For over two decades I have provided weekly clinical care to prisoners at the Rhode Island Department of Corrections. This experience of meeting thousands of patients has confirmed the epidemiological data suggesting that over half of all current prisoners have an addiction problem. About one in seven has opioid dependence, a consistent and predictable, all-consuming, chronic relapsing and potentially fatal brain disease.
The current epidemic of opioid dependence has been driven by the flooding of the market with increased prescribing of pharmaceutical opioids. Regulatory pressures that have encouraged physicians to prescribe opioids for the management of chronic pain, along with unscrupulous profit-motivated pharmaceutical industry practices, have created this problem. The rise in opioid prescription has had disastrous consequences including unprecedented rates of overdose deaths, which have led to physicians finally starting to reduce their prescribing. The use of prescription monitoring programs as well as increasing physician education and other interventions will also decrease new initiates, but that is unlikely to help those already dependent. Wide distribution of naloxone, an antidote that can be given in an acute overdose; Good Samaritan laws that encourage people to call 911 without fear of arrest; and educating people about how to prevent overdose including not mixing opioids with alcohol or other sedatives will all help save lives, but not tackle the underlying cause.
As physicians clamp down on the availability of prescription opioids, most opioid users will turn to the less-expensive and often more readily-available option of heroin. Their heroin use typically begins with sniffing of powder heroin and then, as their use increases with increasing tolerance, there is often a transition to injecting heroin, which makes for even greater health risks. Many eventually turn to one or more of three basic activities to support their habit: getting involved in the sex trade, the drug trade or stealing.
My patients who have cycled in and out of the incarcerated setting because of opioid dependence provide a vivid description of why recidivism rates are so high. When I ask them if are they planning to relapse to heroin use after release, the answer is invariably "no." But when I ask them what happened the last number of times they've been released from incarceration, the answer is that they have always eventually relapsed to opioid use, despite the best intentions not to.
Most never received treatment, which is more effective than incarceration in the long run and likely even the short run. In either case we should at a minimum coordinate efforts between the criminal justice system and the drug treatment system to work toward the same goal: getting people to stop their illegal and dangerous behavior.
One obvious example of where we are not doing what we can is in the use of methadone among incarcerated populations. Methadone has had a 50-plus-year track record of use in the treatment of opioid dependence. It is highly effective at reducing illicit opioid use and many of the dangerous associated behaviors and outcomes including overdose and death. But in this country, in most jurisdictions, people are forced off of methadone upon incarceration, even prior to conviction, causing predictable painful withdrawal, and putting them at increased risk for relapse and overdose death after release. The Baltimore City jail was a notable exception, as it provided methadone to prisoners since before 2008, but that is not the case with most county jails throughout Maryland.
In the May 29 online issue of the medical journal The Lancet, colleagues and I reported results of a one-month randomized clinical trial comparing continued methadone with forced withdrawal from methadone for people who were in treatment at the time of incarceration. The results show that of those who were on methadone at the time of release, 100 percent continued methadone treatment in the community whereas less than half of those forced off of methadone returned to the methadone clinic, and even at one month this was cost effective.
Ultimately we should move to be more in line with the rest of the world and treat addiction, in particular opioid dependence, as the medical disease it is, rather than as a crime. However in the meantime, we should at least strive to link people to effective treatment at every stage along the continuum — from arrest to reentry and probation or parole. This is good clinical care, good public health and good public safety.
Dr. Josiah D. "Jody" Rich is a professor of medicine and epidemiology at Brown University and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital. His email is JRich@Lifespan.org.