by Douglas Ankney

When Missouri prisoner Robert Hebert learned in January 2023 that he had less than two years remaining on his prison sentence, the father of six and his family shared in the excitement. He planned to look for work in the concrete industry. Along with his wife, Rachelle Hebert, he started talking about visiting Mexico, California, and other vacation spots.

By the first part of February 2023, Hebert was awaiting transfer to another facility for drug treatment — the last leg of his sentence. But on February 7, 2023, Rachelle Hebert received a phone call informing her that her husband was in the hospital from an apparent accidental drug overdose. When she arrived, he was brain dead. He died later that day.

Hebert’s story is becoming increasingly more common. The federal Bureau of Justice Statistics (BJS) reported that from 2001 to 2018, the number of people dying of drug or alcohol intoxication in state prisons increased by more than 600 percent. Overdose deaths increased in county jails by 200 percent, BJS said. Data confirm that the pace of these deaths has accelerated over the years, with 2018 bringing the highest number of prison deaths since records began 20 years ago — though BJS has not yet released data for subsequent years.

Part One of this article outlines a broad overview of the crisis. Part Two discusses the varied ways that illicit drugs enter prisons and jails and the efforts to interdict them. Part Three explores the treatment options for opioid use disorder (OUD), the historical resistance by jail and prison officials to medically assisted treatment (MAT), and the progress being made.

Part One: The Scope of the Crisis – To the Extent It Can Be Known

The opioid crisis within U.S. prisons and jails parallels its explosion across the rest of America. By 2021, 75 percent of all overdose deaths were from opioid use — primarily fentanyl — pushing the nationwide death toll from all types of drug overdose almost 30 percent higher than it was just three years earlier.

Illicit fentanyl is often mixed with heroin, “although it has also recently been detected in cocaine and counterfeit opioid and benzodiazepine pills,” according to the National Institutes of Health (NIH). Arkansas, Maryland, and California have the dubious distinction of being leaders in the number of deaths from drug overdoses among people who are incarcerated. According to The Marshall Project, overdoses never ranked above fifth among causes of death for California’s prisoners prior to 2013. But by 2019, with fentanyl driving a national overdose crisis, only cancer killed more people than illicit drugs in California’s prisons. Visits to emergency rooms and overnight stays in the hospital stemming from drug overdose among prisoners also jumped by more than 50 percent between 2014 and 2017.

Alaska’s prisons rank fourth in the nation for drug overdoses. The major drug problem there is with methamphetamines, according to retired state prison guard Aprelle McCarty. During her 14 years on the job, she observed that “[i]t would come in waves. When the pruno – which was the homemade alcohol that they would make with fruit — when we started seeing a lot of that being made, then we’d know, OK, there’s not as many drugs in the prison because they’re turning to pruno.”

A prisoner identified as John spoke with The Marshall Project via a contraband cell phone and said he had never done hard drugs before entering federal prison about ten years ago. Now John “gets high every day and has tried everything from meth to heroin.” Other prisoners “fall unconscious with some regularity … usually from smoking paper soaked in liquid K2 [a synthetic marijuana], though they’re not really sure if there’s fentanyl or PCP on it, too.”

A survey of prisons in Puerto Rico published in Harm Reduction Journal in July 2009 was perhaps a harbinger of things to come. When 1,155 prisoners were asked: Have you witnessed someone suffering an overdose in prison? A whopping 488 men and 37 women responded in the affirmative. When asked if they knew someone who had died from an overdose in prison, 361 men and 29 women responded in the affirmative.

The widespread use of drugs in prison is not the only reason for the spike in overdose deaths. Drug abuse in prison is “uniquely dangerous,” says University of Chicago Professor Harold Pollack, because “[s]ubstances that come into the jail or prison don’t exactly go through the FDA lab to know what’s in there.” Additionally, “people in prison often use drugs when they’re alone and may be reluctant to call for help if there is a problem,” he added.

“Even if they do seek help, medical care is often scarce and sub-par,” the professor noted. “And access to drugs is erratic, which leads to rapid changes in tolerance, putting users at higher risk for an overdose.”

“If you seek help for your overdosing celly, that is tantamount to snitching,” said Enrique Alan Olivares-Pelayo, who served four years on drug and trespassing charges in Arizona prisons. Policy of the state Department of Corrections, Rehabilitation and Re-entry required that if staff found drugs on anyone, then the entire unit lost visitation privileges, all cells were searched, and the unit was monitored more closely. “You’d be watching someone turn blue and be on the fence about whether you should call for help or not because of the consequences of what’s this going to mean for everyone else,” said Olivares-Pelayo.

A former guard with the Texas Department of Criminal Justice, who asked to remain anonymous because she continues to work in law enforcement, said that “in the highest security areas of the facility, [guards] were required to find a backup before they could open a cell to check on an incarcerated person, even if they appeared to be overdosing.” Often it was not possible to find a second guard or an available guard supervisor to enter the cell, “either because they were busy or because they didn’t want to fill out the paperwork.” Unfilled staff positions at Texas prisons are as high as they’ve been in years, with some units barely half staffed.

According to Health and Justice Journal, opioid use and incarceration are “interrelated problems” in the U.S. That’s because incarceration rates are high among drug abusers. “Even prior to the current opioid-driven overdose epidemic, up to one-third of people who used heroin were incarcerated annually.” Moreover, opioid use disorder (OUD) “is more severe and advanced in justice-involved populations than in the general population” because of “diminished physiological tolerance to opioids” resulting from episodic access to drugs behind bars. This reduced tolerance “has been identified as a significant contributor to risk for drug overdose following release from incarceration,” which also drives a spike in the overall risk of death. As PLN has reported, that risk is up to 13 times higher in the first month following release from incarceration than that of the overall population. [See: PLN, Oct. 2022, p.58.]

Curiously, researchers who conducted a systematic review of medical literature using PubMed and PsycINFO uncovered not one single report of a fentanyl-related overdose in a carceral setting from January 1, 2013, through March 30, 2021. The researchers then Googled the “lay press” for the terms “fentanyl overdose in prison” and “fentanyl overdose in jail” for the same period. The Google search, after duplicate reports were identified and accounted for, resulted in “90 reported events comprising 179 fentanyl-related overdoses.” (An “event” was one or more reported fentanyl-related overdose(s) per day per facility, e.g., three prisoners overdosing on one day at a facility in Texas and two prisoners overdosing at a different Texas facility on the same date would be “two events” with five overdoses total.)

Of those 179 overdoses, 138 (77 percent) occurred in jails and 41 (23 percent) occurred in prisons. Seventy-six (42.5 percent) ended in death. One victim overdosed twice on different days. Forty of the overdoses happened in California, with 13 of the 40 occurring in a single event at Mule Creek State Prison in April 2018; 18 of the overdoses occurred in Florida; 11 in Pennsylvania; and 10 in Ohio. Put another way, California, Florida, Pennsylvania, and Ohio accounted for 79 (44 percent) of the 179 overdoses.

But research suggests that the number of fentanyl overdoses is actually much higher. The Sheriff of California’s Orange County, Don Barnes, told the local Orange County Register in 2020 that 70 detainees at the county jail had been given 129 doses of naloxone the previous year – a 300 percent increase over the 39 doses given to 32 detainees in 2018. But the research team found just one overdose at the jail in 2019 that was reported in the media. Researchers also said they were “anecdotally aware of six events of fentanyl-related overdoses and deaths that occurred in correctional facilities in two different states where the attending clinicians were told by their superiors not to report these cases in the medical literature.”

A similar discrepancy was uncovered by PBS News, which reported that records from the Alabama Department of Corrections (DOC) revealed at least seven overdose deaths in 2021, yet three of those deaths were classified as “natural deaths.”

Part Two: Drug Access and Ineffective Interdiction Efforts

The fact that there is demand for illicit drugs inside jails and prisons ought to surprise no one: “For decades, drug use in America has mainly been addressed through the penal system,” PBS News noted, and now “1 in 5 people behind bars are there for a drug offense.” The Alabama DOC said that drug crimes accounted for 30 percent of new admissions in March 2022. Nationally, drug crimes are far and away the leading cause of arrest, with drug possession — not sale or manufacturing — accounting for almost 90 percent of all drug arrests.

The 2016 National Survey on Drug Use and Health found that one in four people (25 percent) suffering from OUD had contact with some part of the criminal justice system the year before. Part of the reason can be traced to the prevalence of mental illness behind bars and the connection between serious mental illness (SMI) and substance use disorder (SUD). According to BJS, “almost 40 percent of people in prisons and 44 percent in jails have a history of mental illness,” and according to NIH, “[a]round 1 in 4 individuals with SMI also have an SUD.”

In prison, “people are bored and miserable and isolated, often self-medicating for mental and physical health needs that usually go unmet,” said Leo Beletsky, a law professor at Northeastern University studying the intersection of public health and law enforcement. “Is it surprising that there’s such a demand for drugs in detention settings? Absolutely not.”

The small size of a fentanyl dose — a lethal amount is equivalent to about 10 to 15 grains of table salt — and its extreme potency — estimated to be 30 to 50 times more potent than heroin and 50 to 100 times more potent than morphine — makes it the “perfect drug” for smuggling into prisons and jails. Drugs enter lockups in numerous ways. According to staff, as well as current and former prisoners, some of the more common methods include visitors, as well as packages or letters to incarcerated people. This doesn’t account for the majority of smuggled drugs. But it can be successful when friends and family members tuck strips of drug-soaked paper into mail or books, and prisoners either eat the paper or roll it up and smoke it. Prisoners initially entering a lockup or returning from furloughs or outside work details also hide drugs in body cavities.

In January 2015 in Cincinnati, Tehani Teepe, 39, attempted to smuggle heroin to her incarcerated boyfriend, Timothy King, 28, by soaking a Bible in it. Deputies didn’t become suspicious until a drug-sniffing K-9 alerted them. Eventually they found a stain in the Book of Daniel about the size of a half-dollar and had it tested. It proved to contain enough heroin to be broken into 30 or 40 hits and distributed among the detainee population.

Earlier, in March 2011, relatives of three detainees in New Jersey’s Cape May County Jail dissolved suboxone into a paste that they painted into a coloring book. They then mailed it to a detainee as a “gift to Daddy.” Again, authorities didn’t become suspicious until another detainee told them to look for an orange-colored paste. At that point the book was seized, and five people involved were criminally charged.

In August 2022, a Kentucky prisoner died after overdosing on methadone-soaked underwear. Michael Jones was charged with murder after authorities alleged he brought the underwear into the facility upon returning from a court-ordered furlough.

In February 2023, four men were indicted in the U.S. District Court for the Eastern District of California for using a drone to smuggle methamphetamine, heroin, cocaine, marijuana, cellphones, cellphone accessories, butane oil and other items into several California prisons for sale and distribution inside.

Another smuggling method is to hide drugs in balloons that are then swallowed by prisoners. The prisoners return to the facility from visitation or from work furlough and retrieve the balloons from their stools. Other methods are even more unusual. In 2007, prisoners in New Zealand had friends hide drugs in dead birds and then throw the birds over jail walls into the exercise yards.

But recent evidence indicates that the majority of illegal drugs enter jails and prisons via staff. During the COVID-19 pandemic, visitation from family and friends was suspended at most lockups. Teachers, tutors, and volunteers also stayed home. Even attorney visits were restricted. Yet drugs continued to find their way behind bars. In Texas prisons, the Marshall Project reported, “the number of incarcerated people disciplined or charged for drugs actually increased during the pandemic.”

New York City Council Member Carlina Rivera (D-Manhattan), who chairs the Committee on Criminal Justice, pointed out that there was just one overdose fatality at the city’s Rikers Island jail complex from 2017 to 2020, but nine in just the first six months of 2021 — along with 431 overdoses reported by the city’s DOC.

“The fact remains that drugs were getting into the jails even when visitation was suspended during the pandemic,” she said. “So, what is the screening process for staff? And what is the process for mail like?”

Tim Cutt, director of the Missouri Corrections Officers Association, said “it’s widely understood within the [state DOC] that mail is just a small segment of how drugs enter into prisons.” He acknowledged that “the primary channel that drugs enter Missouri prisons through is staff.”

Former federal Bureau of Prisons (BOP) nurse Ruben Montanez-Mirabal, 33, was sentenced in 2023 to six years in prison for smuggling “more than 100 pages soaked with synthetic cannabinoids” into a BOP lockup in Miami. From November 2021 until August 2022, Montanez-Mirabal either gave the pages directly to prisoners or hid them in places for prisoners to retrieve later. The former prison nurse made about $150,000 from the scheme and had access to luxury cars that included a Lamborghini and a Rolls Royce, as PLN has reported. [See: PLN, May 2023, p.63.]

Adam Barger served 25 years of an Alaska prison sentence, including time in Colorado and Arizona prisons where Alaska contracted space. “Narcotics were always more prevalent in facilities where [guards] were getting paid less,” Barger observed. He said friends and family members would wire upwards of $1,000 to guards for simply picking up a package and carrying it to work with them. “For people making $9.50 an hour, that is very very attractive.”

In spite of this evidence, BOP and the DOC in several states have chosen to attack the mail in their main effort to prevent drugs from entering facilities. The current “craze” involves photocopying or scanning all personal mail addressed to prisoners, who are then given either a photocopy or an electronically digitized version to be viewed at a shared kiosk or on a personal electronic device.

While the exact number of U.S. jails and prisons that are scanning mail this way is unknown, a November 2022 report from the Prison Policy Initiative (PPI) counted 14 state prison systems replacing original letters, cards, etc., with either photocopies or digitized images. Those included Arkansas, Indiana, Michigan, Missouri, Nebraska, New Mexico, New York, North Carolina, North Dakota, Ohio, Pennsylvania, Virginia, West Virginia, and Wisconsin. The authors of the report stated that they also “stumbled upon 15 jails that have banned incoming mail in favor of digitized copies.” They acknowledged that the number of jails and prisons photocopying/scanning mail is likely much larger. New York City DOC Commissioner Louis Molina estimated it’s the policy at about 140 jails nationwide.

Other prison systems are implementing the practice in pilot programs at one or more lockups but not yet systemwide. Those include Alaska, Colorado, Delaware, Florida, Iowa, Kentucky, Massachusetts, Minnesota, Mississippi, and South Dakota, as well as BOP.

These policies have met with considerable backlash. As Rolling Stone reported, “[f]or people who are incarcerated, mail offers a link to the outside world that extends beyond words or drawings on a page. Paper letters and cards let [them] hold and touch an item that a loved one held, running their fingers over the handwriting, or smelling perfume on an envelope.” In a recent article for the nonprofit Truthout, Ryan Moser, who is currently serving a sentence in a Florida state prison, wrote about receiving a three-by-five glossy photograph of his father after he died unexpectedly. “I held [it] in my hands for hours, memorizing his features before placing it reverently in my photo album for safe keeping.” But as Moser concluded, prisons and jails increasingly “are taking away those tangible ties to friends and family members.”

“Digitized love just doesn’t feel the same,” agreed journalist Keri Blakinger who chronicled her heroin addiction and 21 months behind bars on a drug conviction in a 2022 memoir, Corrections in Ink. “I was dating someone who liked drawing things instead of using words,” she said, “and having those drawings and being able to look at them and put them on the cell wall — that was all meaningful. That was a way of deepening and preserving a connection with someone in the free world.”

Wanda Bertram, a spokesperson for PPI, said that “mail bans are nothing but the flavor of the week in prison and jail policy,” noting the practice “started gathering steam” around 2017. “Policies like this tend to come in waves,” she said, “because a handful of prisons or jails will do it, and then it will catch on as a trend.”

Numerous studies have concluded that “it is essential for people who are incarcerated to maintain ties with communities on the outside, to better adjust to life after their sentence and to decrease recidivism.” Bertram added, “We’ve rounded up decades of academic research showing what anyone who was formerly incarcerated already knows — which is that the more you’re able to keep in touch with your loved ones, the better chance you stand at maintaining mental and physical health while you’re locked up, doing well in prison or jail programs, and at reentering society after your release.”

Many state prison systems outsource their mail scanning to private companies eager to profiteer off the misery of the incarcerated. A plethora of technical issues have ensued: delayed deliveries, blurred photographs with indistinguishable faces, unreadable letters, and missing pages. One prisoner’s mail started being scanned while he was working to develop his talents as a writer with the nonprofit Empowerment Avenue. He told the organization: “[D]on’t send mail. It’s too long, it never goes through. We’ve given up on mail.”

Professor Andrea Armstrong at the Loyola University New Orleans College of Law, an expert on incarceration law and policy, opined that “while prison and jail officials have a responsibility to maintain safety inside their facilities, they also need to consider public safety after incarcerated people are released, meaning preventing recidivism and easing people’s re-entry into the general population.”

“It is laudable that jail officials are trying to curb drugs within the facility. That is important and it’s exactly what they should be doing,” Armstrong said. “The question is: Can they do it in a way which doesn’t create other harms? And that requires data.”

But there is little, if any, evidence to support the theory that photocopying or scanning personal mail has had any quantifiable impact on the amount of drugs entering facilities. Yet there is evidence pointing to the negative effect the practice has on prisoners.

In June 2022, the Missouri DOC hopped aboard the mail-ban train, contracting with Texas-based Securus Technologies to scan prisoner mail and send digital copies that are viewed on electronic tablets issued to prisoners at admission. Until then, overdoses in Missouri prisons had averaged 31 people per month, based upon records beginning in 2017. After the mail-ban, July and August 2022 saw an average of 37 overdoses per month. And in September 2022, a total of 46 people overdosed in Missouri prisons. Fatal overdoses are designated “accidental deaths” in DOC records, and in 2018 less than 6 percent of deaths inside DOC facilities were “accidental.” From January through June 2023, though, that number shot up to 19.1 percent.

Missouri prisoners report that personal letters which took a few days to receive in their original format now take a week to arrive in an impersonal digitized copy. Amy Breihan, co-director of the state office of the MacArthur Justice Center, called the practice “dehumanizing.” Her organization used to send holiday cards to prisoner clients each winter. But since the start of mail-scanning, the Center ceased sending cards.

To make sense of these seemingly senseless policies, take the advice of PLN Editor Paul Wright: “Just follow the money.” Private contractors – such as Securus and ViaPath Technologies (formerly Global Tel*Link or GTL) – bundle mail scanning with other exploitative communication “services” already provided to prisoners, including telephone calls, video calls/visits and electronic messaging. Prisons usually receive a “commission” — a kickback — from the fees collected from prisoners and their families for these “services.” Any prisoner who can afford it won’t wait a week for a scanned digital image of a letter subject to missing pages when his or her loved one can send an electronic digital message “for a fee.” If the prisoner wants a printed copy, he or she can get one, too — for a fee. The prisons get a portion of every fee and do not have to pay staff to process mail.

Part Three: Progress in Spite
of Prison Officials’ Resistance
to Methods Proven to Reduce
Drug Overdose and Death

NPR News and The Marshall Project report that MAT using Suboxone and methadone is “the most effective treatment for opioid abuse,” citing the American Medical Association and “most other health experts.” But prisons and jails have dragged their feet in providing MAT — “a problem experts say is fueling the overdose crisis behind bars.”

Why do prison and jail officials resist providing these medications? For starters, they insist that prisoners and detainees are “off drugs” while incarcerated — as if pointing to their failed no-drugs policies somehow proves they aren’t failing, after all. As NPR News noted, “[t]he growing overdose death rates among people in prison belie this claim that prison or jail forces drug users to ‘get clean.’”

Officials also wrongly worry that the drugs used in MAT will simply replace those to which someone is addicted — “trading one addiction for another” — though that is not the way MAT drugs work at all.

Another team of researchers reported that “[t]he compounded problem of extremely concentrated, widely available and affordable fentanyl, and the lowered tolerance of individuals during incarceration, necessitates evidence-based interventions.” But most lockups aren’t doing anything, they found, and even “among the facilities that have attempted to respond to the overdose crisis, they have predominantly done so through increasing security and surveillance.”

The problem with that approach is that “increased surveillance and punishment among people using opioids was correlated to less likelihood to seek treatment and begin recovery,” the researchers noted. On the other hand, “there has been little focus on promoting” MAT and other “harm-reduction interventions” that effectively reduce overdose risk.

Medicines to treat OUD are commonly referred to as MOUD. The top three are buprenorphine (a.k.a. Suboxone), methadone, and naltrexone (not to be confused with the emergency overdose medication naloxone, often sold under the brand name Narcan). The U.S. government declared the opioid epidemic a “nationwide public health emergency” in 2017, a year after the 21st Century Cures Act and the Comprehensive Addiction and Recovery Act were signed into law in 2016. Those measures allocated billions of dollars to help states with the opioid crisis, including providing MOUD. But there is little evidence that any of this funding reached carceral systems.

One survey identified 23 states which accounted for 75 percent of all opioid deaths in 2019 and then set out to interview their prison system personnel, ultimately succeeding in 21 of those states. Of the many questions asked, three related to the barriers to providing MOUD to everyone with an OUD in prison. Two-thirds (67 percent) of the state DOCs responded that the state lacked needed funds to hire the medical and clinical staff to administer buprenorphine and methadone, and 43 percent reported lack of funds for naltrexone administrators. Additionally, 50 percent of the prison systems reported that the state lacked funds even to purchase buprenorphine and methadone, and 71 percent reported the same problem with purchasing naltrexone.

But providing MOUD to opioid abusers while they are incarcerated does more than reduce overdoses. It also has long-term effects after release from incarceration. A 2019 study reported in the Journal for Substance Abuse Treatment looked at MAT outcomes from controlled trials involving 807 incarcerated people and found that it increased their engagement with other forms of treatment while also cutting use of both illicit opioids and illegal injection drugs.

The benefits of MAT persist after incarceration, too. An earlier study published in European Addiction Research in 2014 found that those who kept up with methadone treatments after release were 65 percent less likely to be reincarcerated than those who did not. Similar studies of prisoners beginning treatment with buprenorphine and naltrexone showed comparable results.

The bottom line is this: MOUDs work at ending overdoses and OUD, both while incarcerated and after release back into the community. While a majority of prison systems surveyed — over 80 percent — offered at least one MOUD, the treatment was provided only to a limited class of prisoners, such as pregnant women or people already on MOUD before incarcerated, or it was provided only at one lockup in the state.

While not an MOUD, naloxone a.k.a. Narcan is essential in the battle against opioid overdose. Naloxone is billed as “a fast-acting opioid antagonist that blocks the effects of opioids and can thus reverse opioid overdose.” Yet in the 179 overdoses uncovered by researchers in Part One above, naloxone was used in only 39 (22 percent) of the cases.

In a statement, the National Commission on Correctional Health Care (NCCHC) said that “[o]pioid overdose results in death from coma and cessation of breathing” which “is reversible through the immediate administration” of naloxone, “a quick-acting opioid antagonist” that prevents the user from the effects of opioids such as heroin and fentanyl, as well as other prescription opioids. Naloxone administration typically results in a return to consciousness, resumption of breathing, and, in cases of opioid dependence, onset of opioid withdrawal symptoms. In a situation where seconds matter, immediate administration of naloxone saves lives and reduces brain damage.

“Given this widespread need for and acceptance of easy access to naloxone,” NCCHC said, prisons and jails “can play an important role in preventing overdose deaths” by providing both opioid overdose education and naloxone, which research has shown to “reduce mortality.”

“At least five states have jails and prisons that have implemented overdose education and naloxone distribution programs, including providing naloxone kits to high-risk individuals at the time of release,” NCCHC noted, pointing to lives saved from Rikers Island in New York City to North County Correctional Facility in Los Angeles.

NCCHC supports “increased access to naloxone” in prisons and jails and “supports promotion of naloxone use” there. To prevent overdose deaths among those incarcerated and those recently released from incarceration, NCCHC recommends making naloxone kits “readily available to all people in the facility,” including “health staff, custody staff, and, optimally, people who are incarcerated.” Kits should also “be provided upon release to people with [OUD] and others at elevated risk for opioid overdose, as well as visitors.” Prisons and jails should also provide education on “opioid overdose and its signs, correct technique for administration of naloxone, and essential related procedures,” including CPR. Additionally, “[p]olicies, procedures, and training should be in place to ensure emergency transfer of the incarcerated patient to a facility equipped to treat overdose.” Once released from incarceration, those with [OUD] or at high risk for opioid overdose “should receive education on overdose and naloxone use, optimally in conjunction with family/friends/visitors.” And those who work in the facilities where they were held “should receive education on overdose and naloxone use,” as well.

As demonstrated by spiking rates of overdose and overdose death in lockups, the need to turn these recommendations into action has never been more urgent.  

Additional sources: American Addiction Centers, Harm Reduction Journal (July 2009), Health and Justice Journal, Human Rights Watch, Jefferson City News Tribune, Kansas City Star, The Marshall Project, NPR News, New Haven Register, PBS News, Prison Policy Initiative, Rolling Stone, Substance Abuse (Vol. 43 2022), WLWT

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