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A deputy leads a tall, gray-haired man
<br />intotheroomandslidesthebarreddoor
<br />closed, securing it with handcuffs and
<br />a chain. Zirkel asks the man if he saw
<br />the psychiatrist the previous week. He
<br />says he did and was given a prescription
<br />for Prozac, which he started taking.
<br />Since he’s likely to get out soon, Zirkel
<br />suggests that he sign up with the FIT
<br />Program.
<br />She leaves and Green comes in.“I’ve
<br />been in your shoes,”he says.“I’ve been
<br />in this very jail.”The man, who asked to
<br />be identified only by his first name,
<br />Graylin, tells Green he has diabetes,
<br />hepatitis C, and high blood pressure.
<br />He does not have a drug abuse problem,
<br />he says, though he was arrested fordriv-
<br />ing under the influence. His big needs,
<br />he says, will be housing and transpor-
<br />tation.
<br />Graylin was released two weeks later,
<br />and Green has been helping him get
<br />services and housing. He’s also one of
<br />severalFITclients,includingJones,who
<br />will be able to get a free eight-to-twelve-
<br />week course of Harvoni, a drug made by
<br />GileadSciencesthateradicateshepatitis
<br />C. That supply of the drug normally
<br />costs $63,000–$95,000, but Ashkin
<br />and his colleagues have made arrange-
<br />ments with Gilead’s Patient Assistance
<br />Program.
<br />Medication-Assisted
<br />Treatment
<br />Until now, medication-assisted treat-
<br />ment (the prescribing of opioid substi-
<br />tutestopeoplewithopioidusedisorder)
<br />has been banned in nearly all jails and
<br />prisons, including the Orange County
<br />Jail—which leaves inmates to rely on
<br />smuggled drugs, primarily Suboxone,
<br />if they don’t want to go into withdrawal.
<br />One exception is the state of Rhode
<br />Island,whichinJuly2016beganprovid-
<br />ing three opioid substitutes—metha-
<br />done, buprenorphine, and naltrexone
<br />(a long-acting injectable opioid
<br />blocker)—to inmates with opioid use
<br />disorder. The state also organized a net-
<br />work of community clinics that could
<br />continue providing the drugs after peo-
<br />plewerereleased.Astudypublishedlast
<br />year in JAMA Psychiatry demonstrated
<br />the success of this effort.
<br />6 The authors
<br />foundthatinthefirstsixmonthsof2016
<br />(beforetheprogramstarted),twenty-six
<br />people recently released from prison
<br />died by overdose. In the first six months
<br />of 2017 (after the program was up and
<br />running),thenumberof fataloverdoses
<br />fellto nine.Evenmoreimpressively,ten
<br />people died in the first thirty days after
<br />release in 2016, compared with just one
<br />in 2017.
<br />The refusal of most correctional facil-
<br />itiestoprovideopioidtreatmentisdraw-
<br />ing mounting criticism, as well as court
<br />challenges. Last November, in a closely
<br />watched case,Pesce v. Coppinger, Judge
<br />DeniseJ.CasperoftheUSDistrictCourt
<br />for the District of Massachusetts issued
<br />a preliminary ruling that the sheriff of
<br />Essex County, Massachusetts, could not
<br />deny methadone to a man sentenced to
<br />serve time in the county jail. Despite a
<br />six-year history of addiction, the man
<br />was able to stop using heroin and hold
<br />onto a job after he was prescribed meth-
<br />adone in late 2016. Since the jail doesn’t
<br />allowinmatestohavemethadone,being
<br />sentenced there could throw him into
<br />withdrawal and disrupt his recovery.
<br />And that, Judge Casper said, would vio-
<br />late the Americans with Disabilities Act
<br />of 1990.
<br />SomeNorthCarolinajailsandprisons
<br />are starting to shift their stance. The
<br />Orange County Jail began making Sub-
<br />oxone available to a handful of inmates
<br />in August. Ashkin says that the initial
<br />priority will be people already on Sub-
<br />oxone from a community provider and
<br />pregnant women with opioid use dis-
<br />order, to prevent them from going
<br />throughwithdrawalandharmingthefe-
<br />tus or baby. Being on prescription Sub-
<br />oxone under the care of a doctor is con-
<br />sidered far less risky.
<br />Charles Blackwood, the elected coun-
<br />ty sheriff, says that providing medica-
<br />tion-assisted treatment in the jails will
<br />help inmates “transition from heroin to
<br />a drug that will allow them to control
<br />theircravings”andminimizethedisrup-
<br />tive effect on the jail population of hav-
<br />ing inmates go through withdrawal.
<br />“We ’ve got to try something new,
<br />somethinginnovative,”Blackwoodsays.
<br />“When I ran for sheriff, they didn't tell
<br />me ‘Get elected, mistreat people, and
<br />ignore their needs.’They said ‘Take care
<br />of your people. Serve the public.’If you
<br />plant a garden of discontent, you’re go-
<br />ing to have trouble, but if you plant a
<br />garden of good, it’s going to pay back.”
<br />Meanwhile, the North Carolina De-
<br />partment of Public Safety is starting a
<br />pilot program in three prisons that will
<br />give inmateswith a historyof opioiduse
<br />disorder who are “on their way out the
<br />door”achoiceofSuboxone,methadone,
<br />or naltrexone. This will give them a
<br />bridge into treatment and help them
<br />avoid death from overdose, says depart-
<br />ment spokesperson John Bull. The de-
<br />partment will also refer patients to the
<br />FIT Program in the counties where it
<br />operates. Bull says that “it’s a paradigm
<br />shift for North Carolina”that will give
<br />inmates a better chance to overcome ad-
<br />diction and lead better lives.
<br />Back in Chapel Hill, Warren Levy, a
<br />fifty-four-year-old Jamaican who grew
<br />upinBrooklyn,iswaitingtomeetGreen
<br />forthefirsttime.Levywasreleasedfrom
<br />prisonafewmonthsearlierafterserving
<br />a couple of stints. He has prostate can-
<br />cer, sickle cell trait, bipolar disorder,
<br />andahistoryofsubstanceabuse.Hetells
<br />Green he’s staying at a shelter for home-
<br />less men and working at Burger King, a
<br />job that’s bad for his fragile health.“It’s
<br />100degreesinthere,andit’skillingme,”
<br />he says.
<br />Green tells Levy about the FIT Pro-
<br />gram and gives him the number of his
<br />personal cell phone. He also tells Levy
<br />about his own background of incarcera-
<br />tion “becauseI wantyou to feelcomfort-
<br />abledealingwithmeandtoletyouknow
<br />that I've navigated all the systems that
<br />you will have to navigate.”
<br />Levy is convinced.“Sign me up!”he
<br />says.Withintwoweeks,Ashkinhadseen
<br />him for an exam.▪
<br />The refusal of most
<br />correctional facilities to
<br />provide opioid treatment
<br />is drawing mounting
<br />criticism, as well as court
<br />challenges.
<br />1620 Health Affairs October 2019 38:10
<br />Leading To Health
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