Transcription
Culture Shift in Treatment ofAddiction in Correctional SettingsPresented March 06, 2020HERBERT KALDANY, D.O.NJ DEPARTMENT OF CORRECTIONSDIRECTOR OF PSYCHIATRY, ADDICTIONSAND WELLNESS
Mission and Objectives The Mission is to provide you information on the tremendous shift from punitive to treatment basedservices for Addiction in NJ CorrectionsObjective 1 – Discuss the Laws which grew theincarceration population based on Drug UseObjective 2 – The New Science of AddictionObjective 3 – The NJ DOC culture shiftObjective 4 – The NJ Jail culture shiftObjective 5 – The Community culture shiftObjective 6 – Making connections between thesevarious segments at Entry/ReleaseObjective 7 – Correctional Outcomes and Data
Objective 1: Drug Laws Mentally ill people hospitalized dropsfrom the 50s through the 70s due toprograms designed to empty hospitals. Yet we have no increase in the prisoncensus until the 80s, and it keeps rising. The 80s were the time of mandatorydrug sentencing such as the RockefellerDrug Laws in NY and the “3 strikes andyou’re out” in CA.
The Drug Laws and Incarceration The graph shows that most mentally ill people do notcommit crimes. If they did, the graph would begin torise immediately. During this time, commitment laws were just startingto get passed nationally which would limit the statepower to commit [to a hospital] only in cases wherethat person posed an imminent danger to themselves,others or property. However, this graph does illustrate that when drug usebecame illegal, the state was permitted to commit toprison and we see the incarcerated population to risefrom the 80s to present day.
How Addiction Laws tie in to MOUD Mandatory Drug Sentencing came about in part because themain tool for addressing the safety of society was throughpunishment rather than treatment. A 2020 SAMHSA report estimates only 1% of all prisons and jailsoffers MOUD Unpublished research done by the Correctional MH Network in 2017estimates that 40% of state prisons offer some form of MOUD MOUD became a the gold standard around 2015 or so It remains an unpopular modality because the criminal justicesystem: Views addiction as a choice, a moral failing rather than a braindisease/disorderViews addiction as illegal – this was true since the 80s drug lawsDefines people with addiction as addicts rather than looking at the person onthe wholeTreatment of an Opioid Use Disorder mainly follows a communitydetoxification protocol
Objective 2 – The New Science of Addiction &What Modern Science Reveals About Addiction Brain Disease/Disorder Treat the brain and the behaviors shift Just Say No campaign remains a huge failure Is addiction a choice?
National Institute on Drug Abuse, www.nida.nih.gov, 2000.
Reward Pathway Neurons start in themidbrain releasedopamine in thenucleusaccumbens Baseline: steadydopamine Drugs: burst ofdopamine(pleasure/salience)
New circuits created from prefrontal cortex (glutamate)
Blue mature state
Natural Rewards and DopamineLevelsSexDA Concentration (% Baseline)Food% of Basal DA Output200150100Empty50Box Feeding200150100Female Present0060120Time (min)180Sample1 2 3 4 5 6 7 8NumberAdapted from: Di Chiara et al, Neuroscience, 1999Adapted from: Fiorino and Phillips, J Neuroscience, 1997
Effects of Drugs on Dopamine LevelsMORPHINEDose mg/kg0.51.02.510200150100001234400% of Basal Release% of Basal Release250COCAINE5 hr3002001000012345 hr250% of Basal Release% of Basal ReleaseALCOHOLNICOTINE2502001501000123 hr0.250.512.515010000Dose g/kg20001234hrAdapted from: Di Chiara and Imperato, Proceedings of13the National Academy of Sciences USA, 1988;courtesy of Nora D Volkow, MD
Effects of Drugs on Dopamine Levels1100AMPHETAMINE1000% of Basal Release900800DA7006005004003002001000012345 hrAdapted from: Di Chiara and Imperato, Proceedings of the National Academy ofSciences USA, 1988; courtesy of Nora D Volkow, MD
Objective 3The NJ DOC culture shift Started 6-7 years ago Shift from TC Model to Holistic Medical Model Licensed SUD treatment Opened MSCF to treat immediately MOUD being incorporated – clinical bias Peer Navigator/Intensive Recovery Treatment Support at release – synergy with medicationPeer Specialists at IntakePersonal Bias System BiasTraining is KeyTrain Uniform and civilian staff together
Objective 4The NJ Jail Cultural Shift Independent to NJ DOC process until 2017 Drug court – Recovery court in AC CJR - Bail reform impact Introduction of Methadone treatment in ACJ Introduction of Methadone treatment in MCJ CCJ Re-Entry Efforts – all medication options Expansion to other Jails NJ DOC DOH DMHAS Collaboration 2019 Information Exchange barriers
Objective 5The Community cultural Shift Treatment providers getting DEA X Waiver ED treatment of pain ED treatment of Addiction Increase of MOUD in rehabs Centers Of Excellence
Objective 6Bringing All These Pieces Together is Complex Community – Corrections – Community Diversion – Conversion – Dispersion Connecting these 3 systems – Jails, Prisons, Comm. Parole SUD treatment to divert from jails and prisons Jail to Drug/Recovery Court Jail Re-Entry to Community Jail Release to State Prison Prison Re-Entry to Parole Prison Re-Entry at Max Out to Community
Objective 7Correctional Outcomes 129x in risk of death in first 30 days post release IRTS on follow up Overdoses and Deaths Rides Phones Holistic Harm Reduction HIV, STDs, Hepatitis A, B, C Treatment Reduces Drug Diversion NJ DOC example
NJ DOC Lab data December 2015PERIOD COVERED# of SamplesPOSITIVES12/7/15-12/11/15298INSTITUTIONTEST DATESAMPLE BUPBUPOPIOPIOPIOPIOPIConfirmed by ADLConfirmed by ADLConfirmed by ADLConfirmed by ADLConfirmed by ADLPrescribed MedsPrescribed MedsConfirmed by ADLPrescribed MedsOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmConfirmed by ADLConfirmed by ADLOn-Site ConfirmON-Site/ADL CoinfirmOn-Site ConfirmConfirmed by ADLConfirmed by ADLOn-Site ConfirmPrescribed MedsPrescribed MedsPrescribed MedsPrescribed /11/2015# of OPI 10; Rxd OPI 7;# of BUP 7; Rxd BUP Ø, Ø %
NJ DOC Lab data December 2016PERIOD COVERED# of SamplesPOSITIVES12/5/16-12/9/16196INSTITUTIONTEST DATESAMPLE DATEDOACOMMENTSGSCF12/5/201612/1/2016THCOn-Site ConfirmTALBOT12/5/201612/3/2016BUPOn-Site ConfirmKIN-BRIDG12/6/201612/3/2016BUPOn-Site ConfirmNJSP12/6/201612/5/2016OPIPrescribed Meds (On-site)EMCF12/6/201612/4/2016THCOn-Site ConfirmKIN-NEW12/7/201612/6/2016THCOn-Site ConfirmSSCF12/7/201611/28/2016BUPOn-Site ConfirmSSCF12/7/201612/1/2016BUPOn-Site ConfirmBSP12/7/201612/2/2016BUPOn-Site ConfirmBSP12/7/201612/1/2016BUPOn-Site ConfirmBSP12/7/201612/5/2016BUPOn-Site ConfirmNSP12/8/201612/3/2016BUPOn-Site ConfirmNSP12/8/201612/3/2016THCOn-Site ConfirmNSP12/8/201612/6/2016THCOn-Site ConfirmNSP12/8/201612/7/2016OPIPrescribed MedsNSP12/8/201612/3/2016OPIPrescribed Meds# of OPI 3; Rxd OPI 2;# of BUP 8; Rxd BUP Ø, Ø %
NJ DOC Lab data December 2017PERIOD COVERED# of Samples11/27/17-12/1/17110POSITIVESINSTITUTIONTEST DATESAMPLE 711/27/2017OXYBUPOPIBUPBUPBUPConfirmed by ADLPrescribed Meds (On-site)On-Site ConfirmOn-Site ConfirmOn-Site ConfirmConfirmed by ADLEMCF11/29/201711/26/2017OPI/COC/THCOn-Site 2017OXYBUPConfirmed by ADLOn-Site ConfirmCOLUMBUS12/1/201711/28/2017OXY/TCAConfirmed by /29/2017BUPBUPBUPTHCBUPBUPBUPOPITHCBUPOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site ConfirmOn-Site Confirm# of OPI 3; Rxd OPI 0;# of BUP 12; Rxd BUP 1, 8%
NJ DOC Lab data December 2018PERIOD COVERED# of SamplesPOSITIVES12/3/18-12/7/18110INSTITUTIONTEST DATESAMPLE DATEDOACOMMENTSCRAF12/3/201812/3/2018BUPPrescribed 28/2018BUP/BAR/BZOOn-Site ConfirmMEDS/Confirmed by ADLEJSP12/6/201812/16/2018OPIPrescribed MedsEJSP12/6/201811/21/2018BUPConfirmed by ADLEJSP12/6/201811/27/2018OPI/COCConfirmed by ADLEJSP12/6/201812/2/2018THCConfirmed by ADLACWYCF12/6/201812/5/2018BUPPrescribed MedsACWYCF12/6/201812/5/2018BUPPrescribed MedsKIN-NEW12/6/201812/5/2018BUPOn-Site ConfirmSSCF12/7/201812/5/2018BUPPrescribed Meds (On-site)SSCF12/7/201812/5/2018BUPPrescribed Meds (On-site)SWSP12/7/201812/4/2018BUPPrescribed Meds (On-site)SWSP12/7/201812/5/2018BUPPrescribed Meds (On-site)NSP12/7/201812/1/2018BUPPrescribed Meds (On-site)NSP12/7/201812/1/2018BUPPrescribed Meds# of OPI 1; Rxd OPI 1;# of BUP 13; Rxd BUP 9, 69%
PERIOD COVERED10/21/19-10/25/19NJ DOC Lab data December 2019# of SamplesPOSITIVES227 bed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Confirmed by ADL (On-site)On-Site ConfirmOn-Site ConfirmOn-Site ConfirmPrescribed MedsPrescribed MedsPrescribed MedsPrescribed Meds (On-site)Prescribed Meds (On-site)On-Site ConfirmPrescribed MedsPrescribed MedsOn-Site ConfirmPrescribed MedsPrescribed MedsPrescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed MedsPrescribed MedsConfirmed by ADLConfirmed by ADLOn-Site ConfirmPrescribed MedsPrescribed MedsPrescribed MedsConfirmed by ADLPrescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed Meds (On-site)Prescribed MedsConfirmed by ADLOn-Site ConfirmOn-Site ConfirmConfirmed by ADL (On-site)Confirmed by ADL (On-site)Confirmed by ADLPrescribed MedsPrescribed MedsPrescribed MedsPrescribed MedsPrescribed MedsPrescribed Meds# of OPI 1; Rxd OPI 0;# of BUP 54; Rxd BUP 46, 87%54 BUP finds is 3 x more than in 2018. 7 BUP diversions mean 13% only.
THANK YOU!!
The NJ Jail Cultural Shift Independent to NJ DOC process until 2017 Drug court -Recovery court in AC CJR - Bail reform impact Introduction of Methadone treatment in ACJ Introduction of Methadone treatment in MCJ CCJ Re-Entry Efforts -all medication options Expansion to other Jails NJ DOC DOH DMHAS Collaboration 2019
