Prior to 2013, Vermont residents who had previously received MOUD in the community were permitted to continue treatment while incarcerated in state prison for 30 days before being tapered off MOUD. Pursuant to Act 67 (2013), VT DOC began a demonstration project in two facilities (one for males, one for females) that allowed MAT with methadone and buprenorphine to be continued for up to 90 days before being tapered off, with the goals of:
- Increasing access to treatment for inmates;
- Improving health outcomes for inmates, including better transitions into and out of prison;
- Ensuring that treatment for OUD was on par with other health care, and that health care provided within correctional settings was in line with health care provided in the community; and
- Identifying workable systems-solutions to continue providing treatment to inmates.
The same legislation established an MAT workgroup, organized by VT DOC and the Vermont Department of Health’s Division of Alcohol and Drug Abuse Programs, which was later tasked with evaluating and expanding the demonstration project. During the 2017 legislative session, the MAT workgroup delivered its report about the demonstration project with recommendations for improvement, including increasing the dosing schedule for both buprenorphine and methadone to up to 120 days based on medical necessity and expanding the program across all VT DOC facilities.
In 2018, Vermont passed Act 176, which codified a legal definition of MAT, cemented the medical necessity of MOUD as a component of treatment of inmates with an OUD diagnosis, and directed VT DOC to:
- Continue treatment for all individuals with verified prescriptions in the community for as long as medically necessary;
- Screen each inmate for an OUD within 24 hours of admission regardless of treatment status, for those who screen positive for an OUD, assess whether MAT is medically necessary;
- If methadone-specific MAT is indicated, facilitate a Hub methadone assessment;
- Induct all patients prior to release, if medically necessary, as part of release planning;
- Provide care coordination at release using the Hub and Spoke framework;
- Provide counseling per the Vermont Department of Health rules governing MAT for opioid dependence; and
- Evaluate the effectiveness of the program by 2022.
Currently, Vermont integrates OUD treatment in state prisons through existing Hubs. This arrangement helps the state avoid duplication and potential administrative barriers. State correctional facilities are classified under federal law as Interim Maintenance Treatment Programs, which allows them to offer interim methadone continuation without counseling to individuals waiting to access OTP services, and without adhering to onerous OTP-specific requirements. The MAT workgroup considered whether VT DOC facilities should become licensed OTPs in order to provide complementary psychosocial behavioral counseling, but the workgroup estimated a cost of $15,000 for one state correctional facility to become certified as an OTP.
This significant financial investment does not include additional costs associated with certification nor the administrative burdens of complying with rigorous federal requirements. To address these barriers, Vermont legislators authorized VT DOC’s health care contractor to enter into MOUs with Hubs throughout the state to provide MAT at state correctional facilities.
A memorandum of understanding (MOU) establishes the roles and responsibilities of each party:
Hubs are responsible for providing medical evaluations to determine the appropriateness and dosing of methadone, filling medication orders, adhering to a DOC Chain-of-Custody protocol, and communicating with VitalCore pursuant to HIPAA and 42 CFR Part 2 compliant authorization.
VitalCore is responsible for obtaining Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2-compliant consents and authorizations, performing Clinical Opiate Withdraw Scale assessments, and dosing residents with prescribed medications.
VT DOC facilities essentially function as Spokes by integrating care teams into the corrections system – each facility employs intake nursing staff, prescribers (including physicians, physician assistants, and APRNs/NPs), behavioral health staff, MAT case managers, and discharge planners.
By incorporating MAT practitioners into its corrections health care infrastructure, VT DOC has established MAT as the standard of care for individuals with OUD and now provides treatment for OUD as it does for any other chronic disease.
VT DOC relies on Hubs for methadone induction assessments, methadone induction, methadone dose adjustments, clinical treatment support, reentry support, and guest dosing for individuals entering facilities far from their home clinics.
Some Hubs maintain MOUs with VitalCore Health Strategies (VitalCore), VT DOC’s health care contractor. However, individuals receiving care through Hubs are treated as Hub clients and are afforded the protections associated with a provider-patient relationship.