Pubdate: Mon, 30 Nov 2015
Source: Baltimore Sun (MD)
Copyright: 2015 The Baltimore Sun Company
Contact:  http://www.baltimoresun.com/
Details: http://www.mapinc.org/media/37
Author: Josiah D. Rich
Note: Dr. Josiah D. "Jody" Rich is a professor of medicine and 
epidemiology at Brown University and director of the Center for 
Prisoner Health and Human Rights at the Miriam Hospital.

METHADONE IN PRISON MAY REDUCE RELAPSE AND RECIDIVISM

For over two decades I have provided weekly clinical care to 
prisoners at the Rhode Island Department of Corrections. This 
experience of meeting thousands of patients has confirmed the 
epidemiological data suggesting that over half of all current 
prisoners have an addiction problem.

About one in seven has opioid dependence, a consistent and 
predictable, all-consuming, chronic relapsing and potentially fatal 
brain disease.

The current epidemic of opioid dependence has been driven by the 
flooding of the market with increased prescribing of pharmaceutical 
opioids. Regulatory pressures that have encouraged physicians to 
prescribe opioids for the management of chronic pain, along with 
unscrupulous profit-motivated pharmaceutical industry practices, have 
created this problem.

The rise in opioid prescription has had disastrous consequences, 
including unprecedented rates of overdose deaths, which have led to 
physicians finally starting to reduce their prescribing. The use of 
prescription monitoring programs as well as increasing physician 
education and other interventions will also decrease new initiates, 
but that is unlikely to help those already dependent. Wide 
distribution of naloxone, an antidote that can be given in an acute 
overdose; Good Samaritan laws that encourage people to call 911 
without fear of arrest; and educating people about how to prevent 
overdose including not mixing opioids with alcohol or other sedatives 
will all help save lives, but not tackle the underlying cause.

As physicians clamp down on the availability of prescription opioids, 
most opioid users will turn to the less expensive and often more 
readily available option of heroin.

Their heroin use typically begins with sniffing of powder heroin and 
then, as their use increases with increasing tolerance, there is 
often a transition to injecting heroin, which makes for even greater 
health risks.

Many eventually turn to one or more of three basic activities to 
support their habit: getting involved in the sex trade, the drug 
trade or stealing.

My patients who have cycled in and out of the incarcerated setting 
because of opioid dependence provide a vivid description of why 
recidivism rates are so high. When I ask them if are they planning to 
relapse to heroin use after release, the answer is invariably "no." 
But when I ask them what happened the last number of times they've 
been released from incarceration, the answer is that they have always 
eventually relapsed to opioid use, despite the best intentions not to.

Most never received treatment, which is more effective than 
incarceration in the long run and likely even the short run. In 
either case we should at a minimum coordinate efforts between the 
criminal justice system and the drug treatment system to work toward 
the same goal: getting people to stop their illegal and dangerous behavior.

One obvious example of where we are not doing what we can is in the 
use of methadone among incarcerated populations. Methadone has had a 
50-plus-year track record of use in the treatment of opioid 
dependence. It is highly effective at reducing illicit opioid use and 
many of the dangerous associated behaviors and outcomes including 
overdose and death.

But in this country, in most jurisdictions, people are forced off of 
methadone upon incarceration, even prior to conviction, causing 
predictable painful withdrawal, and putting them at increased risk 
for relapse and overdose death after release.

The Baltimore City jail was a notable exception, as it provided 
methadone to prisoners since before 2008, but that is not the case 
with most county jails throughout Maryland.

In the May 29 online issue of the medical journal The Lancet, 
colleagues and I reported results of a one-month randomized clinical 
trial comparing continued methadone with forced withdrawal from 
methadone for people who were in treatment at the time of 
incarceration. The results show that of those who were on methadone 
at the time of release, 100 percent continued methadone treatment in 
the community, whereas less than half of those forced off of 
methadone returned to the methadone clinic, and even at one month 
this was cost-effective.

Ultimately we should move to be more in line with the rest of the 
world and treat addiction, in particular opioid dependence, as the 
medical disease it is, rather than as a crime.

However in the meantime, we should at least strive to link people to 
effective treatment at every stage along the continuum - from arrest 
to re-entry and probation or parole.

This is good clinical care, good public health and good public safety.
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MAP posted-by: Jay Bergstrom