Last month, the Obama administration convened a gathering of correctional officials to emphasize the critical role of the nation’s jails and prisons in addressing the spike in overdose deaths attributed to opioid narcotics.
“Everybody has a role to play in ending the opioid epidemic – including our justice system,” said Michael Botticelli, Director of the White House Office of National Drug Control Policy, at the White House summit on July 17.
“We need to make sure that individuals with opioid use disorders who are incarcerated have access to evidence-based treatment so they can achieve and sustain recovery.”
That conversation continued this week at the National Criminal Justice Association’s annual reform conference in Philadelphia, during a panel discussion Tuesday on expanding medication-assisted drug treatment in correctional facilities.
“I firmly believe medication-assisted treatment is the game changer of my career,” said panelist Christopher Mitchell — who heads the division in charge of drug treatment programs for the Massachusetts Department of Corrections.
Mitchell was one of several dozen criminologists, law enforcement officials, data scientists and policymakers presenting at the 2016 National Forum on Criminal Justice in Philadelphia. The three-day event – which runs through Wednesday – is co-sponsored by the National Criminal Justice Association (NCJA), the Justice Research and Statistics Association (JRSA) and the IJIS Institute (IJIS). The event draws several hundred criminal justice professionals each year for a dialogue on pressing issues impacting public safety.
Tuesday’s panel on medication-assisted treatment was one of two focused on solutions to the opioid epidemic.
Historically, prisons have treated post-release drug and alcohol treatment much like any other reentry service — offering little more than an address or phone number to inmates who request it at discharge.
Only a handful of facilities provide medication to opioid dependent inmates. These include New York’s Rikers Island, which has hosted a successful methadone program since 1987.
In 2014, Mitchell was part of a statewide task force in Massachusetts that led to the creation of the Medication Assisted Treatment Reentry Initiative (MATRI). The program currently provides the opioid antagonist Vivitrol (injectable naltrexone) to qualifying inmates who are discharged from nine state correctional facilities.
Mitchell says the program serves as a vital safety net for returning citizens with a history of opioid abuse.
“Imagine coming out of prison with no support, no ability to even access a computer, how long would it take you to give up? I’d probably last an hour,” he said.
“Once you hand people off to the community, if that community isn’t ready to support them the offender is most likely going to crash and burn.”
For decades that’s pretty much what happened.
The vast majority of incarcerated drug users relapse after release, often within days; data from the 1990s estimated the recidivism rate for drug dependent offenders to be as high as 80 percent.
Incarcerated Americans have been largely denied access to life-saving interventions such as methadone — which despite its proven efficacy in treating opioid dependency remains underutilized even among non-incarcerated drug addicts.
A study published in 2010 by The National Center on Addiction and Substance Abuse (CASA) at Columbia University found that only 11 percent of substance abusers receive any type of professional treatment in jail, and fewer than 1 percent are provided medically assisted treatment.
Thanks to a concerted push from state and federal policymakers, attitudes towards medication-assisted drug treatment (MAT) have changed radically in just a few short years. Connecticut — where 44 percent of overdose victims last year had a prison record — recently became the first state to introduce methadone in all of its correctional facilities.
Pennsylvania’s corrections chief John Wetzel has become a vocal proponent of in-custody treatment for opioid dependency using medication. In June, his department announced it is launching a pilot program in its prisons using Vivitrol, and in the future it plans to include the use of methadone and Suboxone where determined appropriate.
A bill currently making its way through the Pennsylvania legislature would require the Department of Corrections to contract with drug treatment providers that utilize evidence-based prevention and treatment approaches.
Still, panelists say they continue to fight an uphill battle against an entrenched drug treatment system that has scoffed at medication as a “crutch” that doesn’t count as true recovery.
“We’ve had to educate the old-timers, even some practitioners, on the value and benefits of MAT,” said Kim Kozlowski, director of the Syracuse Community Treatment Court (SCTC) in upstate New York.
The SCTC — which serves as a diversionary court for misdemeanor and felony defendants with substance abuse disorders — has adopted a strongly evidence-based approach to treatment that gives participants a choice of protocols and, unlike similar programs in other counties, does not require participants to be abstinent when they graduate the program.
“Some old-school recovery people look at these younger people and they think ‘I had to work so hard and they want a quick fix.’ We try to keep our folks from certain [12 Step] meetings where we know they’ll be stigmatized.”
Even as they embrace new options many prison programs remain resistant to providing the full continuum of care recommended by treatment professionals.
Rhode Island, which was recently praised by the Obama administration as a national leader in prison-based drug treatment, is the only state in the nation to offer all three FDA-approved pharmaceutical interventions (methadone, buprenorphine and naltrexone) to opioid dependent inmates.
Dr. Andrew R. Klein, director of training and technical assistance for the Bureau of Justice Assistance-funded prison and jail residential substance abuse treatment (RSAT), says the risk of diversion remains a factor in expanding treatment.
“As far as I know we’ve never had a case of diverted Vivitrol,” he said. “Honestly I think we would be happy to see more Vivitrol diverted.”
Vivitrol is non-narcotic and works by blocking the effects of opioids on the brain rather than replacing them. It doesn’t produce euphoria and has no known overdose potential. But while prison officials have warned of illicit Suboxone making its way into their facilities, it’s worth noting that the overdose potential from that drug is extremely low.
Meanwhile the benefits associated with Vivitrol — its non-narcotic properties — have also have been shown to undermine its ability to ensure long-term recovery.
According to a study from 2009, while naltrexone “seems an ideal candidate medication for prevention of relapse to opiates” it is associated with “unacceptably” low adherence and retention rates.
“Presumably because naltrexone has no reinforcing properties of its own, blocks reinforcement from occasional lapse to opiates, and has no associated withdrawal syndrome, encouraging its continued use, acceptance of the treatment by patients is low” compared to other medication-assisted treatments, the authors wrote.
Indeed, Mitchell says that only six percent of Massachusetts inmates who apply to participate in the Medication Assisted Treatment Reentry Initiative actually follow through and get a Vivitrol shot (which lasts a month) before leaving prison.
Vivitrol is also expensive relative to other MAT options – costing about $1,000 a month, roughly 40 percent greater than Suboxone and exponentially more than Methadone.
The drug nevertheless has a place in the toolkit of therapeutic options for opiate addiction; but as jails and prisons continue down the road of medication-assisted treatment, placing too much stock on one treatment protocol – either out of fear of misuse or stigma – risks undermining the potential successes of the shifting dialogue on addiction.
Most experts agree that to be successful, treatment for opioid dependency needs to be individualized to patient needs and that medication is just one part of a multi-faceted support system.
“Medication-assisted treatment isn’t the be all and end all,” said Kozlowski. “We require that if participants are going to get MAT they are engaged in some kind of counselling services.
“Our theory is that if they stay on MAT they have to be seeing a clinician and our thoughts are that the longer they are seeing someone the better chance they have of success.”
Christopher Moraff is a freelance journalist based in Philadelphia. He welcomes comments from readers.