Tackling the Opiod Crisis with Meds

There’s not usually much to be happy about around here, says Rhode Island Department of Correction’s medical director, but she is celebrating small achievements in the struggle against opioid overdoses/deaths. In a program initiated in June 2016, RIDOC is tackling offenders’ opioid addictions with the first of its kind comprehensive Medication-Assisted Treatment (MAT) program. A study released last month has shown it has promising results.
It is well known the opioid crisis has reached epic proportions and continues to grow.  According to the Centers for Disease Control (CDC), the most recent data estimates that 142 Americans die every day from a drug overdose. Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have more than quadrupled since 1999, reports CDC’s wide-ranging online data for epidemiologic research (WONDER). Opioids are a prime contributor to our addiction and overdose crisis. In 2015, nearly two-thirds of drug overdoses were linked to opioids like Percocet, OxyContin, heroin, and fentanyl. Further sobering, according to the interim report prepared by President’s Commission on Combating Drug Addiction and the Opioid Crisis: “The average American would likely be shocked to know that drug overdoses now kill more people than gun homicides and car crashes combined.”
The opioid crisis is significantly connected to the offender population. An estimated half to two-thirds of all prisoners have some form of substance abuse disorder. Doctors say there’s a public misconception that incarceration, particularly years-long incarceration, can help prisoners break an addiction.
Yet, one of the biggest problems for offenders who have an illicit substance addiction, is that they are taken off treatment before they are incarcerated and while they are inside they have little or no access to drugs. This lowers their tolerance and so once they are released they have a high risk for overdose and death, explains Jennifer Clarke, MD, the medical director of RIDOC.
In fact a study (Binswanger, et al, 2007) found that in the first two weeks after release ex-offenders have a 13 times higher risk of death than the general population, and the leading cause was overdose of illegal narcotics, the researchers found. Though the study did not look at the reason for the high number of drug overdoses, the researchers surmised that the stress of release and the ex-prisoners' reduced tolerance to drugs after their sentences were major factors.
"If people have been avoiding drug use and they return to their usual doses after release, they will have lost tolerance," said lead researcher Dr. Ingrid Binswanger, of the University of Colorado Health Sciences Center. The 2007 study, which was published by the Journal of New England Medicine, suggests that the criminal justice system is doing an inadequate job easing the transition to society, experts said. While it was published over a decade ago, it still rings true today.
Once ex-prisoners are released and exposed to their old triggers, there is a high risk for overdose and death, concurs Dr. Clarke. It was shown in several states that overdose deaths in the weeks post release were much higher with people who were incarcerated than with the general population, she reiterates. “That’s why it’s so important they are started on treatment before they are released.”
Initiating a program in a large corrections agency is not an easy task, most would agree. Asked about their implementation, says Clarke: “We are very fortunate Governor [Gina M.] Raimondo addressed the crisis head-on,” and put together a task force together to investigate the major areas to decrease mortality, and funds were put in place to address the problem. Because Rhode Island has a combined jail and prison system, the state can sidestep some issues other states have, she notes.
Now, significantly, she says, “We no longer take people off treatment when come in.”
Intakes are assessed and an appropriate treatment regimen of one of the three FDA approved drugs is agreed upon and followed through.  If an offender is not on treatment when they are booked, the DOC addresses their need prior to release and they are also able to start on treatment 60 days prior to release. One advantage of the program, Clarke explains, is a community program that provides the meds is licensed within the DOC, so inmates are already enrolled in the program before they are released. “It allows for seamless enrollment into community-based treatment.”
This is typically not the case in other states, and results from a recent study were encouraging. The study compared overdose deaths in the general population to overdose deaths where a person was incarcerated in the year prior to their death and compared a year before Rhode Island started the MAT program to six months after the program was fully running.
RIDOC Med Study Results Promising
To gauge the early results of the program, researchers compared overdose deaths in the first half of 2016 with those in the first half of 2017, according to STATnews.com, a national publication focused on health, medicine, and scientific discovery. Results were announced online on February 14 in the American Medical Association-sponsored journal JAMA Psychiatry. In the 2016 period, 26 of 179 individuals (14.5%) who died of an overdose were recently incarcerated compared with 9 of 157 (5.7%) of individuals in the 2017 period, representing a 60.5% reduction in mortality.  (Again, they defined recently incarcerated as being released from a correctional facility in the prior year.)
The researchers calculated that officials needed to treat only 11 inmates to prevent one overdose death.
Researchers involved in the study said they “observed a large and clinically meaningful reduction” in post incarceration deaths from overdose among inmates released from incarceration after implementation of a comprehensive MAT program in a statewide correctional facility. They add that it is “remarkable that the reduction in mortality occurred in the face of a devastating, illicit fentanyl-driven overdose epidemic.”
Dr. Clarke observes: Comparing the two time periods, with other factors relatively stable, “we attribute the difference to the MAT program.” In addition, she adds, the Narcan distribution (nasal form of naloxone for the emergency treatment of a known or suspected opioid overdose) decreased during that time period as well.
Missiouri’s Program
Another particularly promising program, which was started in 2013, is a partnership Corizon Health has with the Gateway Foundation, the Missouri Department of Corrections and the Missouri Department of Mental Health  to provide MAT services at several of the institutions within the state prison system. The Recidivism Reduction Project includes pre-release case management and Vivitrol for high-risk patients and post-release tracking and referral to out-patient treatment including Vivitrol, individual counseling and group counseling.
According to Gateway’s 2017 annual report: “During fiscal year 2017, after screening almost 3,000 clients, Gateway provided opioid relapse prevention medication, Vivitrol, to 142 incarcerated clients at seven Missouri Department of Corrections institutions and to 128 clients post release….We continue to see outstanding outcomes in client engagement and retention in treatment of those who receive addiction medication as a component of holistic treatment and comprehensive reentry services both prior to and following release from the Missouri Department of Corrections.
“In 2017,” Gateway furthers, “95% of clients who received MAT engaged in community-based treatment upon release versus an average of 60 percent for non-MAT recipients. Impressively, 90% of the corrections involved clients served by Gateway’s Reducing Recidivism-Medication Assisted Treatment program did not return to custody in an 18-month retrospective through 2016.”
Regular Funding
Going forward in Rhode Island, due to the “impressive results,” Dr. Clarke states, “the state legislature will provide funding for this program in the general budget now (it approved $2 million annually for MAT in their prisons).
“It saves lives, and that is the tip of the iceberg.” With it, she adds, “More are employed…recidivism goes down…more are engaged with their families. Death is going down, and based on all other research, we have to assume those other things have improved as well.”
Other states have started to look to Rhode Island to learn from its MAT program and last August the White House’s commission on combating the national opioid epidemic released an interim report recommending that the Justice Department increase MAT in prisons. The panel noted that multiple studies have shown that inmates who received treatment had lower recidivism rates than those who did not, according to STAT News.com.
In Dr. Clarke’s view: “Governors need to step up to the plate with their crises. They should see it as an opportunity for treatment and thus put the resources in place to enable people to get treatment.”
Stepping It Up
Going forward, RIDOC will continue what they are doing right. When the program began, they enrolled new intakes into the program within “five or six days,” Clarke explains. That number is down to just a few days. They are working toward “expanding treatment to the night they come in.”
Further, Rhode Island is expanding its use of “recovery coaches” an individual who is point of contact that every offender will have immediately at the time they are released.
While a few states may have the MAT therapy on a limited basis, Rhode Island DOC is the first to take it full scale. It is one that provides cause to celebrate and commend.
Says Dr. Clarke: “It has been so wonderful to see patients on the program really doing well in the community. They are participating in groups, and they can participate in other aspects of their recovery more because they aren’t craving the drugs.”