RESEARCH ARTICLE Open AccessAdvancing the implementation a.docx

RESEARCH ARTICLE Open Access
Advancing the implementation and
sustainment of medication assisted
treatment for opioid use disorders in
prisons and jails
Warren J. Ferguson1* , Joan Johnston2, Jennifer G. Clarke3,
Peter J. Koutoujian4, Kathleen Maurer5,
Colleen Gallagher6, Julie White7, Dyana Nickl8 and Faye S.
Taxman9
Abstract
Background: Opioid use disorder (OUD) is among the most
prevalent medical condition experienced by
incarcerated persons, yet medication assisted therapy (MAT) is
uncommon. Four jail and prison systems partnered
with researchers to document their adoption of MAT for
incarcerated individuals with opioid use disorders (OUD)
using their established treatment protocols. Employing the EPIS
(Exploration, Planning, Implementation, and
Sustainment) framework, programs report on systematic efforts
to expand screening, treatment and provide linkage
to community-based care upon release.
Results: All four systems were engaged with implementation of
MAT at the outset of the study. Thus, findings
focus more on uptake and penetration as part of implementation
and sustainment of medication treatment. The
prevalence of OUD during any given month ranged from 28 to
65% of the population in the participating facilities.
All programs developed consistent approaches to screen

individuals at intake and provided care coordination with
community treatment providers at the time of release. The
proportion of individuals with OUD who received MAT
ranged considerably from 9 to 61%. Despite efforts at all four
sites to increase utilization of MAT, only one site
achieved sustained growth in the proportion of individuals
treated over the course of the project. Government
leadership, dedicated funding and collaboration with community
treatment providers were deemed essential to
adoption of MAT during implementation phases. Facilitators for
MAT included increases in staffing and staff
training; group education on medication assisted therapies; use
of data to drive change processes; coordination
with other elements of the criminal justice system to expand
care; and ongoing contact with individuals post-
release to encourage continued treatment. Barriers included lack
of funding and space and institutional design;
challenges in changing the cultural perception of all approved
treatments; excluding or discontinuing treatment
based on patient factors, movement or transfer of individuals;
and inability to sustain care coordination at the time
of release.
Conclusions: Adoption of evidence-based medication assisted
therapies for OUD in prisons and jails can be
accomplished but requires persistent effort to identify and
overcome challenges and dedicated funding to sustain
programs.
Keywords: MAT, Opioid, Criminal justice, Uptake,
Implementation science
© The Author(s). 2019 Open Access This article is distributed
under the terms of the Creative Commons Attribution 4.0
International License
(http://creativecommons.org/licenses/by/4.0/), which permits

unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were
made.
* Correspondence: [email protected]
1Department of Family Medicine and Community Health,
University of
Massachusetts Medical School, 55 Lake Avenue North,
Worcester, MA 01655,
USA
Full list of author information is available at the end of the
article
Health and JusticeFerguson et al. Health and Justice
(2019) 7:19
https://doi.org/10.1186/s40352-019-0100-2
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mailto:[email protected]
Background
One in twenty-nine adults in the U.S. is estimated to
have a lifetime experience of incarceration (Bureau of
Justice Statistics, 2014), and this risk substantially in-
creases for people of color and ethnic minorities (Pettit
& Western, 2004). Estimates further indicate that 80% of
all arrests can be traced to drug or alcohol use and asso-
ciated lifestyles (The National Center on Addiction and
Substance Abuse at Columbia University, 2010). More-
over, with 15% of incarcerated people having a serious

mental illness, co-morbid illness is common; 30–40%
have a chronic medical condition including infections
spread through injection drug use.
The opioid epidemic in the United States has shed light
on the impact of the crisis on criminal justice populations.
The Center for Disease Control and Prevention reports
that in 2016, individuals dying from overdose surpassed
the numbers dying from AIDS at the height of that epi-
demic in 1994 (Centers for Disease Control and Preven-
tion, 2001). The risk of overdose death in the first 2 weeks
following release from prison or jail is particularly high,
with one study estimating a relative risk of 129 times
higher than individuals that do not experience incarcer-
ation (Binswanger et al., 2007). Findings from the 2017 le-
gislatively mandated study of how to address the opioid
epidemic in Massachusetts indicated persistent risk of
overdose death post-release with 60% of individuals re-
ported to have died from overdose were incarcerated in
the year prior to their overdose (Bharel, 2017).
Despite the prevalence of substance use disorders, its
downstream impact on justice involved persons and the
constitutional right to health care for incarcerated per-
sons (Estelle v. Gamble, 1976), few prisons and jails pro-
vide evidence-based substance use disorder treatments
(Nunn et al., 2009; Taxman, Perdoni, & Harrison, 2007).
This is particularly true for the use of medication-
assisted therapy (MAT) for opioid use disorders despite
a growing number of studies demonstrating the efficacy
of the three FDA approved therapies: methadone, bupre-
norphine and naltrexone.
Given the high mortality associated with opioid use dis-
orders, along with scientific evidence on the effectiveness
of beginning MAT in jail/prison on continued treatment

in the community (Kinlock, Gordon, Schwartz, Fitzgerald,
& O’Grady, 2009), MAT treatment initiated during incar-
ceration is gaining momentum. (National Sheriffs Associ-
ation and NCCHC, 2018) It is critical to advance the
science of implementing MAT in prisons and jails. A bet-
ter understanding of the clinical and policy changes re-
quired to improve clinical outcomes is needed.
Implementation of evidence-based practices (EBPs) for
substance use disorders have been rigorously studied along
the continuum of criminal justice involvement including
treatment-based diversion programs, jail- and prison-based
programs and in community corrections. (Belenko, Hiller, &
Hamilton, 2013; Taxman & Belenko, 2019) Yet, adoption of
these EBPs has historically been low in the United States,
and until recently, few have involved MAT. (Belenko et al.,
2013) Typically, security concerns and cost have been inti-
mated as the most important barriers to treatment. How-
ever, the stigma of substance use disorders and
incarceration in the United States have also been intimated
has important barriers to treatment. (Wakeman & Rich,
2018) Thus, as momentum increases to change policies to-
ward adoption of MAT, implementation science methods
are needed to understand the facilitators and barriers to pro-
viding MAT therapies in prisons and jails. Implementation
science can facilitate a better understanding of the clinical
and policy changes required to improve clinical outcomes.
Methadone, an agonist treatment therapy, was ap-
proved in 1972, and studies have demonstrated its effi-
cacy when administered during incarceration, with more
treated individuals at 12-months follow-up reporting less
heroin use or engagement in injection drug use in the
last 30 days (Brinkley-Rubenstein et al., 2018). Individ-
uals taking methadone at the time of incarceration and

who continued it through incarceration were more likely
to be in treatment one-month post-release and less likely
to be using injectable illicit drugs than those treated
without agonists at the time of incarceration (Brinkley-
Rubenstein et al., 2018). More recently, buprenorphine,
a partial agonist approved by the FDA in 2002, was stud-
ied to determine outcomes when administration began
in prison/jail or after release. Individuals receiving
buprenorphine were more likely to remain in treatment
at 6 months post-release and were less likely to be
arrested in the past 30 days (Zaller et al., 2013). Naltrex-
one, a narcotic antagonist, given as a long-acting depot
injection (Vivitrol, Alkermes) was approved by the FDA
in 2010 for prevention of relapse among individuals with
opioid dependence. It has been studied in persons under
criminal justice supervision in community-based settings
who desired to be in opioid-free treatment. An open-
label randomized controlled study of naltrexone monthly
injections for 6 months post-release vs. those not re-
leased on naltrexone demonstrated longer median time
to relapse, lower rates of relapse, and higher rates of
opioid-negative urine drug screens (Lee et al., 2016).
We report here on the implementation and sustainment
of medication assisted treatment in two jails and two
prison systems in New England who were at various points
of implementing medication assisted therapies at the start
of the study.
Methods
Participants
During the conceptualization and proposal for funding
for this project, we approached four prison health care
Ferguson et al. Health and Justice (2019) 7:19 Page 2 of
8

systems based in academic health centers across the
country which agreed to participate in the study. How-
ever, once funding was procured, these four care systems
were not engaged in substance use disorder treatment in
prisons or jails and were unable to participate. Subse-
quently, we attempted to recruit several correctional
health systems in the New England area based on our
knowledge of planned or existing medication assisted
treatment initiatives. Four systems agreed to participate.
Two unified systems (combined prison and jail) in
Rhode Island and Connecticut; and two Massachusetts-
based jail systems, the Barnstable and Middlesex County
Sheriff offices were recruited and enrolled. All signed
memoranda of understanding to participate in the
project.
Design
A breakthrough collaborative methodology was adopted
to engage project teams from each of the four systems.
Breakthrough collaboratives have been employed as in-
terventions to improve outcomes for myriad conditions,
most frequently employing the Chronic Care Model
(Chin, 2011; Chin et al., 2007; Coleman, Austin, Branch,
& Wagner, 2009). The model calls for the development
of change teams within each system focusing on the
functions required to adopt evidence-based practices.
Teams were encouraged to employ rapid cycle tests of
change to refine implementation of evidence-based
MAT practices for further penetration in the system
with more clients or spread across the systems.
Content scaffolding for the implementation science
study was guided by the model of evidence-based prac-

tice (EBP) implementation in public service sectors
(Aarons, Hurlburt, & McCue Horwitz, 2011). This
model describes four phases of implementation: explor-
ation, preparation, implementation, and sustainment
(EPIS) within the inner and outer contexts of influence
on public sector systems.
Learning sessions
The breakthrough collaborative model includes sessions
to teach the knowledge and skills to advance medication
assisted treatment in prisons and jails. Three learning
sessions took place over the 18-month period of engage-
ment. During session one, content experts for both
medication-assisted treatment and implementation sci-
ence presented the evidence base for medication assisted
treatment and the model for implementation science
study respectively. Teams were also oriented to expecta-
tions for engagement including data collection and
monthly progress reports using the EPIS model for three
distinct functions for a treatment program: opioid use
disorder screening, treatment, and referral to
community-based services at the time of release. Six
months later, teams met again, and cross-team small
groups were formed to map their best practices for these
functions (screening, treatment, community-based treat-
ment referral) as well as data collection systems. At the
one-year mark, teams met again to report on their find-
ings during presentations at the peer-reviewed Academic
and Health Policy Conference on Correctional Health
(Ferguson, 2018).
Practice coach
A practice coach was available to teams to provide in-
struction on quality improvement and change manage-
ment strategies. Site visits were conducted by the

practice coach and when possible, the principal investi-
gator, to learn more about the facility, current practices
and progress to date via semi-structured interviews; and
to provide advice when appropriate on strategies to ac-
celerate change. Information collected at these meetings
supplemented information from submitted progress re-
ports to better inform details of facilitators and barriers
to MAT implementation and sustainment.
Data collection
Teams were asked to complete monthly data and narra-
tive progress reports. Aggregated data reports focused
on 1) the proportion of individuals screened for SUD, 2)
the proportion screening positive for SUD, 3) the pro-
portion diagnosed with opioid use disorder who were
treated with MAT, 4) the proportion of those treated
who received community referrals at the time of release
and 5) the number of individuals who kept their initial
outpatient referral appointments.
The monthly progress report utilized a template de-
signed to describe details of adoption and adaptations to
MAT practices, inclusive of facilitators and barriers in-
fluencing implementation and sustainment of the treat-
ment program.
Analysis
Run charts were created and analyzed rates of screening,
treatment and community-based referral. The frequency
of reporting and data content varied among participating
sites based on local resources for data collection. In
addition, it was difficult to compare results across sites
as the populations of focus were different for agonist vs.
antagonist treatment models as well as variations in pro-
gram administration and community-based resources.
Progress reports and site visit meeting notes were ana-

lyzed by two authors (Ferguson, 2018) to catalogue best
practices, innovations or barriers and to identify com-
mon themes that either facilitated or hampered adoption
and expansion of evidence-based practices across the
systems. These were categorized as outer/inner context
influences and according to the EPIS framework.
8
Results
Site and medication assisted treatment descriptions
Table 1 describes the demographics of the four partici-
pating correctional systems involved in the study. The
systems are very heterogeneous from the perspectives of
their size, geographic setting, classification and move-
ment of incarcerated persons and the geographic distri-
bution of communities to which incarcerated persons
return following release. The study began at different
points in the adoption of medication assisted treatment
and on the type of treatment being offered to incarcer-
ated patients (agonist, antagonist or both) as well as the
type of agonist treatment when applicable. The two
Massachusetts jail systems offered antagonist treatment
with depot injectable naltrexone (Vivitrol: Alkermes) ex-
clusively while the two prison systems offered both
agonist and antagonist treatment. Connecticut offered
methadone as their agonist in addition to depot inject-
able naltrexone, while Rhode Island was the only partici-
pating system to offer both methadone and
buprenorphine-naloxone along with depot injectable
naltrexone.

Quantitative findings
Reporting parameters were different depending on the
nature of whether the primary treatment was agonist or
antagonist. For the two sites offering agonist treatment,
the focus was on evaluation of patients from the time of
entry into the system while the two jail systems offering
primarily antagonist treatment focused their efforts on
engaging patients and initiating treatment in the 2
months pre-release. For 9 months, three of four sites re-
ported quantitative data for screening, treatment and
care coordination at the time of release. One site solely
reported only the number of individuals treated from
month to month.
Because of variation in the size of the facilities, the
range of the populations admitted to facilities was large,
40 to 350 during any given month. By the third month
of data collection, sites consistently screened 100% of all
individuals for SUD at the time of intake and screening
rates remained consistent for the duration of project
reporting. The proportion of individuals screening posi-
tive for opioid use disorders was quite high and varied
from month to month with a range of 27–65%. For
those reporting on the rates of provision of medication
assisted treatment over time, the range was again quite
large, from 9 to 61% of those diagnosed with opioid use
disorders during any given month of reporting. With re-
spect to MAT treatment expansion over time, only one
site demonstrated consistent growth in the number of
patients treated over the course of the study.
For the two sites exclusively treating with Vivitrol
prior to release, 100% of individuals were released with
appointments to community-based providers post-
release for the 9 months of data reporting, with show

rates for those appointments varying from month to
month, with a range of 35 to 100%, (mean = 65%). Due
to aggregated data and small number of individuals re-
ceiving treatment, no specific trend line or statistical dif-
ference across sites could be calculated.
Qualitative findings
Outer and inner context influencers of implementation
and sustainment of medication assisted treatment are
depicted in the Fig. 1. While issues such as funding and
staffing levels are important elements of most change ef-
forts, a few deserve special mention given the intersec-
tion of health and criminal justice systems in the
provision of care. Leadership was a critical driver for
successful implementation, both from outer context (e.g.
Governor, Legislature) and from inner context (e.g.
Commissioner, Sheriff). All leaders demonstrated pas-
sion for improving the outcomes of the opioid crisis in
their communities and their leadership was demon-
strated by the commitment of their teams engaged in
treatment. This was also critical for developing a shared
mission between health care and security missions of the
organizations. Community-based partnerships were also
critical elements for success for both outer and inner
contexts. All systems prioritized the importance of care
coordination post-release. Interestingly, the challenge of
establishing community-based treatment may have im-
peded increased rates of treatment in one site.
Contracted services for the delivery of agonist medica-
tions on-site were observed to be an innovation to accel-
erate the spread of treatment from several perspectives.
To implement agonist treatment programs, existent
staffing levels were deemed insufficient. Moreover, ex-
tensive training of existing staff would be required.

Table 1 Characteristics of Correctional Systems studied
Correctional System Jurisdiction Jails/Prisons Number of
Facilities Sites offering MATa Population
Middlesex County Jail and House of Correction County
Jail/HOCb 1 1 1160
Barnstable County Jail County Jail/HOC 1 1 350
Rhode Island Department of Corrections State Jails and Prisons
6 6 3100
Connecticut Department of Corrections State Jails and Prisons
15 3 14,815
aMAT Medication-assisted treatment, bHOC House of
correction
8
Second, the process for obtaining a Drug Enforcement
Agency (DEA) certification as a methadone treatment fa-
cility is expensive and can take up to a year. Thus, con-
tracting with a community-based methadone provider
solved both problems and provided an added benefit for
seamless care coordination at the time of release to com-
munity based treatment programs operated by these
contracted organizations.
Influences on the decision to offer both agonist and
antagonist therapies as opposed to antagonist treatment
only are important. Both in-system and government
leadership influenced the types of therapy offered and

expansion of treatment. At sites offering agonist treat-
ment, a focus on fidelity to evidence-based therapies was
an important influencer, with articulated belief to engage
patients in the best choice of therapy in consideration of
their health care issues. Where antagonist-only treat-
ment was offered, security concern regarding diversion
of agonist medications and the cost of medications were
prominent. Of note, those sites offering agonists often
had to overcome these concerns on the part of their se-
curity missions and health care staff to implement agon-
ist treatments. An important factor influencing both
health care and security staff regarding whether agonist
treatment should be offered was alignment with govern-
ment and institutional leaders’ priorities.
At the start of the programs, systems were engaged in
different phases of medication assisted treatment, from
planning to sustainment. Therefore, most findings focus
on these steps in the EPIS model. While some oper-
ational elements were common for both agonist and
antagonist treatment sites, agonist treatment focuses
largely on treatment at the time of facility intake while
antagonist treatment focuses more on pre-release treat-
ment. Implementation facilitators and barriers identified
through content analysis of progress reports and meet-
ing notes are grouped according to screening, treatment,
community care coordination and data collection in
Table 2. Facilitators for adoption of medication assisted
treatment included: funding; management of culture
change; addition of staff and staff training; networking
with other elements of criminal justice system (proba-
tion, courts) and community based treatment providers;
spread of treatment to pre-trial and work release popula-
tions; developing effective data collection methods and
the use of data to improve processes; organization of

group visits for both education and care delivery; and
strategies to keep individuals in treatment post-release.
Data collection methods and systems were a challenge
for some sites, requiring sites to create their own excel-
type records. Some sites focused on new modules in
electronic medical records and identified dedicated staff
for data collection and analysis.
Barriers to adoption and expansion of best practices
included the amount and design of space; cultural bar-
riers to adoption of SUD treatment by both clinical and
security staff; security, medical or treatment motivation
assessments that prevented access to treatment; move-
ment and transfers between facilities; and large
geographic catchments that precluded consistent post-
release engagement into care. Location of facilities in
states with expanded Medicaid provided opportunities
to work with state Medicaid programs to suspend public
health insurance coverage for covered individuals and
Fig. 1 Outer and inner context influences for MAT. Legend:
Adapted from Aarons (Aarons et al., 2011)
8
Table 2 Operational factors influencing MAT implementation
and sustainment
Screening Aim: Employ an initial screen for opioid use disorder
at intake for 100% of new admissions
Category Barriers:

Solution
s and Innovations: (bold = innovation)
Facility Space at intake not conducive to screening Self-
administered screen with tablet at intake
Culture and
Change
Management
Inconsistent screening due to custody vs. medical priorities
Aligned custody and medical leadership
Policy/Procedure Lack of standardized procedure for screening
and assessment Develop a comprehensive screen to be
completed by Day 2
Education Lack of education on medication assisted treatment
options
and recovery treatment
Video education at intake about treatment program

Staffing & Training Insufficient staff to screen consistently
Train interdisciplinary staff to screen; temporary increase in
staffing during busy times
IT/EMR Use tablet technology for screening linked to EMR
Treatment Aim: To offer system-approved treatment to all
individuals diagnosed
with opioid use disorder unless treatment is contraindicated
Category Barriers

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