The Substance Abuse and Mental Health Services Administration (SAMHSA) has released new guidance for making medications for opioid use disorder (MOUD) available in state prisons. Published earlier in June, the guidance purports to be about MOUD broadly but is essentially about methadone. Which is a bit ironic, because from reading it you’d never know that a state prison might have anything in common with a methadone clinic.
The three Food and Drug Administration-approved MOUD are methadone and buprenorphine, which lower overdose risk, and naltrexone, which raises it. Methadone is the least accessible, and can only be dispensed by licensed methadone clinics, also known as opioid treatment providers (OTP). So corrections departments seeking to provide it either need to become an OTP themselves or partner with one nearby.
The implied focus on methadone is not at all a bad thing. Usually these kinds of documents say they’re about all three MOUD before immediately writing off methadone as a non-starter. But while the guidance is somewhat specific to methadone, it’s not very specific to state prisons. A lot of it reads like generic guidance for adapting methadone dispensing to non-traditional settings—but ones assumed to be less tightly controlled than OTP. So it’s a little awkward.
For example, great care is taken to point out that becoming an OTP will require “consideration of the possibility that controlled medications will be transferred or used by those to whom they were not dispensed.” Corrections departments do consider this. It has occurred to them. Yet SAMHSA continues to reassure them that we can mitigate the risk of diversion by making sure that each dose is counted and stored in a secure area, and by closely observing each patient when they take it. State prisons closely observe people in custody when they take Tylenol.
There are a number of things the guidance gets right, but they’re all underplayed to the degree that you’d almost miss them. It does state that while MOUD is often more effective when paired with counseling, for many people it’s sufficient in and of itself. It also states that long-term treatment is common and often necessary, and that it’s not advisable to think of MOUD as just a step-down. It explicitly states that MOUD should be accessible to people throughout their incarceration, not just at discharge. This is a slightly bold statement for SAMHSA, but the agency doesn’t really expand on it.
More than pretty much any other setting, prisons are already set up with all the infrastructure required to dispense methadone.
Becoming authorized as an OTP requires licensing with the state, registration with the Drug Enforcement Administration and accreditation through SAMHSA, which is less work than it sounds like but more than enough to give corrections departments sufficient pretext to not bother.
But the fact that methadone clinics are already so carceral in nature is why prisons, more than pretty much any other setting, are already set up with all the infrastructure required to dispense methadone. It’s a bit self-defeating of SAMHSA to not even reference this, let alone capitalize on it.
Prisons already have established daily dispensing schedules, wherein everyone who needs a medication dispensed lines up to take it, while staff watches them and checks if they’ve swallowed. Prisons already conduct drug testing. They already have secure vaults for pharmaceutical storage. They have diversion protocols. They have on-site counselors. They have exam rooms. They in theory have at least one licensed medical physician. They don’t exactly have HIPAA-compliant dispensing areas, but this has not stopped them from dispensing other stigmatized medications and it wouldn’t stop them from dispensing methadone.
“Stigma and discrimination are considered primary barriers to MOUD implementation in any setting but may be impediments to improving the correctional treatment system,” the guidance states. “Addressing misperceptions and misinformation regarding MOUD will help dispel stigma. Facilitating a culture change in correctional treatment services may be needed.”
Talking about stigma and discrimination is the kind of thing that sounds right, and might be fine if SAMHSA was in fact writing generic guidance for adapting methadone dispensing to non-traditional environments. But in state prisons, the primary barrier to implementation would be understaffing.
Unfortunately, the fact that just about all state prisons are in the grip of a severe understaffing crisis is the other big thing that SAMHSA seems to not know about them. One person with decision-making power can override stigma, but not the absence of staff.
For prisons that don’t intend to become an OTP, SAMHSA suggests partnering with a local program and facilitating methadone access under three possible models: transporting people in custody to the OTP to take their methadone there; sending staff to the OTP to pick up the methadone and bring it back; and having the OTP deliver methadone to the prison. To a certain extent SAMHSA does seem aware it’s making some throwaway suggestions here, but it would have been a better use of space to explain why.
State prisons often do not have the staff to transport one person to a surgery scheduled a year in advance, let alone dozens to an OTP every morning.
The first two routes are laughable, but only because no one is going to attempt them. If corrections departments did actually promise to start transporting people out to an OTP, for example, we’d have to take the situation more seriously because they’d be starting something they’re not going to sustain, and likely leaving people in worse shape than they were in before.
State prisons often do not have the staff to transport one person to a surgery scheduled a year in advance, let alone dozens to an OTP every morning. Same goes for sending staff to bring methadone back, even if hypothetically it could be done by one staffer once a month. But the guidance seems blithely unaware of this, describing at length how corrections departments will reap the benefits of ongoing meetings and extra trainings and a high level of communication between multidisciplinary teams as they co-create policies.
The third model, partnering with a local OTP and having them bring the methadone into the prison, is much more viable than the other two, if a local OTP has the resources to deliver methadone and a memorandum of understanding can be worked out with the prison. This is absolutely something that would make sense for some corrections departments to pursue, and it’s a little closer to being tailored to them rather than being generic guidance for non-correctional settings. Except that SAMHSA might have mixed up state prisons with county jails.
“Community-based providers are often interested in delivering services in correctional facilities, sometimes for subsidized rates,” the guidance states, “to maintain continuity of care among their patients, thus increasing the likelihood that a resident will return to the OTP post-release.”
Many if not most people incarcerated inside state prisons aren’t going to remain in the community immediately outside that prison after release. Especially in larger states, their home could be hours away. It’s not that relationships with local providers aren’t important—they’re definitely important for connecting people to treatment during their incarceration—it’s just that it somewhat belies the nature of state prisons to refer to “community” as if there’s only one.
Image (cropped) via San Bernardino County Sheriff’s Department
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