Opioid addiction
treatment behind bars reduced post-incarceration overdose deaths
Brown University
A treatment program
for opioid addiction launched by the Rhode Island Department of Corrections was
associated with a significant drop in post-incarceration drug overdose deaths
and contributed to an overall drop in overdose deaths statewide, a new study finds.
The program, launched
in 2016 and the only one of its kind in the nation, screens all Rhode Island
inmates for opioid use disorder and provides medications for addiction
treatment (MAT) for those who need it.
Comparing the
six-month period before the program was implemented to the same period a year
later, the study showed a 61 percent decrease in post-incarceration deaths.
That decrease
contributed to an overall 12 percent reduction in overdose deaths in the
state's general population in the post-implementation period.
While the study, published in JAMA Psychiatry, was designed as a preliminary evaluation of the program, the results suggest that comprehensive MAT treatment in jails and prisons, with linkage to treatment in the community after release, is a promising strategy for rapidly addressing the opioid epidemic nationwide, the researchers say.
"This program
reaches an extremely vulnerable population at an extremely vulnerable time with
the best treatment available for opioid use disorder," said study
co-author Dr. Josiah "Jody" Rich, professor of medicine and epidemiology
at Brown University and director of the Center for Prisoner Health and Human
Rights at The Miriam Hospital in Providence.
"With this study,
we wanted to see if that intervention could impact statewide overdose
mortality, and the answer is a resounding yes."
Dr. Traci Green, an
adjunct associate professor of emergency medicine and epidemiology at Brown and
a senior researcher at Rhode Island Hospital, is the study's lead author. She
said Rhode Island's program could be a national model for how to begin turning
the tide in the opioid epidemic.
"People have been
searching for some way to stop overdose deaths," said Green, who is also
an associated professor in Boston University's schools of medicine and public
health. "Here we have a program that's shown to work, and it's absolutely
replicable in other places.
Not only do we see
that a statewide program treating people using medications for addiction
treatment is possible and reduces deaths, but also this approach intervenes on
the opioid epidemic at its most lethal and socially disrupting point --
incarceration -- to give hope and heal communities."
A unique program
The program grew out
of work done by Rhode Island Governor Gina M. Raimondo's Overdose Prevention
and Intervention Task Force. Both Green and Rich are expert advisors to the
Task Force and study's co-authors included the two Task Force co-chairs, Nicole
Alexander-Scott, MD, MPH, the director of the Rhode Island Department of
Health, and Rebecca Boss, MA, the director of the Rhode Island Department of
Behavioral Healthcare, Developmental Disabilities, and Hospitals.
The nature of opioid
use disorder, Rich says, makes incarcerated populations especially vulnerable
to overdose. People who use opioids build a tolerance, meaning they require an
ever-increasing dose to get the same effect. That tolerance quickly evaporates
during incarceration, when people are forced off the drugs.
"They may have
stopped using while incarcerated, but nothing has been done to change the
pathways in the brain responsible for addiction," Rich said. "So when
they get out, people are likely to relapse, and with their tolerance gone,
they're at high risk for overdose."
Decades of research
from around the globe have shown that MAT is the best path to recovery for
people with opioid use disorder, Rich says, whereas simple detox or "cold
turkey" fails 90 percent of the time.
The MAT program
implemented by the Rhode Island Department of Corrections (RIDOC) consists of
three different drug therapies.
Two drugs, methadone
and buprenorphine, are opioid medications that help to reduce withdrawal
symptoms like drug craving.
The third drug,
naltrexone, blocks people from experiencing the high normally associated with
opioid use. Clinical criteria are used to tailor the best treatment for each
individual patient.
"While
comprehensive treatment for opiate use disorders has not been the traditional
role of correctional facilities, we have shown that it is feasible," said
Dr. Jennifer Clarke, medical programs director at RIDOC, an associate professor
of medicine at Brown and director of the RIDOC MAT program.
"Providing
treatment saves lives and helps people become productive members of society,
positively engages them with their communities and families which makes for
healthier and safer communities."
The treatment is
administered to inmates by CODAC Behavioral Health, a nonprofit provider of
medications for addiction treatment contracted by RIDOC to provide MAT inside
correctional facilities.
Upon release, former
inmates can continue their treatment without interruption at CODAC, primary
care providers, or other Centers of Excellence in MAT locations around the
state.
Patients are also
assisted with enrolling or re-enrolling in health insurance to make sure they
are covered when they return to the community.
While a handful of
programs elsewhere in the nation provide one MAT drug or another to certain
segments of incarcerated populations, Rhode Island's is the only one that makes
the full suite of MAT available to every individual coming in or leaving the
correctional system.
Medications are
continued if they are on them when they arrive and started if they need them
upon arrival or prior to release.
"It's a credit to
Governor Gina Raimondo and the Rhode Island legislature that they've gotten
behind this program and made it happen," Green said. "Without that
commitment and leadership, we wouldn't be seeing the success we're seeing in
this study."
Fewer overdose deaths
The study was designed
as a preliminary assessment of the program's effectiveness in reducing overdose
deaths among recently incarcerated people, meaning those who had been
incarcerated within a year of their deaths.
The research showed
that the number of recently incarcerated people who died from overdose dropped
from 26 in the first half of 2016 -- before the program started -- to just nine
in the first half of 2017, after the program's implementation.
The decrease in
post-incarceration overdose deaths, which occurred within six to 12 months of
initiating the program, was a major contributor to the overall decline in
overdose deaths among Rhode Island's general population in the two study
periods. The number of deaths fell from 179 in the 2016 period to 157 in the
2017 period.
"What's
remarkable is that between 2016 and 2017 there was a huge jump in the amount of
fentanyl and related compounds available on the illicit market," Rich
said.
"So in the face
of a worsening overdose risk, we actually saw a decline in overdose deaths.
We're quite confident that that happened because we've given people these
medicines and they've stayed on them long enough to ovoid an overdose."
The researchers say
the study's positive results likely underestimate the effect of the program.
Though launched in the summer of 2016, the program wasn't fully up and running
at all locations in the correctional system until early 2017. So the 2017 study
period doesn't capture the fully operational program.
The research team
plans to perform further evaluation of the program, looking at longer-term
outcomes among those treated with MAT, as well as how the program might affect
re-incarceration and other population-level outcomes. But these early data make
a strong case that this type of intervention could help stem the tide of opioid
overdoses, the researchers say.
"People may say,
well, Rhode Island is a small state and that's why they were able to implement
this," Green said. "But there are state and county correctional
systems all over the country that are the same size as Rhode Island's. They could
all be doing this, and this study tells us that they should be."
Rich agreed that Rhode
Island's program should serve as a model for similar programs across the
country.
"If people are
concerned about overdose deaths in their community, they should demand that a
similar program of comprehensive MAT be promptly implemented in the
correctional facilities that service their community," Rich said.
The research was
funded by the Centers for Disease Control (NU17CE002740) and the National
Institutes of Health (K24 DA022112, R21 DA044443, T32 DA013911, P30 AI042853).