Inmates denied methadone treatment less likely to seek it once free

May 28, 2015

PROVIDENCE, R.I. [Brown University] -- New trial results published in The Lancet show that inmates forced off of methadone maintenance treatment upon incarceration -- a widespread policy in U.S. prisons and jails -- were significantly less likely to return to the effective addiction-controlling remedy after they were released than those who, because of the study, were allowed to remain in treatment.

In the United States nearly 90 percent of the people undergoing methadone maintenance treatment (MMT) for opioid addiction will be cut off from the medicine if they are imprisoned. But according to the Centers for Disease Control and Prevention "the median death rate of opiate-dependent individuals in MMT is 30 percent of the rate of those not in MMT." The treatment not only saves lives but also reduces the drug-seeking behaviors that lead to crime and the risk behaviors that lead to the spread of diseases such as HIV or hepatitis.

Public health experts therefore have worried that interrupting treatment during incarceration might make people suffering the lifelong battle against addiction more vulnerable after they return to the community. People who have undergone withdrawal from heroin lose their tolerance, for example, but if they resume using they often take the same amount as before. That leads to deadly overdoses.

The new study is the first randomized controlled trial to test whether allowing people to continue MMT upon incarceration increases their likelihood of seeking treatment when they return to the community. The results show that it does. The implication of the finding is that the policy of interrupting MMT for people with addiction reduces their inclination to resume it.

"What we are doing with methadone in our correctional system is we are systematically taking people off it," said study lead author Dr. Josiah Rich, professor of medicine and epidemiology at Brown University and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital. "It's the only medication that is summarily stopped upon incarceration. This study questioned that policy to find out what happens."

A trial behind bars

Rich and his co-authors conducted the trial with 223 people incarcerated for six months or less in the Rhode Island Department of Corrections between June 2011 and April 2013. They randomly divided the inmates into two groups: 114 would gain the opportunity to continue methadone while locked up, and 109 would undergo the same phased withdrawal experienced by all Rhode Island prisoners (in many other U.S. jurisdictions prisoners are cut off immediately).

Upon release, all people in the study were offered financial and logistical assistance to obtain MMT.

The main measure of the study was whether the study subjects attended an MMT clinic within a month after release. The researchers found that more than 97 percent (111 of 114) of the people offered the chance to continue MMT while incarcerated came to a clinic after release, while only 71 percent (77 of 109) of prisoners in the phased withdrawal group did so. Statistical analysis showed that people allowed to continue while incarcerated were twice as likely as the others to engage in MMT after release.

But the study also suggests the difference may really be greater.

Because 45 inmates in the phased withdrawal group ended up being released before the medication had been completely phased out, many of them were still on some dose of the medicine upon release. When Rich and his co-authors compared the outcome for those who were on MMT at release with those who were fully withdrawn, they found that every inmate still on MMT at release continued with treatment in the community while only 48 percent of those off of MMT resumed it. Subsequent statistical analysis showed that people on MMT at release were more than six times as likely as those off MMT to seek treatment after release.

A secondary finding of the study was that continuing MMT in prison was also more cost-effective than cutting it off because higher medical costs, such as emergency room visits, accrued after release for the people withdrawn from treatment than for the ones who stayed on it.

Follow-up at one month after release also showed that people in the group withdrawn from MMT while incarcerated were more likely to self-report returning to opioid use (18 percent did so) than those who stayed on MMT (8 percent).

Correction policy correction?

Rich said the study results have already had an impact in Rhode Island, where prison officials recently decided to lengthen the period of time before phasing out MMT from one week after incarceration to six weeks.

Some public health experts are calling for more.

"[The study] provides another example of how the demands of public security can unwittingly undermine public health," wrote M-J Milloy of St. Paul's Hospital in Vancouver and Dr. Evan Wood of the University of British Columbia in an accompanying editorial in The Lancet. "To not only improve the health of those dependent on opioids but also honor the international legal obligation for equivalence of correctional and community-based healthcare, correctional systems in the United States and other jurisdictions should move to provide in-prison evidence-based treatment for opioid dependence."

Rich agreed that the criminal justice practice of cutting people off from MMT runs counter to the public health goal of fighting addiction. In previous work he has shown that many people avoid ever engaging in MMT because they worry that they will be cut off from it if they are arrested. Cold-turkey withdrawal from heroin is intensely horrible for about a week, Rich said, but withdrawal from methadone can mean months of discomfort including lost sleep. Many people see heroin withdrawal as the preferable way to suffer because it is over more quickly.

Offering MMT in prison rather than ending it might result in more people being in treatment not only during and after incarceration, but also before, Rich said. That, in turn, might reduce the criminal activity that results in incarceration.

"For most of these people, the very reason they are caught up in the criminal justice system is related to their addiction to begin with," Rich said.
-end-
In addition to Rich, the paper's other authors are Michelle McKenzie, Dr. Sara Larney, Dr. John Wong, Liem Tran, Dr. Jennifer Clarke, Dr. Amanda Noska, Manasa Reddy, and Dr. Nickolas Zaller.

The National Institutes of Health funded the study, including through the Lifespan/Tufts/Brown Center for AIDS Research (grants K24DA022112, R01DA027211, P30-AI-42853).

****SIDEBAR ****
Former inmate: Methadone interruption does harm

Once a prisoner, now a recovery coach, Tarah Dorsey said she's suffered and seen others either suffer or avoid treatment because of the prison system's policy of ending methadone maintenance therapy.

PROVIDENCE, R.I. [Brown University] -- One of the times Tarah Dorsey was taken off methadone maintenance therapy by prison authorities, she spent a month in withdrawal, she said, barely managing to sleep a few hours a night in her cell. She said she knows other people who never took up the effective addiction treatment for fear they'd suffer the same fate.

"I know people who came to prison on methadone, got detoxed while they were in prison, went home and overdosed and died," said Dorsey, who now works as a recovery coach at Anchor Recovery Community Center in Pawtucket.

Dorsey overdosed in prison in December 2006. Someone gave her drugs, and because she was no longer on methadone, there was nothing to curb her craving for that high.

"It was a close call," she said. She went to the hospital, she said, and then to solitary confinement for a while.

As someone who has lived in and out of prison with addiction, who has counseled others, and has benefitted from methadone maintenance when she's had access to it, Dorsey said it makes her sad that prisons cut inmates off from therapy.

"To take somebody's medication from them is wrong," she said. "A disease is a disease is a disease, no matter how you look at it."

Brown University

Related Public Health Articles from Brightsurf:

COVID-19 and the decolonization of Indigenous public health
Indigenous self-determination, leadership and knowledge have helped protect Indigenous communities in Canada during the coronavirus disease 2019 (COVID-19) pandemic, and these principles should be incorporated into public health in future, argue the authors of a commentary in CMAJ (Canadian Medical Association Journal) http://www.cmaj.ca/lookup/doi/10.1503/cmaj.200852.

Public health consequences of policing homelessness
In a new study examining homelessness, researchers find that policy such a lifestyle has massive public health implications, making sleeping on the street even MORE unhealthy.

Electronic health information exchange improves public health disease reporting
Disease tracking is an important area of focus for health departments in the midst of the COVID-19 pandemic.

Pandemic likely to cause long-term health problems, Yale School of Public Health finds
The coronavirus pandemic's life-altering effects are likely to result in lasting physical and mental health consequences for many people--particularly those from vulnerable populations--a new study led by the Yale School of Public Health finds.

The Lancet Public Health: US modelling study estimates impact of school closures for COVID-19 on US health-care workforce and associated mortality
US policymakers considering physical distancing measures to slow the spread of COVID-19 face a difficult trade-off between closing schools to reduce transmission and new cases, and potential health-care worker absenteeism due to additional childcare needs that could ultimately increase mortality from COVID-19, according to new modelling research published in The Lancet Public Health journal.

The Lancet Public Health: Access to identification documents reflecting gender identity may improve trans mental health
Results from a survey of over 20,000 American trans adults suggest that having access to identification documents which reflect their identified gender helps to improve their mental health and may reduce suicidal thoughts, according to a study published in The Lancet Public Health journal.

The Lancet Public Health: Study estimates mental health impact of welfare reform, Universal Credit, in Great Britain
The 2013 Universal Credit welfare reform appears to have led to an increase in the prevalence of psychological distress among unemployed recipients, according to a nationally representative study following more than 52,000 working-age individuals from England, Wales, and Scotland over nine years between 2009-2018, published as part of an issue of The Lancet Public Health journal on income and health.

BU researchers: Pornography is not a 'public health crisis'
Researchers from the Boston University School of Public Health (BUSPH) have written an editorial in the American Journal of Public Health special February issue arguing against the claim that pornography is a public health crisis, and explaining why such a claim actually endangers the health of the public.

The Lancet Public Health: Ageism linked to poorer health in older people in England
Ageism may be linked with poorer health in older people in England, according to an observational study of over 7,500 people aged over 50 published in The Lancet Public Health journal.

Study: Public transportation use linked to better public health
Promoting robust public transportation systems may come with a bonus for public health -- lower obesity rates.

Read More: Public Health News and Public Health Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.