Miriam researchers say correctional policies discourage released
inmates from seeking methadone therapy
Rich, MD, MPH
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, 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, MD, MPH, 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, ScB, 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, BA, who were
previously affiliated with The Miriam Hospital and are now with the Yale
University School of Medicine; Nickolas D. Zaller, PhD, 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, ScB,
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, MD, MPH, 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.