Prison-based medication treatment in Rhode Island is reducing overdose deaths

When Rhode Island officials discovered that three of five overdose death victims in the state in 2014 had an incarceration history, it became clear that a cultural shift in how offenders' needs are addressed had to begin. Much broader access to gold-standard medication treatment for opioid dependence had to be offered, in order to mitigate the threat of relapse and potentially deadly overdose for individuals returning to the community from custody.

Now in 2018, Rhode Island has what is believed to be the first federally recognized opioid treatment program (OTP) delivering methadone treatment directly within a correctional facility. Overdose deaths among the recently incarcerated in the first six months of 2017 compared with the same period a year earlier were down 61%. That striking statistic was among the data most frequently cited in presentations by national leaders at last week's National Rx Drug Abuse & Heroin Summit in Atlanta.

“The cultural shift is happening,” Linda Hurley, president and CEO of CODAC Behavioral Healthcare, the Rhode Island-based provider operating the opioid dependence treatment services in the corrections system, tells Addiction Professional. Still, she acknowledges with regard to the effort, “When you're turning a Titanic, it takes time.”

The effort, which Hurley describes as growing out of a “really cool convergence” among CODAC, the Rhode Island Department of Corrections and evaluators at Brown University, involves screening of all inmates upon commitment and prior to release, with medication-assisted treatment (MAT) targeted to three distinct populations:

• Offenders who have already been on MAT in the community and can be maintained on their medication (methadone or buprenorphine) while in custody for up to one year. Upon release, these individuals are immediately connected to an appropriate treatment clinic in the community. This group accounts for more than half of the overall correctional MAT population being served.

• Sentenced individuals who are not currently on medication treatment but have a history of opioid dependence. Hurley explains that these individuals can request induction to any of the three federally approved medications for opioid dependence: methadone, buprenorphine or injectable naltrexone.

• Individuals who arrive at the state correctional system's intake center and may end up staying only a few days before court disposition or who may serve a very short sentence. These individuals can be initiated to methadone or buprenorphine where appropriate pre-release, and are also connected to a community provider. Hurley suggests that this population's needs often go unaddressed because “the shorter amount of time we have them, the lower the engagement.”

Rehabilitative history

Hurley says Rhode Island's corrections system always has been progressive on inmate rehabilitation, even before that word came into vogue nationally. As far back as the late 1970s, CODAC was working in the state prison complex, counseling DUI offenders in a weekend custody program.

In the mid-1990s, pregnant inmates and inmates with HIV were identified as priority populations for receiving methadone while in custody. However, the vast majority of the total inmate population still was being withdrawn from MAT while behind bars.

A major goal of the corrections department's medical program director, Jennifer Clarke, MD, MPH, was to keep offenders on medication treatment longer, thus increasing retention in treatment post-release and reducing overdose death. An infusion of state funding brought in CODAC in a competitive bidding process to operate the enhanced MAT program.

Strong support from Clarke and former corrections director A.T. Wall built momentum for shifting the outlook about medication treatment in prison and overcoming any potential resistance, Hurley explains. CODAC offers supportive counseling, discharge planning and ongoing care in the community along with its medication management services for inmates.

The recognition of CODAC's program as an in-prison OTP reduces wait times for initiating an individual on medication treatment, which Hurley considers a critical benefit.

For inmates who are being newly initiated on medication, the breakdown of which medication they're receiving stands at around 60% methadone and 40% buprenorphine, says Hurley. “If they know something worked for them before, that influences their decision,” she says.

Data from the state indicate that around 7 in 10 individuals from the three target populations combined are remaining on MAT after release. This is seen as a crucial development, as inmates returning to the community after having been withdrawn from medication treatment face a huge risk of relapse to opioid use—a potentially fatal consequence given the presence of fentanyl in the drug supply.

The data on reduced overdose deaths in the offender population, published in JAMA Psychiatry, are receiving national attention. A careful integration of correctional and rehabilitative goals, with realistic timelines in an area of government that can be slow to change, could bring about similar results in other states, Hurley believes. “This is replicable,” she says.