Opinion | The Opioid Treatment Dilemma in Jails

Those of us who work in jails sat up recently as we read this recent news: The Biden administration called on state Medicaid programs to fund opioid treatment programs in jails and prisons. Wow! To understand why that is such a big deal, let me introduce you to the typical jail’s opioid treatment dilemma.

The U.S. currently has a crisis of opioid abuse, fueled mainly by heroin and fentanyl. We used to talk about “heroin addicts,” but it is unusual to find pure heroin on the street anymore. Heroin is usually mixed with fentanyl, meth, ketamine, or any one of a host of other substances. Fentanyl can be used alone or mixed with other substances. Because of this trend, what we used to call heroin addiction is now termed opioid use disorder (OUD). One estimate suggests there are at least 3 million people in the U.S. with OUD. Many people with an OUD problem will eventually wind up in jail.

When a patient with OUD is booked into a jail, the first order of business from a medical perspective should be to treat opioid withdrawal. Opioid withdrawal is a serious medical condition. Patients withdrawing from opioids suffer mightily and without treatment, some will die. The most effective drug that can be used to treat opioid withdrawal is buprenorphine. However, since buprenorphine is itself an opioid, the Drug Enforcement Administration (DEA) has placed administrative obstacles to its easy use in jails. Fortunately, the alpha-agonist drug clonidine (Catapres) is not regulated by the DEA and is also effective in treating opioid withdrawal. Either way, treating opioid withdrawal is time intensive. These people are sick!

In my experience, treatment for withdrawal typically lasts 5 to 6 days (but can vary by drug). However — and this is very important — treatment for withdrawal has not addressed the patient’s underlying addiction. If nothing further is done, essentially all patients will return to opioid use as soon as they get out of jail (the average jail stay at my facilities is 2 to 4 weeks). And patients with OUD released from jail have an especially high risk of dying from inadvertent overdose.

So, why not treat OUD patients for their addiction while still in jail?

The two main medications for OUD (MOUD) are methadone and buprenorphine. As opposed to treating withdrawal for 5 to 6 days, MOUD must persist for months or years and be coupled with classes, groups, and counselling in order to be effective. MOUD clinics that offer the whole package, including therapy, can be found in most cities in the form of methadone clinics or community buprenorphine programs. Since most OUD patients will be in jail for less than a month, the best course of action, by far, would be to treat the patient’s initial opioid withdrawal using buprenorphine and simultaneously enroll that patient in a community buprenorphine treatment program. This way, they can seamlessly continue treatment in the community when they are released from jail.

The advantages of treating opioid addiction in jails using MOUD are huge. Patients are much less likely to return to using heroin or fentanyl upon release from jail. They are much less likely to die from an overdose. Treated patients are much less likely to commit other crimes (burglary, for example) to get money for their drug habit. They are much less likely to get needle-borne infections like hepatitis C and HIV. They are more likely to not return to jail.

This makes so much sense, so the question at hand is: “Why aren’t we already doing this now?”

Well, some jails (and prisons) are, but most American jails are not. The reasons for a specific jail not offering optimal medical therapy for their OUD patients vary, but include:

1. The jail medical practitioner has not been trained in how to prescribe MOUD
2. The jail medical practitioner does not personally go to the jail enough to make an MOUD program work
3. The jail does not employ enough nurses to carry out an MOUD program
4. There is no MOUD program in the community to continue MOUD therapy when patients are released from jail
5. Patients have no insurance and so cannot pay for a community MOUD program when they are released from jail
6. Jail administrators fear that buprenorphine will be abused and diverted if it is allowed into the jail
7. The jail is seriously understaffed with detention officers — too few to adequately administer an MOUD program
8. The jail is hopelessly overcrowded (as many are) and there is no space to house MOUD patients separately from other inmates and no space for MOUD counselling and programming

The common denominator of why not to offer MOUD in jails is money. To run an effective buprenorphine program in a jail, most jails need more nursing hours, more space to put the patients in the program, more medical practitioner hours to prescribe the medication, and so on. In addition, the community buprenorphine program needs funding for their time spent enrolling jail patients, beginning counselling and classes in the jail, and planning for release.

Right now, it is illegal to use any federal funds (Medicaid, Medicare, VA benefits, and so on) for drug treatment in jails. And I know from experience that obtaining the necessary funding for a jail drug treatment program from county commissioners is a tough sell. The Biden proposal would help solve this funding gap in those states that adopt it. My own state, unfortunately, has not done so. It’s time for more momentum nationwide.

Jeffrey E. Keller, MD, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. He is the author of The Best of Jail Medicine: An Introduction to the Practice of Correctional Medicine.