1. Medication Assisted Treatment Programs in
State Correctional Facilities in Vermont
Presented by:
Nicole Beckman Hanna Bliska
Eliza Jane Schaeffer
Hanna introduces everyone:
“Good morning everyone! My name is Hanna Bliska and I am here along with my colleagues Nicole Beckman and Eliza Jane Schaeffer to share our research conducted on Medication Assisted Treatment Programs in State Correctional Facilities in Vermont”
This report was written by undergraduate students at Dartmouth College under the direction of professors in the Rockefeller Center. Policy Research Shop (PRS) students produce non-partisan policy analyses and present their findings in a non-advocacy manner. The PRS is fully endowed by the Dartmouth Class of 1964 through a class gift in celebration of its 50th Anniversary given to the Center. This endowment ensures that the Policy Research Shop will continue to produce high-quality, non-partisan policy research for policymakers in New Hampshire and Vermont.

2. National Opioid Epidemic
Hanna: “We begin our research with understanding how Medication Assisted Treatment Programs were implemented to treat opioid addiction in the United States. We are currently in an opioid epidemic in the United States. In the past few years, the crisis has developed. Between 1991 and 2011, the number of opioid prescriptions tripled, and between 2011 and 2016, the age-adjusted death rate for drug poisoning for all races, all ages, and both sexes rose from 13.2 per 100,000 to be 19.8 per 100,000. This particularly pertains to the incarceration system because more than 65 percent of the incarcerated population in the U.S. meets the medical criteria for substance abuse addiction.”

3. Federal Regulations Narcotic Addiction Treatment Act of 1974
Drug Addiction Treatment Act of 2000
42 CFR 8.12
Enforced by:
DEA; DOJ; HHS; SAMSHA EJ
DATA: regulates buprenorphine clinics, have to get a waiver
DEA: regulations re: medication transportation, medication dosage, inmate transport, continuity of care
42 CFR 8.12: regulates OTPs

4. Interim Maintenance Treatment
Currently used in the VT DOC
Interim Maintenance Treatment (IM) vs. Opioid Treatment Programs (OTP):
IM designed for patients on a waiting list for OTP treatment
IM is less heavily regulated

5. Medication Options Two basic approaches to medication
Agonists: methadone, Buprenorphine
Antagonists: naltrexone (Vivitrol), naloxone
Combination: Suboxone
Agonists: mimic
Methadone: Full opioid agonist; most widely used and researched medication, but can cause overdoses if not carefully regulated
Buprenorphine: Partial opioid agonist; produces effects such as euphoria, but weaker than those of methadone; “ceiling effect” where opioid effects of the drug increase with each dose but eventually level off, even with further dose increases
Antagonists: block
Naltrexone (brand name: Vivitrol): Opioid antagonist; blocks opioid receptors in the brain for one month at a time
Naloxone: Opioid antagonist; life-saving drug (i.e. for emergency usage); brings a patient out of an opiate overdose by stripping the opiate from the opiate receptor
Combination
Suboxone: Partial opioid agonist; mixture of buprenorphine and Naloxone (4:1 ratio); mediates withdrawal symptoms while reducing cravings
Nicole

6. Medication Assisted Treatment in Vermont
EJ -- transition sentence: Vermont is unique in that it utilizes opioid agonists such as buprenorphine and methadone
Vermont (VT) has an extensive MAT infrastructure consisting of regional treatment “hubs” and community-based “spokes” for treatment infrastructure
picture source:

7. Current Vermont Infrastructure
Pilot project and expansion
all 7 facilities
120 days of treatment
sought treatment in the community
buprenorphine and methadone EJ
gradual expansion after successful pilot project
MAT program across the seven prisons operated by the state of Vermont
receive treatment for 120 days
must have received treatment within the past 90 days
can receive naloxone overdose kits before release

8. CASE STUDY APPROACH Hanna:
“In order to show the committee how other MAT programs function around the country in comparison to Vermont’s current program, this team conducted research on the programs of five other states in the United States that offer MAT programs. We decided to look at these programs for many different reasons: because they provided unique facets to their programs or because they had similar rates of opioid use.”

9. Massachusetts vs. Vermont
Differences: MA uses a Vivitrol injection upon release, exit-focused program
Similarities: Community care and individualized programming
Hanna
“One main difference between the program between Massachusetts and Vermont is that Massachusetts’ program offers an exit-focused program that is truly centered around improving recidivism rates. They offer inmates one injection of Vivitrol.”
“One main similarity between MA and VT is that the programs have a prioritization of community care and individualized programming.”

10. New Hampshire vs. Vermont
Differences: NH provides daily treatment to its inmates via oral naltrexone (50 mg/day)
Similarities: Connection with a community provider
Hanna
“One main difference between the program between NH and Vermont is that NH’s program offers both in-house treatment for inmates of 50 mg/day and then also an exit focused program.”
“One main similarity between NH and VT is that the programs have a prioritization of community care, requiring the inmates to connect with a community provider.”

11. Rhode Island vs. Vermont
Differences:
RI administers treatment for up to a year upon incarceration;
RI Community-based discharge planner identifies non- MAT related resources
Similarities: Enrolled in community program upon release

12. Kentucky vs. Vermont Differences: More complex prison system
Not offered in all facilities
Only opioid antagonists offered; dose administered just prior to release
Incentives to continue treatment
Partnership with research university
also worth mentioning is fact that continue to receive regular doses of vivitrol in community, don’t just hop on in to community treatment

13. Missouri vs. Vermont Differences: All care contracted out
Not offered in all facilities
Only opioid antagonists; dose administered just prior to release
Incentives to continue treatment
Similarities: Continuity of care

14. Consideration #1 Expansion to a full OTP
Taking all of these case studies into consideration, we recommend that Vermont consider this.
transition sentence to consideration
-“taking all of these other states into consideration, here are some features VT could consider"
pros: all others do it, interim treatment never really intended as, reduce transportation costs
cons: costs related to transition/establishment, proven to be as effective in other contexts

15. Consideration #2 Partnership with a research institution
three other states that we examined do this, have detailed evaluative data for each year the program has operated, can track progress, make changes as needed

16. Consideration #3 Reconsider medication options Hanna
“One area of our research that Vermont could consider with its MAT program is medicine choice. If they chose, Vermont could, like Massachusetts and New Hampshire, use antagonists like Vivitrol. Our research shows that programs like Massachusetts and New Hampshire use these for their re-entry programs because it reduces recidivism. Vermont could implement a re-entry program. Companies like Alkermes can give free doses to inmates. On the other side, our research shows that Vermont could use agonists, as they can reduce withdrawal symptoms. Additionally, Vermont could continue to use agonists because they are what is used in the community and this could provide patients with a continuity of care.”

17. Consideration #4 Increased treatment time and continuity of care
Hanna:
“In our discussions with Vermont DOC officials, amongst other conversations with medical directors from other states, there has been an expression that continuity of care for patients from the incarceration institutions to the community could be an important part of their program because it could provide inmates with care in the community that in turn could keep them from returning to the system. Additionally, Vermont could consider offering programs that increased treatment time amongst its patients; in Kentucky and Missouri, their programs offer reductions in sentence lengths for inmates that continue treatment. Vermont also could consider offering counselors within its MAT program that could be responsible for providing the community connections to the patients before they are released, like the recovery support navigator in the program in MA. Vermont also could consider establishing a parole program with MAT, as in KY, the recidivism rate was 11 percent for inmates on parole on MAT in comparison to the 28% of the regular paroled population. However, it is possible could not be necessary because Vermont already has a strong community program.”

18. Consideration #5 Potential cost savings EJ
cost not a concern to states with full OTPs
Missouri and KY only two states to collect this data, both saw a return on investment that more than compensated for expenditures Missouri saved $1.03 to $3.76, and Kentucky saved $4.46 for every dollar they spent
reducing crime and recidivism

19. Conclusion Main consideration moving forward: Expansion to a full OTP
Medication options
Continuity of care associated with program success
Cost-savings
Questions? EJ
vt doing good job w access
stacking
chart with similarities and difference
cut beginning
DEA regulation
consistencies about similarities and differences
costs / benefits for each
be careful about advocacy
must state only the rpos and cons
consider this as an option
Nicole Beckman has left.
Nicole Beckman has opened the document.
Hanna Bliska: learning experience for students at UVM
add into
vivitrol as an option
it is an orientation for recidivism and cost savings (other systems that use this focus heavily on the re-entry aspect, which is a missing element here)
slide contrasting IM and OTP treatment programs
cut acronyms
OTP =
IM =
Hub and spoke =
are they on the right track?