Changes to Opioid Addiction Treatment in Federal Prisons Threaten Peoples’ Lives

Treatment for those struggling with opioid addiction in the federal Bureau of Prisons (BOP) is about to get a lot worse, warn a former BOP case manager and a medical professional who recently left the agency.

The BOP directed staff about a month ago to require all participants in medication-assisted treatment (MAT) programs to switch from monthly injections (primarily of buprenorphine, which treats opioid use disorder) to daily strips that are dissolved under the tongue.

The changes further erode the well-being of incarcerated people who struggle with substance use disorder, which the Bureau of Justice Statistics estimates is roughly 47 percent of those held in U.S. jails and prisons. Medical and mental health care in prison is already notoriously poor, and when MAT was first introduced, hopes were high. However, experts warn that the abrupt change in treatment protocol is liable to provoke violence and increase addiction.

“Monthly injections are safer for everyone,” says Andrea Brockman, a regional mental health ombudsman for a state correctional system and a clinical psychologist who worked for the BOP for 11 years before joining the team of the federal Prison Education and Reform Alliance (PERA). “It protects participants from being beaten up, or worse, by people who want the oral strips to sell or use.” She warned the change to strips could increase suicides, overdoses and conflict.

Both the formulary and the clinical guidelines for implementation of MAT have been removed from the BOP’s public website, and the agency has not given a reason for this change, says PERA Executive Director Jack Donson, a former BOP case manager. “This lack of transparency is endemic within the BOP right now.”

BOP Associate Deputy Director Kathleen Toomey told the House Appropriations Subcommittee on Commerce, Justice, Science, and Related Agencies on February 26 that, “While we continue to prioritize hiring, we are making significant changes to reduce costs and maximize our use of existing resources. For example, we reduced all operating budgets by 20 percent…. We’ve saved $10 million by moving to lower-cost drugs where it’s medically appropriate, particularly those for medication-assisted treatment.”

Brockman questions whether strips are indeed “medically appropriate” within a prison setting due to the risk of diversion. An analysis of deaths in federal prison by the U.S. Department of Justice Office of the Inspector General found that 20 percent were due to drug overdose.

The BOP did not respond to a request for comment by the time of publication.

Switching to Strips Provokes Intimidation and Violence

Elain Kay Young, who is incarcerated at FCI Waseca, a low-security federal women’s prison in Minnesota, says there is rampant drug use there.

“We have problems with K2 [a synthetic form of marijuana’s active ingredient] as well, but abuse of the strips is extensive,” she wrote in an email from the prison this month. “People are getting into MAT who do not belong; they are there to get stuff to sell. As a result of these drugs, the women here have bills they cannot begin to pay, and there are constant threats and fights, which endanger everyone. Meanwhile people who really need the MAT program can’t get in, because the prison doesn’t have the proper resources. I know three girls who are desperate to kick [their addiction], but they are stuck on the MAT wait list.”

Such problems could be prevented if the BOP followed the guidelines set out by the Substance Abuse and Mental Health Services Administration. The federal agency recommends dedicated administration rooms where recipients stay until the strips are fully consumed, with accompanying mouth checks. Without these safety measures, the drug can too easily be passed from one person to another via “birding,” a practice in which individuals hide the strips in their cheeks, then regurgitate them into someone else’s mouth.

The staff “does engage in some degree of mouth checks, if you can call [them] that,” says Brockman. “It is a brief mouth-open-tongue-out-and-moved up-and-down thing. But nothing that is adequate. These strips are easy to hide.”

Another problem is the way the BOP is implementing the treatment change. Jason Cooke, who is incarcerated at the federal Atwater penitentiary in California, reported that after two years on the highest-dose, 300-milligram (mg) shot, he was switched to the lowest-dose, 2-mg strip. The retired physician noted that a 2-mg suboxone strip “is quite low when you consider that one injection is equivalent to approximately 16-24 mg a day of the sublingual medication.” After intervention by PERA Executive Director Donson, Cooke was moved up to 8 mg.

“I’m in prison because I was an addict; I robbed pharmacies for Oxycontin, and I was doing an unbelievable amount a day,” Cooke wrote Truthout in an email on January 18. “But I was finally doing good with my injection. Then they took me off, and my whole life changed and now it’s upside down. Are these people trying to make me flip out and start cutting my wrists? Because that’s what’s about to happen. I’m not eating or sleeping. Honestly? I want to kill myself. I’m so tired of feeling this way.”

Inventory and Physician Shortages

USP Atwater is among the first federal prisons to fully transition from the shots to the sublingual strips. Aggravating the situation there is the fact that the strips could not be prescribed until each participant was seen by the doctor, who only comes to the prison one day a week. Cooke says sometimes medical visits are canceled when the prisoners are locked into their cells. The prison often locks down during fog because prison guards stationed in towers can’t see incarcerated people in the recreation yard. On top of that, Cooke says the transition to strips has been marred by constant inventory shortages. “There’s about 80 guys who just started the MAT program and are right now going without their strips for the second week in a row because staff aren’t keeping enough inventory in the pharmacy,” Cooke wrote on February 16. “There are guys who were due for their injection 10 days ago!!”

PERA’s Donson notes that MAT medication should not be in short supply any more than other pharmaceuticals, such as blood pressure medication. He speculated the shortage was caused by poor planning after the transition order came down.

As Brockman pointed out, the switch to strips can have another alarming consequence: more frequent drug use and all that comes with it. Individuals who are forced to wait for a replacement, and/or are switched to a less-than-adequate dose experience withdrawal symptoms that often cause them to seek out stronger drugs. This can result in a range of adverse outcomes: overdose, incident reports, increase in security classification, placement in restrictive housing, and the loss of good conduct time and/or First Step Act release credits.

One individual at the Victorville medium-security prison in California was reportedly placed in solitary confinement after overdosing. In addition, everyone in his unit was punished with loss of phone and email privileges — a factor his friends believe contributed to his death by suicide in February.

As the Prison Policy Initiative noted in a February report, “Ultimately, we find that ‘correctional healthcare’ is not really healthcare in the traditional sense …. [These systems] are designed in such a way that incarcerated people’s health needs are treated more like a nuisance than their ostensible mission. Instead, this walled-off healthcare system functions like a cost control service for corrections departments, organized around limiting spending and fending off lawsuits rather than actually caring for anyone’s health.”

If administered properly in prison, MAT can reduce post-release drug-related mortality by 80 to 85 percent. In other words, the BOP’s rush to cut costs in any way possible is penny-wise and pound-foolish.

Criminal legal reform advocates point out that a fully effective addiction treatment is ultimately not possible in prison.

“Jails and prisons are not healthcare institutions and their mandate for punishment makes patient-centered care impossible and health outcomes worse. Instead, the United States desperately needs healthcare infrastructure that can support people who use drugs outside of carceral settings,” concludes a Prison Policy Initiative report.