CAPT. Chad Garrett  0:15  
Hello, everyone out there who's joined us so far, if you want to take a moment as you join us to put into chat where you're from, that would be cool. Thank you. We are starting in, oh, just a couple seconds now. Thank you very much for taking out the time in your day to join us. You

well. Mike Locke says it is time to go. Mr. Smith got the comms.

Christopher Smith, NPA  1:22  
Thanks Chad. And good afternoon everybody. Hello and welcome to the National Institute of Corrections, clinical, clinical pearls webinar series. I promise I'll get better as we go. My name is Chris Smith, and I'm a national program advisor with the National Institute of Corrections. We are 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 correctional team medicine. Before we begin today's session, I'd like to cover a few important housekeeping items. First, each webinar in this series is scheduled to last approximately an hour. The 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 the 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 this webinar. So practice the chat function. If everybody could please type what summertime activity you are looking forward to, I would appreciate it. Is it time at the beach? Is it is it in the mountains? Or is it reading in the lawn chair in your backyard? Or, like in my case, going through and cleaning out the garage? Go ahead and type whatever your most exciting plans are for the summer. Monica, so you like hiking in the mountains. Amy, gardening.

William, I work for the Bureau prison. So every day is a vacation, because I enjoy that much, but I'm glad you're looking forward to vacation this summer. Oh, I missed you. Denise, we got snorkeling Excellent. All right. Well, I appreciate the answers, guys. If you experience any audio difficulties, we recommend you connecting to the webinar audio via the telephone using the number provided in your registration confirmation email throughout the series, we want to hear from you. You can always email our health programs manager, Mr. Chad Garrett at ca garrett.vop.gov with any questions, concerns or ideas for future events, I and my team for Nic, including some great staff from the NIC library, will be posting information in the chat during the presentation. Again, if you have any questions, please type them into the chat and we will answer as many as we can at the end of this webinar, I just want to say thank you again for joining our webinar, and now I give you captain Chad Garrett,

CAPT. Chad Garrett  4:18  
thank you, Mr. Smith, good morning, good afternoon, everyone, and welcome to Session Six of the National Institute of Corrections clinical pearls, webinar series, a curated collection of insightful evidence, informed conversations highlighting the often underappreciated but critical role of clinical pharmacists in correctional healthcare. Again, my name is Captain Chad Garrett, the Health Programs Manager for Nic, and I am today's facilitator. Today, we turn our lens towards a complex and compelling topic, pharmacist engagement with opioid use disorder. As correctional institutions nationwide continue to grapple with the opioid crisis, COVID. Medical pharmacist are stepping up, not just as medication managers, but as essential partners in a multidisciplinary strategies to improve outcomes, reduce recidivism and restore dignity throughout the evidence based care, as well as providing leadership. Speaking of leadership, we are joined today by two powerhouse practitioners who exemplify innovation, integrity and initiative in the fight against opioid use disorder. Behind the wall, first up, we have Lieutenant Commander Megan Gossett PharmD, a graduate of the University of Kentucky, College of Pharmacy, Lieutenant Commander Gossett brings not only clinical acumen, but also a passion for service. Having commissioned into the Public Health Service in 2021 based at FMC Lexington, she served as the OTP program director and spearheads oud treatments, from managing that referrals to orchestrating the screening process, she is truly on the front lines of transforming policy into practice and outcomes into impact. Joining her today is Commander Trey drought PharmD, another clinical Trailblazer blazer, a proud alum of the University of Pittsburgh, School of PharmD. Commander droughts, trajectory through the BOP has been nothing short of remarkable. From his early days as a staff pharmacist at FCC Petersburg to completing a PGY one residency at FCC Butner and now serving as the national lead Sud clinical pharmacist consultant for the Bureau of Prisons, his work has been pivotal in shaping the way we think about and deliver care for opioid use disorder. Today, he leads a comprehensive clinic focused on oud at FCC, but nurse opioid treatment program where his advanced practice role exemplifies the future of pharmacist driven care models. So my friends grab that virtual copy, silence those side chats and get ready to engage, because when it comes to addressing opioid use disorder and Correctional Health Care, these clinicians are not just part of the conversation. They are writing the script, and with that, commanders, the floor is yours.

Speaker 1  7:20  
Well, thank you so much. That was a very generous introduction. Good morning or good afternoon, depending on where you're. Chiming in from across the country, I saw a lot of different states and correctional environments on there, as Captain Garrett said, my name is Commander Trey drought. I'm an advanced practice clinical pharmacist working at one of the largest federal medical centers within our correctional environment, within the Federal Bureau of Prisons, and that's located in Butner, North Carolina. So that's where I'm chiming in from, as Captain Garrett had said, I'm a residency trained, board certified psychiatric pharmacist who provides comprehensive care through a collaborative practice agreement at our institution with a primary focus on mental health and substance use disorders, as we'll see here, as part of a as part of the national lead Clinical Pharmacy consultant for substance use disorders in the Bop I have the privilege to work alongside 17 other clinical pharmacists who consult remotely to provide clinical expertise and educate on implementing effective substance use disorder treatments across all of our 122 bop institutions, and I'll have the pleasure to speak on that later in this presentation with me today is one of those consultants. Lieutenant Commander Gossett is also a board certified pharmacist. Her specialty is in geriatric pharmaceutical care, and she as well, manages a comprehensive clinic at her Medical Center in Lexington, Kentucky. And I saw she said, Go Cats earlier in the chat. So I guess that's where she's coming from. I say Hail to pit, because that's my alumni there. So with that, neither Lieutenant Commander Gossett nor myself have any relevant financial disclosures or relationships with any commercial interests within this presentation, and the opinions expressed are simply those of the author and not necessarily representative of the Federal Bureau of Prisons nor the Department of Justice. So before we begin, we'd like to know where you're coming from and what your perspective is that you bring to the table. So we just kind of wanted to gage the audience a bit and see what your perspective is today. Are you a practitioner who has significant experience treating opioid use disorder? Maybe you're a practitioner, but you know you have limited to know, or maybe you know some hesitancy with treating opioid use disorder in your correctional setting. Working. Perhaps you're a nurse, paramedic, maybe a pharmacist with a collaborative practice agreement for really any comprehensive or chronic care disease state. Perhaps you're a pharmacist and primarily a dispensing role, or maybe an administrator, a warden, a health service administrator, a supervisor.

CAPT. Chad Garrett  10:24  
So I put a poll up. You can go ahead and answer via that poll. Looks like we've got about 60% of folks have not entered into the poll yet. So far, we've got a fair mix of folks, a couple people in every category so far.

Speaker 1  10:42  
That's excellent. Well, that's that's good. We have a well rounded representation. So hopefully having a lot of different perspectives is a always a positive thing. But yeah, see some pharmacists there with CPAs, excellent practitioners with significant experience. This is great. Glad to see that. Well, thank you all for participating in that poll. We will have some additional polls throughout the presentation, so stay alert with that, and with that, we'll move on. So regardless of your perspective or where you're coming from, by the end of this presentation, we would like all participants to be able to summarize the benefits and challenges of opioid use disorder within the correctional setting. After that, we're going to go through some real life cases to discuss the strategies on where we may be able to integrate treatment for opioid use disorder, and then finally identify the benefits of expanding treatment for oud, specifically through a multi disciplinary team approach. So I'm sure that most of us, certainly if we chimed into this call, most of us are fully aware already that our country is admit an opioid epidemic. And you can see here from this CDC graph that the overdose death rate, on average, year after year, has only continued to increase over time since we started to record it in the late 90s. And with those exposed to the criminal justice system, it's even more prominent. One study shows that up to 65% of incarcerated individuals likely meet the criteria for a substance use disorder, and among that, one quarter of those have opioid use disorder, and upon their release, previously incarcerated individuals have been estimated to have anywhere between 40 to even 100 times greater risk of death from a drug overdose within their first two weeks of releasing to the community setting. And taking that a step further, a New England Journal of Medicine study found that overdose continued to be the number one leading cause of death, even within the first year after a patient's release from our custody. And this really impacts me, especially from a comprehensive clinic standpoint, where I might manage patients who have diabetes, asthma, hypertension, maybe mental health disorders such as depression or anxiety, and I'll invest a lot of time and energy. The patient themselves will invest a lot of time and energy in getting that diabetes under control, managing their asthma, initiating lifestyle modifications that help us manage those conditions. And certainly there's a return on investment. There's a return on that clinical investment that we give in terms of increased quality of life, reduced morbidity and mortality, but to know that the number one leading cause that's most likely going to result in mortality within the first year after a patient's release. It's an overdose. And if we don't recognize that 65% of our patients have some substance use disorder,

Unknown Speaker  14:19  
we may be we

Speaker 1  14:21  
may be disappointed with the result of what occurs after they release, after the work that they've put in and we've put in to invest in their care. So we have an understanding of the problem, and we've even been able to identify a solution, and that is through medications for opioid use disorder. So the following bullet points that you see on the screen here show conclusions from a host of evidence based studies that measure the impact of implementing opioid use disorder, both in and outside of correctional settings. So these are these are not a. Opinion, they're not hopeful outcomes that we'd like to see after implementing opioid use disorder treatment. They are statistically significant conclusions made over multiple decades of robust evidence based medicine. The reality is is we want our patients to release to the community, to become active, healthy members of society. Oftentimes, I'll joke and say, you know, I want to lose all my patients to follow up, certainly not when they're within our custody, but once they release. I don't want to encounter them again in our clinical setting. So as clinicians working in this environment, you know, we don't want our patients coming back. We want them to receive the treatment that they need to create good, healthy neighbors. And you can see here that that's exactly what medications for opioid use disorder shows time and time again. To achieve we see reduced frequency and severity of overdose and death, reduced recidivism, increased safety of both, not only the correctional setting, but the community environment, reduced costs, reduced infectious disease acquisition

CAPT. Chad Garrett  16:15  
and improved employment.

Speaker 1  16:19  
So we identify a problem, we're aware of a solution, but despite that, data shows us that we are not using this solution nearly enough. In fact, in the community setting, less than a quarter of patients that have been identified as having a substance use disorder are actually receiving treatment. So not a polling question, but in the chat, can someone, or multiple people, go ahead and take a guess as to what the treatment rate is for other chronic disease states that we treat, both in the community and correctional environment. Let's take diabetes as an example of the patients who we know have diabetes. What percentage of them in our care across the United States are receiving treatment for that diabetes? What do we think the treatment rate is for diabetes in America?

Speaker 1  17:19  
So I'm seeing 9580 7090, 85 these are, these are all very good, good guesses, great guesses, very accurate guesses. In fact, it's really anywhere between 70 to 80% we'd like it to be 100% of course, right? But it's, it's typically anywhere between 70 and 80% depending on the year that you collected the data, or again, that specific condition that you were looking into. But one thing we can hopefully all agree on is that we're missing out when it comes to substance use disorder. Less than a quarter is not enough. If we treated less than a quarter of patients who we know have diabetes, I would argue that our health care costs would increase significantly as a consequence of that. So let's take it a further step. Let's go through the lens of a correctional setting in 2015 fewer than 1% of correctional environments were offering medications for opioid use disorder specifically. Now, fortunately, that number has increased over the last decade. It sits anywhere between 10 to 15% nationally, depending on what specific correctional environments you're looking at or which specific correctional environments you're including. But again, one thing's for sure, we have progress to make. So with our first objective wrapping up, we've identified the impact of the problem, we've summarized the benefits to treatment, but we also recognize that there are many challenges to incorporating opioid use disorder care into a correctional setting, we certainly recognize that. So let's identify some of the opportunities that we see, and with that, we will turn it over to Lieutenant Commander Gossett. Thank you

Speaker 2  19:17  
so much, Commander droud. So let's get started and explore several key strategies that we can initiate medications for opioid use disorder in our practice settings. The first and most consistent approach is integrating medication initiation within routine chronic care. So for patients with opioid use disorder, regular checkups and monitoring are essential to evaluate ongoing treatment and adjust medication as needed. The transitional phase, whether it's intake or discharge, is a ideal and ideal moment to begin or reinforce medication. This ensures a smooth continuation of care when patients are transitioning between different treatment settings or back to their communities. Medications for opioid use disorder can also be initiated alongside other clinical needs. For example, during a treatment for other condition, a healthcare provider can assess and address opioid use disorder simultaneously, and this can provide a more holistic approach for our patients. Patients requesting assistance during a sick call visit, often seek immediate care for discomfort or withdrawal symptoms. This offers another timely opportunity to initiate or adjust medication and ensures the patients are supported during critical moments of distress. And finally, and probably most importantly, medications for opioid use disorder can be introduced during medical emergencies such as overdoses or acute withdrawal, to stabilize the patient and prevent further complications. Each of these strategies can help create multiple touch points for effective medication initiation, offering flexibility and support for patients across different care settings. So now let's transition into some real world cases that illustrate each of these strategies in action. We'll walk through each example for each approach to better understand how they can be implemented in our clinical practice. So we'll move into some some real world cases. First we have DS. He's a 26 year old male. He's scheduled for his annual preventative health visit today. His vitals show slightly elevated heart rate, but otherwise unremarkable. Patient is noted to be restless during the encounter. They have no history of chronic care concerns and their CMP, CBC, a 1c and lipids that were drawn last month prior to today's encounter are all within normal limits. So part of your preventative health care health chronic care encounter is to discuss his substance use history. He reports of misuse of opioids, specifically prescription opioids, after he had a motor vehicle accident that led him down the path to heroin. He reports a history of daily IV heroin use for about three years, and says that's basically why I'm here. When you ask about his current misuse, you notice DS pauses and hesitates for a minute and becomes a little bit withdrawn, and he says, Not since I've been here. So let's be honest, we're going to open up another poll at this moment. How might you respond to his hesitation regarding to his current substance misuse? Would you dig a little deeper to fully understand the possible misuse of substances, or perhaps maybe you might just accept his answer, because, after all, there's no drugs in prison, right? We'll give you a minute to respond to that poll.

CAPT. Chad Garrett  22:59  
So far, we've got one person who believes there are no drugs in prison. Everybody else seems to be going with dig a

Speaker 2  23:09  
little deeper. Alright, so I'm glad to see a majority would dig a little deeper. But I also appreciate the honesty from those who chose B because it can be challenging to have these conversations, especially when we're changing the previous culture of corrections.

Speaker 2  23:30  
So for the sake of our case, you remind ds that his medical information is private and treatment options are available here for substance use disorders. He continues to share his current misuse of both suboxone and heroin, depending on what he can get that any certain day, and he explains that his last misuse reported was two days ago. A clinical opioid withdrawal scale, or a cow scale was performed. This measures the severity of his opioid withdrawal, and it shows that severe symptoms are present for him and that you do a point of care drug screen, and this shows results that are consistent with what he's telling you. They are positive for heroin. So after risk versus benefits discussion of treatment options for oud and consent forms are reviewed and signed. You decide to induct DS on buprenorphine. All right, so we'll we'll move on to the next case, and maybe this will be a little bit of a more obvious encounter that you would have for oud treatment, and that's for a patient who's already on established medications for opioid use disorder treatment prior to their incarceration. Here we have JT. He's a 43 year old male, and he's transferring into your state facility from a county jail. He reports that he was prescribed suboxone 16 milligrams a day for oud during his medical intake. So we got another poll that we're going to open up.

Speaker 2  25:11  
All right, so what steps might we take next? A, would we go ahead and detox using medications for supervised withdrawal? Or B, do we want to confirm the validity and dose of their prescription?

CAPT. Chad Garrett  25:28  
All right, we've got answers pouring in. So far. It looks like 100% are choosing to confirm the validity.

Speaker 2  25:38  
All right, that's, that's perfect, and that's the way we're trying to move in the Bureau of Prisons, for sure, ideally, we're able to continue his treatment if the order is confirmed. Sometimes patients also transfer in with paperwork, prescription bottles or other means that we're able to conduct a proper medication reconciliation at intake and ensure his continuity of care is provided. So for JT, he was able to continue his treatment without any gap of care because the nurse took the time to confirm the dose and alerted the doctor to provide orders for continuity of care. So let's look at a case where we find an indication for opioid use disorder treatment while treating another chronic disease, or maybe even acute disorder. Substance use disorders often increase the prevalence of experiencing other comorbidities. We have listed here some of the most common comorbidities present among patients suffering from substance use disorders. While screening for substance use disorders, it's always in the it's is always indicated. We see that DS is our first case. These patients with the following comorbidities are also known to have an increase or increased risk for having or developing substance use disorders, and therefore they have an increased indication for screening. Mental health disorders are one of the most common comorbidities to occur with substance use disorders got chronic pain and infectious diseases, including acute cellulitis, that might indicate IV drug use, as well as substance use disorders of a particular substance can often lead to poly substance misuse. So for our next case, we have, as there's this is a 35 year old male referred to the pharmacist led Hep C clinic. He had recent labs that indicate that he's positive for hep C antibodies and he has a detectable viral load of genotype one a he also has a history of depression, which he's currently well controlled, on fluoxetine, 40 milligrams a day, as well as a diagnosis of oud based on his past medical history described at intake years ago, The pharmacist reviews the patient's history, including their substance use history, which is positive for IV heroin and fentanyl misuse. The pharmacist provides education on acquisition of infectious diseases such as Hep C via IV drug use, and they report the patient reports being treated in the past with suboxone that worked really well for them. They deny current IV misuse, but it's getting harder to resist. So the pharmacist, who has a collaborative practice agreement for both Hep C and oud, utilizes his oud diagnosis, his current presentation and updated labs on file to initiate suboxone for oud, as well as Hep C treatment to reduce the risk of reinfection from possible IV misuse in their if their oud had been left untreated.

Speaker 1  28:59  
Excellent. So this is Commander drought, kind of coming back in to wrap up the last two cases. So not all situations in the in really any correctional setting, much less the Federal Bureau of Prisons, not not all situations, do we as the clinician, find the patient, which was kind of the case in a lot of the examples we just went over, sometimes the patient and oftentimes the patient themselves will reach out to us for help. So in the bureau, we call them sick call requests or COP outs, but in this case, Bg is a 37 year old female who presents to sick call with a nurse they're about to release from custody in about two and a half months and express that they're worried about relapsing when they release to the community setting. So research and digging a little bit into her medical and pre sentencing investigation or her background shows that she's pre. Obviously been released before she's had a supervised release twice in the past, back in 2022 and then most recent, more recently, in 2024 and in both of those circumstances, she violated that supervised release, resulting again in recividism and her reincarceration. We can even see the urine drug tests from both of those circumstances. So knowing the increased risk of overdose that we've we've reviewed earlier in this presentation, for those releasing to the community and noticing her continued history of recidivism when released without opioid use disorder treatment, the nurse refers BG to their provider, who fortunately has a collaborative practice agreement and is able to initiate oud treatment prior to their release. The provider also fortunately coordinates with a social worker who can assist BG with continuity of care for opioid use disorder upon their release, and get them plugged in with a provider in their releasing community area who's going to be able to continue that treatment upon release. So for the last case, for our last example, let's kind of go back in time, and we'll recall DS, who was our first case that was there for preventative health, if you remember, and we asked this polling question where, based on their hesitancy, would we dig a little deeper and maybe ask some more probing questions? Or, again, would we maybe just go ahead and move forward again? There's no drugs in prison, so let's kind of see if we maybe would have went down Option B. Or what might happen if at another environment, in another timeline, we went down Option B? So

Speaker 1  32:04  
and that again, is that we accept their answer, we deny that there's any possibility of misuse in a correctional setting. So unfortunately for our DS case. In that timeline, a medical emergency is called in the housing unit, and upon arrival, CPR was already initiated. And you notice that DS, it's DS from the previous week where we kind of had that opportunity to move down Option A, but this is an alternative timeline where maybe we go down B and there's no pulse. They're not breathing. DS, lips are notably darker in color, and fortunately, You're quick to order an intranasal Narcan, which is administered and is available at your institution. DS, does become more responsive with shallow breathing and now a pulse, and you continue, continue to stabilize DS, including a second dose of Narcan, with an additional response to their respiratory rate, and they're transported to a nearby hospital, where they do end up testing positive for fentanyl. So fortunately, ds survives that encounter, thanks to everybody's quick response and thanks for your your diligence to offer and provide Narcan to that patient. DS has since returned from the outside hospital and is here to see you upon intake. And they admittedly feel a little bit guilty for not being honest with you before, before, when they were there for their preventative health care visit, and today they they kind of admit that they were having ongoing misuse of substances in the correctional setting, really whatever they can find is how they express it. So after additional evaluation, again, kind of where we went with DS initially, ds is an eventually inducted on Suboxone for treatment for their opioid use disorder. So we've seen several examples where we might be able to recognize an opportunity to implement opioid use disorder treatment within our practice settings. And with that, let's identify the benefits of expanding this access through, again, a multi disciplinary team approach. So again, we'll turn it back to Lieutenant Commander Gossett, who will start out this third and final objective.

Speaker 2  34:47  
All right, so one of the best ways that we've seen to work in our institutions to coordinate care for opioid use disorder treatment has been to host monthly multi disciplinary meetings. We invite our. Entire medical team, as well as custody staff like our captain or lieutenant, because we found that the success of treating oud in a correctional setting required input from those who work from the front lines on in corrections. By taking a multi disciplinary approach, we can ensure all areas of our institution impacted by oud treatment are on the same page. Members from our other disciplines, such as custody, also provide insight and perspective about specific patients or trends that they're seeing on the compound that would otherwise not be discovered from a single provider treating oud alone. So specifically, at FMC Lexington, we have meetings twice, twice monthly, sometimes just monthly. We're talking about challenging cases. It's great to be able to collaborate with different practitioners. If you have a challenging case, you can pull them in, and they can see that that team approach is there so they don't manipulate one practitioner over another patients that are on our waiting list. So we obviously are treating a lot of patients right now, but we still are prioritizing those patients that are they're still waiting on treatment. And then we talk about our day to day workflow, such as like planning for pill lines that we perform, or how to prioritize a certain patient.

Unknown Speaker  36:24  
Because of these meetings and

Speaker 2  36:27  
widespread information about oud treatment within our institutions, many patients can then be referred through many disciplines and that attend our monthly meetings. For this case, PB was seeing their psychologist for their annual visit due to their diagnosis of anxiety and depression. However, during the encounter, the subject of substance use history was brought up based on their anxiety from their anxiety as a trigger for his substance use. As it turns out, PB was scheduled to release later that year, and was having increased anxiety symptoms over fear of relapsing. Unfortunately, to cope with this, he was misusing suboxone from the compound to self medicate his uncontrolled anxiety. They were referred to the pharmacy led oud and behavioral health clinic to receive an adjustment in their SSRI, which had remained on the lowest dose since initiation, as well as oud treatment prior to their upcoming release. So here, in a separate case, we have also another member of our meeting, the phlebotomist, or maybe someone else that draws labs at your institution refers a patient after noticing scarring and track marks on their on their forearm, and kind of tells them that they're a pretty hard stick when they try to do labs in the in the lab, they remembered a training that they had received in their orientation about oud treatment being offered while in custody, and informed the provider who ordered the lab their observations, this led to treatment for both cellulitis and oud, as well as screening for hepatitis and HIV, which were, fortunately for them, were negative. So this next example is a preview, or circles back to a previous presentation about harm reduction that we had a couple weeks ago. Many of our patients have questions, or perhaps their provider isn't as available or feels as comfortable answering these drug information questions. In the BOP, pharmacists often provide this education. Specifically, many pharmacists across the BOP run harm reduction clinics as part of their OED CPA for those releasing to the community. So let's take a look at the remarkable increase that we've seen in the Bureau of Prisons on the distribution of Narcan within our institutions over the past several years. So starting in 2021 we were just under 500 doses of Narcan dispensed at release. That number was a starting point for what would become a significant rise in efforts to combat opioid use disorder. Fast forward to 2022 we saw a huge jump to over 3000 doses, doses distributed, and this is over a seven fold increase from the previous year. It marks an important change in the way we approach prevention and response. By 2023 that number grew to over 8000 doses, more than doubling 2022 this continued upward trend highlights the growing recognition of the need for widespread access to this life saving intervention, and here we are in 2024 we we reached over 13,000 doses of Narcan distributed a clear indicator of the ongoing commitment to combating the opioid crisis in our institutions. This increase demonstrates our progress and dedication to saving lives. Lives through the prevention and immediate intervention. This upward trajectory and distribution is not just a statistic. It's a reflection of how essential Narcan has become in our efforts to prevent, protect and care for those at risk for overdose. So additionally, as you've noticed in the past, case, past couple of case examples, pharmacists themselves can be utilized to provide oud treatment through collaborative practice agreements or CPAs, and as discussed during one of our previous cases, we've included the impact that this has had for two of our institutions. So here we have FMC Lexington and Butner. So at FMC Lexington, where I manage oud patients, as a pharmacist, we've treated over 400 patients since 2021 This includes initiating treatment and follow up, dose titrations and reviewing your treatment goals. Currently, we have over 150 patients on oud treatment at in Lexington commander droughts institution, as he mentioned earlier, is the largest bop Medical Center, and has a higher volume of patients through the pharmacy led clinics there, they've treated over 260 patients that are currently in their program right now, and have treated 900 Since 2021. We have 49 pharmacists in this in the Bureau of Prisons now that have CPAs that allow them to help treat opioid use disorder.

Speaker 2  41:40  
So here you can see that several states allow pharmacists to prescribe controlled substances under collaborative practice agreements. So we all know that suboxone and methadone are both controlled substances. So if you're at a state or county level institution, these are the states that do allow pharmacists to prescribe controlled substances, and even if you can't prescribe these directly, as we've seen for other cases, pharmacists can get involved in many ways by providing providing Narcan distribution or education, harm reduction information and everything in Between. I'll turn it back over to Trey.

Speaker 1  42:22  
Excellent. Thank you so much, Gosset, so the one of the final things we wanted to share, and that I had briefly mentioned towards the beginning, actually, within our introduction of the presentation, is that the Bureau of Prisons utilizes what we call substance use disorder Clinical Pharmacy consultants. And like I said, that's a group of 17 pharmacists, 18, including myself, that are subject matter experts identified through the BOP to provide clinical and administrative expertise within their assigned regions. So the bureau federally is broken up into different regions, and we have substance use can substance use disorder consultants within each region that are then therefore assigned to over the 122 institutions or complexes across our bureau. So in the in this way, a consultant that said a single institution can provide clinical insight to a provider who may just be starting out their journey, or starting out treating opioid use disorder, they may need additional guidance on where to start, how to prioritize, what treatment selections to make, or perhaps just need consult with a more challenging case, We've had several consultants actually perform remote encounters to manage opioid use disorder through telehealth and collaborative practice agreements, again, maybe where resources in that institution are limited, and with how challenging oud opioid use disorder care in correctional settings can be, And really how arguably new that it is for many providers or institutions, it's been an incredible asset to have these SMEs or subject matter experts available and assigned to each institution, not just simply, again for those clinical questions in terms of treatment selection or dosing, but really also administrative expertise as well in terms of how to administer medications for opioid use disorder, maybe best practices from other institutions on their pill line procedures, and we can learn a lot by sharing those Clinical and administrative best practices between institutions and across consultants where that specific and official line of communication might not otherwise exist. For example, somebody who practices in Virginia at a federal prison oftentimes can teach their consultant something, and that Consultant. Might teach that best practice to another prison located in Kentucky or New York or perhaps even hundreds of miles away in California. So it's it's really a great network of experts where we can kind of convert 17 experts that provide resources for 122 institutions. So to wrap up and to kind of summarize again, we recognize that there's a lot of challenges to implement opioid use disorder treatment within our unique practice setting. But despite those challenges. Implementing opioid use disorder treatment has been shown to reduce recidivism, increased safety, and perhaps maybe most importantly, reduce mortality for our patients, especially upon their release to the community. The indications for opioid use disorder treatment can be identified in many circumstances and opportunities that we face every single day as multi disciplines, referring to those providers and again, utilizing that multi disciplinary approach training everyone you know, From your practitioners, your doctors to your pharmacists, to your nurses, to your phlebotomists, the way that we showed you, maybe even to your other departments, correctional officers, psychologists, case managers. If everyone is aware of what the process is and how to refer patients and what to look for, again, we can really identify, again, that gap in treatment that we continually see, that we can make progress with. And with that, we invite any questions that anybody from the audience has, and we really thank you again for your time to even take the time out of your day to participate.

CAPT. Chad Garrett  47:02  
Thank you so much, Chris, were there any questions? Yeah,

Christopher Smith, NPA  47:04  
I was going to say this is actually a great group for questions, so I hope you guys are ready. All right, from Denise, we have are those getting the medications, also receiving clinical services, including counseling, therapy and groups.

Speaker 1  47:20  
Yes is the short answer to that question. Obviously, across 122 institutions, it may look different based on what their resources are, whether it be the number of psychologists that they have, social workers that they have, I will say we would not deny medications for opioid use disorder simply because there is no access to counseling. Study and data shows that having access to the medication itself, it provides significant harm reduction. So we don't, we don't require that both are available to the patient, but certainly, if it is available, it is part of the opioid use disorder agreement that they sign prior to starting treatment, that if it were deemed necessary and available, that they do participate in that counseling. So ideally, yes, it is available, and I would certainly say that at the majority, if not all, of our institutions, there is certainly a level of counseling, group, individual therapy. We have a whole host of different drug education classes, anger management classes. A lot of different resources are available, fortunately, vocationally and psychology, psychologically for our patients.

Christopher Smith, NPA  48:43  
Good appreciate cancer from and I may mispronciate This name, and if I do apologize from Sofia says I typically work with state agencies rather than the federal, federal level. But I'm interested in learning about more about the BOP and doing it in this space. How does bop track individuals post release to avoid duplication of services and ensure continuity of care, particularly in connecting them to community based providers. Are you utilizing state identification numbers or any other method of continuity?

Speaker 1  49:16  
That is an excellent question. I will say, we do have a team of social workers that deals primarily with that lane. So I might not be able to answer it directly or specifically, but I do know that they conduct what's called an aftercare plan for all of our patients who are releasing directly to the street, if they're releasing to a halfway house, an after a different but similar after care plan is also developed and monitored while they're at the halfway house, trying to remember all the assets of the question they likely utilize, like a PDMP to make sure that there's no duplicate prescriptions or duplicate treatment provided. And. That aftercare plan does involve getting them plugged in with a provider in that community setting and provides follow up from there.

Christopher Smith, NPA  50:11  
Monica asks, How are you dealing with the increased nursing workload that administrating suboxone causes? We feel like we only have time to count Sign Out and administer Suboxone, leaving other patient needs unmet.

Speaker 1  50:27  
That's, that's a, that's a great question, and it's a very understandable concern. You know, we certainly want to recognize that while opioid use disorder treatment is prevalent and prominent to treat it's not the only health care condition, as I mentioned that that is on our radar. We do work in resource limited settings. I certainly don't argue with that. I know at different county and state levels, there's various grants that you can apply for in order to treat for opioid use disorder, whether that be acquiring the medications themselves, staffing financial resources to help, perhaps increase retention or pay or hire staff. A lot of states offer grants of that nature. Federally, we try to keep all of our institutions as well staffed as we can. I will say there's definitely institutions that struggle with exactly what you described. We've been able to, you know, we certainly we can't recommend or offer suboxone self carry. That's not something that we're considering. But there's a lot of other correctional environments, such as Arizona, Delaware, California, that do conduct daily Suboxone or perhaps even methadone pill lines. You know, it does take time, but I think what we can hopefully take away from this presentation is that it's time well spent and does does provide a benefit for us, and it really depends on the institution or your correctional setting. We've we, as the bureau, have learned from a lot of other correctional environments, and I just mentioned a few of them, California, Arizona, Delaware, where we used to kind of require our patients to sit on their hands or be observed for 15 minutes while the film completely dissolves. Over the years, we have become a little bit less restrictive of that pill line process. You know, we really require that the patient present for a mouth check, maybe swish and swallow water to hydrate their palate, they receive that film, and as long as we can observe that it has begun to dissolve. For many of our institutions, they will excuse the patient at that time. So it really just depends on how restrictive or close you want to monitor the patient. It's certainly not to say that there isn't any risk of diversion or introduction of that substance, but with the way that we're doing it, which again, was based on a lot of other correctional environments, we haven't seen any increase in diversion or overdose with implementing those those changes.

Christopher Smith, NPA  53:23  
Thank you, sir and Commander, you kind of touched indirectly on this next question in the previous answer, but I'm going to give you the opportunity more directly. Answer. It says, Does the BOP utilize methadone?

Speaker 1  53:34  
It does, yes. We do have methadone as a treatment option for our patients in custody.

Christopher Smith, NPA  53:43  
Good. Alright. Denise asked, What are you doing with those using mat that test positive for other drugs? Do you follow the requirements, distribute the med on the tiers, etc? Do they get discharged?

Speaker 1  53:56  
I would say that they do not get discharged. I'm not sure what the first tier I'm not sure what the tiers referenced or with that, but ongoing misuse of opioids is a symptom of opioid use disorder, despite treatment or despite progress. You know, our goal with opioid use disorder treatment is to reduce harm, and we have been shown time and time again, like I said, that these medications do just that. Again, continued cravings, even relapse, is part of the spectrum of the disease of opioid use disorder in terms of additional substances outside of opioids, again, we really have to look at them almost as peanut butter and jelly. We can't expect a medication that has pharmacologic properties of the opioid receptor. We can't expect that medication. We might hope that it does, but we can't expect it. To have an outcome for a different substance use disorder, such as stimulants, cannabinoids, alcohol, we really have to kind of treat them differently so we would not discharge the patient. If anything, it likely indicates that we need to lean into or lean more into that patient in terms of counseling, vocational resources, and not necessarily the dose, but it may indicate that as well.

Christopher Smith, NPA  55:31  
Yeah, sounds very similar, if I may, to the bops RDAP program, where a usage of a narcotic or alcohol substance kind of proves that he needs the treatment and won't necessarily get him removed for a singular incident. Okay, sir, we also have Monica, again, along the same lines, but you may have a slightly different adjustment to the answer is, how do you feel about medical diversion?

Speaker 1  55:55  
So diversion, you know, again, it comes down to the institution and the provider. It's really challenging as much as we'd like to have these black and white algorithmic approaches to If This Then That while those types of approaches do help us kind of hone in on a possible response to a behavior, it really is case by case, I will personally say I have discontinued someone's suboxone in response to diversion. It may be after multiple education and counseling, Doc, proper documentation as to why I came to that conclusion, but it very much so we do have to take diversion and the introduction of the narcotic onto our compounds and complexes. Seriously, we do work in corrections, so we have to always recognize that. And again, the community standard for diversion would also at some point hold the patient accountable for that behavior. So I can't say it immediately results in discontinuation or an alternative treatment, but it certainly is not tolerated. All

Christopher Smith, NPA  57:09  
right, I appreciate it. Hey, this is a question that I can answer. Amy asked, if we can have contact information, we have additional questions. Amy, if you can scroll up your chat log, there is a email address for Mr. Garrett, if you want to send your questions to him, he can then direct them to the other two presenters in order to get a proper answer for you. Okay, we are down to two questions left. So if you guys feel able and and the viewers don't mind hanging around for a couple more minutes, we'll get these questions in as well. The questions are, have you found that group or individual therapy has proven to be most effective in the correctional setting.

Speaker 1  57:46  
I can't say I have found one or the other superior and gossip. Feel free to chime in when I'm done with this. If you've noticed anything different at Lexington. I think the best thing that we can provide is options. I think, that probably would show to be superior to only providing group or only providing individual or only providing a certain very you know, A through Z counseling program, options are always better. There are some patients that simply don't feel comfortable sharing in a group and prefer individual. And there's a lot that are vice versa. Gosset, I don't know if you've you know, have anything else to share contribute to that discussion? Yeah,

Speaker 2  58:31  
that's I was going to say the same thing. Our our institution, has groups that they meet every other week. Most of them do prefer the group setting, because it's like minded individuals. They've all been through kind of similar situations, but some don't feel comfortable in those groups, so they also offer the individual treatment too. So I think it's just like with the medication choice, it's what they would prefer or what they are willing to do. So

Christopher Smith, NPA  58:58  
alright, alright, our last question, I'll squeeze it in here real quick. From a clinical and operational perspective, what factors influence the decision to initiate suboxone over vivid I'm hoping for next thing that correctly an incarcerated population, particularly in terms of efficacy, risk reduction and re entry planning.

Speaker 1  59:18  
Yeah, so Vivitrol is the pronunciation there? Yeah, absolutely. So again, it goes back to as much as we'd like to have black and white algorithmic approaches, and certainly we have some factors that help us hone in on a decision. It really is case by case, but certainly what stands out to me is the patient's risk of overdose. So if the if the patient has maybe a moderate to mild opioid use disorder, maybe has not misused an opioid while in custody or for a long period of time, maybe they only have a. Intermittent or micro doses of misuse on occasion, and again, if the patient is willing to take it, you know, in order to be able to initiate naltrexone, the patient does need to be, you know, have a negative urine drug test prior to initiating that naltrexone. And that can be very layered, and probably we could have an entire discussion on the pharmacological treatments and how to consider them in this setting as an entire other presentation. But it really does come down to the severity of the opioid use disorder, their their current look at misuse and how that's impacting their life, and then again, their risk of overdose. So I have you know again, for DS, for example, who you know went to the outside hospital, had fentanyl test positive in their system. That's a patient that that clearly has a significant concern with not only active misuse and opioid use disorder, but death. So you know, I'm going to respond to that severity in kind with the treatment options that I present. Same for a patient who's releasing to the community again, as they're approaching their community release, I'm much more likely to consider additional dosing options that they're going to be able to have access to or willing to take, because again, they're approaching a time frame that's that we know increases their risk of overdose.

Christopher Smith, NPA  1:01:38  
Alright, well, I appreciate it. We've reached one, so I better hand it back off to Mr. Garrett real quick. Thank you for the question and answer session.

CAPT. Chad Garrett  1:01:45  
Thank you. And just like that, one hour together has flown by fast focus and pharmaceutically fabulous, we've explored the evolution of oud care behind bars, examined strategies to embed treatment and everyday practice and celebrated the clinical clout of collaborative teams. Most importantly, we've seen how pharmacists like Lieutenant Commander Gossett and Commander drought are reshaping recovery, redefining roles and raising the bar in correctional health care through our brilliant speakers. Thank you. Thank you so much for your insight, your innovation and your relentless dedication to improving lives one carefully calculated dose at a time. Your work doesn't just move the needle. You've reset the entire scale. To the audience. Thank you for leaning in and learning with us and being part of this ongoing conversation, whether you're prescribing planning or just playing passionate about progress, your engagement matters. Rational health isn't just about containment. It's about care, connection and creating pathways to healing. Just remember, Correctional Health Care is public health. Please take just a few minutes and complete that post course assessment that you'll be led to. This allows us to continue to improve, and it also gives us a chance to see what topics you are most interested in. Remember, this is your education program that we are facilitating for you. So on behalf of the National Institute of Corrections and the clinical Pearl series, thank you for joining us, my friend, stay curious, stay collaborative, and until the next time, keep bringing the change our system needs so badly, but wait, wait, wait, before you run off. Let me tell you about what we're going to be doing next week. Next week, we'll be on session seven, caring for the aging, incarcerated adult, the silver tsunami, I like to call it, and as the incarcerated population ages, professional healthcare systems are facing increased challenges and providing effective and compassionate care. So join commander hunt and Commander stoner as we investigate caring for aging incarcerated adults. So continue challenging the status quo, championing best practice, striving for excellence. Stay engaged, stay curious, stay committed, and we look forward to seeing you next time i.

Transcribed by https://otter.ai