by Alison Knopf
There is a growing partnership between corrections/criminal justice and treatment for substance use disorder (SUD)—especially, treatment for opioid use disorder (OUD).
For example, the Florida Association of Drug Court Professionals sent its staff to the conference of the American Association for the Treatment of Opioid Dependence (AATOD). “This is a favorable move,” AATOD president Mark Parrino, MPH, told AT Forum. The more interested that drug courts become in medication-assisted treatment, the more likely it is that people passing through the system will get that treatment.
Paul Samuels, director and president of the Legal Action Center, made a riveting plenary presentation at the AATOD conference, held in Orlando in October. He called for treatment behind the walls—and instead, even going behind the walls. People with OUD need “high‐quality care,” said Mr. Samuels. All three medications approved by the Food and Drug Administration—methadone, buprenorphine, and naltrexone—should be available.
Mr. Samuels talked about Section 1115 waivers, which could be a way to get around the “Medicaid Inmate Exception,” a rule barring states from using Medicaid dollars to provide health coverage for any incarcerated persons. The Legal Action Center is advocating for this waiver amendment (https://www.lachealthandjustice.org/ny‐medicaid‐waiver‐amend).
Mr. Samuels was joined in the plenary presentation by three officials from within the world of criminal justice, all of whom advocate for more treatment, and treatment instead of incarceration.
The Jail Accreditor
Brent R. Gibson, MD, chief health officer for the National Commission on Correctional Health Care (NCCHC), said the idea that it’s safe to detox from opioids is “old thinking.” Jail officials think that just because opioid withdrawal, unlike alcohol or benzodiazepine withdrawal, isn’t by itself life-threatening, deaths in jails are due to dehydration from vomiting and diarrhea.
Dr. Gibson acknowledged the work of Kevin Fiscella, MD, in developing the guidelines for jail‐based treatment a year ago (see “Jail‐based MAT guide released,” https://onlinelibrary.wiley.com/doi/10.1002/adaw.32152). But before that can happen, a facility “has to recognize that there is a best practice,” said Dr. Gibson, who told AATOD attendees at the criminal justice plenary that “What’s the best way to detox?”—a question he is often asked—is the wrong question. “You don’t want to withdraw them; you want to treat them.”
Sheriff Dennis M. Lemma of Seminole County in Florida praised a fourth medication–not a treatment per se medication, but a life-saving one–naloxone. “Twenty years ago, we weren’t equipped with medicine that brought people back to life,” he told attendees. “Last year alone we deployed naloxone 450 times—we brought 450 people back to life.”
Most of the pill mills in Broward County, near Mr. Lemma’s territory, have been shut down. But where did people go who had become dependent on those pill mills? The streets, he said. “They were looking for their daily dose of drugs to get to their norm so they could function and not be dopesick.”
Like Mr. Samuels, Mr. Lemma thinks that people who go to jail simply because they use drugs should be diverted to treatment. Getting treatment in jail isn’t the solution for them, he said. They should just be given high quality treatment right away.
Jeri B. Cohen, a circuit court judge in criminal court in Miami‐Dade County, wishes every Sheriff could be like Mr. Lemma. She is a strong supporter of methadone, buprenorphine, and naltrexone. She admitted that there are some jail officials who just prefer naltrexone because it is not addictive.
But she is very alarmed by the non-science bent of these officials. Some courts don’t let pregnant women have methadone or buprenorphine, even though these are the first‐line treatment for pregnant women. “Only 26 percent of courts allow an agonist for a pregnant woman,” she said. “How scary is that?” She repeated, for emphasis, “How scary is that?”
Even corrections staff—not just judges—are uninformed about the dangers of naltrexone-precipitated withdrawal to the fetus. “I got a call from a jail the other day, and they said, ‘I have a pregnant woman who is in jail and actively using—should I put her on Vivitrol?’” “A number of women have their children removed because they are taking an agonist therapy,” said Judge Cohen.
Opportunity for OTPs
Corrections presents a huge opportunity for OTPs, not only to expand their patient census, but to fill a treatment gap and to save lives. It is estimated that as many as 80% of jail and prison inmates have a substance use disorder. And those with OUD have a high chance of relapse—and overdose, due to reduced tolerance—when they are released.
There will be multiple prongs for OTPs in the corrections space in the coming months, said Mr. Parrino. One will be what Linda Hurley did with CODAC in Rhode Island, becoming an OTP in the facility itself (https://atforum.com/2019/10/codac-to-provide-induction-for-mat-in-massachusetts-prisons/, https://atforum.com/2018/02/moving-ahead-on-methadone-in-corrections/).
“This is a new brand of sheriff,” said Mr. Parrino of Mr. Lemma. “He has the respect of other sheriffs.” The judge and the accreditor are “thought leaders.” With this kind of collaboration, it will be possible to create more treatment for the most vulnerable, disenfranchised members of our society.