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.
- 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
- “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.
- Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
- Davis vs Carter, #05-1695 US Court of Appeals, Seventh Circuit http://openjurist.org/452/f3d/686/davis-v-carter