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Fighting Fire with Fire

Jacqueline S. Martin, MD

Corizon MAT Pilot in Philadelphia Takes on Opioid Addiction

The opioid epidemic crosses all demographic and geographic boundaries, but one common thread is intensity of use correlates to involvement in the criminal justice system (JAMA Network Open, July 6, 2018, Tyler Winkelman, MD, MSc, et. al.). Similarly, a 2010 report - Behind Bars II: Substance Abuse and America's Prison Population - found 65 percent on inmates in U.S. prisons met the DSM-IV medical criteria for alcohol or other drug abuse and addiction.

Adding to the risk profile, those who had an opioid addiction prior to being sentenced are at a much higher risk of overdose-related deaths than those who have never been incarcerated. According to the National Reentry Resource Center, which is administered by the U.S. Department of Justice, one study in the state of North Carolina found " than it was for the general population in the state."

Recognizing an opportunity to address these inequities and potentially impact recidivism, Brentwood-based Corizon Health, which provides physical and behavioral healthcare for more than 220 correctional facilities across 17 states, decided to tackle opioid addiction in a new manner with an eye toward long-term recovery. In 2018, Corizon launched a year-long medication-assisted treatment (MAT) pilot in conjunction with the Philadelphia Department of Prisons. Corizon medical providers who helped develop and deliver the protocol presented their observational findings earlier this year at the spring conference of the National Commission on Correctional Healthcare held in Nashville. The success of the MAT protocol to date has led Corizon to begin the process of rolling out the program to other facilities under their umbrella.

A Community in Need

The year before the pilot launched, Philadelphia County had the highest overdose rate of any of the country's 10 most populous counties, and opioids were linked to 88 percent of drug overdose deaths.

"The opioid addiction we're seeing is nationwide, but within the city of Philadelphia itself, there was a big drive to do something about overdose deaths ... particularly with opioids," said Jacqueline S. Martin, MD, site medical director for Riverside Correctional Facility and acting director of addiction medicine with Corizon for the Philadelphia Department of Prisons.

"If you were using drugs when you came in, we put you on a withdrawal protocol to help you through withdrawal, but it was basically comfort meds," Martin explained of the procedure prior to the MAT pilot at the women's prison.

Noting the average length of stay in the Philadelphia Department of Prisons is just over 100 days for men and about two months for women, inmates had time to detox but often didn't change their underlying addiction or adjust the amount of drug taken when they returned to using. "If you've had no opiates, no heroine and then are released, you have a higher chance of overdosing on the same amount that was comfortable for you before incarceration," Martin noted.

A Window of Opportunity

Martin said the data showed that if someone incarcerated within the Philadelphia system wasn't released in 14-day period, then they would most likely be held for 30-90 days. "We did have a captive audience," she said quite literally, "where we could initiate treatment."

Inmates with substance abuse issues were identified during the intake process that screened for mental and physical health concerns. Martin stressed those identified as being eligible for the MAT program were absolutely allowed to opt in or out. She added some said 'no' simply because they didn't think they needed the program or because they preferred another option, such as methadone treatment. However, she continued, "The majority of patients that come in with substance use disorder do participate in medication-assisted treatment."

The Protocol

"We use buprenorphine in our program," said Martin. She added patients are given an initial 4mg dose of Subutex. "After that initial dose, the next day and daily after that, the patients take 8mg of buprenorphine and 2 mg of naloxone (Suboxone)," she explained. Additionally, behavioral counseling is available for those who want to access the service but is not a mandatory component of the MAT program.

While the protocol hasn't varied much during incarceration, Martin said the program has been refined as individuals transition back into the community. "When we first started the program, we sent them out with a prescription for a five-day supply. Unfortunately, we found many had a hard time getting the prescription filled for various reasons," Martin noted.

Now, program participants are released with a 15-day supply of medication. "They use it to hold them over until they get to one of the outpatient centers we refer them to," she said, adding Corizon already had links to community health providers through the 'Release with Care' program. While the initiative was originally created to help those with chronic health conditions, Martin said it was adapted to identify centers of excellence in dealing with substance use disorders in partnership with the MAT pilot.

A Strong Start & a Few Skeptics

While the program is still too new to have long-term data on continued sobriety and recidivism rates, the anecdotal evidence supported expanding the program to the men's prison population within six months of launching the women's pilot program. Additionally, Corizon and Riverside have moved out of 'pilot' phase and now offer the MAT program on an ongoing basis.

Martin said what they have seen so far in Philadelphia is promising. She also pointed to a recent study in Rhode Island that compared post-incarceration fatal overdoses before and after implementing a MAT protocol for inmates. Although a relatively small sample size, there was a 60.5 percent reduction in mortality after statewide implementation of a MAT prison program. Similarly, she said the success of Rikers Island methadone program has been well documented for years.

Despite successes being seen at Riverside by Corizon and in the Rhode Island and New York City programs, Martin knows there are those who are skeptical of the approach. Particularly among officers and non-medical personnel, there is a lingering feeling that one drug is just being replaced by another. "There has been a challenge to show this is treatment of a disease," she said.

However, Martin likens it to any other chronic condition. A patient with hypertension can maintain their health by taking any of a variety of evidence-based medications to keep blood pressure in check. Getting off those medications, however, can have a devastating impact and potentially lead to fatal stroke or heart attack. Similarly, she pointed out, "You can take a dose of Suboxone in the morning and go to work and take care of your family. By not taking a maintenance amount of medication, they run a risk of overdosing."

Lessons Learned

"The opioid addiction numbers are staggering and not going away," pointed out Martin. "When you look at reasons for incarceration, you do see a high number of those are related to drug use and crimes committed to support an addiction. The more people we can help break that cycle of addiction, the more those things should definitely improve."

Martin said they have gotten a lot of interest in their program not only from other correctional facilities but also from community programs searching for the best means to address the epidemic. As Corizon has refined the Philadelphia MAT program, the biggest lesson learned has been the need to link inmates to resources upon release.

"We're not just throwing you out there and leaving you to figure it out yourself," concluded Martin. "We're putting all the pieces in play."



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Corizon Health, Inmate Addiction, Jacqueline S. Martin, MAT, Medication-Assisted Therapy, Opioid Addiction, Recidivism
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