Methadone and buprenorphine prescribing and referral practices in US prison systems: Results from a Nationwide Survey

Abstract

Background

More than 50% of incarcerated individuals have a history of substance use, and over 200,000 individuals with heroin addiction pass through American correctional facilities annually. Opiate replacement therapy (ORT) with methadone or buprenorphine is an effective treatment for opiate dependence and can reduce drug-related disease and recidivism for inmates. Provision of ORT is nevertheless a frequently neglected intervention in the correctional setting.

Objective and methods

We surveyed the 50 state; Washington, District of Columbia (DC); and Federal Department of Corrections’ medical directors or their equivalents about their facilities’ ORT prescribing policies and referral programs for inmates leaving prison.

Results

We received responses from 51 of 52 prison systems nationwide. Twenty-eight prison systems (55%) offer methadone to inmates in some situations. Methadone use varies widely across states: over 50% of correctional facilities that offer methadone do so exclusively for pregnant women or for chronic pain management. Seven states’ prison systems (14%) offer buprenorphine to some inmates. The most common reason cited for not offering ORT was that facilities “prefer drug-free detoxification over providing methadone or buprenorphine.” Twenty-three states’ prison systems (45%) provide referrals for some inmates to methadone maintenance programs after release, which increased from 8% in 2003; 15 states’ prison systems (29%) provide some referrals to community buprenorphine providers.

Conclusion

Despite demonstrated social, medical, and economic benefits of providing ORT to inmates during incarceration and linkage to ORT upon release, many prison systems nationwide still do not offer pharmacological treatment for opiate addiction or referrals for ORT upon release.

Introduction

The United States has the world's highest incarceration rate, with approximately 10 million individuals incarcerated each year (Sabol and Couture, 2008, Walmsley, 2008). In 2007, over 2.2 million individuals were imprisoned at any given time, and an estimated seven to eight million others cycled through the country's prisons (facilities designated for long-term confinement upon conviction of crimes) and jails (facilities that house individuals detained for short periods of time, usually 6 months or less, often while they await trial) (Sabol and Couture, 2008). The number of incarcerated individuals has grown steadily since 1980, and in 2007, the number of incarcerated individuals rose 1.8% over 2006 (Sabol and Couture, 2008, Walmsley, 2008). Growth in incarceration rates can be largely attributed to the “war on drugs,” which has resulted in harsher penalties for drug offenses and has led to a threefold increase in drug-related arrests; over half of all sentences in federal prisons are for federal drug-related offenses (Drucker, 1999, Greifinger, 2007). Studies have found that between 50% and 84% of prison inmates have a history of substance use (Drucker, 1999, Greifinger, 2007, Mumola and Karberg, 2006), most in the year prior to incarceration (Mumola and Karberg, 2006). An estimated 20% of state inmates have a history of injection drug use (Mumola and Karberg, 2006), and approximately 24–36% of all heroin addicts, or over 200,000 individuals, pass through the US criminal justice system each year (Rich et al., 2005a). Moreover, prisoners often engage in substance use during incarceration (Clarke et al., 2001, Kang et al., 2005, Krebs and Simmons, 2002, Seal et al., 2008).

Inmates face disproportionately higher burdens of disease with mental illness, substance use and infectious diseases, including HIV/AIDS, hepatitis, other sexually transmitted infections, tuberculosis and others (Greifinger, 2007, Hammett, 2006). Many inmates are uninsured, lack adequate access to health services, and come from medically underserved communities (Freudenberg, 2001). Because correctional systems have high turnover rates and reincarceration rates, inmate health also profoundly affects the health of the communities to which they return (Greifinger, 2007, Nurco et al., 1991). Providing inmates with comprehensive health services, including treatment for chemical dependency with pharmacological therapy and counselling services, therefore offers a unique public health opportunity (Bick, 2007, Rich et al., 2005b).

Inmates’ transitions back to their communities are often associated with increased health risks, particularly increased sexual and drug-related risks (Visher and Mallik-Cane, 2007). Approximately 55% of individuals with a history of substance use will relapse to substance use within 1 month of release from incarceration (Nurco et al., 1991). Relapse to substance use is also associated with increased criminal activity (Hanlon et al., 1990, Nurco et al., 1991), risk of HIV and HCV infection (Inciardi and Needle, 1998), drug overdose (Binswanger et al., 2007, Bird and Hutchinson, 2003), death from drug-related overdose (Krinsky et al., 2009) and reincarceration (Gore et al., 1995, Lipton, 1992). Offering inmates pharmacological treatment and counselling for opiate dependence prior to release decreases the likelihood of drug relapse (Gordon et al., 2008, Kinlock et al., 2008a, Martin, 1999), overdose (Gordon et al., 2008, Martin, 1999), recidivism, and HIV risk behaviors (Springer and Altice, 2007) and increases the likelihood of remaining in long-term drug treatment upon release (Gordon et al., 2008, Kinlock et al., 2002, Kinlock et al., 2008a, Martin, 1999). Incarceration also offers an opportunity to intervene and break the cycle of addiction, health risks, criminal behavior, and reincarceration.

Methadone maintenance therapy (MMT) is an opiate replacement therapy (ORT) that has been used in the United States for nearly 50 years to treat chronic heroin addiction (Dole et al., 1969, McLellan et al., 1993). Methadone prevents withdrawal symptoms and drug cravings, blocks the euphoric effects of other opiates, and reduces the risk of relapse to illicit use of opiates, infectious disease transmission, and overdose death (Gerra et al., 2003, Kreek, 1992, Kreek, 2000). MMT use among prisoners, particularly around the time of release, is associated with reduced drug injection, HIV and HCV transmission (Marsch, 1998, Springer and Altice, 2007), drug-related criminal activities (Gordon et al., 2008, Kinlock et al., 2008b), recidivism, and increased participation in drug treatment programs (Gordon et al., 2008, Kinlock et al., 2002, Kinlock et al., 2008b).

Buprenorphine is an ORT that acts as a partial opioid agonist (Fiellin and O’Connor, 2002). Buprenorphine was approved by the FDA in 2002 for the management of opioid addiction by community and correctional physicians (Comer and Collins, 2002). Buprenorphine is often combined with naloxone and administered sublingually as Suboxone^© to reduce the likelihood of diversion (Comer and Collins, 2002). Since its 1996 approval in France, buprenorphine has been prescribed widely for ORT and is associated with improved stability in housing and employment; reduced self-reported heroin use; and decreased risk of HIV, HBV, and HCV infection; and mortality decline attributable to overdose (Auriacombe et al., 2004, Auriacombe et al., 2001, Carrieri et al., 2006, Fhima et al., 2001). Compared with methadone, buprenorphine has fewer regulations governing its use, lower likelihood of fatal overdose, and is associated with less social stigma. Because buprenorphine must be prescribed by a physician, it also provides opportunities for more routine medical care. Although the cost of Suboxone^© has been a barrier to its widespread use, its orphan drug status expires in October 2009, which will allow generic manufacturing of the medication and anticipated concomitant decreased cost.

Given the health and social risks associated with opiate use, both the Center for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend that correctional systems offer health programs to prevent substance use relapse upon community transition (CDC, 2002, WHO, 2007). In addition, WHO includes both methadone and suboxone in the essential medicines list (EML) (Møller et al., 2007). The EML is a list of pharmaceutical products that WHO recommends that all health systems or governments should make available to their populations. WHO guidelines also hold that drugs made available in the community should also be made available in prison (Møller et al., 2007). The Commission of the European Communities reports that numerous European Union member states have adopted these recommendations: 17 provide methadone maintenance and 10 provide buprenorphine treatment in prisons, although coverage varies widely (CEC, 2007). However, most prison systems in the rest of the world do not offer MMT and buprenorphine in the correctional setting (WHO, 2005, WHO, 2007).

Our 2003 survey examining the attitudes and practices of medical directors of state and federal prisons regarding methadone treatment found that just under 50% of US prison systems used methadone; when used, methadone is limited primarily to the treatment of pregnant inmates or for acute detoxification (Rich et al., 2005b). Only 8% of prison systems referred inmates with a history of opiate dependence to community-based methadone programs upon release; approximately 30% reported that they believed that methadone benefits opiate-dependent prisoners. To assess changes in attitudes and practices during the last 5 years, and to learn more about buprenorphine prescribing and referral practices since its approval, we surveyed the medical directors, their equivalents, or appointed designees of state prisons and the District of Columbia and federal prison systems about their opinions and prescribing practices for methadone and buprenorphine. Our survey also included questions about prison policies related to referring prisoners to community-based ORT programs upon release.