The Treatment Challenge in Jail Settings: Detox and Withdrawal or Continuing Medication?

Jessica Vechinski, MSW
Project Manager, Justice Community Opioid Innovation Network (JCOIN)
Center for Health Enhancement Systems Studies, UW-Madison

Opioid use disorder (OUD) is prevalent among people in the criminal justice system—estimates show that as many as 50–65 percent of people entering the system have an OUD or other substance use disorder (SUD). Yet, access to high-quality treatment that includes medications for opioid use disorder (MOUD) is limited, with fewer than one percent of jails and prisons providing access to medications. This lack of access leads to high recidivism rates and preventable overdose deaths. The risk of death within the first two weeks after release is 12 times higher for individuals with OUD due to fatal overdose, often related to loss of tolerance during incarceration.

A new National Institutes of Health and National Institute on Drug Abuse study conducted by the University of Wisconsin’s Center for Health Enhancement and Systems Studies (CHESS) and George Mason University’s Center for Advancing Correctional Excellence! are testing ways to expand use of medications such as buprenorphine, naltrexone, and methadone for OUD in criminal justice settings. The study, titled Justice Community Opioid Innovation Network (JCOIN), is exploring two evidence-based coaching interventions for disseminating MOUD in justice-involved populations: the NIATx model for process improvement and Extension for Community Healthcare Outcomes (ECHO).

As part of the NIATx intervention, sites are asked to identify a project “aim.” A recurring primary aim that jails have identified is establishing policies and procedures for continuing a prescribed buprenorphine regimen when a person enters the jail setting. Jails and prisons around the country face multiple barriers to use of MOUD for persons with SUD, forcing those individuals into detox rather than continuing care.

This is a topic of considerable debate within jails, justice systems, and state governments. Our study team feels that providing justice-involved individuals with continuing MOUD care is ethical medical practice. Like diabetes, heart disease, or cancer, SUD is a chronic condition caused by behavioral, psychological, biological, and environmental factors. When a person with diabetes enters jail, they receive insulin and continuity of care. But a person on a prescribed buprenorphine regime for their SUD often has no choice upon entering jail other than to suffer through detox and withdrawal.  

Two chronic conditions. One receives continuity of care, but the other does not. Why is that?

Barriers to MOUD in jail settings

Stigma

The view that addiction is a moral failing and not a medical condition is a top reason, combined with the view that public resources should not go to treating a moral failing. A second factor is the pervasive misconception of MOUD as “just replacing one drug with another.” A third significant barrier that keeps jails from providing buprenorphine is the risk of diversion: the person receiving buprenorphine will sell or give the medication to other incarcerated individuals. Yet jails that have administered buprenorphine either by strips or crushed pills have found ways to decrease diversion. Strategies include having the individual eat crackers and drink water or conduct post-dose “mouth checks.”

Lawsuits against jails: Addiction is a disability

The evidence for continuing buprenorphine in jail settings far outweighs the reasons for discontinuing care. The most substantial support comes from cases of justice-involved individuals suing jails on the grounds that addiction is a disability, and that being denied treatment is a violation of the Americans with Disabilities Act. The Act requires that public places or services be accessible to all, including those recovering from alcoholism and drug addiction. Justice-involved individuals have claimed that denying medication while incarcerated is discrimination based on their disability. Even though justice-involved individuals are winning their cases and states are starting to take note, many jails disagree with this position.

One last point to consider

Isn’t rehabilitation one of the main reasons for incarceration? By not allowing an individual who has taken the responsible steps to be on a prescribed buprenorphine regimen to continue care, the jail is not providing adequate healthcare or an environment conducive to rehabilitation.

What do you think?

Should jails be required to continue providing medication to those already on a prescribed buprenorphine regimen when entering the jail?

About our Guest Blogger

Jessica Vechinski is a member of Center for Health Enhancement System Studies (CHESS) at the University of Wisconsin. She serves as the Project Coordinator for a five-year study with the Justice Community Opioid Innovation Network (JCOIN), an initiative funded by NIDA/NIH. The study is testing the combination and dosages of two evidence-based strategies to implement or improve Medications for Opioid Use Disorder (MOUD) programming within justice settings around the country. You can reach Jessica at jvechinski@wisc.edu.

Change Project 911: The Incomplete Walk-through

Mat Roosa, LCSW-R
NIATx Coach

Understand and involve the customer.

This is the first and most important of the five NIATx principles. Much of our NIATx work involves working to understand the customer/client/patient experience—because the customer experience is the critical factor in all service delivery. Strategies to understand and involve the customer can include client interviews, focus groups, or including clients on a change team.

 
The walk-through, one of the five essential NIATx tools, is a role-play exercise designed to give staff the chance to walk in their clients’ shoes. The walk-through allows staff members to focus on a specific part of the service process and gather critical insights into what it feels like to schedule an appointment, find the program, sit in the waiting room, fill out the paperwork, or complete an assessment session.
 
Walk-throughs have helped thousands of people understand the customer experience and identify improvement opportunities. That’s the good news.
 
And now for the bad news: Too often, people just don’t finish the walk-through.

Doing an incomplete walk-through is like taking half of your antibiotics. “Half” of a walk-through can be worse than no walk-through because it can reinforce inaccurate assumptions and may lead you to think that you know things that you do not know. Improvement efforts are difficult to achieve with such a hazy vision.
 
So, what do we mean by an “incomplete” walk-through? The tips that follow will ensure that your walk-through is complete and will help you gain the clear and critical vision required for meaningful improvement.
 
Don't look at it, do it.
Looking at your waiting room from behind the reception window and sitting in the waiting room for 20 minutes waiting for an appointment are two very different experiences. Observing is not the same as doing. The complete walk-through duplicates the client experience.
 
Stay in character...both of you.
As you plan the walk-through, develop a character that includes all of the core details needed to complete the process. If you’re seeking admission to a mental health service, show up with your demographic information and symptoms clearly defined, and stay in character for the entire process. Try to understand the experience through your character’s lens. What would it be like to be having this experience, given this background and current need? If a staff member who is completing part of the process with you starts to step out of character by saying, "At this point in the process, we would typically do X," gently remind them that you want to follow the normal process. We want them to avoid commentary about 'X' and to just do 'X.'
 
Do a chunk of the process. (Not all of it.)
People tend to skip parts of the walk-through process because they have limited time and are trying to do too much. If you only have 90 minutes, don't try to walk-through a process that takes three hours. Plan ahead and dedicate your energies to a manageable part of the process. Select something that you suspect has some challenges that warrant further attention.
 
Do every part of that chunk. (Don’t skip steps.)
Now that you have been selective in your choice for a walk-through, be diligent about completing every part of the sequence. Remember that you are trying to understand both the nuts and bolts of the sequence and how the sequence feels. Skipping some of the forms on the intake clipboard will not give you a true impression of what it feels like to do that paperwork. Many of the stressors that our clients experience are cumulative. Each of our forms or data gathering processes might be easy to complete. But stressors can emerge when a client is asked to complete eight sets of forms and provide the same address and phone number on four of them.
 
Be open to learning. (You don’t already know it.)
 "We can skip this part. I already know how this works" is a phrase often heard in an incomplete walk-through. Work to maintain a humble and curious posture when doing the walk-through. Assume that there are many things that you do not know about the process. This can be challenging when exploring familiar territory, but remember that you are familiar with the staff experience side of the process. The process looks very different from the other side of the desk.
 
Visit the NIATx website to learn more about the walk-through and other process improvement tools. 

About Change Project SOS

Change Project 911 is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a wall that you're not sure how to tackle? Share your story in the comments section below, or email Change Project 911 at matroosa@gmail.com. We’ll offer solutions from our team of change project experts!

About our Guest Blogger

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. Mat also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at matroosa@gmail.com.

Behavioral Health Resources for Service Members and Veterans

The Defense Health Agency’s (DHA) Psychological Health Center of Excellence (PHCoE) provides psychological health expertise to the military community by continuing to improve psychological health care, readiness, and prevention of psychological health disorders. PHCoE utilizes Implementation Science, which helps clinicians implement empirically supported treatments and provides Clinical Support Tools which assist providers in the use of Department of Defense (DOD)/Veterans Administration (VA) clinical practice guidelines for psychological health conditions, including provider, patient, and family guides.

PHCoE provides Prevention and Outreach Support to clinicians and the military community in the prevention and early detection of psychological health disorders through its inTransition program and the Psychological Health Resource Center (PHRC). The PHRC is a 24/7 resource center for service members, veterans, family members, and providers seeking psychological health resources, in addition to other resources. The inTransition program is a free, voluntary, and confidential coaching program that can help connect any service member or veteran with behavioral health care, regardless of discharge status, time in service, or time since separation. inTransition can bridge potential gaps during a service member or veteran’s transition to a new provider or it can provide guidance for someone seeking care for the first time. inTransition is a telephonic program that is available globally 24 hours a day, 7 days a week, 365 days a year. The inTransition coaches assist with identifying each service member or veteran’s needs, helps to create an action plan to meet those needs, navigate the appropriate health care system(s), and provide additional support resources as needed.

The bulk of inTransition’s cases involve service members separating from service. This transition from military to civilian life can be a very difficult time. Service members have a vast number of changes to make in their lives and the lives of their families. It is not a surprise that Service members and veterans often put their behavioral health care, or health care in general, on hold while meeting the challenges of this life transition. Veterans listed their top five difficulties associated with transitioning to civilian life as (Zoli et al., 2015):

• Navigating the VA’s system of care (60%)
• Obtaining a job (55%)
• Adjusting to civilian life (41%)
• Financial issues (40%)
• Skills translation (39%)

 Of the eligible veterans to receive behavioral health care with the Department of Veterans Affairs from 2002-2015, only 62% of those obtained VA health care (Dept. of Veterans Affairs, 2015). Post-9/11 veterans that do not seek mental health support at the VA do so for three main reasons (National Academies of Sciences, Engineering, and Medicine, 2018):

• They don’t know that the VA offers mental health care benefits.
• They are unsure how to apply for VA mental health benefits.
• They are unaware of their eligibility status with the VA.

inTransition can help eliminate these deterrents from getting connected to behavioral health care and assist with the other above needs as well. The inTransition coaches are familiar with and trained in military culture. They can help service members and veterans find transition-related resources (i.e. employment, financial, VA benefits, etc.) and are experienced in navigating the VA medical system.

The need to maintain or get connected to behavioral health care is vital. The inTransition Program is available 24/7/365 to assist service members, veterans, and providers on how to navigate the path for a successful connection to care.

Visit www.pdhealth.mil/intransition or call:

800-424-7877: Inside the U.S.
800-424-4685: Outside the U.S. toll-free
314-387-4700: Outside the U.S. collect

 

References:

Analysis of VA Health Care Utilization among Operation ... (2015). https://www.publichealth.va.gov/docs/epidemiology/healthcare-utilization-report-fy2015-qtr1.pdf

C. Zoli, R. Maury, & D. Fay, Missing Perspectives: Servicemembers’ Transition from Service to Civilian Life — Data-Driven Research to Enact the Promise of the Post-9/11 GI Bill (Institute for Veterans & Military Families, Syracuse University, November 2015)

National Academies of Sciences, Engineering, and Medicine. Evaluation of the Department of Veterans Affairs Mental Health Services. 2018. doi:10.17226/24915

 

Change Project 911: What to Do When the Idea Well Has Run Dry

Mat Roosa, LCSW-R
NIATx Coach

We want to improve, and we have made some changes, but they have not worked. We don’t know what else to do.

Generating change ideas requires time and energy. Teams lose momentum when initial change efforts don’t succeed, and then struggle to develop option B (or C) to continue their improvement efforts. As teams attempt to move multiple priorities forward, they lose energy to exploring new ideas. Worst case scenario? They feel like just giving up and tolerating the problematic status quo.

So what is a busy team with limited resources to do? How can your team develop a new vision? The five ideas that follow can help organizations to generate new ideas to get the change process moving again.

1. Retreat

Whether it’s a quiet day of meditation, or a hasty maneuver on the battlefield, a retreat serves the singular purpose of establishing a safe space to regroup, reconsider, and establish a means of achieving a desirable future. Many teams hesitate to consider the retreat option because they worry about spending the day away from the office with the entire staff, and the prohibitive costs of a conference center and lost productivity. It is best to think of retreats as a process and not as an event. What can you do to create an environment that enables team members to pull back from day-to-day activities to consider alternative paths for the future? How can team members be encouraged to take a time out to consider new ways to solve old problems? Sometimes a single lunch meeting away from regular duties can spark fresh ideas that enable a team to generate new solutions. 

2. Do an NGT, again

The Nominal Group Technique is a structured brainstorming process designed to foster team inclusion. The NGT generates a high volume of diverse ideas based on answering a strong question. The simple rules of the NGT ensure that all members of the team can share their ideas. The lists of ideas that are generated should be saved and reviewed periodically. Conduct additional NGTs periodically to get a new set of responses to the same question. Retreat sessions (see no.1 above) are a perfect place to conduct a 45-minute NGT with the team.

Learn how to conduct an NGT

 

3. Look for ideas from outside

This is one of the five NIATx core principles. Too often, organizational leaders only seek ideas from their own organization or industry. And these “inside” ideas tend to recycle the same set of values and assumptions. So even when leaders may be sharing a new best practice, they do so from a familiar orientation. Consider asking the following questions to find new ways of seeing old challenges.

• Where else does this challenge arise?
  
  
• How do other industries address this challenge?
  
  
• How is their worldview different, and how does that different vision lead to different solutions?

4. Ask the newbies
Why do we do it that way? This curious question has been asked by thousands of new employees when encountering a practice or process in a new work setting. It is often followed by, “At my last job, we used to…” as a way of sharing an alternative strategy.

Too often the response to the first question is, “because that’s how we do it here”, and very quickly the opportunity to learn from new staff members is lost.

• What if every newly hired member of the team were asked to keep a running list of every flaw, and every opportunity for improvement, during their first month of employment?
  
  
• What if we harnessed the power of the curiosity of those who have yet to become comfortable with the business as usual?

It is likely that we would capture a rich set of ideas for change.

5. Crowdsource it
Maybe you have seen the show “Who Wants to be a Millionaire?” When the contestant asks the audience for the answer, the audience is almost always right. Engaging large groups through surveys harnesses a powerful array of experience and knowledge. The crowd will often produce ideas that a smaller team would not be able to generate. Crowds can include the broader staff from your organization, or a wider range of voices from outside of your organization. (See no. 3 above.)

Try any one or more of these five strategies to energize your team’s creative thinking and ignite new ideas to test in your next change project.

About Change Project SOS

Change Project SOS is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a wall that you're not sure how to tackle? Share your story in the comments section below, or email Change Project SOS at matroosa@gmail.com. We’ll offer solutions from our team of change project experts!

About our Guest Blogger

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. Mat also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at matroosa@gmail.com.

How do we Successfully Implement SUD Screening and Referrals in Title X Family Planning Settings? Integration of Services Is Key

Lena Marceno, MSc
Denise Raybon, MPH
Altarum

Can we talk of integration until there is integration of hearts and minds? Unless you have this, you only have a physical presence and the walls between us are as high as the mountain range. — Chief Dan George

How do we break down walls? How do we integrate health care services to holistically meet the needs of our community? Research has shown that integrating care can lead to improved patient experience and health outcomes. In particular, the integration of family planning (FP) services and services for those with a substance use disorder (SUD) is critical to ensuring the reproductive health needs of those with SUD are met.

People with SUD report an unmet need for family planning services, with only half reporting using contraception. Those who do use contraception rely mostly on “moderately effective” methods. These challenges are compounded by the fact that when people with SUD seek care from providers, they often experience stigma, judgment, and shame creating further barriers to their care. Yet the heightened stress, loneliness, and anxiety brought on by the COVID-19 pandemic has only exacerbated the unmet need for behavioral health care services in our communities.

Administered by the Office of Population Affairs (OPA), Title X family planning programs provide services to assist in achieving or preventing pregnancy, STI prevention, and a host of related prevention services. Family planning clinics are well positioned to screen for substance use, as they are often the primary entry point to the health care system for women. OPA strongly encourages its grantees to screen for substance use disorders and provide referrals, when appropriate. However, in a recent survey, only half of family planning clinics reported making external referrals for patients who screened positive for substance use disorder. Reaching a growing number of people with both family planning needs and substance disorders requires an interdisciplinary approach.

To learn more about the impact of this work, watch this short video featuring the voices of the community Altarum serves.

 

With funding from OPA, Altarum is breaking down walls by conducting a multi-faceted research study using an innovative cross-training model. The cross training brings together family planning and SUD providers from the same geographic region and is designed to equip providers with the skills and self-efficacy to effectively screen and refer their clients. As part of the training, participants engage, learn from, and network with one another and create concrete action plans to increase and sustain linkages.

The study also includes financial and economic analyses focusing on the benefits for individual clinics and providers, including expected increases in patient volumes, patient retention, and overall quality of care, as well as broader societal benefits.

The program is available to any Title X funded family planning provider and any behavioral health provider that provides services or treatment for substance use disorder nationwide. If you are interested in learning more, please visit the website, or reach out to Lena Marceno, Project Manager, at linkstudy@altarum.org.