'Behind the Blue': How UK, State Partners Are Working to Help Incarcerated Women With Opioid Use Disorder

On, on, U of K, we are right for the fight today. Hold that ball and hit that line. Every wildcat star will shine. We'll fight, fight, fight-- 

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INTERVIEWER 2: From the campus of the University of Kentucky, you're listening to Behind the Blue. 

KODY KAISER: The University of Kentucky recently received an $8.8 million grant from the National Institute on Drug Abuse, part of the National Institutes of Health, to establish a clinical research center as part of the Justice Community Opioid Innovation Network, or JCOIN, which will support research on quality addiction treatment for opioid use disorder in criminal justice settings nationwide. 

The awards-- totaling an estimated $155 million-- will support the multi-year innovation network, including 10 research institutions and two centers that will provide supportive infrastructure. Here at the University of Kentucky, the grant will be used to create the Kentucky Women's Justice Community Opioid Innovation Network, or WJCOIN, to enhance access to opioid use disorder treatment for women as they transition from jail back to the community. 

In Kentucky, women represent the fastest growing demographic in the criminal justice system, and are also susceptible to unique vulnerabilities that can lead to opioid overdose. Michele Staton, associate professor in the UK College of Medicine Department of Behavioral Science, will serve as principal investigator on the project. Staton will lead a team of experts from across UK's campus, including the colleges of medicine, nursing, public health, and arts and sciences, the Center on Drug and Alcohol Research, and UK HealthCare's Kentucky Telecare. 

I'm Cody Kaiser with UK PR and marketing. On this week's episode of Behind the Blue, UK PR's Alison Perry sits down with Staton, along with Katherine Marks, a UK College of Medicine Research Assistant Professor and project director for the Kentucky opioid response effort within the cabinet for Health and Family Services, and Sarah Johnson, Director of Addiction Services with the Kentucky Department of Corrections. They discuss the partnerships, increases in patient care, and community support this grant will enable in their work. 

MICHELE STATON: Hi, I'm Michele Staton. I'm an associate professor in the College of Medicine Department of Behavioral Science and a faculty affiliate of the Center on Drug and Alcohol Research. 

SARAH JOHNSON: Hi, my name is Sarah Johnson. I'm the director of addiction services for the Department of Corrections. 

KATIE MARKS: Hi, I'm Katie Marks. I'm an assistant professor in the College of Medicine Department of Behavioral Science. And I'm also the project director for the Kentucky Opioid Response effort in the Cabinet for Health and Family Services. 

INTERVIEWER: OK. Thank you all for coming. I want to start by just kind of briefly have each of you describe what you work on, like, what your general focus is in your jobs. We'll start with you, Michele. 

MICHELE STATON: My research primarily focuses on substance users in the criminal justice system who are transitioning from corrections to the community and designing interventions that can target people during that high risk period of community reentry. 

INTERVIEWER: Sarah? 

SARAH JOHNSON: So the Division of Addiction Services within the Department of Corrections is responsible for providing clinical assessments for any individual that is incarcerated within the Department of Corrections or on some form of supervision. So my staff is responsible for providing that clinical assessment and then either linking someone to treatment or actually providing that direct treatment. 

INTERVIEWER: Katie? 

KATIE MARKS: My research interests are in behavioral health recovery, but specifically right now I'm working with the state to use implementation science to understand how we can adopt evidence-based practices across the state in the space of prevention treatment and recovery for opiate use disorder. 

INTERVIEWER: All right. So we are gathered today to talk about a really big grant that UK was just awarded. Michele, I want to have you start off by just kind of talking a little bit about JCOIN, what that is in general terms. And then we'll talk about how the state is partnering with us. 

MICHELE STATON: Sounds great. We are so excited about this new grant. JCOIN actually stands for Justice Community Opioid Innovation Network. And it's a cooperative agreement that's funded by NIH-- NIDA, specifically-- to establish a national network of investigators across the country who are collaborating with justice and behavioral health partners to conduct research that really improves the capacity of the justice system to respond to the opioid crisis. 

And we are really excited here in Kentucky to be one of 10 funded clinical research centers nationally under this JCOIN initiative. And I also want to say that our center is the only center nationally that's focused exclusively on women. 

INTERVIEWER: And how is the Department of Corrections involved? 

MICHELE STATON: So this is going to be targeted at 10 county jails. We're very excited to be able to-- I'm sorry, nine county jails. We're very excited to be able to expand our capacity at actually reaching additional individuals. And the focus being on women is very exciting, as well, because what's happened in Kentucky is that is our highest growing population in the criminal justice system. And unfortunately, currently Kentucky is the second nationally for the highest rate of women incarcerated. 

So this will allow us to target the specialized need of those individual women and help them be successful when they're released from incarceration. 

INTERVIEWER: And Katie, how's the Department of Behavioral Health involved? 

KATIE MARKS: Yeah, so the Department of Behavioral Health has a strong network of community supports that individuals can access when they're re-entering, including providers that can support their medication for opiate use disorder and the other psychosocial interventions that go along with that, as well as recovery supports. There's also the Kentucky opioid response effort, which is a large SAMSA grant that has come to the state. And we want to make sure we leverage all of those resources and ongoing efforts at the same time so that JCOIN can maximize its impact on the state. 

INTERVIEWER: OK. And for the next couple questions, just jump in. You know, you don't have to wait for me to point to you. But can you kind of describe how this will look like in practice, like, how the process will work to help women get access to treatment? 

KATIE MARKS: So I can maybe start. The overall plan for the Kentucky JCOIN center is to implement telehealth in six different jails in both urban and rural areas of Kentucky to deliver what we're calling pre-treatment for medications to treat opioid use disorder-- M-O-U-D. And through those telehealth linkages, we expect that community providers can connect with women in jail prior to release to conduct screening, assessment, medical evaluation, as well as providing a lot of education around the benefits as well as the possible risks with MOUD. 

And then when women are released from jail, they can then enter treatment with those community providers. So that's going to happen in six jails across Kentucky. And those are our target experimental sites. So everybody gets the telehealth treatment component, but then there's also-- it is a randomized controlled trial. So one arm of the study will also get peer navigation to increase the utilization of MOUD as women transition to the community. 

And we're really excited to partner with Voices of Hope here in Lexington to do that, that peer navigation piece. So those are the six experimental sites. And then there will be three comparison sites-- SAP, Substance Abuse Programs, here in Kentucky that currently serve women. And those women already have access to MOUD as part of their treatment during incarceration. And you guys can certainly talk more about that. 

SARAH JOHNSON: So just to explain a little bit about what substance abuse programming currently looks like in our jails, the Department of Corrections contracts with jails to oversee and ensure fidelity in the implementation of substance abuse programming. They use evidence-based curriculum through the Betty Ford Hazelden Foundation. It's a six-month program. It's a cognitive behavioral therapy type program in a modified therapeutic community. 

Typically lasts about six months. We currently offer that in 21 jails. We would like to offer it in more, but we don't necessarily have the capacity due to overcrowding. So this project will allow us to affect positive change in additional people that we currently don't have the capacity to do. And we are targeting jails to add these services that already have an existing substance abuse program, because it already has the infrastructure, the contractual relationship with the Department of Corrections, and the clinical staff in place to help support this project. 

INTERVIEWER: And you talk about-- it's a randomized trial. So are is it really just some women are chosen to do this? Or do they volunteer and say, I want to be part of this? How does it-- how does it work? 

KATIE MARKS: Well, it is a research project. So they certainly will have to volunteer. We will ideally develop a system with DOC to identify women who are nearing the time of release from jail. And then those women will be screened for opioid use disorder. And if they meet sort of that general screening criteria for this study, they'll be referred for assessment and medical evaluation with our community providers using the telehealth linkage. 

So we hopefully will serve somewhere in the vicinity of 900 women over the course of the five year study. But there will be that initial recruitment selection and screening process on the front end to make sure that we identify women who are good candidates for MOUD. 

INTERVIEWER: And you know, you made the point that this is the only one of the projects that's focused on women. And can all of you kind of chip in why do you feel that's so important? 

MICHELE STATON: Well, I think in Kentucky-- Sarah just mentioned earlier that women represent the fastest growing population of incarcerated individuals in the state. And they also have some unique vulnerabilities associated with opioid use disorder. And you know, some of those include a much faster trajectory from initial use to opioid dependence. 

They also face some unique challenges associated with entering treatment, which may be largely related to family obligations and different things like that. So you guys can probably speak to this, as well. 

SARAH JOHNSON: There's also usually-- or frequently-- trauma associated with women and OUD or SUD-- Substance Use Disorder-- in general. So that's also an additional component when you're talking about treatment needs that's unique to women. Not that men don't have that, but it's more frequent with women. 

So there are just specialized needs that the female population has that's different and looks different than what the male population has. 

KATIE MARKS: Absolutely. And I think when we think about serving women, we also think about the impact that it can have on our families in Kentucky. We know that we've got a rapidly growing foster care system. And so to serve these women and help them enter recovery, remission, and long term recovery, we're not just making an intervention point with the woman, but potentially an impact on her family and larger generational impacts. 

INTERVIEWER: As this-- you know, you said women are being incarcerated at higher rates. Correct? Is this unique to Kentucky, or is this across the country? 

SARAH JOHNSON: Kentucky has the second highest rate of incarcerated women. So the growth is national, but it's at a higher rate in Kentucky. So we are really trying to, within the Department of Corrections and specifically within the Division of Addiction Services, targeting services for this population. They represent the highest waiting list when it comes to program needs within our jails. 

So this couldn't come at a better time, because we can not-- we don't have the capacity to offer services for everyone that needs them. And this will allow us to offer more services that we currently cannot offer. 

MICHELE STATON: I also want to add to this that a few of us in this room grew up in rural Eastern Kentucky. And so we also are excited to be able to expand this grant into rural jails and rural communities, because the service delivery system is limited in general for women largely, but is really limited in some of these rural communities. And so that's another huge part of this grant is just, how can we build capacity in those communities, as well, to strengthen treatment and opportunities as women transition from jail to the community? 

INTERVIEWER: Let's talk about that a little bit more. You know, everyone here is from Kentucky. And then three of us are from the same county in Eastern Kentucky. So you know, you wrote-- you are a Kentuckian and working for Kentuckians. And like, how does that make you feel? Like, can you tell me a little bit about how it motivates you and your work? 

KATIE MARKS: I am immensely proud of the good work that's already going on in Kentucky and the opportunity to serve the state in any manner that I can, to know that this is not just an important issue because of the clear social justice ramifications, but because these are-- this is my family and my friends and my community. It makes it that much more personal. And I am just-- I've found boundless energy in my passion for this as a result of this being a Kentucky issue. 

SARAH JOHNSON: I totally agree. Growing up in this community and this state and then working within the criminal justice field and within the addiction field for the last 15 years, I have seen the devastation that substance use disorder has caused across this entire state. It has destroyed families. It has destroyed communities. So to be part of that solution and to be able to help rebuild communities and to restore hope to families, I just feel privileged to be part of that solution. 

MICHELE STATON: I'm not sure there's a lot that I could-- I share those sentiments wholeheartedly. As a researcher, I think sometimes it's easy to sit in an office and play with data and get publications out there. But one of the things I love to do is go out with my research team and talk to people. And I agree that you really can't talk to anybody in some of the communities that we work in who have not been impacted in some way by pretty much opioid use specifically. 

And so I also consider it a huge privilege just to be able to do this work. And we are-- I keep saying it over and over, but we're so excited about this project and the opportunity that it brings, as well as the way that it maps onto and supports and provides some additional resources for a lot of the efforts that are already going on in the state. 

INTERVIEWER: Can you help kind of explain to the average person-- I'm going to play devil's advocate a little bit here-- but to someone listening, they might have this perception that, well, if you have opioid use disorder and you're in jail, you're a lost cause. Can you kind of help dispel that myth and then talk about why it's so important that we get people the treatment that they need? 

KATIE MARKS: I'll let Sarah start. 

SARAH JOHNSON: Absolutely. So we have had a partnership with the University of Kentucky and Center for Drug and Alcohol Research for a long time. They evaluate our programs. They do outcome study on the participants in our programs. And that's available to the general public to review and see the outcomes. 

But what we know about the majority of individuals that are incarcerated is at some point in time, they will be released. I think it's about 98% of the folks that are currently incarcerated will be released. They will be your neighbor. They will go into your churches. They will be your co-worker. So what we want to do is we want to offer them the best evidence-based treatment so that they can have opportunities to change and be different and have a different projectory in life. 

That is our obligation within the Department of Corrections to offer those opportunities for rehabilitation, because the reality is the individual is coming out. And we want them to have something different. I have never met an individual-- and I've worked, like I said, for a long time with individuals with substance use disorder, opioid use disorder-- that said, I want to be addicted to opiates. 

That's not what somebody wants. That's not what they see in their future. It is a debilitating illness that someone has. And we want to offer hope. We want to give them the tools that they need to change that path so that they can be successful. And we have seen that success. I mean, there are a lot of people that are successful that end up turning around and helping others in recovery and become some of the best counselors that we have in substance use disorder treatment. 

So recovery is possible, and we want to make sure that we offer the opportunity and the resources that when somebody is ready and wants that treatment, we have it available for them. 

MICHELE STATON: Yeah, I think the only thing that I would possibly add is that if anybody feels the brunt of the opioid use epidemic, it's the Department of Corrections. And I think that just the increasing numbers of people who end up incarcerated because of addiction is-- it's just staggering. And so we have made tremendous strides in the state around treatment opportunities during incarceration. 

And so I think that because of that, as well as because it's no longer just the, quote unquote, "drug addict found in the alley" that ends up in jail. Like, it's your dad. It's your brother. It's your cousin. I mean, the four of us in this room could probably name four or five people that we know who've been incarcerated because of this. And so I think that because of that, the stigma has sort of changed from, it's only the, quote unquote, "drug addict" who ends up incarcerated. 

It's so many people who end up incarcerated. And I am so excited to be a part of what the state is doing in terms of increasing access to treatment, because what better time to reach people than when you may be sober for the first time in a long time, and really ready to receive treatment? And Katie, you probably have some things to add to that, as well. 

KATIE MARKS: Right. The opportunity to intervene and provide support when someone has entered the justice system is something we can't pass on for a number of reasons. First of all, because that can be a turning point and a moment of motivation for people. Well, we also recognize that it's a very, very vulnerable time. When someone enters jail, they begin to lose their tolerance to opioids. And without treatment when we release them, their risk for overdose death upon return to use is immensely high. 

And so we have to provide the support and the care that they need to not just prevent that overdose risk, but to engage them in long term care so that, again, we can help them enter the long term remission and recovery that they deserve. 

INTERVIEWER: I'm glad you brought that up, because I meant to ask about the, you know, when you're incarcerated, you're kind of forced into withdrawal. And then when you-- you know, coming out you are vulnerable. Because if you go back to using again, you're likely to use the same dose that you were before. And that's why overdose is so high in that population. Correct? 

KATIE MARKS: Exactly. You said it very well. 

INTERVIEWER: OK. 

SARAH JOHNSON: And that's one of the things that the Department of Corrections is working on. We've offered Vivitrol, which is an FDA-approved medication-assisted treatment, in our institutions, substance abuse programs, since 2016 for substance abuse graduates that have an opioid use disorder, and in all of our jail programs since 2018. So we recognize that that can help individuals be successful upon release. And then we have clinicians in all of our probation and parole offices that help for continuity of care, both in a behavioral-based sense and in a medication-assisted treatment sense. 

I also wanted to mention that I forgot we are working really hard in the Department of Corrections to reach out to families and communities for those that are incarcerated, because what we realize and recognize is families and communities have to be ready to receive their loved ones upon release for the individual to have a better opportunity to be successful. 

So we are working on family and community engagement sessions across the state. We're doing those both in our prisons and in the general community to provide education, to help reduce stigma that's associated with opioid use disorder and substance use disorder in general. We're doing a lot of things with media and website to try to just remove the stigma so that people aren't scared to ask for help, aren't scared to reach out when they have a loved one that needs assistance. 

We unfortunately have become the largest provider of substance abuse treatment in the state. The Department of Corrections has. And we take that responsibility very seriously. And we will want to do everything we can to not only treat the individual but to reach out to the families and communities and to prepare them and to reduce the stigma that's associated with the disorder. 

INTERVIEWER: That's a pretty interesting statistic. Department of Corrections is the biggest provider of treatment in the state. I guess I never thought of it that way. But I can see how that would be true. 

SARAH JOHNSON: We have almost 6,000 treatment slots. And that's just the ones that we are contracted with or run. We also make referrals across the state to outpatient and residential treatment programs, utilizing insurance and/or Medicaid. 

INTERVIEWER: OK. One thing I want to ask before I forget, the clinical research center. That's going to-- can you tell me a little bit about-- it's not a physical center, but about what that is and what that means when we say we're going to use some of the funds to establish that. 

MICHELE STATON: Well, that sort of is almost like the umbrella that the project falls under. So JCOIN funded 10 clinical research centers across the country. And each of those centers have a project really similar to ours. So I think six of the projects have some form of linkage to care in some capacity. Two of the centers are focused on policy changes within their states that have had an impact on opioid use, broadly defined. 

And then two of those centers are medication trials. And so each of the-- I think that's just kind of the general term that is used to fund these hubs of research across the country. But for our center, that's basically where the project will operate in terms of the telehealth linkages, the partnerships with the jails, and the partnerships with the community providers. 

INTERVIEWER: OK, so this is a five-year project, right? 

MICHELE STATON: It's a five-year project. 

INTERVIEWER: So what is your goal? What would you like to see at the end of five years? 

MICHELE STATON: There are two major outcomes that we hope to see at the end of the five years. The first is that we get a lot of women into treatment that would have not otherwise had the opportunity to enter treatment. That is the primary outcome of the grant, is MOUD utilization. And really, not just engaging in care, but staying in care, because that's one of the tricky things for this population is there have been huge efforts to start medication before people are released. 

But this is a tricky population when they return to the community. And so we really want to sustain care over time. And then secondly, we really want to see the partnerships that are developed through this grant between the jail sites and the community providers sustained over time. And hopefully we can grow that network when this grant is over. 

As a researcher, I hate to swoop in, carry out a grant, and then leave and everything that happened during the course of that grant also goes away. That's not what we want to see happen with this grant. We want to document everything that happens along the way. There's a big implementation science component to this grant. How do we track and monitor the successes and the challenges along the way so that it's a program that not only sustains in the jail sites that we're working in, but how can it be expanded more broadly across the state? 

SARAH JOHNSON: And I would agree with the same thing. I mean, we would love to be able to take this model and replicate it across all of our jails, because we have 76 jails across the state. And we don't have programming in all of those jails. And a lot of that is due to overcrowding and a lack of ability to offer programming due to a lack of space. So if we could take a model like this that really doesn't require space and replicate it across all of our jails, we would be able to have a greater impact on a lot of individuals across the state that are in need of care. 

KATIE MARKS: This just represents the fundamental value of the partnership between an academic research institution and the state, because it is taking an evidence-based practice and asking, how do we implement this with fidelity and effectively? And what can we learn and what can the state learn? And the state's ready and willing to support the research and then to implement that practice once we have the right protocols and evidence in place. 

And so I see the sustainability of this right here, right now through the investment that the state has by supporting the research efforts. 

INTERVIEWER: And I would assume that, you know, after five years, if you'd take it all across the state of Kentucky, it could also be taken across the country in theory, right? 

KATIE MARKS: Absolutely. Because Kentucky has been at the forefront of the opioid crisis for so long, many states look to Kentucky to learn from and to model policies and projects after. And so I know that we will have a lot to offer nationally at the completion of this. 

INTERVIEWER: It's important for communities and people listening to understand why this is so important. Can you all maybe expand on that a little bit more? 

MICHELE STATON: I think you are doing some great work with families and communities, if you want expand on that. 

SARAH JOHNSON: Yes. I mean, I think student the message that we want to send is that every individual life that we are able to impact, they are redeemable. They have value. They have worth. These individuals that we work with, this could be your brother, your sister, your mother. And we treat individuals just like they were our family. 

We want to make sure that they get good quality treatment. And I know the devastation. Every family has been affected. Every individual across the Commonwealth knows someone or has a connection with someone that has been affected. So if they can imagine if it was their loved one that they know that had been devastated or affected by this disease, how would they want their loved one to be treated? What would they want their loved one to receive? And that's exactly what we want to offer, even if it is in an incarcerated setting. We want to offer the very best treatment so that they have the opportunity to make different choices and then have the care they need when they come out of incarceration and be prepared to change their path after release. 

INTERVIEWER: What's the most satisfying part of your job? 

KATIE MARKS: That's not in my cheat sheet. The most satisfying part of my job is being able to help other people do the good work that they're prepared to do. I'm not a frontline clinician, but to be able to create infrastructure and resources for other people to shine and to both in providing treatment and accepting treatment engaging in those services and a recovery, that is immensely satisfying for me. 

SARAH JOHNSON: I've went from being the front clinician to now heading programs. And I would say that I've enjoyed every aspect of it. And my experience through my career has allowed me to really have a good understanding of the individual clients that are served by my division. But the most satisfying thing for me is being able to have that positive impact on individual lives. 

I've always wanted to be in a position where I could have the most-- affect the most positive change. And I think in my current position, I'm able to develop procedures and policies that support my staff, that I then allow them to offer better services for the clients that are being directly impacted. So even though I no longer have that direct client interaction, I'm making the system better for the clients so that they get the services that they need and they are treated with care and respect. 

INTERVIEWER: All right, Michele. 

MICHELE STATON: I mean, I echo all of that. I think there's so many things that are satisfying about this work. It's hard for me to say the most satisfying. But I guess as a researcher in academia, I've had the opportunity to go other places. And I'm kind of an odd bird, I guess, in that I grew up in Kentucky. I trained at Kentucky. And I stayed at Kentucky. And honestly, Katie said it earlier. Like, when you think about the client populations or the participant populations that we serve, these are our people. These are our communities. 

And that really resonates with me. And when I think about creating opportunities to do work like this, that is so exciting. And the fact that we get to do it here and have an impact on this state, on our state, on our communities, I just love that. And I really can't imagine doing that anywhere else and feeling that same sense of pride. And I like how Katie framed that earlier. 

So there's so many things about that that I-- it gets me really excited. I really am thankful and grateful for the chance to do this. 

INTERVIEWER: That's great. 

KATIE MARKS: Could I add-- 

INTERVIEWER: Of course. 

KATIE MARKS: If you've ever had the chance to listen to a person in recovery tell their story, it is humbling. Their message is humbling. Their hope, their resilience, their process, there's no way that you can walk away from that thinking, how do I create opportunities for other people to have what they have? Because it's beautiful. Recovery is beautiful. 

SARAH JOHNSON: And to be a part of that is just amazing. To be able to give someone an opportunity to have the opportunity towards recovery, because a lot of people are seeking treatment. But they don't know how to have treatment. They don't know how to go down the path of recovery. They don't want the life that they have anymore. But they don't know how to have something different. So to help lead them to a different life and watch that evolve as they go through treatment and as they go through their recovery process, it is-- it is just an amazing thing. It's an amazing thing to be a part of. 

INTERVIEWER: Yeah. 

KATIE MARKS: I agree. 

INTERVIEWER: Is there anything that I haven't asked you that you want to talk about or make sure that you let people know about? 

KATIE MARKS: I really do want to recognize that this grant is only possible because of our longstanding partnerships with the Kentucky Department of Corrections and the Division of Behavioral Health. That really forms the foundation of this cooperative. We were only able to write this grant application because of their work with us. And we had a couple of months to put this $9 million grant together. And they were amazing through that whole process. 

And we not only really value and share their commitment to increasing access to treatment, but their involvement in this JCOIN network is going to be critical, not only at the local level for implementation, but nationally, considering their expertise and their success in delivering treatment for high risk individuals in the criminal justice system. 

And Katie really mentioned that earlier. Folks are looking to Kentucky because we're sort of in the spotlight. And I'm really excited to have the opportunity to walk into this journey with them, because they're pretty awesome. 

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INTERVIEWER 2: Thank you for joining us on this edition of Behind the Blue. For more information about this episode or any other episode, visit us online at uky.edu/behindtheblue. You can send questions or comments via email to behindtheblue@uky.edu or tweet your questions using #BehindtheBlue. Behind the Blue is a joint production of University of Kentucky public relations and marketing and UK HealthCare.