Medications for OUD in corrections: Tips from Linda Hurley, leader of CODAC
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 The first step was for CODAC’s patients who had been prescribed methadone to be withdrawn from the medication once they entered a RIDOC facility, over a course of about two weeks, which was better than immediate withdrawal but still uncomfortable.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.”
For CODAC, creating an onsite dispensary was a collaborative effort between groups often not used to working together:
- 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.”
Next will be Part 2: the RIDOC medical director perspective on how to make OTP-corrections partnerships work