Kimberly Sperber, PhD Director Amber N. Manzo, MS Senior Research Associate

1. Factors Influencing Medication Assisted Treatment in Ohio Halfway Houses and Community Based Correctional Facilities Kimberly Sperber, PhD Director Amber N. Manzo, MS Senior Research Associate This research was supported by grant number 2014-JG-E01-6020, awarded by the Office of Criminal Justice Services, Edward Byrne Memorial Funding, to Talbert House. Points of view or opinions contained within are those of the authors and do not necessarily represent the official opinions or policies of the U.S. Department of Justice or the Office of Criminal Justice Services.

2. Setting the Stage • Opiate overdose is the second leading cause of injury related death nationally, surpassed only by car accidents (Nosyk et al., 2013). • In Ohio, accidental overdoses are the leading cause of death and have been since 2007. • 472% increase in drug overdose deaths from 1999 to 2013 (Ohio Department of Health, 2015). • These deaths cost Ohio $3.6 billion annually, with nonfatal overdoses costing an additional $31.9 million.

3. Setting the Stage • Number of Ohio substance abuse treatment clients with a primary diagnosis of opioid dependence rose from 5790 in FY01 to 24,833 in FY12. • The largest percentage of clients with this diagnosis in any county in FY01 was 14.3%; in FY12 it was 69.7%. Ohio Department of Health

4. Increased Risk • Overall increase in persons with opioid disorders = increase in community corrections clients with opioid disorders • Increased risk to correctional programs and their clients: • AWOLs • Program failures • Recidivism • Death

5. Investigating Barriers to MAT in Community Corrections(2015) • Study Methodology • Replication of National Institutes of Health studies conducted in private and public substance abuse programs • Replicated in Ohio halfway houses and CBCFs • Sought to examine (1) barriers to medication assisted treatment (MAT) and (2) staff attitudes toward MAT. • Funded by OCJS

6. Data Collection • Structured, face-to-face interview with select key staff • Program Director • 1 Clinical Supervisor • 2 Counselors • 1 Medical • Use of structured interview guide to gather information on key independent variables within a number of domains. • Completed 181 key informant interviews

7. Data Collection • Staff Surveys to all staff in each facility • Knowledge about MAT • Beliefs about the effectiveness and appropriateness of MAT for offenders • Endorsement of myths about MAT • 1876 surveys distributed • Response rate = 49% (n=910)

8. Sample Findings INTERVIEW RESPONSES

9. Program Characteristics • 28 halfway houses, 21 CBCFs • Estimates of opioid abuse/dependence on average of 44% for HHs and 64% for CBCFs • 61.2% had no detox services available • 34.7% had access to external detox providers, while only 4.1% provided their own detox

10. Access to Medical Staff

11. Role of Single State Agency

12. Accessing Info on MAT

13. Medical Staff Barriers

14. What Do 910 Practitioners Have to Say? SURVEY RESPONSES

15. Staff Characteristics

16. Diffusion and Staff Perceptions by Medication

18. Summary • Sufficient information on MAT and working in a facility that provided some level of MAT was predictive of diffusion across all 4 medications • Operations status predictive across all 4 medications; negative relationship • Gender predictive across 3 of the 4 medications • 12-step orientation only predictive of Buprenorphine diffusion; negative relationship • Gender, recovery status, level of education consistent predictors of diffusion for methadone and buprenorphine

19. Practitioner Knowledge About MAT • Operations staff provided significantly lower ratings of agreement on items that reflected benefits of MAT • Reduces relapse • Increases employment • Reduces crime • Reduces or blocks the effects of opioids • Increases family stability • Improves birth outcomes for children born to addicted mothers. • They provided significantly higher ratings of agreement to items indicating beliefs about negative outcomes of MAT • MAT rewards criminals for being drug users and interferes with the ability to drive a car. • Supervisory staff provided significantly higher ratings of agreement than both groups of line staff for two items – MAT lowers death rates and MAT increases program retention.

20. Staff Opinions and Concerns • Operational staff were more likely to agree with negative statements associated with medication-assisted treatment. • These items were: • Using medications to treat addiction is substituting one drug for another. • Using medications to treat addiction in correctional programs causes too many problems with diversion and contraband within the facility. • Medications are drugs and you cannot be clean if you are taking drugs. • Using medication in substance abuse treatment is promoting the pharmaceutical companies.

22. Summary • Staff who demonstrated a higher level of agreement with statements indicating positive outcomes of MAT were significantly more likely to endorse the use of buprenorphine, oral naltrexone, and injectable naltrexone as acceptable. • Higher endorsement of items reflecting concerns with MAT produced a significantly lower odds of agreeing that three of the medications were acceptable for use with correctional clients; these medications were methadone, buprenorphine, and oral naltrexone. While not statistically significant at the p=.05 level, staff concerns did approach significance as a predictor of acceptability for injectable naltrexone as well (p=06). • Working in a facility that directly provided MAT was also a statistically significant predictor of endorsing the acceptability of methadone, oral naltrexone, and injectable naltrexone. it served to decrease the probability that staff would endorse methadone as acceptable, however.

24. Summary • Endorsement of outcomes predictive across all 4 medications • MAT implementation was predictive of perceptions of effectiveness of only one medication – oral naltrexone • Working as operations staff predicted lower endorsement of effectiveness for both forms of naltrexone • Working in a CBCF predicted lower endorsement of effectiveness for methadone and buprenorphine • Higher endorsement of concerns associated with MAT was predictive of lower endorsement of effectiveness of methadone only

25. Implications • Identification of key structural barriers to MAT adoption in community corrections settings • Overall low diffusion of knowledge about MAT • Overall low ratings of acceptability and effectiveness of MAT • A mixture of individual and organizational attributes that may be important to future efforts to change staff perceptions

26. Practitioner Toolkit • Staff Education • Fact Sheets • Webinars • Advocacy • Implementation • Implementation Matrix • Client Education

27. Staff Education - Sample Topics • Brain science • Addiction as a chronic care condition • Understanding the role of medication in long-term recovery • Myth busting • Scope of practice

28. Substance Use and the Brain • Repeated use of addictive drugs eventually changes how the brain functions • These changes can last for months or even years • These changes accompany the transition from abuse to addiction and may continue to increase risk of relapse even once someone has stopped using drugs

29. Objective Evidence NIDA (2007) Bringing the Power of Science to Bear on Drug Abuse and Addiction. Rockville, MD : U.S. Dept. of Health and Human Services, National Institutes of Health.

30. Cognitive Deficits • Memory • Difficulty with abstraction • Diminished impulse control • Brain performs similarly to an individual with brain damage

31. Addiction as Chronic Care Condition • Many with addiction will require multiple episodes of treatment over the course of years before demonstrating any sustained period of recovery • In one study, estimated median time from first use to at least 1 drug-free year was 27 years • Estimated median time from first treatment to 1 alcohol and drug-free year was 9 years with 3-4 episodes of treatment (Dennis et al., 2005) • Time to recovery is also impacted by age of first use and duration of use prior to treatment

32. Understanding the Medications • What is the difference between an agonist, a partial agonist, and an antagonist? • How do these medications function? • How do these medications function differently from heroin?

33. Opioid Medications High Full Agonist Activate opioid receptor in the brain; subjective feeling of “high” (e.g., methadone) Opioid Block the opioid receptor; NO subjective feeling of “high” Effect Partial Agonist (e.g. buprenorphine) Antagonist Low (e.g. naloxone) Dose of Opioid Developed by Dr. Erin Winstanley for Talbert House SOURCE: ATTC

34. Phases of MAT • Detoxification • Weaning patients off of addictive substances and managing withdrawal • Used alone, we see high rates of relapse • Stabilization • Withdrawal management, assessment, medication induction, psychosocial counseling

35. Phases of MAT • Maintenance • Medication maintenance and deeper counseling work • Ongoing Rehabilitation • Patient and provider might choose to wean from medication or pursue indefinite medication maintenance • SAMHSA consensus group recommended that patients never be coerced into tapering off of their medications • Decision is to be jointly made between physician and patient

36. Myths • MAT substitutes one addiction for another • Addiction medication is a crutch that prevents true recovery • MAT should not be long term

37. Scope of Practice • Prohibitions against MAT and implications for Americans with Disabilities Act and Rehabilitation Act of 1973 • Implications of recommendations against MAT made by non-medical professionals • Agency policy versus individual staff opinion

38. The Opioid Crisis Continues Current CHHSR Projects

39. Complicating Factors • The recent influx of fentanyl has served to further exacerbate the risk of overdose deaths in Ohio • Number of fentanyl overdose deaths increasing 500% from 2013 to 2014 • Ohio leads the country in the number of confiscations by law enforcement of illicit fentanyl. The second highest rate of confiscations is in Massachusetts, which is only about half that of Ohio. • According to a 2015 Center for Disease Control EpiAid report on risk factors for fentanyl-related overdose deaths in Ohio, the highest fentanyl overdose rates can be found in Hamilton, Montgomery, Summit, Butler, Cuyahoga, and Clermont Counties.

40. Complicating Factors • Risk factors associated with an increased risk of a fentanyl-related overdose death included: • Age, gender, current mental health problem, history of a substance abuse problem, history of opioid abuse, lower education, and recent release from a correctional institution.

41. Reentry and Risk of OD • Highest risk time for a drug overdose for individuals involved in the criminal justice system is 2 weeks post-release from a correctional facility. • For example, a 2010 meta-analysis found that drug overdose was the cause of 59% of deaths within 3 months of release from prison and 76% of deaths within 2 weeks of release. • Research findings demonstrate that the relative risk of death post-release is 3 to 8 times higher during first 2 weeks compared with the subsequent 10 weeks post-release.

42. Current CHHSR Statewide Study 2016 • Factors Influencing Opioid Overdose Preventions and Response Practices in Ohio Community Corrections and Substance Abuse Programs • Includes HHs, CBCFs, OP substance abuse, residential substance abuse

43. Methodology • Telephone interview with program director • Use of semi-structured interview guide • Anonymous, paper-and-pencil survey of staff • Random selection of half

44. Areas of Interest • Document the prevalence of naloxone distribution (ND) programs • Document prevalence of structured overdose prevention education programs • Identify barriers to naloxone distribution programs and OD prevention programs • Examine staff attitudes toward ND programs and OD prevention programs

45. Development of OOPP • Structured, replicable approach to education • OOPPs have been shown to: • Increase knowledge of overdose prevention and overdose risk factors • Increase application of such knowledge during overdose events • Increase the ability to respond appropriately in overdose situation

46. Agency-Wide Initiatives • Opioid Oversight Committee • Mandatory Opioid 101 training for all staff • Community outreach • Drug lab testing for fentanyl

47. Conclusions • We treat and supervise a population at high risk for opioid addiction, overdose, and death • We have a responsibility to deploy evidence-based practices to best of our ability • Requires an understanding of all barriers and opportunities • Requires long-term planning and advocacy

48. Questions & Answers kimberly.sperber@talberthouse.org