Rx16 treat tues_200_1_jarvis_2fiscella_3balonick

Best Practices in TreatingOpioid Addiction in the

Criminal Justice PopulationPresenters:

• Margaret Jarvis, MD, Medical Director, Marworth, Geisinger Health System

• Kevin Fiscella, MD, MPH, Professor of Family Medicine and Public Health Sciences, University of Rochester Medical Center

• Leslie Balonick, MA, CRADC, Vice President, WestCare Foundation, Inc.

Treatment Track

Moderator: Michael C. Barnes, JD, Executive Director, Center for Lawful Access and Abuse Deterrence, and Member, Rx and Heroin Summit National Advisory Board

Disclosures

• Leslie Balonick, MA, CRADC; Kevin Fiscella, MD, MPH; and Michael C. Barnes, JD, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

• Margaret Jarvis, MD – Royalty: Jarvis; Ownership interest: US Preventive Medicine

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– John J. Dreyzehner, MD, MPH, FACOEM – Ownership interest:

Starfish Health (spouse)– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center

Learning Objectives

1. Outline the challenges faced in treating opioid addiction in the criminal justice population.

2. Identify best practices in using medication-assisted treatment (MAT) for opioid addiction in the criminal justice system.

3. Describe best practices in evidence-based behavioral therapy in the criminal justice population.

4. Provide accurate and appropriate counsel as part of the treatment team.

The ASAM National Practice Guideline

For the Use of Medications in the Treatment of Addiction Involving

Opioid Use

What?

The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use

AKA: the ASAM National Practice Guideline1st to include all FDA-approved medications in a single document

Why?

How?Developed using RAND/UCLA Appropriateness Method (RAM)• Consensus process combining scientific

evidence with clinical knowledge• Review of existing guideline and

literature• Appropriateness ratings• Necessity ratings• Document development

Who?• American Society of Addiction Medicine

(ASAM)• Treatment Research Institute (TRI)• Guideline Committee: addiction medicine;

psychiatry, obstetrics/gynecology; and internal medicine

Guideline Committee MembersSandra Comer, PhDChinazo Cunningham, MD, MSMarc J. Fishman, MD, FASAMAdam Gordon, MD, MPH, FASAMKyle Kampman, MD, ChairDaniel Lengleben, MDBen Nordstrom, MD, PhDDavid Oslin, MDGeorge Woody, MDTricia Wright, MD, MSStephen Wyatt, DO

Quality Improvement CouncilJohn Femino, MD, FASAMMargaret Jarvis, MD, FASAM, ChairMargaret Kotz, DO, FASAMSandrine Pirard, MD, MPH, PhDRobert J. Roose, MD, MPHAlexis Geier-Horan, ASAM StaffBeth Haynes, ASAM StaffPenny S. Mills, MBA, ASAM Executive VPExternal Reviewer:Michael M. Miller, MD, FASAM, FAPA

Treatment Research Institute Technical Team Members

Amanda Abraham, PhDKaren Dugosh, PhDDavid Festinger, PhDKyle Kampman, MD, Principal InvestigatorKeli McLoyd, JDBrittany Seymour, BAAbigail Woodworth, MS

Definitions

• Opioid Use Disorder (OUD) is a chronic, relapsing disease defined in the DSM-5

• Bio-psycho-social-spiritual illness• Addiction involving opioid use

All abbreviations and acronyms available in the ASAM National Practice Guideline

Premise

• FDA-approved medications to treat OUD are clinical and cost-effective interventions– Saves lives, saves money– One component, along with psychosocial treatment

• 30% of treatment programs offer medication• Less than half of eligible treatment program

patients receive medications• Missed opportunity to utilize most effective

treatments

Assessment

Diagnosis

Treatment

Special Populations

In Criminal Justice System

• Pharmacotherapy effective regardless of length of sentenced term

• Should get some type of pharmacotherapy and psychosocial treatment

• Opioid agonists and antagonists may be considered for treatment

• Pharmacotherapy initiated minimum 30 days prior to release

How to Get More Information

Treating Opioid Addiction in the Criminal Justice Population:

Evidence from the ASAM Practice Guideline

Kevin Fiscella, MD, MPHProfessor, Family Medicine,

Public Health Sciences, Community HealthUniversity of Rochester School of Medicine & Dentistry

Objectives

• Background• Pharmacotherapeutic options • Legal options for implementing medication-

assisted treatment (MAT) in corrections• Implications of The ASAM National Practice

Guideline• Bibliography

Background

Background

• Few jails or prisons use MAT.

Background


• Few jails or prisons refer inmates to MAT programs upon release.

Background


• Few jails or prisons refer inmates to MAT programs upon release.

• Very few jails or prisons operate opioid treatment programs (OTPs).

ASAM National Practice Guideline:

Best practices

• Universal screening on admission to jail or prison


Best practices


• Comprehensive assessment of those screening positive


Best practices



• Continuation of MAT


Best practices



• Continuation of MAT• Initiation of MAT for those not in treatment 30

days prior to release


Best practices



• Continuation of MAT• Initiation of MAT for those not in treatment• Appropriate monitoring and treatment of

withdrawal


Best practices



• Continuation of MAT• Initiation of MAT for those not in treatment• Appropriate monitoring and treatment of

withdrawal • Pre-release coordination of care


Best practices

Pharmacotherapy

Pharmacotherapy

• Methadone

Pharmacotherapy

• Methadone• Buprenorphine/naloxone

Pharmacotherapy

• Methadone• Buprenorphine/naloxone• Clonidine (not FDA approved)

Pharmacotherapy

• Methadone• Buprenorphine/naloxone• Clonidine• Naltrexone

Pharmacotherapy

• Methadone• Buprenorphine/naloxone• Clonidine• Naltrexone• Naloxone

MethadoneAdvantages DisadvantagesStrong evidence for efficacy and effectiveness

Requires OTP license

50 year+ track record QT effects FDA approved Risk for diversionMaintenance & taper Overdose/death riskInexpensiveUsed in pregnancyLiquid formulation

Buprenorphine/NaloxoneAdvantages DisadvantagesStrong evidence for efficacy and effectiveness

Requires physician license (Data 2000 waiver)

20 year+ track record Risk for diversionFDA approved More expensive than

methadone Maintenance & taperUse in pregnancy (monoproduct)Low risk for death from overdose*

ClonidineAdvantages DisadvantagesEvidence for efficacy and effectiveness for withdrawal use

Less effective than buprenorphine for withdrawal

Inexpensive Not FDA approvedLow diversion risk Requires close

monitoring of vital signs Hypotension combined with dehydration is hazardous

NaltrexoneAdvantages DisadvantagesEvidence for efficacy Effectiveness unknown FDA approved Requires opioid withdrawal Little risk for diversion Less incentive to engage in

treatment post-releasePotential portal to being drug free

Risk for overdose when stoppedExpensive

NaloxoneAdvantages DisadvantagesLife saving Induces abrupt

withdrawal Widely used by first respondersCan be prescribed to at-risk inmates upon release

MAT Options for Jails and Prisons

MAT Options for Jails and Prisons1. Transport inmates to community opioid

treatment programs (OTPs).


treatment programs (OTPs).2. Invite community OTPs into the facility.


treatment programs (OTPs).2. Invite community OTPs into the facility.3. Facilities can obtain state and DEA licenses as

clinics or hospitals permitting use of methadone as “incidental adjunct to medical or surgical treatment.”




4. Correctional physicians can obtain licenses to prescribe buprenorphine.




4. Correctional physicians can obtain licenses to prescribe buprenorphine.

5. Facilities can obtain OTP licenses.

ASAM National Practice Guideline:Implications

Little independent external review of health care in corrections


• Accreditation of health services in corrections is voluntary and only a minority are accredited.


• Accreditation of health services in corrections is voluntary and only a minority are accredited.

• Most review is retrospectively triggered by a high profile incident.

The ASAM National Practice Guideline:

Implications for corrections



For care



For care

For opioid myths



For care

For opioid myths

For rehabilitation



For care

For opioid myths

For rehabilitation

For the opioid epidemic


Implications for care


Implications for care Establishes MAT as standard practice.



Establishes MAT as standard practice.

Promotes evidence-based policies regarding management of opioid use disorders in corrections.



Establishes MAT as standard practice.

Promotes evidence-based policies regarding management of opioid use disorders in corrections.

Potentially helps establish new medicolegal and constitutional standards for treatment of opioid use disorder in corrections.


Implications for opioid myths

Myth #1

Myth #1

Those suffering from opioid disorders are bad people who should be punished.

Myth #1

Those suffering from opioid disorders are bad people who should be punished.

Dangerous Myth

#1 Reality

“Opioid use disorder is a chronic, relapsing disease which has significant economic,

personal, and public health consequences.”

Myth #2

Myth #2

“Medical detoxification is considered the standard of care for individuals

with opiate dependence.”

-Federal Bureau of Prisons Clinical Practice

Guidelines February 2014

Myth #2

“Medical detoxification is considered the standard of care for individuals

with opiate dependence.”



“Anyone incarcerated should be continued on treatment.”

#2 Reality

Myth #3

“Opiate withdrawal is rarely dangerous except in medically debilitated individuals and

pregnant women.”



Myth #3

“Opiate withdrawal is rarely dangerous except in medically debilitated individuals and

pregnant women.”



Dangerous MythMyth #3

Abrupt withdrawal from opioids in jail can be fatal.

#3 Reality

Tragic withdrawal Last May, a 25-year old male heroin user turned

himself into the county jail. He received a standard jail opioid withdrawal protocol: regular vital sign checks, Gatorade, clonidine, hydroxyzine, acetaminophen, Pepto-Bismol, loperamide, and promethazine. Three days later, he was dead. Following a comprehensive investigation including an autopsy, the DA concluded: “All the evidence indicates that [the inmate] died as a natural result of heroin withdrawal.”

Iatrogenic withdrawal

• Abrupt withdrawal of opioids in corrections can be fatal.


• Abrupt withdrawal of opioids in corrections can be fatal.

• Deaths jump dramatically during the first two weeks when inmates with opioid use disorders are released from prison or jail.



Implications for rehabilitation



Rehabilitation

Retribution



Rehabilitation

Retribution

More than 70% of Americans believe that “the main goal of the criminal justice system

should be rehabilitating criminals” -WSJ, Feb 2016

MAT can help rehabilitate

RehabilitationRetribution


Implications for the opioid epidemic



• Engage those with opioid use disorder in evidence-based treatment.



• Engage those with opioid use disorders in evidence-based treatment.

• Minimize trauma and fear associated with MAT due to “Jailhouse detox.”



• Engage those with opioid use disorders in evidence-based treatment.

• Minimize trauma and fear associated with MAT due to “Jailhouse detox.”

• Reduce deaths during imprisonment and following release.

Conclusion

Conclusion

• Failure to treat inmates with opioid use disorder represents an important missed opportunity.

Conclusion

• Failure to treat inmates with opioid use disorders represents an important missed opportunity.

• By addressing the critical need for evidence-based treatment of opioid use disorder within the criminal justice system, the ASAM National Practice Guideline addresses a vital element in our national strategy to end the opioid epidemic in the United States.

Thank-you

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TREATMENT TRACK: Best Practices in Treating Opioid Addiction in

the Criminal Justice Population

PRESENTERLeslie Balonick, MA, CRADC

Vice President of Business Development and Program Integrity

WestCare Foundation, Inc.

Leslie Balonick, MA, CRADC, has disclosed no relevant, real or apparent personal or professional financial relationships with proprietary entities that produce health care goods and services.

OVERVIEW:

Will identify best practices in evidence-based behavioral therapy in the criminal justice population, based on the 1,650-bed substance abuse and reentry program at the Illinois Department of Corrections – Sheridan Correctional Center. Heralded as one of the nation’s most comprehensive prison and reentry program models for medium/high risk men, the Sheridan program been shown to reduce recidivism by 44 percent among those who successfully complete program requirements, according to a 6.5-year longitudinal study. A first-hand perspective on the program’s design and operation and how it can be replicated at other prisons. LEARNING OBJECTIVES:• Outline the challenges face in treating opioid addiction in the

criminal justice population.

• Identify best practices in using medication-assisted treatment (MAT) for opioid addiction in the criminal justice system.

• Describe best practices in evidence-based behavioral therapy in the criminal justice population

ILLINOIS DEPARTMENT OF CORRECTIONS SHERIDAN CORRECTIONAL CENTER

• Opened January 2004• Fully dedicated substance

abuse treatment prison• 1,650 beds• 400 reentry beds• Education and vocational

training• Firm reentry linkage to services• Pre-and-post case management

upon release

ELIGIBILITY CRITERIA• Diagnosed as in-need of

substance abuse treatment

• Volunteers

• 9-36 months left to serve in prison

• Eligible for medium security

• No untreated severe mental illness

• Complex cases (e.g., repeat offenders, risk for violence)

SHERIDAN CLIENT DEMOGRAPHICSAverage Age 33yrs.Race

African American 62.3%White 25.3%

Hispanic 11.6%Other <1%

Marital Status Married 13.1%

Single 86.9%Children

None 35.1%One or More 64.9%

Education Level No High School Diploma or GED 54.9%

HS/GED or Above 45.1%# of Prior Times a Charge has Led to Conviction

None 12.5%1 13.5%

2+ 74%Current Conviction Offense

Drug Law Violation 34.4%Property 35.1%

Other 30.5%

PRIMARY SUBSTANCE USE: HEROIN

• SHERIDAN = 17%

• COOK COUNTY JAIL= 33%

HEROIN-USE CRISIS HITS ILLINOIS . . .

• In recent years, the Chicago metropolitan area was ranked first in the nation in the number of people admitted to emergency rooms because of heroin use. And Cook County was first for the number of arrestees who tested positive for the drug. (Source: Illinois Consortium on Drug Policy)

• Women and youths are increasingly using heroin in the Chicago area. (Source: Roosevelt University Researchers)

In 2015, the Chicago Sun Times published a photo of

“customers” lining up around the block (in daylight) to

purchase heroin.

Intake & Assessment

In Prison

Reentry Planning Home Community Integration

Outcomes

• All male inmates receive a TCU drug screen at R&C• If qualify, can volunteer • R-N-R statewide project in process

• Integrated Assessment/Plan•Evidence Based Practices (CBT and Trauma)• Substance Abuse/Mental Health Treatment•Family Reunification/Fatherhood• Job Preparedness• Vocational and Educational Training

• Integrated Treatment and Reentry Plan• Pre-release Staffings• Family Reunification• Job Preparedness Class• Aftercare Recommendation

• Parole & Case Management• Job Search• Ongoing Treatment/Housing• Engage Recovery Community

• Community Councils• Integrated Staffings

• Lower Recidivism• Employment• Community Engagement• Recovery•Family Reunification

FLOW

Cognitive Behavioral

Therapy (CBT)Milkman and

Wanberg“Criminal Conduct & Substance

Abuse Treatment –Pathways to

Self Discovery & Change”

TherapeuticCommunity

Competency-based life

skills. Knowledge, skills and attitudes

Situational “Life Scripts” (Role Playing) for Relapse PreventionSpirituality

12- Step Support Groups

Vocational,Educational (ESL,GED)

DOC

Paul Kivel’sMen’s WorkYoung Men’s Aggression

Fatherhoodeducation for

all clients (e.g., 24/7

Dads, Inside/Out

Dads)

SHERIDAN’S RECIPE FOR SUCCESS: INSTILL HOPE –

CHANGE IS POSSIBLE!• Research - Real Time Data • Experience Provider (i.e., WestCare Foundation, Inc.) • Integrated Partnership Model (e.g., IDOC, TASC,

Education, Vocational, Health, Mental Health, Community, etc.)

• Development of Community (within and beyond)• Commitment to EBPs and Best Practices + Fidelity• Risk-Need-Responsivity (RNR) Model• Continuous staff development (e.g., coaching,

mentoring)• Coaching and mentoring of clients

LESSONS LEARNED• MAT Sheridan Pilot• Understanding (e.g., street cultures,

populations, emerging drugs, etc.)

ONGOING OPPORTUNITIES AND CHALLENGES

• Risk-Need-Responsivity (RNR) Model• Trauma-informed care in a correctional

environment

RISK NEED RESPONSIVITY (RNR)

• RISK PRINCIPLE: Match the level of service to the offender's risk to re-offend.

• NEED PRINCIPLE: Assess criminogenic needs and target them in treatment.

• RESPONSIVITY PRINCIPLE: Maximize the offender's ability to learn from a rehabilitative intervention by providing cognitive behavioral treatment and tailoring the intervention to the learning style, motivation, abilities and strengths of the offender.

• “Central Eight” Risk/Need Factors:– Antisocial Personality Pattern– Procriminal Attitudes– Social Supports for Crime– Substance Abuse– Family/Marital Relationships (Poor, inappropriate, etc.)– School/Work (Poor performance)– Prosocial Recreational Activities (Lack of interest in)– Criminal History

DR. DAVID OLSEN, LOYOLA UNIVERSITY CHICAGO

Inmates who participated in the Sheridan program were less likely to be returned to prison within the average of 6.9 years following release than the comparison group.

DR. DAVID OLSEN, LOYOLA UNIVERSITY CHICAGO

• Individuals released from Sheridan were14% less likely to be returned to prison.

• Inmates released from Sheridan who also completed a reentry plan had a 44% lower likelihood of being readmitted to prison.

• Inmates released from Sheridan that did not complete aftercare had a higher likelihood of being returned to prison.

A number of the variables produced patterns consistent with the literature on recidivism (e.g., age, race, education level, gang involvement, type of crime, more prior arrests were all more likely to return to prison than their respective reference categories).

INNOVATION BY WESTCARE FOUNDATION

• Our approach to the Therapeutic Community (TC) model

• Focus on Fatherhood:• Specialized curriculum• Fatherhood groups/learning for all clients• Family engagement/education groups

• Integration of CBT in the TC model – First in the nation!

• Our work with Texas Christian University (TCU) tools

QUOTES FROM OUR CLIENTS“I’ve learned a lot from these counselors,” he said. “I’m a problem solver and I learned how to stop using drugs. It’s going to be a battle when I get out, but I know how to win.”

“Welcome to the ‘House of Ambition’ where miracles happen!”

“I have to stay clean and sober when I get out,” he said. “I want to utilize my culinary skills and open my own restaurant.”

“This has been a positive experience,” he said. “I’ve learned a lot about my negative behaviors such as drinking and driving and I know now to think of my family first.”

Best Practices in TreatingOpioid Addiction in the

Criminal Justice PopulationPresenters:

• Margaret Jarvis, MD, Medical Director, Marworth, Geisinger Health System

• Kevin Fiscella, MD, MPH, Professor of Family Medicine and Public Health Sciences, University of Rochester Medical Center

• Leslie Balonick, MA, CRADC, Vice President, WestCare Foundation, Inc.

Treatment Track

Moderator: Michael C. Barnes, JD, Executive Director, Center for Lawful Access and Abuse Deterrence, and Member, Rx and Heroin Summit National Advisory Board

Health & Medicine

Rx16 treat tues_200_1_jarvis_2fiscella_3balonick