Opioid Treatment Programs at the Baltimore City Detention Center

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1 Opioid Treatment Programs at the Baltimore City Detention Center Greg Warren, MA, MBA Director of Substance Abuse Services Maryland Department of Public Safety and Correctional Services

2 OTP Interventions Maintain arrested OTP clients during Pre-Trial Status and reconnect them to their OTP at release Detox heroin-addicted inmates with non-opioids or with methadone Pregnancy protocol Buprenorphine conversion

3 Treatment Flow versus Episode AA/NA OUTPATIENT INTENSIVE OUTPATIENT INTERMEDIATE CARE FACILITY RESIDENTIAL REHAB/DETOX PRISON

4 Baltimore s Challenges Heroin addiction remains high: Supply falls short of demand despite expansion in treatment over past 10 years ~6,200 methadone treatment slots Terminal methadone admissions > 10,000 admissions for heroin treatment in FY 2006 High rate of violent crime Addicts killing addicts

5 Criminal History of Prison-based OTP Patients 1 Mean Age first crime 13.8 Age first arrest 16.5 Age first incarceration 20.6 Lifetime incarcerations 9.1 Past 30 days crime Kinlock, Schwartz Gordon (2005) Past 30 days crimeprofit Criminal Income ($/past 30 days) ,057

6 Scope of the Problem Number of Addicts in Baltimore City 58,000 60,000 Individuals/ 90,000 Bookings annually 90,000 60% Released within 24 hours 54,000 Inmates incarcerated longer than 24 hours 36, % of individuals Alcohol/Drug Dependent 25,200 67% Heroin is Drug of Choice for Baltimore City Residents 16,884 50% (?) Heroin addicts needing Detox 8,400 10% of 6,200 Methadone clients will get arrested annually 620

7 Males Jan- 08 Feb- 08 Mar- 08 April 08 May 08 June 08 July 08 YTD Total Committed 1,655 2,737 3,112 2,960 3,117 2,826 3,017 19,425 Detox w/o Methadone ,973 Detox with Methadone Methadone Maintenance Females Committed ,907 Detox w/o Methadone Detox with Methadone Methadone Maintenance

8 Regulatory and Relationship Issues

9 American Medical Association 2005 Annual Meeting RESOLUTION OPAITE REPLACEMENT THERAPY PROGRAMS IN CORRECTIONAL FACILITIES RESOLVED, That our American Medical Association endorse the medical treatment model of employing Opiate Replacement Therapy (ORT) as an effective therapy in treating opiate addicted persons who are incarcerated.. to institute voluntary (for inmates) opioid replacement treatment pilot programs, (including methadone and buprenorphine maintenance treatment) in jails and prisons and that these programs be accompanied by an evaluation process to determine whether such treatment modalities decrease recidivism, crime, and transmission of infectious diseases among populations at risk in incarcerated settings in the states being studied.

10 Regulatory Issues Pregnancy Protocol State Licensing requirements The concept of admission and discharge Referral process Urine testing Detox dosing periods HIPAA HIV and Hep C education, TB testing Release with a methadone dose

11 Law of unintended consequences Understanding needs means responsibility Overwhelming the Public treatment system New outcome measure for methadone programs and their treatment practices Buprenorphine Can the cultures integrate?

12 The Inevitability of Expansion Lawsuits will compel jurisdictions to act In-Reach from community programs Initiation of methadone prior to release from DOC sentences Methadone detox protocol expansion House all clients together in the same place Methadone for recurring Heroin positive sentenced inmates

13 Treatment Providers Institutional Challenges 42 CFR concerns Holding Treatment slots Willingness to absorb Criminal Justice clients Willingness to adapt tx. approaches to treat addicts with criminologic thinking Accountability issues

14 OUTCOMES OF THE OTP Time period for treatment and dose verification # of individuals treated # of methadone maintenance clients who return to their community program upon release # of heroin detox clients who enter treatment upon release Increasing the # of Clients who have been detoxed saves BSAS and the State money Cost benefit analysis between incarceration expenses and publicly funded treatment

15 Next Steps and Interesting Questions 1. If thousands are detoxed at the Detention Center what impact will that have on treatment capacity? 2. Can Interim Maintenance or Buprenorphine be used as a means to expand treatment capacity? 3. How can we integrate the treatment experience as the individual progresses through different modalities of care?

16 4. Is there a benefit to identifying the individuals who more frequently become incarcerated and who are the treatment failures? 5. Do your existing regulatory and information systems support a public safety and community program linkage?