Closing Treatment Gaps in the Healthcare and Criminal Justice Systems

1. Closing Treatment Gaps in the Health
Care and Criminal Justice Systems
Presenters:
• Jennifer McNeely, MD, MS, Assistant Professor, New York University
School of Medicine
• Gail D’Onofrio, MD, MS, Chair, Department of Emergency Medicine,
Yale School of Medicine
• Ross MacDonald, MD, Chief of Medicine, Division of Correctional
Health Services, New York City Health and Hospitals
Treatment Track
Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of
Science Policy, Office of the Assistant Secretary for Planning and Evaluation,
U.S. Department of Health and Human Services, and Member, Rx and Heroin
Summit National Advisory Board

2. Disclosures
Gail D’Onofrio, MD, MS; Ross MacDonald, MD;
Jennifer McNeely, MD, MS; and Christopher M.
Jones, PharmD, MPH, have disclosed no
relevant, real, or apparent personal or
professional financial relationships with
proprietary entities that produce healthcare
goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Describe gaps in the identification and
treatment of opioid use disorders (OUDs) in
health care systems.
2. Identify approaches for improving identification
of OUDs and engagement in treatment.
3. Distinguish the characteristics of persons most
frequently admitted to the New York City jail
system.
4. Outline strategies to improve outcomes for
frequently incarcerated individuals.

5. Gail D’Onofrio MD, MS
Professor & Chair
Yale School of Medicine
Jennifer McNeely MD, MS
Assistant Professor
NYU School of Medicine
March 29, 2016
Treatment Track: Closing Treatment Gaps in the
Health Care and Criminal Justice Systems

6. Learning Objectives
• Describe screening tools in the identification
of opioid use disorders (OUDs) in health care
systems.
• Identify approaches for improving
identification of OUDs and engagement in
treatment.

7. Disclosure Statement
Gail D’Onofrio MD, MS
Jennifer McNeely MD, MS
Has disclosed no relevant, real or apparent personal or
professional relationships with propriety entities that produce
health care good or services
Has disclosed no relevant, real or apparent personal or
professional relationships with propriety entities that produce
health care good or services

8. &Screening & Treatment of Opioid Use Disorders:
Closing the Gap

9. The substance use disorder
treatment gap
Substance use leads to more
death and disability than
any other preventable
condition
In 2014,
• 21.5 million people w/ SUD
• 2.3 million received
treatment
Robert Wood Johnson Foundation, 2010
Mokdad et al., JAMA 2004
National Survey on Drug Use and Health, 2014
21.5 million
Americans
11%

10. Health care contacts offer an
opportunity for intervention
• 2/3 of people with substance use disorders (SUD) see
a health care provider at least twice a year.
• People with SUD have high rates of ED and hospital
admission
• But… most MDs are unaware of their patients’
substance use
ASAM Policy Statement on Screening for Addiction in Primary Care Settings, 2005
Walley AY, et al., J Addict Med 2012
D’Amico EJ, et al., Medical Care 2005
Friedmann PD, et al., Arch Intern Med 2001
Saitz R, et al., Am J Drug Alc Abuse 1997

11. What are the goals of identifying drug
use in medical settings?
1. Patient safety
• Drug interactions
• Withdrawal
2. Accurate diagnosis
3. Prevention
• Overdose
• Infectious disease
• Comorbid conditions
4. Prescriptions and monitoring
5. Reduce substance use

12. Opening the door to treatment
Medical settings can provide:
• Pharmacotherapy
• Integrated behavioral health care
• Referral to addictions treatment
• Brief intervention for risky use

13. Intensity of Treatment Provided
Proportion of Population Reached
Addiction &
Mental Health
settings
Non-specialty settings

14. Barriers to screening for drug use
• Time
• Workflow
• Knowledge/Training
• Discomfort
• Attitudes
Sterling S, et al., Addict Med Clin Pract 2012
Friedmann PD, et al., J Gen Int Med 2000
Friedmann PD, et al., Arch Int Med 2001
Anderson P, et al., Alcohol Alcoholism 2004
McCormick KA, et al., J Gen Int Med 2006

15. Having the right tools can help

16. Choice of a screening tool depends
on the context
Screening Assessment Diagnosis

17. Characterizing drug screening tools
Screening vs Assessment , Diagnosis
Single substance vs Comprehensive
Self-administered vs Interview
General population vs Specific groups
Low resources High resources

18. Suggested brief screening tools
Low resources High resources
1. Single-item screening question for drugs
2. Substance Use Brief Screen (SUBS)
3. Screen of Drug Use (SoDU)

19. SISQ-Drug
How many times in the past year have you used an
illegal drug or used a prescription medication for non-
medical reasons?
• Identifies unhealthy use (any response >0)
Sensitivity Specificity AUC
Interviewer 85% 96% 0.89
Self-administered 71% 94% 0.83
Smith PC, et al., Arch Int Med 2010
McNeely J, et al., J Gen Int Med 2015

20. Substance Use Brief Screen (SUBS)
5/20/2014

21. SUBS
• Identifies unhealthy use
• Self-administered (computer or paper)
Substance Sensitivity Specificity AUC
Illicit Drugs 81% 97% .89
Rx Drugs 56% 92% .74
Any Drugs 83% 91% 0.87
McNeely J, et al., Am J Med 2015

22. Screen of Drug Use
1. How many days in the past 12 months have you
used drugs other than alcohol? [7+=positive]
2. How many days in the past 12 months have you
used drugs more than you meant to? [2+=positive]
• Identifies drug use disorder
Sensitivity Specificity AUC
92% 93% .93
Tiet QQ, et al., JAMA Int Med 2015

23. Suggested brief assessment tools
Low resources High resources
1. DAST-10
2. ACASI ASSIST
3. TAPS Tool

24. DAST-10
Pros:
• 10 items
• Interviewer or self-administered
• Identifies moderate-risk and high-risk
Cons:
• Does not identify specific substances
• High face validity
Yudko E, et al., J Sub Abuse Treat 2007
Smith PC, et al., Arch Int Med 2010

25. ACASI ASSIST
Audio computer-assisted self interview (ACASI)
version of the WHO ASSIST
Pros:
• Identifies specific substances
• Integrates tobacco, alcohol, and drugs
• Identifies risk level (low-moderate-high)
• Equivalent results to the interviewer version
Cons:
• Requires computer
• Average time to complete = 4.4 minutes (range 1-15)
McNeely J, et al., Addiction 2016
McNeely J, et al., J Sub Abuse Treat 2014

26. Diagnostic Interview
Pros:
• Facilitates treatment initiation by establishing a
diagnosis of SUD
• Substance-specific
Cons:
• Time to administer
• Complexity
• Requires trained interviewer
– Though MINI-Plus has self-administered version
• Does not identify moderate-risk use

27. NIDA TAPS Tool
Screening
(TAPS-1)
Assessment
(TAPS-2)
4-item Screener
• Tobacco
• Alcohol
• Rx drugs
• Illicit drugs
Modified ASSIST-Lite
• 7 items
• Each has 2-3
branching questions
Self-administered (iPad)
or
Interviewer-administered

28. TAPS Tool
• Developed by team of researchers from NIDA Clinical
Trials Network
• Validation study conducted in 5 sites with 2,000
primary care patients
Screening  Assessment
Single substance Comprehensive 
Self-administered  Interview 
General population  Specific groups

30. Screening & Treatment of Opioid Use Disorders:
Closing the Gap

31. Why the ED??
That’s where the
patients are
photo credit: YNHH/Yale University

32. Scope of the Problem
• 21.5 million Americans 12 or older had a substance use disorder in 2014;
1.9 million involved prescription pain relievers & 586,000 involved heroin.
• Emergency Department (ED) visits related to opioids increased
− 145,000 to 420,000 from 2004-2012
• Options for ED providers include referral and since 2002, initiation of
buprenorphine
• One study evaluated the efficacy of referral with or without a Brief
Intervention vs. ED-initiated buprenorphine (JAMA 2015)
– ED-initiated medication is common for other chronic medical conditions
(diabetes, hypertension, asthma)

33. Drug overdose is the leading cause of accidental
death in the US: 47,055 deaths in 2014.
• 18,893 overdose deaths related to
prescription pain relievers
• 10,574 overdose deaths related to heroin
– CDC, National Vital Statistics 2015

34. Overdose
22 year old female presents to ED in private vehicle driven by
friends. On arrival patient pulled out of vehicle by ED staff,
unresponsive with O2 Sat of 53%. Patient responded well to IV
naloxone. Just 2 weeks before, she switched from prescription
drugs to IV heroin.
Why is this different than any
other acute emergency???

35. Innovative Interventions

36. Why not initiate
treatment
immediately ?

37. Intervention for Substance Use Disorders
Project ASSERT
Alcohol and Substance Abuse Services, Education and
Referral to Treatment
Health Promotion Advocates (HPAs) provide SBIRT in ED setting
D’Onofrio G, Degutis C. Integrating Project ASSERT: a screening, intervention, and referral
to treatment program for unhealthy alcohol and drug use into an urban emergency
department. Acad Emerg Med 2010;17:903-911.

38. Project ASSERT 2015

39. A Randomized Trial of ED-Initiated
Interventions for Opioid Dependence
Yale School of Medicine Emergency Medicine
Gail D’Onofrio MD, MS, Patrick G. O’Connor MD, MPH
Steven L. Bernstein MD, Marek C. Chawarski PhD,
Michael V. Pantalon PhD, Patricia H. Owens MS,
Susan H. Busch PhD, and David A. Fiellin MD
Departments of Emergency Medicine, General Medicine, Psychiatry
and School of Public Health, Yale University, New Haven CT
Emergency Department–Initiated Buprenorphine/Naloxone
Treatment for Opioid Dependence: A Randomized Clinical
Trial JAMA. 2015;313(16):1636-1644.

40. Objective
To compare the efficacy of 3 interventions for
opioid dependent ED patients
Referral to
Treatment
Brief Intervention
& Facilitated Referral
Brief Intervention
with ED-initiated
Buprenorphine
Primary Care follow-up
for 10 weeks treatment
329 Patients were enrolled from April 2009 - June 2013

41. Interventions
Referral
Handout of all drug treatment providers/services
in the area relevant to insurance status and
access to a phone
Brief
Intervention
The BNI, discussion of treatment options, and a
facilitated referral to treatment
[BNI, mean time 10.6 (SD) 4.3]
Buprenorphine
The BNI + ED-initiated buprenorphine and
referral to Primary Care in 24-72 hours for
ongoing buprenorphine medical management
(10 weeks), followed by transfer or detoxification

42. Brief Negotiation Interview (BNI)
Raise The Subject
– Establish rapport
– Raise the subject of drug use
– Assess comfort
Provide Feedback
– Review patient’s drug use and patterns
– Make connection between drug use and negative
consequences; risk of HIV/AIDS (e.g. impaired judgment
leading to unprotect sex/sharing needles); MINI feedback
– Make a connection between drug use and ED visit
– Discuss issues related to physical dependence, such as
tolerance and withdrawal
• Manual Driven
• Performed by RAs
• Recorded

43. Enhance Motivation
Assess readiness to change: One a scale 1 to 10 how ready are you to
enroll in program / start buprenorphine/naloxone (Suboxone)?
(Why didn’t you pick a lower number?)
Negotiate And Advise
-Negotiate goal
-Give advice
-Summarize and complete referral / Initiate buprenorphine/naloxone
BNI (continued)

44. Consort Diagram

45. Engaged in Treatment at 30-Days
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ProportioninTreatmentat30Days
30 days
No. (%, 95% CI)
Treatment
Effect
30 day Treatment Engagement
(Referral)
(Brief Intervention)
(Buprenorphine)
38/102 (37, 0.3-0.5)
50/111 (45, 0.4-0.5)
89/114 (78, 0.7-0.9)
p<0.001
P<0.001
Referral Brief Intervention Buprenorphine

46. 7-Day Illicit Opioid Use
0
1
2
3
4
5
6
Baseline 30 Day FU
Days
SRT
SBIRT
SBIRT+BupPC
Baseline
Mean(95% CI)
30 days
Mean(95% CI)
Treatment
Effect
Interaction
Effect
Mean # days of use
(Referral)
(Brief Intervention)
(Buprenorphine)
5.4 (5.1-5.7)
5.6 (5.3-5.9)
5.4 (5.1-5.7)
2.3 (1.7-3.0)
2.4 (1.8-3.0)
0.9 (0.5-1.3)
P<0.001 P=0.02
Treatment Effect: P<0.001
Time effect: P<0.001
Interaction Effect: P=0.02
Referral
Brief Intervention
Buprenorphine

47. Inpatient and ED-Based Addiction Treatment in
the Past 30-Days
Baseline 30 Days
N No (%) p-value N No (%) p-value
% Inpatient Addiction Treatment
Referral 104 10 (9.6) 84 31 (36.9)
Brief Intervention 111 7 (6.3) 91 32 (35.2)
Buprenorphine 114 7 (6.1) p=0.55 100 11 (11.0) p<.001
% ED-based Addiction Treatment
Referral 104 8 (7.7) 69 15 (21.7)
Brief Intervention 111 6 (5.4) 82 12 (14.6)
Buprenorphine 114 5 (4.4) p=0.57 93 18 (19.4) p=0.51

48. Primary Care Treatment
• Physician visits (Primary Care Management)
– Week 1 (30-40 minute)
– Weeks 2, 3, 5, 7, 9 (15 minute)
• Nurse visits (Medical Management)
CTN 030 (POATS)
– Day 1 (30 minute)
– Days 3, 5 (15 minute)
– Weeks 2, 3 (20 minute)
– Weeks 4-10, weekly or q 2 weeks based on stability
(20 minute)

49. Conclusion
• Screening must be integrated in clinical settings
• Interventions need to initiated at the time of entry into
the healthcare system
• Follow up care must be facilitated

50. The latest research shows that
we really should do something
with all this research

52. Research Support
Gail D’Onofrio MD, MS
Jennifer McNeely MD, MS
NIH/NIDA K12 DA033312
SAMHSA U79 T1025362
NIDA U10DA013038
NIAAA 5R01AA022083
NIDA 5R01DA035775
NHLBI 5R18HL108788
NIH/NIDA K23 DA030395
NIH/NCATS UL1 TR000038
NIDA cooperative grant award UG1DA013035

53. Extra slide: For Q & A

54. The Rikers Island Hot Spotters:
Caring for the most Frequently
Incarcerated
Ross MacDonald, MD
Chief of Service, Medicine
NYC Health + Hospitals
Correctional Health Services

55. New York City Jail System

56. NYC Jails
• 12 Jails
– Each with 24/7 Clinic with at least one physician at
all times
• 60,000 admissions per year
– Each gets full history and physical exam
• 10,000 average daily population
– Median Length of stay 13 days, Average 49 days

57. NYC Jails Care Delivery
• Medical
– Sick call
– Chronic care
– Emergency care
– Transtional Health Care Coordiantion
• Mental Health
– Routine referrals within 72 hours
– Stat referrals 24/7
– Specialized units modeled after inpatient
– Mental Health Discharge Planning
• Substance Use Treatment
– Rikers island KEEP program (Opioid Treatment Program)
– CBT-based programming units

58. CHS Clinical Agenda: Incorporating
Human Rights
Patient
Safety
Human
Rights
Population
Health

59. High Risk Population, Dangerous Place
• Risks have generally been ascribed to
individual characteristics of those incarcerated
– Mental illness
– Substance abuse
– Chronic disease
• New Frame:
– Environmental components of the jail confer risk
– Structural components of the process of
incarceration confer risk

60. Health Risks of Jail
• Injury, including Traumatic Brain Injury
• Withdrawal
• Communicable disease
• Medication interruption
• Self-Harm
• Post-release mortality
– Mortality is increased in the immediate post-release
period (2-4 weeks)
• True for Prison – SMR of 12.71
• True for jail (NYC data)- SMR of 8.02
• Driven largely by overdose death
1.Binswanger et al 2007 2. Lim et al 2012

61. Zach Gross, The New Yorker

62. Hot Spotters Methodology
Total Data Collection Period ~6 years
2009 2010 2011 2012 2013 201408
Jail Electronic
Health Record
Implemented
Incarceration Frequency Period
• 78,618
Admissions.
• 57,194
Individuals
• All Patients admitted to NYC Jails in 2013
• 800 most frequently incarcerated since 11/2008
• Compared to 800 randomly selected

63. Hot Spotters , Over ~6 Years
Frequently Jailed
Pts. n=800
Rikers Control
Pts.
n=800
Number of Incarcerations 18,713 3,108
Mean Number of Incarcerations per Person 23.4* 3.9
Sum of Years Incarcerated 1,423 yrs 415 yrs
Estimated Costs of Incarceration $129,105,794 $37,679,178
Length of stay, days
Mean 28* 49
Median 11 13
*p<.0001

64. Control
Hot Spotters
Hispanic
Non-Hispanic Black
Non-Hispanic
White
Other/unknown
73%*
58%
<10%
Mean Age 42*
Mean Age 35*p<.0001

65. Hot Spotters Characteristics
Frequently
Jailed Pts. n=800
Rikers Control
Pts.
n=800
Mental Health
Serious Mental Illness 19.0%** 8.5%
Anti-psychotic Prescribed 37.0%** 15.6%
Substance Use
Significant Drug/Alcohol Use 96.9%** 55.6%
Alcohol Withdrawal in Jail 22.1%** 4.4%
Services
Evidence of Homelessness in Chart 51.5%** 14.7%
Ever with a Medicaid Number 95.9%** 78%
*p<.0001

66. Hot Spotters Chronic Disease
Frequently
Jailed Pts. n=800
Rikers Control
Pts.
n=800
HIV + 10.9%* 4.3%
Hepatitis C 18.3%* 7.4%
Diabetes 8.9%* 4.1%
Epilepsy 8.8%* 5.4%

67. Hot Spotters Charges
88.70%
54.90%
10.30%
42.30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hot-spotters Control
Charge Type
Misdemeanor Felonies

68. Hot Spotters Charges
29.9%
23.8%
5.7% 5.5%
2.80%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Petit larceny Criminal possession of
substance to the 7th
Criminal Trespass in
the second degree
Theft of services Assault of any type
Charges
Hot-spotters Control

69. Institutional Circuit
• A revolving set of institutions that also serve
the role of temporary housing
• “…these and allied systems have the perverse
institutional effect of perpetuating rather than
arresting the ‘residential instability’ that is the
underlying dynamic of recurring literal
homelessness.”1
1. Hopper K et al., Psychiatric Services, May 1997

70. Institutional Circuit
• Where?
– Jails
– Emergency Departments
– Inpatient Wards
• Medical
• Psych
– Skilled Nursing Facilities
– Inpatient Drug Rehab
• Often Court Mandated
– Short-term Detox
– Shelters
• Sometimes cut out of the loop
• Enormous societal cost

71. Qualitative Interviews (n=20)
• 5 women, 15 men
• Median age, 42 years (range 25 - 55)
• 16 black, 2 white, 1 Hispanic/Latino, 1
multiracial
• 17 unstably housed, 8 street homeless
• 12 had not completed high school

72. Participant characteristics (n=20)
• 17 had a prior felony conviction
• 17 reported a history of problem substance use
• 15 reported at least one psychiatric diagnosis
• Nearly all participants had extensive contact
with a wide range of services

73. Criminal justice involvement
• Childhood often characterized by instability
including substance use, mental illness, and
homelessness
• Majority had been arrested and incarcerated as
juveniles
• Early CJ contact set sustained trajectory to life-
long institutionalization
• Current charges were typically for petit larceny,
drug possession, and theft of services

74. “I've been arrested mostly for petit larceny, but I'm only
stealing food to eat. . . Because there ain't nobody who
give nothing to me. I don't have no family, nobody to go to,
to get food. . . I [had] food stamps but I lost my ID. See,
when you're homeless, it's hard to keep your stuff staying
with you. I lose everything. I don't have no steady
foundation. So I'm in the street. What am I supposed to do?
Walk around with a briefcase, homeless? Office desks and
stuff? Put my office here and trinkets down in the
alleyway? You can take that, pick it up and walk. I mean,
hey, it's hard.”
(Walter, age 43)

75. Substance use
• Crack/cocaine was typically the primary drug
– Some participants initiated crack use later in life
leading to more frequent arrests
• All but one who reported problem substance use
had experienced at least one episode of drug
treatment
• Reduction in use of participants’ primary drug
often aligned with a reduction in arrest

76. “I took [drug diversion] twice. I denied all the rest. They
always offer me drug court, all the time. I tell them I'd rather
do jail time. . . Because then the alternative, if I mess it up,
which is more than likely I'm gonna mess up, I'm gonna wind
up doing a whole year, a whole two years, when I could have
just did 90 days . . . I know me, I know who I am. I know I
can't sit in the drug program and do a whole program for a
year. I know I can't do that. I tried it. It doesn't work. . . If you
mess it up, they give you a year, and there's no, "I don't want
to take a year," they're going to mandatory give it to you,
because you already pled guilty. Now I don’t have no option
no more.”
(Trevor, age 25)

77. Housing services
• The environment in many shelters was
experienced as intolerable and unsafe and often
likened to jails
• In some cases, street homelessness was
considered less dreadful than shelters
• Obtaining permanent housing via the shelter
system required wait times of several years

78. “I put everything in, I’ve been waiting and
waiting and waiting and waiting and waiting so
long. . . So long that I went back and got back
into the life of crime just sitting waiting, and got
in trouble. So by that time, the thing of me
sitting here waiting, hoping they’re going to give
me housing, give me somewhere to live, like
damn, I been here almost two, three years. How
long it’s going to take me?”
(Walter, age 43)

79. Bureaucratic competence
• A set of abilities and fluencies including
vocabulary, presentation, literacy, and an
understanding of the importance of tenacity,
all necessary to navigate complex social
services2
• Many participants lacked these skills and were
therefore unable to effectively utilize the
services designed to support them
2. Gordon, L.K. (1975). Bureaucratic competence and success in dealing with public bureaucracies. Social
Problems, 23(2), 197-208.

80. “They don't help out. Once you meet a social
worker or case manager they, they don't do it. . .
They meet you, and they say well, they can't
keep you as a person on their roster or their list
because they so full, but it was nice meeting
you. You have to do things by yourself, and you
don't know how to get around in the
neighborhood doing things.”
(Leah, age 47)

81. Linkage to Supportive Housing
• A data-driven approach
• Leveraging Correctional Health Transitional
Services
• “Mr. B. T. has arrived in full effect - but raring to
go. Had all ID's and paperwork we need, etc. Case
file has been created. He has been given his key,
we are currently going to take him to the
supermarket for food and then to his apartment.
He is very cooperative and a little nervous but
looking forward to his next 'adventure' in life. “

82. New York City Jail System

83. Closing Treatment Gaps in the Health
Care and Criminal Justice Systems
Presenters:
• Jennifer McNeely, MD, MS, Assistant Professor, New York University
School of Medicine
• Gail D’Onofrio, MD, MS, Chair, Department of Emergency Medicine,
Yale School of Medicine
• Ross MacDonald, MD, Chief of Medicine, Division of Correctional
Health Services, New York City Health and Hospitals
Treatment Track
Moderator: Christopher M. Jones, PharmD, MPH, Director, Division of
Science Policy, Office of the Assistant Secretary for Planning and Evaluation,
U.S. Department of Health and Human Services, and Member, Rx and Heroin
Summit National Advisory Board