The Case for Corrections Medication-Assisted Treatment

The Case for MAT in Jails and Prisons

Research shows medication-assisted treatment for opioid withdrawal works, but challenges and obstacles slow its progress.

ails represent perhaps the most unique place to get individuals off drugs and on the path to long-term recovery,” notes Jonathan F. Thompson, executive director and CEO, National Sheriffs’ Association.

Jails have become a revolving door for individuals struggling with mental health and substance use disorders, he continues in a resource guide published in October 2018. “More than 10 million individuals pass through jails around the country annually, with at least half of those individuals having substance use disorders, half of whom are opioid abusers.” “ J

He furthers: “Without effective intervention, this drives our nation’s crime rate dramatically, while those who are most vulnerable remain sick.” However, jails are in a unique position to initiate treatment in a controlled environment, he points out. The resource guide Jail-based Medication-Assisted Treatment, Promising Practices, Guidelines and Resources for the Field, sponsored by National Sheriffs’ Association and the National Commission on Correctional Health Care, outlines a course of action for MAT in jails, and includes jails that have successful MAT programs. (To find this resource online, visit www.ncchc.org/jail-based-mat.) The publication makes clear that pharmacology—i.e., medication-assisted treatment—is widely held to be a cornerstone of best practice for recovery from substance abuse, according to James R. Pavletich, CEO of NCCHC. He notes: “Effective treatment, including MAT, particularly when coupled with evidencebased behavioral treatment, improves medical and mental health outcomes and reduces relapses and recidivism.”

In 2016 the National Institute on Drug Abuse published authoritative research that MedicationAssisted Treatment, utilizing the U.S. Food and Drug Administration (FDA)-approved

medications methadone, buprenorphine, or naltrexone, is considered a central component of the contemporary standard of care for the treatment of individuals with opioid use disorders (OUDs).

Advancing Addiction Science

Evidence strongly supports that the use of MAT increases the likelihood of successful treatment for individuals with OUDs and reduces morbidity and mortality. Research has begun to show that adding MAT to the treatment of those involved in the criminal justice system confers the same benefits and also reduces recidivism. This was collaborated by many studies, including those published in the Journal of Substance Abuse Treatment, Addiction and Criminal Justice & Behavior. The NSA/NCCHC resource guide furthers that “These findings are particularly relevant for criminal justice decision makers— including sheriffs and corrections department officials—given that Bureau of Justice Statistics surveys found that nearly two-thirds (63 percent) of people in jail meet criteria for drug dependence or abuse. Many of these individuals have OUDs and could benefit from access to MAT, a combination of behavioral interventions and medications that have been shown to decrease opioid use, increase treatment retention, reduce overdose, and reduce criminal activity.” In fact, these programs reduce costs as well. According to a 2018 SAMHSA study Medications for Opioid Use Disorders, “Data indicate that medications for OUD are cost effective and cost beneficial.”

Yet, MAT is not widely implemented in corrections and jails, according to the guide. It states: “Notwithstanding the increasing evidence and formal support from many prominent public health and public safety organizations (including the NSA and

NCCHC), substance use treatment providers—both inside and outside of the criminal justice system—have been slow to add MAT to their treatment regimens. In 2011, the Washington County, Maryland, jail became the first to introduce MAT for nonpregnant women and for men. Other county jails and state departments of corrections (DOCs) in Missouri, Pennsylvania, and Massachusetts followed suit.

“However, as of January 2018,” the guide continues, “20 state DOCs did not offer MAT in their drug treatment programs for incarcerated individuals beyond limited methadone maintenance for pregnant women. Out of several thousand local and county jails, fewer than 200 in 30 states provide MAT, and the protocol is primarily limited to the provision rectional facilities are not treated with Medications for OUDs (MOUD). “One in twenty opioid deaths in the U.S. involve a person who has been released from jail or prison in the prior thirty days,” he says. “There is growing recognition by national, state, and counties regarding the urgent need to close the gap between evidence and practice by developing systems that engage people entering jails and prisons in treatment and ensure continuity of treatment upon release including when they are involved in community corrections, i.e., drug courts, probation and parole.”

Correctional health care companies are strong proponents of MOUD treatment and offer it as frequently as they are able. For example, says Wendelyn Pekich, vice president of Marketing,

“....Substance use treatment providers—both inside and outside of the criminal justice system—have been slow to add MAT to their treatment regimens.”

—National Sheriffs’ Association/National Commission on Correctional Health Care guide

of injected naltrexone immediately before individuals are released back into the community. Jails that provide MAT for pregnant women typically discontinue it postpartum, although this is not the recommended standard of medical care.”

Pharmacology is considered a best practice when treating those with OUDs, concurs Kevin Fiscella, M.D., M.P.H., who serves as Dean’s Professor Family Medicine at the University of Rochester Medical Center, and represents the American Society of Addiction Medicine (ASAM) on the Board of Directors of the NCCHC. Dr. Fiscella notes: “ASAM recently released updated treatment guidelines that summarizes the evidence.”

Most people with OUD in corStrategic Communications, and Proposal Development with Wexford, “Wexford Health has been providing medication assisted treatment for many years now. We believe that the MAT program greatly assists in the transition process from jail or prison system back to the community.” All patients with a substance use disorder should have access to appropriate treatment, including counseling, behavioral therapy and all relevant U.S. Food and Drug Administration-approved medications, concurs the firm Mallinckrodt. “For most of the more than 2 million Americans who are incarcerated, a substantial number of whom suffer from Opioid Use Disorder, this is not the case.”

The firm adds that it “has been

at the forefront of addiction treatment for decades and has relationships with a majority of the federally and state licensed opioid treatment providers across the United States.” The company manufactures a range of addiction treatment products, including finished-dose formulations of methadone, buprenorphine and naltrexone.

“We applaud state and local governments who are now beginning to bring treatment within the walls of jails and prisons. In notes Steven Descoteaux, M.D., statewide medical director, Wellpath MADOC and Kim Christie, BSN, RN, CCHP, VP of Partnership Operations. “We have been assisting our state and local government clients with MAT initiation for more than four years but we have always coordinated the assessment and enrollment of pregnant, opiateaddicted patients for MAT.”

They note that Wellpath’s specialty is the provision of medical and behavioral health services to

“Strong executive leadership by jail sheriffs and prison wardens is critical to opening the door to providing MOUD within jails and prisons.”

—Kevin Fiscella, MD, MPH, National Commission on Correctional Health Care

Rhode Island’s Department of Corrections, for example, mortality post-release improved by more than 60 percent. Statewide, this single public policy investment led to more than a 10 percent improvement in mortality among all Rhode Islanders,” according to Mallinckrodt.

Other programs are also on the upswing. NaphCare for example, recorded a more than 200% increase in patients requiring medical care for opioid withdrawal in the more than 40 jails from the period from 2016 to 2019, says Jeffrey Alvarez, MD, CCHP, Chief Medical Officer, NaphCare. “Recognizing the significant impact of this epidemic on jails and local communities,” he notes, “NaphCare implemented advanced withdrawal protocols in 2017, as well as MedicationAssisted Treatment programs. The company offers some level of MAT services at each of our partner sites nationwide—in more than 40 jails across 14 states.”

Others have followed suit. “Wellpath is passionate about Medication-Assisted Treatment,” vulnerable patients in challenging clinical environments. The firm provides care in 33 states, and has developed a MAT division to provide subject matter experts to those who want to implement a program. “We are fielding weekly requests for our assistance and expertise in designing and operating MAT programs.”

MAT programs continue to expand in both jails and prisons, says Dr. Fiscella of the NCCHC. “There is a steady and slowly growing interest. For example, two jails in New York State including one in my community Monroe County and another in Albany have recently begun offering all three types of MOUD in jail. The federal Bureau of Prisons is piloting MOUD in Alabama in partnership with OTPs [opioid treatment programs].”

Unfortunately, current data is lagging. “Hard recent data are hard to come by,” Dr. Fiscella acknowledges. “However, my impression is that it is slowly improving.”

Hindrances to MOUD programs

Very real obstacles make it difficult to implement a MAT program. “Strong executive leadership by jail sheriffs and prison wardens is critical to opening the door to providing MOUD within jails and prisons,” continues Dr. Fiscella. Providing MOUD is much more than dispensing new medication. It requires major changes in internal processes and partnerships with community agencies.

“These leaders not only open the correctional doors to outside partnerships and new processes, but are also critical in changing cultural norms regarding treatment of OUD,” he furthers. But it is not only the executives in these correctional agencies who must adapt. “Internal champions who work under the direction of the sheriff or warden are also critical to driving internal processes including development of MOUs, trainings, treatment protocols, and policies and procedures.”

Handling and administration of these treatment medications require care and adherence to regulations. One issue is inmates diverting the drugs to be used as contraband. “Though all facilities differ in their physical make up, we strive to incorporate all three forms of MAT in a way that is minimally disruptive of daily operations,” note Wellpath’s Descoteaux and Christie. “MAT in the form of buprenorphine comes with challenges related to minimizing diversion. There needs to be a medication pass for buprenorphine that is separate from the other medication passes. We are able to help our medical providers become specially licensed to prescribe buprenorphine, and to train nursing and security staff about handling and administration of this medication. “Providing methadone is even more challenging due to federal regulations and requires partnership with a facility that is

licensed to do so. In most cases, this requires transportation of inmates to the local methadone provider, but our clients and communities are best served when MAT can be administered on-site. If desired, Wellpath or its security partner may be able to acquire its own license to provide methadone. Should this option be pursued, the greater challenge is to build dispensary for methadone on site. This is costly and requires extensive planning and coordination with DEA diversion control, SAMHSA, and other regulatory agencies.”

To meet state and federal licensing requirements, especially to provide methadone, “NaphCare works with our partners to apply for full opioid treatment licensing, when feasible, to be able to dispense methadone ourselves in the jail facility.” Another barrier is the lack of a definitive release date while court proceedings are still occurring. Not knowing when a patient will be released makes it difficult to ensure a connection to a community partner ahead of release, especially when most patients are in jail for a short period of time. In some of our facilities, we have partnered with a local community MAT provider to make access to appointments easier for our patients upon release so that they can maintain their recovery.

While the way forward still remains unknown, Dr. Fiscella sees that doors are cracking open. More jails and prisons are exploring options for MOUD, he says. “During this process, it becomes apparent that partnerships are needed to coordinate care upon entry and upon release. Correctional health care person

ACLU Wins Suit Over BOP

In September 2019 the ACLU of Washington filed a civil rights lawsuit against the federal Bureau of Prisons (BOP) for denying people with opioid use disorder medications necessary to treat their addiction. The lawsuit, brought on behalf of Melissa Godsey, challenges BOP’s policy of refusing to provide people access to Medication-Assisted Treatment, including Suboxone (buprenorphine and naloxone), even though it provides other clinically appropriate medications to inmates.

In December, in response to the lawsuit, the BOP agreed to provide MAT to Godsey, who has opioid use disorder and has been in active recovery with MAT for over a year. (Current BOP policies prohibit someone from continuing on MAT for treatment of opioid use disorder unless the inmate is pregnant.) The settlement in Godsey represents the third time in 2019 that BOP has agreed to provide MAT as part of a settlement agreement. nel must be able to communicate with community prescribers to confirm doses and arrange follow-up to avoid interruptions in care. This requires much closer partnerships between corrections and community than has existed before. This requires correctional leaders reaching out beyond the walls of their facility to the community and vice versa. It is often a slow process of building mutual trust and an effective collaboration,” he concludes.

Programs in Place

Wexford Health offers MAT to inmates upon arrival and at reentry, as needed. This includes pregnant addicted inmates, as well as other addicted inmates presenting with substance use disorders.

The transition from jail or prison back to the community can be overwhelming for many inmates, Pekich says. In fact, Wexford Health has found that by offering MAT to willing inmates upon reentry, it has increased survival, improve treatment retention, and decrease criminal activity and illicit drug use in the community. This in turn results in reduced recidivism rates.

“We have seen our buprenorphine taper reduce needless suffering with thousands of patients across the country undergoing opioid withdrawal,” says Dr. Alvarez of NaphCare. “Additionally, we have seen hundreds of opioid positive women stabilized with their pregnancy by starting and maintaining MAT during their pregnancies while in custody and upon transfer upon release to community partners.”

Addiction is a disease, Mallinckrodt asserts. “Left untreated, we know that it leads to crime, recidivism and, worse, death. State and local governments have an opportunity to break the cycle of addiction while someone with the disease of addiction is in their custody. They must seize that opportunity and provide access to the full range of addiction treatment without further delay.” ✪