All right, good afternoon, everyone, and welcome to today's webinar. We'll give it just a couple minutes here as people continue to join. All right, well, good afternoon, everyone, and welcome to today's webinar titled Improving Continuity of Care for Justice-Involved Individuals, Lessons from the Field, hosted by the provider's clinical support system, Medication for Opioid Use Disorder Project, and the National Council for Mental Well-Being. My name is Rachel Palikde, and I'm a project coordinator of practice improvement here at the National Council, and I will be moderating today's event. So before we get started, I'd like to cover just a few housekeeping notes. So today's webinar is being recorded, and all participants will be kept in listen-only mode. There will be an opportunity to ask questions at the end of the webinar, so we ask that you please submit any questions you have at the Q&A box located at the bottom of your screen. The recordings and our slides will be made available on the PCSS MOUD website within two weeks and also within 24 hours of today's session. You'll receive an e-mail from the address on your screen with evaluation and certificate claiming information. And this is a note that our presentation is prohibited from promoting or selling any products or services, and rather the goal of PCSS MOUD is to increase healthcare professionals' knowledge, skills, and confidence to provide evidence-based practices. All right, so I am pleased to introduce today's speakers, Ed Hayes and Rachel Katz. Ed Hayes is an assistant superintendent at the Franklin County Sheriff's Office, as well as the administrative director of their opioid treatment program, and Rachel Katz is a nurse practitioner director of addiction services at Clinical and Support Options. Please see the chat to reference both of Rachel and Ed's full bios. But Rachel and Ed, we are so thrilled to have each of you with us today. It's our pleasure. Thank you for this opportunity. Yes, thank you. Yeah, so a couple more items. We've got no disclosures to report from our speakers. And then also, just real quick, our educational objectives today will be to describe the context of the opioid crisis and its intersection with the jails and prisons. We'll define the components of the successful jail-based opioid treatment program and also consider continuity of care planning for patients reentering the community from incarceration with opioid use disorder and recognize a program that partners with community health care collaborators. So at this time, I will go ahead and turn it over to Ed Hayes to begin his presentation. Great, Rachel, thank you so much. It's a pleasure to be here, and it's a very important topic. And so we look forward to discussing this with you. Rachel, can you advance the slide? Sure, I. So as Rachel introduced, my name is Ed Hayes and I'm an assistant superintendent. I work in a rural jail in western Massachusetts, and we have been facing this opioid epidemic for over a decade now. And unfortunately, year after year, there seems to be an evolution of it that makes it worse and harder and more difficult for our patients. Jails have become a kind of ground zero for the opioid crisis, and many jails, most of them in our nation, there are over three, four thousand, do not offer any kind of medical treatment for opioid use disorder. And there are a number of very effective evidence based medications and interventions that have been proven to be successful. And so we're going to talk to you about that. Public safety matters, and we believe that the future of public safety is using modern public health strategies and interventions to achieve public safety outcomes. Corrections, unfortunately, is a field that is not often current with the research. So. It is important that we stay connected to what are the most promising evidence based practices and what has been shown to work. Essentially, what we need to do is create a kind of a program inside the jail and then link clients to services in the community to make that happen. It is essential to partner and collaborate with community providers to ensure a continuity of care seamlessly between when someone is incarcerated and when they return to the community slide. Rachel, I'll pass it to you to brief us on the various medications for opioid use disorder. Yeah, absolutely. Thank you, Ed. So there are three FDA approved medications to treat opiate use disorder. The gold standard and the one that has been used the longest is methadone. So methadone is a full agonist, meaning that it meets all of the receptors in the brain that any illicit or prescribed opiate would. So a prescribed opiate would be something like morphine or dilaudid and an illicit opiate obviously would be heroin or fentanyl from the street. So methadone is a daily medication and typically it is dosed in front of a nurse or a medical professional. People usually have to go to a clinic every morning to receive their dose. Often there are high barrier requirements such as counseling, group work, those sorts of things. The other medication that we use is buprenorphine, which is also known as suboxone or subutex. There's a variety of formulations. That is also a daily medication and buprenorphine is a partial agonist. So it meets most of the opioid receptors in the brain. It is also strong enough that it's going to push other things off of those same receptors. So even though it's a partial agonist, it's incredibly strong. When you take it every day, it's either a tablet or a film. It does come as an injectable, which is known as sublocade. And there's a new one on the market called brixadi. And so those are monthly or weekly injections. Buprenorphine is able to be prescribed by any outpatient prescriber based on federal and individual state guidelines. And people can come back in and see their clinician or their medical provider following those providers guidelines. The other medication that we use is naltrexone, which is an antagonist. So an antagonist means that it's going to block those receptors in the brain. So people can't get high. They can't get the euphoria that is associated with illicit opiates. It is either a daily tablet or an extended release injectable, which again would be a monthly injection. And that's known as Vivitrol. And then any clinician can prescribe that and it can be administered through any outpatient site or facility. There is a missed opportunity for medications for opioid use disorder in our prison and jail systems. These numbers are a little bit older. Unfortunately, the state of affairs has improved in the past few years. But nonetheless, the vast majority of jails do not offer any kind of medication for opioid use disorder. 14 states offer methadone or buprenorphine. They did that in 2018. Risk of death was 10 to 40 times higher within two weeks of release in 2018. And we'll look at some statistics in a moment that show that in fact the problem has increased. Less than 5% of people with opioid use disorder were referred to treatment by criminal justice sources, compared to 41% referred by community sources. And the kind of medication that people use or the kind of drugs people use illicitly on the street really correlates to the likelihood of incarceration. And you see here no opioid use is at the far left side with the smallest prevalence of entering into the carceral system. Whereas heroin use is highly predictive of someone entering into the carceral system eventually. Essentially what this graph is telling us is that the state of affairs is poor. Even though jails have become ground zero for the opioid crisis, the vast majority of them do not offer any kind of treatment. And in fact there are several states in the United States in which there are no jails or prisons that offer medical treatment for opioid use disorder. This is really a critical data point, a couple of data points. And offering this kind of treatment in a jail, it can feel really like a heavy lift. And I want to give a kind of a pep talk to people out here. These are statistics from the National Institute on Drug Abuse that are very recent. And it's quite shocking. We've had an opioid use disorder epidemic for over a decade, and less than 18% of people with an opioid use disorder ever receive medical treatment. I'll say that again, less than 18%. That's less than one out of five of people who use opioids get medical treatment. And if someone is using opioids and develops an opioid problem, the average length of time it takes for someone between when they start using and when they receive treatment is 10 years. So imagine how those statistics could change if all of the jails in our country, or even most of them, were able to offer induction at booking. We could really make a profound change and impact on the opioid epidemic in our country if we improve those numbers from less than one in five to what if it were four out of five or five out of five. That would have a huge downstream impact on saving thousands of lives. Next slide. So people, when they're leaving jail, are extremely vulnerable. They're extremely fragile. People often spend a very short amount of time in jail. And so maybe if they have an opioid use disorder, they could have gone through withdrawal, and they could be released in a week if they're a pretrial detainee. Opioid-related death rates from former inmates are higher in the month of release than later, 200 times for people released during the time period of under one month. In this very fragile period when people are exiting jail, they have many things to do. They have to navigate relationships with their families. They have to navigate health insurance, making appointments, employment, and where are they going to live? This is completely overwhelming for many people. And they need support in order to get the kind of care that they need. Slide. I just want to jump in here quickly, Ed, and just say from a biophysical standpoint, this also means that folks in jail likely have gone through withdrawal and so then don't have any opiate in their system if they have not been started on any MOUD. And so when they leave jail, if they start to use illicit or street drugs again, their tolerance has greatly decreased. And so if they use even half potentially of what they were using before, they still have an incredibly high risk of overdose because their tolerance has gone down. This is exactly what we see with the number of fatalities of people who have a short detention and who are released when they go through the withdrawal process. If they do not have access to a medication to support their opioid use disorder, they can become heat-seeking missiles looking for opioids wherever they can. And with the prevalence of fentanyl and all kinds of drugs, it's just a very deadly scenario, highlighting the importance of offering not only medication in the jail, but continuing it into the community. Thank you, Rachel. Slide. Franklin County, Massachusetts is a federally designated rural county. We have a jail with about 160 people, between 160 and 180 post-COVID. Like many jurisdictions in the country, we have methadone deserts. We have very poor transportation infrastructure. And about 66% of women who enter into our facility are screened positive for opioid use disorder, and about 40% of men. Our population in our county is small, 73,000. And so we are like many other jurisdictions where we struggle with how to provide care in this environment. Slide. So this slide is essentially just to say that building a program can take time, and we scaffold upon what we've built before. We started in 2015 by offering Vivitrol, which is, sadly, it's the least effective, evidence suggests, of the medications for opioid use disorder. And in part, this is because the power of the opioids in the street, it's increasing, not decreasing. So there is more and more fentanyl. And in fact, it's becoming harder and harder to even find heroin. What is available is fentanyl, which is far cheaper. Then we began with offering buprenorphine maintenance. What that means is when someone comes into the facility in 2016, we were checking to see if they had a prescription, then we'd continue it. And then by 2018, that was the first heavy lift for us. We began induction. So on day one, when someone is booked into our facility, we do screening, we do assessment, and we're able to offer medications. We offer buprenorphine induction, as it was clinically indicated. And then in 2019, we became an opioid treatment program, which is the jargon for methadone clinic. And our jail, we do not have a vendor offering these services. Our jail itself has become incorporated as a methadone clinic. And part of the DNA of our sheriff's office is we are a jail and we are a methadone clinic. Slide. Treatment in the jail. Reentry has to begin immediately. So when someone comes into our facility and they're booked, they're seen almost immediately that same day, within hours, by nursing staff who will conduct a physical. Our program is assessment-driven. Dual diagnosis case management. And what that means is the majority of the people in our jail have both a substance use disorder, as well as behavioral health disorders. So what we do is we offer a lot of skills building. There's education, psychoeducation about substance use disorders. In our facility, we favor mindfulness-based cognitive behavioral therapy, which is highly evidenced to help people with substance use disorders. And so some people may be familiar with clinical modalities like dialectical behavior therapy, acceptance and commitment therapy. But there are many curricula out there that are good. And there are many to explore. The vast majority of people in our facility have experienced profound trauma. And so this is important that we offer a trauma-informed framework. The treatment that we offer is through a trauma-informed lens. And the importance of this is that the more we are able to meet people where they're at and understand where they're at, the more likely they are to continue their care into the community and the more likely they are to have positive long-term outcomes. Like many jails in the country, we offer educational, vocational training, family programming. We have a robust post-release casework team, as well as a casework team internally in the jail. We'll talk a little bit about that more in a moment. As well as expressive therapies or secondary treatments. These can be very simple, low-cost motivators for people to engage in treatment, like offering a yoga class or a book club or an art class. And in our facility, we rely on a lot of volunteers to come in and to do that. And that enhances people's engagement with other forms of treatment. Next slide. There are essentially four components to our model inside the jail. The first is M.O.O.D. treatment. M.O.O.D. stands for Medication for Opioid Use Disorder, and Rachel explained that very well. Behavioral health is an extremely important component. As we know, the underlying cause of so much addiction is actually trauma. And relief-seeking behavior is people seeking relief from their perseverative thoughts and from their profound traumas that they have. Case management is essential. We need to be on top of it. We need to know and assess the person, screen them for what their needs are, and offer the variety of things that will help support them as they leave the jail, such as health care, substance use disorder appointments, a place to stay, work. There's something listed here called recovery checkups, which is an evidence-based strategy, which is essentially just picking up a phone and calling your patient after they're released and asking, how are they doing? And that's an opportunity for us to connect and support them. And as many of you know, when people come into our jail, they are often very sick. And so medical care, primary care, is essential. We are often the first provider of note that that patient has seen in years if they're using opioids. So people who use injectable drugs are extremely vulnerable to sexually transmitted diseases, to HIV, hepatitis C. And so we can offer treatment and connect people to care into the community if we're not able to treat them in the short time that they're with us. Very essential is that people have access to naloxone kits. Naloxone is Narcan. And Narcan resuscitates people from an overdose where your respiratory system shuts down because of the opioids. Narcan saves lives. Everyone who leaves from our facility, regardless of whether they have an opioid use disorder, has access to Narcan. Because whether they need it or not, someone they know likely does. This information shows when people come into the facility, what kind of medication, if any, are they on. And you can essentially see here that half of people that come into our facility who have an opioid use disorder come to us with no medications. And then amongst the half of people who do have medications, 10% have buprenorphine and about 40% are methadone users. When people leave our facility, when they're in our facility, almost 80% of people use methadone. About 16%, 16, 17% are using buprenorphine. And some of them decide to go off medication altogether. And that's their choice. What we see in the field is that the technology of buprenorphine, in our facility we were prescribing up to 16 milligrams some years ago and now we're seeing prescriptions of excessive 24 milligrams. Sometimes we have people on a sublocate shot and they take daily doses of buprenorphine orally on top of that. And this has to do with the increasing potency of opioids on the street, unfortunately. Methadone is something that we develop tolerance to and it has become, it seems to be more effective at addressing the high levels of opioids that are out there in the street and that people are consuming. Next slide. Something that's very difficult for jails in terms of engaging in treatment and providing treatment is working with pretrial or pre-sentenced individuals. So we're a jail. We have people in Massachusetts, we have people with misdemeanors and low-level felonies. So most people have a stay of about six to eight months if they're a male and maybe three to four months if they're a woman. But the vast majority of people who come into our jail are pretrial detainees. So in one year, we had 144 sentenced individuals. And at the same time, we had 959 pretrial individuals. The pretrial detainees who are with us are sometimes with us for only a few days or a week. And so it's a very rapid pace that we have to be able to provide this care. As we will see, most of our patients in a year are pretrial detainees. Next slide. So many people are worried about diversion, and jails have been very focused on keeping contraband out of the facility, which is an important function of what security staff do in jails. And honestly, Suboxone, which is a form of buprenorphine naloxone, is one of the most frequently introduced contraband drugs for people to illicitly use Suboxone in the jail. So there are some security-minded jail staff that are wondering, well, if we're trying to keep Suboxone out, why would we bring it in? It's a highly evidenced medication. It saves lives. And what we found in our jail is that when we began to offer buprenorphine for people, when we began to do universal screening and offer it to people who need it, the amount of contraband we saw coming into our facility, it dropped precipitously because they no longer needed to find it illicitly as contraband since we offered it directly to them if they need it. So these are a few suggestions for dispensing. The most important thing is that the medication is available. The medical community, the standard of care is a medication-first model. So the most important thing is access to the medication. And there are some things that one can do in a jail to help minimize diversion. It helps to have specialty staff trained on the dispensing process so they know what they're doing. Dispense the medication under the scrutiny of a camera, because often when we're looking for diversion, we check footage, film footage, to see if something had happened. We train not only medical staff but also security staff on how the medication works and what to expect and how dispensing should operate so they're aware and they'll notice if there's a problem. Each and every single day we educate patients before we do dispensing about how the process works. When we're doing buprenorphine, this is a medication that is not—the bioavailability of buprenorphine, if you ingest it, is about only 10%. It is a medication that is absorbed in through the blood vessels of our mouth, so it's absorbed often sublingually or bucally against your cheek. And so that can take about 15 minutes or so for the medication and must stay in your mouth for it to be absorbed well. So we ask that patients minimize their movement so they're not adjusting their face. We wait for the buprenorphine to dissolve and we perform multiple mouth checks. So these are some pictures that were taken by journalists of medication dispensing sites. This person appears to be taking methadone, which is often dispensed in a liquid form. And this is a picture of a patient who agreed to participate in an article for the Associated Press at our jail, and this is a patient who is taking buprenorphine, which we use the generic form, which is a tablet, and we crush it, make it a little bit of a slurry by adding a little bit of water, and that medication rests in the mouth. And using a pen light, we perform a mouth check to ensure that the medication has been dissolved and that there is not residue or medication hidden somewhere in their mouth. Next slide. In Massachusetts, the National Institutes of Health and the National Institute for Drug Abuse funded a large research project called the Justice Community Opioid Innovation Network. And there is a network of researchers who interviewed staff, administrative staff, security staff, medical staff, reentry staff, behavioral health staff and patients at the various jails in Massachusetts. In our state, our legislature mandated that each of our jails offer all of these three forms of medication. And so there was a big qualitative study. Many hundreds of people were interviewed. And the conclusion from the researchers of this qualitative study is that diversion, the title of the paper was Diversion Uncommon and Preventable. As afraid as we all were of diversion being a major issue, it seems to be far less of a problem than we expected if we ensure that we have some protocols that we follow and people are trained to do it. Next slide. This is a little small, so I don't know whether you can read it, but this is a copy of a reentry plan of an individual who is being released from our facility. The information has been redacted about their name, identifying information. But these are essentially the social determinants of health. These are all of the needs that someone might have when they're leaving the jail. And the better that we address these needs, the better the outcomes are for their success. As we saw earlier, people who leave jails are in an extremely vulnerable state. So what we see listed here are all kinds of factors like housing, health insurance, substance use disorder employment, substance use disorder treatment, rather, employment, clothing, Medicaid, peer support. All of these things need to be addressed. And the more that are, the better the outcome. And so reentry begins at day one. We have to begin to work with that patient to find out what they need and do it as quickly as we can, because many of our patients are with us for only days, not for months or even years. I'm going to turn it over to my very good partner, Rachel Katz, who's an important collaborator in the community and who provides excellent care for our patients as they're returning and who is a nurse practitioner and an expert in the field of addictions. Rachel, take it away. Awesome. Hi, everyone. And thank you, Ed, for that really amazing background on the Franklin County Jail and the really incredible work that we're doing here. So, you know, Ed told us that we that our folks who are leaving jail or leaving incarceration are at a massive overdose risk within those first couple of weeks or months after they're released from incarceration. And so not only is starting MOUD and recovery supports while in jail important, we also need to make sure that we are bridging these folks to the community, because starting suboxone in jail is only going to be as good as the client or the patient continuing that suboxone or that buprenorphine in the outpatient setting. And so, you know, what we have done in Franklin County is we have partnered the Franklin County Sheriff's Office and the Franklin County Jail with the Community Health Center of Franklin County. And so in that, we are also able to provide gender sensitive and trauma responsive care. So, you know, just a note that almost all of the clients in the jail who are in the OTP report trauma and nearly all women who are incarcerated report trauma, have a possible opiate use disorder or report current or historical commercial sexual sexual exploitation. So this is not just about people's drug use. This is about their entire lived experience and how that goes back and forth from behind the wall to outside the wall. So what happens is that when someone is incarcerated in the Franklin County Jail, we start from the very beginning, part of that reentry process to develop the relationship of a care provider. And so our folks who are in jail behind the wall start working with the medical team and the nursing team while they are incarcerated. But also that particular team, the medical team and the caseworkers and the discharge planners are also working with folks like myself, with the Community Health Center and with CSO, which is a large behavioral health network, the Salison Project. Right. So we know that trauma is going to disrupt someone's sense of safety and worth and that especially folks with an opiate use disorder carry a lot of shame and stigma and embarrassment. And so the more closely that we can all work together as an integrated care team, then we are able to show up for our patients and really support them and build scaffolding around them and help break down those internal senses of stigma and shame. So I'm going to sort of walk through a quick case study. I'm not going to read all of this because I'm being mindful of time and y'all can read. But this is this is an actual patient of mine who I no longer care for, but who I continue to see in the community. So he's a 37 year old male who initially showed up with me at the Community Health Center to reestablish care. He had been a patient of ours prior, had then been incarcerated for about two and a half years. He had significant mental health history, a significant and long substance use history. He had had several suicide attempts. He'd overdosed multiple times. And finally, in his last incarceration at the Franklin County Jail, he was able to get on to detox using methadone. So we were able to ease his discomfort of withdrawal using a dedicated methadone detox protocol. And he then was transitioned over to buprenorphine naloxone initially, so oral suboxone. And then he received sublocaine, which is that long acting injectable form of buprenorphine. So he got one injection of the sublocaine before he left jail. So the Community Health Center of Franklin County and a lot of the outpatient practices in Western Massachusetts and Massachusetts in general utilize this model of treatment called the office based addiction treatment model. So it was pioneered by Boston Medical Center. It is often known as the Massachusetts model. And essentially it is a low barrier, harm reduction focused model of care that allows registered nurses to carry a panel of patients. So all of the nurses that I worked with had their own folks that they were following and they do a combination of direct medical care, deciding on doses of medications, working with their patients to treat their other health conditions, as well as doing sort of this level of care management or case management. An OBAT team is by definition multidisciplinary and interdisciplinary. So nurses, medical providers, social workers and OBAT as a concept really recognizes the importance of trauma informed care as well as patient led and patient centered decision making. So people can enter into OBAT care and can certainly enter into care at the Community Health Center without being abstinent from drugs. And we do not discharge people from OBAT. That's sort of against the model of OBAT. It is a medication first model of care. And in that way, it is the perfect transition from someone who's coming out of jail, where there is also a medication first model of care sort of coming into the community. So we really want to focus on that continuity of care, right, those warm handoffs. And so coming back to to this case, so if, you know, if a patient remains incarcerated, then the nurse case manager and the OBAT director, who is myself, are able to be kind of kept up to date through this community person who is able to bridge the gap in a way. So in our county, we use a community health worker. So he or she, they are someone who is sort of dually employed. So they were working for the Community Health Center and they were also able to be employed and sort of have full access to the Franklin County Jail and the Franklin County Sheriff's Office. And so if I have a patient who is incarcerated, I am able to work with that community health worker, stay up to date on what is happening with my patient, as well as be actively involved in the discharge planning process and the care management. And that is something that I could do as a provider. It is also something that any of our nurses could do. So again, bringing in that harm reduction, low barrier OBAT model. So this is truly the continuation of our case. So when this patient was released from jail, he had gotten one dose of sublocate and he had also been given an oral prescription. So that's not uncommon. So frequently, people are going to need both the long-acting injectable, as well as the oral medication to take. So he was living in a jail diversion, clinical stabilization. And when he came in, he came in to reestablish care and then also get med resuscitation. And then also, you know, get med refills and adjustments. And he was due for his second sublocate injection. So when I saw him, I was able to look at our mass pad, our prescription awareness tool. I confirmed his last dose of sublocate. I was able to actually speak with his DMH worker and really get up to date on what had been going on with him, like in the moment. And luckily, the clinic I was working for had already gone through a really rigorous process of doing something called buy-and-build sublocate. So what that meant is that we actually purchased in bulk sublocate medications and injections that were not patient-specific. And so we could use them for anyone. So the fact that we had already done that as a federally qualified health center means that that patient that same day could get his second sublocate injection. And that's important because any gap in care, any lack of MOUD potentially puts him at risk for withdrawal, further drug use, further destabilization, reincarceration, right? And so making sure that we're able to really have those warm handoffs and those direct linkages to care is really crucial. So after a couple bi-weekly visits, he started to no-show and he'd become increasingly unstable in his mental health. His living situation was really unclear. I would actually see him in the community and try and kind of find him and track him. I was able to speak with this community health worker who, remember in our model, sort of goes back and forth. So he can be behind the wall and he can come out into the community and he's part of the outreach team. And so he was able to kind of track down this patient and see, you know, try and get some information. We were able to confirm that he had not been involved in a recent overdose. He was not back in jail, he was not in the hospital. And about a week later, I actually saw him in the parking lot. So our re-entry center literally shares space with the community health center. And so I saw this particular patient smoking a cigarette in the parking lot on my way out the door and I walked right up to him and I was like, look, we worry about you, we miss you, you know, please come. He once again, no-showed that follow-up visit. And again, we were able to kind of work connections and work those warm handoffs. We are a small community. We all know each other fairly well. We've been doing this for a while. We know kind of who to call. And so we were able to again, reach out to the Franklin County Sheriff's Office, to our community health worker. And he arrived for his next visit with that caseworker. So someone that he had been able to build relationships with and who he felt as a safe person to come into a medical setting. He had maintained his sobriety. His mental health had declined and he had really struggled, but he had not returned to drug use. And he had really done well on the sublocate injections. He had managed to get DMH and he had gotten a housing voucher. So even in when he was clinically looking very unstable and worrying and concerning, he actually was doing a lot of work behind the scenes with our community partners who were also partnering with the Franklin County Sheriff's Office. So you can see kind of the continuity of care here and the fact that he was able to start making relationships with people while he was still incarcerated. And those same relationships carried him forward back into the community. One month later, he came back. He had gotten his third sublocate injection. He had moved into some stable housing. He remained sober. He had started working towards re-getting custody or shared custody back of his two-year-old son. So some case study take-homes is, it's really important to get those DTUAs, those QSOAs, all of those sort of administrative pieces that allow that sharing of information. And so having patients sign releases of information, making sure that you can share data back and forth in a really seamless way. We always wanna have a trauma-informed lens. So this particular patient had obviously gone through intense amounts of trauma. He had multiple psychiatric conditions. He had had multiple suicide attempts. We know that incarceration in general is traumatic, right? No matter how well we treat OUD behind the wall, jail is traumatic. And so someone who has been in and out of jail, that trauma compounds. And so super important to use that trauma-informed lens to do those warm handoffs, to really prep the patient so that they know what's going on. Co-location of services, right? So the fact that I was able to see this guy literally in the parking lot, like that may not have happened. We may not have been able to re-engage him and get him back into care. So having OBATs and OTPs co-located, having those two things within a jail setting being co-located, and then also making sure that there are socio-legal services either co-located or enough that there's, again, that sort of seamless transition. The continuity of care. So we're continuing the same kind of care, the same model of care, the same shared values from incarceration to the community setting. And so making sure that everyone is on the same page, that we were having regular meetings, we were talking about shared values, again, making sure that everyone was on the same page. And then utilizing this sort of peer professional model. So someone like a caseworker or a community health worker or an outreach worker, someone who can connect with these folks on a peer-to-peer level, but who also has a professional face to them such that they can navigate both worlds. So someone who can understand multiple pathways to recovery, right? That abstinence does not always equal sobriety based on the person. That someone can want different forms of sobriety and different ways to achieve that goal for themselves, always using harm reduction services. So making sure that everyone has naloxone, making sure that people who need syringe exchange or harm reduction outreach, that we're able to do that. And some challenges. So again, that sort of paradigm of that sociolegal involvement, right? So how do you get peer workers and professionals who function from a really harm reduction, boots on the ground, grassroots place to buy into the sociolegal sort of carceral thing? How can we make sure that that is happening, that that's happening well? And so again, lots of conversations about shared values, low barrier, how are we best serving our patients and our clients and our community? A nurse-led OBAT. So this does require a specialized training. This requires a very specialized kind of nurse. How do we set those nurses up for success? How do we manage their time? This is a busy federally qualified health center. Money is always tight. Making sure that we're always staying within that patient or client focused harm reduction framework. And then again, those conversations about trauma-informed care, this full continuum of a person's involvement and that re-involvement, right? Understanding and knowing that people are going to sort of do a little bit of this revolving door thing. So finally, I did see this particular patient last week. He remains sober. He is in a long-term DMH bed in one of our respite. He continues to see his son and he's working on a co-parenting relationship. And he continues on his monthly sublocate injections. So as Ed pointed out, we are one of the poorest counties in Massachusetts. We are incredibly economically depressed. We have incredibly high rates of trauma. And yet our community partners, our carceral partners, our medical providers have been able to establish this shared vision around collaboration. And so even though there's incredible scarcity, we provide a culture of abundance. We provide trauma-informed care. We have an unwavering belief across the spectrum that our patients and our clients want to get better despite their actions. And we really, we hold space for the people who cannot hold it for themselves. And I will turn it back over to Ed. All right. So in 2017, 2018, there was a study in Massachusetts that was a kind of natural experiment where the researchers that I talked about previously, they had studied a kind of a natural experiment. Our jail was offering buprenorphine medication and the jail in the county immediately south to us did not offer buprenorphine medication. Are the demographics of our population the size of our jail? It's very, very, very similar. And what was noticed was there was a reduction in recidivism on patients who were inducted on buprenorphine and who were offered it inside the jail and who had that medication continued for them when they were released in the community compared to individuals in a facility that did not have access to buprenorphine. So as I stated in the very beginning of the presentation, we need to use public health strategies to attain public safety goals. And one of those goals is recidivism. At the end of the day, public safety and public health are just two different lenses looking at the same thing. And so I encourage people to really look at what is working in public health and apply that to the people in your jail. The better off they are, the more emotionally regulated they are, the better their health, the better their mental health, the less likely they are to commit crimes. People with an opioid use disorder who do not have access to opioids will look for them because it feels like they are dying if they do not have access to it. And this was what spurs people to commit crimes. They are seeking relief from their suffering. So the more that we can do to address this, the better the public safety outcomes will seem. Slide. And so this is the paper that was written, Recidivism and Mortality After In Jail Buprenorphine Treatment for Opioid Use Disorder. Buprenorphine saves lives. Buprenorphine lowers recidivism. Buprenorphine and methadone, they achieve public safety and they achieve public health. Slide. All right, questions and answers. I see there are a lot of questions. In the chat, we'll try to answer as many as we can. And perhaps we can get a copy of the questions. And if we don't have time, we could email you some responses to them. We wanna make sure everyone's questions are answered. Caroline, how would you like us to do that? I was gonna say, you're such a star. You read our minds. We were messaging you to say, can we send you these questions afterwards? I wanna thank you for already answering several of them. I wanna thank you for already answering several of them. And you're so quick on the keys. I'll just dive in in order. And I know there are a few we can condense, so I'll do that. But starting off, a question from Mehran Bajoghly, who asks, to your knowledge, are there opportunities for providers to exclusively offer MOUD within correctional facilities, or are they also expected to provide primary services? And what's the most effective method to get further information on this matter? Are there opportunities, let me make sure I understand, for providers to exclusively offer MOUD? As opposed to also being required to offer primary care, exactly. Yeah, so jails are responsible for both. All jails are responsible for providing primary care, and that's often done in our country through a contract with a vendor. And the individuals who are providing, or the agency that is providing primary care, absolutely does not have to be the agency or the individuals that are providing medications for opioid use disorder. So it is entirely possible to have two separate contracts. Now, when that happens, those medical providers should talk to each other, because it's the same patient, and it's all part of the same holistic health package. But yes, buprenorphine, there used to be more barriers and challenges for providers to offer that. Those barriers are, every year, more and more are taken away. So there is no longer the need for a data waiver. It used to be called a special waiver for practitioners to offer buprenorphine. It's simply, it's what, is it, Rachel, about eight hours training that you can do online, and then you're good to go. There's a cap to the number of patients that a provider can handle. But don't forget, telehealth works, and you don't need, and this is responding to some other questions, telehealth, you don't, many rural locations, there are no OBOTs, there are no providers at all. But each of our states has a city in it. And in those more urban centers, there can be clinics where there are addictions providers. And by purchasing some telehealth equipment inside of the jail, that kind of connection could be made. And those resources can be brought into the jail remotely. Thanks so much, Ed, for such a comprehensive answer. On sort of a related note about mood, Michael Weinstein asks, does the induction of buprenorphine, what does it look like? Is it the same for all, or is it individualized? Take it away, Rachel. All right. So the induction of buprenorphine can be really individualized. So when we first started doing this work, it was a standard sort of protocol that followed. And as the drug supply has changed, as fentanyl has come in, as we're seeing things like benzodope, which is benzodiazepines mixed with heroin or with fentanyl, we had to stay really nimble and really sort of limber in our approach. So you can do, and this could be a whole other webinar, but there's a thing called micro dosing or low dose dosing where you start with small doses of buprenorphine and slowly work up. There's also something called macro dosing, which is where you use the buprenorphine and just kind of hammer someone's system to try and knock off the illicit opiates. In a controlled setting like a jail or in a detox facility, we will often kind of limp people through a detox or a withdrawal process with supportive medications. There's no great way. I mean, just like full stop, there's no great way to get someone onto buprenorphine right now. Fentanyl stays in the system for days, sometimes weeks. It can cause something called precipitated withdrawal, which is when someone takes their first dose of buprenorphine and because buprenorphine is so strong, it kicks off all of the other opiates that are on those receptors in the brain. And so if you still have fentanyl or heroin or morphine on those receptors, your first dose of buprenorphine is gonna kick them off. And so then you go into immediate withdrawal. And I've had patients who have had one episode of precipitated withdrawal and will literally do anything in the world to ever have it again, to avoid ever having it again, which is why the fact that RGL has methadone is such a huge deal because methadone does not require any withdrawal. It is literally a one-to-one conversion. And so you can take someone who last used heroin four hours ago and is starting to go into withdrawal, give them their first dose of methadone and they feel better. And we know that people who stay on methadone have better qualities of lives. Their mortality and morbidity rate is much lower. They have better mental health. They're able to re-engage with their lives and their families and parenting and jobs and all of those things that those are the things that actually heal the brain. I saw a question in there about the dopamine receptors and whether or not they heal. So what medication does for someone with opiate use disorder is it just calms down those receptors in the brain. So it takes care of the physical need, those physical cravings and dependents that happen when someone has been taking or using opiates for a long time. What actually heals the brain is re-engaging with your life with providing meaning to your community, to yourselves, to your life. Dopamine is very closely related to oxytocin, which is the love chemical, right? So we think about hugs. We think about meaningful conversation with friends. We think about exercise. Like those are the things that ultimately are gonna neurobiologically heal the brain. Thank you so much, Rachel, for that very comprehensive answer. And I know that we are getting close on time. So I'll put it to the next slide, just to note your emails. And I believe though, Rachel, feel free to correct me and that we will be responding. Oh, sorry, Rachel would like to really correct me that we'll be responding to any unanswered questions in follow-up, but I will turn it to you to share more about that. And thank you both, Ed and Rachel. Absolutely, but yeah, Carolyn, that's right. So we will open it up. If you do have continued questions, this is the emails for both Ed and Rachel. And I believe we'll also have this in the chat, but they have graciously decided to allow us to continue asking questions. So thank you so much to both of you. So this is just a note about our PCSS MOUD mention. So PCSS MOUD is a mentoring program, which is designed to offer general information to clinicians about evidence-based practices. And you can learn more about this mentoring program, both at the website listed on your screen and also in our chat. And if you have a clinical question, you're welcome to ask a colleague through the link that is shown here as well. And also in our chat, this is provided by PCSS MOUD to answer any questions related to medications for opioid use disorder. This is just a shout out to all of our amazing collaborative partners at PCSS MOUD. The continuation of just more partners here. And with that, that is the end of our presentation. However, I will plug that in our chat, we are gonna add information about our next webinar in this series. We also have ways that you can access PCSS MOUD in the chat. But again, thank you so much for joining us today. And I hope that you all have a wonderful rest of your day.

Screening for Substance Use

Primary Care

Dr. Jennifer McNeely

American Psychiatric Association

SAMHSA

Screening Tools

Implementation Guidance

Substance Use Disorders

TAPS tool

continuity of care

justice-involved individuals

opioid use disorder

MOUD

Medications for Opioid Use Disorder Project

correctional facilities

recidivism

holistic approach

trauma-informed care