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Tuesday, July 20, 2004

Opiate Replacement Therapy Rarely Available to Inmates

Opiate Replacement Therapy Rarely Available to Inmates
News Feature
By Annie Turner

Recognizing a huge opiate-addiction problem among inmates, New Mexico is breaking new ground by extending methadone maintenance treatment (MMT) to local prisons. Across the country, however, few prisons provide MMT to patients.

In February, Bernalillo County, N.M., announced the opening of the nation's first public-health office inside a county jail, and said the program would pilot an MMT initiative as part of its patient services.

One month later, the New Mexico Medical Society became the only statewide medical society to endorse prison and jail-based opioid-replacement treatment, passing a resolution calling for "legislation to require the initiation of voluntary opioid replacement treatment ... in jails and prisons in New Mexico." The resolution also stated that addiction-treatment modalities should be evaluated for effectiveness.

The Bernalillo County jail has the nation's second- and third-highest rates of opiate use among female and male prisoners. About two-thirds of the 40,000 men and women processed at the jail annually arrive with drugs in their system. Methadone would be offered to all inmates already enrolled in MMT at the time of their arrest. The clinic also will provide preventive services to inmates, such as immunizations, screening and treatment for STDs, and HIV testing, counseling, and consultation.

"We're establishing that critical link with the community to minimize costs and reduce recidivism as a working partner with the public-health, medical, and mental-health systems," says John Dantis, deputy Bernalillo County manager for public safety.

The effectiveness of this joint project will be assessed by the Behavioral Health Research Center of the Southwest (BHRCS) through process evaluation, a survey, and outcome evaluation. BHRCS will monitor the effects of MMT on inmate infractions, medical visits, and recidivism.

"The establishment of this clinic presents a rare opportunity to test the efficacy of harm-reduction policies in one of the neediest populations in our society," according to BHRCS. "If this approach is shown to be effective, it could serve as a model for the rest of the state and the nation."

Successful Model Remains Unduplicated

Despite compelling evidence of the efficacy and necessity of opioid-replacement treatment in prisons and jails, the Key Extended Entry Program (KEEP) at Rikers Island remains the only unrestricted methadone-treatment program for incarcerated inmates in the U.S.

Since 1987, Rikers has offered KEEP as part of its health services. Unlike the handful of prisons nationally that provide methadone to inmates who were in MMT prior to their incarceration, Rikers allows inmates to participate in KEEP regardless of treatment history, and refers them to designated slots in community-based treatment programs upon release.

KEEP treated approximately 4,000 opioid-dependent inmates serving time for misdemeanors or low-grade felonies in 2000. The program, combining pharmacotherapy and therapeutic treatment, has proven to be "an extremely effective method of reducing recidivism," according to a National Drug Court Institute (NDCI) fact sheet. (For a PDF copy of this document, click here).

Research shows that 78 percent of KEEP patients report to their assigned treatment programs upon release. According to a study by Vincent Tomasino in the January 2001 edition of the Mt. Sinai Journal of Medicine (PDF of article available here), over an 11-year period 59 percent of patients returned to Rikers once, and 20 percent returned twice -- "a remarkably low rate of recidivism, given their long history of drug involvement," according to Tomasino.

Mark Parrino, director of the American Association for the Treatment of Opioid Dependence, last year was named a winner of the Robert Wood Johnson Foundation's Innovators Combating Substance Abuse Award. He plans to use the cash part of the award to implement a pilot MMT program in other prisons based on the Rikers Island model.

"Methadone is a medication that positively transforms a person ... and the physical recovery takes only weeks and is remarkable," says Parrino. "Denying treatment is not just inhumane, but poor public policy that does not benefit the inmate, the criminal-justice system, or society as a whole."

Stigma Limits Access in Prison

While the National Institute of Health and the Institute of Medicine both recommend MMT as a highly effective treatment option for heroin addiction, public reluctance to accept MMT as a valid form of drug treatment may be part of the reason for its inaccessibility in prisons.

Some critics argue that MMT is a "replacement addiction," substituting dependence on one drug for dependence on another. But advocates of MMT say that methadone is a stabilizing agent, transforming an opiate dependency into a medicated condition.

Methadone is not without its trail of overdose casualties, but according to SAMHSA's National Assessment Report, "methadone ... distributed through channels other than [opioid treatment programs] most likely are the central factor in methadone-associated mortality."

The convergence of methadone and the prison system in states like New Mexico makes sense from a criminal-justice perspective as well as from a public-health point of view. The NDCI notes that while many methadone patients relapse, 80 percent of those who stick with the program reduce or eliminate their criminal activity. A study by the National Institute on Drug Abuse reported that MMT decreased weekly heroin use by 69 percent and criminal activity by 52 percent.

The World Health Organization supports the use of MMT for inmates to prevent the spread of HIV and AIDS among intravenous-drug users, noting in a 2004 policy brief (PDF version here), "Prisoners on methadone maintenance prior to imprisonment should be able to continue this treatment while in prison," said WHO. "In countries in which methadone maintenance is available to opiate-dependent individuals in the community, this treatment should also be available in prisons."

Opiate addiction is not the only substance-use disorder being undertreated in correctional facilities. Drug treatment on the whole lacks adequate funding and support to meet inmates' needs, experts say. On average, 30 percent of inmates were under the influence of illicit drugs at the time of their offense, and half of them used within a month of their offense, according to the Office of National Drug Control Policy.

But only 56 percent of state prisons and 33 percent of jails provide on-site addiction treatment, according to a 2002 SAMHSA report (PDF version here).

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