Forced methadone withdrawal in jails creates barrier to treatment in community

PROVIDENCE, R.I. – Methadone treatment for opioid dependence remains widely unavailable behind bars in the United States, and many inmates are forced to discontinue this evidence-based therapy, which lessens painful withdrawal symptoms. Now a new study by researchers from the Center for Prisoner Health and Human Rights, a collaboration of The Miriam Hospital and Brown University, offers some insight on the consequences of these mandatory withdrawal policies.

According to their research, published online by the Journal of Substance Abuse Treatment and appearing in the May/June issue, nearly half of the opioid-dependent individuals who participated in the study say concerns with forced methadone withdrawal discouraged them from seeking methadone therapy in the community after their release.

"Inmates are aware of these correctional methadone withdrawal policies and know they'll be forced to undergo this painful process again if they are re-arrested. It's not surprising that many reported that if they were incarcerated and forced into withdrawal, they would rather withdraw from heroin than from methadone, because it is over in days rather than weeks or longer," said senior author Josiah D. Rich, M.D., M.P.H., director of the Center for Prisoner Health and Human Rights, which is based at The Miriam Hospital.

He points out that methadone is one of the only medications that is routinely stopped upon incarceration. "This research highlights that what happens behind bars with methadone termination impacts our ability to give methadone, a proven treatment, to people in the community," he added."Given that opioid dependence causes major health and social issues, these correctional policies have serious implications."

For the past four decades, methadone has been the treatment of choice for opioid dependence, including heroin, and is on the World Health Organization's list of "Essential Medicines" that should be made available at all times by health systems to patients. This "anti-addictive" medication prevents withdrawal symptoms and drug cravings and blocks the euphoric effects of illicit opioids. Additionally, methadone therapy has been shown to reduce the risk of criminal activity, relapse, infectious disease transmission (including HIV and hepatitis) and overdose death.

However, in the United States, a significant proportion of people who are opioid dependent are not engaged in methadone replacement therapy. Rich says the majority of patients terminate treatment prematurely, often within the first year.

In their study, Rich and colleagues surveyed 205 people in drug treatment in two states – Rhode Island and Massachusetts – that routinely enforce methadone withdrawal in correctional facilities. They found nearly half of all participants reported concern regarding forced methadone withdrawal during incarceration. Individuals in Massachusetts, which has more severe methadone withdrawal procedures, were more likely to cite concern.

"If other evidence-based medicines like insulin therapy were routinely terminated or withdrawn from those who were incarcerated, we would hear about these serious lapses in care. They would likely garner some attention. But routine termination of methadone maintenance therapy has been occurring in the criminal justice system for decades and remains a little discussed and highly neglected issue," says lead author Jeannia J. Fu, Sc.B., a former researcher with The Miriam Hospital who is now affiliated with the Yale University School of Medicine.

Rich adds, "We should examine the impact of incarceration itself, and what happens behind bars, on public health and public safety outcomes, and tailor our policies appropriately. We have methadone, which has been shown to improve public health and public safety, yet we have policies that reduce access to this treatment. The correctional policies on methadone should be re-evaluated in terms of the impact they have on the individual and the community."

This research was supported by National Institutes of Health grants K24DA022112 from National Institute of Drug Abuse and the Lifespan/Tufts/Brown CFAR grant P30AI042853 from the National Institute of Allergy and Infectious Diseases.

Study co-authors include Fu and Alexander R. Bazazi, B.A., who were previously affiliated with The Miriam Hospital and are now with the Yale University School of Medicine; Nickolas D. Zaller, Ph.D., of The Miriam Hospital, The Warren Alpert Medical School of Brown University, and the Center for Prisoner Health and Human Rights; and Michael A. Yokell, Sc.B., previously affiliated with The Miriam Hospital and Brown University and now with Stanford University Medical School and the Center for Prisoner Health and Human Rights.

The principal affiliation of Josiah D. Rich, M.D., M.P.H., is The Miriam Hospital (a member hospital of the Lifespan health system in Rhode Island) and direct financial and infrastructure support for this project was received through the Lifespan Office of Research Administration. Rich is also professor of medicine and epidemiology at The Warren Alpert Medical School of Brown University.

The Miriam Hospital (http://www.miriamhospital.org) is a 247-bed, not-for-profit teaching hospital affiliated with The Warren Alpert Medical School of Brown University. It offers expertise in cardiology, oncology, orthopedics, men's health, and minimally invasive surgery and is home to the state's first Joint Commission-certified Stroke Center and robotic surgery program. The hospital is nationally known for its HIV/AIDS and behavioral and preventive medicine research, including weight control, physical activity and smoking cessation. The Miriam Hospital has been awarded Magnet Recognition for Excellence in Nursing Services four consecutive times and is a founding member of the Lifespan health system. Follow us on Facebook (http://www.facebook.com/miriamhospital) and on Twitter (@MiriamHospital).

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