Treatment behind the walls: States gather to share information

State grantees who run treatment programs for prison inmates with substance use disorders (SUDs) met last week to share best practices, get updates from the federal contractor, and visit local programs. The grants from the federal Residential Substance Abuse Treatment (RSAT) for state prisoners program funded by the Department of Justice are for all SUDs, but the focus was on opioid addiction for the annual conference run by Advocates for Human Potential (AHP) and held in Providence, R.I.

AHP has a contract from the Justice Department's Bureau of Justice Assistance (BJA) to provide technical assistance to prisons and jails that receive BJA money for RSATs. This year, all states except for North Dakota and South Dakota sent representatives to its conference. The meeting usually lasts two days, but this year a day was added so that participants could visit two programs: MAT programs in the state women’s prison in Rhode Island and in the jail in Barnstable, Mass.

Vivitrol re-entry

The program in Barnstable is a Vivitrol re-entry program, where inmates who complete their treatment in jail are then given their first shot of the extended-release naltrexone, explains Andrew R. Klein, PhD, project director for the RSAT technical assistance contract and senior scientist for criminal justice at AHP.

“After they are released, they get connected to clinics on Cape Cod that offer counseling and continued Vivitrol, if they want it,” says Klein.

The program in Rhode Island is similar, he says. But there, even pre-trial detainees are offered Vivitrol. Typically the BJA funding is only for RSATs for sentenced offenders, says Klein. This is because pretrial detainees come and go quickly. “But because Rhode Island is a small state, they can offer the medication to pretrial detainees,” he says.

In both programs, if an inmate enters the facility already taking methadone or buprenorphine as a treatment medication, he/she can continue on the drug, says Klein.

“We’re recommending that the standard of care for SUDs requires offering MAT,” he says, adding that AHP doesn’t specify whether, in the case of opioid use disorders, methadone, buprenorphine, or injectable naltrexone should be used.

“We’re not saying agonist (methadone or buprenorphine) is better than antagonist (Vivitrol),” he says. “But the biggest problem with medications is when people don’t take them.” With Vivitrol, a depot injection, this problem doesn't occur—the medication lasts for a month.

In addition, Vivitrol has the added benefit of not being divertable. Also, it can’t be given when there are any opioids in the system. This makes jail or prison, where inmates do not have access to opioids (at least compared to the non-incarcerated population), an ideal place to detoxify and then start Vivitrol.

Inmates are more likely to go to treatment after they leave prison or jail if they are given medication first, says Klein. But the real question is what happens afterward. For example, there’s a belief that six months of Vivitrol injections are enough to prevent relapse, he says, adding that this is a myth.

“When the FDA did their study, they gave six months, and so there’s an idea in the community that six months is the right number,” Klein says. “But for example, when the Pennsylvania Department of Corrections did its Vivitrol re-entry program, and did six months, there was a huge relapse rate after six months.” Now Pennsylvania is recommending 12 months of shots.

Some inmates who are released on Vivitrol do switch to methadone or buprenorphine, says Klein. “The treatment providers may offer all medications,” he says. “We don’t have great statistics” on what happens after the inmates are out on their own.

Because of Vivitrol's high cost, some states have moved toward administering oral naltrexone instead. In Ohio, a stepdown facility run by the state’s Department of Corrections gives oral naltrexone while the inmates are still there, and a Vivitrol shot when they leave, says Klein.

Growing recognition of need

“Until recently, corrections has not viewed itself as a treatment agency,” says Klein. “Its mission is maintenance of order within the walls.” However, that has begun to change.

“Just recently, corrections is starting to think of itself as harm reduction, and beginning to think they have an obligation to provide treatment,” Klein says.

He adds that the corrections community—like some in the treatment community—is biased against agonist medication. “That’s reinforced by the fact that corrections wants to keep contraband out of their prisons,” he says. Providing methadone or buprenorphine in a RSAT can be a “hard sell,” he says. But in the last four or five years, there’s been a rapid growth in MAT, with almost a dozen prisons providing it, and 114 jails.

In RSATs, correctional officers are involved with treatment as well. “The treatment people come during the day, but the correctional officers are there 24/7,” says Klein. “It’s important to educate the correctional officers and the inmates.” Many people who have been in prison for years don’t realize that before they are released, even if they haven’t used drugs or alcohol in years, the craving will come back, he says.

In Kentucky and Tennessee RSATs, inmates receive two months of Vivitrol. The Kentucky legislature provided funding for the medication, which costs about $1,000 a month. Some states might have deals with Alkermes, the manufacturer, says Klein.

“In general, Alkermes provides the jails and prisons a free dose for the first dose,” he says. In many states, Medicaid will pay for the cost of Vivitrol, while in others there has to be a documented failure with another medication before Medicaid will pay for it.

New mindset

Interestingly, corrections, often thought to be opposed to treatment, is actually leading it in the case of the RSATs, says Klein. “Corrections is actually the tail that is wagging the treatment dog,” he says. “Referrals are only made to substance abuse treatment programs that can provide the medication and the counseling.”

Klein thinks that MAT is poised to take off across the country’s prisons and jails. “I think a lot of them know this is in the wind,” he says. “They are asking questions, and couple states indicated that they are going to start programs, getting copies of protocols.” Many states see only barriers to a treatment program within correctional institutions, which is why visits to facilities such as those seen last week are important. “They need to see this can happen in a real-life correctional institution, that it’s not pie in the sky,” says Klein. “They say that if this can happen in Cranston, Rhode Island, why can’t they have it in their state?”