Opioid Treatment in a Corrections Setting

One Community’s Response

Presented by:Babette Hankey

Chief Operating OfficerThe Center For Drug-Free Living, Inc.

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

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?

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?

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

Overview of Jail Substance Abuse Treatment

Orange County Jail Oversight Commission;Mental Health Substance Abuse and MedicalCommittee, 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

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)

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)

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

Type of Treatment Services Available in Jails

Drug education (43%)

Drug testing (42%)

Detoxification (28%)

Family counseling (19%)

Bureau of Justice Statistics, 2000

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)

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)

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)

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

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

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)

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)

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

Features of Jail Substance Abuse Treatment Programs

Therapeutic communities

Isolated treatment units

Assessment

Program phases

Phases of Jail Substance Abuse Treatment Programs

I. Assessment, intake, orientation, motivational enhancement, and medical detoxification

II. Skill-building, psychoeducational activities, 12-step groups

III. Relapse prevention, transition planning, and community linkage

Features of Jail Substance Abuse Treatment Programs

Restructuring ‘criminal thinking errors’

Specialized mental health services

Transition and re-entry services

Community Linkage and Re-entry Services

Re-entry planning

Linkage with community services

Case management and use of “boundary spanners”

Post-booking diversion programs

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

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

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

Treatment of Co-occurring Disorders in Custody Settings

Highly structured therapeutic approach

Destigmatize mental illness

Focus on symptom management vs. cure

Treatment of Co-occurring Disorders in Custody Settings

Education regarding individual diagnoses and interactive effects of disorders

Basic life management and problem-solving skills

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

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

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

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

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

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

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)

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

Objective

To develop specific policies and procedures for dosing

methadone patients who are incarcerated

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

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

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

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

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

Option 1

A. Jail transports to the clinic

B. Clinic doses at the jail

C. Clinic sends medication to the jail and the jail doses

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

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

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

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

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

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

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

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

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

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

Other Options

Privatize transportation

Jail picks up Methadone

High risk vs. Low risk inmates

Thank You.

OVERVIEW

Profile of Orange County Jail

Historical perspective

Findings

Solutions Presented By:George Ellis

Medical DirectorHealth & Family Services Dept.

Health Services Division

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

Historical Perspective

Challenges 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

Historical Perspective

As a result of tragic events, Orange County Government commissioned:

1) Jail Oversight Commission

2) Change in Leadership and Health Management

Historical Perspective

Health and Family Services Department

Assumes management October 2001

Integrated with Corrections Department

Assessment of Mental Health Services

Lacked: medical/mental health integration

consistent peer review

multidisciplinary case conferences

mental health data

Historical Perspective

Historical Perspective

Changes and Challenges

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

ASSESSMENT OF RECOMMENDATIONS (JOC)

12

40

82

63

14 Public Policy

CriminalJustice

Corrections

Health Services

HFS

211 Recommendations

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

Historical Perspective

HEALTH SERVICES HIGHLIGHTS

•Care

• Community Standard of Care

• Methadone Protocol: cooperative agreement with CFDFL

Thank you.

TREATMENT OF OPIATE DEPENDENCE

IN ORANGE COUNTY CORRECTIONS

Where we have been…….

Where we are going…….

Presented by : Stacy Seikel, MDMedical Director

The Center For Drug-Free Living

TOPICS

Use of methadone in Orange County Corrections

Proposed use of buprenorphine

Future projects

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

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 County’s 3 methadone clinics

METHADONE PROGRAM IN ORANGE COUNTY CORRECTIONS (Con’t.)

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

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

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

ADVANTAGE OF BUPRENORPHINE VS. CLONIDINE

Buprenorphine dosed 1-2 times per day vs. clonidine dosed every 1-2 hours

Less ancillary meds with buprenorphine

BUPRENORPHINE PROGRAM

Focus on Care, Custody and Control

Provide safe humane care for acute opiate withdrawal symptoms (OWS)

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

BUPRENORPHINE PROGRAM

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

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

THANK YOU.

Implementationand

Daily Operations

Presented by:Jina ThalmannDirector of Methadone ProgramThe Center For Drug-Free Living

Presented by:Jina Thalmann

Program Director Opioid Dependency Treatment Program

The Center For Drug-Free Living

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

Challenges to Implementation

Interim Plan-corrections transports inmates to local clinics

Permanent Plan – local clinics transports medication and doses inmates in jail

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

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

Staffing Pattern

Portion of Program Director’s time Part time administrative assistant Part time driver to accompany nurse Part time nursing staff Dosing 365 days/year

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)

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

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)

Solution Focused Approach

Relationship with corrections staff

Relationship with SMA

Relationship with DEA

Thank you.