Comprehensive Planning and Implementation of MAT Program in Correctional Facility

1. Jill Harrington, RN, BSN, CCHP-RN Health Services Administrator, CFG Health Systems, LLC Albany County Corrections and Rehabilitative Services Center Albany, NY

2. • Discuss planning and preparation for MAT program • Discuss 3 Phase approach and rationale for phases • Discuss training –medical staff, mental health, officers • Review multidisciplinary approach • Discuss collaboration with outside agencies • Identify barriers to care • Expectations for further resources possibly needed

3. • Prior to 2019 start of full MAT program: • Agreement with only one local methadone clinic since 2001 • Extended Release Injectable Naltrexone offered starting in 2016 • Detoxification of anyone on any other MOUD was policy…symptomatic treatment offered only • Exception for pregnant women (follow directive of OB/GYN for dosing)

4. • Consult with DOH, OASAS • Obtain resources (Best Practice Guidelines, SAMHSA TIP 43, TIP 60, TAP 30- Information on Medications for Opiate Use Disorder, Buprenorphine: Guide for Nurses) • Revise policy and procedures (addressing MAT maintenance, detox, induction, administration procedures and MAT in pregnant women) • Providers need DEA-X • Set up staff with NYS HCS user names and passwords to access Prescription Monitoring Program

5. • Add drug testing kits to CLIA waiver • Obtain drug testing kits and train staff on use • Format consent forms, releases and other assessment forms (drug testing consent and consent for MAT treatment) • Contact outside agencies and internal departments to form a committee (Catholic Charities, local methadone clinics, drug courts, OASAS, DOH, CASAC’s, Mental Health Corrections) • Collect statistical information that will be needed to determine success • Offer different forms of MAT/MOUD treatment options (methadone, oral naltrexone, long acting injectable naltrexone, oral buprenorphine/naloxone)

6. • Phase 1: Continuation of medication for patients arriving to facility already on prescribed MAT/MOUD-includes methadone, extended release injectable naltrexone, and oral buprenorphine-naloxone • Phase 2: Induction of patients on oral buprenorphine-naloxone reporting OUD on admission that are now County or state sentenced • Phase 3: Using oral buprenorphine-naloxone for detox and/or inducing new patients reporting OUD, regardless of release date • Rationale: Each phase comes with own challenges • Determine further resources needed • Identify barriers • Maintaining organization and communication • Reassess after CQI studies during and after phases- what works and what doesn’t •

7. • DOH can assist in training for medical staff & mental health staff – Training on medication – Dispel misconceptions – Training on administration procedures, risk for diversion – Narcan training for staff and inmates (placed on inmate tablets) • OASAS has provided train-the-trainer for Correction Officers – Explanation of use of MAT – Attempt to change culture of thinking surrounding Bup – Narcan training for all staff- Narcan placed on all housing units, medical emergency bags, visitation area and booking department

8. • Joint collaboration between corrections, medical, mental health, CASACS, outside entities • Open lines of communication • See patients as “all of our patients” • Follow patient from admission to discharge and beyond • All staff need to work together to have a successful program

9. Develop working relationship with a health hub: Catholic Charities, drug courts, community programs to assist in discharge planning process • Develop business agreements with local methadone clinics • Identify discharge and transitional process (frequent meetings-discharge planning and MAT meetings) • Source outside funding available for Narcan (give 2 kits on release), program implementation, medications • Pharmacies- Medical to provide bridge scripts 7-14 days with insurance information • Inmate Service Unit-meet with navigator for Medicaid enrollment • Correctional staff: develop alert system for unexpected releases (medical alert sticker on booking jacket to alert CO in booking to call medical for a script) • Have a Correctional Supervisor assigned to MAT Committee to check outdates, warrants, holds, next court dates etc. on every inmate in MAT program. •

10. • Lack of staff education • Lack of patient participation • Lack of open communication between departments • Stigma of addiction and treatment • Availability of outside prescribers to link patients to care (especially rural areas) • Closed minds • Lack of staffing, resources • Diversion • Bail Reform

11. • Albany’s Diversion Policy: • Notification to inmate of diversion policy (on consent for treatment form) • First attempt: counseling and document • Second attempt: dose is cut in half and documented • Third attempt: taper off med • Will restart med a week prior to discharge, give patient a bridge script and give two Narcan kits on release • Attempts to control diversion: • 1:1 inmate to officer ratio on administration- on camera at all times • Administer in small groups at a special med pass time (12 at Albany) • Switched to films from tablets-once daily dosing, cap at 16 mg • No tucked in uniforms or shirts under uniform • Check hands, mouths prior to administration and after administration (with tongue depressor and flashlight) • Crackers and water given after 15 min. wait time for dissolving

12. • MAT Program Participant Survey (Anonymous) • NYSDOH involvement to gather statistical data, both during incarceration period and after discharge • Monitoring in-house reductions in violence, contraband, overdoses and recidivism • CQI Process and Outcome studies of MAT program

13. • 457 through the program (363 Bup/Naloxone, 63 Methadone, 8 long acting injectable Naltrexone, 4 oral Naltrexone, 19 Buprenorphine mono-product) • 285 Continuations, 172 inductions • Zero overdose deaths of any MAT participants post-release from jail • Recidivism rate dropped to 5% for MAT participants • Average daily number of MAT dosing: 35-40 Bup/Naloxone films, 6 Methadone

14. • Significant increase in alcohol and drug use, overdoses in the surrounding counties therefore increasing jail intakes • Group sessions/ individual counseling stopped or delayed due to COVID-consider non-contact visitation area for 1:1 counseling • Longer bridge scripts needed on release (30 days) to ensure patients can connect with a prescriber (difficult in rural areas with limited prescribers to start with) • Tele-health, video counseling needed if unable to do in- person sessions

15. • More CASACs • Re-entry coordinator • More prescriber hours dedicated to MAT program • $$$- grants • Seek out decreased pricing of medication direct from pharmaceutical companies. • On-going reassessment of needs through each phase

16. • Joint effort • Not an easy undertaking • Working together for common goal • Patient care and safety first • Learning experience • Assistance is out there