Methadone is an effective treatment for opioid dependence.
When people who are receiving methadone maintenance treatment for opioid
dependence are incarcerated in prison or jail, most US correctional facilities
discontinue their methadone treatment, either gradually, or more often,
abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal
and renders prisoners susceptible to relapse and overdose on release. We aimed
to study the effect of forced withdrawal from methadone upon incarceration on
individuals' risk behaviours and engagement with post-release treatment
programmes.
In this randomised, open-label trial, we randomly assigned
(1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were
enrolled in a methadone maintenance-treatment programme in the community at the
time of arrest and wanted to remain on methadone treatment during incarceration
and on release, to either continuation of their methadone treatment or to usual
care--forced tapered withdrawal from methadone. Participants could be included
in the study only if their incarceration would be more than 1 week but less
than 6 months. We did the random assignments with a computer-generated random
permutation, and urn randomisation procedures to stratify participants by sex
and race. Participants in the continued-methadone group were maintained on
their methadone dose at the time of their incarceration (with dose adjustments
as clinically indicated). Patients in the forced-withdrawal group followed the
institution's standard withdrawal protocol of receiving methadone for 1 week at
the dose at the time of their incarceration, then a tapered withdrawal regimen
(for those on a starting dose >100 mg, the dose was reduced by 5 mg per day
to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose
>100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes
were engagement with a methadone maintenance-treatment clinic after release
from incarceration and time to engagement with methadone maintenance treatment,
by intention-to-treat and as-treated analyses, which we established in a
follow-up interview with the participants at 1 month after their release from
incarceration. Our study paid for 10 weeks of methadone treatment after release
if participants needed financial help. This trial is registered with
ClinicalTrials.gov, number NCT01874964.
Between June 14, 2011, and April 3, 2013, we randomly
assigned 283 prisoners to our study, 142 to continued methadone treatment, and
141 to forced withdrawal from methadone. Of these, 60 were excluded because
they did not fit the eligibility criteria, leaving 114 in the
continued-methadone group and 109 in the forced-withdrawal group (usual care).
Participants assigned to continued methadone were more than twice as likely
than forced-withdrawal participants to return to a community methadone clinic
within 1 month of release (106 [96%] of 110 in the continued-methadone group
compared with 68 [78%] of 87 in the forced-withdrawal group; adjusted hazard
ratio [HR] 2·04, 95% CI 1·48-2·80). We noted no differences in serious adverse
events between groups. For the continued-methadone and forced-withdrawal
groups, the number of deaths were one and zero, non-fatal overdoses were one
and two, admissions to hospital were one and four; and emergency-room visits
were 11 and 16, respectively.
Although our study had several limitations--eg, it only
included participants incarcerated for fewer than 6 months, we showed that
forced withdrawal from methadone on incarceration reduced the likelihood of
prisoners re-engaging in methadone maintenance after their release.
Continuation of methadone maintenance during incarceration could contribute to
greater treatment engagement after release, which could in turn reduce the risk
of death from overdose and risk behaviours.
Below: Probability of attending a methadone clinic in (A) the intention-totreat and (B) the as-treated populations. Data are for 1 month follow-up after particpants’ release from incarceration.
Full article at: http://goo.gl/74GZF3
- 1Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA. Electronic address: jrich@lifespan.org.
- 2Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
- 3Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA; National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia.
- 4Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
- 5The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
- 6Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA; Memorial Hospital, Pawtucket, RI, USA.
- 7Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, AR, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
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