Thread by @JonGiftosMD

Yesterday was my last day overseeing addiction & drug user health services for patients incarcerated on Rikers Island. It was an intense almost 4 yrs learning about health risks of jail (there are many), & collaborating w/ dedicated CHS staff to reduce harms for those exposed. 1/

One of my proudest achievements was collaborating w/ medical, nursing & pharmacy to expand access to our jail-based opioid treatment program (KEEP), which had been offering methadone maintenance to patients w/ opioid use disorder since 1987, & buprenorphine since early 2000s. 2/

Jail is a dangerous place, & risks especially high for people w/ OUD. Forced withdrawal, which is norm in most jails & prisons, is associated w/ suffering & a dramatically increased risk of death -- both in jail & during post-release period. Methadone & bupe reduce that risk. 3/

When I started as a line doc in 2016, patients w/ misdemeanor charges w/ an OUD were eligible to start or continue methadone, & patients who entered on bupe were allowed to continue bupe. I routinely cared for patients *ineligible* for medication. The suffering was awful. 4/

Such charge-based restrictions were due to fact that NYS state prison system historically could not receive people on these medications (they now accept some people on methadone), & a felony arraignment charge or violation of parole meant person was at risk for state transfer. 5/

When I took over KEEP in 2017, we immediately analyzed the impact of charge-based restrictions - & found that 70%+ of patients w/ such restrictions returned to the community. Prosecutors charged high, people were routinely restored to parole. The predictive model didn't work. 6/

Given known harms of forced withdrawal, & established benefits of methadone and bupe in reducing post-release mortality, we immediately removed all non-clinical criteria for OTP enrollment. The census increased from 250 to 1000. Treatment rates improved from 25% to >75%. 7/

This change was jolt to system. But CHS doctors, nurses, pharmacists & OTP staff were incredible in their dedication to ensuring access for patients. This change also put pressure on larger system. If you were receiving justice-involved referrals, you must provide MOUD access. 8/

We are in process of analyzing impact of this change on post-release overdose risk, & hope to publish soon -- but in short, the impact was substantial. And as important, we did not have a single fatal overdose in jail among patients admitted after policy change. Meds work. 9/

Jail remains an incredibly toxic & harmful place. While these interventions reduce risk of dying while there, or upon release -- that does not mean jail is safe for anyone, & we must work to reduce & abolish use of these settings for rehabilitative or restorative purposes ... 10/

... but in meantime, we have shown that delivering methadone or buprenorphine maintenance to patients in a large urban jail is feasible, safe & effective, and should be the standard of care everywhere. Thanks to everyone who is fighting to make that a reality. 11/

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