Despite Congress’ directive for the Bureau of Prisons to make Suboxone and other medications widely available, only a small fraction of those who need the help have received it.

Suboxone works to treat Timothy York’s decades-long opioid addiction, effectively quieting cravings.

According to York, contraband drugs and violence are prevalent in the facilities where he has been held since 2008, and this has prevented him from getting the Suboxone he needs. Suboxone enables him to think and communicate clearly, and he has spent tens of thousands of dollars buying it from prison dealers. However, he has not been able to get it on a regular basis.

He was relieved to learn that the federal Bureau of Prisons was starting a program to expand access to Suboxone in 2019, and a pharmacist at the federal prison in Sumterville, Florida, said he was “priority 1” for treatment based on his medical records in 2020.

He still wants to eat.

Despite the fact that he was punished for using Suboxone without a prescription last year, York has been punished again for the same offence. According to his disciplinary log, he was placed in solitary confinement for a month and had his visitor privileges revoked for a year after being caught with the drug. He was also denied phone and email access for four months, and he was denied early release for more than a month in addition.

More than one city shares the same characteristics as York.

More than 20 people with addictions who are incarcerated in a federal prison were interviewed by The Marshall Project, and they all described the terrible repercussions of not being able to obtain the treatment that Congress has ordered prisons to provide.

Many prisoners reported Suboxone, which is about $20 for a small portion of a daily dose on the illegal market, is difficult to acquire. Some have overdosed, while others have gotten involved in risky and illegal money-making schemes to pay for it. Many have lost phone or visitation privileges or been sent to solitary confinement for taking the drug, York included. In 2016, more than 500 Bureau of Prisons employees were disciplined for taking Suboxone without a prescription, according to Bureau of Prisons data obtained by The Marshall Project through a public records request.

An anonymous bureau administrator familiar with the agency’s addiction treatment programs acknowledged the irony of the situation, given the bureau’s position. It is maddening,” he said.

Four years ago, Congress passed the First Step Act, which, among other things, requires the Bureau of Prisons to provide more prisoners with addiction medications, the most common of which is Suboxone. The medications can reduce opioid cravings, reduce the risk of relapse and overdose, and quiet them.

Yet the federal prisons are treating less than 10% of the nearly 15,000 prisoners who require it, according to the bureau’s findings.

In October, 21 prisons were not providing any addiction medication, and 59 others were treating 10 or fewer people—in many cases, just one person, according to bureau data obtained through a Freedom of Information Act request. The rest of the 121 facilities nationwide were treating a few dozen people at most.

The Bureau of Prisons declined an interview request and would not discuss individual cases, but spokesperson Emery Nelson said in a statement that addiction medicine (often referred to as medication-assisted treatment) is the ‘gold standard’ for treatment, and that the Bureau’s goal is to provide high-quality, comprehensive, and accessible medication-assisted treatment at all locations (Nelson, 2018).

The Suboxone program’s low usage rate in prisons is owing to a widespread misconception among prison staff that Suboxone substitutes one addiction for another, as well as to the fact that there is wide discretion among prison staff concerning who may be treated. Each step in the process requires approval from multiple health care providers, resulting in lengthy waitlists that must be crossed.

The Bureau of Prisons has been treating more people since it began its opioid treatment program. In 2019, 41 people received addiction treatment drugs. As of October 2019, 1,035 people received Suboxone, and 80% of them were incarcerated.

Sally Friedman, an attorney with the Legal Action Center, which has been involved in several opioid medication lawsuits against criminal justice agencies, praised the big improvement. However, the Bureau of Prisons must meet its constitutional duty to ensure that all prisoners with opioid dependency disorder receive life-saving treatment, she said.

The lack of widespread addiction medication from the bureau has consequences not only for prisoners but also for its employees: According to Aaron McGlothin, president of the federal prison in Mendota, California’s union, contraband enters the facility through other avenues because of it. Suboxone is not provided, and the BOP is therefore in violation of the law, he says.

People who are incarcerated may be prescribed medications to treat addiction; for years, the Bureau of Prisons actively resisted this practice. In 2018, the First Step Act was signed into law, and as a consequence, prisons and jails across the country began losing lawsuits from prisoners who claimed that it was cruel and unusual to deny them the addiction medicine they had been taking before they were confined.

The bureau issued internal guidance in 2019 specifying that all inmates at all of its facilities would receive addiction medications. However, the term ‘eligible’ is ambiguous, leaving room for interpretation.

Prior to beginning medication, prisoners must overcome several administrative hurdles, including obtaining clearance from mental health and health services, before seeing a physician. A records request from early this year indicated that more than 2,000 prisoners were stuck in limbo, waiting to move to the next phase.

Some believe that the problems at the prison bureau are caused by a culture that is opposed to drug treatment and pitted against prisoners.

A senior bureau administrator who has worked at more than 10 federal prisons says he used to be a Suboxone denier, considering it simply a “crutch.”

“My SHU count went down once I found a doctor who supported Suboxone and administered it to inmates,” he said, describing solitary confinement as the Special Housing Unit. “There were fewer fights, fewer debts, and drug dealers on the compound became unemployed.” This anonymous administrator mentioned, “I was convinced because I had witnessed it in action.”

When the director of a local prison shifted to a different facility, he discovered that the Bureau of Prisons’ official policy of providing addiction treatment was at odds with how institutions treated inmates. In some cases, only one drug was provided, while in others, facilities refused to provide any of the medications until close to release, he said.

“I have reached a point where people have been telling me, ‘It’s only for inmates who are close to their release date’ or, ‘We don’t have enough resources’,” he said. “I have a limited reach; I can’t order a physician to prescribe a medicine.”

Using Suboxone without a prescription in federal prison is considered a “most severe violation level prohibited act,” resulting in prisoners being denied release, having their belongings confiscated, losing their phone and visitation privileges, and being held in solitary confinement for up to six months—a practice human rights advocates have described as torture. Even a brief stint in solitary can exacerbate mental illness, which is often the cause of, or closely associated with, drug dependence.

Drug-related fatalities behind bars are on the rise, and Suboxone treatment is in short supply. A variety of substances are routinely smuggled into prisons and jails via mail, drone drops, visitors, or corrections officers and other staff. In the last two decades, fatal overdoses have increased over 600% inside prisons and over 200% inside jails.

According to internal bureau data released through a public records request, 47 incarcerated people died of overdoses from 2019 through 2021. The data does not specify how many of these overdose deaths were caused by opioids, nor whether Suboxone could have prevented them. However, other bureau information gives some indication: Correctional staff administered Narcan, a substance that counteracts opioid overdoses, almost 600 times during the same period.

Being in prison and surrounded by drugs is not a simple situation,” says Linda Wainwright, who was put in solitary confinement and lost nine months of early release as punishment for using smuggled Suboxone when officials would not give her a prescription. “I pleaded with them to assist me,” Wainwright says.

According to records, a prison psychologist at FCI Fort Dix, a low-security prison in New Jersey, was “shocked” and “at a loss” that Suboxone was repeatedly denied to Tyler Scher. The warden at Scher’s prison, in response to a grievance, stated that the purpose of the Suboxone programme was to prevent “relapse, overdose, and death” among those “scheduled for imminent release from the institution.”

Scher, who is serving 20 years for charges related to his girlfriend’s overdose death, complained of withdrawal symptoms and asserted that he could not stop using drugs without assistance. Drug use even led to solitary confinement, he said, and he had twice been cited for it. When he was in prison, he was offered a medication that he had tried before that didn’t work. When he requested Suboxone, officials told him, “You may resubmit a new request closer to your release.”

Suboxone film strips are frequently prescribed for prisoners. When purchased on the black market, the strips are split into 16 or 32 pieces, each of which is sold for $20.

Prisoners become both creative and desperate in order to pay for things with paltry prison wages.

According to Bureau of Prisons data, less than 1% of people incarcerated in a federal prison received Suboxone prescriptions as of October, one man said. According to a phone interview and letters from The Marshall Project, a man who wished to remain anonymous because he feared Bureau of Prisons retaliation broke his jaw and was sent to protective custody after telling other inmates lies because “I have accumulated debts and have been unable to pay for things.”

Suboxone debts can result in physical danger or violence, according to The Marshall Project.

Michael Swain was on a waiting list to get into the Bureau of Prisons’ Suboxone programme for eight months prior to his overdose. He says he committed a bank robbery to fund his addiction, for which he was convicted of eight years in prison. USP-Coleman was his prison, and he received Suboxone from an underground source, but the supply was erratic.

Last July, he became hooked on a more harmful drug, K2, a synthetic chemical known as Spice, which is impure and variable in potency and causes everything from a mild high to death.

Swain said that he began projectile vomiting, experiencing terrible sweats, and fainted in a phone interview.

He said medical personnel later informed him that he had lain in the infirmary for over an hour, mumbling incoherently and begging them not to let him die, according to Swain. Medical records show that after being brought to a nearby hospital, he had a seizure. Suboxone, a regular dose of which he would have avoided seeking K2, was provided to him.

He is still being told the same thing every time he queries the medical personnel about receiving Suboxone to treat his habit: “You were accepted and are now on the waiting list.”