Rhode Island's Master Plan: A Small State with Big Ideas in Addiction Recovery
CRANSTON, R.I. — CRANSTON, R.I. — Paul Roussell, a 58-year-old lobster fisherman, had been addicted to heroin for almost ten years when he was found with it last summer. He’d progressed from sniffing two bags of heroin every day to ten, then seventeen. To support his habit, he was running drugs for dealers. “I had already planned that I was going to die,” he says.
He was the first to be sent to prison. That could have been the difference between life and death for him. Roussell was offered a chance to quit his addiction through a breakthrough new program within Rhode Island’s Adult Correctional Institutions in this Providence suburb while facing a felony charge of narcotics possession with intent to deliver. “I was very surprised to find out that I was able to have methadone in prison,” he says.
Roussell drank a 55-milligram dose of methadone daily while incarcerated, medication doctors have used to assist individuals in quitting heroin for 50 years. “It was very comfortable, very helpful,” says Roussell, a sandy-haired man with deep blue eyes and a handlebar mustache. “I started feeling like my recovery was kicking in.”
Roussell underwent eight months of inpatient treatment after being released from prison after three months. Now he lives with his parents in Tiverton, his seaside hometown, and works as a gardener and maintenance man in a business park. After completing drug court this month, his case will be dismissed. He drops by an opioid treatment facility on his way to work every morning for his daily methadone prescription. “That keeps me stable,” says Roussell during an interview at Rhode Island’s government campus in Cranston. He’s gone a year without taking heroin. If not for his methadone regimen, he says, “there’d be a good chance of me using it.”
Roussell received addiction therapy in prison because Rhode Island opted to do what no other state had done two years earlier. It began offering all three medications permitted to treat opioid addiction to its convicts in 2016: methadone, Suboxone, and Vivitrol. Each month, around 350 Rhode Island inmates receive one of the three medications. They must continue their treatment after they are released, usually through the state’s Medicaid program, because this is when they are most in danger of relapse and lethal overdose. It’s one of Governor Gina Raimondo’s opioid-crisis initiatives in response to Rhode Island’s ninth-highest overdose death rate among the 50 states.
State officials report that the $2 million program has already saved lives. 26 recently jailed individuals died of drug overdoses in Rhode Island during the first half of 2016. Only nine did over the same period the previous year. That is a 61% reduction in fatalities.
“The magnitude of that drop in mortality is almost unheard of in public health,” says Dr. Josiah Rich, a co-director of the Rhode Island Center for Prisoner Health and Human Rights and a professor at Brown University’s medical school.. It’s a short study relying on overdose death records rather than a randomized test that controls for other factors. Nonetheless, the findings, which were published in February in the American Medical Association journal JAMA Psychiatry, revealed that the medication-assisted treatment program averted one overdose death for every 11 inmates it served.
In contrast to Rhode Island, most prisons in the United States do not provide medication-assisted treatment. It could help almost 400,000 inmates across the country. Drug offenses account for 20% of the nation’s 2.3 million inmates, and estimates of regular opioid use or addiction among offenders range from 17% a decade ago to 25% currently. Some states provide Vivitrol, an opiate blocker, to inmates. However, because methadone and Suboxone are opioids, they are normally prohibited as contraband by correctional officials, who are afraid that offenders will distribute the drugs to other inmates.
Medical professionals and public health officials regard medically assisted treatment for opioid addiction as the gold standard of care. However, it suffers from the popular assumption, even within some segments of the recovery community, that it is simply not possible. “Substituting one drug for another.” On this subject, Trump’s government has issued mixed messages. Former Health Secretary Tom Price told a reporter in May of last year, “If we just simply substitute buprenorphine or methadone or some other opioid-type medication for opioid addiction, then we haven’t moved the dial much.”
Price eventually changed his mind and stated that he supported some MAT programs. In March, Trump unveiled an opioid strategy that favors MAT for criminal offenders.
In jails, attitudes about medication-assisted treatment are beginning to shift, particularly in New England, which has five of the 11 states with the worst fatal overdose rates. Some offenders in Vermont and Connecticut have access to smaller medication-assisted therapy programs, while Massachusetts Governor Charlie Baker signed a bill expanding treatment in the state’s prisons on August 9. Advocates in Rhode Island hope that their state’s strategy will serve as a model for the rest of the country.
“We’re in the middle of a horrible epidemic,” says Rich. “There’s no reason this can’t be done just about anywhere else.”
Addiction Recovery Resources in Warwick, Rhode Island
“It was very comfortable, very helpful,” says Roussell, a sandy-haired man with deep blue eyes and a handlebar mustache. “I started feeling like my recovery was kicking in.”
Roussell underwent eight months of inpatient treatment after being released from prison after three months. He now lives with his parents in Tiverton, his seaside hometown, and works in a business park as a landscaper and maintenance man. After completing drug court this month, his case will be dismissed. He drops by an opioid treatment facility on his way to work every morning for his daily methadone prescription. “That keeps me stable,” says Roussell during an interview at Rhode Island’s government campus in Cranston. He’s gone a year without taking heroin. If not for his methadone regimen, he says, “there’d be a good chance of me using it.”
Roussell received addiction therapy in prison because Rhode Island opted to do what no other state had done two years earlier. It began offering all three medications permitted to treat opioid addiction to its convicts in 2016: methadone, Suboxone, and Vivitrol. Each month, around 350 Rhode Island inmates receive one of the three medications. They must continue their treatment after they are released, usually through the state’s Medicaid program, because this is when they are most in danger of relapse and lethal overdose. It’s one of Governor Gina Raimondo’s opioid-crisis initiatives in response to Rhode Island’s ninth-highest overdose death rate among the 50 states.
State officials report that the $2 million program has already saved lives. 26 recently jailed individuals died of drug overdoses in Rhode Island during the first half of 2016. Only nine did over the same period the previous year. That is a 61% reduction in fatalities.
“The magnitude of that drop in mortality is almost unheard of in public health,” says Dr. Josiah Rich, a professor at Brown University’s medical school and co-director of Rhode Island’s Center for Prisoner Health and Human Rights. It’s a short study relying on overdose death records rather than a randomized test that controls for other factors. Nonetheless, the findings, which were published in February in the American Medical Association journal JAMA Psychiatry, revealed that the medication-assisted treatment program averted one overdose death for every 11 inmates it served.
In contrast to Rhode Island, most prisons in the United States do not provide medication-assisted treatment. It could help almost 400,000 inmates across the country. Drug offenses account for 20% of the nation’s 2.3 million inmates, and estimates of regular opioid use or addiction among offenders range from 17% a decade ago to 25% currently. Some states provide Vivitrol, an opiate blocker, to inmates. However, because methadone and Suboxone are opioids, they are normally prohibited as contraband by correctional officials, who are afraid that offenders will distribute the drugs to other inmates.
Medical professionals and public health officials regard medically assisted treatment for opioid addiction as the gold standard of care. However, it suffers from the popular assumption, even within some segments of the recovery community, that it is simply not possible. “Substituting one drug for another.” On this subject, the Trump administration has sent inconsistent signals. Former Health Secretary Tom Price told a reporter in May of last year, “If we just simply substitute buprenorphine or methadone or some other opioid-type medication for opioid addiction, then we haven’t moved the dial much.”
Price eventually changed his mind and stated that he supported some MAT programs. In March, Trump unveiled an opioid strategy that favors MAT for criminal offenders.
In jails, attitudes about medication-assisted treatment are beginning to shift, particularly in New England, which has five of the 11 states with the worst fatal overdose rates. Some offenders in Vermont and Connecticut have access to smaller medication-assisted therapy programs, while Massachusetts Governor Charlie Baker signed a bill expanding treatment in the state’s prisons on August 9. Advocates in Rhode Island hope that their state’s strategy will serve as a model for the rest of the country.
“We’re in the middle of a horrible epidemic,” says Rich. “There’s no reason this can’t be done just about anywhere else.”
The opioid crisis wasn’t a campaign issue for Gina Raimondo when she ran for governor of Rhode Island in 2014. It was not a campaign issue for the candidates, and it was not discussed in the debate. When she spoke to voters, though, it was brought up. “I would hear about it constantly, mostly from parents who had lost kids,” she said in a recent interview.
The Rhode Island jail treatment program has now emerged as the most innovative aspect of Raimondo’s anti-overdose policy. It’s an achievement she’s touting as she campaigns for re-election in November in a state with a population of a million that has had more than 1,000 overdose deaths since 2015.
“We’re the only state in America that has a state-supported, state-funded, full range of medically assisted treatment in prisons,” Raimondo told a gathering of Rhode Island public health professionals at the Community Overdose Engagement Summit in Warwick, R.I., in June. “And it is working.”
Raimondo established an overdose prevention task team shortly after taking office. Its professional consultants included public-health campaigners and authorities who had fought for decades to establish a methadone program in Rhode Island’s jail system.
“It was met with a lot of resistance over the years,” recalls Rich, a task force advisor, who wrote unsuccessful grant applications for a prison methadone program in Rhode Island 20 years ago. “People who have this disease are thought to be somewhat subhuman.”
Rich once discussed with a jail nurse whether or not to help a drug-addicted inmate in the 1990s. “I said we should give him medication to make him feel better,” he recalls. “She said, ‘No, we don’t do that. He was supposed to suffer. That way, he won’t come back again. ’”
“This is something I’ve wanted to do since I started here 20 years ago,” says Dr. Jennifer Clarke, the medical programs director for Rhode Island’s corrections department. “Once the task force was together, and saw corrections as a priority, we were already ready to come up with a plan.”
Clarke and the other consultants requested a broad program that would provide three types of inmates with medication-assisted treatment (MAT).
Inmates who enter the correctional system with a doctor’s prescription for MAT are no longer removed from the program. Since the 1990s, medical personnel at Rhode Island prisons have been giving methadone patients a week’s worth of the drug before tapering them off—a common procedure in penal systems around the country, according to Clarke. “I think that’s where we’re doing the greatest damage to communities, by taking people off of MAT,” she says.
New convicts who are detoxing from opiates are immediately placed in an induction program, which includes a few days of methadone or Suboxone to help with withdrawal symptoms. “[We] start people on treatment right when they come in the door,” Clarke says. This section was straightforward to implement statewide, given Rhode Island lacks county jails. The smallest state in the country, at just 37 miles wide and 48 miles long, boasts a combined prison and jail facility in Cranston that is staffed by a single physician.
Inmates who have a history of addiction can begin methadone, Suboxone, or Vivitrol treatment a few months before their release. “This was, I think, the most difficult for people to accept,” says Clarke, “that we were taking people who’d been off opiates for years and putting them back on MAT.” However, newly released former convicts are at the greatest risk of succumbing to an overdose. They may have lost their physical tolerance for opiates, but their cravings remain.
“It’s the same thing as smoking,” says Clarke. “[If] somebody’s here for five or 10 years, it doesn’t mean they’re not craving a cigarette the whole time. They haven’t actually quit. They’re not actually in recovery. They’re just away from the substance. ”
In prisons and across the state, the task force devised a four-point plan: greater prescription monitoring, increased availability of the overdose-reversing medicine naloxone, more peer-recovery programs, and more medication-assisted therapy.
Inmates who have a history of addiction can begin methadone, Suboxone, or Vivitrol treatment a few months before their release. Among the public, “There was a little pushback that these are people in prison, and why are we giving health care to prisoners?” says Raimondo. Prisoners are “much, much more likely to overdose and die when they come out,” she argued, “so, for this much money, we could save lives and save money.”
With little to no resistance, the legislature included the funding in the state’s 2017 budget. Raimondo said the unanimity illustrates how the state has banded together to combat the opioid epidemic, which she describes as the state’s most serious public health catastrophe.
“We have a worse problem in Rhode Island than in other states,” she says. “People realize that.”
Methadone and Suboxone can provide a way out of vicious cycles for inmates suffering from severe pain and opioid addiction.
Bill Fox, 53, was sentenced to 26 years in prison in Rhode Island for charges ranging from felony domestic abuse to forgery. He started taking Suboxone three months before his March release from prison. He now lives in a sober house in Providence and receives Suboxone from a state-funded treatment facility. He takes Suboxone three times a day, dissolving the medicine in a thin orange strip under his tongue.
“It keeps me off any hard drugs,” Fox says. “It regulates my life in a roundabout way. It keeps me in check: Here’s something for your pain, and everything else falls into place. ”
Fox claims he took his first opiate medication at the age of 12 for recreational purposes and sniffed heroin at the age of 18 or 19. He claims he began abusing prescription opiates and subsequently heroin following a series of injuries, including a three-story fall twenty years ago while capping a chimney and the staging failed. Fox touches and presses his right knee during the almost hour-long conversation to alleviate the ache.
“The painkillers ruined my life,” he says. He claims he would frequently scam or harass individuals in order to obtain money for OxyContin or heroin. If it weren’t for the MAT program in Rhode Island, Fox says, “I’d be back in jail.”
According to Linda Hurley, president and CEO of CODAC Behavioral Healthcare, a state-funded nonprofit that runs the MAT program before and after jail, prisoners’ drug cravings often get greater as their release date approaches.
“[They have] dreams about using substances, how it’s going to feel,” Hurley says. They find themselves thinking about how they’ll get high once they’re out. They were afraid to seek assistance from the MAT program because they were afraid of losing their jobs. “They’re no longer physically dependent on the substance, but the brain hasn’t healed,” Hurley says. “They’re still addicted.” They’re highly vulnerable to a lethal overdose if they don’t use MAT. In the first half of 2016, 26 of the 179 people who died of an overdose in Rhode Island had spent the previous year in the state’s correctional system. Within a month of their discharge, ten of them died. “When they get out, they don’t have the same tolerance anymore, but the brain wants the same amount,” Healey says.
Other states with prison MAT programs, including West Virginia, Kentucky, and Massachusetts, provide solely Vivitrol injections to offenders shortly before they are discharged. However, in Rhode Island, where offenders choose their medication, just approximately 1% choose Vivitrol. Around 60% opt for methadone, whereas 39% opt for Suboxone.
Vivitrol inhibits the euphoric effect of opioids. However, because it does not alleviate withdrawal symptoms, it is not recommended for freshly jailed offenders. Unlike methadone and Suboxone, Vivitrol does not alleviate pain, and its users must seek comfort from non-opioid analgesics.
“It’s a great medication if the patient wants it and if it addresses [their] symptoms,” says Clarke, the prison medical director. “Like so much else in medicine, the best medicine for an individual is the one they’re going to stick with and take.”
On the advice of a fellow convict, Michael Manfredi selected Vivitrol in 2016. He was on his way out of prison after serving four years for robbery, assault, and breaking and entering. “Every time I was incarcerated, it was due to my addiction,” says Manfredi, 55, who started shooting heroin at 15 and first went to prison, for robbery, at 18. “The previous couple of times that I went, they just sent you out with nothing, no maintenance,” he says.
“Vivitrol for me was a godsend,” says Manfredi. “I’ve lost the desire to use, lost the urge to use, the cravings.” Every 28 days, he visits a center in Providence to receive a Vivitrol injection in his hip and meet with a team of counselors, which includes a social worker and a psychiatrist. He also attends many peer-assistance meetings each week.
“I had to work the program,” he says. “Just getting my shot wasn’t good enough.”
Manfredi now works for a construction company and lives with his adult daughter two years after his parole. “My daughter finally trusts me again,” says Manfredi, who has a long, thin face and who shakes with emotion as he tells his story. “She can go out of the house and not worry that I’m going to take anything and sell it.”
Vivitrol “changed my life,” Manfredi says. “I didn’t think I could be a normal person.”
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Residents of Rhode Island said they hope other states will look at their prison system as a model for combating addiction.
“Other governors have said, ‘Hey, that seems to be working, tell me about it,’” says Raimondo. She promoted the program during a panel discussion about the opioid epidemic at the National Governors Association conference last year. “After that, a lot of them came up to me and said, ‘We want to do that.’”
Supporters of the program have a lot of guidance for other states. “You shouldn’t even think about doing a program like this in a correctional setting if you don’t connect with [inmates] after release,” says Rich, the doctor and prisoners’ health advocate.
In large states, setting up a mechanism to keep ex-offenders in treatment would be more difficult. “If somebody is released in Rhode Island, and they’re a Rhode Islander, they’re probably no more than 40 miles away,” says Clarke.
Under fear or force, inmates may divert medicine to other inmates, so corrections officials must be vigilant. Methadone and Suboxone are moderate opiates that, according to Rich, don’t normally cause a high when taken as prescribed, but they can be abused. “We worry people on treatment may be manipulated,” Clarke says. As a result, the prison provides Suboxone via dissolvable strips, as tablets, while less expensive, take longer to disintegrate and are more easily diverted. Prisoners taking methadone are compelled to drink water and eat saltines following their dose to demonstrate to their fellow inmates that they can not spit the medication up later.
Suboxone is one of the most regularly smuggled narcotics into jails, frequently during visits. Incoming mail screenings have been increased in prisons around the country to catch Suboxone hidden in letters and envelopes. Suboxone was a close second to marijuana as the most prevalent contraband drug in Ohio prisons in 2016, with 5% of convicts testing positive for narcotics.
The correctional department in Rhode Island has not yet combed through its contraband records to determine potential diversion, but Clarke says one warden has informed her that the amount of contraband Suboxone entering prisons may be decreasing. “Because people are being treated.”
Outside of Rhode Island, acceptance of inmate medication-assisted treatment is gradually increasing.
Although criminals expected to be transported to state prison are not eligible for maintenance therapy, New York City has had a methadone program at its Rikers Island jail complex since 1987. Methadone is also available in Philadelphia jails. Two Connecticut jails, as well as Vermont, have MAT programs for inmates who were on methadone or Suboxone before their arrest. Massachusetts will follow suit next year. Governor Baker signed a measure on August 9 that will establish a comparable program for current MAT patients in many state jails.
Trump’s drug plan, announced in March, commits to screening all federal convicts for opioid addiction upon admission and facilitating Vivitrol treatment for those released to residential community centers. Additionally, it urged the federal government to expand funding for state and local drug courts that provide evidence-based treatment for addicted criminals.
Raimondo, who is up for re-election in November, believes the Trump administration isn’t doing anything. “If the president were serious about this, there would be federal funding behind it.
“Our medically-assisted treatment program—that could easily be federally funded,” Raimondo says. “It could be done in 50 states tomorrow. For a small investment, we could save thousands, tens of thousands of lives. ”
Source: https://www.politico.com/magazine/story/2018/08/25/rhode-island-opioids-inmates-219594/
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