# Presentation: 687230

## Psychopharmacotherapy in Correctional InstitutionsRobert P. Schwartz, M.D.Friends Research InstituteSupported by NIDA R01 DA 016237 (PI: Kinlock)

## Psychopharmacotherapy

- Medically accepted standard of care for:
- I. Psychiatric Disorders
- Schizophrenia
- Bipolar Disorder
- Major Depression
- II. Addictive Disorders
- Opioid Dependence

## Psychopharmacotherapy in Corrections

- Key component of inmate mental health care
- subject of class action litigation
- Withholding such treatment is “cruel and inhuman” punishment
- 8th Amendment Violation

## I. Psychiatric Disorders

- Unique aspects of psychopharmacology in correctional settings:
- Lack of freedom
- Coercive sedation not permitted
- Formulary restrictions
- Cost considerations
- Extreme heat
- Neuroleptic Malignant Syndrome
- Continuity of care
- Discharge planning

## II. Addictive Disorders: 

**-10**

**-9**

**-8**

**-7**

**-6**

**-5**

**-4**

**0**

**10**

**20**

**30**

**40**

**50**

**60**

**70**

**80**

**90**

**100**

**% Efficacy**

**Log Dose of Opioid**

**Full Agonist**

**(Methadone)**

**Partial Agonist**

**(Buprenorphine)**

**Antagonist (Naloxone)**

**II. Addictive Disorders: **
**Opioid Agonist and Antagonist Therapy**

## Opioid Agonist Therapy: Jails(Dole et al., 1969)

- Random assignment study
- Pre-release jail inmates at Rikers Island, NYC
- 12 initiated methadone 10 days before release
- 16 controls
- 			_Results at 7-10 months post release_
- 			  _Methadone_			_Controls_
- 	Used Heroin	       83%		  	100%
- 	Addicted	         0		  		100%
- 	Incarcerated	       25%		    	  94%

## Opioid Agonist Therapy: Jails

- Treatment for opioid withdrawal and prevention of post-release relapse
- Commonly provided throughout the world
- 		 ● US is an exception: very small but growing number of programs
- Three uses in Rikers Island (Magura et al., 1993)
- 		● heroin detoxification
- 		● initiate maintenance therapy
- 		● continue maintenance therapy for patients in treatment at arrest

## Barriers to Correction-based Opioid Agonist Treatment 

- Concerns about “addicting” prisoners not currently opioid dependent
- Concerns about drug diversion and violence
- Space constraints
- Competing demand on correctional and medical staffs

## Methadone Maintenance for Prisoners(Kinlock et al., 2007)

- NIDA-funded three-group randomized clinical trial
- Conducted in pre-release prison in Baltimore, Maryland
- 190 adult male participants with completed 6 month follow-up interviews
- 	  ● Out of 211 randomly assigned participants
- ● Not currently heroin-dependent
- ● All had weekly counseling available in prison
- Those receiving methadone, start at low dose and go up slowly:
- 	First dose: 5 mg
- 	Induction: 5 mg increase per week to 60 mg
- 	Maintenance: appropriate dose (average about 80 mg)

** *Study is ongoing. To date, 190 of the 211 randomly assigned participants due for 6-month f/u

## Treatment Conditions

|  | N |
| --- | --- |
| Counseling Only
Counseling in prison and passive referral as usual | 61 |
| Counseling+Transfer
Counseling in prison and access to methadone upon release | 63      |
| Counseling+Methadone
Counseling and methadone in prison, with continuation of methadone upon release | 66 |
| Total |    190 |

## Participant Demographics

|  | % | Mean | SD |
| --- | --- | --- | --- |
| Age |  |  40.3 | 7.2   |
| Race
   African American
 Caucasian
Other | 
  69.5
23.9
6.6 | 

     |  |
| Education |  | 10.9 | 1.8  |

## Substance Use History

|   | Mean | SD |
| --- | --- | --- |
| Age of Onset

Heroin
Cocaine | 

18.6
21.7    | 

4.9
7.5 |
| No. Days use in 30 Days 
Prior to Incarceration
            Heroin 
            Cocaine | 

27.3
18.2 | 

7.5
13.2     |
| Prior Treatment 
                                                     Any
            Methadone | 
    2.7
1.4 | 
2.0
1.0    |

## Prison Treatment Status

-  CO v. C + M (*p *= .001); C + T v. C + M (*p *= .05)
-  CO v. C  + M (*p *= 007); CO v. C + T (*p *= .002)

## Community Treatment Status

- *   CO *v.* C + M  and *v.* C+T (both *ps *= .0001); C + T *v.* C + M (*p *= .03)
- ** CO *v.* C + M and *v. *C + T (*ps *= .0001 and  .007); C + T *v. *C + M (*p *< .02)

## 6-Month Post-Release Follow-up Drug Testing

- * CO  *v.*  C  +  M,  *p* = .001

## Buprenorphine in Prison(Albizu-Garcia et al., In Press)

- _NIDA-funded pilot study_
- 45 adult male pre-release prisoners in San Juan
- High rates of heroin use in prison
- Initiated buprenorphine treatment prior to release
- 			          _Results at 1 month follow-up_
- 7% dropped out in prison
- 83% attended MD appointment in community
- 73% had negative heroin drug test

## Summary

- Pharmocotherapy for psychiatric disorders in jails and prisons should be part of standard medical care
- Methadone started in jails provides humane medical care
- Preliminary 6-month post-release findings indicate that methadone is an effective pre-release strategy in prison
- Buprenorphine appears to be a promising pre-release strategy

## References

- Dole VP, Robinson JW, Orraca J, Towns E, Searcy P, Caine E. Methadone treatment of randomly selected criminal addicts. *NEJM*. 1969;280 (25):1372-5.
- Magura S, Rosenblum A, Lewis C, Joseph H. The effectiveness of in-jail methadone maintenance. *Journal of Drug Issues. 1993; *23:75-99.
- Kinlock, TW, Gordon MS, Schwartz, RP, O’Grady, KE, Fitzgerald TT, Wilson, M. A randomized clinical trial of methadone maintenance for prisoners: Results at 1-month post-release. *Drug and Alcohol Dependence *(In press).
- Albizu-Garcia, C, Caraballo Correa G, Hernandez Viver, AD, Kinlock, TW, Gordon, MS, Antron Avila, C, Colón Reyes, I, Schwartz RP. Buprenorphine-Naloxone treatment for pre-release opioid dependent inmates in Puerto Rico. *Journal of Addiction Medicine *(In press).