By Alison Knopf
One of the most important initiatives occurring in methadone treatment for opioid use disorders (OUDs) is taking place in prisons and jails. In many states, a person who was addicted to opioids and then became incarcerated was left to undergo cold-turkey withdrawal, with no treatment.
Now, states and localities are starting to recognize the cruelty and lack of logic of this kind of plan. Because while most—but not all—of those people survived, when they were released from jail or prison and went back to using opioids, as was likely, they were also more likely to overdose. The dose they had been used to before the abstinence period was enough to make them overdose. And when illicit fentanyl entered the scene, a few years ago, the overdose became even more likely to be lethal.
So, states—starting with Rhode Island (see https://atforum.com/2018/02/moving-ahead-on-methadone-in-corrections/)—are gradually realizing that they need to have treatment behind the walls. Most recently, HB116/SB846 is working its way through the Maryland legislature. This bill would have opioid treatment programs (OTPs) operate within prisons and jails to provide methadone to addicted inmates.
AT Forum spoke with Babak Imanoel, DO, about how the program, which is expected to become law in October, would work. Dr. Imanoel, who is medical director of opioid treatment programs with the Anne Arundel County Department of Health, has been running just such a program in the local jail.
“We know that roughly 70 percent of people behind bars have an opioid use disorder,” Dr. Imanoel told AT Forum. “By starting them on buprenorphine, methadone, or Vivitrol behind bars, their chances of staying in treatment when they leave go up.” Before the program in Anne Arundel County started, the jail there had only abstinence-based treatment, he said. Of 350 people treated in that program, only 1 showed up for treatment after release. Close to 50 percent relapsed within two weeks. “We don’t know what happened to them,” said Dr. Imanoel, of the released inmates. Once the jail started using methadone instead, 85 percent of the people who were released showed up at treatment.
The county health department, where Dr. Imanoel is an independent contractor, is in charge of the treatment program in the jail. “We work with the correctional facility, but we are running the program,” he said.
Reductions in ODs
The Rhode Island OTP-corrections program, on which the Maryland program will be based, showed a 65% reduction in overdose deaths. In Anne Arundel county, there hasn’t been a single OD death in a patient treated with methadone: a 100% reduction in deaths.
In addition, jail staff report—not surprisingly—that inmates getting treatment “are calmer, less likely to get into fights, and use less medical resources,” said Dr. Imanoel.
The current Maryland bill would have an OTP inside every jail system. The OTP could be freestanding, or could be contracted by the jail system. The three approved medications—naltrexone (Vivitrol), buprenorphine, and methadone—would all be offered.
If only Vivitrol or buprenorphine were offered, an OTP wouldn’t be necessary, Dr. Imanoel conceded. “But Vivitrol doesn’t take the craving away to the extent that methadone does, and neither does buprenorphine—it doesn’t keep people in treatment as long as methadone does.” In addition, Vivitrol and buprenorphine are much more costly than methadone. However, the costs of an OTP, which would be needed under federal law if methadone were dispensed—are high, as well. Either way, the bill is going to cost the taxpayer.
The bill would require all three medications to be available. “We don’t want to force everyone to take methadone,” said Dr. Imanoel.
There are two obstacles to the bill: one is the price tag, and the other is that the correctional facilities are fighting it. “They say, ‘We are corrections, people should be punished,” said Dr. Imanoel. “But it’s treatment, it’s just like somebody with diabetes—they should get treatment.” So, while OTPs are 100% in favor of the bill, the jails themselves are not.
For the text of the bill as introduced, go to https://legiscan.com/MD/text/HB116/id/1860222/Maryland-2019-HB116-Introduced.pdf