Smith initially believed it to be a straightforward case of “finders keepers,” according to Andy Schmidt, a Maine attorney who worked on Smith’s case alongside Emma Bond from the ACLU. Police, however, did not interpret it that way. They located her using surveillance and payment data, and they accused her of stealing. The court gave her a 40-day jail term in Aroostook County because the facts could not be contested.
When Smith realized that a prior customer had come back for the money, she took responsibility for her actions and accepted her sentence, according to Schmidt.
The drug that was holding Smith’s life together, a twice-daily dose of buprenorphine, which is a component of a medication-assisted treatment, or MAT, for Opioid use disorder, was what Schmidt claims Smith could not — would not — take from the Aroostook County Jail.
Smith now worried that his five years of sobriety were about to be lost forever.
American opioid use disorder
Smith had cause for concern. Approximately 80,000 Americans died from opioid use disorder (OUD) in 2021. In the entire Vietnam War, more Americans perished than that. It is nearly impossible to estimate the effects of lost wages, lost output, medical expenses, incarceration, and ruined families.
Additionally, OUD rates in American jails and prisons are more than seven times higher than those in the general community.
So it should come as no news that the main cause of mortality among those who are released from prison is opioid overdose. According to some estimates, a person who is released from jail has a more than 100 times higher risk of dying from an overdose than the average person. (see sidebar: What Happens After Prison).
People with untreated OUD can burden their families and communities after release, even if they manage to escape an overdose. They are more likely to commit crimes, use force against their partners, and participate in risky activities that can spread diseases like HIV and hepatitis. Additionally, they run the risk of returning to jail or penitentiary.
Schmidt claims that Smith made it clear that he didn’t want to become a number.
An enforceable Right to Care
Estelle v. Gamble, a seminal 1976 Supreme Court decision, established a constitutional right to health care, including treatment for drug use disorders, for those incarcerated in the United States.
The ideal OUD therapy is MAT, Smith’s method. MAT combines mental health therapy with one of the three FDA-approved drugs: methadone, buprenorphine (Suboxone), or naltrexone (Vivitrol). (Doctors refer to the medications by themselves as MOUDs, short for Medications for Opioid Use Disorder.)
Additionally, it is a therapy that has been successfully used. According to studies, MAT lowers the risk of overdosing and lowers the likelihood of relapsing, future offenses, An overdose death was 80% less likely to occur in the month following release from jail for OUD patients who received MAT in New York City prisons, according to a recent study.
Therefore, you might assume Smith would be able to continue her effective therapy in prison since she has a clearly defined condition and a doctor-recommended course of action.
However, it wasn’t the situation. Smith merely didn’t have access to MAT, as is the case in many prison and jail systems across the nation.
According to Schmidt, the jail intended to make her go through medication withdrawal under duress.
Smith understood what it meant. The worst agony she had ever experienced during a forced medication withdrawal, she testified to the court, as well as her first-ever suicidal thoughts.
But for Smith, the threat of resuming her opioid abuse was more terrifying than the bodily agony of withdrawal. She was aware that not taking her medicine would endanger her future, particularly her ability to care for her children, the author claims.
Because of this, Smith and her legal counsel moved straight to federal court in an effort to get Aroostook County to give Smith the medication she was prescribed. As a result, Smith’s sentence was postponed, which allowed her to avoid worrying about her OUD or withdrawal symptoms—at least until a federal court made a decision.
Why Is Drug Therapy So Disparate?
It all begins with how the standard is phrased: According to the majority ruling in Estelle v. Gamble, the state cannot provide the health care needs of those who are imprisoned with “deliberate indifference.”
Brendan Saloner, PhD, an associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, notes that “what that means” is highly subjective.
The meaning of that standard is determined by the case law of each state, and that case law can differ greatly, according to Saloner. This explains why inmate medical treatment, including that for OUD, varies so much from state to state. There are different treatment choices even in states where MAT is accessible. Some schools offer all three MAT medications, while others only offer one. Some prescribe therapy along with the medications, while others don’t. The medications are not interchangeable, according to experts, and what works for one individual may not be effective for another.
Transfers of prisoners exacerbate the issue. A survey (which did not identify the state) found that over 20,000 prisoners were transferred from one sizable Southeastern state in 2020 alone.
According to assistant professor of family medicine and community health at the University of Wisconsin School of Medicine and Public Health in Madison, Elizabeth Salisbury-Afshar, MD, MPH, the issue is also one of resources.
According to Salisbury-Afshar, drug treatment programs, particularly those for opioid abuse, may need specialized licenses and a large team. For example, qualified employees must observe an inmate as they take their daily methadone. Salisbury-Afshar notes that this can be an issue, “particularly in smaller jails, where there is frequently inconsistent medical staffing.”
Department of Justice: OUD Is a Disability
In 2019, the Aroostook County Jail was ordered by the Federal Court for the District of Maine to provide Brenda Smith with MAT during her incarceration. In her ruling in Smith’s favor, the judge stated that Smith had “regained custody of her four children, secured stable housing for her family, and obtained employment” since becoming sober with the aid of MAT. She’s graduated from secondary school and has started taking college courses.
According to the judge, Smith would suffer “serious and irreparable harm” if her treatment were to stop, which would be against the ADA.
Smith did not have to serve any time because Aroostook County suspended the punishment. But according to David Sinkman, a former deputy U.S. attorney for the Eastern District of Louisiana, the ADA violation played a crucial role in the decision and will alter how future cases of this nature are handled.
Like diabetes, opioid use disorder is a handicap, according to Sinkman.
According to Sinkman, who served as his office’s opioid and civil rights coordinator, “no jail or prison would deny a diabetic person insulin, yet the vast majority of the country’s correctional facilities prevent people with OUD from receiving this doctor-prescribed and lifesaving treatment.”
Sinkman declares, “This is terrible criminal justice, cruel, and bad public health policy.” He claims that inaccurate perceptions and stigma are a contributing factor in the hesitation to provide MAT. Some people, including medical professionals, believe that MAT simply swaps out an existing drug for a new one. However, Sinkman, who is currently a visiting scholar at the School of Global Public Health at New York University, notes that once individuals are informed, they frequently change their minds.
Because of this, numerous important professional associations, including the American Medical Association, National Sheriffs’ Association, American Society of Addiction Medicine, and others, have started to support MAT as the gold standard of treatment for opioid addiction in jails and prisons.
The U.S. Justice Department adopted a similar strategy in April 2022. They issued guidelines stating that access to “evidence-based treatments” should not be denied to inmates suffering from addiction illnesses. If jails and prisons across the nation can’t figure out a method to provide MAT for those with OUD, they could face federal punishment for ADA violations.
It will take some time to implement these initiatives because there are almost 2 million individuals housed in 1,566 state prisons, 102 federal prisons, 2,850 local jails, 1,510 juvenile correctional facilities, 186 immigration detention facilities, and other facilities, according to Sinkman.
Some jurisdictions are, however, already making that transition. Anyone in the Rhode Island prison system can now request cutting-edge therapy for opioid use disorder thanks to a MAT drug treatment program. Former inmates have the choice to continue therapy in a community setting even after being released. Impressive initial findings.
Overdose deaths among inmates exiting prison decreased by 61% in just the first six months of the program.
If this were to be applied to the total prison population in the United States, it would mean thousands of lives that could be saved each year. Sinkman emphasizes the significance of keeping in mind that each of those lives, including Brenda Smith, has a unique tale to share.
