Health and Justice最新文献

Background: In 2018 Massachusetts mandated that county jails offer all FDA-approved medications for opioid use disorder (MOUD) to incarcerated individuals with OUD. Estimating costs needed to implement and sustain an MOUD program are not clearly known in jail facilities. The objective of this study was to identify the type of MOUD model deployed by the jails serving as research sites for the Massachusetts JCOIN hub, determine which resources were utilized at each stage of development, and estimate the associated costs.

Methods: Resources required to implement and sustain the MOUD programs were identified through detailed, site-specific microcosting analyses at six participating jails in Massachusetts. Quantitative resource utilization data were captured primarily through in-person site-visits and semi-structured interviews with key personnel. Unit costs were derived from the Federal Supply Schedule and Bureau Labor of Statistics from a site-specific level perspective. Our customizable budget impact tool, designed to assist jails/prisons with assessing the viability of alternative MOUD models, was used to organize each site's resources and estimate their associated costs. Resources/costs were summarized by site, according to type and phase, and cross-site comparisons were made to identify common program elements and unique models.

Results: Three MOUD models were identified. Model 1 consisted of a vendor hired to deliver and administer methadone daily, while clinical jail staff administered buprenorphine and extended-release naltrexone. Model 2 included facilities that hired a certified vendor to operate an in-house opioid treatment program (OTP) to oversee the administration of all MOUD. Jails in Model 3 became certified OTPs, thereby allowing jail staff to manage all aspects of the MOUD program. There was considerable variability in implementation costs, both within and across models, driven by model-specific factors, but also with switching models, expanding infrastructure, etc. Entering the sustainment phase, the per-person costs of care were quite similar across models but differed according to the proportion of costs considered time-dependent vs. variable.

Conclusion: Our findings represent the most detailed and comprehensive estimates of resource/cost requirements for jail-based MOUD programs. Given the budget constraints faced by jails, the investment required to implement/sustain an MOUD program will likely result in the need to obtain additional funding or reallocate existing resources away from other initiatives.

The opioid overdose crisis intersects critically with the criminal legal system where individuals with opioid use disorder (are significantly overrepresented. Subsequently, incarceration increases the risk of opioid overdose due to reduced tolerance, interrupted social supports, and limited access to treatment. Medications for opioid use disorder (MOUD), such as methadone, buprenorphine, and naltrexone, have been shown to reduce opioid-related mortality and improve outcomes for those in carceral settings. Despite this, access to MOUD in jails and prisons remains limited due to stigma, concerns about medication diversion, and logistical challenges. This paper reviews the current state of knowledge on MOUD in carceral settings, summarizing the prevalence of treatment programs, the role of novel formulations like injectable buprenorphine, and barriers to implementation. It also explores the continuum of care, emphasizing the importance of initiating MOUD during incarceration and ensuring continuation upon release to prevent treatment gaps. Recent policy changes, such as Sect. 1115 Medicaid waivers, offer promising avenues for expanding access, but retention in treatment and post-release outcomes remain significant challenges. The paper provides a comprehensive overview of existing literature and updates on MOUD service delivery, including the impact of recent policy shifts and research on outcomes such as recidivism and health improvement. It concludes by identifying key areas for future research, including strategies to improve treatment retention, address systemic barriers through criminal justice reform, and enhance care coordination during the transition from incarceration to the community.

Background: Substance use disorder affects over half of incarcerated individuals, with 23% experiencing opioid use disorder specifically. Addressing opioid use disorder in jails is crucial due to its association with increased recidivism and overdose. This study investigates the experiences of peer recovery specialists working with individuals with opioid use disorder and criminal justice involvement, focusing on barriers and facilitators to client connections. Qualitative interviews were conducted and thematically analyzed using a hybrid inductive and deductive coding approach. The sample involved five peer recovery specialists, who were interviewed multiple times, across three sites in Virginia between August 2022 to December 2023.

Results: This analysis categorized findings into two main domains: barriers to connection and facilitators of connection. Within the barriers to connection, six themes emerged: jail specific restrictions, client in withdrawal, social determinants of health insecurities, lack of client engagement, disconnection, and adverse peer recovery experience. Jail-specific restrictions was the most common barrier to connection with 91.30% of transcripts referencing at least one code for jail-specific restrictions; 73.91% of all transcripts indicated social determinants of health insecurities; 56.52% of all peer recovery specialist transcripts experienced clients in withdrawal; 52.17% of all transcripts identified lack of client engagement; 43.48% of all transcripts identified disconnection as a barrier; and 34.78% of all transcripts indicated adverse peer recovery specialist experiences. Three themes were identified as facilitators of connection: peer communication skills, connection to services, and positive peer recovery specialist experience. Peer communication skills were by far the most prominent, with 100% of all transcripts indicating a code related to peer communication skills; 60.87% of all transcripts indicated positive peer recovery specialist experience; and 56.52% of all transcripts identified connection to services as a facilitator. Notable discrepancies in code frequency were observed across different sites, suggesting site specific challenges.

Conclusion: This study offers valuable insights into enhancing peer-based support programs within the justice system for individuals with opioid use disorder. Barriers such as jail specific restrictions, client withdrawal, and social determinants of health insecurities pose significant challenges, while effective communication emerges as a critical facilitator. Findings emphasize the need for collaborative efforts between justice and recovery partners to optimize the impact of peer-based support services.

Background: During the COVID-19 pandemic, governments worldwide introduced law enforcement measures to deter and punish breaches of emergency public health orders. For example, in Victoria, Australia, discretionary fines of A$1,652 were issued for breaching stay-at-home orders, and A$4,957 fines for 'unlawful gatherings'; to date, approximately 30,000 fines remain outstanding or not paid in full. Studies globally have revealed how the expansion of policing powers produced significant collateral damage for marginalized populations, including people from low-income neighboorhoods, Indigenous Peoples, sex workers, and people from culturally diverse backgrounds. For people who use drugs, interactions with police are commonplace due to the criminalization of drug use, however, little empirical attention has been given to their experiences of pandemic policing; we aimed to address this gap in the literature.

Methods: We conducted a mixed methods study involving participants of two prospective observational cohort studies of people who use drugs (n = 2,156) in Victoria, Australia, to understand impacts of the pandemic on their lives. Between 2020 and 2022 pandemic-related questions were added to survey instruments; during this period, 1,130 participants completed surveys. We descriptively analyzed the data of participants who reported police interactions related to pandemic restrictions (n = 125) and conducted qualitative interviews with 89 participants. Qualitative data were analysed thematically and integrated with quantitative results.

Results: 11% (n = 125) of survey respondents reported pandemic-related interactions with police; most (26%) were for breaching curfews and 30% received COVID-19 fines. Qualitative interviewees observed increased policing in street-based drug markets and local neighborhoods; many felt harassed and believed policing practices were targeted and discriminatory. Thirty-eight interviewees received COVID-19 fines; some were fined while homeless or travelling to or from harm reduction services. All lacked the financial means to pay fines, resulting in fear of additional criminalizing effects such as additional financial penalties, court orders, criminal convictions, and incarceration; for some fears became a reality.

Conclusion: Our study demonstrates how public health emergency responses centred around policing and criminalization exacerbated harms for people who use drugs, with detrimental effects enduring beyond the pandemic. Results provide insights for future public health emergencies, including highlighting the need for responses that protect, rather than abrogate the health and safety needs of marginalized and criminalized groups.

Background: The number of older adults entering the criminal justice system is growing. Approximately 8% of older prisoners in England and Wales have suspected dementia or mild cognitive impairment (MCI) and experience difficulties in everyday functioning, and disruption to their daily life. At present, no specific dementia/MCI care pathway has been implemented that is applicable and appropriate for use across different prisons in England and Wales. The aim of this paper is to explore the experiences of older adults with dementia/MCI in prison, and a range of key stakeholders, around the day-to-day issues faced by people with dementia/MCI and prison, healthcare, and third sector staff regarding the delivery of support for individuals with dementia/MCI.

Methods: Thirty-two semi structured interviews were conducted with prison, local authority, and healthcare staff; peer supporters; third sector care providers; and individuals with dementia/MCI themselves, across five establishments, to provide multidimensional perspectives of dementia/MCI in criminal justice settings. The data obtained during interviews were thematically analysed.

Results: From the data, six key themes emerged: (I) ethical concerns around trial, sentencing and detainment for people with dementia/MCI; (II) An unforgiving prison system, providing physical and social environments incompatible with supporting individuals with dementia/MCI; (III) An unprepared workforce requiring training in dementia/MCI. (IV) A lack of collaboration leading to sub-optimum management of the support needs of people with dementia/MCI in prison; (V) Peer support 'plugging the gap'; and (VI) staff 'hands tied behind back'.

Conclusions: Results point towards a pressing need to develop more appropriate support systems for individuals with dementia/MCI throughout the criminal justice system. Ethical concerns around the judicial process for individuals with diminished cognitive capacity must be considered. Prison governors should examine ways to make the living environment more appropriate for these individuals, and a joined-up collaborative approach to health and social care should be adopted. Staff must be appropriately trained to support and identify individuals with dementia/MCI. Peer support schemes require formal evaluation, and training/oversight of these schemes should be comprehensive.

Background: Individuals with serious mental illness (SMI) have disproportionately high rates of criminal legal system involvement. For many, this becomes a repeated cycle of arrest and incarceration. Treatments that address symptoms of mental illness are a critical component of the continuum of services for people with SMI in the legal system; yet on their own, psychiatric treatments have not been successful at reducing criminal legal system involvement for this population. Research suggests that criminogenic risk factors, the major drivers of criminal legal system involvement, are disproportionately prevalent among individuals with SMI. However, promising criminogenic-focused interventions have only just begun to be adapted for individuals with SMI. The proposed study will examine the capacity of Forging New Paths (FNP), a novel criminogenic-focused group intervention developed for individuals with SMI, to engage its primary and secondary outcomes when delivered in community mental health settings.

Methods: The proposed pilot study will engage a small-scale clinical trial comprising three cycles of FNP delivered in a community mental health center in a Southeastern state in the U.S. The anticipated total sample size is N = 72 and will consist of community-dwelling adults with SMI who have a moderate or higher criminogenic risk level and a history of criminal legal system contact. This study will examine the extent to which FNP is able to engage its primary (aggression and community tenure) and secondary (criminal attitudes and impulsivity) treatment outcomes.

Discussion: FNP provides an important new service for community-based mental health settings to reduce criminal legal system involvement (and recidivism) among the individuals they serve with SMI.

Clinical trial registration: NCT06290648.

Background: Reentry veterans experience many barriers to achieving physical and psychological well-being. While peer specialists can provide important support to veterans as they readjust to life post-incarceration, their specific activities and qualities most valued by veterans are not well known. The Post-Incarceration Engagement (PIE) intervention, coordinated with VA's Health Care for Reentry Veterans (HCRV) program, links reentry veterans with a peer specialist who provides connection to services and social-emotional support during the reentry process. We conducted a qualitative examination of veterans' perceptions regarding the key qualities and activities of peer specialists that were most valued during their reentry process.

Methods: We interviewed 25 veterans engaged in PIE about their experiences working with a PIE peer specialist. We conducted a thematic analysis. Two project team members independently coded interviews and identified emergent themes that were refined with input from other members.

Results: Veterans found the peer specialist's physical and emotional availability, shared lived experience, and connection to resources to be invaluable for successful reentry post-incarceration. Veterans emphasized how important it was that the peer was consistently available and provided social, emotional, and logistical support. Secondly, veterans found it valuable to work with another veteran familiar with the VA system and to be able to share lived experiences. It provided an instant connection with the peer specialist. Finally, the personalized connections to VA and community resources equipped the reentry veterans with the essential resources to ensure continued success post-incarceration.

Conclusion: Reentry veterans identified several key qualities and activities of the peer specialist that were vital to their reentry success. Our results may be used to inform other interventions aimed at improving the lives of reentry veterans along with other reentry populations.

Background: Medicaid expansion via the Affordable Care Act, more recent legislation and Medicaid 1115 waivers offer opportunity to increase health care access among individuals involved in the carceral system. Effective enrollment of new beneficiaries and temporary suspension and reactivation of existing Medicaid benefits upon release is key to the success of these efforts. This study aims to characterize how jails, prisons and Medicaid agencies are implementing Medicaid suspension and enrollment programs and identifies barriers and facilitators to implementation.

Methods: We conducted 19 semi-structured interviews with 36 multi-state leaders in carceral facilities, Medicaid agencies, local health departments and national policy experts from 2020 to 2021. Interviews covered 4 domains: (1) the role of policy in influencing carceral and reentry Medicaid practices, (2) implementation strategies to suspend and enroll incarcerated individuals into Medicaid, (3) barriers and facilitators to successful implementation, and (4) variation in implementation between jails and prisons.

Results: Participants identified logistical challenges with suspension and enrollment, including limited infrastructure for data sharing between carceral facilities and Medicaid agencies, burdensome bureaucratic requirements, and challenges with Medicaid renewal, particularly in the jail environment. They offered opportunities to overcome barriers, such as the creation of specialized incarcerated Medicaid benefit categories and provision of in-reach services via managed care organizations. Participants also called for improvements to Medicaid reactivation processes, as even when facilities successfully suspended benefits, individuals faced significant challenges and delays reactivating benefits upon release. Participants also called for further loosening of the Medicaid Inmate Exclusion Policy.

Discussion: Findings highlight the need to update data sharing infrastructure, which will be critical to the implementation of the 1115 waivers, as carceral facilities will be subject to Medicaid billing and reporting requirements. In addition to investing in the ability to newly enroll and suspend Medicaid benefits, attention towards improving timely reactivation practices is needed, particularly given the highly elevated risk of mortality immediately after release. Participants calls for further reforms to the Medicaid Inmate Exclusion Policy are consistent with proposed legislation.

Conclusions: Findings can critically inform the successful implementation of Medicaid-based reforms to improve the health of incarcerated and formerly incarcerated people.

Background: First responders (law enforcement officers, emergency medical services, and firefighters) frequently interact with people who use drugs (PWUD). Based on the nature and outcomes of such encounters, these interactions have the potential either to reduce harm, or perpetuate it. Given increased funding and attention for first responder-led interventions involving PWUD, we must identify the most critical training for improving negative beliefs about these interventions and populations. In this study, we aimed to develop and evaluate a novel, evidence-based first responder training with an occupational wellness framing aiming to increase knowledge regarding and improve attitudes toward people who overdose and toward the overdose antidote, naloxone.

Methods: We developed and evaluated the DOTS/SHIELD (Drug Overdose Trust & Safety/Safety & Health Integration in the Enforcement of Laws on Drugs) first responder training with three components: (1) matched first responder and overdose survivor trainers; (2) locally tailored substance use service information and practical referral instructions; and (3) occupational health content designed to make first responders' jobs easier and safer. We conducted pre- and post-tests at 151 Missouri-based trainings (December 2020-May 2023) to assess associated attitudinal changes among law enforcement vs. emergency medical services [EMS]/fire.

Results: Among the matched sample (N = 1,003, 53.9% law enforcement), post-training attitudes toward people who overdose and toward naloxone were more positive than pre-training attitudes. On average, law enforcement held worse attitudes than EMS/fire toward people who overdose, though there were no professional differences in naloxone-related beliefs.

Conclusions: This training approach effectively combines three training components - peer trainers, practical substance use service referral information, and an occupational wellness framing - to positively influence first responders' views toward those who use drugs and toward naloxone.

Background: US chiefs of police hold significant influence over the perceived acceptability and appropriateness of interventions for opioid use disorder (OUD) among the public, elected officials, and subordinate officers. This study assessed whether police chiefs' support for such interventions was sensitive to framing an intervention's benefits in terms that emphasize public health and harm reduction outcomes, versus terms typically indicative of public safety outcomes.

Methods: A two-armed survey utilizing a randomized, between-subjects design tested framing-based variance in support among US chiefs of police for overdose prevention centers, syringe service programs (SSPs), Good Samaritan laws, police naloxone distribution, trustworthiness of officers in recovery from OUD, and related propositions. Of 1,200 invitations, 276 chiefs participated (23%). The two experimental arms (n = 133, n = 143) were demographically balanced between both each other and non-respondents.

Results: Chiefs were more likely to agree that their mission was protecting public safety than protecting public health, even when both were defined using public health outcomes. Chiefs expressed significantly greater support for "overdose prevention sites" than "safe injection sites" (p = .018), low levels of support for SSPs regardless of framing (18% safety; 19% health), and comparably more support for Good Samaritan laws based on framing (62% safety vs. 54% health). Respondents voiced low levels of trust in officers recovering from OUD generally (31%), and significantly lower levels of trust when recovery involved the medication buprenorphine (10%; p < .001). Senior chiefs were significantly more likely to support SSPs (aOR 1.05; CI 1.01, 1.09) and overdose prevention sites (aOR 2.45; CI 1.13, 5.28) than less senior chiefs.

Conclusions: In this cross-sectional survey experiment, support for some interventions for OUD was greater among US chiefs of police when framed to emphasize positive public safety outcomes. Research is required to better understand low support for SSPs, mistrust of officers in recovery for OUD, and greater support for OUD interventions among senior chiefs.