‘A Criminal Justice Approach to a Public Health Problem’: How the Justice System Can Improve SUD Support
In the 1980s, Haner Hernández only requested to attend a drug treatment program in order to get out of prison. Back then, he was only approved to be released from prison and go into treatment because the prison was overcrowded.
For him, the treatment program changed the trajectory of his life. It was located in Boston and was geared specifically toward Latino males.
“Initially, I thought that going to prison was a rite of passage and it made me strong, that it made me credible, that it made me a tough guy, that it made me all of those things,” he said. “The way they approached it was the opposite of that: No, we are not meant to be in prisons and jails as men, Latino men very specifically. We are meant to be productive members of society, of our communities, and we are meant to support our families. They took all that exists within prison culture and turned it on its head.”
Hernández went on to receive his bachelor’s, master’s and PhD. He now works as an addiction recovery specialist. And while treatment benefited him, it’s not for everyone, he said. There are “multiple pathways of recovery,” including faith-based recovery, holistic approaches like meditation and medications. But that’s not the way the justice system treats addiction in the U.S., he said.
About 85% of people in prisons have an active substance use disorder or were incarcerated for a crime involving drugs, according to the National Institute on Drug Abuse. Despite this, there is inadequate access to support in prisons, and additional challenges when leaving prisons. Less than 20% of people with substance use disorder receive formal treatment while incarcerated. The Covid-19 pandemic exacerbated the issue, with overdose deaths soaring in recent years.
But there are solutions being introduced, with some digital health companies stepping in to support this population. While the justice system is nowhere near where it should be when it comes to addiction recovery, Hernández believes there is a brighter future ahead.
What’s available now and what’s missing?
Meghann Perry, founder of recovery support company The Meghann Perry Group, has her own experience when it comes to accessing care in the justice system. She first turned to substances to deal with mental health challenges, and was incarcerated several times during her active addiction. She now practices abstinence-based recovery “primarily because it was the only thing” offered to her at the time. Abstinence-based therapy recommends people completely abstain from consuming controlled substances.
“It was forced on me but it works for me so I’m not going to change it. I really went the traditional route because that was all that was offered and I do wish that I had more choices,” Perry said.
She noted that the “the carceral system has made a ton of progress in the last 20+ years,” including access to medication-assisted treatment and peer recovery coaches.
Indeed, the Federal Bureau of Prisons does have several programs in place to support those struggling with addiction, said Randilee Giamusso, a spokesperson for the Bureau, in an email. She explained that the Bureau has a medication-assisted treatment program for those with opioid use disorder. It also has the Non-Residential Drug Abuse Program, in which a drug treatment specialist creates an individualized treatment plan and the individual attends group therapy for up to two hours per week for 12 weeks. In addition, there’s the Residential Drug Abuse Program, which includes 500 hours of face-to-face treatment over 36 to 41 weeks.
While this is for the general prison population, the Bureau also has a treatment program geared toward high-security males, or those convicted of violent crimes. In addition, it has a program for female incarcerated individuals that is integrated with behavioral health support.
Despite these programs, Hernández believes there are still many problems with the way substance use disorder is handled in the carceral system.
“We have had for decades and decades and decades a criminal justice approach to a public health problem,” he said. “We have the largest prison population per capita in the world. … In terms of formal treatment — talking counseling, groups, utilizing evidence-based models and that sort of thing — we are nowhere near where we need to be in terms of providing access to those clinical services to people who are incarcerated in the U.S.”
While there is a lack of access to support overall, women who are imprisoned especially struggle to receive care, Perry declared. There are fewer women who are incarcerated, and therefore there are fewer programs available for women. In addition, the support that is available isn’t always effective.
“One of the mistakes that we make is we build something for men and we assume that it’s going to work for women,” she said.
“We also have to consider trauma,” Perry continued. “We can’t have a conversation about substance use and incarceration without talking about trauma. Incarceration in and of itself is traumatic.”
This trauma “shows up in every way imaginable” during incarceration for both men and women, Perry said. Yet, the programs offered to this population aren’t trauma-sensitive or trauma-oriented, she declared.
The challenges only mount when people leave prisons. In many states, people lose Medicaid coverage while they’re incarcerated, as is the case with many private insurance plans, according to Perry. This makes it “incredibly difficult to continue or initiate any kind of treatment plan upon release,” she said. Due to the difficulties in accessing care after leaving prisons, 68% of those who commit a drug-related crime are rearrested within three years of release.
Those who are prescribed medications especially experience disruption in their care, as they have to find new treatment providers. About 40% of counties in the U.S. don’t have a single provider that can prescribe buprenorphine, a medication for opioid use disorder.
“There is an additional challenge for patients who are treated with medications for opioid use disorder (MOUD) as we must coordinate with community treatment providers to ensure continuity of care upon release,” Giamusso said. “At times, particularly for patients releasing to rural settings, locating and arranging providers in the community able to treat SUDs requires a significant amount of time and resources to accomplish.”
This disruption in care ultimately just leaves patients at risk of relapsing.
“To discontinue medication or not have a really concrete overlap to continue medication leaves people at such high risk of overdose or return to use and just simply great suffering,” Perry said. “I really think we discount the suffering that happens for people when they are dependent on a substance and are incarcerated, and the agony of the physical withdrawal, the mental and psychological withdrawal from a substance while incarcerated without adequate support. It’s really so inhumane.”
She added that while people may think that this experience is just part of the punishment of being incarcerated, it actually just creates more psychological damage.
Can digital programs fill the gap?
As challenges to seeking care persist for those who are or were incarcerated, some digital solutions are stepping up.
This includes San Francisco-based Bicycle Health, which partnered in February with mental health provider Wellpath and the Federal Bureau of Prisons to provide virtual services for opioid use disorder to patients in the Bureau’s residential reentry centers. Wellpath serves as the care coordinator for those in the reentry centers, and directs them to Bicycle Health if they’re in need of opioid use disorder support. Bicycle Health offers virtual evaluations for patients, medication management of opioid use disorder and drug testing.
The benefit of having a virtual solution for this population is the flexibility it offers, said Ankit Gupta, CEO and founder of Bicycle Health.
“[One] issue is the chaos of life for someone who leaves incarceration, just getting your life back is difficult,” Gupta said in an interview. “You might not know where to find a job or where to live, you might be moving around. So having a provider over telemedicine gives you that stability to continue to be in care versus having to go in person somewhere or constantly having to find a new doctor.”
Gupta’s comments were echoed by Stephanie Strong, CEO and founder of Portland, Oregon-based Boulder Care, another provider for substance use disorder. The company has a couple of programs in place to support those who are incarcerated, but its deepest work is in Southern Oregon with Jackson County Community Justice. Through this program, Boulder Care’s providers work with patients (including through medication-assisted treatment) while they’re incarcerated, and continue to work with them upon release.
“We’re really able to follow someone and make sure they don’t slip through the cracks,” Strong said.
Rochester, New York-based CHESS Health, another digital health company for substance use disorder, offers a solution for community organizations working with those who are incarcerated, as well as a solution for those who are leaving incarceration. The company’s eIntervention solution helps organizations refer patients to providers as they’re preparing for release.
“When individuals leave, they’ve got a list of providers and agencies that they’re supposed to connect with for substance use treatment, potentially for physical health and potentially for social services,” said Hans Morefield, CEO of CHESS Health. “Then those organizations know to expect that individual.”
CHESS Health’s Connections app is patient-facing and offers 24/7 peer support and management tools for those in recovery. The benefit of the app is that it helps patients in between provider visits, according to Morefield.
“[Patients] go in for a great session and then they walk out the door and it’s 167 hours until they’re supposed to come back in a week,” he said. “Even if they are connected with a provider and there is a therapist to see them, there’s still a lot of alone time between sessions when they’re at risk of return to use.”
One of CHESS’ partners is the Oklahoma Department of Mental Health and Substance Abuse Services, which uses the eIntervention tool for referrals and offers those leaving incarceration access to the Connections app. Stephanie Cottrell, program manager of reentry and prison based programs, said the eIntervention solution allows them to give a “really warm handoff” to providers when patients are leaving incarceration. She added that the Connections app has been offering additional support for patients.
“It just keeps them connected. … This allows them to reach somebody 24/7 and not have to worry about burdening somebody,” Cottrell said.
Perry agreed with the above sentiments about virtual solutions for those who are incarcerated or reentering society, stating that she can’t see any “bad sides” to digital support.
Hernández, meanwhile, said that virtual support is a “piece of what we should be doing, but we shouldn’t over-rely on technologies.” Not everyone has access to the technology they need to receive support virtually.
However, some programs provide the needed technology. For example, those in the Oklahoma Department of Mental Health and Substance Abuse Services’ program will get access to tablets through the Certified Community Behavioral Health Clinics it works with. Strong of Boulder Care added that most people have phones, although they may not have smartphones. The company will conduct appointments over a phone call if needed.
What needs to be done?
One thing the carceral system needs to do is take a page out of the restaurant industry, Hernández said.
“When we go to a restaurant … they bring out this revolutionary thing called the menu,” he said. “They don’t tell you you’re having hotdogs whether you like it or not. They ask you, ‘What do you want?’ And if you like it, you get more of it. If you don’t like it, you get something different or you go somewhere else. Recovery pathways are about choice, they’re about equity, they’re about self determination.”
Perry agreed with Hernández on the importance of options for recovery, and that there needs to be better continuity of care when being released from prisons. She added that there needs to be less of a focus on punishment for people who are incarcerated with substance use disorder.
“As much as we can offer these bits and pieces of treatment or support, we’re still entrenched in this culture of punishment for substance use,” Perry said. “It’s incredibly hard to fight that, because ‘we deserve to be incarcerated. We deserve to have to go through withdrawal or figure it out ourselves.’ [There’s a] tough love concept too, which has been proven to not be helpful. Instead of adding support, we withdraw support, and the thing that somebody who’s fighting their substance use needs more than anything is as much support as possible. The carceral system just isn’t set up to offer that.”
Another method of recovery both Perry and Hernández would like to see more of is harm reduction, which does not completely stop drug use but attempts to make the drug use safer. One example of harm reduction is preventing the use of shared needles to lower the risk of HIV transmission.
“There are people who are in pre-contemplation: They’re not ready to stop, they’re not interested in stopping, they want to use drugs. So I want them to the be healthy and alive … so that when they do move from pre-contemplation to contemplation to preparation to action, they’re in a position to do that,” Hernández said.
This is a controversial perspective because some believe that creating a safe zone for doing drugs only encourages and reinforces that risky behavior.
But even more so than harm reduction, the healthcare and carceral systems have to shift to prevention, according to Hernández.
“Most of the dollars that we spend are on treatment,” he said. “Now, I am all for treatment. I believe in treatment. I am a person who benefited from access to treatment. … In terms of an ideal world, we would fund prevention to its fullest.”
Prevention can include properly addressing social determinants of health like housing, employment and education.
“Are we where we need to be? Of course not. But we are not where we were many years ago, many decades ago,” Hernández said.
He noted that while people want “overnight solutions,” that’s not realistic.
“Disparities have been developing on this continent and in the U.S. for hundreds of years. They’re not going to be overturned overnight. But we need to have a commitment not to reduce disparities, but to eliminate disparities.”