An hour before he was arrested, D lay in the back of a repurposed ambulance, parked in Anchor Point on the Kenai Peninsula, while Dr. Sarah Spencer injected him with a 30-day dose of buprenorphine, a medication used to curb cravings for opioids.
D was in the mobile clinic that day in December because he said he’d heard “nightmares” about the lack of treatment for opioid use disorder in Alaska jails and didn’t want to go through withdrawal.
“I knew I had to go to jail, so I wanted to get my shot before I went, so I didn’t get sick when I went in there,” D recounted. (Alaska Public Media is identifying D only by his first initial because he’s worried about his safety.)
The state Department of Corrections does offer medication for opioid use disorder but not for everyone who wants it.
Medical experts like Spencer said that needs to change and that it’s critical to expand access to medications like buprenorphine in Alaska, a state where fatal opioid overdoses remain high, even as the death rate falls dramatically nationwide.
Experts say buprenorphine is a safe, effective and straightforward treatment that dramatically reduces the risk of death from opioid use disorder. They say offering it in Alaska’s prisons, jails and ambulances — where providers regularly encounter people at high risk — could be a way to help reverse the state’s troubling trend.
“It's an incredibly effective, life-saving medication,” Spencer said. “We have very few medications that are this good at saving people's lives, and this is for a deadly disease.”
Buprenorphine keeps people from feeling sick and needing illicit opioids, and if they do use other opioids while medicated, the drugs don’t offer as much reward, so people tend to use less often or not at all.
Downfalls of drug testing
The Department of Corrections did not agree to an interview for this story, but a spokesperson wrote it’s “in the initial stages of expanding” medication for substance use disorder services.
According to multiple sources outside DOC, incarcerated people are generally only given medication for substance use disorders if they’re already taking them when arrested, and only for a short time. That leaves many people who want treatment without access to it. There’s also another problem, they say: When someone in custody tests positive for an illicit drug, that person is usually denied the medication, although a DOC spokesperson said patients’ care is assessed on a “case-by-case basis” if they have a positive test.
Spencer said the urine tests DOC uses to test for drugs are notoriously inaccurate and hard to interpret, and people can test positive for substances long after they’ve stopped using them.
D said that’s what happened to him late last year.
After Spencer gave him the dose of buprenorphine and he was arrested, he went to jail and tested positive for fentanyl, he said. He hadn’t used fentanyl in two weeks, he said, but the positive drug test meant he was denied further medication.
“I thought it wasn't fair,” D said. “Relapse is a part of recovery.”
Spencer, one of the state’s leading addiction medicine specialists, sees DOC’s limitations on who can get medication as a “huge missed opportunity.” It makes no sense to refuse someone treatment for opioid use disorder if they test positive for illicit drugs, she said, likening it to denying someone insulin for diabetes just because they ate a candy bar.
“If you deny people access to the life-saving medication because they're exhibiting symptoms of their disease, it is not following the standard of care,” Spencer said.
DOC Health Director Adam Rutherford said in an interview last year that the department was just “starting to step into the realm of medication” for substance use disorders.
“We've had bridging services for a very long time, but in terms of the induction while folks are here and the ongoing treatment, we're really just starting to step into that realm,” he said.
A life-saving treatment that’s underused
Spencer said she’s frustrated that medications for opioid use disorder aren’t widely available in Alaska’s jails and prisons, especially since people leaving incarceration are one of the highest-risk groups for overdose death. Opioid overdose is a leading cause of death after release, and people leaving incarceration face a risk of dying from an overdose that is more than 10 times greater than the general population.
Annette Hubbard is a case manager who works with Spencer at the Ninilchik Community Clinic on the Kenai Peninsula, providing harm reduction supplies and connecting people to treatment. To serve their patients, Hubbard said, the clinic has to compensate as much as they can for the patchy opioid use disorder care DOC offers. They regularly give medication injections to patients awaiting arrest, like they did for D, she said.
“I routinely check the court docket to see who either has an active warrant (or) who got arrested that day,” Hubbard said. “I do that voluntarily, because I know that the people that I work with, and for, are always at risk for getting arrested.”
They also sometimes work informally with probation officers when patients face longer incarceration, so patients can get a few months of long-acting buprenorphine treatments before going in, to reduce their chance of experiencing withdrawal, cravings, return to use and overdose, Hubbard said.
Some states have started programs to target people in or leaving jails and prisons, to get them medicine like naloxone or buprenorphine, and they have seen overdose death rates decline. Rhode Island was an early adopter in 2016, screening for opioid use disorder and offering medication for it to anyone eligible who was incarcerated. In the first year, the state saw a 12% drop in overdose deaths, and the program did not increase health care costs.
Buprenorphine comes in several forms including a monthly injection and daily oral tablets and films. The injection is still under patent, so it costs about $2,000, but it is covered by Medicaid. Some tablets and films are available as generics, so they are much cheaper, as little as about $20 per month.
Lives transformed
Spencer and Hubbard said they’ve seen many lives transformed by buprenorphine.
D said getting on the long-term injection has been the best thing for him.
“Sometimes I still get high, but it's way less often, like maybe once a month or twice a month compared to every day,” D said. “When you're addicted to heroin, you have to have it every day, otherwise it's not going to be a good day. Believe that.”
Spencer said medication helps people shift from focusing on looking for drugs to rebuilding their lives. And she said opioid use disorder is a chronic disease, so it’s best if people stay on medication long term. That’s partly because the disorder can wreak so much havoc on someone’s life.
“They may have lost their job, they may have lost their housing, they may have gotten divorced, they may have lost their children,” Spencer said. “All these really bad things can happen to you, and it takes a long time to rebuild your life.”
Another group of vulnerable Alaskans
Spencer said another way to reduce overdose deaths in Alaska is ensuring all emergency room providers and EMTs, who often work in ambulances, offer medication to people treated for opioid overdoses. Right now, she said, just some emergency room providers do.
Studies show people who get emergency care for an overdose are much more likely to die from another overdose within the next year, often within days of being treated.
One reason for that is the life-saving drug Naloxone throws people immediately into painful withdrawal, Spencer said, so they might seek out more opioids.
“If you administer buprenorphine to a patient who had an overdose and was given Naloxone, you can very quickly help to relieve those withdrawal symptoms,” Spencer said. “And at the same time as you're doing that, you can help to protect them against a repeat overdose in the next day or two.”
Dr. Michael Levy, who directs Alaska’s EMS system, said opioid overdoses are something emergency providers in Alaska respond to on a daily basis.
The best way to help people after being treated for overdose is to get them to the hospital so they can be monitored and talk with a provider about medication for their substance use disorder, Levy said.
But Spencer underscored that people with substance use disorder often avoid health care because of stigma and mistreatment by providers.
So the best practice, she said, is for people with the disorder to be offered medication anytime they interact with the health care system and that includes in ambulances, because not everyone consents to a hospital visit.
There are several hurdles to create a program where Alaska EMTs administer buprenorphine, both bureaucratic and practical, according to Levy. It would require changes to the scope of practice for some EMTs, in addition to more training and paperwork, he said. While the medication can help prevent overdoses in the short term, Levy said, giving it just once isn’t enough to ensure long-term recovery.
“That can be very beneficial because of limiting the chance of them overdosing again within the next period of time while the drug's still effective,” he said. “But then trying to find that connection to long-term care is another hurdle or opportunity that exists.”
If emergency treatment could somehow become a gateway to longer-term recovery treatment, Levy said, it would serve both patients and EMTs, who see overdoses regularly and face burnout from the stress of reviving people over and over.
But Dr. Quigley Peterson, a multi-region medical director and co-chair on the committee that makes recommendations for emergency service standards statewide, said he doesn’t think a program expanding use of buprenorphine to EMTs in the field would be difficult to implement. He also said offering buprenorphine is valuable even if patients aren’t connected to further recovery options because patients' chance of dying of overdose in the next few days is so high.
“What other intervention can you do in medicine where you can have that much of a chance of saving a life?” Peterson said.
Data also show that even when people are given short-acting buprenorphine after an overdose, they’re still more likely to get further treatment. Peterson said it’s not a magic bullet, but it can be a bridge.
A path forward
A few years ago, some providers in Juneau started offering buprenorphine to patients in the emergency room who were withdrawing from opioids, Peterson said. At first, he said, there was pushback: Some nurses said the program would enable drug use.
But some researchers say that’s emblematic of bias and stigma found throughout the health care system, one of the consistent hurdles all states face when responding to the opioid overdose crisis.
Peterson said the first patient he treated agreed 15 minutes later to see a caseworker to discuss next steps in recovery. That early success helped soften the criticism, he said.
Juneau plans to expand the buprenorphine program so paramedics, eligible EMTs and those working on their mobile integrated health team can offer the medication, Peterson said. The program is modeled after several U.S. cities and states that allow EMTs to administer buprenorphine, with good results.
Peterson also said the committee that advises on emergency services in Alaska is considering a proposal to recommend expanding the ability to dispense buprenorphine to more EMTs, a small step in a long process.
Until the state makes changes, many Alaskans still won’t be offered treatment when they’re most vulnerable to dying from an overdose.
When D was released from jail earlier this year, he said he wasn’t given medication or guidance for treatment. That put him in one of the highest-risk groups for dying from an overdose.
But he said he didn’t seek out street opioids. Instead, he said, he called Hubbard, his caseworker, and re-started his medication: 30-day buprenorphine injections called Sublocade. That was about two months ago, and he said he plans to continue them.
“All in all, Sublocade's been a good thing for me. It saved my relationship,” D said, adding quietly, “I'm still alive.”
