Existing law establishes the Department of Corrections and Rehabilitation and charges it with various duties and obligations. Existing law requires the department to maintain a statewide utilization management program, as defined, in order to promote the best possible patient outcomes, eliminate unnecessary medical and pharmacy costs, and ensure consistency in the delivery of health care services, as specified.

The bill would state the intent of the Legislature to enact legislation to improve inmate health outcomes in state prisons.

Date of Hearing: May 1, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 2332

Author:(Connolly) – As Amended Ver:March 21, 2024

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill requires the California Department of Corrections and Rehabilitation (CDCR) to provide additional training, guidance, and authority to specified physicians and surgeons practicing addiction medicine in state prisons.

Specifically, this bill:

1. Requires CDCR to ensure the uniform application of the California Correctional Health Care Services Care Guide on substance use disorder.
2. Requires CDCR to uphold the terms of the medication-assisted treatment agreement entered into with patients.
3. Requires CDCR to provide physicians and surgeons additional training, guidance, and authorization pertaining to the practice of addiction medicine, including authority to move a patient out of a housing assignment that place the patient at high risk.
4. Prohibits CDCR from assigning specified physicians and surgeons chronic care patient responsibilities in addition to a full schedule of medication-assisted treatment patient responsibilities.
5. Requires CDCR to make every effort to ensure that at least one full-time addiction medicine physician and surgeon is retained at each facility to be assigned medication-assisted treatment patients exclusively.
6. Requires CDCR to establish a working group to improve the integrated substance use disorder treatment program.

FISCAL EFFECT:

Costs to CDCR (General Fund) of an unknown amount, possibly in the millions to low tens of millions of dollars annually, for additional staffing and training required by this bill. CDCR may also incur one-time costs to expand its facilities to accommodate the additional medical staff required at each facility.

According to the Legislative Analyst’s Office, the General Fund faces a structural deficit in the tens of billions of dollars over the next several fiscal years. 

COMMENTS:

1. Purpose. According to the author:

Substance abuse and fatal overdoses rates continue to be the highest in California in comparison to every other state in the nation. With these issues only increasing with the dangerous introduction of synthetic drugs like Fentanyl, quality medical care and addiction treatment for inmates is paramount. While California has taken important steps to provide Medication-Assisted Treatment (MAT) for inmates with substance abuse issues, physicians within our correctional institutions do not receive the proper training and education. AB 2332 addresses this issue by requiring additional training for physicians, surgeons, and dentists in MAT, as well as education regarding substance use disorders.

1. Background. Medication-Assisted Treatment. MAT typically combines medications with counseling and behavioral therapies to treat substance use disorders, including alcohol and opioid use disorders. Medications in a MAT protocol can ease the side effects of withdrawal and psychological cravings for a drug without producing the high associated with the drug. Addressing physical symptoms with MAT can help encourage someone with a substance use disorder to wean themselves off the drug while pursuing long-term sobriety. There are several FDA-approved medications used to treat alcohol and opioid use disorders like buprenorphine, which is generally administered in a doctor’s office, and naltrexone, which is a prescription medication. The FDA and public health organizations have endorsed MAT and found the treatment to be safe and effective in combination with counseling and other psychological therapies.

MAT in State Prisons. Just as in the community, overdoses within state prisons have increased significantly in recent years, particularly overdoses resulting from opioid use. CDCR provides MAT treatment to incarcerated people through the Integrated Substance Use Disorder Treatment (ISUDT) program. According to the ISUDT data dashboard, the program provides MAT to 17,504 incarcerated people, along with other cognitive behavioral interventions and substance use disorder treatment. However, as highlighted in the analysis of this bill by the Assembly Committee on Public Safety, implementation of the ISUDT program faced significant challenges during the COVID-19 pandemic and the program is still not able to provide sufficient treatment to everyone in CDCR who needs it.

This bill adds additional training requirements for physicians and surgeons who practice addiction medicine within CDCR, requires CDCR to provide such medical professionals with more authority over treatment for patients, and prohibits CDCR from requiring addiction medicine specialists from being assigned other chronic patient care responsibilities.

Analysis Prepared by: Annika Carlson / APPR. / (916) 319-2081

Date of Hearing:

Counsel: Ilan Zur

ASSEMBLY COMMITTEE ON PUBLIC SAFETY

Kevin McCarty, Chair

ABPCA Bill Id:AB 2332

Author:(Connolly) – As Amended Ver:March 21, 2024

SUMMARY:

Requires the California Department of Corrections and Rehabilitation (CDCR) to take specific actions in the provision of substance use for incarcerated persons. Specifically, this bill:

1. Requires CDCR to do the following:
   1. Ensure the uniform application of the California Correctional Health Care Services Care Guide on substance use disorder in order to assess and enhance integrated substance use disorder treatment infrastructure, including cognitive behavior intervention, supportive housing, and adherence to the informed consent for medication-assisted treatment for substance use disorder.
   2. Uphold the terms of the medication-assisted treatment agreement entered into with patients.
   3. Provide physicians and surgeons all of the following:
      1. Adequate training to prepare providers for practicing addiction medicine.
      2. Clear guidance on clinical interpretation of urine toxicology tests, ongoing illicit buprenorphine misuse and abuse, polysubstance use, and the misuse, abuse, and illegal distribution of substances.
      3. Ready access to alternative medication, to include naltrexone and buprenorphine at the point of care, as appropriate.
   4. Authorize physicians and surgeons to use a criteria-based approach when prescribing alternative medications, rather than requiring approval.
   5. Ensure that physicians and surgeons have the ability to move patients out of housing assignments that place the patient at high risk.
   6. Provide all of the following training to physicians and surgeons, during regular work hours with time specifically dedicated to the training:
      1. A minimum of eight hours of integrated substance use disorder treatment didactic training and a minimum of three workdays of shadowing an integrated substance use disorder treatment practice.
      2.  In addition to the training described in paragraph (1), eight hours annually of integrated substance use disorder treatment training to include all of the following topics:
         1. Brief cognitive behavioral intervention.
         2. Motivational interviewing.
         3. Rapid induction.
         4. Induction.
         5. Difficult case management.
         6. Higher risk.
   7. Ensure that physicians and surgeons represented by State Bargaining Unit 16 have real-time access to integrated substance use disorder treatment physicians and surgeons qualified and capable of providing consultation or support to manage patients at the point of care, including in-house consultation, central team consultation, and on-call consultation.
   8.  Conduct direct and real-time observation and oversight of a physician and surgeon, only with the physician and surgeon’s consent.
   9. Authorize a provider to determine whether to combine chronic care visits with medication-assisted treatment visits.
   10. Ensure that physicians and surgeons represented by State Bargaining Unit 16 who received extra training during the implementation of the integrated substance use disorder treatment program and are assigned full time to a facility are not assigned chronic care patient responsibilities in addition to a full schedule of medication-assisted treatment patient responsibilities. The department shall give priority to those physicians and surgeons who are currently working or formerly worked extensively in medication-assisted treatment during their service with the department.
   11.  Make every effort to ensure that at least one full-time addiction medicine physician and surgeon is retained at each facility to be assigned medication-assisted treatment patients exclusively.
   12. Monitor the workload of primary care providers to ensure there is adequate time to properly treat integrated substance use disorder treatment patients within the standard 40-hour workweek.
   13. Requires CDCR to establish a working group to improve the integrated substance use disorder treatment program. The working group shall consist of six members of the Union of American Physicians and Dentists and integrated substance use disorder treatment program departmental representation with the authority to make decisions. The working group shall meet quarterly and shall focus on identifying program areas for improvement or additional training that could be offered to State Bargaining Unit 16 employees, in order to enhance program success.
   14. Requires the credentialing process for patients receiving healthcare at CDCR institutions to include addiction medicine as an additional qualification.

EXISTING LAW:

1. Requires CDCR to shall establish a three-year pilot program that will provide a medically assisted substance use disorder treatment model for treatment of inmates with a history of substance use problems. The program shall offer a continuum of evidenced-based care that is designed to meet the needs of the persons being served and that is appropriate for a correctional setting. In establishing the program, CDCR shall consider the following:
   1. Access to services during an inmate’s enrollment in the pilot program.
   2. Access to subacute detoxification and medical detoxification, as necessary
   3. Comprehensive pretreatment and post-treatment assessments.
   4. Ongoing evaluation of an inmate’s program needs and progress at least every 90 days, and appropriate adjustment of treatment based on that evaluation.
   5. Services provided by professionals for whom substance use disorder treatment is within the scope of their practice.
   6. Referrals for medically assisted care and prescription of medication-assisted treatment.
   7. Provision of behavioral health services, including the capacity to treat co-occurring mental illness.
   8. Access to medication-assisted treatment throughout the period of incarceration up to and including immediately prior to release.
   9. Linkages to community-based treatment upon parole. (Pen. Code, § 2694.5, subd. (a).)
2. Requires CDCR to submit reports on the above pilot program to the Legislature on March 1, 2017, and each March 1 thereafter (up until March 1, 2025) during the tenure of the pilot project. The report shall include:
   1.  The planned inmate capacity of the program.
   2. The number of persons enrolled in the program.
   3. The number of persons who leave the treatment program against medical advice and the number of persons who are discharged from the program prior to achieving their treatment goals.
   4. The percentage of participants with negative urine toxicology screens for illicit substances during treatment and post-treatment while incarcerated.
   5. The number of persons who are successfully linked to post-release treatment.

1. Requires CDCR to expand substance abuse treatment services in prisons to accommodate at least 4,000 additional inmates who have histories of substance abuse. In determining the prisons in which these additional treatment services will be located, CDCR may consider efficiency and efficacy of treatment, availability of staff resources, availability of physical space, and availability of additional resources in surrounding communities to supplement the treatment. In addition, the department shall expand follow-up treatment services in the community in order to ensure that offenders who participate in substance abuse treatment while incarcerated in prison shall receive necessary follow-up treatment while on parole. (Pen. Code, § 2694, subd. (a).)
2. Provides that unless there is a security or safety reason not to do so, a substance abuse treatment program funded by CDCR and offered in a CDCR facility shall include a peer counseling component allowing prisoners to receive the necessary training within those facilities to become certified addiction counselors, including necessary course work and clinical hours. (Pen. Code, § 2694, subd. (b).)
3. Requires CDCR to ensure patients receive health care services from licensed or credentialed healthcare providers, verify the credentials and privileges of all licensed medical providers providing patience care services at CDCR institutions, and ensure such providers meet minimum credentials, privileging and performance standards(Cal. Code Regs., tit. 15, § 3999.134.)

FISCAL EFFECT:

Unknown

COMMENTS:

1. Author's Statement: According to the author, “Substance abuse and fatal overdoses rates continue to be the highest in California in comparison to every other state in the nation. With these issues only increasing with the dangerous introduction of synthetic drugs like Fentanyl, quality medical care and addiction treatment for inmates is paramount. While California has taken important steps to provide Medication-Assisted Treatment (MAT) for inmates with substance abuse issues, physicians within our correctional institutions do not receive the proper training and education. AB 2332 addresses this issue by requiring additional training for physicians, surgeons, and dentists in MAT, as well as education regarding substance use disorders.”
2. Background: On June 27, 2016, Governor Brown approved Senate Bill 843, requiring CDCR, under the direction of the Undersecretary of Health Care Services, to develop and implement a three-year MAT Pilot Program at one or more of CDCR’s adult institutions. This legislative mandate was in response to the large proportion of urine drug tests (UDT) that were positive for opioids1, and significant increases in the number of fatal drug overdoses in CDCR, related mostly to opioids. MAT, which is the use of medications in combination with counseling and behavioral interventions, is an effective treatment for patients with opioid-use disorders (OUD). Numerous studies support the efficacy of MAT, with data showing that it is associated with significant reductions in overdose deaths, illicit drug use, and the spread of infectious diseases; it is also associated with increased treatment adherence and retention. Preliminary data from Rhode Island shows that targeting people with opioid addiction releasing from the state’s jails and prisons reduced the death rate among this group by 61%, which contributed to an overall 12% reduction in overdose deaths in the state. In addition, treatment of OUD results in lower criminal justice and health care costs, with estimates showing that every dollar invested in treatment yields a return on investment between $4 and $7. These costs include reductions in drug-related crime, criminal justice costs, and theft. When savings related to health care are included in these calculations, total savings can exceed costs by a ratio of 12 to 1.9 CDCR/CCHCS’ MAT Program utilizes oral long-acting injectable naltrexone and acamprosate to treat alcohol-use disorder (AUD), and oral and long-acting injectable naltrexone for OUD. All medications used as part of the MAT Program are FDA-approved to treat either AUD or OUD. (California Correctional Health Care Services, Medication-assisted treatment for substance-use disorders, Final Legislative Report (March 2019). Available at < https://cchcs.ca.gov/wp-content/uploads/sites/60/Reports/MAT-Final-Legislative-Report-Final-3-1-2019.pdf> [as of April 12, 2024].)

However, as of December 2020, “more than 6,000 California prison inmates [were] awaiting the doctor's appointments they need to receive addiction-treatment medication. (KQED, Thousands of California Inmates Waiting for Access to Addiction Treatment (Dec. 9, 2020). Available at: https://www.kqed.org/news/11849703/thousands-of-california-inmates-waiting-for-access-to-addiction-treatment [as of April 12, 2024].) Additionally doctors have expressed “concerns over the department’s directives for prescribing Suboxone, a brand-name drug that combines the addictive opioid buprenorphine with overdose-reversal drug naloxone. The prisons administer the drug in soluble pieces of film the size of a Band-aid patch. In interviews, three doctors said prisoners often hide the pieces of film instead of ingesting them and sell them to other inmates for as much as $200, often at the direction of gang leaders.” Sacramento Bee, California prison doctors fear drug treatment program could create new addicts (May 24, 2021). Available at: https://www.sacbee.com/news/politics-government/the-state-worker/article251600583.html [as of April 12, 2024].) AB 2332 seeks to reduce substance abuse and overdoses in California prisons by improving the training surrounding substance use disorders for medical practitioners in CDCR correctional institutions.

1. Argument in Support: According to the Union of American Physicians and Dentists “AB 2332 requires the California Department of Corrections and Rehabilitation (CDCR) to address the lack of training by CDCR of physicians required to treat addicted incarcerated persons by way of Medically Assisted Treatment (MAT). CDCR has mandated that civil service physicians prescribe MAT to incarcerated persons without appropriate training or certifications for administering such MAT drugs or determination that such administration is in accordance with medical professional ethics. AB 2332 will require the CDCR to provide physicians and surgeons clear guidance on interpretation of certain toxicology tests, the misuse, abuse, and illegal distribution of substances, and access to alternative medication as well as training consisting of at least 8 hours of integrated substance use disorder treatment didactic training, 3 days of shadowing an integrated substance use disorder treatment practice, and annual training of at least 8 hours covering specified topics.”
   
2. Argument in Opposition: None
   
3. Related Legislation: None
   
4. Prior Legislation:
   1. SB 843 (Committee on Budget and Fiscal Review), Chapter 33, Statutes of 2016, requires CDCR to shall establish a three-year pilot program that will provide a medically assisted substance use disorder treatment model for treatment of inmates with a history of substance use problems. The program shall offer a continuum of evidenced-based care that is designed to meet the needs of the persons being served and that is appropriate for a correctional setting.
   2. AB 1468 (Committee on Budget), Chapter 26, Statutes of 2014, requires CDCR to expand substance abuse treatment services in prisons to accommodate at least 4,000 additional inmates who have histories of substance abuse. In determining the prisons in which these additional treatment services will be located, CDCR may consider efficiency and efficacy of treatment, availability of staff resources, availability of physical space, and availability of additional resources in surrounding communities to supplement the treatment. In addition, the department shall expand follow-up treatment services in the community in order to ensure that offenders who participate in substance abuse treatment while incarcerated in prison shall receive necessary follow-up treatment while on parole.
      

REGISTERED SUPPORT / OPPOSITION:

Support

Union of American Physicians and Dentists (Sponsor)
Initiate Justice

Opposition: None

Analysis Prepared by:

Ilan Zur / PUB. S. / (916) 319-3744