By JC Grant
In mid-2019, about the time I was entering my second year of being in prison, I began to hear people eagerly talk about the advent in California’s prison system of a new medication being prescribed to addicts, or what is now properly described as people with substance use disorders. I didn’t really pay much mind, that is until the prescriptions began to hit the prison yard and I saw people who were without means suddenly pick up the allotted full amount of canteen, and pick up packs of brand new Under Armour shoes and clothing. I wondered what was going on and when I asked around, I was told, “They’re Suboxone rich.”
A pharmaceutical made by Indivior PLC, Suboxone is a prescription combo drug composed of buprenorphine and naloxone. It is classified by the DEA as a Type III narcotic and used to treat opioid addiction. The buprenorphine is the actual narcotic component (a semi-synthetic opioid) and the naloxone is an opioid antagonist, which are in a 4:1 ratio, as 
stated in the National Institutes of Health article Suboxone: Rationale, Science, Misconceptions by Jennifer R. Velander, MD, 2018 (found on their website at nih.gov). What this means is that the buprenorphine gives the user an opioid-like high and reduces cravings, while the naloxone counters the high and prevents overdose from actual opioids. Twenty years ago, the FDA approved the prescribed medication for those suffering from addiction to opioids/opiates (Timeline of Selected FDA Activities and Significant Events Addressing Opioid Misuse and Abuse, fda.gov, 10/04/2022). Before that, methadone was the only similar, viable option, an option that doesn’t prevent overdose, and could only be prescribed at federally licenced clinics. It is why, since Suboxone’s release, state prisons across the country have slowly incorporated Suboxone – usually in sublingual strips – into their prescription formularies and their Substance Use Disorder Treatment programs.
So it was, in 2019, that I witnessed the initiation of one of these programs.
Though generally ignorant and proudly uninvolved in the business of getting high in prison, I was quick to learn through fellow inmates that the small wave of people on Suboxone were making $75-200 per diem selling their strips. People smoke the strips; they mix them with a little bit of water and snort them; or they inject it with stolen syringes from medical. The money made varied, depending on the amount they were prescribed, the way they cut the strips, and whether they liked the person they were selling the bits of strips to. But like Adam Smith was so kind to point out, such prices could not hold when markets become flooded. As more and more people got on Suboxone, the resell value was drastically reduced. At the time of writing, the same strips that sold for $75-200 are now going for $5-10, if that, and many people on the drug take it for taking its sake. All who are prescribed Suboxone must first go through a ludicrously simple screening that consists in answering yes to a handful of historical drug use and cravings questions, then partake in a six-hour a week Substance Use Disorder course for a few months. A curriculum that mainly consists of two-to-three-week cognitive intervention modules that deal with not only the roots of addiction but with criminal thinking, anger management, and other psycho-social rehabilitative subject matter pertinent to substance use and incarceration. Official nomenclature refers to such application of the Suboxone drug to combat opioid use in an individual as MAT, Medical Assisted Treatment, and the use of cognitive behavioral programming and other methodology as ISUDT, Integrated Substance Use Disorder Treatment program. These two things combined, the California Department of Corrections and Rehabilitation and Correction Health Care Services asserts since the initiation to the program in 2019, that the MAT and ISUDT programs have been successful in reducing the amount of deaths from overdose in California state prisons.
In April 2022, CDCR released an updated version of their 2019-2021 “Impacts of the Integrated Substance Use Disorder Treatment Program” report, and in this twenty-four-page report, CDCR makes no substantive claims or shows any figures that indicate the program has been effective in reducing overall substance use, but it does sound hopeful in being able to achieve this with the backing of greater ISUDT programming access to interagency databases and further resources. What the report does state is that “prior to ISUDT program implementation, drug overdose was the third leading cause of death for CDCR’s residents; however by the end of 2020, it had fallen to the eighth leading cause of death, its lowest ranking in nine years.” Since then, the low numbers have remained. Another benefit CDCR sees in the program is in its goal “to reduce the risk of violence affiliated with drug interaction, debts, and prolonged substance use, which may make prisons safer for residents and staff”. CDCR is clear to state that “with the assistance of academic partners, CDCR and CCHS will evaluate the impacts of the ISUDT program on post-release outcomes such as recidivism, relapse, hospitalizations, mortality, housing, employment, and education.”
Three years after the start of the MAT/ISUDT Suboxone program, while I sat playing cards, a young man sat nearby and asked me “Do you mind if I do drugs next to you?” I shrugged and he proceeded to smoke a portion of a Suboxone strip with a couple of batteries, a razor and an empty pen. A safety razor blade makes a bridge between the positive ends of two AA batteries, causing it to super heat, providing a “lighter”. It was this event that prompted my desire to write this piece and research what, to me, seemed like a problem. At the time, I didn’t consider how many lives the drug had saved (I have, in my four and a half years in prison, witnessed two overdoses, all prior to the release of Suboxone into the system), nor did I know what staff, the incarcerated, and medical professionals felt, or had personally experienced with the drug. I was devoid of facts. Afterall, I am extremely limited in data access. So, I asked the man smoking the strip why he did it and he said “I have been clean off heroin for eight years. I will be going home soon and this makes me not want to use it.” I knew then I had to begin my learning and conduct some interviews.
My first interview was with a medical professional, a doctor at the California Department of Corrections and Rehabilitation. When I asked Dr T, who wishes to remain anonymous, what he thought of the program and its expansion (since its start in 2019), he said “It’s like a cult. They [the people who promote the program] protect each other, and once you’re in [the people on the drug] you can never get out. I asked him if he thought prescribing the drug helped the people it was prescribed to and he took a deep breath and said, “The way they [the folks who decided the program should be implemented] see it, is how many people are dying from fentanyl? And I have to remind myself that.”
“But people still misuse it,” I commented.
“Yes.”
“So, it’s like the lesser of two evils?”
“Yes.”
We talked about the various drugs people used in prison and at one point he scoffed, stating “We don’t treat meth addiction. If someone has a dirty UA [urinalysis drug test] for meth, we refer it to Custody. It’s Custody’s problem. We don’t treat that. But if someone is using heroin, then we are supposed to care about that,” referencing that if a urine test shows up positive for an opioid, that will get someone referred to treatment, i.e. the Suboxone MAT program. Dr T went on to tell me that there had been an article in the Sacramento Bee regarding the program (05/24/2021 “California prison doctors object to opioid treatment drug”) which in his opinion supported it. “When the article came out in the Sacramento Bee there was an internal email thread about it, about 5,000 doctors commenting on it. It got so crazy I just started deleting them.” I asked him if most doctors were for or against the program and he said, “Oh, definitely against it.”
I wondered if this perspective was limited to the non-resident population, or did people incarcerated feel the same way. I had to choose a person at random to interview, so I asked someone who was about to be released if he would fill out the proper consent form and sit and have a chat. Mr Adam Bernal agreed. It turned out Mr Bernal had been on the Suboxone MAT program for about six months, but got off it because he wouldn’t be able to qualify for fire camp (where he’d serve a lesser portion of his sentence). “What gets me is you can do all kinds of jobs on it [Suboxone]. You can work in the kitchen with hot pots and pans, but you can’t go to fire camp?” I asked him what his overall thoughts on the program were and he stated, “…It’s like herding sheep to slaughter. All they’re doing is getting you high, then let you get released. Now you’re chemically dependent on something and they want you to integrate into society, but how if you’re dependent on something already? You’re already in a set-back… Yeah, it stops you from doing heroin, but not other things. I think it just helps them get you hooked on something… CDCR is the biggest dope dealer, crack house there is… weed [cannabis] would be a better alternative than orange crack.” Orange crack is one of the names used to refer to Suboxone, because of its color.
Mr Bernal’s statement regarding being released, “hooked” on a substance, got me to wonder if Suboxone in any way paralleled in illegal sales on the street as it did in prison. He did make a good point. People are leaving prison with a desire, a want for Suboxone. Was there an outside black-market demand? So, I took to the law library and did some research. I performed some simple searches for published cases with the key term “Suboxone”, and the search rendered some interesting results. Turns out, there is case after case where people are arrested for possessing, selling, distributing and/or transporting Suboxone, but that isn’t the real surprising part. The surprising part is that the vast majority of the cases involving the using or abusing of Suboxone involve the possession of other drugs. Take, for instance, the case of People vs. Kennedy (2015), where officers found “15.33 grams of methamphetamine, 112 hydrocodone (Vicodin) pills, 49 Xanax pills, 14 diazepam (Valium) pills, seven doses of Suboxone, and a 0.08-gram piece of heroin.” And in that case, an officer testified that Suboxone was commonly sold on the street.
The officer’s comment prompted me to get permission from the Public Information Officer to interview some corrections officers or get a proper statement regarding their view on the MAT program, and collect the numbers on people misusing the drug within CDCR, but I received no response. What I did get was an off-hand comment by one CO, sharing with me that he thought the solution to the illicit trade was that CDCR should have designated prison yards where only people who were on the MAT program could reside. The problem with this approach is that it would allow the heroin trade to resurface on the non-MAT yards, and overdoses as well. But I didn’t think about this until later.
I couldn’t get any official response from CDCR or the institution Public Information Officer, but I knew the general view by the dozen plus COs I’d spoken to: they leaned towards thinking MAT and the dispensing of Suboxone is a terrible thing, and told me that their colleagues felt the same. So, I did a Public Records Act request pursuant to California Government Code Section 6253 asking to see the rules violation (RVR-115) data for the last four years for every prison in CDCR. I specifically wanted to see how many people were getting caught possessing, selling, or misusing Suboxone. Afterall, it was no secret that people got caught with strips in their possession, or trying to “cheek” their sublingual strips. What I got from my request was over 10,000 pages of data. And within a few hours I was able to find the few hundred kernels I was looking for. Or so I thought.
Stay turned tomorrow for part II.
JC Grant is incarcerated in California
