During more than a decade of IV drug use, 34-year-old Ana Vasquez, a homeless IV drug user, has kicked heroin nearly a dozen times in Philadelphia jails, most recently in late November 2017 after she was arrested during a buy-and-bust operation with a single $5 bag of powder cocaine in her possession.
The crime is considered so minor that, even prior to the election of Philadelphia’s new reformist District Attorney Larry Krasner—who ended cash bail for most low-grade misdemeanors this year―Vasquez would have been processed through police headquarters and released to the street on her own recognizance not more than 72 hours after her arrest.
But under Philadelphia’s unique and controversial “detainer” system―which requires that defendants on probation who violate the terms of their supervised release be held without bond until they’ve had a hearing before the judge who originally sentenced them―it would be the middle of January before Vasquez was finally released from Riverside Correctional Facility (RCF), Philadelphia County’s only exclusively female jail.
From there, she hitched a ride seven miles south, back to her home in the city’s Kensington neighborhood, where she spent her first night of freedom braving the frigid weather by getting high on heroin and cocaine.
“No matter how many times you detox in jail, it never gets any easier,” she said, in an interview shortly after her release. “It’s horrible. No one wants to leave their cell [and] you got at least half of the people on the block going through it, vomiting, diarrhea, not eating or sleeping.
“Sometimes they would give us ‘comfort meds’ as they call it, but in reality they don’t do shit.”
So it was a surprise when I got a call from Vasquez last month, a few days after she’d been arrested once again—this time on a more serious felony charge of possession with intent to deliver heroin—and she sounded, well, buoyant.
“They got us on subs,” she said, referring to the drug buprenorphine (an opioid agonist sold under the brand name Subutex). “You believe that? They dose us every day. It took a couple days to get adjusted to it but really, I feel great.
“This is a great program.”
The program Vasquez is referring to provides the option of medical detox from opioids or maintenance using genetic buprenorphine to every incoming inmate suffering from opioid dependency. It was quietly launched as a pilot in February at RCF; and on Aug. 13 it was expanded to encompass all inmates entering the Philadelphia prison system.
“We make such an investment to help people while they are in the system,” said Bruce Herdman, the Chief of Medical Operations for the county’s Department of Prisons.
“It doesn’t make sense not to help them after their release.”
Evidence has long demonstrated that treatment using opioid agonists like buprenorphine and methadone are the best way to do that. Agonists stimulate the same receptors in the brain as illicit opioids. But their long half-life makes them suitable for replacement therapy because they attenuate cravings for 24-36 hours (compared to just four to six hours from the combination of heroin and fentanyl commonly sold in Philadelphia).
Among other things, this reduces the compulsion that comes from the need to constantly redose.
It also keeps people alive long enough to benefit from recovery. Just a week in jail without opioids can reduce a dependent individual’s tolerance enough that the dosage they were accustomed to when they were arrested could be fatal.
Herdman says that research shows inmates kept on agonist therapy in jail are two-thirds less likely to die of an overdose in the early weeks of their release than those who lose their tolerance while incarcerated..
Under Philly’s new program, inmates with opioid dependencies are given a single 8 mg dose of buprenorphine once a day (half the average recommended dose in most outpatient programs). The drug is dispensed as a crushed tablet to make it harder to divert.
Prior to release, those who choose to continue treatment are assigned to a clinic or physician in the community, ideally with minimal, if any, gap between doses. When the program started, it avoided that issue by providing a few days of medication or providing a short-run prescription to hold patients over. But the jail had to put that policy on hold because of limited resources.
Herdman acknowledges his team is still working up the learning curve.
“We found that we could not scale that practice, the logistics are so difficult,” he said. “The volume here is the biggest challenge, the sheer burden of the size. We send 200-some people to court each day and people are released 24 hours a day seven days a week.
“We had to train eight additional doctors to qualify for the federal waiver [needed to prescribe buprenorphine] just to keep up with intakes.”
Dr. Jon Lepley, Chief Medical Officer of Corizon—which is contracted to provide health care services to Philadelphia’s jails—helped pioneer the program in partnership with the prison system after learning about the disproportionate number of inmates who overdosed and died soon after leaving jail.
“Historically, when someone came in they would receive a nursing assessment and if they presented with opioid withdrawal symptoms they would be detoxed with ‘comfort meds,’ like clonidine, promethazine [an antihistamine] and loperamide [Imodium],” said Lepley.
“But attitudes really started changing after Mayor Jim Kenney’s Opioid Commission released its report last year recommending that county inmates be offered the option of medication-assisted treatment. That was a turning point.”
Before launching the program, Herdman and Lepley consulted with officials at Rikers Island in New York City, which started offering heroin-addicted inmates methadone maintenance in 1986. The jail added buprenorphine as an option in 2008.
According to Jonathan Giftos, the Clinical Director of Substance Use Treatment at Rikers, the jail treated 4,000 inmates using methadone or bupe last year, and 70 percent of program participants are on long-term maintenance.
Unlike Philadelphia, Rikers (which has had plenty of time for trial and error) has no dosage cap—inmates are provided an individualized dose and can choose which medication works for them. When they are released they receive either seven days of medication or a 14-day prescription until they see a physician.
It’s also the only jail with a federally licensed Outpatient Treatment Facility onsite, meaning that it prescribe and dispense methadone without needing to contract with one of the city’s already overburdened clinics.
“It’s really rewarding to provide people with evidence-based treatment while they are at such a vulnerable point in their lives,” said Giftos. “For decades the standard of care at other jurisdictions was to provide no medication.
“But now I think we are seeing a new standard of care emerge as more jails are looking at the data and success rates of methadone or bupe provided in a correctional setting.”
However, that needle is moving extremely slowly—given the number of victims who come in contact with the criminal justice system. Despite their proven effectiveness, demand for opioid agonist therapies by jails is virtually nonexistent.
In one randomized study, researchers reviewed 81 requests for proposals (RFPs) for contracted jail healthcare services in 28 states and found that only 11 requested MAT; and all but three limited its use to pregnant women—who can suffer severe complications from improperly managed detox.
As I’ve previously reported, it’s estimated that two-thirds of inmates entering jail have a diagnosable substance abuse disorder, yet few jails even provide basic medical care for managing withdrawal, let alone allow for ongoing maintenance treatment.
Fewer than 10 percent of America’s 3,300 jails offer any medication-assisted treatment at all, let alone long-term agonist maintenance. Instead the roughly 200 jails, that provide MAT to inmates opt for the opioid antagonist naltrexone (sold under the brand name Vivitrol), which simply prevents individuals from feeling the effect of opioid drugs.
There is little data on the effectiveness of naltrexone for long-term success at preventing a relapse on illicit opioids (and to be fair, there’s not a whole lot on buprenorphine either, which wasn’t even an option for heroin addicts until 2002).
Although, a recent study found naltrexone is as effective as a daily oral dose of buprenorphine at preventing relapse after six month, the accuracy of that conclusion is undermined by the fact that more than a quarter of participants were unable to endure the required period of abstinence (up to four days) to even start taking Vivitrol.
But even if the data were sound, relapse prevention is just one measure of success.
Tens of thousands of human beings suffer needlessly through painful withdrawal while incarcerated in county jails, including people like Vasquez, whose entire criminal history is a reflection of a DSM-classified medical disorder. An untold number of them die in the process.
All of them would have a chance to be alive and in recovery today, if the municipalities where they perished had the political will and compassion to spend a fraction of the money treating their symptoms that they’ve shelled out in wrongful death lawsuits.
Philadelphia’s program will provide the option of treatment to thousands of potential inmates this year for just $500,000 out of the prison budget, according to Herdman.
As I recently reported, the ACLU is currently suing jails in three states—Washington, Massachusetts and Maine—for failing to provide appropriate treatment to detoxing inmates.
Dr. Lepley says Corizon will begin including medication-assisted treatment with buprenorphine as a standard protocol in its jail contracts. But that does not mean the facilities will be required to employ it. And the Pennsylvania Department of Corrections told The Crime Report that it will begin piloting SUBLOCADE, the first once-monthly injectable buprenorphine formulation for the treatment of opioid use disorder, with a target date of November 2018.
According to DOC spokesperson Susan McNaughton, the immediate goal will be to use the drug to detox incoming inmates, but the long-term goal is to offer ongoing maintenance.
Christopher Moraff is a freelance writer who covers the intersection of policing, drug use and civil liberties for The Crime Report and other publications. He welcomes comments from readers.