How America’s prisons and jails perpetuate the opioid epidemic

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Melissa Godsey credits the medication Suboxone, also known as buprenorphine, for her recovery from a years-long struggle with opioid and meth addiction. As she told me, the medication has let her “live a normal life.”

But for a while, the 35-year-old from Seattle feared that she would be cut off from the treatment. This week, Godsey had to turn herself in to serve a two-year sentence in federal prison for identity theft — while she was using, she stole credit cards so she could afford drugs. The feds don’t typically offer medications for opioid addiction in prison, even though studies show the medications are the gold standard for opioid addiction treatment and save lives.

With the help of the American Civil Liberties Union, Godsey got an exemption in a legal settlement with the Federal Bureau of Prisons. It’s one of the handful of cases in recent years in which the ACLU was able to push prison officials to offer medications for opioid addiction. But this exemption is still really rare, even as the country is in the middle of a drug overdose crisis linked to nearly 770,000 deaths since 1999.

Just Rhode Island and Vermont officially offer all three federally approved opioid addiction medications (buprenorphine, methadone, and naltrexone) to jail and prison inmates. The 48 other states and the federal government offer them only in limited circumstances or not at all.

The lack of adequate treatment in jails and prisons puts a vulnerable population of around 2.3 million people at risk. About 58 percent of people in state prisons and about 63 percent of those sentenced in jails meet the definition for drug dependence or misuse, compared to 5 percent of the general population, according to a 2017 report from the Bureau of Justice Statistics.

Yet a 2017 study by Johns Hopkins researchers found that less than 5 percent of people who were referred to opioid use disorder treatment through the justice system received methadone or buprenorphine, compared to nearly 41 percent of people referred through other sources.

The result is likely more overdoses and deaths. A 2007 study in The New England Journal of Medicine found ex-inmates’ risk of a fatal overdose is 129 times as high as it is for the general population during the two weeks after release. Other studies have backed up the finding that recently released inmates are at particular risk of overdose. In Rhode Island, a preliminary research letter in 2018 found that the state’s program offering medications for opioid addiction was followed by a more than 60 percent drop in overdose deaths among recently released inmates.

But many local and state lawmakers and jail and prison officials remain skeptical. Some of that skepticism is driven by stigma: the view that addiction is a moral failing, not a medical condition, so public resources shouldn’t go to treating it. Stigma toward medications for addiction — like the myth that medications are simply “replacing one drug with another” — is especially prominent. And there are funding and logistical concerns with better addiction treatment programs in jails and prisons, although Rhode Island and Vermont show those issues can be overcome.

“We have a population that’s incredibly vulnerable,” Sarah Wakeman, medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, previously told me. “It’s really inexcusable that we don’t make this available for people who are at such risk of death.”

Godsey credits buprenorphine for her recovery

Godsey was especially concerned that she would backslide without Suboxone. Since getting on the medication in 2018 through an addiction treatment program, she has been able to start putting her life back together for herself and her kids. (She has custody of three of her four children, who will be cared for by family and friends while she’s in prison.) She plans to go back to school, taking classes while in prison, to get into social work. For the first time in a while, Godsey explained, things feel stable.

“My whole life, it feels like my brain is needing something more. I don’t have enough positive cells in my body to make it so I’m normal,” she told me. “When I’m on Suboxone, it caps that effect. Even for meth, for anything. My brain is no longer searching for something else.”

Godsey had tried to get off buprenorphine before. While staying at housing with Seattle’s Union Gospel Mission, she was told that she had to get off the medication. In the three days that Godsey tried to do that, things rapidly deteriorated.

“I had suicidal thoughts and kept wanting to get loaded,” Godsey said.

A spokesperson for Seattle’s Union Gospel Mission said in a statement that the program tries to be flexible and avoids a zero-tolerance approach, but doesn’t allow medications for opioid addiction because it’s “an abstinence-based program.” (The idea that getting on medication for opioid addiction isn’t “real” recovery is a harmful but prevalent myth.)

Ultimately, Godsey got back on buprenorphine, and she was kicked out of the house. She and three of her kids were forced to live in her dad’s one-bedroom apartment, sleeping on the floor, until she was able to secure an apartment with government aid.

Godsey worried that she would go down a similar path if she couldn’t stay on Suboxone in prison. Not only could that lead to suicidal thoughts, she said, but she was concerned it would lead her to mingle with “bad people” in an attempt to get drugs. In other words, it could hurt her attempts toward rehabilitation while incarcerated.

With the ACLU’s help, she got a very rare exemption.

Prisons don’t do a good job of treating addiction

Although the Supreme Court has found that prisoners are entitled to proper health care, medical services in prison are far from ideal — as jails and prisons avoid paying too much for even lifesaving interventions to reduce expenses. But things appear to be particularly bad when it comes to addiction treatment, a space in which jails and prisons don’t even act like they’re providing adequate care.

In 2018, I contacted the 50 state agencies that control prisons, as well as the Federal Bureau of Prisons, to find out whether they offered medications for opioid addiction. Just one state at the time, Rhode Island, offered all three federally approved medications in its jails and prisons. Since my story, Vermont began offering the three medications in jails and prisons. Delaware reportedly plans to do the same soon.

Separately, Michigan plans to offer the three medications in all state prisons by 2023, and Maryland plans to do so in all its local jails by then as well. Those policies still exclude some populations — local jails in Michigan and state prisons in Maryland — but they’re expansions nonetheless.

Other states are pursuing similar efforts, although it’s unclear how expansive or accessible their programs really are or will be, according to the ACLU.

The ACLU hopes its work, through lawsuits and lobbying, will inspire a change. “The end goal is that everybody in America who is in jail and prison [and] who is clinically indicated gets medication-assisted treatment,” Joey Longley, equal justice works fellow at the ACLU’s National Prison Project, told me. “I think we’re moving in that direction now, based on the litigation and legislation strategy that we’ve taken.”

Godsey, at least, has in some ways been one of the lucky ones in this system. In 2018, she was arrested and jailed over her use of stolen credit cards. But when she got out — still under the supervision of law enforcement — she got on Suboxone treatment. As she put it, “I was already done. I already wanted help. I hated where I was.”

She got custody of three of her kids, who are 6, 12, and 13 years old, back. (The fourth, an 18-year-old, lives with his dad.) She started making plans for her future. As of January, she’s nearing two years in full recovery from opioid and meth use. But federal prosecutors had refused to drop the charges against her.

“I brought my kids [to the sentencing hearing] thinking it was going to be a happy thing,” she said. “But it wasn’t. It was a life-altering thing. The judge said, ‘Your mom will be a better mom when she gets out.’ And two years it was.”

Then came another round of bad news: The federal prison system wouldn’t let her stay on Suboxone while in prison. It took a lawsuit, with the ACLU’s help, to get the Federal Bureau of Prisons to agree to let her stay on the medications while in prison.

Godsey still worries. Although she got an apartment for her kids, and family and friends have agreed to help with them, she’s worried about what will happen with her children while she’s in prison. She described the situation as “the scariest thing I’ve ever done.”

But at least she’ll have a better chance of remaining in recovery by staying on Suboxone.

“I hate doing drugs. I hate it. I hate what it does to my family,” Godsey said. “I don’t want to live if I have to use drugs. Just take me out, because I’m just going to end up hurting everybody. That’s how it feels. If I had to go to prison and feel that, I mean, I couldn’t even envision it.”