WAIMEA, Kauai — Dr. Graham Chelius has lost count of the number of his patients who’ve died from a drug overdose, but it happens frequently enough that he posted this sign on his office wall: “Please help Dr. Chelius: Remind him if you need a Naltrexone shot to have at home for emergencies.”
“Having patients die from an overdose is a regular problem, it’s an everyday possibility,” the Kauai doctor explained. “I want my patients who are at risk of a drug overdose to know that they can talk to me about it, that I want them to talk to me.”
But Chelius aims to use medication to treat his patients for chemical dependency problems long before they get to the point of an overdose.
A family medicine doctor in Waimea, a town of fewer than 2,000 people, Chelius said he has prescribed medication to alleviate withdrawal symptoms and cravings for opioids, methamphetamine, alcohol or other drugs to more than 500 patients.
Medication-assisted treatment is not a miracle antidote to drug dependency, but studies have shown that medications like buprenorphine, also known as Suboxone and Sublocade, substantially reduce the risk of overdose deaths from opioid use and help prevent people from falling off treatment.
But for the sizable portion of Chelius’ patients who end up getting arrested while undergoing medication-assisted treatment, there’s a problem: In jail, the treatment stops.
Studies in the U.S. and other nations show a high risk of death from drug overdose for offenders released from incarceration, especially in the first few weeks after their release when they are much more sensitive to drugs following a period of forced abstinence.
In response, more than 30 states have enacted some form of medication-assisted treatment for inmates in recent years.
Hawaii joined those ranks last August when Chelius, fed up with watching the criminal justice system derail his patients’ treatment, helped staff at Kauai Community Correctional Center launch a revolutionary new program to introduce medication-assisted treatment to inmates.
With Chelius leading the charge as a volunteer, the program at the Kauai jail has evolved into an unfunded pilot project of the Hawaii Public Safety Department. The department’s Health Care Division Administrator Gavin Takenaka said he would like to see the still-developing Kauai program mimicked in correctional facilities across the state.
“Without Dr. Chelius,” Takenaka said, “this would not be happening.”
The use of medication to help inmates recover from drug addiction while doing time in correctional facilities has a controversial history, primarily because some of the FDA-approved medications are opioids, prompting concerns over the efficacy of swapping out one drug for another.
But the tides are turning. The devastation resulting from the opioid epidemic has gradually bolstered support for these programs in prisons and jails across the country. Various national studies show that medication-assisted treatment is more successful than abstinence-based programs. It also helps reduce violent crime and recidivism rates.
The National Sheriffs’ Association now supports jail-based medication-assisted treatment. And in 2018, a federal judge in Massachusetts asserted that failing to provide an inmate the opportunity to continue medication-assisted treatment while incarcerated is a constitutional violation of the Eighth Amendment’s prohibition of cruel and unusual punishment.
Last year, the Hawaii Department of Public Safety submitted an application for a $650,000 federal grant from the Substance Abuse and Mental Health Services Administration to launch a statewide jail and prison-based medication-assisted treatment pilot project. The application is currently under review by The Hawaii Opioid Initiative Operational Working Group.
The federal grant money would allow DPS to hire an addiction treatment specialist, cover medication costs and provide physicians in Hawaii correctional facilities with the required waiver training that allows them to prescribe buprenorphine, which is a controlled substance.
All told, 88% of Hawaii jail and prison inmates show some need for substance abuse treatment, according to research by Dr. Timothy Wong, a research analyst at the Hawaii Interagency Council on Intermediate Sanctions. About 14% of inmates have substance abuse problems that qualify as severe, Wong said.
The state plans to partially model its program for inmates on those already running at correctional facilities in Rhode Island, Takenaka said.
But the new program will more closely reflect the evolving project underway at the Kauai jail, where every Thursday Chelius volunteers his time to meet with inmates who could benefit from medication-assisted treatment.
“When your patients die from an overdose, it doesn’t feel good.” — Dr. Graham Chelius
Many patients don’t want to divulge whether they have a drug dependency problem for fear of legal consequences, Chelius said. Much of his work with the inmates is centered on building their trust.
“The problem is that you don’t want to get in more legal trouble if you’re already in jail,” said Chelius, who discusses his philosophy on chemical dependency and how to treat it on his Youtube channel.
“I think part of it is trusting that this doctor who wants to help you isn’t going to, like, undermine you by telling everybody that, ‘Oh, well, in addition to this guy’s burglary, he has also been using illegal drugs,'” he explained. “So part of it is gaining trust with the inmates so they know that this is a benefit to them, not a harm.”
There are other kinks to be worked out.
Most medical providers in the Hawaii correctional system are not licensed to prescribe key medications because they are controlled substances. A recently planned training session for medical providers at the Oahu Community Correctional Center was canceled due to the coronavirus pandemic.
Another issue is that medications like Sublocade, a long-lasting buprenorphine injection used to treat opioid dependency, are expensive. A single dose, which must be repeated monthly, costs $1,700, Chelius said.
Part of the project’s charge is figuring out how to link inmates to a community medical provider so they can seamlessly maintain their treatment upon release from jail.
Chelius said he’s also working to educate jail staff that the project isn’t only about providing inmates with good health care. It’s a means of addressing overcrowding by slashing recidivism rates, he said.
“It’s a new thing for the state to start thinking of the jail as a place to support a therapeutic program as opposed to a place to punish people,” Chelius said.
Helping start the state’s first medication-assisted treatment program for inmates has been frustratingly slow, Chelius said.
But he’s hopeful that by the end of the year he’ll be able to walk away from the Kauai jail and leave behind a working program that’s running smoothly — one that can be replicated in jails and prisons on the other islands.
“When your patients die from an overdose, it doesn’t feel good,” Chelius said. “It’s not a good day. It’s through my own selfish desire not to have a shitty day that I do this.”
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