Part 1: Medications for OUD in corrections: Tips from Linda Hurley, leader of CODAC
November 2, 2022 by Alison Knopf
Many changes have taken place in Rhode Island, one of the most advanced states in treatment for opioid use disorder (OUD), in corrections. Prior to 1994, any patient in methadone treatment who was arrested and put in jail or prison was not medicated upon commitment, something which Linda Hurley, president and CEO of CODAC Behavioral Healthcare, understandably calls “inhumane.” However, Hurley, speaking at a workshop at the American Association for the Treatment of Opioid Dependence (AATOD) conference in Baltimore November 1, is very understanding of different voices, including those from security and safety officials (corrections), the Drug Enforcement Administration, and others who must collaborate in any kind of care for incarcerated people.
Fast forward to today, and people in the Rhode Island Department of Corrections (RIDOC) system can have any one of the three medications to treat opioid use disorder (OUD) which they prefer, if they need medication. The committing nurse asks them if they need treatment, and they are offered methadone, buprenorphine, or naltrexone. Fewer than 1% choose naltrexone.
CODAC has been the partner for the state’s Department of Corrections for 45 years, so for the OTP to be involved with treatment behind the bars was not as difficult as it might have been otherwise.
A small state with a unified system, Rhode Island has combined prison and jail, which makes treatment much easier.
The attitude changes
“We’re very fortunate that our Department of Corrections is a rehabilitation-focused institution,” said Hurley. But still, the changes were incremental. The first step was for CODAC’s patients who had been prescribed methadone to be withdrawn from the medication once they entered a RIDOC facility, over a course of about two weeks, which was better than immediate withdrawal but still uncomfortable. Those patients who had been prescribed buprenorphine were not given any medication in the RIDOC facility, beyond a “comfort protocol.”
“What we have today is astounding” by comparison, said Hurley, whose presence has helped make Rhode Island one of the leading states in treating people with OUD who are incarcerated.
A core element of the program is patient choice, and all inmates in need regardless of length of stay or sentence can stay in the OUD treatment program.
Whether they were in treatment already, or need to be inducted upon entry to the facility, all inmates have the choice of medication.
The biggest pushback from RIDOC workers was when individuals who had not been on medication were approaching their release date, and even though they were not physically dependent, faced a great risk of going back to using opioids and overdosing. So to face the cravings and help treat the brain changes which were present due to previous opioid use, the inmates were offered medications.
Understand what corrections workers need
Hurley stressed that it’s important to take the time and energy to work out relationships and to understand the needs of corrections workers and officials. If they say “why do you need to give someone medication when they might just divert it, because they don’t need it because they have already detoxed,” don’t assume that they are being “resistant,” she said. They are trying to do their job, and the best way to work with them is to be sensitive to their mission of community safety and security. “We don’t want our [OTP] staff to be at odds with this mission,” said Hurley.
In addition, CODAC staff who work in the RIDOC facilities must be personally and professionally mature. “I think we need to have actual protocols for communication,” said Hurley.
CODAC got the funding first, before there was a lot of time to sit down with stakeholders and work out these issues, so “we did it backwards,” said Hurley (not that there was any choice). But as a warning to other OTPs looking at the future which likely will involve their being involved in treating OUD in corrections, Hurley cautioned that a culture shift is required. “Start slow, if you can,” she said.
For programs currently writing RFPs to get partners, discuss the issues with those partners first, said Hurley. “How much will it cost?” is one of the questions partners want answered. “It sounds very simple, but when you have a compressed timeline, it isn’t simple.” And for OTPs who want to participate in a corrections program, it is critical that the OTP “understand the environment of the state, and the needs of the corrections” departments and workers, she said. “Your competence will be more respected if you get letters of reference.”
Onsite dispensary
For CODAC, creating an onsite dispensary was a collaborative effort between groups often not used to working together:
- RIDOC
- Rhode Island Department of Health
- Drug Enforcement Administration
- Rhode Island Board of Pharmacy
- Substance Abuse and Mental Health Services Administration (CSAT)
- National Commission on Correctional Health Care
“Every entity has their own agenda, one that meets their mission,” said Hurley. “We have to respect all agendas in order to be heard.”
Creating an onsite dispensary is very complex, including finding a place for it, and finding the correct staffing, said Hurley. Staffing is key, because there will likely be conflict, and the OTP staff need to know how to handle this. “When we [OTPs] go into a department of corrections in any state, we will find that a majority of the people who work there take their jobs seriously, and do not want us there,” said Hurley. “You can’t have someone with thin skin, you need people with mediation and negotiation skills being part of the team.”
Report from AATOD: Rhode Island and corrections, Part 2
November 7, 2022 by Alison Knopf
Corrections staff are suspicious of methadone and buprenorphine. They know these drugs can be diverted, they have some kind of vague feeling that they can make people feel better (not the same as getting “high” but the nuances can get lost), and they are concerned about the amount of extra work letting these medications into their institutions will involve. The job of corrections officers is not to cure the world of opioid overdoses or even to provide a healthy life for inmates when they are released, but to protect the safety of everyone inside the prison and jail – at least, that’s the way they view it. So it makes the concept of giving methadone or buprenorphine for addiction difficult for them to understand.
Enter Justin Berk, M.D., who as medical director of the Rhode Island Department of Corrections (RIDOC) is at the forefront of the state’s aggressive move to bring these medications into the state’s prison and jail system. He explained to attendees of a pre-conference workshop at the American Association for the Treatment of Opioid Dependence (AATOD) conference on October 31 how the traditionally resistant corrections force bought into medication-assisted treatment.
With CODAC leading the treatment side (see https://atforum.com/2022/11/report-aatod-5-years-success-rhode-island-corrections/), the state, under the leadership of former governor Gina Raimondo, this small state has gotten farther than any other on treatment for opioid use disorder (OUD) “behind the walls.”
The strategy promoted by then-Governor Raimonda was to increase the number of people receiving treatment, and the rescue strategy was the increase the number of naloxone kits available.
On the prevention side, the effort was to decrease the number of patients getting prescriptions for opioids, said Berk.
The timeline, starting with August 2015 was the creating of a task force, followed by the June 2016 mandate by the governor that medication had to be provided in corrections. The state put $2 million into that project to fund it. “It was major that the governor backed this, so no individual corrections officer could say no,” said Berk.
By November of 2016, CODAC was the only organization that came into the facility.
Berk said that focusing on the target group that is at the highest risk for overdose makes sense, and that group is incarcerated people leaving prison or jail.
In a statistic mentioned frequently during the AATOD conference, which had “collaboration” as a theme and which focused on corrections, harm reduction, and other topics not traditionally thought of as opioid treatment program (OTP) fodder, Berk said:
Initiation of medication assisted treatment in a correctional setting was associated with a 61% reduction in overdose deaths. This means that for every 11 people treated before they are released, there is one less overdose death.
There are different models for onsite medication administration in prisons and jails. In Rhode Island, the model is an external provider coming into the facility.
On-site Vivitrol is preferred by fewer than 1% of inmates, said Berk. He added that some facilities are only offering Vivitrol, which unlike methadone and buprenorphine is an opioid blocker. It is probably a violation of the Americans with Disabilities Act (ADA) not to offer methadone and buprenorphine, said Berk.
In fact, among all of the arguments Berk as a medical doctor can make on behalf of methadone and buprenorphine, the one which sank in most with corrections officials was this: If you don’t offer these drugs, you are going to get sued.
Other provisions of the RIDOC treatment program:
- No one is discharged from the program, only offered alternative therapy. For example, in the case or repeated buprenorphine diversion, “we would say it sounds as if this medication is not for you, you can stay in the program, but with methadone, Sublocade, or Vivitrol,” said Berk).
- There is no ceiling for methadone dosing.
- Dosing is daily.
- Most buprenorphine patients receive 16 milligrams a day, can receive 24 milligrams with medical director approval (this approval is via a simple email, said Berk).
- Dosing is in the morning (because evening dosing caused insomnia, irritating both patients and security, said Berk).
- Discharge planning starts at admission
Medical-security partnerships
It’s difficult to get “security” – the part of incarceration that has to do with managing the inmates – on board with medical when it comes to methadone and buprenorphine, said Berk. “Security continues to be an issue in Rhode Island,” Berk said. Of course, medication for addiction treatment aligns with security’s goals of keeping people safe, he added.
But there is a risk of diversion of opioid agonist medications. Security handles hoarding and diverting, which do occur “on rare occasions,” said Berk. This is not a medical issue.
This is why security, and not medical (the nurse), does “mouth checks” after medication administration, said Berk. This was “nursing doesn’t lose the trust and become punitive.”
So far, there have been 22 diversion incidents across RIDOC.
Funding
At the beginning, the program was only for people sentenced for one year or less, because of the open-ended costs of medications for people on long-term medication treatment. One of the attendees who asked the panel a question said that her facility had started using medication, but that at 6 months people were withdrawn from the medications because there wasn’t enough funding.
Even at RIDOC, the medication program was only for people sentenced to one year or less, at first, said Berk. Gradually, more time was added, as funding grew. “Now, finally, the treatment is covered for life without parole,” said Berk for the RIDOC treatment program. He added that “there was pushback at first, because of costs.”
There was also pushback from corrections staff and officials because, they said, if inmates were going to be there for a long time, they wouldn’t have the risk of relapse when they were released. “We explained that these people have maladaptive behavior because of the disease, and that medication will help,” said Berk. “Then when that didn’t work, we said this is requirement of the ADA, and we’re going to get sued if we don’t do it. That worked.”
Finally, another argument for giving patients methadone or buprenorphine – especially when they first are admitted and are addicted to opioids – is a more practical one. “This may sound like code switching, but the unfortunate truth is that the correction officer’s goal is not providing quality care, it’s “We don’t like having the cell full of diarrhea.” (Diarrhea and vomiting are symptoms of opioid withdrawal.)
That said, it’s true that methadone and buprenorphine, like all opioids, can cause buprenorphine. “CODAC addiction prescribers prescribe three medications: methadone, buprenorphine, and Miralax,” Berk said, not joking. And he added that constipation is made worse by the corrections diet, which could use more fiber.
Confidentiality
Finally, confidentiality is an issue. Berk was asked how, if a prison has a separate medication line for methadone or buprenorphine, the identity of those inmates can be kept confidential, as is required by 42 CFR Part 2. “How do you keep them confidential?” “It’s a mess, in that you can’t,” said Berk. “If you talk to a correctional officer they’ll say everyone knows everyone’s business anyway.” Some facilities say it’s better to have just one medication line, because one methadone-buprenorphine line does make patients vulnerable to harassment from “other inmates and staff and even nursing,” said Berk. This is a good argument for Sublocade (extended release injectable buprenorphine), he noted.
But the bottom line is that prisons aren’t healthcare facilities, which is the only way they would be covered by HIPAA or 42 CFR Part 2, said Berk.
Part 3: Methadone in Rhode Island corrections, the psychology of working with another discipline
November 21, 2022 by Alison Knopf
Getting methadone in prison: It takes work
When a correctional system entertains the idea of something established medicine accepts as gold standard – namely, medication-assisted treatment (MAT) with methadone or buprenorphine for opioid use disorder (OUT) – there is an uphill battle ahead, even for those within the system who believe in it. In Rhode Island, CODAC, the opioid treatment program (OTP) embedded in the corrections system, has put in the time, staffing, and most important the understanding of the psychology of wardens and custodial staff. “This is a very complex issue if you are looking at introducing it into your correctional system,” CODAC CEO Linda Hurley told attendees at the meeting of the American Association for the Treatment of Opioid Dependence (AATOD) in Baltimore last month.
The medication lines, the administration, the impact on overall operations, and the connection between good security and good programming are all part of understanding how corrections systems work,” said Hurley.
She doesn’t like to use the word “resistance” when discussing the feelings of corrections staff to methadone, for this reason: “They are trying to do their job.”
It’s true that a culture shift is required, she said. But this has to be done slowly, if possible, and it’s the job of the OTP to communicate and educate.
The first step when an inmate comes into a jail or prison is to find out whether medication for OUD is needed, and sometimes this is done through computer screening. This isn’t necessarily the most efficient way, though. “The fastest way is for the [corrections] nurse to just ask the question” about this, said Hurley. “If we had just brought nursing in right away, we would have saved time.”
It’s important to recognize that CODAC started with a leg up – it had 45 years of working with the state department of corrections, and a history of support. It’s also important for OTPs to know that CODAC, even though it is the in-facility treatment provider, is not trying to take patients away from other OTPs when the patients are released form the facility. “There have been times when people thought CODAC would grab our patients when they came out” of prison, said one attendee, cautioning others about some of the challenges they would face when trying to start a program like this.
Hurley responded quickly, saying the last time she heard that accusation it was referred to as “pirating.” At the end, 40% of the people who were released were originally receiving treatment from the correctional facility, and statewide CODAC has 48% of OUD patients, “so we are not increasing our number of patients” by virtue of having the corrections-based program. Nevertheless, she said, it’s important for OTPs to pay attention to this as a possible challenge.
As always, working together and communicating is key.
Recent Comments