According to a recent report, the opioid overdose death rate was 120 times higher for those recently released from incarceration compared to the rest of the adult population. That study focused solely on one state, Massachusetts, but the staggering results speak to a wider problem with the criminal justice system across the country. For the past two years, Boulder Care has been partnering with a Community Corrections agency in Southern Oregon to try to understand what is happening and make a commitment to do better for our mutual clients who suffer from OUD.
In our partnership, we’ve been able to start treating patients through Boulder Care while they are incarcerated or housed in a Transition Center. The Community Corrections team screens every person who enters the Transition Center for OUD upon entry. If the screening identifies a possible OUD diagnosis, and the client is interested, a medical appointment with Boulder is scheduled that day. Starting medications for addiction treatment (MAT) before a patient is released, and continuing that care with the patient through release, we’ve seen firsthand how effective it is to provide better, more consistent care for incarcerated people with SUD.
But working inside the criminal justice system together, we’ve also seen how treacherous the journey in and out of incarceration can be for anyone with substance use disorder. Every step is riddled with dangerous pain points that can exacerbate an SUD.
These pitfalls help explain why so many are suffering from overdoses.
To show you just how difficult the challenges are that people are facing, let’s follow one individual — a composite we’ve created to represent the experiences of the many patients we’ve encountered — as he moves through the system. Let’s call him Billy. Billy’s experiences will by no means be the most extreme; in fact, what he goes through is fairly common amongst the outcomes we’ve seen.
Meet Billy
Billy has just been ordered to jail for an old drug possession charge that led to a warrant and now an arrest. It’s a seemingly small and non-violent offense, but it still necessitates a short sentence.
Billy’s been on treatment for an opioid addiction for a while now, and even though it has been going well, this bump in the road could become something much larger and, sadly, more dangerous. Billy had been feeling better. He was holding down a job. But now, even though he’s only being ordered to jail for 45 days, all of that is at risk.
Entering Incarceration
The second Billy enters jail, he is forced into a detox from any substance or treatment he’s on. He can’t keep his MAT prescription, whether it be for Suboxone or methadone, so simply continuing treatment is impossible for him. His provider isn’t even told he’s been put in jail, so they just think he hasn’t shown up to an appointment. And his medical care is controlled by the jail now, so he isn’t allowed to stay with the doctor he has been seeing for almost a year, who he had come to trust. This medical brick wall is something all incarcerated people face — there are virtually no correctional facilities that allow MAT treatment, and all medical decisions are made by the jail, regardless of the patient’s medical history, so incarcerated individuals have no ability to request or advocate for the care they need.
On top of that, Billy’s losing his Medicaid coverage, so he’s also worried about how he’ll pay for treatment when he’s released.
Medicaid is automatically suspended for anyone when they’re taken into custody, and terminated for all jail terms of 30 days or longer.
So Billy has no choice: he can’t continue treatment and he is starting to detox. But detoxing from methadone or Suboxone is very difficult — even worse than detoxing from heroin, especially with only the basic medicinal aids the jail will provide, like Advil, some basic nausea meds, and perhaps some Benadryl to help him sleep. He goes into withdrawal and feels very sick: he’s dehydrated, nauseous, and in pain. He’d do anything to stop feeling this way, even if it means turning to the very opioids he’s been working so hard to stay away from… from someone else in jail. Ironically, it’s easier to get opioids than MAT while you’re incarcerated.
During Incarceration
Once Billy manages to make it through his detox, he starts to feel better. But the detox process was really hard on him, both physically and emotionally.
He knows he never wants to feel that way again, so he’s now scared to think about ever going on medications for addiction treatment again.
Billy feels like an idiot for ever being optimistic about his treatment in the first place — and this setback just confirms for him that he’ll never be successful with any MAT program. Why bother trying, when every time life doesn’t go according to plan it results in this much pain?
The judge on Billy’s case decides he should be transferred to a Work Center — a supervised housing program that is part of the Community Justice system. He’ll have the ability to reduce his sentence by joining a work crew, and even get to leave the work center grounds to do so, which feels a little more like freedom.
But it also comes with more risk to his recovery, and he feels increasingly nervous without medication. In his new housing and work scenario, he’s around other people who are using. He’s starting to get really scared he’ll be tempted to start using again. He doesn’t want to undo the hard work he had been doing before getting incarcerated. Billy’s also terrified to tell his supervisors and Parole Officer that he’s struggling with his SUD. He knows that people with SUDs are stigmatized and often not accepted into programs with transitional housing or job placement after release.
Getting Released
Billy stays the course in the Work Center, and he’s feeling good, if overwhelmed by everything that lies in front of him when he’s released. He has to find housing, a job, see all the people in his life again, and stay healthy. The last thing he should have to worry about is figuring out how to get treatment and how to pay for it.
But even if he is organized enough to reapply for Medicaid, it takes about three to six weeks for a patient to get reinstated. So he doesn’t have healthcare coverage, and he has trouble getting in touch with his old provider. When he does figure out how to connect to his old clinician, they’re willing to see him and rewrite his prescription for MAT, but the pharmacy won’t give him the meds without insurance to cover them.
This small “gap” in coverage quickly turns into a major roadblock, especially when six weeks without medication can have devastating consequences.
Suddenly, even though Billy’s done everything right, he’s thrown into his world of old temptations without any medical support. He’s not feeling well, so he misses a meeting with his parole officer. But his PO doesn’t know why, and tells him he’s going to give him a warrant, which could land him right back in jail.
Billy feels hopeless, but there is one choice he can make. He can go to his old dealer and feel better. But he hasn’t used heroin in quite a long time, and when he does, his tolerance has dropped dramatically. He takes the same amount he used to — or even a little less, just to see how it feels. But his body doesn’t react the way he remembers.
And that’s when Billy overdoses.
How Can We Change Billy's Story?
Billy could have had a different story.
People may look at Billy and think he’s just another statistic, a case of recidivism for someone who didn’t try hard enough, but the truth is that the system isn’t built to give him a fair chance at success.
SUDs aren’t treated like other diseases. If Billy was diabetic, his treatment wouldn’t be interrupted upon incarceration, and even upon release, he could be given enough medication to carry him through the transition back to Medicaid. Through our partnership, we are trying to find a way to work with people like Billy and change their stories.
Working hand-in-hand as provider and parole officer, we found that there is an opportunity to solve many of these pain points with simple interventions, and especially by providing patients like Billy consistent care that follows them throughout the justice system and release.
- By being proactive for people facing imminent incarceration, we were able to plan for their medical needs. We had open conversations with POs to plan for how to continue care as the patient entered jail, while they were incarcerated, and after.
- By designating a Boulder Care clinician as the patient’s medical provider, we were able to stay in contact while the patient was incarcerated, monitor treatment better, and work with the patient and the parole officer to make a plan for how to get the patient their meds when they were released.
- By creating a care team with people on both the medical and the community justice sides, we worked to connect the various different people and departments involved in working with the patient. With a coordinated community response, each agency can give the patient the best chance for success. For example, if the parole officer knows that the patient is in MAT treatment, they can inform the clinician when a change is imminent — was a warrant posted? Is the patient heading into incarceration? How can they all stay in touch? And the clinician, in turn, could talk to the PO about helping ensure that the patient is showing up when needed — setting goals with the patient around required appearances, etc. — and then letting the PO know where things stand.
There are, of course, also some major institutional barriers in place that a small program like ours cannot overcome. We believe the government must move to change in order to better serve inmates with SUDs. We know these changes would lead to far fewer deaths and bad outcomes over time:
- All incarcerated people should be allowed to keep Medicaid coverage while incarcerated, so they can maintain consistent coverage and care even upon reentry
- Denying people access to care during incarceration and when they are released is a violation of their rights and damaging to their health.
- Medical teams should be given proactive information about incarcerated patients, so they know when they’ll be released, what treatments they’re being given, and if there have been interruptions to care. This will allow the team to better plan for ensuring medicine is available as soon as the patient is released.
We’ve been amazed at the improved outcomes we’ve started to see with the SUD patients we’ve been working with together. And we’ve got big plans for how to make the most of the data we’re gathering in order to advocate for policy changes that will better serve these patients. To follow along with our progress, keep an eye out for a journal article outlining the results of the program coming soon.
