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Receive a presentation from the Sheriff’s Office and consider approving a Medication Assisted Treatment (MAT) Program that will be offered in the Solano County jails; Authorize the County Administrator to execute an agreement and any amendments with Health Management Associates to receive $159,347 in federal pass-through funds under the California Medication Assisted Treatment Expansion Project 2.0, for the period July 2019 through January 31, 2020, to develop a Medication Assisted Treatment program in Solano County jails; Approve, and authorize the Sheriff-Coroner to execute, a Memorandum of Understanding between the Solano County Sheriff’s Office, Wellpath, and MedMark Treatment Centers to provide and administer medication to inmate patients under the MAT Program and provide for the continuity of care for inmate patients in custody and upon release; Approve an Appropriation Transfer Request (ATR) of $159,347 to recognize unanticipated Medication Assisted Treatment grant revenue in FY2019/20 and increase appropriations for related expenditures including the salary and benefits of one limited-term full-time position (4/5 vote required); and Adopt a resolution amending the position allocation list to add 1.0 FTE Limited-term Mental Health Clinician (Licensed) to coordinate the Medication Assisted Treatment program
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Published Notice Required? Yes ____ No _X _
Public Hearing Required? Yes ____ No _X _
DEPARTMENTAL RECOMMENDATION:
The Sheriff’s Office recommends that the Board of Supervisors:
1. Receive a presentation from the Sheriff’s Office and consider approving a Medication Assisted Treatment (MAT) Program to be offered in the Solano County jails;
2. Authorize the County Administrator to execute an agreement and any amendments with Health Management Associates to receive $159,347 in federal pass-through funds under the California Medication Assisted Treatment Expansion Project 2.0 for the period July 2019 through January 31, 2020 to develop a Medication Assisted Treatment program in Solano County jails;
3. Approve, and authorize the Sheriff-Coroner to execute, a Memorandum of Understanding between the Solano County Sheriff’s Office, Wellpath, and MedMark Treatment Centers to provide and administer medication to inmate patients under the MAT Program and provide for the continuity of care for inmate patients in custody and upon release;
4. Approve an Appropriation Transfer Request (ATR) of $159,347 to recognize unanticipated Medication Assisted Treatment grant revenue in FY2019/20 and increase appropriations for related expenditures including the salary and benefits of one limited-term full time position for July 2019 - June 30, 2021 (4/5 vote required); and
5. Adopt a resolution amending the position allocation list to add 1.0 FTE Limited-Term Mental Health Clinician (Licensed) to coordinate the Medication Assisted Treatment program.
SUMMARY:
Opioid addiction and abuse, stemming in part from a high volume of prescribed opioid painkillers, is a growing problem nationwide, and many call it a crisis. In 2017, a Solano County Grand Jury report called out the risks that opioid use poses to the County, citing the Center for Disease Control’s data that between 2009 and 2014, there were 50 opioid deaths in Solano County, of which 48 were the result of misuse of prescription painkillers.
Medication Assisted Treatment (MAT) is a proven method to address opioid addiction and abuse. It is the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide a "whole-patient" approach to the treatment of Opioid Use Disorders (OUD). MAT has proven effective in preventing deaths due to opioid overdose. It may also be effective in reducing recidivism rates and long-term costs associated with medical care and incarceration.
The Sheriff’s Office has received two grants for MAT: 1) $25,000 approved by the Board on October 2, 2018, to support a County team assembled to address the challenges of inmate opioid use and to develop a MAT implementation plan, which has been expended in support of the development of this proposed program; and 2) a $159,347 MAT Implementation Grant award for the implementation of a MAT program in the Solano County jails (Board approval requested with this item). The Department will request a time extension and additional funding to support staffing for FY2020/21. At the October 2, 2018, Sheriff’s staff committed to returning to the Board at a later date with a proposal to implement MAT in the Solano County jails. Jails are ideal for MAT because they are a safe, controlled environment where treatment and medication are provided consistently.
The proposed plan includes partnering with the Sheriff’s Office’s medical services contractor Wellpath and local MAT provider MedMark Treatment Centers to provide opioid treatment medication, and hiring a grant funded Limited-Term Mental Health Clinician (Licensed) to coordinate tracking, assessment and placement in the proposed MAT program.
FINANCIAL IMPACT:
The $159,347 MAT Implementation Grant award provides for the initial implementation of a MAT program in the Solano County jails. The MAT Implementation Grant award does not require matching funds. An ATR for FY2019/20 is necessary to recognize the unanticipated grant revenue and increase appropriations for salary and benefits for the new Mental Health Clinician Limited-Term, training, contracted services, and other operating expenses.
MedMark has received a grant from the California Department of Health Care Services to provide methadone and buprenorphine to eligible inmate patients. At this time, there would be no cost to the County for the FDA-approved medications. Should funding expire and alternative funding not be identified, the terms of the MOU between the Sheriff’s Office, Wellpath and MedMark Treatment Centers would be revisited, as would the proposed MAT Program.
The annualized cost of a Limited-Term Mental Health Clinician (Licensed) is approximately $135,784 respectively. Although the term of the agreement is through January 31, 2020, the Sheriff’s Office will request a time extension of the grant term through 2020, and the Sheriff’s staff is pursuing additional grants for FY2020/21 for the position.
The cost associated with preparing the agenda item is nominal and absorbed by the department’s FY2019/20 Working Budget.
DISCUSSION:
According to the U.S. Department of Health and Social Services’ Substance Abuse and Mental Health Services Administration (SAMHSA), in 2013, an estimated 1.8 million people nationwide had an opioid use disorder related to prescription pain relievers, and about 517,000 had an opioid use disorder related to heroin use.
• From 1999 to 2017, more than 700,000 people died from a drug overdose.
• Around 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid.
• In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999.
• On average, 130 Americans die every day from an opioid overdose
In Solano County, the numbers are reflective of the nationwide crisis. In 2016, 343,000 opioids were prescribed, almost one prescription for each County resident, and 6 out of 7 opioid overdose deaths were caused by prescription opioids. In 2017, the prescription rate was 20% higher than the State average, 625 per thousand in the County and 517 per thousand in the State. 10 County residents died from opioid overdoses.
Long-term opioid use causes changes in the brain’s structure and function and results in a chronic brain disease according to the National Academies of Sciences, Engineering and Medicine. MAT, including opioid treatment programs, treats this disease by combining counseling, behavioral therapy, and medications approved by the Federal Drug Administration (FDA) to provide a “whole-patient” approach to treat substance use disorders (SUDs). MAT for opioid addiction is subject to federal legislation, regulations, and guidelines, including the Drug Addiction Treatment Act of 2000 (DATA 2000) <https://www.samhsa.gov/medication-assisted-treatment/legislation-regulations-guidelines> and federal regulations found at 42 CFR 8 <http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42.1.8&r=PART>.
A white paper provides more in-depth information on MAT and may be found in Attachment D. MAT has been clinically effective to alleviate symptoms of withdrawal, reduce cravings, and block the brain’s ability to experience the opiate’s effect. MAT maintenance has been proven to cut overdose rates in half and decrease rates of HIV and hepatitis C transition. Detoxification (use of medications for 1-3 months), in contrast, increases mortality rates and does not improve long-term outcomes. Research shows that a combination of MAT and behavioral therapies is a successful method to treat OUDs. MAT in correctional settings has been proven to lower mortality on release; the Rhode Island Department of Corrections dropped overdose deaths by 61% within a year of implementing their MAT program (which offers all MAT options - buprenorphine/Suboxone, methadone, and naltrexone/Vivitrol) to inmates. In addition, inmates receiving methadone continuation during incarceration are three times less likely to act out than those in forced methadone withdrawal and are also four times more likely to engage in community treatment after release. Additionally, in May of this year, the United States Court of Appeals for the First Circuit in Boston ruled that a rural Maine jail must provide an inmate with medication to continue her treatment for OUD. Violation of the Americans with Disabilities Act (ADA) and the 8th Amendment was implicated when MAT was not provided in jail.
In December 2016, SAMHSA released a funding opportunity for states under the State Targeted Response to the Opioid Crisis Grant (Opioid-STR). The purpose of the grant is to address the opioid crisis by improving access to treatment, reducing unmet treatment need, and reducing opioid overdose related deaths through the provision of prevention, treatment, and recovery activities for OUD. The State of California was awarded an Opioid-STR grant and created California’s sub-grant program, the California Medication Assisted Treatment Expansion Project. Health Management Associates (HMA), a leading independent national research and consulting firm in the healthcare industry, was awarded the California sub-grant and administered sub-grants to local government agencies under the MAT Learning Collaborative Grant. Solano County was awarded $25,000 to support a County team assembled to address the challenges of inmate opioid use and to develop a MAT implementation plan.
The team was comprised of representatives from the Sheriff’s Office as well as the County Administrator’s Office, the Department of Health and Social Services, the Probation Department, the Superior Court of California, County of Solano, the Solano Coalition for Better Health/Solano Opioid Safety Coalition, Wellpath, and MedMark Treatment Centers. The County team attended in-person learning collaboratives to better understand how MAT has been implemented in other jails and jurisdictions, best practices in criminal justice settings, and plan development; participated in monthly coaching calls, webinars, and podcasts; and consulted with advisory groups. After attending the learning collaboratives, the team is recommending that Solano County develop inmate access to MAT while in custody.
Solano County’s MAT implementation plan includes the development and implementation of opioid use disorder screening, assessment, and treatment protocols; MAT training for Custody Division staff and the County’s criminal justice partners (i.e.; contracted medical, mental health, and substance abuse providers; and community-based organizations); and the development and implementation of release protocols.
The proposed program, which would initially be located at the Justice Center Detention Facility with the possibility to expand to the Claybank and Stanton Detention Facilities in future, includes a partnership between the Sheriff’s Office, its contract medical services provider Wellpath, and MedMark Treatment Center Fairfield. MedMark, an authorized opioid treatment provider in Solano County, is federally certified, state licensed, and accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). CARF accreditation signals a service provider's commitment to continually improving services, encouraging feedback, and serving the community. MedMark currently offers MAT for opioid addiction through the use of medication and support services on an outpatient basis. Through the proposed MOU (Attachment C) between the Sheriff’s Office, Wellpath and MedMark, MedMark would provide methadone and buprenorphine at no cost to those already receiving MAT upon booking/incarceration. Wellpath will obtain all proper authorizations for the patient inmates, ensure proper security and dispensing of medications, and monitor the health of the inmates on the MAT program. The proposed MOU outlines the responsibilities of each agency. Wellpath already provides MAT in other facilities and has draft policies and procedures (Attachment E).
In addition to the regularly prescribed medications, SAMHSA has provided funding to DHCS to combat opioid overdose-related deaths throughout California through the Naloxone Distribution Project (NDP). The NDP aims to address the opioid crisis by reducing opioid overdose deaths through the provision of free naloxone, which can reduce the effects of an overdose in an emergency situation. Deputy Sheriffs working in the field and Correctional Officers in the jails will all receive training through NDP and have Naloxone available to administer in the case of an overdose when time is critical to prevent fatalities. Naloxone is a life-saving medication that reverses an opioid overdose while having little to no effect on an individual if opioids are not present in their system. Naloxone works by blocking the opioid receptor sites, reversing the toxic effects of the overdose. Naloxone is not a controlled substance, has few known adverse effects, and no potential for abuse.
The Sheriff’s Office was awarded another grant from HMA, a $159,347 MAT Implementation Grant for the period of March 14, 2019 through January 31, 2020 (to include a no cost extension if needed) to implement a MAT program. The Sheriff’s Office and stakeholders are in support of continuing the County’s MAT efforts with the implementation plan. With Board approval to execute the sub-grant agreement with HMA, the County is recognizing the widespread impact of opioid abuse and the means to address this abuse within the County jails. The grant will cover salary and benefits for the new Limited-Term Mental Health Clinician to serve as the MAT Coordinator working with the County’s criminal justice partners to develop protocols, coordinate training, establish policy and procedures, and capture MAT program data, as well as some training, contracted services, and other operating expenses.
Implementing MAT in the Solano County jails would not only decrease the number of preventable deaths from opioid overdoses, it may also decrease disciplinary issues among inmate patients and resulting injuries to staff, and may reduce recidivism rates upon release back into the community.
ALTERNATIVES:
The Board of Supervisors could choose:
1. Not to approve the MAT Program; however, this is not recommended because it is an evidence-based solution to reduce the number of opioid-related overdose deaths, it may reduce disciplinary issues during incarceration and reduce recidivism upon release, and may be required under the Americans with Disabilities Act; and/or
2. Not to approve the sub-recipient grant agreement; however, this alternative is not recommended as the County would not be eligible to receive the MAT grant award to address the growing opioid crisis within the jail facilities. Moreover, without grant funding, the Sheriff’s Office would be unable to provide inmates with necessary opioid treatment services that may become a barrier in their efforts not to recidivate; and/or
3. Not to approve the MOU; however, this alternative is not recommended as MedMark and Wellpath have experience in providing MAT to inmates and would be valuable collaborators in the County’s efforts to combat the opioid abuse crisis.
OTHER AGENCY INVOLVEMENT:
The agreement with HMA and the MOU between the Sheriff’s Office, Wellpath, and MedMark Treatment Centers have been reviewed and approved as to form by County Counsel. The County Risk Manager has reviewed applicable liability provisions. The Department of Human Resources has prepared the position allocation resolution.
CAO RECOMMENDATION:
APPROVE DEPARTMENTAL RECOMMENDATION