The significance of interagency collaboration in developing opioid agonist programs for inmates.
Many incarcerated incarcerated /in·car·cer·at·ed/ (in-kahr´ser-at?ed) imprisoned; constricted; subjected to incarceration.
Confined or trapped, as a hernia. individuals have heroin dependence upon arrest and relapse to compulsive heroin use soon after release from custody ... thus continuing to commit crimes, obtain and spread lethal infectious diseases, and suffer other adverse consequences of unremitting heroin addiction. Unfortunately, most inmates are not exposed to treatment while incarcerated (Inciardi, McBride and Surratt, 1998; Smith-Rohrberg, Bruce and Altice, 2004); furthermore, effective opioid agonist treatment Opioid Agonist Treatment, or OAT, refers to the treatment of a narcotics addiction in humans via the administration of similar opioid drugs, agonists, and the resultant cross tolerance and physical dependence. (with methadone methadone (mĕth`ədōn', –dŏn'), synthetic narcotic similar in effect to morphine. Synthesized in Germany, it came into clinical use after World War II. It is sometimes used as an analgesic and to suppress the cough reflex. or buprenorphine) is rarely offered in U.S. prisons, despite extensive evidence for its effectiveness in community-based settings.
A substantial proportion of incarcerated individuals have histories of heroin addiction (Inciardi et al., 1998; Kinlock. Battjes and Schwartz, 2002), and readdiction usually occurs within one month of release from incarceration Confinement in a jail or prison; imprisonment.
Police officers and other law enforcement officers are authorized by federal, state, and local lawmakers to arrest and confine persons suspected of crimes. The judicial system is authorized to confine persons convicted of crimes. (Kinlock et al., 2002; Maddux and Desmond, 1981; Nurco, Hanlon and Kinlock, 1991). Readdiction is typically accompanied by increased criminal activity (Chaiken and Chaiken, 1990; Kinlock, O'Grady and Hanlon, 2003; Nurco, 1998), disproportionately high risk of HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. infection (Chitwood, Comerford and Weatherby, 1998; Inciardi et al., 1998), hepatitis B Hepatitis B Definition
Hepatitis B is a potentially serious form of liver inflammation due to infection by the hepatitis B virus (HBV). It occurs in both rapidly developing (acute) and long-lasting (chronic) forms, and is one of the most common chronic and C infections (Edlin, 2002; Fuller et al., 1999; Hagan et al., 2002), overdose death (Mark et al., 2001; Weatherburn and Lind, 1999) and reincarceration (Hanlon et al., 1998; SAMHSA SAMHSA Substance Abuse and Mental Health Services Administration , 2000). Therefore, the development and implementation of effective drug abuse treatment strategies for incarcerated offenders with heroin addiction histories becomes crucial, not only for the rehabilitation rehabilitation: see physical therapy. of such persons, but also for their survival and for the safety and welfare of the public (Kinlock et al., 2002; Smith-Rohrberg et al., 2004).
Prisons provide an important opportunity to engage individuals with heroin addiction histories in drug abuse treatment, as many heroin-dependent persons do not receive such treatment while incarcerated (Inciardi et al., 1998) or in the community (Brown and Needle. 1994; Inciardi et al., 1998; Smith-Rohrberg et al., 2004). However, evidence regarding the effectiveness of prison-based treatment is generally limited to one treatment approach--therapeutic community treatment--and research on prison-based therapeutic communities has documented that community treatment following release is necessary to sustain institutional program effects (Inciardi et al., 1997; Pearson and Lipton, 1999). Since therapeutic community treatment is not universally appropriate, acceptable or effective for all individuals with heroin addiction histories, clearly a variety of effective treatment approaches are urgently needed that span the institution and the community and that address heroin addiction as a chronic relapsing disorder.
More than 30 years of research evidence in community-based settings has found that opioid opioid /opi·oid/ (o´pe-oid)
1. any synthetic narcotic that has opiate-like activities but is not derived from opium.
2. any of a group of naturally occurring peptides, e.g. agonist agonist /ag·o·nist/ (ag´ah-nist)
1. one involved in a struggle or competition.
2. agonistic muscle.
3. therapy with methadone, Levo-alpha-acetylmethadol (LAAM LAAM Latin America
LAAM Levo-Alpha Acetyl Methadol
LAAM Light Antiaircraft Missile ) or buprenorphine is highly effective in reducing heroin addiction, HIV-related risk behavior and criminal activity (Ball and Ross, 1991; Jaffe and Senay, 1971; Johnson et al., 2000; Joseph, Stancliff and Langrod, 2000; Platt et al., 1998; Yoast et at., 2001). Furthermore, and of particular significance, methadone maintenance Methadone maintenance is a way of stabilizing someone who is addicted to heroin or has severe pain problems that are resistant to other drugs.
Methadone Maintenance Treatment has been found superior to other treatment modalities in retaining addicted clients in treatment (Platt et al., 1998). Retention is essential to successful treatment outcome, as research findings have consistently demonstrated that regardless of modality modality /mo·dal·i·ty/ (mo-dal´i-te)
1. a method of application of, or the employment of, any therapeutic agent, especially a physical agent.
2. , the length of time in treatment is directly related to positive post-treatment outcome (Anglin and Hser, 1990; Nurco, Kinlock and Hanlon, 1994; Simpson et al., 1999). In addition, the benefits of methadone maintenance treatment were strongly supported by a consensus development panel of experts convened by the Institute of Medicine (National Consensus Development Panel, 1998). As a result of its effectiveness, the panel strongly recommended that a national commitment should be made to increase access to methadone maintenance treatment for all heroin-dependent individuals under legal supervision.
Despite substantial evidence of the effectiveness of opioid agonist maintenance, the recommendations of the Institute of Medicine panel, and the widespread experience in providing this type of treatment in correctional facilities throughout the world (Jurgens, 2004; McSweeney, Turnbull and Hough n. 1. Same as Hock, a joint.
v. t. 1. Same as Hock, to hamstring.
imp. & p. p. os>
p. pr. & vb. n. os>
n. 1. An adz; a hoe.
v. t. 1. To cut with a hoe. , 2002), opioid agonist programs have rarely been implemented in jail and prison settings in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . The first such experimental program, initiated in 1968, involved prerelease pre·re·lease
Something released before an official or scheduled date.
Of or relating to an interval preceding an official or scheduled release: jail inmates in New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. (Dole et al., 1969). In that study, 12 inmates were initiated on methadone approximately 10 days before their release and then referred to methadone treatment in the community for aftercare. At seven to 10 months post-release, none of the 12 became readdicted, although 10 had used heroin and three had been reincarcerated. In contrast, all 16 members of an untreated control group became readdicted during the follow-up period, and all had been reincarcerated.
A subsequent New York City methadone maintenance program for jail inmates has been operating continuously since 1987. In the Key Extended Entry Program (KEEP), newly admitted jail inmates who are heroin-dependent are started on methadone and arrestees who are enrolled in methadone treatment in the community are maintained on their medication during incarceration and returned to their original treatment programs. KEEP provides approximately 8,000 detoxifications from methadone per year (Catania, 2003). In the initial evaluation of KEEP, individuals who received methadone maintenance treatment were more likely than untreated inmates to be in treatment at the time of follow-up, an average of 6.5 months post-release (Magura et al., 1993). An 11-year analysis of KEEP suggested that jail-based methadone maintenance treatment not only facilitates post-release treatment entry, but also reduces reincarceration (Tomasino et al., 2001).
These positive New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of experiences with jail-based methadone maintenance treatment and the pressing need to reduce the adverse health and criminogenic crim·i·no·gen·ic also crim·o·gen·ic
Producing or tending to produce crime or criminality: "Alcohol is the most criminogenic substance in America" James B. Jacobs. consequences associated with Baltimore's serious and persistent heroin addiction problem (Fuller et al., 1999; Gray and Wish, 1997; Kinlock et al., 2002; Wish and Yacoubian, 2001), led to a pilot study of prison-initiated opioid maintenance treatment (Kinlock et at., 2002) and to a larger, more rigorous ongoing clinical trial with prison-initiated methadone maintenance. The experience gained during these two studies in creating opioid agonist treatment in prison settings, barriers to the implementation of such programs, and recommendations for planning and conducting future studies and programs of this nature follow. The focus of this discussion is on how effective collaboration among correctional, treatment and research staff can help overcome barriers to the development and implementation of in-prison opioid agonist maintenance programs. Given the relative lack of experience in opening, operating and evaluating opioid agonist programs within correctional settings in the United States, this article may serve as a unique and practical guide for interested corrections officials, treatment providers and researchers in the implementation of such urgently needed programs.
Justification for Opioid Agonist Programs for Inmates
In summary, opioid agonist maintenance therapy is an effective and widely used treatment for heroin addiction that has rarely been used with incarcerated individuals who are nearing release. In the jail setting, initiating heroin-dependent individuals on methadone maintenance or detoxification Detoxification Definition
Detoxification is one of the more widely used treatments and concepts in alternative medicine. It is based on the principle that illnesses can be caused by the accumulation of toxic substances (toxins) in the body. and maintaining arrestees already enrolled in drug abuse treatment programs on their methadone dose makes sound clinical sense and has been found effective through years of practice in New York City and elsewhere (Smith-Rohrberg et al., 2004). Initiating inmates who are not currently heroin-dependent but have pre-incarceration histories of severe, persistent heroin addiction on maintenance treatment prior to release is a promising intervention that warrants research to determine its effectiveness. Such research is urgently needed because relapse to heroin addiction is typically extremely rapid following release from prison, the opportunity to engage newly released individuals in treatment is substantially diminished upon readdiction, and the life-threatening, adverse consequences associated with heroin addiction are substantial.
It is recognized that such interventions involving inmates who are previously, but not currently, heroin-addicted is an unconventional approach that is not without controversy. Yet, such approaches are in accord with long-standing federal regulations regarding opioid agonist maintenance therapy eligibility. Another potential concern regarding initiation of nondependent individuals on opioid agonist therapy involves the risk of overdose with the medication itself. For this reason, inmates who are not physiologically dependent on opioids are started at very low doses (e.g., 5 miligrams of methadone) and increased slowly (5 miligrams of methadone per week) to avoid sedating side effects Side effects
Effects of a proposed project on other parts of the firm. . Furthermore, all inmates initiated on medication are informed that they may terminate treatment at any time without penalty, and any individuals ending treatment will be tapered off medication to minimize withdrawal symptoms. Thus, sufficient care is taken to minimize risk while providing a service that can significantly reduce the vicious cycle Noun 1. vicious cycle - one trouble leads to another that aggravates the first
positive feedback, regeneration - feedback in phase with (augmenting) the input of relapse, recidivism recidivism: see criminology. and reincarceration, as well as loss of life from AIDS, hepatitis, overdose and other conditions resulting from heroin dependence.
Planning for an Opioid Agonist Program In a Prison Setting
The authors' pilot study (Kinlock et al., 2002) involved males who were heroin-dependent prior to incarceration and who were incarcerated at a Baltimore prerelease facility administrated by the Maryland Division of Correction. Unlike KEEP, which focuses on shorter-term jail inmates, this pilot project was, to the authors' knowledge, the first that focused on soon-to-be-released prison inmates who had longer periods of incarceration and were not currently heroin-dependent. Inmates with three months to serve before anticipated release and who consented to participate were randomly assigned to one of two conditions. In the experimental condition, after completing a medical examination, participants received thrice-weekly LAAM maintenance and weekly educational group counseling regarding drug abuse. The experimental treatment was provided by staff of a Baltimore community-based opioid agonist maintenance program. Upon release, experimental participants were advised by treatment staff to report to the community-based facility for continuing care continuing care
a professional convention that a veterinarian who is treating an animal is obliged to continue treating that case unless an arrangement is made with its custodian to transfer the care to another practitioner or to a specialist. . All participants, both control and experminental, received information on how to access drug abuse treatment in the community, as well as standard correctional and public safety supervision.
The in-prison treatment delivered in the pilot study generally surmounted sur·mount
tr.v. sur·mount·ed, sur·mount·ing, sur·mounts
1. To overcome (an obstacle, for example); conquer.
2. To ascend to the top of; climb.
a. To place something above; top. any of the usual resistance to such programs described by Magura et al. (1993), including philosophical opposition to opioid agonist treatment (because it is viewed by some as substituting one addiction for another), and concerns about medication diversion, violence and security breaches. More than 90 percent of inmates who completed treatment with LAAM and counseling in prison entered community treatment, compared with fewer than 10 percent of other participants (Kinlock, Battjes and Schwartz, in press). In addition, 53 percent of experimental participants remained in treatment in the community at least six months, while no other participant did so. These promising findings regarding feasibility and post-release treatment attendance led the Maryland Department of Public Safety and Correctional Services (DPSCS DPSCS Department of Public Safety and Correctional Services ) to pursue further, more rigorous study with methadone in the prison and to actively explore the replication of KEEP in the Baltimore City Detention Center A detention center or a detention centre is any location used for detention. Specifically, it can mean:
In the second study, which is ongoing and builds on the pilot study experiences, males with pre-incarceration heroin dependence and three to six months remaining on their prison sentences who meet the criteria
for opioid agonist treatment are being randomly assigned to one of three conditions: counseling in prison without medication but with referral to outpatient treatment; counseling in prison without medication and with guaranteed admission to opioid agonist treatment with methadone in the community within 10 days of release; or counseling and methadone in prison with guaranteed admission to opioid agonist treatment in the community within 10 days of release. The counseling and methadone treatment are delivered by the same provider in the community, which continues to offer treatment upon release.
Both studies were planned by involving all interested parties from the very beginning. Relationships developed during the pilot study contributed to a smooth transition to the larger-scale investigation. Successful implementation of such a program requires ongoing cooperation among diverse correctional, drug abuse treatment, and research agencies, as each of these agencies has different priorities and agendas, and disparities typically surface when rehabilitation efforts are provided in prison (Field, 1998; Miller, Koons-Witt and Ventura, 2004; Senese and Kalinich, 1997). Therefore. it was essential to regularly have structured discussions with leaders from the correctional, treatment and research agencies to work out the design and plans for study implementation. Implementation issues In the Business world, companies frequently set-up a connection between which they transfer data. When the connection is being set-up, it is referred to as implementation. When issues occur during this phase, they are known as implementation issues. of initial concern included choice of the correctional facility and choice of medication logistics.
The two types of facilities in which opioid maintenance programs can operate are jails, which house individuals awaiting trial and those with sentences generally less than one year, or prerelease prisons, which house individuals who are reentering re·en·ter also re-en·ter
v. re·en·tered, re·en·ter·ing, re·en·ters
1. To enter or come in to again.
2. To record again on a list or ledger.
v.intr. society after serving sentences of more than one year. In the case of the current studies. Maryland DPSCS staff at the time did not want to conduct such a program in the jail, though it was the venue preferred by the treatment and research staff, given the success of New York City's KEEP and the need to treat inmates suffering from opioid withdrawal opioid withdrawal Substance abuse An acute state caused by withdrawal of opioid narcotics from a person addicted to narcotics Clinical Sweating, shaking, headache, craving, vomiting, abdominal cramping, diarrhea, insomnia, confusion, agitation, other behavioral . However, corrections officials opposed this plan because the jail handled a much higher volume of inmates (more than 100,000 arrestees per year) with a much quicker and more unpredictable turnover. Therefore, key corrections personnel felt that it would be difficult for their staff to attend to the logistical needs of the program given the high demand on their time. Furthermore, even though the Maryland corrections secretary supported such a program, the warden of the facility at the time was philosophically opposed to opioid agonist maintenance.
The collaboration described above was essential for establishing criteria for the selection of an appropriate facility. Criteria for selection, developed jointly by corrections, treatment and research personnel, included proximity to the community-based maintenance treatment program providing service behind the walls to enable staff to more easily travel to the prison and to ensure released participants easy access to the community-based program: a facility with a sufficient number of inmates who are nearing release yet who have sufficient time remaining to carefully be stabilized on an adequate dose of medication: the extent to which the opioid agonist maintenance program would not interfere with security, transfer of inmates and other routine procedures; and a facility in which the warden and key leadership support program implementation. Only the prerelease center in which both the studies were performed met all four criteria.
In planning each of the studies, the authors collaborated with corrections and treatment personnel to develop criteria for the selection of medication, namely cost, side effects, frequency of administration and extent of stigma associated with the medication. LAAM was selected for the initial study for two reasons: (1) First, correctional staff had concerns about having to move inmates to receive medication, and LAAM had the advantage of being administered only three times per week. This was also an advantage for treatment staff, as they had to go to the prison on a less than daily basis. (2) Another advantage over methadone, which applied to LAAM and also applies to buprenorphine, is that fewer people are philosophically opposed to those medications because they are less familiar with them (Smith-Rohrberg et al., 2004). Nevertheless, methadone has a much longer track record of safety and efficacy than both LAAM and buprenorphine (Smith-Rohrberg et al., 2004) and, being a generic drug generic drug, a drug sold or prescribed under the nonproprietary name of its active ingredients or under a generally descriptive name rather than under a brand or trade name. , is much less costly than buprenorphine.
Logistical concerns included how and where the medication would be stored securely, the hours of medication, designating medication stations and rooms to provide counseling sessions, and the need to provide additional security. Corrections personnel were concerned about storing opioids at the prison even though methadone is administered to pregnant women. In response to these concerns, the staff of the Baltimore opioid agonist maintenance clinic took responsibility for securing and administering medication. Thus, this provision allowed for continuity of care, with the same provider treating individuals in prison and in the community following release. With the same treatment approach provided by the same staff in the institution and community, it would seem more likely that client problems and needs would be recognized and treated in an expedient manner (Field, 1998). A safe was purchased to store the medication at the prison, and appropriate safeguards were taken for security and administration, with only treatment clinic nursing staff having access to medication. The clinic obtained approval from the U.S. Drug Enforcement Agency and the state licensing authority for a medication unit where methodane would be dispensed for the program. Finally, to facilitate access by treatment providers and research staff to the prison, both treatment and research staff obtained official Maryland DPSCS identification cards.
Nature of Collaboration
In the context of developing and evaluating new drug abuse treatment interventions for inmates, drug abuse treatment personnel and correctional employees not only represent agencies with diverse priorities and agendas, but also tend to manifest different beliefs regarding inmate control (Heckert, Jengeleski and Gordon, 1998). In general, the correctional environment places emphasis upon the maintenance of order, security and control of inmates (Heckert et al., 1998; Lombardo, 1989; Miller et al., 2004; Stoikovic and Lovell, 1997). In contrast, the therapeutic culture stresses the need to work with inmates individually as both a control function and as a reward for pro-social behavior. Thus, unlike many drug abuse treatment interventions conducted in a prison setting, such as therapeutic communities, which are set apart from the rest of the prison environment (Inciardi. 2002), opioid agonist therapies provide a humanistic intervention without attempting to interfere with usual custodial practices in a prison environment. Inmates, regardless of whether they participated in the program, remained subject to the same housing, rules, regulations and sanctions for rule violations.
In the early stages of pilot project implementation, a number of conflicts emerged between treatment and correctional staff. Although difficulties were certainly anticipated by research staff given that divergent priorities and procedures become apparent when rehabilitation efforts are implemented in prison, the nature of some of these difficulties was unique to this particular pilot project. For example, unlike many prison-based drug abuse treatment interventions, which are delivered by correctional counselors or case managers, the opioid agonist treatment was delivered by clinicians who lacked experience in providing services in a prison environment. Furthermore, the medical and counseling staff who were responsible for delivering the intervention were not accustomed to, and initially not altogether comfortable with, going outside of their community-based facility to provide services, let alone going to an environment that traditionally places a greater emphasis on security and custodial matters than on more humanistic concerns. In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"
put differently , treatment staff had been highly successful in having individuals who were currently addicted come to them for services; in contrast, these studies required treatment staff to go to a markedly different environment as well as to collaborate with others (research and correctional staff) in identifying inmates who were not currently addicted but otherwise eligible and willing to participate. Therefore, carrying out these procedures on correctional "turf" were at times seen as quite challenging to undertake on the part of treatment staff.
In the planning meetings between treatment, correctional and research staff, the significance was recognized to involve not only key staff, but also several correctional officers who would be most likely to have daily contact with program participants. Since correctional officers are involved in influencing inmates--having daily contact with them, writing passes and escorting them to treatment interventions--these behaviors can impact, positively or negatively, inmate participation in, and commitment to. rehabilitation efforts (Miller et al., 2004; Senese and Kalinich, 1997). This is further compounded by the extent of role conflict among correctional staff that is an inherent contradiction between custody and treatment goals (Farkas, 2000; Josi and Sechrest, 1998; Kifer, Hemmens and Stohr, 2003). A consensual model representing a balance between custody and human services (Farkas, 2000; Johnson, 1996) would help to identify roles more clearly and cause less confusion between officers and administrative personnel. Current rehabilitative re·ha·bil·i·tate
tr.v. re·ha·bil·i·tat·ed, re·ha·bil·i·tat·ing, re·ha·bil·i·tates
1. To restore to good health or useful life, as through therapy and education.
2. efforts in prison are frequently compromised because officers disapprove dis·ap·prove
v. dis·ap·proved, dis·ap·prov·ing, dis·ap·proves
1. To have an unfavorable opinion of; condemn.
2. To refuse to approve; reject.
v.intr. of, or have doubts about, the effectiveness and impact of rehabilitation (Lariviere, 2001). Thus, in the beginning of the pilot study, it was essential for medical staff to conduct a series of orientation sessions at the prison with correctional officers to educate them about the potential benefits and adverse consequences of opioid agonist therapy.
Similarly, a number of correctional officers had expressed concerns about the provision of opioid agonist treatment in their facility. Some of these concerns centered around logistics, space and security, as anticipated. In addition, several officers had voiced their clear philosophical opposition to the delivery of any type of opioid agonist maintenance at the project orientation sessions. Although these officers were informed by key administrators that the project would take place as planned, some continued to express their concerns about such treatment to research staff and, more often, treatment staff.
Several steps were taken to alleviate conflicts between treatment and correctional staff. First, three monthly orientation meetings were held before the beginning of participant recruitment. These meetings established the times and locations for participant recruitment, assessment and treatment (both medication and educational counseling). Immediately prior to the start of participant enrollment, treatment staff held weekly orientation sessions at the prerelease facility. In these meetings, case management and correctional staff were informed about opioid agonist therapy, including its potential benefits and risks, and correctional officers were encouraged to ask about how the provision of opioid agonist therapy would impact security and other aspects of their day-to-day functions. Other meetings also served to reduce conflicts between treatment and correctional staff regarding study implementation.
Selection of Potential Participants
Although 92 percent of the 157 screened inmates initially consented to participate in the pilot study, identifying appropriate treatment candidates was challenging. A crucial lesson was learned during this pilot study concerning the significance of collaborating with corrections personnel to thoroughly screen potential participants for unadjudicated charges that can result in transfers to other prisons and/or extensions of prison time. As was found in the pilot study, the existence of such charges is not easily determined and requires a careful review of an inmate's criminal justice system records, including the FBI database, by the prison's case management personnel. Specifically, 15 percent of study participants were transferred to other prisons and/or received additional time, and therefore, were not able to continue study participation. It was difficult to screen out individuals with unadjudicated charges in the second, ongoing study because the prison's case management staff had to carefully examine the criminal justice system records of each potential participant prior to study enrollment. Given that this task is often time-consuming and is performed by a staff that is already overburdened, additional compensation to these personnel was provided for their assistance.
Several obstacles were discovered in the pilot study with regard to the process of conducting the weekly educational counseling group. Group process was disrupted by the noise from correctional officer walkie-talkies, and the lack of adequate air conditioning air conditioning, mechanical process for controlling the humidity, temperature, cleanliness, and circulation of air in buildings and rooms. Indoor air is conditioned and regulated to maintain the temperature-humidity ratio that is most comfortable and healthful. in the rooms designated for the group during the summer months also presented problems. After a series of meetings between treatment, correctional and research staff, these problems were minimized.
As anticipated and indicated earlier, there were often conflicts in priorities and procedures between treatment staff and correctional staff. Such conflicts are typical when implementing rehabilitation efforts in correctional facilities (Senese and Kalinich, 1997). Therefore, pilot, or initial exploratory studies, are especially helpful in alleviating tension and developing feasible procedures. Such studies appear especially relevant with respect to opioid agonist maintenance treatment programs conducted within correctional facilities because, as noted earlier, such programs have rarely been developed and evaluated, and corrections officials tend to have unfavorable views of such treatment (Magura et al., 1993; Simpson and Knight. 1998).
In addition, collaboration involving corrections, treatment and research personnel was instrumental in alleviating another obstacle that emerged during the second study. An increasing number of inmates were placed on work details outside the prison. These inmates had difficulty attending group educational counseling sessions because their work detail assignment was scheduled at the same time as the group sessions. Consultation with the prison's case management manager was essential in working out these scheduling conflicts.
The larger-scale study prompted the Maryland DPSCS Home Detention Unit to change its policy to allow offenders to receive methadone maintenance treatment. Prior to the implementation of the second study, the unit's policy prohibited any offenders who were being prescribed any psychotropic psychotropic /psy·cho·tro·pic/ (si?ko-tro´pik) exerting an effect on the mind; capable of modifying mental activity; said especially of drugs.
adj. medication or opioid agonist medication to be eligible for home detention. However, they could receive standard parole supervision. Treatment staff and research staff conducted a series of meetings with the unit's new director, a former Maryland state police The Maryland State Police is the official state police force of the State of Maryland. Overview of the Maryland State Police
The Field Operations Bureau comprises twenty-three (23) barracks within six (6) geographical troop areas. officer and an advocate of drug abuse treatment, and key unit staff, in which research and treatment staff explained to unit personnel the nature of the study and answered questions about methadone maintenance treatment. In addition to changing the Home Detention Unit's policy, treatment staff were able to coordinate with unit case managers about informing the unit when their clients reported to the community-based facility, and a receptor site was implemented at the treatment facility so the Home Detention Unit could verify when the client arrived and left. The meetings and the initial experiences in working together helped treatment staff and unit case managers to better understand and appreciate one another's work.
Dissemination of Results
Because of the unique, interagency nature of the pilot project, publications regarding that study included the perspectives of treatment and correctional staff as to the success of the program and the manner in which conflicts were handled (Kinlock et al., 2002). Although both treatment and correctional staff emphasized that opioid agonist maintenance is a worthwhile service for inmates with heroin addiction histories because of the high incidence of relapse following release, representatives of these agencies differed somewhat regarding obstacles to the program. Treatment staff indicated that securing sufficient space within the prison for conducting group counseling was difficult and stressed that the need for such space be addressed well in advance in future interventions of this nature. Treatment staff were especially encouraged by the strong tendency for program participants who remained on medication until release to promptly resume their treatment at the community-based clinic despite their long histories of relapse, recidivism and reincarceration. Correctional staff emphasized that implementing such a program in prison is an extremely challenging endeavor in view of the competing requirements of security and space constraints, but these difficulties can be alleviated through careful planning. Thus, a series of meetings are required in order for corrections, treatment and research personnel to develop and work out operational procedures The detailed methods by which headquarters and units carry out their operational tasks. before study implementation and to continue to meet periodically throughout the study so that new obstacles can be recognized and confronted.
In addition, as a result of possible differences among corrections, treatment and research personnel regarding the nature of problems and how they were resolved, it is imperative that all parties carefully review drafts of manuscripts submitted for presentation or publication. It is also common for interagency differences to emerge about how research results are examined, who should define a problem for investigation and the types of subsequent analyses conducted, and where and to whom the results are disseminated (Welsh and Zajac, 2004). Given these circumstances, it is important for the agencies involved to agree beforehand to report how the study was helpful to all agencies involved, specifically the knowledge that can be used to benefit each agency (Welsh and Zajac, 2004). For example, in the pilot study, treatment staff had been particularly impressed by the promptness by which program participants reported to their community-based facility and by their motivation to continue in treatment despite long histories of rapid relapse and recidivism following previous treatment episodes. Thus, treatment staff became more invested in the notion of expanding their services to this underserved client population. Correctional administrators and staff benefited from the pilot program by learning that another service can be added to the array of urgently needed programs for heroin-dependent offenders and that such a program can alleviate placing an additional burden on a severely overwhelmed system by reducing reincarceration.
Finally, the development of a specific memorandum of understanding A Memorandum of Understanding (MoU) is a legal document describing a bilateral or multilateral agreement between parties. It expresses a convergence of will between the parties, indicating an intended common line of action and may not imply a legal commitment. at the outset of the study can serve to clarify the various roles of key players, contributing to a more smoothly run project. If an initial agreement is not implemented, it may facilitate an atmosphere of intolerance. resulting in a diminution Taking away; reduction; lessening; incompleteness.
The term diminution is used in law to signify that a record submitted by an inferior court to a superior court for review is not complete or not fully certified. of support. In such situations, correctional and treatment staff are far less likely to respond to urgent problems and barriers during study implementation (Miller et al., 2004).
From these experiences in conducting new opioid agonist maintenance programs in correctional settings, the following recommendations are offered to guide future endeavors of this nature.
Planning should be conducted in full partnership with drug treatment and corrections personnel, as well as with research staff when an evaluation is to be included in the program. Specify in advance the roles of treatment and corrections personnel. Conduct a series of regularly scheduled meetings (ideally, the same time and place each week) involving key drug abuse treatment, corrections and research personnel. Prepare and follow a written agenda for each meeting, with sufficient time allowed for unresolved issues. Designate one key person at the prison to be the liaison for the project. In that person's absence, designate a backup.
Involve key prison officials (i.e., warden, assistant warden and chief of security) at key meetings. Have several meetings with key prison staff and treatment staff shortly after funding begins, and before and shortly after participant enrollment begins.
In addition, have a deadline for all parties to agree on the basic design and implementation of the study. Allow for various contingencies should plans not work out. Emphasize resolving differences regarding logistics and space. Make sure that study intervention, recruitment and assessment procedures will not interfere with standard security and other operating procedures at the prison such as visiting hours visiting hours
the times when visitors are allowed to see someone in a hospital or other institution: many prisoners' wives complain about the short visiting hours
visiting hours , mealtimes, commissary COMMISSARY. An officer whose principal duties are to supply the army with provisions.
2. The Act of April 14, 1818, s. 6, requires that the president, by and with the consent of the senate, shall appoint a commissary general with the rank, pay, and emoluments or prison yard time, and work release/detail.
Also, emphasize the need for private rooms for all confidential activities. Emphasize that securing private rooms means that no one other than the necessary research or treatment personnel can see and hear what goes on. Finally, select medication that fits well with the structure and operation of the institution that is widely available in the community upon release.
Implications for Correctional Administrators
Implementing opioid agonist maintenance programs outside the context of research as well as the initiation of other types of prison-based therapeutic programming (e.g., drug-free substance abuse treatment, life skills training, educational training) also requires a key commitment from correctional administrators and line staff. In setting up drug abuse treatment programs in their facilities, correctional administrators must deal with multifaceted logistical and security concerns, including staffing of programs. For example, whether the treatment will be provided by counseling or case management staff within or outside the facility; hours of operation; security of the program; and inmate movement to and from these programs. Administrators and security personnel must ensure that such programs do not interfere with ongoing routines in the prison. Furthermore, administrators must set clear missions and goals of the importance of therapeutic-based programs, as correctional officers are involved in influencing inmates (favorably or unfavorably), meaning that these behaviors can impact inmate participation and morale within these therapeutic programs.
Many incarcerated offenders have heroin addiction histories but are not exposed to drug abuse treatment, neither in the institution or upon release. Opioid agonist therapy programs have the potential to fill an urgent need, as emphasized by the Office of National Drug Control Policy The Office of National Drug Control Policy (ONDCP) was established by the National Narcotics Leadership Act of 1988 (21 U.S.C.A. § 1501 et seq.) and began operations in January 1989. (2001) and the American Association for the Treatment of Opioid Dependence (2004), to ensure a continuum of treatment beginning in the institution and continuing in the community. In addition, the presently described programs deliver continuity of care in a manner consistent with Field's (1998) observation that the most promising interventions for reducing addiction and its accompanying adverse health and crime problems involve corrections-treatment collaborations, with a single team taking main responsibility for rehabilitative efforts, thus being more likely to recognize and treat client needs expediently.
Clearly, corrections, treatment and research personnel can collaborate to accomplish an extremely challenging task--to develop, implement and evaluate new opioid agonist therapy programs for prison inmates with histories of heroin addiction. As such, it can serve as a guide for planning subsequent opioid agonist programs as well as other types of therapeutic interventions in a correctional setting. Researchers evaluating such programs should not simply report on the extent to which the program reduced addiction and its adverse consequences, but also report on the nature of barriers encountered and how they were overcome.
(1) Because of changes in LAAM's labeling, resulting from its association with cardiac arrhythmias in a small number of patients, it is no longer available as a first line treatment for heroin addiction. This change occurred during the end of the pilot study, and all study participants who reported to the community-based clinic were subsequently switched to methadone.
(2) This consideration also applies to buprenorphine, which has been shown effective in an every-other-day dosing schedule (Montoya et al., 2004).
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Timothy W. Kinlock, Ph.D.. is senior research scientist at the Social Research Center, Friends Research Institute in Baltimore. and an adjunct professor in the Division of Criminal Justice. Criminology criminology, the study of crime, society's response to it, and its prevention, including examination of the environmental, hereditary, or psychological causes of crime, modes of criminal investigation and conviction, and the efficacy of punishment or correction (see and Social Policy at the University of Baltimore The University of Baltimore (UB), located in downtown Baltimore, Maryland in the Mt. Vernon neighborhood, is part of the University System of Maryland.
UB recently opened a brand new student center as well as changing the colors to blue and green, and the "UB" logo. . Robert P. Schwartz, M.D., is medical director of the Friends Research Institute and drug addiction drug addiction
or chemical dependency
Physical and/or psychological dependency on a psychoactive (mind-altering) substance (e.g., alcohol, narcotics, nicotine), defined as continued use despite knowing that the substance causes harm. treatment program officer for the Open Society Institute Baltimore. Michael S. Gordon, MS. is a project manager at the Social Research Center, Friends Research Institute.