Jails and prisons: the unmanned front in the battle against the opioid epidemic

If you have type 1 diabetes and wind up behind bars, you’ll get the insulin injections needed to control your blood sugar. If you don’t, there will be public outrage over this violation of your human rights. But if you have an opioid addiction — like type 1 diabetes, a disease that could rob you of your life — and are taking an opioid agonist medication like buprenorphine or methadone to stay sober, it’s virtually guaranteed it will be stopped the day you step foot inside your cell.

Over the next few days you’ll go through a brutal withdrawal and your risk of relapsing will soar. Once you’re released, there’s a good chance you’ll use opioids almost immediately, along with the possibility that you’ll accidentally overdose and die.

This barbaric practice happens across the country every day. As an addiction psychiatrist, I’ve heard horror stories from patients who’ve been through it, most recently my patient Shawn (I’ve changed his name for privacy).

I had been treating Shawn for six months. One day he didn’t show up for an appointment. Unexplained absences aren’t unusual for patients struggling with addiction, but Shawn had always been there, on time, when he said he would. His addiction was in remission, thanks to his diligence, group therapy, and the combination of buprenorphine and naloxone (Suboxone) I prescribe for him. Like methadone, this medication is taken daily to stave off withdrawal symptoms and cravings for opioids.

Worried, I left Shawn a message, but didn’t hear back from him. As the days passed with no word from him, anxiety gnawed at me. Had he overdosed? Was he still alive? He hadn’t given me an emergency contact, so I searched online for an obituary, a morbid ritual that has become commonplace among addiction specialists. The search turned up nothing.

Two weeks later, I spotted Shawn slouched in a chair in the waiting area outside my office. He looked tired and anxious. He explained that he’d been pulled over by a police officer while driving, then arrested on an outstanding warrant for unpaid court fees dating back to when he was actively using heroin. He was taken to a Massachusetts jail, where the rules didn’t allow him to take Suboxone.

Without this medication, he was forced to endure the agony of withdrawal over several days.

“I just laid on the floor moaning and puking everywhere. I was hurting so bad I couldn’t sleep at all. I thought I was going to die,” he recounted. “I told the guards to call you, but they didn’t care.”

An opioid addiction condemns an individual to a vicious cycle that starts with euphoria that is soon replaced by withdrawal symptoms. They can be avoided only by taking more opioids. Stopping cold turkey, by choice or by force, without an appropriate detoxification process leads to extreme bouts of anxiety and severe pain accompanied by repeated episodes of nausea, vomiting, and diarrhea. Cravings for opioids to relieve these symptoms occur over and over. The experience won’t usually kill, but its victims often wish for the mercy of death. Those who have gone through withdrawal and started using opioids again will often do whatever they can to get their hands on the drug so they don’t have to repeat the suffering.

Shawn was lucky. He was in jail for only a little more than a week. And immediately after being released, he started taking the Suboxone he had at home.

Most prisoners with opioid addictions who have their medication stopped don’t have any of it waiting at home for them after their release. Instead, they turn to the streets for illicit opioids to alleviate their cravings. This often leads to overdose and death, because they’ve lost their tolerance to the drugs while incarcerated.

The Massachusetts correctional system isn’t alone in needlessly inflicting the misery of opioid withdrawal on prisoners and putting them at risk of relapsing on heroin — the commonwealth’s actions reflect standard practice around the country.

The U.S. Department of Justice has opened an investigation into whether the treatment of prisoners like Shawn by Massachusetts correctional officials violates the Americans with Disabilities Act. The American Civil Liberties Union recently filed a similar lawsuit against a county sheriff’s office in Washington state. These legal actions reflect the growing awareness that addiction is a disease of the brain and not a moral failing of the soul, so it should be treated like diabetes or any other chronic illness.

The cinder-block buildings and razor-wire fences of correctional facilities across the U.S. hide thousands of opioid-addicted prisoners from the public eye. An estimated 60 percent of prisoners in the U.S are addicted to opioids or other substances.

A staggering one-third of those with opioid addictions — hundreds of thousands of people — are imprisoned each year in the U.S. I have worked as a psychiatrist in a prison and a jail, where I’ve seen far too many individuals undergoing agonizing withdrawals from heroin and other opioids that could have been alleviated with Suboxone or methadone. It infuriated me that I wasn’t able to help them, handcuffed by regulations forbidding the use of these lifesaving medications.

Even after withdrawal subsides, many inmates with opioid addictions experience continual cravings throughout their confinement, magnifying their addiction. Among inmates with untreated addiction, almost all (95 percent) return to using drugs within three years. During the first two weeks after release, the risk of dying — mostly from drug overdose — is nearly 13 times higher than it is among non-incarcerated state residents.

Among people with opioid addictions, taking an opioid agonist reduces the odds of relapsing into drug use and dying from an overdose. Individuals who have already overdosed on opioids are at a significantly increased risk of death from future overdoses, while starting on medication halves that risk. Medication-assisted treatment with Suboxone, naltrexone, or methadone should be available to every opioid-addicted inmate in our criminal justice system. Incredibly, most correctional facilities in the U.S. don’t allow the use of any of these medications.

Individuals with addictions who receive treatment during incarceration are at a much lower risk of relapsing and committing crimes after their release, which helps protect the society at large and saves taxpayer money in the long term. With a re-arrest rate of 67 percent within three years of release among drug offenders, we should be using any available means to reduce recidivism.

Rhode Island is currently the only state using all available medication treatments for opioid addiction in its jails and prisons. Post-incarceration overdose deaths there have plummeted more than 60 percent, contributing to a 12 percent reduction in overdose deaths statewide.

While most state governments are hesitant to support such a radical policy change, the treatment-during-incarceration approach is not new. Many countries in Europe and elsewhere, such as Canada, Australia, and Iran, have long been treating opioid-addicted inmates, in some cases for decades. In the U.S., however, strong opposition from corrections officials and their lobbyists has been one of the most significant barriers to making treatment during imprisonment a reality.

Cost is a primary consideration for them. While it is cheaper in the short term for facilities to simply let inmates suffer, society bears a much larger expense for this strategy later on. There’s also concern about methadone and Suboxone being misused by prisoners, since they are sometimes smuggled in for purposes of intoxication or self-treatment of withdrawal. Yet many countries have navigated the misuse challenge and found that the medications have far more benefits than downsides.

A few U.S. prisons are starting to use naltrexone to treat opioid cravings, since it doesn’t have the potential for causing intoxication and has no street value. That’s a small step forward. Naltrexone doesn’t ease withdrawal symptoms and isn’t effective for cravings in all patients, so it is just one piece of the treatment puzzle.

Seeing just one inmate go through opioid withdrawal without treatment was more than enough to open my eyes to the cruelty of how we treat prisoners with addiction. I’m not sure how correctional officers can bear watching it happen again and again. I’m even more puzzled that state officials think that forcing addicted prisoners to go through withdrawal on their own is the right thing to do, when we have so much data demonstrating the horrific downstream consequences.

We need to get opioid-addicted inmates into treatment and maintain them in it after release.

As the opioid epidemic consumes a generation of Americans, it’s clear that a change in our strategy is badly needed. It’s time for us to expand our efforts inside jails and prisons and open a new front in the battle against this scourge, so we can finally start to subdue it.

Brian Barnett, M.D., is an addiction psychiatry fellow at Harvard Medical School and Partners HealthCare.