With her compassion and knowledge, Linda Hurley, CEO of CODAC Behavioral Healthcare in Rhode Island, is able to convince corrections staff of the benefits of methadone and buprenorphine. But it isn’t easy. In a webinar on using medications to treat opioid use disorder (OUD) in correctional settings this month, Hurley provided clear advice with examples from real programs, including her own. Hosted by the American Association for the Treatment of Opioid Dependence (AATOD), the webinar focused on the importance of providing treatment in justice settings. As AATOD CEO Mark Parrino said in introducing her, there is now a great need for compassionate care, adding that this is also the time “to go from theory to practice.”
While stigma is a problem for opioid treatment programs (OITPs) in the community, it’s a particular problem in correctional settings, where staff are often one of the holdout groups in viewing methadone, and even buprenorphine, as “substitute” addictions. “I’ve been at this for 37 years, and there have been heartening changes,” Hurley said. But more work needs to be done. The key is focusing on the best ways to implement medication-assisted treatment (MAT) injustice settings, as medical settings already know the science.
It is certainly not necessary to go to prison or jail to receive treatment for OUD, and in many cases, those people belong in treatment, not in carceral settings, which are costly and not helpful. But if they are incarcerated and have OUD, there are four basic models to get this care to them, Hurley explained.
• A mobile medication unit, which goes to jails to deliver medication. This model uses a van that has been modified to deliver methadone and buprenorphine to individuals who are in prison or jail. There is much interest in this model, but only limited data. The program is staffed by a doctor and nurse, in the example given by Hurley: Project Kick Start in the Atlantic County Justice Facility in New Jersey, which partners with the John Brooks Recovery Center. This program serves 450 patients a year.
• The external vendor model, which involves the transportation of methadone and buprenorphine from a community OTP to the respective Department of Corrections for daily administration. This would be “couriered” medication. In Vermont, under its “hub and spoke” system, this was implemented in 2018. The facility administers buprenorphine and naltrexone to“spoke” patients, while community-based OTPs provide methadone to “hub” patients. The Vermont Department of Corrections model serves 650 patients a day. After Vermont’s implementation of the program in 2018, MAT during incarceration increased by 0.8% to 33.9%, MAT post release increased, and overdoses, both non-fatal and fatal, decreased.
• The internal OTP model, in which the respective Department of Corrections licenses its own OTP, dispensing and administering medication daily. In this model, the prison or jail becomes a licensed OTP, obtaining approval from the federal Drug Enforcement Administration. The Franklin County Jail in Greenfield, Massachusetts, was approved as an OTP in August 2019. The emphasis is on holistic care during incarceration as well as upon release. The program serves about 40 people a day at a cost of $27 a day per person. There were specific lessons learned: obtaining OTP licensure is time-consuming and complex. There is great importance in a team-based approach with the cooperation of security personnel and medical staff. So far, no outcomes have been published since the facility obtained OTP licensure.
• In the model CODAC uses in the Rhode Island Department of Corrections (RIDOC) system, the OTP vendor is colocated within the prison or jail. The licensed OTP operates within the walls and dispenses the medication daily. The RIDOC system is unified— there are six facilities, combining what is usually thought of as prison (more than a one-year sentence) and jail (shorter sentences or awaiting conviction, sentencing, or release). The average daily census of MAT patients is 2,298, with 6,413 individuals receiving care. The average sentence length is 16.2 months. More than 50% of the individuals awaiting trial are released within six days of commitment.
The criminal legal system represents one of the highest impact avenues to provide treatment, said Hurley, noting that at least 1 in 45 people die in re-entry, when they go back to using drugs and, as they are no longer tolerant, overdose. “This is a highly vulnerable population,” she said of people leaving incarceration who have not used drugs for days. “The risk of relapse two weeks following reentry is extremely high — more than 29 times higher than the general population,’ she said. In addition, not offering treatment is cruel and unusual punishment, a violation of the 8th Amendment of the U.S. Constitution, she stressed. There are also many randomized controlled trials showing that MAT with methadone or buprenorphine is effective in correctional populations.
Given all of these arguments in favor of treatment, why is it so hard to put into place in carceral settings? “These are simply medicines,” Hurley pointed out. The answer is that the medicines — methadone and buprenorphine — aren’t well understood by corrections staff, said Hurley. The other reason is that the disease of addiction isn’t well understood by corrections staff.
Sometimes the best way to convince people to embrace MAT in their facilities, said Hurley, a soft-spoken master educator whose almost motherly demeanor belies her toughness and authoritativeness, is to tell them that they will be happy with the results. “Just say, ‘I urge you to use this because it works,’” she said.
Explaining the disease sometimes means taking the staffers through what is well known as the typical pathway to addiction, using the metaphor of footprints in the sand on the shore as the tide comes in and out. “People use once on a Saturday night, the footprints are there, the tide comes in, and the footprints go away,” she said. “But then you’re using six Saturday nights in a row, and you wake up Sunday morning, and you say I really liked that, I want it again tonight. Now there’s a permanent footpath. And then, you wake up on Monday, and you don’t feel well, because you need it [because you’re in withdrawal].” There is now what Hurley calls a deep foundation, and different spots in the brain know about this new little rural road that it must follow. “And then, there’s a seven-lane highway, and the second you have a spoon, or see anything that reminds you of a substance, you are compelled to use.”
When patients get to the seven lane highway stage, methadone —not buprenorphine or naltrexone —is the most effective medication, said Hurley.
Some tough questions have been fielded by Hurley over the years, and corrections officials want answers. Hurley cuts to the chase. One question from a member of the webinar audience was: “There doesn’t appear to be any end stage for treatment – is this going from one form of dependence to another?” Hurley’s response:“ It is going from one form of dependence to another” (echoing VincentDole, M.D., who invented methadone treatment, and told skeptics cheerfully that “it is a crutch” -- what you would have someone with a broken leg do to get around?) “The reason that methadone works so well, and why people are happy to use it for the rest of their lives, is that it gave them their lives back,” she says. And like many clinicians, when asked by patients about any long-term medication, including methadone,“it’s a medication.” Patients don’t want to rock the boat now that they are doing well.
What about Vivitrol and the criminal justice system? Unlike methadone and buprenorphine, Vivitrol (naltrexone) is an antagonist, an injection given once a month that blocks the effects of opioids. It won’t stop a patient from using opioids, but it will stop the opioids from having any effect. Because it’s not a controlled substance, sheriffs in local jails may prefer it. “I think it’s great,” says Hurley of Vivitrol. “I stress that having three medications [naltrexone, methadone, and buprenorphine, the only FDA-approved medications for OUD] available is always good.” One of the problems with Vivitrol is that it cannot be given to anyone with opioids in their system, or it will precipitate acute withdrawal (severe sickness including vomiting and diarrhea). This means that patients must have already gone through withdrawal, with no opioids in their system for a week. Nevertheless, Hurley supports it as long as it is what the individual wants. Hurley noted that in Massachusetts, much work has been done in the western part of the state with Vivitrol alone. “You’re going to meet the least resistance across the board” in corrections if promoting Vivitrol, she said.“You’ll also buy people some time.” One of the messages Hurley conveys repeatedly to treatment providers and corrections officials alike: “you can’t have good programming without good security.”
Another question is more about what some of the problems all methadone and buprenorphine advocates encounter behind the scenes in corrections: notably, opposition from the powerful unions representing custodial (prison guard) workers. The unions opposed the provision of methadone to inmates in Rhode Island, at first. Why, and what did Hurley do about it? “It went by steps,” said Hurley. First, the unions said it was “too much work,” and cited “understaffing of security.” She sympathized with the security issue. Unlike many medical and harm reduction advocates, Hurley has taken the time to learn the carceral culture so she can communicate better with it. “Anytime someone moves in a carceral facility, there have to be two individuals(jail or prison staff) to accompany that person. So having two medication lines – a special one for methadone – means more work. The unions were opposed to this because there was no plan to compensate them for the extra work.
But then, when CODAC explained that they would bring their own nurses in, the unions complained because they wanted the extra jobs, work, and money. The prison unions in Rhode Island are “strong,” she said. “They put up billboards on I95.” So how did the methadone project end up working? “We won them over because the director of the department said, ‘you’re doing this,’” said Hurley.
