A little-discussed provision deep within the Legislature’s criminal justice bills tackles a critical but contentious aspect of the opioid crisis, requiring prisons and jails to offer inmates all approved addiction medications.
The proposal, phased in over four years, would make Massachusetts only the second state to pledge to provide the full array of treatments, including Suboxone and methadone, to inmates with opioid-use disorder.
“This is a really great move in the right direction,” said Dr. Alex Walley, director of the addiction medicine fellowship at Boston Medical Center’s Grayken Center for Addiction. “If the person has a major substance use disorder, why wouldn’t we provide them the best treatment when we have the opportunity to?”
The provision appears in each of the criminal justice bills that were recently passed by the state House and Senate. Neither bill provides funding, and it’s not clear how much it would cost to offer the medications to inmates.
While medication treatment is commonplace in addiction programs outside of prison, correctional institutions have long resisted providing it during incarceration — even though close to two-thirds of inmates have a substance-use disorder and prisoners with addictions are at extremely high risk of overdose when released.
Currently, even inmates who arrived with a prescription for buprenorphine (best known by the brand name Suboxone) or methadone are usually forced to stop taking the medications.
“You wouldn’t stop insulin if somebody had diabetes,” said Maryanne Frangules, executive director of the Massachusetts Organization for Addiction Recovery, a patient advocacy group.
Of the three medications that treat addiction, only one — Vivitrol — has been widely accepted by correctional officials in Massachusetts and only for use shortly before release. Vivitrol, or injectable naltrexone, is a once-a-month shot that prevents a person from feeling the effects of opioids. Vivitrol’s manufacturer, Alkermes, provides the pre-release shot for free to correctional institutions.
The legislation would force prisons and jails to also offer methadone and buprenorphine after inmates are assessed upon arrival. Those two treatments partially fill the brain’s opioid receptors, quieting cravings for substances such as heroin.
Walley said all three drugs are effective, but none works for everyone.
Correctional officials object to buprenorphine because it is commonly smuggled behind bars, and they fear providing it legally would worsen the problem.
Inmates want buprenorphine because it eases withdrawal symptoms and because it can induce a high in people who have not taken opioids for a long time.
Christopher Mitchell, assistant deputy commissioner of re-entry for the Massachusetts Department of Correction, noted that contraband is no trifling matter in prisons.
Because buprenorphine is valued and expensive, Mitchell said, “it’s causing people to be assaulted. It’s causing people to have hits put on them. . . . People have to go into protective custody because of debts they’ve acquired. In a prison environment, whatever the contraband is, it’s life and death.”
But it’s not clear whether providing buprenorphine in a controlled medical setting will increase black-market use. Rhode Island’s Adult Correctional Institutions have been providing it since last year, with patients under careful observation when taking their daily dose. Anecdotal reports from one jail suggest that providing the drug legally reduces contraband, but data are not yet available.
As for methadone, prison officials have complained that it is too difficult to administer because only federally regulated clinics can dispense it. But Walley pointed out that prisons routinely provide methadone to pregnant women (because withdrawal is dangerous for mother and fetus), showing that the logistical barriers are surmountable.
Rhode Island’s prisons are offering methadone, and the Rikers Island jail in New York City has had a methadone program for 30 years.
Middlesex County Sheriff Peter J. Koutoujian, president-elect of the Massachusetts Sheriffs Association, said that sheriffs — who run the 13 county Houses of Correction for people awaiting trial or with short sentences — have not yet discussed the legislation. But he anticipates widespread concerns about such a mandate, particularly about the cost of providing the medications and the risk of contraband.
One exception is Sheriff Christopher J. Donelan of Franklin County, which is already providing buprenorphine.
“Certainly a program such as this presents risks and challenges,” Donelan wrote in an e-mail. “But we continue to build the program to be as effective and secure as possible, knowing that saving someone from an overdose and potential death is well worth those risks.”
With help from a state grant, Franklin County expects to expand its program from the four or five currently getting buprenorphine to about 20 inmates a day, at an annual cost of $187,758; that figure includes the cost of the drug itself and ancillary services such as nurses and security.
Assistant Superintendent Ed Hayes added that the facility is unable to offer methadone because the local methadone clinic is too busy to take new patients.
The provision on addiction treatment, introduced in two slightly different amendments to the criminal justice bills, faced little debate or opposition in either House or Senate. The Association for Behavioral Healthcare, a trade group for addiction providers, led the advocacy groups pushing for the change.
The requirement would go into effect in five locations in the first year and expand gradually over the next three years, with assessments of costs and effects conducted each year.
A conference committee will meet soon to reconcile the House and Senate versions of the criminal justice measures. The committee can delete the amendment about prison treatment, but Senator John F. Keenan, the Quincy Democrat who sponsored it, said he believes the provision will make it to Governor Charlie Baker’s desk.
Asked for comment, the governor’s office sent a statement saying that the administration “believes that medication assisted treatment is an important tool to treat substance use disorder” and that Baker will “carefully review” the legislation.