The Department of Justice (DOJ) recently "Guidelines for Managing Substance Withdrawal in Jails -- A Tool for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals." Spoiler Alert: This is a fabulous document that is going to cause seismic change and improve the way patients are treated for withdrawal in U.S. jails. You should read it even if you do not work in a jail.
I had been an emergency department (ED) doctor for 15 years when I was asked to provide medical care to the local jail. I had no idea of the different world I was walking into. Take substance withdrawal, for instance. I had seen occasional cases of heroin withdrawal in the ED; rarer still was a patient truly in alcohol withdrawal or cocaine withdrawal. When I started working in the jail, I was blown away by how many withdrawal cases I was seeing. It makes sense: when people go to jail for driving under the influence or heroin possession, they are going to go through withdrawal and some of that withdrawal is going to be severe. People get very, very sick from withdrawal.
It is hard to overstate how common withdrawal is in jails. I'd go as far as to venture a guess that more patients are treated for substance withdrawal in U.S. jails than anywhere else, including all hospitals, doctor's offices, and clinics put together. Most general practice clinics will treat withdrawal once in a while. Even a moderate sized jail will treat multiple patients for withdrawal every day.
But there has always been controversy on how best to treat the various types of withdrawal. Many jails contract medical services to practitioners who have little prior experience in dealing with withdrawal and little training to boot. Many dangerous and false myths about withdrawal persist: the belief that patients do not die from opioid withdrawal, that you can monitor benzodiazepine withdrawal using the alcohol withdrawal scoring system (CIWA-Ar), and that you can treat alcohol withdrawal with Benadryl. All of these false beliefs can and do lead to medical disasters in some jails.
This is where the DOJ Withdrawal Guidelines come in. It is comprehensive (128 pages) but extremely well-written and therefore easy to read. The DOJ Withdrawal Guidelines begins with the proper way to screen, assess, and monitor incarcerated withdrawal patients, and then offers separate sections on the treatment and monitoring of four withdrawal syndromes: alcohol withdrawal, opioid withdrawal, sedative withdrawal, and stimulant withdrawal. An inexperienced jail practitioner or medical supervisor can find step-by-step instructions in each section to help set up a jail's policies and procedures and to answer questions about an individual patient.
I was glad to see the DOJ Withdrawal Guidelines discredit the common myths surrounding withdrawal I mentioned earlier. The Guidelines clearly say that opioid withdrawal can be life threatening, that benzodiazepines are the treatment for alcohol withdrawal, and not to use alcohol withdrawal scoring systems (CIWA-Ar) to monitor sedative withdrawal.
Throughout the Guidelines, the authors define minimal acceptable care. For example, in the section on alcohol withdrawal, the DOJ Withdrawal Guidelines states that a clinical assessment using an alcohol withdrawal tool "should be [initially] conducted at least every 8 hours" (bold font and italics in original). Another is benzodiazepine used to treat sedative withdrawal should not be tapered faster than 25% per week and that patients on a sedative withdrawal taper should be assessed by healthcare staff at least twice per week.
The DOJ Withdrawal Guidelines list only buprenorphine and methadone as acceptable treatments for opioid withdrawal, and state that these medications should be offered within 24 hours of jail entry to all patients with opioid withdrawal. I was happy to see that the DOJ Withdrawal Guidelines did not eliminate the alpha-agonists, clonidine and lofexidine, for the treatment of opioid withdrawal, although they are relegated to being second-line agents. The only two reasons that the DOJ Withdrawal Guidelines envision using alpha-blockers to treat opioid withdrawal are "when patients choose to taper off buprenorphine or methadone, and in preparation for initiation of extended-release naltrexone." To this, I would add that the alpha-blockers are useful in small rural jails without easy access to the legally required resources for methadone or buprenorphine.
Speaking of small rural jails, I wish the authors of the DOJ Withdrawal Guidelines had addressed the special challenges of these jails more thoroughly. Consider, for example, a ten-bed jail in a remote rural town without a hospital. In such a jail, deputies usually pass meds, and a nurse and a medical practitioner may visit only once a week. The only advice that the DOJ Withdrawal Guidelines gives to such jails is to use telehealth and to transfer patients to a hospital if they cannot offer the recommended treatment. This is good advice, but incomplete. For example, in my experience, when such a jail sends a withdrawal patient to the hospital, the patient may be sent right back without having received any meaningful treatment and certainly nothing conforming to these Guidelines. In the next edition of these otherwise excellent guidelines, I would like the authors to outline in more detail how small rural jails can overcome their unique obstacles to conforming to these guidelines.
Overall, the DOJ Withdrawal Guidelines is an excellent first step in improving withdrawal care of incarcerated patients. A Guideline like this, with "oomph" that jails cannot ignore, was sorely needed. But the road is a long one. I would guess that only a small minority of detention facilities already practice all of the principles of care outlined in the Guidelines. Hopefully, a significant group of detention facilities will proactively use the Guidelines to bring their withdrawal care up to standard. However, there will likely be a large group of detention facilities that will not change their substandard practices until they are forced to. The main reason for this inertia is money.
Almost all jails and prisons are underfunded and adherence to the DOJ Withdrawal Guidelines will require a significant amount of money to pay for more nursing hours, more practitioner hours, more security training, better facilities, and so on. State legislators and county commissioners have been historically reluctant to authorize funding to improve the healthcare of their detainees. Often, these changes only happen when driven by lawsuits. My prediction: The DOJ Withdrawal Guidelines are going to be cited in many, many lawsuits. I also predict that, over time, the Guidelines will evolve into the standard of care.
Congratulations to the committee who authored this excellent document! Because of their work, fewer incarcerated patients are going to die from withdrawal. Fewer patients will die from overdose when released from jail. And many more people will begin their lifelong recovery from addiction while incarcerated.
Jeffrey E. Keller, MD, is a board-certified emergency physician with 25 years of experience before moving full time into his "true calling" of correctional medicine. He is the president-elect of the American College of Correctional Physicians, and the author of .