In a March 2014 memo to fellow executive staff, top health officials in the Bureau of Prisons admitted something that researchers have known for years - the federal prison system's drug treatment programs were failing to successfully treat prisoners with opiate abuse disorders. The officials wrote that "abstinence-based programs such as ours" only work for about 10 percent of participants suffering from opiate addiction.
The memo would come as no surprise to policy makers at the United Nations, the World Health Organization and even the White House, who recognize that opiate addiction is a chronic illness and recommend making drugs like methadone and Suboxone available to prisoners instead of simply locking them up and expecting them to stay sober thereafter. As the Obama administration's latest drug czar, Michael Botticelli, said last year as he released a grim report on the number of people with substance abuse disorders in jail and prison, "We can't incarcerate addiction out of people."
The United States has the highest incarceration rate in the world, however, and that has a lot to do with the impact of drug prohibition and the failed war on drugs that took particular aim at regular drug users and communities of color. The federal government now estimates that between 30 and 60 percent of incarcerated people have substance abuse disorders, and 70 percent of prisoners in local jails have committed a drug offense or use drugs regularly. Prescription painkiller abuse has skyrocketed over the past decade, and researchers estimate that at least 200,000 people who are dependent on heroin pass through the criminal legal system every year.
Methadone and Suboxone mimic the effects of opiates, allowing patients with severe opiate dependences to feel normal and function throughout the day. While some people worry that the drugs simply replace one addiction with another, public health experts agree that treating opiate addiction often requires such medication, and methadone in particular is one of the most highly regulated and effective treatments available. Suboxone, known generically as buprenorphine, contains the antidote naloxone to prevent abuse and has been heralded as a crucial tool for combating heroin dependency.
Years of research show that combining counseling with drugs such as methadone, a process known as medication-assisted treatment (MAT), often effectively reduces the use of illegal drugs like heroin, prevents overdose-related deaths, prevents the spread of blood-borne diseases like HIV, and reduces rates of drug-related crime among people with opiate dependences. MAT also reduced recidivism rates, but the vast majority of jails and prisons in the United States do not offer MAT to prisoners, and many facilities cut or attempt to wean prisoners off of prescribed methadone and Suboxone drug regimens while they are incarcerated.
Facing painful withdrawals, some prisoners turn to illegal drugs while behind bars. Plus, studies have shown over and over that prisoners cut or weaned off of methadone are less likely to return to methadone treatment clinics upon release, leaving them at risk of relapsing and committing crime or suffering a fatal overdose.
The mounting scientific evidence in favor of using MAT therapies to help people recover from opiate addiction appears to be having little impact on correctional authorities, who often resist the idea of allowing psychoactive substances in their facilities and perhaps fail to grasp the medical realities of addiction altogether. Policies in some prisons are slowly changing, but advocates say the changes are taking far too long to roll out.
The 2014 memo, along with another undated internal memo circulated among top prison officials, reveals that the White House's Office of National Drug Control Policy is putting pressure on the Bureau of Prisons to implement MAT for substance abuse therapy. The memos contain limited details on plans for a pilot study on a select group of prisoners who would be injected with the drug naltrexone and offered some counseling as they completed their prison sentence and transitioned to halfway housing or house arrest. Naltrexone blocks the effects of opiates, and the study would find out if it could keep prisoners from relapsing back into drug use upon release.
Indeed, in February, the White House announced $13 million in resources to expand MAT services nationwide, plus an additional $2.2 million to fund a MAT pilot program in federal prisons. Bureau of Prisons spokesman Ed Ross, however, told Truthout that he does not know if the results of the naltrexone pilot are available, or if the study has been conducted at all. He said federal prisons will soon be publishing new treatment guidelines for Hepatitis C, a disease that can be spread by injection drug use, but he did not respond to requests for information on how the $2.2 million new federal funding is being spent.
A Mother's Plea
The memos were unearthed by a Freedom of Information Act (FOIA) request filed by Diana Goodwin, mother of Gordon Goodwin, a federal prisoner.
In 2009, Gordon was 20-year-old undergrad at UNC-Chapel Hill when he developed kidney stones and a doctor prescribed him oxycodone for pain. Goodwin soon became addicted to prescription painkillers and eventually transitioned to heroin, which is typically cheaper and often easier to find on the street.
Despite addiction treatment, Goodwin continued on a downward spiral, and he attempted three bank robberies to pay back drug and gambling debts before being convicted and handed a 47-month sentence in 2012.
It's no secret that illicit drugs are often available in prison for a price, just as it's well known that, for many people, opiate addiction is a chronic disease and multiple relapses back into drug use are common. Despite completing a behavioral drug treatment program, Goodwin found narcotics in prison. He has been placed in solitary confinement and moved to different facilities several times, because he ended up in debt to dealers and tested positive for drugs.
Diana Goodwin said her son had been on and off Suboxone before he was incarcerated, but his doctor did not give him the type of dose needed to treat addiction as a chronic disease. She has spent months pleading with prison officials to put him back on Suboxone, but they have so far refused. Goodwin said that it's likely that Gordon's problems could have been prevented if "they had just given him the damn medicine."
Goodwin worries that her son's next relapse could be his last. She recently ran across a press release from the Bureau of Prisons reporting that a man her son's age had died at FCI Fort Dix, a medium security facility in New Jersey. The release offered no explanation for the death although releases about murders and gang violence usually do, and Goodwin said her "mom radar" went off. She looked up the man's criminal history, and sure enough, he had been busted for buying and selling opiates. She assumed he died of an overdose.
"I talked via Prison Talk online to a mother - she said it was an overdose, and all the cells got tossed twice, and they still didn’t find any drugs, and all they found was hooch," Goodwin said.
The story highlights how easily drugs can fly under the radar in even the most strict prison settings, where the medical care available to people with addictions seems to be stuck in the dark ages. Goodwin said that, if the man had been prescribed, or at least offered, the current standard of medical care, then he might still be alive. (Goodwin asked Truthout not to print the man's name because his family has yet to make a public statement.)
"I don't want my son to die in prison, and I don’t want him to overdose when he gets out," Goodwin said.
Overdose and HIV
Gordon Goodwin's story is the sort of middle-class tragedy that the mainstream media has exploited in its coverage of the nation's opiate epidemic, but poor people and people are color are disproportionately represented in jails and prisons for drug-related crimes. Incarceration does little to address the harms of opiate addiction that plague disadvantaged communities and exacerbates some of the factors that drive people toward opiate dependency in the first place.
A 2004 survey found that only 12 percent of jails allowed prisoners already in a methadone program to continue their treatment behind bars, and only 2 percent offered methadone to treat withdrawals. Nearly half failed to provide any detoxification medications at all. A 2008 survey found that only 55 percent of state and federal prisons offered methadone to prisoners, and half of those facilities only prescribed methadone to treat chronic pain or keep pregnant women from suffering withdrawals that could cause a miscarriage. Only prison systems in seven states offer Suboxone to some prisoners, while 15 provide referrals to providers upon release.
Sally Friedman, an attorney for the Legal Action Center, a group that advocates for MAT access, estimated that only a small handful of correctional facilities have expanded access to MAT since the surveys were taken.
"It's incredibly common," Freidman said of correctional policies denying prisoners access to methadone and other MAT drugs. "Not a heck of a lot has changed [since] then. The needle is moving ever so slightly."
That means that, at many facilities, people with opiate addictions battle withdrawal symptoms and severe cravings during incarceration. Doing time in jail and prison is already traumatizing, but being forced to withdraw from opiates or methadone while locked up causes so much pain and discomfort that international advocates and researchers question whether it's the kind of "cruel and unusual punishment" that could be considered illegal under the US Constitution.
"There is this idea that, yeah, suck it up, tough love, this is how you [quit drugs]," said M-J Milloy a Vancouver-based infection disease epidemiologist with the British Columbia Center for Excellence HIV/AIDS. "But every strategy is different. Everyone gets to recovery - or not - in their own way."
Abstinence and forced withdrawals do not work for many people struggling with addiction, as the federal prison system admitted in the 2014 memo. Forced withdrawals can even be fatal, and people have died in jail because they did not have access to medicine.
"The fact that people get thrown cold turkey without medical supervision and sometimes die is indefensible," Friedman said.
Milloy said that, even if you think forced withdrawal is simply a punishment that fits the crime, you are ignoring realities of drug use that have reverberating impacts on public health.
"Even if you don’t care about the health of drug users, even if you think that addiction is the product of them being bad people, even if you believe that, the amount of preventable disease caused by incarceration in this situation is huge," Milloy said.
In the mid-1990s, Vancouver suffered one of the worst HIV outbreaks ever observed in North America. Unlike earlier outbreaks attributed to unprotected sex, this outbreak was linked to injection drug use, despite the presence of a syringe exchange program that served as a model for the rest of the world at the time. A major problem, Milloy said, is that no such programs exist behind bars, and many prisoners share syringes despite the risk of contracting diseases like HIV and Hepatitis C from dirty needles. Cutting prisoners off of MAT increases the chance they will take this risk.
"Thousands of infections were the result of incarceration," said Milloy, who added that HIV patients in one of his research groups told him that "everyone shares" needles once they get to jail or prison.
Milloy's own research shows that, for people who are HIV positive, continuing methadone treatment improves their ability to adhere to HIV treatment regimens, so it's crucial that both treatments are not interrupted during incarceration. That keeps prisoners healthy and minimizes the amount of the HIV virus in their bodies, decreasing the likelihood that they will spread the disease to other prisoners and members of their community upon release.
Fatal overdose is also a serious concern. Milloy points to one study that found rates of fatal overdose to be about 12 times higher among ex-prisoners during the first two weeks after release than the general population.
"Most people stop using drugs in prison," Milloy said. "When they get out, their tolerance has changed, so that initial period after they get out of prison is extremely hazardous to their health."
Continuing MAT throughout incarceration, Milloy said, keeps tolerance levels stable and increases the chance that people will continue MAT programs in their communities upon release from prison, dramatically reducing the chance of a relapse and a fatal overdose. This has huge implications in the US, where the Center for Disease Control reports that deaths from prescription painkillers quadrupled from 1999 to 2011 as sales of the drugs increased at a similar rate.
Painkiller overdose deaths dropped in 2012 for the first time in over a decade and have remained steady, as heightened oversight at medical facilities and law enforcement crackdowns reduced prescribing rates, but the number of deaths from heroin have increased substantially over the past three years, as people who've become addicted to painkillers turn to street drugs to find their fix.
It's the Painkillers and the Stigma, Stupid
The nation's opiate problem, it seems, is not ending any time soon, inside or outside of correctional facilities. So, why are jail and prison officials so wary of MAT?
Eric Wright, a professor of sociology and public health at Georgia State University and chair of the Indiana State Epidemiology and Outcomes Workgroup, said the criminal legal system is often strapped for health-care funding, and people who work at correctional facilities often see drug abuse as a personal failing, not a medical condition.
"People who come out of the criminal justice tradition tend to see drug abuse as a personal behavior problem and not a disease problem," Wright told Truthout.
Depending on which prison official she talked to, Diana Goodwin heard different reasons for why her son was not given Suboxone, but the federal prison system's official medical policy states that Suboxone can only be prescribed for detoxification, not for pain or MAT therapy. One reason for this policy, Goodwin was told, is that prison officials worry that Suboxone and other MAT drugs could be sold or traded to other prisoners, which is called "diversion."
In response to a FOIA request filed by Goodwin and reviewed by Truthout, however, the Bureau of Prisons could not produce any records on instances where prisoners were caught diverting drugs like methadone because prison officials don't track such data, so it's unclear how often diversion actually occurs.
Friedman said diversion is one reason why prison officials are more open to naltrexone, the drug in the federal pilot study, which can be administered with a supervised injection and prevents users from getting high. Naltrexone, however, cannot be given to people with opiates currently in their system and does not treat withdrawal symptoms.
Diversion is also a concern among law enforcement, but the government reports that much of the methadone that has been diverted and linked to an increase in overdose-related deaths in recent years was prescribed to treat pain, not as a MAT therapy for chronic opiate dependence, which is subject to much stricter regulation. At a methadone clinic, patients are given a liquid dose under medical supervision, which is much different than a doctor simply handing a patient a prescription.
Doctors do prescribe Suboxone in pill form, but a case study in Vermont found that Soboxone abuse and diversion was not widespread. The diversion that did occur was clustered in small groups of people, many of whom were simply self-medicating to treat withdrawal symptoms because formal MAT treatment was not available in their communities.
Experts say that, just like community methadone clinics, the strict protocols for administering drugs in correctional facilities can ensure that only the people who need the drugs will use them. Friedman pointed to Rikers Island, the main jail in New York City, which has had a methadone program for years.
"If Rikers Island can do it, jails can do it elsewhere," Friedman said.
MAT programs are designed to reduce drug abuse, not encourage it. MAT, it turns out, is one of the most heavily regulated treatments in all of medicine. Doctors and clinics must receive special federal waivers before treating patients with drugs like methadone. The same kind of strict regulations do not exist for the prescription painkillers that slowly take over the lives of people like Gordon Goodwin.
"What is strange to me is that people focus a lot of attention on MAT when the real problem is the high rate we are prescribing opioids in general across Indiana," Wright said. "There are enough prescriptions filled each year that nearly every Hoosier could have their own bottle of pills."
Wright's interagency working group in Indiana has been warning the state's lawmakers for years about a dramatic upshift in prescription drug abuse in the state, followed by increased use of heroin and other injection opiates, but lawmakers in the conservative and largely rural state continued to put a moratorium on new methadone clinics, forcing some patients to drive hours for treatment.
"If you've got the rise of prescription drugs, then the rise of injection drug use, then a drop in services over time - you drop a little HIV in there, and you can have an explosion," Wright said.
That explosion occurred earlier this year, when an HIV outbreak among injection opiate users in rural Indiana made national headlines and shook communities where many people viewed the disease as an urban problem.
"In some ways, it was predictable, I guess," Wright said.
There is a "silver lining in this terrible cloud," according to Wright. For years, Indiana refused to spend any of its own money on drug treatment and mental health services, relying instead on federal grants, but now the state is moving to bring services to rural areas that were out of reach for public health providers in the past. Medical facilities are sharing records to track painkiller prescriptions, and officials like Republican Gov. Mike Pence are turning their backs on longstanding GOP dogma and embracing limited syringe exchange programs. Wright said there are even efforts to expand access to MAT despite the moratorium on new methadone facilities.
If it took a disaster to spark some change in Indiana's approach to opiates, then what will it take to expand MAT access in jails and prisons? Wright said resistance to MAT in both the political and criminal legal systems is based on the stigma surrounding drug use and a "broader American individualism" that expects people to "pull themselves up by their bootstraps." Still, the writing is on the wall. Even the Obama administration is ready to fund MAT in federal prisons, although it remains unclear how its $2.2 million in new funding is being spent.
Correctional officials say that they are in the business of rehabilitating people, but that's a hard pill to swallow when science shows that their own policies contribute to the social problems they are supposed to be solving. Mothers like Diana Goodwin, who only see their children when visiting hours allow, will be the first to tell you that the system isn't working. Nothing about her son's experience in prison has been "rehabilitative," she said, and the prison officials act as if they are accountable to no one.
"The Bureau of Prisons feels completely invincible, untouchable," Goodwin said.
Beyond their recommendations for protocol behind bars, medical experts agree that people with substance abuse disorders need access to treatment in their communities, as opposed to confinement and punishment. Doing time doesn't just cut people off of medical care like MAT, it cuts them off from their loved ones and the freedom to do the things that make life worth living. This can be as crucial to recovery as having the freedom to work with medical professionals to find a treatment that works. If people continue to be arrested and jailed instead of being offered quality medical care, there will continue to be a lot of pain to kill. It's a vicious cycle that keeps the beds behind bars full of bodies, and it's unclear if that's a cycle the prison bosses are eager to break.