In the United States today, there are more than two million jail and prison inmates, of whom about 15 percent have histories of heroin dependence. Few inmates receive drug abuse treatment while incarcerated or immediately upon release. Research has shown that this population, once released from incarceration, is at high risk of relapse to heroin use, criminal behavior, HIV infection and of overdose death, resulting in a terrible toll on the individuals, their families and our communities.
The World Health Organization supports the international standard that prisoners have the right to access the health services that would be available to them in the community. Health care in prisons is then a human rights issue and treating drug-dependent prisoners in jail and prison is consistent with the spirit of that standard. However, the correctional systems in the U.S. have been slow to embrace this notion and have shown even less comfort with providing medications to treat addictive disorders.
There are now several FDA-approved medications available in the U.S. to treat opioid dependence. Methadone has been available to treat opiate dependence since the early 1970s. Buprenorphine (Subutex and Suboxone) has been available since 2003. Oral naltrexone, an opioid antagonist, has been available since 1984 and the recently-approved Vivitrol, a long-acting, injectable form of naltrexone, is now available. Unfortunately, these medications are infrequently provided to opioid-dependent adults in U.S. jails and prisons and in the community under parole or probation supervision.
There are multiple barriers impeding the improved treatment of opioid-dependent inmates, probationers and parolees. There is an inherent contradiction between custodial and treatment goals. Moreover, many correctional officials may not be aware of the strong evidence supporting the effectiveness of medications in reducing drug use and criminal activity. They may be philosophically opposed to the use of medications or reluctant to increase their budgets to include medical services for addiction treatment. Moreover, many corrections officials in charge of jails and prisons feel their responsibilities end when the inmate is released from their facility.
The question can then be asked: How can change be affected in the criminal justice system to improve the treatment of opioid-dependent prisoners? The answer may lie in current research, the majority of which is funded by the National Institute on Drug Abuse (NIDA).
Two different approaches are being used. The first is to test medications in opioid-dependent prisoners and those newly released from jail or prison. A recent study by Dr. Timothy Kinlock and colleagues at the Friends Research Institute established that adding methadone to counseling in prison increased the likelihood that a prisoner, upon release, would continue to receive drug abuse treatment in the community, reaping the benefits of this medication; e.g., reduced risk of drug use and of overdose. An ongoing multi-site study led by Dr. Charles OBrien at the University of Pennsylvania is underway among adult probationers and parolees to evaluate the effectiveness of long-acting naltrexone, which protects from relapse and overdose for one month. The research team at Friends Research Institute is also conducting a study of the effectiveness of Suboxone in prisoners with histories of opioid dependence.
The second approach is to forge better linkages and enhance collaboration between the criminal justice systems and the treatment clinics where effective medications for the treatment of alcohol and/or opioid dependence are available. The Criminal Justice-Drug Abuse Treatment Studies initiative of NIDA is currently funding a multi-city study. Its intent is to improve service coordination between parole and probation agencies and drug treatment clinics that provide medications for addiction treatment through an intervention aimed at improving knowledge and attitudes among community corrections (CC) staff and enhancing inter-organizational relationships. It is anticipated that improved knowledge and attitudes among CC staff will increase the number of criminal justice referrals to the treatment clinics.
Everyone wins by bringing the power of science to bear on the challenges of drug dependence in the criminal justice system. The opioid-dependent individuals reduce their likelihood of relapsing and dying of drug overdose upon release. A reduction in criminal and HIV-risk behavior improves public safety and protects the public health, and avoided episodes of reincarceration save the taxpayers money.
Frank Vocci, PhD, is President of Friends Research Institute, which promotes health and well-being through research, grants administration, education and treatment.