Drug Treatment Is Reaching More Prisons and Jails

Her father sold her drugs. Her sister was strung out. Friends died around her. 

“I shouldn’t have lived,” Brenda Smith, 35, testified in a Maine courtroom in February. “I have had some pretty close people, like close to me, die of a drug overdose.”

But Smith did live, thanks in part to a drug called buprenorphine, better known by its brand name, Suboxone. Along with therapy, she said, it has helped keep her clean since 2009. “It just makes me feel normal,” Smith testified. “Like when I was 17, before I started using drugs.”

That’s why she was determined not to go off it when was she was sentenced in 2018 to 40 days in the Aroostook County jail in northern Maine for swiping $40 cash from a Walmart self-checkout.

From a previous stay in jail, Smith knew that going back meant discontinuing buprenorphine, effectively forcing her to detox from it, increasing her risk of relapse and death from overdose after her release. So before her sentence was scheduled to begin, she sued the county and Sheriff Shawn D. Gillen to continue taking the medication under the Americans with Disabilities Act. 

“I don’t want to lose everything I have worked so hard to achieve in nine years just blown away,” Smith testified.

Like most county jails and state prisons in America, the Aroostook County jail prohibits not just buprenorphine but also methadone and naltrexone, the other two pharmaceuticals approved by the Food and Drug Administration for the medication-assisted treatment of opioid use disorder. 

Sheriff Gillen did not respond to multiple requests for comment. But in response to Smith’s suit, Craig Clossey, the jail’s administrator, testified that buprenorphine was prohibited because of its high potential for abuse.

In an April 30 decision, the First Circuit Court of Appeals agreed with a lower federal court that the Americans with Disabilities Act did indeed require that Smith be allowed to continue taking buprenorphine while incarcerated. The decision joined a November ruling from a federal judge in Massachusetts in Pesce v. Coppinger. As in Smith’s case, the judge in the Pesce case held that denying medication-assisted treatment to an opioid-dependent prisoner likely violates the ADA. 

The ruling in Smith’s case prompted officials in Aroostook County to convert her sentence to a $100 fine, which she paid. She was able to continue taking her medication under the care of her doctor, according to attorneys at the ACLU of Maine, which represented Smith.

Together, the rulings in the Smith and Pesce cases are helping to expand prisoners’ access to drug treatment. The decisions are “a shot over the bow to all jails and prisons across the nation,” said Steven S. Seitchik, who coordinates medication-assisted treatment for the Pennsylvania Department of Corrections.

Lauranne Howard, substance use coordinator for the Rhode Island Department of Corrections, agreed. “This movement is happening across the country,” she told The Appeal. “Inmates have a right to be provided medical care, and that includes appropriate medication.”

Drug overdoses killed more than 702,000 people between 1999 and 2017, the Centers for Disease Control and Prevention reports. The epidemic killed more than 70,000 people in 2017 alone, according to the CDC, a sixfold increase from 1999. Two out of every three overdose deaths are caused by opioids. President Trump declared opioids a national emergency in August 2017.

Substance use is also closely linked to incarceration. Drug-related offenses were a fifth of all reported crimes from 2007 to 2009, and “more than half of state prisoners and two-thirds of sentenced jail detainees met the DSM-IV criteria for drug dependence or abuse,” a 2017 Department of Justice report found.

Newly released prisoners, their tolerance lowered by a period of forced abstinence, are particularly vulnerable: They are at least 40 times more likely to die of an opioid overdose than someone in the general population, a 2018 North Carolina study found. 

Medication-assisted treatment, or MAT, is the standard of healthcare for opioid use disorder, according to the federal Department of Health and Human Services. 

“Offering MAT in correctional settings has been shown to reduce recidivism, overdoses, and criminal activity among people who are incarcerated, and help support them in their recovery from substance use disorders,” said Evan Frost, a spokesperson for New York’s Office of Alcoholism and Substance Abuse Services.

Of the three drugs approved by the FDA for MAT, methadone and buprenorphine are often preferred by treatment professionals to naltrexone because those medications do not require detox to be effective, according to the National Institute on Drug Abuse. They work by restoring “balance to the brain circuits affected by addiction, allowing the patient’s brain to heal while working toward recovery.” Naltrexone blocks the brain’s opioid receptors, denying users the euphoric effect of opioids. 

But the best strategy, according to the FDA, is stocking all three medications. After Rhode Island’s Department of Corrections started making three opioid treatment drugs available in mid-2016, a study found that fewer prisoners died from overdoses after being released.

Seitchik, the MAT coordinator for Pennsylvania’s prison system, where all three drugs are offered, says more options are the key to helping more people get and stay clean. “Client choice is very important to be successful,” he said. “The best form of MAT is whatever form the individual is willing to be compliant with.” 

For years, MAT has been banned by prisons and jails based on fears it would be diverted to the black market. But providing more MAT options helps offset that, Seitchik said. “If you treat individuals from a medical standpoint, you will reduce that black market that is inside a prison.”

Though MAT is still the exception rather than the rule, that’s starting to change.

Since Rhode Island led the way in 2016, correctional systems in Pennsylvania, New Jersey, Connecticut, Vermont, and Massachusetts established MAT programs that include not just naltrexone but methadone and buprenorphine. 

New Hampshire launched a MAT program in June, and Maine followed this month. Both include naltrexone and buprenorphine, officials said. Virginia and Delaware recently announced plans to start programs as well.

“Not only are correctional systems very aware of the Smith and Pesce decisions, but so are policy makers. They don’t want to be the next defendant in a lawsuit,” said Sally Friedman, vice president of legal advocacy for the Legal Action Center, a group that pushed for the changes for more than a decade.

Howard, who runs Rhode Island’s MAT program, said she had recently hosted corrections officials from as far away as Oregon interested in establishing their own programs. Besides state prisons, county jails are also establishing programs, according to the National Sheriffs’ Association.

Patrick Royal, a spokesperson for the association, told The Appeal that more than 270 jails in 35 states now offer some form of the treatment.

And it could soon become easier. Senators Lisa Murkowski of Alaska and Margaret Hassan of New Hampshire introduced the Mainstreaming Addiction Treatment Act on July 10. The MAT Act would expand access to the treatment, including for those incarcerated. 

Still there are challenges ahead for those seeking to spread the use of MAT in jails and prisons. For example, many drug counselors who tamed their own substance use disorders before MAT was widely available, still favor abstinence. And there are regulatory, political, and funding hurdles to overcome.

“I wouldn’t be able to do this without the governor’s support,” Seitchik explained, referring to the opioid emergency declaration that Pennsylvania Governor Tom Wolf first signed in January 2018 and has renewed five times since. 

Pennsylvania pays for MAT with federal funds provided by the Department of Health and Human Services through its State Opioid Response grant program. 

Medicaid expansion is also critical, Seitchik said, since it allows prisoners to continue MAT once released. 

The federal government will offer $1.4 billion in State Opioid Response grants this year. But money alone is not enough when political will is lacking, advocates say.

New York State, for example, has 54 state prisons, but none provide all three FDA-approved MAT drugs, according to November 2018 legislative hearing testimony by prison officials. Instead, the prison system relies almost exclusively on abstinence and naltrexone.

Thomas Mailey, spokesperson for the state Department of Corrections and Community Supervision, declined to comment.

A bill to require jails and prisons to offer all three MAT medications passed New York’s Senate but is stalled in the Assembly. 

New York, like many states, lacks a “real plan” for MAT, said Allegra Schorr, president of the Coalition of Medication Assisted Treatment Providers and Advocates of New York State.

A real plan is a unified statewide effort that includes all counties, she said. It should say “this is what we’re looking at. This is where we’re going. And this is how we’re going to get there,” Schorr said. “And we don’t have that yet. That’s step one.”

In the absence of such a framework, it’s likely “that the courts may step in,” Schorr added. “This is a major epidemic. It’s far, far from over.”