Sasha Rai, MD Director, Correctional Behavioral Health Denver - PowerPoint PPT Presentation

Sasha Rai, MD Director, Correctional Behavioral Health Denver Health/Denver Sheriff Department

I do not have any relevant financial relationships with any commercial interests.

• Finances and budget associated with running a medication assisted treatment program. • Administrative barriers associated with MAT. • Clinical experience in delivering medication assisted treatment.

Denver Health and Hospital Authority Denver’s safety net healthcare system • Medical Center • Outpatient specialty clinics: • Surgery, Neurology, Oncology, Ophthalmology, Orthopedics, OB-Gyn, Cardiology, etc.) • Psychiatry (mental health, addictions, forensics)

• Nine community health clinics • Community Non-Medical Detoxification facility • Methadone clinic (600 + methadone patients) • Health services for Denver City & County jails • Inpatient & outpatient services to in custody / incarcerated persons for Denver and Department of Corrections.

Existing relationships and services related to substance abuse: — Methadone courtesy dosing 10+ years • Methadone induction and continuation for pregnant offenders • Pilot jail diversion project • DH Hospital, DH Methadone Clinic, Adult Probation, and Denver Jails

— Create buy-in — Establish need / demand — Determine budget — Obtain funding — Partnerships — Identify the population

Leverage existing relationships with partners and other stakeholders — Denver Sheriff’s Leadership • City and County Leadership • Adult Probation • District Attorney’s Office • Drug Court / Behavioral Court / Wellness Court • Community Substance Abuse /MAT Providers • Denver Health and Hospital Authority

Estimate the demand for jail MAT services • Number of opioid withdrawal protocols previous 12 months • Number of individuals involved in Drug Court / Adult Probation related to opioid abuse • Number of individuals that could be followed by Adult Probation in the community

— Leadership & staffing — Clinical type and hours needed — Training Needed — Initial and ongoing — Identify medications to be used and cost — Buprenorphine (sub lingual tablets or strips), Naltrexone tablets and extended release injection — Other costs: Labs, clinician mileage etc

Funding sources: — Federal Funding (SAMHSA) — State Funding (State Substance Abuse Authority Managed Service Organization- Signal) — Colorado State Marijuana Tax revenue — City Funding (Expansion to jail budget) — Determine any revenue that might be available — Community substance abuse providers post release

— Denver Health Hospital — Methadone Clinic — Pharmacy — Adult Probation — Preexisting contracts with Community providers — Denver District Attorney's Office — Drug Court, Behavioral / Wellness Court

— Buprenorphine 3 day detox for all persons experiencing opioid withdrawal — Buprenorphine continued if existing prescription / provider in community — Buprenorphine induction if criteria is met — Denver only charges — Appropriate for Adult Probation

— Staffing consists of 1 FTE Physician Assistant, 2 FTE Registered Nurses and 2 FTE Therapeutic Case Workers. — Medications are funded through a grant. — MAT program consists of Buprenorphine based withdrawal protocol, Methadone maintenance, Buprenorphine maintenance and induction, Naltrexone oral and Extended Release injection induction. — On release, new patients follow up at Denver Health. Denver Health is a public safety net hospital in Denver Colorado. They manage Public Health, Out Patient Behavioral Health, community clinics, Medical and Psychiatric Emergency services and inpatient services.

— Denver Adult Probation — Denver City Specialty Courts — Denver Health Emergency Medicine Service — Correctional Care Medical Facility — Outpatient Behavioral Health Services — Community Substance Use Treatment Providers.

Evaluate for substance abuse risk and acute — opiate withdrawal symptoms Patient are started on Opiate withdraw — when protocol symptomatic and scheduled for monitoring every 24 hours for a duration of 3 days Many patients have high rate of co-occuring — health care needs Implement care comprehensive care plan — Scheduled follow up with Substance Abuse — team for Diagnostic testing Patients enrolled in a community program — are verified as active and treatment continued

— Patients booked into Denver Sheriff Department custody who are already on Methadone, Suboxone or Naltrexone are continued on the medications during incarceration. — Pregnant women meeting criteria for opioid use disorder are inducted on Methadone through admission to our Correctional Care Medical Facility (CCMF). — Denver Adult Probation identifies patients who need to be inducted on Suboxone and induction is then done.

— Goal is to start Suboxone at 4 mg and increase up to 16 mg prior to release. — For Vivitrol, baseline Liver Function Test is done and if it is normal, then Naltrexone is given as a tablet with Vivitrol injection scheduled for the day before release. — Patients are often sentenced for a specific amount of time to a specialized DUI unit in the jail so their release date is easier to find out.

— Medication distributed in medical unit — Deputies control patient flow — Nurse verifies patient identifiers and dose — Patient places the tablets/films under their tongue — Patients are directly observed for diversion by medical staff until tabs/film are fully dissolved

— Program development — Coordination/Collaboration with multiple stakeholders including treatment providers, courts and probation. — Complete biopsychosocial assessments and all intake documentation to enroll individuals in program. — Gatekeeper for inmate access to MAT treatment.

— Ongoing monitoring of patient progress/compliance with treatment. — Case management and care coordination duties.

— Diversion — Inappropriate referrals—people seeking to get ‘high’ in jail — Lack of follow-up after release — Relapse/Continued Use after release

— Systemic Challenges — Chronic homelessness — Barriers to entering treatment — Stigma — Working in the jail environment — Limited funding to expand treatment access — Politics of different organizations clashing

The Denver County Sheriff department houses 2300 inmates at the two facilities and on average has 36,000 intakes done by nursing staff per year. From November 2017 to December 2018: — Total # of patients claiming opioid dependence upon entry to jail: 5570 referrals/2902 Individuals. — Total # claiming moderate-severe opioid withdrawal symptoms: 3158 referrals/1900 Individuals. — Total # inducted on MAT in jail since January 2018: 597 orders/322 Individuals. — Total # screened for J2C: 1828 Individuals.

— Total # enrolled in J2C Between 12/22/17-9/8/18: 187 Individuals. — Total # who followed up at clinic 1x after release: 63 Individuals. — Total # who followed up at clinic 2x or more: 52 Individuals. — Re-incarceration Rates of J2C Enrollees Since Jan. 2018: 1x: 53 2x: 38 3+x: 22.

— Denver Sheriff Health Services MAT Stats from 01/01/2018 – 12/31/2018 — Data from 01/01/2018 - 12/31/2018 — Buprenorphine Withdrawals - 1,513 1,112 — Buprenorphine Continued from Community - 393 302 — Buprenorphine or Suboxone Inductions - 556 344 — Naltrexone Oral Inductions - 298 190 — Naltrexone Sustained Released Injectable - 30 28 — Methadone Continued from Community - 458 319

— There is a HUGE need for these services — Inmates are one of the most at-risk populations for relapse and opioid overdose after releasing. — Increasing access to treatment is #1 priority — More case management services and ancillary support will be needed.

• Address barriers including transportation, daily dosing requirements — Review efficacy of MAT in terms of re- incarceration reduction. — Continue to gather and analyze data — Identify and expand what works, reduce what doesn’t. — REDUCE STIGMA so people are not shamed for seeking treatment/MAT.

— Opioid overdose information sheet — Naloxone rescue kit instructions — Referral information to Denver Health Addiction Recovery Services — Prescriptions for Mental Health Medication — Collaboration with Court Services

Thanks for your time and attention! Questions, Comments, Concerns?