In 2018, Congress passed the First Step Act, a wide-ranging prison reform legislation that, among other things, required the federal prison system to expand access to medications for people addicted to opioids. Amid a historic spike in overdoses, both inside prisons and jails and in the country at large, the idea was to save lives: These medications reduce drug use and protect against overdose, and the weeks just after release are a particularly vulnerable time for formerly incarcerated people.

The Act came with tens of millions of dollars for implementation. Yet bureaucratic inertia and outdated thinking about addiction treatment means the federal program is still serving only a tiny fraction of those eligible, The Marshall Project has learned.

As of July, the Bureau of Prisons had only 268 people on medications to treat opioid dependence, according to Jeffrey A. Burkett, who helps oversee the rollout of the program as the National Health Services Administrator for the BOP. This is less than 2% of the more than 15,000 people the bureau itself estimated were eligible, according to a recent Government Accountability Office report. Even as the Department of Justice — the parent agency of the BOP — investigates other prisons and jails for not providing these medications, the bureau “lacks key planning elements to ensure this significant expansion is completed in a timely and effective manner,” the Government Accountability Office said.

Methadone and buprenorphine — sometimes referred to as “medication-assisted treatment,” or MAT — both activate the opiate receptors in the brain, which quiets the compulsive cravings that are a hallmark of addiction and make it difficult to get high or overdose. They have emerged as the most effective treatment for opioid addiction: Decades of research show that they reduce drug use, overdose, death, crime, and risky behavior like sharing needles. A third medication, Vivitrol, blocks the opiate receptors and prevents the patient from getting high. It is also effective at preventing some of the bad outcomes associated with opioid use, though it is newer and has fewer years of research to back it.

For years, correctional administrators, as well as proponents of “abstinence-based” recovery programs, like Narcotics Anonymous, have been reluctant — if not outright hostile — to the idea of using methadone and buprenorphine (also known by its brand name, Suboxone) to treat opioid addiction. Unlike Vivitrol, which is strictly an opioid blocker, methadone and buprenorphine are themselves opioids and can be abused, which fuels suspicion and mistrust.

“They don't see it necessarily as a medical disease that has highly effective treatment,” says Michael Botticelli, former Director of National Drug Control Policy for the Obama Administration. “If this were any other medical condition, would we see this level of lethargy in terms of implementing what is the standard of care of treatment for a disease?”

At least 20 states now offer one or both medications in most or all of their state prisons, according to new research from Georgetown University and reporting from The Marshall Project — up from about four states in 2017.

Read the full article about the First Step Act by Beth Schwartzapfel at The Marshall Project.