By Anna Black
Three years ago, when staff within Maine’s Department of Corrections (MDOC) were considering medication-assisted treatment (MAT) for residents of their facilities with opioid use disorder (OUD) they didn’t worry too much about the fact there were limited blueprints to follow.
“We concerned ourselves with two things: residents needed help, and we wanted to provide that help,” said Deputy Commissioner Ryan Thornell who oversees the MDOC’s MAT services.
Fast forward to August 2021 and the MDOC’s MAT program is thriving, with more than 1,200 adults participating since the service piloted in July 2019.
Starting from the beginning
Governor Mills paved the way for MAT services at MDOC’s facilities with the signing of an Executive Order directing the state’s recourses to combat the opioid epidemic in early 2019. Prior to that, Thornell and Commissioner Randall A. Liberty, who was the former warden of the Maine State Prison, had engaging discussions and tangible hopes for the eventual implementation of MAT services inside the walls.
With the Governor’s clarion call in place, Thornell and Liberty brought together staff from all levels of the department to participate in a steering committee, including, security staff, nurses, case managers, administrators and clinicians, as well as community treatment providers.
“The multidisciplinary team approach to implementing this service was vital,” said Thornell. “We took a methodical approach, started by constructing a timeline for tasks and identifying the date by which we wanted MAT available for residents.”
The timeline included research, regular group discussions, consults and visits to other counties and states working on MAT, and time for implementation planning. This group of about 15 people started by reading the medical literature on treatment for those with OUD.
“We took our time understanding the science and medical approach, learning about the different types of medications used for treatment,” said Thornell.
As part of their research on the issue, members of the multidisciplinary team met with residents to learn about their needs and their recovery and relapse history. The multidisciplinary team also met with facility security staff and others on the front line of life inside the walls.
“It was important to listen to and engage with security’s concerns about the impact of MAT as contraband,” said Thornell.
This systematic approach to understanding both need and concern helped the multidisciplinary team in developing the implementation plan.
“What we recognized through the conversations with residents, staff and other states was that we needed to address attitudes, fears and reservations,” added Thornell.
Learning from others
One issue was the importance of staff buy-in.
“We got the message from administrators in Rhode Island and Vermont that in order to be successful, officers and clinical staff needed to believe that MAT will make a positive difference,” said Commissioner Liberty.
The MDOC’s multidisciplinary team devoted months to training staff about addiction science, reviewing the medications to treat SUD and dispelling myths that the facilities would suddenly be filled with drugs for diversion.
In total, nearly 500 staff participated in training ahead of the rollout of the pilot MAT program in July 2019. Staff and residents participated in surveys and focus groups at different junctures to help Thornell, Liberty and the multidisciplinary team gauge shifts in attitudes among staff and to identify readiness for implementation.
One of the most important messages staff heard during training was that MAT inside a correctional setting (and the coinciding clinical support) is a key part of the continuum of recovery for justice-involved populations.
“As soon as our staff got on board with the fact that MAT can be a vital part of someone’s journey to a better, healthier life, we knew it was time to roll out our pilot,” said Thornell.
Maine’s initial pilot MAT services started with four of the state’s six adult facilities. The pilot focused on inducting residents who fit medical criteria who were 90 days to release and focused the case management portion on ensuring continuity of care so that as the individual released, they had a solid plan in place to continue treatment, engage with community programs like peer support, harm reduction and community-based recovery groups. By November 2019 the department expanded MAT access to a fifth facility, and three months later, in February 2020 expanded MAT access to the remaining sixth facility, the Maine State Prison.
Less than a year after the pilot, Maine’s Department of Corrections was able to provide different types of buprenorphine and naltrexone to residents six months to release and provide maintenance to those entering the system already on an MAT, including Methadone. By May 2021 eligibility criteria were expanded further, to include residents two years to release.
From pilot stage to universal access
Maine’s Department of Corrections has long believed that relationships matter. MDOC’s college program for instance involves strong relationships and partnerships with multiple educational institutions and stakeholders to ensure robust and quality educational offerings are available to all residents. Similarly, MDOC has strong relationships with employers and the State’s Department of Labor to ensure job training and job readiness programs in the prisons are focused on in-demand jobs and connect directly with hiring employers. A similar approach was taken when developing the continuity of care elements associated with MAT services, a crucial factor in the expansion from a single pilot to department-wide MAT availability.
MDOC had existing relationships with community-based recovery centers and organizations that support reentering individuals.
“There was a culture of recovery within the facilities,” said Thornell. “The existing partnerships and programs we had in place [prior to MAT] were strong, but they weren’t focused enough on the recovery trajectory.”
As the expansion plans developed, the multidisciplinary team focused on reimagining the process of continuity of care.
“We knew we needed to embed the precursor for continuity, which is relationship development,” Thornell explains, so they implemented plans for the community-based recovery programs, community-based case workers and prison reentry specialists, and community-based recovery coaches to be inside the facilities regularly, aiding the residents in their post-release recovery planning. These bonds and the trust have yielded positive results: 780 residents who’ve participated in the MDOC’s MAT program since July 2019 have been released with continuity of care plans in place at discharge.
MDOC and Maine’s Medicaid program (called MaineCare) also partnered to ensure that residents have benefits available immediately upon release, thus ensuring there is no break in medication and/or clinical services.
“We don’t throw people out the door alone, quite the opposite,” said Commissioner Liberty. “We know there’s a significant danger of relapse and death after release from incarceration. We make sure each individual has a plan, has a relationship with a provider, with a recovery center or recovery coach, and we provide Narcan.”
For Liberty it is humbling to think of the small pilot started in earnest two years ago that provided MAT to just over 100 residents and now is reaching more than 800 residents and is universally accessible to any adult, regardless of sentence length.
“We remind people that even a desire for recovery is an accomplishment,” said Commissioner Liberty.
Financing MAT services
Maine has been able to use strategic financing methods to pay for initial, current and forthcoming MAT services.
Costs associated with the first-year pilot during FY 20 totaled $1.2 million and included braided funds in the amount of $450,000 through a partnership with the State’s Office of Behavioral Health (OBH) and the Director of Maine’s Opioid Response, Gordon Smith. With the expansion in FY21, costs increased as projected, but were below expectations, totaling close to $930,000.
Ongoing costs for the service will run close to $1.5 million, which is about $500,000 less than originally anticipated, the added costs related to universal expansion.
As Maine studies the costs associated with this established service, the department will continue to make use of braided funds from state and federal agencies, will tap into overall savings acquired through reduced costs from having more healthier residents, and consider the option of establishing an Opioid Treatment Program within a facility, arguably the most cost-effective manner to provide Methadone.
The benefits of reducing stigma
With the fiscal support of Governor Mills, Gordon Smith and bipartisan legislators, the department has been able to focus on implementing complementary ways of supporting the recovery journey of residents.
Since July 2019, most changes have stemmed primarily from MDOC’s desire to reduce stigma. For example, MAT is provided in the general medline in Maine’s facilities. “We don’t pull people out and stick them in a separate line or room anymore,” Thornell said, as he describes how the medline process for those receiving medications for SUD has been normalized. “A medline is a medline, if we don’t want to stigmatize people for prioritizing their treatment, why would we single them out by having them in a separate medline?”
Another approach the department is taking to normalize treatment is through a change in language. The department has prioritized the of use non-stigmatizing, person-first, person-centered language. Terms like resident, client and person with substance use disorder are now common in vernacular and in policy documents across the department. The MDOC has done away with stigmatizing terms like prisoners, probationers and drug addicts.
“I wonder how many people may have been lost because they felt the sting of shame,” said Liberty.
For many staff working at Maine’s DOC the language matters campaign and the work to normalize treatment isn’t just about the residents. Law enforcement and corrections professionals historically deal with a host of medical and behavioral health problems, often a result of their profession where witnessing trauma can have a lasting impact.
“We’ve seen an increase in staff opening up about their struggles, seeking the staff-oriented peer support network, expressing their feelings about situations more in the last couple years,” Liberty said. “Creating a culture of wellness doesn’t start and stop with our residents, this cuts across the entire system,” said Liberty who himself has been open with staff and residents about his own struggles with depression and PTSD as a result of military services and work in law enforcement and corrections. “We all have burdens. It doesn’t take much to help your neighbor release some of these burdens.”
MDOC will continue efforts to ensure that universal access to MAT is working well, meeting the needs of residents and that it matures to account for cross-over issues like Hepatitis C and changes in medication regulations. When asked about what advice they’d give to other counties and states thinking about implementing MAT for OUD, Commissioner Liberty said, “Don’t delay. This makes a positive difference in the individual residents’ life, in the climate of the facility, and the positive impact trickles down into the lives of the families of the incarcerated and into the communities when our residents release.”
About the author
Anna Black is director of government affairs and spokeswoman for the Maine Department of Corrections.