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Is the Secret to Solving the Opioid Crisis More Opioids?

Medication-assisted treatment in Rhode Island's prisons is preventing overdose deaths among the recently incarcerated.
Bottles of Buprenorphine are seen in a pharmacy in Boca Raton, Florida.

Bottles of Buprenorphine are seen in a pharmacy in Boca Raton, Florida.

America continues to succumb to its opioid epidemic, with official estimates tallying 116 overdose deaths every day. Opioids now kill more than 42,000 people in the United States each year—a figure that represents a fourfold increase over 1999 estimates. As the White House's Commission on Combating Drug Addiction and the Opioid Crisis put it in a recent report, the death toll from opioids in the U.S. is now equivalent to a September 11th every three weeks.

But a study published last week in JAMA Psychiatry shows how, when it comes to opioid addiction, a small intervention can save the lives of particularly vulnerable Americans incarcerated Americans.

Medication-assisted treatment (MAT) is protocol that combines prescribed opioids—such as methadone or buprenorphine—with psychotherapy. Rather than requiring recovering addicts to quit opiates entirely, MAT replaces heroin, fentanyl, and painkillers with slow-release versions of the drug that don't produce the same "rush" but do prevent the onset of withdrawal. At the same time, patients receive cognitive-behavioral or talk therapy to address the underlying roots of their addiction.

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While many communities and clinics have begun offering MAT in recent years, jails and prisons have not. Traditionally, when an inmate arrives in prison, they're forced to quit any substances they're using cold turkey. (Up to 65 percent of inmates struggle with drug or alcohol abuse.) Unfortunately, detox and addiction treatment are not one and the same. The former does nothing to address the constellation of psychological needs that accompany addiction—which is, after all, a chronic brain disease—while subjecting a person to the cascade of physical symptoms that accompany withdrawal.

A pilot program in Rhode Island sought to change that.

Researchers at Brown University, working in conjunction with the Rhode Island Department of Corrections, designed a program where incoming inmates with opioid addiction would receive MAT during their incarceration, instead of being forced to quit cold turkey.

Opioid addiction among incarcerated populations is of particular concern because of an inmate's heightened risk of overdose upon release. Longtime users who have developed a high tolerance opioids will quickly lose that tolerance if forced to detox in prison—without losing their underlying cravings.

"They may have stopped using while incarcerated, but nothing has been done to change the pathways in the brain responsible for addiction," co-author Josiah Rich said in a statement accompanying the study. "So when they get out, people are likely to relapse, and with their tolerance gone, they're at high risk for overdose."

Beginning in late 2016, Rhode Island jails and prisons began offering medication to treat addiction to any inmate with an opioid abuse disorder. At the same time, a network of 12 community clinics were established around the state to continue providing MAT to inmates upon their release.

After a year, the researchers were able to look at statewide overdose statistics to gauge the effectiveness of the program.

In the first half of 2016, before MAT was available in Rhode Island prisons, 14.5 percent of overdose deaths in the state were among the recently incarcerated. By comparison, in the first half of 2017, after MAT was made available to inmates, the recently incarcerated represented just 5.7 percent of overdose deaths—a stunning 61 percent drop in mortality.

"What's remarkable is that between 2016 and 2017 there was a huge jump in the amount of fentanyl and related compounds available on the illicit market," Rich said in the statement. "So in the face of a worsening overdose risk, we actually saw a decline in overdose deaths. We're quite confident that that happened because we've given people these medicines and they've stayed on them long enough to ovoid an overdose."