- ...and we'll make it available on the SAMHSA YouTube channel
for others to access.
So please note, it's being recorded as just mentioned.
Another disclaimer.
The views, opinions, and content expressed today
are the views of the presenters, and do not necessarily reflect
the official position of SAMHSA or HHS.
As noted, everybody's line is muted.
You can submit comments and questions in the chat function.
There will be some time dedicated at the end
for you to pose questions,
but feel free to submit questions throughout.
As the presenters see them,
they will try to answer them throughout.
Otherwise, there will be some time at the end
to go over your questions.
The webinar is accredited for continuing education credits,
one point four five credits.
In terms of how you can obtain the credits,
there will be an evaluation form.
We will send it out via email after the webinar,
but you can also download the form
through the link provided on the screen.
So, after the webinar,
and after you've received the document,
please fill out the document and send it back to Abigail Durak
at the email provided on the screen,
and I will also put up the screen again
at the end of the webinar so you can see it again.
So, we have a great lineup of presenters today and moderator.
The moderator is going to be Jon Berg from SAMHSA.
We're having some technical difficulties with him
joining the call function of the webinar,
so hopefully, he will be able to join
in a few minutes for him to moderate the webinar.
We also have Mark Parrino as a presenter.
He is the president of the American Association
for the Treatment of Opioid Dependence.
He will be providing an overview of the problem.
After that, we have Dr. Andrew Klein.
He's the senior scientist for criminal justice
at Advocates for Human Potential,
and he will be talking about the benefits
of medication-assisted treatment for the criminal justice system.
Then we have Dr. Kathleen Maurer,
and she will provide an overview of her experience
from Connecticut in terms of implementing
medication-assisted treatment for these settings.
So, she will share some of the lessons learned from her state.
After that, we have Kevin Pangburn.
He will be sharing lessons learned from Kentucky,
and he is the director
of the Division of Substance Abuse Services
at the Kentucky Department of Corrections.
Then, as mentioned, after that, we have some time for Q&A.
Jon, were you able to join the call?
It doesn't seem like Jon was able to join,
so I think we'll go ahead and start with the first presenter.
Mark Parrino, I will unmute you, so you're unmuted now.
So, as I mentioned, Mark Parrino is the president
of the American Association
for the Treatment of Opioid Dependence.
He has been involved in the delivery of healthcare
and substance abuse treatments since 1974,
and will be sharing information today about the problem.
Mark. - Oh, I don't know.
Thanks very much, and I'm happy to be with you.
AATOD has been very much involved in this problem
of providing access to medication-assisted treatment
for substance abuse disorders at correctional facilities
for over 20 years.
About 17 years ago,
I was asked to write an article for American Jails Magazine
in their May 2000 edition, and I'm quoting from it.
"It is ironic that methadone
was used as an experimental medication
to treat heroin addiction in the federal prison system
in Lexington, Kentucky, in the 1950s."
And I'm aware that one of our speakers
is aware of this history.
At the present time,
now remember, this is 17 years ago,
Rikers Island was the only correctional system
in the United States
that treats heroin-dependent inmates with methadone,
referring them to treatment programs on release,
and this was called the Key Extended Entry Program.
It still exists at the longest-running
correctional system in the United States.
With regard to the extent of the problem we face,
I believe that most policymakers fully understand
that we are in the middle
of a major opioid use and abuse epidemic.
This has been redocumented with over 90 deaths per day
with federal and state legislatures and policymakers
in counties and municipalities doing a number of things
to increase access to care.
The access to care in correctional facilities
is still restricted, and according to a source
of the Pew Charitable Trust in 2016,
and I'm quoting from the piece,
"Of the roughly 3,200 local and county jails
and 1,800 state and federal prisons in the United States,
fewer than 40 provide addiction treatment
using methadone or buprenorphine for inmates
with an opiate addiction.
But a growing number are beginning to offer
alternative medication such as extended-release naltrexone
or Vivitrol."
And this has been recently reported.
It is also important to reference
a number of training opportunities,
and I know that Dr. Klein is going to be familiar with this
since his organization,
the Advocates for Human Potential, created this.
Nicky Miller was the author;
it was the Residential Substance Abuse Treatment
(RSAT) training and technical assistance tool
about medication-assisted treatment
for offender populations.
This was available on March 10, 2013,
and still provides an extremely good reference source
for training.
So, on the positive side,
there are a number of major events happening,
and I know that Dr. Maurer in Connecticut
is going to talk about what I perceive to be
some of the most progressive policies
regarding the opportunity for inmates
in correctional facilities in Connecticut to get access
to medication-assisted treatment
and then align them with treatment programs,
and I'm going to be looking forward
to that presentation, too.
So, there are...
why don't we go to the next slide, please?
So, there are three meditations federally approved
to treat opioid-use disorders in the United States.
The longest running is methadone
which has been in use since the 1960s
based on Rockefeller studies
at Rockefeller University in New York.
Clearly, it is the most studied
of the three federally approved medications,
just given its longevity in the system of use.
The second is buprenorphine
which has been in use for over 10 years.
Methadone is used exclusively
through certified opioid treatment programs,
certified by SAMHSA,
and also regulated by the Drug Enforcement Administration,
and also regulated by state opioid treatment authorities.
And the last is Vivitrol/naltrexone which,
over the last couple of years, is gaining increased favor
because it is a monthly injectable medication.
It does not have
dependency-producing characteristics,
and it is not diverted,
and so, that is part of the value of that.
Of course, what's been recently reported is,
there is still need
for long-term patient outcome studies.
So, this article was written by Dr. Alan Leshner in 2001.
He was the former NIDA director
and the title is, Addiction is a Brain Disease.
Next slide.
And it's important to keep in mind
that this is "A core concept that has been evolving
with scientific advances over the past decade
that drug addiction is a brain disease
that develops over time as a result
of the initially voluntary behavior of using drugs.
The consequence is virtually uncontrollable
compulsive drug craving, seeking and use
that interferes with, if not destroys,
an individual's functioning in the family and in society.
This medical condition demands formal treatment."
By that, Dr. Leshner means medical treatment.
I know there are lots of debates
about why medication should be used,
how they should be used.
All three have value, the three I've mentioned.
All three should be used as part of a comprehensive treatment
which involves medication
and the use of counseling and other services.
That's what NIDA and SAMHSA have repeatedly documented
over the course of so many years,
and that has not changed at the present time.
Next slide, please.
In this area, NIDA has provided resources, as has SAMHSA.
This one comes from NIDA,
The Principles of Drug Abuse Treatment
for Criminal Justice Populations.
It is available through their website.
It's an excellent overview of this particular topic.
Next slide, please.
This comes back from an NIH consensus statement from 1997,
historical context, and it basically states
"The panel calls attention to the need for
opiate-dependent persons under legal supervision
to have access to methadone maintenance treatment.
The Office of National Drug Control Policy
and the United States Department of Justice
should implement this recommendation."
Once again, this is 1997. This is very slow-moving.
So, the concept here is that the current opioid epidemic,
and I think that Dr. Maurer will discuss this in Connecticut,
basically is moving this along
and implementing this kind of recommendation.
Next slide, please.
This is not an exclusive list.
This talks about different models of treatment.
As I said, the Rikers Island Extended Entry Program
is the longest running.
It has an interesting distinction.
It both continues treatment for patients who are enrolled
in methadone and buprenorphine at the time of incarceration
but it also diagnoses and then initiates treatment
for substance abuse disorders if they are new
and then become inmates to Rikers Island.
Rhode Island is evolving.
CODAC has been delivering medication,
methadone and buprenorphine, to inmates,
but recently, in the last two months,
CODAC has initiated an exciting new opportunity,
and what they are doing is providing the first
fully operational OTP within the jail
under the operational agents of CODAC.
Florida also has medication delivered by local providers.
The Philadelphia prison system like Rikers Island
provides access to care within the prisons,
and the Baltimore County jail
has been offering access to medication,
especially prior to the inmate's release,
and this is becoming a more popular trend
as inmates with former opioid use disorders,
worried about relapse, are now accepting
either buprenorphine or Vivitrol injection,
and New Mexico has access to treatments,
and so does Washington state.
So, this is a more positive development.
Next slide, please.
And just to be clear, generally the opportunities for
medication-assisted treatment in correctional settings
either comes from something like Rikers Island,
or from Philadelphia, and now the CODAC facility,
but more typically, a registered and certified OTP
delivers medication to the correctional facility
and then the correctional facility medical staff
will then dispense the medication to the inmates.
That is fairly typical.
Another opportunity exists when the inmate is transported
from the correctional facility to the OTP
so that the inmate will be medicated
in the outpatient setting,
and then returns to the correctional facility.
This next slide shows a study
that the National Development Research Institutes did, (NDRI)
basically talking about medication-assisted treatment
in the survey in drug courts.
While you may not be able to see this,
you can certainly write me.
My information is at the end of this presentation,
and I can get you the full study.
Ultimately it shows that 50% of the drug courts
did actually refer people to some medication
to treat addiction.
Although there's a far distance to go,
I'd say of all the criminal justice settings,
the drug courts seem to be the most progressive
and most inclined to refer people
to medication-assisted treatment.
Next slide.
This is a Legal Action Center paper.
It's one of the most impressive I've read.
It's a Legality of Denying Access
to Medication-Assisted Treatment in the Criminal Justice System.
It makes a legal case for why
such medication should be provided.
This paper is on their website
and for anybody interested in this topic,
I would suggest that this is required reading.
Next slide, please.
These are the current maps.
It's prepared by SAMHSA of OTPs in the United States.
There are now just over 1,500 fully registered, certified OTPs
in the country.
They're in 49 states.
As you will note in looking at the map,
Wyoming is the only state without providing any OTP.
Also notable is West Virginia.
It still has a moratorium on opening new OTPs
which has been in force since 2008.
Certainly, our hope is that since they have the highest
per capita opiate-related deaths in the country,
they would certainly be looking to open that moratorium.
We think the OTPs will be continuing to expand
over the next several years,
and SAMHSA has done a great job
of moving those applications along.
Next slide, please.
Ultimately, and this is where I conclude,
SAMHSA did a workforce training assessment for SAMHSA
last summer in 2016,
and 50 OTP CEOs from 30 states responded,
and you'll note that they wanted training of jail medical staff,
contractors in provision of the MAT,
and assistance in supporting correctional facilities
to be able to provided such treatment.
Next slide, please.
Continues with why to have memoranda of understanding
between OTPs and Correction, and have cross-training
so inmates would basically be able to get released
and basically admitted to OTPs,
and this would apply to dated de facto practices
which use buprenorphine.
Next slide, please.
The final recommendations, that the jails, drug courts,
and child protective services work with OTPs,
and that the OTPs work with correctional facilities.
The interesting point here is that 70% of the respondents,
OTP respondents, were looking for this.
Next slide.
And this is how you access me if you have any questions
that don't get addressed during this webinar,
and thank you again for the opportunity.
This is simply to set an overview
for the following speakers.
Thank you.
- Thank you very much, Mark.
Before we move on, I just wanted to check.
Jon Berg, are you able to...
can you please if you can, say something?
- Yes, this is...
- Hi, Jon.
Can you try it one more time?
Jon? Are you able to hear me?
Okay. Then we will just move on.
- Can you hear me?
- Yes, I can hear you. Yes.
- Okay. So sorry about that.
I'm not sure what the technical difficulty was.
Firstly, I'll do a brief intro.
- Okay. Thank you.
- So thanks, Ann, for opening today's webinar
on the benefits and cost savings of MAT services
in a correctional setting and for the introduction.
I'm the subject matter expert
on the criminal justice team with CSAT
and appreciate the opportunity
to help moderate this important webinar.
SAMHSA is pleased to host this webinar
on MAT services in correctional settings,
and I would like to welcome the MAT-PDOA grantees today
and thank you for taking time to attend.
The US is facing an opioid addiction crisis,
and it is impacting grantees like you every day
as you work to provide evidence-based practices
in an array of MAT services to your clients.
During five visits and conversations with grantees,
SAMHSA noted that grantees are exploring
how to expand access to MAT
for incarcerated individuals in their states
since this population experiences high rates
of opioid use disorder.
SAMHSA has made it a priority for our grantees
to increase efforts to provide MAT services
to assist those in the criminal justice system,
to provide SUDs including opioid use disorders
to decrease opioid overdoses and decrease recidivism.
The goal of this webinar is to provide an overview
of the problem which Mr. Perrino just provided a great overview,
and we appreciate that.
To describe the benefits of MAT for incarcerated individuals
and those being released back into the community
and provide examples from the field,
we have a great lineup of speakers today,
including speakers from the Department of Corrections
from Connecticut and Kentucky.
Their bios have been provided to you,
so please read them, as I've been asked not to
to allow more time for the presentations.
So, thanks again, Mark, for your presentation.
Our next speaker is Dr. Andrew Klein,
senior scientist for criminal justice
at Advocates for Human Potential.
He has extensive experience with criminal justice,
working with the criminal justice system
and related topics.
We appreciate you taking the time to present today, Andy,
on the benefits of MAT for the criminal justice system.
So the time now is yours, Andy.
- Great. Thank you, Jon.
I assume everybody is hearing me.
Okay. Good.
Yeah, I'm just delighted to speak today
for this SAMHSA webinar,
and I'm delighted to speak to the grantees who have signed up
because I think any failure to address the opioid epidemic
in our correctional facilities is a sorely missed opportunity
because this is an ideal opportunity for us
to begin to offer treatment,
and prevent a lot of tragedy and deaths in the community.
So, I'm excited that you're interested in this.
For the last seven years,
I've been contracted by the Justice Department
to provide technical assistance
to the jail and prison drug treatment programs.
It's the only federal program that offers
incentives for jail and correctional treatment
for persons with substance use disorders.
And I can admit, despite our good work...
could I have the next slide, please.
Basically, if you have a characterized
correctional drug treatment program,
you would say they're a failure.
And we know they are a failure because we know,
no matter how good the program is in-house,
it dissipates very quickly
if nothing happens in the community when they get out,
and we know the majority of inmates now who participate
in drug and in-jail drug treatment programs
don't make it into follow-up treatment
after they get released from jail or prison,
as this slide shows,
from a 2016 publication put out by the Justice Center.
We also know that this is an extremely high-risk population
because we know a third of those incarnated
are basically recycled addicts or persons with use disorders--
we're not supposed to use dramatics anymore,
who have failed community-based treatment,
even mandatory treatment.
So, they've had technical violations
in their parole and probation,
and they're sent back to prison or jail.
So, this is a high-risk, high-need population,
many of whom have already failed abstinence-only treatment.
We also know the death rate
for persons leaving jails and prisons
for a drug overdose death
is 170 times that of the general population,
and there's the site, if you want to study that.
Frequently, you'll read in newspaper articles,
they'll say 12 times as high as the death rate,
but that's the overall death rate for suicide,
homicide, heart attack, et cetera.
If you're just specifically looking for the likelihood
of dying of a drug overdose,
it's 170 times that for this incarcerated population.
So, this is extremely important that we deal with this.
Next slide, please.
Which we can skip because Mark already described this,
but this is... we know now that MAT is the standard of care,
and so, part of standard of care means
that this should be the expectation
and that should be true for Corrections, too,
or dealing with justice-involved populations.
They deserve the same standard of care as everybody else.
Next slide, please.
Mark talked a little bit about some of the models.
Currently, as of last week, as far as we know,
we now have 161 jails offering MAT in 27 states.
That sounds impressive until you realize
there are 3,200 jails across this country.
The majority of state Departments of Corrections
now at least have a pilot MAT program in progress,
and this does not include the traditional methadone programs
given for inmates during the course of their pregnancy.
We also know, as Mark has outlined,
there are a handful of jails and prisons now
that maintain those already on agonist medications
when they get in, and they continue them
rather than making them go detox and go cold turkey.
We also know, as Mark talked about
that Rhode Island Department of Corrections
now offers all three medications,
methadone, suboxone,
(well, they actually use suboxone or buprenorphine)
or naltrexone.
They also are inducing inmates on it who are drug-free,
if they think the person wants it,
and they think that's required for long-term recovery
when they get out of prison.
New Jersey, I understand, is now planning to offer
both buprenorphine and Vivitrol.
Next slide, please.
So, the basic MAT models we have in prisons and jails now,
there are basically four models,
the most common model which is, of those 161 jails
and they all offer this,
which is one naltrexone injection
immediately prior to release
because the naltrexone injection marketed as Vivitrol,
as many of you probably know, it's good for about 28 days.
So, it's perfect, especially for that high-risk period,
when somebody gets out with low tolerance for drugs.
So, it can hold them over
until they get plugged in to the community
and hopefully get into treatment and continued medication.
So, it's generally one injection.
It's very popular because the company that makes Vivitrol
provides it free for the correctional institutions,
just the first one,
not the follow-up injections in the community.
So that's the most common prison and jail model MAT program.
A second one that's newer is they do the one injection
combined with some sort of form of naltrexone maintenance.
So, while the person is in prison,
they have multiple injections,
and you'll be hearing from Kentucky later on
and they'll talk about that they have more than one injection,
and other correctional facilities are giving
oral naltrexone, the pill form,
for at least a month prior to the injection
before they are released.
They'll do the pill form
because it's obviously a lot cheaper
than the injections.
The third model in prisons and jails is maintenance,
agonist maintenance,
and that's either methadone or more recently buprenorphine,
and that's generally for people
who are already on that medication
before they get incarcerated.
So, then they don't have to go through withdrawal,
and the agency provides these medications
while they're in treatment,
and this is generally limited for a certain amount of time.
If somebody has a 14-year prison sentence,
I don't know of very many programs
that are intending to keep them on methadone or buprenorphine
for 14 years, but especially in jails
where the sentences are a lot longer,
it's more feasible to keep somebody
on their maintenance program,
and you'll be hearing a model in Connecticut
about that later on.
Then the fourth model is what Rhode Island has done
and that is all medications including induction
based on need and desire of the individual as appropriate.
So, these are the basic four models.
You'll be hearing about two of the models
in more detail today.
Next slide, please.
So, let me just summarize the best practices
which are common to all of these programs,
and I'll go through them very quickly
because you'll hear more details
from the specific examples given.
Obviously, it's medication-assisted treatment,
so, it's assist treatment.
So, it's not in lieu of,
and except with one state Department of Corrections,
all of these have concurrent counseling
or other treatment programs
while they're enrolled in the medication program
or are going to be released on Vivitrol.
The best practices informed all the participants
of all the FDA-approved medications
because even those programs
that only offer one form or the other,
once the inmate is released, a lot of them switch.
So even in one program, one state,
they've had a couple of hundred so far
that have been released on Vivitrol
and 10% then switch to either methadone or buprenorphine
after their release, which is totally okay.
Obviously, it's a volunteer.
You can't mandate, well, you probably can,
but it's not generally the practice to mandate,
that somebody has to take a medication.
There are some medications that are mandated
if somebody's life is at stake,
but that generally is more on the antipsychotic medications,
not the SUDs medications.
Generally, to make these medications available,
cost-feasible when they get out is these programs enroll.
It's very important to enroll the participant in Medicaid
or arrange for free healthcare or free medication
when they get out for the non-Medicaid expansion states.
And there are prison and jail MAT programs
that operate very well in states
that don't have Medicaid expansion.
So, this is not limited just to the Medicaid expansion states
although that makes it certainly easier.
The other states, you need a state appropriation
or free care [indistinct].
Also, as part of the medication issue,
you have to have the appropriate tests, et cetera,
to make sure the person can tolerate the medication.
Also for Vivitrol or naltrexone,
there has to be at least 10 days of abstinence,
and generally, a lot of these programs,
they give an oral dose,
just to make sure that somebody is not allergic
or will have an adverse reaction
before they give the long-term shot.
Okay. Next slide.
Very important.
So, once you begin the program behind the walls is,
what happens is just as important,
if not more important, after the wall.
Generally, there should be a warm handoff
to the treatment provider in the community.
If you just give the person leaving jail or prison
a list of referrals and say,
"Go make a call when you get out",
it's not going to happen,
and we know it's not going to happen.
Very important to have what we call a warm handoff
so that the community-based program goes into the prison,
meets with the person before they get out
to let them know what's going on and how to get there, et cetera,
or to provide somebody
to actually meet them at the prison door
to take them for their first appointment.
The best practice, obviously,
have continuity of recovery support,
before and after release.
In fact, some prison systems now have people who work
with the inmates three months before their release
and then follow up a year afterwards
to help them maintain their recovery.
Obviously, allow inmates to switch,
to choose which medication is more appropriate for them
over time.
Some people may want to switch off an agonist medication,
go drug-free, and if they can't, if they need assistance,
then go on to naltrexone or vice-versa,
or somebody may become pregnant
and decide it's safer to be on methadone
during the course of their pregnancy, et cetera.
It's very important to encourage people
to take medications and remain on it
for the required amount of time.
The problem is, we don't know really
what that required amount of time is.
The standard is one year for methadone,
at least a year for methadone.
We don't have those standards for buprenorphine or naltrexone,
but the general feeling is, more is better than less.
You can mandate treatments.
You can mandate abstinence.
But you can't mandate, as I said before, medication
in terms of the person is going to be released
on probation or parole.
Next slide.
Some of the common challenges is getting buy-in and leadership
from the Department of Corrections
or the behavioral health agency officials and line staff.
That's very important.
Most of the prison programs that started from the top down,
the governor says, "We're going to do this"
and then the Department of Corrections works on that,
or the sheriff says, "We're going to do this"
and they do it.
Very important issue is getting buy-in
from those who are incarcerated and their families.
Traditionally, these programs typically do not reach
the vast majority of people even in treatment
who recognize they have a problem,
but they don't opt for these programs.
So getting buy-in,
and a lot of them is because their families
may not have an understanding of what's going on
and they discourage them, saying,
listen, you're finally drug-free;
we don't want you back on drugs.
They don't understand the difference.
Specific problems for some prison systems,
if they have contracted medical care,
is to get them to agree to administer these programs
because it adds cost, and if it's not in their contract,
some of them may resist providing this care
even though it is, as I said before,
standard of care.
Also, linking to the methadone clinics
which they've done in Connecticut,
and you'll hear about, if you want to introduce methadone
because prisons are not generally licensed
to be methadone clinics, and you'll hear about that.
Then getting the networks
of community-based treatment providers on board.
I know when one state, Massachusetts,
began its Vivitrol exit program, they found out
there were only four community agencies
that would provide follow-up medication
where the doctors were willing to do that and measure it.
So, they went out there
and they created a network of 30 different agencies.
So, it's very important to facilitate that partnership
between the community-based treatment programs, providers,
and the correctional program.
And then another common challenge was,
a lot of states were all set to go
and then they found out their state Medicaid
had all sorts of preconditions
before they would provide for the medication
or the medication was not on their preferred list
for drug treatment.
So, it was harder to get those prescribed.
So, they actually had to go and work with their Medicaid states
to see if they could get those rules liberated
to get these medications available
because obviously when you're dealing with people
out of prison and out of jail, they're high risk.
So, you shouldn't have any hoops for them to jump through
before they access any of these medications.
Next slide.
So those are a few more common challenges.
Obviously, we're dealing with a high rate of people
with co-occurring disorders.
It's more often the rule than the exception,
and there are some studies that talk about that.
And so, we have to be able to deal with
the co-occurring disorders.
If we're talking about SUDs treatment,
we also have to be talking about co-occurring treatment,
treatment for mental illness,
and that has its own set of problems and challenges.
Next slide.
Does it work?
You know, correctional, there's been a lot of studies on MAT,
especially methadone.
There have been very few studies of MAT
in the context of justice-involved populations,
but we do know this so far.
We know that uniformly the post-treatment referral rates
or people showing up post-release to treatment
are very high for those on MAT, whether it's methadone at 83%,
or naltrexone or Vivitrol at 78%.
They're much more likely to show up to
community-based treatment if they're on MAT
because they want to continue the medication.
If they're not on MAT and just on abstinence only,
the majority as we started this slide, don't show up.
So far, we know from these programs,
even the programs that have been around for three years,
we know there's a lower reincarceration rate
than would normally be expected.
Barnstable, which is a county in Massachusetts,
has one of the oldest Vivitrol release programs.
They've been around for more than three years now,
and they're still only averaging an 18% reincarceration rate
which is much higher than the usual 40% or 50%
reincarceration rate at that institution.
However, we know, too,
that there are no magic cures on any of these programs.
Pennsylvania, when they started the Department of Corrections
Vivitrol release program, they provided for six shots,
and they found that on the seventh month,
they lost a lot of their inmates to relapse,
and they're now recommending one-year injection.
That was confirmed by a study by Dr. Lee
where he compared Vivitrol with abstinence.
It appears that six months works for six months,
but it's probably not enough for injections.
So, we know from methadone
that the recommendation is usually a year of maintenance,
and I would assume the same thing is probably true
of buprenorphine.
We do also know that one of the problems for MAT
in the prison and jail setting
is what Mark and others have referred to,
is the problem of diversion and the extra expense of
safeguarding, not only the medications in the present,
but the prisoners taking those medications
and stopping diversion.
Next slide.
Costs.
We do have one.
The RSAT website
which is the Justice Department TA website,
we have for prison and jail drug treatment programs,
a new study that was done
where we list what every state covers in their Medicaid program
for SUDs treatment and for medication.
So, that will tell you whether there are preconditions
or the availability of payment
for these medications in your state,
and we'll tell you the challenge,
if there aren't, to get them done to do.
We also know in terms of savings so far,
I just took one out of a hat,
Sacramento jail started a program a couple of years ago,
and they halved their recidivism rates,
and so their cost avoidance, they figured by
each successful inmate staying out a day from relapsing
and recidivating saved them $125 a day.
So, we're talking potentially about a lot of savings
even with, you know, not a magic cure rate.
In addition to the savings,
you have tremendous savings in terms of police, prosecution,
courts, and correctional costs,
as well as the reduced medical and healthcare costs
because obviously, treating people
in emergency medical rooms for overdose is very expensive.
A new study just came out that came to my attention.
It was a health plan study of 2.5 million people
covered by health insurance
who had at least one opioid prescription,
and they studied them and they found out
that those of them that were high risk based on
the number of prescriptions they were given in a year,
with treatment and MAT, there was a 40% reduction
in treatment costs over 12 months.
But the real treatment costs... next slide...
are treatments like this of David
who was picked up in Michigan for reckless driving.
He was given a fine of $774.
He couldn't pay it,
so he was given the alternative sentence
of 30 days in jail.
He was on methadone maintenance before he got there
because he had opioid use disorder.
They refused to continue on methadone,
so they put him on a two-day jail detox program
which was not enough.
He then went back to his cell,
and he was suffering from withdrawal,
featuring hallucinations, et cetera.
So, they put him in the psych cell,
which was basically just a cell
where he was under 24-hour surveillance for suicide,
and the next 14 days, he lost 50 pounds,
and he ended up dying on the 16th day in jail
for failure to pay the $774 fine,
and the death was dehydration, starvation,
and acute withdrawal.
And this was in the county jail for operating recklessly.
So, these are the costs.
This is the real cost of failing to provide MAT
for persons in jail.
Next slide.
Mark talked about some of the programs available.
The National Institute of Corrections
and the Bureau of Justice Assistance
have teamed together to develop
Centers of Innovation for MAT Programming
for states and county correctional teams,
and we have various prison and jail model programs
that NIC will have state correctional teams
of community and correctional treatment providers go to,
to learn from these communities
how to develop MAT programs in their prisons and jails.
There is a new Promising Practice Guidelines for RSAT.
It is available on our website that talks about this
that has an appendix of 26 pages
of another promising practice guidelines
which are in the works specifically for MAT
for justice-involved individuals,
and finally, last slide...
Which is the National Institute of Corrections.
Oh, that should say NIC.gov, not NICIC.
On their website,
or if you contact the chief of the Jails Division
at samos@bop.gov
the NIC does offer MAT TA for Corrections
if you were to email them, and they will provide
or fund experts to come to your facility
or your treatment community to advise you how to work with
jail or Corrections to build an MAT program
for justice-involved populations.
Thank you very much.
- Thank you so much, Dr. Klein.
I just wanted to make sure, can you hear me?
- Yep.
- Great. Thanks.
Appreciate the great information on MAT benefits, challenges,
and best practices, and look forward
to your fielding questions at the end of this.
I would like to now turn it over to the next speaker,
Dr. Kathleen Maurer, director of health and addiction services
and medical director
at the Connecticut Department of Corrections.
She is currently developing a system-wide
medication-assisted therapy program
for the Connecticut Department of Corrections.
Thank you for presenting on lessons learned from the field.
I'm turning it over to you now, Dr. Maurer.
- Thank you very much, Jon, and thank you all for attending.
Next slide, please.
My talk is going to be really in two large sections.
One is, and I'm going to skip a lot of this
because we've already heard a lot about
why MAT is important in Corrections
and the second piece of my talk today is,
I'm going to address some questions
that people should be thinking about
when they're thinking about developing a program
in their jail or prison systems.
So, go to the next slide, please.
So, we know that substance use disorders
are markedly overrepresented in Corrections.
We just ran some new data yesterday
and 74% of our total population
has a treatable substance use disorder.
That breaks down between males with 73%
and females with 80%.
As you can see on this data, it's from 2015,
alcohol was the primary drug of choice at this time.
It looks like opioids now have become
the primary drug of choice for our population.
Not surprising, given what's happening in society generally.
Go to the next slide, please.
This is data from our female jail/prison complex.
We only have one in Connecticut,
and basically this also was in 2015/2016.
So, our female population, as I said,
80% of the population has a substance use disorder
requiring treatment, and now, in 2017,
50% of the population has, their drug of choice
is either heroin or other synthetic opiates.
So, that's up about 5% to 7% from a year ago.
Next slide, please.
Of course, we know that treatment of injection drug use
has important public health impacts
and many of our heroin users are injection drug users.
It is critical in Corrections for hepatitis C as well as HIV,
and treating people who have opioid use disorders
helps to reduce the likelihood of reinfection
and infection of others in the community
with these infectious diseases.
Next slide, please.
So, we've already heard that MAT represents
the community standard of care.
This is a document
from the American Society of Addiction Medicine,
it was published a couple of years ago,
and it's their National Practice Guideline
in the treatment of opioid use disorders.
Next slide.
I had an automation on that slide
which pointed out what the second one is, but...
so there is a section in this document
that is specific to the correctional population,
and among other things, this document recommends
use of maintenance of medications,
and induction of medications for people
when they are leaving the criminal justice system.
I also want to point out
that the American College of Physicians,
and I'm an internist among other things,
and so, I belong to ACP; I also belong to ASAM,
but the American College of Physicians,
a pretty conservative medical society,
came out in March of this year
recommending MAT for those in the criminal justice system.
Society is really changing, and the medical community,
and the practice of the medical community,
is changing along with it.
Next slide, please.
So, the other two issues, first of all,
our current practice places releasing offenders
at risk for overdose and death,
and I think we already talked a little bit about this,
the fact that our patients lose tolerance for opioids
when we incarcerate them.
They leave, they use the same doses that they did
before they came in,
and they're highly at risk for overdose and death.
Next slide, please.
And this is some of Connecticut's data
on the proportion of those who die of accidental drug overdose,
what proportion are former correctional inmates,
and if you look at these bar graphs,
the 2015 data, the dark part of that bar
represents people who died of unintentional overdose,
that's who had been in Corrections.
So, it's about three-quarters of the population.
I mean, it's about 3/7 of the numbers of people
who have unintentional overdoses
that have been in the correctional system.
Next slide, please.
And this slide shows the timing
at which those deaths largely occur,
just like in your [indistinct] data,
our data shows the same thing.
The highest number of opioid-related overdose deaths
occur very early after release,
and then they trickle out to fewer and fewer
as the period after release extends,
but this basically confirms what we know
from some of the other research.
Next slide, please.
So, the other issue about the way we treat patients,
i.e., with detox or medical withdrawal
and without any medication on the way out is,
that if you talk to patients when they're released
after a forced withdrawal or detox,
they're very uninterested in taking and getting back
on the opiate agonist therapies.
Methadone detoxes are very uncomfortable for patients
especially because they're often not well managed
in correctional facilities,
and so, patients just have no interest
in coming and getting connected back with methadone providers
because they know the likelihood
of their getting rearrested is high,
and then they are just going to be treated in the same way.
So, they would almost prefer not to use methadone,
and that's been documented in some articles recently as well.
Okay. Go ahead. Next slide.
So, this I think is probably more interesting
to most of you folks, and that is,
what are some of the questions to think about
when starting a methadone or MAT program.
It doesn't have to be methadone or however,
and I support the use of a variety of drugs.
You know, the most important drug,
as Jennifer Clark from Rhode Island says,
is the drug that people will take.
So, what are the questions? First of all, whom to treat?
Second, where to treat?
Third, how to treat?
When to treat?
What meditations to use?
And what to measure?
So, go ahead.
So, first of all, the question is whom to treat.
There are a number of perspectives
so I like to think of it in two ways.
The first is the criminal justice perspective.
So, you have pretrial detainees, the jailed population,
if you're talking about unified systems.
Ours happens to be unified,
but one group that you might select to treat
are those people coming in who may or may not
already be on an MAT medication,
but they can also be inducted onto MAT meds.
The second is the sentenced population.
Typically, people think of treating
the sentenced population in terms of prerelease.
So, it can either be prerelease
or throughout the period of the sentence.
I think most people that are treating
throughout the period of the individual's sentence
are treating someplace less than two years.
We treat people for a sentence of two years.
If they're sentenced for longer than two years,
we will probably withdraw someone from methadone
when they come in.
The second general approach to this
is the medical perspective.
So, if you think of substance use disorders
like diabetes or like asthma or like hypertension,
you simply continue treating people
on the medicines that they came in on.
So that means you continue, you do maintenance
as well as initiating new MAT
for those with opioid use disorder.
And one point I want to make here is
that it's important to establish program criteria of some type
before you get started.
I'm going to show you what we developed in 2012
when we started our first program.
Next slide, please.
I don't really support these criteria
because I think, for a variety of reasons,
we probably made some of the not-best decisions
back then in 2012, but actually, we only had Rikers as a model.
So, we didn't have a lot to base our program on.
But what this criteria does, is it splits up
between clinical and custodial criteria
and when you're working with a custodial organization
and you're the medical people,
you need to have rules like this.
Some of these rules are defined by the DEA
and SAMHSA regulations for methadone treatment.
Others happen to be unique to Connecticut's system
and unique to Connecticut custodial desires.
But, having some kind of program criteria
so that you actually have rules that govern your program,
I think, is very important.
Go ahead.
Next slide.
So, when you do have rules like that
and some people who could or should qualify
don't get treated, and I put this slide in
not because I'm proud of it but because,
and this is actually about a year ago;
I think we've treated about 750 or 800 patients by now,
but what happens when you do have program rules like that,
you have a number of people who don't get treated
who would essentially be qualified for treatment.
But you know, you learn things as programs go along.
Sometimes, in custodial settings,
it's not real easy to change things once they get started.
Okay. So, go ahead.
So, the next question is, where to treat.
So, you need to decide whether to treat
in a single facility or a few facilities.
Some of this depends on the size of your system.
Some of it just depends on
how you can manage the logistics of treatment.
Sometimes, depending on what decision you make,
it may require the movement of patients.
If you have patients coming in who need treatment
and you're not treating at the facility
where they are intake,
they're going to have to be moved.
It's not always straightforward in a custody situation,
for a variety of reasons.
If you use just a single
or a few facilities for treatment,
this can complicate reentry.
You might want to treat people in an area
that doesn't have reentry services,
not going to work.
And one advantage to a single or a few facilities
is that you can concentrate resources
and so, it's a little bit easier to do programs that way.
If you put MAT treatment in all of your facilities,
then you can simply consider MAT maintenance and induction
with the agonist or the antagonist
as another form of healthcare,
and it definitely would simplify reentry that way.
Everybody who is appropriate coming out
would need to have reentry care.
Okay. Go on.
So, this is our system.
The blue arrows are our existing programs.
The two red arrows are programs we're developing right now,
and the green arrow is going to be a proposed...
is actually-- we have an RFT that's going to go out soon
for an induction and treatment center up in our first prison.
So, it's an induction center for pre-release patients,
and it's going to be a treatment center for maintenance
for taking the demand off our other programs,
which are constantly full.
They have capacity, and they are constantly full.
We treat 60 patients every day,
and we just don't have enough room
for the rest who need treatment.
Go ahead.
Next slide.
So, how to treat.
The model can be either in-house staff.
I think that you might find difficult for the agonist,
maybe not so much for the antagonist.
You can use contracted vendors or it can be a hybrid.
In our own case, we use in-house staff to initiate,
this is for the induction piece,
to initiate screening and the assessment process,
and then we hand the patients off to vendors.
We have two vendors who provide the services there
from the community.
That seems to work pretty well.
It helps to educate house staff on what addiction
and substance use disorder assessments are
and what's required.
It increases their knowledge level.
Some of the considerations about making this decision
have to be substance use treatment capability,
resource availability, medical knowledge,
and also medical attitudes
and the availability of contract providers.
Go ahead.
When to treat.
You have to make that decision on really, philosophy
and on what your custodial organization wants.
You can continue maintenance or manage withdrawal.
You can use a variety of different agents.
I think you can initiate therapy if you're doing induction,
either upon admission or shortly thereafter,
or in the prerelease phase,
two to four to six weeks before release,
and/or you can initiate therapy in the community
immediately upon release.
That is not as effective as most of the studies have shown.
And always remember,
this depends on patient wishes and preferences.
Go ahead.
And then, we've already talked a little bit
about the medications, some of the other speakers are,
but, this is a big issue.
It's a question of culture.
It's a question of custodial folks,
of medical folks.
It depends greatly on
what kind of community provider networks
and support you have.
If you start somebody on a medication
that you can't find treaters for in the community,
that's not a good thing to do for your patient.
It also depends, as we've noticed or talked about before,
on insurance coverage in the community,
and one other point is,
it depends too on your appreciation and tolerance
for regulation and audits and so forth.
We use methadone. We use community providers.
We're happy because we get audited
on an every-three-months basis.
We like that. Go ahead.
Go ahead.
Just a quick slide on costs.
It costs about, between $75 and $100 a patient a week
in our state to treat patients.
That's about $5000 per year for a patient,
and induction is about $450 to $600
for a six-to-eight-week induction period.
Go ahead.
And this is just talk,
speaking about when you have a program
what do you measure.
Process metrics and outcome metrics.
So, go ahead.
Go ahead. We looked at recidivism rate
which we define as 90-day re-arrest rates,
and in this case, 11% of our patients
are re-arrested after 90 days.
Go ahead.
And we look at Connect to Care.
This is over a period of 13 months.
Seventeen percent did not reappear
in the provider's clinic.
Eighty-three percent were successfully connect to care.
Go ahead.
And lessons learned.
I just want to say a few things.
Ideally from our perspective,
if we have methadone maintenance,
I think we should be very attentive
to the needs of patients,
and to follow them from jail to prison,
through release and reentry, for continuity of care.
After all, we need to start talking
about addiction treatment as we talk about asthma treatment,
hypertension treatment, diabetes, et cetera.
So, lots of different issues that affect the ability
to manage these programs, including court schedules.
You know, two or three of our people are gone every day
to court out of our program,
sentencing, facility space, and so forth.
Go ahead.
Go ahead.
I want to state that there were a lot of concerns
from custody initially about diversion and other incidents.
We have had almost no incidents.
We had two early on and then nothing.
We've had I think, one in the last year.
So, I do not think that security-based incidents,
diversion, and contraband-related stuff
is an important problem
as long as you deal with the way--
you know, you design your program
to design that kind of opportunities out.
And the last point,
never underestimate the role of stigma
or the power of education.
When we started our programs,
both custodial personnel and medical personnel
were very opposed to them.
After about six months or so,
with the strength of a very good warden
and top custodial people,
the custodial personnel started to support the program,
then the medical people came around,
and frankly, in our jail programs
that currently exist,
we are having requests to expand both of the programs.
So, it's been a pleasant reversal
from a very fairly significant opposition
to MAT to very-- really embracing
and supporting the program,
and I think that should be all.
- Great. Thank you so much, Dr. Maurer,
for great information,
and certainly the great lessons learned.
It's great to hear of the big turnaround in your facility.
Our last speaker is Kevin Pangburn,
director of Division of Substance Abuse Services
at the Kentucky Department of Corrections.
He has served as the director of Substance Abuse Division
at the Kentucky Department of Corrections since 2004.
It is my pleasure to turn it over to Mr. Pangburn
to speak about lessons learned from the field in Kentucky.
- Well, good afternoon, everyone.
There are some advantages to being the last
and there are some disadvantages to being the last speaker.
First of all, I am rewarded by the information
provided by speakers before me
and certainly I could utilize a lot of information.
We could utilize that here in Kentucky.
The downside of that is I guess is,
that much of the stuff
that I may have been talking about
has already been said, but that's a good thing
in that we are all echoing the same experience.
I can talk to you specifically this afternoon
about what's going on here in Kentucky,
how it came about, which I think is significant
and maybe perhaps some lessons we've learned.
Next slide, please.
Or am I doing that on this end? Let's see.
- You can-- I can move the slides for you
[indistinct].
- Yeah I got it. Okay, thank you.
Well, this slide may seem so elementary to people,
but I put it on there for a reason.
This is probably something,
terminology that many of us have taken for granted
knowing that medication with counseling is the best evidence
and certainly encouraged at every opportunity,
but when you put that into practice...
you know, this may seem elementary
but when you're dealing with on a statewide system,
there's a lot of moving parts that go on with
trying to work with other agencies,
providers that are outside your system.
So, I think it's really important to say,
well, "I may believe this"
or "Yes, this is the best evidence."
Staying on top of this with all the people
that are involved in it,
all the agencies that are involved in it
to ensure that you share the same philosophy,
criteria, and protocol,
it is really, really important
and by that, I mean, don't assume
that everyone agrees with you
or that you will in every circumstance.
In Kentucky, we do have some advantages
and I think I want to talk to some of the reasons
why this has happened because we do have support
across our system.
And by that, I mean, strong support.
The Governor's office, Cabinet, General Assembly.
You can read these.
The Department of Corrections, our commissioner,
deputy commissioner, security staff.
Nearly wherever you go that we have strong support
and recognize the advantages to utilizing
medically-assisted treatment.
We are a Medicaid expansion state,
and whether or not
you are a Department of Corrections employee,
whether you work with the drug courts,
community mental health centers,
we all are very, very, very conscious of the need
to continue this in a way that really seems to matter.
You know, people oftentimes talk so much about West Virginia,
but we are Appalachia.
We are at the heart of Appalachia,
and those eastern Kentucky counties
have struggled in a lot of ways.
I'll address that in just a second
about how that's impacted us.
The Kentucky General Assembly in 2015,
enacted Senate Bill 192,
here in Kentucky it's referred to as The Heroin Bill,
and as a reaction to the problem that all of us are dealing with,
this problem with opiates and heroin,
and the bill directed the Secretary of Justice
and Public Safety Cabinet
to determine how to distribute $10 million
for programs to combat prescription drug use
and heroin use in Kentucky.
Three million dollars of that
was given to the Department of Corrections;
$7 million was distributed in other agencies.
Now, I want to be clear about one thing on this,
that for a number of years, well, all of us, I guess,
at some point, have requested money
through the General Assembly
or requested grant money or something to that effect.
We've reached out and said,
"Boy, we could sure use this amount",
or, "I wish we had so-and-so".
And you go to your General Assembly and you say,
this is what we need and rarely do we get that.
However, this money was offered to us.
We didn't seek it.
It wasn't a part of anything we said,
"Well, let's write up a request proposal
"and send it to the politicians
and see if they'll give us some dollars".
They simply offered this as a reaction
to what was going on.
Secondly, I think this, that our Department of Corrections
as well as our Division of Substance Abuse
has grown significantly and historically,
just a brief moment in history here,
I can say to you that in about 2004/2005,
our department had a total of about 475 treatment beds
for those incarcerated in our department
for substance abuse treatment, about 475 beds.
Today we have 5901 treatment opportunities
for people in the Department of Corrections.
We've grown significantly and since 2007
we've had outcome studies
through the University of Kentucky Center for Alcohol
and Drug Abuse that we can verify and validate
the positive outcome from being enrolled
in substance abuse treatment and that's been well known.
We send those to the politicians every year.
We make sure that certain members of the judiciary
have those studies.
So, I think, when it came time to say
hey, this heroin thing is out of whack here
and we need to do something about it,
we sat in a really strategic position
to be those individuals
who provided already validated services.
We, meaning the Kentucky Department of Corrections,
are the largest provider of substance abuse services
in the Commonwealth of Kentucky.
I don't necessarily believe that anyone out there thinks
that you should go to prison to receive treatment,
but, we all know that that's how it oftentimes works.
So, I'm going to tell you a little bit about
how this money was distributed, at least on our end.
We were to provide or contract to provide,
however, I think Kathleen mentioned in her area
that we do use our own employees
our own employees of the department
and the Division of Substance Abuse Services,
to provide these treatment services
in the prison setting.
So, they were very clearly-- they used
evidence-based treatment and--
and even when you have the General Assembly
using terms like that, I think that's significant
when they know what that means and can speak about it
in a way that really makes sense.
So, there were $1 million set aside
for prison substance abuse treatment...
to utilize medically-assisted treatment.
Another portion of that, another $500,000
they realized-- down in Kentucky we also contract
with our county detention centers,
the jails as it were, to house state inmates
particularly those class D inmates,
those lower-level inmates.
Many of them with drug problems.
We contract with them so...
we have substance abuse programs
in many of those jails, 24 of those jails.
We have about 80 jails statewide
and in about 24 of them we have programs.
We contract with people to provide those services.
So, they wanted to expand the opportunity
to receive treatment in the jails.
And the last portion was,
they recognized that in many of these jails
there were county inmates who were not part of
the Kentucky Department of Corrections
who also needed services.
So suddenly, we were a state agency
who had overseen state inmates
and were now going to assist with those county inmates
who may also be in need of treatment.
Now, this next slide shows the reporting
of the illicit opioid and heroin use
in the last 12 months before incarceration.
When folks come into our program,
we naturally gather that information
and then it also tells us a couple of things.
You know, it gives us statistics like this,
but it also says we know who those most
at-risk people are in our programs.
So, when it comes time to actually provide the services,
we can walk up to a person and not a statistic
and be able to say, you know,
"You may fall into a category,
we'll begin the education process" and so forth.
But there were a couple of things that happened.
You begin to see a slight incline there around 2010.
So, between 2010, 2012, along in there,
there were a couple of statutory things that changed
in the state of Kentucky that had an impact on this.
One was that Oxycontin and Opana were reformulated.
We also had House Bill 463 which meant
that there was a different way of classifying our clients
so that some folks would be able to be released earlier.
It made us think a little more broadly
about how to provide services,
and the other one was what we refer to here
as the pill mill, sort of this pipeline from other states,
certain other states, that provided opiates to--
particularly to the metropolitan areas
and largely those areas in eastern Kentucky.
So, when that pill mill stopped, there were no more pills
then there became, you know, an increased interest in heroin,
and that's one of the many, many complex reasons
why that happened here in Kentucky,
Oxycontin and Opana being reformulated
and certain other statutory things that began to see
that increase in heroin use right around 2013.
I think many of you have already spoken about overdose deaths,
so I won't spend a lot of time on that.
Ours is what ours is and certainly the fact
that it exists is what's important.
So, we were asked to create a protocol,
and I think what happened is we began to look around
like many of us do and see what's already out there,
and there really wasn't much of anything out there
in terms of a protocol.
We call this SAMAT,
Substance Abuse Medically-Assisted Treatment.
We call it that in Kentucky.
So, we began to say when a person is released,
we'll just back up and consider all the things
that needed to be done appropriately
whether it's medically, clinically, et cetera,
and then see how long that takes.
So, about seven weeks out we start the process,
and we, I think Andy may have mentioned this,
but, we are one of the few states
that utilizes two injections
while individuals are incarcerated,
and I'll speak to that in just a second,
but, we start out certainly with the education process.
Those people that are most at risk,
who have the history of this prior to coming in,
we start that education process.
Naturally this is voluntary,
people aren't forced into it.
And then, you can read through this, but you know,
we start a screening process, use the UDS drug screen.
If it's clear, then great.
If it's not, then we have other decisions to make.
So, we're evaluating all the way through there.
We're utilizing the orals, Vivitrol.
We only use Vivitrol to make sure
there's no adverse side effects, et cetera.
They see the medical people to make sure
they're clear there, and then we do two injections.
And the reason we do that is this:
We felt like just in terms of the addiction process
that we could provide that one injection
and probably be okay with that
but we felt like that we wanted to really ensure
that people had the best opportunity
at least from our standpoint
because many, many, many times
just before you're releasing somebody
that whole addiction process, that whole brain disorder
begins to kick in again, and that's when the people
that have been clean for a number of years
begin that process again.
So, we wanted to double-up on that and ensure
that people had the best opportunity.
So, they receive two injections through the department
while they're incarcerated.
I'll go to the next part.
The last injection is two or three days
before they're actually released to the community
and there is that warm handoff because the states have...
now this number, we currently have I think 102,
I'm sorry, just by the latest number that happened
since I sent this, but I think some states
have different names for this.
But, in Kentucky we refer to them
as social service clinicians.
Those are the people in our division,
those experts in substance abuse treatment
who work in the probation and parole districts.
So, when a person leaves a jail, leaves a prison,
we hand them off with an aftercare plan,
recognize a need that these people are the priorities,
hand them off to the social service clinician
that will meet with them the next day.
It's their job then to ensure that they become
Medicaid-eligible or some sort of insurance eligible
and that they establish an appointment
for the next injection within that 28-day timeframe.
So, there is that handoff.
Now, I can tell you a couple lessons that we learned here.
Because this is certainly a voluntary program,
we found that inmates were beginning to sign up
for the program in hopes of ingratiating themselves
with the parole board who would maybe
look more favorably upon them prior to release,
and then when they got out they'd say,
"Well, I'm not interested anymore."
So, being able to train people,
train our social service clinicians in a way
that would assist them when they ran into that barrier.
What happens when somebody says no,
when they're sitting in your office on the first day out.
That's really a high-risk individual right there
and what to do with them.
We have spent countless time
training with motivational interviewing,
other techniques, to be able to sort of
counteract that "thanks but no thanks" attitude
that we were finding,
and we found that that's made an impact
and we've been able to assist our people
in that, in a little better way.
So, this is the role
of the community social service clinician.
They've got to make phone contact with that parolee
before release, make sure that immediate Medicaid enrollment,
establish appointment and whatever other elements
of the aftercare plan are part of that.
So, these are the locations where we have programs.
We have 13 prisons and you could see that you know,
we're in nine of them or eight of them,
and right now we have four jails.
We believe that will expand in a short period of time
to incorporate the possibility of other jail programs.
So, that's what we do in Kentucky.
We feel like that this is an ongoing process for us.
Certainly, we're not finished.
We're constantly finessing
and determining other opportunities
and how we can finetune our programs
as well as our staff
to ensure that we not only can put people into program
that we are funded to utilize
but, also be able to do it in the best way
that we can keep them in the program
once they're there.
So, open for questions if anyone has any.
I'm certainly open to that.
Thank you.
- Great. Thank you, Mr. Pangburn,
for your great presentation.
Really appreciate that.
We'll now open up our questions.
If you would type your questions in the chat box,
I would appreciate it.
And Susan, do you have any other further directions
or comments?
- Well, I think we are all set for now.
As Jon said, if you have any questions,
please type them in the text
and we'll give it a few minutes
to see if there are any questions coming in.
[indistinct]
In these next few minutes,
[indistinct] feel free to pose your questions now.
Please note that all of you are unmuted at this time.
If you feel you want to pose a question,
please go ahead.
If there are no other questions,
are there anymore additional comments
from the presenters,
anything else you would like to mention that you think
we haven't been able to get to?
- Actually, this is Jon.
I do have a question if it's okay.
[indistinct] to Dr. Pangburn.
I have a question regarding--
when you are releasing offenders back to the community
and they have received MAT,
you know, do you have any problems in the community
as far as clients not being able to receive the services
they need because they haven't been enrolled
in Medicaid or if they aren't able to find insurance
and or, I guess my other question is
if finding a therapist to work with them in conjunction
with medication-assisted treatment?
- Well, I can speak to that.
This is Kevin Pangburn.
It's not so much we have difficulty.
I'll tell you what our problem was.
It's not so much having the difficulty
in having people enroll
because that was not much of a problem.
The problem was being able to find folks
who would provide the medically-assisted treatment
once they were in the community.
You know, there were some people who said,
yes, we will, and then they didn't,
or there were just some hoops to jump through.
Initially we had a large problem with that.
The community mental health centers sometimes were willing,
some weren't.
But over time, you know, it was a matter of knocking on doors,
finding whether it was clinics, private individuals,
mental health centers.
There are very few gaps anymore,
but we underestimated I think initially.
We underestimated when we went live with this
a little over a year ago
to be able to have an established network
that no matter where you were in a largely rural state
that you would have folks who would be available to provide
that medically-assisted injection once they were out.
That was a problem on the front end.
It's not so much now because we've been able to grow
those opportunities.
We've had help from those who have provided the treatment.
They've been able to say to us, here's part of another network
or, at any rate it's worked out
pretty much the way that we need it now.
There doesn't seem to be too many gaps anymore.
- Great. Thanks. Dr. Maurer, can you speak for Connecticut?
- So, and we depend on our community providers.
Our community providers are
licensed opioid treatment programs, right.
Everybody who treats methadone is.
So basically, a lot of the patients
coming in to our system
have either already been treated by those providers
or are from the community where those providers are.
So, if they're induction patients,
most of them are-- in New Haven, for example.
in that program, most of them are in New Haven.
We have a handful of different OTPs in New Haven
so the primary provider that we use finds,
when they get back into the community,
identifies the clinic that's closest,
the OTP that's closest to the patient's home
and then, gets an appointment--
So, we require our OTPs to do the reentry.
So, they get the appointments for the patient
and then they will treat the patient
until the day of the appointment.
The other thing is most OTPs have very generous
sliding scales for payment.
It's not, you know, it's something less than--
usually less than $20 a week
or less for a week of methadone treatment,
and we do not terminate people from Medicaid.
So, we simply suspend them
and then turning their Medicaid back on
is just like flipping a switch.
So that's very, very easy to do once people leave,
and that has not been a barrier and like 99% of our patients
are Medicaid-eligible when they leave.
So, there are a lot of things that make this--
in our particular situation makes things very convenient
from the reentry perspective
which with substance use disorder treatment and MAT
can be the most challenging of all of the parts.
- You know, Jon, if I could add, one's rural state where they had
even though any doctor theoretically can prescribe
and administer naltrexone/Vivitrol,
most doctors don't know anything about it
or they don't want to treat heroin patients to begin with.
So, in a rural area, they created a Vivitrol van
that makes the rounds once a month because
you only need the injection once a month.
So that way, they're able to go on a schedule
to the various rural communities
to make sure that the persons that were released
from the state correctional facility could obtain
their medication anywhere in the state
in the rural communities where there weren't
permanent community-based providers.
So sometimes, you have to get creative.
- Okay. How very innovative.
- You bet. - Okay.
Well, thank you for your responses
to the different situations in different states
which I'm sure our grantees will face
different obstacles and barriers.
So, all that's very helpful.
Susan, have you gotten any questions?
- No, we haven't received any further questions.
I just wanted to call your attention again
to the last slide regarding how you can obtain
your certificates for attending the webinar.
Again, you can either download the evaluation form
on the link provided here.
We will also send it out to all participants
and then once you've completed the evaluation form,
please send it to Abigail Durak
and then, we will be sending you a certificate.
I would like to thank all of the presenters
and Jon as well for moderating today,
for taking the time and sharing your expertise.
Thank you. - Yes. Thank you.
- Thank you very much. - Thank you very much.
- Thank you.
- Thank you to all the speakers
and to all the grantees. Appreciate your help.
Have a great day.
- Okay. Bye. - Thank you.
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