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Dr. Roy is an internal medicine physician board certified in addiction medicine and a clinical assistant professor at the New York University Department of Population Health. As the former Chief of Addiction Medicine for New York City jails, including Rikers Island, she oversaw addiction treatment and recovery efforts for the city's incarcerated men and women. Previously, she was on faculty at Harvard Medical School and a primary care doctor to Boston's homeless population, among whom the leading cause of death was drug overdose.
Following her participation in our Addiction Speaker Series, we interviewed Dr. Roy to learn more about drug addiction as it relates to the criminal justice system.
The National Center on Addiction and Substance Abuse (CASA): Can you share a little about your experience as the Chief of Addiction Medicine for New York City jails?
Dr. Lipi Roy (LR): Correctional facilities are never optimal settings to receive health care, particularly for medically and psychosocially challenging conditions such as addiction and mental illness. And yet, in the U.S., the largest substance use and mental health facilities are jails and prisons. New York City’s Rikers Island is no exception. Over 50 percent of individuals entering Rikers experience substance use issues. Most concerning, however, is the sad reality that mortality is highest in the first two weeks post-release, mostly due to drug overdose. However, this is preventable and treatable.
As the first Chief of the brand new Addiction Medicine Service, I led addiction treatment and recovery services, including the opioid treatment program, KEEP and the behavioral therapy program, A Road Not Taken. As you can imagine, the job had its challenges! But, I had the privilege of working with doctors, nurses, therapists, substance use counselors, social workers and administrative staff who were truly dedicated to improving the medical and mental health care of the incarcerated population. I also learned a great deal from Department of Correction (DOC) officers, deputy wardens and other leadership. DOC staff do not have an easy job, and I certainly appreciated their service and our working relationship.
CASA: How prevalent is opioid misuse and substance use disorders (SUD) in the New York City criminal justice system?
LR: SUD impact a large segment of men and women who enter the criminal justice system. In the U.S., 62-86 percent of arrestees test positive for recent illegal drug use and 64-76 percent have an SUD. Twenty-three percent of recent arrestees have an opioid use disorder (OUD), placing them at risk of deeply uncomfortable withdrawal symptoms.
In New York City, approximately 20 percent of those arrested test positive for opioids. Nearly two-thirds of individuals entering New York City jails report a history of illicit drug use.
CASA: In what ways is New York City a model for other criminal justice systems in addressing issues related to opioid use?
LR: While I would never advocate for a person to enter jail or prison to receive medical attention if one does happen to enter the system with an OUD, Rikers Island does at least offer medications to treat both acute detoxification and for long-term maintenance. In fact, Rikers is the nation’s first – and still remains the nation’s largest – jail-based opioid treatment program, prescribing evidence-based medications such as methadone and buprenorphine (Suboxone). Treatment also comes in the form of behavioral therapies through the A Road Not Taken program. Rikers is sadly only one of very few correctional settings in the U.S. that offers such evidence-based treatment for OUD, a chronic medical disease.
CASA: In what ways does New York City still need to improve?
LR: While some people receive medications for addiction treatment in New York City jails, the vast majority still do not, often related to legal charges (e.g., an individual headed to state prison would not be eligible for MAT as state facilities do not offer MAT). Correctional Health is working on improving access to medications for this vulnerable group of individuals.
Opioid-related overdose deaths sadly remain a problem in New York City. According to the NYC Department of Health and Mental Hygiene (DOHMH), unintentional overdose deaths have steadily increased from 2011 to 2015; nearly 60 percent involved heroin and approximately 50 percent involve the potent synthetic drug, fentanyl.
We need far more physicians, nurse practitioners and physicians assistants to prescribe lifesaving medications such as buprenorphine. We also need widespread education and training on addiction in general – among health care professionals, law enforcement and other first responders, lawyers, judges, teachers and the general population.
Unfortunately, stigma remains a major barrier to care for most people with substance use issues. As an internist and addiction medicine specialist, I remind people every day of two key points:
CASA: How do racial disparities appear in drug use incarceration rates?
LR: The “War on Drugs” led to mass incarceration which has unfortunately disproportionately affected men and women of color. As far as drug use, race and incarceration, the statistics are staggering. Black Americans make up 13 percent of the U.S. population, 14 percent of drug users, but 56 percent of those incarcerated for drug-related crimes. The reasons are complex, and the ramifications for families, especially children growing up fatherless, and for our society-at-large are disruptive, disturbing and completely unacceptable.
CASA: What steps can people take to help reduce the stigma around opioid misuse and addiction?
LR: A simple yet significant action that everyone can take is to change their language. Studies show that when we use stigmatizing words and phrases such as “substance abuse,” “drug abuser,” “war on drugs,” or “dirty urine,” people with SUDs are less likely to seek care and more likely to perceive discrimination. However, when we use less stigmatizing and more compassionate phrases – “substance use disorder,” “person with substance use issues,” “positive urine” – people are more likely to seek care, and the therapeutic relationship between patient and provider improves.
A major step in reducing stigma is the recognition that addiction is a chronic medical disease, a relapsing and remitting disease of the brain. It is NOT a sign of moral weakness or failure. It’s about pain and suffering, and who can’t relate to that?