Dr. Kimberly Sue is the medical director of the Harm Reduction Coalition, a national advocacy group that works to change U.S. policies and attitudes about the treatment of drug users. She's also a Harvard-trained anthropologist and a physician at the Rikers Island jail system in New York.
Sue thinks it's a huge mistake to put people with drug use disorder behind bars.
"Incarceration is not an effective social policy," she says. "It's not an evidence-based policy. It's not effective in deterring crime. But we continue to rely on it for reasons that have to do with morality."
While a quarter or more of the U.S. prison population has an addiction to opioids, only 5% of those individuals receive medication for their chronic condition, Sue notes, despite the growing agreement among doctors that this approach to treatment saves lives.
Statistics suggest that women might benefit most from improvements in treatment, she says. The rate of death from prescription opioid overdose has gone up nearly 500% among women since 1999, compared with 200% among men. And in recent decades, women's rate of incarceration has grown at twice the rate of men's.
We spoke with Sue about her new book, Getting Wrecked: Women, Incarceration, and the American Opioid Crisis, which is based on firsthand accounts from female inmates she has treated.
This interview has been edited for clarity and length.
What are some of the arguments that jail is not the best public health solution to opioid use?
Incarceration in many cases harms people. We know that, for example, having been in solitary confinement increases your risk of death after release — like in the case of Kalief Browder, a young Bronx man who killed himself after three years at Rikers.
And the rate of opioid overdose in the first two weeks after people leave prison and jail is between 30 and 120 times higher than the general population.
In most of the county-level jails in this country, people are forced to withdraw off lifesaving, stabilizing medications [like methadone] against their will. Methadone is a treatment for opioid use disorder that you cannot access in jails in many places in this country.
There are documented cases of suicide around the country — including in my book — of people who are going through withdrawal in jails and either committing suicide or dying as a combination of medical neglect and loss of body fluids related to dehydration.
Can you describe that example from your book?
One of the women I took care of and interviewed at MCI-Framingham, a women's state prison in Massachusetts, was in the health services unit — where they send people when they're first coming in — and she heard someone withdrawing from methadone. That person was screaming — she was, you know, in agony. And then [my patient] stopped hearing her screaming. [My patient and other prisoners] tried to get the guards' attention. And they found out that she had hung herself.
People going through withdrawal in jail health facilities — it's not the same as being an inpatient in my hospital, with nurses monitoring you and someone with medical training taking care of you. These are cinder block cells where people are going through diarrhea, vomiting, sweats, muscle aches. And many jails around the country are getting lawsuits that are being settled for situations like this.
People in the commercial jail and prison system believe that what they do is the best way, but it's not the equivalent of the standard of care that we offer in the community.
How do jails and prisons explain not having methadone available, if that endangers lives?
And liquid methadone costs pennies. It's not a matter of cost — it's a matter of political will.
The way I like to describe it is, if your brother had a heart attack and then became incarcerated, we would continue all six of the lifesaving medications he was prescribed, no matter what the cost — even hundreds of thousands of dollars a year. But if he had an opioid overdose and became incarcerated, they'd just stop the medication he was prescribed for opioid use disorder — they just wouldn't give it to him.
In no other chronic health condition do we discriminate like this. There's such a stigma that's encoded into our policies.
You write about that in your book: "The crisis we face is not opioids. The crisis we face is a war on people who use drugs, and on our reliance on incarceration as a catch-all policy solution."
Yes. And it's not just opioids. As a doctor who takes care of people who use drugs, I don't have a problem with people who use drugs. But there are so many people in this country who really hate them and don't care if they die. Or don't care if they are able to have lives of dignity and respect.
Is that because of stigma getting in the way? The idea that if you do drugs, you deserve whatever happens to you?
Yeah. The idea that substance use is a disease of the will is very heavily entrenched in American ideology. We have a hatred of people who are dependent on anything — including the government — for support. The idea of people being on welfare, the idea of people not working. We have these very strong puritanical roots and the idea that we make our bed, we lie in it, and you pull yourself up by your own bootstraps. It pits people against each other in a way.
People who use drugs — they have a physical dependence on a substance. It doesn't necessarily mean that they're bad people, but our society tells them that they're bad people.
Notice that I don't call substance use disorder a disease. It's really much more complex than that. I don't want it to be all medicalized, because so much of the answer is not in medicine. If you think about getting addicted to heroin or pills in West Virginia, a lot of it might have to do with poverty. As a doctor, so much of what I'd like to be able to do for you is to give you a job, you know? To give you an education and more opportunities. I'd like to give you a prescription for housing.
How does all this more specifically impact women?
For as long as we've been a country, women have been criminalized — not only for substance use, but for disorderly housekeeping, for leaving marriages, for abortion, for lewd behavior. Women have been criminalized basically for being seen as deviating from a certain upper-middle-class white morality.
Because women have the potential to be pregnant or are often mothers, there's this added moralizing directed at women who use drugs. There have been laws, for example, that send women to jail for twice as long as they would sentence men for drinking in public, because of the idea that women had farther to fall.
Some of the women in my book were low-level drug dealers. And they didn't have anything to give prosecutors, so they would get thrown under the bus by the men who were much higher up who had more information. So they would take the rap.
The rate of incarceration of women is still relatively small compared to that of men, but it's gone up 840% over the past 40 years.
Other countries don't do this. Portugal is held up as one of those models.
What is different in Portugal?
Portugal has decriminalized drug use. So if someone has problematic substance use, they don't go to prison or jail for that.
So, is there no stigma associated with drug use there?
I just listened to a podcast episode by this guy who went around Portugal and asked people, "How does your society feel about people who use drugs?" And the people he interviewed were like, "They're just people struggling. It's not their problem — it's a social problem."
Basically, substance use is treated like a social condition, and all of the services that an individual would need get wrapped around it. They have mobile vans to bring methadone to where you're living. Their system shows that it doesn't have to be the way we do it in the U.S.
After Portugal decriminalized drug use, overdose deaths decreased by 80% and HIV rates went from 52% to 6%. It's not a perfect model, but it's so much better.