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September 2018

Implementing Opioid Agonist Treatment in Correctional Facilities

Author Affiliations
  • 1Department of Family Medicine, University of Rochester Medical Center, Rochester, New York
  • 2Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
  • 3Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
  • 4School of Law, Northeastern University, Boston, Massachusetts
  • 5Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
  • 6Division of Global Public Health and Infectious Diseases, Department of Medicine, University of California, San Diego School of Medicine, LaJolla, California
JAMA Intern Med. 2018;178(9):1153-1154. doi:10.1001/jamainternmed.2018.3504

Every year, 1 in 3 of the 2 million people with opioid use disorder in the United States is arrested.1 It follows that correctional facilities, that is, detention centers, jails, and prisons, have important roles in engaging people with opioid use disorder in effective treatment. Opioid agonist therapy with methadone hydrochloride, a full opioid agonist, or buprenorphine hydrochloride, a partial agonist, effectively treats opioid use disorder and reduces mortality.2 There is no comparable evidence for reduced mortality with naltrexone hydrochloride, an extended-release, full opioid antagonist also approved by the US Food and Drug Administration for treatment of opioid use disorder. Yet opioid agonist treatment is used infrequently in correctional facilities.3 What steps must be taken to change the situation?

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2 Comments for this article
Policy attitudes thwart standard-of-care treatment for opioid-addicted prisoners
Devin Hosea, AB | Princeton University

Fiscella et al ("Implementing Opioid Treatment in Correctional Facilities, JAMA Internal Medicine, online pub ahead of print, 30 July 2018) are generally correct in noting that "attitudinal" barriers prevent the treatment of OUD (Opioid Use Disorder, as defined in the DSM) in detention (jail, prison, or otherwise). This is a polite way of stating that American correctional facilities, in line with a distinctly American view of OUD treatment (as opposed to European and elsewhere), are largely pro-abstinence and anti-MAT (Medication Assisted Treatment).

Within MAT, there are basically three options for medication in the US, as the
authors note: methadone, buprenorphine, and naltrexone. It is quite telling that US prisons are now adopting long-acting naltrexone as a "treatment" for OUD, because unlike buprenorphine and naltrexone, it is an opioid antagonist that deflects the psychotropic effects of opioids, but has no evidence-based efficacy in treating OUD. In short, it "enforces" abstinence by disabling the psychotropic effects of opioids.

There is an irony here unique to prisons and other compulsory environments: the reason that naltrexone has no efficacy (in trials outside of prisons) is primarily due to lack of adherence. So, when patients are deprived of their liberties, and must take naltrexone (either in short or long-acting form), it is much more likely to "work". Put more simply, it doesn't work unless you can *compel* the patient to take it, and even then it just enforces absence by reducing or eliminating the psychotropic effect of opioids. Patients generally won't take it voluntarily, or at least, they won't take it for very long, in a voluntary environment.

Of course, naltrexone will not help the OUD patient-prisoner. Worse still, it will ultimately harm this patient population. In fact, the long-term expected mortality rate from overdose should be even higher, given that regular naltrexone administration reduces tolerance (upon termination of a course of naltrexone Tx), and that recently-discharged detainees are the highest-risk group for lethal overdoses. (See Strang, JS, "Death Matters", Addiction UK, 2015)
American attitudes towards using opioids (or partial agonists) to treat OUD are increasing mortality, now so in prisons even more than in the general population.  Until we let medical science dictate medical policy, instead of "attitudes" based on ignorance of the scientific evidence, the United States will continue to have the highest per-capita OUD mortality rate. 

Devin Hosea
Princeton, New Jersey

Attitudinal barriers to treatment of OUD
Jim Recht, MD | Cambridge Health Alliance Dept. of Psychiatry, Harvard Medical School
This excellent paper spells out some of our barriers to appropriate treatment, and hints at others. Thanks to Devin Hosea for his thoughtful and incisive comment (below).