In Midst of Opioid Crisis, an Addiction Medication Program for Federal Prisons FizzlesThursday, September 28, 2017 By Mike Ludwig, Truthout | Report
In the spring of 2014, as rising rates of opioid misuse and fatal overdoses were capturing the nation's attention, the Office of National Drug Control Policy (ONDCP) was working on a national initiative to expand access to addiction medications known as medication-assisted treatments, or MATs. The ONDCP had just come under the direction of Michael Botticelli, President Obama's new drug czar, whose background in public health rather than law enforcement signaled to some that a shift was happening in federal drug policy.
A memo circulating among top staff at the Bureau of Prisons at the time stated that the White House was "eager" to include federal prisoners in its national drug treatment initiative. The federal prison system's substance abuse programs were not working for the vast majority of prisoners with opioid use disorders, so, the memo said, MAT should be provided as an additional option in federal prisons for the first time. A small number of jails and state prisons already had MAT programs, and the ONDCP had pushed for a federal program since late 2013.
Federal prison officials made plans to run a "MAT field trial" in Texas. Ten prisoners with a history of opioid dependence who were nearing the end of their sentences would receive a series of injections of a controversial drug called naltrexone as they transitioned from prison to a halfway house and then back into the free world. Unlike methadone and buprenorphine, two well-established forms of MAT that are psychoactive and therefore frowned upon by prison wardens, naltrexone blocks the effects of drugs like alcohol and heroin. If the naltrexone helped the participants stay sober after their release, a multi-disciplinary team would expand the pilot to 200 participants in the hopes of eventually offering injections to prisoners nationwide.
Three years later, the Bureau of Prisons has little to show for this effort, according to interviews with experts and documents obtained under the Freedom of Information Act. At least six of the original 10 participants did not complete the initial field trial, and prison officials never expanded the program beyond Texas, despite filing million-dollar budget requests in 2016 and 2017. The results of the field trial were never published, at least not publicly, and official recommendations on how to continue the program were redacted from documents released to Truthout.
In an email statement, the Bureau of Prisons public affairs office said the MAT program continues, although it's limited to "one region of the country" and "medication that we already have on hand." The office would not say how many prisoners are participating in the program.
Meanwhile, methadone, buprenorphine and naltrexone, the triad of treatments approved by the FDA to treat opioid use disorder, are unavailable for that purpose in federal prisons, according to the system's latest formulary. Methadone and Suboxone, a combination of the buprenorphine and the opioid blocker naloxone, may be used to treat initial withdrawal symptoms when prisoners are admitted but not the underlying disorder. Methadone may also be used to stabilize female prisoners with opioid disorders when they are admitted during pregnancy, but treatment ends after the child is born.
Now that President Trump is in the White House, the Bureau of Prisons' most recent budget request does not mention an expanded naltrexone pilot or any other MAT program, noting instead that the field trial was completed in 2015. Kevin Fiscella, an addiction specialist who advises the National Commission on Correctional Health Care (NCCHC), points out that Trump's special commission on "combating addiction and the opioid crisis" recently called on the Department of Justice to increase the use of MAT in jails and prisons. Meanwhile, groups such as the National Governors Association are promoting MAT behind bars at the state level.
"I was very disappointed that the Bureau of Prisons, particularly under the Obama administration, did not show leadership in pushing harder for medication-assisted treatment and using all the appropriate modalities under that," Fiscella, who is a professor of public health at the University of Rochester and a member of the American Society of Addiction Medicine, told Truthout in an interview.
The Bureau's continued failure to offer any type of MAT in the vast majority of facilities appears to fly in the face of the Obama administration's advocacy for an expansion of access to medical treatments. Such reforms may not be a priority under the Trump administration, which has emphasized the role of law enforcement in responding to drug problems rather than public health solutions.
While Obama and Botticelli successfully pushed Congress to pump funding for MAT into public health departments and treatment centers, they did not advocate for drug decriminalization. For many people, using opioids and other drugs remains illegal, and the majority of people incarcerated in the US have experienced drug dependency or misuse. In 2015, 469,545 people were incarcerated for drug-related charges, and 82 percent of drug arrests in 2010 were for possession alone. Most drug users are not addicts, but 80 percent of people who do have opioid disorders go untreated because of financial obstacles, social stigma and limited capacity at treatment centers, the vast majority of which do not offer MAT, according to the Drug Policy Alliance.
A prisoner's chances of dying from an overdose after being released from prison are 100 times higher than that of the general US population.
As long as drugs remain criminalized and addiction goes untreated, local jails will be de facto detox centers in areas hit hard by opioid misuse. This creates deadly conditions within the criminal legal system that have become increasingly visible in media coverage of the "opioid crisis" and "overdose epidemic." Doctors know that treating addiction often requires medication, but correctional officers have long opposed administering methadone and buprenorphine. The two drugs act like opioids in the brain to stave off cravings and withdrawal symptoms, stabilizing patients during recovery and allowing them to live normal lives. MAT patients don't get high off the drugs, but non-patients potentially could, and prison wardens often fear the drugs will be "diverted."
As a result, people with opioid use disorders -- including those already prescribed MAT -- face painful and dangerous withdrawals when they are locked up, often for crimes stemming from drug use or simply being unable to afford bail. Prisoners with opioid use disorders also lose their tolerance, putting them at an increased risk of overdosing. The death rate among prisoners within two weeks of release is already 12 times that of the general US population, but their chance of dying from an overdose is 100 times higher or more.
The MAT Debate Behind Bars
As rising numbers of opioid-related deaths made headlines, state prisons and local jails began experimenting with naltrexone injections sold under the brand name Vivitrol. Vivitrol's manufacturer, Alkermes, marketed the drug to judges, drug courts, jails and prisons as a medication-assisted treatment that can't be used to get high. The company recently came under fire after lobbying for legislation in several states that cornered the market for MAT in Vivitrol's favor. Alkermes also spent $4.4 million lobbying Congress in 2016 alone. Now the drug has gained a foothold in local jails and state prison systems nationwide.
Andrew Klein, a criminal justice scientist who provides technical assistance for drug treatment programs in jails and prisons with the Bureau of Justice Assistance, said there are now MAT programs in 29 state prison systems and almost 200 jails nationwide, although some programs are still in the pilot stage and many only offer Vivitrol injections, not methadone or buprenorphine. At this rate, he said, the federal system may be the last to offer MAT on a broader scale. "Which is too bad, you would hope that the federal Bureau of Prisons would be a leader," Klein said in an interview.
Alkermes now expects Vivitrol sales to jump from around $300 million this year to more than $1 billion in 2021, according to the pharmaceutical industry trackers at FiercePharma.
Vivitrol's success may be exciting for investors, but it has left doctors and addiction specialists deeply concerned. They say Vivitrol doesn't work for everyone, but prison officials are using it as a way to offer MAT without the supposed headaches that come with methadone and buprenorphine.
Fiscella said Vivitrol offers officials a sense of "command and control" over prisoners' bodies that fits into their ideas about criminal justice, even if it doesn't work as well as the other medications. "It's not that [Vivitrol] doesn't have a use, it's just been way over-promoted," he said.
Fiscella said methadone and buprenorphine have been used to treat opioid dependency for years, but Vivitrol was originally developed to treat alcoholism and its ability to treat opioid disorders is not as well established. Vivitrol is good at blocking the effects of opioids, but it also can have severe side effects, including painful sores and an increased risk of suicide and depression. Patients must also be "highly motivated" to keep monthly appointments for injections. Methadone and buprenorphine patients often stick with prescribed regimens because they would start detoxing otherwise. Vivitrol users don't have the same "pharmacological motivation," and those who are exiting prison may struggle to keep up with treatment while dealing with a host of other challenges that come with reentering society after incarceration.
Fiscella said patients are more likely to complete a Vivitrol program when there's a level of coercion involved, such as orders from a drug court. The criminal legal system is inherently coercive, and a defendant or prisoner may enroll in a Vivitrol program to please a judge or parole officer. But is coercion a positive thing? Coercing captive patients into medical treatment raises a host of ethical issues, and research suggests coerced Vivitrol treatment may not be effective in the long-term. A 2016 study found that Vivitrol reduced the rate of relapse among recently released prisoners who were paid to participate, but rates went back up after the paid treatment ended. Patients would have no tolerance to opioids at the end of a Vivitrol program, so the risk of overdosing during a relapse is high.
Joshua Lee, an associate professor of population health at the NYU School of Medicine and a co-author of the study, told Truthout that it makes sense to offer Vivitrol to prisoners who want treatment but are unable or unwilling to access methadone or buprenorphine after being released. However, Klein said that only about 13 percent of eligible prisoners sign up to participate in even the most successful Vivitrol pilot programs.
"The idea still has legs and momentum, because obviously the company markets to criminal justice entities to promote this model," Lee said, adding that there's plenty of research to show that methadone and buprenorphine can improve outcomes when prisoners start therapy at the end of their sentence.
There are other limits to Vivitrol's effectiveness. Vivitrol does not treat withdrawal symptoms, and incarceration often cuts people off from methadone or buprenorphine therapy, forcing them to detox. This is particularly a problem in jails, where prisoners tend to be held for shorter periods of time after being charged with minor crimes. Fiscella said forced detox is traumatic and even deadly, particularly when symptoms like vomiting and dehydration exacerbate existing health problems. The experience can dissuade people from returning to MAT therapy afterwards. For this reason, jails in nearly a dozen states and state prisons in Vermont, Connecticut and Rhode Island offer methadone.
"The pendulum is swinging in the right direction, and bit by bit, we're seeing more access to all of these medications throughout the country," Lee said. "But the status quo is a lack of evidence-based treatment being available in a lot of cases."
Methadone and buprenorphine are highly regulated and administering them requires approval from the government, which critics say creates unnecessary stigma around the drugs and makes them harder to get both in and out of prison. For example, doctors are not allowed to prescribe buprenorphine to more than 275 people at a time, and even that requires a federal waiver. Fiscella wonders if this is one reason why "diversion" is such a concern. Indeed, people are often jailed for possessing buprenorphine without a prescription or trying to smuggle the drug to prisoners suffering withdrawals.
"These problems are not that expensive, it's really a question of commitment, not a question of money," Klein said of the extra work jails and prisons must do to offer MAT. In the meantime, he hopes the interest in Vivitrol is warming the criminal legal system up to MAT and potentially saving some lives in the process.
Lee points out that there is no set "protocol" for administering methadone and buprenorphine to prisoners serving multi-year sentences, which may explain why the drugs are not used in federal prisons, where prisoners tend to be convicted of more serious crimes. However, Fiscella and other advocates say the drugs should at least be available and the decision to use them should be left up to each patient and their doctor. Unfortunately, that's not how medicine works behind bars.
Pulling the Opioid Problem Up by the Root
MAT is slowly finding its way into jails and prisons in one form or another, but it's not happening fast enough to put a dent in the overdose epidemic. Meanwhile, the debate over MAT behind bars raises serious questions over coercion in drug treatment and whether people who use and sell drugs should be caged for breaking the law in the first place.
Prisons exacerbate drug problems whether they provide medical treatment or not.
Monica James is a formerly incarcerated Black trans woman in Boston who works as the national organizer for Black and Pink, a group that supports LGBTQ prisoners and works toward the abolition of the prison-industrial complex. James said she often sees people using drugs on the street near her office and has experienced drug abuse herself. Massachusetts has seen a significant spike in overdose deaths since 2010, and the state prison system recently embraced Vivitrol and connecting ex-prisoners to treatment in the community.
However, James points out that opioid overdoses -- and a system of criminal punishment that makes it harder for drug users to access treatment -- was a problem in communities of color long before the current opioid crisis began making headlines. James said reforms like offering MAT in jail have only come now that "the zip codes have changed," and more people are fatally overdosing in majority-white suburbs and rural areas. Activists even wonder if the data that shows a spike in overdose deaths is inaccurate, because coroners did not track overdoses in Black communities for years.
"They marked it as suicides, you know," James said.
The Obama administration may have promoted MAT and other drug treatments for opioid users but simultaneously pumped money into law enforcement efforts to counter illegal drug sales while criminal penalties for possession were increased in several states. This will certainly continue under the Trump administration, which has pledged to fight drug trafficking tooth-and-nail.
"We keep making adjustments when the zip code changes, and that adjustment that we make is getting tougher on the holder, the supplier, which is generally minority folks, poor folks that are making ends meet and formerly incarcerated folks who can't get jobs," James said.
James said prisons exacerbate drug problems whether they provide medical treatment or not. They do not provide adequate educational resources and mental health care, and finding a job that is legal after being released is not easy for those who have prison time on their record. The prison system takes care of basic needs like food and shelter, but after a sentence is completed, a person must go back to the real world and start paying rent.
"What are they supposed to do, go under a corner and die?" James said. "They get back to doing what they have to do and hope that this time the odds are in their favor."
James said the criminal legal system's response to the opioid crisis addresses the concerns of whiter zip codes, not the underlying inequalities that drive society's drug problems and keep jails and prisons filled with poor, Black and Brown people.
"We have to get to the root," she said. "We know the root, and the root is one that nobody wants to pull up and address."