Rx16 treat tues_200_1_jarvis_2fiscella_3balonick

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

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
Guideline
1st to include all FDA-approved
medications in a single document

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 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

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

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

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

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

Objectives
• Background
• Pharmacotherapeutic options
• Legal options for implementing medication-
assisted treatment (MAT) in corrections
• Implications of The ASAM National Practice
Guideline
• Bibliography

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

prison
• Comprehensive assessment of those screening
positive
Best practices

prison
positive
• Continuation of MAT
Best practices

prison
positive
• Initiation of MAT for those not in treatment 30
days prior to release
Best practices

prison
positive
• Initiation of MAT for those not in treatment
• Appropriate monitoring and treatment of
withdrawal
Best practices

prison
positive
• Initiation of MAT for those not in treatment
• Appropriate monitoring and treatment of
withdrawal
• Pre-release coordination of care
Best practices

Pharmacotherapy
• Methadone
• Buprenorphine/naloxone

Pharmacotherapy
• Methadone
• Clonidine (not FDA approved)

Pharmacotherapy
• Methadone
• Clonidine
• Naltrexone

Pharmacotherapy
• Methadone
• Clonidine
• Naltrexone
• Naloxone

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

Buprenorphine/Naloxone
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*

Clonidine
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

Naltrexone
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

Naloxone
Life saving Induces abrupt
withdrawal
Widely used by first responders
Can be prescribed to at-risk
inmates upon release

MAT Options for Jails and Prisons

1. Transport inmates to community opioid

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.”

treatment.”
4. Correctional physicians can obtain licenses to
prescribe buprenorphine.

treatment.”
4. Correctional physicians can obtain licenses to
prescribe buprenorphine.
5. Facilities can obtain OTP licenses.

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 rehabilitation

 For care
 For rehabilitation
 For the opioid epidemic

Implications for care

 Establishes MAT as standard practice.

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

 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.

The ASAM National Practice Guideline
Implications for opioid myths

Myth #1
Those suffering from opioid disorders are bad
people who should be punished.

#1 Reality
“Opioid use disorder is a chronic, relapsing
disease which has significant economic,
personal, and public health consequences.”

Myth #2
“Medical detoxification is considered
the standard of care for individuals
with opiate dependence.”
-Federal Bureau of Prisons
Clinical Practice Guidelines
February 2014

“Anyone incarcerated should
be continued on treatment.”
#2 Reality

“Opiate withdrawal is rarely dangerous
except in medically debilitated individuals
and pregnant women.”
-Federal Bureau of Prisons
Clinical Practice Guidelines
February 2014
Myth #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.”

• Abrupt withdrawal of opioids in corrections
can be fatal.
Iatrogenic withdrawal

• 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

Implications for rehabilitation

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

Implications for the opioid epidemic

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

• Engage those with opioid use disorders in
• Minimize trauma and fear associated with
MAT due to “Jailhouse detox.”

• Engage those with opioid use disorders in
• Minimize trauma and fear associated with
MAT due to “Jailhouse detox.”
• Reduce deaths during imprisonment and
following release.

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.

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TREATMENT TRACK:
Best Practices in Treating Opioid
Addiction in the Criminal Justice
Population

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.

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 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%

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”
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)

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.”

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