The Value of Detox

Originally published in the National Sheriffs’ Association’s Sheriff & Deputy magazine, March/April 2020 By Jeffrey Alvarez, MD, CCHP, and Amber H. Simpler, Ph.D., ABPP

In what has been characterized as the most perilous drug crisis ever to hit the United States, opioid overdoses claimed the lives of more than 115 individuals per day in the U.S. in 2016, the National Safety Council (NSC) says. And in spite of the overdose-reversing drug naltrexone becoming more widely available, the number of opioid overdoses remains at an all-time high.

The cycle begins innocuously enough: Individuals are prescribed opioids to provide relief from pain. The unfortunate consequence? Their bodies quickly build a tolerance, rendering the drugs less effective and requiring higher dosages to manage pain.

Meanwhile, the opioids cause permanent changes in nerve cells in the brain, and those changes—which can occur with even brief periods of use—prevent the brain from suppressing pain naturally. When the prescription runs out, the pain is more excruciating than ever, because the body has stopped producing natural pain-killing chemicals including endorphins. Patients then seek alternative methods of pain management, and some turn to heroin.

Dependent on drugs

Four out of five people using heroin in 2013 reported their addiction began with use of prescription opioids, according to the National Institute on Drug Abuse. In 2016, 97 million people used opioid pain relievers; about 20% of individuals who use opioid pain relievers for five consecutive days are at risk for becoming opioid-dependent, according to the Centers for Disease Control (CDC), and an estimated 2.1 million Americans suffer from an opioid use disorder (OUD).

Some people first use opioids recreationally, of course, but the outcomes are similar: dependence on a highly addictive substance that can lead to desperate—sometimes criminal—acts to acquire narcotics and fund continued use.

Two-thirds of the approximately 42,000 overdose deaths in 2016 were related to opioids, and the combination of illicit drugs with fentanyl has exacerbated opioid-related fatalities. A synthetic opioid, fentanyl is 50 to 100 times more potent than morphine, according to CDC; as a result, what a drug user thinks is a safe dose of heroin can easily be a lethal dose of fentanyl.

Opioids in jails

The opioid epidemic has hit America’s jails particularly hard. Jails have become de facto residential detox facilities for individuals who are dependent on opioids. In 2016, more than 2.5 million individuals underwent managed opioid withdrawal in jail, compared to less than 500,000 who underwent managed opioid withdrawal in a detox facility or hospital program, CDC says. From 2016 to 2019, NaphCare recorded a more than 200% year- over-year increase in patients requiring medical care for opioid withdrawal in the more than 40 jails where it provides medical services.

Symptoms of opioid withdrawal include dysphoric mood, nausea/vomiting, muscle aches, light sensitivity, chills, sweating, diarrhea, yawning, fever, and insomnia. Physiological withdrawal symptoms can lead to dehydration and electrolyte imbalances that can be fatal.

Individuals entering correctional facilities with opioid dependence are at high risk for opioid withdrawal syndrome (OWS). Left untreated, opioid withdrawal may “result in needless suffering, interruption of life-sustaining medical treatment, and rarely, death,” says the National Commission on Correctional Health Care (NCCHC). “National research shows significant gaps in quality of care for opioid withdrawal in correctional settings, including underuse of recommended protocols and low use of drugs approved for detoxification by the FDA [Food and Drug Administration].”

As a result, NCCHC set the following guidelines:

• All inmates should be screened for potential opioid withdrawal;
• All those who screen positive should be formally assessed within 24 hours;
• All those with significant withdrawal should be treated with effective medication; and
• All those who receive opioid withdrawal treatment should be educated and referred for treatment.

The treatment

Medication-assisted treatment (MAT) is a term used to collectively refer to three FDA approved medications for treating opioid use disorders: methadone, buprenorphine, and naltrexone. It is the most effective way to treat OUD by providing evidence-based, medically managed withdrawal care.

MAT keeps physiological cravings at bay and gives users the opportunity to address the social and psychological issues associated with addiction. A 2015 clinical trial cited in the Journal of the American Medical Association ( JAMA) found “excellent results” for patients who received buprenorphine in an emergency department, with favorable outcomes in addiction treatment, reduced illicit opioid use, and lower use of inpatient chemical dependency programs. Unfortunately, the need for OUD treatment is larger than the availability of MAT.

NaphCare strives to improve care for individuals suffering from opioid withdrawal in jails and wants to help patients entering the jail who may experience severe symptoms of withdrawal. “We believe it’s important to treat withdrawal as a serious condition, as it can be life-threatening to patients while inside the facility,” says NaphCare CEO Brad McLane.

NaphCare has developed a managed opioid withdrawal protocol that uses a “taper” of buprenorphine, administered to patients at the point that they begin to experience moderate withdrawal symptoms that can be managed safely. Over a two-year period, NaphCare refined and implemented the protocol in all of the correctional facilities in which it provides health care services.

The company piloted its first opioid withdrawal program in 2017 at the Washington County (Oregon) Jail, and has since gained approval in many jurisdictions that were initially resistant to MAT concepts. MAT is available at all NaphCare sites, and more than 8,000 individuals have received MAT for OUD to date. The company also partners with community agencies to offer continuity of care after release.

“At NaphCare, we believe in the promise of MAT for the betterment of public health in our local communities,” McLane says. “Not only is it important to safely manage our patients through withdrawal while in the jail, but we also focus on providing solutions to help people continue with recovery after release in hopes that they will not return to the correctional system.”

MAT also helps discourage relapse that can have catastrophic consequences including death from a drug overdose upon release from a correctional facility. Largely because their drug tolerance decreases while in jail, former inmates overdose at rates 130 times that of the general population in the two weeks following release, and 50% of inmates suffering from OUD are more likely to encounter the criminal justice system again if untreated.

“[MAT] helps upon release,” says Washington County (Oregon) Sheriff Pat Garrett. “Not only have [inmates] detoxed in a way that’s more safe, when they get released, their first thought isn’t ‘I’ve got to use, I’ve got to get high to survive.’ I was skeptical about trading one addiction for another, and it turns out that’s not what’s happening. It’s a safer way to detox, the outcomes are better, and in the end, it saves lives.”

Misconceptions about MAT

Common misconceptions about opioid use disorder and MAT in jails can often keep sheriffs from exploring such programs. A few of those myths?

• “Buprenorphine is an opioid that inmates can get high on.” When used as directed, buprenorphine does not cause euphoria; it quells cravings. The “taper” method for managing withdrawal has been used for more than 20 years, and is FDA-approved for treating OUD.
• “Sudden cessation may be uncomfortable, but not fatal.” For the young and healthy, this is usually true, but for those in poor health (common among jail detainees), the added physiological stress of withdrawal can be life-threatening.
• “Opioid misuse is a consequence of moral failing, lack of willpower, or weak character.” Like other addictions, OUD is a chronic brain disease that has biological, psychological, and social components. Understanding the biology of opioid addiction helps explain the necessity of MAT, as well as the need to manage the condition as you would any other chronic, relapsing medical condition—with medication and lifestyle changes.
• “MAT medications are too costly.” While administration of buprenorphine, naltrexone, and/or methadone does carry a cost, it usually isn’t borne completely by the jail offering it as a treatment. NaphCare has worked with clients to obtain more than $1.5 million in grant funding and in-kind contributions to support MAT programs.
  
  MAT programs can also reduce liability for local governments. Two courts have ruled that OUD meets the definition of a “disability” under the ADA, and that the continuation of MAT for OUD patients is a reasonable accommodation jails must provide. Other assumptions that give justice professionals pause about MAT programs —that they are ineffective, difficult to administer, or provide easily misused and diverted drugs— have little foundation. And while a handful of criminal justice officials feel that MAT “rewards” criminal activity or addiction, most admit that MAT is more effective than non-pharmacological treatment approaches.
  
  “Improving the quality of life in our community is our top priority,” says Newton County (Georgia) Sheriff Ezell Brown. “As we see it, that includes providing the most comprehensive care possible to those who are incarcerated with the goal of returning them safely into the community. We believe there is great value to the community at large in taking a more proactive approach that saves lives.”

Jeffrey Alvarez, MD, CCHP, is chief medical officer for Naphcare Inc. Dr. Alvarez also serves on the NCCHC board of directors as the liaison of the American Academy of Family Physicians. Amber H. Simpler, Ph.D., ABPP, is chief psychologist for Naphcare Inc., responsible for collaborating with mental health providers to evaluate and improve clinical and operational processes within correctional settings.