Addressing inmate addiction must be a priority

THE CRIMINAL JUSTICE BILLS recently passed by the Massachusetts Senate and released by the House Committee on Ways and Means provide sensible reform to failed criminal justice approaches, including doing away with some mandatory minimum sentences for minor drug offenses. These reforms are both pragmatic and just. By shifting the focus away from laws and prosecutorial strategies that have not produced results, the Commonwealth has an opportunity to return critical discretion to its judges and encourage local innovation. Conversely, the possible inclusion of new mandatory minimum sentences for drug trafficking resulting in overdose deaths cuts at complete cross-purposes to the intent of this legislation.

Meaningful reform frees up critical resources for reinvestment in approaches that have much more promise of positive impact. One element of the Senate bill, which has been filed as an amendment to the House legislation, presents precisely such an opportunity. This provision is designed to scale up access behind bars to medication-assisted treatment, such as opioid agonist therapy with methadone or buprenorphine. Such an effort will confer both health benefits and cost savings, helping to address our state’s opioid crisis.

An estimated 58 percent of state prison inmates and 63 percent of those serving sentences in county houses of correction meet criteria for substance use disorder, with 26 percent and 28 percent, respectively, reporting a history of opioid use. Missing the opportunity to provide adequate treatment behind bars threatens inmate health and can result in life-threatening events and even deaths.

The paucity of appropriate treatment behind bars and lack of linkage to care after release also means that inmates with substance use problems are put at an extraordinarily high risk of overdose death upon re-entry follow incarceration. Newly-released inmates are 120 times more likely to overdose and die during the first month after re-entry than the general population, according to a 2016 analysis by the Massachusetts Department of Public Health. Therefore, providing such treatment is a clear opportunity to reduce the overall community burden of overdose morbidity and mortality in our state.

Opioid agonist therapy has also been shown to substantially decrease criminal justice re-involvement. Therefore, initiating this treatment in correctional settings and linking individuals to care upon release is almost certain to reduce recidivism and cut law enforcement and correctional costs.

Since many inmates are forced to undergo unmanaged withdrawal from opioids and other drugs at the time they are incarcerated, failure to provide treatment also creates a stressful work environment for correctional staff, who suffer from elevated rates of depression and other stress-related conditions, resulting in burn-out and high turnover.

It is important to note that provision of opioid agonist therapy in correctional settings is not new. Such treatment is broadly and successfully deployed in most peer countries, and is an established international best practice. It is also the current standard of care for pregnant women who are incarcerated. Maintenance treatment is already available in US in selected facilities in New York and Rhode Island; in Massachusetts, it is being rolled out on limited, pilot basis.

A major reason often cited by those who oppose of opioid agonist therapy in correctional facilities is diversion – in which drugs end up in the hands of inmates other than those for whom they are prescribed. While diversion of buprenorphine does occur, the majority of individuals using non-medical buprenorphine do so to self-manage opioid use disorder and withdrawal, not for euphoria. In fact, research suggests an effective strategy to reduce diversion is to increase access to legitimate medical treatment with opioid agonist therapy. While logistical hurdles are real, they are also very surmountable as demonstrated by other countries, states, and programs for pregnant women. An injectable long acting buprenorphine was just recommended for approval by and Food and Drug Administration advisory committee and may be available in early 2018. This formulation should obviate any diversion concerns.

Opioid agonist therapy increases the likelihood of recovery and survival. By expanding the roll-out of this lifesaving therapy within correctional settings, Massachusetts has an opportunity to invest in a proven approach that promotes public health and public safety.

Leo Beletsky is an associate professor of law and health sciences at Northeastern University. Sarah Wakeman is an assistant professor of medicine at Harvard University. Jessie Gaeta is an assistant professor of medicine at Boston University School of Medicine.