This month, the House and Senate will be marking up dozens of opioid-related bills, some of which attempt to expand access to the triad of Food and Drug Administration–approved medications to treat opioid addiction: methadone, buprenorphine, and injectable naltrexone. As physicians who have helped thousands of people sustain their recovery with these proven medications, we welcome enhanced funding and access to them. At the same time, we lament the reality that many of the people with opioid addiction who are among those at highest risk of death are unlikely to receive them: those in jails and prisons.
Drug use is concentrated in the corrections population. At least a quarter of the nearly 2.3 million Americans currently incarcerated are addicted to opioids. Between a quarter and one-third of the nation’s heroin users pass through correctional facilities each year. And their eventual release to the community is a time of high vulnerability.
According to the 2016 Massachusetts opioid death assessment, former inmates were 56 times more likely to fatally overdose within a year after release than members of the general population. A 2014 report from the World Health Organization found ratios of overdose deaths ranged from eight- to 129-fold within two weeks of release.
This is not surprising—thrust back into society, people newly released are at high risk for resuming heroin. There are two factors that make this resumption deadlier: Their tolerance to opioids has likely dissipated over their time behind bars, and the heroin supply is currently dramatically more dangerous because it is tainted with fentanyl, which is 50 times more potent than heroin. Combine these, and the risk of fatal overdose after release is greatly elevated.
But if the stakes are high, so are the opportunities. Many states have started to piece together legislation and strategies that would counter this.
In Rhode Island, for example, Gov. Gina Raimondo’s Overdose Prevention Action Plan called for expanding treatment for people with opioid addiction incarcerated at the Department of Corrections. A comprehensive program (designed by a team including one of us) began in the summer of 2016. All individuals incarcerated are screened for opioid addiction, and those who have the disease are offered the most appropriate, individualized treatment.
There are three options: methadone, buprenorphine, and naltrexone. Methadone is administered daily as a sweet pink drink, buprenorphine as a daily oral strip that goes under the tongue and dissolves, and naltrexone is typically given as a monthly injection. Methadone and buprenorphine are opioids themselves (and are sometimes called “opioid substitution treatment”). At prescribed doses, they do not produce intoxication but instead block both the euphoric effects of opioids as well as withdrawal symptoms, the two main drivers of ongoing use. (For people who are not taking opioids regularly, both of these medications can produce a high.) Naltrexone is a pure opioid “blocker,” so anyone smoking, snorting, or injecting heroin while on naltrexone would experience no effect. Naltrexone has no street value and cannot be abused. Medical staff can also time the administration of the medication, which lasts for four weeks, to the individual’s release, if that date is known.
In Rhode Island’s program, patients interested in treatment choose a specific medication after discussion with clinicians about the pros and cons of each option. A wise rule of thumb prevailed: The best medication for opioid addiction was the one the patient wants to take. The vast majority chose methadone and buprenorphine.
The results were striking. Statewide, comparing the first half of 2016 (before the program) to the first half of 2017 (six to 12 months into the program) there was a 61 percent decrease in post-incarceration overdose deaths among people recently (within a year) released from incarceration. That decrease contributed to an overall 12 percent reduction in overdose deaths in the state’s general population—a truly impressive difference, especially in the face of rampant fentanyl.
A notable feature of the Rhode Island effort was that individuals were not merely given the option of maintaining a treatment they had been undergoing already. The corrections facility actually proactively began treating people who were addicted at admission to the jail.
The intention here is twofold. First, the program aims to protect people from relapsing or overdosing during the risky post-discharge period. Most inmates are pretrial detainees whose release dates can’t be predicted with much accuracy—many end up being incarcerated for only weeks to months. Crucial to the public health success of this program is that inmate patients are able to make a seamless transition upon discharge directly into methadone or buprenorphine treatment in the community. In Rhode Island, this is helped by a subcontract to a statewide treatment program that ensures same-day appointments upon release and helps with logistical issues including enrolling in Medicaid and transportation.
Second, beginning opioid addiction treatment behind bars can protect individuals during detention. This makes sense in facilities where illicit drug use and overdosing are a problem. In our experience, if inmates are given access to these treatments, their use of contraband drugs is suppressed as is, to at least some extent, violence and corruption within the facility. Treating inmates also means less sharing of jailhouse needles that transmit HIV, hepatitis C, and bacterial infections.
The Rhode Island Department of Corrections, the New Jersey Department of Corrections, and Rikers Island in New York are, to our knowledge, the only three systems that offer all three medications.* D.C.; the Metropolitan Detention Center, in Bernalillo County outside of Albuquerque, New Mexico; and the Connecticut state correctional systems are among the few that also initiate methadone and buprenorphine.
Naltrexone is a slightly different story: More than 100 state prisons and jails have opted to use injectable naltrexone in re-entry drug treatment programs in the past four years. When medications are used by the criminal justice system, the strong preference of corrections personnel is for naltrexone. The bias is due to convenience for the system (only one shot a month vs. daily administration) and the lack of potential for diversion and illicit use, a problem that has plagued some correctional facilities that do not offer the medications. Studies are underway to assess the effectiveness of long-acting naltrexone treatment.
But overall, the track record for prison systems making use of these proven treatments remains poor.* Of 3,200 local and county jails and 1,700 state, fewer than 40 (or 1 percent) offer medication treatment for inmates, according a 2016 survey by the Pew Charitable Trusts. A recent survey by Vox found that—not including field trial programs, detoxification, or limited-access treatments (such as for pregnant inmates)—prisons in just 18 states offer medications to fight opioid-use disorder. In nearly all cases, that treatment was naltrexone.
And other than a small naltrexone pilot program, federal prisons do not provide any anti-addiction medication at all. This poses a special problem for the D.C. jail, according to its medical director, Dr. Beth Mynett. Jail inmates in D.C. who are sentenced to prison can only be transferred to a federal facility, as the District itself has no prison system of its own, like states do. “The federal bureau will not allow the transfer of inmates who are on [anti-addiction medications] from jails to prisons,” she says. Other directors in this situation are sometimes reluctant to maintain methadone or continue it in jail, because they are uncertain whether the inmates they treat will eventually end up in a prison that does not offer methadone or buprenorphine.
If that is an inmate’s fate, he will have to endure abrupt withdrawal, aka “cold turkey.” The punishing symptoms include vomiting, diarrhea, muscle cramps, and insomnia. Perhaps worse, the inmate in withdrawal, who is often raising a racket, becomes a target for abuse—“being beaten senseless by other inmates who become sick of their sickness,” in the words of an editorial in the Albuquerque Journal that described the “cost” of ending methadone in corrections.
Making anti-addiction medication available to more of the correctional population does not require an act of Congress. The county jails and state prisons can act on their own. So can the U.S. Bureau of Prisons—and many states look to the bureau as a standard-bearer against which to set their own policies.
Some pressure to accelerate provision of medications and soften entrenched (if thawing) attitudes against such treatment has been brought to bear by the National Governors Association and the President’s Commission on Combating Drug Addiction and the Opioid Crisis. A few state legislatures are working on corrections bills that would require prisons and jails to offer all three medications. The U.S. Department of Justice is investigating whether corrections officials are violating the Americans With Disabilities Act by forcing inmates who were taking those addiction medicines when they entered prison to stop taking them while incarcerated.
One of the heartening aspects of the opioid crisis is the growing cultural consensus, even within law enforcement, that it be managed like a public health issue rather than a criminal one. Even so, many addicted individuals will still enter the criminal justice system. When they do, the public health mission must extend behind bars as well.
Update, May 9, 2018: This sentence has been updated to clarify that it is the track record of the prisons, not the medications, that remains poor.
*Correction, May 9, 2018: This post originally stated that the New Jersey Department of Corrections only offers methadone and buprenorphine, but in fact it also offers naltrexone in addition to the other two medications.