This post was updated Nov. 5 at 8:44 p.m.

Correction: The original version of this article incorrectly stated that Laura Doan did a lateral transfer to Los Angeles County Correctional Services primary care. In fact, she did a lateral transfer to the Los Angeles County Department of Health Services ambulatory care network.

A family medicine physician at Los Angeles County Correctional Health Services found himself in a difficult position last November. Dr. Yang, who asked to be referred to only by his last name out of concerns about retaliation, was troubled by a new CHS policy increasing the use of opiate medications, namely Suboxone, as a treatment for opioid use disorder. 

The new CHS policy requires that all inmates entering the reception area be screened for opioid use disorder and, if they meet the criteria for it, immediately be prescribed Suboxone.

Yang, however, was convinced that increased prescription of Suboxone would be unsafe for patients. 

“Suboxone is a Schedule III controlled medication,” he said. “It’s not a candy.”

Suboxone, the brand name for a sublingual film combining buprenorphine and naloxone, was approved by the United States Food and Drug Administration as a treatment for opioid dependence more than two decades ago, working to minimize cravings and facilitate a transition out of addiction. 

The U.S. Drug Enforcement Administration rates medications from Schedule I to Schedule V in order of decreasing addiction risk, with Schedule I substances having “a high potential for abuse.” A Schedule III substance has “a moderate to low potential for physical and psychological dependence,” according to the DEA.

Yang takes issue with prescribing Suboxone to treat opioid use disorder because of its buprenorphine component, which risks excessive use in a manner similar to other opioids. Buprenorphine is rated Schedule III and is one of only three FDA-approved medications for treating opioid use disorder. It works by stimulating the same brain receptors as illicit opioids. Yang prefers naltrexone, the only FDA-approved medication for opioid use disorder that is not a controlled substance. Naltrexone blocks the opioid receptors in the brain instead of exciting them. 

Yang met with superiors and raised his concerns but said he was met with disagreement and asked to go home hours early. 

Yang decided to take sick leave for the next few weeks, upset that superiors were controlling his clinical decisions. He said he was not allowed to return until he signed a paper agreeing to administer Suboxone. When he eventually returned to work, he chose to prescribe Suboxone only when he considered it medically appropriate. 

His tepidness, however, did not go unnoticed. Superiors deemed his work unsatisfactory.

This February, Yang was placed on administrative leave. He has yet to return to work.

“I stay home. Home is prison now,” Yang said.

LA County runs one of the world’s largest jail systems, housing thousands of inmates across three facility locations – the northern Santa Clarita Valley, Lynwood and downtown LA. Each jail facility is equipped with medical outpatient services, and the Twin Towers Correctional Facility provides inpatient services. 

An investigation by the Daily Bruin, which involved speaking with 13 medical professionals employed or formerly employed at the LA County CHS facilities, found that Yang’s concerns were widely shared among the nursing staff. However, The Bruin also spoke with addiction experts who said most of the protocols in question are standard practice and not atypical. 

Yang and other CHS medical professionals are, nonetheless, opposed to the use of Suboxone as a treatment for opioid use disorder, with concerns primarily rooted in alleged patient welfare risks and provider autonomy.

“For our patients, naltrexone is probably better for patients than other drugs because that’s an antagonist,” Yang said. “If you want to prevent them to have drug overdose, you should use naltrexone, not Suboxone.”

Several studies have found that medical professionals who are uncomfortable with the use of medications to treat opioid use disorder widely view the FDA-approved medications as substitutes for illegal drugs rather than steps toward sobriety. 

The Substance Abuse and Mental Health Services Administration has, however, explicitly stated that medications used are evidence-based treatment options and do not just substitute one drug for another.

These medications are administered as part of medication-assisted treatment programs, which combine the use of medication with behavioral therapy to address both the physical and mental difficulties associated with ending substance misuse. The Medications for Addiction Treatment program at LA County CHS has been steadily growing since its start four years ago, supported by efforts such as the policy change last November.

But many medical professionals at the facility remain hesitant and agree, at least in part, with Yang’s reluctance to administer Suboxone.

Lana Martin, a nurse practitioner formerly employed at CHS, raised concerns about the potential negative effects of immediately administering Suboxone to all patients presenting with opioid use disorder.

“You’re supposed to wait 24 to 48 hours to start them on Suboxone from their last use of an opiate,” Martin said. “Otherwise, you put them in what’s called precipitate withdrawal, right? So you start the withdrawal and you throw them into it harder and faster.”

Julie Dalmatoff-Dalmau, a nurse practitioner formerly employed at CHS, was on board with the use of Suboxone as a treatment for opioid use disorder, but with the new initiative, she feared that the immediacy with which patients were to receive Suboxone posed safety risks. 

Previously, providers could choose to delay a patient’s first Suboxone prescription if their screening raised concerns that there were still substances in their system. Dalmatoff-Dalmau expressed discontent with the new rigidity. 

“It’s very disheartening to know that you cannot taper or cater to the patient itself,” Dalmatoff-Dalmau said. “They have to get this cookie-cutter, blanketed for everyone, prescription.”

To mitigate safety risks, she said providers should have more discretion in deciding when to administer the medication.

UCLA Addiction Medicine program director Dr. Julio Meza echoed these concerns, saying that the interval between the last drug usage and the time of buprenorphine administration is very sensitive. If a patient takes buprenorphine too soon after their last use of opiates, they will very quickly experience severe withdrawal symptoms due to the rapid displacement of the full opioid agonist – heroin, fentanyl or whichever opioid drug the patient took – by buprenorphine, which is a partial opioid agonist. 

Some health care providers and patients in other health facilities across the country accuse opiate medications of acting as a crutch, preventing the patient from achieving sobriety on their own. 

However, Dr. Joy Hao, an associate clinical health sciences professor at the UCLA School of Medicine, said that rather than acting as a crutch, the medication is a critical tool in facilitating recovery for those experiencing opioid addiction. The treatment is as legitimate as blood pressure medication and diabetes medication, she said. 

“In some ways, you could also say a diabetic patient is using insulin as a crutch,” Hao said. “Sure, you can say that. But we all know that diabetes medication and blood pressure medication just don’t have that stigma.”

Meza echoed Hao, drawing a nearly identical comparison between Suboxone and diabetes medication. Buprenorphine is a life-saving medication, in the same way insulin is a life-saving medication for a diabetic patient, Meza said.

“It’s a medication that will come and satisfy … the neurobiological changes that have occurred in the patient’s brain in a safe fashion,” Meza added. “It’s going to decrease the potential for overdose, right? It’s going to decrease a lot of the side effects that … agonists can lead to and, importantly, is going to allow the patient to have a fulfilling life.”

Martin, however, took issue with CHS guidelines on the process of administering Suboxone. She said Dr. Matthew Sexter, the clinical director of addiction medicine at CHS, pressured the nurses to adhere to the new Suboxone initiative.

“Dr. Sexter was pushing, saying, ‘Put them on it (Suboxone) – I don’t care when they last used when they first walk in – so that we stop it all,’” Martin said. 

Additionally, she said nurse practitioners were instructed to give patients multiple Suboxone doses at once rather than spreading the doses out because of a lack of nursing capacity. Martin said these higher, bundled doses are harmful to patients’ immediate health and long-term recovery.

However, when Suboxone is being used to mitigate withdrawal, grouping doses and leaving longer intervals does not necessarily diminish treatment outcomes, Hao said. 

“The efficacy of Suboxone lasts 24 hours, so if the patient is taking it for (a) craving and to manage withdrawal, really, you could just dose it once a day, and that should hold the patient,” Hao said.

Martin, however, said she did not believe all patients actually needed a Suboxone prescription, based on their opioid use history. According to Martin, CHS management encouraged nurse practitioners to order Suboxone for patients who had been clean for as long as multiple years, which does not align with its intended use.

“They were forcing us providers to order Suboxone on every single patient whether they needed it or not, which is completely unethical,” Martin said. “Patients who had done an opiate any time in their life, even if they had an addiction or not 15 years ago, they were like, ‘Well, they have a history, so let’s put them on it.’” 

To push back against procedures that she deemed improper, Martin and other nurse practitioners ordered neurological checks on patients as a “safety feature” to verify the well-being of their patients, she said. Neurological checks, she added, are a means by which medical professionals can ensure that patients are not over-sedated.

Dr. Sean Henderson, the current chief medical officer at CHS, responded with an email requesting that employees stop ordering neurological checks, further upsetting members of the nursing staff, Martin said.

“It’s crazy that every time we try to do something to be safe, they would counteract it and tell us not to do it,” Martin said. 

Staff members who have voiced problems said they felt unheard and disrespected by management.

Dr. Alia Moore, a former senior physician at CHS, said Henderson’s response to differing opinions created a toxic work culture.

“Pushing back on him or suggesting something he didn’t like or offering different perspectives often was met with this immediate hostility,” Moore said.

Martin added that if employees disagreed with Henderson or failed to do what he demanded, they were placed on a “bad list” and usually faced harassment until ultimately being fired or quitting.

“I just learned to gray rock – to not have a response, to not say anything,” she said. 

Because of her disagreement with medical processes in place, Martin ultimately quit.

When Henderson became chief medical officer at CHS, one of his first official acts was to dissolve the professional staff association – an organization that allowed employees to facilitate workplace discussions and engage in continuing medical education training.

Dr. Stuart Shear, a former dermatology specialist physician at CHS, was upset by the decision but said Henderson was unreceptive to criticism.

“‘You’ve hurt the morale,’” Shear said he told Henderson. “‘You created a situation where we feel isolated.’”

An LAist article published in 2022 traces the hostile working environment back over five years, with numerous medical staff detailing a history of conflict and adverse encounters with higher management. 

Dr. Laura Doan, a former physician at the Twin Towers urgent care facility in CHS, raised concerns over aggressive and abusive interactions with Henderson, filing a Policy of Equity complaint and a grievance against Henderson during her time at CHS. The main factors attributed to her decision to leave included gender-based discrimination, abusive workplace culture and retaliation from supervisors, among other problems, according to the LAist article.

Even after her lateral transfer to CHS primary care, Doan said she continues to be contacted by CHS employees under Henderson’s supervision for advice on how to handle the aggression and pressure they face.

“It was just shocking to me that, in 2024, the things I’m hearing from these individuals was almost verbatim the things that he was doing to me during my time when I worked with him back in 2020,” Doan said. “It’s really scary and disheartening for me to hear from individuals that it’s still happening, hasn’t changed, hasn’t gotten better.”

Yang noted that this culture negatively affected the quality of CHS’s provision of care because direct providers were afraid to raise issues. 

“I learned early on not to say anything,” Dalmatoff-Dalmau added. 

Yang added that people often want to speak out, but the fear of retribution holds them back.

“I was the one to talk, speak out, then I was targeted,” he said.

Ultimately, Martin said she felt the mandate for Suboxone prescription undermined her medical knowledge and created a culture that forced her to prioritize avoiding disciplinary action from superiors over listening and responding to the needs of patients. 

“You have these check-off boxes that you get in trouble for,” she said. “You’re not caring what the patient is saying. You’re caring about not getting in trouble from your boss.” 

As the use of Suboxone and other similar opioid medications remains contentious in health facilities across the country, Hao and Meza said it is important to recognize the numerous benefits of medication-assisted treatment.

However, for CHS staff members, because they do not feel like their concerns are being heard or respected by management, four of the 13 CHS medical professionals who spoke to The Bruin have either quit or transferred out of the department. 

“They don’t want me to talk,” Yang said. “They won’t listen to me.”