R.I. prison takes a leap into comprehensive addiction care
CRANSTON, R.I. — Deana Furtado vividly recalls the suffering. The pains were like a truck driving over her legs and a knife stabbing her stomach. She was hot one moment, cold the next, and she endured ceaseless vomiting and diarrhea.
Furtado was withdrawing from methadone, and it went on for weeks. There are easier ways to detox, but Furtado was in prison, where inmates are routinely forced into withdrawal, even from medications that treat addiction. After the drug had left her system, Furtado continued to crave the opioids that had ruled her life for a decade, and they were not hard to find behind bars.
A few months into her sentence, she nearly died of a heroin overdose.
Those parts of her story are not unusual in the American criminal justice system.
But the next part is remarkable. Three months before her release in May, Furtado entered a new program that aims to offer inmates the most up-to-date treatment for addiction.
Furtado met with a counselor, who discussed managing her addiction before and after her release. She tried resuming methadone but had a bad reaction, so she switched to buprenorphine, the drug often known by the brand name Suboxone. That medication shut down her cravings, she said, and made her feel “clean and clear-headed.”
Furtado, 43, remains sober today.
The state line runs down the middle of the street where Furtado lives in Tiverton, R.I. She is thankful that she lives on the Rhode Island side. If Furtado had been arrested across the street in Fall River, she believes, her story might not have taken such an optimistic turn.
Prisons and jails in Massachusetts, as in most of the country, have been slow to adopt the treatments that are recommended for people on the outside. Only a handful of correctional facilities nationwide provide the medications that still the craving and help sustain people in treatment.
Yet in few other places will you find such a high concentration of people with substance use disorders; an estimated 60 to 80 percent of inmates are addicted.
Inmates are also at high risk of overdosing upon release. Incarceration presents a unique opportunity to intervene, and an urgent reason to do so, advocates say.
“You have people for a little while — you can get them evaluated and diagnosed,” said Dr. Josiah D. “Jody” Rich, director of the Center for Prisoner Health and Human Rights at Miriam Hospital in Providence. “This is a potentially deadly disease afflicting many of them. . . . We have treatment and we have medications. And this is a treatable disease.”
In Massachusetts, where opioid overdoses claimed 2,000 lives last year, policy makers are well aware of the important role of jails and prisons. Most correctional settings offer some form of individual and group therapy for addiction, and many work to connect addicted inmates with treatment upon release.
But few have followed the recommendations of Governor Charlie Baker’s Opioid Working Group, which said that inmates should be able to continue medication-assisted treatment while incarcerated and to begin treatment behind bars.
And no prison or jail has taken Rhode Island’s comprehensive approach.
Since last year, the state’s adult correctional institutions have been offering inmates all three medications that treat addiction, along with counseling and treatment groups.
People who arrive already taking a prescribed medication for addiction can continue with that treatment, instead of being forced into withdrawal.
Those diagnosed with an opioid use disorder can start one of the medications while incarcerated, provided their sentence is for a year or less.
And those with longer sentences, such as Deana Furtado, can start medications before release.
In embracing medication, Rhode Island’s prisons diverge sharply from most others.
The two drugs with the strongest evidence for effectiveness in treating addiction are methadone and buprenorphine. But most correctional officials oppose them because they are opioids and can be smuggled into prison, where inmates take them to relieve the symptoms of withdrawal and, sometimes, to get high. They don’t want to do anything to make these drugs more available.
In Massachusetts, prison and jail officials are much more open to a newer and less-tested drug, Vivitrol, the brand name for injectable naltrexone. With one injection, Vivitrol prevents a person from getting high from opioids for about a month. It has no street value and isn’t used illicitly.
But it’s not clear if Vivitrol helps keep people in treatment for the long haul.
All the state-run prisons and most of the county-run houses of correction have Vivitrol programs, in which addicted inmates get a shot shortly before release. But only two jails, in Franklin and Hampden counties, also offer buprenorphine behind bars, both on a limited basis.
And no facility provides methadone, except to pregnant women.
Addiction specialists say that if methadone and buprenorphine were offered as treatment, addicted inmates would not be suffering from withdrawal and craving, and there would be less demand for illicit use.
Those medications address the brain changes that addiction causes, which prevent people from feeling normal when sober, said Dr. Sarah E. Wakeman, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital.
Just going through withdrawal doesn’t “fix” addiction, Wakeman said, and people who don’t get medications are highly likely to relapse — and to overdose.
Furtado personally knew 20 fellow inmates who had died of overdoses after leaving prison. During her sentence of three years and three months, Furtado said, she benefited from participating in groups and from the separation from her previous life. But she knew that life — in which she’d been selling heroin and occasionally using it, despite being on methadone — was waiting for her outside the prison walls. Just one encounter with a former associate, she said, and she’d be using again.
So Furtado was relieved to be offered medication before her release — and to find that it worked so well for her. Now out for three months, she sees a counselor regularly and picks up her medicine every two weeks.
“I feel great,” she said. “This is the longest I’ve been clean since I was 13.”
Dr. Jennifer Clarke, the prison medical director in Rhode Island, said that when inmates and their physicians weigh the treatment options, few choose Vivitrol. Methadone is deemed appropriate for the largest numbers, with buprenorphine coming in second.
The prison takes pains to prevent the drugs from being smuggled in for sale by those who are supposed to be ingesting it, Clarke said. With buprenorphine, she prescribes the drug in the form of a film that dissolves in the mouth; officers and nurses observe the inmates taking it and check their mouths afterward.
A.T. Wall, the prisons’ director, said that correctional officers were initially skeptical of the program, but there has been “a very significant culture shift” since it started.
The staff is coming to realize that the medications contribute to orderliness and safety in the prison, he said. “Using these kinds of medications and using them successfully makes everybody’s lives better,” Wall said.
Would Massachusetts correctional officials consider a similar program?
Christopher Mitchell, assistant deputy commissioner at the Massachusetts Department of Correction, said they had visited the Rhode Island prison to learn about the program. Their conclusion, he said: “That’s good for them.”
Mitchell remains opposed to buprenorphine and methadone behind bars, and expressed satisfaction with the Vivitrol program in Massachusetts prisons, which has so far provided injections to 285 inmates. Vivitrol patients are assigned a “navigator” to help them locate services in the community. A month after release, nearly 80 percent come back for their second injection or continue with another form of treatment, Mitchell said.
The Department of Correction also runs a Correctional Recovery Academy in four prisons, where inmates pursuing recovery live together and participate in a structured curriculum that helps them understand addiction and how to control it. About 1,200 inmates are currently enrolled in the six-month program, Mitchell said, and 60 percent of those who start complete it.
But prisoners cannot enroll if their urine tests positive for drugs. And those who relapse while in treatment face disciplinary action and have to leave the program, at least temporarily.
The 13 county houses of correction contend with a shorter-term population accused of less-severe crimes. They hold people awaiting trial and those with sentences of less than 2½ years.
Most county facilities have Vivitrol programs, but only two also offer buprenorphine.
Hampden County offers the medication to inmates shortly before they leave, while Franklin County allows inmates to continue on buprenorphine if they have a verified prescription for the medication when they arrive. In a recent 12-month period, 44 inmates in Franklin received buprenorphine, most of them pretrial inmates who were there for just a few days.
A recent $100,000 grant will enable the Franklin facility to expand that program to offer the buprenorphine before release. The hope, said Assistant Superintendent Ed Hayes, was to start inmates on buprenorphine and maintain them on the medication throughout their sentence, but it’s not clear whether there is enough money.
Leadership and funding are critical to the success of any prison-based addiction treatment effort, said Dr. Warren J. Ferguson, a University of Massachusetts Medical School professor who has studied inmate health care.
Rhode Island has a leg up in that respect: The program was part of a statewide opioid plan endorsed by Governor Gina M. Raimondo, who persuaded the Legislature to allocate $2 million to support it.
Additionally, all of the state’s jails and prisons are on one campus in Cranston, with one director.
The experience in Rhode Island may end up changing minds, Ferguson said.
“I’m really hopeful we’re going to see some data coming out of Rhode Island that demonstrates, wow, this might really be an improvement to safety and security in the long haul,” he said.
Deana Furtado said it’s sad it took an epidemic of overdose deaths “to have them start looking at us like we’re human beings.
“Anybody else that’s got cancer, anybody else that’s got heart disease, you’re going to give them medication. Why can’t we get medication? You’re going to take it away from us. Why? Why would you do that?”