Helping End Addiction Long-term Franklin County (HEALing FC) is a new program that seeks to engage vulnerable populations incarcerated in the Franklin County House of Correction (FCHOC) and justice involved individuals residing in and near Franklin County in medications to treat opioid use disorders (MOUD) and improve outcomes for medication adherence. The specific program aims are to: 1. Incorporate a holistic gender and trauma responsive treatment program, and an environment to support emotional safety, pre/post release for individuals incarcerated at FCHOC, with a special focus on women, and 2. Enhance and expand the reentry component linking individuals with OUD to community-based providers of MOUD and other supportive services, while incorporating a contingency management model throughout their continuum of care.
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Liz Evans and her team at UMass will conduct an evaluation to understand how to expand capacity to provide MOUD to the target population, assess the populations’ use of MOUD and other health and social services, and assess treatment outcomes. The project is funded by the Substance Abuse Mental Health Services Administration (SAMHSA) for five years starting September 1, 2021.
evaluation of the Community Opportunity, Network, Navigation, Exploration, and Connection Team (CONNECT)
Community Opportunity, Network, Navigation, Exploration, and Connection Team (CONNECT) will use an evidence-based regional hub and spoke model to create the first opioid overdose rapid response team to serve the 30-towns located in rural Franklin County and North Quabbin region of Massachusetts. The CONNECT program aims to reduce opioid overdoses through rapid response times and multi-sectoral collaboration, as well as the expansion of naloxone availability and appropriate use. It will also enable first responders and bystanders to safely handle fentanyl and other illicit substances to “save lives safely.” The CONNECT program has seven main goals: 1. Provide real-time 24/7 assistance to survivors and witnesses of an opioid overdose; 2. Make in-person follow-up visits, within 72 hours to assess health and social needs; 3. Deliver comprehensive evidence-based care including peer support or trauma-informed practices to connect individuals to pharmacotherapy, community-based services and recovery supports; 4. Use “warm handoffs” to ensure opioid overdose survivors and witnesses navigate care across systems; 5. Expand naloxone availability and appropriate use by first responders and community bystanders focusing on naloxone deserts; 6. Create a database to track CONNECT participants for care coordination and conduct trainings on protections for bystanders who assist during an overdose; and 7. Establish safety protocols on fentanyl and other licit or illicit opioid exposure. Liz Evans and her team at UMass will evaluate the implementation of CONNECT and assess its effectiveness. The project is funded by the Substance Abuse Mental Health Services Administration (SAMHSA) for two years starting September 1, 2020.
Holyoke Early Access to Recovery and Treatment (HEART) Internship Program
The HEART Program is located in Holyoke, a city in need of public health interventions to address the opioid epidemic, particularly among Hispanic and Latinx populations. The Holyoke District court leads the program with input from key collaborators, including Professor Evans and her team of interns, Amelia Bailey and Samantha Hano. The program is designed to provide same-day access to medications and other treatment for opioid use disorder (OUD) for individuals who appear before the Holyoke District Court, and thereby reduce not-fatal and fatal opioid overdose events.
The Massachusetts Justice Community Opioid Innovation Network (Mass JCOIN)
mPIs: Peter Friedmann, Elizabeth Evans
Funded by: National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH). Grant No. UG1DA050067, Clinical Research Hub
Limited access to effective medications for opioid use disorder (MOUD) that reduce overdose risks is a major cause of the opioid crisis. Most U.S. jails and prisons do not provide MOUD. After incarceration is a high risk period for fatal overdose. In Massachusetts, a 2018 law mandated that county jails deliver all FDA-approved MOUDs. This presented an opportunity to form the Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) in partnership with jails, the MA Department of Public Health, and community treatment providers to conduct an effectiveness-implementation study. MassJCOIN is part of a national network led by the National Institute on Drug Abuse and funded by the NIH HEAL Initiative to re-envision how the justice system responds to addiction.
The specific aims of MassJCOIN are to:
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Perform a longitudinal treatment outcome study among incarcerated individuals with OUD who receive naltrexone, buprenorphine, methadone, or no MOUD in jail to examine post-release MOUD initiation, engagement and retention, as well as fatal and non-fatal opioid overdose and recidivism;
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Conduct an implementation study to understand systemic and contextual factors that facilitate and impede delivery of MOUDs in jail and community care coordination, and strategies that optimize MOUD delivery in jail and for coordinating care with community partners;
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Calculate the cost to the correctional system of implementing MOUD in jail, and conduct an economic evaluation from state-policymaker and societal perspectives to compare the value of MOUD prior to release from jail to no MOUD among matched controls. Read more about MassJCOIN in our recent article, which appeared in the Journal of Substance Abuse Treatment.
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Evaluation of the Franklin County Sheriff’s Office Medication-Assisted Treatment (MAT) Reentry Initiative
PI: Elizabeth Evans
Funded by: Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT). Grant No. 1H79T1081387-01
The Franklin County Sheriff’s office, in collaboration with the Hampshire County Sheriff’s Office, is implementing a program to expand capacity to provide medications to treat opioid use disorder to jail detainees (n=300) and to implement a comprehensive community reentry program. The project will form multi-sectoral collaborations with key community partners to ensure a continuity of care and an integrated behavioral health and opioid use treatment approach.
The evaluation of the initiative will utilize a mixed methods pre-post research design to evaluate project implementation and assess its effectiveness. The evaluation consists of two aims:
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an Implementation and Process Study to understand how to expand capacity to provide medications to the target population, and
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an Outcome Study to assess medication utilization and outcomes, both during and after incarceration.
The evaluation will provide information on rates and predictors of medication engagement and adherence in the community after exit from incarceration. It will also help to establish best practices for providing health and social services to criminally involved individuals during incarceration and afterwards.
Post-Release Opioid Use Trajectories after MAT in Jail
PI: Peter Friedmann Co-I: Elizabeth Evans
Funded by: National Institute on Drug Abuse (NIDA) Grant No. UG3DA044830-02S1, Administrative Supplement to Drug Injection Surveillance and Care Enhancement for Rural Northern New England (PI: Friedmann)
Individuals with opioid use disorder (OUD) who are involved with the criminal justice system and released from incarcerated settings are at a critical risk for accidental injuries, infectious diseases (HIV, hepatitis C), and premature deaths. A potentially key strategy to address the opioid epidemic among criminal justice populations is to increase access to medication for addiction treatment (MAT), particularly buprenorphine (Bruneau et al., 2018; HHS, 2016). Implementation of MAT in U.S. criminal justice settings is scarce. The Franklin County Correctional Facility (FCCF) in Greenfield, MA is one of the fewer than 30 jails in the nation to treat opioid use disorder with buprenorphine [1, 4]. FCCF is located in a federally designated rural county in Western Massachusetts, an epicenter of the opioid epidemic [2]. FCCF initiated its MAT program in 2015 to treat the approximately 46% of FCCF inmates with a prescription opioid or heroin use disorder [3]. As of April 2018, FCCF has provided MAT to 252 individuals: 83 have been treated with extended release naltrexone (Vivitrol or XR-NTX) and 169 with buprenorphine/naloxone (bup/nx). Hampshire County (located immediately south of Franklin County) is home to a similarly rural population but, in contrast to the FCCF, the Hampshire County Correctional Facility (HCCF) does not provide bup/nx. The differences in MAT provision between these jails in adjacent counties presents a unique opportunity for a natural experiment to examine what happens to individuals when they return to the community after receiving MAT while incarcerated. Existing studies that have examined outcomes after receipt of in-jail MAT often are limited by small sample sizes, a short-term detoxification approach, no contemporaneous non-treated comparison groups, and disparate outcomes during incarceration or upon release. To our knowledge no studies include a substantial rural population as is present in Franklin County. Existing research also does not address longer term outcomes such as whether individuals who receive MAT while in jail, relative to those who do not receive in-jail MAT, demonstrate differential trajectories of opioid use over time, and whether individuals who receive in-jail MAT continue to seek and receive MAT in the community.
The goal of this administrative supplement to Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) (PI: Friedmann, DA044830), is to gain understanding of the trajectory of opioid use after release from jail for individuals who received MAT while incarcerated. This 1-year study will provide post-incarceration trajectories of opioid use among 500 targeted participants (n=250 from each jail) and examine the association with in-jail MAT treatment, individual factors, and subsequent community-based treatment in rural Massachusetts.
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The specific aims are as follows:
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To determine post-release outcomes of individuals treated with MAT while incarcerated versus individuals who did not receive MAT while incarcerated.
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To investigate individual characteristics and treatment factors associated with post-release MAT access, utilization, and outcomes among study participants who did and did not receive MAT while incarcerated.
The primary outcome is the trajectory of post-incarceration opioid use. Other long-term outcomes of interest include: alcohol and other drug use, mental and physical health, quality of life, criminal justice status, HIV/HCV risk behaviors, and mortality. Treatment access and utilization factors of interest include: predisposing personal factors, treatment experiences, and perceptions and attitudes towards treatment. Study results will enable better characterization of previously understudied aspects of treatment and recovery among criminal justice populations with opioid use disorder. Findings will also inform efforts to expand MAT in correctional settings, including H4725 in Massachusetts that includes the creation of a two-year pilot program amongst six correctional facilities to expand access to MAT for patients with OUD in the criminal justice system. This proposed supplement is within the scope of the parent award in that it will provide better understanding of a community response strategy to opioid use disorder aimed at high-risk individuals in the rural U.S.
Exploring shared decisionmaking as an ethical response to the opioid epidemic
PI: Elizabeth Evans
Funded by: The Greenwall Foundation, Making a Difference Program
A national public health emergency, the opioid epidemic has resulted in extraordinary numbers of accidental injuries, infectious diseases, and premature deaths, contributing to a historically unprecedented shortening of American life expectancy. Addiction medicine experts largely view opioid use disorder (OUD) as a chronic health condition that is best treated with long-term, or even life-long, treatment with medications for opioid use disorder (MOUD, e.g., buprenorphine, methadone, naltrexone). In contrast, MOUD social stigma means that many patients utilize addiction treatment without medications, believing that MOUD is merely “replacing one drug (e.g., heroin) for another (e.g., methadone);” others prematurely discontinue MOUD against medical advice. Patient treatment preferences are among the major reasons why only about 10% of people with OUD ever access MOUD and, of those who do, many do not receive MOUD long enough for it to be beneficial. It is in this context that newly formed multi-sectoral opioid task forces are taking extraordinary collaborative actions to engage vulnerable populations in MOUD. For example, MOUD is being offered to patients with OUD when receiving emergency department services and to prisoners at exit from incarcerated settings. At the same time, there is increasing support among policymakers and the public for the involuntary civil commitment of people with OUD to treatment, but typically to settings that do not provide MOUD. Finally, stakeholders areanalyzing “big data” on opioid users from health, criminal justice, and social services systems for surveillance and aggressive outreach efforts. Collectively, these actions may save lives, but ultimately be experienced by patients as coercive or harmful, and infringe on patient autonomy, privacy, and civil rights. A broader problem, therefore, is that current responses to the opioid crisis may be of limited impact, unfairly distribute resources and intended benefits, and ultimately erode patient and public trust in the ability of healthcare and its partners to resolve the crisis.
The overall project objective is to explore shared decision-making as part of a new and practical normative ethics framework for responding to the opioid epidemic. We will create a patient advisory council made up of a diverse group of patients with OUD and their allies (family, friends) and convene it with clinicians, criminal justice leaders, policymakers, and other community stakeholders to examine the following aims:
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assess whether and how patients with OUD want to be (a) engaged in decisions regarding whether to enroll in MOUD, (b) told that MOUD is the best option, or (c) treated against their will, and
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assess whether and how patients with OUD should participate in decisions regarding how big data on opioid users is collected, stored, shared, interpreted, and used.
We will investigate these aims with key informant interviews, focus groups, and surveys. Findings will inform the creation of policies and protocols that are respectful of patients’ healthcare needs, preferences, and values, while also empowering patients to work in partnership with others in determining how the opioid crisis should be addressed.