Withdrawal Management in Correctional Settings
states support incarcerated individuals in need of withdrawal management by requiring state or local correctional settings to provide withdrawal management services, via either statewide law or protocol/policy, as of June 2023.
What are withdrawal management protocols in correctional facilities, and why are they important?
Withdrawal management protocols outline a comprehensive approach to the treatment, monitoring, and long-term recovery plan of individuals in a correctional facility who are experiencing withdrawal from drugs or alcohol. [1]The term “correctional facility” encompasses both jails and prisons, which are related—but distinct—entities. Jails are short-term holding facilities for the newly arrested and those awaiting trial or sentencing, typically operated by a city, local district, or county. Prisons are institutional facilities under the jurisdiction of the state or federal government where convicted offenders serve longer sentences. FAQs: Jail vs. Prison, Prison Fellowship https://www.prisonfellowship.org/resources/training-resources/in-prison/faq-jail-prison/ (last accessed Nov. 20, 2023). Best practice guidelines for withdrawal management recommend that, for individuals in custody who are intoxicated or undergoing withdrawal, correctional facilities should: (1) allow qualified healthcare professionals to monitor those individuals within a safe housing environment; (2) incorporate specialized treatment for pregnant and postpartum individuals; (3) create defined protocols to prevent suicide and self-harm during and after cessation of substances; and (4) initiate or continue clinically appropriate medications, including medication for addiction treatment (MAT), such as buprenorphine and methadone. [2]Model Withdrawal Management Protocol in Correctional Settings Act, Legislative Analysis and Public Policy Association (July 2021), https://legislativeanalysis.org/model-withdrawal-management-protocol-in-correctional-settings-act/.
In addition to medical management, proper protocols specify screening, assessment, and continued care procedures. [3]Id. Without withdrawal management protocols, an inmate’s withdrawal from drugs and alcohol can be fatal. This issue is particularly important for jails, which house a population that shuffles between in-custody and release.
Justice-involved individuals are at elevated risk for dangerous withdrawal outcomes
Individuals with co-occurring substance use and mental health disorders comprise 15 percent of people arrested annually. [4]More Than 1 in 9 Adults with Co-occurring Mental Illness and Substance Use Disorders Are Arrested Annually, Pew Charitable Trusts (Feb. 6, 2023), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2023/02/over-1-in-9-people-with-co-occurring-mental-illness-and-substance-use-disorders-arrested-annually. This population is at an elevated risk of severe withdrawal symptoms and complications. [5]Medically Supervised Withdrawal for Inmates with Substance Use Disorders, Federal Bureau of Prisons (Feb. 2020), https://www.bop.gov/resources/pdfs/medically_supervised_withdrawal_cg.pdf.
There is a significant unmet need for comprehensive withdrawal protocols
From 2000 to 2019, mortality in jails due to drug or alcohol intoxication increased by 397 percent, [6]E. Ann Carson, Mortality in Local Jails, 2000-2019 Statistical Tables, U.S. Department of Justice Office of Justice Programs, Bureau of Justice Statistics (Dec. 2021), https://bjs.ojp.gov/content/pub/pdf/mlj0019st.pdf. indicating a critical need for screening and timely delivery of treatment and services. Withdrawal from substances such as opioids, in the absence of MAT, places individuals at higher risk of subsequent overdose death, as detoxification lowers an individual’s tolerance to substances but does not treat the underlying chronic disorder. [7]Alexander Y. Walley, et al., Association between mortality rates and medication and residential treatment after in-patient medically managed opioid withdrawal: A cohort analysis, 115 Addiction 1496–1508 (Feb. 25, 2020), https://doi.org/10.1111/add.14964. Withdrawal without appropriate medical monitoring and the initiation of MAT contributes to high rates of relapse and overdose deaths following release from incarceration. [8]Peter D. Friedmann & Joji Suzuki, More beds are not the answer: transforming detoxification units into medication induction centers to address the opioid epidemic, 12 Addiction Science and Clinical Practice (Nov. 15, 2017), https://doi.org/10.1186/s13722-017-0092-y.
Beyond the compelled withdrawal from illicit substances, some facilities require incarcerated individuals to cease MAT and any prescription opioids used to manage pain. [9]Guidelines for Managing Substance Withdrawal in Jails: A Tool for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals. U.S. Department of Justice Office of Justice Programs, Bureau of Justice Assistance (June 2023), https://www.cossup.org/Content/Documents/JailResources/Guidelines_for_Managing_Substance_Withdrawal_in_Jails_6-6-23_508.pdf. However, in most instances individuals who undergo forced withdrawal from MAT later experience an aversion to such treatment after release, due to the severity of withdrawal symptoms. [10]Jeronimo A. Maradiaga, et al., “I Kicked the Hard Way. I Got Incarcerated.”: Withdrawal from Methadone During Incarceration and Subsequent Aversion to Medication Assisted Treatments, 62 Journal of Substance Abuse Treatment, 49–54 (Mar. 2016), https://doi.org/10.1016/j.jsat.2015.11.004. Such forced withdrawal from MAT may, therefore, act as a barrier to future treatment initiation. Moreover, rapid discontinuation of opioids can be especially dangerous for pregnant individuals, causing premature labor, fetal distress, and miscarriage. [11]Jail-based Medication-assisted Treatment: Promising Practices, Guidelines, and Resources for the Field, National Commission on Correctional Health Care & National Sheriffs’ Association (Oct. 2018), https://www.ncchc.org/wp-content/uploads/Jail-Based-MAT-PPG-web.pdf.
By providing clear protocols and training and education on SUD and withdrawal for all correctional staff, individuals at risk for overdose, withdrawal, or other medical issues may be better identified before these issues reach a critical point. [12]Dying Inside: To End Deaths of Despair, Address the Crisis in Local Jails, O’Neill Institute for National & Global Health Law (Dec. 2022) https://oneill.law.georgetown.edu/wp-content/uploads/2022/12/ONL_Big_Ideas_Dying_Inside_P5.pdf.