RIDOC medical director on reaching out to corrections staff on methadone and buprenorphine
Corrections staff are suspicious of methadone and buprenorphine. They know these drugs can be diverted, they have some kind of vague feeling that they can make people feel better (not the same as getting “high” but the nuances can get lost), and they are concerned about the amount of extra work letting these medications into their institutions will involve. The job of corrections officers is not to cure the world of opioid overdoses or even to provide a healthy life for inmates when they are released, but to protect the safety of everyone inside the prison and jail – at least, that’s the way they view it. So it makes the concept of giving methadone or buprenorphine for addiction difficult for them to understand.
Enter Justin Berk, M.D., who as medical director of the Rhode Island Department of Corrections (RIDOC) is at the forefront of the state’s aggressive move to bring these medications into the state’s prison and jail system. He explained to attendees of a pre-conference workshop at the American Association for the Treatment of Opioid Dependence (AATOD) conference on October 31 how the traditionally resistant corrections force bought into medication-assisted treatment.
With CODAC leading the treatment side (see https://atforum.com/2022/11/report-aatod-5-years-success-rhode-island-corrections/), the state, under the leadership of former governor Gina Raimondo, this small state has gotten farther than any other on treatment for opioid use disorder (OUD) “behind the walls.”
The strategy promoted by then-Governor Raimonda was to increase the number of people receiving treatment, and the rescue strategy was the increase the number of naloxone kits available.
On the prevention side, the effort was to decrease the number of patients getting prescriptions for opioids, said Berk.
The timeline, starting with August 2015 was the creating of a task force, followed by the June 2016 mandate by the governor that medication had to be provided in corrections. The state put $2 million into that project to fund it. “It was major that the governor backed this, so no individual corrections officer could say no,” said Berk.
By November of 2016, CODAC was the only organization that came into the facility.
Berk said that focusing on the target group that is at the highest risk for overdose makes sense, and that group is incarcerated people leaving prison or jail.
In a statistic mentioned frequently during the AATOD conference, which had “collaboration” as a theme and which focused on corrections, harm reduction, and other topics not traditionally thought of as opioid treatment program (OTP) fodder, Berk said:
Initiation of medication assisted treatment in a correctional setting was associated with a 61% reduction in overdose deaths. This means that for every 11 people treated before they are released, there is one less overdose death.
There are different models for onsite medication administration in prisons and jails. In Rhode Island, the model is an external provider coming into the facility.
On-site Vivitrol is preferred by fewer than 1% of inmates, said Berk. He added that some facilities are only offering Vivitrol, which unlike methadone and buprenorphine is an opioid blocker. It is probably a violation of the Americans with Disabilities Act (ADA) not to offer methadone and buprenorphine, said Berk.
In fact, among all of the arguments Berk as a medical doctor can make on behalf of methadone and buprenorphine, the one which sank in most with corrections officials was this: If you don’t offer these drugs, you are going to get sued.
Other provisions of the RIDOC treatment program:
- No one is discharged from the program, only offered alternative therapy. For example, in the case or repeated buprenorphine diversion, “we would say it sounds as if this medication is not for you, you can stay in the program, but with methadone, Sublocade, or Vivitrol,” said Berk).
- There is no ceiling for methadone dosing.
- Dosing is daily.
- Most buprenorphine patients receive 16 milligrams a day, can receive 24 milligrams with medical director approval (this approval is via a simple email, said Berk).
- Dosing is in the morning (because evening dosing caused insomnia, irritating both patients and security, said Berk).
- Discharge planning starts at admission
It’s difficult to get “security” – the part of incarceration that has to do with managing the inmates – on board with medical when it comes to methadone and buprenorphine, said Berk. “Security continues to be an issue in Rhode Island,” Berk said. Of course, medication for addiction treatment aligns with security’s goals of keeping people safe, he added.
But there is a risk of diversion of opioid agonist medications. Security handles hoarding and diverting, which do occur “on rare occasions,” said Berk. This is not a medical issue.
This is why security, and not medical (the nurse), does “mouth checks” after medication administration, said Berk. This was “nursing doesn’t lose the trust and become punitive.”
So far, there have been 22 diversion incidents across RIDOC.
At the beginning, the program was only for people sentenced for one year or less, because of the open-ended costs of medications for people on long-term medication treatment. One of the attendees who asked the panel a question said that her facility had started using medication, but that at 6 months people were withdrawn from the medications because there wasn’t enough funding.
Even at RIDOC, the medication program was only for people sentenced to one year or less, at first, said Berk. Gradually, more time was added, as funding grew. “Now, finally, the treatment is covered for life without parole,” said Berk for the RIDOC treatment program. He added that “there was pushback at first, because of costs.”
There was also pushback from corrections staff and officials because, they said, if inmates were going to be there for a long time, they wouldn’t have the risk of relapse when they were released. “We explained that these people have maladaptive behavior because of the disease, and that medication will help,” said Berk. “Then when that didn’t work, we said this is requirement of the ADA, and we’re going to get sued if we don’t do it. That worked.”
Finally, another argument for giving patients methadone or buprenorphine – especially when they first are admitted and are addicted to opioids – is a more practical one. “This may sound like code switching, but the unfortunate truth is that the correction officer’s goal is not providing quality care, it’s “We don’t like having the cell full of diarrhea.” (Diarrhea and vomiting are symptoms of opioid withdrawal.)
That said, it’s true that methadone and buprenorphine, like all opioids, can cause buprenorphine. “CODAC addiction prescribers prescribe three medications: methadone, buprenorphine, and Miralax,” Berk said, not joking. And he added that constipation is made worse by the corrections diet, which could use more fiber.
Finally, confidentiality is an issue. Berk was asked how, if a prison has a separate medication line for methadone or buprenorphine, the identity of those inmates can be kept confidential, as is required by 42 CFR Part 2. “How do you keep them confidential?” “It’s a mess, in that you can’t,” said Berk. “If you talk to a correctional officer they’ll say everyone knows everyone’s business anyway.” Some facilities say it’s better to have just one medication line, because one methadone-buprenorphine line does make patients vulnerable to harassment from “other inmates and staff and even nursing,” said Berk. This is a good argument for Sublocade (extended release injectable buprenorphine), he noted.
But the bottom line is that prisons aren’t healthcare facilities, which is the only way they would be covered by HIPAA or 42 CFR Part 2, said Berk.
Coming up: Part 3 of methadone and buprenorphine in the RIDOC system — summing up.