Approximately 50% of the US prison population has a substance use disorder. What role should the prison system play in fighting the opioid epidemic?
Important distinction: While they are often used interchangeably, jails are short-term facilities, often run by local governments. In contrast, prisons are long-term facilities that are run by the state or federal government. For this post, I am talking exclusively about prisons.
Every 25 seconds, someone in America is arrested for drug possession. Those who are sent to prison because of their possession will join 456,000 people serving time for drug charges. That accounts for one-fifth of the US prison population. Addiction is a chronic brain disorder that can be incredibly disruptive to a person’s life. A drug charge, especially one that leads to time in prison, only does more harm to a person struggling from a substance use disorder. A person may have to post bail and pay other fines, lose their job while in prison, and have a harder time finding a new job after they get out because they must label themselves a convict. Furthermore, in states like Wisconsin, Georgia, and Missouri, a person can have their Medicaid coverage terminated. All of these policies put people with a substance use disorder further in the hole. Fortunately, there is movement to turn the criminal punishment system into a more positive force in confronting addiction. The prison system can be leveraged to combat the opioid epidemic.
Drug courts are specialized court programs that provide alternatives to prison. They address those charged and convicted on drug and alcohol charges, as well parents with pending child welfare cases with a substance use disorder. There are over 30,000 drug courts in the United States. Participants in drug court programs are less likely to be re-arrested and less likely to test positive for drugs than those who did not participate in these programs. These outcomes save society about $6,000 per person, overall.
Despite these positive statistics on drug courts, program completion ranges from 30% to 70% across the country. Those who fail to complete the program are often sentenced to long prison sentences. This raises concerns about their overall effectiveness in reducing criminal punishment for those suffering from a substance use disorder.
Treatment in Prisons
A substance use disorder does not resolve itself once a person arrives at prison. Access to treatment, including medication-assisted treatment, in prisons is dismal. In 2016, Rhode Island became the first state to offer all three MAT options for opioid addiction—methadone, buprenorphine and naltrexone—to prisoners. Massachusetts recently began providing buprenorphine to prisoners and has plans to offer methadone as well. The evidence from Rhode Island is promising. Prisoners with an opioid addiction are 129 times more likely than non-prisoners to have a fatal overdose in the two weeks after being released from prison. By making MAT available, Rhode Island reduced the rate of fatal ODs in newly released prisoners by 61%. Despite this success, only 30 prisons across the country allow inmates to take methadone and buprenorphine. Most forbid the use of these drugs because they believe they poses a security risk.
The Americans with Disabilities Act, which was passed in 1990, includes protections for those recovering from a substance use disorder. However, lawyers rarely used the law for patients requiring buprenorphine or methadone in prison. Fortunately, times are changing. The US Attorney for Massachusetts has been investigating prisons for not offering MAT to inmates. Court cases in Massachusetts, Maine, and Washington state, although impacting only the plaintiffs, have allowed those in recovery to continue their MAT while serving time. These cases set a hopeful precedent. Another good sign was the National Sheriffs’ Association’s endorsement of offering buprenorphine and methadone to inmates.
“King of the Jailhouse Drug Trade”
Those who oppose offering MAT opioids in prisons cite the increasingly common practice of prisoners trading their buprenorphine to those who haven’t been prescribed it. The trading of prescription drugs is very common in prisons. For instance, buproprion, a drug used to treat depression and nicotine addiction, is known as “poor man’s crack” and is often abused by prisoners. To address this problem, a new form of buprenorphine is being developed. It comes in a fast-dissolving wafer, instead of the slower-dissolving films and tablets that prisoners can smuggle in their mouths. However, the company that has patented this buprenorphine wafer, Purdue Pharma, is also behind the aggressive marketing of Oxycontin that many believe to have kickstarted the opioid epidemic. Currently, there is no indication that the involvement of Purdue will slow down the development of buprenorphine wafers, which have not hit the market.
Prisons are unique social environments without access to official currency. In place of bills and coins, prisoners use things like cigarettes, ramen noodle packets, and, yes, prescription drugs to create their own economy. This is a fact that policymakers will have to consider when expanding access to MAT in prisons.
Medicaid Access After Prison
Treating a substance use disorder is a long haul! I can, and often does, need to continue after a person leaves prison. Depending on which state a person lives in, an adult’s Medicaid coverage can either be suspended or terminated. Because of the SUPPORT Act of 2018, Medicaid coverage for incarcerated juveniles cannot be terminated, and is instead suspended. In 16 states and the District of Columbia, Medicaid coverage is suspended during their sentence, but is easily reactivated when they leave. 15 states suspend coverage for a limited period of time, so people with longer sentences still lose coverage. And 19 other states terminate Medicaid coverage regardless of sentence length, forcing newly released inmates to reapply. A seamless transition of a prisoner’s life, including their treatment, from prison to outside life is a critical factor in helping newly released prisoners stay on the right path.