Missouri Prisons and Jails are Killing Their Residents by Restricting Access to Medication for Opioid Use Disorder

Mr. Rey at his HVAC graduation with his mother, sister, and his late father, ==

In 2018, like so many Americans, Mr. Rey was prescribed oxycodone as pain treatment following a traumatic brain injury. Predictably, this prescription turned into a years-long fentanyl addiction. When Mr. Rey was arrested and booked into county jail, he was taking Suboxone, the undisputed standard of medical care for opioid use disorder. He was committed to getting clean and this medication was the only solution that worked.   

In jail, his prescription was continued (a rarity), allowing him to continue exercising, communicating with family, and avoiding fentanyl. Mr. Rey’s progress depended upon medication for opioid use disorder (“MOUD”), which allowed him to escape the constant mental and physical torture of fentanyl cravings. Thanks to Suboxone, the rehabilitative purpose of Mr. Rey’s incarceration was taking shape. 

Then Mr. Rey was transferred to prison.  

The Missouri Department of Corrections, unlike the county jail where Mr. Rey was initially housed, maintained an unwritten policy of indiscriminately discontinuing people’s Suboxone prescriptions. This choice is akin to telling a diabetic incarcerated person, “Sorry, we don’t provide insulin here.” However, stigma against opioid use (and the lie that Suboxone gets you high or replaces one drug with another) often shields prisons from appearing so discriminatory.  

This stigma is illogical, seeing as opioids (primarily synthetic opioids like fentanyl) are the leading cause of death for people under age 50 in the United States. In 2023, over 105,000 people died from opioid overdoses, with hundreds of thousands more surviving solely due to timely Narcan administration. In the criminal justice context, the opioid crisis runs wild. Overdose is the leading cause of death among people returning to their communities after incarceration. On the inside, an overwhelming two-thirds of incarcerated people in American jails and 65% of people incarcerated in American prisons are living with an active substance use disorder, often an opioid addiction. 

Despite the overwhelming prevalence of opioid addiction, less than half of U.S. jails provide access to medication for opioid use disorder. Even fewer U.S. prisons provide MOUD. The results are deadly. 

Mr. Rey experienced debilitating withdrawal when Missouri DOC discontinued his Suboxone. He begged to continue his prescription but was repeatedly denied. Withdrawal itself can be fatal, causing severe gastrointestinal pain, nausea, vomiting, diarrhea, crashing blood sugar, shakes, headaches, and worst of all, intense opioid cravings. Having been denied access to his medication, Mr. Rey, like so many incarcerated people, resorted to self-medicating with fentanyl.  

Fentanyl is widely available in Missouri prisons and often sold by the very guards employed to protect incarcerated people.  

Inmates do not leave prison, and many facilities now open and photocopy all mail, ban delivery of books and publications, and only offer virtual visits. As drugs continue flowing in and overdoses continue happening at alarming rates, there is nowhere else to look besides the people who do enter and exit our prisons daily. Last week, a Jefferson City Correctional Officer was charged with smuggling methamphetamine into the prison. In early March, a correctional officer was charged with plotting to bring fentanyl into South Central Correctional Center, the prison in Licking, Missouri where Mr. Rey is incarcerated. And earlier this year, Michele Buckner, the former warden of South Central Correctional Center was removed as warden for permitting staff to bring illicit drugs into the prison through an unmonitored back door.  

This cruel oversight and its effects cost Mr. Rey his life – multiple times. 

This cruel oversight and its effects cost Mr. Rey his life – multiple times. 

Denying MOUD Causes Overdose Death Spirals 

In his first two years at South Central Correctional Center, Mr. Rey overdosed on fentanyl and died three times. Each time, he was brought back to life with multiple doses of Narcan. After his first overdose, Mr. Rey sent countless health service requests, begging to re-start Suboxone. “Please, I do not want to die in prison,” he repeatedly wrote. In response, he was chained to a bench for hours then sent to solitary confinement for nine months.  

In solitary, Mr. Rey overdosed and died a second time. After his second overdose, he was sent back to his housing unit, which was full of fentanyl. He pled to see a doctor, admitted to his addiction, and wrote prayers for those denying him care. The prison’s response: Do nothing.  

In November 2024, shortly after we retained Mr. Rey as a client, he tragically overdosed a third time. Again, he required Narcan to come back to life. Again, he was sent to solitary confinement. 

Only after this third overdose and a demand letter written by MacArthur Justice Center on Mr. Rey’s behalf did the Missouri Department of Corrections finally provide him with his previously prescribed Suboxone. This overdue correction can never repair the trauma of being ignored and denied access to medically necessary, life-saving medication for opioid use disorder for nearly three years. 

 “Every day was a living nightmare,” says Ms. Paula Moore, Mr. Rey’s mother. 

 “Every day was a living nightmare,” says Ms. Paula Moore, Mr. Rey’s mother. “Every time I received a phone call, I feared it would be news that my son died.” 

No one should have to die to receive the basic standard of care for their disability. Nor should anyone have to wait until they are 60 days away from release to access lifesaving medication. Historically, the Missouri Department of Corrections has maintained these discriminatory, unwritten standards for access to suboxone.  

Mr. Rey is one of few incarcerated people in Missouri lucky enough to access Suboxone – and he paid the price. Similarly situated individuals have been told they did not “die recently enough” to access Suboxone, meaning they overdosed in prison, but not after the “cutoff date” Missouri DOC arbitrarily set to qualify for care. Others have been diagnosed with severe opioid use disorder and told they should receive suboxone but cannot because they have too much time left on their sentence. Many are just ignored. And while a few individuals have successfully received referrals for Suboxone, the majority end up waiting weeks if not months before finally starting a prescription.  

Worse, when individuals finally do meet with a doctor, many are told their only option is to take Naltrexone – a medication for opioid use disorder that does absolutely nothing to curb opioid cravings. Naltrexone is an antagonist medication, meaning it blocks opioid receptors and prevents you from getting high, but does nothing to control opioid cravings. For this reason, it is widely viewed as ineffective to treat opioid use disorder. Conversely, Suboxone is a partial agonist medication, meaning it both blocks opioid receptors to prevent overdoses, and stimulates these receptors in a controlled manner to manage opioid cravings. Research suggests oral Naltrexone – the medication hundreds of incarcerated Missourians with opioid use disorder are now being forced to take – is no more effective at treating opioid addiction than a placebo.  

Already this year, at least one individual has tragically died after repeatedly overdosing, requesting access to Suboxone, and being denied because he had too much time left on his sentence. His family lost a husband, father, son, and friend whose life likely could have been saved if the Missouri Department of Corrections heeded his need for medical care. At least four other individuals have died from suspected overdoses in Missouri prisons since January. Recently, there were 28 overdoses in one day at Mr. Rey’s prison, South Central Correctional Center. 

“We all know using fentanyl, it’s only a matter of time until we die,” said one incarcerated person who has been addicted to opiates since age 13 and is presently serving time due to overdosing while on parole. He has requested suboxone multiple times while in Missouri prisons but is consistently rejected because he does not have a known release date. “Fentanyl controls everything. I just want help to get off it so I can live to see my family, my children, and my grandchildren again. Suboxone is the only thing that helps.”  

Even at Ozark Correctional Center, a Missouri prison presenting as a long-term substance use disorder treatment center, individuals with opioid addictions have been discontinued from Suboxone prescriptions that were active at the time of their arrest and told their only option is to take Naltrexone. There is no good reason for a substance use disorder treatment center to deny people the FDA-approved medication that treats their substance use disorder.  

Today, Missouri DOC and their medical provider, Centurion, still lack a medication for opioid use disorder policy that binds all Missouri prisons and clarifies that all offenders with OUD must have access to all medications for opioid use disorder, including buprenorphine. Such a policy is essential to ensure accountability and keep our incarcerated populations and the communities supporting them safe. Without clear medications for opioid use disorder policies and protocols, treatment of incarcerated people with opioid use disorder widely differs across prisons. 

Beyond being cruel and unusual, denying access to the three FDA-approved medications for opioid use disorder is also illegal.  

Denying MOUD Often Violates State, Federal, and Constitutional Rights 

Missouri law requires meaningful access to medication for opioid use disorder in Missouri prisons and jails, including Suboxone. Missouri Revised Statutes Chapter 191, Section 1165(7) reads as follows: “The department of corrections or state entity shall make available the MAT services covered in this section [which include access to Buprenorphine, Methadone, and Naltrexone], consistent with a treatment plan developed by a physician, and shall not impose any arbitrary limitations on the type of medication or other treatment prescribed or the dose or duration of MAT recommended by the physician” (emphasis added). Missouri DOC’s failure to provide timely access to MAT, and their contracted medical provider’s insistence on only prescribing Naltrexone, patently violates this Missouri law and constitutes illegal, “arbitrary limitations on the type of medication” of MAT prescribed to people in Missouri DOC custody. 

Missouri DOC’s practices also violate federal law. 

In 2022, the Department of Justice issued a formal guidance clarifying that the Americans with Disabilities Act (“ADA”) applies to people with opioid use disorder. The ADA is a federal statute guaranteeing that people with disabilities have meaningful access to the same opportunities as everyone else to participate in state and local government programs. The ADA specifically protects people with disabilities from discrimination by prisons and jails.  

Accordingly, as the DOJ guidance clarifies, prisons and jails cannot maintain blanket policies denying continuation of medication for opioid use disorder, nor can they force an incarcerated person to take one medication for opioid use disorder over another (e.g., only providing access to naltrexone, but not suboxone). While ADA protections do not apply if an individual is actively using illicit substances, such individuals are protected by the ADA, even if they are in active use, if they are seeking health services to which they are otherwise entitled. Courts hold that in practice, this means “it would be entirely illogical [for a prison or jail] to refuse to treat opioid use disorder in patients who use opioids.” 

Apart from the DOJ’s advocacy on behalf of incarcerated folks’ access to medication for opioid use disorder, courts nationwide hold that denying access to such medications violates the ADA and, in some cases, the Eighth Amendment’s prohibition on cruel and unusual punishment.  

For example, in 2019, the District of Maine (affirmed by the First Circuit) held that an incarcerated person’s prescription for buprenorphine must be continued because (1) opioid use disorder is a disability, (2) denying this medication causes forced withdrawal and irreparable harm (thus the plaintiff would be likely to succeed on his ADA and Eighth Amendment claims), and (3) medication for opioid use disorder is medically necessary. Recently, the New York Civil Liberties Union settled a similar case with Jefferson County, which ended their jail’s discriminatory practice of denying access to buprenorphine for incarcerated people with opioid use disorder (even when naltrexone, another MOUD, was available). 

Missouri DOC and Jails Must Provide MOUD to All Offenders with OUD 

There is no legal or moral reason to deny incarcerated people access to life-saving medication – especially when that medication treats the most common substance use disorder nationwide. As Mr. Rey’s story shows, denying medication for opioid use disorder is fatal. Regardless of the crime one is convicted of, prison policies constituting a functional death sentence cannot survive. Nor can prisons or jails decide which inmates’ lives are worth saving based on how close they are to the door, or whether they have already overdosed and died within prison custody.  

Missouri Department of Corrections must immediately alter its medication for opioid use disorder policies, making buprenorphine meaningfully accessible to all incarcerated individuals living with an opioid use disorder. 

Equally pressing, county jails across Missouri must terminate their inhumane and deadly blanket policies denying continuation of medication for opioid use disorder for people who enter jail custody with prescriptions. These policies not only violate state and federal law, but they also guarantee forced withdrawal, increased fentanyl dependence, and extreme overdose risk inside prison and within our communities. 

MOUD denial causes death and recidivism. It is bad policy and puts blood on Missouri prison and jail officials’ hands. This wreckage on our state and loved ones must end. 

If you or a loved one is living with an opioid addiction and being denied medication to treat that disorder by a Missouri prison or jail, please reach out to the MacArthur Justice Center for help. Likewise, if you are presently taking Suboxone or another medication for opioid use disorder and at risk of incarceration or arrest, please reach out as it is very likely your prescription will be discontinued. Thank you. Contact: 314-266-4203, or MacArthur Justice Center, ATTN: MAT PROJECT, 906 Olive Street Suite 420, St. Louis, MO 63104. 

Resources

MAT Self Help Guide: MoDOC’s “MAT Program” is the name of its program to improve incarcerated individuals’ access to medication for opioid use disorder, also known as Medication Assisted Treatment. The MacArthur Justice Center put together this guide to assist those incarcerated with navigating the MAT program.