' @) US. DADiment of Justice Federal Bureau of Prisons Metropolitan Correctional Center New York, NY 10007 Institution NUMBER: NYM6031.01C DATE: April 10, 2007 Supplement SUBJECT: Detoxification and Treatment Programs PURPOSE: To establish procedures to ensure the Metropolitan Correctional Center, New York, is in compliance with federal regulations for methadone detoxification and detoxification from other abuse substances, i.e., opiates, alcohol, and narcotics. REFERENCE: Program Statement 6031.01, Health Services Manual, dated January 15, 2005, Drug Enforcement Administration (DEA) regulatory controls relating to registration, security and record keeping of institutions having a narcotic treatment program. Institutional Supplement 6501.5(A), is rescinded. INTRODUCTION: The Clinical Director will establish guidelines for evaluation and treatment of inmates who require detoxification from mood and mind altering substances such as alcohol, opiates, hypnotics, sedatives, etc. The guidelines will include specific detoxification protocols to be implemented upon order of medical staff. Treatment and supportive measures will permit withdrawal with minimal physiological and physical discomfort. Metropolitan Correctional Centers, Metropolitan Detention Centers, Federal Transportation Centers and jail units may provide methadone detoxification if clinically indicated. This program requires special registration. If an institution has a methadone detoxification program then the institution Chief Pharmacist will complete and maintain registration for a methadone program. Methadone is permitted to be administered or dispensed only for detoxification or temporary treatment of patients. If Methadone is administered for treatment of heroin dependence, for more than three weeks, the procedure passes from treatment of the acute withdrawal syndrome (detoxification) to a maintenance program. This institution has the authority to conduct only a detoxification program by the Food and Drug Administration and has been assigned an identification number. Detoxification suppresses major physiological and psychological signs and symptoms of withdrawal. Each inmate possibly needing detoxification will be evaluated by the physician for an appropriate detoxification schedule. D NS: A. The following are the definitions of terminology used in discussing detoxification: EFTA00035317 compere naeynen

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° fo) 1. DRUG - A chemical compound or biological substance producing a physiologic effect when taken internally. 2. ABUSE OR DRUG ABUSE - The use of a drug for non-medical reasons. Typically this use is to satisfy an addiction or habituation or for altering ones perception. 3. ADDICTION - physical dependency on a drug with a characteristic withdrawal or abstinence syndrome, leading to chronic use, including narcotics, barbiturates, etc. 4. HABITUATION - Psychologic dependency on a drug leading to chronic use. 5. NARCOTIC - A natural or synthetic opiate drug for pain relief which in increasingly larger doses produces dependency. Also, an addictive group of drugs including heroin, morphine, methadone, etc. 6. ALCOHOL - Ethyl alcohol in water solution. PROGRAM PARTICIPATION: Inmates on detoxification will not be hospitalized unless deemed necessary by medical staff. The medication will be administered on the units by medical staff. The physician is to determine the need based on the history, clinical findings, and verification of any Methadone Maintenance Program the inmate may have been enrolled in. The physician must document this information on the chronological record of medical care. CLASSIFICATIONS: A. At this facility the classification for treatment includes: 1. All inmates committed with a history of alcohol use or physical findings indicating dependency. 2. All inmates committed with a history of drug use or physical findings indicating dependency. 3. All inmates discovered to be drug or alcohol dependent during the course of their incarceration. CLINICAL ASSESSMENT GUIDELINES: A. Subjective: Subjective withdrawal complaints - presence or absence of: bone and muscle pain, nausea and/or vomiting (subjective if not observed), diarrhea. B. Objective: EFTA00035318

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re) co) Pulse, blood pressure, temperature; 2. Presence or absence of: Yawning, restlessness, lacrimation, dilated pupils, hyperactive bowel sounds, skin - goose flesh, sweating, jaundice, tracks; 3. Liver size and presence or absence of tenderness 4. Verify patient participation ina MMTP. (Methadone Maintenance Treatment Program). 5. Urinary Dip Stick screening test for Opiates and Methadone 6. Order RPR test for Syphillis screening Assessment: 1. It is the responsibility of all medical staff to identify all inmates who are or may be drug dependent by taking a thorough medical history, including a drug history and the performance of a complete physical examination as a part of the inmate intake screening process. 2. Inmates diagnosed as having either alcohol or drug dependency should be enrolled in the following protocol at this facility. a. Be seen by the medical doctor as soon as possible for determination of: 1. Diagnosis 2. Medical orders including pharmacologic support if deemed necessary. 3. Special precautions to ensure inmate and staff security. 3. After an inmate has been evaluated for methadone detoxification, he or she may be: a. Only observed because history and physical do not support the need for detoxification. These patients will have: 1. Poor history for drug use/withdrawal; 2. No subjective findings; 3. No tracks; or 4. The inmate decides he or she does not want detoxification. b. Placed on continued observation because subjective and objective findings suggest that, though unlikely, it is possible that the inmate will undergo withdrawal. Because the length of time between arrest and evaluation for methadone detoxification can be in excess of 48 hours, inmates may often fail to exhibit the objective signs of opiate withdrawal. The subjective component of the opiate withdrawal syndrome, however, persists for up to ten days. Inmates who have a history of drug addiction, have evidence of recent drug use (old/new tracks), and complain of the subjective symptoms should not be placed on EFTA00035319

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© fo) continued observation, but should be placed on the Methadone Detoxification Program. Placed on 7-Day Detoxification because subjective and/or objective findings are consistent with acute withdrawal (see above). Placed on 21-Day Detoxification schedule because the inmate was on a verified MMTP*. If the program cannot be verified at the time of evaluation, the inmate will be started on 7-Day Detoxification whether or not he or she shows drug withdrawal signs. When the program is confirmed, the inmate should be reexamined and seen by the Clinical Director to determine whether or not he or she should be continued on the 7-Day schedule. 7-DAY PROGRAM Day 1= 20 mg. Day 2= 20 mg. Day 3= 20 mg. Day 4= 20 mg. Day 5= 10 mg. Day 6= 10 mg. Day 7= 10 mg. 21-DAY PROGRAM Day 1= 40 mg. Day 2= 40 mg. Day 3= 40 mg. Day 4= 30 mg. Day 5= 30 mg. Day 6= 30 mg. Day 7= 25 mg. Day 8= 25 mg. Day 9= 25 mg. Day 10= 20 mg. Day 11= 20 mg. Day 12= 20 mg. Day 13= 15 mg. Day 14= 15 mg. Day 15= 15 mg. Day 16= 10 mg. Day 17= 10 mg. Day 18= 10 mg. Day 19= 5 mg. Day 20= 5 mg. Day 21= 5 mg. EFTA00035320

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° re) 1. For inmates who decide they do not want detoxification, a refusal for treatment form must be signed. 2. For inmates who will receive methadone (seven or 21 day schedules): a. Record the information on which the decision was made on the progress note or intake physical form. If the inmate is on a MMTP and automatically gets methadone, this should also be recorded on the progress note or intake form. b. Write and sign the order for a methadone 7 or 21-day schedule, whichever is applicable, on the medication order sheet (duplicate form). All mid-level practitioner orders must be countersigned by a physician prior to administration (or a physician telephone order taken). c. All methadone patients should be given their first dose at the time of intake. Fill out the 7-day form and indicate date and time given as day one. If given on the next date as a day two. If patient is verified on MMTP, the 21-day schedule should begin. d. If a patient is a late court return, stat medications should be administered. e. If a patient is verified on a MMTP dosage lower than our 21-day schedule (less than 40 mg) the lower dosage should be maintained until the next scheduled change, ¢.g., patient maintained on 30 mg. An order should be written to start methadone 21-day detoxification on 30 mg. All higher doses on the Administration Record should be crossed-out and replaced with "30 mg." It still remains a 21-day detoxification schedule. f. There are patients who have been on very long term MMTP programs. These patients should be evaluated by the Clinical Director or detoxification specialist for determination of possibly lengthening the detoxification process on an individualized basis. g. Make appointment for the patient to see a psychologist for counseling. h. If a patient is on methadone detoxification (7 or 21-day) and confirmation of pregnancy is established by both urine and gynecological examination, the patient has the option to either detoxify or be maintained on a dosage level to be determined by the Clinical Director until completion of pregnancy and/or discharge. I. If patient is discharged during the course of pregnancy, a psychologist should be called to help counseling. j. It should be explained to the patient that pregnant opiate users are to be maintained on low doses of methadone after the first trimester. Detoxification can possibly cause damage to the fetus. EFTA00035321

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k. Patients must sign a consent form for methadone. If the patient is past the first trimester and refuses methadone, a Refusal of Treatment Form must be signed. 1. All patients who have histories of drug abuse, even if not placed on a detoxification program, should be encouraged to have a counseling session regarding realistic plans post discharge and/or to seek supportive counseling. The psychology staff is available for counseling. If not available in the building they can be consulted by telephone for suggestions. In addition, they should be consulted when difficulties arise in determining addiction status. m. In the case of delirium tremens, barbiturate or ethyl alcohol withdrawal or severe opiate, withdrawal when the medical doctor is not present in the facility, the doctor on call is to be contacted by the ranking medical officer on duty for instructions. n. A list of all inmates currently undergoing detoxification will be maintained and updated by the Clinical Director. 0. If the physician feels that the inmate is unable to receive proper care for detoxification at this facility, the inmate may be considered and processed for transfer in accordance with current Health Services Manual policy. p. Inmates on detoxification will not be approved for transfer without notifying the Clinical Director. q. Only physicians properly registered with the DEA will prescribe methadone at this facility. Under no circumstance will mid-level practitioners prescribe methadone. r. Inmates will not be transferred prior to completion of the detoxification treatment, unless it is to another BOP facility which has a detoxification program. 11. RESPONSIBILITY: The Health Services Administrator and Clinical Director are assigned the responsibility of enforcing regulations pertaining to the Methadone Detoxification Program. The Health Services Administrator will establish the policies to assure compliance with the Federal Regulations. 12. EFFECTIVE DATE: This Supplement is effective upon issuance. Approved by: Warden DISTRIBUTION: Warden, Executive Staff, Department Heads, AFGE President EFTA00035322 eee nearer