# Presentation: 161257

## Meeting the Medical Needs of Drug-Involved Offenders

**Peter D. Friedmann, MD, MPH**
**Associate Professor of Medicine & Community Health**

## Meeting the Medical Needs of Drug-Involved Offenders

- Opportunity To Improve Public Health
- Post-release Mortality And Morbidity
- Other Primary And Secondary Prevention

**Notes:**
Public health/safety connection: individuals in CJ system group with complex and many needs including drug abuse, infectious disease including HIV/AIDS, Hep B and C, mental illness.  Majority will be released to community bringing these problems with them.  Have impact on service delivery systems of community and impact individuals within community.  Also, link between drug use and participation in violent crime.  Evidence-based tx interventions have resulted in reduction in criminal activity and violent behavior.

## Correctional Populations Have A High Prevalence Of Medical Conditions

- Current / past risk behaviors
- Parenteral drug use
- Tattoos
- Unsafe sexual practices
- Direct toxic effects of illicit drugs or caustic agents
- Poverty and living conditions
- Close living quarters – TB, HBV, MRSA
- Unaddressed HTN, DM

## Incarceration and Disease

- Colsher 1992. Bureau of Justice Statistics 1999, NCJ 187456; Prev Med 1999;28:92-100; Baillargeon 2002. Hammett 2002; Hornung 2002. Macalino 2004;Maruschak 2005. MacNeil 2005; Bernstein 2006.

## Opportunity to Improve Public Health

- Poor access to routine medical care in community
- Underinsured
- Care-seeking episodic, symptom-related, costly

## Inmates Have Constitutional Right To Adequate Medical Care(Estelle vs. Gamble, 1976)

- Unique opportunity to deliver health care to hard-to-reach population:
- “...the period of confinement [incarceration or detention] provides a unique chance to reach an otherwise exclusive group, whose risk factors and prevalence rates far exceed those of other populations.”
- 			--Glaser and Greifinger, 1993

## High Turnover Rates

- Inmates come from, and return to communities with health disparities
- May serve as high-risk “reservoir”
- >2,000,000 confined at any one time
- > 12 million releases from jail each year

- MMWR 2003;52.; Harrison & Beck 2005
- Am J Pub Health 2002;92:1789-1794.

## Clinicians should know the common medical conditions among inmates or ex-inmates
Screen for common conditions
Treat or refer for treatment
Counsel to reduce transmission
Provide preventive interventions 
e.g. vaccination

- Screen for common conditions
- Treat or refer for treatment
- Counsel to reduce transmission
- Provide preventive interventions
- e.g. vaccination

- Opportunity to Improve Public Health

**Notes:**
Public health/safety connection: individuals in CJ system group with complex and many needs including drug abuse, infectious disease including HIV/AIDS, Hep B and C, mental illness.  Majority will be released to community bringing these problems with them.  Have impact on service delivery systems of community and impact individuals within community.  Also, link between drug use and participation in violent crime.  Evidence-based tx interventions have resulted in reduction in criminal activity and violent behavior.

## Meeting the Medical Needs of Drug-Involved Offenders

- Opportunity To Improve Public Health
- Post-release Mortality And Morbidity
- Other Primary And Secondary Prevention

## Release from Prison - A High Risk of Death for Former Inmates

**Binswanger IA et al. N Engl J Med 2007;356:157-165**

- RR=12

- RR=4

- RR=3.2

##  33-year Follow-Up of Heroin-Dependent Criminal Offenders in California Civil Commitment Program 1962-1964

**Source: Hser and Anglin et al. “A 33-year Follow-Up of Narcotics Addicts”.  Archives of General Psychiatry. 2001;58:503-508**

**Dead**

**Incarcerated**

## Causes of Death among Former Inmates

- Adjusted for Age, Sex, and Race

**Opioids**
**Prison detox =>****↓****tolerance**

**Notes:**
Figure 1. Mortality Rates among Former Inmates of the Washington State Department of Corrections during the Study Follow-up (Overall) and According to 2-Week Periods after Release from Prison. The dashed line represents the adjusted mortality rate for residents of the State of Washington (223 deaths per 100,000 person-years), and the solid line represents the crude mortality rate among inmates of the state prison system during incarceration (201 deaths per 100,000 inmate person-years).

## Mail Survey Regarding Availability of Methadone in US Prisons 

- 39 state prison systems plus federal BOP responded:
- 88% of US prisoners
- 48% use methadone in rare situations
- Detox
- 32% for pregnant women
- 42% for inmates on MMR
- 32% for opiate withdrawal
- MMT
- 68% for pregnant women
- None offered MMT to any other population

- Rich et al. 2005

## Opioid Overdose

- The Triad:
- coma, pinpoint pupils, respiratory depression
- Naloxone (Narcan) 0.4 mg/ml IV/IM, repeat as needed, up to 1-2 mg.
- Short acting
- Some communities distributing naloxone and training IDUs in its use
- OD “Good Samaritan” laws for 911 calls
- victims and witnesses of drug overdose who seek medical help immune from possession charges

## Cardiomyopathy in Methamphetamine Users

- Case-control study
- 107 cardiomyopathy patients age <45
- Adjusting for age, BMI, and renal failure, methamphetamine associated with 3.7x risk of cardiomyopathy
- Mechanism of injury related to excess catecholamine
- Cardiomyopathy associated with ventricular arrhythmias

- Yeo et al. Am J Med 2007

## Causes of Death among Former Inmates

- Adjusted for Age, Sex, and Race

**Involved in drug economy**

**Notes:**
Figure 1. Mortality Rates among Former Inmates of the Washington State Department of Corrections during the Study Follow-up (Overall) and According to 2-Week Periods after Release from Prison. The dashed line represents the adjusted mortality rate for residents of the State of Washington (223 deaths per 100,000 person-years), and the solid line represents the crude mortality rate among inmates of the state prison system during incarceration (201 deaths per 100,000 inmate person-years).

## Mortality in Delinquent & Community Youth

- *Crude U.S. mortality for the years 1996-2001 was computed from the National Vital Statistics Reports.

- Detained Population

- General Population

- 0

- 200

- 400

- 600

- 800

- Annual Deaths per 100 000 person-years

**Total**

**Male**

**Female**

- 83.5

- Crude U.S.
- Mortality
- Ages 15-24*

- 806

-  184

- 847

- 887

- 435

-  228

-      60

- 807

- 283

- 36

-  233

- 42

- 315

- 22

- 501

- 18

-   195

- 83

- Teplin, Northwestern Juvenile Project

**Notes:**
SLIDE 8:  How does this death rate compare to the general population’s?  
The overall death rate was more than 4 times the general-population’s, even after controlling for demographic differences. Nearly 97% of youth who died were involved in the drug economy.
Among females, the mortality rate was nearly 8 times the general population rate.  
African American males had the highest mortality (an astonishing 887 deaths per 100,000 person-years).  
Compare this to 83.5 for all youth in this age group (the red horizontal line).  (END SLIDE 8)
These youth are at great risk for early violent death: nearly all use drugs and most are involved in the drug economy.
Over a mean follow-up of 7.2 years, 65 youth died.  (NOTE:  74 participants, or 4% of the sample, have died as of 9/13/06)
This pie chart shows that all died violently.  
More than 95% of deaths were homicides or deaths by “legal intervention” (killed by a police officer). (END SLIDE 7)

## Causes of Death among Former Inmates

- Adjusted for Age, Sex, and Race

**Notes:**
Figure 1. Mortality Rates among Former Inmates of the Washington State Department of Corrections during the Study Follow-up (Overall) and According to 2-Week Periods after Release from Prison. The dashed line represents the adjusted mortality rate for residents of the State of Washington (223 deaths per 100,000 person-years), and the solid line represents the crude mortality rate among inmates of the state prison system during incarceration (201 deaths per 100,000 inmate person-years).

## Hepatitis B and C

- Parenteral spread
- IDU
- Tattoos
- 66% of HCV in prison
- not associated with IDU
- Sexual (hep B)
- Fever, jaundice, elevated LFT’s
- Often minimal symptoms
- IgM or viral load to diagnose acute dz.

## Slide 20

## Acute HCV Infection with Progression to Chronic HCV Infection

## HCV Monitoring and Maintenance

- Liver enzymes: every 6-12 months
- Viral load:
- annually, or if LFT elevated
- Genotype, staging biopsy if treating
- Annual AFP, US if chronic

- Immunizations
- Hep A and B
- Avoid liver toxins
- Alcohol
- Acetaminophen

## Hep C: Treatment

- Pegylated Interferon/Ribavirin
- 54 % SVR* *
- 1 year treatment
- one injection per week, two pills per day
- Genotype 2 & 3 better response
- ? Restrictions
- active drug abuse
- psychiatric disease

## HCV Treatment: Side Effects

- Flu syndrome		82%
- Psych complications	20%
- Cannot cont. tx		20%
- Bone marrow sup 	  5%
- Feels like withdrawal
- 	*“**dope sick”*
- Relapse trigger!

## Alcohol Is A Common Substitute for Drugs

- Alcohol not detected in forensic drug screens
- Alcohol accelerates progression of HCV
- Screen
- “Do you sometimes drink alcoholic beverages?”
- “How many times in the past year have you had...”
-   		-5 or more drinks in a day (men)
-   		-4 or more drinks in a day ( women)

## Causes of Death among Former Inmates

_**DUI**_
**Seatbelts**

**Notes:**
Figure 1. Mortality Rates among Former Inmates of the Washington State Department of Corrections during the Study Follow-up (Overall) and According to 2-Week Periods after Release from Prison. The dashed line represents the adjusted mortality rate for residents of the State of Washington (223 deaths per 100,000 person-years), and the solid line represents the crude mortality rate among inmates of the state prison system during incarceration (201 deaths per 100,000 inmate person-years).

## Causes of Death among Former Inmates

**Depression**
**Suicide screening**
**Guns**
_**Alcohol**_
**Social support**

**Notes:**
Figure 1. Mortality Rates among Former Inmates of the Washington State Department of Corrections during the Study Follow-up (Overall) and According to 2-Week Periods after Release from Prison. The dashed line represents the adjusted mortality rate for residents of the State of Washington (223 deaths per 100,000 person-years), and the solid line represents the crude mortality rate among inmates of the state prison system during incarceration (201 deaths per 100,000 inmate person-years).

## Causes of Death among Former Inmates

_**Smoking-related**_
**HTN**
**DM**
**Cholesterol**

**Notes:**
Figure 1. Mortality Rates among Former Inmates of the Washington State Department of Corrections during the Study Follow-up (Overall) and According to 2-Week Periods after Release from Prison. The dashed line represents the adjusted mortality rate for residents of the State of Washington (223 deaths per 100,000 person-years), and the solid line represents the crude mortality rate among inmates of the state prison system during incarceration (201 deaths per 100,000 inmate person-years).

## Causes of Death among Former Inmates

**Smoking-related**
**Colon screening**
**Prostate**
**Cervical**
**Breast**

**Notes:**
Figure 1. Mortality Rates among Former Inmates of the Washington State Department of Corrections during the Study Follow-up (Overall) and According to 2-Week Periods after Release from Prison. The dashed line represents the adjusted mortality rate for residents of the State of Washington (223 deaths per 100,000 person-years), and the solid line represents the crude mortality rate among inmates of the state prison system during incarceration (201 deaths per 100,000 inmate person-years).

## The 5 A’s

- ASK about alcohol use and smoking
- ASSESS severity and readiness to change
- ADVISE abstinence as safest
- Negotiate cutting down if necessary
- ASSIST using counseling, referral, pharmacotherapy and other resources
- ARRANGE follow-up to monitor progress

**Notes:**
In summary, a patient-centered, cross culturally efficacious evidence-based approach can be used to efficiently address alcohol problems in generalist healthcare settings.  In such an approach:
Ask about alcohol use using validated screening approaches that can identify the spectrum of problems from risky drinking to dependence such as the CAGE questionnaire and quantity and frequency questions.
Assess the severity of identified problems by following up on positive screening responses, looking for red flags, and asking about coexisting conditions that place people at higher risk for problems or that may suggest a need for abstinence.
Advise cutting down or abstaining, negotiate treatment options, and assist in goal setting, and further treatment when necessary, including referral, pharmacotherapy and AA.
Arrange follow-up to monitor progress.
All of this should be done with attention to cross-cultural efficacy, arguably a feature of any doctor patient encounter.  One way to do this is to demonstrate respect, attend to the patient’s explanatory model by understanding how the patient makes sense of the world and their health/health behaviors, be aware of the patient’s sociocultural context (avoiding stereotyping), mitigate power and status differences, express empathy, make sure the patient feels heard and understood, elicit the patient’s concerns about drinking, and by doing all of these, establish a trusting and effective therapeutic alliance.

## HAART has decreased AIDS mortality 60% in USA  

## Slide 32

## Antiretrovirals

**NRTIs:**
- AZT, ddI, d4T, 3TC, FTC, Abacavir, Tenofovir
- Combivir (AZT/3TC)
- Truvada (FTC/Tenofovir)
- Epzicom (3TC/Abacavir)
**NNRTIs:**
- Efavirenz,  Nevirapine,
- Etravirine (investigational)
**Protease inhibitors:**
- Lopinavir/r, Atazanavir/r,
- Fosamprenavir/r
- Indinavir, Saquinavir, Nelfinavir, Darunavir/r, Tipranavir/r

**Fusion inhibitor:**
- Enfuvirtide
**HAART combination:****	**
- Atripla (Efavirenz/FTC/Tenofovir)
**Investigational drugs:**
**CCR5 inhibitors:**
- Maraviroc, Vicriviroc
**Integrase inhibitor:**
- MK0518
**Maturation inhibitor:**
- PA457

## One Pill Once a Day!!

## Indications for HIV/AIDS Treatment 

| Clinical Category | CD4 | HVL | Recommendation |
| --- | --- | --- | --- |
| Symptomatic
AIDS | Any Value | Any Value | Treat |
| Asymptomatic
AIDS | <200 | Any Value | Treat |
| Asymptomatic | >200 but <350 | Any Value | Treatment Offered Controversial |
| Asymptomatic | >350 | >55,000 | Controversial
3yr risk >30% |
| Asymptomatic | >350 | <55,000 | Defer Treatment,
3yr risk <15% |

## HIV Screening: Revised CDC Recommendations (MMWR 9/22/2006) 

- Screening in all healthcare settings
- Includes correctional settings
- Test high risk persons annually
- Consent for general medical care should assume consent for HIV screening
- Separate consent for HIV testing required in 28 states
- Testing voluntary but on opt-out basis: inform patients that HIV testing will be performed unless they decline
- Inability to counsel should not bar testing

## Acute HIV: Signs and Symptoms

- Fever 		96%
- Pharyngitis	70%
- Adenopathy	74%
- Rash 		70%
- maculopapular - face, trunk, extremities,
- mucocutaneous ulceration
- Lab Abnormalities
- Leukopenia, thrombocytopenia, LFT’s elevated

- Headache	32%
- Myalgias	54%
- GI symptoms 	30%
- Nausea, vomiting or diarrhea
- Thrush		12%
- Neuro sx	12%
- Aseptic meningitis
- Facial palsy

## Diagnostic Testing for Acute HIV Infection

- High level of suspicion if compatible clinical syndrome or recent high-risk behavior
- plasma RNA test and HIV antibody test
- Test all patients with signs/symptoms consistent with HIV infection

## Sexuallly Transmitted Infections

- STI risk factor for HIV transmission – annual antibody test
- Syphilis - annual VDRL/RPR
- Hepatitis B - vaccinate
- Genital warts
- _Dysplasia_: cervical, vulvar, perineal, anorectal
- Pap Smears
- HPV vaccination???
- Chlamydia – screen all women
- Gonorrhea – casefind
- Herpes – suppression with antivirals to reduce transmission
- Sexual activity high after prison
- Abstinence is safest
- Protective measures, contraception

## Meeting the Medical Needs of Drug-Involved Offenders

- Opportunity to improve public health
- Post-release mortality and morbidity
- Other primary and secondary prevention

**Notes:**
Public health/safety connection: individuals in CJ system group with complex and many needs including drug abuse, infectious disease including HIV/AIDS, Hep B and C, mental illness.  Majority will be released to community bringing these problems with them.  Have impact on service delivery systems of community and impact individuals within community.  Also, link between drug use and participation in violent crime.  Evidence-based tx interventions have resulted in reduction in criminal activity and violent behavior.

## PPD for Tuberculosis

- Read reaction:  48-72 hours
- Measure _only_ induration using mm
- Annual CXR if previous +

## Tuberculosis Screening: PPD>15mm positive regardless of risk factors

_**> 10 mm positive**__** **__**if:**_
- Recent immigrant from endemic area
- IVDU
- High risk residential
- Jail/prison, nursing home, homeless shelter
- High risk clinical
- DM, CRF, malignancy, wt. loss, gastrectomy/bypass
- Children < 4 exposed to high-risk adults

_**> 5 mm positive if:**_
- HIV positive
- Recent TB contact
- CXR with TB changes
- Organ transplants
- Immunosupressed

## Preventive Health Care – Vaccinations

- Hepatitis A
- Hepatitis B
- Pneumococcal vaccine
- Influenza vaccine
- Tetanus
- ?Hemophilus influenza vaccine
- ?HPV

## Methamphetamine Associated with  Tooth Destruction

- Source: Richards, JR and Brofeldt, BT, J Periodontology, August 2000.

## Summary

- High prevalence of medical problems in prisoners and ex-offenders
- Acute & Chronic
- Most related directly or indirectly to drug use
- Many ways to intervene effectively
- Educate about risks
- Screening / case-finding
- Preventive measures
- Condoms
- Vaccines
- Treatment