Treatment of Opioid Use Disorder During Incarceration

Change is coming, but slowly.

In the past, many county jails and state prisons refused to allow patients prescribed methadone or buprenorphine to remain on their medication during incarceration. Most experts felt this was denying medical treatment to inmates, something which – we thought – was not allowed in the United States. But due to the stigma against opioid use disorder and the medications commonly used to treat it, our patients were denied treatment repeatedly.

Now there’s hope on the horizon.

Last month, a patient with opioid use disorder, successfully being treated with methadone, was sentenced to thirty days in jail in DuPage County, Illinois. The Chicago Tribune covered the story, but you can also read pertinent details on the website of the Legal Action Center (LAC). [1]

This patient, instead of resigning herself to a miserable thirty days of methadone withdrawal, decided to petition the court system to allow her to be able to take her prescribed medication as usual. I probably don’t have to point out to my regular readers that methadone treatment for opioid use disorder reduces the risk of death by at least three- fold. Remaining on her usual medication would prevent relapse once she’s released from jail, commonly a time for overdose death. And of course, continuing her medication would prevent agonizing withdrawal syndrome.

This patient had been in treatment for her opioid use disorder since 2019 but got a DUI back in 2016. It took five years for her to be sentenced to jail time for her DUI. In her lawsuit, the patient asked a federal judge to make sure she was allowed to take her usual medication as prescribed. The complaint stated that depriving inmates of needed medical treatment for opioid use disorder is cruel and unusual punishment and violates the Americans with Disabilities Act. The complaint correctly stated that the refusal to continue the patient’s treatment placed her in grave and immediate danger.

She brought her lawsuit with the help of the LAC, working with the American Civil Liberties Union. DuPage County, where she would serve her sentence, was alleged to have an unwritten policy of prohibiting people from dosing with methadone or buprenorphine, even when prescribed by a physician. The county denied this, saying that each patient’s needs were evaluated on a case-by-case basis after a physical exam. However, no non-pregnant inmate was ever allowed to remain on methadone or buprenorphine in the jail’s history.

Based on that last fact, it strains credulity to believe this patient would have received her methadone as usual had she not brought her case.

From what I understand by reading internet reports, the federal judge said this patient had not yet been denied her medication, so she needed to wait until it was denied before she could bring her lawsuit to court.

County jail officials, likely sensing the shitstorm that would descend upon them if they denied this patient her medication after attention her lawsuit had received, finally decided to do the right thing, and give the patient her medication.

County officials made some sort of laughable statement that a “headline-grabbing lawsuit” wasn’t needed for this patient to get proper care, and that they would have done the right thing without a lawsuit…but I doubt that. I am judging DuPage County’s attitudes and actions by the ones I’ve encountered at rural North Carolina’s county jails.

In May of 2019, a federal judge ruled that a patient in Maine, sentenced to forty days in jail, must be allowed to remain on her usual daily dose of Suboxone. She was in recovery on this medication for five years before she was sentenced to this term. The judge said that denial of medication-assisted treatment would cause serious and irreparable harm to the patient, and that denial would violate the Americans with Disabilities Act. The patient asked Maine’s division of the ACLU to assist her attorneys in bringing her suit against the county jail.

Attorneys for the county jail had argued that medical personnel at the jail are able to manage opioid withdrawal symptoms, apparently meaning withdrawal could be managed without Suboxone. But they lost the case, and the patient remained on Suboxone during incarceration.

I was very happy with the outcome of this case, and a few others like it, scattered around the country these last two years.

In my state of North Carolina, there are now around five counties that will allow patients in treatment for opioid use disorder to remain in treatment. These counties are to be congratulated for their progress. However, in my county, patients prescribed methadone or buprenorphine products for opioid use disorder are NOT ALLOWED to dose in our county’s jail while incarcerated. The jail medical personnel have some sort of a detox protocol that involves clonidine (which may help a little) and clonazepam. The latter medication, of course, serves to place inmates at even higher risk of death if they relapse back to opioid use once they leave jail.

Use of clonazepam is not part of any legitimate opioid withdrawal protocol that I’m aware of. Plus, it is a controlled substance. If the jail is willing to dose controlled substances, why not just dose the patient with the evidence-based, life-saving medication that the patient is already on?

I have tried talking to county jail medical personnel. The nurses who work there are sympathetic, for the most part, but medical policy about patients on methadone or buprenorphine seems to be set in stone by someone above them. I once talked via phone to the jail doctor, but it went very badly. He was like other doctors of a certain age, who feel they must talk much, much more than they listen. I had to interrupt to get any time to speak at all, and he then became derisive towards medication-assisted treatment in general and dismissive toward me personally. So much for my attempt at gentle education in the name of cooperation. Not everyone remains teachable throughout life.

I’ve been trying to get patients at our opioid treatment program to reach out to our state’s ACLU branch when it’s obvious they will be sentenced to a jail term and denied their usual medication for opioid use disorder. So far, none have taken this step. I’ve tried to call the ACLU for them, but was told I don’t have standing, and it must be the patient who calls to ask for their help.

Understandably, many patients worry that filing a lawsuit to be able to get their usual medications may backfire. If they don’t win, they fear angering the prosecutor or judge. They worry they may face more severe punishment if they attempt to advocate for themselves.

I understand their fears, and I can’t tell them it’s unfounded. If they bring a suit and lose, perhaps they would be treated more harshly. The law enforcement and judicial system in this county is not as forward-thinking as I would prefer, though it is improving.

Our opioid treatment program participated in a three-year grant that paid for treatment for patients involved with the criminal justice system. This grant just ended last August. Our staff worked with local probation and parole officers, who got to see first-hand the dramatic improvements in patients’ lives when evidence-based treatment with medication for opioid use disorder is available. Some of those officers still refer their clients to us, even after the grant ended. But other officers remain cool towards our treatment program, though at least they have stopped telling our patients they must get off of methadone or buprenorphine to remain on probation. Small victories.

Many jail systems, large and small, say they can’t allow methadone or buprenorphine dosing of inmates already prescribed these medications because of diversion risks. Staff say such medications would be diverted from the patient for whom it is prescribed, presenting overdose risks to other inmates.

That argument suggests that jail personnel are unfamiliar with observed dosing protocols that OTPs use every day. We could teach jail staff these simple techniques. And again, if the jail is already giving out doses of clonazepam, what steps are they now using to make sure the dose goes to the patient for whom it is intended?

And from what I see and hear from patients who have been incarcerated, plenty of drugs are already circulating in some jails and prisons. Availability seems to vary a great deal at different facilities, for whatever reason, but these places don’t allow methadone or buprenorphine through approved channels.

It’s possible to find creative solutions to all the issues that make methadone and buprenorphine administration difficult for incarcerated patients.

Jail systems say they don’t have the manpower to bring each patient to the opioid treatment program to be dosed each day. However, that would not be required in every case.

Most patients could be issued take home doses for whatever time frame the medical director feels in appropriate. For example, a relatively stable patients could be brought to our OTP for observed dosing every two weeks, with daily take -home doses issued for the thirteen days in between visits. These doses could be given, via chain of custody forms, to jail personnel to be taken to the county jail and stored in a locked container. Chain of custody is a method where there is documentation of which personnel are in possession of the medication each step of the way. When a dose if given to the patient, jail personnel watch to make sure it is consumed and can document this.

Or perhaps OTP staff could bring the medication to the local jail and do observed dosing there, then, when appropriate, leave daily doses of medication in the care of medical personnel to be stored in a locked safe until the next dose is due.

For patients on sublingual buprenorphine products prescribed by office-based providers, the methods could be much simpler. The patient could bring in their bottle or box of medication with them when they report for incarceration, and the medication can be stored under lock and key. It can be dosed daily, with jail personnel watching to make sure the medication dissolves and no residue remains under the tongue or in the mouth, to prevent diversion.

Sublocade could be an excellent option for buprenorphine patients. This is an injection that can be given once monthly, so that the jail personnel would only need to bring that patient from the jail to the provider once per month for their injection, instead of worrying about daily dosing. And with the injection, diversion of medication would not be an issue. Soon, we may have weekly injections available, also eliminating fears of medication diversion.

My point is that I believe we can work together to find solutions to every possible problem raised by continuing patients on life-saving methadone and buprenorphine, if only we have the will to do so.

These half-assed, county jail “detox protocols” must stop. They are insufficient to prevent withdrawal, not evidence-based, and they place patients at unnecessary risk of overdose death once the patient is released. They interrupt a legitimate medical treatment that has more evidence to support it than nearly anything else we do in the field of medicine.

Medically fragile patients can die from improperly treated opioid withdrawal during incarceration. I’ve blogged about this before. Who can forget the case of David Stojcevski, who died from benzodiazepine and methadone withdrawal, sixteen days into his incarceration? He lost forty-four pounds and suffered from hallucinations and seizures during his time in this county jail. The family brought lawsuits against the county jail, which still has not been resolved. The county jail employees pointed their fingers to Correct Care Solutions, a company that was supposed to have provided medical care to their inmates. Of course, Correct Care Solutions pointed their fingers at county jail employees. Since all this happened, Correct Care Solutions was bought by another company and merged into Wellpath LLC. This new company is also plagued with lawsuits alleging improper care of inmates. [2]

I’m going to continue to tell my patients facing incarceration about recent lawsuits, and I’m going to continue to point them towards the Legal Action Center in New York, and our state’s chapter of the ACLU. I’d love for one of my patients to make a little history in the cause of patients’ rights.

And I’ll testify for my patients for free, with pleasure, if I am asked.

  1. https://www.lac.org/news/dupage-county-sheriff-sued-for-access-to-life-saving-medication-to-treat-opioid-use-disorder
  2. https://www.metrotimes.com/news-hits/archives/2020/03/12/lawsuit-targets-billion-dollar-company-making-life-and-death-medical-decisions-in-michigan-jails

10 responses to this post.

  1. I just sent the US attorney and the ACLU vice president the name of the county your OTP IS IN AND THEY will be hearing about the quote that you gave so hopefully they come will bring suit against your county. great work doctor and congratulations on your advocacy award. I only wished to see you in person and
    that I finally got to meet you to see you get the award I won it two years ago and gave it to Zac and usually the former award winners sit at the same table so I was so excited when I heard you made it through the process so big congratulations and this is an example of the things you do to advocate for people like me and a lot of us with opioid use disorder.

    Reply

  2. Posted by Christopher Dover on March 8, 2021 at 5:08 am

    I’m pretty sure Australia is one of the countries (where I live) that allows an opioid dependent person to remain on their methadone or suboxone in prison. But we have some other very Draconian laws out here for example a ban on e-cigarettes.
    To remove diversions just dose the person daily in prison without any take-aways.

    Reply

  3. Posted by Mark Wulff on March 8, 2021 at 6:42 am

    Thank God these inmate patients have advocates.
    It would be hard to think of any crueler nor inhumane punishment than to force someone cold turkey off Suboxone or Methadone albeit some are fortunate enough to have some mitigation of symptoms with Clonidine and Clonazepam.
    A death sentence implemented swiftly would be kinder, I know it would have for me if I had been put in that position.

    Reply

  4. Posted by Tracy Goen, MD on March 8, 2021 at 1:39 pm

    Dr. Burson,
    I have been following your blog for a few years now and was happy to see your latest post. I am the medical director at the Buncombe County Detention facility in Asheville and we have implemented an MAT program here with strong support from the Sheriff and the county commissioners. After having practiced in TN, this has been an inspiring experience. The tide is finally changing and we are doing all we can here to hasten the turn. Thank you for expressing your experiences and thoughts on this subject.

    Tracy H. Goen, M.D.
    Diplomate, American Board of Addiction Medicine
    Fellow, American Society of Addiction Medicine
    American Academy of Addiction Psychiatry
    Medical Director, Buncombe County Detention Center
    Medical Director, Swain Recovery Center/The Women’s Recovery Center
    NC Society of Addiction Medicine
    Medical Examiner, FMCSA
    Medical Review Officer
    Assoc. Clinical Professor, Quillen COM, ETSU

    Reply

    • Thanks for writing, that is excellent! Would you be willing to explain how you run the program and coordinate with the OTP/OBOT practices in your area?

      Reply

  5. Posted by Donna Strugar-Fritsch on March 12, 2021 at 10:40 pm

    On a more positive note, the National Commission on Correctional Health Care and the National Sheriffs Association partnered on a document in Nov. 2018 calling for access to all FDA approved forms of MAT for OUD to be made available to all jail inmates under the auspices of a medical treatment plan. https://www.ncchc.org/jail-based-MAT

    The American Correctional Association partnered with ASAM on a document in Feb 2018 calling for the same. https://www.asam.org/docs/default-source/public-policy-statements/2018-joint-public-correctional-policy-on-the-treatment-of-opioid-use-disorders-for-justice-involved-individuals.pdf?sfvrsn=26de41c2_2

    Several State Opioid Response programs and philanthropies and BJA have funded efforts to help jails and prisons implement MAT. There are even Project ECHO teams helping rural jails start MAT. In CA, we have multi-agency teams in 35 counties working in a Learning Collaborative and their jails have provided MAT continuation and in-custody inductions to > 8500 jail detainees. I have worked with jails in many other states as well. Today, the question is not IF a jail should treat OUD with evidence-based practices, but HOW. Not all jails have been asked to embrace this, though, and of course much work remains. That said, an effective approach is to “teach” the jail that its professional organizations expect them to do this and share the documents. You can also refer them to the Bureau of Justice Assistance Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP) which has tons of resources and grants to help jails get on board with treatment. https://bja.ojp.gov/program/cossap/overview

    PS I really enjoy your blog

    Reply

  6. Given the high prevalence of SUD among people who are incarcerated, states should prioritize treating these individuals with OUD using methadone or buprenorphine the medications supported by the most evidence, and then connect them to maintenance care upon re-entry into the community.

    Reply

  7. Posted by lilley toole on November 8, 2021 at 5:22 am

    I’m so glad I found this blog and began subscribing to it. I’m beginning to realize the importance of patient rights. I was denied methadone maintenance at the only outpatient clinic in my county after I filed a complaint with attorney general’s office. This put me in a terrible position. I had unsuccessfully tried to detox off methadone for years at the time I filed my complaint. In the past I’d be readmitted immediately with no questions asked when I tried and failed to withdraw on my own. Within one week approximately I realized that I still was having trouble. The clinic’s doctor refused to provide me a fourteen day detox, which regardless of a patient’s exit(voluntary or involuntary) I read was an entitlement provided to everyone. I was also not allowed to be officially readmitted either. In seventeen years on methadone maintenance I had only been denied treatment there once. After I filed my complaint. He asked me if I had actually filed against him with attorney general’s office and I admitted that yes I had. I recognized substandard treatment was harming me but without Medicaid reimbursement (not until after 2019) I couldn’t afford a private methadone clinic. I had to continue using the community outpatient clinic. I was trying to manage the best way I could within the system. Nearly twenty years on Methadone and the attorney general’s office didn’t assist by helping me locate adequate care or make some kind of reasonable accommodations. Although, until Medicaid picked up the tab, there’s practically nothing a person seeking medicated assisted treatment could do. The attorney general’s office didn’t bother to explain how my complaint might deny me adequate care once he was notified. Hell, I wasn’t denied access to just adequate care, I was was denied access to any kind of care at all. Too sick to function or file suits on my own, too poor to hire a lawyer. I began self medicating and within one year contracted Hepititis C. Also contributed to being homeless and addicted to heroin. I would hope the ACLU wants to help me but I’m not sure how to communicate properly with them. They defend people in jail constantly but what about someone like me? I just wanted to receive adequate care, informed patient consent and not have my damn constitutional rights violated. I took it for granted that I could trust the professionals in my community. Was that not ok? Are the things I mentioned merely rhetorical and not realistic? Would I find a doctor willing to help me request help reaching the ACLU and explaining what opioid dependency is like without any medical care? I’m devastated and I’m still praying my daughter’s HEP C tests are negative soon. I gave birth to a beautiful one year old baby but she suffered too. I’ll die if she’s got my hep c from pregnancy. I’m on Suboxone now. Life’s beginning to improve. They’re all lucky it i didn’t die from the lack of community support I didn’t get back then. Any suggestions how to get ACLU to recognize I need help??? Please don’t hesitate to email me here. prettygalprettycool@gmail.com
    prettygalprettycool@gmail.com
    I’ll be researching in the meantime. Pray for me. Pray for my daughter. Thank you very much

    Reply

    • I think if you put your state’s name and ACLU into the search engine, it will give you the information you are seeking.
      As to the other thing…I don’t think any doctor who has been reported to the state attorney general by a patient would want to treat that patient afterward.

      Reply

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