In the wake of more than 64,000 drug overdose deaths in 2016-many of which were opioid related-the U.S. Department of Health and Human Services declared the opioid epidemic a nationwide public health emergency in 2017. That same year, it unveiled a five-point strategy to deal with the epidemic, with the first strategy aimed at improving prevention, treatment, and recovery support services. By early 2018, eight bills seeking to address the epidemic were introduced in Congress.
Yet these efforts have largely overlooked inmates in the U.S. correctional system who are addicted to opioids. This population continues to be provided with few, if any, treatment options while incarcerated.
A LACK OF TREATMENT
According to estimates, more than 2 million people are incarcerated in the United States, the country with the highest incarceration rate in the world. About two-thirds of this population-1.5 million prisoners-meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for alcohol and/or other drug abuse and addiction, according to a 2010 report from the National Center on Addiction and Substance Abuse at Columbia University (now the Center on Addiction). An additional 458,000 inmates were identified as being "substance involved," meaning they didn't meet the DSM-IV criteria but were under the influence of drugs or alcohol when an offense occurred, violated laws pertaining to drugs or alcohol, were substance abusers, or stole money to buy drugs. Only about 11% of the inmates who met the DSM-IV criteria received any type of professional treatment.
Methadone, buprenorphine (or buprenorphine-naloxone), and naltrexone have been approved by the U.S. Food and Drug Administration for the treatment of addiction or to prevent relapse. Yet, few of the more than 5,000 U.S. prisons and jails have instituted the use of medication-assisted treatment (MAT), even among inmates who used such medication prior to incarceration. As a result, opioid addiction is generally untreated during incarceration, and people frequently resume drug use when they are released.
Those who haven't been treated in prison also have a high risk of overdosing upon release. Overdoses tend to occur more frequently after a period of abstinence, which leads to loss of tolerance to the drug. The use of MAT in prison can significantly cut this risk. A study published in JAMA Psychiatry in April 2018 describes a greater than 60% reduction in the number of postincarceration deaths due to overdose among former inmates who received treatment.
BARRIERS TO TREATMENT
One of the main obstacles to implementing a treatment program is cost, which is a valid concern for correctional institutions, explains Brian Barnett, MD, a fellow in forensic psychiatry at Case Western Reserve University and University Hospitals in Cleveland, Ohio. As part of that program, he works at Summit County Jail in Akron. Many people who qualify for Medicaid while living in the community aren't eligible when imprisoned, he notes. Facilities, therefore, must rely on state funding for prisoners' care. "They aren't getting enough funding to pay for Suboxone [buprenorphine-naloxone] or other types of MAT," he says. "So, at a federal level, that issue needs to be fixed."
Another issue, Barnett notes, has to do with safety and "cheeking." Prisoners sometimes pretend to swallow their medications, taking them out of their mouths later, so they can sell them or combine several doses to take at once. This is an especially common practice with drugs that are sedating. "Facilities worry about this a lot and regularly do surprise checks on inmates and find stashes hidden in various places," he adds. "Therefore, with Suboxone and methadone, they're concerned that a black market will develop in their facility or that inmates might save up so they can get high and maybe unintentionally overdose-although this would be very difficult with Suboxone, since it has a ceiling effect that makes overdose nearly impossible."
Methadone is primarily available in liquid form, which makes it easier for staff to ensure it has been swallowed. By contrast, Suboxone is often provided as a film to be dissolved under the tongue. "Logistically, this is a real challenge, because the nurses have to watch these patients for several minutes and check their mouths," explains Barnett. "There are two forms of long-acting injectable buprenorphine now available, which will be great for solving this problem."
The downside is that these formulations are new and under patent, which makes them expensive and unlikely to play a treatment role in correctional settings. Increasing interest in this issue suggests that change is coming, albeit slowly, notes Kevin Fiscella, MD, MPH, dean's professor in family medicine and a professor of public health sciences and community health at the University of Rochester Medical Center in Rochester, New York. "Compared to five years ago, there has definitely been an upsurge in interest, especially in jails," he says. "The National Sheriffs' Association, in conjunction with the National Commission on Correctional Health Care, has issued a resource [Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field, published in October 2018], where they discuss all three medications [methadone, buprenorphine, and naltrexone] and suggest that all three should be available." Fiscella points out that the jail within his own community has begun offering all three options within the past three months. "There is slow progress, but there still are obstacles and challenges and a lot of work to be done."
These challenges differ depending on the modality. To dispense methadone, for example, a facility needs to partner with a licensed opioid treatment program. "Another option," says Fiscella, "is for the prison to obtain its own license, which Rikers Island in New York has done." Fiscella agrees that cost is an obstacle, not only to obtaining the drugs but for hiring and training personnel to administer them. "Another issue, which doesn't get enough attention," he says, "is the need to form adequate linkages with community providers. The person is going to be leaving the facility, and there needs to be continuous administration of the medication, and it requires close coordination with a community prescriber."
INROADS TO PROGRESS
Rhode Island has rolled out one of the most comprehensive treatment programs, in which all three medications are available to all inmates. The state has allocated about $2 million this year to the program, which also assists inmates to obtain insurance and transition to addiction programs after they're released. But Rhode Island has a unique situation-it's a small state and all prisons and jails are on one campus, under one medical system, notes Warren Ferguson, MD, director of academic programs at Commonwealth Medicine's Health and Criminal Justice Program at the University of Massachusetts Medical School, where he also founded and cochairs the Academic and Health Policy Conference on Correctional Health.
Other states are moving ahead, although not to the same extent as Rhode Island. "New Jersey has started treatment in its prisons, and, as of April 1, seven of 14 jails in Massachusetts and five prisons have as well, via legislation signed by Governor Charlie Baker," Ferguson says. "Connecticut also does limited methadone treatment."
Barnett points out that more facilities are using naltrexone, which is unlikely to be abused, even though it doesn't seem to be as effective as the other medications and patients tend to stay on it in the community for only a short while. "In Canada, they use methadone in their facilities," he adds. "They don't have the same regressive federal regulations [as we do], so that's the main reason we can't replicate that here."-Roxanne Nelson, BSN