How Virginia’s opioid epidemic motivated VADOC to explore medication-assisted treatment
VADOC’s program involves the use of Vivitrol, an FDA-approved non-narcotic that prevents the euphoric effects of opioids and reduces cravings
By Gregory Carter, VADOC
Editor's note: When it comes to inmate healthcare, correctional facilities are facing a perfect storm. A growth in geriatric inmates poses significant challenges in regard to management of chronic diseases and environmental modifications; drug-addicted inmates are flooding correctional facilities; and in many jurisdictions, jails and prisons are now the largest providers of mental healthcare services. This special coverage series reviews key ways facilities can prepare to battle the storm.
At the Virginia Department of Corrections (VADOC), reentry is our business. It sits at the core of our mission, our vision and our values.
When it comes to offenders with a history of substance abuse, preparing them for a life free of drug dependency is a critical part of the reentry process. This is especially true for those battling opioid addiction, as they return to communities searching for solutions to curb an opioid abuse crisis of epidemic proportion.
According to the Virginia Department of Health (VDH), 813 Virginians died from overdoses of fentanyl and/or heroin in 2016. An additional 471 people died from prescription opioid overdoses. In 2017, the fentanyl/heroin overdose death total jumped to 938. Deaths from prescription opioids in 2017 increased to 507. VDH reports that heroin and opioid overdoses accounted for more than 10,000 emergency department visits in both 2016 and 2017.
The staggering rate of opioid abuse in society at large coupled with the 12 confirmed overdose deaths in Virginia prisons since 2015 prompted VADOC officials to explore additional treatment options for offenders beyond the intensive substance abuse treatment programming already being offered.
Learning lab reviews addiction strategies
A study conducted by the VADOC Statistical Analysis & Forecast Unit showed that 1,316 (10.5 percent) of the 12,539 state responsible offenders released in FY2017 had a positive test for opioids within the first 12 months following their release. That same year, the National Governors Association selected Virginia and seven other states to participate in a learning lab designed to develop strategies to expand opioid addiction treatment. The learning lab was hosted by the state of Massachusetts, which had already successfully implemented many of the strategies, including medication assisted treatment (MAT). At the conclusion of the learning lab, plans to introduce MAT as a treatment option in Virginia began to develop.
Medication Assisted Treatment Reentry Initiative pilot launches
In July 2018, VADOC announced the launch of MATRI (Medication Assisted Treatment Reentry Initiative), as a pilot program.
The program involves the use of naltrexone (Vivitrol), an FDA-approved non-narcotic that prevents the euphoric effects of opioids and reduces cravings. The drug is administered shortly before the offender is released and remains active in his or her system for 28 days. Once the offender is released, the treatment transitions into an outpatient substance abuse treatment program provided by a local Community Service Board (CSB). These outpatient programs provide the participant with a setting for additional counseling and support in addition to the continued monthly injections of Vivitrol.
The participant remains under the supervision of a probation officer (PO) and maintains regular contact with a recovery support navigator (RSN), a position newly created for the purpose of facilitating MATRI.
MATRI is completely voluntary and only available to incarcerated offenders or probationers suffering from opioid use disorders. Participants must first complete the Intensive Substance Abuse Treatment Program from a VADOC Cognitive Therapeutic Community (CTC) or a VADOC Community Corrections Alternative Program (CCAP).
MATRI is currently offered to CTC offenders housed in two prisons – Indian Creek Correctional Center and Virginia Correctional Center for Women – and to CCAP probationers at Cold Springs Detention & Diversion Center, Appalachian Detention and Diversion Center, and Chesterfield Women’s Detention and Diversion Center.
In addition, eligible participants must be releasing to one of three target reentry locations – Norfolk City, Richmond City and Tazewell/Buchanan County. These areas were selected based on data collected that measured opioid use among offenders in Virginia’s prison system.
How MATRI candidates are selected
Potential MATRI candidates are selected through an initial screening. The RSN provides detailed information during an orientation, explaining the program requirements and the risks involved with taking Vivitrol. Throughout the process, participants are warned repeatedly about potential adverse effects related to Vivitrol, especially the potential overdose if any opioids are used during treatment. This includes commonly used pain medications and cold remedies containing opioids.
Offenders recommended for MATRI must complete a series of evaluations to determine suitability for the program. A mental health screening is conducted by a Qualified Mental Health Professional (QMHP) to look for acute mental health contraindications. These may include acute psychiatric distress, risk of suicide or significant cognitive limitations that prevent the offender from giving informed consent to participate.
If there are no psychological contraindications, a medical assessment is conducted to evaluate overall health and liver function. Participants are given a urine drug screen. In addition, medical staff examine the patient for signs of physiological opioid dependence and indications of opioid analgesics. MATRI participants must be opioid-free for at least seven days before they are administered Vivitrol.
Once offenders are medically cleared and provide consent for treatment, the RSN works to coordinate the support team in the community. This involves scheduling appointments with the CSB treatment provider and the probation officer. When appropriate, family members are also educated about the MATRI program, its requirements and its risks.
Within 30 days of release, a Narcan challenge is performed by medical staff to ensure that the MATRI participant is free from any opioid-related substances before starting any form of opioid-blocker. Once the participant successfully passes the Narcan challenge, the medical provider will prescribe and begin to administer oral naltrexone to establish tolerance of treatment. This trial may be completed anywhere from 3 to 30 days before release. If the offender tolerates oral naltrexone and wishes to receive a dose of Vivitrol upon release, the RSN finalizes plans for the participant’s discharge. Within a week of release, the MATRI participant receives one dose of Vivitrol and reviews the Treatment Recovery Plan with the RSN.
Vivitrol remains effective for 28 days. Therefore, it is crucial that participants meet with the local CSB counselor, the RSN and the PO within 24 hours of release, or as soon as feasible. The CSB counselor ensures the participant is placed into the appropriate American Society of Addiction Medicine (ASAM) level of substance abuse service. The CSB counselor coordinates the next Vivitrol injection, approximately 21-28 days post-release and arranges future monthly injections and lab work.
For up to 11 months post-release, the RSN maintains regular contact with each MATRI participant. VADOC probation officers, trained in Dialogue and EPICS, provide encouragement and hold participants accountable.
The collaborative effort of the CSB, RSN and the PO ensures that participants uphold their agreement to attend periodic individual counseling sessions, weekly self-help group programming, and any additional programs recommended by the treatment team. Failure to do so may result in termination from the program.
The MATRI program is still in its infancy in Virginia as both offenders and staff continue to learn about the program and its requirements. More offenders are showing interest and VADOC anticipates that as interest grows, so will participation among those offenders being released to the three pilot locations. If proven successful in the pilot locations, VADOC will look to expand the program to additional regions experiencing high levels of opioid abuse.
About the author
Gregory Carter is community relations coordinator for the Virginia Department of Corrections (VADOC).