ADAPTING YOUR COURT STRUCTURE

Transcription

1 ADAPTING YOUR COURT STRUCTURE Developed by: National Drug Court Institute NDCI, March 2018 The following presentation may not be copied in whole or in part without the written permission of the author of the National Drug Court Institute. Written permission will generally be given upon request.

2 DEADLY OUTCOMES High risk to overdose and die Requires rapid upfront interventions Basic needs such as food and stable living must be addressed prior to other concerns Quick linkage to treatment and frequent on-going communication with treatment and case manager

3 DRUG USE DISORDERS: HIGH RELAPSE RATES High Probability of Relapse some say 50% after 1 st year Multifactorial Reasons for Relapse Genetic (heritable vulnerability) Environmental (exposure) Biological (demonstrated pathophysiology) Behavioral (lifestyle aspects) National Institute on Drug Abuse (NIDA) A chronic, relapsing brain disease characterized by compulsive drugseeking and use despite harmful consequences and by longlasting structural and functional changes in the brain

4 COURT ADAPTATION 1: TEAM

5 MAT: TEAM BELIEFS Have open discussion of team s perceptions False beliefs It s not real recovery It s just replacing one drug with another One medication should work for everyone Focus should be on ending medication quickly

6 EXPAND THE TEAM Prescriber Psychiatrist Physician Nurse Practitioner Physician Assistant Registered Nurse

7 HOW? Some ideas for finding prescribers: Patient s own physicians Local Federally Qualified Health Centers (FQHCs) American Society of Addiction Medicine (ASAM) membership directory and American Psychiatrist and Psychologist Association (APPA) The local American Medical Association(AMA) chapter. See if you can present at a meeting or conference, or if they will work with you to find physicians willing to provide MAT.

8 HOW? An high-level influential person from your Department of Public Health or state medical society. Ask this person to make an appeal to physicians on your behalf. The pharmaceutical company that developed the medication. A representative may also be able to help you recruit physicians.

9 EXPAND THE TEAM Identify consumer groups MARS Recovery Coaches Family Members

10 IDENTIFY THE NEIGHBORHOOD Law Enforcement/Probation Recreational/Libraries Mental Health Services Family Therapy Faith Community Community Foundations Schools/Colleges/Universities Government Agencies/Officials Drug Court Social Services Service Organizations Housing Arts Health Employment/Job Training Mentoring Programs Residents Transportation Literacy Programs Treatment Businesses Community-Based Organizations

11 TEAM TRAINING NEEDS On-line Mental health treatment Substance use treatment Trauma What else?

12 CHRONIC PAIN

13 WHAT IS CHRONIC PAIN? Most common complaint among those seeking medical care Pain lasting longer than the normal time for healing Persistent pain that is either constant or intermittent

14 EXAMPLE OF OPIOID PAIN RELIEVERS

15 EVOLUTION OF AN EPIDEMIC The Joint Commission recommendation Drug companies marketing strategy (safe, non-addictive) Stage set for increased opioid prescribing

16 EVOLUTION OF AN EPIDEMIC Time-release version of oxycodone, OxyContin, was introduced in 1996 Heavily marketed Chances of addiction were touted as miniscule because of the timerelease formulation

17 CONSEQUENCES Alarming increases in negative consequences related to their abuse. Emergency department visits increased from 144,600 in 2004 to 305,900 in 2008 Treatment admissions for primary misuse of opioids other than heroin increased from 1% of all admissions in 1997 to 5% in 2007 Overdose deaths due to prescription opioid pain relievers more than tripled in the past 20 years

18 REACTIONS New more tamper proof drug formulations Restrictions on doctor prescribing Efforts to stop online sales On June 16, 2016 delegates testified at the AMA s annual meeting that pain should be removed as a "fifth vital sign."

19 PRESCRIPTION DRUG MONITORING PROGRAMS (PDMPS)

20 PRESCRIPTION DRUG MONITORING PROGRAMS Collect electronically transmitted Rx data From prescribers & dispensers (i.e., pharmacies) Allow prescribers and dispensers to check their active patients Rx history Instituted in DC and all states but Missouri A few states mandate participation Medicaid officials may have access but private health plan case managers, pharmacy managers, fraud control, & Medical Review Officers currently do not

21 USES FOR PRESCRIPTION DRUG MONITORING PROGRAMS Prevention Early intervention Surveillance Education

22 YOUR EXPERIENCE How many of your clients report being prescribed opioid medications for chronic pain?

23 WHY OPIOIDS AREN T A GOOD CHOICE TO TREAT CHRONIC PAIN Overdose Risk Risk of addiction Tolerance Withdrawal Cognitive impairment Reduced coordination Brain (neuronal) changes Constipation Low testosterone Impaired healing Obstructive sleep apnea Hyperalgesia

24 PRENATAL EXPOSURE TO OPIOIDS HAS PREGNANCY IMPACTS An increasing percentage of women of childbearing age are using opioids Increased risks for stillbirth, prematurity, birth defects Medication Assisted Therapy (MAT) cannot be stopped during pregnancy Neonatal Abstinence Syndrome is on the rise Opioid withdrawal symptoms for newborn on delivery Withdrawal treatment of newborn is tapered & stopped over several days or weeks as symptoms subside

25 HELPING YOUR CLIENTS NAVIGATE WITH THE PROVIDER

26 BEST APPROACHES FOR DEALING WITH CHRONIC PAIN AMONG OPIOID USERS Step 1: Begins with a discussion on the causes of pain, non-narcotic medications, and advice on how to resume normal activities Step 2: self-management techniques, meditation, tai chi, yoga, exercise, injections, therapeutic massage, acupuncture, physical therapy, and spinal manipulation

27 BEST APPROACHES FOR DEALING WITH CHRONIC PAIN AMONG OPIOID USERS Step 3: Targets patients who need even more intensive interventions before they can return to normal activities in work and family life. The intensive interventions are often coordinated by interdisciplinary pain center-based teams and may rely on opioids

28 SUMMARY: OPIOIDS AND PAIN Opiate abuse is a huge national problem, but so is chronic pain. There are many effective ways to treat chronic pain that don t involve opioids If opiates are used there are safe ways to use them and monitor patients to keep them safer. For those who have developed addiction, treatment can be effective

29 PAW has Fact Sheets on Much of This Material or search wvu SAMHSA fact sheets

30 COURT ADAPTATION 2: PROCESS

31 COURT HEARINGS AND JUDICIAL MONITORING More frequent court hearings may be needed Hearings provide a good opportunity to recognize and reward positive behavioral change Language is important! Treat like any other treatment show no bias.

32 COURT ADAPTATION 3: TREATMENT

33 TREATMENT Table Exercise with the RFP

34 CASE MANAGEMENT Intensive Smaller caseloads Identify existing services Reduce conflicts between providers Assist the client (consumer) Consistent messaging about recovery

35 SAMPLE WEEKLY SHEET

36 PREPARING CLIENTS FOR MEDS Encourage clients to: Express concerns Ask questions Take notes Take as prescribed Open to medication prescribed

37 WORKING WITH THE FAMILY Counseling Community support Engage Non-traditional Narcan training

38 COURT ADAPTATION 4: SUPERVISION

39 COMMUNITY SUPERVISION CHALLENGES Smaller and specialized caseloads Case plans developed based on a validated assessment- time specific identifying problem, goals and strategies. More frequent home visits as often times these clients move frequently, have criminal associates that are present

40 COMMUNITY SUPERVISION CHALLENGES Medication Monitoring- Often times clients are prescribed medications that are addictive or mood altering. They also are hopefully receiving MAT as determined by a Physician We must be diligent in monitoring the medications. DEA data base/ Medication Letter/ Pill counting

41 EXAMPLE DOCTOR LETTER Your patient is currently on supervised probation and in the Drug Court Program. They have been diagnosed with a Substance Use Disorder and are currently in Substance Abuse Treatment. As part of the Drug Court program, your patient must provide documentation to the Probation Department within 72 hours if they are prescribed any pain medication, muscle relaxants, stimulants, anxiety medications or any other mood altering medication. As you know, all of these medications can be harmful to the treatment and recovery of Substance Use Disorders. If at all possible we would ask they be given an alternative medication, but we know this is not possible in all cases. In an effort to support the client in the recovery process we require frequent drug testing and monitor the DEA database to ensure the client is not seeking medication from multiple physicians. Unless the following documentation is faxed to us, any positives drug test will result in a sanction for the client up to and including incarceration. Therefore we would ask that you please Fax the following information to:

42 EXAMPLE DOCTOR LETTER Patient Name: Date of Service: Diagnosis & Code(s): Medication(s) prescribed: Dosage(s) Prognosis & length of treatment Name and address of agency Phone number FAX Number: Physician Name (please print) DEA #: Physician signature Date:

43 COMMUNITY SUPERVISION CHALLENGES Fugitive warrant receive priority Significant upfront supervision and then taper off as they become more stable and are meeting case plan goals Update case plans to ensure participant is achieving progress towards decreased likelihood of reoffending

44 ADJUST EXPECTATIONS Lifelong engagement in treatment is necessary and desirable. Highly structured program Titration is not appropriate unless the doctors discuss with the clients

45 PHASE ADJUSTMENTS Proximal Goals Distal Goals

46 FLEXIBLE INCENTIVES AND SANCTIONS No zero tolerance Wide range of rewards/incentives Considerations: Housing Medications Treatment participation

47 Considerations in Responding to Participant Behavior 1) WHO are they in terms of risk and need? 2) WHERE are they in the program (i.e., what phase)? 3) WHICH behaviors are we responding to (i.e., are they proximal or distal)? 4) WHAT is the response choice magnitude? 5) HOW to deliver and explain the response?