Implementation of a Telemedicine-MOUD Program in a Rural Jail during COVID-19

INTRODUCTION/BACKGROUND. More than 10 million individuals pass through U.S. detention centers on an annual basis, of whom nearly two-thirds (63%) meet criteria for drug dependence or abuse.1 Overdose risks associated with criminal justice discharge into the community is particularly high immediately following release, and is a leading cause of death for recently discharged incarcerated individuals.2 Despite proven efficacy, treatment with medications for opioid use disorder (MOUD) is underutilized in jail settings,3 particularly in rural areas.
Our addiction medicine treatment team at the University of Maryland School of Medicine has been providing telemedicine-based MOUD (tMOUD) to rural municipalities across the state since 2015.4,5 Through our various partnerships with community programs, our clinicians have treated hundreds of patients with the combination of telemedicine via videoconferencing and remote buprenorphine prescription. Here we describe a new program of telemedicine-based clinical service to provide new or continuing buprenorphine treatment for individuals detained in rural jails. Further, we report outcomes from the first cohort of incarcerated patients from Talbot County Detention Center, a 148-inmate-rated facility located on Maryland’s Eastern Shore.
METHODS. Bi-monthly meetings with jail and healthcare staff established: (i) a process for identification and screening of eligible patients; (ii) methods for delivery of medications, (iii) release of healthcare information (including screening tools and results of urine toxicology) from the jail records to guide best practices, and (iv) coordination of the telemedicine encounters and medication prescription procedures. In addition to establishing telemedicine hardware and software capability within the jail, HIPAA-compliant communication and document transfer (TEAMS) and data collection (REDCap) platforms were established. Retrospective chart review was conducted as a consent-waivered protocol approved by the UMB IRB and includes jail intake baseline data for incarcerated individuals enrolled into the tMOUD program from August 15, 2020 to December 31, 2020.
RESULTS. A total of 6 incarcerated patients entered the tMOUD jail program, two of whom were referred from the community for continuing care coordination. Patients were mostly male (67%), non-Hispanic White (83%), with an average age of 30.7 years. At baseline, all six patients tested positive for an opioid (including buprenorphine for the two patients continuing treatment), 50% tested positive for 3 or more substances (67% fentanyl+), and 60% reported injection drug use. Patients averaged 22 days in tMOUD care, had at least two tMOUD encounters (mode=4), and all were dispensed buprenorphine while in custody. Referrals for continuing treatment were offered to all patients prior to discharge, with two successful connections to community treatment.
DISCUSSION. As the demand for addiction medicine provision continues to increase in rural areas, and in light of the COVID-19 public health crisis, telemedicine is becoming the de facto standard of care platform for difficult-to-access settings and populations. Here we describe successful implementation of jail-based tMOUD treatment, with treatment engagement and initiation occurring prior to the high-risk period of discharge. The fact that this program was launched during the height of the pandemic highlights the flexibility and sustainability of tMOUD. Challenges and obstacles to implementation of tMOUD in a correctional system are discussed.

References: 1. Bronson J, Stroop J, Zimmer S, Berzofsky M. Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009. U.S. Department of Justice Office of Justice Programs, Bureau of Justice Statistics; 2017. Accessed October 10, 2019. https://www.bjs.gov/content/pub/pdf/dudaspji0709.pdf
2. Binswanger IA, Blatchford PJ, Mueller SR, Stern MF. Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009. Ann Intern Med. 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005
3. Krawczyk N, Picher CE, Feder KA, Saloner B. Only One In Twenty Justice-Referred Adults In Specialty Treatment For Opioid Use Receive Methadone Or Buprenorphine. Health Aff (Millwood). 2017;36(12):2046-2053. doi:10.1377/hlthaff.2017.0890
4. Weintraub E, Greenblatt AD, Chang J, Himelhoch S, Welsh C. Expanding access to buprenorphine treatment in rural areas with the use of telemedicine: Buprenorphine in Rural Areas With Telemedicine. Am J Addict. 2018;27(8):612-617. doi:10.1111/ajad.12805
5. Weintraub E, Greenblatt AD, Chang J, et al. Outcomes for patients receiving telemedicine-delivered medication-based treatment for opioid use disorder: a retrospective chart review. Heroin Addict Relat Clin Probl. Published online March 27, 2020. https://www.heroinaddictionrelatedclinicalproblems.org/harcp-archives-doi-articles.php

Learning Objective: Participants will be able to describe the implementation of a new program of telemedicine-delivered medications treatment program for opioid use disorder established in a rural jail.