1 PURPOSE POLICY AND PROCEDURES FOR PROVIDING NARCOTIC ADDICTION TREATMENT TO PREGNANT OPIOID DEPENDENT INMATES INCARCERATED IN THE COUNTY JAIL To outline the procedures used in recognizing and providing health service care for pregnant opioid dependent inmates. POLICY It is the policy of the County Jail and the Correctional Health Services to provide specialized treatment and services for incarcerated pregnant opioid dependent women. BACKGROUND The abrupt discontinuation of heroin frequently causes physical and psychological discomfort for the pregnant woman. There are, however, significantly greater risks for the unborn child that may include a higher incidence of premature delivery, spontaneous abortion and intrauterine death. Methadone is currently the only approved pharmacological therapy for opiate addiction during pregnancy. When used for opioid detoxification and/or maintenance, Federal and State laws prohibit this medication from being ordered and dispensed by any entity other than a licensed methadone clinic. Recognizing the difficulties this presents for the inmate who is opioid dependent and pregnant, the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure (DAPL) and the U.S. Drug Enforcement Administration (DEA) have approved an exception process to permit off-site dosing at the ABC County Jail (JAIL). The following protocol delineates the mechanisms that will allow the XYZ Correctional Health Services (HEALTH SERVICE) to arrange for off-site dosing at the JAIL using methadone for incarcerated opioid dependent pregnant women while maintaining compliance with the guidelines set forth by the regulatory entities. INITIAL INMATE SCREENING When a woman enters the JAIL and states that she is pregnant and opioid dependent, HEALTH SERVICE medical staff will verify or diagnose the pregnancy. They will also document the evidence of current opioid dependency using indicators such as: presence of needle marks, physical signs of withdrawal, the date of last opioid use or verification of methadone treatment. Preliminary pregnancy and opioid testing are to be performed using the urine testing kits available at the JAIL. Confirmatory pregnancy and urinalysis will be performed at the Narcotic Treatment Program (NTP). If a woman is admitted on a Saturday, Sunday and any other day the NTP is closed, HEALTH SERVICE may consider the 3-day rule see end of this protocol for information.
2 TRAINING OF HEALTH SERVICE/JAIL STAFF The HEALTH SERVICE will assure that HEALTH SERVICE and JAIL staff including transporting officers and officers assigned to the women s unit are knowledgeable of the signs and symptoms of methadone over dose or inadequate dosing and medication interactions. Staff will also be educated on the benefits of methadone treatment for pregnant opioid dependent inmates, the fundamentals of drug and alcohol treatment, and confidentiality requirements. PROCEDURES: THE PREGNANT INMATE IS CURRENTLY ENROLLED IN A NTP, AND THE PREGNANCY AND OPIOID DEPENDENCY ARE VERIFIED, THEN: 1. The HEALTH SERVICE will coordinate dosing with the NTP per this protocol after obtaining a consent to release information form, consistent with HIPAA, 28 Pa. Code , and 42 CFR, part 2. This consent form is then faxed to the appropriate NTP. 2. The inmate will be transported daily to NTP for dosing and observation until the inmate is stabilized on her methadone dose and the NTP physician determines that daily attendance is not medically indicated. Standard transportation and security procedures related to health service transportation of inmates for off-site visits will be followed. 3. All decisions regarding the methadone treatment will be made by the NTP physician with input from the HEALTH SERVICE medical staff. HEALTH SERVICE staff will communicate an inmate s signs and symptoms of methadone over dose, inadequate dosing, and/or medication interactions to the NTP physician. 4. Arrangements will be made with the NTP for treatment on a weekly basis During this once a week visit, a dose will be administered and counseling conducted per the established treatment plan. Methadone doses for the six additional days that the patient is not transported to the NTP will be delivered to the JAIL by the transporting JAIL officer via a carry-pack for the off-site dosing. Carry-packs will be hard-sided, locked containers with one key held by the NTP and one key maintained in the narcotics box of the HEALTH SERVICE infirmary medication cart. 5. Each dose will be labeled in accordance with the pharmacy labeling requirements and include the specific date for dispensing each methadone dose. The carry-pack will be filled and locked by the NTP dispensing staff in the presence of the JAIL transporting officer. The JAIL transporting officer will sign a receipt for the locked carry-pack on a methadone chain of custody form. A copy of the receipt is maintained by the NTP and the original is placed in the locked carry-pack. 6. Upon return to the JAIL, the transporting JAIL officer will directly deliver the locked carrypack to an HEALTH SERVICE nurse in the infirmary. The nurse will open and count the contents of the carry-pack in the presence of the JAIL officer and both will sign the chain of custody form. If possible, the inmate will also sign the chain of custody form at that time.
3 7. The HEALTH SERVICE nurse will then place the methadone carry-pack in a locked medication cart in the infirmary where its contents will be verified daily when the locked box is opened. The inmate self-administers the methadone dose for that day in accordance with standard practice for accounting for other controlled substances. 8. In the event a dose is regurgitated and such action is witnessed by either HEALTH SERVICE or JAIL staff, HEALTH SERVICE will consult with the NTP physician to determine appropriateness of re-dosing. In the event a dose is spilled and such action is witnessed by either HEALTH SERVICE or JAIL staff, HEALTH SERVICE staff will determine appropriateness of re-dosing. HEALTH SERVICE will make proper documentation and notation on the relevant bottles. The NTP will be contacted and arrangements will be made to accommodate the need for a replacement dose: either one will be transported to the JAIL, under the same conditions as above, or the woman will be transported to the NTP one day sooner than previously scheduled. 9. Each day when the methadone dosage is to be given, the HEALTH SERVICE nurse will open the locked medication cart and remove the methadone carry-pack. In the presence of a JAIL officer and the woman, the methadone carry-pack will be opened and the dosage for that day will be given. The inmate will self-administer and sign the receipt of each daily methadone dose on the chain of custody form. 10. In preparation for the weekly transport of the inmate to the NTP, the transporting JAIL officer will count the empty methadone bottles with the HEALTH SERVICE infirmary nurse, receive the locked empty carry-pack, and sign the chain of custody form. 11. Every seven days or more frequently as determined by the NTP physician, the inmate is transported to the NTP for counseling and other services including required urine drug screens. JAIL security staff are not permitted to attend the actual counseling session. A single room with one door shall be used and the security staff may stand outside the room. Auditory privacy must be maintained while visual privacy shall be limited to the minimal amount necessary to ensure the security of the pregnant inmate. 12. Upon arrival at the NTP, the transporting JAIL officer will give the locked carry-pack and the chain of custody form to the NTP dispensing staff who will sign and retain the methadone chain of custody form. The carry-pack will be refilled and the cycle will be repeated. 13. When the inmate is released from JAIL, all remaining doses are to be returned to the NTP. At no time are they to be given to the released woman. 14. The infirmary will notify the NTP of the woman s release and last day dosed. THE PREGNANT INMATE IS NOT CURRENTLY ENROLLED IN A NTP, AND THE PREGNANCY AND OPIOID DEPENDENCY ARE VERIFIED, THEN:
4 1. The HEALTH SERVICE will determine health service necessity and initiate referral and conversion/ treatment with [name of the appropriate hospital trained in conversion] in accordance with the hospital established conversion therapy. 2. Arrangements will be made by the JAIL, through the HEALTH SERVICE, for the inmate to be transported to XX Hospital for the medically determined period of time necessary for a safe conversion. 3. HEALTH SERVICE and XX Hospital, will arrange for admission to a NTP. The NTP physician will determine the frequency of visits until the woman is medically stabilized. Once stabilized, the once a week off-site dosing protocol will be followed. DEA 3-DAY RULE [21 CFR (b)] "Nothing in this section shall prohibit a physician who is not specifically registered to conduct a narcotic treatment program from administering (but not prescribing) narcotic drugs to a person for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral for treatment. Not more than one day's medication may be administered to the person or for the person's use at one time. Such emergency treatment may be carried out for not more than three days and may not be renewed or extended." 1. Prior to initiating this emergency treatment, the HEALTH SERVICE nurse will contact the HEALTH SERVICE physician who must examine the inmate and order the medication. 2. Per the citation above, HEALTH SERVICE is permitted emergency dosing of one dose per day for no more than three (3) consecutive days of methadone when arrangements have been made for ongoing treatment at a methadone clinic. HEALTH SERVICE will provide the necessary documentation for this exception, and the emergency doses of the medication will be provided via the health service staff of the HEALTH SERVICE sufficient to prevent physical symptoms of withdrawal. TERMINATION OF TREATMENT If the inmate receiving methadone treatment gives birth while still incarcerated, a humane detoxification of not less than 7 days (longer if health service is warranted), will be planned by the NTP, the HEALTH SERVICE health service staff, XX Hospital physicians and ordered by the NTP physician. No set dosage reduction schedule will be established for all women following birth. A patient being maintained on 130 mgs. of methadone will need a longer time to withdraw than woman maintained on 75 mgs. dosage. The dose reduction should not exceed 10% of the previous day s dose. CONSIDERATIONS Monday is not a preferred day for transporting the inmate to the NTP for dosing and pick-up of the take home methadone doses due to potential conflicts with NTP holidays and closures.
5 FAILURE TO COMPLY In the event that the inmate refuses to participate with any aspect of this protocol, the matter is to be discussed between the NTP and the HEALTH SERVICE, consistent with 4 Pa. Code of the confidentiality regulations. The inmate will be advised of the risks to her pregnancy. HEALTH SERVICE will be responsible for following established procedures when an inmate refuses health service treatment. PAYMENT RESPONSIBILITY: YYY is responsible for payment of the pregnant inmate's inpatient hospital stay. YY County is responsible for payment of outpatient methadone maintenance; payment fee will reflect rates as established in the provider contract with YY County. By signing below, all parties agree to the conditions stated above. NTP Director Date Health Service Director Date JAIL Warden Date
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