As harrowing as the experience of arrest and incarceration can be, the stage at which someone is released from custody can prove even more stressful, particularly for an individual with a substance dependence. A Brown University researcher has co-authored a new study that pinpoints a particularly troubling problem for many incarcerated individuals with opioid dependence: the typical requirement that they be weaned off maintenance medication while behind bars, and what that could mean after their sentence is served.
The study, published online last week in The Lancet, found in a sample of around 200 Rhode Island inmates that individuals who were taken off methadone while in custody were two times less likely than those staying on the medication to return to methadone treatment in the community within a month after release.
“That's a real problem, because that period is a dangerous time,” for relapse and associated problems, says Josiah D. Rich, MD, MPH, professor of medicine and epidemiology at Brown and co-founder of the Center for Prisoner Health and Human Rights, an entity that gives voice to human rights issues in the criminal justice system.
Rich often starts lectures to groups of professionals by stating that he has spent every Tuesday for the past two decades behind bars, as he has studied the effects of criminalization and incarceration from a public health perspective. He says that when he talks to inmates about the day they are to be released, “Most of the time they're terrified. The day they get out is worse than the day they go in. They can't get a job, they don't have any money. Every potential trigger is there.”
The study, conducted from 2011-2013, randomly assigned inmates of the Rhode Island Department of Corrections who had been receiving methadone maintenance treatment at the time of their arrest to either continuation of that treatment or a tapered withdrawal in accordance with usual correctional guidelines. The latter group received their usual methadone dose in their first week behind bars, followed by a tapering in increments of 3 to 5 mg a day depending on their baseline dose.
The study primarily examined engagement in community-based methadone maintenance treatment after release, with information gathered via follow-up interviews with participants one month post-release. Researchers found that all but four of the 110 individuals who had stayed on methadone treatment while in custody returned to a community clinic within a month, while 19 of 87 individuals who were tapered off methadone did not return to community-based care. In addition, only 8% of the individuals receiving continuation treatment while in custody used opioids in the month post-release, compared to 18% of the individuals who had received the taper.
Hospital visit, overdose and death rates were similar between the two study groups, researchers found.
Rich believes that this research reveals some telling findings at a time when the pure economics of carrying out punitive drug policies have opened the door to reform. Looking long-term, “We're not going to construct more prisons. That ship has sailed,” he says.
In fact, he says, Rhode Island officials responded to the findings of this study by adjusting their protocols regarding the methadone taper for inmates. Rather than keeping methadone-maintained individuals on their original dose for only one week before beginning the taper, that period has been extended to six weeks, Rich says.
He points out that some opioid-dependent individuals have expressed that they don't want to initiate methadone treatment for fear that if they end up arrested and jailed, they will experience an extended methadone withdrawal (with major sleep disturbance). Ironically, for many this makes heroin withdrawal while in prison seem to be a more desirable option, because while the symptoms of heroin withdrawal are generally more distressing, they are shorter-lasting, he says.