A new study has shown the effectiveness of an opioid treatment programme for prisoners in the US state of Rhode Island, offering profound implications for national policy.
Getting arrested isn’t fun. It makes it much harder to get a job, government benefits, support from friends and family, and more. But it is also particularly dangerous for people who use drugs. Periods of abstinence, whether by choice or by lack of access to drugs in prison, reduce the body’s tolerance, and when people who use drugs are let out of jail, they are at a much higher risk for overdose if they start using again. Without many options outside the prison gate, going back to drugs isn’t uncommon. In the wake of the US’ opioid crisis, Rhode Island started screening all inmates for opioid use disorder and offering medication-assisted treatment (MAT) for anyone who needs it.
MAT is a strategy for treating problematic patterns of drug or alcohol use by prescribing a similar replacement drug, usually administered in a clinical setting, in order to manage chronic symptoms of dependence. It is typically combined with an element of behavioural therapy as well.
The programme in Rhode Island makes use of treatment with three different drugs. The first two, methadone and buprenorphine, are long-lasting opioids that lack the intense high of substances like heroin. These are used to alleviate withdrawal symptoms and decrease or prevent cravings. The third is naltrexone, which blocks one’s ability to get high on opioids entirely and may reduce urges to use them. Each therapy is tailored to individual patients by clinical criteria, to create a robust and comprehensive treatment programme that can be followed up after release.
A study of the six months before and after the programme’s implementation has shown overwhelming reductions in post-incarceration overdose deaths, lowering them by 61 per cent, from 26 overdose deaths of recently-incarcerated people before the program started to just nine after implementation. This accounts for a 12 per cent drop in the state’s overall overdose death rate. "This program reaches an extremely vulnerable population at an extremely vulnerable time with the best treatment available for opioid use disorder," says study co-author Jody Rich. She goes on to add that during the study, there were increases in the supply of fentanyl and other powerful opioids. Thus, she concludes, “[even] in the face of a worsening overdose risk, we actually saw a decline in overdose deaths.”
While some US states offer similar opioid dependency treatment options, they lack such comprehensiveness, and most don’t provide any sort of easy follow-up after a prisoner has served their time. This is crucial, because of the increased vulnerability of populations fresh out of jail. It is important to note that Rhode Island is quite a small state, but the programme could be implemented at the local scale by cities or counties willing to make a change for the better.
A common line of criticism is that MAT does nothing more than substitute one drug for another. One problem with this critique is that it leans entirely on the inflexible abstinence-only rhetoric that has taken such a firm hold on the conversation around drug use in the US. Programmes that stress complete sobriety have saved many lives – but they don't work for everyone. They represent just one place on the vast and varied spectrum that is harm reduction, yet they are present (and often the only option) in the programming of most prisons and rehabilitation centres.
MAT is a viable and efficacious form of treatment that can be an important transitional phase to abstinence style recovery – if the patient so desires. Abstinence purists argue that one must go straight to “cold turkey”, but many struggle to make such an abrupt change, for behavioural or chemical reasons. Old habits die hard, and dependence can be very difficult to overcome in general, let alone all at once. Additionally, many people have or can have a relationship with drugs that can be healthily maintained without stopping entirely. Yet, despite evidence of the effectiveness of MAT, abstinence is still commonly seen as the only legitimate treatment goal.
We are at the crossroads of two major national flashpoints in the US: the opioid overdose crisis and the continued rise of the prison industry. While further reforms to both health and incarceration are certainly necessary, this is a promising step toward a more humane criminal justice system.
Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System was published by the Journal of the American Medical Association on February 14, 2018.
