Preventing Opioid Overdose at Reentry through Jail- and Community-based Programs

January 14, 20202:00-3:30pm ET

Michele Worobiec, JD, CCMBruce W. Herdman, PhD, MBA

Hosted by SAMHSA’s GAINS Center

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Welcome and Housekeeping

Dan Abreu, MS, CRC, LMHCSenior Project AssociateCriminal Justice Division

Policy Research Associates, Inc.

The views, opinions, and content expressed in this presentation and discussion do not necessarily reflect the

views, opinions, or policies of the Center for Mental Health Services (CMHS), the Center for Substance Abuse

Treatment (CSAT), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department

of Health and Human Services (DHHS).

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Disclaimer

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Welcome Dan Abreu, MS, CRC, LMHCSenior Research Associate, Policy Research Associates, Inc.

Opening Remarks Jon BergSenior Public Health Advisor, SAMHSA

Presentation Michele Worobiec, JD, CCMVice President and Chief CounselTreatment Alternatives for Safe Communities (TASC)

Bruce W. Herdman, PhD, MBAChief of Medical OperationsPhiladelphia Department of Prisons

QuestionsClosing Remarks

Dan Abreu, MS, CRC, LMHCSenior Research Associate, Policy Research Associates, Inc.

Agenda

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Opening Remarks

Jon BergSenior Public Health Advisor

Center for Substance Abuse TreatmentSAMHSA

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Introducing Today’s Presenters: Michele Selig Worobiec, JD, CCM

• Is Vice President and Chief Counsel for Treatment Alternatives for Safe Communities (TASC).

• Provides executive leadership in corporate governance, legal risk management, policy and legislative initiatives, justice system relations, and national and international consulting.

• Served previously on the bench in Ohio for seven years, presiding over criminal and civil cases as well as the drug, mental health, and veterans courts.

• Was previous policy counsel for the Supreme Court of Ohio. • Holds a number of leadership positions, including serving as a board

member of the National Alliance for Model State Drug Laws (NAMSDL).

Introducing Today’s Presenters: Bruce W. Herdman, PhD, MBA

• Is Chief of Medical Operations at Philadelphia Department of Prisons, Pennsylvania.

• Has held numerous health care administration positions in Philadelphia, including Executive Director of the Philadelphia Mayor's Commission on Health, Senior Vice President for Psychiatric Services at Pennsylvania Hospital, Vice President for Risk Arrangements and Ancillary Services at Independence Blue Cross (PA), and Senior Vice President of Provider Network Management at Keystone Mercy Health Plan (PA).

• Is responsible for the delivery and quality of the medical, behavioral health, and dental services provided to over 25,000 incarcerated individuals annually at the prison and in the community.

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Preventing Opioid Overdose Death at Reentry: Framework

January 14, 2020

Michele Worobiec, JD, CCMVice President and Chief Counsel

Treatment Alternatives for Safe Communities (TASC)

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Framework: The Five Critical Activities

1. Minimize drug-enabling housing.2. Minimize overdose deaths within two weeks of release.3. Maximize rapid access to drug treatment.4. Minimize drug market activity.5. Minimize overdose deaths beyond two weeks; maximize

ongoing recovery.

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Benefits of the Five Critical Activities

∙ Community safety

∙ Lives saved∙ Successful

recovery

The five critical

activities

Crime & drug use reduction

• Activities may benefit many, but the framework is focused on people who are justice-involved and at highest risk of overdose (OD), including:

Those with a known history of opioid use including OD.

Those who have received opioid overdose reversal with naloxone (Narcan®) in the past.

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Target Population for the Framework

• Potential sources of individualized information:

Medical records (jail or other provider, if released)

Client (self-report, urinalysis)

Arrest and conviction record

Prescription Drug Monitoring Program (PDMP)

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Target Population for the Framework (Continued)

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Minimize Drug-enabling Housing.

Critical Activity 1

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Activity 1: Minimize Drug-Enabling Housing.

Why do this?• People, places, and things…

• Can be found in the home.• Are where the person is likely to spend much of their time.

• Saliency of drug experiences makes “it” real even if drugs and paraphernalia are not present.

• Person needs to avoid triggering environments.• Others in home might be in recovery or actively using drugs.

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Critical Activity 2

Minimize Overdose Death within Two Weeks of Release.

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Activity 2: Minimize Overdose Deaths.

Why do this?• There is a 12x increase in overdose (OD) deaths upon

release from any residential setting where substance use has not been possible. This includes jail, residential treatment facilities, and

other restricted settings.• Risk for OD death is higher than all other heightened risks

at reentry.

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Activity 2: Minimize Overdose Deaths (Continued).

Why do this?• Upon release, people may quickly return to pre-incarceration

drug dosages.• Tolerance for higher dosages no longer exists.• This is especially acute for opioids. Impact of fentanyl

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Critical Activity 3

Maximize Rapid Access to Drug Treatment.

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Activity 3: Maximize Rapid Access to Drug Treatment.

Why do this?• The path to reducing drug use requires rapid access to

and retention in the appropriate level of treatment, including when someone returns to using substances.

• Inclusion criteria should not require subjective items such as motivation for change or readiness for treatment.

• Rapid access provides opportunity to address co-occurring diagnoses (often mental health).

• Reduced drug use reduces crime.

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Critical Activity 4

Minimize Drug Market Activity.

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Activity 4: Minimize Drug Market Activity.

Why do this?• Drug Market activity… Disrupts the community/neighborhood. Creates fear in the public. Brings street gang activity and heightened police presence. Instigates crime, especially violent crime: shootings,

battery, and theft. Provides ready access to drugs.

(Resource: National Network for Safe Communities Drug Market Intervention)

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Critical Activity 5

Minimize Overdose Deaths Beyond Two Weeks.

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Activity 5: Minimize Overdose Deaths Beyond Two Weeks.

Why do this?• There is continued high risk of OD beyond two weeks

(risk reduces with treatment).• Treatment engagement and retention are key. • Substance use disorders may be chronic and recovery is

a lifelong process.• Relapse ≠ failure and is often part of the process.• Recovery supports are needed for durable recovery.

Critical Activities needed for those who are at highest risk of opioid overdose death:

• Housing that does not support drug use• Tight wrap around and handoffs that start immediately and last

for at least two weeks post release• Rapid access to all needed drug treatment• Minimized drug market activity• Ongoing monitoring and recovery support beyond those first

two weeks

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Framework Summary

Medication-assisted Treatment for Justice-involved People: The Role of the Jail

January 14, 2020

Bruce W. Herdman, PhD, MBAChief of Medical Operations

Philadelphia Department of Prisons

Philadelphia Department of Prisons (PDP): Charges

(Source: Philadelphia Department of Prisons; April 2019 snapshot)

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Who We Serve

People in the Jail: Characteristics #/%

African American 66%

Hispanic 19%

Caucasian 12%

Other 3%

Average age 34

Average grade completed 11

Average reading level 5th Grade

Experiencing homelessness 30%

From medically underserved areas (“MUAs”) 80%

Percentage with health insurance (on release) 92%

Average # of incarcerations 6.5 – 7.9

Average # of aliases 2.6

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(Source: Philadelphia Department of Prisons; April 2019 snapshot)

Days to Release

2%

13%20%

25% 28% 31% 34% 35% 36% 37% 38% 39% 40% 41%

57%

67%74%

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The Illness Opportunity

Serious Mental Illness 16%Behavioral Health Caseload 37%HIV 2.5%Chlamydia 3.6%Gonorrhea 0.9%Syphilis 2.2%Diabetes 5%Hypertension 12%Seizure Disorders 6%Substance Use Disorder (SUD) 75%+Hepatitis C 18% / 8.2%

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(Source: Philadelphia Department of Prisons; as of October 2019)

Drugs “On board” at Admission (2013 Data)

• 41% of all citizens incarcerated in PDP reported drug use.

• 74% of all citizens incarcerated in PDP tested positive for use at admission. 59% marijuana 22% cocaine 21% benzodiazepines 14% opiates 8% Phencyclidine (PCP) 4% amphetamines 3% methadone 3% barbiturate

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Resources

Services Delivery

Cardiology, Dentistry, Dialysis, OB/GYN, Optometry,Physical Therapy, Podiatry, Primary Care, Psychiatry, Routine Chronic Care, Wound Care

On Campus

All Other Specialists Off Campus

Laboratory Services 2-day turnaround or “STAT”

Pharmacy Same day or “Stock Meds”

X-ray Digital

Facility Staff

Corizon 250 FTEs

Centurion 119 FTEs

AmeriHealth All Hospitals / 90% of all physicians

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Pennsylvania: The Opioid Epidemic

2014: Pennsylvania Physician General standing order for naloxone

2015: 702 drug overdose deaths in Philadelphia

2016: 907 drug overdose deaths in Philadelphia

2017: 1172 drug overdose deaths in Philadelphia

2018: 939 drug overdose deaths in Philadelphia

2019: 1100+ drug overdose deaths in Philadelphia

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Pennsylvania Department of Prisons (PDP) SUD Programming

1993 2004 2017 2018 2019 2020OPTIONS treatment program (Opportunities for Prevention & Treatment Interventions for Offenders Needing Support)

Methadone maintenance by community treatment provider (CTP)

Public Service Announcement (PSA) Education of Inmates, Visitors & Officers

Nasal naloxone (Narcan) kit distribution (N=5,500 Kits)

Buprenorphine induction women’s jail pilot: 5-day prescription for buprenorphine at discharge

Release with Care Program

Buprenorphine induction: Women & Men; No prescriptions

Naltrexone (Vivitrol)

Buprenorphine-naloxone (Suboxone) induction: Women & Men; 5-day prescription for buprenorphine-naloxone on Release

CTP visits on campus

Buprenorphine induction: Women & Men; five days of Suboxone pills on release

Referrals and discharge summaries to Community Treatment Programs

Enrollment in Medical Assistance

Methadone induction

Buprenorphine extended-release (Sublocade)

Current medical assistance enrollment (90%)

Peer Navigation

Coordination with Department of Behavioral Health

Rigorous Program Evaluation

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• Release with Care staff meet patients within the 3rd business day after release. Patient and staff select a community medication-assisted treatment (MAT)

Center of Excellence. A referral is sent to that community MAT Center of Excellence. Post release appointments are made for sentenced patients. A discharge summary is sent to the relevant Center of Excellence on release.

• Patients on buprenorphine-naloxone (Suboxone) receive at least 5-days of medication (buprenorphine-naloxone pills) on release to the street.

• Release with Care staff complete and submit medical assistance (MA) applications the first day after release (MA is effective the day of release).

Preliminary results: 42% of women in the buprenorphine-naloxone program released with a prescription for buprenorphine-naloxone received substance use or behavioral health care or both within 30 days of release. 34

Current Discharge Planning/Execution

• Offer methadone induction (now only offered to pregnant patients with opioid use disorder (OUD)).

• Offer Sublocade at release.• Expand peer navigation services before/after release.• Coordinate MAT releases with Department of Behavioral Health.• Enhance cognitive behavioral therapy services.• Complete rigorous program evaluation.• Coordination with Probation and Parole.

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2020 Program Plans

Issues

• Waiver Limitations • Drug Enforcement Administration (DEA) Oversight • Diversion • Cost • Stigma• HIPAA• Housing

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Preventing Opioid Overdose Death at Reentry: Corrections Transition Program

January 14, 2020

Michele Worobiec, JD, CCMVice President and Chief Counsel

Treatment Alternatives for Safe Communities (TASC)

• CTP is located at Sheridan Correctional Center in Chicago, IL.

• Residents engage in substance use treatment, vocational and/or educational training, employment readiness programming, and specialized reentry case management.

• As a condition of parole, participants agree to continue community substance use treatment (or aftercare) and case management for at least 90 days.

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Corrections Transition Program (CTP)

• TASC provides specialized case management to assess needs, link participants to planned services, engage clients and monitor their progress, and respond to additional needs that emerge.

• Grant funding supports initiating medication-assisted treatment (MAT) prior to release.

• Parole agents attend to program compliance and community safety issues.

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Corrections Transition Program (Continued)

People are eligible for the program who:• Voluntarily choose to participate. • Are in need of substance use treatment. • Have between 9-36 months left to serve in prison. • Are eligible for placement in a medium security prison. • Have no disqualifying offenses.• Do not suffer from severe mental illness that would

interfere with their participation.

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Entry Into the Program

Admissions Process:• Department of Corrections screens residents for initial

eligibility. • Clinical substance use assessments determine the need

for treatment.

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Entry Into the Program (Continued)

Pre-Release Case Management Services• Strength and needs-based assessment for treatment,

housing, employment, other• Discharge planning• Post-release placement in community services• Health care coverage navigation

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TASC’s Specialized Case Management

Post-Release Case Management Services• Ensure engagement in substance use treatment and

other needed services upon release.• Monitor progress through client engagement and

communication with providers.• Identify and respond to additional needs that emerge. • Offer high intensity services to address risk for

overdose death and other urgent needs.

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TASC’s Specialized Case Management (Continued)

• Improved justice goals 21 percent lower risk of re-arrest for a new offense (33

percent lower risk if the participant was at Sheridan Correctional Center for at least nine months)

44 percent lower risk of re-incarceration

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Key Research Findings: Program Benefits

• Improved well being More successful in obtaining and keeping a job Improved levels of psychological and social functioning and

reduced criminal thinking patterns

• Improved rate of aftercare admissions and completion Achieved through coordination of pre-release planning,

community-based partnerships, and transformation of the parole model

More successful in overcoming barriers to effective re-entry

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Key Research Findings: Program Benefits (Continued)

Trends among participants who experienced recidivism reinforce the framework’s critical activities.

Housing• Those who returned to their original neighborhood

returned to substance use sooner. • Those living in neighborhoods that were perceived as

unsafe and/or where drug dealing was common returned to substance use sooner.

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Factors Related to Recidivism and Substance Use

• Activities Unemployed participants engaged in criminal activity sooner. Those who spent time with people engaged in substance use

and/or criminal activity returned to substance use sooner. Those with gang involvement engaged in criminal activity and

returned to substance use sooner.

• Treatment Those who did not complete aftercare engaged in criminal

activity and returned to substance use sooner.

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Factors Related to Recidivism and Substance Use

The Corrections Transition Program addresses the key needs for those at highest risk of opioid overdose death:• Housing that does not support drug use is secured prior to

release.• Tight wraparound and handoffs start immediately and last for

at least two weeks post-release for a seamless transition from pre- to post-release case managers.

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Back to the Framework

• Rapid access to all needed drug treatment continues with the appropriate levels of care in the community.

• Minimizing drug market activity factors into service planning, partner relationships, and advocacy.

• Ongoing, specialized case management goes beyond the first two weeks.

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Back to the Framework (Continued)

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Additional Resources

https://store.samhsa.gov/product/Use-of-Medication-Assisted-Treatment-for-Opioid-

Use-Disorder-in-Criminal-Justice-Settings/PEP19-MATUSECJS

https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA18-

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Substance Abuse and Mental Health Services AdministrationSAMHSA’s mission is to reduce the impact of substance abuse

and mental illness on America’s communities.www.samhsa.gov

1-877-SAMHSA-7 (1-877-726-4727) ● 1-800-487-4889 (TDD)

GAINS Center for Behavioral Health and Justice TransformationThe GAINS Center focuses on expanding access to services for people with

mental and/or substance use disorders who come into contact with the justice system.

https://www.samhsa.gov/gains-center1-800-311-4246

Thank You

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