NASHP

Opioid Use Disorder Treatment: How Vermont Integrated its Community Treatment Standards into its State Prisons

May 3, 2021 by Eliza Mette and Jodi Manz

The opioid epidemic has resulted in the incarceration of individuals with opioid use disorder (OUD) for drug-related crimes. When incarcerated without access to treatment, people with OUD undergo forced abstinence from substance use, which reduces tolerance and increases their risk of overdose death following release. Recognizing these challenges, Vermont extended its statewide Hub and Spoke treatment model into its corrections system to provide best OUD treatment practices, which includes medication-assisted treatment.

Introduction

What are medications for opioid use disorder (MOUD)?

Medications for OUD include naltrexone, methadone, and buprenorphine.

Methadone is an opioid agonist that activates the brain’s opioid receptors in controlled doses, and buprenorphine is a partial opioid agonist that activates those receptors to a lesser degree. Naltrexone is an opioid antagonist, which binds to opioid receptors, effectively blocking euphoric effects. All of these MOUD are more effective than abstinence from opioids in leading to recovery.

The opioid epidemic has resulted in the incarceration of individuals with opioid use disorder (OUD) for drug-related crimes. A federal report covering 2007 to 2009 found half of all individuals in state prisons or with jail sentences met the criteria for drug dependency. When incarcerated without access to treatment, people with OUD undergo forced abstinence from substance use, which reduces tolerance and increases their risk of overdose death following release.

Recognizing these challenges, Vermont and other states are exploring incarceration as an opportunity to provide treatment services, reduce the risk of overdose after release, and ensure continuity of treatment following reentry.

Vermont, with an overdose death rate of 23.8 per 100,000 in 2019, has extended its innovative, statewide Hub and Spoke treatment system model into its corrections system to curb overdose deaths and provide best OUD treatment practices to its prison population. Using this model, the Vermont Department of Corrections (VT DOC) has integrated medication-assisted treatment (MAT) using medications for opioid use disorder (MOUD) into all of its state prisons.

The History of Vermont’s Hub and Spoke Model

Vermont’s Hub and Spoke Model developed out of a collaboration among the Department of Vermont Health Access, the Vermont Department of Health, and Vermont Blueprint for Health to address the increasing rates of OUD and drug overdose deaths in the state. After receiving approval from the Centers for Medicare & Medicaid Services (CMS) for its 2013 State Plan Amendment, Vermont converted its existing MAT services system into a system of Hubs and Spokes.

  • Hubs, or opioid treatment programs (OTPs), provide intensive care and more complex treatment to individuals with OUD. As licensed OTPs that are subject to federal regulations, Hubs may prescribe and administer methadone in addition to other forms of MOUD. Each regional Hub also supports its area’s Spokes.
  • Spokes are waivered primary care providers that offer integrated OUD treatment and may prescribe buprenorphine and administer naltrexone.

The Hub and Spoke model has enabled Vermont to significantly ramp up its OUD treatment capacity. As of 2017, the state increased buprenorphine-waivered physicians by 64 percent and had a concurrent 50 percent increase in the number of individuals engaged in treatment.

Integrating the Hub and Spoke Model into Corrections Settings

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.[1]

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.[2]

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.

Keys to the Program’s Success

  • Cultivate a recovery-oriented system of care. VT DOC partnered with fellow state agencies as well as the state’s legislature to shift the paradigm around providing substance use disorder (SUD) services in corrections. All VT DOC health care is delivered through one health contractor, VitalCore Health Strategies (VitalCore), which was selected through a competitive bidding process. When developing the program, VT DOC, the state legislature, the Department of Health, and advocates built MAT clinical guidelines, policies, and procedures, which VT DOC included as an appendix to its request for proposals, and further incorporated as appendices to its contract with VitalCore.

VT DOC’s current medical director has extensive experience in developing similar programs in state departments of corrections and is helping to champion the program’s medication-first approach, under which counseling alongside MOUD is voluntary and encouraged, rather than mandatory (unless it is deemed medically necessary). VT DOC also no longer imposes mandated tapering, and its policies and protocols encourage building resilience and self-empowerment.

Ultimately, the decision to treat is made by the medical provider, and the provider and the patient determine which of the three FDA-approved medications should be prescribed as part of treatment. VT DOC also relies upon non-physician providers, including advanced practice nurse practitioners, nurse practitioners, and physician assistants to provide critical prescriber capacity. Program prescriber capacity currently exceeds demand – VT DOC would be able to provide MAT to twice as many participants should the need arise.[3]

  • Integrate peer supports. VT DOC has created an internal peer training program to provide peer support services to individuals at all VT DOC facilities. Those interested in participating complete a preliminary five-day training session followed by monthly check-ins with VT DOC leadership. Once fully trained, these Open Ears Coaches provide services to their in-facility peers. In 2019, 328 hours of Open Ears training and check-ins were conducted and 11,306 Open Ears sessions were held across all in-state facilities. The Open Ears Coach position is a recognized VT DOC facility job, and those who complete the training are paid a daily rate regardless of the number of peer-to-peer interactions they complete. Although the peer training program is very similar to community-based training provided through the Vermont Recovery Network, Open Ears Coaches are not certified peers under the state’s certification process, and VT DOC does not endorse them as such. Upon release, however, Open Ears Coaches can leverage their experience and work towards peer certification.[4]
  • Ensure continuity of care. In keeping with the integrated, person-centered intention of its treatment program, the final component of VT DOC’s treatment planning begins at intake; comprehensive discharge planning starts upon entrance into the program to ensure thorough treatment documentation, appropriate referral upon discharge, and medication maintenance as necessary.

VT DOC relies on its MAT Care Coordination policy to ensure consistency across facilities: during the MAT medical determination assessment process, the MAT care coordinator completing the medical intake will verify with the individual which community they will release to, the date of their release, and the potential community treatment providers they intend to use. This creates an individualized approach to care planning in which the patient is provided with information about community Hubs and Spokes and given MAT FAQ to support continuity of care.

The MAT care coordinator is also responsible for ensuring an individual’s seamless transition into the community by making appointments with community-based providers and providing the information necessary to continue MAT care coordination. Upon discharge, nursing staff will print and provide the individual and caseworker with community referral appointment dates and times, MAT community resource information, a last dose letter, an MAT bridge dose called into a convenient pharmacy if necessary, and a take-home supply, if appropriate.

The state anticipates that over time, discharge planning will be conducted by a registered nurse with a specialty in MAT. VT DOC is also working towards partnering with the state’s Medicaid agency to provide more intensive case management at release through the Vermont Chronic Care Initiative (VCCI). This service will be offered to residents who meet program criteria,[5] and those who qualify and are interested will be referred to VCCI upon release.

  • Provide ongoing funding for sustainability. Vermont state agencies and policymakers have collaborated over the past several years to ensure the sustainability of this program. In the first year of program implementation, VT DOC relied on $400,000 in Tobacco Settlement funding in combination with $400,000 in general funds from the Agency of Human Services’ budget. The following year, VT DOC received approximately $1 million in state opioid response (SOR) funds from the state’s Department of Health, in addition to $430,386 in the state’s general funds to VT DOC through the FY20 budget. Currently, the bulk of the funding for the program – $1.48 million – is integrated into the base of the agency’s budget.

VT DOC aligns payment for OUD services to established Medicare and Medicaid rates, building these costs into its health care contract with VitalCore. For the first month of MOUD dosing, VT DOC uses the Medicare bundled rate for assessment, induction, and dosing. The second month and ongoing dosing is reimbursed at the state’s Medicaid rate of $12/day for this same bundle of services. VitalCore bills back by incident for the provision of services to individuals who are incarcerated.

  • Tackle diversion. Buprenorphine diversion does occur within Vermont’s correctional facilities – program leadership acknowledges it as a component of the psychosocial behavior of OUD that may never be entirely eliminated – rather than a reason to stop treatment to a population that needs it. VT DOC frames diversion as a symptom of the underlying disease and emphasizes the importance of providing necessary treatment to people with a chronic disease to ensure that medical decision-making is autonomous and distinct from security.

VT DOC changed its buprenorphine dosing procedure[6] during COVID-19 to a quick mouth check in order to minimize exposure between residents and staff and experienced a corresponding uptick in diversions. In response, VT DOC has implemented new practices and reinforced existing clinical guidelines to specifically address diversion. VT DOC tracks all known diversions that occur across the system on a daily basis. Once a diversion incident has been identified, the prescriber and MAT case manager immediately review the individual’s treatment plan and make any necessary adjustments.

Looking Forward

Though still awaiting the results of an independent program evaluation, Vermont officials estimate, based on preliminary pharmacy and service utilization records, that approximately 67 percent of those individuals who are released within 30 days of having received MAT in DOC custody are connected to treatment within the community post-release. VT DOC is in the process of conducting a series of internal analyses to evaluate the effectiveness of its program to date, including its impact on access to and engagement in treatment, as well as overdose post-release.

More broadly, the outcomes from these evaluations will be used to inform policy changes to the program, improve safety nets, and strengthen cross-agency collaboration. VT DOC is in the process of developing a preliminary public facing dashboard with the Department of Vermont Health Access (DVHA), which it hopes to be able to share publicly within the next month.

The COVID-19 pandemic has presented challenges to the VT DOC treatment model. Currently, when entering the prison system, people must quarantine for 14 days after intake, which makes initiating treatment difficult. Monitoring dosing has proved challenging with personal protective equipment in place, as VT DOC staff are less able to fully observe individuals as they ingest their buprenorphine doses. VT DOC has also had to significantly cut back behavioral health services as a result of state restrictions on in-person services in congregate settings during the pandemic and stop methadone referrals altogether, as Hubs were only dosing current patients for a time and were not able to induct individuals via telehealth per Drug Enforcement Administration rules. As a result of state efforts to keep prison census low during the pandemic, VT DOC has also seen a drop in number of participants in the program.

Despite these challenges, state leaders indicate they are confident that the program will endure, noting that legislative decisions to codify MAT as the standard of care for OUD and to ensure treatment parity for incarcerated persons have been key to the program’s success. Through these policy initiatives, treatment for OUD is embedded in the VT DOC health care infrastructure in the same way as treatment for other chronic conditions, an approach that Vermont’s leaders suggest makes MAT in corrections the rule, not the exception.

Notes

[1] Vermont Department of Corrections MAT Program: Clinical Approach, Dr. Kathleen Maurer, Regional Medical Director, VitalCore Health Strategies, NE ASAM, 2020.

[2] Ibid.

[3] Vermont Department of Corrections MAT Program: Clinical Approach.

[4] Vermont Department of Corrections Northern State Correctional Facility Open Ears Facility Level Guidance.

[5] Vermont Chronic Care Initiative: Case Management Services.

[6] Vermont Department of Corrections Buprenorphine Dosing Procedure.

Acknowledgements: The National Academy for State Health Policy is providing this brief with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and wishes to thank Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. The authors would also like to thank Annie Ramniceanu, executive director of Addictions and Mental Health for the Vermont Department of Corrections, for sharing her clinical expertise and extensive state policy experience in support of this report.

Q&A with Annie Ramniceanu, executive director of Addictions and Mental Health in Vermont’s Department of Corrections


Knowing that medication-assisted treatment (MAT) for opioid use disorder (OUD) can be stigmatized as a treatment, what is the approach of Vermont’s DOC?

Our MAT policy is to provide anything that is medically necessary, for as long as medically necessary, at any time. Referring to OUD treatment programs as “special” actually adds to the stigma of treatment. Instead, we normalize these services and treat them as a standard of care. 

How does treatment within the DOC compare to treatment that an individual would receive in the community? 

Vermont is trying to bring the best community standard of health care into corrections by establishing a recovery-oriented system-of-care framework. 

How does Vermont DOC integrate people with lived experience into treatment?

Our Open Ears Peers function as emissaries and ambassadors for a resilience movement. 

How have you approached discussing DOC staff response to buprenorphine diversion?

Vermont is building a culture of health inside the DOC that includes a compassionate and humane response on every level, including custody training.

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