[Read Part 1 and Part 2 of this series]
One of the most commonly cited statistics in overdose prevention comes from a study of people leaving Washington State Department of Corrections (WDOC) prisons: that in the first two weeks following release from incarceration, people are 129 times more likely to die of overdose compared to the general public.
Something often left out of that discussion is that scores of people enter that period of risk while still in custody—reentry doesn’t necessarily happen all at once. Many people spend the last leg of their sentence in some type of partial confinement like work release, where people go out to a job in the community during the day and return to a minimum-security facility at night. Another form is what’s known in Washington State as graduated reentry (GRE), where people wear an ankle monitor while living at home or at another approved address like a halfway house.
In any proposed prison overdose education and naloxone distribution (OEND) program, partial confinement settings are likely going to be the first that corrections departments are willing to get on board with. Those settings house people who still in custody, but who have less surveillance and more access to drugs. They’ve already reentered their communities.
WDOC, like many corrections departments around the country, allows prisoners nearing release or transfer to partial confinement to request a naloxone kit from medical. This policy should be opt-out, rather than opt-in.
But while naloxone kits are available for people being moved from full confinement to community custody or to GRE, that’s not the case for people headed to work release—even though that and GRE are where overdose risk is highest.
The reentry centers that house people on work release have kits in common areas, but those centers aren’t the only places people are at risk. They’re at risk out in the community, at work or on furlough or on the bus. It doesn’t help in those situations that there’s naloxone sitting back at the reentry center; people need to have it with them for it to work.
Almost every public discussion about overdose prevention for prisons or jails emphasizes getting naloxone into people’s hands the moment they’re released. Providing naloxone kits to everyone going to reentry centers is really just taking that “naloxone upon release” approach and extending it to folks who got missed, which makes sense and should be done. But that approach, on the whole, is wrong.
We know overdose risk goes up upon release. But the day someone gets out of prison isn’t the day they take on that risk; it’s the day they arrive. We know that people are headed toward this for years before it actually happens; by the time they reenter the community some have been sitting for decades in the exact same known location, starving for ways to pass the time. Yet the current approach is to not engage them that whole time and then, the day they become higher-risk, hand them a brochure or have them watch a short video.
In Washington State, the overwhelming majority of prisoner overdose deaths don’t take place inside prisons. But prisons are the only really viable places to implement OEND intended for prisoners, because to be effective they need to be based in peer education.
Instead of a video or brochure, an effective prison OEND would include something more like a 40-hour class people could complete for programming credits. Once certified, they could opt to complete the training again in two years the same way people refresh certifications for CPR.
By the time people are released they’ve spent years getting their naloxone information exclusively from cops, who are notoriously misinformed. This is why so many people in prison believe that seizures are a sign of fentanyl overdose; that fentanyl overdose means you should give someone five back-to-back doses of naloxone; that naloxone should be used for non-opioid overdose; that naloxone isn’t strong enough for fentanyl; that fentanyl is in marijuana. None of these beliefs are true and some of them are harmful.
After the San Diego County Sheriff’s Department made naloxone accessible in jail common areas, it reported that people in custody successfully averted an overdose by administering the victim 10 doses of naloxone. Their only training had been a three-minute video shown at orientation. The most widely publicized example of jail OEND participants administering naloxone, from the Los Angeles County Sheriff’s Naloxone Custody Pilot Project in 2021, shows no clear signs of actually involving an opioid overdose at all.
It’s ineffective to withhold overdose prevention education from prisoners found out of compliance with policy. Drug use is out of compliance with policy.
There is precedent for public health groups delivering “training of trainers” education to people in custody, meaning that after some OEND participants became certified they went on to become certified to deliver that training to their peers. But like all other correctional-setting OEND, this has focused on people with imminent release dates and doesn’t actually give anyone in custody naloxone.
Peers certified by the local health department could facilitate in-depth conversations about how to distinguish an opioid overdose from a stimulant overdose, or from a mental health or medical episode. How to identify respiratory depression, when to do a sternum rub, the right way to perform rescue breathing. How naloxone actually works, why you should wait at least two minutes between doses, what causes precipitated withdrawal.
Many programs are only open to prisoners who’ve been infraction-free for a certain amount of time. For a prison OEND to be effective, it needs to waive that restriction. Not just because making overdose prevention accessible to everyone, regardless of their disciplinary record, doesn’t encourage or enable drug use. But because it’s ineffective to withhold that education from prisoners found out of compliance with policy. Drug use is out of compliance with policy. So is helping someone who’s overdosing.
It’s the things people learn while in prison that they take with them when they go home. In prison, you can save someone’s life and get sent to the hole, while officers can prevent everyone from intervening and be protected. When someone’s just spent years being denied access to naloxone and any overdose prevention education, they’re not going to undo that conditioning by reading a brochure. Especially if they have other things to worry about that day.
Top image and inset graphic via Washington State Department of Corrections