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Medically treating opioid use disorder in prison saves lives

In Maryland, opioid overdoses now kill more people each year than guns and car crashes combined. With more than 2,000 deaths in 2017, Maryland ranks among the five states with the highest rates of opioid-related overdose deaths at double the national average.

The state needs to make progress in saving lives — and fast. A terrific opportunity is the Medication Assisted Treatment in Detention Act (House Bill 116/ Senate Bill 846). This legislation would require jails and prisons in Maryland to provide access to all three FDA-approved medications for opioid use disorder to individuals during incarceration. With some modest improvements, the legislation, if passed, could begin driving overdoses down within a year of implementation.

In Maryland, people recently released from detention are 8 to 10 times more likely to die from overdose than the general population. When detained, people lose their tolerance to opioids and do not receive the necessary treatment, placing them at extremely high risk for drug overdose and death after release if they were to take the same dose of opioids as before. This bill would be a much-needed intervention because it increases access to a key tool in fighting the opioid epidemic: evidence-based medications. Providing evidence-based treatment during detention and ensuring coordinated care after release will put people on the path to recovery. This will save lives, reduce crime and improve entire communities’ safety and health.

The FDA has approved methadone, buprenorphine and depot naltrexone for opioid use disorder. Studies show that medications for opioid use disorder like buprenorphine and methadone are much more effective for treating opioid use disorder than counseling alone. These medications reduce the risk of dying from overdose, decrease illicit opioid use, increase treatment retention and reduce infections of HIV and hepatitis C. This means treatment not only helps the person with addiction, but also their families and communities.

Access to all three FDA-approved medications is essential. People respond differently to different medications and may have medical or other reasons for their choice. Unfortunately, misconceptions around these medications are common. Policymakers sometimes question when someone might be able to be “weaned off methadone,” suggesting that treatments for opioid use disorders simply substitute one addiction for another.

As public health students and researchers, we want to clarify these common misconceptions. Addiction is a chronic brain disease characterized by craving and compulsive drug-seeking. Appropriately managed treatment medications do not create these behaviors nor induce euphoria. These medications provide medical treatment for a chronic health condition — which often means that patients may never be able to be stop taking the medication safely. We would not think of a diabetic as “addicted” to insulin or expect them to be “weaned off” of insulin; instead we think of insulin as a life-saving treatment. The same should apply to these medications.

The benefits of medication for opioid use disorder have been specifically tested in prisons and jails, which is why national expert groups such as the American Society for Addiction Medicine and American Correctional Association recommend its use. One study found that incarcerated individuals with opioid use disorder treated by medications had an 87 percent lower risk of death than those untreated. Improved survival can continue post-release, especially when individuals are linked to ongoing treatment in the community. In Rhode Island, a statewide program similar to the one proposed by the Medication Assisted Treatment in Detention Act resulted in a 60 percent decrease in overdose mortality following release.

Currently, access to medications for opioid use disorder in Maryland correctional facilities is extremely limited. This is not only inhumane; it’s unconstitutional. Denying access to treatment violates the Eighth Amendment of the Constitution, which bars cruel and unusual punishment, and the Americans with Disabilities Act and the Rehabilitation Act. According to an analysis by the law firm Akin Gump, continuing to limit access to medications could result in Maryland “being forced to implement court-mandated reforms, and facing costly litigation from individuals with opioid use disorder, advocacy organizations, and the Department of Justice.”

The Medication Assisted Treatment in Detention Act is an important step forward. The bill could be strengthened by adding a requirement for clear guidelines and timelines around treatment, creating strong oversight and technical assistance mechanisms and bolstering requirements around post-release planning. These plans should include health insurance enrollment and referral appointments to providers who can continue to provide medication treatment in the community.

Passing this bill will expand treatment for opioid use disorder and save lives. Given the scale of Maryland’s opioid crisis, it is not an opportunity we can waste.

Sachini Bandara (sbandara@jhu.edu) is a postdoctoral fellow at the Center for Mental Health and Addiction Policy Research at the Johns Hopkins Bloomberg School of Public Health. Jenny Wen (jwen13@jhu.edu) and N. Jia Ahmad (jia.ahmad@jhu.edu) are medical students and Master of Public Health candidates at Johns Hopkins University. These views are our own and do not represent our institution.

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