IN DECEMBER, a federal district court judge in Massachusetts ordered the Essex County jail to provide an entering inmate methadone so that he could continue his successful methadone treatment of the last two years. The individual had failed on the other opioid medications, buprenorphine and naltrexone. He had overdosed and been revived with naloxone multiple times. He and his doctor feared that if he were forced to stop taking methadone for his 60-day jail commitment for operating after revocation, he would relapse and risk death.
The Essex jail offers a sophisticated medical detox program, a model RSAT treatment program that provides injectable naltrexone for those who want it. Although it is not a licensed methadone clinic, the sheriff announced he would not appeal the ruling and accommodate the individual even if correctional officers had to drive him daily to a methadone clinic.
The ruling has prompted headlines across the country like the following from the Santa Fe New Mexican – “Ruling in Massachusetts opioid treatment case could affect New Mexico.” Yes and no. The ruling from a single federal judge carries no legal precedent, even among his colleagues on the Massachusetts district court. However, it will prompt more demand from individuals facing jail time, advocates of medication-assisted treatment, and more lawsuits. The American Civil Liberties Union has already lodged similar suits in Maine and the state of Washington.
The real issue is should jails and prisons provide opioid medications for those already on these medications or for those who request them to prevent relapse upon release? The answer is not clear cut one way or the other.
First, it makes little sense for jails and prisons to offer medication that is not available to individuals when they are released and go home. Methadone clinics are few and far between, inaccessible to most persons, especially those living outside major cities. In Franklin County, for example, there is only one clinic.
Even within cities, many methadone clinics are full, not accepting new patients. Further, in states without Medicaid expansion, and in other states where Medicaid does not cover methadone, the cost of methadone treatment may make it out of reach to many individuals. The same problem exists with buprenorphine. Only certified doctors and other medical personnel may prescribe buprenorphine. They, too, are in limited supply, nonexistent in less populated counties. A 2015 study found 60 percent of suburban counties, 53 percent of counties with small towns, and 82 percent of rural counties do not have a single buprenorphine prescriber.
While doctors do not have to be certified to prescribe naltrexone, most doctors do not prescribe it.
Second, it may be problematic to continue individuals on opioid medication if they are unable or unwilling to abide by the rules. The Middlesex jail, for example, has found that the majority of individuals entering with prescriptions for methadone or buprenorphine are mixing their prescribed medications with additional narcotics, benzodiazepine, and alcohol. A large Medicaid study across New York documented that more than a third of persons being treated for opioids using agonist medication (medication that activates the opioid receptors in the brain) were obtaining narcotic prescriptions outside of their maintenance prescriptions. In one instance, an individual was found to have received 49 prescriptions for hydrocodone, oxycodone, or methadone while on medication assisted treatment for opioids. Both increased doses and mixing of medications while on agonist maintenance can make overdoses more likely.
Third, polydrug-abusing individuals who lack steady employment, housing, and strong family support may not be in a good position to be able to sustain a regimen of daily medication, particularly for buprenorphine. The delivery system for buprenorphine – outpatient through doctors’ offices – was not designed for individuals prone to criminal behavior. Studies increasingly reveal that diversion of medication, especially buprenorphine, is the rule, not the exception, in the community. With a study finding that more than 11,000 children and adolescents were reported to poison control centers for exposure to buprenorphine between 2007 and 2016, the last thing jails and prisons should be doing is increasing that deadly exposure in the community. The recent introduction of injectable buprenorphine may ultimately help, but the cost will be prohibitive.
Fourth, the limited number of jails and prisons that induce individuals on methadone or buprenorphine upon entrance are finding most do not continue these medications after release. A study of individuals continued on methadone when incarcerated in Connecticut prisons found only 40.6 percent re-engaged within the first 30 days upon release. Similarly, the Rhode Island corrections department reports that 32 percent of those induced on methadone or buprenorphine continued on these medications after release.
Their motivation to begin agonist medication understandably appears to be avoidance of the agony of withdrawal from opioids, not a commitment to long-term recovery after release. Once released on methadone or buprenorphine, these individuals must either enter detox, withdraw cold turkey, or return to illicit drugs. The retention rate for injectable naltrexone after release is also problematic, but stopping does not result in withdrawal.
Medication-assisted treatment adds value to any drug treatment program. All of the issues raised above can be addressed. But simply providing medication to incarcerated individuals is insufficient, and may even be harmful in some cases. Jail and prison medication-assisted treatment requires concurrent treatment, support, and tight monitoring as well as seamless transition to comprehensive community aftercare, support, and supervision upon release. This requires coordination, commitment, and increased resources currently unavailable to jails and prisons, the Massachusetts parole and probation departments, and to the communities individuals will be released to.
Andrew Klein is the senior scientist for criminal justice at Advocates for Human Potential of Sudbury.