By Alison Knopf
A new program in New York has finally made it possible for methadone patients in the KEEP program at the New York City Rikers jail—the first behind-the-walls opioid treatment program (OTP) in the country—to continue their treatment if they are sentenced to incarceration upstate. The program, a partnership between NYC Health and Hospitals/Correctional Health Services, the New York State Department of Corrections and Community Supervision (DOCCS), and NYS Office of Alcoholism and Substance Abuse Services (OASAS), is expected to affect about 200 to 400 patients a year, said Jonathon M. Giftos, MD, clinical director of substance use treatment for NYC Health and Hospitals/Correction Health Services.
The new program, which takes effect July 1, applies to one upstate prison, in Elmira. This is the first time methadone will be allowed in state prisons. Buprenorphine is not included in the program. This means that patients on methadone in Rikers will no longer need to taper off the medication before going to Elmira, but instead can stay on it. This is a huge improvement.
The state has been helpful, said Dr. Giftos. “My experience with the state DOCCS leadership has been very positive,” he told AT Forum. “They are operationally very careful, and so they are making sure that there are clear protocols and contingency plans.”
So, yes, New York’s DOCCS is cautious, but the leadership is very much in favor of methadone for inmates. “It’s like a mission for them,” said Dr. Giftos. “They’re trying to make it work.”
What about custodial staff, though? These are the workers who actually interact with inmates, and who are most likely to have the view that methadone is “switching one addiction for another.” Dr. Giftos hasn’t spoken to custodial staff in state prison. But he works with them at Rikers, where they are not judgmental.
How the Project Came About
New York City has been discussing the importance of allowing patients who are taking methadone or buprenorphine to stay on their medication when being transferred to state facilities. The city “slowly influenced the state,” said Dr. Giftos. There has also been political pressure put on the state from public health advocates.
Up until 2017, methadone patients at Rikers who had a felony arraignment charge, and therefore faced the possibility of being convicted and having to go to a state prison, were tapered off their methadone. This was just on the “off chance” that they would be convicted, but it applied to every Rikers inmate who was taking methadone and facing that charge. In 2017, this was changed: regardless of arraignment charge, Rikers patients could stay on methadone (or buprenorphine), but if they were convicted, they would be tapered off either drug.
The state’s Elmire prison will now accept inmates on methadone, but only if their sentence is for two years or less. The reason for this time limitation, said Dr. Giftos, is that they wanted a pilot that captured patients at highest risk of overdose during the post-release period. The assumption was that patients with shorter-stay prison sentences would be most destabilized by a taper, and therefore would be at the highest risk of relapse and overdose after release.
However, there’s not much data to back up this theory. It’s true that someone who has been in recovery for five years has a much lower chance of relapse than someone in recovery for two years, but this is based on voluntary recovery, not forced “institutional remission,” a term based on the idea (which is not accurate) that drugs are not available in prisons, and therefore everyone there is not using.
How methadone will be dispensed in Elmira took a lot of planning, said Dr. Giftos. Unlike Rikers, which has a completely licensed and accredited OTP, Elmire doesn’t. The state prison system partnered with the state’s substance abuse services at OASAS to work with third-party OTPs, so that patients who are enrolled in KEEP at Rikers and want to stay on methadone can do so.
Here’s how it works. First, the methadone patients are moved to Downstate Correctional Facility, in Fishkill, where they receive five days of courtesy dosing from Lexington Center for Recovery, under Dr. Giftos’ methadone order.
After those five days, the patients are transferred to Elmira, where they begin to receive methadone from United Health Services (UHS), and the OTP. Even though they are not going to UHS for services, the patients are enrolled in the UHS OTP, and UHS doctors and staff deliver the methadone weekly to the Elmira facility.
One story that has never been told is that the pilot program for this was done in New York, where KEEP patients were medicated by Samaritan Village. “This was the first pilot where we worked out the logistics,” said Dr. Giftos. It was only for people who were going to get services for 120 days or less.
It is unclear why methadone, but not buprenorphine, was included in this Elmira project.
About 200 to 400 patients a year will be affected, now being allowed to continue their methadone when transferred from Rikers to Elmira, said Dr. Giftos.
The full OTP services will not be provided in Elmira—just the methadone. Any counseling and other services will be provided by correctional health staff.
But even having the methadone is crucial to patients. “I cannot tell you how many patients have said to me, ‘Methadone saved my life, I cannot believe that I have to come off this medication,’” before going to a state prison, said Dr. Giftos. And now, the gratitude that they have, just because they can stay on their treatment, it’s hard to describe,” he said.
“Lexington Center for Recovery is proud to be a partner in this endeavor to provide ongoing methadone treatment to those addicted to opiates within the New York State criminal justice system,” said Adrienne Marcus, PhD, executive director, Lexington Center for Recovery, Inc. Her statement was issued at the time of the announced plan, June 20.
But the plan falls short of what OTPs across the state wanted: full medication-assisted treatment for all incarcerated patients who need it.
Assembly member Linda B. Rosenthal, chair of the Assembly Committee on Alcoholism and Drug Abuse, said, “Our obligation to provide basic, life-saving health care to New Yorkers is the same on both sides of a jail cell wall,” and commended New York City for this expansion.
However, the assembly member wants more, as do OTPs in the state. “I am fighting for legislation at the state level to ensure universal access to MAT, and to guarantee that all correctional facilities have robust MAT programming,” she said.
Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates (COMPA), cited “fiscal reality” when it comes to having an OTP in every jail and prison in the state. “Ideally it would be great to have the full Rikers program in all facilities, but we recognize that that’s a very expensive model,” she told AT Forum. “I don’t think we’re going to be able to achieve that, because the costs are so high.”
But using the Elmira dosing model gets Schorr’s full support. “We’re able to get medication into the facility and into the patients, and that’s something we haven’t done before,” Ms. Schorr said.
She sees this program as “an important first step.” It’s only for people who have been identified as having an opioid use disorder and are already taking methadone. Other people in the inmate population, including some in Elmira, would benefit from methadone, but won’t get it because they aren’t from the Rikers OTP. “But we have to start somewhere,” she said.
In Rhode Island and Connecticut, OTPs behind the walls are a reality. But those states are both small, and have the benefit of a unified system, said Ms. Schorr. “I understand, as a provider, that this is not something you can just roll out. There has to be a thought process, a learning curve.”
The budget needs to include funding for OTPs in prisons. “I think we have to push the governor on this,” said Ms. Schorr. Some advocacy organizations seem to want to give up on the opioid crisis. “I don’t even know what to say about that,” she said. “The Assembly didn’t manage to pass the bill, and that’s a real disappointment. It should have passed. Then we would have something to bring to the governor.”
In the meantime, changing the correctional system in New York won’t happen overnight. “Having talked to them, I can see it’s like turning an ocean liner,” said Ms. Schorr.