Posts Tagged ‘Suboxone in jail’

Suboxone Patient Wins Lawsuit

 

 

 

 

In Maine, as in most other states in the U.S., patients on medication-assisted treatment for opioid use disorder weren’t allowed to take their life-saving medications while incarcerated.

All that changed in October of this year, when the American Civil Liberties Union settled a lawsuit with the Maine Department of Corrections. The ACLU sued on behalf of Zach Smith, who has been on Suboxone for five years as treatment for opioid use disorder. He was told he would have to stop taking Suboxone during his incarceration. I wrote of the pending case in my blog on August 12, 2018.

We know that if denied his medication, he would go through physical opioid withdrawal and would be at higher risk for overdose death, particularly immediately after release from incarceration.

The ACLU took his case and settled a lawsuit with the Maine Department of Corrections, which ultimately agreed to allow him to continue on his medication. Jailers warn that this was a “special case” and that they would not necessarily allow other prisoners to take buprenorphine as prescribed by a physician. However, this appears to be a clear precedent for other patients and other lawsuits.

I think this is a landmark case for our patients. MAT is the standard of care, and it should be illegal to refuse to provide this treatment to people who are sentenced to incarceration. The diversion of Suboxone films has been an issue for many years because patients in opioid withdrawal can’t access suboxone through any legal channel. This creates a black market for suboxone, and jailers across the country have complained loudly about this situation – that is of their own creation.

The ACLU is supporting patients in their fight to continue medication-assisted treatments during incarceration is other states, too. According to the ACLU website, a similar case is pending in Washington state.

If you are a patient – or know a patient – who is being denied medication-assisted treatment during incarceration, I hope you have a lawyer who is willing for fight for your rights. If you do not, consider reaching out to the ACLU in your state:

For North Carolina: https://www.acluofnorthcarolina.org/

 

ACLU Sues to Allow MAT During Incarceration

 

 

 

I was sent a link to this article that made my day:

https://bangordailynews.com/2018/07/26/mainefocus/aclu-lawsuit-demands-maine-man-get-addiction-treatment-in-jail/

This article reports that the ACLU (American Civil Liberties Union) has taken the case of a man in recovery on medication-assisted treatment who must serve a nine-month jail sentence starting in September in Maine. This man, Zachary Smith, has been in recovery on a buprenorphine product for the past five years. Ordinarily, the jail has a policy of NOT continuing medication-assisted treatment to inmates, leading to forced withdrawal from these medications.

Opioid withdrawal doesn’t (usually) kill healthy adults but can be fatal to people in fragile health. Acute withdrawal does cause significant suffering, and it leaves the person at increased risk of death from overdose upon release from incarceration.

The ACLU says there are two reasons why denying this medical care is against the law. First, denying medical treatment to inmates violates our 8th amendment against cruel and unusual punishment. Second, the Americans With Disabilities Act recognizes opioid use disorder as an illness covered by that Act. This means denying appropriate medical treatment for this condition is discrimination.

The ACLU filed a preliminary injunction to speed up a hearing of the case prior to the beginning of the jail sentence. This means the case will be heard – hopefully – before Mr. Smith must show up for his sentence in early September.

I was so happy to see this case. I think it could be a watershed moment for this nation, one way or the other. I have never understood how it could be legal for a person to be denied medical care while incarcerated, yet it happens across this country every day. In most jails, patients in treatment for opioid use disorder with medication-assisted treatment are denied their medication.

I’ve blogged about this before. I’ve even called the NC chapter of the ACLU myself, many years ago, to ask for help, but was told I had no standing, and that it needed to be the patient to contact the ACLU for help. But my patients sentenced to jail are often reluctant to bring an action against their local jail, feeling they might receive retribution of some sort – a very realistic concern, at least in my area.

Can you imagine the uproar if any other group of patients with chronic illness were denied medical treatment? What if patients with heart disease were denied life-sustaining medications during incarceration? What if diabetics were denied their insulin? For all I know, this may be happening. If it is, citizens of this country should not stand for this. We shouldn’t stand for it for people with substance use disorders, either.

Since all of this is happening in Maine, I was curious if North Carolina has any similar cases pending. I went to the website of the North Carolina chapter of the ACLU and found nothing advocating for inmates to be continued on medication-assisted treatment for opioid use disorder.

However, I did find that our state chapter of the ACLU filed a federal class action lawsuit against North Carolina’s Department of Public Safety’s policy of denying treatment for Hepatitis C to incarcerated people with the virus. The current class action suit was filed on behalf of all people incarcerated in NC with Hepatitis C.

https://www.acluofnorthcarolina.org/en/press-releases/aclu-incarcerated-people-sue-nc-failure-provide-life-saving-treatment

Current expert recommendations are that all incarcerated people receive Hep C testing, since according to data from the Center for Disease Control, around one-third of all prisoners are infected with Hepatitis C.

In the past, recommendations were to wait until the person with the Hep C virus developed liver damage before treating. Those expert recommendations have changed. The current recommendation is that all people with active Hep C infection should be treated. Experts now also recommend treatment even if the patient has not stopped illicit drug use.

The NC Department of Public Safety’s present policy is that incarcerated people with Hep C infection that’s caught early, when at its most treatable, are forbidden to receive treatment while incarcerated.

This article says there’s no law for universal testing of prisoners for Hep C, and the decision to test is left up to personnel at each jail site.

Both issues are important, though to me, continuing access to medication-assisted treatment appears more pressing, and could prevent more deaths in the short term.

I will follow these cases, and give updates to my readers.

 

 

Methadone and Buprenorphine During Incarceration

aaaaajail

I recently got this comment to my blog and I hope the writer won’t mind that I’m highlighting his comment. This comment represents one of my pet peeves: patients in recovery from opioid addiction who dose with methadone/buprenorphine are frequently denied their medication if incarcerated.

“Hello, i was recently convicted of an addiction related crime that happened over a year ago, since the indecent I’ve cleaned up my act, have been taking suboxone for over 12 months, 8mg, 3 times a day and now have to go to jail were I’m going to be denied my medication by jail officials/laws, I’ve been in jail before and i kno they do next to nothing for withdrawing opioid patients? From what i hear, it could take months for that type of dosage to get out of my system? Now being a former i/v heroin user of about 7 years, I’ve done a#on my body and feel my health isn’t exactly top notch, i am legitimately concerned about this withdrawal! Should there be sum kind of law protecting us patients? Aren’t these dangerous withdrawal symptoms? Thanks in advance for your response in this matter!”
I am so sick of hearing about patients on methadone or buprenorphine being denied their treatment while incarcerated! I’d love to see someone sue the excrement out of a jail or prison for denying this life-saving medical treatment.

Most counties jails in rural North Carolina won’t allow patients who are prescribed methadone or Suboxone for opioid addiction to take their medication while in jail. I hear (second-hand) that some jails allow chronic pain patients with opioid prescriptions to take their medication, though this may vary according to the county.

As a health care provider, of course I’m opposed to any refusal to treatment a patient while incarcerated. I think it’s a violation of the 8th Amendment about cruel and unusual punishment, but since I’m no legal scholar, I’ve searched the internet for more information about this situation. I found a great article co-authored by a doctor and a lawyer. They make the point that opioid addiction is a complex illness, and forced withdrawal causes severe physical and psychological suffering. Also, because opioid withdrawal makes people especially vulnerable, they may be coerced into giving testimony that incriminates themselves. They are less able to make decisions. (1)

Prisons are charged to provide as much care as is available to prisoners as general population, yet opioid addicts are denied access to medication-assisted treatments for addiction. These treatments are, as you probably know if you’re a regular reader of this blog, one of the most evidenced-based medical treatments in all of medicine.

Jails face legal implications for the prisoners under their control if adverse health consequences occur during withdrawal. A healthy young person usually won’t die from opioid withdrawal, but a medically fragile patient may die. Then the jail can be sued successfully for wrongful death, as happened in Orange County, Florida. But what a shame that it has to come to that to see any change in jail protocol.

A few years ago, I wrote to both the Tennessee and North Carolina chapters of the ACLU (American Civil Liberties Union), thinking if any legal organization would be willing to take up this issue, it may be them. One person with the NC chapter wrote back that in order to take up a case, they need a specific person with a specific case, and that person needs a local lawyer with whom they can work.

I other words, as a physician, I can’t get something stirred up. It has to be a person who is denied treatment with methadone or buprenorphine while in jail.

That’s what I’m hoping to do with my blog post. My readers know many people. If you are reading this and know someone facing incarceration who will be denied their usual medical treatment of methadone or buprenorphine while incarcerated, encourage them to get a lawyer, and ask that lawyer to ask for outside help.

Here’s the website for North Carolina: http://www.acluofnc.org/

As one might imagine, Tennessee’s chapter of the ACLU has many issues to keep them busy, so check it out at http://www.aclu-tn.org/ On their homepage, there’s an article about Tennessee’s contract with a corrections company that operates facilities in that state. It’s interesting reading, and may help us make sense of some of Tennessee’s horrible decisions around addiction issues (follow the money!). Also check out the TN ACLU’s article of protest against the recent law that makes using drugs during pregnancy a crime instead of a health issue.

I know that AATOD (American Association for the Treatment of Opioid Dependence) works with the Legal Action Center in New York, and they have a great website: http://www.lac.org You can read about their advocacy efforts nationwide, and check out their blog, which has advocacy information about this specific issue of medication-assisted treatment behind bars. I believe that the Legal Action Center works with local lawyers nationwide to serve as a resource. I don’t think the LAC actually takes on the cases of patients in states other than New York, but they also may be able to offer help and resources to other lawyers.

My patients tell me it’s difficult to find a local lawyer willing to take on the case of medication-assisted treatment behind bars. Often, such patients are seen as “bad” for having the disease of addiction. Some lawyers may not want to risk the working relationships they have with the judges in their area by advocating for an issue that the lawyer may not find compelling.
Additionally, it’s easy to intimidate many patients on MAT because they already feel shame and stigma. They have a legitimate fear of making their situation worse if they protest poor treatment by the criminal justice system.

I understand all of that, and I’d probably feel the same way. But what’s being done to patients on MAT – forced withdrawal from life-saving treatments of methadone/buprenorphine – isn’t right, and it’s an abomination to human rights. Let’s support these patients in every way possible. Get lawyers, ask them to advocate for you. If they won’t, contact some of the above resources and write back to me about what their response was.

If you are a friend or relative of a person in such a situation, make noise. Write politicians, call the jails, and call judges, particularly those that are elected. Tell jailers how appalled you are at the senseless suffering of patients denied their usual medical treatment.

Most importantly for this issue and others: register to vote. Find out your elected officials’ positions on the legal issues surrounding addiction, and vote accordingly. If you are an addict in recovery, vote. If you are a friend or family member of someone in recovery or in addiction, vote. Let politicians know you will vote against them if they fail to make good laws based on science.

As for me, I have a standard letter I’m willing to send to my patients’ lawyers and to the judges hearing their cases, advocating strongly for them to be allowed to continue their evidence-based treatment with methadone/buprenorphine.

And yes, I vote.

1.Bruce RD and Schleifer, RA, “Ethical and Human Rights Imperatives to Ensure Medication-Assisted Treatment for Opioid Dependence in Prisons and Pre-trial Detention, International Journal of Drug Policy, 2008, February; 19(1): 17-23.

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