Improving access to opiate addiction treatment for prisoners.

Larney highlights the limited evidence base regarding the impact of opiate substitution therapy (OST) in prisons on injection drug use (IDU), IDU-related HIV risk behaviors, and HIV outcomes, calling for new research on this important topic (1). Given that nearly all heroin injectors nationwide are incarcerated at some point during their lives, the correctional setting provides an important opportunity to treat a hard-to-reach population with proven, evidence-based pharmacological therapy (2). We recently conducted a nationwide mixed-method survey of state and federal prison medical directors about OST prescribing attitudes and practices; our findings help explain several of the complex factors underlying this limited evidence base (3). We found that in spite of the proven health, social and economic benefits of providing OST (4–8), only 55% of prisons in the United States provide methadone to inmates in any circumstance, and most provide only to pregnant women (3). Only 14% of prisons provide buprenorphine to prisoners while incarcerated (3). While this represents a marked improvement in access to OST in correctional settings since 2002,(9) only a minute fraction of the estimated 200,000 incarcerated individuals with opiate dependence have access to OST (3). Moreover, our survey found that the overwhelming majority of prisons also do not offer referrals to OST providers and programs to inmates upon release because of preferences for drug-free detoxification over pharmacological treatment of opiate dependence and limited partnerships with community providers, among other reasons (3). Many prisons adopt abstinence-only policies because of philosophical opposition to pharmaceutical treatment of opiate dependence and preference for abstinence-only programs for incarcerated individuals (3). These policies reflect a common misconception that opiate dependence is cured when drug use and withdrawal symptoms cease and ignores empirical evidence demonstrating high rates of relapse and alarmingly high rates of opiate overdose among people recently released from prison (10–11). Other factors also play a role in limiting OST in correctional settings; even medical directors receptive to providing OST often face administrative and budget constraints that limit implementation of OST programs (3). Moreover, other research finds that security concerns and philosophical opposition to OST by correctional staff can impede expansion of OST in correctional settings (12). We have a twenty-year history of collaborating with the Rhode Island Department of Corrections and have managed to overcome many of these barriers. However, doing so has required significant time and commitment from both parties. This collaboration has resulted in numerous federally-funded research and service grants which have greatly benefited hundreds of opiate dependent individuals leaving the correctional setting. Building the evidence base about the health, social and economic benefits of providing OST in correctional settings will likely require more than simply financing new research studies. Advancing OST research and programs in correctional settings will require educating medical directors and administrators about the social, medical and economic benefits of OST; overcoming administrative and political opposition to pharmacological treatment of opiate dependence; understanding and successfully addressing the security concerns of prison officials and staff; and overcoming severe budget constraints.