When people who are dependent on opioids are incarcerated and denied access, they go into withdrawal—an often-painful condition with symptoms that include vomiting and diarrhea. Some incarcerated people have even died from this enforced “cold turkey.”
Yet the huge majority of such people in US prisons and jails do not receive the medications that could spare them this experience—and even more importantly, greatly improve their chances of survival after release.
Even those prisoners who are given “comfort medications”—a taper using buprenorphine, for example—will still experience craving when that taper is done. As soon as they are released, they are likely to seek opioids again. In today’s streets, whatever they get is likely to be adulterated with illicit fentanyl. And with lowered tolerance after a period of enforced abstinence, if they go back to using the same amount as before, they’re at heightened overdose risk even if the substance is fentanyl-free.
The CDC notes evidence that around 10 percent of opioid-involved overdose deaths are of people who were released from institutions in the month prior. Many advocates and experts—including, in April, a nationwide group of 58 law enforcement and criminal justice officials—have decried this situation as unconscionable.
Yet progress—where it exists at all—is scattered and varies by state. Maryland passed significant legislation in April, requiring availability of all three opioid use disorder (OUD) medications—methadone, buprenorphine and naltrexone—in local jails.
But whenever you hear “all three,” think primarily of methadone. Because access to that is the real need and the real challenge.
There are three main benefits to methadone: It’s cheaper than buprenorphine or naltrexone, making it more realistic to roll out on a large scale; it has no ceiling effect, so works for even patients who need high doses because of their metabolism or history; and there is evidence that patients prefer it.
Both methadone and buprenorphine are opioids; naltrexone works by blocking the effects of opioids. It is not popular, although some patients do want it.
Yet only opioid treatment programs (OTPs) certified by the Substance Abuse and Mental Health Services Administration and the Drug Enforcement Administration are allowed to dispense methadone to treat OUD. Buprenorphine and naltrexone can be prescribed and dispensed outside the confines of an OTP—making access easier, even if affordability or desirability are lower. Bringing methadone into a prison or jail requires an OTP partnership.
There are innovative ideas in other states. Pennsylvania’s corrections department is going to pilot injectable buprenorphine—something custodial staff like because unlike with oral drugs, there is virtually no opportunity for diversion. And in Massachusetts last November, a federal court ordered a local jail to allow a man to receive methadone.
Routine Suffering, Rare Exceptions
Forward steps remain exceptions. “I’ve seen plenty of guys come into county jail or federal holdovers right off the street and suffering from heavy heroin withdrawals and not get any type of treatment whatsoever,” said Seth Ferranti, a writer who served 21 years of a mandatory minimum sentence for selling LSD and cannabis.
“They laugh at them and mock them, making light of their misery.”
“They are just left to cope cold turkey, and without their fellow addicts helping them cope they would have most likely died,” he told Filter. “Jail staff treat prisoners like scum and heroin addicts even worse. They laugh at them and mock them, making light of their misery.”
It’s important to talk to people who have “been there”—not just to doctors and experts, who can be co-opted by the systems they work for. “I have never seen jails or holding facilities give prisoners any type of withdrawal treatment during my 21 years of incarceration,” said Ferranti, who was released in 2015. “Our country continues to criminalize drug use and lock people up for what are considered health problems in more progressive places. It is unethical.”
Some experts indicate that things may be changing for the better. However, “the problem seems to be getting the system set up,” said Jonathan Giftos, MD, clinical director of substance use treatment for the Division of Correctional Health Services of NYC Health and Hospitals.
It’s not a problem for him: Rikers Island, for all its terrible faults, has the first and one of very few jail-based OTPs in the country. “Most patients who pass through the jail system with opioid use disorder are off treatment, but 25 percent are already in treatment,” Giftos told Filter. “If they were forced to withdraw, there’s a significant risk of an overdose.” Medications for OUD given in correctional settings are associated with a 75 percent reduction in mortality, he added. “These are deaths that can be prevented.”
“We never would withhold medication as a disciplinary tool.”
Methadone at Rikers was formalized through an OTP in 1987. There’s no stigma against it there, said Giftos. “Everyone from corrections staff to clinical staff is comfortable with methadone.” The jail currently has about 1,000 patients in the OTP.
These patients experience varied complexities in terms of physical and mental health issues, as well as readiness for change, said Giftos. “Some people have a quiet treatment experience without any issues. Others may struggle with their medication, having their dose adjusted. But we never would withhold medication as a disciplinary tool.”
Standing Up for MAT Rights
Rosie Russo, MSW, a social worker with the criminal defense practice of the Bronx Defenders, advocates for clients to receive methadone through the NYC Health and Hospitals Corporation, which provides healthcare at Rikers.
But that doesn’t work for some clients, who get transported upstate where there is no treatment. “If we have a client who is dependent on opioids and gets arrested on felony charges, that’s a big obstacle,” she said.
Even before this client is convicted or has made a plea, methadone is not allowed, because felony charges mean the person is likely to end up in a facility upstate, not in the county jail.
“They want to wean them off, because there’s no methadone upstate,” Russo said. This means that clients facing felony time are going through withdrawal in Rikers—not necessarily cold turkey (“I don’t want to say medical assistance is not available,” said Russo)—but “I have had clients tell me they are getting no medical attention, and they are shaking and sweating.”
Police officers sometimes use drugs themselves, for months, to build up trust. And they go after people who “look as if they are addicted.”
Most of Russo’s clients are “just users, not kingpins of drug organizations,” she said. She described the typical manner in they get arrested. An undercover police officer begs them for drugs, seeming desperate. They pay with pre-marked money that can be traced. In some cases, the clients aren’t even involved in the actual sale—they just help make the connection. The police officers sometimes use drugs themselves, for months, to build up trust on the street. And they go after people who “look as if they are addicted,” said Russo.
“I’m not a lawyer, but as far as I know it is legal for cops to do these predatory buy-and-bust tactics, and there’s no way to prevent it,” she said.
“I have a client now who is a Latino male in his mid-40s,” she continued. “He’s sitting in jail; his case took nine months to resolve … during that entire time he was facing felony charges and waiting to see if he would be allowed into treatment court.” Treatment court itself is risky, as Russo noted and Filter has reported.
Bronx Defenders is client-centered, and a big part of Russo’s role is helping her clients to get whatever help they want for their substance use issues.
“I have long conversations with clients to assess where they are,” she said. “If they want to be connected to harm reduction organizations because they’re not ready to stop using, we do that.” If they want to stay in the community and access treatment, she tries to make that happen too, if it’s possible. “Most of the time, someone will feel more comfortable in their own home” than in residential treatment, she noted; and methadone, like buprenorphine, is provided on an outpatient basis.
Barriers to Vital Jail-OTP Partnerships
“The only way methadone in jails is going to work is with partnerships” with OTPs, said Kevin Fiscella, MD, an addiction medicine expert who is on the board of directors of the National Commission on Correctional Health Care (NCCHC).
Last year, in partnership with the National Sheriffs’ Association, the NCCHC released Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field. Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), a membership organization of OTPs, praised the guide in his speech at the annual NCCHC conference.
Fiscella helped draft it, and told Filter that most facilities “are not going to go through the trouble of getting an OTP.” Typically, health services for incarcerated people are contracted out, so it would involve working with a vendor.
“The irony is your right to healthcare is only guaranteed if you’re incarcerated,” he said. But jail personnel’s mistrust of OTPs is not to be underestimated. “Without a partnership, even if someone incarcerated is already in an OTP [pre-incarceration], they don’t have access to methadone,” said Fiscella.
A dose for an incarcerated person—including transport and handling—costs about $10-15. The cost of the methadone itself is more like 10-15 cents.
Part of the problem—a big disincentive for OTPs to get involved with jails—is reimbursement. Once someone is incarcerated, federal Medicaid can no longer be used for any healthcare, including methadone. Can state departments of corrections or county jails be persuaded to pay for it?
A dose of methadone for an incarcerated person—including transport and handling—costs about $10-15, said Fiscella. The cost of the methadone itself is more like 10-15 cents. The best plan is for the jail itself to pick up the methadone at the OTP and bring it back to the patient, he said. “Otherwise, the OTP is bearing all these costs.”
Methadone has the highest retention rates in treatment, said Fiscella. “We don’t have good data for Vivitrol [naltrexone], but most people, given the option, won’t choose that.” It’s also important to note, he said, that if people are given options, and what they get is what they choose, they’re more likely to continue treatment.
Forcing a patient to have a certain kind of treatment is not only clinically inappropriate, it’s also unethical—as a recent report from the National Academies of Science, Engineering and Medicine made clear.
“What’s very sad is that the federal Bureau of Prisons hasn’t set the standard,” said Fiscella. “You’re subjecting people to punishment, and traumatizing them. How can the federal government have authority when they don’t have it in their own house?” He cited the BOP website as proof of how antiquated and inhumane the agency is when it comes to MAT. For example, it says: “Substance abusers are rarely accurate in their description of patterns of drug use.”
“Inhumane as it sounds, the medical provider often prefers detoxification to maintenance.”
Wendell M. France, Sr., a retired major with the Baltimore Police Department and former deputy secretary of Maryland’s Department of Public Safety and Correctional Services, is now an advocate for drug policy and criminal justice reform with the Law Enforcement Action Partnership (LEAP)*. He ran the city jail, and said the hardest issue is that correctional institutions have contract medical and mental health services. This means that anything maintenance-based—like daily buprenorphine and methadone administration—is “an issue based on available dollars you have to spend for that type of program,” he told Filter.
“It’s not that they’re bad at it. It’s that they don’t have a free hand to do it,” he said. In other words, authorities don’t build that treatment protocol into the contract, so there’s no money for it. “There’s a medical provider, a mental health provider, and a pharmacy provider,” he continued. “All three of those providers are supposedly in synch for the inmate population, but if a pharmacy provider is awarded a contract, and doesn’t build MAT into the cost, then someone has to pay the cost, or the service won’t be provided. So, inhumane as it sounds, the medical provider often prefers detoxification to maintenance.”
The prevalence of people dying from opioid detox is low compared to alcohol detox, he added. “If you’re a sheriff running a jail system or in a small county, you probably would benefit from getting educated about what should be in the mental health contract, so you have a better way of providing some oversight. The demand has to come from the person who’s going to pay them for their service.”
In the case of Maryland’s new requirement that all three medications be provided in all county jails, it was supported by the state’s corrections agency, France noted. “It isn’t everything, but at least it gives us the beginning toward providing methadone maintenance.”
Jonathan Giftos agrees that funding MAT in jails is tricky. “Payment for correctional health is complicated in general,” he said, noting that it is usually funded by county or municipal dollars due to the federal Medicaid exclusion policy. “So you have cities that have more resources that will generously fund correctional health, like New York City, and smaller ones that can’t.”
In addition, the public is often unsympathetic toward incarcerated people, causing a problem for pro-reform policymakers seeking funding. Allowing continued Medicaid access for incarcerated people is an option worth exploring.
Improving an Awful Situation
Despite the barriers, there are many—and growing—opportunities for partnership between OTPs and prisons and jails.
One OTP chain in Arizona, for example, has developed a close relationship with corrections and drug courts. And in Rhode Island and Connecticut, OTPs are already operating in prisons and jails. The Rhode Island program, in which an outside OTP brings the treatment to prisoners, is considered model.
And if you believe in the power of money, with the right model, corrections represents a big untapped market for OTPs.
Sharing intelligence is important. More jails should ask Rikers, for example, about how to deal with the conflicting roles of incarcerating and medically treating people.
Giftos is a clinician first, and has no illusions about the contradictions inherent in his role, and the harmful effects of jail itself.
“Regardless of how I personally feel about whether we incarcerate people, and despite a lot of the best efforts of correctional and healthcare staff, jail is not a therapeutic space,” he said. “In a perfect world, we would love to be delivering care in the community.”
He thinks that community OTPs are a vital resource for jails that don’t have the resources and expertise to provide treatment. “The whole country is learning about treatment of opioid use disorder as we navigate this overdose crisis.”
Giftos himself has been asked for technical assistance from correctional health systems around the country. “They are curious, and they want to do the right thing, but they’re struggling to find the resources to do so.”
You don’t have to go to jail to get treatment for cancer or a tooth abscess. And neither should jails—even the minority that provide MAT—act as our de facto treatment system for opioid use disorder.
*LEAP is the fiscal sponsor of The Influence Foundation, which operates Filter.