Part 2: One Month Out

Feb 22, 2019

This is the second episode of “The Rules Are Different Here,” a four-part series on mass incarceration in New Hampshire. Listen to the first installment, or explore the full series.

Recovering from opioid addiction can take months or years, in part because the disease is not only a physical dependence but also a mental health disorder. Anxiety and depression frequently coincide with addiction.

Getting incarcerated for opioid-related charges presents a daunting challenge: navigate the healthcare system of a prison or jail and undertake the deeply personal work of treating mental illness.

As part of our series Only in NH, in which we answer listener questions about the state, we’re addressing a question from a listener named Jeanne: how do prisons in New Hampshire deal with the opioid crisis?

“What types of medically assisted treatment are prisons providing to incarcerated Granite Staters with substance use disorders?”—Jeanne 

A case manager at a rehab facility, Justin, spent time at the state prison in Berlin, New Hampshire, and says incarceration worsened his addiction. “I got high the whole time I was in Berlin,” he says, “it was really easy. I left prison with a worse habit than I went in with.”

In the social and psychological context of prison, Justin struggled to imagine how he would recover. “I didn’t think it was ever going to happen any other way than it had been happening. I was just misinformed by the misinformed,” Justin says. He eventually found treatment in the form of a residential program that he could afford by working for his stay. But getting out of the prison environment, he said, into a positive and constructive one was crucial to rebuilding his life.

Among those incarcerated with a substance use disorder, many echo Justin’s experience. Incarceration can create financial, social, and psychological roadblocks to recovery. 

By some estimates, over 60 percent of people in prisons nationally have a substance use disorder, which is about 10 times the overall rate. A number of factors contribute to the high rate of substance use disorders among the incarcerated population. For one thing, possession of a controlled substance like heroin is a crime. But in addition, the incarcerated population is disproportionately low income and “especially likely to face barriers in accessing healthcare,” according to Sentencing Project researcher Nazgol Ghandnoosh. “If you ask people why they didn’t get treatment... the main reasons that they state is that they couldn’t afford health insurance or the cost of treatment.”

The New Hampshire Department of Corrections has not compiled data to estimate the number of people incarcerated with a history of drug or alcohol misuse, although plans are currently underway to do so. In some county jails, the proportion could be a high as 60 to 70 percent, according to jail superintendents. 

Nationwide, rural communities, in particular, lack access to addiction services, which increases the chance that someone addicted to heroin or other opioids winds up in jail or prison, Ghandnoosh says. “What happens then is that the criminal justice reaction to the problem compounds the health problem.” New Hampshire faces a shortage of mental healthcare resources as well addiction services such as affordable rehab programs and sober housing.

On a regular basis, people who arrive at county jails in New Hampshire undergo withdrawal from opioids, an experience sometimes compared to an intense flu and which last longer than a week. Denise Hartley, medical services supervisor at Valley Street jail in Manchester estimates that an average of ten people per day are treated for withdrawal at her facility, mostly from opioids, and potentially an equal number undergo withdrawal without alerting medical staff.

Detoxing from opioids while incarcerated carries an underappreciated danger after a person is released. “When they are released,” Ghandnoosh says, “they have a much lower tolerance to the drugs than when they went in. Most people are not aware of how much their bodies have changed during incarceration.”

With heroin, like with most drugs, the body develops a tolerance that requires an increasingly higher dose to achieve the same effect. After remaining abstinent in jail or prison for several months, says Ghandnoosh, it’s easy to accidentally inject more heroin than the body can handle. “If they resume drug use at anywhere close to the levels that they were previously, they are very likely to die of an overdose.”

In one study of individuals who died within six weeks of release from incarceration in New York City, almost half were overdoses. The rate of overdoses following incarceration in New Hampshire has not been measured, though the Office of the Chief Medical Examiner and the Department of Corrections are planning to compile that information.

Another challenge to addressing opioid addiction in jail is the psychological toll of incarceration. Emotional support from friends and relatives can sustain a person through addiction recovery—but in prison, that support network is either gone or truncated. “It’s almost like a disconnect” from the outside world, says Sam Hayes, a therapist at a rehab clinic in Nashua. “You have this mentality, it’s angry, it’s fearful… It’s that whole ‘don’t ask, don’t tell,’ I’m going to hold my emotions in.” Hayes helps patients to unlearn the lessons of incarceration, and he says it can take months for them to feel comfortable enough to make progress in therapy.

If you’re incarcerated in New Hampshire and facing these challenges associated with substance use disorder, there’s a good chance you’re not receiving proper addiction treatment. According to medical experts, the most effective treatment for opioid addiction involves medications that can loosen the grip of opioids on the brain. The FDA has approved three medications for the treatment of opioids (methadone, buprenorphine, and naltrexone), which are used in combination with therapy and group counseling.

For the moment, you can’t get a prescription for any of those medications while you’re incarcerated in New Hampshire unless you meet a few narrow exemptions, primarily for pregnant women and those staying for a very short time and who have already been prescribed one of the medications. State prison facilities and some county jails also offer one shot of naltrexone, a one-month dose, when a person is released.

One doctor concerned by this lack of access to addiction medications is Margaret Bahder, a psychiatrist in Belmont who specializes in addiction and was one of the first in New Hampshire to prescribe buprenorphine. “When I started in 2006,” Bahder says, “I had a lot of people who were addicted to pain medication, OxyContin especially back then. Throughout the years, Fentanyl changed the game totally on the street. It is so addictive.”

“It’s killing them in the sense that they don’t even realize how addicted they are and how difficult it is for them to stop.

Bahder does not believe the broader opioid crisis will be resolved without improved access to medications such as buprenorphine. “I think there’s a lot of people that still believe that some counseling and group intensive programs without medication will be the same effect, and I disagree with that. I don’t think, not providing medication on top of counseling and group sessions, I don’t think we can beat the opioid epidemic without medication.”

Although medication is only one component of addiction treatment, it’s the component currently most lacking, especially inside of prisons. Medical professionals such as Dr. Bahder warn that medication does not replace other elements of treatment, like therapy, or the social services that help people recover, like access to housing and health insurance.

For some, medications do not help them surmount addiction, or they simply don’t want to take any medication that can potentially be misused, and given the complexity and personal nature of substance use disorders, there can often be multiple avenues to recovery.

Nonetheless, experts agree medication is a crucial tool for providers in treating opioid addiction. The Substance Abuse and Mental Health Services Administration (SAMSHA) has stated that medication assisted treatment is the standard of care for addiction to opioids.

“There is no miracle treatment,” says Bahder. “But it’s really nice to see people, when they take a first dose of Suboxone, most often what they would say is, ‘I couldn’t believe that I can feel so normal.”

An incarcerated person’s right to medical care under the Eighth Amendment, which prohibits cruel and unusual punishment, is well established, but the particular right to medication for addiction treatment is less clear. Henry Klementowicz, a lawyer for the New Hampshire branch of the American Civil Liberties Union, says that it depends on where in the country you are.

“The ACLU of Massachusetts brought a lawsuit against a jail in Massachusetts in federal court, where that jail did not provide methadone to a person whose doctor had prescribed methadone and who came before the court and said, you know, this is a life-saving treatment that I need or there’s a real risk of relapse and death,” says Klementowicz. “They raised a constitutional challenge under the Eighth Amendment with cruel and unusual punishment. They raised a challenge under the Americans with Disabilities Act, and a federal judge in Massachusetts agreed, and ordered that the person had to be provided methadone in jail.”

That ruling in Massachusetts addressed the narrow situation in which a person already had a prescription when they were incarcerated, but did not cover the larger population of individuals who are incarcerated and would benefit from medication assisted treatment.

Some medical professionals working inside of prisons and jails here in New Hampshire want to provide medication for addiction regardless of the legal landscape. One problem they face is that Suboxone, a brand name for buprenorphine and one of the most common and effective medications, is itself a type of opioid. It works by blocking some of the receptors in the brain that respond to heroin while activating a few of them, enough to keep a person from going into withdrawal.

If you take more than you’re supposed to, or if you don’t have a tolerance to opioids, that little bit of activation will get you high. Suboxone is sold illicitly inside and outside of jails, and so providing the drug legally requires that corrections officers and medical staff ensure it is not diverted for unapproved use.

“A lot of people I see are on Suboxone,” says Bahder. “They’re going to court, they have to go to jail or prison for a certain period of time, and they know they are not going to be able to continue Suboxone. Well, what happens is they go through withdrawals, they leave the jail, and most likely what happens if they cannot get to a program right away,they relapse and the cycle continues.”

In the last few years, depending on the state, the world of corrections has begun to acknowledge a need to increase access to addiction medication. New Hampshire is poised to begin providing Suboxone and Vivitrol, a form of naltrexone, more widely within the state prison system.

This idea is more complicated than it sounds, and New Hampshire is not the first state to try it—that distinction goes to Rhode Island. The medical program director for the Rhode Island Department of Corrections is Jennifer Clarke, who previously worked as a primary care physician for the department.

“Having worked here for so many years, I’ve known so many people who have died,” she says. “People who… I’ve helped them with their pneumonia, helped them with their diabetes, but my hands have been tied as far as helping them with their opioid use disorders.”

“They’ll tell me that they know they’re going to use. The disease is so strong for certain individuals. They’re afraid of dying. They beg me to start them on methadone. I can’t do it, I can get them an appointment, but those take time. And they get out and they die of an overdose. And that feels terrible. It feels terrible knowing there’s something I could do to help, but because of a policy, I’m not allowed to do it.”

Three years ago, Clarke was promoted to a position where she could begin to affect policy. “I have for years been thinking about what the best treatment would be, what I would want to see? So, when I got this job, I had been thinking about it for years,” Clarke says.

When the governor established an opioid task force in 2016, Clarke went to them and made her case for making medications like Suboxone widely available inside the state’s incarceration facility.

“We have to remember that forced abstinence is not treatment,” says Clarke. “So just because somebody is not using drugs while they’re incarcerated does not mean that they have been ‘cured’ of addiction.”

An important part of her plan was to refer patients to a provider outside of the prison when they were released, so that they could continue taking the medication if they had the insurance and the money to do so. Rhode Island has a unified prison system, meaning there are no county jails and everyone who is incarcerated in the state is in one facility, which made it easier to implement Clarke’s new policies.

“We were able to demonstrate a sixty percent decrease in mortality post-release,” says Clarke. “I wasn’t expecting such a large decrease, but that was very exciting. I think that really energized our whole group to sort of kick up the whole pace at which we provide services.”

Others took notice of that sixty percent drop in mortality. Rhode Island became a role model for other states. Their system was a sort of proof of concept, and now states like Massachusetts have tried to scale that strategy up to larger, more complicated prison systems.

Jennifer Clarke has a talk that she gives to corrections professionals about how to do what Rhode Island is doing. One of the people who has heard that talk is Paula Mattis, who runs the medical services division of the New Hampshire Department of Corrections. The department received a federal grant in 2019 for several million dollars that it will use to make Suboxone available in the state prisons along with naltrexone.

The ten county jails in New Hampshire, where people go for any sentence that’s less than a year, and which handle a higher volume of people, will not receive that federal money. Some of them do have plans to start using medication for addiction treatment, but they’ll need to come up with their own funding.

Other types of programs that focus on therapy and providing resources after release are gaining momentum in jails around the state as well, such as the Hillsborough County Department of Corrections 24-person intensive addiction treatment program and the Belknap county jail’s new addiction and mental health treatment wing

There remains a tremendous shortage of mental health providers in New Hampshire, and the waiting list to get on Suboxone can be months long.

If you have questions about opioids, prisons, or any other topic in New Hampshire, email us: wordofmouth@nhpr.org.