THE COLLEGE HILL INDEPENDENT


Criminal Treatment

Rhode Island’s efforts to treat opioid-use disorders in its prison population

by Julia Rock

Illustration by Sophia Meng

published November 10, 2017


Michael is set to leave the prison in two days, ending an 80 day sentence for possession of a controlled substance. He wears the same navy blue jumpsuit that the other individuals in the Intake Facility here at the Rhode Island Department of Corrections wear. “In late 2014 I got addicted to opioids—percocet and oxycodone. I struggled with it for about a year. I came in and out of the correctional institution... every time I came in here I was going through withdrawals… anxiety, getting aggravated, [and going through] depression.” Michael explained the intense physical and emotional pain that he experienced each time he was admitted to the facility and went through withdrawal. “When you come in, the last thing you want to do is deal with everybody. You’re in cell block with 120 people and you’re withdrawing off a drug and that’s killing you inside—making you feel sick—and you’re dealing with 119 other inmates.”

When Michael was admitted to the facility at the beginning of last summer, he learned that the Department of Corrections had launched a program which would administer him a daily dose of Suboxone, one of the opioids used to treat opioid-use disorders. Unlike opioids such as percocet and fentanyl, Suboxone is not addictive and helps to reduce cravings and withdrawal symptoms for individuals struggling with addiction. Michael was administered a daily dose of Suboxone for the 45 days that he spent incarcerated at the facility. However, upon release, Michael found it difficult to visit a treatment facility every day: “I stopped going to it because I have three kids—a hectic schedule—you have to go there every morning. I didn’t have a license. So I stopped going. Seven days later I returned to prison. Quickest I’ve ever returned to prison in my life.” Michael explained that the challenges he faced upon leaving prison made it difficult to pursue treatment, and that in an effort to make money for his family upon release, he dealt crack cocaine and was reincarcerated. The in-prison Suboxone treatment was insufficient to support Michael in the massive challenges that he faced upon leaving. Although the administration of Suboxone within the facility was a positive step towards treatment for Michael, the fact that he had been incarcerated posed massive barriers to his recovery that couldn’t be counteracted by medication treatment.

When Michael was incarcerated for possession of a controlled substance seven days later, he was again started on a treatment program with a daily dose of Suboxone. “I have been able to do so much more stuff since I’ve been back... having the program within the facility itself allows inmates to not focus so much on how they feel on a day-to-day basis. When you come here, it’s the drug that put you here, for most of us.” While serving his current sentence, Michael has found that he is able to focus on things beyond the painful symptoms of withdrawal that he had previously experienced. To Michael’s point, a large proportion of inmates in the facility have been incarcerated due to their struggles with addiction: according to the National Center on Addiction and Substance Abuse, an estimated 65 percent of inmates in the United States have some form of substance use disorder. For an inmate like Michael, who wasn’t able to access treatment until he was arrested, the criminal justice system has become a replacement for comprehensive health care services. The criminalization of substance abuse disorders was one of the main factors contributing to Michael’s incarceration. However, Michael’s ability to receive treatment was contingent upon the fact that he was incarcerated and received treatment in the prison.

Treatment for substance abuse within prisons isn’t an antidote for the violence and harm caused by the mass incarceration of individuals struggling with addiction. A reliance on the criminal justice system to address issues of substance abuse has left individuals like Michael struggling to seek treatment outside of prison, and stuck in a cycle of addiction and incarceration. Nonetheless, Michael is grateful that he had the opportunity to start treatment during his time at the prison. He thinks that his experience here has been more positive than it had been in previous times because he has been able to focus on recovering from addiction. He plans to visit an addiction treatment facility near his house every day when he leaves: the facility is three minutes from his house and he can receive the medication in the morning before he goes to work. 

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In 2016, 336 Rhode Islanders died from opioid overdoses; 12 percent of those individuals had been incarcerated at the ACI within the past year. Dr. Jennifer Clarke, the Medical Programs Director at the Rhode Island Department of Corrections (DOC), estimates that of the 12,000 individuals who move through the prison system in Rhode Island each year, 15 to 20 percent have an opioid use disorder. Dr. Clarke oversaw the launch of the Medication-Assisted Treatment (MAT) program in the Rhode Island DOC facilities, which was responsible for supplying the Suboxone that Michael received while he was incarcerated. Dr. Clarke is proud of the program’s success in helping inmates recover from addiction and reducing the probability that they will overdose or return to the facility. Dr. Clarke told the Independent: “I think we all know that incarceration is not the answer for mental health and addiction problems.” However, she still wants to do what she can to help incarcerated individuals struggling with addiction: “While I can’t change the criminal justice system, what I can be part of is providing and advocating for the services for those who are incarcerated.” 

Before the current program was implemented, incarcerated people in Rhode Island who were using methadone as treatment before they were incarcerated were kept on methadone for seven days before being withdrawn from the drug. However, the spike in overdose deaths in Rhode Island and across the country has encouraged the state to invest more resources in addiction treatment. In August 2015, Governor Gina Raimondo signed an executive order stating that, “Rhode Island is in the midst of a public health crisis” due to opioid addiction and overdose, and set up a task force to investigate the crisis and make recommendations to the governor. Ashbel T. Wall II, the Director of the DOC, and Dr. Clarke were both appointed to the task force, and advocated for the expansion of the MAT program in correctional facilities. Around the same time, Dr. Josiah Rich, a professor at the Warren Alpert Medical School of Brown University, Dr. Clarke, and a group of their colleagues published a study which found that individuals who were administered methadone while they were incarcerated were more likely to continue treatment after leaving prison and less likely to overdose.

In the summer of 2016, the Governor announced that two million dollars would be allocated in the 2017 budget to set up the MAT program in Rhode Island’s correctional facilities. The program makes three drugs available to help treat opioid addiction: methadone, buprenorphine (Suboxone), and naltrexone (Vivitrol). Methadone and buprenorphine are opioid drugs used to treat addiction by easing withdrawal symptoms and preventing cravings; naltrexone is used to block opioid receptors so that individuals cannot experience the effects of opioids. The program at the DOC is administered by a behavioral health nonprofit in Rhode Island called CODAC, which provides substance abuse and behavioral health services across the state. In the DOC, CODAC provides screening for individuals entering the facilities to assess whether they qualify for methadone or buprenorphine treatment. The screening process typically involves an interview as well as bloodwork and other physical examinations. CODAC administrators then establish a treatment plan for the individuals, depending on how long they will be staying at the facility. 

Individuals like Michael, who were administered treatment drugs during their time in the ACI are encouraged to continue their treatment upon release. Individuals transitioning to care outside of the prison are allowed to begin treatment immediately, even if they do not have health insurance, and work with people in the clinic to get set up on a health insurance plan. All health insurance plans in the state are required to cover the treatment that CODAC provides. Dr. Clarke told the Independent that CODAC has been able to help almost every inmate transitioning out of the facility get health insurance, and that the few individuals who have been unable to pay for the treatment have been administered it anyways.

Rhode Island’s MAT program has been praised as a national model for providing quality rehabilitation services to inmates; in July of 2016, the White House Director of National Drug Control Policy Michael Botticelli visited the state’s correctional facilities and praised the program as a model for other states to replicate in fighting the opioid crisis. Administrators from prisons across the country have contacted Dr. Clarke and visited the Rhode Island facilities to learn about implementing similar programs in their jurisdictions. For Michael, if the program saves one life, the program has been successful: “That’s one life where they get to go home and take care of their kids. They get to go home and see their parents again.”

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The median length of stay for an individual at the prison is four days, which means that the DOC has a small window of time to help an individual begin treatment. Dr. Clarke told the Independent, “A lot of people come in and out. We are a public safety agency too. So if we put effort into those thousands of people who come in and leave and spend very little time with us, [we can] hopefully get more and more people into treatment in the community.” The prison sees a large number of Rhode Islanders who struggle with opioid use disorders, which has made it a useful point of intervention for helping individuals get started on treatment. According to Dr. Clarke, about 350 individuals access treatment each month through the program. However, there are evidently less violent ways to reach individuals in need of treatment for opioid use disorders. For example, in the Belltown and Skyway neighborhoods in Seattle, a privately funded program called Law Enforcement Assisted Diversion (LEAD) directs individuals arrested for low-level drug offenses and prostitution towards community-based services instead of processing them through the criminal justice system. Since the program was established in 2011, it has been found to reduce an individual’s odds of future arrest by 60 percent as compared to individuals who were processed through the criminal justice system. 

The Rhode Island MAT program has been successful in reaching people because individuals struggling with addiction are targeted by law enforcement and the criminal justice system as engaging in criminal behavior. However, the criminalization of addiction is neither a just nor effective method of treating substance abuse problems. Additionally, the criminalization of addiction problems falls disproportionately on minority communities. According to the Sentencing Project, black people in Rhode Island make up 28.9 percent of the prison population, but only 5.5 percent of the state’s population. Hispanic people in Rhode Island make up 21.3 percent of the prison population, but 13.6 percent of the state’s population. The administration of the medications in the ACI involves high levels of security in order to insure that individuals are not “diverting” the medications, or saving them to give to other inmates. Dr. Clarke explained that the medical staff and the correctional officers have worked closely to monitor the process of administering the medications to reduce the risk of diversion in the facility.

The state has chosen to invest in the MAT program in order to help incarcerated people recover from substance abuse problems and avoid reincarceration. This policy works within the state’s current framework of criminalizing substance abuse, while also enhancing its commitment to the fight against the opioid epidemic and improving the rights of incarcerated people. Catherine Rolfe, the Deputy Press Secretary for the office of Governor Raimondo, explained that the state has emphasized treatment for incarcerated individuals because a large percentage of inmates in Rhode Island have been incarcerated for drug-related crimes. Rolfe wrote in an email to the Independent, “By receiving medication-assisted treatment... incarcerated individuals are more likely to recover and less likely to end up back in prison. That’s good for Rhode Island, and is part of the Governor’s larger focus on Justice Reinvestment, which aims to improve Rhode Island's criminal justice system while reducing costs by promoting rehabilitation.” Rolfe’s statement points to the fact that even though the Governor’s office has emphasized the importance of rehabilitation within the DOC, the office has not challenged the characterization of individuals struggling with substance abuse as criminals.

Outside of the facility where Michael has spent too many months of his adult life, an American flag and a Rhode Island flag fly on a tall flagpole, just enclosed in the coils of barbed wire which separate the prison from the outside world. In a perverse way, the flags seem to mark the prison, and its nearly 3,000 inmates, as important components of the state’s identity and institutions. As long as Rhode Island continues to bring people who struggle with addiction here, instead of to treatment facilities or recovery centers, the state’s efforts to fight the opioid epidemic will continue to clash with the state’s criminalization of addiction. Dr. Clarke is optimistic that Rhode Island’s program will soon be the national standard for addiction treatment for incarcerated people: “I believe that it’s going to be inevitable soon that all facilities will be providing treatment.” Hopefully, an expansion of services for incarcerated people struggling with substance abuse will expand as Dr. Clarke anticipates. However, Rhode Island should be investing in making treatment more accessible and diverting individuals struggling with addiction to treatment services. Rhode Island should fly its flag in front of facilities where individuals can visit each day for treatment without wearing a jumpsuit or having a correctional officer watch as they take administered medications.

JULIA ROCK B'19 wants a freer path to recovery.