At the Ninilchik Community Clinic on the Kenai Peninsula, Dr. Sarah Spencer prepped a patient for a 30-day buprenorphine shot to treat her opioid use disorder.
Spencer’s patient is a woman, H., who said she has a warrant out for her arrest and is expecting to go to jail for about six months. We’re identifying H. by her first initial because she spoke critically of the Alaska Department of Corrections and she’s afraid of retaliation from staff in jail.
H. said there are contraband drugs in jail, and she wanted the shot so she has the best chance of maintaining her sobriety for as long as she can while she’s incarcerated.
“I wanted to cover my bases, because I really, really wanted to do good,” H. said. “I didn't want to go backwards.”
Her predicament highlights a critical gap in Alaska's correctional health care: research shows medication-assisted treatment dramatically reduces overdose deaths and improves recovery outcomes, but the state’s correction system offers only limited access to these life-saving medications.
Spencer said that puts incarcerated Alaskans at heightened risk of relapse and fatal overdose when they leave.
“There is no population that's at higher risk than people who have been recently incarcerated and a big part of that is because it only takes two weeks for people to lose their tolerance to opioids,” Spencer said.
Alaska’s Department of Corrections declined an interview for this story, but right now, they provide limited access to medication for opioid use disorder. Inmates can access medication during pregnancy or people already taking medication can continue but only for 30 days. Inmates who test positive for illicit drugs have been denied medication, according to former inmates and community providers. But a representative for the department wrote in an email that those care decisions are made on a “case-by-case basis.”
Megan Edge, the director of integrated justice at ACLU of Alaska, said treatments for opioid use disorder can also make someone test positive for opioids on a drug test. And she said ironically, Alaska DOC sometimes denies people care based on those results.
“We have seen this really inconsistent approach to the opioid epidemic in a carceral sense that has resulted in death and continues continuous cycles of harm and addiction in entire families and in communities,” Edge said.
She said it’s often difficult to access health care while incarcerated and depends heavily on individual staff.
Spencer said limiting access to medications for opioid use disorder is against best practices.
“If a patient isn't continued on their medication or isn't offered medication, you're really missing that opportunity to stabilize this life threatening disease while they're in DOC custody,” she said.
Spencer said that Alaska could do better and pointed to Rhode Island’s system as a gold standard. In 2016, Rhode Island started offering treatment for substance use disorders to anyone eligible in the state corrections system and within a year, the overdose death rate among people recently incarcerated declined 60%.
Dr. Jennifer Clarke, who developed the program when she was medical director at the Rhode Island Department of Corrections, said “It was like practicing medicine with one hand tied behind my back,” before she could freely dispense medication for substance use disorders.
And she said the results of the new program were palpable. When people weren’t going through withdrawal and having cravings, they could focus better on recovery.
“I heard multiple times people would tell me, this was the first time I could really participate in the treatment classes, in the behavioral therapy,” Clarke said.
But Clarke said it wasn’t always easy. The program required $2 million in funding to start, the backing of the then-governor, faced many logistical hurdles. And she said she faced stigma.
“I was called frequently a drug pusher,” Clarke said. “So, with the medical staff, I would just talk data. I'm like, ‘We're scientists. We believe in science. We're going to follow the science.’”
Rhode Island started their program almost a decade ago, but other states have been slow to offer medications. Fewer than half of jails offer some access to medication for opioid use disorder, according to a JAMA study from last year.
Redonna Chandler, a psychologist formerly at the National Institute on Drug Abuse said medication can be hard to access for anyone with opioid use disorder, and often jails and prisons don’t have providers with the expertise necessary to give the medications.
“It's still a patchwork of programs,” she said.
And because medications like buprenorphine are opioids themselves and help with withdrawal, there are black markets inside jails and prisons.
“You'll hear a lot of concerns about diversion and about pills being diverted, but there are ways to deal with and get around that, either through other formulations or through the ways in which you would administer the medication,” Chandler said.
In the meantime, patients like H. in Ninilchik can only count on treatment outside incarceration.
“It would just be so huge to be able to get it in jail too, and then gain that strength to be able to help yourself when you did hit the streets again,” H. said.
She expected her last buprenorphine injection to last her partway through her stay in jail, and she hopes when she gets out, she’ll go right back to treatment.
Alaskans struggling with a substance use disorder who want help can call 2-1-1.
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