Harm Reduction in California Part III: MAT in Prisons and Jails

Photo of older man behind prison bars looking at camera

In the first two articles in our Harm Reduction in California series, we focused on California’s response to the overdose/opioid crisis, while this article will focus on harm reduction initiatives in California prisons and jails. To catch up on the topic before reading this article, please navigate to the blog section of our website and review the information we provide:

Harm Reduction in California Part I: The SOS Workgroup

Harm Reduction in California Part II: The California Harm Reduction Initiative (CHRI)

This article will focus on an important piece of California’s response to the nationwide opioid and overdose crisis, which has claimed over a million lives in the U.S. since 1999. California is at the forefront of harm reduction efforts in the country. They formed their SOS workgroup in 2014, and the California Harm Reduction Initiative in 2019. These responses anticipated the response of other states in adopting harm reduction legislation, such as New Jersey in 2022, and predated the inclusion of harm reduction programs in our new National Drug Control Strategy, also implemented in 2022.

Medication-Assisted Treatment in Prisons and Jails in California: The Integrated Substance Use Disorder Treatment Program (ISUDT)

In 2019, the California Department of Corrections and Rehabilitation (CDCR) and the California Correctional Health Care Services (CCHCS) created a program called Integrated Substance Use Disorder Treatment (ISUDT) to offer substance use disorder treatment – including medication-assisted treatment (MAT) – to incarcerated individuals in California.

The initial goals of ISUDT in the CDCR were to “reduce SUD-related morbidity and mortality, and recidivism.” With implementation of the program, however, the goals expanded and became more specific. These are the current goals of the program, as of 2024:

  • Reduce SUD-related mortality and morbidity, and associated health care costs.
  • Create a rehabilitative environment in state prisons, improving safety for residents and staff.
  • Successfully reintegrate individuals into their community at time of release
  • Improve public safety and promote healthy families and communities
  • Reduce recidivism and associated criminal justice costs

Upon implementation of the program in 2020, the ISUDT identified five core program components:

  1. Substance Use Disorder (SUD) Screening and Assessment
  2. Medication Assisted Treatment (MAT)
  3. Cognitive Behavioral Interventions (CBI)
  4. Supportive Housing
  5. Enhanced Pre-Release Planning and Transition Services

We’ll describe each of these core components below.

ISUDT in California: Harm Reduction and MAT in Prisons and Jails

Here’s a brief explanation of each ISUDT program component.

SUD Screening and Assessment

This component of ISUDT involves evaluating all individuals for addiction upon intake to the CDCR.

  • Upon intake, CCHCS staff screen patient for SUD – which includes screening of alcohol use disorder (AUD), opioid use disorder (OUD), and other addiction disorders – using standard assessment tools created by the National Institute on Drug Abuse (NIDA) and the American Society for Addiction Medicine (ASAM).
  • If a screening indicates SUD, CCHCS clinicians determine the severity of the disorder and the appropriate level of care for individual needs.
  • CCHCS clinicians prioritize three groups for treatment:
    • Patients scheduled for release within 15-24 months
    • Patients at highest risk for overdose
    • Patients on MAT prior to intake

Medication Assisted Treatment (MAT)

This component of ISUDT involves treating patients diagnosed with AUD or OUD with medication-assisted treatment (MAT) with FDA-approved medications.

  • For AUD, CCHCS physicians can prescribe Acamprosate and Naltrexone.
  • For OUD, CCHCS physicians can prescribe Naltrexone, Buprenorphine, Methadone, and Naloxone.
MAT programs prevent symptoms of withdrawal and allow patients individuals to participate in treatment and rehabilitation programs.
  • CDCR and CCHCS built an internal primary care provider (PCP) workforce to deliver MAT services.
  • CCHCS PCPs prescribe medication to ISUDT patients, which distributes the workload over a large group of PCPs rather than a small group of addiction specialists.
  • Between 2020 and 2022, all 500 CCHCS PCPs received specialized training to support patients with SUD
  • Between 2020 and 2022, all 500 CCHCS PCPs obtained Drug Enforcement Agency (DEA) X-waivers, which allows them to prescribe buprenorphine, one of three medications for opioid use disorder (MOUD).
The CCHCS program prepares their PCPs to manage patients is currently one of the largest programs in the country designed to incorporate primary care providers in SUD treatment.

Cognitive Behavioral Interventions (CBI)

Evidence indicates that SUD programs and MAT programs that include therapy and counseling – i.e. cognitive behavioral interventions (CBIs) – improve outcomes, compared to SUD and MAT programs that don’t include CBIs.

  • The cognitive behavioral interventions used by CCHCS are based on cognitive behavioral therapy (CBT)
  • CBT based CBI helps patients understand the connection between thoughts, emotions, and behavior.
  • CBI helps patients:
    • Identify and process self-destructive thoughts, beliefs, and/or attitudes
    • Change unwanted behavior
    • Develop emotional regulation skills, general coping skills, stress management skills, and techniques to tolerate adversity and distress
  • Participants can choose from three CBI pathways, managed by their alcohol/drug counselors:
    • Life Skills
    • Outpatient Treatment
    • Intensive Outpatient Treatment

Supportive Housing

This component of ISUDT was meant to involve housing participants in SUD treatment in rehabilitative housing units separate from the rest of the incarcerated population. Research shows that, compared to patients with SUD who don’t live in separate supportive housing units, patients with SUD who live in separate supportive housing have:

  • Lower rates of relapse
  • Lower rates of recidivism

While each CDCR location identified appropriate supportive housing space for ISUDT program participants, the COVID-19 pandemic delayed implementation of the program until Summer 2022. As of April 2023, a total of 14,976 ISUDT participants lived in supportive housing units.

Enhanced Pre-Release Planning and Transition Services

Leading up to discharge, ISUDT staff work to lay the groundwork for a successful transition to the community after incarceration. In this component of the ISUDT, select CDCR staff work to:

  • Assessing the participant’s current needs
  • Collaborate to develop a comprehensive pre-release plan
  • Facilitate connections with the community resources, which include:
    • MAT appointments
    • SUD counseling appointments
    • Mental health appointment
    • Health insurance resources
    • Housing resources
    • Vocational resources
    • Educational resources

Since implementing ISUDT in January 2020, CDCR staff have connected over 2,000 program participants with community SUD providers. These connections have the potential to reduce overdose rates, relapse rates, rates of premature mortality, and rates of recidivism. In addition, they help create a soft landing for patients upon release, and minimize the stress and challenges associated with rebuilding a life after incarceration.

Evidence-Based Outcomes: Impact of the ISUDT on Prisons and Jails in California

One requirement for all opioid response programs established as a result of the California SOS Workgroup and the California Harm Reduction Initiative (CHRI) is complete data transparency. This includes timely and accurate reporting of outcomes for all new overdose/addiction mitigation programs and harm reduction programs in the state. Public-facing data resources include:

Here’s a summary of the data reported on the ISDUT Data Dashboard as of February 28th, 2024, with additional data collected from two reports: “Impacts of The Integrated Substance Use Disorder Treatment Program April 2022,” and “Impacts of the Integrated Substance Use Disorder Treatment (ISUDT) Program on Morbidity and Mortality April 2023.”

Overall Data: ISUDT 2020-2024

  • 92,985 patients screened for SUD
  • 39,661 assessed for SUD treatment needs
  • 27,033 evaluated for MAT
  • 17,127 prescribed MAT
  • 10,156 patients receiving CBI
  • 24,048 received SUD treatment
Based on this information, the ISUDT program in the CDCR is largest provider of MAT among jails and prisons in the country.

Now let’s review the data on overdose in California prisons and jails.

Overdose Data: ISUDT 2018-2021

  • Overdose rate, all drugs:
    • 2018-2019 (Before ISUDT): 49.3 deaths per 100,000
    • 2020-2021 (After ISUDT): 22.8 deaths per 100,000
That’s a 54% decrease.
  • Overdose rate, opioids:
    • 2018-2019 (Before ISUDT): 39.8 deaths per 100,000
    • 2020-2021 (After ISUDT): 20.4 deaths per 100,000
That’s a 50% decrease.
  • Patients with OUD not on MAT:
    • 5 deaths per 1,000
  • Patients with OUD on MAT:
    • 8 deaths per 1,000
A difference of 29%.

Next, the general health outcomes for patients participating in the ISUDT.

Hospitalization/Disease Data: ISUDT

  • 18% decrease in hospitalization rates for overdose
  • 21% decrease in skin/soft tissue infections
  • 29% lower reinfection rate for hepatitis C virus (HCV) for patients with OUD on MAT compared to patients with OUD not on MAT

Finally, let’s look at the outcomes of the pre-release and release programs established by the ISUDT:

Pre-Release and Release Initiatives: ISUDT

  • 95% of patients submitted Medi-Cal application (health insurance through state program)
  • 75% of Veterans connected to VA services
  • 86% offered state ID card
  • 93% on MAT received medication upon release
  • 84% of MAT patients had a post-release MAT appointment scheduled
  • 97% of patients on MAT received naloxone training and kits upon release

Another insight included in the ISUDT report caught our attention. Program participants, CDCR, and CCHCS staff report the ISUDT program is life-changing for patients who adhere to treatment. Also, before the implementation of the ISUDT, state officials projected that 50 percent of patients offered MAT would accept and initiate treatment. However, upon implementation, their projections fell far short of reality: almost 90 percent of patients offered MAT accepted and initiated MAT.

Harm Reduction and MAT in Prisons and Jails in California

In the final article on our series on harm reduction in California, we’ll report on the role Pinnacle Treatment Centers and Aegis Treatment Centers take to support MAT programs in California prisons and jails. Our Director of Government Relations (California), Javier Moreno, coordinates this ongoing effort. Javier collaborates with the CDC and the CCHCS to provide MAT with methadone to patients opioid use disorder (OUD). Javier is also instrumental in working to provide continuing MAT services, counseling, and therapy to ISUDT patients upon their return to the community.

Look for Part IV of our Harm Reduction in California Series, coming soon.

The materials provided on the Pinnacle Blog are for information and educational purposes only. No behavioral health or any other professional services are provided through the Blog and the information obtained through the Blog is not a substitute for consultation with a qualified health professional. If you are in need of medical or behavioral health treatment, please contact a qualified health professional directly, and if you are in need of emergency help, please go to your nearest emergency room or dial 911.