Maximizing Opportunities*Intervention Points for the Opioid and Mental Illness Driven Addiction Crisis)

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“To effectively address the Opioid Driven AddictionCrisis we must go as far upstream as possible,meet people where they are and provide hope and healing”

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Criminal Justice System Opportunities for Intervention

Arrest Intake Bond Conditions

Preliminary Hearing

Trial Court Arraignment

Other Pre-Trial Appearances Plea/Trial Sentencing

Arraignment

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Jail visits*

• 25%*of individuals that died from opioid use between 2010-2017 had been incarcerated within a year of their death.

• While a Maryland Study found that over 60% of people that died of a drug overdose had recent interaction with the criminal justice system. –*https://mdpsych.org/wp-content/uploads/2018/09/Haas_2018.pdf

Marion County Indiana Note: All statistics from Indiana are the work of Dr. Brad Ray: https://nationalcenterforstatecour ts.box.com/s/qj1tjw6ntgybgvqbfp 6gnw03p600qw9w

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MAT in jails

• Rhode Island implemented new MATstrategies in 2017 and found a 12.3%decrease in overdose death after release. This is despite the fentanyl epidemic thathad reached Rhode Island at the time.

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2671411*

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Tennessee Numbers*

172,388 arrests in 2018*

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EMS Encounters

• EMS naloxone encounters have risen from 542 in 2011 to 1791 in 2016, and 10% had passed upon follow up.

• 35% of those were drug related

Marion County Indiana*

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EME-Emergency Medical Event

• Emergency medical services and Emergency room visits • 28,026 EME encounters that were non fatal overdoses in

Indiana 2014-2017 • 73 % had died at follow up from non drug related causes • Repeat patients have a 55% greater chance of death • Less than 20% of deaths had a prior overdose event • This means more than 80% had a prior EME, a touch point

where intervention could have taken place

Indiana 9

Emergency Department visits-CDC*

• “During July 2016–September 2017,emergency department (ED) visits amongthose aged ≥11 years for opioid overdoses in the United States increased 29.7% overall ”

https://www.cdc.gov/mmwr/volumes/67/wr/mm6709e1.htm*

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Tennessee Emergency Services • In 2017, there were 15,949 nonfatal overdose

outpatient visits. –This could be through emergency departments,

or other medical services that lasted 23 hours or less

• There were 7, 708 nonfatal inpatient visits –That is visits that were 24 hours or longer

https://www.tn.gov/health/health-program-areas/pdo/pdo/data-dashboard.html

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Tennessee Recovery Oriented Compliance Strategy

“TN ROCS”

Maximizing our Opportunities in the CriminalJustice System)

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Joseph Booker Slone*

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Essential Components of the MostSuccessful Recovery Oriented

Compliance Strategies)

1.*Accurate assessment and referral to an appropriate level of treatment for an appropriate amount of time

2.*Frequent accountability

3.*A big stick

Evaluations of physician health programs (PHPs) and the Human Intervention Motivational Study (HIMS) for commercial airline pilots boast long-term recovery rates of up to 90 percent. These programs contain all three of the elements referenced above.

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Drug Recovery Courts)

•* Serve nonviolent high-risk/high-need individuals

•* Application required/voluntary •* Strict adherence to 10 Key Components of

a Drug Court •* Multiple phases and close-ended •* Heavy demand on time and energy of team

members •* Heavily dependent on volunteer human

resources •* Population served limited to a small

percentage of justice-involved people with behavioral health disorders

•* Implementation and scalability are limited

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Drug Recovery Courts)

Cannot serve everyone

According to the Bureau of Justice Statistics, more than half (58 percent) of state prisoners and about two-thirds (63 percent) of sentenced jail inmates met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for drug dependence or abuse during 2007–2009

We need all hands on deck!!!!

Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007–2009, NCJ 250546*

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With 78,000 on supervised release, there are at least 46,800 that have a SUD. Meanwhile, only 2,000 are being served by drug courts and at least 44,800 are left in the gap.

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It is likely at least 7,800 TDOC*inmates in Jails have an SUD*

While 13,140 in prison could be diagnosed as well.

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Pregnant Women*

with Opioid Use Disorder*

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Institutional Bias Against Medication to Assist Treatment ofOpioid Use Disorder

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Pregnant Women with OUD-routinely treated with only medication)

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Expanded to entire pre-trial & probation population

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Essential Requirements of TN ROCS)

•*A trusted person or an organization provides accurate screening, assessments, and referrals to appropriate or best available level of treatment (criminal justice liaison)

•*A trusted person or an organization provides appropriate level of supervision*(TDOC, Community Corrections)

•*Judge (Tennessee judiciary)

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Criminal Justice Liaison (CJL))

•*Performs a “triage” service using a variety of screening tools such as ASI and CAGE. The CJL then engages the client in clinical assessment, relying on techniques of motivational interviewing and the client’s biopsychosocial information to develop a treatment plan

TDMHSAS 26

Criminal Justice Liaison (CJL) cont’d)

•*Criminal justice liaison distributesresults to:

– Defense counsel: may obtain the full assessment and recommendations

– Prosecuting attorney: obtains summary of recommendations

– Judge: obtains summary of recommendations

•*Provides a warm/rapid connection to services

•*Provides continuing support and advocacy

TDMHSAS 27

Community Supervision Officer)

•*TN ROCS participant begins by reporting weekly to the community supervision officer to be monitored for compliance with behavioral health treatment plan and attendance of the “Prevention through Education” class offered by the Tennessee Department of Health

•*Scheduled and random drug screening

•*Direct communication with the court when noncompliance occurs

TDOC) 28*

Tennessee Judiciary)

•* The individual on the TN ROCS docket appears before the court to review compliance with the behavioral health treatment plan and to make adjustments to terms and conditions of supervision where necessary

•* The judge may initiate, permit, or consider ex parte communications authorized by law –*Tenn. Sup. Ct. R. 10, Canon 2, Rule of Judicial

Conduct 2.9, Comment 4 •* Affirmation by the judge is critical to the success

of the individual –*In one study of drug courts, significantly better

outcomes were achieved by drug courts that offered higher and more consistent levels of praise and positive incentives from the judge (Zweig, et al., 2012)

Zweig, J. M., Lindquist, C., Downey, P. M., Roman, J., and Rossman, S. B. (2012). Drug court policies and practices: How program implementationaffects offender substance use and criminal behavior outcomes. Drug Court Review, 8(1), 43–79 29

Importance of Judicial Affirmation

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Decreases in Jefferson and Grainger Counties

Tennessee 2008-2012 All Drugs Tennessee 2013-2017

https://opioidmisusetool.norc.org*

Courtesy: Betty Ann Bryce 31

Community Assessment Tool

Rural county

Counties trending up v. down

https://opioidmisusetool.norc.org Courtesy: Betty Ann Bryce 32

Success Stories)

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TN ROCS Successes)

•*Over a three-year period, at least 34 out of 34 pregnancies were healthy births •*Over a three-year period, 30 out of 34 mothers retained custody of their children •*Recidivism rate for any new criminal offense is 32 percent, including people who

had as few as one appearance on the ROCS docket •*Significant reduction in jail population

•*50 percent reduction in burglary rates in Grainger County •*Philosophical and cultural shift •*“Scalability” and implementation: easier and faster than specialty courts

•*Former Governor Bill Haslam included as a key component of “TN Together Plan” to combat the opioid crisis

•*Governor Bill Lee & Legislature continue expansion across Tennessee

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Paths to Placement Into TN ROCS)

•*Original sentence: Compliance with behavioral health treatment plan is a condition of predisposition release or sentence

• Violation of conditions of supervised release: Compliance with behavioral*health treatment plan is a condition of predisposition release or sentence*

•*No eligibility restrictions: Individuals must be eligible for predisposition release or supervised release as part of a sentence

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Progression of Interventions*

Lower Risks/Needs

HigherRisks/Needs

Highest Risks/Needs

• Regular docket • TN ROCS

• Drug Recovery Court • Residential Drug Recovery Court*

• Local jail • Penitentiary

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TN ROCS)TN ROCS can serve the “GAP” population. The GAP population is composed of individuals who are commonly at a lower risk of recidivism yet have high needs related to a substance abuse disorder and frequently a mental health disorder

Drug TN)Recovery ROCS)

Courts)Serves high risks for recidivism X*Serves high needs for behavioral health and X X*other services)Application required (voluntary participation) X*Utilizes three essential components of DRCs X X*No eligibility restrictions for sentences X*permitting probation)Highly dependent on justice system X*volunteers)

TN ROCS utilizes the three essential components of a successful recovery orientedcompliance strategy to scale up the court’s response to the opioid crisis in all criminal justicecourts 37

TN ROCS Resources)

• Coming soon: www.tjoi.org –TN ROCS: sample orders, judgments, behavioral

health treatment plan recommendations, supervising officer compliance report, checklist for compliance appearances

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Where Public Health Meets Public Safety

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TN Department of Health “Prevention through Education” Initiative

• Health Department-Jail voluntary class & provision ofLARCS

• In approximately ½ of Tennessee Jails • Class attendance for men & women mandatory as

condition of supervised release • Other Community Outreach, e.g. OBOTs • Class will soon include education about infectious

diseases commonly associated with illicit drug use andhow to access treatment and other harm reduction services

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Journal of Public Health Management & Practice-Is the Health Department Jail Collaboration

-Perceived as Voluntary?-Cost Effective?

• https://journals.lww.com/jphmp/pages/default.aspx

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The Cabin*

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Our babies*

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Local Churches wanted to help expand the number ofwomen and babies served

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Help build Hope*

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Community builds Hope*

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Treatment Center provides Hope & Healing

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Sophia our First does homework at Treatment Center*

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Staffed 24/7, transportation, utilities, insurance, CostsSavings/Benefits:

Recovery CabinCosts/Benefits*

– Costs of Operations: $135,000 per year.

– 16 x $67,500(28 day NAS hospital stay) = $1,080,000or $216,000 per year

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The opposite of addiction is not recovery it is relationship

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GO AHEAD!”

“I leave this rule for others when I'm dead Be always sure you're right — THEN

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1 UNIVERSAL QUESTION

• WHAT DID YOU DO WITH WHAT I GAVE YOU?*

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2 GREATEST COMMANDMENTS

LOVE YOUR GOD WITH ALL OF YOUR BODY, HEART & SOUL

LOVE YOUR NEIGHBOR AS YOURSELF

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ONE UNIVERSAL QUESTION$

WHAT DID YOU DO WITH WHAT I*GAVE YOU?*

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