Site and medication assisted treatment descriptions

Table 1 describes the demographics of the four participating correctional systems involved in the study. The systems are very heterogeneous from the perspectives of their size, geographic setting, classification and movement of incarcerated persons and the geographic distribution of communities to which incarcerated persons return following release. The study began at different points in the adoption of medication assisted treatment and on the type of treatment being offered to incarcerated patients (agonist, antagonist or both) as well as the type of agonist treatment when applicable. The two Massachusetts jail systems offered antagonist treatment with depot injectable naltrexone (Vivitrol: Alkermes) exclusively while the two prison systems offered both agonist and antagonist treatment. Connecticut offered methadone as their agonist in addition to depot injectable naltrexone, while Rhode Island was the only participating system to offer both methadone and buprenorphine-naloxone along with depot injectable naltrexone.

Table 1 Characteristics of Correctional Systems studied Full size table

Quantitative findings

Reporting parameters were different depending on the nature of whether the primary treatment was agonist or antagonist. For the two sites offering agonist treatment, the focus was on evaluation of patients from the time of entry into the system while the two jail systems offering primarily antagonist treatment focused their efforts on engaging patients and initiating treatment in the 2 months pre-release. For 9 months, three of four sites reported quantitative data for screening, treatment and care coordination at the time of release. One site solely reported only the number of individuals treated from month to month.

Because of variation in the size of the facilities, the range of the populations admitted to facilities was large, 40 to 350 during any given month. By the third month of data collection, sites consistently screened 100% of all individuals for SUD at the time of intake and screening rates remained consistent for the duration of project reporting. The proportion of individuals screening positive for opioid use disorders was quite high and varied from month to month with a range of 27–65%. For those reporting on the rates of provision of medication assisted treatment over time, the range was again quite large, from 9 to 61% of those diagnosed with opioid use disorders during any given month of reporting. With respect to MAT treatment expansion over time, only one site demonstrated consistent growth in the number of patients treated over the course of the study.

For the two sites exclusively treating with Vivitrol prior to release, 100% of individuals were released with appointments to community-based providers post-release for the 9 months of data reporting, with show rates for those appointments varying from month to month, with a range of 35 to 100%, (mean = 65%). Due to aggregated data and small number of individuals receiving treatment, no specific trend line or statistical difference across sites could be calculated.

Qualitative findings

Outer and inner context influencers of implementation and sustainment of medication assisted treatment are depicted in the Fig. 1. While issues such as funding and staffing levels are important elements of most change efforts, a few deserve special mention given the intersection of health and criminal justice systems in the provision of care. Leadership was a critical driver for successful implementation, both from outer context (e.g. Governor, Legislature) and from inner context (e.g. Commissioner, Sheriff). All leaders demonstrated passion for improving the outcomes of the opioid crisis in their communities and their leadership was demonstrated by the commitment of their teams engaged in treatment. This was also critical for developing a shared mission between health care and security missions of the organizations. Community-based partnerships were also critical elements for success for both outer and inner contexts. All systems prioritized the importance of care coordination post-release. Interestingly, the challenge of establishing community-based treatment may have impeded increased rates of treatment in one site. Contracted services for the delivery of agonist medications on-site were observed to be an innovation to accelerate the spread of treatment from several perspectives.

Fig. 1 Outer and inner context influences for MAT. Legend: Adapted from Aarons (Aarons et al., 2011) Full size image

To implement agonist treatment programs, existent staffing levels were deemed insufficient. Moreover, extensive training of existing staff would be required. Second, the process for obtaining a Drug Enforcement Agency (DEA) certification as a methadone treatment facility is expensive and can take up to a year. Thus, contracting with a community-based methadone provider solved both problems and provided an added benefit for seamless care coordination at the time of release to community based treatment programs operated by these contracted organizations.

Influences on the decision to offer both agonist and antagonist therapies as opposed to antagonist treatment only are important. Both in-system and government leadership influenced the types of therapy offered and expansion of treatment. At sites offering agonist treatment, a focus on fidelity to evidence-based therapies was an important influencer, with articulated belief to engage patients in the best choice of therapy in consideration of their health care issues. Where antagonist-only treatment was offered, security concern regarding diversion of agonist medications and the cost of medications were prominent. Of note, those sites offering agonists often had to overcome these concerns on the part of their security missions and health care staff to implement agonist treatments. An important factor influencing both health care and security staff regarding whether agonist treatment should be offered was alignment with government and institutional leaders’ priorities.

At the start of the programs, systems were engaged in different phases of medication assisted treatment, from planning to sustainment. Therefore, most findings focus on these steps in the EPIS model. While some operational elements were common for both agonist and antagonist treatment sites, agonist treatment focuses largely on treatment at the time of facility intake while antagonist treatment focuses more on pre-release treatment. Implementation facilitators and barriers identified through content analysis of progress reports and meeting notes are grouped according to screening, treatment, community care coordination and data collection in Table 2. Facilitators for adoption of medication assisted treatment included: funding; management of culture change; addition of staff and staff training; networking with other elements of criminal justice system (probation, courts) and community based treatment providers; spread of treatment to pre-trial and work release populations; developing effective data collection methods and the use of data to improve processes; organization of group visits for both education and care delivery; and strategies to keep individuals in treatment post-release. Data collection methods and systems were a challenge for some sites, requiring sites to create their own excel-type records. Some sites focused on new modules in electronic medical records and identified dedicated staff for data collection and analysis.

Table 2 Operational factors influencing MAT implementation and sustainment Full size table

Barriers to adoption and expansion of best practices included the amount and design of space; cultural barriers to adoption of SUD treatment by both clinical and security staff; security, medical or treatment motivation assessments that prevented access to treatment; movement and transfers between facilities; and large geographic catchments that precluded consistent post-release engagement into care. Location of facilities in states with expanded Medicaid provided opportunities to work with state Medicaid programs to suspend public health insurance coverage for covered individuals and efficient reactivation at the time of release. At times, arranging for access for community-based treatment follow-up was a barrier.