How some jails treat heroin addiction
Medication-assisted treatment program expands in Wisconsin
MADISON - The woman who sat across from Cheylene Schank had been in jail for 45 days.
She wanted out. Soon.
To do that, she needed to get enrolled in a treatment program for her heroin addiction. Her probation officer made treatment a requirement of her release.
Schank, an addiction specialist and caseworker with Journey Mental Health Center, explained the medication-assisted treatment program.
While still in jail, the woman will receive her first
injection of Vivitrol, a prescription that blocks the receptors in the brain where opioids latched.
Once released, she will be required to attend group and individual therapy, meet with a recovery coach and remain drug-free.
Vivitrol, a brand name for naltrexone, will stop heroin, painkillers and other opioids from having an effect, Schank said.
“You don’t get high and it helps with cravings,” Schank explained. “You get the shot every four weeks, on Friday.”
The woman in the blue jail uniform nodded.
As the heroin crisis continues unabated in towns big and small in Wisconsin, policymakers, law enforcement and addiction specialists are working to expand access to treatment. That means meeting people where they are, even in jail.
Treating addiction in jail
Over the past five years, 219 people have gone through the Dane County Jail opiate treatment program.
Of them, 43 percent have accomplished their treatment goals, according to Todd Campbell, the county’s adult community services administrator.
“Sustained sobriety, stable living, stable employment — those are the big markers that we look for,” he said.
The program will cost about $125,725 this year, with 82 percent coming from federal grant funding funneled through the state and the rest coming from the county, Campbell said.
The Vivitrol program in Dane County — and similar models in Sauk and Ozaukee counties — depends on partnerships among law enforcement, jail medical staff, mental health and treatment providers and county social services.
In Dane County, the goal is to have participants as stable as possible on the medication before they are transferred to a medical provider through their health insurance, Campbell said.
Typically, people are in the grant-funded program at least three months, he said. The average length of treatment for those who successfully complete the program is about 8 1/2 months.
Correct Care Solutions, the jail’s medical provider, agreed to provide the first Vivitrol injection while people were still in custody, said Kathryn Rindy, director of clinic-based services for Journey Mental Health. “That was a key, crucial part,” she said. Studies have repeatedly found those who do enter jail or treatment are at a higher risk of a fatal overdose, or “hot shot,” if they relapse because their tolerance is lower.
Getting people started on medication-assisted treatment while in custody can help lower that risk, as the death toll from the opioid epidemic continues to climb.
In Wisconsin, 827 people died from an opioid overdose in 2016, the most recent year statewide data is available.
In Milwaukee County alone, 337 people died from opioid drugs in 2017. Already this year, 168 opioid drug deaths have been confirmed, according to the Milwaukee County medical examiner’s office.
The growing, and grim, tally has been attributed to the rise of fentanyl, a powerful opioid nearly 50 times stronger than heroin.
Painkillers led to heroin
Inside a jail pod, Schank asked the woman about her addiction.
The woman said she started abusing prescription painkillers about 12 years ago. She tried anything she could sniff, including heroin, which became her drug of choice. She soon switched to injecting it.
She estimated she had overdosed at least 10 times. Her addiction, she said, is what has landed her in and out of jail in recent years.
Schank went through a dozen forms with the woman. Much of the paperwork was so Schank could share and receive information from the various agencies involved in the woman’s life: her old treatment centers, her new ones, her probation agent, jail medical staff and her employer.
Like every program participant, she will need to have a liver test to make sure she can metabolize the medication, Schank said.
The test meant another two weeks in jail.
The woman asked if the lab work could be fasttracked or if it was ever completed ahead of schedule. Schank offered a sympathetic smile and said no. Then she asked the woman to rank her motivation for the program on a scale of one to 10, with 10 being the highest.
Seven, the woman replied.
And the driving factor?
Getting out of jail, she said.
It’s a common motivator. Although the program is technically voluntary, a probation agent may make treatment a requirement of a person’s release, Campbell said.
“That’s part of the challenge of getting them engaged in treatment is having that external motivation become more internal,” he said.
Differences between Vivitrol and Suboxone
The jail program is an example of medication-assisted treatment, considered the gold standard of care for opioid addiction.
The prescribed medication can help people deal with withdrawal, giving them the brain space to consider what is a healthy choice and work through counseling and other treatment.
Although it’s been widely studied and found to be effective, medicationassisted treatment does not have universal support. Some 12-step programs, in particular, view it as replacing one drug with another.
Three medications are commonly used: methadone, buprenorphine (Suboxone) and naltrexone (Vivitrol).
Methadone and Suboxone are opioids, taken orally. Vivitrol is not an opioid and comes in a monthly injection, making it less likely to be abused. It also is more expensive: A monthly dose of Vivitrol can cost between $500 and $1,000.
Alkermes, the manufacturer of Vivitrol, has aggressively marketed the medication to correctional facilities, drawing a stark distinction between it and Suboxone, and donated hundreds of samples to jails across the country.
But a long-awaited study comparing the two drugs published late last year found the two were similarly effective.
The relapse rate for Suboxone was about 56 percent, compared to 52 percent for Vivitrol in the 24-week research period.
The study also found people assigned to take Vivitrol were much more likely to quit before starting treatment because the medication requires a period of sobriety.
More than a quarter of the study’s participants assigned to Vivitrol dropped out before taking the first dose, compared to only 6 percent in the Suboxone group.
‘You need to be honest’
Schank explained Vivitrol’s possible side effects — headaches, extra tiredness and fogginess — to the woman.
Then she offered a warning: Anyone who takes Vivitrol while still using heroin or other opioids is forced into withdrawal.
“You need to be honest if you use,” Schank said.
A few program participants received their first Vivitrol shot, got out of jail and relapsed in the following weeks. When it came time to get their next shot, they did not disclose they were using, received their dose and went into withdrawal.
“People have done it and regretted it,” Schank said.
Withdrawal is extremely painful and has been described by people as the worst case of flu they’ve ever had and feeling close to death.
It’s so severe because of how heroin and other opioids interact with the brain. The drug molecules latch onto brain receptors that influence involuntary heart rate and breathing.
If someone stops using heroin, those receptors are all raw.
Because Vivitrol requires a period of sobriety — usually about 10 days — before the first dose, jails can be unique transition points, said John Gilane, a counselor who coordinates Ozaukee County’s medication-assisted treatment program in the jail.
“There are so few places where we can actually send somebody to monitor their withdrawal, where they’re safe and won’t run out and go use heroin after 48 hours,” he said.
“Jail is one of those places.”
Challenges in Milwaukee County
The idea of starting addiction treatment with Vivitrol in jail is spreading. Other counties in Wisconsin and the state prison system have experimented with similar projects.
But Milwaukee County faces particular challenges with the size of its jail population and existing partnerships with other providers.
Justice Point monitors people free on bail and awaiting trial and typically functions as an access point for other services. Armor Correctional Health Services, the jail’s medical provider, is currently the subject of several lawsuits and criminal charges alleging falsification of health records.
“It starts to add a lot of variables,” said Mike Lappen, administrator of the Milwaukee County Behavioral Health Division.
Lappen, who previously worked for Ozaukee County and helped set up the jail program there, said he has had discussions with Milwaukee County judges and other officials about the possibility.
There’s also the cost of using Vivitrol, including the pre-dose liver test, and coordinating health insurance plans, he said.
“You need a doctor willing to prescribe it and inmates willing to take the drug,” he said. “Building rapport and engaging in a very large jail with a changing population and limited resources — that’s a real challenge.”
The best chance of ending addiction comes from those who enter treatment willingly.
“For some people, jail is absolutely rock bottom,” Lappen said. “For some people, it’s not and they have no interest in getting sober.”
“This is one more opportunity and one more way to connect,” he said.
Looking ahead to recovery
Schank began to wrap up her assessment.
She had spent 45 minutes with the woman inside the Dane County Jail and still had several other inmates to check in with that morning.
The expectation is complete sobriety, Schank told the woman.
The woman half-jokingly asked about marijuana, noting Madison does not criminalize it.
“You are in recovery for a mind-altering substance and marijuana is a mindaltering substance,” Schank replied.
She recapped the next steps for the woman: the liver test, the first injection behind bars and her post-release treatment, drug tests and counseling sessions.
Schank asked if she was ready. “Yeah, let’s do this,” the woman said.