There have been increasing reports of deaths in jails due to opioid withdrawal — deaths that could have been easily prevented by appropriate medical care. ADAW talked to medical experts this week about what’s going wrong with these tragic cases.

Opioid withdrawal is often viewed as relatively benign compared to withdrawal from benzodiazepines or alcohol, which can be accompanied by fatal seizures. However, there is a clear standard of care for opioid withdrawal, which has symptoms that can range from mild to severe, with vomiting and diarrhea so intense and prolonged that dehydration and death can result.

The federal Bureau of Prisons has a clear protocol on opioid withdrawal, but this applies only to federal prisons. The deaths are taking place mainly in local jails. There are no standards for opioid withdrawal in jails.

“The level of care is probably better” in federal prisons, said Kevin Fiscella, M.D., M.P.H., liaison from the American Society of Addiction Medicine (ASAM) to the National Commission on Correctional Health Care, which is currently revising its opioid withdrawal position statement. Fiscella, who is a professor at the University of Rochester Medical Center in Rochester, N.Y., said management of opioids within corrections is a particular interest of his.

Everyone we talked to said that maintenance treatment with methadone or buprenorphine should be considered instead of management of withdrawal. However, in reality, many jails and prisons simply do not provide access to agonist medications, in which case withdrawal should be treated the way it is in hospitals providing detoxification, they agreed.

“Part of the problem is that there’s a misconception that people don’t die from untreated opioid withdrawal,” said Fiscella. “In fairness, this is something we’ve all been taught in medical school.” Otherwise healthy people fare better with untreated withdrawal, but people who are incarcerated are often not healthy, he said. “About once a month we hear about someone who is incarcerated in opioid withdrawal and dies during that period,” he said. Direct causes are dehydration due to vomiting and diarrhea with accompanying electrolyte imbalance. Another cause is aspiration pneumonia, when vomit gets into the lungs. “These deaths have clearly happened — cases have gone to the coroner and been documented,” said Fiscella. But he added that there may be many more cases that aren’t reported. “These direct causes are the ones we know about, but the estimate of one a month may be just the tip of the iceberg,” he said.

It’s also hard for jail staff to diagnose withdrawal, said Fiscella. “When someone is in acute withdrawal, it’s hard to tell what their problem is,” he said. “They hurt everywhere, they’re throwing up and they have diarrhea, and their blood pressure is going up.”

An even more pernicious problem is the mindset of many custodial staff who believe that inmates, when they say they are in withdrawal and need medication, are faking and just want drugs. “Custodial staff have become accustomed to lying; they are very suspicious of inmates, and essentially assume that anything an inmate says is a lie,” said Fiscella. But custodial staff should not be deciding whether an inmate needs medication or not, he said. “In a well-run jail, you should have health care staff who are making these decisions; you should not be relying on custodial staff on a routine basis to tell you that someone is sick,” he said.

Detox isn’t treatment

Opioid withdrawal should be managed the same way regardless of the setting in which it is taking place — corrections or medical — said Geetha Subramaniam, M.D., deputy director of the Center for Clinical Trials Network at the National Institute on Drug Abuse. “It is inhumane to have someone suffer through opioid withdrawal,” she said. Acute withdrawal usually lasts five to seven days, and symptoms include sniffles, runny nose, goose bumps, shivering, sweating, muscle cramping, diarrhea, yawning, blood pressure and pulse lability, and vomiting, she said. “But there’s no test to show that someone is in withdrawal, and it may just look like a bad case of the flu,” she said.

Treatment for opioid withdrawal is more than providing methadone or buprenorphine, added Subramaniam. “It is a whole supportive system,” she said. “You have to give other medications to reverse stomach cramping, nausea and diarrhea,” she said. In addition, they need to have treatment, because they will be at high risk for relapse when they are released, she said. “At no time should detoxification be considered treatment — it is just the management of a certain period,” she said. “Medications won’t magically control the desire to seek drugs.”

Jail realities

Even if opioid withdrawal isn’t life-threatening, not treating it is “inhumane,” said Jeanette M. Tetrault, M.D., associate professor of medicine and director of the addiction medicine fellowship program at the Yale University School of Medicine. And severe withdrawal, with prolonged vomiting and diarrhea, is “messy — why would they want that mess?” she asked.

“The problem is that it’s not medical people making the decisions; it’s based on the warden’s own biases,” said Tetrault of withdrawal management in jails. “But I think they know enough that an acute withdrawal process could progress to something life-threatening.”

But jails are places where safety and security are the primary goals, not medical care, said Tetrault. “There’s a lot of movement of people in and out of jails,” she told ADAW. Even obtaining medications for chronic conditions like high blood pressure is difficult in jail.

“Most jails are small jails, and the only health care they have is a nurse who comes in occasionally,” said Pamela F. Rodriguez, president and CEO of TASC (Treatment Alternatives for Safe Communities). “Medication is just not done in many jails — it’s an issue of security, and they don’t have the resources to verify medications.” This is not true in a big city jail like Chicago’s, where there is access to medical care, Rodriguez told us. But in most jails, they do little screening for any health problem except for mental health, to monitor for suicide.

What can be done

NIDA’s Subramaniam said the responsibility to provide adequate care to inmates going through withdrawal is with the corrections departments. “I would put the burden on the criminal justice system,” she told ADAW. “They should have a good rationale for not continuing maintenance treatment, and at the least they should be covering opioid withdrawal.”

Several years ago, Fiscella wrote a study on the national standards in jails, and found that it was rare for any jail to use an opioid agonist to treat withdrawal, which is the standard of care. About half of the jails used clonidine, which is not recommended due to the risk of hypotension, and can also result in a rebound reaction, said Fiscella. Currently, only a handful of jails use methadone or buprenorphine to treat opioid withdrawal, which is the standard of care and is used routinely in detoxification in treatment programs and hospitals.

There are three main barriers to treating opioid withdrawal in jail, said Fiscella: the mindset, staffing and costs, and concerns about diversion. The fourth is a rule by the Drug Enforcement Administration that methadone can’t be given by jails for more than three days, said Fiscella, noting that methadone is much less expensive than buprenorphine.

Ultimately, there will be lawsuits, with evidence that jails are not abiding by medical standards and caused deaths, said Fiscella. “Courts will be looking at constitutional challenges because of inhumane care, and this will make a difference to the big vendors” of correctional health care services, he said.

In the meantime, jail systems need to recognize that when someone is admitted in opioid withdrawal, it is an opportunity for treatment, preferably with medication.

For the federal Bureau of Prisons guideline for withdrawal, go to https://www.bop.gov/resources/pdfs/detoxification.pdf.

For the ASAM practice guideline, go to http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24.

Bottom Line…

Deaths due to withdrawing from opioids in jails could be prevented by standard medical care, but bias against inmates is a barrier to care.