Why are US prisoners not allowed sex changes or methadone?

Great Debates
21

I do prescribe methadone to inmates. But only as a pain medication (for severe malignant pain as a rule), NOT to maintain an addiction. I also prescribe buprenorphine to inmates (aka methadone lite) but only to detox an opioid addict who needs it. Most opioid withdrawal is unpleasant but completely non-life-threatening. But some folks coming off of high dose methadone do need an opioid taper, hence the use of buprenorphine.

Addiction maintenance for opioids is still somewhat controversial, and it works as a harm reduction strategy, but is fraught with peril in the form of drug diversion, misuse by the addict, and overdose resulting in severe debility and death. In a controlled environment such as a prison, complete abstinence is considered the better model of treating opioid addiction. It’s tried and true, with many thousands of former hopeless opioid abusers following that model and staying clean long-term. So why provide a dangerous narcotic to a person in a very high-risk environment when there are safer alternatives? Beats the hell out of me.

Transgendered patients can and do get hormone treatment in prisons. I know, because I prescribe a fair amount of estrogens, progesterone, and spironolactone to MTF transgendered patients. But gender reassignment surgery is still controversial. A number of studies show that transgendered patients who take hormones and dress/live as their gender of choice but don’t have the surgery are happier and do as well or better than those that had the surgery. Given that, why provide a high risk, irreversible surgical treatment when medical treatment seems to deliver outcomes which are as good? Evidence that surgery is better for a select subset of transfolks is often anecdotal, or based on very small numbers of patients.

If it becomes clear that surgical outcomes for carefully selected patients give better outcomes than medical treatment, then I will advocate for my inmate patients to be considered for the surgery. But right now, I don’t think the evidence merits it. But anyway, the final decision does not lie with me, but rather in the prison system I work in (Wisconsin) all recommendations for such new treatment (starting hormones, being considered for surgery) are made by the psychologists and psychiatrists treating the gender identity disorder.

Politics does rear its ugly head, and several state legislatures have passed laws forbidding using hormones or surgery to treat patients. But these laws have thus far been set aside by the federal courts, who seem to feel the state should not legislate decisions about individual medical choices. It’d be sort of like the state deciding to forbid the use of insulin to treat type II diabetic inmates, because if they just lost weight and follow their diets, they should be able to get by without it.

22

But what is life? I know that you managed to get off opioids very succesfully and I salute you for that. But there are many opioid addicts who just cannot - or at least not without all their days on earth being hell. Were it a case that physical withdrawal were all there is, then I would have more sympathy for the view of withdrawing opoids, after all the super duper worst case is 90 days of suffering (not that this should be ignored - 90 days of suffering opioid withdrawal is a far worse experience than most people will ever go through) but surely it has to be accepted that there are many addicts who will never, ever, get through the psychological torment of PAWS.

I don’t see how any humane state can subject them to those experiences. Tis a sentence of anhedonia at best.

That’s just speaking about what I at least partly understand first hand. But then we come to the transexuals. It is barbaric enough that a country like the US doesn’t provide proper healthcare, but once we co come to prisons where healthcare is supposed to be provided, Sevencl makes it ever so clear the intense suffering that this minority who is persecuted by practically EVERYONE is ignored for expediency. I salute your willingness to look at the literature and justify your treatments, but firstly I suspect you are in the minority - I honestly think that the usual situation is more like how it was described in my OP - and secondly surely this is something from the experts to look at anyway? It must be one of the most complex fields of medicine, given how it involves neurology, physiology, psychology, surgery, and so on…

P.S. I hope you don’t feel that I’m “picking” on you Qadgop - you’re in my top five posters easy - it’s cause I can expect a decent answer to this that I’m addressing it towards ya!

23

QtM was an opioid addict?

24

You got decent answers, you just need to accept that your premises may be flawed.

Most opioid addicts normalize psychologically after a few weeks, frankly. Cravings are not so soul-crushing as you seem to think. Unpleasant, yes. But once you’re over the physical withdrawal, it’s not nearly so bad. Anhedonia grossly overstates the experience of psychological withdrawal most of the time. Why keep someone doped up permanently for a temporary problem? That seems far crueler than allowing their nervous system to remodel back to baseline off the drug. I’ve dealt with thousands of opioid addicts in my life, from all walks of life (including impoverished refugees, rock stars and former governors.) Nearly all agree that their best times were when they were off the opioids. Attempt to kill all of life’s pain with opioids, and you greatly diminish all life’s real pleasures too.

As for the transfolk, we are trying to use proven strategies to reduce their psychological suffering. But they need to pick up the pieces of their lives too, and do their share of the work. I met my first transsexual patient in 1978, and I’ve worked with many since then. Many are looking for the next fix outside of themselves to make it “all better” (a trait shared by many other patients). But you know what? Usually that next fix just doesn’t work well or last long. And each fix gets more extreme. So we do hormone adjustments, treat depression and anxiety appropriately, push cognitive behavioral therapy, and encourage them to work to fit in the world, not expect us to remodel the world for them so they can feel better in it. Most have told me that they are about as happy as they decide to be at that point.

We treat legitimate medical needs. Not all the wishes and wants of our patients, even if they perceive them as ‘needs’. That way lies madness.

25

Yes, he’s talked about it in several threads.

26

Clean and sober over 22 years now. :cool:

27

To be clear, I meant a decent further answer. Everything I have ever seen you say on this board is decent, and I mean that :slight_smile:

28

Nope, opiate withdrawal is not particularly risky. It’s really unpleasant for the junkie, but it’s not risky. Now, cold turkey off alcohol can potentially kill you, but we don’t allow alcoholics to have booze in prison.

Cold turkey isn’t a usual treatment for addiction because it just gets the gunk out of the physical body, it does nothing for the psychological aspects of addiction which are much more likely to lead to a relapse. However, during the course of drug treatment an addict might choose to detox rapidly rather than drawing it out over weeks medicine does accept that, provided proper mental support is provided before and afterward to reduce the chance of re-using.

There is a technique called ultra rapid detox which attempts to compress withdrawal from days to mere hours. That is somewhat controversial, as it must be done under anesthesia which can further complicate the process and does carry some risk.

Some other drugs - alcohol and benzodiazepines - might require a tapering off of the drug for safety, but if a prisoner requires that they can be checked into a hospital until that’s done, then sent to prison without drugs in their system.

29

But methadone is meant to be a temporary solution – it’s not supposed to be a complete subsitute for opioids. I was always lead to understand that it’s only for the initial period of quitting, otherwise there’s the chance that people become addicted to methadone instead.

30

Not true actually, although it is often described that way. In practice the “dirty secret” is that most people who end up on methadone, except if it’s for a very rapid detox (in which case methadone is a pretty retarded choice tbh) are on it for life. And everyone is better for it so long as moralist conservatives don’t find out.

Sure, it’s even better if they end up on say heroin or dipipanone or similar, as then they are less zombified. But said moralists are very hard to bring around to such a way of thnking.

31

I’m feeling kinda cheated. Junkies in prison get methadone while I, a drunk who was never in the penal system, was stuck with cold turkey. :mad:
:wink:

32

Interesting…a Federal judge (Mark Wolf) has just ordered the State of Massachusetts to pay for gender changing surgery for a convicted murderer (one named Kosilek). This will cost the taxpayers about $150,000, plus $700,000 in legal fees. Kosilek murdered his wife 10 years ago, and has claimed that he is actually a woman. Talk abot insane…but this is completely logical (in this judge’s “mind”).

33

Cold-turkey heroin withdrawal sucks. It sucks worse when you’re in jail. Freezing cells with inadequate blankets, cellmate drama, gross food and having to shit your guts out in front of other people makes for a truly miserable experience. Thankfully, when I was a junkie, the most I had to deal with was being locked up overnight and then released on two separate occasions. I copped immediately afterward both times, and ended up using more than I would have otherwise because of the stress of being arrested (on one occasion my car, which I lived in, was impounded, the other time I missed work and got fired soon afterwards).

Now, I don’t think methadone would have been too helpful for me. For one, in the county jail systems I have had the pleasure to deal with, it takes FOREVER to see a nurse/doctor. After I was off dope, I was on medication for strep throat and was arrested for criminal trespass in Texas. They would not let me keep my antibiotics with me, and it took 3 days before I could get a doctor’s appointment, by which time I had already developed a staph infection in addition to the remnants of the strep throat. With a moderate heroin habit, I would generally be horribly sick for at most, 5 days. If I had to wait 2-3 days for a medical appointment, that means I would be halfway through acute withdrawals by that time. One might as well go cold turkey and get it out of one’s system all together.

What would have been helpful, I think, would have been referral to a non-jail rehabilitation place, an option for free methadone maintenance, or even appointments with a counselor. Incarceration for drug addicts does not work too great. Everyone I know who has been locked up for possession for a few months or years starts using again almost immediately. Rather than providing methadone for people in prison, maybe we should be making it easier for people to get low-cost, high-quality drug treatment on the outside. This needs to include cheap, easily obtainable methadone and buprenorphin, because it does work very well for some people and enables them to lead productive lives.

34

Define “initial period”. When I worked at a clinic that offered methadone maintenance when a person was brought in and placed on the program we expected them to be on methadone at least two years. In addition to a lot of counseling, that was the usual timeline before we’d attempt the first taper. Note I said “attempt” and “first”. It wasn’t uncommon for people to be on it much longer than that.

This usually shocked the “civilians” who, thanks to news stories about celebrities, seemed to have the impression that “curing” addiction was something you could do in 30-90 days.

Now, the “addiction to methadone” thing - opiate addicts, by definition, have a physical dependence on opiates. The idea with methadone is to swap methadone for heroin, but not give enough methadone to produce a high but rather to prevent withdrawal. That is the theory. In practice, getting that dosage right is tricky, not to mention the patient has incentive to attempt to manipulate the providers to get a higher dose than really needed for the purpose for that pleasant, slightly buzzed feeling.

^ This, to some extent. Personally, I’d rather have someone on a maintenance dose who can function as a human being, hold down a job, attend to personal hygiene, take care of their family, etc. rather than someone dysfunctional. We had a number of people at the clinic who were “long term” methadone maintenance, in some cases, for over 30 years. These folks all had decent jobs they had held for decades, they entirely paid for their own treatment out of their own pockets (that is, cost the taxpayer nothing), they were healthy, and they were law-abiding citizens. I find that much preferable to attempting to get these folks completely “sober” with a cycle of relapse-treatment-replapse-treatment. Yet that is not a popular notion. The “moralists” want complete sobriety at any cost.

Hey, I’d rather everyone be able to function without drugs, too, but let’s get a grip on reality. Not everyone is going to achieve that state. I think harm reduction is a very important concept.

Is there anything that doesn’t suck worse when you’re in jail?

I agree, incarceration and forced detox/withdrawal doesn’t work well. It fits in with the “moralist” notion that if we just get the damn drugs out of a person’s system they’re cured. Well, they aren’t. It works for people with drug dependence, which is a physical condition minus the psychological baggage of addiction but it doesn’t work on addiction… but then, many people have no notion of the difference between dependence and addiction in the first place.

The clinic I used to work at had a sliding scale - if you were employed you had to pay some percentage of your treatment (for the long-term clients with a good income that was 100% of cost) so the unemployed yes, got free treatment - which pisses the hell out of conservative/moralist/outraged taxpayers. We also had one hell of a long waiting list because we had more people knocking on our door than we had room to accommodate. ALL the methadone clinics in Chicago at the time had long waiting lists (I assume they still do) even the ones providing shitty treatment.

A junkie in full blown raging addiction can’t afford treatment - often they can’t afford their drugs much less food and shelter, at least not through legal means. Yet there are many who’d rather pay for incarceration that does nothing to really solve the problem rather than treatment that has some chance of solving the problem, and is also cheaper.

The world is a crazy place.

35

Qadgop, I was wondering, in the documentary sevencl posted several of the transsexual inmates attempted to or succeeded at cutting off their testicles or penis. Would that change your recommendation at all?

The prison, of course, attempted to frame it saying they were just being manipulative. And maybe, to an extent, they were. But if you want something to the extent you would cut off your penis, “manipulative” doesn’t seem like an appropriate word. One of them, Linda, describes how the minute she cut off her penis it felt like a huge weight was lifted off her shoulders, she felt much better. Would you say there might be cases where a transsexual does need surgery, for their own safety?

36

Sorry, this is clear: I mean would it change your recommendation for prisoners who try that?

37

I think OP already answered the question. If you want to pay a surgeon to mutilate your genitals, you can do that on your time and dollar instead of asking me to financially subsidize your delusions.

38

I’m not going to examine and rebut every point raised, as I’ve got other things to do today.

But I will make a few additional comments.

I’m certainly not claiming that forced abstinence is curative of addiction. But it can enhance the chances for sustained remission and improve responses to treatment. And since patients who are incarcerated are generally healthier both medically and mentally when they abstain from their drug of choice, I can’t see a reason to continue supplying it in a prison setting to maintain an addiction. We certainly don’t consider giving alcoholics ongoing access to alcohol in prison, nor do we give cocaine addicts continued access to that substance. Not without a clearly demonstrated need. This is not a ‘punitive’ approach, this is a therapeutic one.

I just wish we had more slots for addiction treatment in prison, and in the community. It’s been shown to be very, very cost-effective and has saved a lot of lives. But funding for it is very hard to come by. Millions for incarceration, but pennies for treatment. Silly.

As for the transfolks who self-mutilate; well, that’s a thorny topic. Lots of people self-mutilate who don’t have gender identity issues, and aren’t looking for surgery. So merely the act of self-mutilation doesn’t make me want to rush out and get someone gender-reassignment surgery.

But as I mentioned upthread, there may well be selected subclasses of transfolk who do have better outcomes with gender reassignment surgery, and if they can be identified with a reasonable degree of certainty, then surgery is an appropriate option to consider. And I do advocate for incarcerated folks to have their legitimate medical needs met by providing the community standard of medical care, just like for non-incarcerated folks.

But that doesn’t mean they get to have any treatment they want.

And I have dealt with folks who have tried to remove their own genitals. It’s not a happy circumstance.

39

I recognize that the debate over these surgeries is relevant to the thread topic, but describing them this way is going to lead to thread hijacks and probably to flaming. Try to be a little less inflammatory here.

40

Thanks, I see.

I was absolutely horrified in the documentary that there are prison who don’t even recognise transsexualism at all, and refuse to continue medication. Baffling. I’m glad there are also Qadgops around! :slight_smile: