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PUBLIC POLICY STATEMENTS


Joint Public Correctional Policy Statement on the Treatment of Opioid Use Disorders for Justice Involved Individuals

Adoption Date:
February 12, 2018
Joint Public Correctional Policy Statement on the Treatment of Opioid Use Disorders for Justice Involved Individuals

A Joint Statement by the the American Correctional Association (ACA) and the American Society of Addiction Medicine (ASAM)

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Introduction

Seventeen to nineteen percent of individuals in America’s jail and state prison systems have regularly used heroin or opioids prior to incarceration.i While release from jail and prison is associated with a dramatic increase in death from opioid overdose among those with untreated opioid use disorder (OUD), there are considerable data to show that treatment with opioid agonists and partial agonists reduce deaths and improves outcomes for those with opioid use disorders.ii,iii Preliminary data suggest that treatment with an opioid antagonist also reduces overdose.iv As a result, the 2017 bipartisan Presidential Commission on “Combating Drug Addiction and the Opioid Crisis” has recommended increased usage of medications for addiction treatment (MAT) in correctional settings.v

Policy Statement
 
 The American Correctional Association (ACA) supports the use of evidence-based practices for the treatment of opioid use disorders. ACA and the American Society of Addiction Medicine (ASAM) have developed recommendations specific to the needs of correctional policy makers and healthcare professionals. These recommendations will enable correctional administrators and others, such as community corrections, to provide evidence-based care to those in their custody or under their supervision that have opioid use disorders.
 
ASAM recently published a document entitled The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Usevi that includes treatment recommendations specifically for individuals in the justice system. Pharmacotherapy, behavioral health treatment, and support services should be considered for all individuals with OUD that are involved in the justice system.
ACA and ASAM recommend the following for correctional systems and programs:
 
A. Screening/Prevention
  1. Most deaths from overdose occur during the first few days following intake to the correctional facility. Screen all incoming detainees at jails and prisons using screening tools with psychometric reliability and validity that provide useful clinical data to guide the long-term treatment of those with OUD and with co-occurring OUD and mental disorders. Opioid antagonist (naloxone) should be available within the facility and personnel should be trained on its use.
  2. Pre-trial detainees screened upon entry that are found to be participating in an MAT program to treat OUD and who are taking an opioid agonist, partial agonist, or antagonist should be evaluated for continuation of treatment on that medication, or a medication with similar properties. There are effective models for continuing treatment with each of these medications in the justice system.
  3. Pre-trial detainees and newly admitted individuals with active substance use disorders who enter with or develop signs and symptoms of withdrawal should be monitored appropriately and should be provided evidence-based medically managed withdrawal (“detox”) during the period of withdrawal. Validated withdrawal scales help gauge treatment. Several medications have been shown to improve withdrawal symptoms.
B. Treatment
  1. All individuals who arrive into the correctional system who are undergoing opioid use disorder treatment should be evaluated for consideration to continue treatment within the jail or prison system. Individuals who enter the system and are currently on MAT and/or psychosocial treatment should be considered for maintenance on that treatment protocol.
  2. Treatment refers to a broad range of primary and supportive services.
  3. The standard of care for pregnant women with OUD is MAT and should therefore be offered/continued for all pregnant detainees and incarcerated individuals.
  4. All individuals with suspected OUD should be screened for mental health disorders, especially trauma-related disorders, and offered evidence-based treatment for both disorders if appropriate.
  5. Ideally, four to six weeks prior to reentry or release, all individuals with a history of OUD should be re-assessed by a trained and licensed clinician to determine whether MAT is medically appropriate for that individual. If clinically appropriate and the individual chooses to receive opioid use disorder treatment, evidence-based options should be offered to the individual.
  6. The decision to initiate MAT and the type of MAT treatment should be a joint decision between the provider and individual who has been well informed by the trained and licensed clinician as to appropriateness of the therapy, as well as risks, benefits, and alternatives to this medical therapy. MAT should not be mandated as a condition of release. In choosing among treatment options, the individual and provider will need to consider issues such as community clinic or provider location/accessibility to the individual, insurance access or type and medical/clinical status of the individual.
  7. Treatment induction for the individuals who choose treatment for opioid use disorder (MAT) should begin 30 days or more prior to release, when possible.
C. Reentry and Community Supervision Considerations
  1. All individuals returning to the community who have an OUD should receive education and training regarding unintentional overdose and death. An opioid antagonist (naloxone) overdose kit or prescription and financial means (such as insurance/Medicaid) for obtaining the kit may be given to the individual, along with education regarding its use.
  2. When possible, an opioid antagonist (naloxone) and overdose training should include the individual’s support system in order to provide knowledge about how to respond to an overdose to those who may be in the individual’s presence if an overdose does occur.
  3. Immediate appointment to an appropriate clinic or other facility for ongoing treatment for individuals returning to the community with substance use is critical in the treatment of opioid use disorder. As such, ideally the justice involved population’s reentry needs should be addressed at least 1 to 2 months prior to release in order to avoid any interruption of treatment.
  4. Reentry planning and community supervision should include a collaborative relationship between clinical and parole and/or probation staff including sharing of accurate information regarding MAT.
  5. Parole and probation staff should ensure that residence in a community-based halfway house or similar residential facility does not interfere with an individual’s treatment of OUD with MAT.
D. Education
  1. Scientifically accurate, culturally competent, and non-judgmental training and education regarding the nature of OUD and its treatment should be provided to all justice system personnel including custody officers, counselors, medical personnel, psychologists, community supervision personnel, community residential staff, agency heads and leadership teams.
  2. This training should include education about the role of stigma involving substance use disorders and the subtle but very real impact that stigma has on those suffering from substance use disorders and those treating them.
References

i BJS. (2017, June). Special Report. Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009.
ii Binswanger IA, Blatchford PJ, Mueller SR, and Stern MF. Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009. Ann Intern Med 2013 Nov 5; 159(9): 592–600.
iii Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ 2017;357:j1550
iv Lee JD, Friedmann PD, Kinlock TW, et al. Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders. N Engl J Med 2016;374:1232-42.
v https://www.whitehouse.gov/sites/whitehouse.gov/files/ondcp/commission-interim-report.pdf
vi ASAM. National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (ASAM, 2015).

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