20120523

Methadone? In a Jail?

The question was raised recently about how to handle inmates who prior to jail,  were enrolled in a methadone or Suboxone program to treat narcotic addiction.  Should they continue the methadone or Suboxone in jail?  Or should they instead be enrolled in the jail opioid detoxification program (we use clonodine at my jails) and withdrawn?

This is a problem I suspect prisons do not have to deal with.  But it is a common, every day, problem for jails in cities where such methadone programs exist.  In Boise, there are two such programs.  They do good and valuable work for the community.  I am a fan.

But whether to continue methadone treatments in jail is a clinical decision that is a balancing act between two conflicting principles:

1.  The best interest of the patient.  It is not in the best interest of the patient to stop treatment for heroin addiction and, as a result, have the patient relapse into heroin use.  It is also not in the patient’s best interest to put them through a partial opioid detoxification program only to have them immediately restart methadone the day they get out of jail.  On the other hand, for some inmates, continuing methadone therapy in jail simply means perpetuating their addiction, not helping them to recover.

2.  The safety and security of the jail.  Any time you allow a schedule 2 narcotic inside the walls of the jail, you have potentially compromised safety and security.  Other inmates (some of them also narcotic addicts) will find out about the methadone use and may threaten the inmate getting the methadone.  They will complain that they were not also allowed access to methadone.  Also, the more controlled substances you allow in the jail, the more chance that some day some turns up missing, triggering a big and nasty investigation.  I’ve seen both happen.

There is no one right answer for all patients.  Like many other medical interventions, the trick is to weigh the expected benefits of continuing methadone treatment against the potential harms, both to the patient and security of the facility, of allowing the methadone therapy to continue.

Two Conflicting Cases

There are clearly some cases where the proper decision is to allow the methadone therapy to continue.  Take, for example, the case of a heroin addict who has been clean for 8 months while participating in methadone treatment and has to serve 6 days in jail for a charge that is not related to substance abuse–let’s say petit theft.  Let’s also say this patient has made all the arrangements with their methadone clinic to continue therapy for the six days while in jail.  It simply does not make medical sense to put this guy on clonodine for six days and then have him return to methadone the day he gets out of jail.

On the other hand, there are clearly some cases where the proper decision would be to immediately discontinue methadone and treat the patient for withdrawal.  An example here would be the patient who has been obtaining methadone from several sources and is in jail for felony trafficking charges.

Since there are clear cases on both sides of the question, for me the goal is to define the circumstances under which I will allow methadone into my jail.  This basically involves writing a policy on the subject, hopefully with the help of both jail administration and with input from the area methadone programs, as well.  My policy on methadone (and Suboxone) maintenance therapy in jail contains three main rules.

Three Rules for Allowing Methadone in Jail

1.  I myself cannot prescribe methadone for the treatment of narcotic addiction.  It is illegal.  In order to prescribe methadone for such patients, I and the jail would have to apply for and be accredited to become a Methadone Treatment Center by the DEA.  You can find the rules for such a center here. The DEA is a stickler for this rule.  I personally know of two local physicians who were disciplined by the DEA for prescribing narcotics for addiction without the proper accreditation.  (I can, on the other hand, legally prescribe methadone for an ankle sprain if I want. What can you do?)

There are some jails that have applied for methadone treatment program status.  More power to them.  I have not, nor will I do so.  In my opinion, the headaches of such a program in my jails would far outweigh the benefits.  (But if your jail has applied to be a methadone treatment program, I would like to hear about it!  Comment or email me!)

Since I cannot legally prescribe methadone for these patients, the first rule of a jail methadone policy is that an accredited methadone program has to prescribe and deliver the medication.  The two programs in my city will do this as long as the patient pays, in advance, a $25.00 a day fee.  If the inmate cannot pay, the methadone program will not deliver the methadone.  Since I cannot legally prescribe it, we are done–the patient gets no methadone.   I will do what I can for them, using clonodine.

2. The second rule for a jail methadone policy is that it cannot go on forever.  Since clonodine treatment for methadone withdrawal takes about two weeks, I use 2-3 weeks as an arbitrary cut-off time for ongoing methadone treatment in the jail.  If an inmate is going to be in jail for longer than that, she will be withdrawn.  However, I sometimes have another option besides clonodine for such patients.  If the inmate can afford the $25.00 a day delivery fee, the methadone programs I work with will deliver a rapid taper of methadone, usually decreasing the total dose by 5 mg a day.  I then may still supplement with clonodine after that.

3.  The third rule is that the methadone has to be meticulously accounted for and meticulously stored.  Only medical employees should accept the methadone from the program.  Deputies should not be involved in this process, except as escorts.  The transfers must be accounted for on paper, similar to “chain-of-evidence” documentation.  The jail must have a double-locked, secure area for storage of schedule 2 narcotics, as required by the DEA.  Many smaller jails simply cannot adhere to this level of narcotic security and so cannot participate in such a methadone maintenance program.

I have discussed here maintaining methadone maintenance for patients taking methadone for narcotic treatment.  What about patients taking methadone for chronic pain?  My rules for them are similar but not identical.  More about them in a future post.

Under what circumstances will you allow methadone maintenance therapy into your facility?  Please comment!

 

 

28 thoughts on “Methadone? In a Jail?

  1. James Ondricek

    Your Methadone policy sounds similar to one that we have had for years in the Davis County Jail. We have just changed it however to no longer allow Methadone. We previously allowed Methadone for up to 30 days if the methadone clinic provided it and scheduled a regular reducing doses to allow for a, no longer than 30 days taper from the methadone, with the exception of a pregnant inmate currently on methadone program. (We have had one pregnant female on methadone here in the past and we did keep that exception in our policy.) Now however we just discontinued methadone or Suboxone in our jail. We have had up to 6 different Methadone Clinics in our area that have brought in methadone and we have had up to 4 different inmates at one time on Methadone with some having orders for split doses etc. The Chain of Custody paperwork with the Methadone is a hassle and we had one inmate that had difficulty paying for her Methadone and the clinic would bring in Methadone for a while then stop it until her family brought in more money and then start bringing it in again. She went back and forth on methadone to a Clonidine taper a couple of times until I told the clinic they were not welcome back here unless they were going to consistently provide the meds, we could taper her ourselves with a Clonidine taper. Last week we just received a letter from a Disability Lawyer threatening to sue us if we did not allow access to Methadone for his client. Our county attorney reviewed our new policy and we have now officially stopped allowing Methadone in our jail. This was at the request of our physician and we were the last jail in Utah, as far as I know, to allow Methadone in a jail.

    Reply
    1. Jeffrey Keller Post author

      Interesting, James. The success of my program absolutely depends on close cooperation with the two methadone clinics in town. I have not, to date, had any of the hassles you describe. If I could not work as a coordinated team with the local methadone clinics, I also would have to shut down my jail’s methadone program. The program absolutely depends on our being on the same page. However, one consequence of not allowing methadone into the jail under any circumstances is a big increase in the “Hassle Factor” of dealing with lawsuits, lawyers, outside doctors, grievances, etc.

      Reply
    2. Walescca Garcia

      James,
      I reside in Florida and work for a MAT and there seems to be a legal issue with us transporting methadone from our clinic to the jail. So I was wondering the following:

      What state do you reside?
      Is there a legal exception for these methadone clinics to transport methadone from their facility to yours?
      Or do they have a satellite office in your jail?

      I pose the same questions to you Jeffery, as you too indicated that your local methadone clinics transport to your jail for in jail inmate dosing.

      Thanks

      Reply
      1. James Ondricek RN

        Reply to Walescca Garcia, I live in Utah and the methadone that we used to allow in our jail was transported by a nurse from the various methadone clinics to the jail. It was transported in a lock box by a nurse every week and when they delivered it, they would call one of our nurses up front to sign a count sheet. They would leave a daily dose record for the inmate to sign each day that he took the methadone and we would give that back to the methadone clinic nurse the next week when they dropped off the next week’s supply. We did not have a methadone clinic license and did not want anything to do with that. I think the clinics just treated us like they did on any of their other clients that were on take out doses. They used the same paperwork. Each dose was marked for a specific date to be used and if the inmate was released from jail with doses left over, the clinic would send out a nurse to retrieve the lock box with the left over doses to take back to the clinic. We did not send methadone out on the streets with an inmate when he was released. I hope this helps. By the way, we no longer allow methadone in the jail. Also I just remembered that 20 years ago when there was only one methadone clinic in Utah, they would deliver methadone to a local pharmacy. The pharmacist would come over to the jail every morning and dose the inmate himself and our nurses never had anything to do with it. They contracted with a local pharmacy to do this for them and we just let the local pharmacist in the building. It was the same pharmacist every day. We did not pay for it nor did we ever take any doses into our custody he administered it himself. Let me know if you have any further questions.

        Reply
  2. Al Cichon

    A couple of quick notes:
    1. There is a provision (Federal Law?) that allows ER physicians to prescribe for a short term in an emergency opiate medications for sobriety maintenance. I’ll find and send it to you.
    2. On one occasioin I was able to obtain permission from OSA to prescribe an opiate for a pregnant femal who had been on methadone when it was not ppossible to obtain support from any other source – about 48 hours.

    Reply
    1. Jeffrey Keller Post author

      Thanks Al. Back when I practiced in the ER and such patients came in, I was unaware of such a loophole in the law. I will be interested to read it. I also have continued methadone treatment for pregnant inmates, but with coordination with their OB. You could argue that such treatment is not Methadone detoxification which is tightly regulated by the DEA, but rather obstetrical treatment for the benefit of the fetus, which may be allowable.

      Reply
  3. Leslie Robertson

    Another instance where we, meaning you, allow methadone longer term in the jail is when the inmate is pregnant. We then work with a local high risk OB clinic and coordinate for the baby’s detox if delivered while mother is incarcerated. In the most recent case, once other women in the dorm discovered she was taking methadone, she was pressured to save her urine so others could drink it for any residual methadone.

    Also, I think a key to the success we’ve had coordinating with the methadone clinic was face to face meetings to discuss options and cooperation. I must admit I had some real reservations when the clinics opened, but we all quickly recognized that not only do we share patients, but also goals. The communication has been open if not downright friendly.

    Reply
  4. John Wood, MD

    I have had methadone clinics contact me in the past about bringing methadone into the jail. They are usually friendly initially, and then become adversarial when they think you are not seeing it their way. I am probably too cynical. I have seen way too many methadone clinic patients who have had “dirty urines” with multiple other narcotics. The methadone clinics will gladly bring in the methadone every day as long as they are getting paid. Miss one payment and they are cut off. They don’t give tapering doses to the less fortunate, nor do they give clonidine.

    Methadone has a long half life. Somewhere between 23 and 123 hours. Even at the low end of 23 hours it would take 3 to 5 days for the blood levels to decline enough to show signs of withdrawal. At the higher end, withdrawal may not occur for two weeks.
    I feel someone coming in for a short stay in jail on whatever dose of methadone will be able to weather the storm with use of our withdrawal protocols. I also don’t think these inmates are better served knowing that if they commit an unrelated crime then they can still get their methadone. Why are they still committing crimes if they are such model citizens while getting their methadone treatment? See, I AM too cynical.

    Reply
    1. Jeffrey Keller Post author

      Thanks for the comments, John. I have had much friendlier relations with my local methadone clinics (knock on wood) than you have had. That is one reason why I have developed the policies I use. I respect your position, as well, though. Before I developed the policy I have, I used to also be a hard liner in never allowing methadone into my jails under any circumstances. But besides the medical considerations, I realized that I was spending a lot of time answering grievances and fighting with attorneys, clinics and outside doctors. One advantage of a policy similar to the one I outlined is that the responsibility for continuing methadone or Suboxone treatment in the jail rests now with the inmate, not me. There is a mechanism for them to do this. And if they can’t swing it, the fault is theirs, not mine. From a time management and hassle-management perspective, this program has been successful.

      Reply
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  7. Jenna

    I realize my comments are overdue so my comments are going to be to the point. Going to jail is AVOIDABLE. If you want to commit a crime that is a choice…and if you value your methadone treatment then its simple…DON’T GO TO JAIL. I’m so tired of people living better in jail/prison than they do on the outside. If you commit a crime they aren’t sending you to a hotel..its supposed to be uncomfortable (and opiate withdrawal won’t kill you..especially if you are provided with comfort meds like clonidine, zofran and maybe a light benzo like librium). You wind up in jail and don’t get methadone you have no one to blame but yourself..either stop commiting crimes are become a better criminal and don’t get caught..that is if you really value your methadone.

    Reply
    1. jeffk2996 Post author

      Thanks for the comment, Jenna! In my mind, the issue is one of the best medical care that we can provide our patients. If an inmate is only going to be in the jail for two weeks, then it does not make much sense medically to put them through a withdrawal program only to have them resume methadone the day they get out of jail. It also does not make sense from a time management standpoint. Putting a patient through the withdrawal program takes a lot of time and effort. If the patient just resumes methadone anyway, the time the medical staff devoted to the patient was wasted and would have been better spent elsewhere.

      Reply
    2. Angela

      I think you are not thinking of a very important factor here. There are a lot of situations where an addict commits a crime, misses a court date, and ends up with outstanding warrants. Then decides to change their lives and gets on a methadone treatment program. Living a clean life not commiting crimes. But it takes a lot of time, as an addict, to fix everything they have ruined in their lives. as they are living right and trying to mend things they have broken they still all the while have these outstanding warrants. Sometimes the only way to clear them up is to turn theresleves in to whatever county jail their warrant is out of. Im not so sure they should be denied treatment.

      Reply
  8. sharalyn

    I see both sides of this debate. I worked as a Clinical Coordinator at a Methadone clinic in Alabama for 6 years. All the clinics in AL are for-profit. I think that’s where many of the problems originate. At for-profit clinics, patients are counseled to maintain on Methadone Maintenance long term. They are told to consider their MMT to be akin to a diabetic maintaining on insulin. They give “lip service” to the idea of detoxing each month by writing a sentence in the clients notes thst they have asked them if they want to start a dextox program. The AL State Methadone Authority requires them to ask. But in reality, they don’t. They just record that detox was offered, and refused, month after month, after month. A daily dose of Methadone dispensed at a for-profit clinic is quite expensive, averaging $15.00 to $25.00 a day. Although the clinics PR touts MMT as a therapy that allows an addict to resume “normal life”, working a job and maintaining a home and family relationships, what I saw in my 6 years at a clinic of about 200 clients, was quite different. Sure, there are always those who are model clients (a few); but, the vast majority of ours had to beg, borrow, or steal, the money for their daily dose. I saw quite a few handing over the majority (or all) of their Medicare/Medicaid checks to the clinic each month, too. In random drug testing I saw 80% or higher testing positive for polysubstance use. If we just complacently sit back and condone, or actually assist in, maintaining this long-term use of Methadone for addictions treatment, are we not actually contributing to the problem of crime in our communities? In states where MMT is administered under the umbrella of the state mental health/substance abuse departments, they have a finite view of the use of MMT with an ultimate goal of weaning the addict off the use of all drugs, including Methadone. The counseling components are not a sham as I have seen at for-profit clinics. The actual cost of the daily dose is a small fraction of the price charged by the for-profit clinics. And there are incentives built into these state administered programs for successful completion of each phase of treatment leading to a drug free lifestyle. The for-profit clinics are cash cows that make their owners rich. And they will use their resources to fight any effort to close them down. But the more of these for-profit Methadone clinics that are allowed to open, the harder it will be to get rid of them in the future. It may already be too late to fight them. I think it’s going to take a community and state wide effort to combat this ongoing problem of legalized methadone dope dealing. Until then it seems that everyone is trying to work around the problems/issues that long term Methadone Maintenance Therapy produces rather than discuss ways we can aggressively combat it. That poor, suffering addict, is going to continue to suffer as long as he is tied to a for-profit Methadone clinic and has to come up with all that cash everyday, or face gut wrenching withdrawal. Thanks for listening!

    Reply
  9. Gary

    It is against human rights in England to force heroin & methadone withdrawal.. Many ex-convicts have successfully taken lawsuits against Her Majesty’s Prisons (HMP) and won… These lawsuits was due to aggressive heroin & methadone withdrawel forced upon convicts on arrival in to institutions up and down the country… Some who was not guilty at court got in to the tens of thousands of pounds sterling in compensation… I think this will follow suit in the USA very soon as desperate people do desperate things and innocent officers end up in the middle by trying to stop the flow of heroin in to prisons… When someone is maintained on methadone in prison they are a lot likely to be calm and not want to upset their current situation by being blocked/holed… I am saying this as a 20+ years ex heroin addict who has been on naltraxone (nalorex) subutex (bupranorphine) and currently on 20mls of methadone from 140mls and i am realy comfortable on 20mls even though in the next 6 months i will be clean for the first time in 20+ years… In my experiance i have been in private rehabs (detox 5) government rehabs and i have done numerous RAW DETOX’S in prison through the 1990′s and the thing that has worked for me has been methadone simply because i wanted it to… I went up on to a high dose and got 18 months behind me without using (clear time) this has been paramount in my battle with addiction to have my days ticking by without the madness of scoring and all the chaos that goes with being an addict… Now it is 2 years and 10 months with out using and have began to decrease my dosage because i have to be on nothing for what i want to do next which involves driving…. Anyway if you are prescribed methadone or bupranorphine in the UK and you get remanded you automaticaly get your methadone or bupranorphine on arrival the next day after a phone call is made to the community drugs team (CDT)… Thanks for reading…

    Reply
    1. Gary

      I meant to finish the above comment by saying i hope that the US follows the UK example and makes prison withdrawal something that is put back in to the convicts hands because all it does is make him more determined to use when he gets out when withdrawal is forced on to a person…

      Reply
    2. sharalyn

      Thank you Gary! And good luck with your effort to lobby the UK and USA governments to provide free opiate drugs, and/or Methadone and Soboxone, to people arrested on FELONY offenses in our respective countries. I hope you have DEEP POCKETS because I, for one, do not care to pay for any recreational drug use by prisoners in the penal system here, or across THE POND.
      But why not approach the large pharmaceutical companies, world wide, and ask THEM to provide free opiate drug, to any and all unfortunates/inmates housed in the penal system either here in the USA, or in the UK.
      I’m sure they will be happy to provide you, and all your friends, with a free dose of Opiate Drugs daily, for as long as you are awaiting trial.

      Reply
  10. Joanne

    This has been a useful blog, thank you. I am a new counselor at a methadone clinic. One of my clients is facing 5 days of jail time. She has been a model client for two years and has been fully engaged in her recovery. I agree that individual circumstances should be evaluated and if a client has been compliant and abstinent from illicit drugs for an adequate time period, why make them stop and risk relapse and possible death. It is the stigma of methadone and uneducated people judging something that they know very little about that perpetuates this problem. I am trying to advocate for her with the courts, however, I have been the only one at my facility willing to do so. “Rookie mistake?” I hope not.

    Reply
  11. James Ondricek RN

    Maybe you should talk to the medical director or Health Services Administrator at the jail your client will be doing her 5 day commitment. I have already commented above that we no longer allow Methadone in our jail except for pregnant inmates but there may be room for an exception for a 5 day commitment. We have made allowances for Weekenders in our jail. They would be required to be housed in the medical unit, while receiving Methadone but in all reality they would probably be housed in medical anyway while going through withdrawals. I know I would much prefer a counselor contact me directly about such a request than have them go directly through the courts and try to get a court order. I can tell you flat out, that if I received a court order for Methadone in jail, I would fight that court order but if the counselor contacted me directly and explained the situation, I would at the very least consider the possibility of making an exception to the rule of no methadone.
    Another possibility you may want to consider is having your client request from the judge either Work Release or Ankle monitoring and drug testing in lieu of 5 days in jail. I am not sure if that is available where you are at but those things both happen here in our county. Just a thought…

    Reply
    1. Joanne

      Thank you James. I will try the direct contact with the jail’s medical staff. She is trying to get house arrest in lieu of incarceration but with a public defender it’s hard to predict how much effort will be put into persuading the judge to consider other options. Thanks again for your input.

      Reply
  12. Mark Hirschman

    I have been involved for the past 10 years with a variety of methadone programs that have provided continued methadone AND counseling for inmates who are incarcerated in the Philadelphia Prison System. The program started with the prison receiving the license and having their medical care provider provide the methadone. After about a year they gave the license up as there were problems with diversion and ‘disinterest’ by the provider to provide the service. The program was initially short term detox (30 days) then long term detox (180 days) and eventually maintenance.

    The program was then taken over by an existing methadone program who provides maintenance approach. Inmates have to be verified as being on a methadone program prior to being incarcerated and their home program had to agree to accept them back on discharge from jail before they are included in the program. The only exception are pregnant opioid inmates. They are sent to a local hospital to be initiated and stabilized on methadone and then are picked up by the program for treatment. The program transports the medication on a daily basis to the inmates while the prison provides ‘security’. The program tries to “invisible” so that inmates are identified as receiving “special medication” as opposed to broadcasting that they are on methadone. The program also has counselors placed in each of the facilities to provide counseling (Recovery model of treatment vs. Harm Reduction). The expectation is that each inmate receives a minimum of 1 hour of individual and 4 hours of group counseling each month.

    The program has been very effective in reducing recidivism in 12 months from the overall prison number of ~45% to below 20%. The greatest hurdle has been in educating some of the correctional officers to reduce their “giving drugs to drug addicts” attitude. Most do seem to change their minds after working with the inmates and program and seeing the difference in behavior and attitudes.

    Based on this I feel that there is definitely a place for methadone maintenance in jails. In fact only inmates who are tapered are those verified as having a sentence of 2 years or more which will result in their being sent to a state facility where methadone is not available.

    Reply
    1. Jeffery Keller MD Post author

      Thanks for the comment, Mark. I applaud your efforts. Besides the inmates who are tapered off of methadone because they have over two years to serve, many others will not qualify for your program based on your inclusion criteria. The most common reason for discontinuation of methadone while incarcerated that I have seen is that the inmate cannot afford to pay the methadone program’s fee. Who foots the bill in your program? Is this part of the jail’s budget or do the inmates have to pay for their own methadone? Also, how much does the programming cost?

      Reply
      1. Mark Hirschman

        There is no cost to the inmates. The cost of the program is covered by redevelopment funds from the state medicaid system that come as part of the savings resulting from Philadelphia having a managed health care plan as opposed to a ‘fee-for-service” system. The prison has no direct costs or payments to the program other than providing office space and officers for security during the medication events. There are some savings to them and the prison health care system providers since there is a reduced number of inmates needing medical detoxification services as well as a reduced number of “suicide” threats/attempts resulting from withdrawal symptoms.

        We are providing service to an average of 160 individuals each month as well as providing medication for a 1 to 2 week period following release until they can be accepted/readmitted by their home program. I am not certain about the overall budget (I am the clinical director) but the cost in Philadelphia of a methadone program is about $9000/year/individual for medication, counseling and associated medical costs.

        And yes, it has been very satisfying being involved with this treatment option as well as being challenged trying to integrate treatment services with security concerns.

        Reply
        1. Jeffery Keller MD Post author

          Well, that is the main reason the program works, Mark! There is funding for it. Most jails and prisons do not have public funding for such a program. The local methadone programs here charge the patient a $25.00 a day fee to deliver their methadone to the jail to keep it going. Many (if not most) of the patients cannot pay this fee.

          Reply

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