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The Portland Phoenix
July 19 - 26, 2001

[Features]

Climbing the walls

Does methadone have a place behind bars?

By Sam Smith

Jennifer sits in the small interview room of the Cumberland County Jail, her frizzy hair held up in a scrunchy the same incarceration-orange as her jumpsuit. She’s been back in jail for a couple of weeks, serving a 90-day sentence. She shot a bag of heroin and got caught when she tried to falsify a court-ordered urine test.

“I was at this guy’s house. He owed me $500. He gave me a bag and a brand new needle,” she explains with a shrug.

This is Jennifer’s second visit to county since the beginning of the year. She got busted for trafficking in February and spent 20 days behind bars. Twenty days when she was forced to withdraw from methadone. Twenty days she remembers as some of the worst in her life.

Last December, the Cumberland County Jail discontinued its four-year-old “methadone protocol,” a partnership with the methadone clinic Discovery House that allowed methadone users to be dosed by jail staff. The jail now uses a “withdrawal protocol.” Methadone proponents oppose the change.

The debate over methadone use in correctional facilities isn’t just a local one; jails around the country are wrestling with the appropriate use of the drug that helps ease a heroin addict’s cravings.

But the stakes could soon rise in Portland. Cumberland County Jail administrators point out that the population of inmates on methadone numbers only about two dozen a year, but with three new methadone clinics poised to open in Portland, some fear that number could soon rise.

Meanwhile, Cumberland County’s decision to discontinue its protocol is being felt by inmates like Jennifer.

The 34-year-old Portlander had been taking methadone for three years. She says she’s gone through heroin withdrawal before, but never methadone.

“I was dying,” she says. “When you’re on methadone for three years it stays in your bones. Being in jail without it just about kills you. I mean, the chills, the sweats, the cramps, the leg cramps, the muscle aches. You might as well just keep your mattress on the floor because you’re going to be on that toilet every five minutes either puking or shitting. I couldn’t eat anything. I couldn’t drink anything. I’d rather come off heroin than methadone any day.” Jennifer is the first to admit she wasn’t the model patient; she was still using heroin during the three years she was on methadone. But she wonders what might have happened if Discovery House and the jail could have maintained their relationship.

“If they would allow us to take the methadone, I don’t think I would have gotten in trouble again,” she says. “I would have been clean and been able to just do my methadone. Because I had to [withdraw], when I got out I didn’t want to go back on methadone. I got out and got high for a week. I haven’t taken methadone since February, and I won’t.”

It wasn’t until late last year, when the Cumberland County Jail switched healthcare providers, that Sheriff Mark Dion says he was even aware Discovery House wasn’t dosing inmates seven days a week. Because of staffing shortages at the methadone clinic, Discovery House relied on jail staff to administer the drug on Sundays and holidays. Dion says Prison Health Services, the previous healthcare provider, didn’t have a license to dispense methadone, and shouldn’t have caught Discovery House’s slack. He points to this now as yet another reason why the company deserved to lose its contract with the jail.

When Primecare Medical, Inc. was awarded the healthcare contract in November, their chief medical officer at the jail reviewed the methadone protocol. She said her staff was not licensed to dispense methadone for opiate addiction, and with Discovery House unable to dose everyday, the protocol should be discontinued. Despite protests from Discovery House, the protocol ended in December.

John Destefano, program director at Discovery House and architect of the methadone protocol, says the issue of Primecare’s license to dispense methadone is irrelevant because under the state-sanctioned arrangement, the jail administers the drug on Sundays and holidays under Discovery House’s license. And that is still the protocol, he points out, at several other jails in the state, including jails in York, Androscoggin, Franklin, Kennebec, Knox, Somerset, and Penobscot counties.

Joanne Ogden, the state methadone authority in the Office of Substance Abuse, says Destefano is mostly correct: the nurses at the jail do not need a special license, but they aren’t operating under Discovery House’s license.

“When they’re in jail, as far as we’re concerned, they should self administer,” says Ogden. “The nurse would only keep it and give it to them to self administer. The nurse doesn’t have to have a special license. It’s basically like a take-home dose patients can receive from Discovery House.”

Destefano says, rather than an issue of licensing, the problem most likely lies in Cumberland County Jail’s attitude toward methadone.

“I guess the kindest way I’d put it is that the [jail] may not see the need for methadone,” he says. “They might not see the benefit it would have for someone in jail. Some people would say that the person doesn’t need methadone because they’re in jail. Some people believe it’s just replacing one drug for another.”

And Destefano is partly right: that is the attitude of the jail, but Dion maintains it’s not the reason for killing the protocol.

“Is methadone a reasonable strategy? It might be,” Dion says. “Although I have some questions about methadone as just substituting one addiction for another. And the current medical staff has a philosophy that fits into withdrawal [from methadone] as opposed to sustaining use.”

But, he continues, the jail will not stand in the way of Discovery House dispensing methadone, as long as it doesn’t expect the jail’s staff to do any dosing.

“They don’t come in on Sundays and holidays,” he says. “That’s their choice, which leads me to wonder about what their philosophy around patient care is. Seems more economically driven than care driven.”

And if anyone is qualified to speak about economically driven healthcare, it’s Dion. While he has questions about the efficacy of methadone treatment, he is under no illusions that the jail’s ability to manage addiction among its inmates is adequate.

“I have one substance abuse councilor for everyone here,” he explains. “I should have eight or nine if we really want to intervene in the conduct. But we really don’t. We wink and nod under the tablecloth as to what we really want to get done here.”

And when he says “we,” he’s indicting us all, the entire community. While rehabilitation of criminals is a noble goal, it’s not the directive Dion is receiving by way of his budget. And that, to him, is a reflection of the community’s values.

“I can get authorization to hire more correctional officers, even though I have 42 vacancies, because there’s always an affinity for that kind of security expenditure,” he says. “But it’s harder than Hades to get money allocated for substance-abuse issues.

“We as a community label a lot of addicts as traffickers, so we criminalize them. But, if we dealt with their addiction, we might in essence be doing the biggest part of crime prevention.”

And, he says, as far as methadone goes, “in terms of what I can pay for, the withdrawal strategy’s what makes the most sense economically.”

And if that means Jennifer has to writhe in pain for 20 days, well, she’s in jail to be punished, right?

But aside from economics, there is still the attitude, expressed by Dion and Primecare’s medical staff, that methadone is not medicine, it’s a replacement drug. It’s not needed. While the jail’s budget may reflect the community’s priorities surrounding appropriate care of inmates, Dion and Primecare’s view of methadone, say advocates, is a similar reflection of the community’s attitude toward the drug. This negative perception of methadone is keeping it out of jails, they say, and this is not unique to Cumberland County.

In May, the Lane County Jail in eastern Oregon announced it would no longer provide methadone to inmates who were enrolled in a clinical program before incarceration. Unlike Cumberland County, the Oregon jail’s staff was dosing inmates every day. The jail’s medical supervisor said because of staff shortages, and the time-consuming nature of methadone treatment, it was not feasible to continue the program. Lane County, like Cumberland County, now relies on a “withdrawal protocol,” which entails administering five different drugs, in tapered doses, over a three-day period, before cutting the inmate off entirely. (Jennifer says she was put on the withdrawal protocol at Cumberland County.)

Trisha Hedin, a legal assistant with the Eugene, Oregon, public defenders office, who has been looking into the legality of the issue, echoes Destefano’s take on the problem.

“In my experience,” she says, “some of this policy comes from negative judgments about methadone. That it’s a drug, that it’s just replacing one with another. People don’t realize the medical advantage of methadone. There’s a lack of education about it.”

As a treatment for opiate addiction, methadone has been in use for over 30 years. And as Dr. Blair Carlson, with the American Society of Addiction Medicine and a board member of the National Commission on Correctional Health Care, says, “No treatment in medicine has been studied harder than methadone.”

Studies have shown the drug to be effective at not only reducing an addict’s dependence on opiates, but also reducing the likelihood of correctional recidivism among opiate addicts, a group more prone to end up behind bars than the general public.

In a 1969 study published in the New England Journal of Medicine, researchers worked with two groups of 16 New York City addicts who had at least a four-year history of opiate use. One group received methadone, the other group received no treatment. One year later, three who had received methadone were back in jail, while all 16 who had received no treatment were back. Those same 16 had all returned to daily heroin use; none of the methadone users had returned to daily use.

At Rikers Island, the New York City prison, a methadone treatment program was established in 1987. It is the only program in the country where prisoners who are not enrolled in treatment at the time of arrest can be given methadone once inside. They are stabilized on methadone and then referred to a community-based treatment program once released. Studies have shown a reduced recidivism rate among 62 percent of the inmates enrolled in the program. A reduced rate was shown among 100 percent of the inmates enrolled in the program who were also Medicaid recipients, thus making their medication more affordable.

Dr. Carlson says information like that is not reaching the right people.

“I think that’s our fault, [the American Society of Addiction Medicine],” he says. “We haven’t carried the message well enough. There are people in the jails who are afraid of methadone. Our job is to get to them.”

While Hedin in Eugene presumes officials at the Lane County Jail need to be better educated on the benefits of methadone, she is investigating whether the jail is breaking the law in keeping methadone from its prisoners. Can a jail withhold a legal medication prescribed by a doctor when the results will be an excruciating withdrawal?

One legal issue involves the Americans with Disabilities Act, which covers opiate addicts who are not currently using. In 1998, the Supreme Court ruled the ADA applies to prisons and jails. The question is, does a jail discriminate against a disabled person — the opiate addict — when it forces him or her to go through the type of withdrawal Jennifer endured in Cumberland County?

Helen Bailey with the Disability Rights Center in Augusta says the courts have never spelled that out.

“I don’t think there’s an answer to that,” she says. “I think it’s arguable their failure to provide methadone is a denial of medical treatment on the basis of disability based on drug addiction.”

Other legal issues involve conflicts with state law. In Vermont last month, for instance, the state supreme court ruled the Vermont Corrections Department would be fined $1000 for every day it continued to refuse methadone treatment to one of its inmates. It was a unique case in that the inmate, Keith Griggs, was under court order to take part in a methadone treatment program, but there were other issues as well.

“The first argument,” says Dawn Seibert, an attorney with the Vermont Prisoners’ Rights Office, “was the court-ordered, substance-abuse treatment. The other had to do with a Vermont statute that says the department of corrections is to provide medical care ‘in accordance with prevailing medical standards.’ Taking Griggs off methadone cold turkey was not considered the prevailing medical standard.”

The Cumberland County Jail, on the other hand, does not force inmates to go cold turkey. They use their withdrawal protocol.

The National Commission on Correctional Health Care is reviewing the Cumberland County Jail’s medical services for the first time this fall. The NCCHC is an accreditation board for jails and prisons, and their standards are often considered benchmarks by the courts. Judith A. Stanley, director of accreditation, says the jail’s withdrawal protocol for methadone users will most likely meet their standards, although she says there would preferably be some form of psychological counseling after withdrawal.

Still, Dr. Carlson, the NCCHC board member, says he’d rather “be put in a Turkish prison than go through methadone withdrawal.”

“I see addiction as a disease,” he says. “It’s not just a bad person. True, that person made a mistake, but the world is full of people who make mistakes. But there they are, they get in jail, and what they ought to get there is humane treatment. Let’s not forget, all these people in jail will be getting out. These are people going back into the community.”

Major Jeffery Newton, the Cumberland County Jail administrator, says when we talk about these issues we need to keep some perspective on things.

“We’re not talking about a lot of people,” he says. “We have 10,000 people here a year; probably less than 20 people a year are on methadone.”

Destefano at Discovery House puts the number slightly higher than that; he estimates they were dosing about 35 inmates a year before December.

But if Lane County, Oregon, can serve as any example, that number could climb soon.

In the mid-90s, Lane County’s heroin problem began to blossom. In 1998, heroin overdoses jumped 26 percent from the prior year, and more than double the number from 1994. The county set a new record that year with 33 overdose deaths.

In response to the increased number of addicts, new methadone clinics opened in the area to help relieve the three-month waiting list at the county’s non-profit clinic. There are now three clinics in the area.

Lane County Jail officials point to the additional methadone clinics, and the associated rise in methadone use, as reason for the rise in users at their facility. A rise so steep they were unable to continue administering the drug.

State officials estimate the population of opiate addicts in southern Maine has doubled over the past five years, partly due to increased addiction to painkillers like Oxycontin, which methadone can also treat. There are currently three methadone clinics in the state, one in Winslow, a new clinic in Bangor, and Discovery House in South Portland. Three new clinics have recently been proposed for Portland.

Discovery House’s Destefano estimates that about 10 percent of Portland area addicts are currently on methadone. With more clinics and increased accessibility, he’d hope to have 20 percent of that population on the medication.

This concerns Newton.

“If we’re going to create a larger population of individuals who are on methadone,” he says, “I hope that those agencies who are providing that care dialogue with us about how they want to deal with those individuals who are incarcerated. They are more than welcome to come in and dispense. We’ll facilitate that. But they need to be the ones coming in and doing it. If they are expecting us to do part of their job, we’re not going to do it.”

Whether the number of inmates on methadone doubles along with a doubling of the methadone-user population, or even if it stays the same at 20 to 35 a year, the impact of medical complications can be disproportionate to their size. Or so citizens of Orange County, Florida have learned.

While experts say it is rare that someone could die withdrawing from methadone, two inmates at the Orange County Jail have died in the past four years after being taken off the drug.

According to the Orlando Sentinel, the Florida jail’s healthcare system has been recommended for accreditation, similar to the accreditation Cumberland County is seeking. The jail does not administer methadone. Their withdrawal protocol entails close supervision of inmates, with medication administered to treat the symptoms of withdrawal.

In 1997, Susan Bennett was arrested for forging prescriptions. She was in a methadone program at the time. Twelve days after being incarcerated and experiencing the vomiting and diarrhea associated with withdrawal, she was found dead in her cell. She died of a heart attack brought on by malnutrition and imbalanced electrolytes, which was caused by her vomiting and diarrhea.

Bennett’s family sued the jail and county for $10 million. They were awarded $3 million.

The Orange County Jail is self-insured, which means taxpayers footed the bill. The Cumberland County Jail is similarly self-insured.

It’s yet to be seen how much the family of Karen Johnson will seek in damages from the Orange County Jail. Johnson was admitted to the facility last month, and was released to a hospital 10 days later unconscious and nearly dead. Her family took her off life support soon after.

Johnson was enrolled in a methadone program when she was apparently arrested for leaving the scene of an accident and taken to jail for breaking the provisions of an earlier home-confinement ruling. Jail administrators now voice confusion over why, in fact, she was being held.

Johnson was taken to a local hospital after passing out while being booked. She was administered 10 milligrams of methadone a day, a low dose, for the seven days she was there.

She was returned to jail, where she was no longer receiving methadone. Johnson’s family has been told she choked on her own vomit, induced by her withdrawals.

When an inmate is admitted to the Cumberland County Jail and tells officers he or she is on methadone, the jail verifies this with a call to Discovery House. Jail officials say at that point the methadone clinic knows one of its patients is at the jail and could establish a dosing regimen with the inmate, which the jail would facilitate, but not administer.

Dion says even if the methadone clinic still visited users, some would still be left out because they can’t afford the medication.

“If methadone was so good, and places like Discovery House gave a damn about addicts, they wouldn’t be structured as for-profit enterprises,” he says. Discovery House is a for-profit clinic. “The addicts who are really in bad shape are usually the ones who can’t afford treatment.”

Destefano says since the methadone clinic is unable to dose seven days a week and since the jail won’t dose on Sundays and holidays, they have no choice but to leave their patients in jail without medication.

“We want to do this at [the jail’s] request, not at the patient’s request,” says Destefano. “[Jail officials] don’t want to take any responsibility for dosing. They don’t want to have anything to do with it, which is the problem. We can’t take full responsibility for that.”

Dr. Carlson, with the American Society of Addiction Medicine and the NCCHC, says there’s too much finger pointing going on in Cumberland County, without anyone focusing on the goal at hand.

“One thing that disturbs me here,” he says, “is the people who run jails and who run our governments are supposed to be capable of finding solutions. In this case, nobody is trying to find a solution.”

But he levels criticism at Discovery House as well.

“The methadone clinic should step up here and do what’s right,” he says. “They don’t have to deal with as much bureaucracy as the jail.

“The other thing is, just don’t give the dose on Sunday. The inmate will go through a bit of withdrawal, which is a bit of a false withdrawal, because they’re scared to death. But you don’t lose your tolerance missing a Sunday.”

In the rush to lay blame, Dr. Carlson fears we’re losing sight of the primary goal.

“I think the big deal here is to do the humane thing.”

Ogden with the Office of Substance Abuse agrees.

“We really are in support of having them maintain their dosing while in jail,” she says. “When they’re taken off methadone it makes problems for the inmate, it makes problems for the jail. It’s just less of a problem to keep them on, and it’s more humane.”

Sam Smith can be reached at samssmith@hotmail.com.

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