Jail officials, doctors divided on care of opioid-addicted inmates
August 8, 2016 12:00 AM
Destiny Salsgiver, a nurse at Armstrong County Jail in Kittanning looks on as Dr. Louis Gaston talks to reporters .
Patrick Fabian, an Armstrong County commissioner, sits in one of the new observation rooms inside the Armstrong County Jail in Kittanning. Other county jails are creating units with glass doors, where guards can watch inmates with substance abuse issues around the clock.
Phillip Shaffer, warden at the Armstrong County Jail in Kittanning.
An exterior view of the Armstrong County Jail in Kittanning
By Maia Silber / Pittsburgh Post-Gazette
First came the vomiting. For days, Crystal Lynn Rathbun heaved everything in her guts, until she felt like her body had been drained.
Then came the insomnia. Nearly a month passed before she could stay asleep in her cell for more than four or five hours a night. She felt cold all the time, even though she wore two sweatshirts, two jumpsuits, and two sets of underwear.
Correctional facilities such as Allegheny County Jail, where Ms. Rathbun awaited trial on heroin possession and child endangerment charges, are on the front lines of the nation’s addiction epidemic. Most of the 1.5 million incarcerated Americans who abuse alcohol or drugs undergo cold-turkey detox behind bars. For opioid users, it’s a horrible experience, but one that often fails to deter them from using again on the outside.
Today, Ms. Rathbun is clean, enrolled in a recovery program, and trying to spend more time with her four children. She’s lucky: Many who detox in jail relapse, and sometimes overdose, upon their release, or else end up behind bars again. As jail officials struggle to care for the men and women shaking and shivering in their cells, they remain divided about how to keep them clean -- and alive-- once they leave.
Research has shown that maintenance treatments like methadone and buprenorphine reduce relapse and overdose. Because these drugs are opioids themselves, though, many jails are reluctant to provide them to anyone except pregnant women, who can miscarry during withdrawal. Fewer than 40 correctional facilities nationwide offer such drugs, according to a Pew Stateline study.
No county jails in southwestern Pennsylvania offer methadone or buprenorphine to inmates suffering from opioid withdrawal. In interviews, some wardens cited the cost and security risks associated with maintenance treatments as barriers. Others expressed their aversion to the drugs.
“I’m not going to bring those drugs into the facility,” said Warden Brian S. Miller of Fayette County. “If you were a gambler and you were in the casino every day of the week… and I locked you in a room and gave you scratch-off tickets, how’s that helping?”
Patients, not criminals
Warden Edward E. Strawn has worked at Washington County Jail for over two decades. “Twenty-five years ago, I dealt with criminals,” he said. “Today, I deal with patients.”
He described addiction as a “burden” on jails as well as society, diverting resources and attention he thinks would be better spent on violent perpetrators.
Officials at Armstrong and Fayette counties estimated that as many as four out of five of their inmates go through some sort of withdrawal.
“It seems like almost everyone who comes in is detoxing from something,” Acting Warden Michael Kraus of Greene County said.
Like Mr. Strawn, Louis Gaston, a physician at Armstrong County Jail, has worked in the same facility for more than two decades. He too has noted the spread of opioid addiction. “It’s overloading the system,” he said. In 2015, Armstrong had a higher per capita overdose death rate than any other Pennsylvania county except Philadelphia.
Not only do opioid users often wind up in jail, they are often incarcerated multiple times. According to the National Center on Addiction and Substance Abuse at Columbia University, inmates who were under the influence of drugs or alcohol at the time of their arrests had been arrested an average of 5.9 times before.
“It’s a revolving door,” said Jennifer Passarelli, the deputy warden of security/treatment at Butler County Prison.
“They’re Gonna be Sick”
At county jails across Southwestern Pennsylvania, the process of identifying and treating people like Ms. Rathbun begins at intake, where correctional officers administer drug tests and monitor inmates for signs of withdrawal — shaking, sweating, or drifting off in the middle of a conversation. Usually, guards do not have to wait for such signs.
Opioid users “are honest with you,” Mr. Strawn said. “They know they’re gonna be sick.”
Withdrawal looks and feels a little like a severe case of the flu, many say. “It’s hard to watch,” said Destiny Salsgivers, a nurse at Armstrong County Jail. “It’s uncontrollable.”
Inmate deaths from opioid withdrawal -- alcohol withdrawal is far more dangerous -- are rare, but since 2015, there have been at least four high-profile cases nationwide.
Especially because detox increases the risk of suicide, most jails either house detoxing inmates in direct observation areas or check on them at regular intervals. Some counties, such as Armstrong, are creating observation units with glass doors, so guards can watch inmates with substance abuse issues around the clock.
Armstrong and Indiana have also piloted programs through which departing inmates get Vivitrol, a drug that prevents them from craving opioids for 30 days, if they agree to seek treatment upon their release.
"I don’t think we have good evidence [the Vivitrol is] going to work,” said Dr. Kevin Fiscella, an addiction specialist at the University of Rochester. He cited a New England Journal of Medicine study that found that adult criminal offenders who used naltrexone (the generic name for Vivitrol) were less likely to relapse during treatment, but might still falter afterwards. More research, he said, would be needed to support the drug’s use.
Even officials at jails that have expended special effort to connect inmates with treatment programs on the outside find that many users wind up back behind bars -- or worse.
Laura Williams, the Director of Substance Abuse Programs at Allegheny County Jail, says she often hears about the fate of former inmates from those who return to jail. “They’ll say, “You know, so-and-so, they didn’t make it.’”
At a fact-finding hearing at Allegheny County Courthouse on Tuesday, Dr. Latika Davis-Jones of Allegheny’s Bureau of Drug and Alcohol Services said that county overdose data has shown that many died of overdose within 30 days of jail release.
The state prison system will develop a plan to keep inmates on prescribed maintenance drugs, according to Secretary of Corrections John Wetzel. A review of 14 studies of buprenorphine and methadone use in jails and prisons found lower rates of relapse associated with those treatments.
In southwestern Pennsylvania, though, jail officials cited both practical and philosophical concerns about such drugs. Medication assisted treatments, like other programs to support inmates recovering from addiction, require money and resources.
Warden Phillip Shaffer of Armstrong County believes that the decision to use methadone or buprenorphine is a personal one, but he does not think that it’s necessary for jails to provide such drugs.
“We just do what’s absolutely necessary, because it’s taxpayers’ money,” he said.
According to Todd Haskins, the vice president of operations at PrimeCare, a medical provider for several Pennsylvania correctional facilities, a monthly supply of buprenorphine brands Subutex and Suboxone for one person would cost about $80 to $100 a month, not much more than many other prescription medications. From the jail’s perspective, of course, that’s still an additional cost.
Still, the National Institute on Drug Abuse estimates a savings of over $12 in reduced substance-related crime, criminal justice, and health care costs for every dollar spent on treatment.
Other jail officials cited security concerns. “We try to avoid any type of addictive narcotic,” Warden Strawn of Washington County said. “It’s usually not good for people to know we’ve got that stuff locked up in here.”
Some wardens expressed skepticism about drugs such as methadone and buprenorphine. “While [users] are here, they have the best chance of getting clean,” said Warden Bill Schouppe of Beaver. “If they’re here for an extended period of time, you have a better chance of putting them through a treatment program without any issues.”
Some experts think detox in jail doesn't address addiction. “The idea that a punishing withdrawal is going to discourage use is naive and is not supported by any data we have over the last 50 years,” said Dr. Fiscella.
“The whole idea of detox is a flawed one,” said Dr. Josiah D. Rich, a professor at Brown University and the director of the Center for Prisoner Health and Human Rights. The idea that jails “just stop you from taking this medication for a period of time and then put you back into your same environment and expect you to be cured, is absurd."
Some though, think that these effects come at a cost. “To me, it’s just substituting one addiction for another,” said Ms. Salsgiver of Armstrong County.
Dr. Rich offered a different perspective. “What these treatments do is allow people to have the breathing room to move in the direction of recovery,” he said.
Maia Silber: firstname.lastname@example.org, @msilber6. Rich Lord contributed to this report.
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