In prison, addiction is drug-free

BROWN (US)—Many prison systems across the country do not offer medical treatment for heroin and opiate addiction, despite the demonstrated social, medical, and economic benefits, a new study finds.

The majority of prisons in the U.S. prefer drug-free detoxification to opiate replacement therapy. Researchers at Brown University, Miriam Hospital, and the Center for Prisoner Health and Human Rights, say just half of all federal and state prison systems offer opiate replacement therapy with the medications methadone and buprenorphine, and only in very limited circumstances.

“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,” says lead author Amy Nunn, assistant professor of medicine at Brown’s Warren Alpert Medical School.

“Improving correctional policies for addiction treatment could dramatically improve prisoner and community health as well as reduce both taxpayer burden and reincarceration rates.”

The United States has the world’s highest incarceration rate, with approximately 10 million individuals cycling through the prison system each year. More than half of inmates have a history of substance use and more than 200,000 people with heroin addiction are incarcerated annually.

Inmates face disproportionately higher burdens of mental illness, substance use, and infectious diseases, including HIV/AIDS. Their transition back to their communities is often associated with increased sexual health and drug-related risks, and more than half relapse within one month of their release.

For the last four decades, methadone has been the treatment of choice for opiate dependence because it prevents withdrawal symptoms and drug cravings, blocks the euphoric effects of other opiates, and reduces the risk of relapse, infectious disease transmission, and overdose death.

The drug buprenorphine is a newer treatment for opiate replacement that has less likelihood of overdose and is associated with less social stigma. Like methadone, it prevents withdrawal symptoms when an individual stops taking opioid drugs by producing similar effects.

Both methadone and buprenorphine are included in World Health Organization’s list of essential medicines that should be made available to patients by health systems at all times. Despite this, only 23 states provide referrals to treatment for inmates upon release from prison.

“Opiate addiction, like all forms of addiction, causes long-term changes to the structure and functioning of the brain, which is why it is classified as a disease,” explains Josiah Rich, the study’s senior author and codirector of the Center for Prisoner Health and Human Rights.

“Addiction requires treatment just as other chronic diseases, like diabetes and cancer, do. Unfortunately, there is a large gap between the number of prisoners who require addiction treatment and those who actually receive it.”

For the study, the Miriam/Brown research team surveyed medical directors at all 50 state departments of corrections, along with the Federal Bureau of Prisons and the District of Columbia prison, about their facilities’ opiate replacement therapy prescribing policies and referral programs for inmates leaving prison. The researchers received 51 responses.

Although it appears methadone is offered more frequently that buprenorphine, only 28 facilities (55 percent) offer it under any circumstances. More than half of these provide it only to pregnant women or for chronic pain management.
Approximately 45 percent of facilities provided some community linkage to methadone treatment post-release. Seven prison systems (14 percent) offer buprenorphine in some circumstances, while 15 facilities (29 percent) offer referrals for some inmates to community buprenorphine providers upon release.

A majority of the facilities surveyed said they prefer drug-free detoxification to replacement therapy, and several prison systems expressed security concerns about providing methadone and buprenorphine to inmates. Twenty-seven percent of medical directors said they did not know how beneficial methadone is for treating inmates with opiate addiction, while half were unaware of the benefits of buprenorphine.

A lack of partnerships with community providers appears to be one major barrier to providing the therpy after incarcerations. Many providers also cited their focus on inmate health during incarceration, rather than upon release.

“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,” Nunn says.

“Most prisons also do not provide referrals for substance use treatment for prisoners upon release. 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.”

Researchers from the University of Rochester School of Medicine and Dentistry contributed to the study, which was published online by Drug and Alcohol Dependence and was supported by grants from the National Institutes of Health’s National Institute on Drug Abuse and Center for AIDS Research, and the Tufts Nutrition Collaborative.

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