Treatment of Opioid Use Disorder During Incarceration

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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