Everyone who has posted to this forum has added wonderful information. I can sense the enthusiasm that each of the contributors brings to this work. We are all learning more each day about the link between health equity and justice. Many of the folks we work with in RSAT programs experience significant health disparities, limited access to care and a number of inequities.
- Sentenced drug offenders are disproportionately African American (30%) and Latino (40%).
- They tend to lack economic means and opportunity. In some prisons up to 90% of convicted drug offenders had public defenders.
- They also tend to have a much higher rate of co-occurring mental health problems than is normally seen among those with drug and alcohol problems (about 74%).
- They may not have had educational opportunities. Jails and prisons house the largest concentration of functional illiteracy in the US.
- Nearly a third of all state prisoners report a physical, mental, development or cognitive/learning disability.
- The majority have been exposed to significant violence, in childhood and adulthood.
Then, there are the physical health issues. The prevalence of hepatitis C is six to seven times higher in jails and prisons than among the general population, and the rate of HIV diagnosis is four times higher. One-half of men and two-thirds of women leaving prison were diagnosed with chronic physical health conditions such as asthma, diabetes, hepatitis, or HIV/AIDS. Smoking rates are double those of the general population. Upon re-entry, the risk of death (from all causes) is 12 times as high as the risk of the general population. Drug overdose (40 to 129 times as high), suicide, homicide, heart disease and cancer are the main causes of death.
Now imagine we are ten years ahead in time, and 32 million people have gained coverage for mental health and substance abuse services. Another 30 million, who had minimal coverage for prevention and recovery services, now have access to expanded services. The children of our RSAT clients have grown up with health care coverage. They are now routinely screened for Traumatic Brain Injury and led exposure. They also have coverage for the full array of preventive services recommended by the US Preventive Service Task Force and the “Bright Futures” guidelines (HRSA & AAP).
The reason I mention both the current disparities and a vision of a future without them is because I believe we need to inspire offenders if they are to enroll and engage in healthcare upon release. In more immediate terms, they also need to understand the critical role of immediate access to services upon release:
- Each offender who has successfully participated in intensive, long-term treatment has made a significant investment of time and effort. Now, there is an opportunity preserve those gains.
- The investment they have made into treatment lays a foundation. However, without follow up during the transitional period, the foundation can erode, quickly.
- Coverage and immediate access to services upon release can double or triple their chances of success.
To some extent, there are opportunities to improve services for the justice population in all states, through the exchanges. In states that have opted, through health reform, to expand Medicaid to adults with incomes at 133% of federal poverty (roughly $29,500 per year for a family of four), the potential is greatest. However, other states may eventually follow suit, and may expand some type of safety net coverage in the future.
A few potential areas of interest:
A remedy for lack of capacity to implement detox protocols
Medically managed detoxification of inmates can reduce contraband, drug diversion and distribution, and disciplinary infractions related to substance use in custody settings. It has the potential to contribute significantly to public health by reducing the spread of communicable disease in crowded custody settings. However, some state and many county facilities do not have protocols in place for medically managed detox and/or do not have the capacity to offer it.
Assisting inmates who are in withdrawal is considered a good practice and an ethical responsibility. The Federal Bureau of Prisons (BOP) has developed clinical practice guidelines for detoxification of inmates with addictions to various drugs and to alcohol. BOP guidelines maintain, “Every effort should be made to ameliorate the inmate’s signs and symptoms of alcohol or drug withdrawal.” BOP guidelines support the option of admission to community hospitals under certain circumstances.
“Detoxification can be safely and effectively accomplished for inmates in a variety of housing placements, including: locked jail units, general population, observation cells in the health services unit, and Special Housing Units, or when necessary as inpatients in a community hospital.” Detoxification of Chemically Dependent Inmates - Federal Bureau of Prisons. Clinical Practice Guidelines, August 2009: http://www.bop.gov/news/PDFs/detoxification.pdf
Pharmacological treatments are becoming more widely available.
The Federal Drug Treatment Act of 2000 allows for the use of buprenorphine for opioid addiction by private physicians through office-based treatment. It also has increased the use of opioid replacement treatment in community-based programs. As the ACA is implemented, expanded of coverage for addiction treatment may allow many more people to access methadone or buprenorphine treatment. Jails and prisons may see increases in the numbers of people entering custody settings who are already taking prescribed medications for treatment of an addiction.
When these medications are abruptly discontinued upon intake to a secure facility, it is problematic for several reasons. Institutions may leave themselves open to legal challenges. Some research has also shown that forced methadone withdrawal in custody discourages offenders form seeking methadone therapy post-release (Addiction Treatment Forum, April 2013).
Detoxification from methadone or buprenorphine would be covered prior to admission, for enrolled and or eligible offenders. It could be arranged through collaboration with community providers. RSAT programs can begin prepare for these potentialities by making sure they use some type of withdrawal severity assessment. The National Commission on Correctional Healthcare offers a withdrawal assessment/screen that they recommend administering with 2 hours of admission. There are also others available.
Medications options for the treatment of alcoholism and opioid addiction that are not controlled substances
Naltrexone and Acamprosate are both helpful with alcohol dependency. Naltrexone is also approved for treating opioid addiction. Offering these medications in RSAT settings is more viable if there is a possible source of coverage to continue them upon release. Although the long-acting injectable form of Naltrexone is expensive, the pill form is not. Since custody settings are uniquely suited to administer directly observed treatment (watching the offender take the pill), it may be possible to begin offenders on the oral medication and transition them to the injectable upon release, or upon transfer to a work release facility, when they potentially may have coverage.
Although it is not guaranteed, the advent of post-release coverage for MAT also puts a new light on pre-release planning. There is now a possibility that the US correctional system can utilize MAT to its benefit at a level that is more on par with other countries.
Stay tuned for the next post on a fascinating concept: Offenders are covered by their parents’ plans (Medicaid or plans purchased through the Exchanges) until their 27 birthday. This is a demographic group that patronizes our correctional facilities quite regularly! They do not have to live with their parents, or even be in touch with them be eligible.
Also…Contracting for what you need: New business models will arise to meet the needs of the covered population. Corrections can craft requests for information and requests for proposals from a variety of health-related commercial contractors. Find out how to drive the process of tailoring contracted services to meet your needs!
~Niki Miller