(Read the first part of this series here)

No One prison in the United States currently has an Overdose Education and Naloxone Distribution (OEND) program that puts naloxone directly into the hands of inmates. However, they wouldn’t need to reinvent the wheel to implement one. The necessary medical and security infrastructure already exists, and naloxone could be integrated with few adjustments and almost no cost.

Naloxone kits stored in cells and toiletsor wherever prisoners are allowed access, would be a vast improvement over no accessible naloxone. But naloxone is the most effective when people can keep it on them.

Unlike OEND’s focus on community access, the following routes would make naloxone available to individuals. This won’t work for everyone, no matter how sturdy they are. “Good Samaritan” policy is implemented, for many people in detention it is not possible to be associated with drug use. Which they would be if they asked for naloxone, whether or not they use drugs themselves. But similarly, allowing prisoners to partner up if they want to — and some would — would make naloxone immediately available not only to them but to anyone with whom they share a cell or dormitory , without waiting years for a culture change.

Prescription and over-the-counter

Prisons distribute drugs to so-called “pill line”. Or two lines of pills, as is the case in Washington Department of Corrections facilities. One line is for drugs that are considered to be at risk of diversion or use without a prescription and operates much like a methadone clinic; if you take your medicine three times a day, three times a day, you wait in line to take your medicine and take your medicine under supervision when it’s your turn. The second range of pills is intended “keep from anyone” (KOP): medicines that you can take with you to your cell to use later. Naloxone could be prescribed using the exact same process, 30 days at a time.

Since 2023The Food and Drug Administration has approved several naloxone products for over-the-counter sale, meaning you don’t need a prescription to buy them. In prison, however, everything requires a prescription. But for a product without risk of addiction or diversion – aspirin for example – the prescription will be issued in KOP.

The KOP also allows prisoners to carry approved medical equipment, such as asthma inhalers. If you have asthma, refilling your KOP inhaler prescription works the same way some needle service programs work. “one-on-one” exchange. You have to return the old one to get a new one.

Another avenue already integrated into correctional medical services is what is known in Washington State as a Health Status Report (HSR). These are issued to inmates by medical providers and essentially serve as permits to carry various medical devices and equipment outside of the usual medications. If you use hearing aids, you need a KOP prescription for the batteries, but you get the devices themselves through an HSR. If you have complications from smoking and need a CPAP machine, same thing. Providers can issue an HSR for anything if there is a sufficient medical reason.

There is also a non-medical route: selling naloxone at the police station.

Distributing naloxone to prisoners in this manner would be a natural fit for OEND’s small pilot projects, as it requires the medical provider to meet with participants in person. Infection control staff would be the logical choice in any facility, due to the correlation between substance use and HIV/hepatitis C.

There is also a non-medical route: selling naloxone at the police station. This would be the equivalent of an over-the-counter product. You need a prescription for aspirin, but you can also buy it at the police station if you can afford it.

Sales could be made according to an individual protocol. A few county jails have sold vapes this way, albeit at a higher price than corrections could likely get for naloxone.

The kits would be considered too sensitive to be packaged and delivered with standard precinct orders, but there is already an individual protocol for items like that: they are issued as property. Televisions, for example. You’re only allowed to have one, and you can’t buy a new one from the commissary if you don’t return the old one.

Adding naloxone to a prison system’s asset matrix, the list of items inmates are allowed to possess, would potentially involve a policy change. This is not a reason why it can’t be done, it just means that the administration should make every effort to do it, while the other options could simply be integrated into existing infrastructure.

Security

Generic intramuscular naloxoneunlike nasal sprays like Narcan, is currently at least a failure in probably any US corrections department because it comes with a needle. And many assumed that an OEND pilot couldn’t use the nasal sprays for the same reason: they also contain a hollow needle. This is what pierces the sealed compartment containing the naloxone when the device is deployed.

Some prisoners are allowed to have embroidery needles or papers containing staples. The glucometers, with the small lancet to check your blood sugar, are issued HSR. These are not considered safety risks because they are not hollow. The needle inside nasal spray devices is hollow and, although it is a larger gauge than anyone would prefer, could be used to inject drugs. However, the security measures to control this already exist.

Each time a person with asthma picks up their new KOP inhaler, it is labeled with their identifying information, the date the prescription was filled, and the expiration date. In Washington state, officers are already required to inspect every cell every day and conduct more in-depth inspections at least once a week. All they would need to do is check that the device has not been tampered with, meaning that the plastic casing has not been opened to access the needle inside.

Medical equipment that could be used as a weapon – canes for example – is constantly distributed.

Another option is to give prisoners the same plastic boxes that naloxone is already kept in police stations. Boxes are not lockedbut have a tamper-proof security label. If the box has been opened, it is impossible to hide it. Officers could simply check to see if the box was opened during these same routine inspections.

Medical equipment that has sometimes been used as weapons – canes for example – permanently receives an HSR. It is understood that the potential safety risk is negligible and far outweighed by necessity.

Every time the doctor writes a HSR, a copy is sent to the staff of the inmate’s living unit asking them to inspect it during cell searches, as well as what signs of tampering to look for.

Naloxone is not dangerous. It cannot be used to get high, is not toxic if poorly administeredand would have no monetary value in prison.

Prisons exist to control and surveil. They are designed to implement exactly these types of protocols. Resistance to inmates’ access to naloxone does not come from security concerns. It comes from police culture and the moralization of drug use, and anything that suggests that prisoners have anything resembling autonomy.

It doesn’t ask them to do anything they aren’t already doing. I just ask them to do their job.

Part 3 of this series will be released later in December

Image (cropped) via Michigan Department of Corrections