To the Editor:
In January of 2023, the Office of Inspector General (OIG) in Connecticut released their Annual Report for 2022, which indicates that there were nine fatalities in 2022 from suspected drug overdoses among those in custody of CT Department of Correction (DOC). All nine deaths were ruled to be accidental.
These deaths are tragic, as no one should be dying in the custody of a state agency from a drug overdose, as drug overdoses are a preventable cause of death. These fatalities cannot be overlooked. These men were someone’s friend, parent, son, brother, cousin, neighbor, colleague. Nine people gone too soon.
James Allen Hayes
Illicit substances are making their way into prisons and jails across the nation. However, the Connecticut Office of Inspector General is still in the process of finding who provided the drugs to these men who died while in DOC custody. We know that as recently as one year ago a correctional officer was accused of bringing in drugs to Cheshire Correctional Institution in CT. Other states have also determined correctional staff smuggle drugs into facilities. Drugs make their way into correctional facilities through other ways, such as visitors or other incarcerated peoples.
Given that drugs enter Connecticut correctional facilities, what can we be doing better in Connecticut prisons or jails to prevent the harms of drugs? Even one death is too many. Nine is beyond unacceptable.
Let us begin with the recognition addiction is NOT a criminal behavior. Instead, it is a chronic medical condition impacting the brain, producing a very high risk of relapse. However, in the United States, we often criminalize those who use substances or those with substance use disorders. This practice largely began in the early years of the 20th Century when the United States established narcotic farms (i.e., prisons) to incarcerate individuals with repeated violations of drug laws. The problem worsened in the 1970s, when Richard Nixon’s administration – with the assent of Congress and most state governments – deliberately targeted Black communities across the US by carrying out a “War on Drugs.” This set of policies continues to wreak havoc on minority communities and White communities with few socio-economic resources. Importantly, criminalizing substance use has forced many people into prisons and jails when they should be receiving treatment for their chronic condition.
In these carceral facilities, it is more difficult for people to maintain their use of substances, as drugs are considered contraband. Perhaps you are thinking, well… isn’t being incarcerated helping them from using drugs then? Isn’t it better if they were just forced to stop?
However, abstinence-based treatment approaches for substance use disorders can be dangerous. Stopping use of drugs like opioids, inducing a period of abstinence, increases the risk of overdosing should one access contraband opioids. The safest approach for treating those with opioid use disorders in correctional settings would be universal access to evidence-based agonist medication treatment of opioid use disorders. This includes buprenorphine, methadone, or extended release naltrexone. Moreover, there are many prevention practices aimed at limiting opioid overdoses that have substantial data supporting them, such as drug supply testing and education about how to use substances safely.
All staff within DOC in Connecticut are trained on how to recognize the signs of an overdose (e.g., unresponsiveness, slowed breathing, vomiting). The Connecticut DOC staff are also taught how to administer naloxone (i.e., Narcan, administered nasally) which has the potential to reverse an opioid overdose and save a life. 100% of Connecticut DOC facilities have naloxone on their premises, placed throughout the prisons or jails for staff members to easily access if they are responding to an overdose. Yet, in most cases, correctional officers typically do not carry naloxone while on duty.
Additionally, when people are newly incarcerated, the DOC provides a similar training at facility orientations that covers recognizing overdoses and how to give someone naloxone. For Connecticut jails and York Correctional Institution (i.e., the only facility in the state that houses women), the facility orientations tend to occur within a few days of entry. For facilities in CT that house sentenced people, they will receive this training at orientation after 1 to 2 weeks of facility entry. Incarcerated men and women may receive this training again if they attend a substance use treatment program during their time. However, incarcerated men and women in Connecticut DOC do not have direct access to naloxone, despite it being a safe and non-abusable medication. Lastly, when incarcerated people are released back into the community after serving time, CT DOC offers them a naloxone kit, for free, alongside training if they need it.
Beyond these prevention measures, Connecticut DOC does provide some treatment services for incarcerated people with a diagnosed substance use disorder. In 2021, Connecticut DOC reported that approximately 425 incarcerated persons daily were receiving medication for their opioid use disorder. Since then, the number of people treated has increased to around 950 daily.
So, what more can we do?
To start, we need mechanisms that improve health and safety for carceral settings without exposing incarcerated individuals to strip searches, which is considered a form of state-sanctioned sexual violence. Connecticut DOC can invest in body scanning technologies to search for contraband, like substances, and require all individuals who enter correctional facilities – including all staff – to pass through these machines. These machines, which have been used in correctional facilities in Norway, have had great success at detecting concealed substances – without making people remove their clothes.
There needs to be an increased focus on examining why people are engaging in substance use in the first place, and subsequently helping people work through these challenges. This is especially important when we consider that many men and women entering prisons and jails often have a history of trauma (i.e., experiences of sexual abuse or neglect when they were young). To address these needs, CT DOC should increase access to programs for incarcerated people related to peer support or support groups, trauma informed care, and mental health care – including therapy and counseling.
Connecticut DOC should implement improved procedures for substance use disorder screening, diagnosis and treatment. In the US, it is estimated that 65% of incarcerated men and women have a substance use disorder. With approximately 10,000 incarcerated men and women under custody in CT prisons and jails at a given point in time, we are drastically undeserving people with this medical need if we have less than 500 people receiving medication for opioid use disorder. Moreover, it is possible that improved access to treatment for substance use disorders will curb incarcerated folks’ desire or need for other substances, which might reduce illicit substances making their way into facilities.
Harm reduction at its core meets individuals where they are with their substance use and tries to provide services for them to use substances safely. To combat the growing issue of substance use and overdose fatalities, public health practitioners have promoted the use of harm reduction approaches to limit the negative impacts that coincide with substance use. For instance, a harm reduction organization might offer syringe services programming for those who inject drugs to help decrease rates of HIV or hepatitis transmission. Importantly, harm reduction utilizes programs and methodologies that are evidence-based and grounded in human rights. These programs must be integrated into carceral settings.
This effort is supported by harm reduction specialists, such as Carol Jones at Alliance for Living in New London. She states, “Harm reduction is all about love… Harm reduction helps people who use drugs stay alive and lessen the harms associated with their use. It also comes from a place of support and connection – without shame or stigma. When I was treated with respect, and I felt that I mattered, I was able to address my own use of substances without judgment. Prisons, as a system, lack empathy and care for people who use drugs. To save lives, harm reduction programs must be accessible to incarcerated people.”
Connecticut DOC should thus consider implementation of the following: (a) improved, continuous education for incarcerated people and correctional staff regarding the signs of an overdose as well as the ever changing drug supply in Connecticut, (b) access to naloxone and fentanyl test strips for incarcerated individuals, and (c) have all correctional staff carry a naloxone kit on their person.
Ultimately, at its core, harm reduction is necessarily at odds with criminalizing drugs, given that criminalization ignores that substance use is a health issue that deserves treatment and care, not a criminal sentence. In the context of drugs and substances, decriminalization refers to shifting certain behaviors from being considered a criminal offense to something more along the lines of a civil offense or perhaps diversion to care.
And this is possible. Oregon citizens voted in 2020 to pass Measure 110, or the Drug Addiction Treatment and Recovery Act, which decriminalized simple possession of illicit drugs by removing criminal sanctions and instead people receive a citation. This citation may carry a fine, which can be avoided through the completion of a health assessment, set up by Oregon’s recovery 24-7 hotline team. Secondly, we can look to Portugal, which has served as a leading example globally of drug decriminalization reform. Portugal decriminalized simple possession and use of all illicit drugs in 2001. In doing so, previously criminalized activities related to substance use were shifted to be administrative violations. Simultaneously, the country invested in improving access to health services for substance use disorders (e.g., syringe exchange, treatment for use disorders, and more).
In sum, to prioritize the health of Connecticut, we should see that drug decriminalization is an important step towards this end.
Lastly, Connecticut DOC needs to inform the public in more depth about overdoses and overdose fatalities occurring in facilities. There is very limited information the public is able to access currently about these deaths, or what led to them.
For instance, we can see from the news that Robert Bracey was arrested on Wednesday, June 22, 2022 for having 3 ounces of fentanyl at his apartment. He was meant to appear in court for arraignment on July 6, 2022. This means Robert Bracey was in Connecticut DOC custody pre-trial (i.e., he was charged with a crime but not proven guilty of the crime) because he could not post a $175,000 bond. Yet, we know from the OIG report he died on Saturday, June 25, 2022. Just 3 days after his arrest.
Here in Connecticut we have so much to learn, and so much to improve on. How many non-fatal overdoses occurred in 2022? What is the demographic information of the people who are overdosing or dying from overdoses? Where did the overdoses occur in each facility? What can be done differently in the future to ensure another overdose does not happen at that location again? When are incarcerated people most at risk of an overdose in terms of day time, in relation to the length of their sentence, and other factors? What facilities are doing the best at prevention of overdoses and what can we learn from them?
Hill is an epidemiologist and a PhD student at Yale School of Public Health. She is a steering committee member of Stop Solitary CT