Session to Address Lack of Treatment for Opioid Use Disorder Among Incarcerated

One group of individuals is among those in the United States not receiving the necessary care to treat their opioid use disorders. Because these individuals are incarcerated, they do not have access to pharmacotherapy, including buprenorphine, methadone, and naltrexone.

A prisoner’s right to adequate medical care while incarcerated is founded in a landmark Supreme Court case. In 1976, Estelle v. Gamble held that prisoners have the right to access care, the right to care that is ordered, and the right to a professional medical judgment.

D1-Wakeman

Sarah E. Wakeman, MD

“They generally do not receive detoxification services, so they have to suffer and go through the pain of withdrawal. If there is available treatment for the opioid use disorder, it is based on peer support, psycho-education, or therapeutic communities. No one receives these medications that we know are life-saving,” said Sarah E. Wakeman, MD, Medical Director of the Massachusetts General Hospital Substance Use Disorder Initiative, Boston.

Dr. Wakeman will present “Treatment of Opioid Use Disorder within Correctional Facilities” from 2 to 3 pm Friday in Room 410. She will provide an overview of incarceration in the United Sates and the epidemiology of opioid use disorder among prisoners. She also will review national and international research and experiences with addiction treatment within correctional facilities, with a focus on the evidence for opioid agonist treatment for prisoners with opioid use disorders.

“This session is relevant because the vast majority of people who are inside correctional facilities are there because they have substance use disorders. They’ve been directly arrested for drug-related crimes, or they’ve committed a crime as a part of their actions related to their substance use,” said Dr. Wakeman, also an instructor in medicine at Harvard Medical School.

Although the prevalence of substance use disorder is as high as 85 percent in some facilities, the care inmates receive does not mirror what addiction specialists consider evidence-based standard of care in the community.

“There is at least the expectation that for all other chronic diseases the care while people are incarcerated should be identical to the care they would receive in the community,” Dr. Wakeman said.

She pointed to a number of promising U.S. and international research studies, which found that opioid agonist maintenance among prisoners reduces illicit opioid use, crime, recidivism, and cost. Yet, she said, there continues to be a stigma that medication treatments are merely replacement drugs, not in line with the punishment mindset of prisons, and an avenue for additional smuggling of drugs into prisons.

“We have this huge gap between the science and the practice showing that these medications are effective not just for treating disease but for actually preventing people from going back to prison,” Dr. Wakeman said.

Beyond the needed advocacy for these individuals, Dr. Wakeman noted that addiction medicine specialists would inherit these patients when they return to their communities.

“We know that 95 percent of people in prison eventually will be released, so we are missing this great opportunity to start treatment while they are incarcerated and then provide linkage to care once they get released,” she said.

Dr. Wakeman worked in a state prison during medical school and, since becoming a physician, has run a post-prison release clinic and oversees her organization’s resident rotation in prison health. That background makes her fully aware of the dual loyalty physicians are called upon to have when caring for prisoners.

“In general practice, our sole loyalty as a physician is to the patient and what is in his or her best interest. In working with incarcerated populations, there is this additional entity, which is the correctional facility,” she said. “The goals of incarceration often run counter to the goals of medical care or what would be therapeutic for the patient. As a physician, you find yourself caught between those loyalties.”

The session will conclude with a summary of international examples about how changes in drug policy impact substance use, morbidity, and cost.

“In many other countries, the standard of care is to provide medications while people are incarcerated. We’ll review how a country’s overall drug policy can have a profound effect on both addiction and the intersection between the criminal justice system and addiction,” Dr. Wakeman said. “We’ll present some examples as we think about what lessons can be learned and potentially be applied in America.”

ASAM itself has had a long-standing policy statement that recommends providing care for persons who are incarcerated in addition to advocating to address the needs of care planning around pre- and post-release for the incarcerated population.