Withholding methadone from inmates is wrong

Addiction treatment is effective and inexpensive

I WILL NEVER forget the pained look on my patient Jorge’s face when I asked him why he stopped taking methadone to treat his opioid dependency. He was in my office, answering detailed intake questions to resume treatment for his addiction.

Jorge came to me after a stint in county jail. He could not post bail after he was arrested on an outstanding warrant and wound up behind bars. He was forced to detox from methadone cold turkey.

“It went on for weeks,” Jorge said, with a faraway look in his eyes. “It was like having the worst case of flu, and it didn’t stop. I wanted to die. I will never go back on methadone because I don’t ever want to go through that again.”

Unfortunately, I have treated many patients like Jorge. They’re prescribed methadone, an effective choice for managing the symptoms of opioid withdrawal, and the treatment is withheld in jail or prison. Eliminating methadone without proper planning wreaks havoc on the mind and body. I think it should be illegal, and I am not alone.

There has been a flurry of activity about the plight of incarcerated persons with substance use disorders over the past couple of weeks. The US Department of Justice is investigating whether Massachusetts prison officials are violating the Americans with Disabilities Act by forcing incoming individuals to stop taking drugs like methadone to treat addiction.

While there seems to be some momentum for change, Massachusetts reforms to date have failed to cover the use of all FDA-approved medications to treat opioid use disorders in correctional facilities.

Gov. Charlie Baker increased the budget of the Massachusetts Alcohol and Substance Abuse Center, a prison treatment facility, by $3 million. The funding did not include approval of methadone and buprenorphine, treatment options to replace opioid drugs (agonists) at brain receptors. It only covered injectable naltrexone, a medication that blocks opioid receptors in the brain (antagonists). During the same timeframe, policymakers removed from criminal justice reform legislation the mandated expansion of opioid treatment to include all FDA-approved medications.

In one study comparing buprenorphine and naltrexone at multiple sites, results indicated a higher level of acceptance of buprenorphine compared to naltrexone injections. For those individuals who used both medications over six months, both demonstrated effectiveness. There have been no studies in prisons or jails that compare these medications in terms of their effectiveness. However, in Rhode Island, where incarcerated individuals are offered options for all three medications where appropriate, most individuals choose to take methadone or buprenorphine. Most believe that injected naltrexone is less popular because it requires withdrawal like Jorge’s prior to its administration.

Prisoners like Jorge are falling through the cracks every single day we fail to move on this issue.

Methadone became an approved treatment for opioid use disorders 45 years ago. It has proven efficacy, is inexpensive, and dosing is virtually foolproof. Liquid methadone is attached to a calibrated pump and linked to an electronic health record with doses poured into a cup. The patient is observed while swallowing. A nurse checks the patient’s mouth to make sure a foreign object – like a cotton ball – has not been used to absorb the liquid. It has been safely administered to justice-involved individuals at correctional facilities in other states, including Rhode Island and Connecticut.

As recently published in a preliminary report in the Journal of the American Medical Association Psychiatry, a $2 million investment has led to a 60 percent reduction of opioid deaths among individuals leaving Rhode Island prisons and jails.

While Massachusetts Department of Correction officials have visited Rhode Island to learn more about its program, they have publicly stated that treatment expansion to include agonists poses a security risk and is too costly. I believe it’s far costlier to stay the current course.

Approximately one-third of those in Massachusetts prisons have an addiction to narcotics. It’s a problem that will get worse before it gets better, especially if we do not evolve to effectively and ethically treat prisoners with opioid disorders in our correctional facilities.

As a leader who thoughtfully considers the balance of security issues with medical treatment, I understand why buprenorphine dissolving strips as a treatment option causes anxiety for correctional officials. This medication is easily smuggled into correctional facilities and diverted within its walls. Yet, its use has been successfully implemented in Rhode Island and arguments to suggest that methadone poses similar risks are baseless.

Opioid use disorders are disabling medical conditions and methadone is a proven treatment. Correctional facilities would never withhold insulin from diabetic patients. Why should we condone this practice for incarcerated patients with another medical disorder?

The answer perhaps lies with the stigma faced by individuals afflicted with opioid addiction, especially those who are incarcerated. There isn’t the same level of empathy for a person who is incarcerated with an opioid use disorder, though the impact of withholding medication can have devastating consequences, as it did in Jorge’s case.

Meet the Author

Warren J. Ferguson

Guest Contributor, UMass Medical School
Sadly, changes in correctional facilities’ health policies often require legal action, even though it’s crystal clear we need to do the right thing here. It’s estimated that we will spend $1.2 billion taxpayer dollars to incarcerate individuals in Massachusetts in 2018, often poor minorities for low-level offenses. A modest amount of that money would be better spent helping justice-involved individuals access the medications they need to treat opioid disorders.

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.