Pain management rarely means opioids for San Diego jail inmates

Ted Estacio watches an inmate take her medicine at the Las Colinas Detention and Reentry Facility.
Ted Estacio watches an inmate take her medicine at the Las Colinas Detention and Reentry Facility.
(K.C. Alfred / San Diego Union-Tribune)

It wasn’t long ago that a complaint of pain at a San Diego County jail easily scored an inmate a prescription for an opioid.

These days, the highly addictive, frequently abused painkillers have been largely swapped out for Tylenol and ibuprofen as part of a program to stem the cycle of opioid addiction behind bars.

So much so that an inmate with an opioid prescription is a rarity.

Last month, only 23 inmates, including those with cancer, were prescribed an opioid. That’s less than 1% of the total jail population.


The number represents a 98% drop from the beginning of 2013, when nearly 1,000 inmates were prescribed more than 77,000 narcotic painkiller pills.

“This really cleaned up the jails,” said Dr. Alfred Joshua, the Sheriff’s Department’s chief medical officer who implemented the program in 2014. Sheriff’s officials report fewer opioids being diverted to other inmates, fewer inmates being bullied for their prescription pills, fewer overdoses and an overall calmer environment in the daily medication lines.

“Any process that will help someone overcome addiction can only be viewed as successful,” said sheriff’s Cmdr. Mike Hernandez, who heads the medical services division.

However, authorities have noticed an uptick in attempts to smuggle heroin into the jails, a trend officials attribute only partly to the reduction in prescription opioids. Under the 2011 Public Safety Realignment law, some inmates are serving longer terms in jails rather than prisons — an average of 215 days — and are directing smuggling operations, Hernandez said.

“They’re mirroring what they do in state prison,” he said.

Pain treatment is especially critical behind bars, where up to three-quarters of the population have a history of substance abuse or are jailed on drug-related charges.

“Traditionally, they’d come in with back pain and get a prescription,” Hernandez said. “Now that the physicians have found alternatives to opiates, they’ve learned that when they come into our facilities they may not be receiving opiates.”


The ongoing education about the dangers of opioids has helped change inmates’ expectations, said Joshua.

“A lot realize that it does more harm than good,” the doctor said.

However, some inmates have accused the Sheriff’s Department of going too far with its policy. The reduction in opioid prescriptions has prompted a handful of federal lawsuits against Joshua and the department from inmates who claim their conditions warranted stronger pain treatment.

None of the inmates has prevailed in court thus far.

Joshua says the program doesn’t rule out opioid prescriptions altogether but gives a good deal of discretion to the physicians who treat the inmates. Prior medical records provide important clues to whether an inmate legitimately requires opioids, he said. The doctors are mainly looking for a current prescription by a consistent provider or a current chronic pain diagnosis.

The select few who are granted opioid treatment are strongly counseled about the risks involved and warned of a zero-tolerance policy against diversion. Nurses and jail deputies make sure that inmates aren’t “cheeking” or “tonguing” the narcotics to give them to other inmates. If an opioid patient is caught trying save a dose, he or she might be taken off the opioid and given a non-narcotic alternative.

The doctors are also following recommendations based on recent research that shows over-the-counter stalwarts acetaminophen and ibuprofen can be more effective at treating pain than opioids. Inmates can request a higher level of painkiller, but that doesn’t always mean the doctor will agree.

Inmates who feel they aren’t being treated properly can file grievances to the command staff, and as a last resort, a lawsuit.


But it’s a high bar the inmate has to meet for a claim of cruel and unusual punishment.

The Constitution does not mandate “comfortable prisons” but prohibits extreme deprivations such as the “wanton and unnecessary infliction of pain” or conditions that deprive “inmates of the minimal civilized measures of life’s necessities,” U.S. Magistrate Judge Mitchell Dembin said, citing a Supreme Court decision in one such San Diego lawsuit.

Difference of medical opinion is not enough.

The National Commission on Correctional Health Care advocates for alternatives to opioids when appropriate, noting that the custodial environment provides a good opportunity to regularly assess how patients are functioning and monitor the efficacy of their treatments.

“Therefore, when patient function remains poor and pain is not well controlled, and other options have been exhausted, a therapeutic trial of medication, including opioids, should be available,” the commission wrote in its pain management guidelines.

It’s an issue that the Prison Law Office, a California-based nonprofit that advocates on behalf of inmates and prisoners, has closely monitored.

“When they have restricted those medications, we’ve made sure there’s a medical basis for doing so and other alternatives available,” said the group’s executive director, attorney Donald Specter.

“I think generally now there’s recognition in the community about the dangers of opioids,” he said. “The same guidelines in effect in the community should also be present in the prisons.”


Davis writes for the San Diego Union-Tribune