Medication Assisted Treatment for Incarcerated: Why it Matters

Opioid Addiction

Opioid addiction first emerged as a serious problem in the U.S. during and after the Civil War, when opioids were prescribed widely to alleviate acute and chronic pain. The development, along with the diffusion of hypodermic technique (needles) administering opioids had a profound effect on opioid use and addiction in the 20th century and beyond. The post-war era (Civ-il, WWI & WWII) saw mass immigration of Europeans and an increased population of the poor with increased drug-related crime and trafficking due to the dependence upon opioids.

An increase in drug-related crimes, prison overcrowding, riots, and deaths lead to an outcry for addressing opioid addiction (Center for Substance Abuse Treatment (U.S.) (2014).

In 1958, the American Bar Association and American Medical Association issued a report recommending that an outpatient facility prescribing opioids to treat addiction be established on a controlled experimental basis (Brecher and Editors 1972). Dr. Vincent P. Dole is credited with the research and development of methadone maintenance for the management of heroin addiction within the outpatient clinics.

As the need for treatment and the opioid epidemic has increased the development of buprenorphine (1980), naltrexone (the 1980s) and suboxone (2002) have followed (Center for Substance Abuse Treatment (U.S.) (2014).

There are currently three medications used to treat opioid addiction: Methadone, Naltrexone (commercial name Vivitrol), and Buprenorphine (commercial name Suboxone). Methadone was first introduced in 1937 in Germany. By the 1960s it was being used in the U.S. to treat heroin dependency. Methadone, given in tablet or liquid form, changes the way the brain and nervous system respond to pain in the body.

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It reduces or eliminates the unpleasant symptoms of withdrawal. Buprenorphine (Suboxone) is a synthetic opioid that produces less euphoric effects than heroin or methadone. Like, methadone, it contains chemicals that link with opioid receptors in the brain to reduce pain and produce feelings of well-being. Suboxone is a much newer drug that was only FDA-approved in 2002. Naltrexone is an FDA-approved opioid antagonist. It blocks certain receptors in the part of the brain that trigger dopamine release and reinforces the vicious and compulsive addiction feedback loop. When these areas of the brain are blocked, the craving for alcohol and opioids is eliminated or significantly reduced. A benefit to Naltrexone is that it can be administered once a month. But is less effective than Methadone and Suboxone because it is only decreasing the cravings and can only be administered after detox.

The inception of Studying Opioid Treatment in Prison Settings

Despite substantial evidence of effectiveness in reducing heroin addiction and its adverse public health and public safety consequences, and its widespread use in other nations, opioid addiction treatment programs have rarely been implemented in jail and prison settings in the United States. There have been a few instrumental studies that have demonstrated the clear evidence-based need for creating MAT clinics in prisons and establishing treatment before release. The first such experimental program, described by Dole, Robinson, Orraga, Towns, Searcy, Caine (1969) showed that 12 inmates, incarcerated in a New York’s Rikers Island, who began methadone maintenance approximately 10 days before release from and were referred to an outpatient MAT clinic for aftercare had lower relapse rates and re-incarceration rates at 7-10 months post-release then did 16 untreated controls. This led to the 1987 inception of the first jail-based methadone program, named Key Extended Entry Program (KEEP). This program is still in active existence today (Gordon, et al. 2008; Center for Substance Abuse Treatment (U.S.) 2014; Farahmand, et al. 2017).

In Baltimore, a study evaluated the impact of prison, initiated methadone maintenance versus other treatment modalities and outcomes at 6 months and 12 months after release. This study evaluated the pre and post-release initiation of Methadone among incarcerated men. Another study in Rhode Island complimented the Baltimore study. Both studies found that methadone initiation prior tobeforeto before releasing from incarceration significantly increased the likelihood of successfully entering outpatient-based treatment centers and deceased the time to treatment postrelease. In the Baltimore study, participants who received methadone prerelease were more likely to remain in drug treatment programs at -3, -6- and -12-month follow-up. In the Rhode Island study, although more participants who were offered methadone prerelease were enrolled in an outpatient-based treatment center the numbers did not reach statistical significance. In contrast to the Baltimore study, the Rhode Island Study was limited to inmates with previous methadone experience. The Rhode Island study included men and women whereas the Baltimore study recruited only men (McKenzie, et al 2012; Gordon, et. al 2008; Gordon et al. 2017; Farahmand, et al 2017).

Forty years of experience and research evidence in community-based settings have shown that opioid addiction therapy, involving primarily methadone maintenance, is highly effective in reducing heroin dependence, crime, and HIV transmission. Prisons offer a significant opportunity to engage individuals with heroin addictions in drug abuse treatment and recovery. Most heroin-dependent people do not receive such treatment while incarcerated or upon release. This lack of treatment contributes further to the vicious cycle of relapse, recidivism, and re-incarceration (Gordon, M. S., Kinlock, T. W., Schwartz, R. P., & O’Grady, K. E. (2008); McKenzie, Zaller, Dickman, Green, Parihk, Friedmann, & Rich, (2012). Fox, et. al. 2015; Binswanger, et al. 2007).

Court of Public Opinion

Just over half of US prison systems offer any methadone and those that do only offer it to very few prisoners under limited circumstances (6, 16). While there is limited research recognizing the positive health, economic and societal benefits of MAT, the lack of MAT is often due to the preference for drug-free detoxification, security concerns, logistical barriers due to tight federal regulation of methadone, and philosophical opposition to MAT among staff at multiple levels (16) (Ludwig, A. S., & Peters, R. H. (2014). Medication-assisted treatment for opioid use disorders in correctional settings: An ethics review. International Journal of Drug Policy, 25(6), 1041-1046). Even among correctional systems that do provide MAT, linkage to after-care post-release remains a challenge and many participants report financial barriers and difficulty negotiating community placement in treatment (38) (McKenzie et al. 2012). Drug Courts cite concerns about liability, lack of qualified medical staff, and the difficulties with reimbursement. In Probation and Parole, the major issue that emerged was the availability of MAT from community treatment programs (Friedmann, et al. 2012; McKenzie, et al. 2012) Research-ers piloting the use of methadone in correctional systems in Rhode Island and Baltimore found several obstacles to initiating methadone maintenance treatment in prison settings. This in-cluded storage included incarceration intact program beforeand handling methadone, increased workload for nursing staff, concerns about diversion and overdose, medical liability, and views of addiction as a moral failing (Farahmand, et al. 2017; Rich et al. 2015; Gordon et al. 2008).

Underlying Barriers to Prisoner Self-determination

In the USA, as in many other settings, the main societal response to the harms of opioid addiction is arrest and imprisonment (Milloy & Wood, 2015, p. 316). The criminalization of drugs was a tectonic policy shift that helped position the U.S. as the world leader in incarcerationcontact. Drug and property offenses are the most common reason for individuals to comeindividualsmethadonen-tact with the prison system (Bureau of Justice Statistics, “Substance, Dependence, Abuse and Treatment of Jail Inmates, 2002” NCJ 209588, July 2005; and Drug Use and Dependence, State and Federal Prisoners, 2004,” NCJ 213530, October 2006; Milloy & Wood, 2015, p. 316).).

Unlike other serious chronic conditions such as cancer, diabetes, or HIV/AIDS, individ-uals with opioid dependence will often have their medically effective treatment—such as reported, the standard treatment for opioid dependence—discontinued on incarceration in most US correctional institutions (Fiscella, Moore, Engerman, Meldrum (2004); Fiscella K., Pless, Mel-drum, Fiscella P. (2004). In a nationally representative survey of 500 US prisons, only 12% re-ported that individuals who enter custody on a methadone treatment programprogram are maintained on this programme during their time of incarceration (Fiscella, et al. 2004). Furthermore, in the prisons that do not provide methadone, most institutions reported that they have no standard protocol to taper individuals off methadone. Therefore, for the estimated 30,000 individuals on methadone who cycle through a correctional facility each year in the USA, the first days of their detention are spent in the pain and discomfort of physical withdrawal (Fiscella, et al. 2004: Rich, et al. 2015). The serious side effects of withdrawal from Methadone are often worse than withdrawal from Heroin (Gossop & Strang, 1991; Bone, C., Eysenbach, L., Bell, K., & Bar-ry, D. T. (2018). Our Ethical Obligation to Treat Opioid Use Disorder in Prisons: A Patient and Physician’s Perspective. The Journal of Law, Medicine & Ethics, 46(2), 268-271). This is one of the key factors why incarcerated individuals are resistant to entering into MAT treatment (Fis-cella, et al 2004; Gossop & Strang, 1991; Bone, et al. 2018).

In addition to precipitating painful withdrawal symptoms, forced methadone withdrawal during incarceration can increase an individual’s risk for relapse, overdose, and, re-arrest at re-lease from prison (Fu, J. J., Zaller, N. D., Yokell, M. A., Bazazi, A. R., & Rich, J. D. (2013). Forced withdrawal from methadone maintenance therapy in criminal justice settings: A critical treatment barrier in the United States. Journal of Substance Abuse Treatment, 44(5), 502-505). The increased risk of death may be explained by a decrease in tolerance to Methadone. Once released from Prison, the individuals who do not recognize that they are now unable to tolerate their prior levels of methadone or heroin end up dying if they resume using without medical guidance (Gordon et al. 2017; Binswanger et al. 2007; Bone, et al. 2018; Milloy & Wood, 2015).

Even if all prisons eventually offer MAT during incarceration or at leastbeforehandbefore to before release, the individual still needs to seek treatment. Prisoners who were interviewed cited reasons for there the r to resistance to MAT. These barriers included the fear of forced withdrawal due to the inability health-related to afford treatment, feasibility, transportation, and elevated risk of adverse health related outcomes (Bone, et al. 2018; Farahmand et al. 2017; Ludwig & Peters 2014; Wood & Millor 2015; Fox et al. 2015).

Despite the supporting evidence regarding the benefits of providing methadone before opioid-addicted release, most correction agencies in the US do not offer a form of MAT in their facilities (Bruce and Schleifer, 2008; Dolan et al. 2007; Friedman et al., 2012; Gordon et al., 2014; Lee et al., 2015; Magura et al., 2009; Nunn et al., 2009). Prison systems continue to experience increased incarceration rates of opioid addicted individuals. Given the high rate and risk of relapse, crime, overdoses,   and disease transmission after incarceration, the timing of enrollment and initiation of MAT is critical (McKenzie, et al. 2012.). This study is designed to support the need for MAT, at least prior to release and also while incarcerated.

Reference

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