The Case for Medication-Assisted (MAT) Treatment in Jails and Prisons
By Christopher Johnston, MD ABPM-ADM, Chief Medical Officer, Pinnacle Treatment Centers
Earlier this year in Allegheny County, Pennsylvania – an area hit hard by the opioid epidemic – a group of doctors, nurses, medical researchers, paramedics, addiction counselors, and community leaders sent an open letter to three prominent local officials: the Allegheny County Jail Warden, the County Manager, and the County Executive.
In the letter, they called on these officials to prioritize the implementation of a medication-assisted treatment (MAT) program in the county jail that has been in the works since 2017. Here’s an excerpt from the letter:
“In the past five years, nearly 3,000 people have died of an overdose in Alleghany County. By the County’s own reporting, about 1 in 5 of the deaths was among people who had been in jail in the past year, many within weeks of their release…MAT is an evidence-based treatment that has been shown to reduce overdose risk and criminal behavior. In the midst of the COVID-19 pandemic and rising fatal overdoses, we were moved to write this open letter to publicly state the dire need for this treatment option.”
To say they’re pleading for the immediate implementation of this program is not an overstatement. They know MAT is a lifesaving treatment that helps people overcome addiction. It’s accepted worldwide as the gold standard treatment for people with opioid use disorder (OUD). In addition to helping people with OUD themselves, MAT programs benefit families and communities, as well.
Here’s a quick review of the benefits of MAT. Evidence shows that for people with opioid use disorder, MAT programs:
- Decrease opioid use
- Decrease opioid-related overdose deaths
- Decrease criminal activity
- Decrease transmission of infectious diseases
- Increase social functioning
- Increase time in treatment
It’s easy to see how MAT programs work for the good of the whole, as well as the people who participate in them. People in MAT programs have a better chance of keeping a job and participating in family life, which supports a solid community foundation. Decreased criminal activity is a clear plus for any community, and a decrease in the transmission of infectious diseases is good for public health.
As a physician working in addiction treatment, I see the benefits of MAT every day, which means I’m an advocate. But I digress: I’m making the case for MAT in jails and prisons.
Addiction in Jails and Prisons: By the Numbers
First, I’ll outline the scope of the need for quality, evidence-based addiction treatment in the incarcerated population in the U.S. A special report prepared by the U.S. Department of Justice in 2017 and revised in 2020 included detailed data on addiction prevalence and treatment in the criminal justice system. In a study involving more than 1.5 million inmates that examined data collected between 2007 and 2009, researchers found that:
- 5% of state prisoners met clinical criteria for substance dependence or abuse
- 7% met criteria for dependence
- 8% met criteria for abuse
- 3% of local jail prisoners met clinical criteria for substance dependence or abuse
- 2% met criteria for dependence
- 1% met criteria for abuse
- 15% of prisoners in state and local jails met criteria for opioid abuse
- 9% of state prisoners who met clinical criteria for substance dependence or abuse received treatment
- 4% who met criteria of opioid abuse received medication-assisted treatment
- 4% of local jail prisoners who met clinical criteria for substance dependence or abuse received treatment
- 6% who met criteria of opioid abuse receive medication-assisted treatment
In addition, the same report indicated that:
- 21% of inmates in state and local jails said they were incarcerated for crimes committed to obtain money to buy drugs.
- 15% of inmates in state prisons and 14% of inmates in local jails for violent offenses committed those offenses to obtain money to buy drugs.
[Note: These studies occurred before clinical designations for addiction and abuse were revised and reclassified as substance use disorder (SUD), alcohol use disorder (AUD), etc.]
That’s the scope of the problem: more than half the people currently in state prison or local jails meet clinical criteria for dependence or abuse. Of those, less than 30 percent of state prisoners received treatment, and less than 20 percent of local jail prisoners received treatment. And of those, less than one percent of state and local prisoners received MAT.
That’s the scope of the human need – and that’s enough to advocate for expanded use of MAT in prisons and jails.
However, there’s another angle here: there’s a solid argument to be made that MAT is a federally protected right.
Medical Care for Incarcerated Individuals
In a four-page brief published in 2019, the non-partisan, non-profit healthcare advocacy group The Center for U.S. Policy points out that a Supreme Court (SCOTUS) decision made in Estelle v. Gamble (1976) establishes a responsibility for correctional facilities to provide adequate medical care to all inmates with serious illness or injury.
Here’s how the relevant section of the SCOTUS decision reads:
“Deliberate indifference by prison personnel to a prisoner’s serious illness or injury constitutes cruel and unusual punishment contravening the Eighth Amendment.”
I’m neither a lawyer nor a constitutional scholar, but two phrases in that sentence jump right off the page: cruel and unusual and contravening the Eighth Amendment. As I remember the Eighth Amendment, it’s what prohibits a state or federal government from imposing unduly harsh or excessive penalties as punishment for crimes after conviction.
In 2021, we know that an addiction such as opioid use disorder (OUD) meets the criteria for a serious medical illness, and the gold standard for the treatment of that illness is medication-assisted treatment.
Therefore, it appears that MAT programs like those the community advocates in Pennsylvania are encouraging local leaders to prioritize have already been recognized by the highest court in the land as humane, reasonable, and protected under the Eighth Amendment.
In the same way federal law – based on the precedent set by Estelle v. Gamble – requires a prison or jail to provide an individual with diabetes or a heart condition their prescribed medication after incarceration, it follows that a prison or jail should be required to provide an individual diagnosed with OUD their prescribed medication.
That’s the legal argument for MAT in jails and prisons, which, alongside the demonstrable human need for evidence-based addiction treatment in jails and prisons, bolsters the case for universal implementation of MAT programs for incarcerated individuals in need of treatment.
At Pinnacle, we work closely with jails and prisons providing services allowable by our state and federal authorities. Incarcerated pregnant women are a high priority for us and we provide more flexible hours, priority assessments, and the much needed “M” of the MAT. Jail employees bring the women to our facility, where they, too, are engaged with our staff and learn what goes on behind the walls of a MAT program. We also work with many prisons and their medical teams to provide medication to all inmates with an OUD, who have been deemed appropriate for MAT by a physician.
MAT in Prisons and Jails: Support from People in High Places
In 2017, Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA), wrote an article about a major funding effort called the Justice Community Opioid Innovation Network (JCOIN), which will operate under the mandate of the National Institutes of Health HEAL (Helping to End Addiction Long-term) Initiative. Dr. Volkow describes this new funding push as “an aggressive, trans-agency effort to speed scientific solutions to stem the opioid crisis.”
Dr. Volkow explains the benefits of researching effective means to scale MAT to meet the national need for enhanced OUD treatment for incarcerated individuals:
“Effectively delivering OUD treatment in the justice system will give individuals with OUD a chance of recovery, and will make a huge difference in reducing the toll of the opioid crisis in the U.S. It will also bring about additional health and economic benefits like reducing the spread of HIV and hepatitis C and reducing the costs from re-incarceration and family disruption, which are much higher when OUD is not treated.”
Medical professionals like Dr. Volkow aren’t the only ones who advocate for comprehensive implementation of MAT for OUD in the justice system. In April, 2020, The Pew Charitable Trusts, a non-profit organization known for its long history of philanthropy and financial support for non-controversial groups such as the American Red Cross and the Woods Hole Oceanographic Institute, published a position paper called “Opioid Disorder Treatment in Jails and Prisons: Medication Provided to Incarcerated Populations Saves Lives.”
Here’s an excerpt from the position paper:
“Given the high prevalence of SUD among people who are incarcerated, states should prioritize treating these individuals with OUD using methadone or buprenorphine—the medications supported by the most evidence—and then connect them to maintenance care upon re-entry into the community.”
They go on to recommend policymakers at all levels should earmark funding to allow:
- Jails and prisons to screen individuals for OUD, and provide medication for opioid use disorder (MOUD, a.k.a. the “M” in MAT) and counseling.
- Jails and prisons to track MOUD treatment outcomes.
- State and local entities to work together to ensure seamless connections to community-based OUD treatment and other services.
The Pew Trust views MAT in prisons and jails as both a public safety issue and a public health issue. I see it as a human issue. The policy group I quote in the previous section sees it as a legal issue. For broader perspective, the office of the President of the United States defines the opioid crisis as a national emergency.
The Case for MAT in Jails and Prisons is Strong
It’s rare to see such divergent groups with varying interests agree almost completely on what some people may still consider a controversial issue. The accord between these groups shows the progress we’ve made on the opioid crisis – and reveals how far we have to go.
Our progress can be seen by the fact we finally have near-universal acceptance of the medical model of addiction, which implies an overall reduction of stigma around addiction treatment: witness the support of the various people and organizations mentioned in this article for treatment approaches based on the medical model. And I didn’t include support from traditionally conservative groups like The National Sherriff’s Organization.
The distance we have to go is revealed by the fact that although the federal government declared the opioid epidemic a national crisis almost four years ago and called for, among other things, the expansion of MAT and a restructuring around prescribing guidelines for addiction medication, we still haven’t expanded that treatment and restructured guidelines to adequately support a group of people who are unable to support themselves: incarcerated people with OUD.
I can understand the hesitancy of some. With rare exceptions, people in prison and jail have broken the law, and I get that there are people who think mental health and addiction support for incarcerated people is inappropriate. Be that as it may, I’m a doctor. I offer medical support and care to anyone who needs medical support and care.
Anyone means everyone.
I’ll reiterate one last fact that supports the expanded use of MAT in prisons and jails: it improves communities by reducing criminal activity, recidivism, and the spread of disease. When we offer support to incarcerated people with OUD by providing them the latest evidence-based treatment, we help everyone. We make our communities safer, healthier, better places to live. In that way, MAT in prisons and jails is not at all controversial, but rather, logical, sensible, and eminently practical.
Holly Broce, president, Opioid Treatment Program Division, Pinnacle Treatment Centers, contributed to the content of this article.