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The Rhode to Recovery

Prescription pain pills are seen dumped out on a table at Grissom Air Reserve Base, Ind. Airmen who take prescription pills that are not their own or are taken after the time allotted could find themselves facing severe discipline. (U.S. Air Force photo illustration/Tech. Sgt. Mark R. W. Orders-Woempner)

Although America’s opioid epidemic is already killing formerly incarcerated individuals at staggering rates, prison and jails across the nation continue to fuel the crisis. For decades, we have been told by medical professionals that addiction is a chronic disorder of the brain, yet a seismic disconnect persists between the research of addiction and the physical treatment of addiction, especially in correctional facilities. Despite disproportionately high rates of substance abuse in the criminal justice system, America’s prisons and jails remain frightfully — and often fatally — ill-equipped to provide adequate treatment.

Currently, most American correctional institutions “treat” substance use disorders with forced drug withdrawal. Yet research shows that quitting cold turkey fails 90 percent of the time. The lack of effective treatment, coupled with the often insurmountable barriers of post-incarceration reintegration, often leads to recidivism, relapse, and drug overdose, which is the leading cause of death among the recently incarcerated. In fact, a study by the Massachusetts Department of Public Health found the opioid overdose death rate among recently incarcerated individuals to be a staggering 129 times higher than the rest of the adult population.

Rhode Island has, however, turned a vitally important corner with a different—and lifesaving—approach to treating opioid addiction behind bars.  Though the opioid epidemic plagues criminal justice systems across the nation, the situation in Rhode Island is particularly dire: The state’s overdose death rate is ranked fifth-highest among the 50 states. In response to this crisis, Governor Gina Raimondo established the Overdose Prevention and Intervention Task Force in 2015 to study and implement the best policies to reverse the opioid crisis. The task force aims to improve and expand access to opioid addiction medication in the state’s correctional facilities, and it has shown promising progress. Throughout 2016 and 2017, the Rhode Island Department of Corrections (RIDOC) dramatically revised their opioid treatment program, most notably by universally expanding medication-assisted treatment, which has been described as the gold standard of care for patients suffering from opioid use disorder.

Medication-assisted treatment, commonly referred to as MAT, pairs rehabilitative therapy with low doses of opioids that either appease cravings without getting the patient high or block opiates from reaching the brain’s receptors. The theory behind the program isn’t new, but Rhode Island’s commitment to its universal implementation sets a precedent for the rest of the nation. Rhode Island is currently the only state that screens every individual who comes into the correctional system for opioid use disorders. It’s also the only state that offers counseling and customized daily prescription of methadone, buprenorphine, and naltrexone—the three types of drugs approved by the Food and Drug Administration to treat addiction—for inmates in recovery. “We’re the only state in America that has a state-supported, state-funded, full range of medically assisted treatment in the prisons,” Raimondo proclaimed at the Community Overdose Engagement Summit in Warwick, RI in June of 2018, “[and] it is working.”

And she’s right—it is working. Since the program’s introduction, Rhode Island has seen a 61 percent decrease in post-incarceration deaths and a 12 percent reduction in overdose deaths in the state’s general population. A report published in the Journal of American Medical Association in February 2018 posited that the MAT program prevented one overdose death for every 11 inmates treated. Dr. Josiah Rich, Professor of Medicine and Epidemiology at Brown University and director of the Center for Prisoner Health and Human Rights at the Miriam Hospital in Providence, declared that the “magnitude of that drop in mortality is almost unheard of in public health.”

Beyond the state level, the success of Rhode Island’s prison opioid program has been recognized nationally and internationally. The World Health Organization, the American Medical Association, and the National Institute on Drug Abuse have all approved MAT as an effective means of treating opioid use disorder. Nonetheless, other states have been late in following Rhode Island’s footsteps: As of 2017, only 23 out of the 3,200 jails around the country provided opioid therapy medications to inmates. A 2018 Vox investigation of the role of prisons in fueling the opioid epidemic revealed that 28 states offer no medical treatment to incarcerated people suffering from opioid use disorders. As such, it is estimated that some 80 percent of the nation’s incarcerated population who could benefit from MAT are not receiving it. We now have treatment programs offering dramatic results for current and recently incarcerated people—so why aren’t more corrections facilities using them?

There are several obstacles barring a nation-wide adoption of MAT-like programs. First is the institutionalized stigmatization of substance use disorder. In America’s prisons and jails, the focus remains on punishment, not treatment. Despite peer-reviewed research recognizing opioid addiction as a chronic disease, many correctional facilities, along with vast swaths of the public, continue to vilify substance use disorder as a moral failing. This explains why correctional staff were initially concerned about bringing opioids into the facility, especially when so many resources are currently focused on keeping contraband opioids out. This concern, however, is easily mitigated. The RIDOC women’s facility, for instance, shifted from pills to strips of Suboxone that melt on the tongue, thus reducing drug distribution and security concerns. Anecdotal evidence has even suggested that the prison market for opioids has dwindled as treatment enrollment increased, further attesting to the success of MAT over traditional opioid-crackdown attitudes.

Another concern is cost. Rhode Island’s MAT program has an annual budget of $2 million. Although this may seem like a hefty sum, the program ultimately benefits the economy by reducing recidivism rates and improving economic productivity of inmates upon release. One can look to similar, smaller-scale programs in Missouri and Kentucky for successful implementation programs: For every dollar spent on opioid treatment programs there, around $3.76 to $4.46 was saved, respectively.

And yet, we must rethink opioid addiction treatment both behind and beyond the metal bars of correctional facilities. Rhode Island’s MAT program is not only a model for other states’ correctional facilities, but it also challenges our current approach to opioid abuse beyond the metal bars of correctional facilities. A report published by the Surgeon General in 2016 revealed that just 10 percent of Americans with drug use disorder obtain specialty treatment for their disease, largely due to shortages in the supply of care. Further research by the Foundation for AIDS Research found that even when substance use disorder treatment is available, fewer than half of facilities offer opioid addiction medication. Correctional facilities across the country fail to support inmates who enter the criminal justice system on MAT, then refuse them access to MAT during incarceration and release them back into their communities without the resources they need to survive, let alone recover. In order to prevent relapse, patients suffering from opioid use disorder must continue to receive care and support even after they are released from prison, care that must be provided by established programs in the broader community. Rhode Island, once again, has set a leading example: Any incarcerated patient within the RIDOC is linked to a network of dosage centers across the state. As such, upon release, patients can continue to receive their dose within their community with as smooth a transition as possible. Forced withdrawal is just one murky brushstroke on a vast and ugly canvas illustrating the human rights and healthcare crisis which exists at the intersection of addiction, criminal justice, and public health in the United States. Incarcerated Americans, most of whom are people of color from low-income communities, are substantially more likely to suffer from a substance use disorder or mental illness than their non-incarcerated peers. The failure of America’s public health system to provide accessible and routine preventative care to such communities leaves many low-income individuals with substance use disorders without treatment, funneling them towards the criminal justice system. The RIDOC’s MAT program is being championed as a model for the rest of the country, and rightly so: America’s prisons and jails offer a unique opportunity to care for under-served populations. Even then, expansion of MAT programs is just facet of what must be a multi-pronged approach in response to substance use disorders and the societal stigma with which they are associated. We must invest in community-based treatment so the criminal justice system does not become the de facto public health provider for low-income communities. People suffering from substance use disorders must be fundamentally seen as patients, not prisoners. Before that is understood, little will change.

Photo: “Prescription pain pills