Providing opioid use disorder treatment in jails and prisons saves lives
This week, the New York Times editorial board pointed out one of the central failures of the response to the national overdose epidemic: the failure to make known and effective treatments widely available. As with every feature of the overdose epidemic, the numbers are staggering: “More than 80 percent of the roughly two million people struggling with opioid addiction in the United States are not being treated with the medications most likely to nudge them into remission or prevent them from overdosing.” [New York Times Editorial Board]
This applies to two medications in particular, methadone and buprenorphine, both opioids. The limits on their availability, particularly that of buprenorphine, have created a denial of care “so pervasive and egregious” that it “amounts to a serious ethical breach on the part of both health care providers and the criminal justice system.” [New York Times Editorial Board]
Until these medications are available in more jails and prisons, the failure to treat people will continue to have deadly consequences. In an email to the Daily Appeal, Dr. Kimberly Sue, medical director of the Harm Reduction Coalition, described the importance of providing methadone and buprenorphine—collectively known as “opioid agonist therapy” and considered the gold standard of care—in jails and prisons.
“Being incarcerated, forcibly detoxed, and released from these settings actually places our patients at disproportionately high risk for relapse and death,” Dr. Sue wrote. “Discharge from jail or prison is a chaotic, unstable time and if patients have lost opioid tolerance as a consequence of jail policies in combination with a toxic street supply (fentanyl in the heroin or other drugs including cocaine), this could equate to significantly increased chances of overdose and death upon release.”
The effectiveness of medication-assisted treatment (MAT) in jails and prisons is well-established. New York City has had a MAT program at Rikers Island for over 30 years. More recently, in 2016, the state of Rhode Island began offering methadone and buprenorphine, as well as naltrexone, in all of its correctional facilities. In Rhode Island as well as at Rikers, people are allowed to stay on methadone or buprenorphine if they have been on those medications. They are also screened for opioid use disorder and offered treatment. In Rhode Island, people are also offered treatment pre-release, as a safeguard against relapse post-release. [Erick Trickey / Politico]
(Some jails and the federal prison system make naltrexone, known by the brand name Vivitrol, available, but not methadone or buprenorphine. There is less evidence of naltrexone’s effectiveness and provision of all three medications is considered best practice. In Rhode Island, less than 1 percent of the incarcerated patients were on naltrexone. [Erick Trickey / Politico])
The results of Rhode Island’s program have been remarkable. A small study found that overdose deaths among people recently released from prison in 2017, after the program started, fell 61 percent compared with the same period the previous year. Nine people died in 2017, but 26 died in 2016. Dr. Josiah Rich, a professor at Brown University’s medical school and co-director of Rhode Island’s Center for Prisoner Health and Human Rights told Politico, “The magnitude of that drop in mortality is almost unheard of in public health.” [Erick Trickey / Politico]
Thanks to litigation brought by ACLU state affiliates and other advocates, judges are also beginning to push back against inhumane and unscientific jail policies. This month, a federal judge in Maine issued a preliminary injunction in favor of a woman scheduled to start a jail sentence on Monday. According to the Press-Herald, there were 418 drug overdose deaths in the state in 2017 and a projected 376 deaths in 2018. The ACLU won a previous settlement in September regarding the provision of MAT for a man entering a state prison and the governor has ordered the state to look into broader access in prison.
Brenda Smith, the plaintiff in the recent case, has been on buprenorphine since 2014. Her doctor, after an unsuccessful attempt at tapering her use of the medication, has kept her on a maintenance dose that allows her to live a healthy, stable life. In her order, U.S. District Judge Nancy Torresen noted what Smith had been able to accomplish because of treatment: “With the help of her medication, Ms. Smith has been in active recovery for her opioid use disorder for approximately ten years … Smith has regained custody of her four children, secured stable housing for her family, and obtained employment. She has earned her high school diploma and has begun to take college courses … it has been five years since her last use.” [Smith v. Aroostook County]
For people with opioid use disorder, appropriate treatment can be the difference between life and death. As Judge Torresen noted in her order, “People who are engaged in treatment are three times less likely to die than those who remain untreated.” The deaths that are prevented are also those of people in custody. Medication-assisted treatment has been shown to lower the risk of death by overdose or suicide and an “overall 75 percent reduction in all-cause in-custody mortality.” [Smith v. Aroostook County]
Dr. Sue of the Harm Reduction Coalition criticized the belief “that methadone or buprenorphine is substituting one drug for another.” The reality, she wrote, is “this medication is lifesaving, similar to insulin for patients with diabetes or statin therapy for high cholesterol to prevent a fatal heart attack. Sheriffs and judges like drug court judges would never deny these categories of medications to patients or feel empowered to make these decisions, however, because opioid use disorder is viewed so differently (as a sin, a moral failing, a bad choice) many of these professionals feel entitled to determine medical treatment.”
There are over 10 million admissions to jails across the country each year. Some estimates put the number of people with drug abuse or dependence at 58 percent of people in prison and 63 percent of people in jails who are sentenced. While many sheriffs resist offering medication for opioid use disorder, there are others who have recognized the importance of treating the overdose epidemic in jails. Dr. Sue pointed to a guide released last year by the National Sheriffs’ Association that suggests medication is a crucial part of treatment. An assistant superintendent at the Franklin County Sheriff’s office in Massachusetts told the Associated Press last year, “Jails are really America’s ground zero for the opioid crisis. It’s the perfect opportunity to make a public health intervention.” [Philip Marcelo / Associated Press]
Dr. Sue explained the necessity of treatment, rather than criminalization and stigma, in ending the overdose epidemic: “Valuing the lives of people who use drugs by treating them with [opioid agonist therapy] during jail and prison, and not incarcerating them in the first place for substance use disorders, could very well make a dent in the numbers of Americans that die a year.”
Coming next week: The Daily Appeal will look at the delivery of medication-assisted treatment in jails and the efforts to pass legislation funding MAT in more jails and prisons.