Prisoners forced off methadone less likely to return to treatment

By Kathryn Doyle (Reuters Health) - When people on methadone maintenance therapy are incarcerated, many are forced to stop taking it, and are less likely to restart methadone treatment on their release, according to a new study. A once-daily dose of methadone relieves withdrawal symptoms from heroin and other opiate drugs, blocks the high that an opiate would give and relieves drug cravings, according to the Centers for Disease Control and Prevention. Maintenance treatment should continue for at least one year and some people may benefit from taking methadone for a number of years. Methadone is one of the most tightly regulated medications we have, but is highly effective in treating heroin or opiate addiction, reducing HIV transmission, criminal behavior and overdose deaths, said lead author Dr. Josiah D. Rich of Brown University in Providence, Rhode Island. “When people have opioid dependence, physiologically, they develop tolerance and have to keep taking a higher and higher dose,” to avoid withdrawal, Rich told Reuters Health by phone. Withdrawal from heroin is painful and “diabolical,” he said, and drives people to do desperate things. Withdrawal from methadone is more prolonged and less intense, but still painful. In either case, becoming incarcerated and going through withdrawal removes tolerance, which increases the risk of drug overdose or death on release, he said. “That is the perfect storm, to take someone off medicines and put them through reentry to society,” Rich said. “For many people with opioid dependence, going out is worse than going in.” For the study, Rich and his coauthors recruited inmates of the Rhode Island Department of Corrections who were enrolled in a methadone maintenance program at the time of arrest and wanted to remain on methadone while incarcerated. Almost all the inmates he approached for the study said they wanted to continue on methadone, Rich said. The inmates, who were all set to be incarcerated for six months or less, were randomly assigned to either continue taking methadone in jail or to forced tapered withdrawal, which is the standard in U.S. corrections facilities. There were about 100 inmates in each group, and 22 percent of participants were women. In the continued methadone group, 96 percent of inmates returned to a community methadone clinic within one month of their release from prison, compared to 78 percent of those in the forced-withdrawal group, as reported in The Lancet. In the continued methadone group, there was one non-fatal drug overdose in the month after release from prison compared to two in the forced-withdrawal group. The continued methadone group also had one hospital admission and 11 emergency room visits compared to four and 16, respectively, in the forced-withdrawal group. Continued methadone maintenance after release may reduce the risk of death from overdose or risk behaviors, the authors write. “The most critical time is the transition back into the community, what kind of support can we give so they can make it without relapsing?” Rich said. Addiction is a chronic relapsing condition, he said. “It is estimated that in the United States, about 10 percent of the people receiving methadone treatment are incarcerated every year . . . this works out to 30,000 people per year on methadone who enter prisons or jails,” said M-J Milloy of the British Columbia Center for Excellence in HIV/AIDS in Vancouver, Canada, who coauthored an editorial accompanying the new results. More than 90 percent are forced off of methadone on incarceration, Milloy told Reuters Health by email. People are taken off methadone when they are incarcerated “because that’s the way we’ve always done it,” Rich said. Continuing therapy would cost money and can be very hard to administer in a controlled way, he said. “But this is right when they really could benefit from methadone,” he said. Fear of being incarcerated and forced off the drug actually deters opioid users in the community from trying methadone treatment, he said. “We are hamstrung, we can’t use this tool to treat deadly disease because of what’s going on behind bars,” he said. In Portugal, people are no longer incarcerated for simple drug possession charges, he said. “They changed the laws and do not incarcerate for using drugs, low-level dealers get picked up and put into treatment,” Rich said. “They’re getting better outcomes than we are.” In other countries, including Canada, the U.K. and Australia, prisoners are maintained on methadone safely and effectively, and they can even initiate methadone in prison if desired, Milloy said. The best example of a U.S. prison providing methadone, though it is the exception rather than the rule, is the Rikers Island Correctional Facility in New York City, he said. “This is linked to a wide range of benefits, including lower rates of re-offending post-release,” he said. SOURCE: http://bit.ly/1QqHzfn and http://bit.ly/1AOxbMz The Lancet, online May 29, 2015.