Our County Commissioners are Right about MAT
By Representative William M. Marsh MD
Our County Commissioners face a difficult decision regarding medication assisted treatment (MAT) in our county jail. And unfortunately this is not a simple black and white decision as portrayed in the front page article in the October 3rd edition of the Conway Daily Sun.
Everyone agrees that MAT should be available for inmates who began MAT prior to being incarcerated. This was the issue litigated in Aroostook County, with an appeal decided by US First District Court last April. Yet even in this case, it is not clear that ALL inmates should continue MAT. The American Society of Addiction Medicine in its public policy statement “Joint Public Correctional Policy Statement on the Treatment of Opioid Use Disorders for Justice Involved Individuals” dated 2/12/18 states only says “all individuals who arrive into the correctional system who are undergoing opioid use disorder treatment should be evaluated for consideration to continue treatment within the jail or prison system. Individuals who enter the system and are currently on MAT and/or psychosocial treatment should be considered for maintenance on that treatment protocol.” It is not necessarily appropriate for ALL such individuals to be continued on MAT – for some incarceration may be an opportunity to get off opioids.
However, that is not the question raised by Superintendent Henry’s proposed policy. The question is whether we should initiate MAT on individuals in our jail who have never been on MAT previously. Starting someone on MAT – especially without their informed consent – is not benign. Suboxone and similar drugs used for MAT are known to be addictive. The legislature discussed this last year in the context of my HB369 which was signed by the Governor 7/14/19, requiring the Prescription Drug Monitoring Program to be queried when prescribing such drugs. Starting an inmate on MAT while in jail commits them to a lifetime of addiction, which could easily be construed as cruel and unusual.
Furthermore, Suboxone is capable of being diverted if it is injected rather than taken orally. Superintendent Henry may not have fully considered the consequences if this occurs in the jail, but clearly this would create the potential for transmitting diseases such as hepatitis and AIDS in the jail.
It is not clear whether the jail’s medical officer has the expertise in addiction to differentiate those inmates who would benefit from MAT from those who would benefit from withdrawal. They are not a specialist trained in addiction. The American Society of Addiction Medicine recommends “Ideally, four to six weeks prior to reentry or release, all individuals with a history of Opioid Use Disorder should be re-assessed by a trained and licensed clinician to determine whether MAT is medically appropriate for that individual. If clinically appropriate and the individual chooses to receive opioid use disorder treatment, evidence-based options should be offered to the individual.”
We do not currently have the local resources to make such a determination. However, I have introduced legislation (LSR 2023) to take advantage of a recent change to Federal Law (21 U.S.C. section 831(h)) and allow this to be done using telemedicine. Once such resources are available, it might be very reasonable for the Commissioners to revisit this policy.
I see remarkable parallels between the marketing of Suboxone and related drugs to the marketing of OxyContin and related drugs back in the 1990s. Both ignore the addictive potential of the drugs being recommended to the medical community, and both are remarkably lacking in hard evidence.
Do others remember that in 1998, Purdue began it’s aggressive marketing campaign including the video "I got My Life Back" distributed to MD offices? Last month Reuters reported that Purdue Pharma LP filed for bankruptcy protection, succumbing to pressure from more than 2,600 lawsuits alleging the company helped fuel the deadly U.S. opioid epidemic.
Do others remember the role the Joint Commission for the Accreditation of Hospitals played? In 2000 the Joint Commission published a guide on pain management, sponsored by Purdue Pharma, denying addiction is an issue in pain control. In a case filed in 2017, Kenova v JCAHO, 4 West Virginia cities are suing the Joint Commission because they “grossly misrepresented the addictive qualities of opioids.” In 2001 the JCAHO published new standards requiring pain to be monitored as 5th vital sign. This spring 27 West Virginia hospitals filed suit against the JCAHO because they “zealously” enforced the standards through its accreditation programs.
Our Commissioners are taking a big step by allowing MAT for those on it prior to incarceration in our jail. We need to be prudent, evaluate this policy change, and make sure we have appropriate clinical resources in place before we consider starting people on MAT while they are in our jail. And we need to recognize the addictive qualities of the opioids used in MAT so we don’t once again make the problem worse through unintended consequences.
Representative Marsh is a Republican from Brookfield serving his second term in the NH House and on the County Delegation. He is a retired ophthalmologist who practiced at both Huggins Hospital and Memorial Hospital. He has served as a Trustee of Huggins Hospital since 2004 and as the Health Officer of Brookfield since 2002.