Medication-Assisted Treatment (MAT) and the Department of Corrections
As part of its ongoing mission to better equip reentrants as they return to their communities, the Department of Corrections (DOC) began providing Vivitrol (Naltrexone for extended release injectable suspension) for female reentrants at SCI Muncy (2014). Vivitrol is a non-narcotic medication indicated for the treatment of alcohol use disorder as well as opioid use disorder. Penn State University researchers evaluated this initiative and ultimately recommended the DOC consider expanding it to men’s institutions.
As of June 2017, Vivitrol is available at the following State Correctional Institutions (SCIs): Cambridge Springs, Chester, Dallas, Graterford, Houtzdale, Laurel Highlands, Mahanoy, Mercer, Muncy, Quehanna, Retreat and Waymart. Ultimately, the PA DOC intends on having Vivitrol available at each SCI across the Commonwealth.
With many serious mental and physical health conditions, including substance use disorder (SUD), reentrants require essential health care immediately upon release from incarceration. To address this issue, the PA DOC and the PA Department of Human Services (DHS) have collaborated to create a process ensuring that Medical Assistance (MA) benefits are in place for reentrants on the date of their release. The SCI completes the COMPASS application for the reentrant prior to the scheduled release date. Upon receipt, the County Assistance Office (CAO) processes the application. If the individual is eligible, MA is authorized no sooner than seven days prior to the individual’s release date from the SCI, using the release date as the MA begin date. This partnership has resulted in the development of a more effective and expedited continuum of care.
Focus on Innovation: PA MAT (pdf)
Many treatment facility staff, who conquered their own addictions without medication, favor an abstinence model, and provider skepticism may contribute to low adoption of MAT. Staff in Community Corrections' Community Contract Facilities (CCFs) have expressed that their corporate offices do not support the use of MAT and are therefore hesitant to personally participate in MAT expansion. Additionally, many individuals utilizing MAT are met with harsh criticism from the 12-step community.
Substance Use Disorders has been generally treated as if it were an acute illness, rather than a chronic disease. Research results suggest that long-term care strategies of medication management and continued monitoring produce lasting benefits. The use of MAT for those suffering from addiction should be insured, treated, and evaluated like other chronic illnesses.
Planning for Future Expansion
DOC plans to take a sharply focused approach in its plans to expand MAT both now and into the future. In order to bring this mission to fruition, DOC will undertake the following measures as it advances its expansion plans.
Since it is a less expensive option than Vivitrol, Revia (oral naltrexone) will be considered for administration during the incarceration period. Over the long term, DOC plans to include Methadone and Buprenorphine (i.e., Bunavail, Probuphine, Suboxone, Subutex, Zubsolv, etc.) as standards of care where determined appropriate. Any decisions regarding MAT expansion will take PA licensing restrictions into account and ongoing collaboration with other state agencies shall continue in order to ensure that there are no adverse impacts on current licenses to provide alcohol and other drug (AOD) programming.
Options for MAT expansion include:
• Medication-Assisted Opiate Detoxification: For new commitments, parole violators, and diversion cases
• Maintenance: For those offenders who are committed to DOC and who are already receiving MAT
• Initial Prescriptions: For those offenders who are committed to DOC and who are not in need of detoxification, but who could benefit from MAT from the time of DOC commitment
Social workers, or staff in a treatment classification, are the main points of contact for coordination between internal and external stakeholders. A MAT statewide coordinator was hired in March 2016 within the PA DOC Bureau of Treatment Services (BTS). This individual provides training and technical assistance to site coordinators (i.e., social workers), and is the liaison with the Bureau of Community Corrections (BCC), PA Board of Probation and Parole (PBPP) Points of Contact (POCs), Single County Authorities (SCAs), and community-based treatment providers.
Medications for Opioid Use Disorder
The following medications are approved by the FDA for use in opioid addiction treatment in conjunction with psychosocial therapy:
Methadone, a synthetic opioid, is an agonist that mitigates opioid withdrawal symptoms and, at higher doses, blocks the effects of heroin and other drugs containing opiates. Maintenance of opioid addiction treatment with methadone is approved “in conjunction with appropriate social and medical services.” Used successfully for more than 40 years in the treatment of opioid dependence, methadone at therapeutic doses (generally 80-120 mg) has been shown to eliminate withdrawal symptoms produced by stopping use of heroin and prescription opiate medications because it acts on the same targets in the brain as those drugs. Methadone can be dispensed only at an outpatient Opioid Treatment Program (OTP) certified by SAMHSA and registered with the Drug Enforcement Administration (DEA), to a hospitalized patient in an emergency, or as a three-day bridge until a patient can be scheduled with an OTP. SAMHSA-certified OTP facilities provide daily doses.
Buprenorphine, approved by the FDA in 2002 to treat opioid dependence, is a partial opioid agonist that, when dosed appropriately, suppresses withdrawal symptoms. Although buprenorphine can produce opioid agonist effects and side effects, such as euphoria and respiratory depression, its maximal effects are generally milder than those of full agonists like heroin and methadone. Physicians are permitted to distribute buprenorphine at intensive outpatient treatment programs that are authorized to provide methadone if providers are trained in its use. Additionally, a special program has been established so that buprenorphine can be prescribed by physicians in office settings and dispensed by pharmacists.
In order to prescribe this medication, physicians must complete a training course and receive a waiver granted by the DEA. Buprenorphine was tested in clinical trials for addiction treatment in the United States both by itself and in combination with naloxone, a drug used to counter the effects of an overdose of opiates such as heroin or morphine. The buprenorphine/naloxone combination is sometimes referred to as Bup/Nx (marketed under the brand name Suboxone®). Formulations approved for drug abuse treatment are intended to be taken sublingually (placed under the tongue and allowed to dissolve). When taken this way, the naloxone has little effect. However, if a patient injects Bup/Nx, the naloxone (an antagonist) enters the bloodstream and will block the buprenorphine, causing the patient to enter opioid withdrawal. This combination formulation may deter abuse through injecting because abusers are motivated to avoid unpleasant withdrawal symptoms.
Naltrexone is a non-addictive antagonist used in the treatment of alcohol and opioid dependence. The medication blocks opioid receptors so they cannot be activated. This “blockade” action, combined with naltrexone’s ability to bind to opioid receptors even in the presence of other opioids, helps keep abused drugs from exerting their effects when patients have taken or have been administered naltrexone. As an antagonist, naltrexone does not mimic the effects of opioids. Rather, it simply blocks opioid receptor sites so that other substances present in a patient’s system cannot bind to them. If a patient who has been administered naltrexone attempts to continue taking opioids, he or she will be unable to feel any of the opioid’s effects due to naltrexone’s blocking action. Naltrexone is administered in an injectable, long-acting formulation (marketed under the brand name Vivitrol®), which is designed for once-monthly dosing.
The FDA approved this medication for use in people with opioid use disorders to prevent relapse. Naltrexone should be used only in patients who have been detoxified from opioids and have been opioid free for 7–10 days. Naltrexone is non-narcotic and non-addictive; however, as with other medications that interact with the opioid receptors, there is a risk of overdose if a patient who is being treated with naltrexone misses a dose and takes an opioid, or if the patient takes large quantities of opioids in an attempt to “break the blockade.” Compliance measures that closely monitor patients during the treatment period may be beneficial.
Handouts, Links, Documents, Articles and Videos
By Helen Ubinas | Philadelphia Daily News | October 19, 2015
Massachusetts, Missouri and Pennsylvania corrections officials and offenders discuss Medication Assisted Treatment.