I recently ran across this news article on NPR (found here) about the problem of treating the large number of opioid addicted patients who are coming to our jails. There is a growing movement that all opioid addicted patients should be offered Medication-Assisted Treatment (MAT) while in jail–meaning one or more of three drugs: methadone, Suboxone or Vivitrol. The article does a good job in pointing out that this is a complicated problem. Having been on the front lines of this problem for many years in my own jails (and so having that great teacher–experience), I would like today to present my own thoughts on using MAT in jails. (MAT in prisons is a separate subject that I will address later).
First, it is important to recognize the distinction between treating opioid withdrawal (also called Detox) and the long term treatment of addiction. These two are often confused–and that is a mistake. Treating withdrawal is not the same thing as treating addiction. Take, for example, a patient who has been using heroin and then comes to jail. He is going to go through heroin withdrawal, which typically lasts for around 5-7 days. He needs to be treated for this for this. It is inappropriate, bad medicine and dangerous to allow him to suffer through a “cold turkey withdrawal! (See my thoughts about that here ). While the MAT drugs methadone or Suboxone can be used to treat withdrawal, they are not better in this setting than alpha-blockers like clonidine or lofexidine and are much more tricky to use. The Cochrane review analyzed the available literature on this subject and concluded:
Cochrane Review. Clonidine, lofexidine, and similar medications for the management of opioid withdrawal. 6 May 2016
“We detected no significant difference in efficacy between (opioid withdrawal) treatment regimens based on clonidine or lofexidine and those based on reducing doses of methadone over a period of around 10 days . . .”
I use clonidine to treat opioid withdrawal in my jails. It works very well. But having treated the symptoms of withdrawal, the patient still has the problem of addiction. When he is released from jail, there is a strong likelihood that he will relapse into heroin use. Treating the patient’s addiction is different than treating the withdrawal. Treating the addiction is a long term process that may take takes years and typically involves MAT, counselling and AA style group meetings. When the NPR article says “(MAT) is now considered to be the most effective method of treating opioid abuse disorders,” it is talking about the long term treatment of addiction.
I agree with this. However, the average length of stay in a typical county jail is less than a month. Many are released within days. This means that MAT in a jail must be coordinated with a community based MAT program on the outside that patients can transition to when they get out. The ideal situation is this: If a patient is in a community MAT program before they come to jail, their MAT medication should be continued while they are in jail and then again seamlessly continued when they are released. (I have written about this before, here ) This requires a lot of communication between the community MAT programs and the jail.
Once a strong relationship is developed between the community MAT program and the jail, then–and only then–can the jail develop a program to begin MAT treatment of heroin addicted patients while they are in jail. Then, the patients who begin MAT therapy in jail can continue that treatment at the community program when they get out of jail. But the relationship with the community MAT program must precede such a program. In my opinion, it does no good to start someone on MAT in jail when there is no possible way to continue it when they get out.
Why would it not be possible to continue MAT when a patient is released from jail? There are two big reasons for this. The most common reason is that there is no community program! Big cities usually have one or more community MAT programs, but little cities and towns–where the majority of county jails are located–often do not. And if there is no program in the community, it does no good to start short term treatment in a jail that is discontinued immediately when patients are released.
The second reason why patients may not be able to continue MAT after release from jail is that they cannot afford it. MAT programs charge their patients. While insurance may cover opioid treatment programs, many, if not most, of the opioid addicted patients in a jail do not have insurance and cannot afford the fees of a community MAT program. Once again, in my opinion, it does no good to start someone on MAT in a jail just to leave them hanging once they are released because they cannot afford to continue.
The bottom line is that MAT opioid treatment programs have to be community based. Jails should be part of the community program, by cooperating and coordinating closely with the community program, but small jails especially cannot effectively function alone. In the meantime, all jails, even small jails in rural communities, can effectively treat opioid withdrawal.
As usual, what I have written here is my opinion, based on my training, research and experience. I could be wrong! Feel free to disagree but please say why in comments. This particular article deals with jails, not prisons. MAT use in prisons is a separate subject for later discussion.
Do you use MAT in your facility? Please comment!
Thank you again for an insightful and well written article. I agree 100% with the need to make referrals and connection to outside custody so patients can continue their treatment once outside of custody. Communities need to do better to increase capacity for community based MAT treatment. However, I would like to respectfully disagree with “it does no good to start someone on MAT [without continuing when they’re released]”.
From a “Harm Reduction” point of view, there is still a value/benefit to starting MAT in the jail even if the capacity in the community is not sufficient. Specifically, those who are placed on Opioid agonist/partial-agonist therapy, do not lose their tolerance to Opioids, thus are at a much lower risk of overdose when they leave jail. We all know release from jail is a very risky time for overdose deaths, therefore, initiating MAT, even if they don’t continue, can significantly reduce that risk of overdose.
If we wait until a “comprehensive” treatment program is available to start MAT, many people will die from OD before we start MAT. So my opinion is, start retooling your system now, so MAT can be started as soon as possible. Harm reduction is still a benefit, even if they relapse after leaving jail.
Thanks, Hsein! I am interested in your jail’s program. Do you use Suboxone, methadone or Vivitro (or all three)? I assume that you are using methadone/Suboxone to treat withdrawal? When you say that patients who are treated with MAT in a jail, even for just a few days, have a reduced risk of overdose when released, do you have statistics from your jail/community that bears this out? Thanks again for the comment–this is a great topic for discussion! JeffK
Excellent. Therein lies the issue. Community funding for these programs. Until and unless politicians realize that to combat this issue, there MUST be adequate community facilities at a cost. And until and unless we tax payers are willing to PAY for these programs, the problems are not going to go away. I don’t care if you’re liberal or conservative, we have to be willing to pay for our communities and people to solve social issues. We created them; now let’s solve them. Drugs is one of the main, if not the main, problems of today . We NEED to address the root causes as well as the perceived solution.
What are your thoughts on the harm reduction aspect of MAT? When we allow those who suffer from OUD to detox when they are arrested, we destroy their tolerance, allowing for an increased risk of post release overdose.
Even if their is no difference in the efficacy of bupe vs Clonidine as far as treating detox is concerned (I am not familiar with the study). Bupenorphine products provide this benefit that not only Clonidine/lofexidine fail to provide, it significantly decreases their risk of overdose/death post release.
Thanks, Jill! I agree that using MAT in jails probably reduces risk of overdose post release. How much this reduction is in a jail setting has not been evaluated in a large study (as far as I know). Also, there are two other post-release risk reduction strategies besides MAT: Vivetrol and naloxone distribution. Of course, no therapy is perfect, including MAT. All therapies have their risks and potential harms which must be weighed against the potential benefits.
Here’s evidence you asked for. 60,5% OD mortality reduction in Rhode Island. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2671411#related-tab
Thanks, Martin! See my critique of this excellent study in MAT in Jail: Response to Reader Questions.
You say that methadone withdrawal can be treated with clonidine. So then would you say it is a failure on the nurse when someone goes 8 days straight with no sleep, to the point they are hallucinating seeing ants crawl across the floor etc. all while on a standard clonidine assisted withdrawal protocol. I am curious what you would have done in this situation. Becaue nothing was done. The jail clearly did not understand the severity and extreme dangers of cold turkey methadone withdrawal (81mgs for 4 years). Just a standard protocol of clonidine and Librium were administered obviously having no effect. Should patient (inmate but clearly needing medical care) have been taken to hospital?
Thanks for sharing your experience, William. The bottom line is that you were not properly treated. You should have been re-evaluated at least daily and given bigger doses of clonidine until your symptoms were tolerable. “One-size-fits-all” dosing does not work for any withdrawal syndrome, whether alcohol, benzodiazepine or opioid withdrawal.
Thank you for your response. To think the only reason I was there was for possession of a substance that has been my lifesaver (medical marijuana) as I have 3 crushed discs and major degeneration in my back which is what led to pain pill addiction and the methadone in the first place. I unfortunately was driving thru a state that doesn’t believe marijuana is medicine and chooses to lock hard working, 60hr week citizens for a plant that has been healing people for thousands of years. This event set a chain of events in motion that led to hallucinating on day 13 of no sleep watching imaginary ants attack me across the floor, having to untwist testicular tursion (issue I’ve had previous) while in my jail cell Bc they thought I was just lying trying to get to a hospital and get drugs. So with them following detox protocol, I have a hard time thinking that anybody should ever have to go thru that, if they followed protocol like they stressed. I don’t know who these studies get for participants but I could not imagine anything but methadone relieving those withdrawal symptoms. Cuz when I finally was released on day 14 I went to the clinic and they gave me an emergency 10 mgs, when I was on 81 at the time and it immediately made me feel a million times better. But as you say I should have been given increasing doses of clonidine which clearly they didn’t cuz they were following protocol and accusing me of lying so protocol would say to reduce clonidine over time I would assume. When someone hasn’t slept for that amount of time isn’t that a major concern as psychosis is clearly kicking in with the hallucinations etc?
Well sir – again you are the guiding light.
The ‘general’ practice in the current facility is if stay (sentenced or unsentenced) is (anticipated to be) less than 14 days & they are current, compliant and not incarcerated for a current substance related crime. When the medicine is available, we will continue MAT. On release we contact the prescriber and require a written approval of release with any remaining medications (fax form available on request). Exception; pregnant offenders MAT until delivery. Others with longer anticipated stay are tapered (when available) 25% every 4 days – then treated with medication supported withdrawal [Clonidine, Bentyl, Ibuprofen. Most other facilities in the state also maintain pregnant individuals. . However, until recently all the others D/C’d MAT at the Sally Port.
We generally do not start de novo at this time. Though, just completed waiver training.
The courts (state) and the legislature are involved in this issue and it is expected to change. Your ideas on the need for a ‘warm’ hand off are right on target. Given that a few have greater length of stay – some in-house services (counseling) will also be necessary.
We happen to have a good relationship with the local Methadone program and have visited them a few times. The practice locally is to continue 1. if sentenced, 2. prepaid (clinic requirement) 3. offender must pick up (transport has taken them) . However, the largest local Buprenorphine program is not as collaborative – will not assist in obtaining medications despite our willingness. Oh Well.
Thanks, Al! I agree that MAT should be continued while the patient is incarcerated, if possible. This requires the cooperation of the local MAT program, which sometimes is not forthcoming.
Pingback: What is the most common mistake made when treating withdrawal? | Jail Medicine
Dr. Keller, would you offer a few words on your opinion re: the arresting officer’s presence (or lack thereof) as it pertains to privacy and/or truthfulness during the
intake evaluation with a nurse?
should the arresting officer be sitting at table and using any information given to a nurse to, say, order specific blood tests or use the inmates background information to bolster claims of impairment?
For example : a suspicion of alcohol DUI arrest that becomes a suspicion of drug impairment DUI after the nurse asks an inmate whether they are going to experience any withdrawals in the coming day(s) and receives an affirmative answer.
this strikes me as problematic–ethically and medically–maybe even a little unscrupulous, but I’d be curious as to your thoughts on the matter. I would guess that many people would simply lie to the nurse.
That’s exactly what does happen. They lie on intake, delaying treatment for a few days until they can put in a sick call and be honest with the nurse finally. I was in a facility that would actually punish you if you pulled that move.
It is without doubt inappropriate for an arresting officer to be present during the medical intake process. It is not only ethically & medically inappropriate but also legally. HIPPA principles apply.
This is exactly how I feel. I started in this group not as a doctor but randomly as a person who unfortunately was incarcerated for medical cannabis while on methadone and was forced to undergo what everyone here had deemed unnecessary and painful lack of treatment etc. so I bring a little different angle but I can absolutely say without a doubt I would not be comfortable being honest with a nurse while a corrections officer is within earshot.
They generally do not in a Correctional Institution, Read the Exemption Clause
The arresting officer is not part of the correctional facility.