Justice secretary touts treatment over incarceration; 'We have to distinguish who we are mad at and who we are actually afraid of'

Justice and Public Safety Secretary
John Tilley (Photos by Melissa Patrick)

By Melissa Patrick
Kentucky Health News

State Justice and Public Safety Secretary John Tilley told foreign scholars visiting Kentucky Friday that treatment, instead of incarceration, is what is needed to help people who suffer from addiction -- a stand that is still a hard sell for some in Kentucky.

"The best place to treat addiction is not a prison cell," Tilley said. "And I still have policy makers in this state who think that is OK, when there is absolutely no evidence, no evidence that that approach enhances public safety."

Tilley and other experts spoke to nearly 90 Fulbright scholars from 49 countries at a University of Kentucky seminar.

Tilley said prosecutors tell him they are "hard-pressed" to find someone in the system who isn't there because of a drug-related offense, that 95 percent of their cases are related to addiction. He noted that since 1970, Kentucky's population rose 38 percent and its prison population rose 700 percent.

"We're beginning to realize that we can't change that behavior with punishment," he said. "We're not going to punish people into sobriety."

But some law-enforcement officials still oppose syringe exchanges that can prevent disease and accidents, and steer people into treatment, said keynote speaker Beth Macy, author of Dopesick: Dealers, Doctors and the Drug Company that Addicted America. "It all seems to collapse in that murky area between healthcare and criminal justice," said Macy, who began covering the opioid epidemic as a newspaper reporter in her hometown of Roanoke, Virginia.

Tilley said he is working on removing drug possession as a felony offense in Kentucky, as more than 15 states have done, "but there are too many who are unwilling to take that leap." He said at least 2,000 Kentuckians are in the prison system only for possession.

Tilley was instrumental in passing Kentucky's 2015 anti-heroin bill, as a state representative from Hopkinsville. Among other things, the bill created a system in which Kentucky counties and cities could authorize syringe exchanges; increased penalties for high-volume traffickers; allocated money for drug treatment; and let the Department of Corrections medicate inmates with opioid-use disorders.

Tilley, a Democrat, was appointed justice secretary in December 2015 by Republican Gov. Matt Bevin. "This is a nonpartisan piece of our government," he told the foreign visitors. "It's about justice and results, and we can all agree on those things."

He said Kentucky is working on many reforms to keep people with addictions out of prison, including, but not limited to: efforts to train police officers on how to recognize mental illness and addiction, and how to use crisis interventions and de-escalation techniques; using social workers in police departments to help find resources for people, instead of locking them up; efforts to help prisoners re-enter the workforce when they are released; pilot programs that offer medication-assisted therapies to inmates; and a program called the Angel Initiative in all 16 state police posts, which lets a person with an addiction to come in and be driven to the nearest treatment bed.

'A failed model' that varies unjustly from court to court

Tilley said the state must stop putting non-violent, low-level, non-sexual offenders in jail, and described how incarcerating worsens social problems.

He said Kentucky has the nation's second highest female incarceration rate, which has put more children into foster care, now numbered at  more than 10,000. "It's all tied together," he said. "We have to distinguish [between] who we are mad at and who we are actually afraid of."

Tilley pointed to research that shows addiction is a disease of relapse and requires many attempts for a person to become sober, and when you add criminal entanglements, it is a "set-up for failure."

He added, "It's a failed model. Why in the world would we try to treat what I think is a public health nightmare with a criminal justice system that was never designed to do this?"

He added that people with addictions who are arrested in Kentucky are treated differently across the state, depending on judges' understanding of addiction and the availability of wrap-around services to help offenders. "It's incredibly disparate, and it's unjust," he said. "It is injustice at its best."

Most who need treatment don't think they do, and most don't get it

Ty Borders, the director of UK's Rural and Underserved Health Research Center, told the scholars Friday that most people who have been diagnosed with substance-use disorders don't think they need treatment, and most who need treatment don't get it.

He said a national study found that only 17 percent of people with a heroin-use disorder in urban areas, and 24 percent in rural areas, thought they needed treatment; and among those with disorder involving prescription drugs, only 8 percent in urban areas and 13 percent in rural areas saw a need.

"The biggest predictor of people actually trying to get treatment for drug use disorder is whether they perceive any need for it," Borders said.

Not many more with a substance-use disorder actually got treatment.

The study found that in 2014-15, about 13 percent of Americans aged 18-64 who had a drug-use disorder got any type of treatment for it. That number was higher among those with an opioid-use disorder, around 24 percent, largely because there is a medication available to treat it, Borders said.

"These are really low rates, especially when you compare these to rates of treatment for hypertension, diabetes, cancer, et cetera," he said.

Ty Borders

On another point, Borders said that while more primary-care providers than ever are able to prescribe buprenorphine, a medication to treat opioid addiction, there are still concerns that their patients aren't getting appropriate counseling and therapy that is supposed to go with it, compared to what they would get from a psychiatrist.

He said Kentucky data show that the proportion of Medicaid patients who were prescribed buprenorphine and also received counseling at the same time increased in 2014-16, but the percentage who actually got the drug went down duruing that period.

"That means fewer people are getting access to this drug, if they had an opioid use disorder and they were covered by Medicaid," he said, adding that one reason for this could be that insurance firms that manage Medicaid  have put in prior-authorization requirements and other mechanisms that make it harder for providers to get approval for payment by the program.

Rep. Kim Moser, R-Taylor Mill, filed House Bill 121 to address this issue, but it got stuck in the Senate and is not far enough along in the process to pass on March 28, the last day of the legislative session. Moser told Kentucky Health News that it's important for patients to be able to get their medication-assisted treatment drugs without any delay because it keeps them from cycling in and out of jail or emergency rooms, and prevents overdose deaths.

Borders said there continues to be a great need for more buprenorphine prescribers in the central and western parts of the U.S., where some people have to drive more than 100 miles to get this medication.

Part of the problem is that the U.S. Drug Enforcement Administration requires health-care providers to either be board-certified to prescribe addiction medications or to take eight hours of training to get certified to prescribe, and then are only allowed to treat 275 patients annually.

Borders said research shows there are more buprenorphine prescriptions in states that expanded Medicaid to people who earn up to 138 percent of the federal poverty level, as Kentucky did. Borders attributed this to more people having access to a health-care provider and therefore the drug, and also being more able to pay for it because they have insurance.