Date of Award

6-2019

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)

Department

Nursing

Faculty Chair

Gloria Nam

Faculty Reader

Antwinett Lee

Executive Summary

Medicolegal Considerations in the Management of Opioid Use Disorder with Buprenorphine by Jail Health Services: Executive Summary

In 2017, over 2.1 million people in the United States were estimated to have an opioid use disorder (OUD; Substance Abuse and Mental Health Services Administration, 2018), with over 200,000 opioid dependent prisoners passing through the correctional system each year (Nunn, Zaller, Dickman, Trimbur, Nijhawan, & Rich, 2009). Incarcerated individuals with OUD are at higher risk for overdose and death (Alex et al., 2017; Binswanger, Blatchford, Mueller, & Stern, 2013; Lim et al., 2012). Buprenorphine-based medication assisted treatment (MAT) is a long-term treatment strategy for OUD (Volkow, Frieden, Hyde, & Cha, 2014), but aspects of prescribing buprenorphine can be disconcerting to staff in jail health service (JHS), particularly around issues of liability (S. Roosma-Goldstein, personal communication, October 10, 2018).

Problem/Purpose Statements

Opioid use disorder is disproportionately observed in incarcerated populations, adding to the societal burden incurred by the current opioid epidemic (Bronson et al., 2017; Dolan et al., 2007). Increased access to effective treatment interventions that begin in the correctional setting and continue into the community are needed (Chandler, Fletcher, & Volkow, 2009; Hedrich et al., 2012), as well as information for providers concerning best practices and medicolegal implications of prescribing these treatments.

The purpose of this DNP project was to address and clarify the medicolegal implications for prescribers who provide buprenorphine for the treatment of OUD in the correctional setting. Exploration of these issues will benefit JHS staff who are currently navigating emerging policy changes and national practice recommendations with the added potential for increased willingness to prescribe buprenorphine, thus addressing OUD as both a local public health concern and a national crisis.

Methods

This DNP project took place in a large county jail and applied to prescribing providers within JHS. Employing an evidence-based implementation design, a literature review article was synthesized with clear statements of review findings, implications for JHS providers and culminating recommendations. These recommendations will be incorporated into already existing clinical practice guidelines. A single academic detailing session was presented to JHS providers to discuss the literature review findings and provide peer-to-peer supported learning.

Evaluation of this DNP project used a pretest-posttest design in which data was collected via a Qualtrics questionnaire, using a seven-point Likert Scale to assess both the subjective understanding and confidence levels of providers before and after the learning intervention.

Results/Outcomes

The project objectives regarding the implications of prescribing buprenorphine to incarcerated populations were met. The average pretest ranking of perceived understanding was 3.3, which increased to 6.8 following the learning intervention. And the average pretest ranking of current comfort level in prescribing was 5.1, which increased to 6.1 following the learning intervention. There were no unanticipated findings during the course of this DNP project.

Implications

Clarification for JHS providers regarding the medicolegal implications of prescribing buprenorphine in the correctional setting can improve both understanding and confidence, resulting in increased potential to prescribe this treatment and further address OUD within a high-risk population. These findings are applicable and transferable to other correctional facilities and as a means of supporting JHS staff who are responsible for implementing this movement, explanation of personal liability should be shared to help clarify the reality and alleviate concerns.

References

Alex, B., Weiss, D., Kaba, F., Rosner, Z., Lee, D., Lim, S., … MacDonald, R. (2017). Death after jail release: Matching to improve care delivery. Journal of Correctional Health Care, 23(1), 83–87.

Binswanger, I. A., Blatchford, P. J., Mueller, S. R., & Stern, M. F. (2013). Mortality after prison release: Opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Annals of Internal Medicine, 159(9), 592.

Bronson, J., Stroop, J., Zimmer, S., & Berzofsky, M. (2017). Drug use, dependence, and abuse among state prisoners and jail. Bureau of Justice Statistics. Retrieved from https://www.bjs.gov/content/pub/pdf/dudaspji0709.pdf

Chandler, R. K., Fletcher, B. W., & Volkow, N. D. (2009). Treating drug abuse and addiction in the criminal justice system. JAMA, 301(2), 183.

Dolan, K., Khoei, E. M., Brentari, C., & Stevens, A. (2007). Prisons and drugs: A global review of incarceration, drug use and drug services. Retrieved from http://kar.kent.ac.uk/13324/

Hedrich, D., Alves, P., Farrell, M., Stöver, H., Møller, L., & Mayet, S. (2012). The effectiveness of opioid maintenance treatment in prison settings: A systematic review. Addiction, 107(3), 501–517.

Lim, S., Seligson, A. L., Parvez, F. M., Luther, C. W., Mavinkurve, M. P., Binswanger, I. A., & Kerker, B. D. (2012). Risks of drug-related death, suicide, and homicide during the immediate post-release period among people released from New York City jails, 2001-2005. American Journal of Epidemiology, 175(6), 519–526.

Nunn, A., Zaller, N., Dickman, S., Trimbur, C., Nijhawan, A., & Rich, J. (2009). Methadone and buprenorphine prescribing and referral practices in US prison systems: Results from a nationwide survey. Drug Alcohol Depend, 105(12), 83–88.

Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality. Retrieved from https://www.samhsa.gov/data/

Volkow, M., Frieden, T., Hyde, P., & Cha, S. (2014). Medication-assisted therapies-tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063-2066.

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