When the U.S. Centers for Disease Control issued a dismal report this month showing that hospitalizations for suspected opioid overdose were still skyrocketing nationwide—up almost 30% year-over-year overall—we searched the data for pockets of positive news that the rest of the nation might learn from.
There were three states—Massachusetts, New Hampshire, and Rhode Island— where, contrary to national trends, overdose mortality and overdose hospitalization rates were both dropping, according to the data. The CDC suggested that those positive trends might be “related to implementation of interventions including expansion of access to medication-assisted treatment” (MAT).
Further inquiries led us to an astoundingly effective MAT program in Rhode Island, directed toward a population notoriously vulnerable to overdose death: recently released inmates. According to early results, published in a letter in JAMA-Psychiatry last month, the program slashed such deaths 61% (from 26 to 9) when one compared groups of inmates released before and after the initiative began.
The decrease was so dramatic that it was the major factor in a 12.3% drop in Rhode Island’s statewide overdose deaths (from 179 to 157) during the two six-month periods studied. (For the latest available, rolling 12-month period, from August 2016 to August 2017, the U.S. Centers for Disease Control and Prevention’s provisional figures show a 3.6% decline in overdose death for Rhode Island—one of 15 states to show declines. The other 35 states and the District of Columbia registered increases, including double-digit jumps in 22 states.)
“We’ve been getting calls from all over the country since publishing the results,” says Josiah (Jody) Rich in an interview. A professor of medicine and epidemiology at Brown University School of Medicine, Rich was a co-author of the JAMA letter.
MAT provides addicts with opioid substitution medication—usually either buprenorphine or methadone—together with counseling and support therapy. Though the medications are themselves opioids, they do not require injection, can be administered just once a day or less, do not cause euphoria or other debilitating effects, and permit patients to resume a normal, productive life. MAT does not aim to get the patient off opioids entirely, but, rather, contemplates that the patient will continue receiving the medication long-term—possibly for the rest of his or her life. The danger of abstention, is that such patients, if they relapse, run a heightened risk of overdose death, because they will have lost the tolerance they once built up.
“Every leading public health organization endorses MAT’s role for treating opioid use disorder,” says Caleb Alexander, “yet only one third of addiction treatment programs even offer MAT.” Alexander, the co-director of the Johns Hopkins Center for Drug Safety and Effectiveness, is the one who first suggested TORI look at the Rhode Island program.
It’s long been recognized that recently released inmates are at particularly grave risk for overdose, Rich explains. “If you have opioid use disorder,” he says, “because of its nature, you increase your use, and your tolerance goes up. You use more and more. The more desperate you become, the more likely you will be incarcerated.”
Most jails and prisons don’t provide opioid-substitution therapy, except to pregnant inmates. So prisoners are usually forced off drugs, losing their tolerance, but without any effective treatment.
“When they get released,” Rich continues, “they relapse. They have no tolerance. They drop dead.
“It’s even worse nowadays because of fentanyl,” he adds, referring to the extremely powerful synthetic opioid, often illicitly manufactured and trafficked from China or Mexico, whose prevalence on the street has been skyrocketing since 2013.
For many years Rhode Island Department of Corrections (RIDOC) had provided a very limited methadone program, available only to pregnant women or inmates staying less than 60 days. In late 2015, after Governor Gina Raimondo formed the Overdose Prevention and Intervention Task Force, RIDOC’s medical director, Jennifer Clark, M.D., sought funding to greatly expand the program to offer MAT to all inmates who sought it. She won $2 million in funding, and started rolling out the program in July 2016 and had it fully operational by January 2017.
The new program offers a choice of methadone, Suboxone (a brand of buprenorphine plus naloxone), or naltrexone (Vivitrol). (Naltrexone, which is also used by recovering alcoholics, is a non-opioid that blocks craving and withdrawal.)
The genius of the program, however, is that the MAT services inside Rhode Island’s jails and prisons are provided by a group—CODAC Behavioral Health—that also runs a network of 12 outpatient treatment facilities scattered throughout the state. That means that when an inmate is released, treatment can continue seamlessly at a facility near the inmate’s home.
“He’s already on the computer system,” Rich explains.
As release approaches, inmates are even coached on how to apply for Medicaid as soon as they got out.
Traci Green, an epidemiologist at both Boston University Medical Center and Brown University School of Medicine, tracked the program’s data. As soon as it became statistically significant, her team published it as a letter in JAMA-Psychiatry.
“I didn’t want to wait with the kind of mortality reductions we were seeing,” she says. “This was provocative and important and so timely.”
The paper compared overdose deaths among the 4,005 inmates released during the first six months of 2016, before the program started, and 3,426 inmates released during the first six months of 2017. In the first group, there were 26 overdose deaths within a year of their release. Of those, ten deaths (almost 40%) occurred within just 30 days of the inmate’s release. More than half died after less than four months of liberty.
Among the after-treatment group, the number of overdose deaths dropped to nine, with only one dying in the first month. The median length of time before death for this group was 190 days. (Even correcting for the fact that fewer inmates were released during the second six-month period, the drop in rate of overdose death was still 60%.)
Fentanyl was the predominant cause of overdose death in both groups—precipitating 62% of the first group’s deaths, and a chilling 89% of the second’s.
Since the results were published, out-of-state prison officials have shown great interest in the program, according to Lauranne Howard, RIDOC’s substance abuse coordinator. “We’ve hosted at least five visits from other correctional facilities,” she says.
Nevertheless, transferring the lessons of the Rhode Island program to other venues will face hurdles.
Ideologically, some corrections officials are still skeptical of MAT, disparaging it—as did then Health and Human Services Secretary Tom Price last May—as substituting one opioid for another.
More challenging still will be creating treatment networks to help inmates upon release. Many counties currently have no methadone clinics and no physicians certified to prescribe buprenorphine, which, by federal law, requires an eight-hour training program.
“You can have the best program inside the correctional institute,” says Rich, “but if you don’t connect to treatment on the outside, it will have no impact. In fact, it may even have a negative impact.”