In 2017, drug overdoses became the leading cause of accidental death in the United States, with opioids driving this epidemic. In the last 10 years, there have been one quarter million deaths attributed to opioid overdoses; half of these opioid related deaths occurred in the last three years, and one quarter in 2017 alone. According to the CDC, in 2017, opioids killed more people than gun violence, car accidents, or breast cancer. While the opioid epidemic may have been sparked by prescription drugs, the advent of highly toxic synthetic opioids—estimated to be 50-10,000X more potent than morphine—has spiraled the opioid epidemic into a crisis much deadlier than anyone could have anticipated. I have some thoughts on the opioid crisis, some of which stem from my experience as a current second-year law student working with nonviolent drug offenders, but mostly from my own experience as recovering addict who has lived through incarceration and has lost several friends to overdoses.
First and foremost, it is essential to recognize that addiction is a disease. Like many diseases, addiction is genetic, progressive, chronic, and often fatal if untreated. Just as diabetes affects the pancreas or emphysema affects the lungs, addiction affects the brain. The power of addiction arises from the way in which it hijacks the “control center” of the brain—a portion of the frontal lobe that is responsible for virtually every aspect of executive functioning and behavioral control. One would think that the risk of going to jail or death would be enough to deter anyone from using drugs. However, addiction is not a choice; it is a disease that is far more powerful than the threats of our penal system or any other deterrent. Like almost any other disease, addiction responds to treatment and medication—it does not respond to punishment or incarceration.
My opioid addiction, like so many others, began with an injury and a legitimate prescription for pain medication. In 2012, a car accident left me with a compound ankle fracture that required multiple surgeries to repair. At the time, I was a medical student and my doctors were quite comfortable prescribing painkillers, but the addictive potential of these medications wasn’t really discussed. Suffice it to say I learned the hard way that addiction does not discriminate based on education level, profession, or anything else for that matter.
From 2013-2015, my life was a revolving door in and out of jails and drug rehab clinics. Up until then, I had been consistently advised that therapy-based rehab was the gold standard of addiction treatment, period. Every doctor who knew of my opioid addiction encouraged me to go to rehab, and every court that branded me as a criminal ordered me to go to rehab. But even after a 28-day rehab stint at the world renowned Hazelden Betty Ford Clinic, I still couldn’t manage to stay clean for more than a few days. It’s not that I didn’t want to get clean; I just didn’t think I could. Everything I had done to address my addiction, including the “gold standard” of treatment, had failed, and I had already resigned to the idea that I was on the losing side of a deadly battle.
In July of 2015, I was arrested for drug possession and spent five days in jail. After five days of cold-turkey detoxing in jail, my cravings and physical withdrawal symptoms were quite severe. Naturally, the first thing I did when I was released was get high, but because I had been incarcerated for such a short period of time, I didn’t bother to think about the fact that my body’s tolerance might have decreased while I was off drugs. I remember nodding off, and the next thing I knew, I was in an ambulance being pumped full of Narcan and told that I had just overdosed.
During the hospitalization following my overdose, I was told about a medication called buprenorphine that, when used in conjunction with behavioral therapy, was supposed to be highly effective in treating opioid addiction. This combination of medication and therapy was called “medication assisted treatment” (MAT) and, much to my surprise, was considered the gold standard for opioid addiction treatment. The medication aspect of MAT turned out to be the crucial missing link to my opioid addiction treatment over the years. Rehab was useful for teaching me coping skills and identifying environmental triggers, but it did not resolve the underlying neurochemistry which left me vulnerable to these triggers. That’s where the medication came in.
There are three FDA-approved medications commonly used treat opioid addiction: buprenorphine, naltrexone, and methadone. These medications, which cost between 40 cents and $3 per dose, are all used to promote abstinence and prevent overdoses in some way. The medications address what therapy alone cannot: the underlying neurochemical changes that manifest in addictive behaviors. In fact, a study published in the American Journal on Addictions suggests that medication is at least 70% of opioid addiction treatment; adding counseling or other forms of behavioral therapy only drives up the success rate. The latest research regarding the efficacy of medications like buprenorphine and naltrexone have been so promising that many treatment centers, including Hazelden Betty Ford, now routinely offer them to opioid addicts. As someone who has been in sustained remission for over three years since starting MAT, the efficacy of this treatment is something to which I can personally attest.
Given the lethality of incarcerating opioid addicts, along with advances and availability of effective treatment over the last several years, it seems logical to provide MAT in correctional centers—if for no other reason than to keep people alive. Unfortunately, our criminal justice system is still operating under the misguided notion that enforced abstinence is a viable response to the disease of addiction. The inadequacy of this approach is evident from the statistics alone: 95% of addicts return to using once they are released from jail, and 60-80% reoffend within one year. This is particularly troubling for opioid addicts, particularly with the rising prevalence of heroin being laced with synthetic opioids like fentanyl and carfentanil (which are estimated to be 50-100X and 10,000X more potent than morphine, respectively). These highly toxic synthetic opioids, coupled with the body’s reduction in tolerance, makes recently incarcerated opioid addicts 129X more likely to overdose after being released from jail.
If our system insists on criminalizing drug addiction, thereby taking this deadly public health crisis into its own hands, our correctional centers should shoulder the responsibility of and actually treating and contributing to the rehabilitation of incarcerated addicts. My proposal that we expand access to MAT to jails and prisons is hardly a novel concept. There is a wealth of data and anecdotal evidence suggesting that the few jails who offer MAT to inmates with opioid addictions (which is currently less than 1% of all U.S. correctional facilities) results in far fewer overdoses post-release, and increases the likelihood that they will stay in treatment and avoid returning to jail. According to a 2016 study published in JAMA Psychiatry, inmates with opioid use disorder who were offered MAT were 61% less likely to die from an overdose after a 12-month period. Similar studies have shown up to a 75% reduction in post-release overdoses and 50% reduction in recidivism after a 12-month period.
While the statistics pertaining to opioid addiction and incarceration may be damning, they are little more than numbers on a page. Understanding the real-life impact of the opioid epidemic, and how our jails and prisons are contributing to it, requires hearing the stories of the people whose lives were reduced to these statistics.
Amanda Gelman was a former cellmate of mine and the first person I’d ever met who died of an opioid overdose. After being incarcerated for a little over year, Amanda died of a heroin overdose on the same day that she was released. She had been in jail for violating her probation—which she was on for a nonviolent drug offense—because she failed too many drug tests. Amanda’s girlfriend, who was incarcerated in another county at the time, also died of an overdose less than three months later.
Summer Bruce was another former cellmate who died of an overdose shortly after leaving jail. Summer was a heroin addict and had been in and out of jail for various nonviolent drug offenses between 2011 and 2016. On 12/10/2016, she was found dead in the bathtub of a halfway house with a needle containing fentanyl-spiked heroin in her arm. At the time of her death, she was out on bail for a pending nonviolent drug offense. Allegheny County revoked her bond and issued a warrant for her arrest on 12/27/2016 for failing to appear in court. The warrant for her arrest is still active.
Marley Fisher and I were not cellmates, but we might as well have been. Marley was incarcerated for violating her probation, which she, too, was on for a nonviolent drug offense. We met in 2014 when we were both in solitary confinement for drug-related reasons. We spoke to each other through the wall vents to pass the time and keep each other company. I learned that Marley had died of an overdose when I visited her Facebook page in the summer of 2017 and saw the words “Remembering Marley Fisher” at the top.
After Marley died, her mother created a Facebook page called “Pittsburgh Won’t Forget U,” in support of others in the area who had lost loved ones to overdoses. For months, I quietly watched as familiar names continued to pop up in new posts. I decided I could no longer sit back and watch while the list of people I had once known continue to grow. Until then, I had been silenced by the shame and guilt surrounding my own addiction and incarceration. I realized that in speaking out, I had nothing to lose that could be worse than the loss that these families are forced to endure. In 2017, there were 735 deaths in Allegheny County alone. In a post, Marley’s mom acknowledged the alarming death toll by simply saying, “Please make it stop,” which is why I decided to start Addiction 2 Action (A2A), a campaign dedicated to uniformly expanding access to MAT to incarcerated opioid addicts. My mission is simple: to make it stop.