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 Or should they instead be enrolled in the jail opioid detoxification program (we use clonodine at my jails) and withdrawn?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!
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.
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.
I hear a lot of horrible excuses of why jails cannot be bothered by hassle and its really disheartening to think that we are too lazy for paperwork on something that will greatly help our addiction, relapse and overdose issues. these are people with families that have done the work to change their life for the better and who are we to say that in order for them to clear up any preexisting legal baggage that they have to stop using the medication that quite literally saved their life. our society has some major priority problems.
As far as I’m concerned, not one dime should be spent on an addict’s comfort. If they want to get clean, there are recovery meetings in jail for free. I KNOW because I am in recovery and I bring meetings into the local jail. Methadone is a friggin scam and a paycheck for the providers. It’s just transferring addictions. We are dealing with that in our own family. You will NEVER convince me otherwise.
Thanks for commenting, Cathleen! Methadone is certainly a controversial topic, that’s for sure.
Cathleen, It is obvious that your dislike of methadone is fueled by emotional thinking since you admit that you will never change your mind regarding methadone. This necessarily implies that it is a dogmatic belief.
If methadone use was simply “transferring addictions” then all factors would be the same other than the specific opioid of use. But this is not true. Methadone users are medically supervised. Methadone treatment may not be perfect, but it is better than doing nothing. The evidence shows that liberalization of drug policy works. Just look at what happened after Portugal decriminalized all drugs.
Recovery meetings work for some people, but the selection offered in jail is limited to mostly AA. You probably bring a 12 step meeting to the jail. You should offer something like SMART recovery instead. Expecting everyone who wants to get clean to attend AA or NA is ridiculous because the 12 steps require a belief in the supernatural. The 12 traditions of AA specifically mention a “loving god”. AA even states that it believes addiction is a “spiritual” problem… And it has been demonstrated in studies that 12 step meetings are effective, but no more effective than any other recovery group. The important thing is to attend a recovery group, but the belief in a higher power? Not necessary. Therapy in addition with medication-assisted treatment have been shown to be even more effective than therapy alone.
As for your comment about comfort, I have only this to say: a similar argument could be made by someone who thinks that jails and prisons shouldn’t provide mattresses, or air conditioning, etc. to inmates because “not one dime should be spent on a [criminal’s] comfort”.
What substances did you abuse if you don’t mind me asking?
I am a nurse, and worked in the Jail for a year, my past has been mostly ER for 30 years. They may be an addict, but they still are a human being, and should be treated for their condition, which is real. They an addiction problem…some people have high blood pressure, diabetes….etc…the point is that without these medications the person could die. No different than an inmate that is in withdrawal from on opiate. We may not approve of their actions, but we are not to judge them. They need medical help, or they could even die. The patient that is in a methadone program has to pay upfront for their Methadone, and so should they in Jail, or they do not get it in the clinic. Methadone should be tapered and then another medication used. I may not like or approve of any drug use, but they are still human beings and it is our job to help them medically as much as we can.
I agree with you completely.
Without methadone it is cruel and unusual punishment.
Denying methadone patients that were enrolled in accredited Methadone Treatment Programs is criminal and represents cruel and unusual punishment. Anyone who argues on the basis of the poor morals of the addict should be forced to detox from methadone in jail for a lesson in humility. Clonodine doesn’t do jack for withdrawal and I can tell you from experience. The purpose of jail is house people awaiting trial or transfer, in most cases these people are not convicted of any crimes, to subject them to torture is a crime against humanity. Plenty of people get addicted after accidents and the next time you think about judging someone, you should think twice before you get behind the wheel because car accidents happen to everyone.
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 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.
I previously worked for many years and now work doing MAT in the community. In my state, the Department that governs addiction services can issue a waiver for Methadone to be issued for the specific patient to be administered by a residential facility as long as that facility has the capability to securely store the Methadone and document administration. We currently do this at two sites.
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.
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.
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.
Thanks for the comments, Leslie. I had forgotten about the urine-drinking episode! I am going to insert both of your comments into the original article for future reference!
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.
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.
You’re incorrect about the time it takes to reach withdrawal. Most people start withdrawing within 24-72-hours. I’ve never seen anyone on a maintenance dose of methadone last 5-days before withdrawals set in. That’s just crazy. A half-life isn’t necessarily a very good broad indicator. Remember that some people process methadone more efficiently and may require a dose twice daily (morning and night) to keep a concentrated amount in the blood.
Source: Years of personal experience.
I know this post is old, I just wanted to point that out.
WOW !! I’ve been on Methadone Maintenance for 20 plus years , and as far as withdraws go ! I can say , from personal experience , withdrawal starts 24 to 36 hrs and every min. that goes by it gets worse ! As far as Heroin and certain Opiates like Oxycontin ,even Morphine ,,,, As severe as the withdrawals are , after 6 or 7 days ,,,,a person starts to feel like they ” Won the battle ” { not the war ! } And Weathering the storm is posable !Like 4 inches of snow !! Weathering the storm from Methadone Withdrawal is like getting 4 feet of snow ! ” I don’t like using term Weathering the storm ,, Because it’s ”surviving the Torture ” !!!!! And torture it is !! After the first 24 hrs of withdrawal ,the flue like symptoms set in like a bomb . Then , it progresses into severe body aches , shaking, can’t eat , hard to concentrate ,,you get so weak it takes every bit of strength one has just to shower or brush your teeth ,wash your face , ect. Try to sleep , forget it , maybe for an hour ,and that is because you are so exhausted your body just shuts down ! But while laying down your body is shaking , legs are kicking and your shaking ,,sweating , there is so many things going on within our body ! And , this continues for 3 yo 4 weeks before it even starts to subside , and these symptoms start to become manageable !!!Thats the true horror of forcing someone to go cold turkey after being on Methadone Maintenance for several years or more ! There is however , Medically Supervised Detox done slowly is the effective and painless way to detox from Methadone …. { AND , ONLY WHEN THE PATIENT IS READY TO , AND HAS DECIDED TO DETOX AT THERE OWN PACE ” } Any person on a Methadone Maintenance Program and is denied and forced to go Cold Turkey and suffer through these horrible withdrawals is Cruel and Inhuman ! Equal to Torture !
I believe that they should receive there Dolophine (Methadone) in ALL jails….. These inmates are already paying the debt to society. If they are in a treatment facility they should be able to dose. I have seen the death of an inmate from 140 mg withdrawal! Unacceptable to the fullest! The DEA created this epidemic and there solution is to bring in the CDC, and use there dictatorship to bully us doctors! They want me to cut my patients off of methadone…. Well I say NO! Heroin use is up 77% and a majority is because there doctor was “threatened” by the DEA/CDC….. Lets get the medicine into the jails, so they can be helped, I am willing to put my licenses on the line TO DO THE RIGHT THING!
i dont agree with your timelines. I have spent 15 years studying pharmachology, methadone is metabolised by a difference of 100 fold. The half life can be as small as 7 hours in some patients and serum levels can drop well below a stable level after 24 hours. This is why some patients recieve split dosing. So while 1 patient can skip his dose for a day and be fine 99 others will be defocating on themselfes within 36 hours.
Here are links to web sites that discuss the DEA exception
http://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_07.htm
https://www.naabt.org/documents/three-day-rule.pdf
Just in case google 21 CFR 1306.07(b)
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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.
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.
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.
Angela that’s exactly what my situation is like. I’m a recovering heroin addict on the methadone program and I have maintained my abstinence from street drugs since I got on the program. I am now a year and four months clean and consider the methadone program a blessing. It has helped me get my life together and although my family initially had reservations about the program they have grown to appreciate it as well as they’ve seen what good it has done in my life. When I first got clean I had an outstanding warrant for a d.u.i and a possession charge. The possession charge got dropped but unfortunately I ended up having to go to jail for three days on the d.u.i charge. I did not get dosed for those three days. although it was just a few days I can tell you going that small amount of time without my dose was awful. The second day without was painful but the third day was extremely bad. I was vomiting, I had a migraine, I was restless.. my legs and back hurt immensely. I could not get comfortable at all and I could not sleep. i don’t believe anyone charged with a non violent crime should have to deal with that sort of pain. I know it was my fault that i was in jail to begin with but it was something I had done while I was using and I feel that methadone treatment in my case is a good thing. Not a negative thing that should be taken away while I’m serving time trying to clean up the mess I made while I was using. I can understand why some people feel cynical about the program especially when people are still using and committing new crimes while on the program. I just believe every situation is different and should be treated as such.
You seem very uneducated. Jail is effectively a warehouse for those charged AND those convicted doing their time or waiting transport to prison. In the US one is supposed be ‘innocent until proven guilty’ and as such inmates who cannot afford to post bail and are waiting for trial may be stuck there with those who are career criminals. I would hate to see you get falsely accused–this can happen to ANYONE–however perhaps it might change your perspective. People don’t ‘come to jail’ as you put it–they get arrested and charged with a crime and upon arraignment plead not guilty or guilty. Many inmates end up taking plea bargains because they have jobs and families and cannot take the chance of having to fight a case from jail only to lose at trial. Also, you really must be superhuman to call Clonidine and Zofran ‘comfort meds’. I happen to have a serious medical condition and along with it comes dangerously high blood pressure and cyclic vomiting. Comfort meds…SMH….I guess if it’s all about comfort, stop taking MY clonidine and let my blood pressure stay at 165//90. Maybe you want me to stop taking my insulin too? Or is it just addicts you were talking about? And Librium isn’t a ‘soft Benzo’, whatever that means. It actually has a longer half-life than things like Ativan or Alprazolam which makes it better for tapering. The jail in my city uses Valium and does a 3 week taper for those coming in with prescriptions for other benzos and I believe those using it on the street who can provide a positive UA within 24 hours of coming in from the street. It works quite well and is painless. If an inmate is caught trying to divert his or her MAT or withdrawal meds, they are cut off. The threat if this works for most.
Anyway, for anyone doing a withdrawal protocol I will add my 2 cents, or at least what I use and have seen work:
Clonidine
Tizinidine
Promethazine
An extra strength NSAID for pain and something for diarrhea
Benadryl, 25-50 mg at night
I, however, highly support and recommend MAT in jails and prisons and the continuation of care rather than causing more instability in the lives of these patients.
When you are treating someone as a physician, you cannot see them as anything less than a patient that needs continuation of care and proper, humane, fair treatment. It shouldn’t matter if they are in a jail cell or inside the walls of a convent.
–Jade
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!
Interesting comments, Sharalyn! Thank you!
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…
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…
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.
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.
Relapse? Death? how much metadone is your “Client” taking daily?
I think she means Relapse or Death from illicit drugs if the jail makes her come off Methdone and then in 5 days releases her to the streets…
The client is on 95 mg of methadone and has been for two years. Relapse can mean death with many opiate addicts. The numbers of opiate deaths in my state (Ohio) have risen 400% in the past few years. If the client does not attend the clinic for 5 days her dose will be cut in half or in some cases stopped until she can see the doctor to get her methadone resumed. The common action by most people with opioid dependance is to use when the withdrawal symptoms become unbearable. Many overdose deaths occur when the user has just left a rehab facility and have been clean for several weeks or months.
In June 2011 a woman did die of heroin withdrawal at this particular jail. Her family filed a lawsuit in July 2013. The documents that the attorney filed were available on line. It was a sad situation to read about. The inmate’s complaints about feeling sick and having heart palpitations was ignored and the guard’s called referred to her as a “f#ck@ing junkie”. On the fifth day they could see from the monitor in her cell that she wasn’t moving. When they finally went in to check her she was deceased. According to the court documents, Upon finding her deceased, no resuscitation efforts were made nor was 911 called to help her.
The stigma associated with methadone that is perpetuated by non-medical (and some medical) individuals that are in positions that are suppose to provide care and safety for inmates and those that have involvement with the criminal justice system, and patients in clinics and hospitals is disgusting. Prison guards, Judges, prosecutors, public defenders, and probation officers are not doctors and are not qualified to diagnose and choose the level of care for anyone. Yet, they do.
It took six months but it looks like she will get to take her methadone while she is incarcerated next month. It felt good to finally get the public defender, the chief probation officer, and the judge to acknowledge her methadone therapy as treatment. But it should not have been this hard.
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…
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.
Good news on the struggle to get methadone for one of my clients while she has to do a 5 day sentence…… Perseverance and education won out! My client will be allowed to take her methadone during the 5 days she has to spend in jail. The doctor at the clinic wrote a letter, along with others from the clinic to the chief probation officer of that county. It took over 6 months but through my client’s good example of what methadone has done for her and how well she is doing in her recovery….. SHE WILL BE ABLE TO CONTINUE HER MAT IN JAIL!!!
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.
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?
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.
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.
Is this all of PENNSYLVANIA or just Philly
In Oklahoma in 2011 Gov. Mary Fallon signed SB854 into law, stating that (in abbreviated form for here) jails MUST dose patients on methaone maintenance, whether from a treatment clinic or by a licenced private practice Dr., in order to provide for the welfare of the patient. This stems from a suicide and subsequent lawsuit in Payne Co., OK of a patient on methadone maintence who was refused his methadone legally licenced M.D. Now if a jail refuses to follow the law the jail can have hefty fines and prison sentences handed out to the Dr who did now follow said law. When you go to medical school you know that you are to follow the hippocratic oath, which states in one of the last verses, ” I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”
In my opinion, the risk vs. benefit of withdrawing a patient off his/her regimen just because you don’t want to deal with the “headache” of paperwork or what-have-you is a flagrant violation of the legally binding oath one takes when one becomes a MD is ludicrous. Hence why we have the law here in Oklahoma.
Thanks for the chance to post!
Dr. Christopher van Whittaker, Ph.D , Addiction Counselor VAMC
Every state should have a similar law. I think it’s shameful that it took a suicide and the subsequent fear of liability to get a state to simply do the right thing. Denying existing mmt patients a prescribed medication for a chronic condition, especially when it causes such suiffering, is barbaric, uinethical, and a breach of the Constitution and the AMA (not to mention deliberate indifference to medical necessity). I commend you for standing up for your patients. Committing a crime does not negate the need for medical treatment. With any other medical condition, this wouldn’t even be an issue. Unfortunately, the pervasive stigma attached to addiction and methadone is rampant in the criminal justice system, and judges are more than willing to play doctor.
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Fascinating discussion.
I have yet to see our local Methadone clinic ever discontinue a client off the stuff.
Heroin addiction withdrawal is much worse than Methadone, how come we don’t support everyone with Methadone? If so inclined, support them with PO Percocet.
Don’t forget; methadone is probably one of the most toxic narcotics out there. From a pharmacological standpoint, methadone is a nightmare. My first goal with inmates is for them to survive their incarceration. What they do after they leave is not my concern.
WOW! You don’t care what happens to them after they leave your facility? Really? Before you judge a treatment option, learn more about it based on evidence based studies, then from those who will testify that methadone save their lives or someone they love. Methadone withdrawal IS WORSE than heroin.
It is prescribed by a medical doctor. Are you a medical doctor? Are the Judges and Probation Officer’s doctors? Are the correctional officers doctors? NO! Yet they want to deny medication that is legally prescribed to a patient! How is that fair? Would you deny them their diabetes or blood pressure medication?
Better yet, sir, go to the morgue or a few funerals in your area of those that have died from a heroin overdose. Many right after leaving a NON-medically assisted treatment facility!
The scientific evidence and medical, behavioral, and public health research overwhelmingly supports methadone maintenance treatment in jails/ prisons. There are hundreds of reports and studies recommending medication assisted treatment be implemented in jails and prisons, yet over 95% of US correctional facilities do not utilize this life-saving treatment, even for existing methadone patients. The ones that do, usually only dispense methadone to pregnant women. (Sadly, the day they give birth is often also the day they begin cold turkey withdrawal. How’s that for trauma?)
In fact, the lack of medication assisted treatment in the criminal justice system is literally killing people. Methadone and buprenorphine maintenance treatment in jails and prisons would decrease illicit substance use within correctional facilities, decrease the spread of disease among inmates (and decrease the inevitable subsequent spread of disease into the community at large), decrease relapse and recidivism rates (along with the associated exorbitant costs of relapse and recivism), and decrease overdose and overdose death rates among those released from jails/ prisons.
The truth is that, although addiction yields serious behavorial consequences (as well as emotional and psychological consequences), the nature of opioid addiction is biological, and it must be treated as such if it’s to be treated effectively. If we are insistent upon treating addiction as a criminal behavior, akin to theft and assault, or as an inherently behavioral or psychological problem, with no consideration for its neurochemical and metabolic nature, our methods will continue to be ineffective.
Yes, the behavioral consequences of opioid addiction often involve “real” criminal actions (crimes other than simply having or using the drugs one is addicted to) for which a debt to society must be paid. But imposing punishment and/or suffering beyond that sentence is a breach of the Constitution. Opioid withdrawal (especially the henious but sickeningly common practice of witholding methadone from existing patients) cannot be part of “learning a lesson”. Witholding treatment is barbaric, unethical, against 50 years of medical advice and evidence, and essentially illegal. Denying methadone to an existing patient is a breach of the US Constitution as well as the AMA. The Legal Action Center has published a comprehensive report on the denial of MMT to inmates. A link to the report and other valuable information can be found on the LAC’s website as well as AATOD’s website. There is also a SAMHSA publication called “Know Your Rights: For Those on Medication Assisted Treatment,” which has invaluable information regarding housing and employment rights and puts laws like the ADA, the Fair Housing Act, and the Rehabilitation Act into context for the MAT patient. The National Alliance for Medication Assisted Recovery (NAMA Recovery) at http://www.methadone.org is an abundant resource for anyone interested in MAT advocacy or more info on methadone.
Wow how about personal responsibility? If you want to continue methadone stay Sober and stay out of jail. Nearly all of my MTD folks test dirty for other illicit drugs and they are not continued on methadone. The ones who are compliant will continue until sentenced then taperd off.
Ok, Jennifer Whitehead CMA, there are lots of legally prescribed medications that have been given to patients on the outside that will be not allowed in a jail. The jail has its own physician and once a person is incarcerated they lose the right to shop for whatever doctor will prescribe whatever they want. Our doctor is the Medical Authority for our facility and he is the only person legally allowed to prescribe any medication to a current inmate. We take them off various meds like: benzodiazepines, muscle relaxants, sleeping pills, Opiates, and other highly abused meds every day. I do not see your correlation with Methadone and how it’s illegal or unethical to stop it in a jail. Yes, they may have withdrawals but we are trained to deal with that, and we do so all the time. No one has ever died from any type of withdrawals in our jail except possibly alcohol withdrawals and those are much more life threatening than Methadone withdrawals any day.
Yeah and you know what James, alcohol, in your words the most dangerous drug to withdraw from is legal–says a lot about our society doesn’t it!
Benzodiazapene withdrawal is also lethal just like alcohol withdrawal .. you can die from the physical withdrawal from not having benzodiazapene just like from alcohol .. methadone withdrawal can also lead to death but usually in individuals with a pre existing conditions ..herion withdrawal the same thing. So the comment that only alcohol withdrawal is life treating if l incarcerated with no meical assisted detoxification or treatment is an absolute falsehood
Well, Jennifer W., thanks for not including world peace to your “in fact” myths about the benefits of methadone – in jail.
Why is it that the more passionate a person is about their position, the less they are willing to reconcile their position with the evidence based on good science? So why do we deliberately ignore the science behind addiction? For example,
Dr. George Koob’s life’s work confirms that the chronic brain disease of opiate addiction is caused, in part, by opiates AND more opiates are only injuring the brain more. This is from Dr. Koob’s talk to several hundred addiction specialists at the 46th annual American Society of Addiction Medicine (ASAM) conference in Austin TX on April 26th 2015.
What many have thought for a long time is so clearly proven by the neuroscience research that I can understand it: Drugs of abuse damage brains! Folks, the SCIENCE (FACTS as we know them) says opioids continue to make the chronic brain disease worse. We call addiction a “disease” and compare it to diabetes. But do we treat diabetes with daily doses of donuts just because patients feel better when they eat them? Wait doctor, recidivism is going down when we do this: giving them donuts keeps them from breaking into Dunkin Donuts and getting arrested for stealing donuts.
Is someone feeding us crazy pills? Please convince me, using the best available neuroscience that we’re not buying really really bad logic created in the chronically diseased brain of addicts. Because it looks to me that we’re just re-arranging the deck chairs on the Titanic and speciously calling it harm reduction.
Cold turkey opiate withdrawal, no matter how one got there, should never be considered ‘part of the punishment’ for anyone. Opiate dependency and the horrific withdrawals are treatable medical conditions. Not treating them is inhumane! Insurance companies absolutely recognize and cover the treatment of medically assisted opiate detoxification and so should jails.
Why not give these folks the opportunity to get off methadone and better their lives? Fear of the detox keeps people on methadone. Being forced to do it as an inmate (using clonidine to help) could be the BEST thing.
I used 160 mg of methadone (pills) every day for 10 years. I experienced the beginnings of detox many times and, yeah, it was BAD with nothing to help. When circumstances eventually stopped my access to methadone I was terrified. But after 3 days in the hospital, using clonidine, I was clean. The ONLY significant discomfort was 1 day with a scratching feeling in my legs, “restless legs.” For about 2 weeks afterwards, my body – especially my legs – were very weak. But my head was getting clear. Methadone is itself a narcotic and in my experience can keep you in a fog and dull your emotions. For me, getting off finally got me back to feeling human and “alive.” At least some of the inmates in your jail might end up feeling the same, and grateful for it! And for the others, the methadone clinics will still be there when they get out.
(Note: This only happened 2 months ago, so it’s not like I forgot how bad it was – it just wasn’t!)
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In New Zealand prisons, inmates were once weaned off methadone involuntarily using the ‘prison detox’ regime of reducing the daily dose by 5 mg a day until off. Nowadays most inmates are continued on methadone, though when I reviewed prison methadone clients a few years ago I did encourage them to reduce off as this was a good opportunity to do so. A nursing colleague who worked in an Australia prison said the staff there found several bags of vomit in a kitchen freezer from a prisoner on methadone treatment, who would regurgitate his stomach contents, freeze them in a plastic bag and then pierce the bag and drain off the methadone which apparently stays liquid at temperatures well below the freezing point of water.
Those of you who say methadone and other substitution medications are imperfect solutions to treating opioid dependance are 100% correct. These medications are in no way an ideal form of treatment. However, they are the most effective treatment we have for supporting long-term recovery. Those of you who have said that methadone treatment is trading one addiction for another are correct. It would be much more ideal if the patient could maintain sobriety without any sort of substance, but the facts are, most people have gone through multiple traditional treatment programs before entering a methadone program. Traditional methods just don’t work, long-term, for opiate addicts. We need to let go of our antiquated ideas of “true” recovery. There is nothing fundamentally wrong with those who are unable to stay clean using traditional methods of recovery. We need to support the method that has the most statistical proof of success. Methadone and other substitution medications have the highest long-term success rate for the treatment of opiate addiction. The patient on long-term MMT does not get high from their dose. They are able to drive, work, study, take care of their children and participate in many other activities that they couldn’t do safely while in active addiction. I agree that many of the for-profit methadone clinics don’t provide enough support and guidance towards eventually tapering off medication. They don’t provide enough therapy period. This is why we need to support clinics that have the addicts best interests at heart. We need programs that asses each patient’s needs on an individual basis and help to connect them with the best resources (housing, education, employment, mental health and health care in general) to help them be successful in long-term recovery. These people ARE worth saving! Wether they have a criminal record or not, it is in our best interest to help people reach their highest potential. This also means giving those who are incarcerated the best tools to help them be successful upon release. Those who are prescribed substitution medications are much more likely to make good choices when they leave jail, resulting in decreased overdose, homelessness, crime and recidivism.
It’s called harm reduction treatment.. the whole concept behind methadone maintence treatment . Thank you plz look this up for more information on how methadone treatment was formed and what it’ was originally designed for and the whole concept behind this kinda of treatment in the beginning
I was on Suboxone when I went to jail and my county did a fantastic job of helping the withdrawals by using Tylenol #3 and a cocktail of Gabapentin, Clonidine, Diazepam, and Lomotil. The diazepam was also because I was coming off of a very high dose of benzodiazepines. Now I was expected to be in jail for a long time, In fact it was 4 years. So in that case I agree with the OP doctor. If someone is serving a short sentence then yes continue the medication. Unfortunately the liability of a Schedule 2 narcotic in jails just is too much. So if the patient is going to be in house for a lengthy time, then I would DC the methadone and taper with another agent, if I were a physician, but I am not. I am from a county in North Texas and they are very proactive in detoxing people from opioids and benzodiazepines and it works, they also get you involved with the mental health aspect to see if some underlying cause for the substance abuse could be managed. Overall, it was miserable but the jail did a great job of helping me to taper back off of the Suboxone and Xanax.
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Are you kidding me with this? Its a medication that they are being prescribed. It should be illegal for you to hold that from ANY patient. That is immoral and shameful. If I were them I would SERIOUSLY take the jail to court and sue. That isnt right and God forbid those that suffer and die from the lack of care given. There are plenty of jails that allow that medication. I looked it up. So why wont you? Honestly. It used to be difficult but not anymore. There is something else causing you not to do it. Maybe personal….IDK. I just know, for sure, that its wrong.