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/

Brief thread on what I perceive to be a problematic, yet common set of views that underlie way our criminal justice system (and larger society) engages people who use drugs and/or struggle with addiction. Not all views held by all people, but these tend to travel together. 1/x 1. Many judge harshly the decision to start using substances. Despite an evolving understanding of role of genetic risk factors, & of common environmental exposures including trauma, mental illness, stress & poverty, many continue to view substance use & addxn thru a moral lens.

In light of recent discussion, I wanted to share brief primer on prescribing methadone maintenance for those interested. It will largely be drawing from the following article on Safe Methadone Induction & Stabilization, as well as clinical experience. 1/

drive.google.com/file/d/0Byheg1… First off, I was troubled but not surprised by my informal Twitter poll that showed the vast majority of medical trainees have little to no exposure to methadone prescribing for opioid use disorder. Outside of dose verifications for admitted patients, experience was limited. 2/

Jail: the churn vs. the grind (THREAD)

For past 2.5 years I have worked as a physician caring for patients in NYC jail, and as an advocate for humane drug policy. In light of #CloseRikers and efforts to transform jail-system, I wanted to share brief thread on jail dynamics. 1/ First, I want to remind people there is fundamental difference between jails & prisons. Jails city/county based & largely hold people detained pre-trial (many held in on bail). Most people do not know when they are leaving & unplanned release the norm. Key words: flux, chaos. 2/

This was a complex story to tell. And I appreciate @richschapiro overall thoughtfulness, and for including my quotes of caution around the lessons we take from Ms. Rivera’s journey through the justice system. A few extra thoughts. #Thread nydailynews.com/new-york/ny-me… In early 2017, reporting by NYDN made public the location of a gathering space for PWID known as “The Hole” in South BX. In a reflexive & short-sighted response, NYC bulldozed site w/o replacing it with safer alternative such as a SIF/SCS for people not ready/able to stop using.

Stigma, revealed.

A clinician approaches me to say that he disagrees w/ our effort to offer patients w/ opioid use disorder methadone or bupe maintenance while incarcerated. Better, he says, for us to “detox” as many patients as possible so they are “normal” when they leave. 1/ I shared some data, citing increased mortality risk for patients w/ OUD during post-release period & evidence suggesting these medications associated w/ large reduction in that risk. He responds by saying, “Well, I just don’t want to pay for it ... you know, as a tax payer.” 2/