Can giving inmates access to addiction medication help ease the opioid crisis?
Some Massachusetts inmates who are about to be released will soon gain access to a medication for opioid addiction that has long been barred from most correctional settings.
With grants announced Monday, the houses of correction in Franklin and Hampden counties will expand their ability to offer buprenorphine, a drug commonly known by the brand name Suboxone, to inmates with a diagnosed opioid use disorder, starting within a month of their release.
Only a handful of prisons and jails nationwide dispense buprenorphine as treatment. The medication has been frowned on by many correctional officials because it is an opioid often smuggled into prisons for illicit use.
But buprenorphine is also a legal, prescribed medication known to stop cravings, help keep addicted people engaged in treatment, and prevent overdoses.
The grants are part of a new state program, involving five counties and focused on easing inmates’ re-entry into society.
The state Department of Public Health is dividing $500,000 in federal money among five of the state’s 13 county-run houses of correction, with each getting $100,000. But only Franklin and Hampden will offer buprenorphine.
Franklin County currently offers buprenorphine only to inmates who were already taking it with a prescription when they arrived. The grant enables the facility to also initiate buprenorphine treatment for addicted inmates shortly before departure.
Hampden County has been offering buprenorphine to inmates before release, and now can expand that program.
The sheriffs in Bristol and Middlesex counties have indicated they would consider introducing an injectable form of buprenorphine if it becomes available. Such a drug would be harder to use illicitly. The drug, currently under review by the US Food and Drug Administration, would involve a shot once or twice a month.
The grants will also help all five counties cover the cost of providing injectable naltrexone, known as Vivitrol, which is already widely used in the state’s jails and prisons for inmates about to leave. Additionally, the money supports extensive case-management and linkages to treatment and recovery services in the community, starting 60 days before release and lasting up to a year after.
The grants do not include assistance providing methadone, the third medication for opioid addiction, which will remain unavailable for inmates in Massachusetts (except for pregnant women, who receive it to protect them and their fetuses from the harms of withdrawal).
“It’s definitely a step in the right direction,” said Leo Beletsky, associate professor of law and health sciences at Northeastern University. “In many ways, it’s too limited. We need to be bolder in the context of the current crisis.” He said addicted inmates need medication during their sentences as well.
“Up to 80 percent of people who are in jails and prisons have a substance use issue. The treatment that is provided is not evidence-based and not helping people,” Beletsky said.
Inmates are arguably the most vulnerable population caught up in the opioid crisis gripping the region. In Massachusetts prisons, more than half of incoming inmates are identified as substance abusers and a third of those people reported taking opioids.
Upon release, the risk of overdose is staggeringly high. In Massachusetts, opioid-addicted people recently released from incarceration are 56 times more likely to die of an overdose than the rest of the population, according to a state health department analysis.
The $500,000 for the new program, the Medication Assisted Treatment Re-Entry Initiative for Houses of Correction, comes from a $11.7 million grant from the federal Substance Abuse Mental Health Services Administration in response to the opioid crisis.
“Funding from the Department of Public Health will help provide important substance misuse treatment services to a rehabilitating population that we know is significantly more susceptible to the opioid epidemic upon their release,” Governor Charlie Baker said in a statement.
The county facilities hold people who are awaiting trial or who have sentences shorter than 2½ years. The state prison system, for people with longer sentences, is not involved in the new re-entry program.
While the grants will help pay for Vivitrol, that medication is not new in correctional settings. The state prisons and nine county houses of correction already offer Vivitrol to addicted prisoners shortly before their release.
Worcester County Sheriff Lewis G. Evangelidis said the grant would enable him to hire a full-time employee to manage the Vivitrol program within the facility and partner with treatment providers after release. “Vivitrol can be an incredibly effective tool. We think it’s the most effective tool available,” he said. “I’m hoping we’re going to see a dramatic reduction in overdoses and deaths.”
Correctional officials have favored Vivitrol because it is not an opioid and does not get used illicitly; as an injection, it is hard to smuggle into prison, and there is no market for it because it doesn’t produce a high. Patients receive an injection once a month that prevents them from getting high if they inject heroin or take another opioid during the 28 to 30 days when the medication remains active.
But addiction specialists say that the evidence for Vivitrol’s effectiveness at keeping addicted people in treatment is much weaker than that for buprenorphine and methadone. And the risk of overdosing on heroin, fentanyl, or other opioids is very high for those who fail to get another Vivitrol shot at the end of the month.
Dr. Sarah E. Wakeman, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital, said that patients on Vivitrol know they can’t get high but many still want to. For many people with severe addiction, Wakeman said, Vivitrol “doesn’t relieve the craving in the way that methadone and buprenorphine do.”
Aside from officials’ resistance, there are other obstacles to providing buprenorphine and methadone in correctional settings. By law, people who are incarcerated are automatically cut off from Medicaid, so prisons and jails have to pay all their health costs.
Methadone is inexpensive, but providers must follow an array of cumbersome federal regulations. Buprenorphine costs more, about $10 to $12 per daily dose, and requires substantial staff time: To prevent inmates from hiding the medication to sell later, each inmate must be observed for 15 minutes while the medicated strip dissolves in their mouths.
Still, buprenorphine and methadone are standard treatment in prisons across Western Europe, Canada, Australia, and the United Kingdom. In the United States, fewer than 40 prisons and jails offer either medication, according to a survey last year by the Pew Charitable Trusts.
Recently, Rhode Island became the first state to offer all three addiction medications to inmates diagnosed with opioid addiction in all the jails and prisons.
Dr. Ruth Potee, medical director of the Franklin County House of Correction, said that contraband buprenorphine is popular with inmates primarily because they’re trying to treat their withdrawal symptoms and continued cravings. If it were provided as part of legitimate treatment, Potee said, “diversion would not be a problem.”