Archive for the ‘methadone in jail’ Category

Smuggling Suboxone

I was intrigued by an article I saw on my internet homepage. It was titled: “When Children’s Scribbles Hide a Prison Drug”

http://www.nytimes.com/2011/05/27/us/27smuggle.html?_r=1&hpw

 This article describes unique ways Suboxone is being smuggled into jails. Law enforcement officials associated with both state and county jails from Maine and Massachusetts were interviewed. They say prisoners and their accomplices make Suboxone into a paste and smear it over the surfaces of papers sent to prisoners from their families. The article mentions the paste being spread over children’s coloring book pages, and under stamps. Suboxone films have been placed behind stamps or in envelope seams. Correctional officers now have to inspect material coming in the mail to prisoners much more closely.

 I had several thoughts. First, yet again, I’m struck by the creativity and cleverness of addicts. If only they could channel this energy in the right direction, amazingly good things could come to them, instead of the continued hardships brought by addiction.

 Then I felt sad that such actions described in the article would taint the reputation of a medication that has the potential to save lives, when used appropriately. Such illicit use of Suboxone gives ammunition to those who would prefer that office-based treatment with Suboxone didn’t exist.

 Then I wondered, how many of these prisoners have a legitimate prescription for Suboxone, but are denied their medication by prison officials? How many are legitimate patients of methadone clinics, also denied their medication while imprisoned, who know that Suboxone will alleviate some of the opioid withdrawal they are feeling? How many of these people are addicted to opioids, not in any kind of treatment, but who know Suboxone will treat their withdrawals?

At least one study supports the idea that many people use Suboxone illicitly not to get high, but to prevent withdrawal. Dr. Schuman-Olivier studied 78 opioid addicts entering treatment. Nearly half said they had used Suboxone illicitly prior to entering treatment. Of these people, 90% said they used to prevent withdrawal symptoms. These addicts also said they used Suboxone illicitly to treat pain and to ease depression.

Many law enforcement personnel and members of the legal community have strong biases against medication-assisted treatments. They don’t understand that addiction is a disease, and that methadone and buprenorphine are legitimate, evidence-based treatments. They have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine.

 But no matter what law enforcement personnel think they know, when they deny prescribed, life-saving medications, I believe they’re practicing medicine without a license.

The article mentions one woman who, with the aid of the Maine Civil Liberties Union, sued because her Suboxone treatment had not been continued while she was in jailed for a traffic violation. She settled out of court, but her lawyer made the excellent point that if inmates are denied their medications, they will try unlawful means to get it.

Other patients and their families have brought successful lawsuits against the jail facilities. In at least two cases, in the same Orange County, Florida jail, patient/prisoners were allowed to go through withdrawal for so long that they died. The estate of one person won a three million dollar judgment against the county. (1, 2)

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

Orange County now works with local methadone clinics. If a prisoner is a current patient of a clinic, his clinic will send a week’s worth of medication in a locked box via courier. Nurses at the jail have the key to the box, and administer each day’s dose. The jail doctor consults with the medical director at the methadone clinic. Prisoners still have to pay out of pocket to get the medication, so the only cost to the jail is the time required for personnel to administer the medication. It’s certainly much cheaper than paying three million to the estate of a dead prisoner, not to mention much more humane.

I wish the county jails around the methadone clinic where I work would approach the problem of opioid addiction and treatment in a collaborative way. Sadly, only seven state prison systems offer medication-assisted treatment with methadone or buprenorphine.

Rikers Island, in New York City, gives us another example of how such a system could work. There, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity. (3)

Drug courts trying to save money would be well-advised to look at the Rikers Island program. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (3, 4)

I know from comments written to this blog that there are many more people abusing Suboxone than I previously imagined. For sure, some of the prisoners getting smuggled Suboxone are misusing it. But I don’t think the majority are using for anything other than prevention of withdrawal, since they are usually not offered any other effective treatment for this medical condition.

  1. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
  2. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
  3. Par`rino, Mark, “Methadone Treatment in Jail,” American Jails, Vol: 14, 2000, issue 2, pp 9-12.
  4. California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295

 

The Narcotic Farm: A Bit of History

We don’t have to keep re-inventing the wheel.

We can investigate the success rates of addiction treatment methods used over the past century, see what worked, and what didn’t work. We can use programs of proven benefit or we can continue to spend money on programs repeatedly shown to have little benefit.

From 1935 until 1962, drug addicts were treated at a unique facility, part jail and part treatment hospital. Initially named the United States Narcotic Farm, it was later changed to the U.S. Public Health Service Narcotics Hospital. Even after this name change, most people still called it the Narcotic Farm.

This facility was located on twelve acres of Kentucky farmland. The facility was created by the Public Health Service and the Bureau of Prisons, meant to serve a dual purpose. It was a treatment hospital, where drug addicts could voluntarily be admitted for treatment of their addiction, and it was also a federal prison, where drug offenders were sent to serve their sentences. About two thirds of the inpatients were prisoners and the other third were addicts, voluntarily seeking help for opioid addiction. Both types of patients were treated side by side. For over forty years, it was the main drug addiction treatment center in the United States, along with a similar facility in Ft. Worth, Texas, which opened in 1937.

            The Narcotic Farm was a massive institution for its time. It had fifteen-hundred beds, and housed tens of thousands of patients over its forty years of operation. It was located in a rural area of Kentucky, which gave it space for numerous operations to engage the prisoners – now called patients – in all types of job training. (1)

             The Narcotic Farm really was a farm. Besides growing many types of vegetables, there was a working dairy, and livestock including pigs and chickens. These operations provided food for the patients and staff of the facility and provided work for the patients. The patients provided the labor to keep the farm going and it was hoped they would simultaneously learn useful trades. In addition to farming, they learned skills in sewing, auto repair, carpentry, and other trades. Besides teaching new job skills, it was hoped that fresh air, sunshine, and wholesome work would be beneficial to the addicts. (1)

            For its time, the Narcotic Farm was surprisingly progressive in its willingness to try multiple new treatments. For the forty years it operated, many different treatments were tried for opioid addicts. It offered individual and group talk therapies, job training, psychiatric analysis, treatment for physical medical issues, Alcoholics Anonymous meetings, art therapy, shock therapy, music therapy, and even hydrotherapy, with flow baths to soothe the nerves. Despite these options, the Farm apparently retained many of the characteristics of a prison, with barred windows and strict security procedures. (1)

             The Narcotic Farm had its own research division, the Addiction Research Center (ARC), which became the forerunner of today’s National Institute on Drug Abuse (NIDA). The Narcotic Farm did pioneering work, using methadone to assist patients through withdrawal, and helped establish the doses used to treat opioid addiction. Methadone was used only short term, for the management of withdrawal symptoms, and not for maintenance dosing at the Narcotic Farm. The Farm also trained a dedicated group of doctors and nurses, who were pioneers in the field of addiction treatment. It provided new information on the nature of addiction.

             Admission to the Narcotic Farm allowed an opioid addict some time to go through opioid withdrawal, eat regular meals, work in one of the farm’s many industries, and have some form of counseling. However, after leaving the hospital, the addicts were entirely released from care and supervision, with no assistance to help re-enter their communities. Most times, they returned to their same living situation and old circumstances encouraged relapse back to drug use and addiction. As a result, two follow up studies of the addicts treated at the Narcotic Farm showed a ninety-three percent and ninety-seven percent relapse rate within six months, with most of the relapses occurring almost immediately upon returning home. Many addicts cycled through the Public Health Hospital multiple times. (1)       

            The Narcotic Farm was eventually turned over to the Bureau of Prisons in 1974, as the treatment for addiction was de-centralized. Since the studies found high relapse rates for addicts returning to their previous communities, it was hoped by moving treatment centers into communities, these addicts could have ongoing support after they left inpatient treatment.

  1. Nancy P. Campbell, The Narcotic Farm: The rise and fall of America’s first prison for drug addicts, (New York, Abrams, 2008)

 

This is an excerpt from my new book, “Pain Pill Addiction: Prescription for Hope.” 

Available at http://prescriptionforhope.com

 and on Amazon and Ebay

and many bookstores

Pain Pill Addiction: Prescription for Hope

Finally, here’s the cover of my book about pain pill addiction and its treatment. It’s available at http://prescriptionforhope.com or you can order it from Amazon, and soon from Barnes and Noble.

My book contains much of what I’ve been blogging about. I wrote the book because there are so few sources of reliable information about the treatment of opioid addiction (pain pills). It seems  that abstinence-based programs don’t like to talk about medication-assisted programs, and some methadone clinics don’t let their patients know about other options. Methadone and buprenorphine can be life-saving when used appropriately, but they have some drawbacks, as well.

There’s not one single right answer for all opioid addicts. Some treatments work for some patients, but no treatment works for all patients. In my book, I present the data supporting treatment methods, so opioid addicts and their families can chose the best course.

If you like this blog, you’ll like my book. I also have a chapter in the book about the unjust stigma patients face when they are treated with medication-assisted methods. It takes a strong person to stay on a treatment that helps them, despite criticism from friends, family, law enforcement, and even unenlightened medical professionals.

Judges Behaving Badly

When a valid form of addiction treatment is criticized by someone who knows next to nothing about it… I nearly always go into a dither. I’m better than I used to be, but not much.

Recently, a patient at one of the methadone clinics where I work said he appeared before a judge for offenses committed prior to entry into treatment at the methadone clinic. The patient says the judge ordered him to get off methadone as part of his sentence, which also included public service, intensive probation, and monetary fines. I’m going to make sure the patient’s report is accurate before I begin my literary assault by letter. But I suspect the judge actually said what my patient reports.

It amazes me a judge would foolishly practice medicine, by dictating what an opioid addict, ill with a disease, can or cannot do to get treatment for their disease.

It’s not like methadone is a flash in the pan. It’s been around for 45 years. It’s one of the heaviest evidence-based treatments in all of medicine. Plus, we have several studies showing opioid addicts who leave methadone treatment have a death rate at least eight times higher than opioid addicts who stay in methadone treatment. (1, 2)

 That’s death rates. And dead addicts don’t recover.

If other equally effective options were available to this young man, I wouldn’t be as upset by the judge’s ruling. If the patient could afford to stay in a medical detoxification unit for seven to ten or more days, followed immediately by prolonged inpatient residential drug rehabilitation of thirty to ninety days, I might agree with the judge. But this young man can’t afford that kind of treatment. State funded treatment exists, but usually patients can stay a week in a detox and one, maybe even two weeks in rehab, which is rarely enough for an opioid addict. Outpatient treatment, without replacement medication, results in relapse rates consistently shown to be in the range of 96%.

In my letter to the judge I’m going to try to gently educate, which seems to be the best approach to the law and order type people. In my letter to the judge I’m going to cite several studies, and direct the judge towards an excellent NIDA (National Institute on Drug Abuse) website with all essential information regarding treatment of opioid addiction with methadone: http://international.drugabuse.gov/collaboration/guide_methadone/index.html

This wonderful tool, in a question and answer format, contains valuable information about methadone and its use in the treatment of opioid addiction. It contains references to all of the best and most commonly cited studies about methadone. If you have questions, check it out.

1. Scherbaum N, Specka M, et.al, Does maintenance treatment reduce the mortality rate of opioid addicts? Fortschr Neurol Psychiatr, 2002, 70(9):455-461.

2. Zanis D, Woody G; One-year mortality rates following methadone treatment discharge. Drug and Alcohol Dependence, 1998: vol.52 (3) 257-260.

Law Enforcement Behaving Badly

Many law enforcement personnel and members of the legal community resist medication-assisted treatments. They seem to have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. I find it difficult to work with these professionals. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine. Law enforcement personnel have ways of letting methadone patients know they are regarded as if they’re still using drugs.

            When I worked at a methadone clinic in the mountains of North Carolina, we had a Tennessee resident, a pregnant woman, who committed a crime before she sought treatment at our methadone clinic. By the time she was sentenced to three months of incarceration, she was seven months pregnant. She asked to begin her sentence after delivering her child and her request was denied by the judge. He said he would cure her addiction by placing her in jail and then, at least, the baby wouldn’t be born addicted to methadone. He had been informed she was in treatment at a methadone clinic in North Carolina.

The patient contacted her counselor at the methadone clinic, in a panic, because she knew she could miscarry if denied methadone.  Opioid withdrawal could even kill her fetus. Her counselor called me and related all of the details.

I was surprised that a judge would make a medical decision like that, and if he did, it was only because he didn’t have information about methadone. I called the judge’s office, but couldn’t get through to him. I explained everything to his clerk, and believed the patient would either be given methadone in jail or have her sentence postponed.

The next day the patient called, and said she was still going to start her sentence in two days, and that the judge hadn’t changed his mind. I called the judge again, and was told the judge wasn’t going to come to the phone to speak with me, the clerk had relayed the message, the mother was going to jail and no, she would not be given methadone.

Now irritated and worried, I composed a letter, detailing the possible medical complications that could occur, as a result of the judge’s uninformed and ill-advised decision, and told him this was a medical decision that should be made by doctors. I described the preterm labor that could occur, if the mother was allowed to go into withdrawal. The fetus may not be able to survive if born at seven months’ gestation. I ended with a plea that no matter what he thought of the mother, the baby at least should be given the best chance for survival. I faxed a copy to the judge and a copy to the patient’s lawyer. Later, I heard she was allowed to deliver a healthy baby boy, prior to beginning her three month sentence.

Recently, I was asked to speak at an addictions conference, in the heart of the Blue Ridge Mountains, about methadone and its use in the treatment of opioid addiction. The speaker who gave a presentation after me was a lawyer with the local drug court. He explained how drug court got addicts, who committed crimes related to drug use, to participate in treatment, rather than just sending them to jail.

During the question and answer session, he was asked if patients on methadone could participate in the drug court program. He said no. When asked why this was, he said that to participate, the addicts must be completely drug free. Another member of the audience asked why this was the case, if methadone was a legitimate treatment and it had been started by a physician.

            The lawyer did not give a clear answer, but turned to the program director of a local outpatient treatment center, sitting in the audience.  The drug court contracts with this outpatient treatment center, to provide the counseling needed for the addicts participating in drug court. This program director said that addicts on methadone couldn’t come to the counseling his center provided because they “would give their methadone to other patients and nod off in treatment sessions.”      

            This was a clear example of the biases methadone patients face. I had just completed a lecture about methadone and had explained how opioid treatment center patients don’t receive take home doses for at least the first three months, and how patients on the right dose are not sedated, unless they use nerve pills or other sedatives. In the above case, both the court and the treatment program were opposed to methadone, and they didn’t have a clear policy on buprenorphine.

            That said, at present, the majority of drug courts don’t allow participants to be on methadone, though methadone has been shown to be very cost effective as well as beneficial to opioid addicts.

            At Rikers Island, in New York City, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity.

            Drug courts would be well-advised to look at the Rikers Island program, for an example of the effectiveness of methadone maintenance. They should also consider the amount of money it can save the community. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (1)

            Many jails will not dispense methadone to prisoners who are patients in at a methadone clinic, even if they are doing well and on a stable dose. Many times, these patients are allowed to go through a terrible withdrawal. Patients tell me they have been taunted for being ill from withdrawal from methadone, and refused access to medical care. This refusal to treat an illness with an accepted and effective medication has been costly to at least one county in Florida.

            In 1997, an Orange county jail inmate died after being denied her usual dose of methadone. She spent twelve days in withdrawal, before she was found dead in her cell. The family sued the county and won a three million dollar settlement. (2) Then in 2000, a second person died in the very same Orange county jail, under nearly identical circumstances. (3) She had been a patient at a methadone clinic for about five months, before entering the jail. She was denied her medication, and was found unconscious three days later, from an apparent seizure. She was then taken to a hospital, and her family removed her from life support five days later.

            In 2001, Orange County decided to offer methadone to patients who were already established at a methadone clinic, and continue their dosing. They’ve worked out arrangements with a local methadone clinic to provide the necessary methadone. Opioid addicts who are not established in any kind of treatment are treated with a standard opioid withdrawal protocol. Soon, Orange County may begin to use buprenorphine in this jail setting.                                                                                                                                                              More jail facilities would be wise to heed the experience of Orange County.

            In Cook County, Illinois, a man serving a ten day sentence for a traffic violation died of methadone withdrawal on his sixth day of imprisonment. He was an established patient of a methadone clinic, but the jail refused to provide his methadone medication. He made repeated requests for medical attention, but was denied care, despite his obvious physical suffering, witnessed by at least three jail employees. (4) He died of a cerebral aneurysm, as a result of opioid withdrawal. His wife and estate sued the county, for failing to provide timely medical treatment, charging them with deliberate indifference to the suffering of the prisoner. 

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

            On a positive note, more jails and prisons across the U.S. are beginning to offer access to medication assisted therapies, with both methadone and buprenorphine. Colorado has several counties that coordinate care with local treatment centers. A clinic within Albuquerque’s city detention center offers treatment with methadone. Rhode Island’s department of corrections contracts with a local treatment center, to treat opioid addiction. The jail in Seattle-King County, Washington, plans to offer both methadone and buprenorphine soon.

            Will this country ever become civilized enough to provide appropriate medical care to patients on replacement medications while they are in jail? I hope so. Sadly, it appears that litigation is the only way to get the attention of some jail facilities.

  1. California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295
  2. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
  3. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
  4. Davis vs Carter, #05-1695 US Court of Appeals, Seventh Circuit http://openjurist.org/452/f3d/686/davis-v-carter
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