How the Smallest State is Defeating America’s Biggest Addiction Crisis

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Politico Magazine on 8/25/2018 by Erick Trickey

A prisoner at Rhode Island’s John J. Moran Medium Security Prison, watches television during free time on December 10, 2013 in Cranston, Rhode Island. | Getty

Rhode Island inmates get opioid replacements while they’re locked up and it seems to be keeping them from overdosing when they get out.

CRANSTON, R.I. — By the time police caught Paul Roussell with heroin last summer, the 58-year-old lobster fisherman had been addicted to the drug for almost 10 years. He’d gone from sniffing two bags of heroin a day to 10, then as many as 17. He was running drugs for dealers to afford his habit. “I had already planned that I was going to die,” he says.

He went to prison first. That may have saved his life.

Inside Rhode Island’s Adult Correctional Institutions in this Providence suburb, while facing a felony charge of drug possession with intent to deliver, Roussell was offered a chance to break his addiction through a groundbreaking new program. “I was very surprised to find out that I was able to have methadone in prison,” he says.

Every day while locked up, Roussell drank a 55-milligram dose of methadone, the medicine doctors have used for 50 years to help people get off heroin. “It was very comfortable, very helpful,” says Roussell, a sandy-haired man with deep blue eyes and a handlebar moustache. “I started feeling like my recovery was kicking in.”

Released from prison after three months, Roussell spent eight months in residential treatment. Now he’s living with his parents in Tiverton, his seaside hometown, and working as a landscaper and maintenance man in a business park. His case will be dismissed after his graduation from drug court this month. Every morning, on his way to work, he stops by an opioid treatment clinic for a daily methadone dose. “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.”

Roussell got treatment for his addiction in prison because, two years ago, Rhode Island decided to do something no other state has done. In 2016, it began offering its prison inmates all three medications approved to treat opioid addiction: methadone, Suboxone, and Vivitrol . About 350 Rhode Island prisoners each month take one of the three medicines. Crucially, they continue their treatment after their release, usually through the state’s Medicaid program, when they’re at the greatest risk of a relapse and a fatal overdose. It’s among the opioid crisis reforms championed by Governor Gina Raimondo in response to Rhode Island’s overdose death rate, ninth-highest among the 50 states.

The $2 million program has already saved lives, state officials say. In the first half of 2016, 26 recently incarcerated people died of drug overdoses in Rhode Island. In the same period last year, only nine did. That’s 61 percent fewer 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 small study based on overdose death records, not a randomized test controlled for other possible causes. Still, the results, published in the American Medical Association journal JAMA Psychiatry in February, suggested that the medication-assisted treatment program prevented one overdose death for every 11 inmates it treated.

Rhode Island’s approach is rare in the nation’s prison systems, most of which offer no medication-assisted treatment. Roughly 400,000 inmates nationwide might benefit from it: 20 percent of the nation’s 2.3 million inmates are incarcerated on drug offenses, and estimates of regular opioid use or addiction among inmates range from 17 percent a decade ago to 25 percent now. Some states offer inmates Vivitrol, an opioid blocker. But because methadone and Suboxone are also opioids, corrections officials usually ban them as contraband, concerned that inmates might divert to other inmates.

Doctors and public-health officials consider medically-assisted treatment the standard of care for opioid addiction. But it suffers from a widespread belief, even in parts of the recovery community, that it is simply “substituting one drug for another.” The Trump administration has given mixed signals on the issue. In May of last year, former Health Secretary Tom Price told a reporter, “If we just simply substitute buprenorphine or methadone or some other opioid-type medication for the opioid addiction, then we haven’t moved the dial much.” Price later backtracked, saying he supported some MAT programs. Trump’s opioid policy, released in March, supports MAT for criminal offenders.

The distrust of medication-assisted treatment in prisons is starting to change, especially in New England, home to five of the 11 states with the highest fatal overdose rates. Vermont and Connecticut operate smaller medication-assisted treatment programs for some inmates, and on August 9, Massachusetts Governor Charlie Baker signed a bill that expands treatment in the state’s prisons. Advocates in Rhode Island say they hope their state’s approach becomes a model for the nation.

“We’re in the middle of a horrible epidemic,” says Rich. “There’s no reason this can’t be done just about anywhere else.”

***

When Gina Raimondo was running for Rhode Island governor in 2014, the opioid epidemic wasn’t a campaign issue. The candidates didn’t run on it, and it didn’t come up in their debate. But it did come up when she spoke to voters. “I would hear about it constantly, mostly from parents who’d lost kids,” she said in a recent interview.

Now, Rhode Island’s prison treatment program has emerged as the most innovative part of Raimondo’s anti-overdose strategy. It’s an accomplishment she’s talking about as she runs for re-election in November, in a state with a population of 1 million that’s seen 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 the 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.”

Soon after she took office, Raimondo created an overdose prevention task force. Its expert advisers included public-health advocates and officials who had wanted to get a methadone program going in Rhode Island’s prison system for decades.

“It 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.”

Once, in the 1990s, Rich got into a disagreement with a prison nurse over whether to help an inmate suffering from drug withdrawal. “I said we should give him medication to make him feel better,” he recalls. “She said, ‘No, we don’t do that. He’s 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 advisers asked for a broad program that would offer medication-assisted treatment (MAT for short) to three types of inmates.

Inmates who come into the corrections system with a doctor’s prescription for MAT are no longer taken off it. Since the 1990s, Rhode Island prison medical staff had been giving methadone patients a week’s worth of the drug, then tapering them off it—a standard practice in corrections systems around the country, Clarke says. “I think that’s where we’re doing the greatest damage to communities, by taking people off of MAT,” she says.

New inmates who are withdrawing from opiates go straight into an induction program —a few days of methadone or Suboxone to ease withdrawal symptoms. “[We] start people on treatment right when they come in the door,” Clarke says. This part was simple to implement statewide, because Rhode Island has no county jails. The smallest state in the union, just 37 miles wide and 48 miles long, it has a combined prison-and-jail system in Cranston with a single medical staff.

Inmates with histories of addiction can choose to go on methadone, Suboxone or Vivitrol 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.” But just-released former inmates are at the highest risk of dying of an overdose. They’ve lost their physical tolerance for opioids, but they haven’t lost their cravings.

“It’s the same thing as smoking,” says Clarke. “[If] somebody’s here for five, 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.”

The task force created a four-point plan: better prescription monitoring, more access to the overdose-reversing drug naloxone, more peer-recovery programs and more medication-assisted treatment, in prison and across the state.

The prison MAT program faced skepticism, but not vocal opposition, says Raimondo. Legislators pressed her to make the case for the $2 million program. 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.” The legislature included the funding in the state’s 2017 budget, with little to no opposition. Raimondo says the consensus reflects how the state has come together to deal with the opioid epidemic, which she calls Rhode Island’s biggest public-health crisis.

“We have a worse problem in Rhode Island than other states,” she says. “People realize that.”

***

For inmates with chronic pain and opioid addictions, methadone and Suboxone can offer a path out of vicious cycles.

Bill Fox, 53, has spent 26 years in Rhode Island’s prison system, for crimes ranging from felony domestic violence to forgery. He went on Suboxone three months before his release from prison this March. Now, he’s living at a sober house in Providence and receives Suboxone at a state-funded treatment center. He takes Suboxone three times a day, letting a small orange strip containing the drug dissolve under his tongue.

“It keeps me off any of the hard drug stuff,” 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 says he first took an opioid painkiller at age 12, for fun, and first snorted heroin at 18 or 19. He says he used prescription opioids and then heroin after several injuries, including a three-story fall 20 years ago when he was capping a chimney and the staging gave out. Throughout a nearly hour-long interview, Fox rubs and presses his right knee to ease its ache.

“The painkillers, they ruined my life,” he says. He says he’d often con or bully people to get money for OxyContin or heroin. If not for Rhode Island’s MAT program, Fox says, “I’d be back in jail.”

Prisoners’ cravings for drugs will often get worse as their release date approaches, says Linda Hurley, president and CEO of CODAC Behavioral Healthcare, a state-funded nonprofit that administers the MAT program before and after prison.

“[They have] dreams about using substances, how it’s going to feel,” Hurley says. They catch themselves starting to plan for drug-seeking once they’re out. Afraid, they’ll turn to the MAT program for help. “They’re no longer physically dependent on the substance, but the brain hasn’t healed,” Hurley says. “They’re still addicted.” Without MAT, they’re extremely vulnerable to a fatal overdose. In the first half of 2016, 15 percent of the people who died of an overdose in Rhode Island—26 out of 179—had been in Rhode Island’s corrections system a year before. Ten died within a month of their release. “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, offer only Vivitrol injections, just before inmates are released. But in Rhode Island, where inmates choose which medication they’ll go on, only about 1 percent choose Vivitrol. About 60 percent choose methadone, while 39 percent choose Suboxone.

Vivitrol blocks opioids from producing a high. But it doesn’t help with withdrawal symptoms, so it isn’t appropriate for newly incarcerated inmates. Unlike methadone and Suboxone, Vivitrol doesn’t relieve pain, and its users have to turn to non-opioid analgesics for pain relief.

“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 one they’re going to stick with and take.”

Michael Manfredi chose Vivitrol in 2016 on a fellow inmate’s recommendation. He was finishing a four-year prison stint 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 urges to use, the cravings.” He goes to a center in Providence every 28 days to get a Vivitrol injection in his hip and to meet with a team of counselors, including social worker and a psychiatrist. He also goes to several peer-help meetings a week. “I had to work the program,” he says. “Just getting my shot wasn’t good enough.”

Two years after Manfredi’s release, he works for a construction company and lives with his adult daughter. “My daughter finally can trust 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 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.”

***

Rhode Islanders say they hope other states use their prison program as a model for fighting addiction.

“Other governors have said, ‘Hey, that seems to be working, tell me about it,’” says Raimondo. At last year’s National Governors Association conference, she talked up the program while on a panel about the opioid epidemic. “After that, a lot of them came up to me and said, ‘We want to do that.’”

The program’s supporters have plenty of advice 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.

Setting up a system to continue ex-inmates on treatment would be a bigger challenge in big states. “If somebody is released in Rhode Island, and they’re a Rhode Islander, they’re probably no more than 40 miles away,” says Clarke.

Corrections staff have to guard against prisoners diverting the medicine to other prisoners under threats or coercion. Methadone and Suboxone are mild opiates that usually don’t trigger a high at prescribed doses, says Rich, but they can be abused. “We worry people on treatment may be manipulated,” Clarke says. So the prison administers Suboxone in dissolvable strip form, because tablets, though cheaper, take longer to dissolve and are easier to divert. Prisoners on methadone are required to drink water and eat saltines after drinking their dose, so their fellow prisoners know they can’t spit up the medication later.

Suboxone is among the drugs commonly smuggled into prisons, often during prison visits. Prisons across the country have tightened their inspections of incoming mail to catch Suboxone secreted in letters and envelopes. In Ohio prisons, where five percent of inmates tested positive for drugs in 2016, Suboxone ran a close second to marijuana as the most popular contraband drug.

Rhode Island’s corrections department hasn’t yet sifted its contraband records to try to measure potential diversion, but Clarke says one warden has told her the amount of contraband Suboxone coming into the prisons may be dropping, “because people are being treated.”

Outside Rhode Island, acceptance of medication-assisted treatment for inmates is slowly growing. New York City has had a methadone program at its Rikers Island jail complex since 1987, though inmates likely to be sent to state prison aren’t eligible for maintenance therapy. Philadelphia jails have a methadone program too. Vermont has a MAT program for prison inmates who were on methadone or Suboxone before their arrests, as do two Connecticut jails. Massachusetts will do the same next year. On August 9, Governor Baker signed a bill that will create a similar program for existing MAT patients in several state prisons.

Trump’s opioid initiative, announced in March, pledges to screen all federal inmates for opioid addiction when they enter prison, and facilitate Vivitrol treatment if they’re released to residential community centers. It also called for increased federal support for state and local drug courts to provide evidence-based treatment to addicted offenders.

Raimondo – who faces a tough re-election race in November — says the Trump Administration isn’t doing enough. “Like so much of what they do, they don’t have any serious policy,” she says. “If the president were really 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.”