National Association for Drug Court Professionals 2018 Conference Houston

Transcription

1 National Association for Drug Court Professionals 2018 Conference Houston Integrating Medication and Mental Health Services for Participants with Opioid Use and Co-Occurring Disorders in Adult Drug Court Judge Jeri B. Cohen Circuit Court Judge Miami-Dade Adult & Dependency Drug Courts Patricia Ares-Romero, MD Chief Medical Officer

2 Disclaimer The opinions, findings, and conclusions or recommendations expressed in this publication/program/exhibition are those of the author(s) and do not necessarily reflect the views of the U.S. Department of Justice, the U.S. Department of Health and Human Services, or grant-making components. This project was supported by Award No DC-BX-0002 awarded by the U.S. Department of Justice s Bureau of Justice Assistance, and by Award No. 1H79TI awarded by the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration.

3 Opioid Epidemic in Florida The rise in heroin & fentanyl use has resulted in deaths: 952 heroin-related deaths 1,390 fentanyl-related deaths Miami-Dade County 139 heroin-related deaths 164 fentanyl-related deaths (3 rd highest in Florida) ØPublic Health Emergency was declared statewide for the opioid epidemic on May 3, 2017

4 Fentanyl-Related Deaths In 2016, non-pharmaceutical fentanyl from foreign clandestine labs was the major factor contributing to the dramatic escalation in opioid deaths related to adulterated heroin and counterfeit medications across Florida and the nation. In 2016, most heroin deaths in Florida involved at least one or more other drugs detected in the decedents. That demonstrated the polysubstance use patterns of the opioid epidemic.

5 Cause of death The graph to the right tracks (1) the number of drug occurrences for the various opioids shown in the blue bars, (2) the number of those cases considered to be a cause of death in the green bars, and (3) the percent of each opioid s occurrences which are a cause of death on the red line graph.

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8 OPIOID FACTS In 2016, non-pharmaceutical fentanyl from foreign clandestine labs was the major factor contributing to the dramatic escalation in opioid deaths related to adulterated heroin and counterfeit medications across Florida and the nation. However, several Florida medical examiners warn that the most dramatic rise of opioid deaths, particularly those from poisonous fentanyl analogs is due partly to the arrival of carfentanil, the most toxic of opioids. *Carfentanil is considered to be 10,000 times more potent than morphine.

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12 Situation in Courts Opioid epidemic. President, ONDCP & public health officials calling for increased use of MAT SAMHSA/DOJ mandates: drug courts must allow MAT if they get federal funds. More states passing laws (NY, NJ, IL) US survey: about 50% courts prohibit MAT Similar issues with probation, parole, and child welfare system. 92,000 children in out of home placement because of parental drug abuse in

13 Population Served in Adult Drug Court (ADC) As of 2016 ADC had 405 active participants. 22% of participants report opioid addiction 78.5% below county living wage 51.2% below poverty level 30% reported Spanish as their primary language spoken.

14 Situation Before the Clinic A federally funded evaluation performed in 2016 identified the need to focus on opioid use disorder and medically assisted treatment (MAT) In 2015, Miami-Dade had a 40% increase in heroin deaths over 2014 and 365% increase Fentanyl deaths from 2014 The complexity of the participant s needs required enhancements to the services that were existing ( 6 public detox beds; no detox on demand; people waiting for hours in emergency rooms)

15 Situation Before the Clinic Opioid use surged with clients coming into ADC with addiction issues not previously seen No outpatient MAT services or immediate residential Managing Entity was not seeing the issue The Opioid Response Partnership was a targeted attempt to meet the needs of individuals with opioid addiction who were unable to access services in a timely manner and consequently, were dying before accessing care.

16 Situation Before the Clinic Medications used to treat opioid use disorder are expensive and participants were unable to afford treatment Once an individual was stabilized with MAT, there was a waiting period for residential treatment placement. Using several providers who required appointments and payment Many individuals were homeless Treatment was hostile to MAT

17 Opioid Response Partnership Goals & Objectives 1. Expand case management services to focus on the opioid population in drug court 2. Improve immediate access to opioid use disorder treatment and services facilitating stabilization and rehabilitation by : streamlining system of referral and follow-up for detox and treatment between the Adult Drug Court, Jackson Outpatient MAT program, South Florida Behavioral Health Network and other community providers; Providing residential and outpatient treatment and referrals for social services through community providers; Meeting the needs of pregnant women Moving people out of the jails

18 In Court History Court drug tests defendants and significant others at first court hearing Court takes an extensive family history of drug usage, mental health issues and trauma Services are set up on demand Family is engaged A case manager is assigned Assessment is scheduled A subsequent hearing is set within 2-3 days

19 Assessment The participants are scheduled, once arraigned to obtain an indepth assessment The assessment includes: Mental health screening form to assess mental health ACE (Adverse Childhood Events) to assess for trauma TCUDS-V (Texas Christian University Drug Screening) to assess for severity of drug use RANT (Risk and Needs Assessment) to determine the risks and needs of each participant Treatment is immediate

20 RANT Web-based tools that can be administered by non-specialists in 15 minutes or less Criminogenic risks are those characteristics of offenders that make them less likely to succeed in treatment or comply with drug court requirements without close monitoring (ie: early onset of substance abuse, early onset of criminal activity, deviant peer affiliations, prior treatment failures, unstable living arrangements) The needs are those areas of psychological impairment that, if effectively addressed, can substantially reduce the likelihood of return to substance abuse, crime and other misconduct (ie: substance use disorder, mental health, trauma, developmental issues) The RANT will categorize each participant into one of four quadrants:

21 Risk and Need Quadrants High Risk / High Need Standard Drug Court Track (10 Key Components) Status Calendar Intensive Treatment Compliance is proximal Sobriety is distal Focus consequences on treatment and supervision High Risk / Low Need Specialized Track (Accountability emphasis) Status Calendar Pro-social rehabilitation Prevention Services Abstinence & compliance are proximal Low Risk / High Need Specialized Track (Treatment emphasis) Noncompliance calendar Intensive Treatment Treatment is proximal Focus on treatment compliance Low Risk / Low Need Specialized Track (Diversion emphasis) Noncompliance Calendar Preventive services Focus consequences on abstinence

22 Facility Overview Jackson Behavioral Health Hospital provides a full continuum of care for children, adolescents, adults and seniors. We offer individual, couples, family, and group therapies. Whether inpatient or outpatient, from treatment through discharge, all services are supportive, and safe environment. At Jackson Behavioral Health Hospital, we are committed to meeting the needs of each client at each stage of treatment. TEAM MEMBERS: Patricia Ares-Romero, M.D. Chief Medical Officer Stephen McLeod-Bryant, M.D. Jeff Newport, M.D. Tamala Russell-Reed, ARNP Lavonia McCoy, LPN Jorge Larrea, MHS Romy Perez, LCSW Clara Lora Ospina, PsyD Jack Bartel, Psychology Intern

23 Jackson Behavioral Health MAT Clinic Immediate comprehensive behavioral health services Detoxification [Withdrawal Management] MAT Maintenance Complete Psychiatric Evaluation Individual and Group Therapy Medical Services Family practice ARNP University of Miami Medical partners LCSW, therapist and patient navigator participate in court staffing weekly for ORP clients

24 Nursing station and Mental Health Specialist area Reception and waiting area

25 MAT Protocol / Work flow Patients are referred from the Miami-Dade Drug Court Warm greeting & welcome by staff Urine toxicology screen and vital signs of the patient taken by Licensed Practical Nurse (LPN) Laboratory studies are drawn by LPN History and Physical Exam completed by our Family Practice - ARNP Psychiatric evaluation is provided by one of our psychiatrist Opioid Use Disorder medication determined by physician in conjunction with the patient. Suboxone/Subutex Naltrexone/Vivitrol System relief

26 Medication Assisted Treatment (MAT) Medical Protocol An evidence-based practice that utilizes medications in combination with behavioral therapies for the treatment of substance use disorders. I MAT with buprenorphine for opioid use disorder consists of three phases: Stage 1: Induction Phase (duration approximately 1 week) Goal is to find the minimum dose of buprenorphine at which the patient experiences minimal symptoms of withdrawal Stage 2: Stabilization Phase Dosage adjustments and frequent contact with patient during early stabilization Once stable dose is reached and monthly toxicology tests free of illicit opioids, physician determines less frequent visits are acceptable Stage 3: Maintenance Phase Longest period that a patient is on buprenorphine (period indefinite)

27 Suboxone Initial dose of Suboxone / buprenorphine received in clinic, patient is observed Patient is introduced to the therapist and scheduled for the next day or following day Treatment goal is 3 visits to our clinic weekly Patient is only given a 3-4 day supply of the medication at a time Patient is also given Narcan Kit on initial visit with education Urine drug screen prior to medication and every visit *

28 Buprenorphine Sublingual form retains patients in treatment and reduces illicit opioid use more effectively than placebo Reduces HIV risk behaviors Buprenorphine implants can be effective in stable patients (Probuphine) clinical trials showed to be as effective as relatively low dose sublingual (Suboxone) on patients already clinically stable Buprenorphine extended-release injection (Sublocade) FDA-approved in 11/17 to treat patients with moderate to severe OUD who have first received treatment with trans-mucosal for at least one week

29 Methadone Reduces the risk of overdose-related deaths Reduces risk of HIV and hepatitis-c infection Lowers the rate of cellulitis Lowers the rate of HIV risk behavior Reduces criminal behavior

30 Naltrexone Reduces illicit opioid use and retains patients in treatment more effectively than placebo vs no medication (random control trials) Longer time to return to substance 10.5 weeks vs 5 weeks Lower rate of return to use 43% vs 64% Higher percentage of negative urine screens 74% vs 56%

31 Goals of Treatment Increase the retention rate of participants / patients Decrease the rate of new arrests and convictions while enrolled in the program Decrease the number of participants incarcerated in the 12 months following program Increase the number of participants completing treatment programs Increase the length of time participants are able to maintain sobriety Act as a bridge of treatment to Inpatient rehabilitation treatment when needed

32 Medication management Treatment Modalities Therapeutic interventions [patient specific] Cognitive Behavioral Therapy Trauma centered treatment Motivational enhancement/interviewing Family therapy Addiction groups Psychosocial support Recovery oriented care Case management

33 Patient Centered Care Effective treatment attends to multiple needs of the individual and not just the drug use No single treatment is effective for everyone Treatment needs to be appropriate to the individual age, gender, ethnicity and culture Recovery-oriented approach in order to achieve and sustain better health, and improve their quality of life

34 World Health Organizations (WHO s) principles of good care for chronic disease Develop a treatment partnership with the patients Focus on the patients concerns and priorities Support patient self-management of illness Organize a proactive follow-up Work as a clinical team Ensure continuity of care

35 Maintenance Treatment OUD medication gives patients the time they need and ability to make necessary life changes associated with long-term remission and recovery such as: Changing people, places and things Minimizes cravings Avoids withdrawal symptoms Allows people to manage other aspects of their lives Parenting Attending school Work

36 Duration of Treatment with OUD Medication Discontinuation should be done slowly and carefully to avoid relapse Opioids change the reward circuitry in the brain affecting: Cognition Emotions Behaviors Discontinuation should be done on knowledge of the evidence base for the use of these medications, individualized assessments, and an individualized treatment plan. The best results occur when a patient receives medication for as long as it provides benefit maintenance treatment

37 Cost Effectiveness and Benefits Data indicates that medications for OUD are cost effective Methadone and buprenorphine are more cost effective than OUD treatment without medication Counseling plus buprenorphine leads to significantly lower healthcare cost than little or no treatment Additional benefits include: Reduce expenditures due to decrease crime Reduce expenditures related to decreases in the use of the justice system Improved quality of life Reduced healthcare spending Greater earned income

38 Key Insights Most of our patients began their OUD with prescription opioids and escalated to illegal drug use [Oxycodone and Heroine]. Significant percentage of our patients are tired of using opioids but have been unable to stop on their own. Trauma history is common in our patients. Hepatitis C Mood disorders both previously diagnosed and undiagnosed. Education on OUD treatment has been challenging for families and patients. Better outcomes evident with strong engaged family support.

39 Challenges Boundaries with clients Necessity for intensive follow-up Failing to show up for appointments Need to wait hours before starting medication Precipitated withdrawal Diversion of suboxone Challenges with corrections

40 Challenges Opioid Task Force resulted in increased communication and education for law enforcement and fewer arrests, creating an issue with meeting required numbers ( However, the Miami Dade Drug Court has expanded the legal criteria for entry into drug court in order to accept more individuals with opioid use disorder, i.e., probationers and some violent offenders High volume of potential participants low number of staff Sustainability Uninsured clients/participants

41 Challenges in the Community Lack of knowledge regarding MAT in residential programs. Participants are still being told that it is a drug and he/she is not truly in recovery while on MAT. Programs are hesitant to allow the participants to leave to clinic appointments and return with medication. NA and sober living houses Financial limitations

42 Process Flow Suboxone in Jail

43 Next Steps Education & Capacity building for other court personnel and providers regarding MAT and the ORP Expand MAT services (separate from ORP funding) to dependency court and other client populations in need Expansion of eligibility requirements for client intake Ongoing partnership with law enforcement and other stakeholders (Opioid Task Force) Collaboration with jails for MAT dosage prior to client release Sustainability planning and funding diversification

44 Coordination with others in the Community City of Miami Beach Task Force [Marchman Act] Quarterly Stakeholders Meetings Miami Dade County Opioid Task Force Crisis Intervention Teams Needle Exchange Program

45 County and ORP Demographics Population Demographics Miami-Dade County % General ADC Clients % OR Project % Gender (Male) 49.4% 81.1% 71.9% Hispanic (all races) 65% 72.3% 53.9% Black (Non-Hispanic) 19% 14.3% 4.5% White (Non-Hispanic) 15% 11.6% 41.6% Mean Age 38.2 years 29.5 years 31.2 years

46 ORP Client Characteristics Heroin, Morphine, Percocet, Fentanyl, Oxycontin, and Suboxone (misuse) were reported Clients reported polysubstance use (cocaine, marijuana, benzodiazepines) Just 12% reported injection drug use; self report and underreported 14% reported depression at follow-up, compared with 25% at baseline 45% reported experiencing lifetime trauma

47 Data from 2016-present 1,123 admissions into the Adult Drug Court 240 of these (approx. 22%) were identified with opioid use disorder Of the 240, 52 cases were not filed by the State Attorney s Office, leaving a total of 188 OUD cases entering ADC since 2016.

48 Data from 2016-present Of the 188 cases which were monitored: Predominantly white (95%) and male (68%) 94 were referred to the Opioid Response grant ( although the data is for all opioid related admissions since 2016, the clinic did not begin accepting referrals until mid However, we did have a physician that was working with us to provide MAT in the interim) Of the 94 that were referred, 29 refused MAT and returned to drug court with no clinic treatment (Included in non-mat data) 65 were placed on MAT (95% suboxone, 5% Vivitrol)

49 DATA Of the 65 who accepted MAT services at the clinic: 4 successfully completed ( 6%) (although the project has been ongoing for less than one year, some participants were referred to the clinic after having been active in the program, mainly as a step down from residential) 17 did not complete the program (26%) with one resulting in death) 44 remain active in drug court (68%)

50 Data The remaining 123 participants either did not receive MAT or received MAT outside of the clinic Did Not receive MAT Received MAT (not at the clinic) 88% Suboxone 6% Vivitrol 6% Methadone Successfully Completed Remain active 15 4 Did not complete (Includes participants on open warrant, refused treatment or were unsuccessful in the program) ( This includes participants receiving MAT prior to the implementation of the clinic. There were limited resources only for those who were able to pay. No structured program in place ) 91 32

51 Data 57% of those identified as opioid use disorder and NOT accepting MAT did not complete the drug court program. The remaining 44% are either still active in Adult Drug Court or have successfully completed the program. 35% of those identified as opioid use disorder who ACCEPTED MAT did not complete the drug court program ( this includes those who received MAT at the clinic as well as those who received it elsewhere). The remaining 65% are either still active in Adult Drug Court or have successfully completed the program.

52 Data Successfully completed and received MAT 84% Suboxone; 16% Vivitrol Successfully completed without MAT Average # of relapses Average months involved in drug court Average number of treatment episodes 86% had between 0-1 relapses 14% had between 2-4 relapses 12 months 14% over 18 months 86% had 1 treatment episodes 14% had 2 treatment episodes Attended residential 65% 50% 66% had between 0-1 relapses 34% had between 2-4 relapses 13months 13% over 18 months 64% had 1 treatment episodes 36% had 2 treatment episodes A treatment episode is defined as the period of treatment between admission and discharge from a facility. If the participant transitioned from residential to outpatient successfully, that is considered to be the same treatment episode.

53 Dependency Drug Court 40% of DDC clients have an opioid use disorder or alcohol use disorder 27% opioids 13% alcohol Use of Medication Assisted Treatment (MAT) - (Suboxone, Naltrexone, Vivitrol, etc.) 72% On Medication Assisted Treatment 24% Not on Medication Assisted Treatment 4% Began DDC less than 1 week ago

54 Dependency Drug Court Of the 24% not using MAT: 80% opioid use disorder All assessed for MAT eligibility, but declined 20% alcohol use disorder Ineligible due to medical concerns Six treatment facilities currently offer MAT services

55 Disposition Does the child need to be placed in the custody of DCF? Is DCF s permanency plan appropriate? Is DCF making reasonable efforts to achieve that plan? What is known about prognosis for opioid use/addiction? What is known about treatment? What is known about the capacity of opioid abusers to enter and stay in recovery? What is known about relapses? Evidence exists that shows Medication Assisted Treatment (MAT) is very effective for opioid use disorders. These medications such as buprenorphine (e.g., Suboxone, Subutex) and methadone are not heroin/opioid substitutes. They are prescribed or administered under monitored, controlled conditions and are safe and effective for treating opioid addiction when used as directed by relieving withdrawal symptoms and/or reducing cravings. Most individuals receiving MAT also need counseling to address underlying problems that contribute to drug use such as trauma, other mental health conditions, and unhealthy relationships and violence. Appropriate medication for opioid use disorders should not have adverse effects on intelligence, mental capability, or employability. If a person on MAT appears high it is likely that they are also using other substances. What case specific information does the judge need to know? Does the case plan include evidence-based treatment that the parent can access? Does the case plan identify, and address concrete supports the parent needs to engage in treatment? Does the case plan identify other substances the parent is abusing? Are these adequately addressed? Does the case plan identify any co-occurring disorders/issues (e.g. mental health, domestic violence, chronic physical health problems)? Are these adequately addressed? Have children under age 3 been referred for a Part C (IDEA) evaluation? Are child developmental delays being addressed? Does the case plan include an evidence-based parenting program as part of or in addition to drug treatment? If neglect or drug exposure was significant, has the childparent relationship been evaluated and is there a treatment plan to improve that relationship?

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