Americans have been struggling with opioid dependency since at least as early as the Civil War, when men came home from battle with “Soldiers’ Disease”—addiction to the sedatives they were given for amputation—and now today, a rash of prescription pain pill abuse has lately given way to a rise in injection heroin abuse. According to Dr. Josiah Rich, the lead author of a new study in The Lancet, that same opioid addiction epidemic is now overlapping with a long trend of national mass incarceration, to deadly effect.
Rich, a professor of medicine and epidemiology at Brown University and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital, has been working to measure the impact of methadone treatment in jail and prison—which most facilities do not currently provide—on the long-term health of addicted inmates. For his most recent study, he and his colleagues randomly assign several hundred incarcerated people in the Rhode Island Department of Corrections to a continuation, or a cutoff, of their methadone maintenance-treatment program.
The results showed that the people who stayed on methadone while they were locked up were twice as likely to continue treatment in methadone clinics upon release. By contrast, those who were cut off from their methadone while incarcerated were more likely to go back to abusing heroin or other opioid drugs when they got out.
"That’s not how methadone treatment works; you can’t just turn it on and turn it off, because it’s a long-acting medicine, so you have to gradually build up their tolerance over time."
Years of research have shown that strictly monitored doses of methadone (or similar drugs in that class, like buprenorphine, naltrexone, or clonidine) are the safest and most effective treatment for this type of addiction. The evidence indicates that methadone therapy reduces drug use, crime, HIV and other diseases transmitted by needle-sharing, and overdose death. And yet, while jails and prisons are obligated to provide life-saving medications to inmates for other health issues, most don’t provide methadone.
According to the Bureau of Justice Statistics, under one percent of inmates in state prisons across the United States get help detoxing, only 6.5 percent get drug counseling, and a mere 0.3 percent get “maintenance pharmacotherapy” of any kind. A survey by the Journal of Urban Health found that 90 percent of people who are prescribed methadone will be forced to either abruptly stop, or quickly taper, that medication.
For jail and prison officials, maybe it doesn’t seem worth the trouble at first, Rich says. Methadone withdrawal—like heroin withdrawal—is messy, and miserable, and makes addicts feel like they are dying. It causes sleep deprivation so severe that it can push them to the edge of psychosis, or beyond. But for all that, the process of withdrawal is not usually, in itself, deadly. So maybe jails and prisons would rather leave addicts alone for a few days and deal with them later. But the ramifications for “later,” weeks or months after that abrupt withdrawal, he argues, can be devastating.
Cut-off policies can stem just as much from a lack of understanding as much as from a lack of resources. Heroin addiction isn’t a virus, and methadone isn’t like a quick course of antibiotics, Rich explains. It’s more like hypertension than, say, a stomach bug. “People think about addiction like an infection—you treat it, it goes away, and you’re done,” Rich says. “But it’s not an acute disease. It is a chronic, relapsing condition.”
Rich stresses that addiction permanently changes the pathways in people’s brains; that can’t be undone through a few nauseous nights. Some people who undergo methadone treatment will be able to gradually taper their doses over time, but some will take methadone for the rest of their lives. Each case is different, but jails and prisons tend to treat them all the same—cutting their supply all at once, no matter what.
“That’s not how methadone treatment works; you can’t just turn it on and turn it off, because it’s a long-acting medicine, so you have to gradually build up their tolerance over time,” Rich says. “Then when you take them off, they lose their tolerance. And for most people, when they lose their tolerance, their risk of overdose goes sky-high.”
In fact, as Rich and his colleague Sarah Wakeman cited in a previous article, “the 2 weeks after release have been shown to be associated with a substantial increase in mortality, especially from overdose.”
As a result of his most recent study, Rich says, the Rhode Island Department of Corrections is adjusting its methadone policy and allowing for a longer period of time before it starts to taper the doses it gives its inmates. He is hopeful that other jurisdictions will follow the example, and will start to re-think how they handle this vulnerable population of people who have already made the commitment to seek treatment for their addictions.
“Particularly with someone with opioid dependence, we know that if you rip someone out of their social setting, and their household and their environment, their job, and out of their drug treatment, and then just kind of kick them back in, they're set up for failure,” Rich says. “It is an extremely high-risk population at an extremely high-risk time. Just in the middle of their high-wire act, you're taking their trampoline away.”
True Crime is Lauren Kirchner's weekly column about crime and criminal justice issues.