Buprenorphine and methadone maintenance in jail and post-release: A randomized clinical trial

Abstract

Buprenorphine has rarely been administered as an opioid agonist maintenance therapy in a correctional setting. This study introduced buprenorphine maintenance in a large urban jail, Rikers Island in New York City. Heroin-dependent men not enrolled in community methadone treatment and sentenced to 10-90 days in jail (N=116) were voluntarily randomly assigned either to buprenorphine or methadone maintenance, the latter being the standard of care for eligible inmates at Rikers. Buprenorphine and methadone maintenance completion rates in jail were equally high, but the buprenorphine group reported for their designated post-release treatment in the community significantly more often than did the methadone group (48% vs. 14%, p <.001). Consistent with this result, prior to release from Rikers, buprenorphine patients stated an intention to continue treatment after release more often than did methadone patients (93% vs. 44%, p <.001). Buprenorphine patients were also less likely than methadone patients to withdraw voluntarily from medication while in jail (3% vs. 16%, p <.05). There were no post-release differences between the buprenorphine and methadone groups in self-reported relapse to illicit opioid use, self-reported re-arrests, self-reported severity of crime or re-incarceration in jail. After initiating opioid agonist treatment in jail, continuing buprenorphine maintenance in the community appears to be more acceptable to offenders than continuing methadone maintenance.

Effect of Incarceration History on Outcomes of Primary Care Office-based Buprenorphine/Naloxone

“…These findings are similar to other studies where methadone was initiated in either the community or prison; 36,37 studies evaluating buprenorphine/naloxone initiated in prison have not followed participants for more than 3 months but are similarly promising. 38,39 Given the evidence, all criminal justice settings, including prison, jail, parole, and probation, should consider initiating buprenorphine/naloxone for opioid dependent individuals or provide linkages directly to opioid agonist treatment programs in the community, but the reality is that most facilities have not actualized either. As such, individuals with a history of incarceration are apt to connect to treatment services upon release, possibly in officebased treatment programs.…”

How Should a Health Care Professional Respond to an Incarcerated Patient's Request for a Particular Treatment?

“…To take one example, in a randomized controlled trial of opioid agonist therapies at a large jail, 7 of 116 men were discontinued on the medications out of concern for diversion over a one-month study period [11]. The health impact of medication diversion is unknown: between 2000 and 2013, 4-9 percent of county jail inmate deaths and 1-2 percent of state prison inmate deaths were attributed to alcohol or drug intoxication, although the source of those substances is not reported, and many deaths are likely not due to medication diversion [12].…”

“…Notably, no data that we know of exist to suggest that diversion occurs at a higher rate or that it is more problematic in correctional settings. Using the numbers from the clinical trial cited above, over a month, perhaps 5 percent of incarcerated recipients diverted opioids [11]; national rates in the community setting in the US and France have been quoted as 0.08 percent and 20 percent, respectively [27].…”

One Good Decision: The Policy Argument for Extended Release Naltrexone in the Criminal Justice Setting

“…But this stigma is both overblown (relative to agonists) and overbroad (relative to antagonists). Although the efficacy of agonist-based MATs like methadone and buprenorphine in the CJ setting is well-established (Gordon et al 2008;Magura et al 2009), CJ professionals could still have legitimate concerns about their use. The first is the potential for abuse.…”