Maybe a bit controversial topic but we decided that it is important to speak about medications for OUD in Jails and Prisons in the US. Read this article to learn more on the legal acts and the medications itself. Let's dive in!
These kinds of medications it's proven to work, and we will discuss that a bit later, however many jails and prisons don’t offer them.
People with OUD are a vulnerable population. If you have diabetes type 1 and you go to jail you will be offered the needed injections in no time, as that will be a violation of your human rights. However if you have OUD and go to prison your therapy will usually stop.
One lesser known fact is that there is the Americans with Disabilities Act (ADA). The ADA recognizes the past addiction to alcohol or drugs as a disability as it affects brain and neurological functions. Let’s learn more!
Medications for OUD in Jails and Prisons
Here are the events concerning Medications for OUD in Jails and Prisons chronologically that might interest you:
3400 B.C
Historically, opiates the word is derived from the opium poppy while opioids referred to synthetic drugs that affect the “mu receptors”.
The earliest reference to opium dates back to 3400 B.C., when poppies were cultivated in Mesopotamia. The Sumerians called the opium poppy “Hul Gil” or simply the “Joy Plant”. Then around 460-357 B.C, Hippocrates acknowledged opium's use as a narcotic.
1972
There have been three MOUDs (Medications for opioid use disorder) approved by the US Food and Drug Administration (FDA) – methadone, buprenorphine, and naltrexone. Encouragingly, now a growing number of correctional facilities are offering MOUDs. Methadone was approved for treating opiate addiction in the mid-1960s and was approved by FDA for this use in late 1972.
1973
The Rehab Act from 1973 protects against disability discrimination in a wide range of contexts. It states that “individuals with a disability” shall, not be excluded from the participation in, be denied the benefits of, which includes drug addicts. However the only condition is to not be consuming alcohol or drugs anymore.
2014
In October 2014, under the direction of the Vermont Legislature, the DOC began a two-facility pilot project providing OUD individuals with these kinds of drugs for 30 to 90 days. Treatment included medication and counseling as required under Vermont law.
Individuals taking either buprenorphine or methadone who were incarcerated past 90 days were medically withdrawn. There were a total of 323 people, 98% (406 admissions) either completed the 90-day maintenance period or were on continued medication when released from detention that was before the expiration of the 90-day period. Just 7 individuals were disenrolled from the pilot for violating the program conditions.
The DOC reported a cost of $1,600 per month to administer the medications through the pilot program. Security associated with the pilot program—such as correctional officers cost approximately an additional $1,100 per month.
Building on this facility buprenorphine maintenance pilot, on May 25, 2018, the Vermont governor signed into law Act 176, establishing medication and counseling as the prevailing medical standard for the treatment of OUD.
2017
In 2017, there was declared an opioid crisis by the national health emergency. At the time, over 2.1 million people in the United States had OUD , and two out of three drug overdose deaths involved opioids. Meaning, overdose deaths from opioids, including prescription opioids, heroin, and synthetic opioids, increased nearly six-fold since 1999. That is why Donald J. Trump issued a nationwide call to action.
He suggested three steps:
● Step 1: reducing demand and over-prescription
● Step 2: cutting down on the supply of illicit drugs.
● Step 3: helping those struggling with addiction through treatment and recovery support services.
2018
Research from in 2018 by the Pew Charitable Trusts determined that only 14 states or territories in the U.S. offered methadone or buprenorphine maintenance in any of their jail or prison facilities, 39 offered injectable naltrexone as a preventative measure prior to release, and only one state (Rhode Island) offered all three FDA-approved medications for OUDs.
2019
Let’s go back to recent history. BOP in 2019 has proved naltrexone as eligible for incarcerated individuals. However methadone and buprenorphine use is still under inclusive.
Most jails and prisons forbid methadone and buprenorphine, even when legitimately prescribed, on the grounds that they pose safety and security concerns.
However, around the country, see MAT in jails and prisons that it is not just good policy, but that it is legally required under the Rehabilitation Act, the Americans with Disabilities Act, and the Eighth Amendment.
2022
There are two basic models of MAT in correctional settings now, by New Jersey and Rhode Island.
The first model provides the full range of medications for OUD, with the purpose to stabilize individuals over the course of their sentences and after release. The second model, exemplified by Kentucky and Massachusetts, focuses on relapse prevention.
While there are additional excellent programs that could have been featured here, the panel of experts considers these to be well-delineated and replicable.
Types of MOUDs
The use of MOUD is a relatively recent phenomenon, with just a few exceptions. Today, only a small number of prisons and jails provide even one of these medications. Accordingly, there are fewer studies examining the effects of this treatment on returning citizens in prison than there have been for those in communities. Here are the three types:
● Methadone
● Buprenorphine
● Naltrexone
Methadone
Methadone as we explained is the strongest full agonist medication, which binds preferentially to mu opioid receptors in the brain, blocking the effects of illicit opioids like heroin. It also reduces withdrawal symptoms and cravings for opioids.
Delivered in the proper dosage there is no experience of intoxication, euphoria or sedation, and you could perform daily tasks safely and effectively. But be careful as methadone is an opioid, it causes physiological dependence, and can cause serious side effects including respiratory suppression. Most serious side effects will occur, within the first 2 weeks of methadone treatment.
When used to treat OUDs, methadone must be prescribed from a federally regulated opioid treatment program (OTP); Methadone is typically dispersed in liquid form, but is also available as a pill.
Buprenorphine
Buprenorphine is a partial agonist and it partially stimulates opioid receptors in the brain while also producing some blockade effects. It effectively treats withdrawal symptoms and cravings but it is less likely to cause intoxication or dangerous side effects like methadone. Buprenorphine can also cause physiological dependence.
It is commonly administered as a pill or buccal film. Buprenorphine is also available as a monthly injection or subdermal implant that lasts for approximately 6 months, and the effects appear to be superior to the oral formulations.
It may be combined with another medication, with no problem, like with naloxone, which is far less stronger. This combination has been proven to significantly reduce inappropriate usage.
Buprenorphine may be prescribed outside of a licensed OTP by physicians or other qualified medical practitioners who have completed a requisite training course and received accreditation referred to as a DATA-2000 Waiver.
Naltrexone
The last of the medications for OUD in Jails and Prisons that we elaborate in this article is Naltrexone. This drug is a full antagonist medication that binds to opioid receptors in the brain but does not stimulate those receptors. It does not cause physiological dependence, intoxication, or serious side effects.
You can find Naltrexone in pill form and an injectable version, Vivitrol, it is FDA-approved for treating opioid and alcohol use disorders, and the effects last for approximately 28 days. It is also available as a subdermal implant; however, the implant is not FDA-approved in the US.
Although the oral formulation does not reduce opioid cravings, Vivitrol was reported to reduce cravings in randomized trials.
Naltrexone does not require special licensure or certification to administer and it can be prescribed or dispensed by any licensed medical practitioner.
It is non-addictive and has relatively minimal side effects, fewer concerns are commonly expressed about tapering a naltrexone regimen. Some experts recommend taking naltrexone for at least one year; also some have been treated successfully for at least five years with no negative effects.
How to choose which drugs to prescribe?
Medical practitioners advise you to take a multitude of factors into account when deciding which medication to use. Here is what you can consider:
● Person’s medication preference and their motivation for change
● Other prescription medications being taken by the person
● Age at onset, duration, and severity of opioid use
● Co-occurring psychiatric or medical conditions
● Prior history of use of MOUD
● Prior response to MAT
● Family history of mental health and/or substance use conditions
Dosing
Suggested average methadone doses are approximately 30 to 50 mg per day over brief intervals of a few weeks to about 6 months. However, significant improvements have been reported when doses exceeded 60 mg (and often higher than that) over several months to more than a year.
Benefits of medications for OUD in Jails and Prisons
Why do we bother so much to get accessibility to this kind of medication for all justice involved individuals with OUD?
The answer is simple: there are many benefits, for the prisoners and the society.
● Reduced risk of overdose
● Reduced risk of HIV or viral hepatitis infections
● Lower rates of cellulitis
● Reduced criminal in the community
● Reduced rates of psychiatric complications in the society
Why is it so difficult to incorporate medications for OUD in jails and prisons?
There are three major reasons why prisons don’t use medications for OUD:
● Misconceptions
● Concerns of security
● You need registered with the U.S. Drug Enforcement Agency to use
Misconceptions
Some of the reluctance of criminal justice leadership to adopt MAT comes from a misunderstanding of MAT and the mechanisms. That is mostly because some officials and practitioners view these medications as a replacement to regular drugs. They see it as “substituting one drug for another”. Incorrect perceptions about the functions of MAT medications and their side leads to an underutilization of this evidence-based treatment.
Concerns about security
Concerns about security and the risk of diversion cause some jails and drug courts to either limit or deny access to buprenorphine or methadone, misuse, and potential overdose are also liability concerns for some courts.
Some jails and prisons simply do not have the capacity to treat SUD in their facilities.
You need registered with the U.S. Drug Enforcement Agency to use
Many jails and prisons think that they can provide methadone maintenance therapy only if they are registered with the U.S. Drug Enforcement Agency as an OTP. However, they may also make methadone accessible without having to become certified as OTPs through agreements with community-based OTPs. That will allow methadone to be securely transported to a facility from an OTP or enable inmates to be transported to a community-based OTP for dosing. More information about these options can be found in the Federal Guidelines for Opioid Treatment Programs.
Economic Costs
State Medicaid offices can take steps to ensure that all three medications approved for OUD treatment are included on the formulary for the purpose of treating opioid use disorder. This will enable individuals in the community to access the medication in a timely manner.
The Council of Economic Advisors to the White House have estimated that the economic cost of the opioid crisis is $504.0 billion. The average annual cost per person of incarceration in U.S. prisons of methadone maintenance treatment—approximately $24,000 versus $4,700 annually per person.
A California study, outside of the prison context, found that providing treatment saves approximately $17,550 per person treated over six months, compared to forcing detoxification.
The decision to obtain medication for opioid or alcohol use disorders, and the specific medication chosen, should be the individual’s, after consultation with medical and treatment providers, not imposed by a justice or treatment agency.
Conclusions
MAT drugs work by binding to opioid receptors in the brain, which are the same receptors that would otherwise be activated by heroin or morphine. Without these drugs, returning citizens who struggled with opioid abuse are at risk for relapse, or overdose.
The term “medication-assisted treatment” in no way suggests medications are less important or less effective than behavioral interventions for OUDs. In the early stages of treatment, evidence suggests medication alone may be adequate to enhance treatment retention and initiate abstinence.
Providing dependent drug users a highly addictive drug is always risky and for that reason it requires tight guidelines as to how much and for how long the drugs should be made available.
The state may need to lead conversations to foster changes in MAT programs. Thinking about recovery as an outcome of a jail-based program can be a shift from traditional approaches and will require correctional staff.
Some programs offer only one or two of the three FDA-approved MAT medications. Others require that dosages of MAT be so low that they are clinically ineffective. Incarcerated people should have meaningful access to all of the three MAT medications that are medically appropriate for them at a clinically appropriate dosage.
Let us know what you think in the comments!
Reference:
Suboxone as MATS began being used in FCI Terminal Island by FBOP in 2021. Program functioning satisfactorily, although constant problems with inmate diversion. Definitely humane though --- I got off Buprenorphine in 2017 after sentencing, as the BOP "did not believe in MATS" at the time. It was rough, but I am clean now !! What better place to withdraw than Federal Lockup