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
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
“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
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
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
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
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 firstname.lastname@example.org.