Opioid Treatment
in a Corrections Setting
One Community’s Response
Presented by:
Babette Hankey
Chief Operating Officer
The Center For Drug-Free Living, Inc.
Background

Chairman’s Jail Oversight Commission




Review jail related programs/policies
Several Task Force





2001
Response to jail deaths
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 Medical
Committee, 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 shortterm 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. nonrecipients
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.
II.
III.
Assessment, intake, orientation,
motivational enhancement, and
medical detoxification
Skill-building, psychoeducational
activities, 12-step groups
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 Cooccurring 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 for
Co-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 shortterm
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
Other Options

Privatize transportation

Jail picks up Methadone

High risk vs. Low risk inmates
Thank You.
OVERVIEW

Profile of Orange County Jail

Historical perspective

Findings

Solutions
Presented By:
George Ellis
Medical Director
Health & 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
Historical Perspective

Lacked:
 medical/mental health integration

consistent peer review

multidisciplinary case conferences

mental health data
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)
14
12
Public Policy
40
63
Criminal
Justice
Corrections
Health Services
HFS
82
211 Recommendations
Historical Perspective
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
HEALTH SERVICES HIGHLIGHTS
•
Care
• Community
Standard of Care
• Methadone
Protocol:
cooperative
agreement with
CFDFL
Thank you.
TREATMENT OF
OPIATE DEPENDENCE
IN ORANGE COUNTY CORRECTIONS
Where we have been…….
Where we are going…….
Presented by :
Stacy Seikel, MD
Medical Director
The Center For Drug-Free Living
TOPICS

Use of methadone in Orange County
Corrections

Proposed use of buprenorphine

Future projects
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 IN
ORANGE 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 DrugFree 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. CLONIDINE
FOR 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
THANK YOU.
Implementation
and
Daily Operations
Presented by:
Jina Thalmann
P
Program Director
r
Opioid Dependency Treatment Program
e
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 DrugFree 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
Thank you.