Connecticut, spurred by opioid overdoses and the epidemic of opioid use disorders, as well as by the high proportion of inmates in state jails and prisons with a substance use disorder, is instituting a statewide policy to make sure everyone in treatment with methadone gets to stay on the medication upon incarceration. To medical experts, this is an obvious necessity: how can you withhold a legal prescription and essential medication from someone? But in the corrections systems across the country, there is a widespread belief that methadone (and buprenorphine) are “substituting one addiction for another,” and that withdrawing in jail or prison is the best thing that could happen to someone. The next step — after keeping someone on methadone who is already on it — is inducting people who are dependent on heroin or pills when they are incarcerated. And Kathleen F. Maurer, M.D., medical director of the state’s Department of Correction, started the initiative three years ago with both steps in mind.
The Connecticut program got started when a former corrections commissioner was told by the treatment community that patients on methadone needed to stay on methadone when incarcerated. “’You’re not doing right by our people’” was the message, recalled Maurer, who spent an hour describing the program to ADAW last week. “The commissioner told me to go to New York and see what they do, so we went,” she said. At Rikers, the jail in New York City, methadone has been given to inmates for years. “They said, ‘It’s inhumane not to give methadone,’” she recalled. At about the same time, the Connecticut Department of Mental Health and Addiction Services (DMHAS) was encouraging the corrections department to continue methadone treatment for patients already on it.
There are 15,400 inmates in Connecticut prisons and jails; 80 to 85 percent of them have a substance use disorder that requires treatment. The primary drugs of abuse are alcohol (31 percent of inmates), marijuana (30 percent) and opioids (25 percent) based on February 2016 data.
Praise from counselors
Counselors in the state, and experts from outside the state, have nothing but praise for the program, and hope it can go further by inducting everyone who wants methadone onto the medication — not just people already in treatment. “Since we support all paths to recovery, we strongly support the plan to expand methadone treatment in the prisons to help those who are opioid dependent upon incarceration,” said Jeffrey Quamme, executive director of the Connecticut Certification Board, which certifies addiction counselors and other professionals in the state. “Not only does it help the treatment system in the Department of Correction by adopting this evidence-based practice, we also believe that helping inmates avoid terrible withdrawal symptoms is not only humane, but lessens the burden on the correctional custodial staff and medical providers by avoiding having to respond to the issues associated with the symptoms of withdrawal,” Quamme told ADAW. “This is an absolute positive step forward for the Department of Correction.”
And Yngvild Olsen, M.D., medical director for the Institute of Behavior Resources in Baltimore and past president of the Maryland chapter of the American Association for the Treatment of Opioid Use Disorders, agrees. “The national resistance in the criminal justice system, both state and federal systems, against continuing patients who are on methadone when they get incarcerated is a travesty,” she told ADAW. “If it were diabetes and people were taking insulin and got incarcerated, no one would question the need to continue that medication.”
Even in prison systems, there is a need to ensure that people with diabetes have appropriate food, access to diabetes management and exercise, said Olsen. “The same thing should be there for people with an opioid addiction who take methadone as part of their treatment,” she said. And while there are correctional facilities where treatment behind the walls is being implemented, in most instances it does not include a medication, and when it does, that’s injectable naltrexone (Vivitrol), she said. “It’s the stigma against methadone” that is at play, she said.
One problem for corrections departments treating people in jails and prisons is funding. While medical care has to be provided, medical vendors do not provide methadone, which is only provided by opioid treatment programs (OTPs), strictly regulated by federal and state governments. Another factor is Medicaid, which can’t be used for anybody in prison or jail. The two OTPs who are working with Maurer’s program now — the APT Foundation in New Haven and Recovery Network of Programs (RNP) in Bridgeport — are doing so for free, bringing in the medication for their patients or, in about half the cases, for other OTPs’ patients. The OTPs have contracts to do this — but there is no money involved.
There was another problem in Connecticut: the public health code doesn’t allow methadone to be dispensed in prisons or jails. “We went to the deputy commissioner of public health and asked to do this, because it’s the right thing to do,” said Maurer. “They were skeptical at first.” But they relented, and she herself wrote the language authorizing the Department of Correction to provide methadone in jail — not as an OTP. That got put in a bill that the state legislature passed, and allowed the Department of Public Health to license corrections to have a community provider to come into the facility. “We do not have, and did not want to have, a full-blown clinic in our facility,” said Maurer, noting that jails are not big and are all overcrowded, and do not have computer systems to manage patient charts (“everything is paper and pencil for now,” she said).
APT from New Haven did get funding initially, from the Substance Abuse and Mental Health Services Administration via a technical assistance grant. APT did education for corrections staff, which was essential. “Our custody officers and even medical people were uninformed and opposed to methadone. But the warden, Jose Feliciano, became “very invested in this,” said Maurer. “It was our job to make sure everybody understands that this is a disease,” she said, adding that the warden has been one of the strongest role models in spreading this message.
Role of OTPs
Despite not being paid, OTPs want to be involved. “They’re doing this because they don’t want to see their patients lost,” she said. Several years ago when RNP in Bridgeport heard about it, it wanted to get in as well, even without funding. “The person who runs RNP told me he’d been trying to get into correction facilities for 10 years,” recalled Maurer. When his patients got arrested, he told her, “’You detox them, you don’t give them methadone, then you send them out with nothing, and they’re lost, they don’t get back to me,’” she said. “I told him, ‘I hear you. If it takes money to do this, I can’t do it because we don’t have any. But if we can do it without money, call me tomorrow.’” He called her, and together they set up the logistics.
Medicaid pays $4,000 a year for patients in an OTP, but right now APT and RNP are providing counseling twice a month for free in the corrections program, as well as dispensing the methadone.
The OTPs are also responsible for re-entry — when inmates leave prisons and jails. Many inmates go to halfway houses, and this is a problem because technically they are not allowed to leave them for the first two weeks.
Finally, the OTPs should be paid, said Maurer. “We originally had funding from DMHAS. They were going to share the cost, and they put in $35,000 a year; we put in the other $35,000,” said Maurer. However, the Department of Correction only put in money for the first year; the second year, only the DMHAS portion was paid. And now there is no money.
“I just lost 3 out of 10 staff to layoffs,” said Maurer of the correction medical office. The layoffs were not proportional on the custody side: out of 6,000 custody officers, 40 were laid off. So the idea of expanding the program to induction, putting new patients on methadone, is particularly problematic. Maurer hopes to get more space for inmates on methadone by doing more diversion; working with prosecutors, judges, public defenders and OTPs, she wants to “provide diversion to treatment for people who come in with nonviolent crimes that are drug-related,” she said. “We are incarcerating people because they are sick.” So far, 100 offenders have been diverted to treatment, with a success rate of 75 percent, she said. This diversion program has funding from the Public Welfare Foundation.
Olsen said that the large contracts with medical corrections systems usually leave out methadone and, to a great extent, buprenorphine. “They say it’s too much of a regulatory burden,” said Olsen. “For me those arguments need to be looked at through a different lens. Correctional systems have to understand that opioid treatment is effective.”
And while buprenorphine does not have the same regulatory burden, corrections systems are usually opposed to it because the film is so easy to divert, Olsen and Maurer said.
Finally Olsen noted that people do die from opioid withdrawal in jail — whether they were on methadone or on illicit opioids — mainly from dehydration and electrolyte imbalances. Withdrawal means almost constant diarrhea and vomiting, as well as other symptoms. It can last for a week. While it technically hasn’t been viewed as life-threatening — compared to the seizures of alcohol or benzodiazepine withdrawal — it can be, said Olsen. “There have been many recent examples of even young people who have experienced complications of opioid withdrawal and died as a result,” she said.
Connecticut is expanding a program that would provide methadone to all inmates currently in treatment with the medication, and hopes to expand it to induct inmates dependent on any opioids but not yet in treatment.