Treatment of Opioid Use Disorders in Jails and Prisons Why, When, and How

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1 Treatment of Opioid Use Disorders in Jails and Prisons Why, When, and How Kevin Fiscella, MD, MPH Professor, Family Medicine, Public Health Sciences, Community Health University of Rochester School of Medicine & Dentistry

2 Medical detoxification is considered the standard of care for individuals with opiate dependence. Opiate withdrawal is rarely dangerous except in medically debilitated individuals and pregnant women.

3 Medical detoxification is considered the standard of care for individuals with opiate dependence. Opiate withdrawal is rarely dangerous except in medically debilitated individuals and pregnant women. -Federal Bureau of Prisons Clinical Practice Guidelines February 2014

4 Medical detoxification is considered the standard of care for individuals with opiate dependence. Opiate withdrawal is rarely dangerous except in medically debilitated individuals and pregnant women. -Federal Bureau of Prisons Clinical Practice Guidelines February 2014

5 Jail Detox Tragic endings

6 Jail Detox Tragic endings Last May, a 25-year old male heroin user turned himself into the county jail last after telling his parents he was afraid to detox in jail. His parents hoping for tough love declined to post bail. He was transferred to the jail medical unit. He received a standard jail opioid withdrawal protocol: regular vital signs checks, Gatorade, clonidine, hydroxyzine, acetaminophen, Pepto- Bismol, loperamide, and promethazine. Three days later, he was dead. Following discussion with the forensic pathologist and review of medical records, the DA concluded: All the evidence indicates that Mr. Tabor died as a natural result of heroin withdrawal.

7 Why?

8 Treatment of opioid use disorders in jails and prisons is too often substandard

9 Treatment of opioid use disorders in jails and prisons is too often substandard Opioid agonist treatment is routinely abruptly stopped following arrest (before conviction).

10 Treatment of opioid use disorders in jails and prisons is too often substandard Opioid agonist treatment is routinely stopped Opioid agonists are infrequently used to detoxify patients regardless of the severity of withdrawal.

11 Treatment of opioid use disorders in jails and prisons is too often substandard Opioid agonist treatment is routinely stopped Opioid agonists are infrequently used to detoxify patients regardless of severity of withdrawal Opioid treatment is generally not initiated prior to release.

12 Treatment of opioid use disorders in jails and prisons is too often substandard Opioid agonist treatment is routinely stopped Opioid agonists are infrequently used to detoxify patients regardless of severity of withdrawal Opioid treatment is not initiated prior to release Patients are not routinely referred to opioid treatment programs prior to release.

13 Why is reform needed?

14 Why is reform needed? Treatment for opioid disorders in corrections is generally not evidenced-based.

15 Why is reform needed?

16 Why is reform needed? Poor treatment is bad medicine Poor treatment is inhumane.

17 Why is reform needed? THE LANCET July 2015

18 Why is reform needed? Poor treatment is bad medicine Poor treatment is inhuman Poor treatment perpetuates stigma around opioid use disorders.

19 Why is reform needed? Poor treatment is bad medicine Poor treatment is inhuman Poor treatment perpetuates myths Poor treatment represents a missed opportunity to halt the opioid epidemic by engaging patient in evidence-based treatment.

20 Why is reform needed? JAM A January 14, 2009-Vol 301, No. 2

21 Why is reform needed? JAM A January 14, 2009-Vol 301, No. 2

22 Why is reform needed? Despite increasing evidence that addiction is a treatable disease of the brain, most individuals do not receive treatment. Involvement in the criminal justice system often results from illegal drug-seeking behavior and participation in illegal activities that reflect, in part, disrupted behavior ensuing from brain changes triggered by repeated drug use. Treating drug-involved offenders provides a unique opportunity to decrease substance abuse and reduce associated criminal behavior. Emerging neuroscience has the potential to transform traditional sanction-oriented public safety approaches by providing new therapeutic strategies against addiction that could be used in the criminal justice system. -Chandler et al, JAMA, 2009

23 ASAM and NCCHC recommend reform

24 ASAM National Practice Guideline Summary of Recommendations

25 ASAM National Practice Guideline Summary of Recommendations 1. Pharmacotherapy, has been shown to be effective and is recommended for prisoners and parolees regardless of the length of their sentenced term.

26 ASAM National Practice Guideline Summary of Recommendations 1. Pharmacotherapy, has been shown to be effective and is recommended for prisoners and parolees regardless of the length of their sentenced term. 2. Individuals with opioid use disorder who are within the criminal justice system should be treated with some type of pharmacotherapy in addition to psychosocial treatment.

27 ASAM National Practice Guideline Summary of Recommendations 3. Opioid agonists (methadone and buprenorphine) and antagonists (naltrexone) may be considered for treatment. There is insufficient evidence to recommend any one treatment as superior to another for prisoners or parolees.

28 THE LANCET July 2015

29

30 ASAM National Practice Guideline Summary of Recommendations 3. Opioid agonists (methadone and buprenorphine) and antagonists (naltrexone) may be considered for treatment. There is insufficient evidence to recommend any one treatment as superior to another for prisoners or parolees. 3. Pharmacotherapy should be initiated a minimum of 30 days before release from prison.

31 NCCHC Recommendations

32 NCCHC Recommendations 1. Screen detainees/inmates upon entry using valid instruments

33 NCCHC Recommendations 1. Screening of detainees/inmates upon entry using valid instruments that are available from a variety of sources. 2. Assure that correctional and health staff receive appropriate training screening.

34 NCCHC Recommendations 1. Screening of detainees/inmates upon entry using valid instruments that are available from a variety of sources. 2. Assuring that correctional and health staff receive appropriate training in receiving screening. 3. Provide formal evaluation for substance use disorders and comorbidity, including concurrent mental health disorders, by qualified health professionals trained and experienced in managing comorbid disorders.

35 NCCHC Recommendations 1. Screening of detainees/inmates upon entry using valid instruments that are available from a variety of sources. 2. Assuring that correctional and health staff receive appropriate training in receiving screening. 3. Formal evaluation for substance use disorder and comorbidity, including concurrent mental health disorders, by qualified health professionals trained and experienced in managing comorbid disorders. 4. If ordered by a correctional physician, continue prescribed medications for substance use disorders.

36 NCCHC Recommendations 5. Assess opioid and alcohol/sedative withdrawal using valid withdrawal scales.

37 NCCHC Recommendations 5. Assessment of opioid and alcohol/sedative withdrawal using valid scales such as the Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-Ar) and the Clinical Opiate Withdrawal Scale (COWS). 6. Provide evidence-based treatment such as cognitivebehavioral treatment and medication-assisted treatment of substance withdrawal.

38 NCCHC Recommendations 5. Assessment of opioid and alcohol/sedative withdrawal using valid scales such as the Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-Ar) and the Clinical Opiate Withdrawal Scale (COWS). 6. Evidence-based treatment such as cognitive-behavioral treatment and medication-assisted treatment of substance withdrawal. 7. Provide evidence-based behavioral and pharmacological treatment for substance use and mental health disorders.

39 NCCHC Recommendations 5. Assessment of opioid and alcohol/sedative withdrawal using valid scales such as the Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-Ar) and the Clinical Opiate Withdrawal Scale (COWS). 6. Evidence-based treatment such as cognitive-behavioral treatment and medication-assisted treatment of substance withdrawal. 7. Evidence-based behavioral and pharmacological treatment for substance use and mental health disorders. 8. Provide prerelease referral for, and coordination of, treatment for substance use and mental health disorders.

40 Why Not?

41 Correctional health care is marginalized

42 Limited regulatory oversight

43 Correctional culture

44 Bias against medication-assisted treatment

45 Bias against medication-assisted treatment

46 Lack of funding for health care $ services in jails and prisons $

47 Poor exchange of health information

48 Poor exchange of health information

49 Poor exchange of health information

50 Poor exchange of health information

51

52 DEA

53 DEA

54 When?

55 When to treat?

56 When to treat? Continue existing agonist treatment among people arrested and detained.

57 When to treat? Continue existing treatment among people arrested and detained Use opioid agonists for detoxification.

58 When to treat? Continue existing treatment among people arrested and detained Use of opioid agonists for detoxification Initiate opioid agonists prior to release.

59 How?

60 How to do it?

61 How to do it? 1. Jails and prisons can partner with community opioid treatment programs to dose inmates in jail or prison.

62 How to do it? 1. Jails and prisons can partner with community opioid treatment programs to dose inmates 2. Physicians working in jails and prisons can obtain a license to prescribe buprenorphine.

63 How to do it? 1. Jails and prisons can partner with community opioid treatment programs to dose inmates 2. Physicians working in jails and prisons can obtain a license to prescribe buprenorphine 3. Jails and prisons can obtain a facility license as an opioid treatment program.

64 How to do it? 1. Jails and prisons can partner with community opioid treatment programs to dose inmates 2. Physicians working in jails and prisons can obtain a license to prescribe buprenorphine 3. Jails and prisons can obtain a license for an opioid treatment program 4. Jails and prisons can obtain state and federal licenses for health care services.

65 Why?

66 It s the right thing to do

67 When?

68 Now

69 How?

70 Leadership

71 The Governor

72 The Legislature

73 Counties

74 NYSAM

75 NYSAM 1. Create a position statement that establishes a single standard for treatment of opioid use disorders whether in corrections or the community.

76 NYSAM 1. Create a position statement that establishes a single standard for treatment of opioid use disorders whether in corrections or the community. 2. Advocate Albany to mandate use of medication-assisted treatment within corrections in NYS.

77 NYSAM 1. Create a position statement that establishes a single standard for treatment of opioid use disorders whether in corrections or the community. 2. Advocate Albany to mandate use of medication-assisted treatment within corrections in NYS. 3. Advocate for mandatory accreditation of health services including substance abuse treatment within jails and prisons.

78 Thank-you

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