Well, greetings, everyone. My name is Tony Decker, and we'll be talking about substance use disorders and the criminal justice settings. Dr. John Loepple did the original presentation for this when we started the board review course, but he has subsequently moved on to bigger and better things. He's now a writer for the questions. And because of that, for the integrity of the test, anyone who writes questions cannot participate in teaching a board review course. So you got me. I provided a little bit of input on this, but most of this is John's work. Dr. Loepple is board certified by the American Osteopathic Board of Family Physicians, as am I. He has a CAQ in addiction medicine from the American Osteopathic Association, as do I. He is certified in correctional health as a health professional by NCCHC, and he was the site medical director and director of the infirmary and addiction medicine for the Philadelphia Department of Prisons from 2012 to 2019. He currently is the director of addiction medicine at Penn Medicine Lancaster General Health, and he has no financial disclosures or conflicts to report. I also have no conflicts, no financial arrangements with prohibited organizations. I am a member of the past president's council of the American Osteopathic Association, American Osteopathic Academy of Addiction Medicine, as is Dr. Loepple. The opinions that I expressed in this presentation are strictly my opinions. I retired after 37 years of federal service with the Indian Health Service, the Department of Defense, the VA, and then I have recently taken a position as the chief medical officer of the Division of Developmental Disabilities for the state of Arizona, but I do not represent any state or federal organization. I was the chief medical officer for the Illinois Youth Centers, which is part of the Illinois Department of Corrections, and it is for 13 to 17-year-olds who are adjudicated to be adults and provided care to about 6,000 members at that time. Our objectives for this presentation are pretty deep. First is to review the epidemiology of substance use disorders and related behaviors in the criminal justice settings in the U.S. To understand the delivery of health care in the criminal justice setting and unique opportunities that are encountered in both jails, prisons, and detention centers in regard to provision of both prevention and treatment of substance use disorders. Discuss special considerations when working with alcohol withdrawal syndrome and medications for opioid use disorders in the criminal justice settings. To recognize the effectiveness of providing medications for opioid use disorders in the criminal justice setting and to review problem-solving court and recognize the effectiveness of drug courts in reducing the rates of incarceration and recidivism among individuals with substance use disorders. The last thing is something that has happened over the past five years, and that is to discuss the high rates of fatal overdoses in the post-incarceration phase that has unfortunately become part of the fentanyl epidemic. We look at the criminal justice system in the United States. The U.S. incarcerates more people out of their citizenry than any other developed nation that is not a dictatorship. So in the U.S., we have incarcerated population sets between 1996 and 2006, and you can see that here, it rises to a peak in 2006. And then with drug courts and other types of interventions with early release, we've seen a gradual decrease in that population, about 12% decrease from 2008 to 2018 has been observed. Now, when we look at how many people are actually incarcerated in the U.S., the numbers are astronomical. 2.3 million people are currently confined in jails, prisons, and related detention facilities in the U.S. We are not speaking of undocumented aliens who are in the U.S. and are in detention. These would be people who've gone through the judicial system. Now, when we look at that, a little over half, 1.2 million people are in state prisons, about 630,000 people are in local jails, and somewhere in the area of two and a quarter, 226,000 people in federal jails. Then you can see a breakdown that happens again. Youth represent about 44,000. This does include some immigration detention center data from the late 2010s, and it also includes involuntary commitment with only about 22,000 people there. Nonetheless, it's a large population, and the sad thing is that we have a significant recidivism rate of this population that navigate through correctional facilities. When we talk about jails versus prisons, typically jails are locally operated, either by municipality, city, or county. They're typically shorter term, and they are also used as holding for people who are awaiting trial or serving a very short sentence. Prisons, on the other hand, are typically run by state or federal facilities. They are much longer in term, and typically it's post-conviction and serving a prolonged sentence. Now, when we look at the epidemiology of substance use disorders within correctional facilities, about two-thirds meet the criteria for a substance use disorder. This would be the incarcerated population. 20% have alcohol or other substances involved in their behaviors, over 50% alcohol involved in their criminal behavior, nearly 20% regularly use opioids prior to incarceration, and marijuana was seen approximately in 1% of all inmates. Now, that was data captured in 2010. That information has changed somewhat because marijuana use is now legal in 42 of the states and most likely will become legal across the country with the current efforts to classify marijuana products as Schedule III, but we have had a significant epidemic of overdose deaths in this country secondary to synthetic opioids. When we look at from the 1980s until the noughts of the 2000s, 2001 to 2010, we saw about 3,000 deaths per year nationwide secondary to heroin. Heroin made a dramatic change. The cartels became the main supplier of heroin in the US. Black tar heroin typically was coming from Mexico and from South American countries. It has a significant amount of vegetable matter inside the sap and it would oxidize into a black tar and was sold that way, typically smoked, but sometimes injected. But then around the late 2000 noughts, 2008, 2009, 2010, we started to see a rise in synthetic opioids in the form of counterfeit tablets, mostly with fentanyl. Now, fentanyl is not the only product. There's a variety of congeners of fentanyl and there's also some other opioids that are non-fentanyl that are very cheap to make. Heroin typically costs in 2023 about $40 a gram to harvest and to purify to the form that can be sold. Fentanyl costs somewhere in the area of $8 to $10 a gram for its equipotent dose. The problem, and Arizona has become sort of the nidus of the fentanyl epidemic, is that 56% of all the fentanyl interdicted in 2023 was interdicted in Arizona. That's for the entire country. At the same time, the tablets that are used for counterfeit OC-30s or MS-30s, 60% of them contain two milligrams of fentanyl. The typical dose in the emergency room, if you're giving fentanyl for a fracture or for severe pain, is going to be between 50 and 100 micrograms, IV. Fentanyl is typically smoked in the tablet form and you can deliver the vast majority of the fentanyl into the vascular tree through the pulmonary compartment very quickly. This is 2024, May, when I'm giving this lecture. The price for a sleeve of 10 tablets at the local gas stations in Phoenix is $5, 50 cents a tablet, and six of those 10 tablets are enough to cause a death. Six individual tablets, because they have more than two milligrams of fentanyl. So we do have a real problem. One of the things that we noted in 2022, and I'm on the governor's task force for overdose evaluations, we literally look at every opioid overdose that occurs in Maricopa County, and we have other counties that send their cases to us too. We had 1,600 overdose deaths in 2022, 800 were post-incarcerated members who died within 45 days of their discharge from incarceration, secondary to an opioid overdose, of which over 90% was secondary to fentanyl. Typically it was fentanyl and methamphetamine, some fentanyl and aprazolam or Xanax. When we look at the epidemiology of substance use disorders and mental health disorders in the criminal justice setting, we start to see some significant overlap. The percent of inmates with substance use and mental health disorders, two-thirds have a substance use disorder, and clearly a third have a mental health disorder, and about one out of four have both a co-occurring substance use disorder and a mental health disorder. When we look at the general population, this is from the National Survey of Drug Use and Health, in 2017, SAMHSA reported that about 7.9 or 8 million people had both the co-occurring substance use disorder and a mental health disorder, but the vast majority of people with mental health disorders did not have a substance use disorder, and a significant part of those who had substance use disorder did not have a mental health disorder. When we look at the dominant role of alcohol and substance-involved crimes, you start to see several things here. In the total inmate population, these are state and federal facilities, 56% had an alcohol involved in their activity that resulted in them being put into incarceration. A little bit more than that, associated with violent crime, a little bit less for property crime, a little bit less than that for drug law violations, and then all other crimes about 52%. But it's very consistent across the board that alcohol plays a role in a little over half of all people who result in incarceration. The high risk of death after release from jails and prisons, as I talked about earlier, was seen as early as 2005, 2006, and 2007, as we started to see an upswing in the amount of opioids that were prescribed opioids and diverted into the community. We start looking at this from a standpoint of, how is this related to people who go into incarceration and come out? Unfortunately, people who get out of prison don't have the same regimentation nor the same monitoring as they had while they're in incarceration. When we look at this information here, we can start to see from the standpoint of deaths per 100,000 person years, that first one to two months is at a higher risk, but the first two weeks are at the highest risk for overdose deaths. This is looking at a study that was published in the New England Journal of Medicine, and 5% of all deaths from opioid overdoses occurred in people who were released from jails or prisons, and that was in 2007. In 2022, in Maricopa County, it had risen to 50%. Now, back in 2007, there was not that much fentanyl available, and unfortunately, people who have been incarcerated for more than two weeks will typically lose their opioid habituation. And so, they go through withdrawal, very unpleasant experience, but when they get out, typically there's some kind of event, celebration, party, or just being with friends, and going back to using opioids at the same dose that people used before is very tempting. And unfortunately, poor decision-making is a major contributor to overdose deaths. Now, when we look at the regulatory barriers and challenges within the criminal justice system, the Social Security Act of 1965, inmate exclusion clause. So, Medicare excludes reimbursement for periods of incarceration. So, for persons on Social Security, they lose Social Security when they go into incarceration. Commercial plans typically exclude coverage of incarcerated individuals. So, even if you had insurance from whatever source, either employment or from a spouse or another caretaker, you lose that coverage when you become incarcerated. The assumption is that the state or the municipality that's taking, made the decision to incarcerate you is now responsible for your health services. Short periods of confinement and a constant turnover, or what's called a churn population, is normal in jails. So, the member who has an event that results in incarceration, many times, has recidivism to repeat those events. If they continue to use alcohol or other drugs of abuse, it enhances that likelihood. It enhances that likelihood. One of the reasons why working towards recovery is such an important part of treatment while incarcerated. The legal aspects of health care in the criminal justice system go along with the Eighth Amendment. Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted. Our Founding Fathers incorporated that into the amendments to the Constitution, and that still is a protector for people who are incarcerated. When we look at the legal aspects of health care in correctional facilities, things happen and they typically become court cases. So, in 1976, Estelle versus Gamble, the Eighth Amendment guarantees a right to adequate health care. In 1987, United States versus De Coligaro, prison medical care must be at a level reasonably commensurate with modern medical science and of a quality within prudent professional standards. Now, that means that you have to have access to care, you need to have competent care, and you need to have some compatibility in that system to receive the care and have ongoing care. In 1994, Farmer versus Brennan was a deliberate indifference for people who are incarcerated, and that was deemed a cruel and unusual punishment. So, establishment of correctional health care became a standard after the 1970s. So, prior to that, there were really no standards, and health care was denied, and many times injuries were not taken care of, and members who were incarcerated had significant complications of injuries that occurred while incarcerated. In 1970, the American Bar Association Commission on Correctional Facilities and Services started communicating with prisoner rights. In 1976, the American Medical Association Jail Program established the standards for health services in jails, and in 1983, the National Commission on Correctional Health Care became reality. So, when we look at the legal aspects of health care and correctional facilities or correctional settings, the Eighth Amendment holds that inmates must receive adequate food, clothing, shelter, and health care from prison officials. The Fourteenth Amendment requires due process and applies the same standard to pretrial detainees in jail. The quality of health care should be reasonably commensurate with the prevailing standards of care in the community, and deliberate indifference occurs when a prison health official is aware of a substantial risk to an inmate and disregards or fails to act, thus exposing the inmate to serious damage to future health. The National Commission on Correctional Health Care, NCCHC, and the American Correctional Association establish nationally recognized standards of health for correctional facilities and operate voluntarily accreditation programs, and I have the websites at the bottom of the page here. Now, in correctional medicine, the goal is to provide as much of the correctional care within the facility. This would include chronic care services for chronic diseases such as diabetes, asthma, COPD, renal failure with dialysis units, and other types of intervention strategies. They can be municipal or state employees or contracts with local health care providers, and this is a very common event, especially in the rural settings, where the providers in the community become the providers for correctional medicine. Increasingly, national corporations are serving hundreds of jails and prisons, and this has waxed and waned, not only from the standpoint of health care services, but also from the standpoint of actually running facilities of incarceration. Certified medical assistants, nurses, primary care physicians, psychiatrists, optometrists, dentists, and podiatrists are commonly seen as employees of correctional services. Jails have a unique focus on intake and urgent care because the sentences typically are small or they're a pending trial. Prisons typically are longer term, and their health care focus is more for chronic care, so diseases that have chronic care disorders do receive those services. Now, one of the problems that's been identified in facilities of incarceration is that there are two drugs that seem to get into the prison setting. They are available through prescriptions, but if they are in as contraband, and it's interesting how they can be put in. For instance, buprenorphine can treat opioid withdrawal very successfully. There have been numerous cases of buprenorphine getting into the facility because it can be made into a film, and that can be put into books or can be dissolved into pages, dissolved into clothing items, and a person simply needs to suck on that to get the buprenorphine out. The same thing goes with fentanyl because it's such a potent opioid, small amounts, almost microscopic amounts, can be enough to cause a mu receptor agonism that could be desirable on the part of the prisoner. So, long-term care also includes hepatitis C treatment, HIV treatment, things like that. Now, health care behind the walls has a very interesting look that is very similar to other clinics. However, because these individuals are incarcerated, they do have a higher level of security and confinement during this time, and there's a very clear process of monitoring those who are incarcerated while they're in the health care setting. So, in the Philadelphia jail system in 2016, there were 30,000 intake screenings, 143,000 sick call visits, 13,000 chronic care visits, almost 300,000 prescriptions issued, 40% of the individuals left within two weeks. So, they're only in for a fortnight, and then they're gone. 55% were released within 30 days. This is looking at the Philadelphia jail system. The average length of stay is 100 days, 60 days for women, and 110 days for men, and the ratio of men to women is 10 to 1 in most facilities across the country. When I was at the Illinois Youth Centers, we had five facilities, one for females and four for males. We had a maximum security facility in Joliet, Illinois, which had 260 teenagers there. The average sentence was 26 years. Valley View was a facility just for sexual perpetrators, and they had over 3,000 adolescents there, male, in that program. Each of our facilities had a hospital, negative air pressure rooms for those who had contagious disease, including tuberculosis, surgical suites for minor surgery, and a full cadre of nurses, physicians, nurse practitioners, PAs, and providers. On the other extreme, small jails in rural settings are challenged. Typically, in the rural settings, they hold less than 50 detainees at any one time. They typically will have an R.N. on duty 40 hours a week, such as Monday through Fridays, a physician one call per week for a sick call, and then if there's an emergency, the inmate would be taken to the local emergency facility with a minimum of two attendants, and usually would be shackled and handcuffed during that time. Video telemedicine is an option for providing. Buprenorphine therapy is not an option for providing unseen homeoagonist care. Now, during COVID, we had some exceptions, but those exceptions have been dropped. There's been some question as to whether we can go back to that again, and to essentially get around the requirement in the DEA that you must do a history and a physical examination prior to prescribing a Schedule II opioid. The nice thing about the telemedicine system is it's much more secure. It allows for face-to-face real-time, bi-directional communication and assessment. The diagnostic tools can be administered by the registered healthcare provider, such as a nurse, for blood pressure, vital signs, examination, and an adjustment of the camera to get close-up views of skin lesions or things like that. At the same time, some people do not like, want, or desire any type of telemedicine contact. While they're incarcerated, you need to be careful. Why is that? You need to be aware and be sensitive to the possibility that there's another agenda going on. At the Department of Corrections in Florence, Arizona, the average inmate was seen in sick call over 200 times per year. The state of Arizona decided to put a 25-cent charge to be seen in a medical setting, and the average number of visits dropped from 200 down to 12 on an annual basis. There was litigation against that because the state is required to provide healthcare services. Florence had an air-conditioned health unit, and they actually had several parts of the prison that were not air-conditioned, so several interventions had to be done. Jail needs to dispense medication. Diversion control is difficult and challenging, but it is possible, so direct-observed therapy for all medications is the expectation. Careful control of any instrument that could be used as a weapon has to be exercised. Patient evaluation in jails and prisons in the jail setting, compulsive drug use is abruptly and involuntarily interrupted. Those of us who believe that you're not going to get controlled substances inside of a facility, including the Schedule 1s, which are illegal drugs, are misguided. I mean, drugs are available if people have a way to get them in, so whether it's brought in by friends, family, brought in by other staff of the prison, brought in by drones. That's happened several times in the U.S., so there's several possibilities of contraband getting into the incarceration setting. The first interaction with a patient may require management of intoxication, intentional or unintentional overdoses, or withdrawal states, and so treating alcohol withdrawal can be a very challenging situation, especially if you have a person whose SIWA scores are rapidly rising. That person needs to be in the sick bay, if not in the ICU. But people who have overdosed on opioids, especially the fentanyl congeners, may not be found quickly because they become uptunded, and when someone doesn't make noise, they typically don't get attention. The patient might not intend to stop using drugs upon community reentry, and this is one of the reasons why, after losing their habituation to opioids, going back to using opioids, which may be highly desired by the individual, could result in an overdose event. Naloxone for first responders and for jail and prison staff to reverse opioid overdose is standard of care. Most of the defibrillators and AEDs, and I know that they have them at the Sky Harbor Airport, just going through there two weeks ago, have naloxone nasal injectors inside the AED box, and to take the basic cardiac life support CPR course, the basic health providers course, you must take the section on reversing an opioid overdose. So typically, the person has respiratory depression, may be uptunded, there's a decline in the respiratory rate and the volume of inspiration, although they may have an apneic episode and then have a deep breath, they typically have meiosis and stupor for the person who is overdosed. The goals in taking care of the agitated patient in the jail or prison is, number one, keep the patient safe, and number two, keep the staff safe. Intoxication states are typically self-limited for stimulants, although an individual can overdose on cocaine, and if a person has pre-existing cardiac problems, any of the amphetamine-type drugs can facilitate a cardiac arrhythmia that could become fatal. You want a calm and quiet environment. Benzodiazepines, such as diazepam or lorazepam, can be used for stimulant and or PCP or hallucinogen intoxication. Sending the patient to the emergency room is not always the safest option if the patient can be managed in the health center at the facility. When we start looking at withdrawal management while in jail, withdrawal management for alcohol withdrawal, benzodiazepine withdrawal, and barbiturate withdrawal is potentially life-saving. So I always say treat the withdrawal that can hurt you the most, which is another lecture in this review course. Recognition of alcohol and benzodiazepine withdrawal becomes important. There's two different ways to approach this, and which is a fixed protocol or a prophylactic treatment. And my thing is that you need to be careful because if a person has rapidly increasing CEWA scores or seizures, you're already behind the ballgame, and that person really needs to be in an intensive care unit. I've had many patients on Presidex going through alcohol withdrawal, which is not an anti-seizure medication. So you still have to give them anti-seizure medications such as phenobarbital and or benzodiazepines. But the Presidex is anesthetic, and that's to prevent them from continuing with behaviors or activities that could harm themselves or others. Opioid withdrawal is not life-threatening. That is not completely true because people with significant ischemic heart disease can double or triple their cardiac output during opioid withdrawal, and myocardial infarctions are common in that population, renal failure, electrolyte disturbances, and this could be a suicide attempt from the standpoint of a person going through a exposure of opioids while incarcerated. Cocaine is stimulant withdrawal. You want to screen for suicide and abusive behaviors. You also want to make sure that there is no possibility of the person having other drugs of abuse on their body, and so that does require a search, which has to be done per protocol. Alcohol withdrawal syndrome in jails. So we do have screening for alcohol withdrawal syndrome. The potential is of critical importance. So when you look at people having seizures, that's typically a state that once they start going into recurrent seizures, it's going to be very difficult to reverse that without aggressive management and typically in the intensive care unit. When a person has significant withdrawals, which include delirium tremens, hallucinations, and a rapid rise in their CEWA score, you're going to want to aggressively pursue that rather than just watching the situation. People can have hallucinations and confusion three to seven days after their last use, and for those who have methadone exposure, they can also have a late onset effect because the half-life is highly variable from individual to individual and highly variable in the same individual with other drugs of interaction. Now when we look at DTs with alcohol withdrawal, typically the person is going to be over the age of 35. Their blood alcohol was most likely greater than 200 milligrams per deciliter. The current or recent set of use, and you want to review the pharmacy drug monitoring program data if it's prescribed, but keeping in mind that illicitly obtained medications will not be in the PDMP. Also remember that a person who's in an opioid treatment program getting methadone will not have their data in the pharmacy drug monitoring program. A person who has a prior event of alcohol withdrawal syndrome is more likely to have a subsequent event. That's called a kindling phenomenon. So a person who says they have seizures when they withdraw from alcohol, you want to aggressively pursue that person. A history of alcohol withdrawal seizures or a history of DTs also contribute to the likelihood of repeat events with acute withdrawal syndrome. When we look at the prediction of alcohol withdrawal severity scale, the PAWS, and then when they start going down this list here, you can put down yes or no as answers, and they are going through the prior history. In other words, in the past 30 days, do you have a prior history of recent intoxication? And then a variety of questions. Have you ever gone through alcohol use disorder rehabilitation or treatment? And this is to give you an idea of what needs to happen in regard to treatment. Benzodiazepine tapers are important for people who have significant withdrawal syndrome or are progressing rapidly. Hypertension and hyperthermia are late signs of withdrawal, and so you don't want to wait until a person has that to initiate the benzodiazepines. When we start looking at opioid withdrawal in a criminal justice setting, management of the withdrawal is not effective to treat addiction disorders. So the thing to remember is that you're treating the withdrawal, you're giving either buprenorphine or other types of sedative hypnotics to deal with the withdrawal symptoms. Buprenorphine is excellent to treat opioid withdrawal. So it can stop the withdrawal or significantly reduce it within minutes of administration. Elevated blood pressure in combination with intravascular volume stress can complicate opioid withdrawal and alcohol withdrawal, and you want to avoid dehydration, diuretics, and avoid angiotensin blockade. Clonidine is an effective treatment for both alcohol withdrawal with hypertension and opioid withdrawal. Tapering doses of opioid agonists, if you can engage the community for ongoing care, is beneficial. Now, a patient who is on methadone and then incarcerated is going to go into withdrawal. Buprenorphine will help a little bit, but keep in mind that methadone lasts for two to four weeks inside of an individual, so you can't put them on buprenorphine that quickly because it could put them into a precipitated withdrawal. If you're in a facility that allows opioid treatment program care, methadone treatment, that may be the best option at that time. Because withdrawal is such an uncomfortable experience and people realize they can get fentanyl and because of its small, small size, individuals may be able to get this if they have any physical contact with outside visitors. Make sure that you're screening for suicide and depression. All patients that come into a correctional facility, suicides occur at the front end of incarceration and on after months. So it's, and again, unfortunately, it's a very common event. Number one way that a person commits suicide in a facility of incarceration is the sheets they sleep on or their jeans or pants. When we start looking at medications for opioid use disorder, and that's called MOUD, in jails and prisons, the detainment does cause significant issues because the person is not able to self administer the opioid of choice. So people receiving medications for opioid use disorder prior to incarceration, they may be forced to discontinue. Standard of care right now is if you're on buprenorphine when you go in, you should continue on buprenorphine. Some people feel that jails need to be punitive. In other words, you have to suffer when you go into jail. That is against the constitution and that is against the law in most states. Now, we've had some sheriffs, locally elected sheriffs, who've said that they're not going to use naloxone on people with overdoses because those people deserve to die. Those people typically have lost their litigations by the community against them. Individuals using opioids at the time of incarceration often are not offered evidence-based treatments such as buprenorphine for treatment. Now, that has gotten much, much better. In the state of Arizona, we have about 3,000 members who are being treated with buprenorphine right now. The total population of people who are opioid dependent is over 10,000. So only about a third of those who meet criteria for buprenorphine treatment are getting it. And part of the issue is inadequate staff to treat that population. Forced abstinence from opioids, whether they're prescribed or otherwise, can result in loss of tolerance, or I should say loss of tolerance and physiologic withdrawal. So a person who is in jail for 10 to 14 days and is not able to access opioids that they have taken before will still have symptoms of opioid withdrawal for the first five to seven days, but they will have lost their tolerance to opioids. And what they could take in the past may become a fatal dose in the future when they're discharged from the facility. Individuals on prescribed medications for opioid use disorder are less likely to re-enter treatment after release when medications for opioid use disorders are discontinued. So treating a person with ongoing, for instance, buprenorphine actually enlightens and enhances the likelihood that that person will continue with agonist therapy upon discharge. Now, we do have sublocade now, and many facilities do provide an injection of sublocade for people who have stabilized on buprenorphine while they're incarcerated. That provides them with one to two weeks of protection, but they will go into withdrawal after that sublocade wears off. So when we talk about regulatory challenges in medications for opioid use disorders in the criminal justice setting, methadone still requires opioid treatment program registration. There's federal and state oversight. It's not the standard of care in most correctional facilities, although there have been some states that have approved such interventions. Buprenorphine requires an OTP license or a data 2000 waiver until 2000 and I think it was 18 when the waiver requirement was changed so that it would include nurse practitioners and PAs, and then 2022 when it was dropped altogether. One of the interesting things about that termination of requirement for the waiver is that there has not been an increase in accessibility for buprenorphine treatment. So despite the fact that we increased the number of prescribers from 20,000 to over 100,000 prior to 2022 and then dropped the requirement for the DEA waiver for buprenorphine, we have not increased accessibility of buprenorphine, which is very challenging because it is a very well-documented intervention strategy for people who are opioid dependent. So it was, I remember I got my waiver in 2002 and we were capped at 30 people for the entire facility, the Phoenix Indian Medical Center. Then they made it a cap for the individual prescriber. Then they made it a special arrangement for people could apply for up to 100. Then it went up to 275. Then they dropped the waiver altogether, but overall availability of buprenorphine has not had an increase despite those interventions. Short periods of confinement, constant turnover, and fragmented healthcare benefits maximize the pathology and minimize the benefit. So we need to be aware that we have some people who need to receive members when they get out of incarceration for ongoing care. And if you're on buprenorphine when you're in the facility and you're not on it when you get out, you will go into withdrawal and you most likely will lose your recovery. Telemedicine options for the data 2000 waiver physicians was definitely beneficial for the accessibility of many of our rural and frontier patients. The Indian Health Service is one of those places where the number of providers was very low, but telemedicine allowed us to maximize coverage there. In the Department of Defense, I was providing buprenorphine treatment for several forts. And Fort Drum is a good example up by the Canadian border had a very significant problem with opioid use disorders. And we were able to keep our active duty on buprenorphine and maintain them in the military for up to a year. So why should we provide medications for opioid use disorders in the criminal justice system? Addiction is a chronic but treatable medical disorder. The MOUD, medications for opioid use disorders is a standard of care and well-established in the general community. Involuntary withdrawal of medications for opioid use disorder or involuntary abstinence in a controlled environment a controlled environment results in unequivocal increased risk of death upon release. And like I said, we're talking about 50% of the deaths in Maricopa County in 2022 were people who were released within 45 days. Legal considerations, the eighth amendment guarantees a right to health care for detainees. Medical care at a level reasonably commensurate with modern medical science and prudent professional standards is expected. And a failure to address opioid use disorder can be interpreted as deliberate indifference. So medications that we have available, methadone, which we talked about already, it's difficult because opioid treatment program is required. However, there's significant movement right now at the DEA to enhance the availability of methadone. Methadone is a drug that can hurt you and help you, but it is a drug that has had significant effectiveness in regard to opioid use disorder and opioid dependent members. Buprenorphine, we've already talked about, sublingual buprenorphine and intraoral buprenorphine, and now injectable subdermal buprenorphine. Naltrexone is a mu receptor antagonist. It can be given in an injectable with 360 milligrams. In Vivitrol, it can also be given as a pill, 50 milligrams, that blocks the effect of exogenous opioids. And naloxone nasal spray should be for all patients who have an opioid use disorder and those that could become at risk. And so I think that having them in everybody's home that has teenagers and young adults is important. When we look at methadone special considerations, you have to have an OTP, opioid treatment program license. The jails and prisons can obtain these, and so some facilities have that. The VA programs across the country is the largest OTP system in the United States. An OTP in the community can also provide treatment for those who are incarcerated. It often takes several weeks to reach a stabilized dose, so that's going to be watching closely with daily direct-observed therapies. Interaction with other drugs is significant, and there's a variety of drugs that can enhance the methadone level or can metabolize the methadone. Safety concerns if diverted to an opioid-naive individual should be high because methadone does have a high rate of toxicity. Buprenorphine special considerations, medication administration can be challenging because people have to put it in their mouth or it has to be injected. There's no evidence of increased accessibility with the termination of the waiver, which is a real challenge for all of us that really wanted accessibility to increase. Diversion and misuse is highly visible in correctional settings for fentanyl and for buprenorphine, and correctional staff historically encounter buprenorphine and fentanyl products as contraband when they do searches. Naltrexone special considerations in jails and prisons, it is a desirable form of medication for opioid use disorder in the eyes of the institution because it's not abusable. It is not an opioid agonist. It's an antagonist. You need to know the time and date of release of this person, and a few patients with opioid use disorder seem to prefer this form of treatment. When they offered in Rhode Island Department of Corrections, all three forms of methadone, buprenorphine, and naltrexone, only four out of 303 individuals selected naltrexone. So when we look at the effectiveness of medications for opioid use disorders in the criminal justice system, Lee showed the length and median time to relapse or loss of recovery increased probability of an opioid-free urine. So the longer a person is on treatment and in treatment, the better, and reduced frequency of overdoses, fatal and non-fatal. With the long- acting naltrexone injection provided by the criminal justice system compared to usual care. So there was a longer time, and typically, the shots last at least two weeks in some people as long as four weeks. Enrolled participants with a stated preference for opioid-free treatment would opt for the naltrexone option. Marston showed a 75% reduction of all-cause mortality and an 85% reduction in drug-related poisonings within four weeks after release among inmates provided with opioid agonist treatment. So the treatment group was two and a half times more likely to enter treatment after release, and that is with agonist therapy. So we're talking about buprenorphine and or methadone. Green showed a 60% reduction in opioid overdose deaths among those recently incarcerated individuals in Rhode Island after all forms of medications for opioid use disorder were made available in jails and prisons throughout Rhode Island Department of Corrections. The estimated number needed to treat to prevent one death was only 11. So that shows the benefits that this has in using MOUD for opioid-dependent patients. And this is our references here for those. So when you look at the percent of prison and jail inmates with previous incarcerations, one-third had a non-substance-involved previous reason for incarceration, but with substances were involved, it was over half had a previous substance-related incarceration. So when we look at problem-solving courts, seek to address the illness and the psychosocial dysfunction underlying criminal behaviors, which means treatment. Many of us as physicians are not the best at therapy. I mean, psychiatry is automatic because they're trained to do so. Typically in primary care, we have to move quickly, but you can provide competent, compassionate, and accepting care to maximize the benefit to the member. Focus on one type of offense or offender, interdisciplinary interventions, which means using social workers and therapy and sober support and fellowship as part of the treatment package, and address the underlying issues, which includes trauma-informed care. And don't jeopardize the individual by dropping their rights to safety while incarcerated or out. When we look at the drug treatment courts, drug courts in 2012 were far more common than all the other mental health, family courts, youth specialty courts, DWI, hybrid alcohol and drug courts. So drug courts are common. They're available. The individual needs to choose and participate in that intervention. When we look at drug treatment courts, offender screening, typically the best are going to be your nonviolent offenders, voluntary participation, and the presence of a treatable substance use disorder, alcohol and or opioids being the best. Stimulants are difficult, including cocaine and the methamphetamines. Judicial interaction led by a judge or judge, a treatment team supports the court. Monitoring becomes the critical part of this whole process, which means the individual voluntarily agrees to have urine drug screening and other types of screening as needed, including hair, nails, oral solutions, etc. When we look at the effectiveness of drug treatment courts, drug court implementation varies. They reduce recidivism, and it is much more cost effective. Decreased rates of re-arrest, increased time between arrests, and upfront costs are offset by reduced involvement with law enforcement and decreased incarceration. It's less likely for a person to engage in substance use during program participation compared to the traditional probation strategies. So in summary, going over all the things that we've discussed, 6.4 million people make up the total criminal justice population in the U.S. 2.3 people are incarcerated in the U.S., and 65% of incarcerated individuals meet the criteria for a substance use disorder. Keep in mind that many people are in the criminal justice system either awaiting trial or are on probation. So the 2.3 million people are incarcerated, and the other 4.1 million people are either prior waiting for trial or are in the probationary status, still being monitored. Alcohol is involved in more than 50% of the crimes that lead to incarceration, and 17 to 19% of incarcerated individuals were using opioids prior to incarceration. So we have landmark legal cases that interpret the Eighth Amendment to guarantee detainees a right to health care. Regulations result in fragmented care within jails and subsequent barriers for re-entry into the community. Providing medications for opioid use disorders in jail and prisons are more effective than not doing that. Substance use is associated with an increased risk of recidivism and subsequent incarceration. These, by the way, in the summary, are things that I would be aware of for the exam. And problem-solving courts offer an alternative to traditional incarceration, and that means that drug treatment courts are the most widely utilized problem-solving court in the U.S. So I have further reading, and I do have one article that goes over the opioid overdose deaths. It was published in 2022 in the American Journal of Public Health. There are also two other articles I have attached to the presentation from the Journal of the American Medical Association that also looks at this. Our data from Arizona in Maricopa County has not been published, and we are actually going through 2023 right now. The good news is it looks like 23 is a decrease in overdose deaths secondary to fentanyl. We don't know if it's because of decreased use, or if it's because of increased use of naloxone, or if it's because of more people being on agonist therapies. But you do have the websites for correctional medicine at the bottom of this page and the American Osteopathic College of Occupational and Preventive Medicine, which also has a certificate of additional qualifications, a CAQ in correctional medicine. I'd like to thank you for your participation and preparation for the boards, and I wish you the best for passing the boards and for taking care of this population, which unfortunately so few of us are willing to do. So thank you again for that. Be well.

substance use disorders

criminal justice

opioid use disorders

alcohol withdrawal

fentanyl epidemic

drug courts

correctional healthcare

recidivism

post-incarceration