Sheriff Warns That New White House Drug Policy Could Be Boon To Prison Suboxone Smuggling

Call it the opioid face-off.

In one corner is Middlesex Sheriff Peter Koutoujian; in the opposing corner is President Barack Obama's administration.

At issue is something called Suboxone, a treatment for opiate addiction containing buprenorphine and naloxone, which are narcotics.

"Suboxone is the most smuggled contraband in corrections today," Koutoujian told WGBH News. Koutoujian supports expanding drug treatment options, but is wary of more Suboxone falling from legitimate pharmacies onto the black market and into jails.

Meanwhile, earlier this month, U.S. Health and Human Services Secretary Sylvia M. Burwell announced that the federal government would revise the regulations governing how buprenorphine is prescribed.

In an effort to increase the use of the treatment drug, President Barack Obama's health-care regulators want to pump up the cap on how much of the drug doctors can prescribe and will expand on the current limit of 30 patients per doctor. According to a HHS press release, the new regulation "will be developed to provide a balance between expanding the supply of this important treatment, encouraging use of evidence-based MAT, and minimizing the risk of drug diversion."

“Updating the current regulation around buprenorphine is an important step to increasing access to evidence-based treatment — helping more people get the treatment necessary for their recovery,” said Burwell when introducing the changes, according to HHS.

Suboxone can be abused on its own and is a big problem at the Middlesex House of Correction and Jail in Billerica, according to Koutoujian.

"The challenge with Suboxone though, is that it is a diverted drug," he said. "It is something that can be sold on the black market. For the purposes of corrections, it is often smuggled in or attempted to be smuggled in and it is contraband inside our facility."

According to Koutoujian, who's been Middlesex County Sheriff since 2011, inmates take advantage of Suboxone in liquid form and have come with several clever ways to smuggle it behind bars. Some prisoners have gone so far as to disguise drug-laced paper as artwork from children, something the New York Times reported on as early as 2011. The Times article lists Suboxone as accounting for 12 percent of contraband seized in the state system. The Massachusetts Department of Corrections did not have data on whether it was the most-smuggled drug in the system for 2014.

Koutoujian said sometimes even the paper of the envelope itself contains the drug "so that when it gets to that inmate inside, it can be taken orally and they can get a high from it."

Under the brand name Suboxone, buprenorphine is part of a push for more medication-assisted treatment (MAT), which uses medicines like buprenorphine, counseling and behavioral therapy to treat patients addicted to more dangerous opiates like heroin.

It's important to have more than one treatment method for addiction, Alexander Walley, an assistant professor of medicine at Boston University School of Medicine, said, so different treatments can be used on different patients. Walley, the director of the Addiction Medicine Fellowship Program and the Inpatient Addiction Consult Service at Boston Medical Center, sees the spike in jailhouse smuggling of Suboxone as a reflection of the growing numbers of opiate addicts in the area.

As head of corrections for Massachusetts's largest county, Koutoujian runs an opiate treatment program at his Billerica jail using Vivitrol, a drug that blocks many of the pleasurable effects of opiates and helps in recovery.

"On the outside of correctional facilities, I think there's an important place for medically-assisted treatment," he said. "And methadone is one form and Suboxone is another form. I think as a society, we need to make sure that we are cautious about our expansion of access to Suboxone, because we can't be using something that was a step down for opiates now being used as a step up to opiates."

For Walley, the very fact that diverted Suboxone is so popular in jails shows that needs for more treatment of addiction behind bars.

"While I respect the view of the corrections personnel in their concern about buprenorphine being smuggled in, one of the major reasons it's being smuggled in is because they aren't treating people with it," Walley said. "It is really the standard of care and the corrections system is not providing that standard of care to their patients."

"It's fantastic that they want to start treating people who are incarcerated with Vivitrol, but the big concern and the unproved part of it is whether people get that next injection, whether they actually get treatment when they leave incarcerations."

The state Department of Corrections' director of reentry and program services, Chris Mitchell, says the state system has recently begun to consider an inmate's risk to overdose upon release along with the traditional metric of risk to recidivate.

"Our substance abuse treatment continuum is really based on an assessed need, then guides them through an intensive residential or nonresidential treatment experience which then follows them up until the point of release through a graduate program," Mitchell told WGBH News.

Mitchell described the "supportive wraparound services" the state now offers to released inmates, including Vivitrol injections, as intended to help keep them clean.

"What we were able to do was provide a true pathway from prison to the community that was bound by a treatment plan that was actually following them into the community to whatever the health center was that was going to be treating them," Mitchell says.

According to the federal Department of Health and Human Services, overdoses of prescription opioid pain relievers killed more than 16,000 Americans in 2013 and opiate deaths have more than doubled between 2010 and 2013.