Pubdate: Fri, 06 Jul 2018
Source: Chicago Tribune (IL)
Copyright: 2018 Chicago Tribune Company
Author: John Keilman



Why don't more jails use them?

After Neila Rivera began using heroin as a teenager, she fell into a
predictable and depressing pattern. She'd get locked up and go through
detox, only to return to drugs as soon as she got out.

It's a routine that has become more dangerous as heroin, now commonly
mixed with powerful synthetic opioids like fentanyl, has become more
unpredictably potent: Studies show that people released from
incarceration, their drug tolerance lowered from abstinence, are far
more likely than others to overdose.

Rivera, 36, expects she will soon be released from the Cook County
Jail. But this time, she hopes, will be different.

She is among about 100 Cook County detainees who are taking a
medication called buprenorphine while they're locked up. Buprenorphine
and its close cousin methadone stave off withdrawal symptoms and curb
the hunger for drugs because they, too, are opioids.

"It gives me hope because every time I left Cook County Jail, I went
straight to get high," Rivera said. "I didn't have anything to hold my
cravings down. So now I feel like when I leave this time, I can make

Though some experts say buprenorphine and methadone are the best way
to combat overdose deaths, the treatments are rarely used behind bars.

"It's attitudinal," said Dr. Kevin Fiscella, a board member of the
National Commission on Correctional Health Care. "(Officials) won't be
swayed by scientific data. They see it as one bad drug for another --
why would you do that? They think if a person goes through a tough
withdrawal, they'll think twice about using again."

But even some facilities that have changed course have found that
offering the medication can be complicated.

Cook County's program reaches only about 1 in 10 detainees who enter
the jail addicted to opioids. Officials say they want to expand but
are limited by a scarcity of health clinics on the outside where
ex-inmates can continue the regimen.

"There's no question that patients on medication-assisted treatment
face a lower risk of overdose when they're released," said Dr.
Stamatia Richardson, who runs the program. "But in our system, it
can't just be the jail (offering the meds)."

Public health officials frequently refer to methadone and
buprenorphine as the gold standard of heroin addiction treatment.
Decades of research have shown that the medications are more effective
than abstinence-based programs at keeping patients off illicit opioids.

But use of the medications has been limited by a lack of funding and
providers, as well as a persistent stigma that users are trading one
addiction for another. Federal officials say only a third of treatment
programs offer the medications.

The divide is even more severe behind bars. Only 1 percent of the
nation's 3,200 jails provide methadone or buprenorphine, even though
roughly 20 percent of people entering the system are opioid dependent,
said Andrew Klein, who consults with the federal Bureau of Justice
Assistance on providing treatment to the incarcerated.

He said corrections officials are hesitant to offer the medications
because of the expense, the red tape and the possibility that the
drugs could be misused. It is not an idle fear: Klein said in one
prison that offers methadone, women have soaked up the liquid with
tampons concealed in their cheeks, intending to sell it to other inmates.

"It requires security staff," he said. "You can't hand out methadone
and (buprenorphine) like it was aspirin."

Instead, the usual protocol for opioid dependent inmates is to go
through detox -- a medically supervised withdrawal from the drugs
their bodies crave. It can last for a week or more and produce
agonizing discomfort, but once it's over, some officials believe
inmates are ready for a fresh start.

"They're in the perfect environment to (go through) withdrawal," said
Deputy Chief Dave Adams of the Will County Sheriff's Office. "Why
would we continue (using opioids) when we have the resources here to
help them get through that detox?"

Other collar county jails follow similar policies. Lake County Sheriff
Mark Curran said the medications "aren't really doing anything from a
long-term perspective; they just make the landing a little bit softer."

His jail offers 12-step meetings and other support to detainees with
drug issues, and when they leave, they can opt for a shot of Vivitrol
- -- a non-opioid medication that suppresses drug cravings for about a

The Lake County Health Department will continue the treatment for
people released from the jail, but so far, few have taken that offer.

"You would think that if you're incarcerated, your freedom taken away,
that that would be (like hitting) bottom," Curran said. "But for some
people it's not."

Despite resistance among corrections officials, some jails that use
opioid medications say they've gotten good results.

Rikers Island, New York City's main jail, has offered methadone for 31
years. Dr. Jonathan Giftos, who oversees the program, said the
medication is rarely diverted even though it's administered thousands
of times a week.

When inmates are released, they're guided to clinics to continue the
treatment. Giftos said officials reviewed the outcomes of people who
had gone through the program and found that only a handful had died of
an overdose after leaving jail.

"It reemphasizes the fact that methadone is protective against
overdose," he said.

Rhode Island has seen even more striking results. After its
corrections system began using buprenorphine and methadone two years
ago, statewide overdose deaths dropped 12 percent. Only nine
fatalities in 2017 involved people who had recently been incarcerated,
compared to 26 the previous year.

"That, we are pretty convinced, is the result of this comprehensive
program," said Dr. Josiah Rich, a Brown University professor of
medicine and epidemiology who studied the policy.

The Cook County Jail's fledgling buprenorphine program has yet to
establish a track record, but it has made substantial changes to the
way some people with an opioid addiction are treated.

Everyone used to go through detox, even those who were on methadone or
buprenorphine when they were arrested. Now those detainees can keep
taking the medications, while others who enter jail with a heroin or
pain pill addiction can start buprenorphine before they leave.

Detainee Megan Powers, 27, had used the medication during an earlier
rehab and was successful; it was only after she stopped taking it from
fear she was "catching another habit" that she relapsed and got locked
up on drug-related charges, she said.

She said she has a provider lined up to continue the treatment once
she's released, and is optimistic about staying sober.

"I've done it before and I'll do it again," she said.

Neither the Cook County Medical Examiner nor area coroners track
whether people who die of overdoses had recently been incarcerated.
But a keyword search of Cook County death cases unearthed numerous

A woman who had just left prison was found dead in a van after
dropping her daughter off at school. A man, out of jail for six days,
died at a friend's house. A woman whose jail release papers were still
in her purse fatally overdosed in a motel room.

The death of a 21-year-old man, outlined in medical examiner reports
and court records, is especially illustrative.

He had been a typical kid growing up in the western suburbs, his
mother said, a fan of video games and anime and a whiz with technology
(she asked that his name not be used because some family members
remain unaware of his addiction).

But he started using heroin in his late teens, and in 2015, was
arrested for drug possession. He got probation and entered a treatment
program where he received buprenorphine, but used it improperly; his
mother said he appeared to be sharing the medication with friends and
taking large doses trying to get high.

Within months, he was arrested again and wound up in the DuPage County
Jail for six weeks.

By policy, almost all detainees there go through detox. The exception,
as with other jails, is pregnant women: They get methadone since
withdrawal can threaten the health of a fetus.

Detainees can also sign up for recovery classes or get education from
a nurse, though many don't stay long enough to be placed into
programs, said Lisa Zegar, the jail's health care administrator.

The young man's mother said he had a rough withdrawal behind bars, but
appeared healthy and cheerful when he was released, joking around with
her before heading out with friends. When he returned home in the
early morning, he grabbed a snack in the kitchen and headed down to
the furnished basement.

That's where she found him hours later, slumped on the couch, a
syringe and two empty heroin baggies close by. The medical examiner
ruled that he died of an accidental overdose.

DuPage County Jail officials do not offer methadone or buprenorphine
- -- Zegar called methadone in particular "another form of addiction" --
but like many others in the criminal justice system, are considering

Some research has shown that it helps to prevent relapse among people
who have detoxed, though Fiscella said the potential downside is that
ex-detainees will discontinue treatment once they're free, putting
themselves at risk for an overdose.

Given the young man's experience with buprenorphine, his mother isn't
sure how he would have fared had he been given the medication while
incarcerated. But she thinks it would have been worth a try.

"Maybe it would help, because when he came out of rehab he didn't
overdose," she said. "Was that because of (buprenorphine)? Maybe it
could have helped, maybe it couldn't. I don't think it would be a
magic bullet. But it could have bought time."
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