Josiah “Jody” Rich, co-director and co-founder of the Rhode Island–based Center for Prisoner Health and Human Rights, has spent more than 20 years fighting a multifront war against opioid addiction among the U.S.’s incarcerated. The physician and his colleagues battle prison systems with onerous and outdated rules for inmate health care—and the double stigma that shadows prisoners who are also drug addicts.
But Rich’s determination to see that these inmates get the treatment they need has not wavered. Working with Jennifer Clarke, medical programs director for the Rhode Island Department of Corrections, and others, Rich created a program that produced a dramatic drop in overdose deaths among recently released prisoners in the state. The initiative, hardly radical in concept, simply continued medication-assisted treatment (MAT), such as methadone, for incoming prisoners who were already using them. It also linked them with postincarceration care. These are commonsense measures, but the policy runs counter to the vast majority of U.S. correctional systems, which cut off MAT for new inmates.
Rich spoke with Scientific American about his work, the nature of addiction and the opioid epidemic that is reaching into communities and homes throughout the country.
[An edited transcript of the interview follows.]
How did the inmate treatment plan, which you reported on in JAMA Psychiatry, work?
We rolled out all three Food and Drug Administration–approved medications [methadone, buprenorphine and naltrexone] and screened everybody coming through the door for this disease. And within the first year of implementing [the plan], we documented a 61 percent drop in mortality after leaving the facility. It’s still preliminary data—the numbers are small but statistically significant. And there’s not a lot of misclassification there: you’re either dead, or you’re not dead.
Why is the time after leaving the facility so critical?
The [first of] two fundamental properties about opiates that are different from other addictive substances is the withdrawal phenomenon, which is diabolical and which causes so many problems. And the second is tolerance. The more you take, the more you need to take to get the same effect. And the more you take, the more you can take. Tolerance develops in days to weeks, and if you come off in days to weeks, your tolerance drops. So when we take someone off, when we force them through detox or give them medicines to be comfortable through it, and then they go and resume at the same level they did use, they’re set up for overdose.
And the people who are incarcerated are the people with the most advanced disease, and [after release] is the absolute worst time for them, because they’re getting thrown back into a high-density trigger environment with no tolerance. You could say the same thing for detoxes. When somebody comes out of detox, they are at high risk for overdose. Detoxes are killing people.
How do methadone and the other medications work?
They block you from getting high, and they keep you from going into withdrawal. And those are the two main drivers. They work by different mechanisms, so I don’t really care which of these medicines you take; I just care that you take one. Ninety percent of people relapse if all they do is get taken off the meds [without MAT].
These meds are that good?
I often use the quote Winston Churchill had about government. He said, “Democracy is the worst form of government except for all those other forms that have been tried.” And that’s kind of where we are with these medicines. They work. They’re the best thing we have. But there’s a lot of room for improvement.
What is withdrawal like without one of the medicines?
When you stop using heroin, you have, like, six to eight hours from your last dose before you start having this world of hurt fall down on you. Imagine the worst flu you ever had in your life—your body’s aching, you feel about as miserable as you could—and then imagine the worst stomach bug you ever had. You’re vomiting, you have diarrhea. Now put them together, and multiply it by 1,000. That’s what comes crashing down on you. It’s not even pain; it is a feeling that you are dying. And people do the most god-awful desperate things to either get out of that or avoid it.
This is not a pneumonia that you can cure with a short course of pills. This is a chronic, relapsing condition. And I try to hammer that into people’s heads. If I took a glass of water and filled it with cholera toxin and said, “Don’t drink this glass of water; it’s got cholera toxin; you’ll die the most horrible death you can imagine”—and then I locked you in a room—nobody is going to touch that glass in the first 24 hours. After 48 hours, somebody might think about it, take a little sip, just try it to see. By 72 hours, we’re all drinking that water. The primitive brain takes over and says, “It’s liquid; put it in your body.” End of discussion, because you are dying. That’s what people [addicted to opiates] experience. That’s what ultimately drives most of this insanity.
Given all that, the idea to continue MAT for inmates seems more logical than revolutionary.
It’s simple public-health medical care: diagnose, treat, link to care for chronic disease. And I ran into a brick wall, again and again and again.
Did that surprise you?
I was surprised multiple times. From the day I went in and talked to one of the head nurses and said, “We have this patient who is suffering from withdrawal from opiates. And we have the medicines that can make him feel better. And why don’t we give them to him?” And she said, “Oh, no, we can’t do that.” And I said, “Why not?” And she said, “Well, they have to suffer.” And I said, “We’re health care professionals. Our job is to alleviate pain and suffering.” “Oh, no,” she said, “they have to suffer so they won’t come back.” And I said, “Yeah, but that’s not working. And that’s not fair.”
How common is that sort of thinking?
We have placed a strong emphasis on addressing the problem of addiction to drugs by using the criminal justice system. This, of course, is intertwined with the tremendous stigma around addiction and drug use, which allows the general public—and politicians and health care providers—to treat people with addiction as if they are some lesser species and it is okay to impinge on their rights. And turning that battleship around is unlikely to come out of Washington, D.C. It will be the states and communities that promote and document successful and innovative approaches. It is happening: Vermont passed a bill last summer, Connecticut passed a bill last month, Maryland passed a bill. People are desperate to do something. The feds mostly need to just get out of the way.
But there is role the federal government can play, isn’t there?
What I think Washington can do is use the same approach that was effective with HIV—namely, the Ryan White CARE Act. This provided sustained and creative multidisciplinary funding that allowed the creation of tailored interventions to address a complex problem. Next we need to keep our foot on the gas in terms of research at all levels related to this epidemic. And finally, the federal government can play a role in the training of the health care workforce to address this problem. Right now, we are failing to adequately train physicians and other providers to treat opioid use disorder.
You mentioned stigma. How big of a factor is that?
This is a terribly stigmatized condition. The people who have it, the family members of the people who have it, the people who take care of people who have this disease, the medicines that are used to treat this disease—it is, across the board, stigmatized. And that makes it all worse. We wouldn’t say, “Oh, diabetes, that’s a character weakness; that’s bad. If you have diabetes, you can’t eat any sugar, that’s the enemy. So if we catch you with sugar, that’s it, you’re going to jail.” We would never do that.
How do other countries deal with opioid addiction?
First of all, methadone is an essential medicine from the World Health Organization. I think buprenorphine is as well. This ignorance about the use of medications [to treat addiction] is not a worldwide phenomenon; this is an American phenomenon. Most of the world has pursued a somewhat different approach. Europeans look at us like we’re absolutely nuts. They say, “Don’t you know punishment doesn’t work for addiction?” But here it’s, “Oh, well, they did the crime, they gotta do the time.”
And this opioid crisis is predominantly an American crisis. It came from American doctors overprescribing opioids.
Has the Rhode Island program become a model for other states and institutions?
We hope so. We get calls all the time. Two weeks ago, there were 50 people here from all over the country who came to spend two days, mostly with Jennifer Clarke. They want to know how they can do it in their own facilities. They wanted to talk to the inmates and talk to the officers. You know, kick the tires and look under the hood.
How optimistic are you about the future?
I am quite optimistic that we’re going to move forward with getting these medications into correctional facilities. I’m far more optimistic than I’ve ever been before. It’s not like it’s a done deal, but the conversation definitely changed this past year.
And I think the sentiment around Congress is: they’re hearing it. It’s palpable. I spent a lot of time this past year down in the halls of Congress. I’ve been down there four or five times, and they get it. They’ve lost kids, their peers have lost kids, their constituents have lost kids. They’re hearing about it regularly. Last month I spoke at the Freshmen Working Group on Addiction, which is a bipartisan working group. And they are poised to move forward.
When it comes to opioid addiction, we’re not just talking about inmates anymore, are we?
In Rhode Island, it’s hard to find a family that hasn’t been impacted one way or another, either directly or indirectly, through a neighbor or something. And the overdose deaths are just the tip of the iceberg. This is a horrible disease. It burns a swath through families and through communities.