MAT and Utilizing Collective Impact with Drug Court Michael C. White, MCJ

Transcription

1 MAT and Utilizing Collective Impact with Drug Court Michael C. White, MCJ

2 Key Terms MAT (Medicated Assisted Treatment) OTP (Opioid Treatment Program) (Clinic) OUD (Opioid Use Disorder) NAS (Neonatal Abstinence Syndrome) CHSX (Correctional Health Services) DCS (Department of Child Services) DOC (Department of Corrections) ED (Emergency Department)

3 National Statistics An opioid related death occurs every 16 minutes. 92 people die from opioid overdose every day. 35,000 people died in 2016 (Underestimated due to coroner identification). More people die every year from opioid overdose than car accident fatalities.

4 Prevalence of Opioid Abuse 24.6 million people ages 12 or older (9.4% of the population) have a substance abuse diagnosis. Only 10% think they need treatment. 1.9 million Americans abuse or are addicted to opioids, while 517,000 Americans are addicted to heroin. Opioid addiction disease occurs in every socio-economic and ethnic group in the United States. 23% of heroin users develop chronic opioid addiction disease (SAMHSA). Of the hundreds of thousands of individuals entering America s jails and prisons each year, it is estimated that approximately 15-20% are addicted to heroin (U.S. Department of Health Services 2007, Chaiken, 2000).

5 Overdose Deaths

6 Overdose Deaths

7

8 Drug Overdose by Gender

9 Overdose Deaths and Criminal Justice 1 in 10 Opioid overdose deaths occur from a released inmate with the highest risk occurring immediately following release (Persaud 2016). The study matched release record to coroner reports.

10

11 Medication Assisted Treatment (MAT) Scientific research has firmly established that treatment of opiate dependence with medications (MAT) reduces addiction and related criminal activity more effectively and at far less cost than incarceration. Legal Action Center, 2011 The highest probability of being effective, National Institute of Health Consensus Panel, U. S Department of Health and Human Services Meta-analysis of over 300 published research articles confirmed MAT to be clinically effective

12 Practicing Medicine from the Bench Determining the appropriate level of care for a particular client must always be done by a duly trained and licensed or certified clinician, such as an addiction counselor, social worker, psychologist, or physician. Under no circumstance should a judge or other nonclinical trained criminal justice professional order a higher or lower level of care than has been determined to be necessary by an ASAM placement or comparable assessment (assuming that the indicated level of care is realistically available). To do so would, in essence, be akin to practicing medicine or another clinical specialty without a valid license. -NDCI Bench book. Pg. 81

13

14 Medicated Assisted Treatment Agonist; is a drug that activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in the brain fully resulting in the full opioid effect. Methadone is a full agonist. By fully occupying the mu-opioid receptor, methadone lessens the painful symptoms of opiate withdrawal and blocks the euphoric effects of other opioid drugs. Unlike heroin and other misused opioid agonists, methadone is longer lasting, usually 24 to 36 hours, preventing the frequent peaks and valleys associated with drug-seeking behavior. No optimal length of treatment with methadone has been established; however, 12 months is considered a minimum for methadone maintenance.

15 Medicated Assisted Treatment Partial Agonist; activates the opioid receptors in the brain, but to a much lesser degree than a full agonist. Buprenorphine is a partial agonist, meaning it does not completely bind to the mu-opioid receptor. As a result, buprenorphine has a ceiling effect, meaning that its effects will plateau and will not increase even with repeated dosing. Buprenorphine does not produce euphoria and does not have some of the dangerous side effects associated with other opioids. The optimal duration of treatment is unknown, and decisions to discontinue treatment with buprenorphine are patient-specific. Once this decision is made, the process of safely tapering the buprenorphine dose often spans many months.

16 Medicated Assisted Treatment Antagonist; is a drug that blocks opioids by attaching to the opioid receptors without activating them. Antagonists cause no opioid effect and block full agonist opioids. Naltrexone is an opioid antagonist, meaning that it covers, rather than activates, the mu-opioid receptor, effectively blocking the effects of opioids if they are used. Opioid antagonists do not produce any euphoric effects, so no physical dependence is associated with their use. Opioid antagonists are recommended for relapse prevention and for abstinence-based treatment, not for withdrawal management.

17

18 Diversion Efficacy Safety Ease of Access Detox Cost Suboxone Highly diverted. 10x more diverted than methadone Little regulation involved in OBT setting 40%-50% retention rates (3 months) Methadone Easily diverted from pain management clinics. Rarely diverted from OTPs. CDC assessment shows that diverted methadone comes from pain clinics, not OTPs Most heavily regulated form of treatment 50%-80% retention rates (1 year) Less researched than methadone. May be more effective in pregnancy than methadone according to 1 study 32mg ceiling effect, no effective for treating heavy opioid users Efficacy supported by more research than any other treatment for any other chronic disease According to CDC, SAMHSA, WHO, methadone is the gold standard of treatment for opioid use disorder Gold standard for treating pregnant women Less overdose potential than methadone Less potential for abuse than methadone (bc naloxone) High overdose potential, especially in non-otp setting High potential for abuse (users can feel euphoria if improperly dosed) Not identified in PDMP (Due to 42 CFR part 2) Easy access from OBT, BH Facilities, OTPs Treatment may not be comprehensive 48,148 Pts total (2013, FDA) Extremely difficult to access. Can only be accessed from an OTP Most comprehensive treatment (OTP only) 330,308 Pts total (2013, FDA) 24-hour detox needed prior to starting No detox needed prior to starting $6000/year for medication alone Approximately $250- $500/month for ancillary services $4000 per patient per year, all inclusive Vivitrol Non-divertible <15% retention rates (3 months) Most effective in a controlled environment (non-op setting) Very little research to support efficacy (received FDA approval after 1 study) In OP setting, no more effective than placebo No research on effects in pregnant women Only works for minority of patients with specific genetic preference Not as effective in treating cravings as methadone or Suboxone No overdose potential No abuse potential Not controlled substance Not suitable to those at risk of depression Easy access from OBT, BH Facilities, OTPs Treatment may not be comprehensive 3,781 Pts total (2013, FDA) 7-14 days detox needed prior to starting $13,200/year for medication alone Approximately $250- $500/month for ancillary services [i] Research shows Suboxone is 10x more diverted than methadone: [ii] CommitteesMe etingmaterials/scie nce Boar dtothefoodanddrugadministration/ucm pdf [iii] Buprenorphine may be more effective than methadone in pregnancy: s-relea ses/ bupr enor phine-treatme nt-pr egnancy-less-distress -ba bies [iv] CDC assessment shows the recent increase in diverted methadone correlates with increased pain clinic activity: html/mm6 126a5. htm [v] By month 6 in Vivitrol treatment, only 8 out of 171 pts remained in treatment: /pii/s [vi] NEJM Study: The prevention of opioid use by extended-r elease naltrexone did not persist through follow-up at week 52 and week 78, approximatel y 6 months and 12 months, respectivel y, after the treatment phase had ended. /full/ /n EJM oa #t= article [vii] s/pm C /# R7

19 Additional Support Services Front Desk Client enters clinic Check in and pay if necessary Need counseling services? Need medical provider? Place in queue to be medicated Client leaves clinic Clinician Coordinate care with adjunct providers Actively advocate for client rights Provide counseling or case management services Identify need and refer to elevated care Medical Provider Specific training and experience in addiction therapy OB services for pregnant patients Provide medical services Monitor PDMP for medication misuse Nursing Provide delivery service Diversion checks Testing required? Perform testing Provide client s medication Central Support Actively advocate for client rights Monitor success of program through data Community education Bill client, private insurance, Medicaid

20 Services Provided Medication Management Counseling Case Management Group Counseling (Relapse Prevention, IOP, MRT) Urine Analysis Community Based Services Diversion General Medical and Referrals Collaborating with OB/GYN, Residential, IOP, Etc Delivery of Medications Conduct a Prescription Check with the PDMP

21

22

23 Reduce Opioid Dependence

24 American Society of Addiction Medicine (ASAM) Levels of Care The least intensive, but safe, level of care...

25 ASAM Levels of Care

26 Criminal Justice and MAT Access to MAT in the criminal justice system presents even greater difficulty. A negligible number of jails and prisons offer addiction medication, and most people successfully engaged in MAT are forced to stop abruptly upon incarceration, thereby increasing the likelihood of relapse, recidivism and death (LAC 2015). The White House Office of National Drug Control Policy s recently announced plan to prohibit drug courts receiving federal dollars from forcing people receiving MAT to stop taking their medications is a significant step down the road of ensuring good MAT access in courts, federal and state prisons, jails, and correctional programs (ASAM 2015). Broad-brush policies denying access to MAT in the criminal justice system are not only harmful, but also violate the Americans with Disabilities Act and other anti-discrimination laws (LAC 2011)

27 Things to Consider 80% of opioid dependent people return to use within (2) years after participating in abstinence based treatment, 93% will with detox. These outcomes are reversed with MAT treatment (Gavin, 2012) Approximately 95% of incarcerated opioid users return to use within 3 years of being released from custody (Marlowe, 2003). In cost vs benefits analysis, programs for high risk individuals that have positive outcomes of 10% (gain employment, no relapse/recidivism, positive community relations) the program pays for itself (Belenko& Peugh, 1998). On average, while MAT costs $4000 per person a year, incarceration per year is an average annual cost of $27, (Federal Register, 2011).

28 Criminal Justice Outcomes Utilizing Methadone Compared to untreated opiate addicts, the risk of re-arrest is 18 percent higher for persons who stay in methadone treatment for 90 days or less, but is 10 percent lower for those in treatment 91 to 365 days and 61 percent lower for those who stay more than one year 7 ƒ Compared to untreated opiate addicts, the risk of a felony conviction is 53 percent higher for persons in methadone treatment for 90 days or less, 63 percent lower for opiate addicts in methadone treatment 91 to 365 days, and 83 percent lower for those in methadone treatment for more than one year. ƒ Similarly, the risk of any conviction is 27 percent higher for persons who stay in methadone treatment for 90 days or less, 43 percent lower for opiate addicts in methadone treatment 91 to 365 days, and 72 percent lower for those who stay in methadone treatment for more than one year.

29

30 Drug Courts and MAT NADCP supports the use of MAT and states that the use of MAT has been proven through rigorous scientific studies to improve substance dependent offenders retention in counseling and to reduce illicit substance use, rearrests, technical violations and reincarcerations (SAMHSA, 2014). In 2013, half of all Drug Courts and DUI courts surveyed did not utilize, did not have access, or did not accept the use of MAT. However, detox was available for 67.5% of participants.

31 How Did We Get Here (Arizona)? SAMHSA and Drug Courts (grants) 1/letting-drug-court-participants-usemethadone-reflects-changing-approach/ Judges in New York not allowed to rule on medical issues mon-sense-wins-inny_560ae76ce4b0dd d54?2fg30udi SAMHSA and Residential (grants) n-addictiontreatment_55cd1855e4b055a6daafe67f Local: Graves V. Arpaio (methadone clinic inside of jail) Mercy Maricopa Integrated Care MMIC, November 12 th, 2015

32 Arizona Drug Courts Maricopa County Drug Court Pima County Drug Court and DTAP

33 Drug Courts Supported County Superior Court Drug Courts Trauma Informed Care Drug Court (Abused Women) Veterans Court Mental Health Court DTAP (Drug Treatment Alternative to Prison)

34 How do Participants Connect to MAT Support Identifying Appropriate Participants 1. Attending Staffing's 2. Program Manager Referral 3. Probation Officer Referral 4. Commissioner/Judge Referral 5. Sanctions and Remands (In-Reach) 6. Self Referral

35

36 How can a MAT Provider add Additional Support Monthly or Contract Specific Updates Coordinating Transitions in Levels of Care (Residential Placement, Provide Medication Support i.e. Delivery) Attend Staffing's Keep the Court Informed of Local and State Changes (Political/State Insurance/Agencies) Coordinate Care for Sanctions and/or Remands Conduct a Prescription Search on the PDMP

37 Collective Impact 1. All participants have a common agenda for change including a shared understanding of the problem and a joint approach to solving it through agreed upon actions. 2. Collecting data and measuring results consistently across all the participants ensures shared measurement for alignment and accountability. 3. A plan of action that outlines and coordinates mutually reinforcing activities for each participant. 4. Open and continuous communication is needed across the many players to build trust, assure mutual objectives, and create common motivation. 5. A backbone organization(s) with staff and specific set of skills to serve the entire initiative and coordinate participating organizations and agencies. (Kramer and Kania)

38

39 Decision to seek support 'A1(* I Com1mu1nii. y N edical Ser ice - Legal Advocates Psychiatric Evaluation and 51:!riou ly Menta ly Ill Services

40 2 Year Outcomes MAT Outcomes vs Detoxification and Residential. A Comparison: A local study of detox-residential yielded 7-12%, outcomes from (SAMHSA Grant and Published in NIDA)(Follows National Trends) Currently an average of 76% compliance in Maricopa County Drug Court for OUD populations. Similar averages in Pima County Drug Court (70%). Currently, Felony Diversion Program in Maricopa County are 100%. (sample size of 8).

41 Examples of Collective Impact in Action Graham County Veteran Participant Department of Corrections Felony Diversion Program

42 Maricopa County Jail

43 Jail Support for Drug Court (In-Reach) Induction? Stabilization Period Opportunity to Combine Efforts and Reassess Plan Ability to Hold Participant Accountable (Remand and Sanction) Reach-Out Program Reach-In Services Coordinate Care to DOC

44 Alhambra Intake Center to Tucson Prison Complex (Terminated) Alhambra Tucson Prison Complex

45 Reentry Centers Maricopa County Reentry Center Pima County Reentry Center

46 MAT-PDOA Grant Grant goals: The project will create a bridge between criminal justice involved individuals with opioid use disorder (OUD) and access to Medication Assisted Treatment and outpatient services 1. Increase number of incarcerated individuals enrolled in Medication Assisted Treatment services 2. Decrease Illicit Opioid use 3. Decrease Re-incarceration 4. Decrease stigma of Medication Assisted Treatment use with the criminal justice population 5. Decrease Tobacco use with Medication Assisted Treatment clients

47 Grant Requirements: MAT-PDOA Grant 1. Client is involved with the legal system within past 4 months. "These individuals must be participating in drug courts, probation, parole, and/or be within 4 months of release from various detention facilities in Maricopa or Pima Counties." 2. Client has history of use of opioids or heroin and desire for MAT. 3. Client is Non Title-19 (Uninsured) or Private Insurance that does not cover Medication Assisted Treatment clients will be served annually for 3 years.

48 Current Collaborators for MAT-PDOA Contracted with the Maricopa County Superior Court Drug Court A contractor for Maricopa County Jails (Jail) Health Services, coordinating all care of OTP/MAT patients (Stepup, Step-down Model) Arizona Department of Corrections (Prison) reentry support center Specialty Pilot Program(s) District Attorney (William Montgomery in collaboration with the Maricopa County Superior Court, and other agencies) Support Maricopa County Veterans Court, Mental Health Court, and Family Court DCS early intervention programs and ongoing support

49 Jail JAIL: Jail screen patient (SBIRT) upon entry into jail. They will either induct pt or continue care CMS goes into jail to conduct assessment and orders/adjusts doses Yes Pregnant No Jail contacts their clinic and (if the clinic respondes) continues treatment in jail Yes Already in Tx Jail inducts patient into treatment Patient receives MAT in Jail CHSX Nursing Manager sends out weekly list to Matt. List only contains names of newly inducted patients or CMS existing patients CMS will provide information on available clinics No Patient will be located near CMS clinic CMS puts patient release date on calendar and goes in every week to meet following weeks releases. CMS will work with CHSX Nursing Manager to arrange for Matt's meeting and Matt will coordinate with CMS clinics for intake If patient is non-compliant during drug court, they get remanded. Karen Barnes will contact us to meet with the patient upon entry into jail. This jail term is ussually days. Patient Has AHCCCS (Suspended) Yes Drug Court CMS DRUG COURT: Drug Court screens them prior to hearing to detmine that they are drug court eligible Prison/DOC Reentry MRC will contact CMS for referral on Wednesday evening via emai (person is being sanctioned)l Drug Court Judicial Assistant sends CMS Staff docket with list of court attendees CMS attends Drug Court STAFFING and identifies with the tx team OUD patients. During Droug Court, CMS will also give progress reports on all CMS Drug Court patients In Reach or Out- Reach (Will be determined Thursday After staffing, CMS will meet with the patient to screen them Out In Patient wants treatment at CMS CMS will give patient resources for other treatment options CMS will screen patient, coordinate intake for Friday Morning CMS will coordinate treatment between the clinic manager and the patient. Our goal is to get themj in treatment withinj hours MRC will transport Client for initial Medical Provider Will conduct assessment at Clinic Nurse will devilvermeds M-W-F Remand : Drug Court Program Manager referral (> 30 No CMS will screen/transition patient. Patient will be released with any medications still on MRC premises CMS will meet with patient and cooridnate for them to be transitioned at CMS CMS screens potential grant participants Patient is eligible for grant Peer Support conducts GPRA and includes questions for web portal and for data collection Peer Support will meet patient at release and follow taxi to CMS clinic Peer Support inputs data into web portal Peer Support starts tracking log for patient Patient comes to CMS clinic to get intake completed Patient will be going into residential Patient begins receiving MAT at CMS clinic Patient will be receiving MRT CMS delivers MAT to residential Patient continues TX at CMS General Referal from Parole at MRC. (may need a higher level of care but not MRC yet, general BHT will conduct Bio/Psycho/Social and coordinate delivery services goes Nurse will obtain signed Medication goes Delivery Form and place medication in locker system as dictated by MRC Peer Support will be availble to attend MRC on Wednesday mornings for Telemedicine followups and medication adjustments MRT Counselor case manages and counsels patient

50 In Closing Neither Suboxone nor Methadone is a miracle cure. Medications allow addicts time to develop a foundation for their lives, seek out counseling, find community connections, repair relationships, develop positive social networks, and allow their brains to heal. Cognitive Therapies and the adoption of pro-social core beliefs are the ultimate agent of change.

51 Resources gpra.samhsa.gov/csat/view/docs/sais_gpra_costoffsetsubstanceabuse.pdf

52 Referral In Action