(30) A Medications for Addiction Treatment (MAT) Release Program in the CDOC

Background & Introduction: The Colorado Department of Corrections (CDOC) seeks to help incarcerated patients lead safe and healthy lives, both while in custody and through transition back into the community. Community re-entry represents a vulnerable time for incarcerated patients. High mortality rates after release from prison are well documented,^1,2,3 with overdose as the leading cause of death. In the first two weeks after release from prison, incarcerated patients are 129 times more likely to die of a drug overdose than other state residents.¹ Opioids remain the largest driver of overdose deaths.³ Access to medications for addiction treatment (MAT) within the correctional system can have profound implications: after the Rhode Island Department of Corrections (RIDOC) implemented its MAT program, post-incarceration overdose deaths decreased by 61%, contributing to a 12% reduction in state overdose deaths that year.⁴ Unfortunately, implementation of full-scale MAT programs in the correctional setting remains slow, particularly in larger states, due to stigma and structural/operational challenges. As the CDOC continues to work towards its own full-scale MAT program, we prioritized this high risk population. We recently implemented a MAT Release Program, to provide incarcerated patients with opioid use disorder (OUD) access to MAT services prior to release. The objective of this study was to describe outcomes of the MAT Release Program.

Methods: The MAT Release Program began in 9/2022 and remained operational through study completion, in 12/2023. Funds were obtained internally and through a Comprehensive, Opioid, Stimulant, and Substance Use Program (COSSUP) grant. Incarcerated patients with opioid use disorder (OUD) were first identified and sorted by facility and release date, using an internal data analytics software platform. About 3-6 months prior to release, patients met with a MAT Provider and were continued on medication or offered either an in-house sublingual buprenorphine induction or a one-time IM naltrexone injection prior to release. Due to funding availability, from 9/2022-4/2023, patients were offered a one-month induction; from 4/2023-12/2023, patients were offered a three-month induction. In addition, about 1 month prior to release, patients were also offered a telemedicine visit to establish care with a community MAT Provider. Patients who completed these appointments were also scheduled for follow-up within ~1 week of release. Community follow-up and prescription refill data was obtained as part of normal program operations, inputted manually, and validated twice before data analysis. Post-incarceration opioid overdose fatalities were obtained for quality improvement, through an interagency agreement with the Colorado Department of Public Health and Environment (CDPHE).

Results: Study Population: From 9/2022-9/2023, a total of 8,962 incarcerated patients were released from CDOC custody. Of this, a smaller subset of 2,258 patients carried a diagnosis of opioid use disorder (25.19%) within the electronic health record (EHR). Roughly 1,224 of these patients (54.21%) were enrolled in the MAT Release program and accepted medications prior to release. MAT Patient Demographics: Patients who enrolled in the MAT Release Program ranged from 19 to 66 years, with an average age of 35.4 years. Three-quarters of patients were male (74.35%). The majority of patients were Caucasian (55.23%) and Hispanic (32.92%), although the study sample also included African American (5.88%) and Native American (5.06%) patients. Of those who enrolled in the MAT Release Program, 937 patients (75.98%) were treated with buprenorphine prior to release, including 930 patients on SL buprenorphine/naloxone, 5 patients on SL buprenorphine, and 2 patients on SQ buprenorphine. In addition, another 267 patients (21.98%) received a one-time IM naltrexone injection prior to release. The remaining patients were released on methadone, to their respective home methadone clinics. Continued Treatment: A total of 105 patients completed a telemedicine visit with a community MAT provider prior to release. Of these, 46 patients (43.81%) attended their scheduled follow-up within 7 days of release. Engagement in care continued to decrease over time: only 28 patients (26.67%) were still engaged in care at 30 days and still fewer, only 13 patients (12.38%) were still engaged in care at 90 days. Continued Medication Engagement: Among the 930 patients treated with SL buprenorphine/naloxone prior to release, 428 patients (44.8%) received a medication refill from a community provider within 14 days of release. This number remained constant over the month, with 401 patients (42.2%) receiving a medication fill within 30 days of release. Medication maintenance continued to decrease over time, with 34.9% of patients receiving a fill within 31 to 60 days post-release and furthermore to only 25.6% of patients receiving a fill within 60 to 90 days post-release. Post-incarceration Fatal Opioid Overdoses: A total of 23 opioid overdose deaths occurred during the study period, including 9 fatal opioid overdoses among patients on buprenorphine/naloxone and 10 fatal opioid overdoses among patients who released with medication. However, within the first 30 days of release, only 1 fatal opioid overdose occurred among patients on buprenorphine/naloxone (n=1 of 921) and four fatal opioid overdoses occurred among patients on no treatment (n=4 of 1142). Within 30 days of release, the rate for fatal opioid overdose in patients who received buprenorphine/naloxone was 48 per 100,000 (n=1), compared with 192 per 100,000 (n = 4) for those who received no medication. This translates to a 75% reduction in overdose deaths when a patient is released on buprenorphine.

Conclusion & Discussion: Our work highlights the feasibility and importance of implementing a medications for addiction treatment (MAT) program in the correctional system. Over the study period, from 9/2022-12/2023, with a total of two addiction medicine providers, over half (54.21%) of all patients with an opioid use disorder (n=2258) were on MAT at time of release. Medication engagement following release from prison paralleled existing trends seen in the community. Almost half of patients (44.8%) received a refill of buprenorphine/naloxone from a community provider within the first two weeks of release, but this number declined rapidly over time. At 90 days following release, only 25.6% of patients continued to receive buprenorphine/naloxone refills from a community provider. We believe this data highlights the need for continuous medication and behavioral health throughout incarceration, rather than a “release” program. In line with existing literature,4 patients on buprenorphine/naloxone were significantly less likely to die from a fatal opioid overdose within 30-days post release (48 per 100,000) when compared to those on no medication (192 per 100,000). This highlights the life-saving nature of MAT. Continued efforts are needed to expand MAT services within the correctional setting.

References:

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