Dawn Noggle, PhD, CCHP
Mental Health Director
Maricopa County Correctional Health Services
Arizona achieved a landmark in May becoming the first state in which every county signed a Stepping Up Proclamation with La Paz signing in May! Tireless advocacy to reduce the incarceration of the seriously mentally ill by volunteer led David's Hope made this possible. Natassia Walsh, the Stepping Up National Coordinator, and featured guest speaker for the August Statewide Stepping Up Summit, is calling Maricopa County next week to hear more about our efforts which are attracting national attention. Join leaders across the state to hear more and contribute by attending the
Across Arizona, Counties, in tandem with the Regional Behavioral Health Authorities (Health Choice, Integrated Care, Mercy Maricopa Integrated Care and Cenpatico Integrated Care) continue to bolster training and resources for officers to avoid unnecessary jail bookings, to increase diversion opportunities once mentally ill individuals are brought to jail and to strengthen connections to care upon release to interrupt this revolving door that so negatively impacts the lives of individuals who need treatment and social supports rather than incarceration.
Stepping Up acknowledges that we must address individuals with substance use disorders (SUD). As with the seriously mentally ill, these are predominately low risk individuals who wind up in jail accused of nonviolent offenses, rather than directed to "solutions", effective treatment and support for problematic substance use. Less guidance has been offered in the Stepping Up Toolkit
specific to addressing this population.
At Maricopa County, as part of Stepping Up, Correctional Health Services decided to actively address substance use in the jail population. We implemented the SAMHSA best practice SBIRT (Screening, Brief Intervention and Referral to Treatment) in March 2016. This has been an ongoing effort over the past 15 months involving changes to our electronic health record (to incorporate evidence based screening questions) and training of all mental health and nursing staff to screen all individuals (remaining past the 24 hour Initial Appearance Court). We have also, with the help of Public Health, are training mental health staff and medical/psychiatric providers in "brief interventions", and are increasing referrals to substance misuse treatment while incarcerated (CHS Intensive SUD program, Mosaic (see video link) and referrals to community agencies upon release, including "warm hand offs" to increase service engagement. A shift to Motivational Interviewing is foundational to SBIRT and all strategies addressing substance use/misuse. Providing educational materials and encouraging abstinence alone, we know, are failed interventions. As our electronic health record reports are completed, CHS will be able to routinely report and trend substance use and misuse, brief interventions and treatment referrals and ultimately the impact on overall jail recidivism. Fundamental to all Stepping Up efforts is the 2 pronged approach to develop baseline data (e.g. number of SMI designated; number of individuals at risk for and having SUD) and to measure impact of interventions on decreasing the use of jail for a low risk population better served in the community. Maricopa County was awarded a National Association of County Organizations (NACO) Achievement Award in June 2017 for this implementation.
Stepping Beyond: Meeting the Opioid Crisis Head On
Across the nation we know from CDC data that in 2016 there were at least 60,000 deaths related to opioid use. The CDC has called this the worst drug overdose epidemic in our history. In Arizona 790 died from opioid overdoses, an increase of 74% over the past 4 years. In recognition of Arizona's becoming one of the most impacted states, on June 5, 2017 Governor Doug Ducey declared a Public Health State of Emergency.
The Governor's Initative calls for the following steps:
* prevent prescription opioid drug abuse through appropriate prescribing practices,
* develop guidelines to educate healthcare providers on responsible prescribing practices,
* expand access to treatment, especially Medication Assisted Treatment (MAT), and
* reverse overdoses through the distribution of naloxone.
The governor is also requesting up to date reporting by Counties and agencies across the state for more "real time" information regarding overdoses, deaths related to overdose and attempts to reverse overdose (e.g. via naloxone and narcan). In response, Maricopa County Public Health is coordinating our County's reporting to the Governor's Office suspected opioid overdoses and administration of naloxone.
Recommendations for a "full spectrum" public health response to the opioid crisis are being established (such as the Drug Policy Alliance June 2017 document http://www.azdhs.gov/prevention/womens-childrens-health/injury-prevention/opioid-prevention/index.php). Echoing Stepping Up, there is a call to increase access to community based effective treatment, especially for individuals with greatest social determinant risk; to increase education to reduce stigma and to raise prescribe awareness; to increase harm reduction strategies focusing on safety and keeping people alive (over the outdated concerns that anything other than promoting abstinence is "risky"); and to decrease "criminalization" when community based treatment is the most appropriate response. Notably these recommendations are strongly urging harm reduction strategies such as increased availability for overdose reversal medications, including for law enforcement (e.g. naloxone) and family members along with those at risk. We must also increase the safety for IV drug users including safe injection sites and needle exchanges.
Correctional Health Services has certainly been seeing the rising tide of opioid use. We have been actively tracking individuals reporting opioid use/dependence booking into our jails for the past 18 months. Our records show well over 900 individuals per month reporting ongoing opioid use (with our average daily census floating around 8,000). We have implemented a "full spectrum" approach involving continuation of Medical Assisted Treatment (MAT) for individuals on methadone treatment in the community which includes coordination of care and warm transfers upon release. Despite lingering negative responses by some quarters, methadone, as an agonist treatment, has been established through research to prevent relapse back to illicit substances and to decrease further criminal justice involvement. Despite this, only 12% of opioid dependent individuals are engaged in such treatment. CHS also provides in custody intensive substance use disorder treatment (Mosaic Program-see video).
Most recently, CHS has begun a multi-agency Vivitrol Pilot (including Darwyn Chern, MD, Chief Medical Director of Partners in Recovery and AZ Society of Addiction Medicine Board Vice President, Saul Perea, MD, Terros, Charles Booker, MD, CleanSlate, and representatives from Community Bridges, Cross Roads, Maricopa County Adult Probation, the Maricopa County Sheriff's Office (MCSO), and Community Medical Services. Candidates who have completed intensive treatment and who agree to continue treatment with one of the above community partner agencies will receive a Vivitrol injection prior to release. Vivitrol, an antagonist treatment, is known to reduce cravings and can be administered monthly. Arizona Department of Corrections has also begun administration of Vivitrol for consenting individuals with Opioid Use Disorder, prior to prison release. This treatment provides a safe bridge to the most important next step, ongoing psychosocial and pharmacological treatment. Yavapai County Jail has already successfully implemented such use of Vivitrol and Mohave County is in planning stages.
Beginning July 1, CHS is taking another critical step in the battle to reduce overdose deaths. Leaving jail and prison is a known high risk time for overdose. Individuals who have been abstinent for a period of time can easily overdose. Returning to a dose previously tolerated can be fatal. Perhaps the "supply chain" poses the greater risk as it contains opioids and synthetic derivatives, such as fentanyl, 50 to 1,000 times stronger than typical heroin, easily available through the "dark web". CHS will begin distribution of naloxone "kits" for opioid dependent individuals, not on MAT, releasing from custody. We are budgeting to provide 400 kits a month, which indicates how serious this problem is in our community. Our initial July supply is being provided by Sonoran Prevention, the agency that has been out there providing education and reversal kits to law enforcement across the Valley. Haley Coles, Sonoran Prevention Director, reports that between September 2016 and end of May 2017, her staff have distributed 9,131 naloxone kits and received reports of them being used to reverse an overdose 822 times. 538 kits have been provided to law enforcement between January 2017 and end of May 2017. In addition, Sonoran Prevention, in tandem with Maryvale Police Department, began a needle exchange program providing clean syringes, a program known to reduce risk of infectious disease. Such harm reduction efforts are essential to reversing the disturbing trends we are witnessing in Arizona and across the country. Sonoran Prevention is essentially a behavioral "start up" agency designed to address this crushing and previously unmet community need. With a bare bones staff and without a "bricks and mortar" office, Arizona may yet see a slowing if not reversal of overdose deaths in 2017 with their efforts and law enforcement's decision to serve as first responders. Time will tell as data is collected.
Stay tuned for more on other steps we will all be taking to address the opioid epidemic. New efforts will be seeded by the federal Health and Human services STR (State Targeted Response to the Opioid Crisis) grants, one of two rounds of funding to be provided to states under the SAMHSA administered 21st Century Cures Act. According to Shana Malone, AHCCCS's leader and architect for this campaign:
"AHCCCS and partnering state agencies, health plans, universities and community providers will soon be launching statewide prevention and treatment activities through the Opioid STR grant to address the continuum of opioid misuse, abuse and dependency."
More to come in the next Stepping Up update!
The Arizona Psychiatric Society thanks Dr. Noggle for her comprehensive updates that keep our community informed about the progress made by Maricopa County, counties across Arizona, and community organizations, including David's Hope, NAMI Arizona, Mental Health America Arizona, and many others, to advance Stepping Up initiatives to reduce people with mental illness in our jails. We greatly value and hope you enjoy Dr. Noggle's updates and the additional linked resources provided for your benefit. We look forward to continued updates on progress made in Arizona and hope you will be a part of this important initiative.