Call to Order and Roll Call
The Program Review and Investigations Committee met on Thursday, September 14, 2017, at 10:00 AM, in Room 131 of the Capitol Annex. Senator Danny Carroll, Chair, called the meeting to order and led the audience in a prayer and the Pledge of Allegiance. The secretary called the roll.
Present were:
Members: Senator Danny Carroll, Co-Chair; Representative Lynn Bechler, Co-Chair; Senators Wil Schroder, Dan "Malano" Seum, Reginald Thomas, Stephen West, and Whitney Westerfield; Representatives Chris Fugate, Brian Linder, Donna Mayfield, Ruth Ann Palumbo, Rob Rothenburger, Arnold Simpson, and Walker Thomas.
Guests: Lee Rust, Founder and CEO, Freedom Forever Ministries; Jim Erwin, Commissioner, Cookie Crews, Administrator, Health Services Division, Department of Corrections; Janet Conover, Warden, Kentucky Correctional Institution for Women; Dr. Craig Meeks, Regional Psychology Director, Dr. Lester Lewis, Regional Medical Director, Correct Care Solutions; and Van Ingram, Executive Director, Office of Drug Control Policy.
LRC Staff: Greg Hager, Committee Staff Administrator; Chris Hall, Colleen Kennedy, Van Knowles, Jean Ann Myatt, Shane Stevens, Joel Thomas; and Kate Talley, Committee Assistant.
Minutes for August 11, 2017
Upon motion by Representative Rothenburger and second by Senator Westerfield, the minutes for August 11, 2017, were approved by voice vote.
Presentation on Prescribing of Drugs to Female Inmates
Ms. Rust said the vast majority of women in prison are victims of some type of childhood trauma, usually from a family member or close family friend. Typically, they turn to drugs by their 20s. Women are usually addicts when they get to prison.
At the local level, they are usually prescribed medication at the inmate’s request upon entry. Anti-depressants and anti-anxiety drugs have side effects including obesity, emotional numbness, and lethargy. These women are not in position to take advantage of programs, work on resolving issues in their lives, or take care of children. When they are released, they often stop taking prescribed medications.
On average, a female inmate has 2.2 children. Many of these children are in the foster care system, which costs approximately $45,000 per child per year. Children in foster care are often abused.
Female inmates are 10 percent of the prison population. Costs are more than $100,000 per year, including the costs of taking care of the inmate’s families.
Ms. Rust said that she has filed multiple open records requests to obtain the cost of prescription drugs for women in prison, but the Department of Corrections (DOC) cannot provide a breakdown by gender.
The recidivism rate is 68 percent to 70 percent. Inmates manipulate the system to obtain medications for emotional relief. Poor emotional health leads to physical health problems.
In response to questions from Representative Bechler, Ms. Rust said DOC has not given her information on what drugs are most commonly prescribed to female inmates. Antidepressants and antianxiety medicines are labeled as psychotropics. National studies show that when psychotropics are prescribed, women are often categorized as mentally ill rather than emotionally ill, which raises concern. Most of the prescribed psychotropics prescribed are actually mood inhibitors.
In response to questions from Senator Westerfield, Ms. Rust said access to information from prisons has been better since the current administration took office. Cyndi Heddelston, the Executive Staff Advisor for DOC, has been very helpful.
Senator Westerfield said Kentucky has the highest rate of incarcerated parents.
Senator Carroll commented that conversations with Secretary Tilley and Deputy Secretary Grate were very supportive of this meeting.
In response to a question from Senator West, Ms. Rust said DOC did not have any information by gender. Confidentiality should not be an issue since the information requested is not identifying.
Ms. Rust commented that she spoke with a retired warden who housed both women and men in his career. He observed that the men had a pill call window while women had a carport. He also mentioned that the women had a lot of seizures that he thought was related to medication.
Senator West commented that the timing on this meeting coincided with a story in the Lexington Herald-Leader about 10 counties suing pharmaceutical companies for overprescribing.
Mr. Erwin said there are 3,138 women incarcerated in state custody. This includes 912 who are in prison: 719 in the Kentucky Correctional Institute for Women (KCIW) and 193 in the Western Kentucky Correctional Complex (WKCC). There are 2,210 in jails including 1,548 class D, C, and DE (class D extended) felons and 662 in controlled intake and controlled intake pending. There are also 16 women in halfway houses.
Ms. Conover said that 85 percent of the inmates at KCIW are white; 13 percent are black. KCIW is the only female secure prison in the state and houses all custody levels. KCIW has prioritized intake for medical and mental health needs. KCIW serves as the intake for inmates from county jails, as enacted by HB 191 in 2007.
There are 433 inmates participating in chronic care clinics for issues such as hypertension, asthma, and seizures. Cancer treatment is also being given for 52 inmates. Mental health treatment at KCIW has a five-level coding system. Inmates are screened within 24 hours of arrival. Currently, 151 inmates require no services; 48 inmates receive follow-up as needed; 368 inmates have scheduled evaluations, may be on medication, but are housed in the general population; 144 inmates receive frequent evaluations and medication adjustments; and 8 inmates are under constant watch. Group and individual therapy services are provided. On staff, there are four psychologists, one psychological associate, three social service clinicians, and four practicum students. Psychiatric services are provided on site and via tele-psyche services. KCIW has 350 treatment slots for evidence-based programs such as parenting, anger management, moral reconation therapy, and behavior modification. KCIW has 48 beds to treat substance abuse issues and 48 beds in a dual diagnosis program to treat inmates with substance abuse and mental issues.
Mr. Erwin said HB 463, enacted in 2011, requires that DOC provide only evidence-based programs. DOC continues to review programs and alter what programs are provided based on client needs. Both medical and mental health services are contracted outside of DOC. An RFP is being prepared for a new contract.
Ms. Crews said DOC currently has a contract with Correct Care Solutions (CCS) for medical, dental, and pharmacy services and for an electronic health record. CCS partners with Norton Healthcare to provide as many in-house services as possible. The main objective of the health services division is to provide good healthcare to those in custody. CCS also provides mental health services.
Dr. Lewis said CCS’s medical health service operates like a managed care system, with a focus on chronic care. CCS has a prescription formulary, but the ability to work off the formulary is available. Norton Healthcare provides OBGYN services for female inmates, which is considered a specialty service. Other specialty services are available and the recommendations from those specialists are followed as much as possible. Chronic care management focuses on maintaining or slowing the progression of conditions. Chronic illness is lifelong, and CCS works on a plan to treat those illnesses. Acute care is available when necessary. With a concentrated population, it is important to distinguish what a patient needs and what a patient wants. Pain is a subjective complaint. CCS carefully reviews pain prescriptions and the patients who use them.
Dr. Meek said the mission of CCS’s mental health service is to improve functioning and maintain the safety of its patients. The mental health service is working to determine if patients are being prescribed more than one medication in a single category, which has been addressed now that a single provider is administering psychiatric services. Mental illness is difficult to diagnose. Most diagnoses are made on observation and patient self-reports. Over 90 percent of all inmates have self-medicated for years prior to being incarcerated. In many cases, medication is necessary to allow inmates to participate in the mental medical health service evidence-based programs. KCIW does have a high percentage of inmates on medication, but the cost compared with benchmark facilities is low.
Mr. Erwin said DOC has a therapeutic level of care committee that reviews all aspects of the health of inmates. DOC is working to compile data for the various statistical requests it has received. KCIW has a concentrated population of inmates with medical needs. Most female inmates who require medical services are sent to KCIW. DOC has calculated some data compared to other state’s facilities with similar populations and class D felons. At KCIW, just over 92 percent of inmates are on prescription drugs. Over 75 percent of those inmates are taking some type of psychiatric medication. Studies show that in the general public, women age 18 to 40 have a higher rate of prescription drugs than do men. KCIW has a quarterly average of nearly 496 inmates on psychiatric medications. On a quarterly basis, KCIW spends nearly $182 for each of its 716 inmates, but just over $197 on each inmate who receives treatment. KCIW has just under 70 percent of its inmates on psychiatric medications, spending nearly $20 on each inmate.
In response to questions from Senator Carroll, Mr. Erwin said DOC realizes that the data should be improved. DOC should continually reassess and reevaluate practices. The opioid addiction will likely present new issues to be addressed.
Dr. Lewis said CCS is responsible for the healthcare of the entire state correction community. There is a quarterly pharmacy therapeutics meeting with a national consultant to determine issues that need to be addressed. If the data for KCIW and WKCC were blended, the overall percentages would be lower. The number of female inmates is increasing and sentences are longer.
In response to a question from Senator Carroll, Mr. Erwin said DOC works with the University of Kentucky on the Criminal Justice Kentucky Treatment Outcome Study to provide medical and mental health treatment opportunities for inmates when released. Inmates are released with medication. DOC will need to work to get data on how many addicted inmates are released.
Dr. Lewis said addiction is a lifelong illness. CCS only prescribes opiates for short-term and terminal illnesses. Inmates are not released with prescriptions for opiates. CCS is working to reduce Neurontin use for patients.
Dr. Meek said CCS does not prescribe benzodiazepines, such as Valium or Xanax, to anyone. Mental illness needs to be treated appropriately. Trauma changes how its victim’s brains work; a holistic approach needs to be used for treatment. Abstinence is not enough.
In response to questions from representative Rothenburger, Dr. Lewis said follow-up after release depends on the patient’s condition. Patients are given 30 days of medication for chronic illnesses. DOC and CCS attempt to get the patients insurance, appointments, and referrals. Mr. Erwin said the electronic health record is beginning to show benefits. Dr. Meek said the electronic health record does not have the capacity to get records electronically from prior medical providers.
In response to questions from Senator Carroll, Dr. Meek said CCS is trying to reduce the percentage of inmates on psychiatric prescriptions. Except for permanent psychiatric illnesses, the goal is to treat and reduce symptoms. KCIW receives the most serious medically and mentally ill inmates of any female prison within the state. Overall, KCIW differs from other states’ facilities because other states have more women’s prisons among which inmates with illness are distributed. Dr. Lewis said most seriously mentally ill people end up in corrections. Many statewide facilities closed and no community support systems were available. Mr. Erwin said he would get the information on how much money is spent annually on medications in the female institutions separate from the male institutions. Ms. Crews said getting the information will be difficult, because one drug can treat various illnesses, some physical and some psychiatric. Dr. Lewis said he will work to find out how much money is spent on medications alone. Ms. Conover said she can provide the percentage of KCIW’s budget that is spent on medications.
In response to questions from Representative Bechler, Mr. Erwin said he will look into the quarterly amount spent on medications for KCIW and WKCC. Dr. Lewis said there are very few malpractice lawsuits and few federal lawsuits, which are usually settled or dismissed.
In response to questions from Senator Carroll, Ms. Crews said the prescription contract is $20 million, but DOC will provide the actual amount spent. Dr. Lewis said primary care medication costs are minimal. Major costs come from specialty and brand name medications.
Senator Carroll commented that medication should not be used to control inmates, especially female inmates.
Mr. Ingram said trauma and adverse childhood experiences are large factors in the substance abuse and opioid issues facing the state. Developing better mental health services for those who are traumatized at a young age when it occurs will lead to better outcomes. Follow-up mental health services are important, but mandating inmates to participate is not feasible.
In response to questions from Representative Simpson, Mr. Erwin said everyone has the right to refuse medical care. The parole board can set stipulations for those with substance abuse issues, but otherwise it can only make recommendations for released inmates. The Criminal Justice Policy Assessment Council may suggest steps the legislature can take to help.
In response to a question from Senator West, Mr. Ingram said SB 200, enacted in 2014, has improved community services relating to juvenile detention centers. There is a need to train teachers, ministers, and other community members to recognize children who need services for adverse childhood experiences.
In response to a question from Representative Rothenburger, Mr. Ingram said the Suboxone and methadone clinics are getting a lot of attention, especially in regards to the 1115 Medicaid waiver. Discussions on how to improve substance abuse treatment are going on everyday throughout the state.
The meeting was adjourned at 11:39 PM.