Opioid Epidemic and Criminal Justice - PowerPoint Presentation

1. Opioid Epidemic and Criminal Justice Populations:Best Practices Dr. Chanda BrownDirector, Charleston Centercfbrown@charlestoncounty.org

2. AgendaWe Have an Epidemic!Criminal justice populationsWhat Are Opioids and Opioid Use Disorder? Is it Treatable? Stigmas & MythsTreatment Effectiveness & Outcomes

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4. National Drug Overdose Deaths RisingData sources: CDC Wonder and drugabuse.gov

5. By Gender

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8. We have a problem!Overall, Americans consume up to 80% of the World’s prescription opioids. Source: Centers for Disease Control and PreventionOn an average day in the U.S., according to the Department of Health and Human Services, health care professionals dispense more 650,000 Opioid Prescriptions. Each day: 3,900 people initiate nonmedical use of prescription opioids for the first time.Each day: 580 people use heroin for the first time.Each day: 120 People die from an opioid-related overdose. (U.S. DHHS)Overdose deaths have surpassed motor vehicle fatalities as the country’s leading cause of injury death.Overdose deaths are leading cause of death for individuals under age 50More Americans have died from an opioid overdose than the number of Americans who died in Vietnam War

9. AgendaWe Have an Epidemic!Criminal Justice PopulationWhat Are Opioids and Opioid Use Disorder? Is it Treatable? Stigmas & MythsTreatment Effectiveness & Outcomes

10. SUD and Criminal Justice PopulationsDrug misuse is implicated in at least 3 types of drug related offenses1. offenses defined by drug possession or sales2. offenses directly related to drug misuse (stealing to get money for drugs)3. offenses related to a lifestyle that predisposes the drug user to engage in illegal activityTreatment offers the best alternative for interrupting the drug abuse/criminal justice cycleSouth Carolina Statistics2017 SC Department of Corrections dataTotal inmate population: 19,98918,538 Males (6180/ or 35% of which have SUD)1451 Females (755/ or 52% of which have a SUD)

11. SUD and Criminal Justice Populations ContinuedThe negative impact of the opioid epidemic touches every aspect of public safety and the judicial system. There is an increasing number of children entering foster care. From 2012-2016 the percentage of removals due to a parent’s SUD has increased from 13% to 32.2% according to National Center for State CourtsOpioid overdose, misuse and abuse impacts loss of home and property, conservatorship and bankruptcy.

12. AgendaWe Have an Epidemic!Criminal Justice PopulationsWhat Are Opioids and Opioid Use Disorder? Is it Treatable? Stigmas & MythsTreatment Effectiveness & Outcomes

13. What Are Opioids? Medicines that relieve painCan be natural (from the poppy plant) or synthetic (man-made)Common Prescription Opioids:Hydrocodone (Ex: Vicodin, Lortab); Oxycodone (Ex: OxyContin, Roxicodone, Percocet)Commonly prescribed for a variety of painful conditions, including dental and injury-related pain Morphine (Ex: DepoDur, Astramorph, Duramorph) Often used before and after surgical procedures to alleviate severe painFentanyl 50-100 times more potent than Morphine; Used to treat severe pain, often in patch formCodeine Often prescribed for mild pain; Can also be used to relieve coughs and severe diarrhea

14. What Do Opioids Do? Reduce and relieve painCan sometimes create a sense of euphoria HIGHLY habit forming and addictiveSide Effects:Drowsiness and sedationMental ConfusionNausea and vomitingConstipationPinpoint (constricted) pupilsSlowed or depressed vital signs Body temperature, blood pressure, pulse and respiration ratesOverdose and Death

15. What is HEROIN? How is it used? An illegal narcotic used recreationally to achieve effects similar to those caused by prescription opioidsComes from the opium poppy flowerCan look like white or brown powder or black tarStronger, cheaper, easier to get than prescriptions pillsAlso more dangerous- you never know what it is cut/mixed withOther names: horse, smack, junk, brown sugarInjection (most common and most dangerous)SnortSmokeNo matter how you use it, it gets to the brain quickly.Heroin is HIGHLY ADDICTIVE- you quickly build a tolerance for it and need more each time to feel the same results.

16. What is HEROIN? (cont.)How does it make you feel? Relieves painInstant rush good feelings and happinessFollowed by slow, dreamlike euphoriaSide Effects and RisksSlows vital signs (heart and pulse rate, breathing, blood pressure)ItchingNausea and vomitingCollapsed veinsInfections of the heart lining and valvesSkin infections like abscesses and cellulitisHigh risk of contracting HIV/AIDS, hepatitis B, and/or hepatitis C Lung diseases (pneumonia and tuberculosis)Miscarriage

17. Opioid Misuse/DependenceSigns and SymptomsPhysical Signs Change in appetitePupil sizeSmall: opioid intoxicationLarge: opioid withdrawalNausea VomitingSweatingShakingBehavioral SignsChange in personality/attitudeChange in friendsChange in activities, sports, hobbiesPoor attendance / gradesIncreased isolation; secrecyWearing long sleeved shirtsMoody, irritable, nervous, giddy, or nodding offStealing

18. Chronic DiseaseOnce you have it, you’ve got it“Disease” implies there is a “medical” componentCauses are usually multifactorialTreatments must usually be multi-modalResponse rates are variable and depend on the patient, the treatment itself, and outside factorsDrug Dependence, a Chronic Medical IllnessTitle of an article in JAMA, Oct 4, 2000, Vol. 284, no. 13, pp 1689-1695Compares drug dependence to type 2 diabetes, hypertension, and asthmaGenetic heritability, personal choice, and environmental factors are comparably involvedMedication adherence and relapse rates similar across these illnesses

19. Chronic Disease ComparisonDiabetes Genetic predispositionLifestyle choices are a factor in development of the diseaseSeverity is variableThere are diagnostic criteriaOnce diagnosed, you’ve got itAddictionGenetic predispositionLifestyle choices are a factor in development of the diseaseSeverity is variableThere are diagnostic criteriaOnce diagnosed, you’ve got it

20. American Medical AssociationClassified addiction as a medical illness in 1956Added addiction to the International Classification of Diseases codes in 1991Despite AMA and Surgeon General, we still have an uphill battle to fight in regards to treating addiction like the disease it is AND not trying to arrest our way out of addiction. NIDA (2009)Indicated that “addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior.”

21. AgendaWe Have an Epidemic!Criminal Justice Population What Are Opioids and Opioid Use Disorder? Is it Treatable? Stigmas & MythsTreatment Effectiveness & Outcomes

22. Medication Assisted Treatment (MAT) of Substance Use DisordersMAT = FDA approved medication + behavioral therapyInvolves a combination of medication that targets the brain AND psychosocial interventions (i.e. counseling, skills development)Aimed at improving treatment outcomesFor most, medications combined with psychosocial treatment is superior to drug or psychosocial treatment on its own.Source: psccmat.org

23. MAT and the Criminal Justice Involved IndividualMedications can be an important component of treatment for an offenderAllows the brain to function more normally, enabling the offender to make important lifestyle changesNational Institute of Drug Abuse established that MAT “increases patient retention and decreases drug use, infectious disease transmission and criminal activity” (NIDA, 2012)Surgeon General (2018) recognized that upon release, incarcerated individuals are at greater risk for overdose and death after release due to return to use and lowered tolerance to opioids.

24. MAT Options: One size does NOT fit allOpioid treatment medications work in quite different ways and may be more or less effective for particular types of patients. In the midst of an epidemic of opioid overdose and opioid use disorder, all evidence-based medications should be accessible to patientsSource: ADAI

25. MAT Options: MethadoneHow it works Activates opioid receptors in the brainBlocks the effects of heroin and painkillersDaily dosingWhy it worksLessens cravings for heroin and other opioidsLessens withdrawal symptomsLeads to less heroin useFewer medical complicationsImproves social and work functioningDispensing is highly regulatedCan only be used in Opioid Treatment ProgramsImage & Data Source: pewtrust.org

26. MAT Options: BuprenorphineHow it works Partially activates opioid receptors in the brainDaily dosing as a pill or film6-month dosing as an implant inserted beneath the skinWhy it worksReduces drug use and protects patients from overdoseConsidered safer than methadoneLess monitoring neededCan be prescribed by primary care providers who complete a special training courseImage & Data Source: pewtrust.org

27. MAT Options: Naltrexone(also known as Vivitrol)How it works Completely blocks opioid receptors in the brainDaily dosing in oral formsMonthly dosing as extended-release injectable formsWhy it worksUsed after detoxification to prevent relapseNo abuse potentialNo overdose riskNo withdrawal when medication is stoppedCan be administered in a primary care physician's officeSingle doses effective up to 30 daysImage & Data Source: pewtrust.org

28. Role of Naloxone (Narcan)Opioid antagonistReverses opioid effects, thereby can reverse overdoseHas been used by EMS for decadesCan get Narcan at local pharmacy. SC has a blanket prescription for citizensMust always notify authorities to take overHolds harmless anyone who prescribes/dispenses/administers in good faithSome states also grant immunity to drug users present who try to help; they will not be arrested for possession/use during this helping episode

29. AgendaWe Have an Epidemic!Criminal Justice PopulationsWhat Are Opioids and Opioid Use Disorder? Is it Treatable? Stigmas & MythsTreatment Effectiveness & Outcomes

30. Barriers to implementing MAT programProvider, public and client attitudes and beliefs about MATSubstituting one drug with another/abstinence only model. Not supported by science. Withholding medications greatly increases risk for relapse and overdose deathLack of an appropriate infrastructure for providing medicationsPayment policiesNeed for staff training and developmentPolicies, and regulations that limit MAT implementation

31. Common Myths About Medicated Assisted Treatment (MAT)Myth #1: MAT just trades one addiction for another.FACT: Methadone is a treatment for opioid addiction, not a substitute for heroin. Methadone is long-acting, requiring one daily dose. Heroin is short-acting, and generally takes at least 3-4 daily doses to prevent withdrawal symptoms from emerging. Methadone stabilizes the patient and does not produce euphoric effects “high”. It also does result in over-sedation.Myth #2: Once on stable doses of Methadone, patients become addicted it.FACT: Patients taking methadone are physically dependent on it, but not addicted. When used in MAT, methadone is a medication for a chronic illness, such as insulin for diabetes, inhalers for asthma, and blood pressure pills for hypertension. Source: thinfluence.org

32. Common Myths About Medicated Assisted Treatment (MAT)Myth #3: MAT patients are not able to perform well in many jobs. FACT: Patients on a stable methadone dose, not using other non-prescribed or illicit medications should be able to do any job they are otherwise qualified to do. A person stabilized on the correct dose is not sedated, in withdrawal, or euphoric. The most common description of how a person feels on methadone is “normal.”Myth #4: Methadone is not advisable for pregnant women.FACT: Evidence has shown that the best possible outcome for a pregnant woman addicted to opioids and her fetus is to take either methadone or buprenorphine rather than tapering off and attempting to be abstinent during pregnancy. Methadone does not cause abnormalities in the fetus and does not appear to cause cognitive or any other abnormalities as their children grow. Source: thinfluence.org

33. AgendaWe Have an Epidemic!Criminal Justice PopulationsWhat Are Opioids and Opioid Use Disorder? Is it Treatable? Stigmas & MythsTreatment Effectiveness & Outcomes

34. Correlates of Good Outcomes in Opioid MaintenanceAdequate dosingLength of retention in treatment (NIDA, 2009, indicated that a minimum of 12 months is required for methadone maintenance to be effective)Consistent therapeutic relationship with a counselorPsychosocial services, including psychiatric evaluation and treatment when needed

35. How is appropriate dose determined and how long should a person be on MAT?Appropriate dose is determined by a certified medical provider, in consultation with the patient. Includes history and physical and bloodwork. Individually tailored based on an individual’s medical and physiological needsNot a “one size fits all” model for dosage or length of timeLength of time includes three phases Stabilization- withdrawal management, assessment induction and counselingMedication maintenance- deeper level of counselingOngoing rehabilitation- patient and provider may taper or engage in long term maintenance

36. Length of time continuedAccording to National Institute of Drug Abuse- for methadone maintenance, twelve months of treatment is minimumSurgeon General in statement from 9/2018 shared two studies.Patients who received MAT for less than 90 days did not show improved outcomesAnother study suggested that individuals who receive MAT for fewer than 3 years are more likely to relapse than those who are in treatment for 3 or more years.

37. Treatment Effectiveness Source: pewtrusts.orgOver a decade of good research shows that:Medicated Assisted Treatment…Significantly increases a patient’s adherence to treatmentNumerous studies show that MAT reduces drug overdose deaths recidivism, and infectious disease among criminal justice involved personReduces illicit opioid use compared with nondrug approachesReduces criminal activity, particularly criminal behavior related to use and dealing Reduces infectious disease transmissionAccording to National Institute of Health “The safety and efficacy of narcotic agonist (methadone) maintenance treatment has been unequivocally established.”

38. What is best practice for someone with Opioid Use Disorder who is also involved with criminal justice system?Treatment that includes both medications and behavioral therapy– but remember, not everyone meets criteria for a detox bed or inpatient bed and if mandated at that level and not qualified you are putting an undue financial burden on treatment agencyConcern that mandated treatment won’t work- need to be ready. But legal pressures can help increase treatment attendance and improve retention. Civil commitment process can save a life. PTI/Drug Court/all work but work better when coupled with MAT

39. 9 components of effective Drug Court Program1. Counseling and other services PLUS medication are essential.2. Courts are selective about treatment programs and private prescribing physicians.3. Courts develop strong relationships with treatment programs and require regular communication regarding participant progress4. Screening and assessment must consider all clinically appropriate forms of treatment5. Judges rely heavily on the clinical judgement of treatment providers as well as the court’s own staff6. Endorsement of medication-assisted treatment by all members of the drug court team is the goal, but not a prerequisite.

40. 9 components continued7. Monitoring for illicit use of medication-assisted treatment medication is a key component of the program and can be accomplished in different ways8. Medications for medication-assisted treatment are covered through government and/or private insurance programs often times9. Medication-assisted treatment operates very similarly to other kinds of treatment From Center for Court Innovation/Legal Action Center

41. Surgeon General ReportIn November 2016, Former Surgeon General Dr. Vivek Murthy put out the biggest Surgeon General Report on addiction since the landmark 1964 report addressing tobacco.Emphasized addiction was a disease that caused changes in the brain circuitry Emphasized that MAT was crucial in combating the opioid epidemic and that it was NOT substituting one drug for another. Further adding that MAT should take years for best outcomes.September 2018 Surgeon General Dr. Jerome Adams further supported Dr. Murthy’s report and published report specifically about opioids and importance of long term MAT treatment

42. 21st Century Cures ActEnacted December 2016 and included:Landmark mental health reform billMonies for states to fight opioid epidemicPrescription drug monitoring programsPrimary care involvementTraining in best practicesPrevention educationState Targeted Response Funding (STR) and State Opioid Response Funding (SOR)

43. What Federal, State, Local, and Tribal Governments can doProvide leadership, guidance and a vision in supporting scientific approach to addressing substance use disordersCollect and use data to guide your local response to people and places at highest riskImprove coordination among systems and agencies (health care, criminal justice, behavioral health, law enforcement, social services)Implement criminal justice reforms that are more health-focused

44. What Can You DoJudges are effective at using their convening power to bring target agencies and community stakeholders together. Implement law enforcement diversion programs and/or prosecutor diversion programs to deflect people with SUDs from criminal justice systems into treatment as soon as possible.Incorporate strategic screening questions into intake forms to flag individuals at risk for overdose or in need of treatmentCivil Commitment process can be an effective strategy to assist families

45. SUMMARYOpioid addiction is a chronic, relapsing “disease” similar to diabetes mellitus type 2Relatively few medications exist for opioid addiction, but efficacy is goodMAT is the standard of care for most, including criminal justice populations and pregnant patients with opioid addictionNaloxone should have an increasing role in preventing overdose deathsThe choice of medication should be individualized, as always in medicine -- there is no “one size fits all”Ideology, stigma and lack of knowledge still remain significant barriers to effective MAT