Withholding Suboxone medication in jail

Much thanks to a reader for sharing a story out of Maine from several months ago. The story refers to a common situation that doesn’t really register unless one happens to look at things with a different frame of reference. Should NPs be withholding Suboxone medication in jail?

The story refers to a woman jailed for driving on a suspended license.  The local Sheriff has a policy at the jail that people on buprenorphine or methadone for opioid dependence are ‘S.O.L.’– I think that is the official term– so the woman sued the jail for ‘cruel and unusual punishment.’  From my reading of the article it appears that special accomodations were made to allow the suit to simply go away, allowing the Sheriff and everyone else to delay making a formal decision on their degree of hypocrisy.  But the issue will surely return– to this jail and to others across the country.

I saw this situation over and over when I worked as a psychiatrist for the WI Dept of Corrections, and I admit that I never gave it much thought.  There is a double standard when it comes to certain areas of medicine, not only in regard to addiction, but to other psychiatric disorders as well.  For example, medical agencies have made it clear that ‘ADD’ and ADHD’ are real illnesses– as real as any other non-psychiatric illness. 

But in prison, patients with ADD do not have any ‘right’ to treatment for that condition.  And opioid dependence, regardless of any talk about ‘disease models of addiction,’ is not treated like other diseases after the jail doors close!  I regularly saw patients come into prison after experiences in county jails that can only be described as ‘horrific;’ men or women with high opioid tolerances from methadone programs, forced to stop methadone ‘cold turkey’ with no consideration of treating their withdrawal– let alone continuing methadone.  Opioid-dependent patients on buprenorphine were treated in the same way.

I have had patients who are treated with buprenorphine in my psychiatric practice go to jail for a range of offenses. Those with Huber privileges can often continue buprenorphine.  But those not on Huber are forced to go through withdrawal– a bad enough experience at home, and a horrible experience in a jail cell.  People in such a situation will take whatever they can find in order to relieve the misery of withdrawal, and in jail the choices of illicit medications are less than on the street, leading some addicts to relapse in their cells.  

In the best case, the people forced off buprenorphine are eventually released from jail in a state of severe craving for opioids, with a tolerance that has been driven to a dangerously low level- placing them at significant risk for death by overdose.  An analagous situation would be depriving diabetic inmates of insulin, and releasing them to a roomful of cookies!

Of course, opioid dependence is not diabetes.  But it IS an illness– right?