Full length articleA randomized, open label trial of methadone continuation versus forced withdrawal in a combined US prison and jail: Findings at 12 months post-release
Introduction
Prevalence of opioid use disorder (OUD) is exaggerated among those who are incarcerated (Mumola and Karberg, 2006). Just over 23% of state prisoners report ever using heroin or other opiates and 13% report regular use prior to incarceration (Mumola and Karberg, 2006). In addition, people who have recently been incarcerated are at extreme risk of overdose during community re-entry (Binswanger et al., 2007). A recent study that investigated all causes of mortality of people who were formerly incarcerated in Washington State found that overdose was the number one cause of death (Binswanger et al., 2013).
Methadone-maintenance treatment (MMT), the combination of behavioral therapy, counseling and methadone provision, is an effective, evidence-based approach to address opioid use disorder and overdose (Connock et al., 2007). Numerous studies have documented the far-reaching benefits to implementing MMT in correctional populations, including post-incarceration reductions in illicit opioid use (Mattick et al., 2009; Kinlock et al., 2009), re-incarceration (Deck et al., 2009; Larney et al., 2012), mortality and overdose (Degenhardt et al., 2011; Kerr et al., 2007), and HIV risk behaviors (MacArthur et al., 2012) among others (Rich et al., 2015, Zaller et al., 2013, McKenzie et al., 2012, Heimer et al., 2006; Dolan et al., 2003).
In the United States (US), there are over 3200 local and county jails and 1800 state and federal prisons, but few facilities offer addiction treatment using MMT (Vestal, 2016; Lee et al., 2015). In 2008, less than 0.1% of the total prison population received any form of buprenorphine or MMT (Larney and Dolan, 2009), and, while 28 state prison systems make MMT available to those who are incarcerated, a majority restrict treatment to special populations (e.g., pregnant women; Nunn et al., 2009).
When MMT or other forms of medication for addiction treatment (MAT) (Wakeman, 2017; e.g., buprenorphine) are not provided in the correctional setting, individuals who are addicted to opioids experience symptoms of withdrawal. Opioid withdrawal can include severe physical discomfort and psychological distress, risk of suicide, and leads to loss of opioid tolerance, thereby increasing risk of fatal and non-fatal overdose post-release (Merrell et al., 2010). Also, while the current literature points to the clear benefit of providing MMT during incarceration and linkage to treatment in the community, less is known about the long-term effects of MMT access during incarceration.
The objective of the current study was to identify the long-term effects of providing access to MMT for people who are incarcerated. From 2011–2014, we conducted a randomized control trial to assess the impact of continued MMT versus forced withdrawal from methadone in people who were incarcerated for six months or less, on fatal and non-fatal overdose, substance use, emergency department use, treatment engagement in the community, and HIV risk behaviors such as injection drug use and transactional sex. Baseline results indicated that forced withdrawal from MMT reduced the likelihood of MMT engagement post-release in the community (Rich et al., 2015). In the current study, we present outcomes measured at 12 months following release.
Section snippets
Study design
The study was conducted at the Rhode Island Department of Corrections (RIDOC), a unified, statewide prison and jail system. All participants gave written informed consent. This study was approved by the Institutional Review Board of the Miriam Hospital in Providence, Rhode Island (RI), and the RIDOC Medical Research Advisory Group. In addition, the study was reviewed by a data safety monitoring board every six months for the first two years of recruitment, then once per year until the study
Results
A majority of participants who completed the 12-month follow-up were male (78.2%), White (78.8%), and had not finished high school (39.7%). The median age of all participants at baseline was 32.6 years [IQR: 28.4, 40.9]. See Table 1 for all participant demographic details. Those who received methadone on the day before release were significantly more likely than those not dosed with methadone on the day before release to have been incarcerated for a shorter period of time. When analyzed by
Discussion
The objective of this study was to identify the long-term (12 months) effects of providing access to MMT to people who are incarcerated before their release into the community. The results of this study demonstrate that 12 months post-release individuals who received MMT while incarcerated were less likely to report heroin and injection drug use in the past 30 days and experienced fewer non-fatal overdoses. They were also more likely to be continuously engaged in MMT in the community. These
Conclusion
The US is experiencing an epidemic of escalating opioid use, and those who have recently been incarcerated are at increased risk of overdose and risky drug use post-release. Nonetheless, access to MMT in correctional settings or upon discharge remains rare in the US. Our findings indicate that providing MMT to individuals who are incarcerated can affect long-term outcomes including continuous treatment engagement, using heroin, injecting drugs, and non-fatal overdose in the first year after
Contributors
All authors made significant contributions to the study's design and conduct. L-BR (lead writer), MM, and AM shared responsibility in developing initial drafts and writing this report. AM conducted study analyses. NZ, ED, SL, and JDR critiqued the analysis plan, assisted with the interpretation of findings, and contributed to multiple versions of this brief. All authors contributed to and have approved the final manuscript for publication.
Role of funding source
This work is supported by NIH grant R21DA029201. The work of Dr. Rich is also supported by NIH grants K24DA022112 and P30AI042853. Dr. Brinkley-Rubinstein is supported by the UCLA HIV/AIDS, Substance Abuse and Trauma Training Program (HA-STTP) (R25DA035692), and the Lifespan/Brown Criminal Justice Research Program on HIV and Substance Use (R23DA037190). The funders had no role in the design, analysis, interpretation, writing, review, preparation, or decision to publish this manuscript.
Conflict of interest
No conflict declared.
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