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Drug overdose deaths surge in California prisons due to fentanyl

Inmates walk in a yard by a high wall with a guard tower above. The mood seems orderly.
Inmates walk around the prison yard of San Quentin State Prison. State prisons are encountering a surge in drug overdoses. | Source: Jeremy Chen/The Standard

Drug overdose deaths in California state prisons rebounded to near-record levels last year, even as corrections officials touted the state’s intervention methods as a model for prisons and jails across the United States.

At least 59 prisoners died of overdoses last year, according to a KFF Health News analysis of deaths in custody data the California Department of Corrections and Rehabilitation is required to report under a new state law. That’s more than double the number who died of overdoses in 2020 (23) and 2021 (24).

Prison officials would not provide the number of overdose deaths in 2022, saying they are still being analyzed for a report to be released later this year. But attorneys representing prisoners said they believe there were substantially more fatal overdoses in 2022 than in the previous two years.

The new numbers are a big setback for state officials, who poured resources into overdose prevention efforts after a record 64 overdose deaths in 2019 gave California prisons the highest drug overdose death rate of any state correctional system in the United States.

With nearly 94,000 state prisoners, California is one of the nation’s largest providers of medication-assisted drug treatment. The prisoners’ attorneys still support California’s pioneering program, saying there would be even more deaths without it.

“Fentanyl. That’s I think probably the main cause from what I hear,” said Don Specter, a lead attorney in the major class-action lawsuit over poor medical care of California prisoners, referring to the synthetic opioid at the heart of the nation’s overdose crisis. “Nothing else has really changed too much. It’s very pervasive.”

A hand holding a Narcan nasal spray device, used for emergency opioid overdose treatment.
The overdose-reversal drug Narcan is displayed during training. | Source: Matt Rourke/AP Photo

With a lower prison population than in previous years, California’s 2023 numbers represent a record high overdose death rate of at least 62 per 100,000 prisoners—and the numbers are likely to rise further as the cause of death is determined in some cases.

“National data has shown an alarming increase of overdose deaths across the country, largely driven by synthetic opioids (primarily fentanyl),” Ike Dodson, a spokesperson for California Correctional Health Care Services, said in an email. He added that prison officials “continue to evaluate substance use disorder treatment to improve the safety and well-being of all who live or work in a state correctional facility, including plans to broadly expand access to Narcan,” an overdose reversal device.

Until now, California’s increasingly comprehensive drug intervention program had been an apparent success story.

In January 2020, when the prison population was about 124,000, the state began using drugs like buprenorphine, naltrexone and methadone to lessen drug users’ cravings and the crash of withdrawal symptoms while helping them stay away from dangerous opioids. The new program’s focus on medication-assisted treatment appeared to be working after deaths fell to 23 that year.

The medication-assisted treatment is one of five core components of the prison system’s approach: screening every arriving prisoner for substance use; use of medication where needed; therapy; supportive housing in prisons; and pre-release planning and post-release assistance. Officials say all five have now begun to varying degrees, at a cost of $270 million for the fiscal year starting July 1, 2024.

By 2021, the prisons’ reported overdose death rate fell to 25 per 100,000, less than half the rate before the program began and well below the overall national average.

There also was a nearly one-third drop in drug-related hospitalizations and emergency room visits among California prisoners receiving the medication-assisted treatment, researchers for the program said in a progress report last year.

In promoting the approach, corrections experts last year cited California’s “immediate and significant” progress in reducing deaths, emergency hospitalizations and drug misuse-related infections. While the use of medications to help keep prisoners from using opioids is rapidly expanding, it remains underused nationally in other prison and jail systems, the report said.

But last year’s preliminary overdose death toll in the state’s prisons was close to the record numbers of 2018 and 2019. Overdoses likely caused 11 deaths in October, according to attorneys representing prisoners—the most they had seen in a month.

Drug-related hospitalizations also have seen a more recent surge, attorneys representing prisoners said, citing the state’s data in a December court filing.

Efforts to crack down on the smuggling of drugs and other contraband into prisons have had limited effect.

Corrections spokesperson Alia Cruz said the department favors a “multilayered approach” that couples prison security with deterring smuggling and disrupting gangs and other drug distributors.

There were 236 smuggling arrests last calendar year, up significantly from the 2020-21 and 2021-22 fiscal years and similar to 2019-20 but about one-third fewer than in 2018-19. “Miscellaneous” seizures, which include fentanyl and other opioids, were up about 14% through the first nine months of 2023, the last data available, over the same period a year earlier.

Prison medical staff began carrying naloxone, a medication that can reverse opioid overdoses and is often sold under the Narcan brand, in 2016. Only in late September 2023 was it made centrally available in every housing unit for officers’ emergency use.

“That’s a good start, but all officers should carry the medication, which should be administered as quickly as possible to be most effective,” said Steven Fama, another attorney who represents prisoners and tracks prison treatment programs.

J. Clark Kelso, the federal court-appointed receiver who controls prison medical care in California, said during a court hearing in December that he is considering using his authority to obtain more naloxone. Fama said fewer than 10% of prisoners had been offered naloxone to carry for emergency use, with prison officials citing supply shortages for the delay in broader distribution.

The first group of state prisoners to be offered naloxone was at Richard J. Donovan Correctional Facility in San Diego County in August 2023. It had been averaging 35 overdoses a month, fatal and nonfatal, between October 2022 and March 2023, or more than one a day.

California “is leading the nation in this area,” prison officials said in the court filing, citing in part its policy of offering naloxone to all departing prisoners. They said the state is committed to making naloxone available to all prisoners as well. Statewide, California is partnering with a private manufacturer to produce a lower-cost generic form of naloxone nasal spray and expects to have it available by the end of 2024.

Despite the recent surge, California’s program “has and does save lives, and change lives,” Fama said. “Without this treatment, the number of overdoses, we believe, would be far larger.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.