If you’re incarcerated in a Washington state prison with an opioid-use disorder, a very specific set of circumstances must occur if you want access to addiction treatment medication.

You might be eligible if your release date is in 90 days or less, if you’re in prison because you violated parole, or if you have a sentence shorter than six months and are already on medications like methadone or buprenorphine.

If none of those conditions apply but your addiction is severe, you may be left hoping a sympathetic medical provider sends your case to Catherine Smith, the director of addiction medicine at the state Department of Corrections. According to her, she’s the only person who can go “outside of the rules.”

“I have started people who were struggling with continuing ongoing use while they were inside, someone with multiple overdose episodes, things like that,” said Smith, who is one of the few board-certified addiction specialists employed by a state prison agency in the United States.

Medication-assisted treatment is widely considered the “gold standard” for treating opioid addiction and studies show incarcerated people are much more likely than others to use opioids  — and die of overdoses shortly after release. In Washington, overdoses were the top cause of unexpected deaths within state prisons during the 12-month period that ended in June last year.

Smith said the goal is to one day offer medication for opioid-use disorders to every incarcerated person who needs it. But expanding the program will require more funding.

Some of that money could be approved during the legislative session that begins next week, as lawmakers adjust the state’s two-year budget.

Corrections has requested $8.7 million for the opioid treatment program. Gov. Jay Inslee’s proposed budget only includes part of that request.

“It is a common misconception from the outside that if we aren’t providing a service it’s because we don’t want to, don’t think it’s necessary or don’t care,” Smith said. “But as the director of addiction medicine and an addiction physician, I do want to treat people as much as we can. Our services are limited to how many resources are allotted.”

How Washington compares to other states

Washington’s very specific rules for providing medication in prisons to treat opioid addiction are the product of a pilot program. The program, Smith said, was initially focused on helping people who were about to leave prison.

Overdoses are the most common cause of death after release from Washington’s state prisons, according to a 2022 study that analyzed Department of Corrections data from 2014 to 2019.

But only up to 30% of eligible incarcerated people will receive medication to treat addiction in fiscal year 2024, according to the department’s budget request. If the Legislature were to fully fund the agency’s request, projections show that figure could rise to about 60% by 2027.

As of January 2022, at least 32 states offer medication to treat incarcerated people for opioid addiction in prisons. But the availability of treatment across different jails and prisons in those states can vary, according to research from the California Department of Corrections. 

Five states offer medication-assisted treatment for incarcerated people regardless of release date. Rhode Island is the only state that offers all three opioid-use disorder treatment medications approved by the Food and Drug Administration.

In Washington, naltrexone and buprenorphine, known by the brand name Suboxone, are available.

Eight of Washington’s 11 state prisons currently offer medication-assisted support. Smith said the Department of Corrections has talked about what it would take to offer the medication in its three other corrections centers: Cedar Creek, Mission Creek and Olympic. The three facilities are minimum security and don’t have the necessary staff to support the program.

“Right now, we hardly have enough staff to provide the dosing in our major facilities,” Smith said.

Contraband medication

Against the backdrop of the state’s limited medication treatment program, contraband buprenorphine is circulating in prisons. From Oct. 1, 2022 to Oct. 12, 2023, there were more seizures of buprenorphine in state prisons than fentanyl and methamphetamine combined.

Wanda Bertram, a spokesperson for the criminal justice think tank Prison Policy Initiative, said the high amount of buprenorphine contraband discoveries in Washington’s prisons suggests that people may be self-medicating.

“It’s just an obvious case of people actually making up for a clear deficiency,” Bertram said.

However, Smith, the Department of Corrections addiction treatment specialist, said those using buprenorphine illicitly are probably turning to the easiest drug to get inside prison. Buprenorphine is easier to smuggle in than other drugs because “it looks almost like Listerine strips,” Smith said.

“There is a black market for Suboxone or for buprenorphine inside the facilities. And I think probably only a very small portion of that is for people who are seeking out treatment,” Smith said.

Illicit buprenorphine use inside jails, as opposed to prisons, is more likely to point to self-medication because withdrawal is more likely in a jail setting, according to Smith.

Research on unsanctioned buprenorphine use in prisons is limited. One study of 300 prisoners suggests that although people are more likely to use the drug to “get high” while inside prison, they are more likely to use it therapeutically once released.

A Marshall Project investigation found that in federal prisons, people have turned to illicit buprenorphine to self-medicate because it’s largely unavailable through legal means.

Obstacles to the program

MaryAnn Curl, chief medical officer for the Department of Corrections, said the agency’s greater focus on medication-assisted treatment in recent years reflects the rise of fentanyl, an especially deadly and inexpensive opioid.

Curl also noted a broader shift toward destigmatizing addiction treatment. “Addiction care is no different than cancer care, or diabetes care, or hypertension care,” she said.

Despite launching the medication treatment program in 2019, the Department of Corrections did not see any money from the Legislature for it until July 2023. That sum was a fraction of its full request, Smith said.

The Department of Corrections has received federal grants for the program. The agency hasn’t received any funding commitments for it from the more than $1.1 billion in legal settlements the state has secured from companies that produced or distributed legal opioids. Half of that money goes to cities and counties, while the remainder goes to the state.

Although Inslee included another $4.7 million in his latest budget proposal for medication-assisted addiction treatment in prisons, the amount only covers about half of the Department of Corrections’ request.

The governor did propose fully funding efforts to combat illicit drugs in prisons, primarily through body scanners to screen visitors.

Corrrections requested $6.5 million for body scanner staff and operations. Inslee’s spending plan includes $7.9 million. The higher sum is due to salary changes in a union contract with prison staff, said Chris Wright, a Department of Corrections spokesperson.

Mike Faulk, a spokesperson for the governor’s office, said in an email that body scanners are a “less-invasive approach to managing contraband than past practices.”

“It’s a practical way to keep dangerous narcotics out of corrections facilities,” he said.

Washington recently expanded Medicaid coverage for people nearing release from jails and prisons, including medication-assisted treatment for addiction. The new coverage rules will take effect in 2025.

Bertram, the Prison Policy Initiative spokeswoman, said that focusing on contraband discovery is ineffective, and funding should be directed to treatment.

“Prison systems can take the approach they’re currently taking, which is to crack down on all presence of drugs, to say ‘the only acceptable behavior is abstinence,’” Bertram said. “But it’s just not realistic. There’s so much demand in a prison context because it’s miserable in there.”

But Marc Stern, a professor at the University of Washington and former medical director for the Department of Corrections, said contraband discovery and treatment are both important.

Stern said he was pleased to see the Department of Corrections’ efforts to provide medication for opioid-use disorder, including the hiring of Smith.

“I know parts of the program are not in place,” Stern said. “I do know they’re working on it.”

by Grace Deng, Washington State Standard

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