A ruling by the U.S. Court of Appeals for the First Circuit in Boston that an inmate is entitled to receive medication for her opioid use disorder was a big win in the ongoing battle against the stigma that those with substance use disorders face on a daily basis. The controversy spawned by the decision underscores how much more work needs to be done to ensure that individuals with these disorders receive the treatment they need and are not judged simply as people of poor character making bad choices.
Brenda Smith, a resident of rural Maine and in recovery from opioid use disorder, was arrested for taking $40 from a Walmart change dispenser that had been left by a previous customer. After being convicted of theft but before she was incarcerated, Smith and her representatives asked that she be allowed to continue to take her twice-daily dose of buprenorphine, which had been prescribed by her physician as part of a medication-assisted treatment approach.
Jail officials would not let her continue the medication, which she had used for nearly 10 years, during which time she had regained custody of her children, secured stable housing, and been gainfully employed. The federal court found that Smith’s request was reasonable and stated that “[t]he Defendants’ out-of-hand, unjustified denial of the Plaintiff’s request for her prescribed, necessary medication — and the general practice that precipitated that denial — is so unreasonable as to raise an inference that the Defendants denied the Plaintiff’s request because of her disability.”
Smith’s case isn’t unusual. Prisoners across the country are routinely denied medications that can help them stay free of opioids — and prevent post-incarceration overdose deaths. In its “Treatment Behind Bars” series, the Pew Charitable Trusts estimated in 2018 that under 1% of U.S. jails and prisons allowed access to medication-assisted treatment for opioid use disorders.
Denying medication for substance use disorders is a barbaric approach. Imagine officials denying insulin to a prisoner with diabetes or hypertension medications to one with high blood pressure. The outcry would be fast and furious. But there is something about substance use disorders that causes people to fall back on a moralistic approach rather than acknowledging a disease that kills Americans at an alarming rate.
It may be the element of choice that makes it difficult for people to fully accept the disease model of addiction, as in “He/she chose to use drugs, so how can we say it is a disease?” That kind of thinking ignores the fact that many chronic diseases, such as diabetes and heart disease, are influenced by the negative choices people make. This does not make them any less real or medical.
In the criminal justice system, where individuals with addictions are thought of as criminals first and people with addictions second, we can’t forget or ignore the latter category. The phrase “cruel and unusual punishment” certainly applies to denying a prisoner medication prescribed for an opioid addiction, since withholding such medication would quickly cause the individual to experience severe physical withdrawal symptoms, which in some cases could have serious medical ramifications in addition to the extreme discomfort. Symptoms, while generally not life-threatening, may include, nausea, vomiting, diarrhea, extreme muscle cramps, and abdominal pain, not exactly what we should subject people to experience as part of their sentences.
The abrupt cessation of a medication-assisted treatment such as buprenorphine is a clear demonstration of the attitude that a substance use disorder is not a medical condition requiring treatment but solely a poor choice. As the National Institute on Drug Abuse points out in its Principles of Drug Addiction Treatment, “medications are an important element of treatment for many patients.” The last thing an individual with an opioid use disorder needs is to be arbitrarily removed from such an essential medication, even if by legitimate incarceration. Like other chronic diseases with high relapse rates such as hypertension and asthma, substance use disorders need to be treated in an ongoing manner, often with numerous treatment episodes to make long-term recovery possible.
It is unconscionable that an educated society should even consider denying legitimately prescribed medication for any condition — physical, mental, or otherwise — during incarceration. In my Virginia counseling practice that focuses on the treatment of individuals in recovery from substance use disorders, I have heard numerous stories of people who did not receive adequate access to prescribed medications for conditions such as bipolar disorder and anxiety when serving their sentences. While some prisons and jails across the country are starting to prescribe medication-assisted treatment for opioid addiction, many are not on board due to the expense of the medication, concerns over its legitimate purpose, and its potential for its misuse.
Misuse is, of course, a legitimate concern. Some medications, even those targeted to help support recovery, like buprenorphine and methadone, can be diverted or abused. Appropriate precautions need to be taken through proper dispensing procedures. But rather than simply having a policy against providing any such medications, prisons and jails need to have procedures in place to ensure that inmates receive the medications they need in ways that reduce the potential for misuse and diversion.
Law enforcement and emergency personnel can and should have important roles to play in our efforts to stem the opioid crisis. Many agencies have devised creative ways to be of help, such as establishing safe zones for disposing substances or advocating for treatment when appropriate instead of incarceration. Since 2016, for example, the Rhode Island Department of Corrections has implemented a program to offer medications such as buprenorphine, methadone, and naltrexone to prisoners to minimize the risk of overdose in the risky days immediately following release. In New Hampshire, the Manchester Fire Department’s Safe Station program has notably helped more than 1,000 people with substance use disorders access treatment by opening its doors to those in need and establishing a safe place for citizens to seek help. Other police and fire stations across the country have followed suit with similar programs.
Blocking individuals from receiving duly prescribed medications to support recovery from addiction is archaic and inhumane. I hope that other jails and prisons, as well as policymakers, heed the lesson of the recent appeals court ruling.
Kevin Doyle is an associate professor and chair of the education and counseling department at Longwood University in Farmville, Va., where he teaches in the counselor education program, and has a private counseling practice in Charlottesville, Va.