April Sanders is doing her best not to let the staff at Mabel-Basset Correctional Center in Oklahoma know that she's in pain. She gave birth a few days earlier, and now her hands are shaking, and she's experiencing hot flashes followed by bone-deep chills that leave her slicked with cold sweat. Her stomach is churning—she doesn't have diarrhea yet, but she knows it's coming. The anxiety is so intense it's palpable; her heart races, her legs feel like they have worms crawling through them, and she can't stand still. She avoids the guards, because she doesn't want to be sent to the infirmary, but it's hard. This is prison, after all.
Sanders is enduring a forced two-week methadone taper, down from 120 mg daily. Most people who decide to taper from similar doses outside of prison do it over several months, or even a couple years, based on how well they tolerate each decrease. When I myself chose to taper from methadone (a long-acting opioid often used to manage recovery from addiction to heroin or other opiates) after having a child, it took about six months to come down from just 60 mg—half Sanders' dose.
Sanders gave birth to her son on September 14, while incarcerated on drug charges. Since having her baby, Rightway Methadone Clinic and the Oklahoma Department of Corrections have been fighting about how to handle taking Sanders off methadone. Albert Rios, the program director at Rightway, says that the two-week taper was a hard-won compromise.
"Our recommendation is that they taper at a slow pace," he tells me, "but the prison doesn't see it that way. There's a lot of research that if you taper too quickly the risk of relapse is high."
When I describe Sanders' story to Robert Newman, president emeritus of Beth Israel Medical Center and former assistant commissioner for addiction at the NYC Health Department, he has a blunt opinion. "It is simply medical malpractice, there's no way to sugar coat it," he says. "There is nothing to justify it. There is no benefit that can be aimed for." In response, the Oklahoma Department of Corrections says that the institution "has specific policies and procedures in place for the treatment and security of inmates that are in our custody." According to data published by Stateline last year, fewer than 40 correctional facilities in a handful of states provide agonist medicines (which block other opioids by attaching to the same receptors) to treat opioid addiction. Pregnant inmates housed outside of those facilities may get a brief stay from their detox, but face the consequences of withdrawal while recovering from childbirth.
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Whatever the morality or legality of Sanders' situation, it doesn't change the pain she's unnecessarily experiencing. That includes not only the physical pain of an ill-advised rapid methadone taper, but also the aftermath of childbirth—for which she reports having received no aftercare from the prison staff. That means no pain meds, no sitz bath, no breast pump. She says she did receive an ice pack for her milk-clogged breasts. Add to that the emotional toll of being separated from her newborn son, who she was only able to visit twice briefly in the hospital before being returned to Mabel-Basset. As disquieting as Sanders' story may be, it's not uncommon.
Donna Kleyling gave birth to her daughter in December 2016 while incarcerated on a paraphernalia charge at Northampton County Prison in Pennsylvania. She had been receiving methadone while pregnant before being arrested while pregnant. But Northampton—like most prisons across the United States—does not provide methadone to the general inmate population. Withdrawal during pregnancy can cause premature delivery or miscarriage if not conducted under careful medical supervision, which is a huge liability for a jail or prison.
As a result, many correctional facilities will provide agonist drugs such as methadone or buprenorphine to pregnant women who test positive for opioids. Once these women give birth, the medication, which creates a physical dependency, is discontinued. Kleyling says the prison staff provided her with a few doses of codeine, a short-acting opiate, but they stopped administering it by the time she began experiencing methadone withdrawal, about a week after her last dose. Mary Jeanne Kreek, a researcher who was part of the team that developed methadone treatment in the 1960s and who now heads the addictive diseases lab at Rockefeller University, says that it's normal for someone who is using a therapeutic dose of methadone—which she defines as 80 mg or higher—to have withdrawal delayed for up to a week after the last dose. Several patients have reported that once the withdrawals begin, they can last up to three months. Kleyling was forced to endure an intense, cold-turkey methadone detox a week after performing natural childbirth, a time when the body demands rest, not added stress. Because she was booked on a paraphernalia charge, it's impossible to ignore the fact that she would not have been forced to endure such treatment if the United States' drug laws better reflected the findings of addiction research. There's no medical basis for this kind of taper, Kreek says. It appears to stem from the common misconception that methadone provides a pleasurable high, which goes against the punitive nature of prison. But methadone works differently than the opiates people commonly abuse, which is why it's used for addiction recovery. A long-acting opioid with a half life between eight and 59 hours, it builds up in the patient's system and remains stable over time. Heroin, on the other hand, delivers rapidly and lasts a short period of time, creating intense euphoria. All of this to say: Methadone, when used correctly, does not get you high. And studies have shown that when administered to inmates, it helps reduce the rate of relapse after they are released. For Kleyling, the nightmare is over. She is now sober, lives at home with her daughter, and works to support them both. But Sanders' has only just begun her detox. How many other women are due to experience the same fate? Rios and Sanders tell me there are currently three other opioid-dependent pregnant women at Mabel-Basset, and countless more in facilities with similar protocols across the country. Many of them, like Sanders and Kleyling, will give birth naturally and then be forced to endure severe withdrawal while still physically and emotionally recovering.
Rios says that the prison dosing program was established in April 2017, in response to a pregnant, opioid-dependent woman who was arrested. When I asked what happened to that first patient—a woman named Sarah Peters-Helton—he said he didn't know. "They just stopped bringing her up here after she had the baby. We were not able to titrate her," he tells me. The prison staff told him she had declined further services.
That sounded strange to me, given the fear most methadone patients have about suddenly losing access to their medicine. So I contacted her husband and asked him to have her call me. When Peters-Helton spoke to me over the pre-paid prison calling system, the story she told me was very different from the report the prison gave Rios.
Peters-Helton delivered by C-section on August 18. She was on 50 mg of methadone, a moderate but still significant dose that she was taking to manage addiction to oxycodone and other opiates. Unlike Sanders, whose son was sent to the Neonatal Intensive Care Unit for monitoring, she was able to room with her newborn for three days while she stayed in the hospital. After she returned to the prison, she was placed in a solitary medical observation unit in order to be detoxed under supervision. There, she was denied access to the phone for four days, meaning she could not call her husband to check on her son's health that entire time. Peters-Helton is now back in general population.
Peters-Helton tells me she was given hydrocodone for a few days while detoxing from methadone at the prison. She does not know what happened to the oxycodone/acetaminophen tablets the hospital prescribed for her post-op pain. She was not tapered from the methadone. She says that they simply stopped bringing her the doses the clinic had provided.
"It was very rough," she says of the withdrawal. "My bones hurt. I had cold and hot sweats. My skin crawled. My incision [from the C-section] burned." Her husband tells me that when Peters-Helton was finally able to call him, she was crying in agony. Like Sanders now, Peters-Helton says she pretended the withdrawal had abated so she could be released from medical isolation, but that she was then given a top bunk and forced to carry her belongings on her own. Her incision ended up re-opening. When we spoke a week later, it was still healing. Because detoxification guidelines for inmates are so open-ended and do not specifically govern postpartum inmates, there tends to be a lot of variance, even within the same state. The general procedure, by all accounts, appears to be a forced taper. Jill Ferson, the clinic director at Mt. Vernon Hospital Methadone Clinic, reports providing methadone for pregnant patients housed at Bedford Hills Correctional Facility for Women and Westchester Women's Corrections, both in New York state. She says the care her clinic is able to provide to these women differs greatly depending on the facility. "What's really nice about Bedford is that they work with us to taper these women after pregnancy…We have a woman from Bedford who gave birth three or four weeks ago and is still coming to the clinic," she says. "At Westchester, once the women give birth, they usually cut the dose by half one day, wait maybe a day or two, and then take them off." My many attempts for a comment on this from the Community Relations office at Westchester were unsuccessful. John McCarthy, assistant professor of psychiatry at University of California, Davis, worked with pregnant women on methadone as a psychiatrist and addiction medicine physician for 40 years. He says that withdrawing women immediately after they give birth is "ridiculous," and not something he ever did while treating women who were not incarcerated. Newman, of Beth Israel Medical Center, agrees. "To let a patient go under withdrawal is unnecessary," he says. "It's cruel and inhuman punishment. We should not permit vicious hostility toward patients." Kreek tells me about the medication-assisted treatment programs she saw in the prisons of Sweden, Iran, and Israel. "What do these countries have in common?" she asks, "Politically, ideologically: next to nothing. They provide medication-assisted treatment because it's right and because it works."
Correction: The headline of this story was altered slightly to reflect an accurate timeline. The women in this story were not forced to begin tapering until after they gave birth.
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