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Best Practices in Treating Opioid Addiction in the Criminal Justice Population

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Rx16 treat tues_200_1_jarvis_2fiscella_3balonick

  1. 1. Best Practices in Treating Opioid Addiction in the Criminal Justice Population Presenters: • 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
  2. 2. 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
  3. 3. 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
  4. 4. 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.
  5. 5. The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use
  6. 6. What? The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use AKA: the ASAM National Practice Guideline 1st to include all FDA-approved medications in a single document
  7. 7. Why?
  8. 8. 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
  9. 9. Who? • American Society of Addiction Medicine (ASAM) • Treatment Research Institute (TRI) • Guideline Committee: addiction medicine; psychiatry, obstetrics/gynecology; and internal medicine
  10. 10. Guideline Committee Members Sandra Comer, PhD Chinazo Cunningham, MD, MS Marc J. Fishman, MD, FASAM Adam Gordon, MD, MPH, FASAM Kyle Kampman, MD, Chair Daniel Lengleben, MD Ben Nordstrom, MD, PhD David Oslin, MD George Woody, MD Tricia Wright, MD, MS Stephen Wyatt, DO
  11. 11. Quality Improvement Council John Femino, MD, FASAM Margaret Jarvis, MD, FASAM, Chair Margaret Kotz, DO, FASAM Sandrine Pirard, MD, MPH, PhD Robert J. Roose, MD, MPH Alexis Geier-Horan, ASAM Staff Beth Haynes, ASAM Staff Penny S. Mills, MBA, ASAM Executive VP External Reviewer: Michael M. Miller, MD, FASAM, FAPA
  12. 12. Treatment Research Institute Technical Team Members Amanda Abraham, PhD Karen Dugosh, PhD David Festinger, PhD Kyle Kampman, MD, Principal Investigator Keli McLoyd, JD Brittany Seymour, BA Abigail Woodworth, MS
  13. 13. 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
  14. 14. 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
  15. 15. Assessment Diagnosis Treatment Special Populations
  16. 16. 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
  17. 17. How to Get More Information
  18. 18. Treating Opioid Addiction in the Criminal Justice Population: Evidence from the ASAM Practice Guideline Kevin Fiscella, MD, MPH Professor, Family Medicine, Public Health Sciences, Community Health University of Rochester School of Medicine & Dentistry
  19. 19. Objectives • Background • Pharmacotherapeutic options • Legal options for implementing medication- assisted treatment (MAT) in corrections • Implications of The ASAM National Practice Guideline • Bibliography
  20. 20. Background
  21. 21. Background • Few jails or prisons use MAT.
  22. 22. Background • Few jails or prisons use MAT. • Few jails or prisons refer inmates to MAT programs upon release.
  23. 23. Background • Few jails or prisons use MAT. • Few jails or prisons refer inmates to MAT programs upon release. • Very few jails or prisons operate opioid treatment programs (OTPs).
  24. 24. ASAM National Practice Guideline: Best practices
  25. 25. • Universal screening on admission to jail or prison ASAM National Practice Guideline: Best practices
  26. 26. • Universal screening on admission to jail or prison • Comprehensive assessment of those screening positive ASAM National Practice Guideline: Best practices
  27. 27. • Universal screening on admission to jail or prison • Comprehensive assessment of those screening positive • Continuation of MAT ASAM National Practice Guideline: Best practices
  28. 28. • Universal screening on admission to jail or prison • Comprehensive assessment of those screening positive • Continuation of MAT • Initiation of MAT for those not in treatment 30 days prior to release ASAM National Practice Guideline: Best practices
  29. 29. • Universal screening on admission to jail or prison • Comprehensive assessment of those screening positive • Continuation of MAT • Initiation of MAT for those not in treatment • Appropriate monitoring and treatment of withdrawal ASAM National Practice Guideline: Best practices
  30. 30. • Universal screening on admission to jail or prison • Comprehensive assessment of those screening positive • Continuation of MAT • Initiation of MAT for those not in treatment • Appropriate monitoring and treatment of withdrawal • Pre-release coordination of care ASAM National Practice Guideline: Best practices
  31. 31. Pharmacotherapy
  32. 32. Pharmacotherapy • Methadone
  33. 33. Pharmacotherapy • Methadone • Buprenorphine/naloxone
  34. 34. Pharmacotherapy • Methadone • Buprenorphine/naloxone • Clonidine (not FDA approved)
  35. 35. Pharmacotherapy • Methadone • Buprenorphine/naloxone • Clonidine • Naltrexone
  36. 36. Pharmacotherapy • Methadone • Buprenorphine/naloxone • Clonidine • Naltrexone • Naloxone
  37. 37. Methadone Advantages Disadvantages Strong evidence for efficacy and effectiveness Requires OTP license 50 year+ track record QT effects FDA approved Risk for diversion Maintenance & taper Overdose/death risk Inexpensive Used in pregnancy Liquid formulation
  38. 38. Buprenorphine/Naloxone Advantages Disadvantages Strong evidence for efficacy and effectiveness Requires physician license (Data 2000 waiver) 20 year+ track record Risk for diversion FDA approved More expensive than methadoneMaintenance & taper Use in pregnancy (monoproduct) Low risk for death from overdose*
  39. 39. Clonidine Advantages Disadvantages Evidence for efficacy and effectiveness for withdrawal use Less effective than buprenorphine for withdrawal Inexpensive Not FDA approved Low diversion risk Requires close monitoring of vital signs Hypotension combined with dehydration is hazardous
  40. 40. Naltrexone Advantages Disadvantages Evidence for efficacy Effectiveness unknown FDA approved Requires opioid withdrawal Little risk for diversion Less incentive to engage in treatment post-release Potential portal to being drug free Risk for overdose when stopped Expensive
  41. 41. Naloxone Advantages Disadvantages Life saving Induces abrupt withdrawal Widely used by first responders Can be prescribed to at-risk inmates upon release
  42. 42. MAT Options for Jails and Prisons
  43. 43. MAT Options for Jails and Prisons 1. Transport inmates to community opioid treatment programs (OTPs).
  44. 44. MAT Options for Jails and Prisons 1. Transport inmates to community opioid treatment programs (OTPs). 2. Invite community OTPs into the facility.
  45. 45. MAT Options for Jails and Prisons 1. Transport inmates to community opioid 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.”
  46. 46. MAT Options for Jails and Prisons 1. Transport inmates to community opioid 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.
  47. 47. MAT Options for Jails and Prisons 1. Transport inmates to community opioid 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. 5. Facilities can obtain OTP licenses.
  48. 48. ASAM National Practice Guideline: Implications
  49. 49. Little independent external review of health care in corrections
  50. 50. Little independent external review of health care in corrections • Accreditation of health services in corrections is voluntary and only a minority are accredited.
  51. 51. Little independent external review of health care in corrections • Accreditation of health services in corrections is voluntary and only a minority are accredited. • Most review is retrospectively triggered by a high profile incident.
  52. 52. The ASAM National Practice Guideline: Implications for corrections
  53. 53. The ASAM National Practice Guideline: Implications for corrections  For care
  54. 54. The ASAM National Practice Guideline: Implications for corrections  For care  For opioid myths
  55. 55. The ASAM National Practice Guideline: Implications for corrections  For care  For opioid myths  For rehabilitation
  56. 56. The ASAM National Practice Guideline: Implications for corrections  For care  For opioid myths  For rehabilitation  For the opioid epidemic
  57. 57. The ASAM National Practice Guideline: Implications for care
  58. 58. The ASAM National Practice Guideline: Implications for care  Establishes MAT as standard practice.
  59. 59. The ASAM National Practice Guideline: Implications for care  Establishes MAT as standard practice.  Promotes evidence-based policies regarding management of opioid use disorders in corrections.
  60. 60. The ASAM National Practice Guideline: Implications for care  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.
  61. 61. The ASAM National Practice Guideline Implications for opioid myths
  62. 62. Myth #1
  63. 63. Myth #1 Those suffering from opioid disorders are bad people who should be punished.
  64. 64. Myth #1 Those suffering from opioid disorders are bad people who should be punished.
  65. 65. #1 Reality “Opioid use disorder is a chronic, relapsing disease which has significant economic, personal, and public health consequences.”
  66. 66. Myth #2
  67. 67. Myth #2 “Medical detoxification is considered the standard of care for individuals with opiate dependence.” -Federal Bureau of Prisons Clinical Practice Guidelines February 2014
  68. 68. Myth #2 “Medical detoxification is considered the standard of care for individuals with opiate dependence.” -Federal Bureau of Prisons Clinical Practice Guidelines February 2014
  69. 69. “Anyone incarcerated should be continued on treatment.” #2 Reality
  70. 70. Myth #3
  71. 71. “Opiate withdrawal is rarely dangerous except in medically debilitated individuals and pregnant women.” -Federal Bureau of Prisons Clinical Practice Guidelines February 2014 Myth #3
  72. 72. “Opiate withdrawal is rarely dangerous except in medically debilitated individuals and pregnant women.” -Federal Bureau of Prisons Clinical Practice Guidelines February 2014 Myth #3
  73. 73. Abrupt withdrawal from opioids in jail can be fatal. #3 Reality
  74. 74. 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.”
  75. 75. Iatrogenic withdrawal
  76. 76. • Abrupt withdrawal of opioids in corrections can be fatal. Iatrogenic withdrawal
  77. 77. • 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. Iatrogenic withdrawal
  78. 78. The ASAM National Practice Guideline Implications for rehabilitation
  79. 79. The ASAM National Practice Guideline Implications for rehabilitation
  80. 80. The ASAM National Practice Guideline Implications for rehabilitation More than 70% of Americans believe that “the main goal of the criminal justice system should be rehabilitating criminals” -WSJ, Feb 2016
  81. 81. MAT can help rehabilitate
  82. 82. The ASAM National Practice Guideline Implications for the opioid epidemic
  83. 83. The ASAM National Practice Guideline Implications for the opioid epidemic • Engage those with opioid use disorder in evidence-based treatment.
  84. 84. The ASAM National Practice Guideline Implications for the opioid epidemic • Engage those with opioid use disorders in evidence-based treatment. • Minimize trauma and fear associated with MAT due to “Jailhouse detox.”
  85. 85. The ASAM National Practice Guideline Implications for the opioid epidemic • 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.
  86. 86. Conclusion
  87. 87. Conclusion • Failure to treat inmates with opioid use disorder represents an important missed opportunity.
  88. 88. 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.
  89. 89. Thank-you
  90. 90. Bibliography Amato, L., M. Davoli, C. A. Perucci, M. Ferri, F. Faggiano and R. P. Mattick (2005). "An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research." J Subst Abuse Treat 28(4): 321-329. Bird, S. M., C. M. Fischbacher, L. Graham and A. Fraser (2015). "Impact of opioid substitution therapy for Scotland's prisoners on drug‐related deaths soon after prisoner release." Addiction 110(10): 1617-1624. Bird, S. M., A. McAuley, S. Perry and C. Hunter (2015). "Effectiveness of Scotland's national naloxone programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison." Addiction. Binswanger, I. A., M. F. Stern, R. A. Deyo, P. J. Heagerty, A. Cheadle, J. G. Elmore and T. D. Koepsell (2007). "Release from prison--a high risk of death for former inmates." New England Journal of Medicine 356(2): 157- 165. Binswanger, I. A., M. F. Stern, T. E. Yamashita, S. R. Mueller, T. P. Baggett and P. J. Blatchford (2015). "Clinical risk factors for death after release from prison in Washington State: a nested case–control study." Addiction. Bird, S. M., A. McAuley, S. Perry and C. Hunter (2015). "Effectiveness of Scotland's national naloxone programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison." Addiction. Chou, R., M. B. Weimer and T. Dana (2014). "Methadone overdose and cardiac arrhythmia potential: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline." J Pain 15(4): 338-365.
  91. 91. Bibliography Cousins, S. J., L. Denering, D. Crevecoeur-MacPhail, J. Viernes, W. Sugita, J. Barger, T. Kim, S. Weimann and R. A. Rawson (2015). "A demonstration project implementing extended-release naltrexone in Los Angeles county." Subst Abus: 1-9. Egli, N., M. Pina, P. Skovbo Christensen, M. Aebi and M. Killias (2009). "Effects of drug substitution programs on offending among drug-addicts." Campbell Systematic Reviews(3). Fiscella, K., A. Moore, J. Engerman and S. Meldrum (2005). "Management of opiate detoxification in jails." Journal of Addictive Diseases 24(1): 61-71. Gibson, A. and L. Degenhardt "Mortality related to naltrexone in the treatment of opioid dependence: A comparative analysis NDARC Technical Report No. 229." Friedmann, P. D., R. Hoskinson, M. Gordon, R. Schwartz, T. Kinlock, K. Knight, P. M. Flynn, W. N. Welsh, L. A. Stein, S. Sacks, D. J. O'Connell, H. K. Knudsen, M. S. Shafer, E. Hall, L. K. Frisman and C. J. D. Mat Working Group Of (2012). "Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions." Subst Abus 33(1): 9-18. Fu, J. J., N. D. Zaller, M. A. Yokell, A. R. Bazazi and J. D. Rich (2013). "Forced withdrawal from methadone maintenance therapy in criminal justice settings: a critical treatment barrier in the United States." J Subst Abuse Treat 44(5): 502-505. Gisev, N., S. Larney, J. Kimber, L. Burns, D. Weatherburn, A. Gibson, T. Dobbins, R. Mattick, T. Butler and L. Degenhardt (2015). "Determining the impact of opioid substitution therapy upon mortality and recidivism among prisoners: A 22 year data linkage study."
  92. 92. Bibliography Gordon, M. S., T. W. Kinlock, K. A. Couvillion, R. P. Schwartz and K. O'Grady (2012). "A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Prediction of Treatment Entry and Completion in Prison." J Offender Rehabil 51(4): 222-238. Gowing, L., R. Ali and J. M. White (2009). "Buprenorphine for the management of opioid withdrawal." Cochrane Database Syst Rev 3(3). Gowing, L., M. F. Farrell, R. Ali and J. M. White (2014). "Alpha2-adrenergic agonists for the management of opioid withdrawal." Cochrane Database Syst Rev 3. Kinlock, T. W., M. S. Gordon, R. P. Schwartz, T. T. Fitzgerald and K. E. O'Grady (2009). "A randomized clinical trial of methadone maintenance for prisoners: results at 12 months postrelease." J Subst Abuse Treat 37(3): 277- 285. Koehler, J. A., D. K. Humphreys, T. D. Akoensi, O. Sánchez de Ribera and F. Lösel (2014). "A systematic review and meta-analysis on the effects of European drug treatment programmes on reoffending." Psychology, Crime & Law 20(6): 584-602. Krupitsky, E., E. V. Nunes, W. Ling, A. Illeperuma, D. R. Gastfriend and B. L. Silverman (2011). "Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial." The Lancet 377(9776): 1506-1513. Krupitsky, E., E. Zvartau, E. Blokhina, E. Verbitskaya, V. Wahlgren, M. Tsoy-Podosenin, N. Bushara, A. Burakov, D. Masalov and T. Romanova (2012). "Randomized trial of long-acting sustained-release naltrexone implant vs oral naltrexone or placebo for preventing relapse to opioid dependence." Archives of general psychiatry 69(9): 973- 981.
  93. 93. Bibliography Lim, S., A. L. Seligson, F. M. Parvez, C. W. Luther, M. P. Mavinkurve, I. A. Binswanger and B. D. Kerker (2012). "Risks of drug-related death, suicide, and homicide during the immediate post-release period among people released from New York City jails, 2001–2005." American journal of epidemiology 175(6): 519-526. Lo‐Ciganic, W. H., W. F. Gellad, A. J. Gordon, G. Cochran, M. A. Zemaitis, T. Cathers, D. Kelley and J. M. Donohue (2015). "Associations between trajectories of buprenorphine treatment and emergency department and inpatient utilization." Addiction. Martin, J. A., A. Campbell, T. Killip, M. Kotz, M. J. Krantz, M. J. Kreek, B. A. McCarroll, D. Mehta, J. T. Payte, B. Stimmel, T. Taylor, M. C. Haigney and B. B. Wilford (2011). "QT interval screening in methadone maintenance treatment: report of a SAMHSA expert panel." J Addict Dis 30(4): 283-306. Mattick, R. P., C. Breen, J. Kimber and M. Davoli (2009). "Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence." Cochrane Database Syst Rev(3): CD002209. Mattick, R. P., C. Breen, J. Kimber and M. Davoli (2014). "Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence." Cochrane Database Syst Rev 2(2). Merrall, E., A. Kariminia, I. Binswanger, M. Hobbs, M. Farrell, J. Marsden, S. Hutchinson and S. Bird (2010). "Meta- analysis of drug-related deaths soon after release from prison." Addiction (Abingdon, England) 105(9): 1545. Nienaber, B. G., Ed (2016). Key findings from statewide surveys in Florida, North Carolina, Nevada, Kentucky, Missouri, and Wisconsin, The Tarrance Group.
  94. 94. Bibliography Nunn, A., N. Zaller, S. Dickman, C. Trimbur, A. Nijhawan and J. D. Rich (2009). "Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey." Drug & Alcohol Dependence 105(1-2): 83-88. Pacyga, J. S. (2015). The investigtaion of the death of Tyler Ray Tabor at the Adams County Detention Facility at 150 N.19th Avenue, Brighton, Colorado on May 17, 2015. Paone, D., E. Tuazon, M. Stajic, B. Sampson, B. Allen, S. Mantha and H. Kunins (2015). "Buprenorphine infrequently found in fatal overdose in New York City." Drug Alcohol Depend 155: 298-301. Penn, J. V. (2015). "Standards and accreditation for jails, prisons, and juvenile facilities." Oxford Textbook of Correctional Psychiatry: 359.
  95. 95. Bibliography Merrall, E., A. Kariminia, I. Binswanger, M. Hobbs, M. Farrell, J. Marsden, S. Hutchinson and S. Bird (2010). "Meta-analysis of drug-related deaths soon after release from prison." Addiction (Abingdon, England) 105(9): 1545. Nienaber, B. G., Ed (2016). Key findings from statewide surveys in Florida, North Carolina, Nevada, Kentucky, Missouri, and Wisconsin, The Tarrance Group. Nunn, A., N. Zaller, S. Dickman, C. Trimbur, A. Nijhawan and J. D. Rich (2009). "Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey." Drug & Alcohol Dependence 105(1-2): 83-88. Pacyga, J. S. (2015). The investigtaion of the death of Tyler Ray Tabor at the Adams County Dention Facility at 150 N.19th Avenue, Brighton, Colorado on May 17, 2015. Penn, J. V. (2015). "Standards and accreditation for jails, prisons, and juvenile facilities." Oxford Textbook of Correctional Psychiatry: 359. Peterson, J. A., R. P. Schwartz, S. G. Mitchell, H. S. Reisinger, S. M. Kelly, K. E. O'Grady, B. S. Brown and M. H. Agar (2010). "Why don't out-of-treatment individuals enter methadone treatment programmes?" Int J Drug Policy 21(1): 36-42. Rich, J. D., A. E. Boutwell, D. C. Shield, R. G. Key, M. McKenzie, J. G. Clarke and P. D. Friedmann (2005). "Attitudes and practices regarding the use of methadone in US state and federal prisons." Journal of Urban Health 82(3): 411-419. Rich, J. D., M. McKenzie, S. Larney, J. B. Wong, L. Tran, J. Clarke, A. Noska, M. Reddy and N. Zaller (2015). "Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial." Lancet (London, England) 386(9991): 350.
  96. 96. TREATMENT TRACK: Best Practices in Treating Opioid Addiction in the Criminal Justice Population
  97. 97. PRESENTER Leslie 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.
  98. 98. 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
  99. 99. 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
  100. 100. 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)
  101. 101. SHERIDAN CLIENT DEMOGRAPHICS Average 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%
  102. 102. 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.
  103. 103. 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
  104. 104. Cognitive Behavioral Therapy (CBT) Milkman and Wanberg “Criminal Conduct & Substance Abuse Treatment –Pathways to Self Discovery & Change” Therapeutic Community Competency- based life skills. Knowledge, skills and attitudes Situational “Life Scripts” (Role Playing) for Relapse Prevention Spirituality 12- Step Support Groups Vocational, Educational (ESL,GED) DOC Paul Kivel’s Men’s Work Young Men’s Aggression Fatherhood education for all clients (e.g., 24/7 Dads, Inside/Out Dads)
  105. 105. 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
  106. 106. 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
  107. 107. 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
  108. 108. 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.
  109. 109. 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).
  110. 110. 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
  111. 111. 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.”
  112. 112. Best Practices in Treating Opioid Addiction in the Criminal Justice Population Presenters: • 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

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