
I just got back from the NC Society of Addiction Medicine’s spring conference, and it was even better then I’d hoped. The presentations were informative and inspiring. Today I feel even more enthusiastic about helping our patients.
The sessions about providing care to incarcerated patients with opioid use disorder were particularly beneficial. We got to hear how Durham County is successfully providing all three FDA-approved evidence-based medications as treatments for opioid use disorder, as well as various counseling and other services. They can serve as a model for all one hundred North Carolina counties.
We had a presentation from a lawyer who reported all the cases around the country that have been settled in favor of patients who were denied medical care for opioid use disorder. It’s obvious from that information that all jails and prisons will ultimately make all three medications available– depot naltrexone, buprenorphine products, and methadone – to treat patients with opioid use disorder who are incarcerated. It’s no longer a matter of if…but how long it will take and how many lawsuits need to be brought before carceral facilities will offer these life-saving treatments.
The same is true for opioid withdrawal. It is no longer acceptable to give a few clonidine pills on day four and call it “withdrawal management.” Though most healthy adults don’t die from opioid withdrawal, medically more fragile patients certainly can and do die from withdrawal. Families who brought lawsuits for wrongful death have won giant awards, sometimes up to seven figure awards.
Last week I was excited to read this headline in our local paper last week: “$1.46 Million Awarded to Help Free Inmates from Addiction.”
Finally, I thought. All those letters I’ve been writing, begging the local jail to continue methadone and buprenorphine for our patients with opioid use disorder when they enter jail have worked. Someone is now interested in helping our patients with opioid use disorder.
Then I read the article.
It’s not bad news but it wasn’t as good as I’d hoped.
As it turns out, a grant was awarded for depot naltrexone injections for people with opioid use disorder, as well as alcohol use disorder. Jail inmates diagnosed with either disorder will be offered the injection, better known under the trade name Vivitrol. This monthly injection of naltrexone blocks opioid receptors and prevents any euphoria from illicit opioids. Some of the studies on Vivitrol also show it lessens cravings for opioids.
Then when the inmates are released, they will be referred to Project Lazarus, a local non-profit agency that will provide services for people with substance use disorders. At Project Lazarus, patients on Vivitrol will be assigned peer support specialists and group counseling sessions. Their Vivitrol injections will be continued for about six months, at an expected cost to the grant program of around $1500 per injection.
According to the newspaper article the sheriff’s office felt there was a need for a medication assisted treatment program at the Wilkes County Jail. However, this grant will not fund the two medications that are most heavily evidence-based for the treatment of opioid use disorders: buprenorphine or methadone. Apparently these two medications, deemed narcotics, are still not allowed in the jail.
I have such mixed feelings. This grant is a good thing, as far as it goes. Vivitrol is an evidence-based treatment that can help patients with opioid use disorder and alcohol use disorder. I suspect there may be as many or more people with the latter disorder who can be helped.
But to allow Vivitrol but not the more heavily evidence-based medications methadone and buprenorphine still violates the ADA and denies appropriate care to patients. It also means that the jailers and jail medical personnel will remain open to lawsuits from patients and action from the Department of Justice.
Years ago, I tried to talk to our county jail’s medical director, and it did not go well. I tried to convince him to allow our patients on methadone or buprenorphine to stay on their medications while incarcerated. Not only did he refuse to consider my request, but he called me a legal drug dealer and I called him… I think I compared his intellect, unfavorably, to a sack of hair. It wasn’t a great interaction.
Vivitrol is a tricky drug to start. If one of our opioid treatment program patients ends up in the county jail, I hope the medical personnel – likely a nurse – giving the Vivitrol injection knows not to give the Vivitrol too early, before the patient has completed acute withdrawal from methadone or buprenorphine.
Vivitrol’s not an easy shot to give. It’s viscous and you have to give it slow enough to minimize pain but fast enough, so it doesn’t clot in the needle.
Patients can have bad reactions to Vivitrol even if they are not physically dependent on opioids when the shot is given. Many specialists make sure the patient can tolerate the medication by giving a few days of oral naltrexone before giving a month-long shot. Will providers know about this option? Or will they give tester doses of naloxone IV or IM?
Will patients be pressured into taking the shot, since they will be in an environment that expects them to follow orders? There’s tremendous danger of abuse of power in such a setting. Patients may feel like they must start Vivitrol in order not to get on the bad side of the legal system. I hope they will be able to consult their lawyers about this if they have misgivings.
Some patients considering Vivitrol fear what might happen if they get into an auto accident or other trauma. They worry they wouldn’t be able to get pain relief once given a Vivitrol shot. That is a legitimate concern, though the Vivitrol can be over-ridden by an infusion of fentanyl in a worst-case scenario. Naturally, patients fear the emergency department doctor that they see for trauma would not be willing to give fentanyl. The drug company that makes Vivitrol does includes a little wallet card in each dosing kit, intended to notify caregivers that the patient is on Vivitrol.
I’ve decided to see this Vivitrol grant as a good thing. It’s a first step. Hopefully as jail medical personnel get more comfortable helping patients with alcohol use disorder and opioid use disorder they will be more open to also allowing buprenorphine and methadone.
Maybe after the jail is using Vivitrol for a few months, I’ll call and try to mend the fences with their medical director.