In 2018, Congress passed the First Step Act, a wide-ranging prison reform legislation that, among other things, required the federal prison system to expand access to medications for people addicted to opioids. Amid a historic spike in overdoses, both inside prisons and jails and in the country at large, the idea was to save lives: These medications reduce drug use and protect against overdose, and the weeks just after release are a particularly vulnerable time for formerly incarcerated people.
The Act came with tens of millions of dollars for implementation. Yet bureaucratic inertia and outdated thinking about addiction treatment means the federal program is still serving only a tiny fraction of those eligible, The Marshall Project has learned.
As of July, the Bureau of Prisons had only 268 people on medications to treat opioid dependence, according to Jeffrey A. Burkett, who helps oversee the rollout of the program as the National Health Services Administrator for the BOP. This is less than 2% of the more than 15,000 people the bureau itself estimated were eligible, according to a recent Government Accountability Office report. Even as the Department of Justice — the parent agency of the BOP — investigates other prisons and jails for not providing these medications, the bureau “lacks key planning elements to ensure this significant expansion is completed in a timely and effective manner,” the Government Accountability Office said.
Methadone and buprenorphine — sometimes referred to as “medication-assisted treatment,” or MAT — both activate the opiate receptors in the brain, which quiets the compulsive cravings that are a hallmark of addiction and make it difficult to get high or overdose. They have emerged as the most effective treatment for opioid addiction: Decades of research show that they reduce drug use, overdose, death, crime, and risky behavior like sharing needles. A third medication, Vivitrol, blocks the opiate receptors and prevents the patient from getting high. It is also effective at preventing some of the bad outcomes associated with opioid use, though it is newer and has fewer years of research to back it.
For years, correctional administrators, as well as proponents of “abstinence-based” recovery programs, like Narcotics Anonymous, have been reluctant — if not outright hostile — to the idea of using methadone and buprenorphine (also known by its brand name, Suboxone) to treat opioid addiction. Unlike Vivitrol, which is strictly an opioid blocker, methadone and buprenorphine are themselves opioids and can be abused, which fuels suspicion and mistrust.
“They don't see it necessarily as a medical disease that has highly effective treatment,” says Michael Botticelli, former Director of National Drug Control Policy for the Obama Administration. “If this were any other medical condition, would we see this level of lethargy in terms of implementing what is the standard of care of treatment for a disease?”
At least 20 states now offer one or both medications in most or all of their state prisons, according to new research from Georgetown University and reporting from The Marshall Project — up from about four states in 2017.
Which State Prison Systems Offer Medications for Opioid Use Disorder
States labeled “Yes” offer at least two of the three FDA-approved medications for opioid use disorder at all or most of their facilities. States labeled “Limited” offer medications only as a small-scale or time-limited pilot program, or only make them available to people under narrow circumstances (e.g. to detoxify people from opioids when they enter prison, or only for pregnant women). States labeled “Only Vivitrol” offer a Vivitrol program but do not offer methadone or buprenorphine. “No” means the state prisons do not offer medication-assisted treatment (MAT) of any kind to people inside the prisons. The remaining states did not provide information about their MAT programs despite multiple requests.
In 2018, the National Sheriffs’ Association published a resource guide arguing that more jails should provide access to buprenorphine and methadone. Hundreds of jails now do so — still a fraction of the nation’s 3,000 jails, but up dramatically from about 30 just two years ago. Also in 2018, a federal judge for the first time ordered a sheriff to provide methadone treatment to a man scheduled to serve 60 days in jail, ruling that not to continue the treatment the man had been receiving in the community would likely be discriminatory and cruel. Since then, at least eight additional cases have resulted in prisons or jails providing or expanding access to these medications.
In passing the First Step Act, Congress intended for the federal prison system to keep pace with the approach to addiction treatment that had evolved in the face of the opioid epidemic. The Act called for federal officials to expand access to MAT among those awaiting sentencing, people in prison, and to those living in halfway houses or under probation after release.
In 2019, Hugh Hurwitz, then-acting director of the BOP, submitted a plan to Congress as the Act required. In it, Hurwitz described MAT for opioid addiction as “one of the top priorities for this program,” and said the Bureau was offering Vivitrol. But the report didn’t specify how many patients were receiving Vivitrol, and never mentioned either of the other two medications. Four senators wrote a follow-up letter to then-Attorney General William Barr, chastising Hurwitz’s vague assurances and demanding to know the agency’s plans for expanding access to methadone and buprenorphine. Barr never responded, said Laura Epstein, a staffer for Democratic Sen. Maggie Hassan of New Hampshire, one of the signatories.
The bureau’s official silence on methadone and buprenorphine was set against the backdrop of the Department of Justice’s “Opioid Initiative,” which then-Assistant Attorney General John Gore described in 2017 as a program to ensure that people who get treatment for drug addiction “do not face unnecessary and discriminatory barriers to recovery.” Justice officials have threatened to sue at least three correctional agencies because not providing all three medications may violate the constitutional rights of people in prison with documented opioid addiction. Earlier this year, the U.S. Attorney’s office in New Jersey wrote to Cumberland County Jail officials that the medications are “the standard of care for treating Opioid Use Disorder, as it is far superior and more efficacious than other possible treatments.”
Yet even as the Department of Justice investigated other prison systems for not providing addiction medications, the Bureau of Prisons was doing precisely the same thing.
Melissa Godsey learned this the hard way in 2019, when she went before a federal judge for sentencing. Godsey was living in a Seattle homeless shelter with her children when she pleaded guilty to a credit card and identity fraud scheme she committed while in the throes of heroin addiction. By the time of her sentencing, she had been on Suboxone for about a year, and it had completely transformed her life, she says, freeing her from constant cravings and allowing her to focus on school and parenting. Yet even as the judge handed down a 2-year prison sentence, not a single federal prison was providing buprenorphine to people like her who were entering prison already enrolled in a treatment program, according to a federal official in court that day.
In the months before she reported to prison, she tried to taper off it, but she felt the old compulsions creeping in and even contemplated suicide. “If I had withdrawn in prison, I would have reached for anything to make it stop,” she said.
Godsey sued Bureau of Prisons officials, who ultimately agreed to provide her Suboxone during her prison term. It was the third time that year that the bureau agreed to provide addiction medications in response to lawsuits — and the last, as the agency finally began to roll out the MAT program bureau officials had been discussing as far back as 2016.
In the meantime, overdose deaths continued their grim climb, reaching a record 93,000 nationwide last year. It’s not just in the free world, either. Overdose deaths jumped by more than 600% inside prisons and by more than 200% inside jails in the last 2 decades, according to recent federal data.
Yet since the bureau began its MAT program in 2019, only 821 patients have been treated. The Maine Department of Corrections — which incarcerates 1% as many people as the federal prison system — has provided MAT to about the same number of people in that same time period, according to numbers provided by officials there.
In Maine, preliminary data shows a huge reduction in overdose deaths through the MAT program: People were 60% less likely to die of overdose in their first year out of prison if they had participated, said Ryan Thornell, Deputy Commissioner of Maine’s Department of Corrections. Once the Maine DOC helped the staff reimagine Suboxone differently from “the substance everybody was trying to keep out,” the black market demand inside the state’s prisons plummeted, Thornell said. Disciplinary write-ups for a wide range of incidents — fights, assaults on staff, positive drug tests, even self-harm — are also way down.
BOP Health Services Administrator Jeffrey Burkett provided the bureau’s enrollment numbers via email in response to questions from The Marshall Project, but phone calls and emails to the Bureau’s Public Affairs office to arrange an interview with Burkett or someone else from the agency’s MAT program were not returned.
Less than half of those treated by the BOP have taken buprenorphine or methadone, Burkett said: the majority were on Vivitrol. This medication is favored by corrections but not commonly prescribed in the community, says Dr. Joshua Lee, a New York City physician who has studied the use of MAT in correctional settings.
Vivitrol “does decrease cravings, and that’s good,” says Dr. Josiah Rich, an addiction specialist who cares for patients in the Rhode Island prison system. But the outcomes are better on methadone or buprenorphine, largely because people favor the other two medications and are more apt to seek them out and stay on them when they get home.
Because risk of overdose death is 129 times higher among those just released from prison than among the general population, ensuring that people stay on their meds when they’re released is essential. In Rhode Island, a program to provide all three addiction medications in the state’s prisons and jails reduced overdose deaths among the recently incarcerated bymore than 60% in two years.
The Bureau of Prisons is a massive bureaucracy that takes time to change direction. It runs about 200 facilities in 36 states, plus more than 150 halfway houses where tens of thousands of people are released each year to spend the last months of their sentences. Only 19 of the contractors who provide drug treatment services to people in halfway houses and on home confinement have staff qualified to provide an injection like Vivitrol and contracts that allow them to do so, according to the Government Accountability Office. The remaining contractors are not required to provide MAT, so unless the provider is willing to renegotiate existing contracts, the bureau has to wait, sometimes years, until it’s time to renew those contracts.
More than 100,000 people are also under supervision after release from prison, watched by probation officers all over the country. “We can do everything right, and it would still be pointless and counterproductive if U.S. Probation doesn't do what they need to do,” says William Bickart, who retired in 2020 after 30 years as a psychologist at the BOP. “We could get the drugs on board with these guys right up until the last day of confinement, but when they go over to U.S. probation, and if probation doesn't carry it forward, it doesn’t work.”
The First Step Act made similar demands on the Administrative Office of the United States Courts, which runs the federal probation program, as it did on the federal prison system. MAT is provided "relatively infrequently" to those on federal probation, the director of the office told Congress in his report.
The BOP allocated more than $70 million over the last two years to implement its MAT program, including about $37 million Congress provided to implement the Act, according to the GAO.
An internal BOP memo published in November and obtained by the Marshall Project lays out some early general guidance for medical staff implementing the MAT program. It says that people arriving in prison on already-established treatment plans are now allowed to stay on their medication. Those who want to begin medication once they’re already locked up can go through a process to determine whether they’re eligible, the memo says, though it provides few details about what eligibility looks like beyond a diagnosis of opioid use disorder and a medical screening.
Botticelli, the former drug czar, says blaming the size and complexity of these policy changes at the Bureau of Prisons is a red herring. “The data are unbelievably compelling in terms of the people who are overdosing and dying when they’re leaving jails and prisons, which requires a level of urgency,” he said. “If this were not addiction treatment, would we buy the argument that it’s just a big bureaucracy?”
Many state correctional systems — from the smallest (Delaware, Rhode Island) to the second-largest (California) have implemented MAT programs, treating people held in all or most of their facilities with all three FDA-approved medications.
The internal BOP memo acknowledges that the program is “a cultural shift for the agency at large” and won’t work unless it has full support from all employees.
There are so many moving parts that to get them all in alignment takes a champion at the very top, says Bickart, the former BOP psychologist. “To a large extent, the people at the highest level of the bureau don’t even know these obstacles. This is where we’re stuck. People at the top don’t have the bandwidth for details. When you work for the bureaucracy, you’ve got to try to get their attention.”