Making addiction treatment work for inmates

Comprehensive approach needed for those in criminal justice system

AS A PHYSICIAN, who treats and supports individuals battling substance abuse, I try to be available when the call for help comes, especially from those involved with the criminal justice system.

The call for help from John, a former inmate who has struggled with addiction and cycled in and out of prison, arrived via text from an unrecognized number. He went MIA awhile back, after being a no-show for buprenorphine to treat his addiction to heroin.

“I need your help.”

John’s struggles have always gutted me. During his last relapse, he wept and pleaded for a second chance. His begging was so visceral that I felt embarrassed about the power I had.

“I just committed my third felony by cashing a bogus check,” he cried. “If I get arrested and convicted, it will be my third offense. They will throw away the key.”

How could I say no?

In the United States, there are 2,000 people released from prison each day, and many are non-violent offenders just like John.

Warren Ferguson

Dr. Warren Ferguson

Sixty-five percent of inmates meet the medical criteria for drug addiction, but just 11 percent receive treatment while incarcerated. They leave still in the throes of addiction, ill-equipped to deal with the challenges of freedom. Seventy-six percent will return to jail or prison within five years of release, and for good reason. Everything is stacked against them.

For John, it was the innocence he lost during his formative years. It was the sexual abuse he endured at the hands of a priest, while in service to God. It was the relentless replay of unspeakable acts in his mind, which was never quiet. It was post-traumatic stress disorder. It was hepatitis C, tobacco, and a few other ailments.

Mostly, it was the solace he got from drugs. Heroin gave him a temporary reprieve from 50 years of untreated emotional pain.

Most inmates like John don’t make it on the outside. Once released, they have trouble navigating their seemingly endless issues alone, return to drugs, and wind up back behind bars. It’s a vicious, costly cycle.

I’m hopeful our new correctional health practice collaborative, funded by the National Institute of Drug Abuse and the Agency for Health Care Research and Quality, can lead us toward change.

The University of Massachusetts Medical School has joined forces with the state departments of corrections in Connecticut and Rhode Island and Massachusetts sheriffs who oversee houses of correction in Middlesex and Barnstable counties to help individuals like John.

Our collaborative is focusing on the areas of substance use disorders — commonly known as drug addiction. We will guide these correctional partners as they work to implement health care practices that have been proven to work in community settings.

The first step is to assess current screening and treatment practices for opioid addiction, then make recommendations for improvements, and, finally, implement proven practices to create a model. We want to treat all people behind bars who are facing addiction. That means we must be aware of and prepared to implement all treatment options that have been proven to work.

We know the risks are high. A seminal study of Washington State published in 2007 in the New England Journal of Medicine suggests that inmates released from prison are 129 times more likely to die from an overdose the first two weeks following release.

The partners in the collaborative include four jail and prison systems carrying out strategies to diagnose and treat  inmates with substance use disorders, specifically dependence on opiates that are either heroin or prescription drugs.

All of the partners have made addiction treatment behind bars and coordinating care at treatment facilities after release a priority, which the National Commission on Correctional Health Care calls a rarity.

The treatment initiatives vary across these four systems, but all are evidence-based – which means they have been used in the community for years and are backed by clinical research.

One of the initiative’s primary goals is to determine which strategies are used successfully in jails and prisons, where they can be improved upon and how they might be implemented in other correctional settings. We must learn what these states and counties had to do to explore, prepare, implement and sustain these treatment practices in order to spread them across the nation’s correctional institutions.

In Massachusetts, Middlesex County Sheriff Peter Koutoujian offers opioid-addicted inmates returning to the community a medication assisted program with an injectable form of naltrexone (licensed as  Vivitrol), which blocks opiates from binding to brain receptors and causing a “high” while also curbing the craving for drugs.

The program ensures released inmates are enrolled into Medicaid and offers the critical component of post-release counseling with the assistance of a patient navigator.

Koutoujian spearheaded a successful bipartisan effort to pass legislation that suspends, rather than terminates, Medicaid benefits for those entering Massachusetts correctional facilities. This law eliminates the need for a lengthy and complicated enrollment process after release for justice-involved individuals.

In 2012, the Barnstable County Correctional facility became the first adult detention center in Massachusetts to launch a Vivitrol program, and statistics show it has reduced recidivism. According to Sheriff Jim Cummings, 82 percent of the 178 inmates given an injection of the opioid blocker at release have not been incarcerated again.

The Connecticut Department of Correction treats addicted inmates with methadone, a medication that mimics opiates to relieve opiate withdrawal and cravings but without leading to a “high” from the medication. This medication is effective and is prescribed in community-based treatment facilities that are highly regulated because the medication can be abused and also cause overdose.

The department has treated more than 600 opioid-addicted inmates with the drug at its Bridgeport and New Haven jails since the program began in the fall of 2013. Commissioner Scott Semple is working to expand the methadone program to three more jails and offer it to inmates before release. Semple said he’s looking to the collaborative for support of these efforts.

In Rhode Island, the Department of Corrections last year launched a cutting-edge program that provides opiod-addicted inmates with three options for medication-assisted therapy. They offer methadone and Vivitrol but also buprenorphine, a medication that combines the effects produced by methadone and Vivitrol, providing the relief from opioid withdrawal while blocking the “high” of abused opiates. It also has a lower potential for overdose.

After a successful roll-out at their smallest facility in August, medical programs director Dr. Jennifer Clarke wants to extend the program to all facilities. Clarke admits there is still much to change before every inmate is screened and treated, but she sees value in sharing Rhode Island’s processes and lessons learned.

If we can get individuals suffering with addiction effective treatment while incarcerated, we could not only stop a cycle, but also save money and lives. It costs about $47,000 a year to incarcerate an inmate, according to the Bureau of Justice Statistics. Getting an inmate clean and keeping that individual out of jail is an automatic cost savings. More importantly, that individual can have a productive life.

We all know people like John, individuals who spend most of their lives incarcerated because they can’t kick a drug problem. The only way to help people like him is to do better at diagnosing and caring for inmates who have substance use disorders, ensuring that treatment will meet their needs and be effective.

Collectively, we will figure out how. We will draw on all collaborative partners’ experience to formulate evidence-based, patient-centric practices to curb drug addiction in our correctional facilities.

We will work hard so inmates like John don’t fall through the cracks.

Dr. Warren J. Ferguson is director of academic programs for the University of Massachusetts Medical School’s Health and Criminal Justice Program and chair of the Academic Consortium on Criminal Justice Health.

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