When Tom Derbyshire woke up on the floor of his former jailmate’s house, he didn’t understand what had happened. All he knew was that he was in withdrawal — again — and needed to fix it as soon as possible.
He would eventually learn that he had overdosed while using heroin, possibly laced with fentanyl, with a couple of guys who he met during his recent stint in jail. A few days later, Derbyshire woke up withdrawing and confused again. This time, he was in the bathroom of a Wal-Mart, and he had been revived by paramedics — which meant he had to run, because if the police took down his information, he would probably go right back to jail for violating the terms of his release.
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The two overdoses took place within days of each other in early April 2018, both less than two weeks after his release from Atlantic County Jail in New Jersey. Derbyshire, a 40-year-old tile setter with a history of opioid addiction, had been picked up for a bench warrant and a probation violation related to drug use.
He spent two months inside, during which he was involuntarily detoxed from opioids. He described the jail’s withdrawal protocol as two daily cups of a sports drink while being held on 23-hour lock down in a cell with two other men. Every other day or so, someone would check his vitals, and that was it. No methadone, no follow-up care after his release. And Derbyshire isn’t unique. In his case, he was not able to get methadone because he had not been incarcerated enough — one of many requirements at his facility’s program.
David Kelsey, the Atlantic County Jail warden, commented that “since its inception [the methadone treatment program] has provided services and referred to treatment eight hundred individuals.” In most other facilities, evidence-based treatment is not offered to anyone. But unlike Derbyshire, many of those who overdose after release don’t get up again.
As the nation struggles to slow the spread of the novel coronavirus, jails and prisons are beginning to release groups of people who are deemed safe for community return. Detention facilities in the United States are notoriously overcrowded, making them transmission hotbeds should the virus find a way in. Already, staff and inmates have tested positive in facilities in Florida, New York, and other places around the nation. California recently announced plans to release 3,500 people from state prisons, and New York City has already released 900. Montgomery County, Alabama, released over 300 people. The majority of people being identified for early release are those who have been accused or charged with non-violent offenses, many of which involve drugs.
A study out of Washington State found that in the first two weeks post-release, the relative risk of fatal overdose among former inmates was 129 times higher than the general population. A longitudinal study out of North Carolina found the risk of fatal overdose was 40 times higher than the general population in the first two weeks after release; for heroin users specifically, the risk was 74 times higher. And a 2019 article published in the journal of Addiction Science and Clinical Practice named post-release opioid-related overdose the “leading cause of death among people released from jails or prisons.”
The reasons behind this dramatic rise in risk are complex. The most obvious factor is that when people are forcibly detoxed from opioids but not provided adequate treatment for the underlying addiction, they return to their communities with significantly decreased tolerance but no more tools to help them deal with cravings than they had when they went in.
“They’re not cured, they’re not treated, they’re not in recovery, they just haven’t been able to use,” said Lipi Roy, a clinical assistant professor at NYU Grossman School of Medicine and an internal medicine physician who specializes in addiction. “Whether [the period of incarceration] be three months or three years, it doesn’t matter … The brain doesn’t forget.”
But new research suggests it’s not just a matter of simple tolerance. The unique social, environmental, and psychological factors faced by people who were recently released from incarceration also contribute to the enormous elevation in overdose risk. Now more than ever, as community supports shutter or limit their services in response to the pandemic and people are urged to stay home, those being released from incarceration are entering a new world filled with more stress and less stability and support than ever before.
“Decarceration without re-entry support systems is only going to be a halfway measure,” said Sheila Vakharia, the deputy director of research and academic engagement at the Drug Policy Alliance. “You can’t let people walk out the doors and assume they will be safer outside than inside.”
“If you think of a person in this situation, they may not have a place to live or the same social networks as when they went in. They might be more worried than usual of being arrested so they may be more likely to inject in hidden places and alone and to rush the shot,” said Megan Reed, a PhD candidate at Drexel University’s school of public health and the principal investigator in an NIH funded study on overdose risk after release. “Very few of the harms we associate with drug use have to do with the drug itself or the actual drug impact on the body; it’s the conditions in which somebody is using.”
The brain doesn’t forget.
Incarceration is a highly destabilizing experience that carries a host of other potential negative outcomes. While incarcerated, people are at risk of losing employment, housing, and even custody of their children, especially during long periods of detainment. Furthermore, the stigma associated with arrest and incarceration, or simply the difficulty and expense of communicating with the outside world while behind bars, can disrupt important familial and social relationships, leaving people with a smaller and weakened support system upon release.
Reed also pointed out that many people who have criminal justice involvement enter the system at heightened risk of fatal overdose. For example, people experiencing homelessness are at both heightened risk of overdose and incarceration. Rates of HIV and mental illness — both independent risk factors for fatal overdose — are also high in detention facilities. Many of these are also thought to be risk factors for severe cases of COVID-19, adding an extra source of anxiety for vulnerable people during the outbreak.
This pre-arrest susceptibility combined with decreased tolerance and the stress and uncertainty that people are facing after they have been released from jail or prison creates a perfect storm of dangerous vulnerabilities. “You have concentrations of other overdose risk factors already inside, and the communities that people are returning to are the same communities that are most impacted in the first place,” said Reed.
Exacerbating all of this is a lack of access to the most effective treatments for addiction to opioids, methadone and buprenorphine. Both are opioid-agonist medicines that reduce craving and withdrawal by filling the same receptors as short-acting opioids like heroin, but without delivering a euphoric high in patients who are properly maintained. They are both approved by a slew of licensing bodies, including the World Health Organization, which has included them on the list of essential medicines because of their proven efficacy in treating opioid use disorder and reducing harmful consequences of use, such as fatal overdose. Unfortunately, the majority of detention facilities in the United States do not offer these medications to inmates who are not pregnant.
“Because most correctional facilities still don’t offer standard of care treatment for opioid use disorder with methadone or buprenorphine, people are released not on treatment back to the community. Unsurprisingly, recurrence rates for opioid use are high and because people’s tolerance is reduced their risk of overdose increases dramatically,” said Sarah Wakeman, medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital and an assistant professor of medicine at Harvard University.
The federal government recently loosened regulations around the prescribing of methadone and buprenorphine during the pandemic, but did not address access to people who are currently incarcerated.
Research has shown that maintaining people on medications for opioid use disorder while incarcerated and providing low-barrier referrals upon release will dramatically reduce the post-incarceration overdose rate. Wakeman and other experts also suggest dispensing naloxone, the drug that can reverse an opioid overdose, to people who are being released back into the community.
Spurred by lawsuits and activism, an increasing number of facilities are beginning to offer access to these medicines, but the majority of detention centers remain reticent. This is unlikely to change without a major shift in the way the criminal justice system views and handles drug use and addiction.
“Our justice system is the biggest houser of people with substance use disorders and mental health disorders in this country,” said Vakharia. “[But] they weren’t built for this…they were built to house the ‘bad guys’ in the most simple understanding of how that works and what that means. They were never built or staffed to think of the long term, nuanced needs of people with these multifaceted challenges.”