Philadelphia has one of the highest drug death rates in the country, and each year, thousands of city residents with opioid use disorder (OUD) pass through the city’s jails. For years, Philadelphia’s jail system has been providing methadone maintenance for individuals who were already receiving it. In 2018, the jails expanded their efforts, initiating another form of medication-assisted treatment (MAT), buprenorphine, for anyone who showed signs of opioid withdrawal upon entry. The Pew Charitable Trusts sat down with Bruce Herdman, chief of medical operations for the Philadelphia Department of Prisons (PDP), to discuss how this new policy is working and how patients are connected to treatment after release. This interview has been edited for clarity and length.
Q: What’s one of the biggest impacts the opioid crisis has had on Philadelphia’s jails?
A: A substantial portion of our population has withdrawal symptoms when they’re admitted to PDP, including those related to alcohol, benzodiazepines, and opioids. We have protocols to address all three, but we are seeing the most related to opioids. Last year, we put about 5,250 individuals—25 percent of the people admitted—on a clinical opioid withdrawal protocol to manage the risks and discomforts of withdrawal.
Q: Tell us about your new policy.
A: We’d been providing MAT in the jails for over 15 years through the NorthEast Treatment Centers—originally just methadone, but only for people who were already receiving MAT through a treatment program in the community. So it was a small portion of our population receiving medication-assisted treatment. We still offer that, but more recently the Mayor’s Task Force to Combat the Opioid Epidemic in Philadelphia recommended that we initiate treatment ourselves, using a second FDA-approved medication, buprenorphine, for individuals with verified OUD who may not have been receiving community treatment already but were willing to start. So in February 2018, we started providing buprenorphine in the women’s jail, and in September we expanded the program to the facilities that hold men. About 90 percent of the women and 80 percent of the men who are eligible choose to participate in the program. So far, we’ve had over 1,500 people in our jails receive this medication. We offer cognitive behavioral therapy as well.
Q: Are you finding that your patients are continuing with treatment after release?
A: Preliminary data suggest that there’s significant participation in treatment following release. Data from the state’s prescription drug monitoring program in 2018 indicated that at least 40 percent of women leaving our program with a prescription for buprenorphine filled it after release, and at least 20 percent of them subsequently filled a prescription written by a treatment program in the community. A preliminary review of claims data suggests that perhaps 50 percent of this cohort received some form of behavioral and/or substance use treatment after release. Data for men aren’t yet available, but results of a larger study—which includes men—will be coming soon.
Q: What challenges do people face in continuing treatment after release, and how do you help?
A: The nature of addiction, health insurance coverage, community provider availability, and housing are all challenging for people with OUD. We can help get them started on treatment while they’re with us, but overcoming these barriers is difficult.
With state government assistance, we’re now able to ensure enrollment of all inmates in Medical Assistance [Medicaid], which helps facilitate access to medications and community treatment programs when patients are released. For those serving sentences, we also assist in making post-release appointments with community MAT providers of the patient’s choice. For all others, including those being held in jail while awaiting trial, we can only provide a referral, because we have just hours’ notice before their release. Around 80 percent of PDP patients are not serving sentences.
Even with our assistance, it can be hard for people leaving jail to get into treatment in their communities right away. One factor is that the majority of folks are released from PDP at night, when providers are not open for business. Another barrier is that the wait to get an appointment can be long. Providers may have intake processes that take days before treatment can begin.
Q: What advice do you have for other jails or prisons considering expanding MAT for inmates?
A: Ideally, you get the mayor or another high-level official to tell you to do it. So that was our license, so to speak, to go forward with expansion of MAT. Then you need to involve the security staff of your institution, since they have to monitor administration of the treatment, and make sure they’re on your side. We’ve developed a great relationship with security, so when we went to do this program, we didn’t face any major roadblocks.
You also have to train your providers and develop treatment protocols. These are direct-observation medications, which means that security must be present to ensure these medications are taken as prescribed, so we bring every patient in each facility together to receive medication. Everyone is lined up, and we administer the medication to everyone at one time—that decreases the amount of security and nursing time necessary to complete the process. Recently, we switched from buprenorphine to suboxone, which contains buprenorphine and naloxone, the medication used to reverse opioid overdose. The combination of buprenorphine and naloxone decreases the risk of misuse and overdose after release. We also instituted a process that sends MAT patients home with at least five days’ worth of suboxone pills, to give them more time to get treatment in the community. Other jurisdictions might benefit from using this model.
Q: What do you wish policymakers and the public better understood about your work?
A: Prisons and jails have a great opportunity to address the unmet physical, behavioral, and substance use disorder health needs of the individuals entering their systems. We can be the provider starting large numbers of people with OUD on paths to recovery. It’s a terrible thing that so many people are incarcerated, but incarceration does allow us to provide care and effective links to community providers for people who’ve previously been left behind.
For more information on the Philadelphia Department of Prisons and its programs for incarcerated individuals with substance use disorders, including OUD, click here.