Written by Linda Hurley, President/CEO – CODAC
Pre-COVID 19
In 2016, Rhode Island Department of Corrections (RIDOC), in collaboration with CODAC Behavioral Healthcare, became the first state correctional system to initiate a comprehensive program to screen all individuals for opioid use disorder, offer treatment with all three FDA approved medications (methadone, buprenorphine, and naltrexone) to all medically eligible incarcerated people, to provide linkage to care in the community after release and to co-locate a DEA, CSAT approved opioid treatment program within the correction facility. The General Assembly of the State of RI approved $2 million in funding, primarily to expand RIDOC’s MAT program. RIDOC continued to contract the treatment on the inside and the transition to care on the outside to CODAC, Inc., a state-certified Center of Excellence in the treatment of opioid use disorder. For individuals reporting current MAT during commitment, nursing staff obtain written consent to confirm medication and dose with current prescriber/pharmacy and MAT is continued. If MAT is not confirmed, individuals are referred to the program. Individuals are assessed according to ASAM criteria and referred to a medical provider for further evaluation and treatment initiation. The decision of which MAT to offer a patient is determined clinically, based primarily on past experiences, patient preference and logistical considerations. Group counseling, individual counseling, discharge planning services, and pre-release enrollment in health insurance are all part of the comprehensive treatment services. If needed, CODAC staff provides community health insurance enrollment post-release. CODAC also provides facilitation of the transition to opioid treatment to the provider and in the community of the patients’ choice post -release. In 5 years, these pillars of success have not been changed. The relative risk of overdose death for those recently incarcerated and released has significantly, remarkably declined.
Though the principles of care have not been changed the number of patients served, where they have been served and expansion of services provided has shifted dramatically. Growth in all three areas of number people served, length of care and medication, counseling and wrap-around services – provided both inside and in the community – dramatically increased pre-COVID 19.
COVID 19
COVID 19 shifted our services in a natural experiment that hopefully will have long lasting results and are as follows:
1. Regulation to increase availability of Take-Home medication to mitigate exposure. Take Home medications particularly methadone have historically been highly regulated. CODAC increased the availability for medication management and self-administration. Letters were written to city leadership and police chiefs to inform communities of this increase in medication. To date, according to RI State Police there has been no increase in found prescribed methadone, confiscated methadone or Medical Examiners reports of unauthorized methadone. This may have been another example of regulatory stigma. We hope to continue this relaxation of regulation. Patients being released from the Department of Corrections did not see any higher amounts of adverse events than others receiving buprenorphine or methadone.
2. Again to mitigate exposure, telehealth services were introduced. Telemedicine including telephonic, provider meetings, medication management services, health home services, and counseling services and recovery services actually increased
patient utilization of care. (Soon to be released in the Journal of Addiction Medicine)
3. Methamphetamine and fentanyl have continued to increase, contributing dramatically to fatal overdose here in Rhode Island.
4. We are currently exploring funding for a pilot program to fund re-entry transitional housing for those with opioid disorder, inclusive of those utilizing Sublocade as their medication
The Numbers:
From July 2016 to April 2020, the average daily dose of MOUD increased by 80%.
In the year prior to COVID – overage daily dose was approximately 300.
After COVID the average daily dose was 200, representing a 33% reduction.
Since December 2016 through December 2020 CODAC has provided MOUD to over 18,000 commitments to RIDOC.
59% methadone
40% buprenorphine
1% extended release naltrexone
40% new inductions at commitment
57% continued from the community
3% pre-release induction of sentenced population
Diversion:
Incredibly rare. Over 14-month period, 22 instances of MOUD diversion. During the same period over 125,000 doses were given out.
Brown University School of Public Health research faculty are subcontracted by CODAC to evaluate the program by tracking metrics such as number of individuals receiving treatment, post-release treatment follow-up rates.
This initiative has been operationalized for 5 years. It is in Rhode Island and western Massachusetts among other states. It continues to grow and sustain lives. Once again we continue to repeat the statement nationwide that it is not if we can do this, it is how quickly.
