical and mental health
• Created specialized acute medical/mental health
  unit
• Developed a mental health staffing model

64
HEALTH SERVICES HIGHLIGHTS

• Care
• Community Standard of Care
• Methadone Protocol cooperative agreement with
  CFDFL

65
Thank you.
66
TREATMENT OF OPIATE DEPENDENCE IN ORANGE COUNTY
CORRECTIONS

• Where we have been.
• Where we are going.

Presented by Stacy Seikel, MD Medical
Director The Center For Drug-Free Living
67
TOPICS

• Use of methadone in Orange County Corrections
• Proposed use of buprenorphine
• Future projects

68
PREVELENCE OF OPIATE DEPENDENT INMATES IN
ORANGE COUNTY CORRECTIONS

• In 2003, 250 inmates received methadone treatment
• Approximately 300 per year receive treatment for
  opiate withdrawal symptoms

69
METHADONE PROGRAM INORANGE COUNTY CORRECTIONS

• 2 deaths in jail - costing millions
• The Center For Drug-Free Living and Orange County
  Corrections collaboration
• The Center For Drug-Free Living provides
  methadone for inmates registered in any of Orange
  Countys 3 methadone clinics

70
METHADONE PROGRAM IN ORANGE COUNTY CORRECTIONS
(Cont.)

• Nurse from The Center For Drug-Free Living
  transports methadone to the jail and administers
  methadone

71
INMATES WITHDRAWING FROM OPIATES WHO ARE NOT
REGISTERED IN A METHADONE CLINIC (20-30 PER MONTH)

• Currently treated with clonidine
• If symptoms unrelieved with clonidine, patients
  may require hospitalization
• Currently considering the use of buprenorphine

72
BUPRENORPHINE VS. CLONIDINEFOR TREATMENT OF
OPIATE WITHDRAWAL

• Extensively studied by CTN
• Buprenorphine clearly superior in the relief of
  withdrawal symptoms
• Clonidine causes low blood pressure and sedation
• Clonidine does not relieve muscle aches, insomnia
  or drug cravings

73
ADVANTAGE OF BUPRENORPHINE VS. CLONIDINE

• Buprenorphine dosed 1-2 times per day vs.
  clonidine dosed every 1-2 hours
• Less ancillary meds with buprenorphine

74
BUPRENORPHINE PROGRAM

• Focus on Care, Custody and Control
• Provide safe humane care for acute opiate
  withdrawal symptoms (OWS)

75
BUPRENORPHINE PROGRAM

• Decrease problem behaviors (disciplinary reports,
  etc.)
• Decrease hospital expense for management of
  withdrawal
• Decrease use of medical resources, sick call,
  for management of OWS

76
BUPRENORPHINE PROGRAM

• Evaluate
• Use of ancillary meds
• Number of hospital transfers
• Staff acceptance
• Patient acceptance

77
GOALS. . .

• Immediate
• Start using buprenorphine for treatment of opiate
  withdrawal
• Long Term
• Linkage to outpatient treatment
• Track recidivism
• Possibly add low dose of buprenorphine prior to
  release

78

• THANK YOU.

79

• Implementation
• and
• Daily Operations

Presented by Jina Thalmann Program Director
Opioid Dependency Treatment Program The Center
For Drug-Free Living
Presented by Jina Thalmann Director of Methadone
Program The Center For Drug-Free Living
80
Previous History with Dosing Inmates

• No formal agreement with county jail
• Liability for staff transporting methadone
• Lengthy wait times (sometimes 4 hours) to dose
  inmates
• Cost of overtime to program
• Nurse perception of harassment by corrections
  officers
• Stopped dosing inmates in jail in 1999

81
Challenges to Implementation

• Interim Plan-corrections transports inmates to
  local clinics
• Permanent Plan local clinics transports
  medication and doses inmates in jail

82
Interim Plan

• Staff attitude-both in clinics corrections
• Security of clinics
• Impact on clinic atmosphere
• Disruption in operations-both in clinics and
  corrections
• Coordination
• Very costly to corrections

83
Permanent Plan

• Support of SMA
• Support of DEA
• Formal agreement between Orange County and The
  Center For Drug-Free Living
• Staff attitude-both in clinics and corrections
• Recruitment of nursing staff

84
Staffing Pattern

• Portion of Program Directors time
• Part time administrative assistant
• Part time driver to accompany nurse
• Part time nursing staff
• Dosing 365 days/year

85
Costs

• Initial contract was per dose rate of 24.00
• Current contract is per day rate of 211.65
• Jail does on site panel urine drug test upon
  arrest (8/per test)

86
Process

• Client arrested
• Identifies self as client of local clinic
• Consent signed and fax to The Center
• The Center sends fax to home clinic requesting
  records
• Nurse calls medical provider for dosing orders
• Medication transported to jail

87
Unanticipated Challenges

• Slow response from some clinics
• Lack of dependability of some nursing staff
• Scheduled dosing times interrupt some corrections
  functions (i.e. court, meals)

88
Solution Focused Approach

• Relationship with corrections staff
• Relationship with SMA
• Relationship with DEA

89

• Thank you.