Need Suboxone at the Allegheny County Jail? Get up at 3 a.m.

Every night, Benjamin Sabo is jolted awake in his cell at the Allegheny County Jail.

A guard’s voice blares through the speaker mounted on the cell wall, rousing him from bed: “Sabo, your medication!”

He fights his grogginess and leaves his cell, joining a group of incarcerated people who, like him, have opioid use disorder . They sit in chairs while a nurse crushes tablets that treat the disease. They contain buprenorphine and are known by the brand name Suboxone .

She places the crushed tablet under his tongue and tells him to stay seated until it’s fully absorbed through the mucous membranes, which takes about 10 minutes. He opens his mouth so a corrections officer can shine a flashlight into it, illuminating every crevice to make sure all traces of the tablet have dissolved — a security protocol to make sure he took the medication as directed.

He returns to his cell and tries to fall back asleep. It’s a futile effort: He’s suffered from insomnia since he was a child and lies awake past sunrise, feeling the effects of buprenorphine — a synthetic opioid — wash over him.

This late-night distribution of Suboxone is part of the jail’s expansion of its medication-assisted treatment program in December — when it began offering medications for opioid use disorder [MOUD] to those who didn’t have a valid prescription when they were booked. The expansion followed the county’s agreement with the U.S. Department of Justice [DOJ], announced Nov. 30 , to provide such medications to all for whom it would be “medically appropriate,” instead of just continuing treatment for those fortunate enough to have a prescription before they’re arrested.

Sabo said he receives Suboxone in a single 24-milligram dose, often between 3 and 4 a.m., but always in the middle of the night while he’s sleeping, or trying to sleep. It’s not how he received it in the community several years ago, when he took three 8-milligram doses during waking hours, as directed by a doctor. He doesn’t feel he can recover on his current dosing schedule in the jail, which he described as “crazy” and “useless.”

“When they wake me up at that hour … it triggers a lot of more traumatic thoughts and scares me,” said Sabo, 35, who is a victim of gun violence. “It makes me not even want to go down and receive my medication. But I know if I don’t, then I’ll go through withdrawal. And I just don’t feel good most of the time because of the hour of the night that they give it.”

PublicSource spoke to medical experts, advocates, members of the county’s Jail Oversight Board, current and formerly incarcerated people receiving MOUD and their families. The consensus: The jail has taken a step forward in offering treatment for opioid use disorder to more people — unlike many carceral facilities in the state and country — but needs to do more to implement the DOJ agreement and best practices, which don’t include late-night administration of crushed medication.

The expansion of the program is “good to see, and the fact that they’re both inducting [new patients] and continuing — that’s great,” said Eric Hulsey, a senior technical advisor for Vital Strategies , a public health advocacy organization, and a former manager of behavioral health analytics for the county.

In 2021, Hulsey helped write an open letter — signed by more than 180 community members — urging jail and county officials to immediately offer buprenorphine and other “life-saving medications” to all incarcerated people with opioid use disorder.

But late-night distribution “is not what I had envisioned,” he said.

A jail official told PublicSource she knows “it’s not ideal to do it on that shift,” which takes place from 10 p.m. to 6 a.m. She attributed the decision to logistical and administrative challenges around the expansion of the program.

“That’s just kind of where we’re at right now,” said Renee Madden, deputy health services administrator of behavioral health, during an interview in April. But the jail is working on improvements: It’s hiring more nurses who are trained in substance use recovery treatment, with the goal of shifting the medication pass to an earlier time frame, she added.

A Jail Oversight Board member is hugely disappointed by the information she’s received about Sabo’s plight and the experiences of others receiving MOUD in the jail.

“The way that we’re doing it now is so detrimental to people who really could be getting a lot of help from an effective program,” said County Councilor Bethany Hallam, the board member who, along with many other people, has been pushing the jail to increase access to MOUD for years. “And so the fact that it is happening in this way blows my mind and is extremely frustrating, because again, for years I’ve been told it’s happening, it’s happening, it’s happening. This is what you came up with? This was the best you could do?”

The fight to bring MOUD to incarcerated people

Opioid use disorder is a brain disease that involves continued use of opioids such as heroin or fentanyl — even if a person wants to stop due to harmful effects.

People with the condition are criminalized at higher rates, according to research by the Prison Policy Initiative , an advocacy group that studies mass incarceration. Using 2017 data from the National Survey on Drug Use and Health , it found that over half of people arrested more than once that year reported a substance use disorder.

MOUD is the standard of care for people with the disease. Methadone and buprenorphine are particularly effective because they activate opioid receptors in the brain to relieve cravings, but access to them has historically been tightly regulated.

“I think it’s so hard for people to understand that giving people Suboxone is like giving people blood pressure meds or diabetes meds,” said Andrea Fox, the chief medical officer at the Squirrel Hill Health Center , who’s treated opioid use disorder patients who weren’t offered the drug in the jail. “It’s a life-saving treatment for chronic disease that people really benefit from.”

Both medications are safe when taken as prescribed, yet jails and prisons across the country have shown a reluctance to offer them . Stigma attached to the disease and “outdated views” among corrections officials “who think you’re replacing one drug with another” are part of the problem, said Sarah Bleiberg Bellos, a staff attorney at the Pennsylvania Institutional Law Project [PILP], which provides legal aid to incarcerated people.

The stakes are high when people are deprived of MOUD after they’re booked into jail: They endure painful withdrawal symptoms and face a high risk of death if they use after they’re released, due to their decreased tolerance for opioids.

In 2021, a majority of Pennsylvania’s jails — 42 of 62 — provided no MOUD, limited MOUD or ineffective medication, according to a PILP report co-authored by Bellos. Just four jails at the time offered to start opioid use disorder patients on buprenorphine or methadone. The Allegheny County Jail wasn’t one of them, though it was among 16 jails continuing MOUD for those with prescriptions.

That landscape may be changing, according to data provided by the Pennsylvania Department of Corrections [DOC]. A spokesperson wrote that about 40 county jails may now be continuing MOUD for those with a prescription, though the department doesn’t know how many are both inducting and continuing. She said the data may not be complete because information is voluntarily provided by jails, which the state doesn’t control.

Legal aid lawyers said they’re seeing increased access to MOUD in jails and prisons around the country, in part due to advocacy, lawsuits and the Biden administration’s enforcement of the Americans with Disabilities Act [ADA], which protects people in recovery from opioid use disorder.

“Anytime the U.S. government wants to put its weight behind an issue, that’s going to have an impact,” said Bellos. “What happened at ACJ is one example of that,” she said, though advocates had been doing this work “long before the DOJ got involved.” Their efforts have “started to have an impact on jails and really push them forward, recognizing how important this medical care is.”

‘It doesn’t take eight years to get this going’

In November, the Justice Department announced it had investigated a complaint from a person who said the Allegheny County Jail had denied him methadone, which he was receiving in the community before his arrest — an alleged violation of the ADA. It reached an agreement with the county to resolve the claims, which said the county’s failure to provide methadone to incarcerated people with opioid use disorder had denied them an equal opportunity to benefit from health care.

The county admitted no wrongdoing under the terms, but agreed to start offering treatment to all people with opioid use disorder incarcerated at the jail with any Food and Drug Administration-approved medications for the disease. It also agreed to contract with a licensed opioid treatment provider to start people on methadone, which is subject to stricter regulations than buprenorphine.

About a month later, the jail announced it had started patients without a prescription on one of three buprenorphine products: Suboxone (buprenorphine and naloxone tablets), Subutex (buprenorphine-only tablets) and Sublocade (a monthly buprenorphine injection). The county also issued a request for proposals to find a methadone provider, with the goal of inducting patients in the jail by October.

It was the milestone advocates had spent years fighting for: The Allegheny County Jail now offers greater access than the state’s prison system, which only inducts pregnant people on methadone or Subutex, and offers naltrexone — which can be less effective — to all other patients, according to a DOC spokesperson. Naltrexone blocks the effects of opioids, but will cause withdrawal symptoms.

A jail spokesperson said the jail had spent years laying the groundwork to expand its medication-assisted treatment program, which allowed it to act quickly after the agreement went into effect. Its program began eight years ago and progressed from offering MOUD only to pregnant people, to continuing it for people with a prescription, to induction for those without one.

How the Allegheny County Jail’s medication-assisted treatment program evolved over time

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In May 2021, PublicSource reported that nine people in the jail were receiving Suboxone, while 16 people were receiving naltrexone. By the end of last month, 173 people were receiving Suboxone, 42 were receiving Sublocade and eight were receiving Subutex. There were also 28 receiving naltrexone and another 28 continuing methadone through the jail’s contract with Tadiso , a licensed opioid treatment provider. That’s a more than tenfold increase in people receiving some type of MOUD in the jail.

“We were already working on all of these things,” said Madden, who is a licensed clinical social worker. “And I think the timing [of the expansion] just kind of came coincidentally together [with the agreement].”

Advocates see things differently.

Hulsey, who left the county’s Department of Human Services in 2019, said he had “reached [his] tipping point of fury” over the jail’s slow-walking on the issue while the opioid overdose epidemic raged in the region . It’s why he helped lead the organizing around the 2021 open letter that urged county officials to offer buprenorphine to incarcerated people who need it.

“It doesn’t take eight years to get this going,” he said, noting the county had access to the funding and expertise to get a program off the ground sooner. “The sad thing is it took a U.S. attorney and … ADA compliance to put them in a consent decree or equivalent situation … to force them to do this.”

‘The lack of sleep affects his ability to heal’

Sabo has a round face, close-cropped dark hair and wears glasses. He spoke to this reporter from behind a pane of glass in a visiting booth at the jail.

He had a difficult childhood: The youngest of five siblings, he was raised in Munhall by his mother, who suffered from alcohol use disorder. The family was evicted from housing and stayed with friends because they couldn’t afford to pay rent. Sabo struggled academically and left school when he was in the eighth grade, but he still had dreams: He wanted to be a professional skateboarder like his idol Mike Vallely .

At 21, he was prescribed Percocet for pain after a violent encounter outside a bar, which led to his opioid use disorder. He distributed opioids to support his addiction and cycled in and out of jail on charges such as criminal mischief and disorderly conduct.

He’s now incarcerated following his arrest in early October, awaiting trial in Beaver County for charges related to theft and check forgery, and faces a federal indictment alleging fentanyl distribution and firearms counts.

Sabo’s family is extremely worried for his health: In addition to insomnia, he was diagnosed with hypertension and mental health conditions such as depression and post-traumatic stress disorder. He has an infected leg wound and is at risk for amputation, according to a March 7 letter addressed to Madden, which was written by Jaclyn Kurin, a staff attorney for the Abolitionist Law Center , a public interest law firm.

“The lack of sleep affects his ability to heal, puts an unnecessary strain on his body, and makes it difficult for him to function during the day,” Kurin wrote. “The experience of being awoken in this manner is triggering and exacerbates Mr. Sabo’s mental health symptoms.”

His sister, Melanie Duffett, is a registered nurse. She believes he should receive Suboxone in three doses during waking hours, which kept him abstinent for several months in 2016.

“He wants to be clean, he’s looking at a lot of time, he deserves the care and treatment of a human being,” she told the Jail Oversight Board in March.

Advocates, legal aid lawyers and Hallam are supporting Sabo’s family by pushing the jail to distribute buprenorphine during waking hours, which they say is consistent with the standard of care in the community.

“They’re creating an environment that’s psychologically torturous and disabling,” said Tanisha Long, a community organizer for the Abolitionist Law Center. “These people aren’t getting the full benefits of being in recovery because they’re being woken up between 1 and 3 a.m.”

A jail spokesperson wrote that “while the timing may not be ideal,” most patients are grateful they’re receiving MOUD, which many other jails in the area don’t offer.

It’s why some people are forced to detox when they’re transferred to another facility, which is what happened to Sabo when he was taken to the Beaver County Jail for a court hearing in December. Beaver County Commissioner Chairman Daniel Camp didn’t respond to multiple emails requesting comment, and calls to that jail’s medical department went unanswered.

Why the jail is providing Suboxone late at night

Madden explained why the jail is providing Suboxone late at night: It takes longer to distribute than other medications because nursing and corrections staff must wait with patients while the tablets are dissolved under their tongues — which is how buprenorphine is absorbed into the bloodstream.

She said the jail doesn’t want to disrupt the daytime recreation of other incarcerated people, who must be in their cells while patients with opioid use disorder take Suboxone.

And more nurses must be hired and trained to provide MOUD, which she said the jail is in the process of doing. It’s struggled to fill health care positions in recent years and relied heavily on overtime labor.

“We would want to wait until we are absolutely ready to move that time,” she said, “so that it continues and is sustainable.”

A legal aid lawyer said the jail could be distributing Suboxone during its overnight shift — when fewer people are awake — to reduce the amount of staff it needs to follow security protocols, which are a top priority for jails.

“It’s important to remember that the 10-minute waiting period isn’t actually a required part of getting treatment,” said Rebekah Joab, a senior staff attorney at the Legal Action Center in New York, which was among the first to argue that denying incarcerated people access to MOUD violated the ADA. “Jails have made those protocols themselves, so it’s not technically something they have to do.”

The requirements Madden described are unique to MOUD and reflect how jails treat opioid use disorder differently from other health conditions, said Bellos, the PILP lawyer.

Even jails that provide this care “have all kinds of restrictions, weird requirements, or problems with program administration that lead to people not actually getting the treatment that they need,” she said.

If these requirements haven’t been imposed for medical reasons, they could pose a problem for the jail’s ability to comply with the ADA and its agreement with the Justice Department, she added.

The U.S. Attorney’s Office for the Western District of Pennsylvania — which signed the agreement — declined to comment through a spokesperson.

What doctors think of the jail’s approach

PublicSource described the jail’s distribution of Suboxone to four addiction medicine specialists. Two spoke on the record, while one was prevented from doing so by their employer and another declined because their facility receives funding from the county. None said they would dose a patient during non-waking hours.

“I think waking people up in the middle of the night is not consistent with standard of care,” said one doctor who declined to be named. “And I just don’t know anywhere else in medicine where you would do that.”

The jail’s policy of giving a single dose is likely to be effective, but doctors said a patient should be put on the regimen that works best for them. Some patients, like Sabo, feel better on smaller doses throughout the day, which one doctor said can be a powerful psychological need.

If a patient was receiving Suboxone before they were booked into the jail, they should be continued on the same regimen, said another doctor who declined to be named. But that may not be possible if the jail is only able to distribute it during the overnight shift.

Margaret Jarvis, who served on the board of the American Society of Addiction Medicine , called the jail’s decision to crush Suboxone tablets “just bizarre,” adding she’s not aware of any other providers that do it. It poses two risks: The staffer administering the tablet could lose part of the dose, and the act of crushing the tablet could remind a person of their drug-using days.

“I don’t see a need to trigger them like that,” said Jarvis, the chief of addiction medicine at Geisinger , a health system in central and northeastern Pennsylvania.

A jail spokesperson wrote that “there are diversion concerns with all medications in correctional settings,” indicating the tablets are crushed to reduce the risk of Suboxone being used or distributed in ways that are not prescribed. He said the practice doesn’t change the drug’s efficacy when it’s administered under the tongue, which PublicSource confirmed with three doctors, including one with medical toxicology expertise.

Experts said concerns about diversion are part of why so many jails either don’t provide MOUD or do so in ways that are at odds with evidence-based care. Some doctors are less concerned.

“The more Suboxone in the world, the better,” said Fox, of the Squirrel Hill Health Center, who’d only be worried if a patient was selling it to obtain more dangerous drugs. Even when diverted, Suboxone is often used for therapeutic effect and prevents overdose deaths, she added.

Nearly all doctors said they were glad the jail was offering Suboxone to more people, some of whom may become their patients after they’re released.

What’s next for access to MOUD at the jail?

Madden said the jail will keep working to improve its medication-assisted treatment program and is focused on moving the medication pass off the overnight shift. It doesn’t have a deadline for achieving that goal, according to a spokesperson.

New County Executive Sara Innamorato has pledged to improve correctional health care. She’s aware the jail’s staffing shortage has led to Suboxone being distributed in the middle of the night, and is “ prioritizing hiring … to ensure all individuals held at ACJ receive appropriate care while in custody,” a county spokesperson wrote.

The county will face an uphill battle while trying to find the staff to do this work, said Wanda Bertram, a spokesperson for the Prison Policy Initiative. Most medical professionals don’t want to work in jails and prisons, and would rather work in hospitals or community-based treatment centers.

“This is really just further evidence that jails are not ideal places for delivering MOUD,” she added. But treatment should be offered “if you’re going to warehouse people in these facilities.” This tension points to “a crucial flaw in our nation’s reliance on criminalization [of drug use]: these institutions were never intended to be — and can never function as — health care providers,” her group wrote in a briefing earlier this year.

Sabo is facing the possibility of being sent to federal prison. If convicted, he hopes it will be a minimum-security facility in West Virginia that’s within driving distance of his family, especially his mother, with whom he talks every day.

The federal prison system has had its own problems with providing MOUD, but he expects to receive better care in one of its facilities.

Until then, he’ll wait for the changes Madden says are coming.

“I would like to get my medication in a reasonable hour of the day,” he said. “I would like for them to be medical professionals about it and not just do whatever is easiest for them.”

Venuri Siriwardane is PublicSource’s health and mental health reporter. She can be reached at venuri@publicsource.org or on X, formerly known as Twitter, @venuris .

This story was fact-checked by Ladimir Garcia.

This reporting has been made possible through the Staunton Farm Mental Health Reporting Fellowship and the Jewish Healthcare Foundation.

The post Need Suboxone at the Allegheny County Jail? Get up at 3 a.m. appeared first on PublicSource . PublicSource is a nonprofit news organization serving the Pittsburgh region. Visit www.publicsource.org to read more.