Public Policy Statement on Access to Appropriate Detoxification Services for Persons Incarcerated in Prisons and Jails
Addictive diseases are common among people living in the United States, and studies show that the prevalence of addictive diseases among inmates in jails and prisons is higher than occurs in the general population. Many patients with addiction have physiologic dependence on the agent to which they are addicted, such as alcohol, prescription sedatives or opioids, or heroin. When individuals dependent on such drugs experience an abrupt cessation of use, a withdrawal syndrome can ensue with both physiological and psychological components. The acute withdrawal syndrome can constitute a medical crisis, causing significant symptoms, and in some cases causing death even in previously healthy individuals. While opiate withdrawal itself is usually not fatal, it can lead to tremendous discomfort, and fluid and electrolyte disturbances related to the vomiting and diarrhea of withdrawal can exacerbate co-occurring medical problems in the withdrawing individual, potentially precipitating sudden death.
The use of alcohol, nicotine, and illicit drugs is forbidden in jails and prisons, and appropriately so. But beyond prohibitions against possession and use of contraband, many correctional facilities have policies and procedures that prohibit the use of opiate medications by inmates, even if these have been prescribed by a physician prior to the moment of incarceration. It is not uncommon for jails, prisons, and correctional halfway houses to forbid residents to continue methadone maintenance once the individual has been placed in such a facility; when methadone maintenance treatment is abruptly discontinued, acute opiate withdrawal will ensue. Other correctional facilities have inadequate policies and procedures or inadequately trained personnel to appropriately recognize signs or symptoms of alcohol, sedative, or opiate withdrawal in individuals they serve. Thus, through neglect or through administrative rules, individuals suffering from chemical dependency may not receive appropriate evaluation and management of an acute withdrawal condition. It is unfortunately the case that some individuals do experience withdrawal symptoms, and these symptoms are ignored, discounted, or intentionally not intervened upon. A sometimes-stated rationale for denial of proper medical care for withdrawal syndromes, is the belief that making addicts experience the suffering of withdrawal will somehow deter them from returning to further drug use. A related rationale for denial of appropriate withdrawal management care is the contention that drug addiction is volitional and that the pain of withdrawal is an appropriate consequence for misbehavior. There is no evidence to support such beliefs, and there is significant evidence from behavioral psychology that punishment of undesirable behaviors is not an effective means of promoting positive behavior change.
The U.S. Supreme Court has held that the proscription of cruel and unusual punishment by the Eighth Amendment of the United States Constitution requires that proper medical care be rendered, when indicated, to individuals who are incarcerated. In accordance with such rulings, correctional facilities assure that qualified medical personnel are routinely available to treat people in custody for medical conditions such as diabetes mellitus, cardiac disease, and surgical emergencies such as appendicitis. Patients with treatable medical conditions are not required to suffer or die while in custody—except, tragically, in the case of addictive disease. Withdrawal syndromes are medical conditions, and they require the same medical evaluation and treatment as other medical conditions. Correctional facilities which do not provide appropriate evaluation, treatment and referral for serious cases of alcohol withdrawal, place themselves in a position of civil liability for any harm or death incurred by individuals in withdrawal; still, too many jails and prisons still do not provide these basic health care services to inmates.
Health care services in jails and prisons have received increasing attention in recent years as the number of prison beds has mushroomed and the number citizens incarcerated in America has grown dramatically. Correctional facilities can receive guidance on appropriate policies and procedures for screening and referral of health care conditions by consulting a national quality assurance body, the National Commission on Correctional Health Care.
In light of these circumstances, ASAM recommends the following:
1. Individuals brought into custody by criminal justice authorities should receive appropriate general medical screening to assure that their medical needs will not go unaddressed during their incarceration. The circumstance of being under arrest, detained, jailed, or imprisoned should not preclude access to and provision of medically necessary treatment for alcohol and other drug withdrawal.
2. Individuals with addiction who are placed in jails or prisons, should not be discriminated against because of their diagnosis. Prisoners and other detainees with addiction should receive the medical care necessary to manage withdrawal syndromes, just as they receive the medical care necessary to manage any other acute illnesses or injuries.
3. Given the high prevalence of substance use and addiction among individuals who are arrested or detained in jails or other correctional facilities, individuals should be screened for the presence of, or risk of, addiction and withdrawal at the point of entry into a criminal detention facility. Appropriately trained personnel should conduct screening. When screening identifies a condition of withdrawal, or a significant likelihood that withdrawal is present or could develop, affected individuals should be seen by a licensed health care professional who can make a definitive diagnosis. When medically necessary, such health care professionals should render appropriate detoxification services for the withdrawing individual, or arrange transfer to a health care facility where services will be provided.
4. Jails and prisons should revise any policies and procedures that preclude ill detainees from receiving necessary and appropriate health care services, including withdrawal management services, appropriate to their condition.
5. Whenever possible, jails and prisons should be encouraged to seek accreditation by the National Commission on Correctional Health Care.