Opioid detoxification is now a primary role of county jails: NPR



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In Massachusetts, in July, several inmates in Franklin County Jail, seated, were watched by a nurse (left) and a correctional officer after receiving their daily doses of buprenorphine, a medication that helps control opioid cravings. According to some estimates, at least half or two-thirds of the current US prison population has a substance abuse or addiction problem.

Elise Amendola / AP


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Elise Amendola / AP

Confronted by a flood of drug-dependent inmates and lawsuits, US prisons are struggling to adapt to an opioid-related health crisis that has turned many drug treatment centers into addiction treatment centers the most important of their region.

In an attempt to solve the problem, more and more prisons are adding some form of drug treatment to help detainees safely detox and keep clean behind bars and after their release.

But the potential abuse of treatment drugs raises serious concerns, as does the efficiency and cost of programs for which prisons have simply not been designed or built.

"Prison has never been traditionally a caregiver or the main provider of detoxification in the country – that's what they've become," says Andrew Klein, research scientist specializing in justice Advocates for Human Potential, which advises on drug treatment programs in prisons and across prisons in the United States.

A "critical situation"

The National Sheriffs Association estimates that at least half of two-thirds of the current prison population has a substance abuse or addiction problem. Some counties say the number is even higher.

"We are in a critical situation," said Peter Koutoujian, spokesman for the issue and Sheriff of Middlesex County, Massachusetts, one of the states hardest hit by the epidemic of 39; opioids.

"We have to physically and medically detox about 40% of our population out of the street," he says, "and probably between 80 and 90% of our population inside is addicted or alcoholic."

Koutoujian, who is also vice president of America's top sheriffs, said the best way to treat opioid-addicted inmates is one of the most pressing issues prisons face today. 39; hui.

"We have not managed to deal with it because, quite frankly, the company has not mastered it either, thus preventing [drug addicted] people come to our institutions or support them once back outside, "he says.

"The point is that you should not have to come to prison to be good [treatment] said Kutoujian. You should be able to do this in your own community so that you do not have to disrupt your life by being incarcerated. "

An ever-increasing number of prisons – 85% of which are run by local sheriffs – are trying to expand the use of drug-assisted drug treatment behind bars, including buprenorphine and methadone, among others drug addicts.

"Dead addicts do not recover"

Prisons in states hardest hit by opioids – including Ohio, Kentucky, West Virginia, Rhode Island, and Massachusetts – are striving to expand this use of medicine, which is now widely regarded as the most effective method of treating disorders of opioid consumption. The National Sheriffs' Association recently released a comprehensive guide to best practices for drug-assisted treatment in prison, in collaboration with the National Commission on Correctional Health Care.

"Deceased drug addicts are not recovering, so this is our opportunity to engage this population," said Carlos Morales, director of correctional health services in San Mateo County, California, just south of San Francisco.

Morales is using it to expand access to medication for an older addiction treatment model, which has long been based on abstinence and a "cold turkey" approach.

"We know that if you're an opiate, you come here, you detoxify yourself and you go out – it's a 40% overdose chance," says Morales. "And we have the potential to do something about it."

Felipe Chavez, who spent time in San Mateo prison for selling fentanyl, is participating in the prison's new opioid treatment program. Chavez says that opioids dominate his life since he started taking oxycodone tablets at the age of 12, as a result of an injury.

"I smoked them," says Chavez. "Then I went to heroin, and then the heroin went to fentanyl."

With his sleepy eyes and loose clothes, Chavez looks younger than his 23 – a bit like a teenager in his pajamas. But the bright orange color of everything he wears, up to the plastic fangs, means that he's at the San Mateo County prison infirmary in Redwood City, in California, where he receives his regular dose of methadone.

Yet Chavez is one of the lucky ones here. As he was participating in a local methadone treatment program prior to his arrest, he was allowed to continue using this synthetic opioid substitute in prison. Methadone and a few other drugs help convicted opioid consumers like Chavez get angry and, in theory, protect themselves from more potent and destructive opioids.

"It's all about whether you want to be clean or not, you know," said Chavez. "Methadone is just here to help, you know, I mean, you have to focus on methadone, because you have to start somewhere."

With methadone treatment, he says, "I feel more normal, like a normal person."

Prison as an "opportunity to intervene"

Doctors who treat prisoners have the challenge of extending the use of methadone or other medical treatment is that it is unclear, at least initially, what role plays the opioid addiction in the problems of the prisoners; their drug use is often linked to mental health problems.

"The opiate part of the problem is usually not part of the indictment documents, so it's hard to say," says Dr. Robert Spencer, San Mateo County Medical Director of Correctional Health. Addiction, mental health and crime "are intimately linked," said Spencer. "It's often a form of self-medication, an attempt by them to change their symptoms, which gives us the opportunity to step in and move forward."

Drug addiction experts say more research is needed to confirm the long-term benefits of drug treatment in prison. But so far, studies have shown that medication-assisted treatment can reduce fatal overdoses, relapses, and the spread of infectious diseases such as HIV.

Nevertheless, this type of drug-based approach is relatively new in San Mateo – as in many prisons in the country. For nearly a quarter of a century, San Mateo's flagship drug treatment program is an abstinence-based approach called Choices. Up to now, only a dozen of the approximately 1,000 inmates in prisons are receiving medical treatment.

The director of correctional health, Morales, wants to develop these figures. But he is still worried about costs, efficiency and safety. He says detainees can amass – then sell, trade or abuse – some of the opioid drugs that are among the main contraband products currently in prison.

In addition, prison reforms in California to reduce overcrowding and reclassify some sentences have resulted in county jails harboring more inmates for longer periods of time.

This, added Morales, has led to a kind of merry-go-round for repeat offenders: an increasing number of detainees with multiple bookings and short prison sentences; people who do not receive the treatment they often need.

"I do not think our scenario is still good," he says. "We do not explain it well [to inmates]and we must do our best to advocate that someone use assisted medical treatment – and to get the correct protocol, so that it is not isolated people who practice it. "

Prisons need to create the dynamics of routine treatment by engaging staff and inmates to talk about the success of this approach, he said. "And frankly, we are not sufficiently developed – these are the challenges we face."

It's a similar story at the national level, where the number of prisons offering drugs to drug-using inmates is low.

Only 10 to 12% of the country's 4,000 prisons try to use some form of addiction medicine as part of a treatment.

"Although that number does not represent the majority of prisons five years ago, it was nil," says Klein. "And the number is increasing every week."

Some offer access to opioid substitutes, namely buprenorphine and methadone, which can help opioid users to detox and then calm their cravings. In theory, in the long run, these drugs can help people who have become opioid dependent not to use destructive and potentially life-threatening street versions.

But the majority of medical treatment programs assisted by a prison are nowadays limited to injectable naltrexone, administered at the release of the prisoner.

Also known by its brand name Vivitrol, naltrexone is an injectable drug that could trigger withdrawal symptoms in a person who is physically dependent on opioids. but it also blocks brain receptors for opioids and alcohol for 28 days.

Opioid-addicted offenders are at a much greater risk of overdose upon release, as their tolerance for illicit drugs is often significantly reduced after a period of abstinence. Suddenly, a dose that had raised them once could now be fatal.

The concerns about accountability and the need to improve the management of withdrawals are also at the origin of the increase in the number of MATs. About 80% of all alcohol and drug detoxification activities occur in prisons. And at the national level, over the last 10 years, counties and states have paid more than $ 70 million for the death of inmates related to substance abuse weaning, according to a Klein count. More than 50 similar lawsuits are still pending.

According to Klein, the challenge is much larger than prisons for a public health system that has not yet caught up with the opioid crisis. "MAT is totally underused in the community, let alone in prisons," he said.

The problem is particularly difficult for prisons in more rural and semi-rural counties, which often have limited access to drugs, the doctors who will administer them, and the follow-up programs that prisoners can use once released.

To provide methadone, for example, a prison must be certified as a methadone treatment center or in partnership with a community health center.

"Even if [rural jails] Carrie Hill, director of the National Sheriffs Association's Center for Jail Operations, says, "This is a huge problem."

But a county may not have a doctor with the licenses needed to provide treatment medications, says Hill.

Most rural areas "do not have a single doctor who is allowed to prescribe even buprenorphine," Klein says. "It is very difficult for a prison to find a doctor who can prescribe it to an inmate who may need it." Most counties in rural areas and suburbs do not have methadone clinics they can count on. . "

Hill adds that sheriffs in his group are working on ways to expand treatment and recovery support services in rural areas, including town-country treatment partnerships; additional funds to significantly expand telemedicine and broadband services; and mobile anti-opioid drug treatment units that can provide drugs for treatment in hard-to-reach prisons.

The group is in discussion with its federal partners to obtain the necessary medical exemptions to do so.

Advocates of MAT expansion say that drugs save lives. "In prison, [when] we have someone stabilized – off street drugs – they can start to calm down and [we can] Find out if we can help with drugs, "says Klein," what a tragedy if we miss this moment. "

The Massachusetts legislature, with Koutoujian's encouragement, has cleared a pilot program in seven counties for the best evidence-based opioid treatment in prison. Starting in August, prisons will offer all forms of drug treatment and will closely monitor efficacy data, including relapse rates, overdose and recidivism.

Although he supports MAT in general, Sheriff Kutoujian says he's worried that drugs alone will not solve the problem of drug treatment of inmates. This type of reflection, he says, first plunged us into this crisis.

"Medication-assisted treatment is very important, but people need to remember that if you do it without the treatment part – counseling and support – it will fail, and we will simply fall prey to another easy solution that will just does not work. "

"We have to make sure, if we are going to use assisted drug treatment," says Koutoujian, "that by leaving our facility, they will have access to the drugs.Do they have health insurance to cover these drugs?" and treatment and navigators to help them through this very difficult time? they? d not, in many ways we could prepare them for greater failure.?

Meanwhile, in San Mateo Prison, inmate Felipe Chavez said he wanted to serve his sentence, reconnect with a little girl that he barely knew and try to "live a different life." ".

"I mean, I know everyone says that while they're here," says Chavez. "But, you know, I'm really trying to get my family together, change the way of life."

To do so, says Chavez, he wishes for the moment to stay in the prison's drug-assisted treatment program, to help him stay away from the fentanyl and stay alive.

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