At the Somerset County jail in rural Maine, prisoners addicted to opioids used to receive a daily pill to keep cravings in check. But as soon as they were released, their access to the medicine ended.
As their cravings surged, they were re-entering society at high risk for withdrawal, relapse and overdose — dangers that newly released prisoners confront nationwide.
“A lot of these inmates are our neighbors and it’s in our best interest to assimilate them back into the community, but some would end up dying,” said the Somerset County sheriff, Dale P. Lancaster. “For me, that’s not acceptable.”
Hoping to change those grim outcomes, Sheriff Lancaster decided to try providing a different — and far less common — form of the medication, buprenorphine: an extended-release shot that subdues urges for about 28 days.
According to a recent analysis in the journal Health and Justice about his jail’s pilot project, the switch had a remarkable effect. The long-acting injection afforded newly released prisoners a crucial buffer period after they were discharged, with more time to set up continuing addiction treatment and stabilize their lives.
The jail’s experience is “an important step in showing where we as a society can go to cut back on people dying from this disease,” said Dr. Josiah Rich, a national expert in addiction and incarceration at Brown University, who was not involved in the project.
Of the more than 1.2 million prisoners in the United States, up to to 65 percent of prisoners have active substance use disorders, according to some studies. (Sheriff Lancaster estimates that the figure in his jail is closer to 75 percent.) Many treatment specialists argue that county jails and state and federal prisons could be poised to interrupt that cycle of addiction, which often includes crimes of theft, violence and drug sales, with repeat episodes of incarceration.
But addiction treatment for prisoners is relatively scarce and the expensive, extended-release shot, commercially known as Sublocade, scarcer still — not only for incarcerated people but for those in the community who do not have access to health insurance.
Yet the outcome of the Somerset jail project, together with a smaller 2021 study from a New York City jail, suggest the promise that such shots could hold. After being released, the Somerset County prisoners who got the shot were three times as likely to continue treatment as those at another rural Maine jail who received the daily pills. Between September 2022 and September 2023, three prisoners from the jail where the pills were dispensed died from overdoses within three months of being released; a fourth died by suicide. None of the former Somerset prisoners who had received the injections died.
Although that comparison study has concluded, the jail continues to offer the shots.
“It’s not fun to take meds every day, so the shot was really freeing,” said Amanda, 34, a former Somerset prisoner who asked to be identified only by her first name to protect her family’s privacy. “I felt like I was living, not just an addict. It made me feel like a regular person.” She is now in a recovery program.
Prisoners in other Maine jails are even requesting to be transferred to the Somerset facility for the injections, said Alane O’Connor, the lead author of the report and director of addiction medicine at the Somerset County jail.
But for all its potential, Sublocade, approved in 2017, is not widely used in treatment settings outside of prisons either. The chief barrier is cost.
A monthly injection of Sublocade has a list price of about $2,000. A month’s supply of the pills lists from about $90 to $360, depending on the dose.
Many private insurance plans cover both options, but for uninsured patients, clinics must weigh a cost-benefit calculus between the shots or the pills: “Do we serve 25 people the more expensive medication or do we serve 100 and give them the cheaper medication?” said Rachel Winograd, director of addiction science at the University of Missouri, St. Louis.
Buprenorphine works because it is itself an opioid — one just potent enough to satisfy cravings and prevent withdrawal symptoms but not powerful enough to make people high.
But because the effects of buprenorphine pills (also given as strips that go under the tongue) wear off within 24 hours, patients must be vigilant about sticking to a precise schedule. That can be hard enough for anyone, but adhering to strict dosing regimens is particularly difficult in an understaffed jail, where guards march small groups of prisoners, men and women separately, to and from the medical room all day long.
Amanda, the former Somerset prisoner, said that before the jail started giving the shots, she might get her pill in the morning but, some days, wouldn’t get another until the next afternoon. Inevitably, she would feel the jittery sweats and nausea that signal withdrawal.
Another drawback: Prisoners would try to secretly palm the pills to trade or sell later, Sheriff Lancaster said. So guards would sit knee to knee with them, watching as they downed cups of water to clear their mouth. After that, a nurse would place a crushed-up pill under their tongue. They would swallow. Then the nurse would peer deep into the prisoner’s mouth.
Next, prisoners had to eat saltines. More water. Another mouth check.
The monthly shot alleviated these burdens on both the jail’s staff and prisoners. The medicine pools into a hard, marble-size lump under a person’s belly that releases steadily over four weeks.
But the most striking impact of the shots may well have been after the prisoners were released.
In a rural area with far-flung pharmacies, few addiction services and transportation hard to come by, it is hard for a newly released prisoner without immediate access to the pill to prevent becoming dopesick. Drugs are far easier to come by; many people would resume taking doses they had before being jailed. Particularly with unstable quantities of fentanyl in the supply, they were at great risk of overdose.
The Somerset jail, which complements injections with counseling, has been helping to set up prisoners with social and medical services upon release. When Jason Downs, 35, got out of jail nearly two years ago, Somerset staff arranged with an area hospital to get him the shots.
Mr. Downs has received the shot every month since and been able to work steadily. “The shot is a straight, gradual release,” he said. Unlike the pills, he added, “it doesn’t make you feel hyper or exhausted at the end of the day, like you just ran a marathon.”
According to the Jail and Prison Opioid Project, only 375 of 876 state prisons provide medication for opioid use disorder. A report from Georgetown Law School last year noted that the availability of treatment for prisoners was slowly improving, thanks to litigation and policy changes.
But Medicaid generally does not cover prison health care. Last year the Biden administration began allowing states to apply for Medicaid waivers for substance abuse treatment for incarcerated people. About 10 states so far have been granted the permission but Maine, under court order to provide addiction treatment, is not yet among them.
To pay for the shots, the Somerset jail received grants from the state’s Office of Behavioral Health and from the county’s portion of the settlement funds from the national opioid litigation. The sustainability of such financing is uncertain.
“Grants have end dates,” said Dr. Milan Satcher, an expert at Dartmouth Health on the health impacts of addiction and incarceration. She noted that for several years, the New Hampshire state prison had a limited grant to offer Sublocade. “When a grant runs out,” she wrote in an email, “facilities and patients are right back at square one.”
There are other hurdles to widespread use of the shot besides cost.
To give the injections, doctors and other clinicians must obtain special government certification. In addition, Sublocade needs to be refrigerated, but most physicians do not have storage. (Brixadi, a new competitor brand that doesn’t need refrigeration, is less well-known.)
Some patients are reluctant to try the monthly shot, fearful that if they are not taking something daily, their cravings will not be well-managed. Many say it is very painful. Others prefer the familiar ritual of taking a pill on their own.
“It scratches the itch of an old routine,” Dr. Winograd, a psychologist, said.
The Somerset County jail pilot project was not a randomized controlled study, which is the gold standard in medical research. But researchers tried to align factors common to the two rural jails that were being compared. In that one year, Somerset gave monthly injections to 46 men and 24 women; the other jail gave buprenorphine daily pills to 122 male prisoners, and eight women.
After the former prisoners re-entered their communities, researchers examined electronic pharmaceutical records for evidence of addiction medicine.
Upon release, approximately 67 percent of the Somerset prisoners kept up their treatment without interruption. At the comparison jail, only 23 percent did.
None of the four prisoners from the comparison jail who died had continued their addiction treatment.
Dr. O’Connor, co-chair of the state’s Opioid Response Clinical Advisory Committee, said that as word of the Somerset program spreads, she is getting inquiries from other county sheriffs about how to bring the shots on board.
She is also hearing from former prisoners: With shots hard to locate close to home, they have to return to pills to remain in recovery.
“Many wanted to stay on the shots, so they would come back to the jail asking our help in finding a provider,” Dr. O’Connor said.
Noting that correctional facilities are not exactly known as addiction treatment trailblazers, she added: “I just love the fact that they identify a jail as a supportive place to find treatment. What’s better than that in terms of feedback?”
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