Doctors who treat people with opioid addictions often hear of former patients who have to restart their treatment after leaving jail or prison. Or worse, their former patients die of drug overdoses soon after their release.
“They go back using what they’re used to,” said Dr. Eric Morse, an addiction medicine specialist in Raleigh. “They can’t tolerate that dose and they die.”
A study of former North Carolina prison inmates found their risk of overdose deaths after release was 40 times higher than the general population. Researchers at the UNC-Chapel Hill Gillings School of Global Public Health and the state Department of Health and Human Services published their findings in the American Journal of Public Health in 2018.
The risk of overdose deaths was highest in the first two weeks after former inmates were released from prison, the researchers found. The risk of heroin overdose within the first two weeks of release was 74 times higher for newly released prisoners than it was in the general population.
Specialists who prescribe federally approved medications for opioid addiction have tried for years to convince jails and prisons to allow their patients to continue taking them while incarcerated.
So far, doctors have been frustrated. In 2019, the state Department of Public Safety began a limited program for pregnant women in the NC Correctional Institution for Women in Raleigh. Fourteen pregnant women are enrolled and are prescribed either methadone or buprenorphine, DPS spokesman Brad Deen said in an email.
The COVID-19 pandemic delayed expansion of the pilot program to three more prisons, Deen wrote, but the department intends to start medication-assisted therapy or “MAT” this fall. The therapy will be part of reentry programs at two minimum security prisons – Wake Correctional Center, Orange Correctional Center, and the minimum-security section of the Women’s Prison.
“Cruel and unusual punishment”
The prisons will use a different approach than what some doctors prefer. Selected inmates will begin MAT treatment as they prepare for release and continue treatment after they leave prison. UNC’s Formerly Incarcerated Transition Program will help them with reentry.
DPS knows of only a few instances of people who have been prescribed MAT when entering prison, Deen wrote. If DPS learns that medication-assisted therapy is more common than previously known, the department will use that information as it decides the future of the program, the email said.
The state prisons’ plan “is better than nothing,” Morse said. “It’s a step in the right direction.”
But he questioned DPS’s assessment that people coming into prison haven’t used MAT or don’t need it. Morse suspects the department’s numbers are low because a lot of people are forced into withdrawal before they get to prison.
“I think it’s kind of cruel and unusual punishment” to force someone on a medication to stop using it, he said. “Why not just keep them on it throughout?”
A handful of county jails allow inmates to continue talking medication for opioid addictions.
Eddie Caldwell, executive director of the NC Sheriff’s Association, said the organization has never discussed medication-assisted therapy for opioid addictions, and does not keep track of jails that allow it.
Dr. Jana Burson, an addiction specialist in Wilkes County, said five jails do.
Patients can be in stable recovery by the time they are sentenced to jails where they no longer can take the medications that treat their opioid addictions, Burson said. “They’re forced to undergo withdrawal,” she said. “Once they are off their medication, and once they get out, they are at much higher risk of overdose deaths.”
Learning from other states
Access to medication-assisted treatment has been shown to cut post-release overdoses in other states.
In 2016, Rhode Island started offering adults with opioid addictions who entered the corrections system MAT while incarcerated; these patients also were treated after their release. Researchers reported a 60% drop in opioid overdose deaths in people with addictions who were recently released, though researchers warned of the study’s small sample size.
In contrast to DPS, the NC Department of Health and Human Services encourages jails to allow people with opioid addictions and who are on MAT to stay with it while incarcerated. DHHS also offers advice on how to do it. Spokeswoman Catie Armstrong said in an email that the department is working with the prison department on the pilot program for prisons.
County jails say they are worried about diversion – that inmates prescribed methadone or buprenorphine will pass it to someone else, Burson said.
Methadone is a liquid, and “it’s not hard to watch someone swallow their dose,” she said.
Buprenorphine film or pills are held under the tongue until they dissolve. It would be easy to ensure that inmates who take it don’t store it in their mouths, she said.
Some jails oppose MAT on principle, Burson said, while officials in some counties think they’re helping people by getting them off the medication.
Many people with opioid addictions who are incarcerated face quick tapers from the medications before they’re locked up and an intense withdrawal once they’re behind bars.
There’s a lingering stigma against methadone treatment, said Mary Anne Hughes, a nurse practitioner at a methadone clinic. “By the time we get them, they’re not getting high,” she said of patients. “They’re using it not to get sick.”
Burson said it may take a lawsuit to force jails to allow people to continue taking medications for opioid addiction while incarcerated, pointing to court actions in Illinois and Maine.
In the Maine case, a federal appeals court said a county jail needed to supply a drug used to treat opioid dependence called Suboxone to a woman facing a 40-day sentence, according to a CBS station in Portland.
Burson said there are creative solutions that answer North Carolina jails’ objections.
“It boggles my mind how hard it is to get treatment,” she said.
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