1. MAT IN PRISON: ON THE INSIDE
Radha Sadacharan, MD MPH
AMERSA Panel November 2nd 2017
Instructor, Department of Family Medicine, Brown University
Staff Member, Center for Prisoner Health and Human Rights

2. DISCLOSURES
I have no conflict of interest in relation to this presentation

3. MASS INCARCERATION IN THE UNITED STATES
Before we dive into MAT in prison, I’d like to take a few minutes to talk about corrections in the United States. We have 5% of the world’s population, and 25% of the world’s prisoners. I like this graphic from the prison policy initiative, which shows that the majority of incarcerated people in our country are in state facilities, including prisons and local jails, while a minority are in federal prisons. This pie also breaks down the major reasons that 2.3 million people are incarcerated.

4. Not only are more people incarcerated in state facilities, the rate of incarceration has skyrocketed since the 1970s, tracking closely with the War on Drugs, and disproportionately affecting communities of color. While federal prisons in the United States have also seen a rise in the rate of incarceration, there is a clear difference between state and federal prisons. Local jails tend to have high turnover rates, as jail populations include those who cannot make bail, persons awaiting trial, and inmates serving shorter sentences.

5. THE EPIDEMIC OF INCARCERATION
What history also tells us it that even after violent and property crime rates fell, the incarceration rate continued to rise. There are high rates of untreated mental illness and substance use in justice-involved populations. Part of this can be traced back to the deinstitutionalization, or dissolution, of state mental health facilities in the 60s and 70s. We’ve now replaced them with correctional facilities as the treatment centers for many people. Cook County Jail in Chicago is the largest single-site jail in the United States. An estimated 1 in 3 inmates there has a mental illness. All new employees receive 60 hours of advanced mental health treatment training at orientation. I bring this example up because it demonstrates the changes we can make locally. Substance Use Disorder treatment is no different.

6. RHODE ISLAND, THE DOC, AND OUR OPIOID PROBLEM
12% (254 of 2062) of sentenced inmates residing at the RIDOC as of April 2015 screened for substance misuse indicated an opioid as their drug of choice
15-20% of people committed have an opiate use disorder
60% of fatal overdose victims in 2014 had been incarcerated
<20% of fatal overdose victims had been incarcerated in the last year
In 2014, twice as many overdose victims were recently incarcerated, compared to 2009
A little background about Rhode Island and the way the opioid epidemic was affecting our state prior to MAT initiation in prison.

7. RHODE ISLAND GOVERNOR’S OVERDOSE TASKFORCE
Reduce Opioid Overdose Deaths by One-Third Within Three Years
Every Door Is The Right One
In August 2015, the Governor issued an executive order to establish a broadly representative Task Force and to obtain expert input to develop strategies to address the opioid epidemic. Stakeholders included Department of Health, Community Treatment Centers, Hospitals, Police/ First Responders, Corrections, Academics, Legislative Representatives, People in Recovery, Family Members Impacted, and Community Providers. I can’t imagine how big that room was. In November 2015 the Task Force presented the Governor with a strategic plan
The long term goal is “To reduce opioid overdose deaths by one-third within three years.” Treatment Strategy: Every Door Is The Right One : This includes the medical system (Emergency Departments, hospitals, clinics, etc.), The criminal justice system, Drug treatment programs, The community
Funding 2 million dollars for corrections, which is not insubstantial in the state of Rhode Island.

8. THE STANDARD OF CARE The World Health Organization (WHO)1
National Institutes of Health (NIH)2
National Institute of Drug Abuse (NIDA)3
…and countless other health institutions4
Have endorsed the effectiveness of MAT and have urged correctional systems to provide inmates with the same evidence-based treatment that is available in the community
Why is this?
Citations: (1) UNODC/WHO. United Nations Office on Drugs and Crime/World Health Organization. HIV/AIDS Prevention Care, Treatment and Support in Prison Setting. A Framework for and Effective National Response. 2006
(2) NIH (National Institutes of Health). (1997). Effective treatment of opiate addiction. 15 NIH Consensus Statement. November 17–19).
(3) NIDA. (2012a). Medication-assisted treatment for opioid addiction. Retrieved from
(4) Boucher, R. (2002). Case for Methadone Maintenance Treatment in Prisons, The. Vt. L. Rev., 27, 453.

9. MAT IN CORRECTIONS Benefits Evidence
Reduces illicit opioid use post-incarceration
Mattick, Breen, Kimber, & Davoli, 2009
Reduces criminal behavior post-incarceration
Deck el al., 2009
Reduces mortality and overdose risk post-incarceration
Degenhardt et al., 2011; Kerr et al., 2007
Reduces HIV risk behaviors (i.e., injection drug use) post-incarceration
MacArthur et al., 2012
95% of people who are incarcerated will return to their communities. The benefits post-incarceration of providing MAT in correctional facilities are numerous. It has been found to reduce illicit opioid use and criminal behavior after release, reduce mortality and overdose risk post-incarceration, and reduce HIV-risk behaviors.
References:
Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.Cochrane Database Syst Rev, 3.
Deck, D., Wiitala, W., McFarland, B., Campbell, K., Mullooly, J., Krupski, A., & McCarty, D. (2009). Medicaid coverage, methadone maintenance, and felony arrests: Outcomes of opiate treatment in two states. Journal of addictive diseases, 28(2),
Degenhardt, L., Bucello, C., Mathers, B., Briegleb, C., Ali, H., Hickman, M., & McLaren, J. (2011). Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta‐analysis of cohort studies. Addiction, 106(1),
Kerr, T., Fairbairn, N., Tyndall, M., Marsh, D., Li, K., Montaner, J., & Wood, E. (2007). Predictors of non-fatal overdose among a cohort of polysubstance-using injection drug users. Drug and alcohol dependence, 87(1),
MacArthur, G. J., Minozzi, S., Martin, N., Vickerman, P., Deren, S., Bruneau, J., ... & Hickman, M. (2012). Opiate substitution treatment and HIV transmission in people who inject drugs: systematic review and meta-analysis. Bmj, 345.
Rich, J. D., McKenzie, M., Larney, S., Wong, J. B., Tran, L., Clarke, J., ... & Zaller, N. (2015). Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. The Lancet.
Zaller, N., McKenzie, M., Friedmann, P. D., Green, T. C., McGowan, S., & Rich, J. D. (2013). Initiation of buprenorphine during incarceration and retention in treatment upon release. Journal of substance abuse treatment, 45(2),
McKenzie, M., Zaller, N., Dickman, S. L., Green, T. C., Parihk, A., Friedmann, P. D., & Rich, J. D. (2012). A randomized trial of methadone initiation prior to release from incarceration. Substance Abuse, 33(1),
Heimer, R., Catania, H., Newman, R. G., Zambrano, J., Brunet, A., & Ortiz, A. M. (2006). Methadone maintenance in prison: evaluation of a pilot program in Puerto Rico. Drug and Alcohol Dependence, 83(2),
Dolan, K. A., Shearer, J., MacDonald, M., Mattick, R. P., Hall, W., & Wodak, A. D. (2003). A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system. Drug and alcohol dependence, 72(1),
Additional social, medical, and economic benefits of providing MAT to inmates who are opioid-dependent are well-documented
(Rich et al., 2015; Zaller et al., 2013; McKenzie et al., 2012; Heimer et al., 2006; Dolan et al., 2003)

10. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomized, open-label trial. JD Rich et al. Lancet 2015.
Probability of attending a methadone clinic in (A) intention-to-treat and (B) as-treated populations at 1 month follow-up after release from incarceration.
What’s more, in Rhode Island, methadone continuation, not even initiation, during incarceration, has also proven beneficial for post-release follow-up. Inmates of the Rhode Island Department of Corrections who were enrolled in a methadone maintenance-treatment program in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, were randomly assigned (1:1) to either continuation of their methadone treatment or to usual care--forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, established in a follow-up interview with the participants at 1 month after their release from incarceration. Extrapolated, continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviors.

11. RIDOC OVERVIEW Unified Correctional System 6 Facilities
Average daily census 3,100
FY 2015
12, 650 commitments
Large percentage of <1yr sentence
Monthly awaiting trial census
Intake
HSC
Maximum
Medium
So, back to the RIDOC. The RIDOC is a unified correctional system, meaning jails and prisons are operated by the state department of corrections, as opposed to county and state jurisdictions. This is relatively uncommon – less than ten states have unified correctional systems, including Alaska, Connecticut, Delaware, Hawaii, and Vermont. All facilities in Rhode Island are also on one physical campus, consisting of 6 inmate housing facilities that house an average of 3,100 inmates at a time.
2 awaiting trial buildings had over 12,000 commitments in the FY On average the monthly awaiting trial population census runs between 6 & 700, the average LOS is 23 days with the median LOS being 3 days.
73% of male and 89% of female inmates were sentenced to 1yr or less in 2015
The DOC health services unit is a State run healthcare service under the direction of the Medical Programs Director, Dr. Jennifer Clarke, without whom none of this would have been possible. The services provided include medical, mental health, dental, & health education. Additionally the state contracts with numerous community providers for specialty medical services.
Women’s
Minimum

12. STAKEHOLDERS Patients DOC staff MAT program: CODAC Nurses Providers
Warden, Deputy
Correctional Officers
MAT program: CODAC
Discharge Planners
Nurses
Providers
BRASS – warden, deputy, chiefs.

13. MAT IMPLEMENTATION
This is the intake services center at the RIDOC. The women’s facility includes intake for women, and the census is generally less than 200.

14. RIDOC MAT IMPLEMENTATION TIMELINE
December Began depot-Naltrexone program
May buprenorphine continuation (Women’s)
June 2016
Stopped withdrawing people from methadone (prior policy was up to 60 days)
Started pre-release MAT inductions in Women’s Division
July MAT RFP released
August 2016
Buprenorphine and methadone inductions at women’s division
September 2016
Hired 3 part-time staff to begin screening and assessment
Began maintaining patients on buprenorphine for men and methadone inductions
October CODAC selected as MAT vendor
November 2016
CODAC staff begin full program implementation
Pre-release inductions
Naltrexone program was prior to funding received from governor, based on work that Barnstable County had done.
CODAC is a statewide non-profit provider of substance use and behavioral healthcare services. This is the cog that makes the whole project turn.

15. GOALS
Screen everyone upon commitment and prior to release with assessments as appropriate
MAT if appropriate for 3 populations:
Continue MAT for 6-12 months
Initiate MAT upon commitment
Initiate MAT prior to release
Seamless community transition
Comprehensive MAT services – Medication, Residential Treatments, Recovery Coaches, Group Therapy etc.

16. Discharge Planning Starts When Treatment Starts
On MAT continue 12 months
Intake
Within 4 days
*goal <24 hours
Prior to release
Computer based
Screen
Negative
DONE
Positive
Urine Screen
Assessment
Documentation of addiction
Treatment Plan (groups/urine)
Consent form signature
Case management
MAT
This is the flow-chart of our process of screening at the DOC.
Naltrexone
Methadone
Buprenorphine
Discharge Planning Starts When Treatment Starts

17. PRELIMINARY FINDINGS

18. Between initiation of this program in April of 2016 and two months ago, we have continued to increase the number of patients who are receiving MAT, especially methadone and suboxone. This also takes into account the fact that patients are being released, so while numbers look like they’re holding steady, it actually represents the dynamic entry of new patients into the program and exit of patients on release. We did switch over to a new EMR system at the end of August so unfortunately we don’t have data yet for September and October of this year.

20. CHALLENGES
Diversion
Skepticism
Data collection
Screening
Transition outside – Looking Forward
As you can imagine, there have been challenges along the way.
From a security standpoint, diversion is a big deal. We have been working with correctional officers and the wardens and deputiess on better communication between security and CODAC when this does happen. Additionally, medications are currently entered in disciplines as “contraband,” which we are working on changing the system to track specific medication diversion, so we can find out more easily if diversion is occurring.
In terms of skepticism, one of the biggest pieces of feedback is: why use taxpayers’ dollars for this? Focus on the purpose of the program, that it is about saving lives. Improve function after release (employment, health, recidivism etc.). For example, by hopefully keeping someone out of jail for a year, we can save $65,000 taxpayer dollars. And MAT inside doesn’t cost anything near that amount.
Data collection: We are keeping track of numbers screened, numbers eligible for MAT, how many have started on MAT, % compliant with MAT (medication, treatment groups, programs etc.). We are also tracking number of bookings (fights/ breaking prison rules).
Screening: As mentioned before, right now we’re able to screen within four days after arrival at intake. Our goal is less than 24 hours. One of the reasons is that if we are too far out in terms of screening, a urine screen could be negative, which in the grand scheme of things is one data point, but helps build the whole picture, especially for staff. There are unfortunately a lot of competing factors for time, so we’ve started doing night screenings on the day of being committed, and doing these three nights a week. We have a plan to get more screeners who will also be doing other health screens at the same time, so that in total they don’t take more than 15 minutes.
% continue with a provider for MAT on release: Track above by type of MAT, Track by length of time on MAT, Post release urine drug screens with probation and parole
Recidivism, Mortality
NIH Funding
Medicaid data
Recovery coach

21. HINDSIGHT IS 20/20 Start slow Provider Time & Workspace Screening
Underestimated the needs
Nursing workload increased
Screening
Computer-based works – saves time
Timing difficult (court, enemy issues, contract providers not a priority)
Time to treatment and assessment
Urine negative if delayed
Released before treatment
Screening – moving this to night of admission, currently now administering screening three nights a week
Staff education – The plan is now for all new hire correctional officers to start receiving education during orientation about MAT

22. HINDSIGHT IS 20/20 Sharing information
Data sources corrections, DOH, PDMP, Medicaid billing data, CODAC etc.
Dosing
Film dissolves faster
Moving towards giving in AM:
Safer because overmedication can be observed
Patients feel better
Work-release
Keep people on treatment – may be >12 months

23. STAY TUNED
We are examining reductions in mortality, implementation of the project and its effects on attitudes and behaviors of prison staff, inmate health and safety outcomes on the inside and post release; qualitative and quantitative evaluations all underway. Rhode Island Hospital is starting a transitions clinic, with the expert help of people like Dr. Wong.

24. ACKNOWLEDGEMENTS