Addressing the Opioid Crisis in Rural Communities by Engaging Incarcerated Females in a Re-Entry Program

The U.S. Department of Health and Human Services (DHHS) initiated a proposal that focuses on three aims to increase quality improvements in healthcare (U.S. Department of Health and Human Services [DHHS], 2015). One aim is to provide better care with a focus on achieving meaningful health outcomes; another aim is to provide affordable quality health care; and the third aim is to, “improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and, environmental determinants of health in addition to delivering higher quality care” (U.S. DHHS, 2015, Introduction section, para. 1). Following an extensive rural community and clinical site assessment and literature search, the authors chose a clinical project that addresses the third aim. The assessment and literature search revealed some common themes to guide the project development; including the following: (a) substance use disorder is a national epidemic, (b) female incarcerated adults are a vulnerable population, (c) post release is a high risk time for opioid overdose, (d) lack of access and resources contribute to opioid overdose, (e) evidence based interventions are available, and (f) successful transitioning to the community post release can have a positive impact.

Substance Use Disorder (SUD) has become a national epidemic, described as a medical illness caused by repeated misuse of a substance or substances (Bukten et al., 2017; Marsden et al., 2017; U.S. DHHS, 2016). The Centers for Disease Control and Prevention (CDC) reports, on average, 115 opioid related deaths daily in the United States (U.S.) (2017). The newly released male and female prisoners are a vulnerable aggregate of the opioid epidemic (Bukten et al., 2017; Gisev et al., 2015; Groot et al., 2016; Marsden et al., 2017; & Parmar, Strang, Choo, Meade, & Bird, 2016). The President’s Commission on Combating Drug Addiction and the Opioid Crisis 2017 Report identified the incarcerated population as a special group requiring increased outreach, access to services, and more tailored or intensive services (The Council of Academic Advisors [CEA], 2017).

The Female Incarcerated Individual

Within this special group, females were identified as a unique subgroup. The female population in the criminal justice system continues to rise in a historically male institution, increasing the need to address female-related needs, particularly those related to substance use (Johnson et al., 2013). The Substance Abuse and Mental Health Services Administration reported a 400% increase in female opioid overdose deaths in the year 2011 (SAMHSA, 2015). Research has shown that women use drugs more frequently and for different reasons than men, thus creating the need to effectively address the unique needs of incarcerated women in terms of aftercare (Johnson et al., 2013).

Residents living in rural areas have higher rates of opioid use disorder (OUD), a subcategory of SUD, and face substantially more barriers to OUD treatment (CEA, 2017). According to Johnson, Mund, and Joudrey (2018), due to the lack of medication assisted therapy (MAT) for individuals with OUD during 2015, the rate of drug overdose deaths in rural areas surpassed that of urban areas. Binswanger et al. (2012); Chavez (2012); and Kendall, Redshaw, Ward, Wayland, & Sullivan (2018) recommend pre-release programming of overdose education, re-entry programs, and naloxone prescriptions as valuable means in reducing opioid overdose post release. The time period following release from incarceration can be a challenge and is recognized as a highly stressful time (Kendall, Redshaw, Ward, Wayland, & Sullivan, 2018).

Healthy Outcomes Post-release Education Program for Females

The implementation of a successful re-entry program for the vulnerable female incarcerated population has the potential to reduce the risk of opioid overdose death and negative health outcomes post-release; thus, improving health outcomes for the individual, family unit, and community. After collaborating with representatives from various disciplines in the community and state, the authors developed a re-entry program titled, “Healthy Outcomes Post-release Education” (HOPE).

Rosswurm and Larrabee’s Model for Evidence-Based Practice Change served as a useful framework to develop and integrate an evidence based practice change in a southeastern rural county jail (Rosswurm &Larrabee, 1999). The model will also guide the authors in monitoring the outcomes and disseminating the results of the project. Sister Callista Roy’s Adaptation Model (RAM), a nursing practice deductive theory, was used to guide the development of the re-entry program to assist female inmates to adapt and make changes when stressful situations are experienced in the post release environment. The RAM has contributed to advancing the science of nursing and nursing education for many years (Wills, 2014). The RAM model is composed of four interrelated adaptive systems: (a) physiologic-physical mode, (b) self-concept-group identity mode, (c) role function mode, and (d) interdependence mode (Roy, 2009). Each class will be facilitated by a community representative that is considered an expert in the particular course content. The HOPE program class schedule and specific interventions are described below.

Class One Focus: Self-Concept Adaption

General education and a presentation on substance use disorder (SUD), the correlation between SUD and mental health, self-awareness, self-care, and self-esteem will be provided. Participants will identify 2-3 personal goals upon release. Local resources will be provided in a HOPE package to be provided upon release.

Class Two Focus: Physical Adaptation

Females will participate in the TN Department of Health training course on the use and administration of intranasal naloxone for opioid overdose. Once naloxone education is complete, a certificate of completion and twin pack dose of naloxone will be included in the HOPE package. Education regarding medication-assisted therapy (MAT) will be presented during class time, along with available community resources providing MAT. Females will participate in the American Heart Association Hands-Only CPR training for lay people. Contact information for a recovery coordinator through the TN Department of Mental Health & Substance Abuse Services will be provided in the resource packet.

Class Three Focus: Role function

The focus of this class will be identification of new roles upon reentry into the local community setting. Discussion and resources regarding employment and furthering educational opportunities will be presented. Participants will be able to complete a skills assessment and self-identify personal interests. The value of maintaining sobriety to be able to adapt and function in the identified roles will be discussed.

Class Four Focus: Interdependence

This last class will focus on identifying and developing healthy relationships and support systems. Partner abuse, the prevention of sexually transmitted infections, and safe sex will be discussed and resources will be provided in the HOPE package.

Conclusion

The implementation of an evidence-based re-entry program using Rosswurm and Larrabee’s Model for Evidence-Based Practice Change and Sister Callista Roy’s RAM model has the potential to influence attitudes and behaviors; thus, empowering females to be prepared to successfully adapt to the post release environment. Together with the collaboration of community and state representatives and the implementation of proven interventions that address the behavioral, social, and environmental determinants of health for females in a rural county jail; the HOPE program has the potential to decrease opioid related overdose risks; thus, positively impacting the overall health of the individual, the family unit, and the community.