Contextualizing medications for opioid use disorder and peer support service provision in the probation system with implementation science.

BACKGROUND: Medications for opioid use disorder (MOUD) is an evidence-based approach that reduces opioid-related mortality, particularly among criminal legal-involved persons who are at increased risk of adverse outcomes related to OUD. Implementing evidence-based approaches in the context of probation settings requires an in-depth understanding of specific contexts to improve intervention efficacy and effectiveness. Here, we use the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to understand implementation contexts for MOUD provision in the probation setting. METHODS: In-depth individual interviews were conducted with key programmatic stakeholders (treatment providers and probation staff involved in service provision for people on probation). The study examined stakeholder perspectives regarding MOUD and Peer Support Service (PSS) implementation among people who are involved in community supervision. Deductive and inductive thematic analysis was conducted, and subsequently the codes, subcodes, and themes were mapped onto the EPIS framework to better understand implementation contexts. RESULTS: We deduced key inner, outer, and bridging contexts that shape treatment service provision for individuals with OUD who are on probation. Inner contexts include a strong organizational climate that supports MOUD implementation and enthusiasm for peer support services. Outer contexts include difficulty navigating insurance among providers, treatment costs, and systemic stigma towards MOUD. Bridging contexts include a lack of collaboration/communication between relevant agencies (e.g., probation and courts). CONCLUSIONS: Findings indicate the implementation is complex and requires a coordinated effort between correctional systems, probation agencies, and community-based treatment providers.

Monitoring Motivational Interviewing Strategies: Creating Provider and Client Reports to Encourage Implementation.

BACKGROUND: Motivational interviewing (MI) is an evidence-based practice that has been successfully applied to at-risk youth. Well-validated measures that track MI integrity may not be used in practice settings due to the time to complete them, recording requirements and training involved. A simpler, less resource-intensive instrument may encourage programs and providers to attend more to the quality of MI use during implementation. PURPOSE: To validate a method involving two measures, Youth and Provider Logs, to assist in monitoring MI use. METHODS: Clients and providers reported on provider behaviors consistent and inconsistent with MI during the session. Factor analyses were conducted to examine whether measures showed clear scales assessing MI use and analyses were conducted to assess validity of these measures. RESULTS: Both Youth and Provider Logs showed a clear and consistent 3-factor structure assessing MI-consistent behavior, MI-inconsistent behavior, and alcohol-related topics. Significant correlations were found between Youth Logs and youth reports of rapport with providers, and satisfaction with services. Provider MI-inconsistent scores were significantly inversely predictive of observer fidelity scores over time. CONCLUSION: This study offers provider and client measures for tracking use of MI in sessions, which are a simpler, less resource-intensive method for monitoring MI, and may encourage fidelity during implementation.

The clustering of physical activity and screen time behaviours in early childhood and impact on future health-related behaviours: a longitudinal analysis of children aged 3 to 8 years.

BACKGROUND: Meeting physical activity and screen time guidelines has been associated with improved health in children. Research has shown that lifestyle behaviours happen in combination and can be tracked into later life. Thus, a complex approach is needed to identify the effects of physical activity and screen time altogether. This study aims to identify clusters of both behaviours in a cohort of Irish 3-year-old children (n = 8833) and determine the association with sociodemographic characteristics and behaviours at age 5 and 7-8. METHODS: Data from the "Growing Up in Ireland" study collected between 2010 and 2016 was used in this study. Two-step cluster analysis was used to understand how physical activity and recreational screen time behaviours group together among 3-year-old children. Binary logistic regressions were conducted to examine if cluster placement at age 3 determined physical activity and recreational screen time behaviours at age 5 and 7-8 years, while controlling for gender of child, gender, age and employment status of the primary caregiver. RESULTS: Six clusters were identified in 9771 (49.3% female) 3-year-old children with the majority falling into a "High Active & Mixed Screen Time" (23.2%). Those in the "High Active & Mixed Screen Time" cluster at age 3 were more likely to engage in all physical activities reported at age 5 (p < 0.01) and age 7-8 (p < 0.01) when compared to a "Low Active & Screen Time Exceed" cluster. Children categorised in a "Moderate Active & Screen Time Below" and "Moderate Active & Screen Time Exceed" were more likely to engage in the same physical activities at age 5 and 7-8 (p < 0.05 - p < 0.01). However, children in the latter cluster were also more likely (p < 0.05) to play on a computer or tablet device. CONCLUSIONS: This paper highlights the importance of establishing positive health-related behaviours during early childhood, as this predicts future engagement in health-promoting activities. Regardless of screen time level, being part of a cluster with moderate or high levels of physical activity positively influences a child's future physical activity at age 5 and again at age 7 -8 years. The multiple layers of influence on a child's development should be leveraged to support the adoption of health-enhancing behaviours.

Substance use workforce training needs during intersecting epidemics: an analysis of events offered by a regional training center from 2017 to 2020.

BACKGROUND: Intersecting opioid overdose, COVID-19, and systemic racism epidemics have brought unprecedented challenges to the addiction treatment and recovery workforce. From 2017 to 2020, the New England Addiction Technology Transfer Center (ATTC) collected data in real-time on the training and technical assistance (TA) requested and attended by the front-line workforce. This article synthesizes practice-based evidence on the types of TA requests, topics of TA, attendance numbers, and socio-demographics of TA attendees over a 3-year period spanning an unprecedented public health syndemic. METHODS: We assessed TA events hosted by the New England ATTC using SAMHSA's Performance Accountability and Reporting System post-event survey data from 2017 to 2020. Events were coded by common themes to identify the most frequently requested training types/topics and most frequently attended training events. We also evaluated change in training topics and attendee demographics over the three-year timeline. RESULTS: A total of 258 ATTC events reaching 10,143 participants were analyzed. The number of TA events and attendance numbers surged in the 2019-2020 fiscal year as TA events shifted to fully virtual during the COVID-19 pandemic. The absolute number of opioid-related events increased, but the relative proportion remained stable over time. The relative proportions of events and attendance rates focused on evidence-based practice and health equity both increased over the 3-year period, with the largest increase after the onset of the pandemic and the murder of George Floyd. As events shifted to virtual, events were attended by providers with a broader range of educational backgrounds. CONCLUSIONS: Results of the current analysis indicate that the demand for TA increased during the pandemic, with a prioritization of TA focused on evidence-based practice and health equity. The practice-based evidence generated from the New England ATTC may help other training and TA centers to anticipate and nimbly respond to the needs of the workforce in the face of the intersecting epidemics.

Virtual training and technical assistance: a shift in behavioral health workforce access and perceptions of services during emergency restrictions.

BACKGROUND: To respond to the COVID-19 pandemic, the Substance Abuse and Mental Health Services Administration-funded Technology Transfer Centers had to rapidly adapt to ensure that the behavioral health workforce had continuous access to remote training and technical assistance (TTA). Although the Technology Transfer Centers have historically relied partially upon virtual methods for delivering TTA, the shift to a strictly virtual approach necessitated by COVID-19 restrictions has raised new questions for how to best proceed with services when social distancing guidelines are relaxed. The objective of this exploratory paper was to compare TTA provision in the six-month period prior to (9/1/19 thru 2/28/20) and during (4/1/20 thru 9/30/20) early COVID-19 restrictions to determine the extent to which the shift to virtual service provision impacted the behavioral health and medical workforce. Specifically, we examined participants' access to TTA, geographic reach of TTA, and workforce perceptions of satisfaction and utility with TTA provision. METHOD: Participant and event-level data were analyzed to compare the following metrics before and during the COVID pandemic: number of events and attendees; participant demographics; zip codes reached; coverage of rural, suburban, and urban areas; and perceptions of satisfaction with and utility of training. RESULTS: Findings showed a 40% increase in the number of events delivered (p < .001) and a 270% increase in the number of attendees (p < .001) during the COVID period when TTCs relied exclusively on virtual delivery. Geospatial analyses linking zip codes to a schematic of rural, suburban, and urban classifications throughout the United States revealed significant increases in the number of zip codes reached during the COVID time period. Satisfaction levels were comparable before and during the pandemic. CONCLUSIONS: Findings show that expanded access to TTA services via virtual formats resulted in reach to more diverse attendees and regions, and did not come at the expense of satisfaction. Results suggest that virtual TTA should continue to be an important component of TTA offerings post-pandemic.

Implementing Coordinated Specialty Care in CMHC Youth and Young Adults with Severe Mental Illness: Preliminary Outcome Assessment.

This study assessed impact of Coordinated Specialty Care (CSC), expanded to include both first episode psychosis (FEP) and severe mental health disorders (e.g., depression, bipolar disorder, trauma) in youths attending Community Mental Health Centers (CMHCs). Eligible youth and young adults (ages 16-26 years, N = 201) were recruited from two CMHCs and assessed every 6 months. Paired sample t-tests were performed comparing pre- and post-treatment observations. Statistically significant decreases from pre to post were found in sad and anxious feelings and in days hospitalized for psychiatric emergency and increases were found in subjective health ratings and employment status. This preliminary assessment supports the effectiveness of expanded inclusion criteria for participation in the CSC model.

Addressing social stressors in a brief motivational interview improve mental health symptoms for Latinx heavy drinkers.

OBJECTIVE: Depressive and anxiety symptoms co-occur with hazardous drinking among Latinxs. This secondary analysis of a clinical trial to reduce hazardous drinking (motivational interviewing adapted to address social stressors [CAMI] vs. motivational interviewing [MI]) examined effects on anxiety/depressive symptoms. Discrimination and acculturation were examined as moderators. METHODS: Latinx (n = 296) hazardous drinkers (2+ occasions/month of heavy drinking; 4/5 drinks/occasion, females/males) were randomized to CAMI/MI. Generalized estimating equations analyzed how treatment conditions and interactions were related to depressive and anxiety symptoms after controlling for covariates. RESULTS: Baseline symptoms (anxiety, depression) exceeded clinical thresholds (Anxiety ≥8, M = 14.62, SD = 13.52; Depression ≥ 12, M = 18.78, SD = 12.57). Cultural adaptation of motivational interviewing (CAMI) showed significantly lower anxiety and depressive symptoms (6/12 months, respectively) than MI. CAMI with high baseline discrimination reported significantly less depression than MI (12 months). CONCLUSIONS: Explicitly addressing social stressors may be a beneficial adjunct to treatment for Latinx drinkers.

Post-release treatment uptake among participants of the Rhode Island Department of Corrections comprehensive medication assisted treatment program.

The Rhode Island Department of Corrections (RIDOC) recently implemented the first state-wide, comprehensive medications for addiction treatment (MAT) program in the US. The objective of this study was to elucidate perceived barriers for individuals who participated in RIDOC's MAT program while incarcerated. Of the 588 individuals eligible for this study, 227 phone surveys were completed with 214 individuals. Data relevant to demographic characteristics, probation/parole status, retention in MAT treatment, MAT type received during incarceration, MAT treatment history, location where they received community treatment, perceived barriers to treatment, and future goals for MAT were collected. Simple percentages, frequencies, means, and standard deviations were calculated with SPSS. Most participants (82.4%) reported continuing MAT post-release and a majority (74.3%) received treatment at an opioid treatment program. Those who did not connect with treatment post-release reported transportation issues (23.1%) and not wanting to continue MAT (20.5%) as major reasons for not continuing treatment. The most commonly reported goal for treatment was to continue MAT long-term (43.5%). Results indicate that most participants linked to MAT treatment post-release. Participants reported reasons for why they did not continue MAT and had mixed intentions about continuing MAT in the future. Results provide identification of novel factors, such as side effects, time between release and treatment linkage, and family and friends' opinions that influence MAT continuation post-incarceration. Results highlight areas of exploration to influence treatment retention, including the role of probation/parole officers and the potential for peer support specialists to assist in reducing stigma and increasing interest in MAT.

Comparing the Validity of Self-Report and Urinalysis for Substance Use among Former Inmates in the Northeastern United States.

BACKGROUND: Problems with self-reported drug use include difficulties with recall and recognition as well as the desire to respond to questions in a socially desirable manner. Various methods have been developed to improve and/or validate estimates based on direct questioning of individuals regarding their substance use. For this study, we were interested in validating self-reported use of: 1) tobacco, 2) marijuana, and 3) other substances (i.e., heroin, cocaine, opiates, oxycodone, benzodiazepines, methamphetamine, phencyclidine, and barbiturates) employing urinalysis among inmates who participated in a randomized controlled trial of a smoking abstinence intervention in a tobacco-free prison located in the northeastern United States. METHODS: Two-hundred and seven men and women with a mean age of 34.9 (standard deviation = 9.0) completed questions regarding their substance use on a 7-day Timeline Follow-Back and provided urine specimens three weeks following prison release. RESULTS: Self-reported tobacco and marijuana use were highly consistent with urine drug testing in terms of overall agreement and Kappa (93.7% and.804 for tobacco, respectively; and 90.3% and.804 for marijuana, respectively); however, consistency was much lower for other drug use grouped together (62.7% and.270). DISCUSSION: Although some former inmates may not accurately report substance use, our findings indicate that they are in the minority, suggesting that self-report is valid for tobacco and marijuana use but much less so for other drugs grouped together. Future research should be conducted with a larger and more diverse sample of former inmates to establish the generalizability of our findings from this study.

Predictive Validity of a Cigarette Purchase Task in a Randomized Controlled Trial of Contingent Vouchers for Smoking in Individuals With Substance Use Disorders.

INTRODUCTION: A cigarette purchase task (CPT) is a behavioral economic measure of the reinforcing value of smoking in monetary terms (ie, cigarette demand). This study investigated whether cigarette demand predicted response to contingent monetary rewards for abstinence among individuals with substance use disorders. It also sought to replicate evidence for greater price sensitivity at whole-dollar pack price transitions (ie, left-digit effects). METHODS: Participants (N = 338) were individuals in residential substance use disorder treatment who participated in a randomized controlled trial that compared contingent vouchers to noncontingent vouchers for smoking abstinence. Baseline demand indices were used to predict number of abstinent days during the 14-day voucher period (after the reduction lead-in) and at 1 and 3 months afterward. RESULTS: Demand indices correlated with measures of smoking and nicotine dependence. As measured by elasticity, intensity and O max, higher demand significantly predicted fewer abstinent exhaled carbon monoxide readings during voucher period for individuals in the noncontingent vouchers condition. Breakpoint exhibited a trend-level association with abstinent exhaled carbon monoxide readings. Demand indices did not predict abstinence in the contingent vouchers group, and did not predict abstinence at 1- and 3-month follow-ups. Left-digit price transitions were associated with significantly greater reductions in consumption. CONCLUSIONS: The association of cigarette demand with smoking behavior only in the group for whom abstinence was not incentivized indicates that CPT assesses the value of smoking more than the value of money per se and that vouchers counteract the effects of the intrinsic reinforcing value of cigarettes. Results provide initial short-term evidence of predictive validity for the CPT indices. IMPLICATIONS: This study provides the first evidence of the validity of the CPT for predicting early response to brief advice for smoking cessation plus nicotine replacement in smokers with substance dependence. However, demand for cigarettes did not predict voucher-based treatment response, indicating that incentives serve as a powerful motivator not to smoke that acts in opposition to the intrinsic reinforcing value of cigarettes and that the indices reflect the value of smoking more than the value of money per se.

Exploration of Incarcerated Men's and Women's Attitudes of Smoking in the Presence of Children and Pregnant Women: Is There a Disparity Between Smoking Attitudes and Smoking Behavior?

INTRODUCTION: A major health challenge facing persons who are incarcerated is tobacco smoking. Upon reentry to the community, concerns regarding smoking cessation may be less likely to receive needed attention. Many individuals have partners who are pregnant and/or reside in households where children and pregnant women live. We explored incarcerated adults' attitudes of smoking in the presence of children and pregnant women and how post-release smoking behaviors are influenced by their attitudes. METHODS: Two hundred forty-seven incarcerated adults participated in a smoking cessation randomized clinical trial in a tobacco-free prison. An instrument was developed to examine smoking attitudes and behaviors around children and pregnant women. Moderating effects of smoking factors on post-release abstinence were examined by evaluating interactions between smoking factors and treatment group. RESULTS: Four factors were defined using factor analysis: smoking around children; impact of smoking on child's health; awareness of environmental tobacco smoke (ETS) risk for pregnant women; and importance of smoking avoidance during pregnancy. We found moderation effects of smoking factors on smoking outcomes which included: treatment group by smoking behavior around children (ß = 0.8085; standard error [SE] = 0.4002; P = .04); treatment group by impact of smoking on child's health (ß = 1.2390; SE = 0.5632; P = .03) and for those smoking 50% fewer cigarettes post-release, treatment group by smoking impact on child's health (ß = 1.2356; SE = 0.4436; P < .01). CONCLUSIONS: Concern for smoking around children and pregnant women and awareness of ETS risk for pregnant women was not found to be significantly associated with smoking outcomes and requires additional investigation. Among individuals who continue to smoke post-release, effective ETS interventions are needed aimed at protecting children and pregnant women with whom they live.

General and religious coping predict drinking outcomes for alcohol dependent adults in treatment.

BACKGROUND: Religiosity is associated with improved treatment outcomes among adults with alcohol dependence; however, it is unknown whether religious coping predicts drinking outcomes above and beyond the effects of coping in general, and whether gender differences exist. METHODS: We assessed 116 alcohol-dependent adults (53% women; mean age = 37, SD = 8.6) for use of religious coping, general coping, and alcohol use within 2 weeks of entering outpatient treatment, and again 6 months after treatment. RESULTS: Religious coping at 6 months predicted fewer heavy alcohol use days and fewer drinks per day. This relationship was no longer significant after controlling for general coping at 6 months. CONCLUSIONS: The relationship between the use of religious coping strategies and drinking outcomes is not independent of general coping. Coping skills training that includes religious coping skills, as one of several coping methods, may be useful for a subset of adults early in recovery. SCIENTIFIC SIGNIFICANCE: This novel, prospective study assessed the relationship between religious coping strategies, general coping, and treatment outcomes for alcohol-dependent adults in treatment with results suggesting that the use of religious coping as one of several coping methods may be useful for a subset of adults early in recovery.

Measuring behaviors of individual adolescents during group-based substance abuse intervention.

BACKGROUND: Group treatment is delivered in youth correctional facilities, yet groups may be iatrogenic. Few measures with demonstrated psychometric properties exist to track behaviors of individuals during groups. The authors assessed psychometrics for the Group Process-Individual Level measure (GP-IL) of group treatment. METHODS: N = 152 teens were randomized to 1 of 2 groups (10 sessions each). Adolescents, counselors, and observers rated teen behaviors at sessions 3 and 10. GP-IL assesses reinforcement for deviancy and positive behaviors, member rejection, and counselor connection and praise. RESULTS: Internal consistency and 1-month stability were demonstrated. Concurrent validity is supported by correlations with measures expected to be associated with group behavior (e.g., coping skills). Counselors and observers rated more deviancy during interactive skills-building groups versus didactic psychoeducational groups (P ≤ .005). Scales evidenced incremental validity. CONCLUSIONS: GP-IL offers a sound method of tracking adolescent behaviors for professionals working with groups. Counselors ratings were most reliable and valid overall.

Racial Differences in Medications for Opioid Use Disorder Initiation in a Carceral Setting.

BACKGROUND: The opioid overdose crisis significantly affects marginalized communities, with people of color experiencing higher rates of overdose and barriers to treatment. The syndemic of opioid use disorder and mass incarceration exacerbates racial health disparities. Some carceral facilities offer medication for addiction treatment, though no significant research explores differences in type of treatment uptake by race in these settings. This study focuses on the racial differences in medications for opioid use disorder (MOUD) preferences among incarcerated individuals. METHODS: A retrospective cohort study was conducted at the Rhode Island Department of Corrections (RIDOC), examining MOUD-type preferences (buprenorphine or methadone) among incarcerated individuals. The study utilized RIDOC electronic medical records from January 1, 2017 to December 31, 2022, involving 3533 unique incarceration events. Participants were categorized by race (White vs non-White) and MOUD status (new initiation vs community continuation), with logistic regression models. RESULTS: The study found no direct racial disparity in preferences for MOUD type. However, an interaction between race and MOUD initiation status significantly influenced MOUD-type preference. Among those initiating MOUD during incarceration, non-White individuals were more likely to choose buprenorphine compared to their White counterparts. CONCLUSIONS: This research provides new insights into the intersection of race, incarceration, and MOUD preferences. While direct racial disparities in MOUD type were not observed, the analysis uncovered a notable interaction effect: race influences the relationship between MOUD initiation status and the selected MOUD treatment during incarceration. Specifically, data demonstrate that the likelihood of choosing buprenorphine varies significantly based on both racial background and whether the treatment was initiated during incarceration or in the community. Further research is needed in different geographic settings to understand the broader implications to help guide equitable healthcare delivery in jails and prisons.

Old tech but not low tech: telephone-based treatment provision for substance use.

The future of telemedicine for substance use treatment hangs by a thread, as the United States awaits approval of proposed regulations and laws to increase care access in light of the 2022 Centers for Medicare and Medicaid Services revisions allowing for audio-only care. Telemedicine improves patient care access and outcomes. Audio-only telemedicine can be an effective and viable modality for individuals without technology resources (devices, internet services, and literacy), those with reduced telehealth service utilization (Black individuals or those with unstable housing, who are older, with low income, or with low education), and those living in rural locations. Studies suggest that telephone visits for buprenorphine treatment are well-accepted by patients and providers, making telephone visits essential in care access to reduce disparities. Telephone counseling for patients in substance use treatment is convenient, flexible, and empowering and can augment therapeutic alliances and treatment goals. Both providers and patients advocate for patient-centered hybrid care to include telephone-only treatment, which enhances service productivity and care access; reduces no-show rates, costs, and stigma; and is sustainable. Numerous solutions can expand technology access, proficiency, assimilation, and trust. Despite being "old" technology, the telephone remains an essential resource for substance use treatment.

Provision of medications to treat opioid use disorder via a mobile health unit: A scoping review.

INTRODUCTION: Mobile health units (MHUs) provide a variety of low-barrier services to populations that face systemic barriers to healthcare access. However, MHUs are not a common delivery method for medications to treat opioid use disorder (MOUD), and, of these, there is no consensus regarding MHU targeted objectives and outcomes. This scoping review seeks to summarize the state of the literature examining the delivery of MOUD by MHUs in the United States. METHODS: A search of PubMed, PsycInfo, and CINAHL on February 21, 2023, found 223 articles. Two authors completed title and abstract and full text reviews and extracted data relevant to intervention and study design, program objectives, and study outcomes. Ten articles fit the study's inclusion criteria (nine total interventions). RESULTS: Of the 10 studies, six were cohort designs, three were cross-sectional (one with qualitative interviews), and one study conducted qualitative interviews only. Most studies were located in the Northeastern United States. MHU interventions primarily aimed to provide MOUD and to retain populations in treatment. Two interventions aimed to engage patients and then transfer them to fixed-site MOUD providers. Across four interventions that provided buprenorphine, 1- and 3-month retention rates varied from 31.6 % to 72.3 % and 26.2 % to 58.5 %, respectively. Qualitative interviews found that MOUD delivery from the MHU was characterized by less stigma/judgment and greater privacy compared to fixed-site, and it was flexible and low-barrier. MHUs were reportedly underutilized by the target populations, suggesting a lack of awareness from community members with opioid use disorder. CONCLUSIONS: MHUs that deliver MOUD are both under-provided and -utilized. Future research should continue to assess MOUD provision from MHUs with an emphasis on robust study design, application to other formulations of MOUD, and evaluation of outcomes such as participant satisfaction and key informant perceived challenges. REGISTRATION: Submitted to Open Science Framework (OSF) Repository on February 6, 2023.

"It's just us sitting there for 23 hours like we done something wrong": Isolation, incarceration, and the COVID-19 pandemic.

For the millions of people incarcerated in United States' prisons and jails during the COVID-19 pandemic, isolation took many forms, including medical isolation for those sick with COVID-19, quarantine for those potentially exposed, and prolonged facility-wide lockdowns. Incarcerated people's lived experience of isolation during the pandemic has largely gone undocumented. Through interviews with 48 incarcerated people and 27 staff at two jails and one prison in geographically diverse locations in the United States, we document the implementation of COVID-19 isolation policies from the perspective of those that live and work in carceral settings. Incarcerated people were isolated from social contact, educational programs, employment, and recreation, and lacked clear communication about COVID-19-related protocols. Being isolated, no matter the reason, felt like punishment and was compared to solitary confinement-with resultant long-term, negative impacts on health. Participants detailed isolation policies as disruptive, detrimental to mental health, and dehumanizing for incarcerated people. Findings point to several recommendations for isolation policy in carceral settings. These include integrating healthcare delivery into isolation protocols, preserving social relationships during isolation, promoting bidirectional communication about protocols and their effect between facility leadership and incarcerated people. Most importantly, there is an urgent need to re-evaluate the current approach to the use of isolation in carceral settings and to establish external oversight procedures for its use during pandemics.