Prisoners Taking Effective Methadone Doses Report to Methadone Treatment Programs After Release

“To be effective, [opioid addiction] treatment must begin in prison and be sustained after release through participation in community treatment programs.”—Nora D. Volkow, MD, Director, National Institute on Drug Abuse (NIDA)^a

A simple goal, but rarely achieved. So it’s refreshing to hear of a detention system that actually views incarceration as “an opportunity for prevention and treatment, including initiating methadone treatment prior to release”—a system where inmates’ doses are titrated to effective levels, and inmates report to methadone treatment programs (MTPs) after release.

That system is the Rikers Island Key Extended Entry Program (KEEP), offering methadone treatment to opioid-dependent inmates of New York City’s jails. The KEEP program began in 1986; today its goal remains to relieve or prevent opioid-dependent inmates’ withdrawal symptoms, and to engage inmates in long-term, effective methadone maintenance treatment (MMT).

The Effective-Dose Effort

In July 2007, in response to a trend toward low-dose methadone prescribing, KEEP initiated an evidence-based, dose-adjustment, quality-improvement (QI) protocol to maximize the therapeutic effects of methadone, and to improve inmates’ reporting rate to MTPs after release. They trained counselors, physicians, and pharmacists in the QI guidelines, which call for gradual titration to methadone doses of 70 mg per day or higher, as necessary, at increases of 5 to 10 mg per day.

About 650 opioid-dependent prisoners were enrolled in the QI study. Roughly half were in MTPs at the time of arrest. The group was fairly representative of the Rikers’ population—average age, 40 years, 72 percent men, 40 percent African American, 41 percent Hispanic, and 19 percent Caucasian/other. Data were collected in July and November, 2007.

Results

The methadone dose at the time of discharge ranged from 15 to an exceptionally high 1,140 mg/day, with a median of 50 mg/day. The proportion of patients reaching effective doses increased significantly among those incarcerated at least 21 days, allowing time for titration. At discharge, significantly fewer patients (34 percent vs. 72 percent) were within the lowest methadone dosage range—15 to 30 mg/day—than those discharged before the QI program began.

In addition to providing the best results, effective doses yielded the best rates of reporting to MTPs upon reentry. In fact, all prisoners who reached 55 mg/day or higher—even those not in the QI study—reported to an MTP post-release.

The authors note some shortcomings in their study, published January 2012 in Substance Abuse. Gradually increasing a prisoner’s methadone dose requires several weeks, so the short length of stay of many jail prisoners made it difficult to reach an optimum dose before their release. The authors also said it would be helpful to add more data to the study, especially on dosage, and to follow up with prisoners after reentry, to see if they remained in treatment.

Here’s some evidence from follow-up data from NIDA: a graph showing that prisoners started on methadone one month before release are more likely to be in treatment and heroin-free six months later than those who receive counseling alone. Dr. Volkow, who presented this slide at a Blending Conference in April 2010, called for implementation of this evidence-based treatment nationwide, calling it a “win-win scenario.”

Dr. Volkow’s initial premise doesn’t seem so difficult to carry out. So why aren’t other jails and prisons doing what KEEP has done? We look forward to hearing your comments on your experiences with medication-assisted treatment in your probation, parole, jail, or prison system.

References

^aNational Institute on Drug Abuse. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-based Guide. National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, MD. NIH Publication No. 06-5316. Published September 2006, Revised January 2012.
http://www.drugabuse.gov/publications/principles-drug-abuse-treatment-criminal-justice-populations

^bHarris A, Selling D, Luther C, et al. Rate of community methadone treatment reporting at jail reentry following a methadone increased dose quality improvement. Subst Abus 2012;33(1):70-75.