Jails finally offer drug treatment, but is it the right kind?
July 9, 2017 | By Terry DeMio
Inmates with heroin addiction can be more likely to die within days of leaving lockup than if they stayed on the streets. That’s why addiction specialists are calling for jails and prisons to provide medication-assisted treatment to this vulnerable population.
It took until 2016, but six of seven jails in the Cincinnati region either offer at least one form of medication-assisted treatment or plan to do so, an Enquirer review shows.
Treatment for incarcerated inmates is so new that there’s been no time to test whether it can break the cycle of crime that often accompanies addiction. A Warren County judge who pioneered the treatment there in 2013 says ex-offenders on the medication are living their lives and not returning to his court.
Despite the near blanket availability of treatment programs, the Enquirer review also shows none of the local jails offer all three FDA-approved medications for heroin and opioid addiction disease: methadone, buprenorphine and injectable naltrexone. Offering all the options is important, experts say, because there is no one-size-fits-all treatment.
Rhode Island shows it can be done, but the program that started in 2016 costs the state roughly $1.9 million annually.
“Our governor saw overdose deaths as an important issue that needed to be addressed head-on with the best possible science,” said Dr. Jennifer Clarke, medical director of Rhode Island Department of Corrections.
The Rhode Island prison and jail program is so unusual that neither Clarke nor experts at the National Center on Addiction and Substance Abuse could think of another like it in the nation.
“Unfortunately, evidence-based treatment is not standard practice in the criminal justice system,” said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse.
Care for addicted inmates matches that for people on the outside only in one situation: Pregnant women generally receive methadone or the buprenorphine brand medication Subutex while incarcerated. Every jail in Southwest Ohio and Northern Kentucky provides it, the Enquirer review of jail policies shows.
“This is necessary for care of the unborn child,” said Kevin Pangburn, director of the Kentucky Department of Correction’s division of substance abuse services, referring to his state’s program.
Nearly every jail in the Cincinnati area has at least one medication for at least part of its non-pregnant, addicted population. It’s injectable naltrexone, known best by its brand name, Vivitrol.
“It’s better than nothing,” said Dr. Joshua Lee, associate professor in New York University’s Departments of Population Health and Medicine.
“The research doesn’t really create a hierarchy between treatments,” said Lee, an addiction expert. “All are good options.” A medical practitioner should decide which works best for each individual, he said, adding, “That’d be how you treat cancer or colitis.”
The extended-release medication is a non-narcotic that blocks the effects of heroin and opioids for about a month. Then the next shot is given. It’s accepted by the criminal justice system because primarily because it’s non-narcotic. The other two medications, methadone and buprenorphine, are synthetic opiates that have a bias against them, Vuolo said.
Suburban county judge pioneers treatment
Warren County Common Pleas Judge Robert Peeler was a regional trailblazer in pursuing medication-assisted treatment in Greater Cincinnati, with a justice program that he started in March 2013. Self-education convinced him it could work, Peeler said. He tried it after people he’d seen in court ended up dying outside jail.
“We had 22 people in our court over a two-year period that died of accidental overdose,” Peeler said.
Three stand out in his memory. Peeler had released them all.
“One was a young man,” Peeler said. “He convinced me that he wasn’t using. No drugs were in his system.” The judge saw no reason to lock him up. But shortly after Peeler let him go, the man overdosed and died.
Then came the deaths of two women whom Peeler had sent to a rehabilitation program.
“They did well. They were motivated,” Peeler said. “They died within a week of their release.”
Peeler learned about injectable naltrexone. He knew it would require little change in the current jail process. The state approached him about a pilot program after Peeler tried it with one of his drug court participants in 2012. The option became standard in March of 2013.
Talbert House and Solutions provide the treatment to Warren County’s low-level, nonviolent felons with opioid or heroin addiction. The inmates are connected to the medical services as they leave jail ordered to be on an ankle monitor, at first.
Peeler’s court covers the treatment cost until the recipient has a job and health insurance.
Since the program’s inception, 3,264 drug tests had been administered through May on those who were provided with the Vivitrol option, and 96 percent were drug-free. Of the 4 percent positive results, most showed alcohol. Fewer than 1 percent were positive for heroin or opioids, court records show.
One medication becomes the norm in area jails
Another treatment program, Clermont County’s Community Alternative Sentencing Center, bubbled up by August 2013 but it offered no medication.
It offers misdemeanants with opioid or heroin addiction a program in a separate jail wing. The program, run by Greater Cincinnati Behavioral Health Services by 2015 started to provide two medications for opioid and heroin use disorder: buprenorphine and injectable naltrexone. Clermont’s isn’t considered a jail program, but a community alternative.
Hamilton County jail’s recovery pod program, which started in 2016, soon will include, for the first time, medication-assisted treatment, officials vow. Exactly when and what kind is still undecided, said jail spokesman Mike Robison.
Kenton, Clermont, Campbell and Butler counties all have one or another form of medication-assisted treatment for some of their heroin- and opioid-addicted populations, the Enquirer review shows. Some programs are for inmates, others are for people in alternative-sentencing court or probation programs.
Boone County does not provide medication treatment. There, Judge-executive Gary Moore said the county is watching treatment programs in jails in Northern Kentucky to learn how well they go. He said Vivitrol programs look promising.
Some state prisons, as well as county jails, usher people into the hands of medical professionals who provide Vivitrol before the inmates are released. The Kentucky General Assembly in 2015 passed legislation to fund medication-assisted treatment and provided $3 million for the programs along with a specified non-narcotic medication. Again, that’s Vivitrol.
Kentucky Sen. Chris McDaniel, R-Taylor Mill, said that Vivitrol “continued to come back as the best standard of care for the medication-assisted treatment part” of the Kentucky bill even though national addiction experts do not place the non-narcotic above the others. But McDaniel said that Vivitrol made sense for jails as part of a processing-out program to help those with the addiction disease as they depart.
“They have 30 days,” McDaniel said, referring to the amount of time the medication lasts before a new shot is needed. “That gives you a pretty good platform to get back into society” with a job, housing and more.
Inmates get two shots before leaving Kentucky’s prisons, if they qualify for the medication, want it and if the prison provides it, said Pangburn of the state’s corrections department. They’re guided to outside providers who give the shots after the inmates’ release.
Compared to methadone and buprenorphine programs, Pangburn said, “It’s simpler.”
Some courts with specialty dockets in the region offer medication as part of their treatment programs, too.
Change Court, a Hamilton County program for victims of human trafficking, is one. Currently, the special docket court is filled with women who have heroin addiction. It provides methadone, buprenorphine or naltrexone through community resources if participants qualify for and want it, said Municipal Court Judge Heather Russell.
Clermont County Common Pleas Court Adult Probation Department has been making use of a state grant to help with medication assisted treatment.
Treatment lessens overcrowding, said Julie Frey, director of probation services. And crowding is one of the results of a heroin-addicted community that commits low-level crimes to get money for their drugs.
The Ohio Department of Corrections and Rehabilitation has multiple transitional programs for inmates incarcerated and those on their way to being released. The work is funded and led through a partnership with the Ohio Mental Health and Addiction Services department. Addiction and pre-release transitional programs are included, said Dr. Mark Hurst, medical director with the addiction services department. Medication with the current treatment, he said, is “on the horizon.”
Judge calls attitudes toward treatment ‘frustrating’
Peeler said he’s open to any of the FDA-approved medications, but the Warren County jail isn’t set up to provide all of the current options.
Lee said that’s a common problem. Smaller jails have too little staff to manage such programs, which have strict administrative oversight from the federal Drug Enforcement Administration and require extra work and security.
Peeler stands up at events about the opioid epidemic, meets with other judges and public officials and proudly introduces graduates of his court who vouch for the medication initiative.
He believes there’s a long way to go before medicine will be accepted by the criminal justice system as a key component for those with heroin addiction. And that bothers him.
“The most frustrating part of this whole problem is this perception. Your disease of addiction is why they complain about treating this disease,” Peeler said.
“If they really examine it, they will see that cardiovascular disease, diabetes, are also lifestyle issues,” the judge said. “And they are treated with medication.”
Why provide drug treatment in jails?
The bottom line to addiction experts is that medication-assisted treatment – medication and psycho-social counseling with wrap-around services – is the standard care for opioid and heroin addiction. Simply put: It works best.
Here’s why some criminal justice systems are using medication:
- .Lives are saved. A New England Journal of Medicine study showed that people released from incarceration without addiction medication were 130 times more likely to experience an overdose in the first two weeks after release. “MAT (medication-assisted treatment) prevents overdose, so it is important that individuals are receiving treatment during this time,” said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse.
- Jail space can grow if people get the best treatment, and incarceration costs go down as recovery rates – without recidivism – go up. The National Institute on Drug Abuse says that conservative estimates show that “every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft.”
- Lockups across the country experience a revolving-door syndrome as inmates with opioid or heroin addiction are released, go back to using and get arrested again.
The lack of buprenorphine and methadone use in the criminal justice system to treat opioid addiction lies, in part, in myths about these medications, Vuolo said.
There’s a “philisophical aversion based on common misperceptions” about the two drugs, states a study published in the National Center for Biotechnology Information. There’s an idea that abstinence is best for everyone with addiction, and that the two medications, which are themselves opiate-based, simply trade one drug for another.
That’s false, addiction experts say. Addiction is “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences,” according to the National Institute on Drug Abuse. Those properly treated with any of the medications for opioid and heroin addiction do not display such behaviors.