Heroin addiction treatment in prison

The United States has the world’s highest incarceration rate. Approximately 10 million individuals are sent to prison each year, and more than half of them have a history of substance abuse. Further, more than 200,000 have a history of heroin addiction. A recent study suggests that the prison system could improve addiction treatment offered to inmates.

Nunn et. al. found that opiate replacement therapy (ORT) with methadone or buprenorphine (Suboxone) is frequently neglected in prison, even though it has been proven to be an effective addiction treatment for opiate dependence that can reduce drug-related disease and rates of recidivism (2009).

The researchers surveyed medical directors from prisons across the nation about their ORT policies as well as addiction treatment referral policies. The study found that 28 percent of the prisons offered methadone to inmates in some situations. However, over 50 percent of the prisons that offer methadone do so only for pregnant women or chronic pain management. Only 14 percent of the prisons offered buprenorphine to some inmates. (Buprenorphine is a relatively new drug for ORT that presents less likelihood of overdose compared to methadone.)

The most common reason cited for not offering ORT was that the prison preferred “drug-free detoxification over providing methadone or buprenorphine.” Several prisons also cited security concerns. Remarkably, 27 percent of prison medical directors stated that they did not know how beneficial methadone is for opiate addiction, and 50 percent of them were unaware of the benefits of buprenorphine.

They study also found that less than half (45 percent) of prisons provide some type of referral to heroin addiction treatment to prisoners who are being released.

“In spite of overwhelming scientific evidence demonstrating that pharmacological treatment for addiction has greater health and social benefits than abstinence-only policies, many prison directors are philosophically opposed to treating substance use. Most prisons also do not provide referrals for substance use treatment for prisoners upon release,” said Amy Nunn, lead author of the study and assistant professor of medicine at Warren Alpert Medical School of Brown University. “These trends contribute to high reincarceration rates and have detrimental impacts on community health. Our interviews with prison medical directors suggest that changing these policies may require an enormous cultural shift within correctional systems.

“Pharmacological treatment of opiate dependence is a proven intervention, is cost-effective and reduces drug-related disease and reincarceration rates, yet it remains underutilized in U.S. prison systems. Improving correctional policies for addiction treatment could dramatically improve prisoner and community health as well as reduce both taxpayer burden and reincarceration rates.”

More than half of heroin-addicted prisoners relapse within a month of their release. Improving addiction treatment in prison would facilitate their return to society. Do prison system medical directors have access to current information about addiction treatment? One might also ask: Do prison systems have adequate incentives for reducing reincarceration rates?

This study may not adequately address the financial aspects of prescribing ongoing methadone or buprenorphine. Buprenorphine, not yet available as a generic medication, is expensive. One option that prisons have apparently not widely considered is to offer methadone for free, beginning one month prior to discharge from prison, or buprenorphine if the inmate (or his or her family) would pay the cost difference. It may be sensible to show inmates during the majority of their incarceration that life without opiates might be manageable. However, because the transition to the outside world is likely to be highly stressful, methadone or buprenorphine is likely to lead to a substantial reduction in relapse and recidivism. The discharged inmates who later wish to come off the methadone or buprenorphine, when their lives have stabilized, are always free to do so.

Reference

Nunn A, Zaller N, Dickman S Trimbur C, Nijhawan A, Rich JD. Methadone and buprenorphine prescribing and referral practices in US prison systems: Results from a nationwide survey. Drug and Alcohol Dependence. 2009; 105(1-2): 83-88.