Evidence Based Treatment for Justice-Involved Populations in Allen County, Indiana

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The United States is in the midst of an overdose epidemic. In 2017, there were over 70,000 drug overdose deaths, more than two-thirds of which were associated with opioids.1 The nexus of the criminal justice system and community-based treatment has substantial capacity for mitigating the effects of the current overdose crisis. Nearly two-thirds of incarcerated individuals meet the criteria for substance use disorder, and 20% for an opioid use disorder, though few of these individuals receives evidence-based treatment.

 

To address the issue of treatment in justice-involved populations, the State of Indiana has distributed funding to implement new initiatives that increase access to treatment and reduce overdose deaths through the provision of prevention, treatment, and recovery activities. One such initiative is the Allen County Substance Use Treatment Pilot Program, which was established by Senate Enrolled Act 510 as a four-year pilot program to provide treatment to those under correctional supervision.

Figure 1: Allen County Substance Use Treatment Pilot Program Case Flow Diagram
Figure 1. Allen County Substance Use Treatment Pilot Program Case Flow Diagram​​

The Allen County Substance Use Treatment Pilot Program is a residential treatment program that involves evidence-based treatment in a safe housing environment, most often a non-hospital residential facility staffed by licensed addiction treatment personnel, with stays that can span from a few weeks to several months.2 More than twenty years of research suggests that the treatment intensity possible with residential services—in terms of length of time spent in treatment—is positively associated with better recovery outcomes.3–5  As part of the residential services, medications for opioid use disorder are also offered, which is the gold standard of treatment for opioid use disorder, with research demonstrating improved treatment retention, increased abstinence, reduced risk of overdose, reduced the likelihood of recidivism and crime, and reduced risk of HIV or Hepatitis C infection. 6-9

Figure 1 outlines the case flow process for participants, who must be at least 18 years old, charged with a felony offense in Allen County, and under court ordered supervision. Clients must have a diagnosed substance use disorder and have been previously unable to engage in recovery. An assessment process determines the American Society of Addiction Medicine (ASAM) Level of Care, and eligible clients may transfer directly from jail to transitional living or treatment. During the course of treatment, clients work with providers to coordinate a discharge plan with a referral to a recovery residence, an intensive outpatient program, or a personal residence.

 

Short-Term Outcomes

Figure 2. Short-Term Outcomes from the Allen County Substance Use Treatment Pilot Program
Figure 2. Short-Term Outcomes from the Allen County
Substance Use Treatment Pilot Program

Although the Allen County Substance Use Treatment Pilot Program was signed into law in 2017, there were a number of barriers to its successful implementation that persisted through 2018. Most notable were state restrictions on the use of funds for purchasing and rehabilitating brick and mortar facilities and "not in my backyard" sentiment from local community members towards establishing these services for justice-involved persons with substance use disorder. However, strong and well-established partnerships between Allen County criminal justice agencies and treatment providers facilitated the project's perseverance and the pilot program was launched in the spring of 2019.

As of December 6, 2019, 107 participants have been referred to the pilot program with more than half (53%) of participants referred by Allen County Community Corrections, followed by 30% from Allen County Superior Drug Court and 17% from Allen County Adult Probation. In looking at treatment and criminal justice outcomes, it is important to note the limited follow-up time among the participants in these preliminary analyses. For example, at the time of this analysis only 25% of clients had six months of follow-up time. However, the initial data show that 44% of clients had completed treatment at the highest level of care (3.5 ASAM) and 34% were receiving a medication for opioid use disorder. Moreover, only 8% of program participants have had new involvement in the criminal justice system through either a re-arrest or technical violation.

 

Conclusions

Across the United States, criminal and legal systems have struggled to provide evidence-based treatment for substance use disorder, specifically medications for opioid use disorder. Allen County has been successful in implementing a new pilot program that provides intensive residential treatment for justice-involved individuals. This implementation likely would not have been achieved without strong alliances between criminal justice and treatment stakeholders or the leadership of The Lutheran Foundation, which has partnered with local substance abuse treatment facilities—Park Center, Shepherd's House and Redemption House—to expand the treatment and housing availability in the area. To date, the pilot program has enrolled more than 100 participants, almost half of which have successfully completed treatment and very few of whom have had any additional involvement in the criminal justice system. Future research will continue tracking treatment and justice outcomes, as well as explore any new and persistent barriers to sustain these treatment efforts.

 

References

  1. Centers for Disease Control & Prevention. Opioid Overdose. https://www.cdc.gov/drugoverdose/index.html. Published 2018. Accessed December 5, 2019.
  2. Reif S, Braude L, Lyman DR, et al. Peer Recovery Support for Individuals With Substance Use Disorders: Assessing the Evidence. PS. 2014;65(7):853-861. doi:10.1176/appi.ps.201400047
  3. Condelli WS, Hubbard RL. Relationship between time spent in treatment and client outcomes from therapeutic communities. Journal of Substance Abuse Treatment. 1994;11(1):25-33. doi:10.1016/0740-5472(94)90061-2
  4. Simpson DD, Joe GW, Brown BS. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors. 1997;11(4):294-307. doi:10.1037/0893-164X.11.4.294
  5. Hubbard RL, Craddock SG, Anderson J. Overview of 5-year follow up outcomes in the drug abuse treatment outcome studies (DATOS). Journal of Substance Abuse Treatment. 2003;25(3):125-134. doi:10.1016/S0740-5472(03)00130-2
  6. Bell J, Strang J. Medication Treatment of Opioid Use Disorder. Biological Psychiatry. 2020;87(1):82-88. doi:10.1016/j.biopsych.2019.06.020
  7. Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. Medication Treatment For Opioid Use Disorders In Substance Use Treatment Facilities. Health Affairs. 2019;38(1):14-23. doi:10.1377/hlthaff.2018.05162
  8. Connery HS. Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions. Harvard Review of Psychiatry. 2015;23(2):63. doi:10.1097/HRP.0000000000000075
  9. The Pew Charitable Trust. Prescription Drug Monitoring Programs: Evidence-Based Practice to Optimize Prescriber Use.; 2016. http://www.pewtrusts.org/~/media/assets/2016/12/prescription_drug_monitoring_programs.pdf.

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