Last Friday, the Public Health Committee of the Connecticut General Assembly held a public hearing regarding Senate Bill 172: An Act Concerning Access to Treatment for Opioid Use Disorder in Correctional Facilities. There was strong testimony supporting the bill. The public health committee has yet to vote on it.
So why should legislators prioritize opioid addiction treatment in correctional facilities?
Because opioid addiction is a chronic, relapsing condition, merely enforcing abstinence during incarceration is no solution for it — worse, it can be a death sentence by making overdose following release more likely as a result of lowered tolerance. Tragically, yet not wholly unexpectedly, 52 percent of Connecticut overdose deaths in 2016 involved people with a history of incarceration.
We know that medication-assisted treatment (MAT) with buprenorphine, methadone, and injectable naltrexone works. It is the standard of care in OUD treatment. Research shows that as barriers to accessing MAT drop, so do opioid overdose deaths. MAT saves lives, lowers the risk of contracting infectious diseases, and may reduce recidivism. And it is cost-effective. Not surprisingly, the World Health Organization considers buprenorphine and methadone to be essential medicines.
Conversely, we know that strategies that do not involve MAT can endanger people’s lives—particularly after periods of abstinence, due to decreased tolerance. As a result, people are at an exceptionally elevated risk of overdose after discharge from correctional facilities. This is supported by a 2013 Annals of Internal Medicine article reporting a substantial increase in the risk of overdose among former inmates, especially within one week of release.
Expanding access to treatment for OUD in correctional facilities has been successfully implemented in the State of Rhode Island, with a reported 60.5 percent reduction in overdose deaths among those recently incarcerated. The results are all the more notable given the recent surge in fentanyl overdoses. The Rhode Island model was lauded by former drug czar, Michael Boticelli. The current administration’s opioid commission has also recommended increased access to MAT in correctional settings.
The rest of the country cannot continue to lag behind as opioid overdose deaths continue to surge. The Centers for Disease Control and Prevention reported a 30 percent rise in emergency room visits related to opioid overdoses from July 2016 to September 2017. This figure does not include morbidity and mortality due to other opioid-related causes, and the devastating effects on the lives of individuals and their communities.
Such tragic data remind us of the pressing need to treat people with OUD, regardless of setting. The entire country has a responsibility to provide incarcerated individuals with adequate medical care for opioid use disorder, and to stop gambling with their lives.
One of the arguments against expanding access to MAT is that it would lead to drug diversion. While it is true that buprenorphine and methadone are controlled substances, their life-saving effects by far outweigh their risks.
Not only are there strategies to mitigate diversion risk, such as supervised dosing and the provision of injectable or rapidly disintegrating formulations, but the overall risk of diversion is expected to decrease by adequately treating OUD, and thus reducing the demand for illicit drugs.
This is supported by a 2010 article by Harvard University researchers. The study results accord with other research that illicit use decreases when people with OUD gain access to MAT, but they also suggest that even when used illicitly, buprenorphine is usually taken to self-treat and rarely to attain euphoria.
Moreover, discharging people on MAT with adequate aftercare would not only lower their risk of overdose, but also of further involvement with the illegal drug market.
We do not deprive incarcerated individuals of needed treatment for other life-threatening medical conditions. Imagine denying insulin to a person with insulin-dependent diabetes because they enter a correctional facility.
And imagine that they die as a result. This is analogous to the matter at hand. We cannot deprive inmates of access to essential, life-saving medications. The availability of treatment in all settings is needed and has clear social advantages.
In summary, opioid addiction is a life-threatening condition, but one for which effective treatments do exist. Fyodor Dostoyevsky wrote that “the degree of civilization in a society can be judged by entering its prisons.” There is both an opportunity and an obligation to deliver adequate medical care for OUD in the correctional system.
Elected officials across the country have a duty to save lives by expanding access to opioid use disorder treatment in correctional facilities
Bachaar Arnaout M.D., is an assistant professor of psychiatry at the Yale School of Medicine and a Public Voices fellow with The OpEd Project