Upload
annice-robertson
View
214
Download
0
Tags:
Embed Size (px)
Citation preview
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
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
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
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
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