Although the general attitude toward methadone and buprenorphine is not favorable on the part of many workers in correctional facilities, the trend is changing. This is partly due to the clear evidence that inmates with opioid use disorders (OUDs), once released, have greatly higher risks of overdosing than the general population, and partly due to several recent cases in which people with opioid use disorders died during forced detoxification without medication.
This fall, the National Commission on Correctional Health Care (NCCHC), in partnership with the National Sheriffs’ Association, released guidelines on medication-assisted treatment (MAT) in jails. And Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), made the plenary speech at the annual conference of the NCCHC this fall.
The guide, “Jail-Based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field,” is important because jails, as shorter-stay facilities, have been less likely than prisons to offer methadone. For the guide itself, go to https://www.ncchc.org/jail-based-MAT.
Kevin FiscellaContributors to the guide are Kevin Fiscella, MD, MPH, an addiction medicine expert who serves on the NCCHC board of directors, and is a professor in the department of family medicine at University of Rochester, New York; Andrew Klein, PhD, of the Advocates for Human Potential, Inc.; and Jennie M. Simpson, PhD, of the Office of Policy, Planning, and Innovation at the federal Substance Abuse and Mental Health Services Administration.
Dr. Fiscella talked with AT Forum about the importance of opioid treatment programs (OTPs) in helping correctional facilities move ahead with instituting MAT.
“There’s a huge opportunity for partnership between OTPs and correctional facilities,” said Dr. Fiscella. This is particularly true for current OTP patients. “When someone gets into jail, if the jail personnel are doing what they should be doing, they should be confirming the dose of methadone, and having at least a minimal relationship with the OTP for coordination of care,” he said. Building on this minimal collaboration to a create genuine partnerships could prove mutually beneficial to OTPs and jails.
Getting Methadone to the Inmate
One of the big logistical problems is getting the methadone into the jail—or taking the inmate to the OTP for it. The Drug Enforcement Administration (DEA) is, it is fair to say, obsessed with the security of the methadone, requiring a specialized pharmacy for it (when used for treatment for addiction, not when used for treatment for pain).
Having an OTP in the jail, much like KEEP at Rikers, or the system in Rhode Island, where the vendor operates in facilities, would be best, but most likely this would be impractical in jails across the country.
However, jails have worked with OTPs on records and dosing of existing patients. “If they could build on that partnership, so the OTP does the dosing, then jails could get around the issue of needing an OTP license,” said Dr. Fiscella, noting that this is unlikely to happen in most small county jails, given the cost and logistics. “Most are probably not going to become OTPs, at least not in my lifetime,” he said.
“Short of that, you’re talking about transporting the person, which requires sheriff deputies taking the patient in custody to the OTP,” said Dr. Fiscella. Preferably, though, it could mean the OTP giving the methadone to the deputy, who then takes it to the jail; or having the OTP transport the methadone to the jail.
Stopping Methadone at the Time of Arrest: “Barbaric”
Early in his career, Dr. Fiscella was medical director of an OTP. “I was struck by the fact that as soon as someone got arrested, their methadone was abruptly stopped,” he said. “It was barbaric. I saw patients who evaded their warrant because they were terrified of jailhouse detox, of withdrawal.”
With an OTP, every drop of methadone has to be accounted for. It’s never clear when someone will be released. There are tracking problems. Methadone stored in jails can be diverted—even by jail staff. Some states, such as Vermont, have overcome these challenges.
Pregnancy Is a Different Situation
If the inmate is pregnant, this relationship is particularly important. Even jails that don’t otherwise offer agonists will often offer them during pregnancy, because of the risk to the fetus in withdrawing from opioids on which the mother is dependent. Typically, workers in jails and prisons who care for inmates (custodial staff) are opposed to agonists, thinking of them as merely prolonging an addiction. But when it comes to the babies, they are more willing to work with OTPs. These partnerships involving pregnant inmates can potentially be expanded to all inmates with OUD.
“Even in the minds of some hardened custodial staff—more sympathy for the fetus than the woman,” said Dr. Fiscella.
“There are jails that will use opioids, including methadone, to treat the pregnant woman, and believing it is legal, because they’re not treating the mom, they’re treating the fetus,” added Dr. Fiscella. A better alternative to meeting the needs of pregnant inmates is provide treatment through partnerships that fully conform with DEA regulations.
How OTPs Can Help
The time has come for OTP leadership to reach out to the local sheriff, for their own current patients, and for any possible new patients who could be admitted via the correction health system, said Dr. Fiscella. “Ask, ‘What can we do to work together better?’ Having those face-to-face meetings is crucial.”
Remember, though, that the biggest problem is that the OTP and the Sheriff are part of two extremely different, siloed institutions. “And now we’re asking them to begin collaborating, when they’re both inherently suspicious of the other.” Overcoming this mistrust takes time and persistence.
What About Buprenorphine and Vivitrol?
As for buprenorphine, there’s already a lot of mistrust because the Suboxone strips have been so easy to smuggle into jails, said Dr. Fiscella. Never mind that the reason that they are being smuggled in is to treat the inmates with OUDs who are sick (i.e., withdrawing). Other forms of buprenorphine might help mitigate these concerns.
Some sheriffs think that a two-week detoxification with buprenorphine is a humane way to treat opioid-dependent new inmates. But maintenance treatment is better. One way to convince the sheriff to work with the OTP is to explain the high risk that people will die of an overdose when they leave the facility. Neither jails nor OTPs want to see anyone die from opioid overdose. This common interest can become the foundation for partnerships.
Finally, Vivitrol, a favorite among many correctional workers because it is not addictive, is going to be difficult to for OTPs to fight. Dr. Fiscella concedes this. In fact, OTPs do treat patients with Vivitrol, and can help supervise the humane detox that can take place in jail, transferring people to Vivitrol when they leave. The challenges with this are, 1) most patients would prefer methadone or buprenorphine, and in this country, patient choice counts; and 2) if the patient doesn’t get repeat Vivitrol shots after discharge, he or she is just as likely to overdose as the patient who is put on abstinence-only treatment after hard detox in jail.