This article is part of an ongoing New Bedford Light series examining the far-reaching impacts of addiction.
DARTMOUTH — The Bristol County Sheriff’s Office is expanding its treatment program for addicted inmates who are serving sentences, providing medication meant to manage opioid withdrawal symptoms, cravings and the risk of overdose.
When medication-assisted treatment started at the Bristol County Jail and House of Correction in North Dartmouth in 2021, inmates could get one of three medications for drug addiction only if they had a prescription when they entered. Other inmates addicted to opioids could attend group meetings or talk with a therapist, but many would be left to scrounge for illicit drugs inside the jail.
That is changing now, as Bristol County joins the majority of Massachusetts counties in allowing inmates to qualify for medication even if they were not receiving it when they arrived. The change is on track to nearly double the number of inmates receiving medication.
“The research says it works,” said Sheriff Paul Heroux, who took office after the MAT program was first established. “It’s pretty straightforward. Addiction is a medical issue.”
Heroux said he has intended to broaden the MAT program from the time he took the position in January 2023. The former Attleboro mayor and state representative said he took office with a long to-do list, and said it has taken time to set the stage for what could be a significant expansion of MAT.
The effort will provide sentenced inmates within 120 days of their release with one of three medications: methadone, buprenorphine, and naltrexone, also known as Vivitrol.
Eventually, the sheriff’s office will consider further expanding the effort by lifting the 120-day requirement and including pre-trial inmates, said Judy Borges, the Bristol County Sheriff’s assistant director of medical services. She said those discussions could begin in late winter.
Significant expansion
Under the program established by Heroux’s predecessor, Thomas Hodgson, about 90 sentenced inmates have been receiving one of the medications approved for addiction treatment by the U.S. Food and Drug Administration. That’s roughly a third of the sentenced population in a system that accommodates between 600 and 700 inmates daily. A little more than half are pre-trial detainees; the rest are serving sentences for offenses carrying a maximum penalty up to two-and-a-half years.
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As of a few weeks ago, some 70 sentenced inmates had applied for the expanded MAT program, and requests were continuing to be submitted, said Borges. Inmates asking to join the program are being screened based on their history of illicit drug use, earlier participation in a MAT program, and choice of a community clinic for continued treatment.
Borges acknowledged the 120-day requirement limits the program’s reach.
“The idea is to put the priority on those [inmates] leaving soonest,” Borges said.
She said it can take weeks to find the right dose of liquid methadone, less time usually on Subutex, a pill form of buprenorphine that is also known as Suboxone in the sheer strip form. The county is also providing Brixadi, an injectable, time-released form of buprenorphine that is relatively new to clinical use. The third medication, naltrexone, or Vivitrol, is an injectable drug that works differently in the brain from buprenorphine and methadone.
Managing overdose risk
Inmates struggling with addiction are at substantial risk of overdose soon after they’re released, evidence shows, because their tolerance for the substance has likely diminished in jail due to abstinence or less use. Under those circumstances, using the drug again can lead to overdose, even death.
The risk of death from drug overdose within two weeks of being released from prison or jail was 129 times higher than for people who had not been jailed, according to research published in 2007. Some 60% of people who died of drug overdose in Massachusetts had been behind bars the year before, according to a study published in 2017.
Along with establishing a medication regimen, the MAT program in Bristol County will provide a prescription that the inmate can take with them when they leave, and a contact in the community who can help keep them on track with their treatment.
Dr. Josiah D. Rich, an expert on drug treatment in prison populations who co-founded the Center for Health and Justice Transformation — a nonprofit devoted to improving health care for people in the criminal justice system — said he applauds the Bristol County MAT expansion, even with the 120-day limit.
“That they’re doing it is great; they should be commended for that,” said Rich, a professor of medicine and epidemiology at Brown University. While cautioning that he doesn’t want to make “the perfect the enemy of the good,” he said “they could do better” by opening the effort to more inmates.
Heroux said that when he took office, it was only a question of when, not if, the jail would expand the MAT program. As far as he could see, all the research on medication treatment for addicted people in jail has shown that it reduces overdose deaths and the likelihood that people released will continue to use drugs and return to jail.
Rich said the research is clear.
“There’s no argument against it” based on evidence, Rich said. He does take issue with the terminology, as the phrase “Medication Assisted Treatment” suggests the medicine is only augmenting treatment, when it essentially is the treatment. He prefers the term “Medication for Opioid Use Disorder,” or MOUD.
“The medications are the most powerful tool we have,” Rich said.
Such medications have been around for decades. Methadone was first approved in 1972, buprenorphine in 2002, naltrexone in 2010.
Treatment lags behind
Addiction experts often compare the condition to type-2 diabetes. Lifestyle choices as well as genetics can contribute to both conditions. Both involve biochemical regulation: diabetes is a disorder of the body’s ability to regulate glucose; addiction interferes with the body’s ability to regulate dopamine, a biochemical messenger produced in the brain. Among its other functions, dopamine is part of the process that produces pleasure sensations.
Research supports the comparison of addiction to type-2 diabetes, which is commonly treated with drugs, including injectable forms of the hormone insulin. But addiction treatment lags behind in using the available medications.
In 2021, only one-fifth of the 2.5 million U.S. adults with opioid use disorder were receiving medication treatment, according to research by the National Institutes of Health and the Centers for Disease Control published last summer. Rich said there is no reliable figure for the percentage of people in jails and prisons who receive medications, but he estimated it would be under 20%.
It’s taking time for medications to catch on in American jails and prisons, where the approach has faced resistance for several reasons.
Lauranne Howard, who has overseen the drug treatment program for the Rhode Island Department of Corrections, an early MAT adopter, said security officers have had the “very legitimate concern” about bringing drugs into the prison while they’re trying to keep smuggled drugs out. There’s also the cultural stigma surrounding drug abuse, and the concern that MAT amounts to substituting one form of drug use for another.
Howard said Dr. Jennifer Clarke, the Rhode Island agency’s medical director when the medication program was introduced in 2016, held many meetings with security staff members to explain how the medications would be used and why they were necessary. Resistance has diminished considerably, but probably will never vanish altogether, Howard said.
Borges acknowledged that there is no perfect way to stop medications from being “diverted” from the proper use in the program to illicit use elsewhere in the jail. The potential benefits, however, outweigh the risks, she said.
Even in the recovery world, support for MAT, or MOUD, is not unanimous.
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David Daniels, program director at Rise Recovery Support Center in New Bedford, does not dispute the research on the effectiveness of medications. However, he said his own experience in years of addiction recovery, both in prison in upstate New York and outside, left him with mixed feelings about MAT.
He said he felt that treatments with methadone and forms of buprenorphine “kept me alive for a decade.” At the same time, he wonders if that also “kept me locked into the problem maybe for longer than I needed to be,” because, in his view, he was not entirely substance-free.
Daniels, who is 42, said he did not feel right in a “spiritual” sense until he was able to be free of any drug, illicit or otherwise. He said he has just marked a year of complete abstinence.
“If the goal is complete abstinence, then I don’t know if (MAT) is the greatest” option, Daniels said.
Rich said the goal could be abstinence for some recovering addicts, but not all. Some may have to continue taking medication indefinitely, much as a diabetes patient would stay on insulin.
People on medication for drug addiction “should stay on the medication until they’re ready to get off,” he said. “That can vary from patient to patient.”
Research supports medication
What is consistent is the research on MAT for jail and prison inmates. Some studies are clearer than others, but the weight of evidence shows that the approach works by a number of measures.
Inmates who received MAT in jail were less likely to reoffend, according to a study published in 2022 on the MAT program for inmates in Franklin and Hampshire counties in Massachusetts. The research looked at recidivism — defined as being jailed, arraigned or having a probation violation after being released — among 469 former inmates. Of those, 197 had received medication when they were in jail, 272 had not.
More incidence of recidivism was found in the group that did not receive medication by a margin of 62.5% to 48%.
Published in the journal Drug and Alcohol Dependence, the study concluded, “Findings support the growing movement in jails nationwide to offer buprenorphine and other…medications for opioid use disorder.”
On the other hand, a review of 24 previous studies — in other words, a study of studies — published in 2019 in the Journal of Substance Abuse Treatment did not find that MAT reduced recidivism, but that it was beneficial in other ways.
Of the 24 studies, 18 involved treatment with methadone, three with buprenorphine and three with naltrexone. The results, considered meaningful only for the largest sample of methadone treatment, showed that the approach in prison and jail increased community treatment engagement after the inmate was released and curbed illicit opioid use.
In 2018, a limited study of the Rhode Island MAT program showed that overdose deaths among inmates released from prison dropped from 26 before the MAT program to 9, a difference of 60%.
Appearing in JAMA Psychiatry, published by the American Medical Association, the research found that overdose deaths in the population as a whole dropped 12%, from 179 to 157. The study compared the same six-month period, January to June, in the year before the MAT program began and in the first year of the program.
The programs in Rhode Island and Bristol County are part of an attempt to close a longtime gap between what the research shows works and how drug treatment is actually practiced.
In 2015, Rich and Dr. Sarah E. Wakeman argued, in an article published in the Journal of Addictive Diseases, for jails and prisons to catch up with the evidence.
“The persistent gap between treatment supported by scientific evidence and much of the treatment available within correctional facilities is both unethical and unwise,” they wrote, citing a 1976 U.S. Supreme Court decision that requires jails and prisons to provide a “community standard of care.”
Besides the inequity for inmates, untreated addiction eventually spills out into the community, they wrote: “Taxpayers will share the impact. The toll of untreated addiction is costly, morbid, and can be fatal.”
Email reporter Arthur Hirsch at ahirsch@newbedfordlight.org.
