As opioid addiction rises, public health advocates in Maryland are calling for more treatment where many addicts end up: in jails and prisons.
In Maryland, only Baltimore and a few counties offer any treatment in their jails. The state-run jail in Baltimore offers only detoxification. The state offers some counseling in its prisons and continues detox for 21 days. But advocates and treatment professionals say it's not enough to keep addicts off the drugs over the long term.
Addressing addiction more comprehensively, advocates say, with a wider variety of medications and continuing counseling, could not only cut addiction rates but reduce crime and the spread of infectious disease such as HIV and hepatitis.
"The main reason people get incarcerated is they have a mental-health or substance-abuse issue that leads to criminal activity," said Scott Nolan, director of the Drug Addiction Treatment Program at the Open Society Institute-Baltimore.
"This is one of those things with government, you make an investment now to see improvements later," he said. "There would be financial savings, but citizens would also have a better quality of life."
The challenge isn't new, but the misuse of heroin, fentanyl and prescription painkillers has caused a spike in overdose deaths in the state. There were nearly 1,260 last year, nearly twice as many as in 2010.
The Department of Public Safety and Correctional Services, which runs the Baltimore city jail complex and state prisons, reports that 65 percent to 70 percent of offenders enter the system with a substance-abuse problem, from alcohol to heroin.
Yet for opioids, only a limited amount of methadone is provided to wean those addicted to opioids, and only to those who can prove they are already on it.
About 2,000 people enter the corrections system in the city each month, but only about 100 people are in the methadone program. Dr. Sharon Baucom, the medical director for the corrections department, said that's because detainees cycle through the jail quickly.
Those who are allowed to use methadone in jail can continue on the drug for 21 days if they are convicted and transferred to prison. Counseling also ends in three weeks, and begins again only when prisoners are within two years of release, when addicts are considered vulnerable to relapse and overdose.
That's far short of what is needed, says Kathleen Westcoat, president and CEO of Behavioral Health System Baltimore, which oversees mental-health and substance-abuse programs in the city.
Westcoat said her organization has approached Gov. Larry Hogan's office about expanding services in the correctional system to mirror those available in the community. That includes a range of medications, continued beyond detoxification, and ongoing counseling.
"There is a lot of momentum now nationally and statewide, and attention is being given to the issue," she said. "The timing is right to shift the paradigm in how jails operate in terms of substance-use disorders."
Those discussions continue, Hogan aides say. In the meantime, corrections officials say, they have looked for ways to expand treatment, including training inmates in the Eastern Correctional Institution in Westover to act as drug-counseling peers to addicted fellow inmates.
"What's most important is that more effective treatment will be available to offenders before, during and after incarceration," said Shareese Churchill, the governor's spokeswoman.
Anne Arundel County has provided methadone to its detainees, and Washington and Harford counties have offered naltrexone, an injection that helps prevent relapse but not withdrawal.
Nationally, addiction specialists say, few correctional facilities provide much more. But as the number of people addicted to heroin and prescription painkillers surges, they say, it's time to expand access to counseling and medications for prisoners, because different treatments work for different individuals. Many say buprenorphine, another medication widely used to wean addicts from opioids, should be an option.
Amy Nunn, an associate professor of behavioral and social sciences at the Brown University School of Public Health, says funding, logistics and politics all have made it difficult to expand drug-treatment programs in correctional systems.
Nunn co-authored a 2009 study published in the journal Drug and Alcohol Dependence that found 28 states administer some methadone in their prisons, and seven give out buprenorphine.
"Sometimes it was approached as a moral issue rather than a medical one, because all the evidence shows this is an effective medical and public health strategy to detox people," Nunn said.
In the Baltimore jail, which offers methadone but not buprenorphine, cost is a factor, Baucom said.
Methadone costs 40 cents a dose. Buprenorphine — also known as "bupe," and marketed as Suboxone — costs $3 a dose.
Another factor: Methadone, a liquid, is more difficult to smuggle into prison.
Buprenorphine is the most common contraband drug found in state-run correctional facilities because it's widely distributed as a thin film that is easily concealed on paper or under a stamp.
To stem the amount of the drug available for smuggling, correctional officials asked the state Medicaid program to curb its use outside of jails and prisons.
Medicaid responded by largely replacing the film with a pill. That move led to a backlash among treatment advocates, who said switching medications could destabilize patients and lead to more overdoses.
The advocates said the film should be available not only to Medicaid patients but to those in jails and prisons. They said any smuggling was likely the result of people trying to relieve withdrawal symptoms and cravings.
While abuse is possible, Suboxone contains another drug called naloxone that prevents euphoric highs.
Denying the drug to those who might benefit from it "is plain wrong," said Dr. Michael Fingerhood, an addiction specialist and an associate professor at the Johns Hopkins University.
"If a patient comes in on blood-pressure medication, they receive it," he said. "But if one of my patients is on buprenorphine, he/she does not receive it and likely receives nothing, not even methadone. If patients received treatment, the smuggling of medication would dissipate tremendously."
Dr. Leana S. Wen, the Baltimore City health commissioner, suggested that her department launch a pilot program with buprenorphine in Baltimore jails.
"Everything has costs, but it's not appropriate to ask what is the cost and not what is the value," she said. "And what is cost if it's not done?"
Others who study addiction say continuing treatment gives addicts a better chance of avoiding relapse.
Dr. Josiah Rich, a professor of medicine and epidemiology at Brown University's Warren Alpert Medical School, said those who continue drug treatment in jail are more likely to return to treatment when they are released than those whose treatment is discontinued.
He said Maryland has been "ahead of the game" in offering methadone in community settings and in jails, but he believes buprenorphine could help more people.
"They should explore the use of buprenorphine on people it's been working for," he said. "It's not the same medication as methadone, and the system should have clinical determination [for detainees] rather than another policy like a financial one."
To combat smuggling and abuse, Stephen Magura said, correctional officials should consider the newest form of buprenorphine: an implant.
Magura, director of the Evaluation Center at Western Michigan University, said the implant delivers a steady stream of medication for six months, providing ongoing treatment rather than short-term detoxification.
It has been approved by federal regulators only for those already being treated with buprenorphine, which means correctional facilities would have to put detainees on film or pills first. And each implant costs $5,000. But Magura said savings from daily dosing of prisoners and a reduction in smuggling and security concerns could help offset costs.
"With some creative thinking, the implant could be helpful to correctional systems," he said. "But the decision would have to come from up high, with mayors and governors. Correctional facilities on their own won't provide care for six months when people don't stay in jail that long. They're only mandated to provide care while people are there."