Opioid addiction treatment behind bars reduced post-incarceration overdose deaths in Rhode Island

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).