Unknown Speaker 0:14 All right, it looks Unknown Speaker 0:16 like it is time for us to begin. Speaker 1 0:21 Hello and welcome to the NIC clinical pearls webinar series. My name is Sarah Davis, and I'm a national programs advisor with the National Institute of Corrections. We're thrilled to have you join us for this informative nine part series exploring the integration of clinical pharmacists into primary care and highlighting proven approaches for carceral team medicine. Before we begin today's session, I would like to cover a few important housekeeping items. Each webinar in this series is scheduled to last approximately one hour. These sessions will be recorded and once captioned and made, 508 compliant will be available on the NIC website. This is a Listen Only event, meaning participant microphones are muted. However, we strongly encourage engagement through WebEx chat function. Please use the chat to share your thoughts, ask questions or request technical support. We will address as many questions as possible during the Q and A portion at the end of the session. Okay, let's practice, practice the chat function. Please list your responses to the following question in the chat, which do you like better for breakfast? Pancakes or waffles or neither? Please type your answers in the chat. I saw neither me. Either. Can we do a both? You can, okay, Penny, neither, Dre, both, Speaker 1 2:15 I agree. There are all of them, if you experience any audio difficulties, we recommend connecting to the webinar audio via telephone using the number provided in your registration confirmation email. Throughout the series we want to hear from you, you can always email the Health Programs Manager Chad Garrett at ca Garrett, dot, B, O, p.gov, with any questions, concerns, comments or ideas for future events, and now I'll hand it over to Captain Chad Garrett. Speaker 2 2:59 Well, awesome. Thank you so much. As correctional healthcare continues to evolve, harm reduction strategies play a critical role in mitigating substance use related risks and infectious disease transmission, both within our facilities and upon re entry into the community, we all know that a vast majority of incarcerated individuals will be released, which is one reason I love to say Correctional Health is public health. Join Lieutenant Commander Herzog and Lieutenant Commander Dunleavy as they examine some experience based harm reduction programs that improve health outcomes and support successful reintegration. So let's meet our experts real quick. Lieutenant Commander Allison de levy has over eight years of experience as a pharmacist with the United States Public Health Service. Her career began with the Indian Health Services in Claremore, Oklahoma, where she completed a PGY one pharmacy practice residency and remained as an inpatient clinical pharmacist for four years. She then transferred to the Federal Bureau of Prisons, where she served as a staff pharmacist at FCI Elton and managed a met clinic for about 60 patients. Lieutenant Commander dunlady currently serves as a transitional care pharmacist with the Federal Bureau of Prisons central office. Her collateral duties include participating as a member of the continuing education and Pharmacovigilance advisory groups, and serving as a regional substance use disorder clinical pharmacist consultant. Lieutenant Commander Lauren Herzog is a Board Certified Clinical Pharmacist at FCC Butner, specializing in infectious disease. She also serves as a secondary oncology pharmacist and a national HIV consultant. Prior to joining the BOP, she also worked for the Indian Health Services, but in Gallup, New Mexico, where she completed her PGY one pharmacy residency and worked as an emergency medicine pharmacist. Now outside of work, Lieutenant Commander Herzog enjoys CrossFit, hiking with her dog and. And traveling. I know you did not tune in to hear me. Let me give you over to this amazing team who will elucidate and illuminate on harm reduction and re entry. Commanders, the floor is yours. Thank Speaker 3 5:16 you, Captain Garrett, for that wonderful introduction, and thank you all for joining us today as we continue our webinar series today with a discussion on harm reduction and re entry. Neither Lieutenant Commander Hertzog or myself have any relevant financial disclosures or relationships with any commercial interests. The opinion expressed in this presentation are those of the authors and do not represent the opinions of the Bureau of Prisons or the Department of Justice. Today, we're going to discuss the principles of harm reduction and how these principles apply to the correctional setting. We're also going to identify harm reduction strategies that can be applied to our population to reduce the risk of opioid overdose and HIV infection when they transition to the community. We all work in corrections, so I know we're all used to being asked to run a marathon with nothing but a pair of flip flops, and some hope so finally, we'll talk about the common obstacles that we face when implementing harm reduction in the correctional setting, and then propose some solutions for how we might overcome those challenges. Before we get started, I'd like us all to just take a moment to look at these items and think about how often you might use them. For most of us, it's likely multiple times a day that we're washing our hands or buckling and unbuckling our seat belts. I know we're all excited for the warmer weather so we can ride our bike or wear a sunscreen and life jackets out on a boat instead of wearing our masks and worrying about influenza A Believe it or not, we all practice harm reduction every day. So when you look at different problems that you face or decisions that you make daily, you might be surprised at how often harm reduction is a part of that process, while we all may use some type of harm reduction every day, the principles of harm reduction are particularly significant to how we apply these strategies to more specific issues like substance abuse, disorder and HIV. These principles illustrate how and why harm reduction prioritizes the dignity, rights and autonomy of individuals. It empowers people who use drugs to share information and support each other, and gives them a voice in the creation of programs and policies that are meant to serve them. It also recognizes barriers such as poverty, racism and trauma, and it establishes quality of life as a criteria for success, not necessarily the cessation of all drug use. Harm Reduction also calls for non judgmental provision of services and resources, emphasizing safety over abstinence, and it understands that drug use is complex. It doesn't attempt to minimize or ignore the real dangers that are associated with drug use, as we move on to the background and the goals of harm reduction, I want to help you first understand why the need for these programs is so urgent. Since 2019 the US has experienced a significant rise in drug overdose deaths, which were exacerbated by a worldwide pandemic and then driven by increasing availability of highly potent synthetic opioids containing fentanyl. As you can see on this graph, from 2019 to 2023 there was about a 45% increase in overdose deaths from over 73,000 to over 106,000 in 2023 we finally saw the first decrease in drug overdose deaths in the US since 2018 however, it was only about a 3% decrease, so we still have a long way to go. We know that there is an urgent need for these programs in the US. But you may be wondering, how is harm reduction significant to me as a correctional health care provider. I care for these individuals while they're in my custody, and then what they do when they're released is not my concern, right? Well, that's actually far from the truth. Opioid overdose is the number one cause of death among individuals released from incarceration, and opioid users in the criminal justice system have a 10 to 40% higher risk of overdose after release compared to the general public, as shown in this graph, and the highest risk occurs within the first two weeks of release. These individuals also often have underlying conditions such as chronic pain, HIV or mental issues, mental health issues that may contribute to overdose risk. Incarceration also leads to limited access to health care and mental health follow up, which can exacerbate substance use disorder. And many individuals will also have a decreased tolerance for opioids because they were using in smaller amounts or not using at all during incarceration. So this decreased tolerance along with. With the increasing prevalence of synthetic opioids in the community, is also a major contributor to post release overdose risk, Speaker 4 10:10 along with overdose substance use, leads to an increased risk of transmission of infectious disease such as HIV. HIV is a preventable disease, but the 10 year incident rate in previously incarcerated individuals is 5.58% compared to 4.72% among those without any previous incarceration history. This also leads to an increased spread throughout the community. We can also model our Correctional Health to align with that of the general public. The ending the HIV epidemic in the United States, otherwise known as a he initiative, was introduced in 2019 by the Department of Health and Human Services. It aims to reduce new HIV infections by 90% by 2030 the BOP follows this model, composed of four pillars, first, diagnose all people with HIV as early as possible, and then we want to treat people with HIV rapidly and effectively to reach sustained viral suppression. And then we want to prevent new HIV transmissions by using proven interventions where we will focus most of our time today. And lastly, we want to respond quickly to rapid HIV transmission. Speaker 3 11:25 Lauren, I appreciate you mentioning how Correctional Health can align with that of the general public. It's so important to remember that Correctional Health is public health. Every person's health has inherent value to themselves and their loved ones. In the movement of individuals in and out of prison walls has an effect not only on our incarcerated population, but our community as a whole. We can drone on all day about graphs and studies, but in reality, each of these numbers and data points are human beings, and every incarcerated adult that you encounter is someone's parent, child or friend, they will be someone's neighbor one day, and each of these deaths causes irreparable harm to families and the community. Harm reduction strategies are a significant part of substance use treatment that give individuals time to realize that recovery is possible and time to work towards that goal of recovery, it is possible, but we need to do more to implement these programs within our population and allow people to become good neighbors instead of becoming another statistic. One of the many barriers to harm reduction implementation are the misconceptions and the stigma that surround the background and goals of these programs. So now that we all have a solid background on the topic, I'd like to take a quick break for a knowledge check. So I'm going to read several statements about harm reduction, and I'd like you to utilize your chat feature and respond as to whether you believe these statements are Fact or Fiction. So our first statement is that harm reduction is only for people who use illicit drugs. Do you believe that is fact or fiction? Unknown Speaker 13:16 I'm seeing a lot of fictions in the chat, Speaker 3 13:18 right? That is correct. So as we discussed in the beginning of the presentation, harm reduction applies to many more behaviors than just drug use, right from seat belts to helmets to hand washing, most people engage in some form of harm reduction every day. The next statement is, harm reduction considers the role of abstinence in substance use disorder treatment, fact or fiction. You Speaker 4 14:03 it looks like the consensus here is fact, Speaker 3 14:06 correct. That is a fact. Harm reduction services aim to meet people where they are, whether that means they aren't ready to go to treatment, they're ready for abstinence, or if they're somewhere in the middle, the main goal is to keep people alive and healthy as long as possible, and provide connections to a variety of resources. Our next statement is law enforcement can support syringe service programs, fact or fiction, you Unknown Speaker 14:46 it's looking like a lot of fact again, Speaker 3 14:49 right? Again, that is a fact so law enforcement can support syringe service programs by creating policies to ensure people using or working at these programs aren't targeted for. Arrests in and around their locations. When people feel safe using these programs, they're more likely to engage in healthier behaviors and access additional support services as well. And our last statement is that harm reduction enables risky behavior, fact or fiction. I Unknown Speaker 15:28 It looks like fiction on this one, right? Speaker 3 15:31 That is fiction. So harm reduction accepts that some people do engage in risky behaviors, but there's no judgment for that behavior. This doesn't mean that risky behaviors are encouraged. Harm Reduction acknowledges that they're very real harms associated with these behaviors, and it doesn't try to minimize the impact of them. Thank you all for those responses. So now I'd like you all to meet Mr. Jones. Mr. Jones is a 58 year old black male with a history of opioid use disorder, IV drug use and multiple sexually transmitted infections prior to incarceration, he's six months out from his transfer to halfway house, where he'll remain in bop custody for an additional nine months. He no longer has a relationship with his family, and he will be unhoused when he releases from bop custody, we're going to be following Mr. Jones through his re entry planning process and applying harm reduction strategies to ensure that he has a successful transition back to the community. This is something I do every day as a transitional care pharmacist, but I will tell you more about that a little later. Mr. Jones is currently prescribed buprenorphine for opioid use disorder, which he initially began taking in the community. Medication for opioid use disorder or mood is a life saving appropriate treatment for many patients, especially those with moderate to severe opioid use disorder, There are currently three FDA approved medications for the treatment of opioid use disorder, buprenorphine, methadone or naltrexone. And if you tune in to this series on April 17, you can learn more about the mechanisms of these medications and some of their benefits, which include reducing the risk of overdose death and infectious disease transmission, reduced criminal behavior and increase retention and treatment programs. I'm going to ask you to utilize the chat once more and just let me know what discipline you practice. Do we have nurses on today? Pas physicians, lab techs? Looks Speaker 4 17:41 like a lot of pharmacists and nurses so far, I did see a psychologist, excellent, Speaker 3 17:45 awesome. So when Mr. Jones presented for our intake, our nurse did a great job of verifying his prescription to ensure continuity of care. Our pa then made sure to complete a full substance use disorder history and medication reconciliation. Since then, Mr. Jones followed up with our clinical pharmacist who manages the mood clinic. So as you can see, there are many ways Health Services staff of all disciplines can be involved in Oh, you d care. Correctional institutions face numerous challenges when implementing mood in the form of structural, regulatory and logistical barriers, funding and staffing needs and also concerns regarding diversion and the different types of mood come with unique implementation challenges. For instance, you may be concerned with having sufficient resources to prevent diversion of buprenorphine, whereas regulatory barriers were usually most common regarding methadone, such as needing a licensed provider to dispense it. Now, trexone presents a challenge because many patients aren't familiar with its benefits, or they mistakenly believe that it will induce withdrawal. However, needing additional funds for medical and clinical staff has been the most common barrier to making all three forms of mood available to those who need it. While oud treatment is one novel piece of harm reduction that involves correctional medical staff, there are many other pieces to this puzzle. Speaker 4 19:20 That's right. Staff can be involved in another piece of the harm reduction puzzle, the prevention and inhibition of the spread of HIV. If you remember back to the ending the HIV epidemic slide earlier, pillar one focuses on diagnosing the disease as early as possible. The BOP recently switched to an opt out testing approach, and all adults, all patients are tested within 30 days of intake, unless they refuse. This helps ensure we have all appropriate inmates treated, or at least offered treatment, which is the core of pillar two. All individuals who test positive for HIV are offered treatment, whether that be from their primary care provider or a clinic. Local infectious disease pharmacist. The BOP uses collaborative practice agreements that allow credentialed pharmacists to receive and review consults for patients with HIV and start or modify treatment as appropriate. The BOP also has a team of HIV consulting pharmacists who review charts for every federal bop patient who has HIV quarter on a quarterly basis, ensuring appropriate and effective antiretroviral therapy. This helped bridge the gap for institutions with limited providers, so that no patient is being go is going untreated. The goals of treatment are to become undetectable, which is a quantitative viral load of less than 200 copies of HIV per milliliter of blood, while over 93% of our patient population is considered undetectable, majority do not have any detected virus at all, meaning no copies of the HIV virus are registering on routine lab draws. The reason why being undetectable is so important is this saying u equals u or undetectable equals on transmittable, abundant clinical evidence supporting this idea that patients with an undetectable HIV viral load cannot sexually transmit the HIV virus to their partners. U equals you also encourages compliance with HIV medications and helps reduce some of the stigma surrounding the virus. The third pillar, and the one where we are going to focus most going forward, is prevention. There are numerous ways to prevent an infection, such as post exposure and pre exposure prophylaxis treatment, as well as what is the most important intervention, in my opinion, education, a 2018 article published by the NIH highlights the importance of prevention and summarizes the purposes of this presentation. It states that HIV risk is exceptionally high immediately following release from prisons or jails due to relapse to substance use, discontinued healthcare engagement, homelessness and under insurance compounds, other health disparities, there are barriers we need to help with these patients to overcome, and where you as providers are valuable at intervening. Speaker 3 22:13 Thanks, Lauren. I'm looking forward to hearing more about the ending HIV initiative, but first I'd like to discuss one barrier will commonly encounter in the correctional setting as it affects the lives of HIV patients, and can also have a major impact on oud treatment among correctional staff. OED treatment is offered often considered inferior to abstinence based treatments and viewed negatively as a substitute for addiction, which leads to policies that restrict its use. HIV stigma can discourage people from getting tested, sharing their status with partners and accessing HIV services. How many of you have heard these terms surrounding substance use and HIV, clean or dirty drug screen infected with HIV, junkie or HIV sufferer, if you could utilize your chat function again and just share some terms that you might use that we could replace these terms with that are not considered stigmatizing language. Speaker 4 23:21 So far, I've seen positive or negative urinalysis instead of cleaner, excellent, yep, a person with HIV or a patient with HIV, Speaker 3 23:32 excellent. And that goes for person with substance use disorder as well. And then, instead of using infected, we could use terms such as diagnosed or acquired. So the BLP encourages all staff to adopt person first, recovery oriented language when discussing substance use disorder and HIV among themselves or with our population, hearing peers and leadership use language that's person first and non stigmatizing can help to shift the mindset of someone who might have negative perceptions of these Unknown Speaker 24:07 disorders. Speaker 3 24:11 The typical concern regarding harm reduction models is that they remove consequences and barriers, making continued use, quote, unquote, easier and more likely to continue, of course, after today's presentation, you know that that's not true, but continued comprehensive training and education is significant to maintaining positive attitudes surrounding harm reduction and also to normalize addiction as a health issue. One way medical staff can decrease stigma is by integrating OED and HIV treatment with regular health care. When patients are seen in chronic care clinic where other co existing conditions are also treated, rather than having a specialized separate appointment, they feel less isolated. And the treatment of addiction as a disease is normalized, another way to reduce stigma in the correction. Setting is to track outcomes and share the evidence of the program effectiveness with your staff. This can also support policy reforms that will prioritize the treatment and rehabilitation when policies are backed by evidence, it's easier to gain acceptance and understanding from both staff and our patients. Education and Awareness are also strategies that can reduce stigma. For example, the BOP addiction medicine team distributes a monthly oud newsletter and that provides education, treatment, success stories and testimonials that challenge the misconceptions and also encourage open dialog, another major barrier faced by Correctional Health care workers is funding. So funding is a major obstacle when it comes to hiring staff to manage these programs, obtaining medications and providing harm reduction in re entry planning. So where do we begin to address these issues, and how has the Bureau of Prisons been successful in overcoming some of these hurdles. Some ways you may obtain funding for these programs is through grants provided by agencies such as SAMHSA the CDC and HRSA state Medicaid programs may also cover the cost of mood and prep for individuals incarcerated in state and county jails, especially if that facility provides continuity of care. You can collaborate with community organizations that may lead to some opportunities to share resources or CO apply for grants. The passing of the first step act in 2018 was really a turning point for the BOP with a goal of reducing recidivism and improving outcomes for our population. It authorized funding to support the implementation and expansion of our mood programs and also the expansion of reentry services to focus on mood. And since the expansion of mood and prep in the BOP began, we do continue to advocate for the budget to prioritize these programs based on their cost effectiveness and the public health benefits, and this has led to the creation of research teams and task forces who monitor harm reduction and aftercare outcomes and report this information to leadership and stakeholders. Speaking of funds, Lauren, I know prep can cost upwards of $20,000 per year for one patient, can you tell us a little more about prophylaxis medications and other harm reduction strategies for HIV? Speaker 4 27:28 Yes, of course. Research has shown that harm reduction strategies have reduced the risk of HIV infections associated with drug use and related behaviors such as sharing needles and risky sexual behaviors, including unprotected sex and the exchange of sex for drugs or money. For example, syringe service programs contribute to decreased needle sharing and more hygienic injection practices. Multiple studies show that programs reduce the number of new HIV infections. Treatment options are available for pre and post exposure to HIV, it is our job as clinicians to screen and identify people who may benefit from this type of intervention. And as I said, earlier education alone is vital to ensuring patients understand how HIV is transmitted and what resources are available for them upon release. We are first going to talk about post exposure prophylaxis, or PEP, as it as it is a little bit more straightforward. Pep is a medication taking after a potential HIV exposure. There is occupational versus non occupational. Occupational being something that happened at work, like a needle stick and non occupational would be something that happened outside of work, like any type of sexual contact. If someone has an exposure and the source can be tested, they should be to rule out any active infection that could have transmitted. If the source cannot be tested or the source is still high risk, Pep must be started within 72 hours of exposure. The treatment options for pep are mtricitabine with tenofovir of any formulation, so Truvada or descovy plus dolutegravir or twice daily raw teglovir. This regimen is 28 days long, and patients should be screened for HIV, hepatitis B and hepatitis C, and have renal function tested at baseline and then again at six weeks, three months and six months, pre exposure prophylaxis, or prep, on the other hand, is a once daily medication taken by an HIV negative individual at an increased risk of acquiring HIV to reduce transmission risk. And although it is FDA approved for high risk individuals, the CDC recommends prescribing it for any patients that ask. Now you may be questioning this, but you need to remember that everything we previously discussed and the stigma surrounding HIV and its patient population and with efficacy reduction rates of 99% for sexual contact and 74% for. Injection use. It is important that we're offering this treatment when it is asked for to protect our patients and communities. The medications for PrEP are mtricitabine and tenofovir disapproxyl, which comes as a single tablet formulation called Truvada or mtricitabine and tenofovir elafenamide, otherwise known as descovy. These treatment options are both oral tablets that are taken once daily. We will go a little bit more in depth about some of the basic prescribing clinical pearls on the next slide for both of these agents. But I first want to talk about the other and much newer treatment option, which is the cabotegravir injection. This is an injection that can be given every eight weeks for PrEP. And while this does sound like a really great option, it does have some cons. It is costly, as it is only available in its brand formulation, aptitude, and because of its cost, it is not readily available for coverage assistant programs like Ready, set, prep. However, there are some states that do have treatment assistance programs in place to make this option affordable to patients here at the BOP, we are not yet utilizing this medication due to the difficulty coordinating continuity of care as our patients can release anywhere in the country. The other downside of this medication is there is research suggesting that if a patient does acquire HIV after using cabotegravir for PrEP, they're at a higher risk for integrator inhibitor resistance, and integrator inhibitors are one of the backbone components of HIV treatment therapy. And now, as promised, we are going to go through a quick, high level overview of some of the clinical pearls when prescribing prep. First off, we need to gather an HIV test, Hepatitis B test and hepatitis C test at baseline. We cannot start someone in prep if they are HIV positive, as these are incomplete treatment regimens and would lead to an increased risk of resistance. For this reason, we also need to test them every three months for HIV. We test for Hepatitis B and C, as these medications can exacerbate an Hepatitis B infection, and we want to make sure that we are starting our hepatitis C patients on the correct treatment if needed. We also want to test at baseline and every three months for sexually transmitted infections in this higher risk population. And lastly, we have to have a renal function test and pregnancy test on board in our female patient population every three months, as these drugs can affect the kidneys and treatment may need to be altered if the patient becomes pregnant. Truvada is our first treatment option, and this is a really solid medication with a high efficacy rate for PrEP as it has been around since 2004 this can be used in all patients, and has a fairly cheap, generic formulation, making it super easy to prescribe. However, the tenofovir disapproxyl component is known to cause renal injury and osteoporosis and should be used in caution in these patient populations. Descovy is a newer, approved agent for PrEP, but it can only be used in those who are assigned male at birth, however, it is much more well tolerated and does not have as severe renal or bone effects. Both medications should be taken once daily, and patients should be counseled on the importance of adherence. The more missed doses, the less effective the treatment is at preventing HIV. If more than five days are missed, the patient should be counseled on secondary means of protection from HIV. Once treatment is started or restarted after missing doses. It takes seven days to be fully protected from transmission through receptive anal sex, and 21 days to be fully protected through receptive vaginal sex or intravenous drug use. It is also important to educate patients that prep only protects them against HIV, not any other sexually transmitted infections or hepatitis, and that other safety measures should be practiced if there is high risk. Speaker 3 33:54 Thank you for sharing those excellent clinical poor pearls. Lauren, so whether we're discussing mood or HIV prophylaxis medications. Continuity of care is a critical element of reentry. Planning reentry can be a really stressful time. It can trigger an increase in cravings to use illicit drugs and alcohol. Continuity of care from the institution into the community is crucial for preventing recidivism and relapse, so crucial in fact, that the VOP established a team of pharmacists and social workers dedicated to transitional care. The Transitional Care team coordinates with re entry staff, medical staff, patients and community treatment services to ensure that individuals transitioning to the community have the resources they need to continue their current treatment and also access adequate health care. So circling back to our patient, Mr. Jones, he's now only a couple months out from his release, and he sends a cop out to medical stating that he's worried about continuing his OED treatment, and he wonders how he's going to get medical care, because he'll now be a full term release with no. House time. In this case, a healthcare provider at his institution would meet with Mr. Jones discuss his aftercare planning process so this individual can be a nurse, med tech, pharmacist, provider. They would collect information regarding his housing, income, insurance and transportation, and they would provide all that information to the Transitional Care Social Work team through an aftercare referral. Our transitional care social workers would then develop an individualized aftercare plan for Mr. Jones, and this would be sent back to the institution point of contact, who would then be responsible for counseling Mr. Jones on his aftercare plan. So if you could use your chat function once more and just let me know, based on what we discussed about Mr. Jones, what are some of the risk factors that we would want to address in his aftercare plan? You Speaker 4 36:03 so far, I'm seeing that he's unhoused, right, financial trouble, treatment availability, another, another vote for unhoused, Speaker 3 36:16 right? Yes, those are all correct. So Mr. Jones is also currently prescribed mood, and as we've learned, continuing that treatment is vital to limiting his risk of overdose upon release. So as you can see in our aftercare plan here, he is provided with specific community provider information and instructions for intake, including what to bring to his appointment. I It also to ensure continuity of care in the event that there's a delay in receiving treatment in the community, Mr. Jones will receive a 30 day supply of the suboxone that he's prescribed. And as you all mentioned, Mr. Jones will also be unhoused, and he doesn't really have a social support system, so providing resources for shelters and information to apply for services such as Medicaid are also going to be important pieces of his re entry plan. Overdose education and naloxone distribution is another harm reduction strategy that can be utilized by correctional agencies. So I'm sure most of us know naloxone is a safe and quick acting method of treating opioid overdose, and it's been shown to reduce overdose deaths among formerly incarcerated adults by 61% when it's provided upon release. This graph illustrates the trend in naloxone distribution upon release within the BOP so as you can see, the Harm Reduction Program continues to reach more individuals at risk every year, with over 4500 Naloxone prescriptions written in 2024 Mister Jones, our patient, presented to clinic for a mood follow up appointment, and he says he's doing fantastic. He hasn't thought about using any illicit substances in months. He's been keeping busy with his education programs and Rec and he has a great support system in the unit. So if you could let me know in the chat, based on this information, would you offer Mr. Jones and Naloxone for release? Yes or no. I mean, it sounds like he's doing great and he's not actively using right. Speaker 4 38:32 So far, the consensus has been Yes, excellent, Speaker 3 38:35 yes. I would definitely offer him Naloxone for release. As a clinical pharmacist, I would counsel him on administration, technique, signs and symptoms of an overdose and high potency opioids. And when it comes to education, I also don't limit these interactions to simply an opportunity to train on how to use naloxone. It's also an opportunity to have a conversation about safer consumption in general. So as we previously discussed, many individuals released from incarceration have a decreased opioid tolerance, and they also don't have a lot of information about how to use substances safely. So Naloxone education can be a gateway to having an honest conversation about someone's substance use, even if, like Mr. Jones, they seem motivated to not use anymore and just talk about what happens when they find themselves in a position where they want to use again, what about Mr. Jones' history of STIs and IV drug use? Lauren, how can we support Mr. Jones upon his release to lower his risk of HIV transmission? Speaker 4 39:42 That's another great question in his continuity of care. But I first wanted to mention that we must remember that re entry can be an overwhelming time. Some of our patients have not been responsible for coordinating their own healthcare in decades. Let's just imagine entering custody when smartphones were just becoming a thing. And you are now releasing in a time of telehealth visits and MyChart, it is our job to provide as much education and coordination as we can to ensure that these patients are entering society prepared for what is ahead. Sometimes we are so eager to focus on the medication assistance and risk of reuse in the community that we forget about the risk of transmittable diseases at the BOP as high risk patients are 30 to 90 days from re entry, we try to assess and provide prep as needed for re entry into the community. Our goal is to provide prep with our preferred agent, Truvada, at at least 30 days prior to release, so that it is at its effective and therapeutic level by time of release, we then re educate them on the importance of compliance and provide patients with an appropriate supply of medication. We can also coordinate with social work or instruct our patients with a trusted family member in the community to work on what I like to call their exit health care plan prior to release, it is here where we can inform them about finding a provider in the community for continued health care and prescribing prep and ways to help make prep more affordable if it isn't already free in their state. Some good resources include drug manual manufacturing or assistance programs, Ready Set prep state programs and the patient advocate Foundation, all which are linked in the slide. We do our best to screen all these high risk individuals for re entry. But we aren't perfect, and some may fall through the cracks. To try and eliminate this, we try and inform our population and let them advocate for themselves and their own health care. This is the email bulletin that we send to the entire population nationwide, informing them that HIV prep and nasal Naloxone are available to them upon release. It is posted in both English and Spanish versions. This bulletin now gets reposted on an annual basis, and I know some institutions that even post this throughout their complex so that the patients can see it when they're out and about on their jail on their day. For staff, the updated HIV Management Guide and document containing recommendations about HIV prep is readily accessible to all providers. Additionally, the HIV consulting pharmacist group released a webinar to promote HIV prep, which was targeted to all members of the healthcare team. What is really amazing is in the BOP, as we've been mentioning throughout this presentation, we have 126 pharmacists operating under a collaborative practice agreement who can also help screen and prescribe PrEP and Narcan upon release. This helps identify even more high risk individuals and take some of the prescribing burden off of the other providers. Speaker 3 42:46 As you can see, creating successful reentry plans is certainly not a one man job. It often takes coordination of correctional staff, health services, social work, psychology and re entry staff to ensure successful transitions of our patients from custody to the community, you may consider implementing monthly team meetings to discuss those individuals who are high risk, such as those with substance use disorder or chronic medical issues. Holding regular team meetings and having multiple individuals who are invested in harm reduction leads to improved outcomes and ensures that no patients fall through the cracks prior to release. You may also consider implementing standard operating procedures that help address harm reduction for individuals with substance use disorder, for example, screening all individuals at high risk for overdose or HIV transmission to offer harm reduction information, mood or prep, and these screenings can be conducted by any member of a healthcare team. Collaboration with local organizations can also lead to free resources such as Naloxone, harm reduction education and medical referrals for patients transitioning to the community. The BOP has developed several tools for assisting staff patients and community treatment specialists in coordinating reentry and transitional care. The OED reentry toolkit was created by our transitional care team, social work team. It is an informational packet that's provided to any patient on mood Prior to release, and any other individual who may benefit from the information. It contains Narcan education, recovery support worksheets, community support services, fentanyl test, strip education and mood education as well. The OED re entry guide is also provided to any individual on mood or anyone else who may benefit, and that contains contact information for outpatient providers by state and county, the transitional care team also created a virtual pipeline, and this is where community treatment specialists can view mood patient data such as medication administration dates, and that helps them to assist in the coordination of the aftercare appointments if. So back to our patient, Mr. Jones. He's been reading through the OED re entry toolkit that we provided, and he has some questions about fentanyl. He tells you that a friend bought marijuana from a dealer he didn't know. It turns out that the marijuana was laced with fentanyl, and his friend unfortunately died from an overdose. So Mr. Jones wants to know how he can protect himself, over 82% of all opioid overdose related deaths are caused by fentanyl and other synthetic opioids, and the prevalence of these synthetic opioids has drastically increased in recent years, and many individuals released from incarceration don't understand the difference, and they don't understand safe consumption techniques if they were to find themselves using again. So fentanyl test strips can be used to identify the presence of fentanyl and fentanyl analogs in drugs, powders and other substances. Studies have shown that individuals who've used fentanyl test strips were five times more likely to engage in protective behaviors such as having Naloxone available, using with someone else, using more slowly, or sharing the fentanyl results with others. However, a major limitation to the use of these fentanyl test strips is that they're not legal in all states, so it is important to refer your patients to the state Opioid Treatment authority in their release state for information about availability and legality. So the clinical pharmacist, I would provide Mr. Jones with all of this information, and I would counsel him on the use benefits and risks of the fentanyl test strips. Mr. Jones says he'll never go back to injecting heroin, but he has heard that there are places where you can exchange dirty needles or get more Naloxone if you need it. He asks where these places are located and how he could find one. The map you see on the right illustrates the 563 syringe service program locations that have been published by the North America syringe exchange network. Research has shown that comprehensive syringe focused programs are safe and effective. They promote cost savings, and they also play an important role in harm reduction. SAFE Disposal of needles prevents reuse and sharing of needles, and it also limits the number of used needles that litter our communities. So I would review all of this information with Mr. Jones and direct him to the OED re entry Toolkit, which he can also reference. I would also counsel him that syringe service locations distribute naloxone and also offer services such as vaccinations, screening for infectious disease and referral for physical and behavioral health care. Lauren talking about needles. How has access to sterile needles affected the incidence of HIV and Hep C Speaker 4 47:49 in general. Substance use impairs judgment, which can lead to engaging in risky behaviors. On top of that, increased risk sharing needles increases the risk of infection. For people who inject drugs, they are at an increased risk of contracting both HIV and viral hepatitis. Needle sharing is the second riskiest behavior for HIV transmission at about 10% and the leading cause of hepatitis C transmission at 80% the CDC 2020, viral hepatitis surveillance report showed that the incident rate of acute hepatitis C doubled since 2013 and increased 15% from 2019 as you can see on the graph, it is on an upward trajectory and models what we saw earlier with the overdose graph. Since COVID, we have seen another sharp increase in hepatitis C infections, if you could just place or drop a one in the chat, if you have seen this increase as well in your practice. Speaker 4 48:58 Okay, I see a couple of people are seeing the same thing as well. Well, I am too, and the BOP is switching to an opt out testing approach so that more people, hopefully will be getting screened. And the case loads are growing significantly. And while we have it focused as much as on hepatitis in this presentation, as hepatitis C cannot be treated for prophylactically, it can still be screened for and education can be provided on risk reduction strategies such as needle exchange programs. And while hepatitis C cannot be prevented with a medication, it can be treated and cured. So once again, it is important that we are screening our patients and treating accordingly. One last intervention that I wanted to mention that we can make in terms of harm reduction is screening for both hepatitis A and B immunity. While we cannot pharmacologically prevent a hepatitis C infection, we can immunize against both hepatitis A and B, and this can be done by drawing a simple lab type. To see if our patients are immune. If not, we can try and vaccinate before re entry, or recommend the vaccination upon release. This is also something I would recommend periodically for all of us who work in correctional settings, hepatitis immunity waivers over time, even if you were vaccinated when you were younger. So make sure you are protecting yourself and checking your immunity and getting vaccinated if you wish, periodically. Speaker 3 50:27 In summary, today, we have learned that harm reduction strategies aim to minimize the negative impacts of substance use in the correctional setting, these strategies can be utilized to reduce the risk of overdose and HIV transmission, post release, stigma as well as limitations in funding and staffing are some of the most common obstacles to implementing these programs in correctional facilities. But despite these challenges, by utilizing the resources you have available, providing ongoing education to staff and our patient population, and engaging in community partnerships, you can be successful in applying these strategies to your practice as a correctional healthcare worker. That concludes our presentation today. Thank you all for your time and attention. At this time, we will take any questions Speaker 2 51:17 outstanding. Thank you guys so very much. I do have a couple questions from chat. So the first one is, while being housed, how many times can Narcan be administered to an inmate in a given situation? Speaker 3 51:34 You know, I don't believe that there is a limit on the Naloxone doses themselves. It'll be different in every situation as to what healthcare staff you have available. You know as to when you would move on to other methods of resuscitation, or when you would want to call an ambulance for more advanced care. I Speaker 4 51:57 can speak a little bit to this too. Yeah, sure. So the max dose of naloxone at a time is the two milligram dose, and this can be administered every two minutes. There is no real maximum amount of doses you can administer. And I can speak from experience that as we're seeing some of these more synthetic drugs come about that it's taking more doses, or it's taking the patients more time just to metabolize these drugs and get them out of their system. So while naloxone is really important and you should provide that, you should also be focusing on the support of measures, like she mentioned as well, and making sure that we're going through our basic BLS, ACLs, if necessary. Unknown Speaker 52:47 Perfect. Speaker 2 52:49 Next question, what do you give to the inmate that uses Wasp dope? Speaker 3 52:58 We have seen quite a bit of that in the BOP with any, you know, acute case of intoxication, of the Wasp dope, as they call it, if there was any respiratory depression, and you know, we did not know what that patient was using, we would still administer Naloxone, because it Can't hurt right, better to be safe than sorry. Unfortunately, our mood medications are not going to be useful for any illicit substance that is not opioid based. So while we can still provide that individual with resources, such as more psychological resources, a referral to psychology, unfortunately, our pharmacological options are not going to assist them with those types of addictions. Unknown Speaker 53:49 Thank you. Speaker 2 53:51 Let's see, have there been any studies that have looked at the impact of harm reduction programs on healthcare costs, Speaker 3 54:04 sure. So there haven't been many studies that looked at costs specifically in the correctional setting, but harm reduction has been found to have a significant impact, just overall, on healthcare costs in the US. So I believe at its height, the opioid epidemic costs about $95 billion a year to the US, and an additional 78 billion or so continually. There was a study conducted in Rhode Island that concluded that for every overdose death prevented by harm reduction strategies, over $800,000 could be saved in the costs that were related to emergency medical care for that overdose. They also found that the Lifetime Medical costs that could be saved by preventing just one HIV infection would be over $250,000 Speaker 1 54:58 so. Oh, wow, Speaker 2 55:03 it looks like we have one, maybe two more questions we'll see. Could you provide any examples of specific impacts that harm reduction has had on re entry outcomes? Speaker 3 55:18 Sure. So circling back to that Rhode Island study, they found that individuals with opioid use disorder who did receive mood while they were incarcerated were about 33% less likely to be re arrested within their first year of release, and then individuals who continued mood post release, they found they had about a 60% reduction in overdose death when we're talking about those syringe service programs, those participants are about 25% less likely to face future charges for drug related offensive offenses, and they're about five times more likely to enter treatment, and also about five times more likely to stop injecting drugs, which also leads to a significant decrease just overall in overdose, overdose deaths and HIV transmission. Speaker 2 56:14 Cool, looks like we have two more. So how is everyone dealing with? Oh, my a, made up word, let me spell it for you, X, Y, l, a, z, I, N, E, Speaker 3 56:31 Lauren, have you dealt with that in your institution at all? I Speaker 4 56:34 have not seen this at my institution. I did just do a quick little literature search on it, because I saw it pop up in the chat. It is, it looks like it's a horse tranquilizer. It does not respond to any like Narcan or any of our opioid reversal agents, and it is an analog, interestingly, of clonidine, which is a blood pressure lowering medication. So really important to just keep up with the supportive care and observation on these patients. Probably would also recommend EMS and er follow up if it's something that severe. Speaker 3 57:12 Yeah, I haven't seen any use in any of the institutions I keep track of, but it is something that we are aware of in the transitional care team. It's something that we have added information to our oud reentry toolkit, and there are also test strips for xylazine as well as fentanyl. And again, the legality of those is common, you know, hit or miss, so it's something that you have to look into, but it is definitely something we are keeping our eye on. Speaker 2 57:42 Thank you. And do you recommend er follow up after Narcan administration for an inmate with chronic care versus healthy inmates? Speaker 3 57:51 We the BOP does have a policy that requires er follow up for any Narcan administration, so any individual who is administered Narcan, whether that is found to be from opioid use or another condition, is evaluated at an outside medical facility, Speaker 2 58:12 perfect. Let me just do one more run through here and see if I see any more questions. Unknown Speaker 58:20 I am not seeing Speaker 2 58:21 any right off the top, so I want to tell you guys again, thank you so much for putting this on. I know how hard you guys have been working on it, and it was awesome. So thank Unknown Speaker 58:35 you. Thank you. Oh, very good. Unknown Speaker 58:39 And with that, I'm going to thank you guys for your time, Unknown Speaker 58:48 and Speaker 2 58:53 just really want to thank you for your time attending today. I know how busy you guys all are, and I want to take this opportunity to selflessly promote for next week, so you can join us again next week, same bat channel, same bat time, where we'll be looking at HIV screening, treatment and prevention. I'll stay on for just a little bit with that, but with that, I would like to say thank you very much. Stay curious, stay committed, and we're looking forward to seeing you again next time. Have a good day. Unknown Speaker 59:31 Thank you. Thank you. You Transcribed by https://otter.ai