Implementing evidence based strategies in a system like a school, jail or community organization can come with many challenges. Components of effective program implementation, such as, staff development and training, structuring of the environment, teaching skills, behavioral change strategies such as shaping, generalizing and reinforcing skills, or data collection and reporting – large scale program implementation and evaluation can be achieved with support.

Additionally a group of colleagues and I have begun to offer services for correctional institutions considering expanding their Medication for Opioid Use Disorder. Agencies will likely face many barriers in program and planning implementation – we can help!!

Likely barriers and/or challenges we have overcome include:

  • Licensing
    • Federal regulations are often outdated and do not correspond to offering treatment within a correctional context.  As such, agencies will likely face challenges when applying to be licensed and accredited from the Drug Enforcement Agency (DEA),the Substance Abuse and Mental Health Service Administration (SAMHSA), and from state public health agencies.  
  • Culture shift 
    • Modern treatment paradigms can introduce philosophical dilemmas for corrections agencies – such as the dialectics between harm reduction versus abstinence based treatment and punishment versus treatment modalities.  MOUD requires agencies move toward a public health model of corrections that conceives evidence based treatment and practices as a mechanism for cultivating public safety.
  • Addressing internal bias with staff
    • Correctional environments have a long history of adverse control policies which vicariously affect inmates and staff.  It is not uncommon for staff at correctional agencies to have developed bias toward individuals who struggle with addiction and criminal behavior.  A trauma informed training protocol increases capacity and resiliency of staff members.  
  • Medication adherence & compliance for inmates
    • It is not uncommon for MOUD to be used as a form of financial currency between inmates.  Moreover, individuals who have used MOUD in the past have often developed unhelpful habits – inconsistently taking MOUD leading to relapse.  Behavioral practices that shape individual’s habits by promoting adherence to MOUD and reducing diversion are paramount.  
  • Integrating previously siloed divisions within a correctional institution
    • Correctional institutions have a history of working in silos.  MOUD programs require treatment teams to be integrated in order to
      • help with all behaviorally influenced conditions
      • subtract from, not add to, the workload of the divisions
      • help improve behavioral change skills
      • improve care outcomes 
      • help decrease the medication culture 
      • improve identification of undiagnosed problems
      • be accessible
      • avoid rigid rules that make care less accessible – a consultation approach is recommended
  • Ensuring both policy and practice are in regulatory compliance with federal and state regulations
    • Correctional agencies face barriers when implementing policies and treatment practices because the regulations were not originally written to be implemented in correctional settings.  Navigating policy implementation, overcoming regulatory compliance obstacles and obtaining specific regulatory waivers may be challenging.
  • Funding of MOUD and programming
    • Funding a MOUD program requires effective data collection and analysis, projective budgeting skills and strong political advocacy.  Unfortunately, it is not uncommon for an administrator to hold multiple responsibilities which require them to execute the aforementioned work while also attending to grant writing, reporting deadlines, and meeting supervisory demands.  To be effective, a program needs a well established workflow process and administrators with specific skills to overcome these barriers.  
  • Staff Training
    • Correctional officers, supervisors, and administrators; licensed behavioral health clinicians, reentry case workers and medical; and education staff complete cross-training on security, core trauma-informed treatment principles, motivational interviewing and evidence-based treatment interventions.  During the academy, all new uniformed officers participate in training on criminogenic risk need responsivity (RNR) assessment and practice and on principles of behaviorism and substance use disorder, with in-service training offered annually. All human service personnel receive intensive three-day training in RNR and are certified to administer the LS/RNR.  Weekly, behavioral health and multidisciplinary consultation team meetings occur, and each unit has a case management meeting focused on specific client needs.  Monthly didactic lectures are held to further staff skills in specific CBT treatment modalities and quarterly training retreats provide more in-depth opportunities to reinforce critical areas, such as cultural sensitivity, staff resiliency and secondary trauma. 
  • Client misunderstanding and lack of knowledge about MOUD options
    • As the field of MOUD becomes more sophisticated, FCSO has found that inmates generally are unclear about the available range of MOUD treatment options.  MOUD options counseling and coaching on the effective practice of medication adherence is beneficial.
  • Difficulty finding and training appropriate medical and behavioral health staff to operate OTP programming
    • Most behavioral health clinicians and medical staff do not receive in depth training at their colleges to treat OUD – nevermind the lack of educational experiences with inmates in the criminal justice setting. By developing relationships with local educational facilities and by acting as a training site for medical and behavioral health interns, programs can more effectively cultivate the best candidates for future employment opportunities.  Additionally, staff who have been hired have benefited from staff training protocols previously aforementioned.
  • Inter agency coordination to support continuity of care post release
    • Specific strategies outlined in the Transitions from Jail to Community (TJC) protocol help to cultivate and strengthen relationships.  Access to these community resources are critical to inmates’ continuity of care when reentering the community after incarceration.  Developing qualified service organization agreements (QSOA) and memorandum of understandings (MOU) with specific agencies ensures that the inmate does not experience a lapse in access to MOUD, primary health care, counseling and securing their basic needs of housing, employment, food security and transportation.