Presented at the Maine Public Health Associations' Annual Meeting - October 5, 2010

1. Amanda Edgar City of Portland Public Health Division Substance Abuse Prevention Program (207) 756-8053 aedgar@portlandmaine.gov www.substanceabuse.portlandmaine.gov www.facebook.com/portlandprevention www.twitter.com/portprevent Public Health in the Correctional Setting: Challenges & Opportunities

2. National Statistics “65 PERCENT OF ALL U.S. INMATES MEET MEDICAL CRITERIA FOR SUBSTANCE ABUSE ADDICTION, ONLY 11 PERCENT RECEIVE ANY TREATMENT” “Of the 2.3 million inmates crowding our nation's prisons and jails, 1.5 million meet the DSM IV medical criteria for substance abuse or addiction, and another 458,000, while not meeting the strict DSM IV criteria, had histories of substance abuse; were under the influence of alcohol or other drugs at the time of their crime; committed their offense to get money to buy drugs; were incarcerated for an alcohol or drug law violation; or shared some combination of these characteristics... Combined these two groups constitute 85 percent of the U.S. prison population.” SOURCE: CASA Columbia, February 26, 2010 (Behind Bars II: Substance Abuse and America’s Prison Population) http://www.casacolumbia.org/templates/PressReleases.aspx?articleid=592&zoneid=79

3. National Statistics (cont’d) “Female inmates make up 8.4 percent of the total inmate population--up from 7.7 percent in 1996. “Female inmates are likelier to have a substance use disorder than are male inmates (66.1 percent vs. 64.3 percent). This holds true for both state prisons and local jails, but among inmates in federal prisons, males have higher rates of substance use disorders than do females. “Female inmates are likelier than are male inmates to suffer from co-occurring substance use and mental health disorders (40.5 percent vs. 22.9 percent). “Failure to address their [women’s] substance-related problems can perpetuate both high recidivism rates and a high rate of juvenile delinquency among their children.” SOURCE: Behind Bars II: Substance Abuse and America’s Prison Population, page 30-1

4. National Research & Case Studies

5. “A Public Health Model for Correctional Health Care” Issue: Traditionally many correctional facilities provide a minimum of necessary care to their inmates and return them to the community with undetected, untreated or under-treated disease which have major consequences not only for the individual, but also for the health of the community as well. Setting: Hampden County Correctional Center in Ludlow, Massachusetts Project: The Hampden County Correctional Center (HCCC) is an innovative community-based model of correctional health care. Inmates who participate in the program are less likely to recidivate and are more likely to be seen at community health care centers. Lessons Learned: Evidence from this project suggests that health care provided in a correctional setting should not only be comprehensive, but also continuous upon release into the community in order to facilitate reintegration and prevent recidivism. To support this continuity of care model, many key players need to be at the table, including the court, corrections, the health department, substance abuse, mental health, academia, community-based organizations, volunteer agencies, and the community. SOURCE: NIH, National HIV Prevention Conference (1999) http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102187764.html

6. “A Public Health Model for Correctional Health Care” Key elements for successful implementation of the model include: Support of the model from high-level correctional administrators, including a dedication to improving inmate and community health; Commitment to collaborate openly with state agencies and local non-profit providers; Willingness to substantially change the existing correctional health care system and culture; Commitment to aggressively seek new sources of funding and support to implement and sustain the model.

7. “A Public Health Model for Correctional Health Care” The benefits of adopting a public model of correctional health care are many, including: Improved inmate & community health Improved public safety Improved correctional staff safety Improved use of the health care system Cost savings for communities High quality health care at a cost no greater than the national average

8. “A Public Health Model for Correctional Health Care” The following five elements form the basis for all services and programs: Early assessment and detection Prompt and effective treatment at a community standard of care Comprehensive health education Prevention measures Continuity of care in the community upon release

9. “Infection control in jails and prisons” Abstract: Compared with the general public, newly incarcerated inmates have an increased prevalence of human immunodeficiency virus infection, hepatitis B virus infection, hepatitis C virus infection, syphilis, gonorrhea, chlamydia, and Mycobacterium tuberculosis infection. While incarcerated, inmates are at an increased risk for the acquisition of blood-borne pathogens, sexually transmitted diseases, methicillin-resistant Staphylococcus aureus infection, and infection with airborne organisms, such as M. tuberculosis, influenza virus, and varicella-zoster virus. While incarcerated, inmates interact with hundreds of thousands of correctional employees and millions of annual visitors. Most inmates are eventually released to interact with the general public. Tremendous opportunities exist for infectious diseases specialists and infection-control practitioners to have an impact on the health of correctional employees, the incarcerated, and the communities to which inmates return. SOURCE: PubMed- Abstract, 2007 http://www.ncbi.nlm.nih.gov/pubmed/17879924 Bick, Joseph. Clinical Infectious Diseases 2007; 45:1047–55 http://www.wvidep.org/Portals/31/infection%20control/Jail%20Infxn%20Control.pdf

10. “Characteristics of inmates witnessing overdose events in prison: implications for prevention in the correctional setting” Background: There is scarce information about drug overdose in prison. In correctional institutions without a drug free environment, awareness of overdose events is an important public health concern. This study explores the frequency with which inmates in a state penitentiary system report having witnessed drug overdose events in prison. It also explores whether participants who have witnessed an overdose in prison and know someone who died from an overdose in prison significantly differ from those that do not in selected sociodemographic variables and drug use history toidentify a target population for prevention interventions. Data comes from a cross-sectional survey of sentenced inmates in the state prisons of Puerto Rico. A complex probabilistic, multistage sampling design was used. A total of 1,179 individuals participated for an 89% response rate. Results: Factors associated with witnessing an overdose event in prison include: male sex, age 25 or older, drug use during current incarceration, and drug injection in prison. Factors associated with knowing someone who died from an overdose in prison include: male sex, age between 25–35, previous incarcerations, and drug use during current incarceration. Conclusion: Witnessing a drug overdose is a frequent occurrence within the prison system. The likelihood of witnessing an overdose is greater with being male, polydrug use and drug injection in prison. Findings signal an urgent public health challenge that requires prompt interventions to reduce this drug related harm within the correctional system, including adequate access to medication with opiate agonists. SOURCE: Harm Reduction Journal (2009) http://www.harmreductionjournal.com/content/6/1/15

11. Local Statistics: Cumberland County Jail Average Daily Inmate Population 350-400 (+/-) Average Daily Population By Gender Male – 82% Female – 18% Average Daily Population By Race White – 76% Black – 11% Latino/Hispanic – 10% Other – 3% Average Daily Population By Judicial Status Sentenced - 39% Pre-Trial – 25% Federal Detainees – 24% Pre-Arraignment – 5% Probation – 7% SOURCE: Cumberland County Jail 2008 Annual Report http://www.cumberlandso.org/PDF%27s/Annual%20Report%202008/CCSO%202008%20Annual%20Report.pdf

12. Our Programs: What We Offer Portland Women’s Task Force Informational brochures on opiate addiction & treatment during pregnancy Weekly support gathering for moms in recovery Advocacy to provide medications that treat addiction in the correctional setting Overdose Prevention Project Print materials on how to respond to an overdose Staff trainings on substance abuse trends Educational support groups Cumberland County Jail (twice/week for men and women) Maine Correctional Center (once/month for women) Overdose Prevention Jeopardy HBO: Addiction (DVD) Overdose Risk Assessment Quiz

13. Educational Support Groups: The Numbers January 2008-December 2008 GROUPS HELD: 107 PARTICIPANTS: 485 Male: 279 Female: 206 January 2009-December 2009 GROUPS HELD: 78 PARTICIPANTS: 403 Male: 304 Female: 99 January 2010-June 2010 GROUPS HELD: 43 PARTICIPANTS: 251 Male: 175 Female: 76

14. Barriers/Challenges: Our Experience “Red Tape” within the correctional setting Staff turn-over Funding challenges Training calendar/structure Inmate cell searches You may arrive onsite only to be told you have to come back another day once the searches have been completed (often, searches are due to reports of contraband within the facility) Wide-spread illness If there is an outbreak of an illness, your services may be compromised (i.e.: you have to wait until it’s clear to go back in)

15. Opportunities on the Inside Even though medical services are provided, incarcerated individuals are ripe for services and interventions as they often lack access to wide-ranging services on the inside “Captive” audience Many correctional settings rely on volunteers to provide services to inmates due to funding or staffing issues “For many, it is the first time they have received adequate health care from a caring group of providers. The commitment to continue their care is evident in the high rates of inmates who keep their medical appointments after release.” (PH Model for Correctional Health, MPHA) Building relationships with correctional facility staff Access to sub-populations Adolescents Men Women Prenatal, pregnant or postpartum women Minority populations LBGTQ populations Aging/elderly population IV drug users

16. Opportunities on the Inside (cont’d) HIV/STD/Hepatitis education/prevention Portland Public Health offers testing on a weekly basis to all interested inmates @ CCJ Smoking cessation tools Chronic disease prevention Multi-lingual/multi-cultural support services LGBTQ support services Substance abuse education/prevention, treatment resources Mental health education/support Parenting tips/support Pre-natal health screenings Suicide prevention Oral Health Reproductive Health Violence/trauma prevention Linking inmates to community health centers post-release Training of correctional facility staff Domestic violence education/support Family Crisis Services offers support groups to women @ CCJ & Windham Correctional Center

17. References & Resources “Behind Bars II: Substance Abuse and America's Prison Population” CASA Columbia, February 2010 http://www.casacolumbia.org/templates/PressReleases.aspx?articleid=592&zoneid=79 “Characteristics of inmates witnessing overdose events in prison: implications for prevention in the correctional setting” Harm Reduction Journal 2009; Jul 9;6:15. http://www.harmreductionjournal.com/content/6/1/15 Cumberland County Jail Annual Report (2008) http://www.cumberlandso.org/PDF%27s/Annual%20Report%202008/CCSO%202008%20Annual%20Report.pdf “Infection control in jails and prisons” Bick, Joseph. Clinical Infectious Diseases 2007; 45:1047–55. http://www.wvidep.org/Portals/31/infection%20control/Jail%20Infxn%20Control.pdf http://www.ncbi.nlm.nih.gov/pubmed/17879924 “A Public Health Model for Correctional Health Care” Massachusetts Public Health Association http://www.mphaweb.org/PublicHealthModelforCorrectionalHealth.htm NIH, National HIV Prevention Conference (1999) http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102187764.html “A Public Health Model for Correctional Healthcare” : 104-page manual (2002) http://www.mphaweb.org/documents/PHModelforCorrectionalHealth.pdf

18. QUESTIONS?COMMENTS?

19. Amanda Edgar City of Portland Public Health Division Substance Abuse Prevention Program (207) 756-8053 aedgar@portlandmaine.gov www.substanceabuse.portlandmaine.gov www.facebook.com/portlandprevention www.twitter.com/portprevent Contact Information