<v ->Hello, my name is Dr. Debra Pinals.</v> Today, I'm going to be presenting Introduction to the Criminal Justice System and Medications for Opioid Use Disorder. I'm the Director of the Program in Psychiatry, Law, and Ethics, and adjunct clinical professor of psychiatry at the University of Michigan. As faculty for this educational activity, I have no relevant financial relationships with ineligible companies to disclose. Today's target audience is through PCSS, and the overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. And now, let me turn to my educational program. At the conclusion of this activity, participants should be able to: describe police lockups, jails, prisons, court systems, probation, and parole; discuss pathways for persons with opioid use disorder who encounter the criminal justice system and the importance of medications for opioid use disorder across systems of care; and describe opportunities for MOUD providers working with justice-involved individuals to enhance treatment outcomes. Let me start with the case vignette. This is the case of Mr. A. Mr. A is a fairly typical person that you might see in any clinical setting. He's a 28-year-old male with a history of substance use disorder. He began drinking alcohol at the age of 12 and his opioid use started at age 19. He's had a history of treatment with medications for his opioid use disorder when he was prescribed methadone, and he adhered to that treatment regimen for about a year until he dropped out of care. He has a medical history of hepatitis C and he has a criminal history, where he was recently arrested on a charge related to robbery and assault. He had broken into a neighbor's home to take jewelry, which he intended to sell to support his opioid use. In terms of his social history, he has 11th grade education and he never obtained his GED. He's had periods of homelessness, he's been in and out of jail and prison for seven years. And as a child, he was placed in foster care and he was sent to different schools due to behavioral dysregulation. Mr. A is now being held in jail, awaiting trial for his recent arrests, and the jail has withdrawal management protocols that include what they call comfort measures. His lawyer for his criminal case has indicated that there's potential for him to get involved in a drug court as an alternative to incarceration. You are seeing Mr. A as a clinical provider, and yet you're unfamiliar with all of the issues related to his criminal involvement. And this presentation will get into some of the details to help us understand better the trajectory for Mr. A in terms of his criminal justice pathway. For example, Mr. A is now in jail. What happens in a jail for him? What are some differences between jail and prison? And he's being considered for a drug court, but what is a drug court? These are burning questions that you want to know. And after today's presentation, you will have some of these answers. As another case example that we can think about in going through this presentation, we can think about the case of Ms. B. Again, a fairly typical case that we might see for somebody who moves in and out of criminal justice pathways. Ms. B is a 30-year-old female. She has a history of substance use disorder. When you look at her lifetime course, she has 7 1/2 years of heroin use, 12 years of alcohol use, and episodic cocaine use. She's had periods of daily cannabis use since the age of 15 and she has received inpatient and residential supports for her substance use disorder, but she's never been on medications for her opioid use disorder. She has been diagnosed with HIV, and she has a criminal history, and she's currently in prison for possession and distribution of controlled substances. She has a parole hearing next month and she's eligible for release in three months. She has a 3 1/2-year lifetime history of incarceration and she has three children in custody of her mother. She has a sexual trauma history from the age of 18 and she has a psychiatric history that involves multiple psychiatric hospitalizations for PTSD, depression, and suicide attempts. So now, she's coming out of prison potentially with this parole hearing. But what does prison reentry entail? Meaning, reentry into the community after a period of prison. What does the data tell us about risks associated with prison reentry? And what is a common framework that helps correctional systems stratify individuals by risk of criminal recidivism? Also, what does the data show about outcomes when medications for opioid use disorder when a medication is or is not available in jails and prisons, and what does this mean for the provider who is seeing patients who are recently released? These questions and more will be discussed. Let's start by talking about elements of the criminal justice system. First, it's important to realize that the way into the criminal justice system occurs through courts, and state court structures vary. The general breakdown that we can think about are that there are courts that handle criminal matters and courts that handle civil matters. So for example, criminal courts would handle somebody who is arrested and charged with a crime, and they would also handle what we call Specialty Courts, like drug courts, mental health courts, courts for people who've been arrested on operating under the influence, and those type of matters. Courts that handle civil matters often handle things, like civil disputes, where somebody's suing somebody else for money; or even civil commitment in mental health proceedings; or malpractice cases. Probate courts, probate and family courts, often cover matters such as divorce, or guardianship, or other family issues. And then, of course, there's juvenile courts that handle matters for youth. Depending on the state, the age of juvenile jurisdiction will vary, typically under the age of 18 would be handled in a juvenile court, although some states continue to see youth ages 16 and up in adult courts. Juvenile courts might also handle matters when there are issues for children who are skipping school or involved in what's called status offenses, like violating curfews and needing additional services to support them. In terms of the criminal system, when we think about correctional populations in the United States, we have to think broadly. Typically, our mind goes to people that are incarcerated or held within a place of detention. And we're going to talk a little bit about the differences of those places in a moment. But overall, it's very important to think about correctional populations more broadly, with some people held in jails or prisons, but others on community supervision. Of the total number of people as of 2019, and admittedly these are statistics from pre-COVID, we had about 6 1/2 million adults that were under correctional supervision. And of those, only about 2 to 2 1/2 million were held in an incarcerated setting. The rest were under some type of community supervision, whether that's probation or parole. What we saw over time in the last decade, there has been some decline in the incarcerated population, and this was primarily due to a decrease in the overall prison population. However, the parole population grew between 2009 and 2019 as the only correctional population with an overall increase during that period. This is important for treaters to realize because it's very fluid. People who are on parole can move back into the prison system and vice versa. And so the reason why it's important to look at this as a system is because from a care perspective, individuals will be moving in and out of community supervision to an incarcerated setting, and that's important for continuity of care. Again, here is the breakdown of what we saw in 2019. Of the total numbers of people on community supervision, there were about 4 1/2 million people, with most of those people on what's called probation and some of those on parole. Again, for the total incarcerated population, there were about 2 million people, 2.1 million people if you round up, with most of those people in prison, just under 1 1/2 million and 734,000 held in jail. So it's important to understand what these different systems are. This is another way of looking at this data, and this is more recent since COVID and presented by the Prison Policy Initiative. And it really does show, again, that the majority of people that are incarcerated are held in state prisons with the rest in local jails. And, of course, there's a whole different system of federal prisons and jails that I'm not going to spend too much time talking about. There's also people held in immigration detention, there's youth territorial prisons, and then those that might be involuntarily committed for other purposes, which we're not going to spend much time talking about during today's webinar. It's also important to realize that there are huge racial disparities in correctional settings compared to the general population. We see that the average rate of Black, Latinx, and white imprisonment per 100,000 residents is very disproportionate. If we look at the Black population and the Latinx population compared to the white population, we see the racial disparities are profound and there are many structural and complex reasons for this, but it's very important to realize that these disparities do exist and that there are many policies and efforts underway to try and combat that. What about the prison population and substance use disorders? It's very hard to know the substance use disorder prevalence within the prison population. We know that many people are incarcerated on drug-related offenses, and studies estimate that 65% of the prison population have a diagnosable SUD, and 20% did not meet official criteria for SUD but were under the influence of drugs or alcohol at the time of their crime. So let's talk about the different settings where people may be held, and we can think back on our case of Mr. A or Ms. B to understand their journey through these various settings. First, upon arrest, an individual is generally taken to a lockup. A lockup is a place where somebody is going to be held for up to 72 hours. It is usually managed by a local municipality, although many municipalities have contracted relationships with the local jail. For example, in the community where I stay, the local lockup is the same as the local jail. However, the lockup is going to be where somebody is held from the time of arrest until they can appear in court for processing of their case. Because lockups have short lengths of stay, typically, programming is not available to them. It may be difficult for people to access medications and it may be difficult for people to access medical services. For somebody with an SUD, this can be a very difficult period where they may be experiencing withdrawal or having mental health challenges, including suicidal thoughts. Now, a jail is the next stop. A jail houses various populations, including those that are considered pre-trial or awaiting trial. So after somebody appears in court, they are arraigned or formally accused of the crime. They may be held in custody based on a bail or bond determination that they need to stay in a place of detention because of failure to appear or a public safety risk that they're seen to pose depending on how the state's bail statute is structured. There's also going to be a population of people in jail that have been sentenced sometime, that's called the House of Corrections side of the house, but they're going to be sentenced for generally up to 1 year Anyone sentenced for longer would be sent to a prison. We'll talk about prisons in a moment. And there may be other populations within a jail. For example, many jails contract out to hold people under ICE detention, or they may even have people held under civil contempt proceedings. The jails are going to be managed generally by a county, usually through the County Sheriff. Now, it is required that there be medical substance use disorder and mental health services within the jail. And it is clear that these are not going to be funded by Medicaid, as somebody might be receiving services in a community setting, except for if the person needs medical hospitalization outside of the jail. So for example, if a jail inmate has a heart attack and needs to go to a critical care unit for inpatient hospitalization for their medical condition, it is possible that the jail will recoup Medicaid for the cost. But otherwise, the cost of services for people within a jail are going to be funded by the county, through the county, and through the sheriff's budget. Programming may be available and should be available, but it is highly variable because jails vary in size and counties vary in how much they spend on their jail, mental health, substance use, and medical services. Jails can be small. There can be rural jails with 10 beds, 10 cells, or there can be large city jails with thousands of people housed in them. Jails also have very transient populations because you often have a pre-trial population, people will be moving in and out. They may be posting bond so they might be released. They may have a court date, where they're allowed to leave on a personal recognizance. There may be many things going on. So as a care provider working in a jail, you may see a patient one day and you may not see them after that, very transient population. So even a jail that has, say, 500 beds may turn over those beds many times in a month. Thus, treatment for people with opioid use disorder and alcohol use disorder may be challenged. They also may be challenged by the rules and protocols of the jail, which are going to be focused on institutional security and safety, and there's a great deal of concern for medications that have, quote, diversion potential. Now, the tides are changing with regard to medications for opioid use disorder, but it is still very often a problem that jails are not providing those types of treatments. And so traditionally, there has been only withdrawal management for people who are coming into the jail who may have an opioid use disorder. Now, a prison is different than a jail. A prison is a setting of incarceration for individuals sentenced for periods of over one year, and the duration of incarceration can be up to a life sentence. So you get people who are going to be serving from more than a year to their entire life within that prison. Prisons are managed by state agencies. And again, I'm not talking about the federal system which has its own system in the Bureau of Prisons, that's its own system of prisons and places where people are held pre-trial. But the state agencies will generally have a budget that comes from the state legislature that will allow them to contract, and generally these are going to be contracted services. Some states still provide their own services, but they will provide medical, and mental health, and substance use treatment through pretty typically contracted providers. It is constitutionally required that prisons, just like jails, provide medical, substance use, and mental health services. But these services, again, are going to be coming out of state budgets, taxpayer dollars, and they will not be recouping federal funding through Medicaid services, except for when somebody, again, is medically hospitalized. Now, the programming within a prison is generally going to be more robust than it is within a jail because people are staying longer, and you're generally going to see all levels of care available within a prison, but it will still have the parameters of prison overarching in how it's structured and supported. However, although many prison systems are looking at shifting, treatment with medications for opioid use disorder and alcohol use disorder can be challenged by the rules and protocols of the prison even though these treatments are recognized as needing to be available as they are in the community. Many prisons are still struggling and do not provide medications for opioid use disorder, but these trends are shifting, again, with some prisons being more ahead of that curve than others. Now, what is reentry? Reentry is the term that we use when people are transitioning from a jail, or a prison, or a carceral setting back into their communities. Planning for re-entry can have challenges and release dates can shift. This is part of the problem. You might be planning for somebody to come back to their community on a particular date, but the person may have earned good time for good conduct and their release date might be moved. So for treatment providers working in the reentry space, there are many things and logistics that need to be coordinated. Legally, a prison or a jail cannot hold somebody beyond their release date. So it's not like you can say, "Hey, wait a minute, I'm not ready. Our clinic doesn't have an appointment until next week. Can you hold them for another week?" As soon as they are legally authorized to be released, they must be released. Now, some places do releases at odd hours, like midnight releases, and this can be a real challenge, obviously, for somebody who needs to go into a care and treatment setting after their release. And so systems and communities are very often now working on changing the release times to make them more practical and reasonable for people who need treatment interventions. The other thing that can be challenging about prison reentry, unlike jails that are usually run in the counties, and so people are in their local setting, a person may be incarcerated in a prison far away from their home or where they want to return to. So I could be incarcerated in a rural part of my state, but wanting to return to a more urban region. And then, even if there's transportation that's going to be provided, it can be hard to make appointments and get arrangements made from far away. Again, there are unpredictabilities where a criminal case may result in an unexpected release by the courts, leaving somebody to navigate their service needs by themselves, which is why sometimes, when we're working in emergency departments, we get people who walk in saying they were just released from prison, they thought they had a residential program lined up, but everything fell apart, they became suicidal, they started to use again, and they show up in the local emergency room. So this really emphasizes why it's very important for there to be coordination, though it also highlights why this can be so difficult. Now, what is community supervision? I mentioned this before. Let's talk a little bit about probation and parole. Probation can be pre-trial or post-trial. It is generally ordered at the time of trial sentencing by a judge, and probation officers monitor adherence to terms such as compliance with treatment, refraining from contact with certain persons if that's part of the provisions of probation, and having the individual sign releases of information for probation and the treatment provider to speak. Parole is managed usually through a board, a Parole Board, and an individual may be released from prison on conditions of parole. There are community-based parole officers that, again, monitor compliance with terms. And if the person violates parole, they could be returned to the prison setting. On probation, if a person violates probation, they generally would be sent back into jail, although there are certain exceptions to that. Individuals actually can be on probation for one set of charges and parole for another, and so they may have dual supervision requirements. So when you are seeing patients, it is useful to say and ask them whether they have terms of parole, or probation, or both, and to understand what those terms are. We know that there's an increasing prevalence of substance use disorders in the criminal justice population and that according to a Bureau of Justice Statistics report, looking at data from 2007 to 2009, which is admittedly old, but the report came out in 2017, we see large numbers of people, approximately 60%, who will have a DSM-IV, Drug Dependence or Abuse. Of course, that's not DSM-V criteria, but you can see the prevalence rates of substance use disorders, and you can see that people who regularly use heroin or opioids for state prisoners is about 16 or 17% and 19% in the jail population. With the opioid crisis, this has gone up. We also know that the mortality in state and federal prisons, the number of suicides increased 20% from 2017 to 2018, and that overall unnatural causes of death, including suicide, homicide, drug or alcohol intoxication, and accidents, accounted for 17% of deaths in state prisons in 2018. And the percent of state prisoner deaths related to drug or alcohol intoxication increased by more than 600% between 2001 and 2018. So within the carceral setting, we are seeing the impacts of the crisis in substance use disorders, and overdose, and suicide. Other features of justice-involved adults include high rates of mental health disorders; high rates of co-occurring substance use and mental health disorders; high rates of co-occurring medical conditions, including infectious diseases, HIV, sexually transmitted diseases, and hepatitis A, B, and C; chronic medical conditions and cancers; high rates of trauma of all kinds. And treating substance use disorders can help with recidivism, although what we see is that this is still lacking in terms of its availability. We know that medications for opioid use disorder in carceral settings and after incarceration can save lives. And that, for example, in Rhode Island, after implementing MOUD in Rhode Island prisons, post-incarceration overdose deaths decreased by 61% in the first year. And studies out of Europe and Australia showed reduced mortality and deaths by in-custody suicide and post-release by adding MOUD. When we talk about trauma, it's important to understand the Adverse Childhood Experiences studies. The Adverse Childhood Experiences study looked at the degree that people had experienced prior to the age of 18, any number of adverse childhood experiences, including exposure to household dysfunction, abuse, abandonment, and the like. And what we know is that the greater the number of adverse childhood experience one has had, the more likely they are to have difficulties throughout life in social, emotional, and cognitive impairment; adoption of high risk behaviors; disease, disability and social problems; and even early death. And we know that individuals with greater Adverse Childhood Experiences have increased justice involvement, increased non-medical prescription opioid use, and increased illicit drug use. So the population that we're trying to address really has high trauma history, and we need to be mindful of that. Now, how does the criminal justice system look at risk factors for criminal recidivism? The criminal justice system tends to stratify and classify individuals as part of its framework for how they provide supervision and classification. And this is based on data that comes out of the early 1990s from Andrews and Bonta, and the Risk-Need-Responsivity Paradigm, which is also called the RNR Paradigm. In this paradigm, basically what happens is there's a stratification of risk of recidivism that helps the criminal justice system focus resources on the cases that are most likely to recidivate. It also looks at needs. With risks come criminogenic needs or dynamic factors that might lead people to reengage in criminal behavior, such as antisocial behavior, substance use, antisocial attitudes, and criminogenic peers. And then, there's a component of responsivity, which implies that individuals' responsiveness to intervention may vary, and the intervention should be tailored to personal aspects of the individual such as learning style, culture, and whether they have mental illness that may make it difficult for them to respond to criminal justice supervision. According to this research literature, there are eight main, what they call the Central 8 Criminogenic Risk Factors. The first four have to do with antisocial behaviors, and cognitions, and peers. So for example, a history of antisocial behavior, antisocial personality patterns, antisocial cognition or thinking, and attitudes. And then, the other four are things that the traditional behavioral health system is used to working with, which is family or marital discord, poor school or work performance, few leisure or recreational activities, and substance use. The original studies called it substance abuse, so I've stuck to the original terminology, even though I know we don't use the term abuse anymore in terms of substance use disorders. But these eight criminogenic risk factors, and especially the first four, are highly correlated with return to criminal recidivism. Substance use is among one of those, partly because people engage in behaviors that get them into trouble, partly it's because of our policies that lead to the criminalization of substance use disorders. But when we look at how populations are worked with to try and reduce their criminogenic risk, it's really important that we also look at how we work with people around their substance use disorder needs. So for example, if you look at a grid-type arrangement, for people that are high on criminogenic risk and also have a high degree of functional impairment due to their serious substance use disorder, these individuals in the top right should have a very carefully executed plan where the correctional supervisors and the treaters work hand in hand to help that person adhere to the terms of their correctional supervision, as well as adhere to the terms of their treatment so that they have the best potential to achieve success in their recovery. For people with low criminogenic risk and low functional impairment, that type of treatment doesn't need to be as tightly coordinated, but it is important to think about the needs of an individual and their likelihood of returning to the criminal system as something that we want to think about as we're working with individuals to understand a little bit better how to support them. So many people have been working on these types of treatment plans, treatment support plans. This comes out of work we've done through what's called the Mission Model, which looks at people with co-occurring disorders and helps develop treatment plans for people coming out of jails and prisons. And what we do is we identify: What are their criminogenic risks, and then what are potential approaches that case managers and peers can work on to help reduce the individual's likelihood of a return to the criminal system? So, for example, if the goal is to reduce antisocial acts, then what can we do when we meet with them weekly or biweekly in individual therapy, and how do we help them maintain services? If they engage with antisocial peers, how can we engage them? If you look at the bottom right, if we want to decrease that association, how can our recovery coaches and peers help engage these individuals in positive social activities, help with peer support that will introduce them and accompany them to pro-social, community sober gatherings, and things like that that will help reduce the likelihood of their involvement in the criminal system? Another way of looking at how we interface with individuals with substance use disorders who are involved in the criminal system looks at things across the Sequential Intercept Model. The Sequential Intercept Model was first reported in 2006 in an article in Psychiatric Services. This model poses that individuals move through the criminal justice system in predictable ways. And that through these predictable ways, if we can identify their needs, and it started as a framework for people with serious mental illness but has now been shifted to be applied to people with opioid use disorder as well. If we can identify how people move from arrest, to court arraignment, to incarceration, to reentry, to probation and parole, then we can intercept and route them out of the criminal system and into the treatment system by improving access to treatment, opportunities for jail diversion, and engagement with community resources. The Sequential Intercept Model has been now depicted on this graphic where we can see it begins with Intercept 0, which was added in 2017 to the model with improved crisis services, things like Good Samaritan laws and the like. Intercept 1, Intercept 2 at initial detention, Intercept 3 with jails and courts, Intercept 4 at reentry, and Intercept 5 with community corrections, where if at each point along the way, the systems and services could identify individuals who have needs for opioid use disorder services that these individuals could be routed out of criminal processing and more into treatment. So for example, what could happen at Intercept 0 for people with opioid use disorder? While there could be real prevention efforts, and there's a lot going on in this space: overdose education, naloxone availability, crisis warm lines, 988 crisis hotline, peer support in emergency rooms, crisis drop off centers, sobering centers, sterile syringe programs, and even Good Samaritan laws where people can call for help without fear of arrest are really important Intercept 0 efforts. Again, the 988 National Crisis and Suicide Prevention Lifeline has now opened itself up for people to call with substance use crisis as defined by the collar. Peer warm lines, where people with lived experience can call each other and talk through difficult times and receive support. And even something called Angel programs, which are modeled after the original Angel program, which came out of Massachusetts, wherein people can go to the state police or to local police and literally turn themselves in and bring themselves to the police for help where they can be connected to an angel who will get them into treatment and services in lieu of fear of arrest or incarceration. These are excellent examples of Intercept 0 and 1 efforts to help divert people from the criminal route. Intercept 1 involves more directly police and pre-booking jail diversion types of responses. We see throughout the United States more efforts around minimizing the involvement of police in behavioral health crises. We see co-response models and even mental health-based mental health response, like mobile crisis teams that are getting more and more traction across jurisdictions, as well as specialized training for law enforcement, such as crisis intervention team training to help in those situations where law enforcement are called to the scene, but where they can provide better supports and services without excessive use of force. At Intercepts 2 and 3, we have the interface with the courts, initial appearance, pre-trial jail diversion, Specialty Courts, and jail-based services linked to communities. For example, Specialty Court Services. Specialty Courts, including drug courts, mental health courts, and other types of OUI courts, trafficking courts, are all based on these models, where instead of just calling, quote, balls and strikes like a traditional court, the court becomes a problem-solving entity with the goal of reducing repeated arrest rates, reducing the days people spend incarcerated, helping them improve in remission and recovery from mental illness and substance use conditions and improving linkages to services. In these types of Specialty Court Services, you have a judge and a treatment team baked into the framework of the court. Individuals come to court on a weekly basis until they graduate to go less frequently. So, for example, in our case of Ms. B who was being considered for a drug court, she might be eligible to serve her time, instead of in jail, as an alternative to incarceration, she might be able to be involved in a drug court where the focus will be on her recovery. She will report to the judge regularly until she shows that she's able to adhere to the terms and be on her road to recovery, at which time she will be able to be returning to court less frequently until she graduates from the program. Drug courts started around 1989 and there are thousands of them around the country, mental health courts started about a decade later, and veterans treatment courts started about a decade after that, with the idea that these are all based on a Specialty Court model where the court becomes a problem-solving entity where you have the individual at the center, a judge overseeing the program, you have specialized probation officers very often, as well as case managers and others, and clinical treatment providers weighing in on what should happen in terms of services that the individual might benefit from, all with the goal of keeping people out of prison and in recovery. Drug courts come with these 10 key components that include integrating substance use services with the justice system case processing; using a non-adversarial approach to promote public safety, but also protect the due process rights of the individual; identifying eligible participants and promptly placing that individual in a drug court program; providing access to a continuum of treatment services; monitoring abstinence through frequent testing; coordinating strategies of response to compliance, using ongoing judicial interaction with each drug court participant; monitoring and evaluating the achievement of program goal and effectiveness; continuing interdisciplinary education; and forging partnerships to enhance program effectiveness. Now, drug courts often receive federal funding, and federal funding now supports access to MOUD. And it is important for patients and persons in drug courts to be able to have access to any of the medications for their opioid use disorder that would be available to anybody in society. Now, Intercepts 4 and 5 look at the reentry efforts for people coming out of jails and prisons and returning to community supervision. Reentry to the community can be challenging for people who may not have as much community support. Ongoing cravings within jail and prison could risk on an individual's return to use. And we see some stark data in this regard. The risk of death of released Texas prison inmates was found to be 12.7 times higher within two weeks of release than for state population residents, and this is prior to the opioid crisis. A more recent study out of North Carolina showed that inmates released compared to the general population were 40 times higher to have an opioid overdose at two weeks post-release, 11 times higher even one year post-release, and 8.3 times higher throughout the study period. This is stark data that tells us that these post-release outcomes are really fraught, and we need to do better at helping people coming out of jails and prisons. Now, there has been a model that has been promulgated for many years about helping with reentry called the APIC Model, which involves assessing individuals screening for their behavioral health needs and risk, and then assessing them if they screen positive. Planning for those individuals as they're getting ready for release, which includes collaborating across the systems to ensure that there's a tight plan for them. Identifying those critical periods that might be difficult. For example, the time surrounding release when people might be queued right back into substance use. And so providing those wraparound supports for them, perhaps utilizing a peer or recovery coach to help them make positive choices for themselves as they move from the carceral setting into the community. And then, coordinating. If they are on terms of supervision, coordinating a firm but fair approach, but using positive rewards and supports to help people move into their recovery in a safe manner, which includes providing cross-training, data analysis, and developing mechanisms to share information across what might be a community supervisor, as well as a treatment provider, to help maximize the success of that individual. Post-release care to consider for people with opioid use disorder includes ongoing treatment and evaluation for their infectious diseases, prevention of cancer, and basic medical care since we see the complex comorbidities involved with people who are moving in and out of the criminal system who have opioid use disorder. We want to look at where urine drug screens fit in and how overdose prevention can be critical given those overdose rates. Naloxone access post-release has become an increasingly part of the National Dialogue. Treatment and addressing trauma, including sexual assaults, given the high incidents of sexual assaults in jails and prisons, can be very important, as well as assessing for post-traumatic stress disorder, depression, and suicide risk throughout people's post-release period and over the long-term. Now, let's talk again about Mr. A and drug court. For Mr. A, he confers with his attorney. And with drug court, he has the chance for an alternative to incarceration. That might mean 18 months to three years under community supervision of a drug court program. But for Mr. A who's otherwise facing a much longer sentence of prison, this could be an important agreement. And frankly, the drug court might help him to achieve the sobriety and the recovery that he has been longing to achieve. So questions you might ask Mr. A is really understanding what his history of criminal justice involvement has been. How has he worked previously with probation or parole? How many years has he been incarcerated, and what programming has he received while incarcerated? What would his current involvement in drug court and current terms look like? If you're seeing him in your clinic, it would be helpful to understand what is he required to do, or what is he going to be required to do if he's going to be engaged in this drug court? Who is on his treatment team for the drug court? There may not be a prescriber on his treatment team. In fact, usually, there aren't prescribers on drug court treatment teams. So, it's going to be important to realize that you want his prescriber to be connected to his drug court team so they can communicate with each other and make sure that the prescriptions are going well and that his adherence to treatment is going well in addition. Who is in his life as a support, and are there valid releases of information to allow that free flow of communication? And what are the terms and conditions he must follow? If you're working with Mr. A in the clinic, these can be helpful points of discussion for you to really get to know Mr. A better, to understand what the framework of his life is, and help support his recovery and success. Now, what about medications for opioid use disorder? Let's say you want to start prescribing a medication. Drug courts, as I mentioned, have had a historical negative view about medications for opioid use disorder. However, the current policies for drug courts are that these medications should be accepted, especially if these drug courts receive federal funding, very often if they receive state funding as well. So drug courts often now have relationships with local providers and refer patients to those providers. But again, since they don't usually have prescribers directly involved in the team meetings, it's important for there to be open communication. And providers may need to help patients communicate reasons why a particular medication is being used. Sometimes, I recommend that prescribers help give the patient a card that explains their medication so that they can show it to their treatment court team. Coordination with those court professionals can be helped with written or verbal communications to advocate for the proper medications to treat the opioid use disorder. Now, what about Ms. B? Ms. B is looking at reentry from the prison. Reentry planning for her should include linkages to providers in the community, a naloxone rescue kit given her history of heroin use, and these are often now given to the individual or their family as part of reentry planning. Her risk of overdose is very high if she returns to the same levels of use as she was prior to incarceration. And we saw from the data about those risks. So it's really important that in the reentry planning, both the carceral providers, as well as the community providers, provide that safety net and ensure that she and anyone around her has access to naloxone rescue kits. Also, supervision by parole or probation may be part of her community requirements. So if you are seeing her in a clinical setting and you're assessing her, these are questions you might ask her. Tell me about your history of criminal involvement. Help me understand how much time you've spent in jail or prison and what that's been like for you. Tell me about how you've worked with probation or parole before, and what's been difficult for you? Has it helped you in any way? How can I help you work with them more successfully? Tell me about the programming you've received for your substance use disorder during the time that you've been incarcerated. Tell me about the current terms and conditions you have for where you can live, for programming that you have to participate in, again, so that I can help you support your success. Who's in your life right now as a support that understands your pathway to recovery. Do you have access to naloxone? Was it distributed to you? Where is it? How are you going to access it in the event of an overdose? Is there a valid release of information to allow communication, and can we ensure that that communication is available so that we can help you achieve success? These are the types of things that you might want to talk to Ms. B about when she comes to your clinic. It's very important that we increase access to medications for opioid use disorder across the continuum. These medications have historically been available in jails and prisons for pregnant women. But now, more and more jails and prisons, as I mentioned, are starting programs to allow medications for opioid use disorder. Typically, these will be buprenorphine and/or naltrexone, especially injectable formats. But this is moving further and further along to have the same medications available in the community as are available in the carceral settings. Concerns about diversion of medications, like buprenorphine, have prevented the expansion in many facilities, but again, advocates are trying to shift this discussion. Now, more and more claims of violations of the Americans with Disabilities Acts against some jails and prisons and litigation in that space for not providing MOUD have been successful, putting more and more jails and prisons on the alert that these medications must become available over time. Now, information sharing is also challenging because of 42 CFR Part 2, which can limit communications with others for patients who are in primary substance use treatment. HIPAA also limits communications related to mental health and healthcare. There's also state laws that govern information sharing. However, despite these very restrictive laws, a valid release allows for communication. And very often, I see situations where nobody's asked for a release. So the first thing you should do with your patient is ask for these releases of information so that you can share information and then share information only that's necessary to further the person's recovery. For individuals under court or community supervision, communication can be complicated, but the community supervisors can also seek those releases. Best practice programs involve mutual work with community supervisors to develop protocols related to what information is going to be shared or not shared, again, to help that person achieve recovery, which includes not having to face recidivism into the criminal system. If a patient is mandated to one type of MOUD, for example, a judge has ordered only buprenorphine or only Vivitrol, this can be a real problem. There is the Legal Action Center that provides a number of legal resources for people, including a sample treatment letter, publications, information for defense attorneys, and even training materials. And it's very important to access these types of resources for yourselves and for your patients to help them understand what their rights are and their risk of being discriminated against if they have an opioid use disorder. So these are excellent resources that I highly recommend. Mr. A and Ms. B are now in recovery and early remission, but they still have additional rights that protect them from discrimination: the Americans with Disabilities Act, the Rehabilitation Act of 1973, the Fair Housing Act, and the Workforce Investment Act all protect them for rights. And there's information available through SAMHSA about their rights, and it's very important that we educate our patients about the rights that they have to protect them against discrimination. So in conclusion, let me just say that the criminal justice experience of patients should be understood and explored by treatment providers. It is a whole world unto itself that our patients are experiencing, and the best way we can help our patients is to understand the worlds in which they live. There can be a revolving door in and out of the criminal system that can be itself traumatizing. And so we need to understand the difficulties that our patients face. There is a high risk for gaps in care due to various systems involved and high morbidity and mortality associated with disruptions in care. Maximizing personal understanding of the criminal justice system, laws, and best means of coordinating care between treatment and corrections and courts can be helpful. And medications for opioid use disorder for criminal, legal, and juvenile justice-involved persons are gaining increasing attention locally and nationally, and you should be familiar with local practices so that you can help your patients best. Here are my references. The PCSS Mentoring Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorder. PCSS Mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment including medications for opioid use disorder. There is a three-tiered approach that allows every mentor or mentee relationship to be unique and catered to the specific needs of the mentee, and these come at no cost. For more information, visit us at pcssnow.org/mentoring. If you have a clinical question in the PCSS Discussion Forum, ask a colleague. A simple and direct way to receive an answer related to medications for opioid use disorder. Designed to provide a prompt response to simple practice-related questions. Go to pcss.invisionzone.com/register. PCSS is a collaborative effort led by the American Academy of Addiction Psychiatry, in partnership with numerous organizations outlined on this slide. Educate, Train, and Mentor, that's PCSS. And thank you for your attention.

criminal justice system

medications

opioid use disorder

evidence-based practices

healthcare professionals

probation

parole

correctional settings

substance use disorders