Effectiveness of Opiate Replacement Therapy Administered Prior to Release From a Correctional Facility - 1

Study Overview
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Brief Summary
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Much of the HIV/AIDS epidemic is driven by transmission from or to persons addicted to opiates. Many of these individuals pass through a correctional setting each year, creating an opportunity for linkage to substance abuse treatment. The purpose of this study was to evaluate the effectiveness of initiating opiate replacement therapy prior to release from incarceration on reducing HIV risk behaviors and drug relapse. In addition, this study evaluated the effectiveness of short-term payment versus non-payment of community opiate replacement therapy immediately following release from incarceration.

Detailed Description
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A substantial proportion of individuals addicted to heroin are incarcerated while addicted and a majority of individuals released from a correctional setting have a history of heroin addiction. The period immediately after release from incarceration is a particularly high-risk time for HIV transmission and other problems, including drug relapse and overdose. Methadone treatment is the most widely used opiate replacement therapy in the United States and has been shown to decrease HIV risk, as well as drug use, addiction relapse, and criminal activity. The purpose of this study was to evaluate the effectiveness of initiating opiate replacement therapy prior to release from incarceration on reducing HIV risk behaviors and drug relapse. In addition, this study evaluated the effectiveness of short-term payment versus non-payment of community opiate replacement therapy immediately following release from incarceration. Participants in this were randomly assigned to 1 of 3 treatment groups. Participants enrolled in Group 1 initiated methadone opiate replacement therapy about 1 month prior to release from incarceration. They proceeded with a methadone program of their choice upon release and received short-term payment to cover treatment costs. Participants enrolled in Group 2 were referred to a methadone program of their choice and received short-term payment to cover treatment costs. Participants enrolled in Group 3 were referred to a program of choice upon release from incarceration without receiving financial assistance. All participants had the opportunity to partake in existing support programs available at the Rhode Island Department of Corrections while incarcerated and in the community upon release. Follow-up assessments occurred at Months 1.5, 6, and 12. These included interviews and urine specimens for toxicology analysis to verify self-reports.

Official Title
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Opiate Replacement Therapy at Release From Incarceration

Conditions
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HIV Prevention, Opioid-Related Disorders

Intervention / Treatment
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* Behavioral: Pre-release Initiation of MMT
* Behavioral: Post Release Initiation of MMT.
* Behavioral: Standard of Care Plus


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Currently incarcerated at the Rhode Island Department of Corrections with a scheduled release date at least 28 days after enrollment Incarceration length not to have exceeded two years at the time of enrollment Heroin dependent with self-reported heroin injection in the month prior to incarceration OR enrollment in a methadone treatment program prior to incarceration for heroin addiction with a history of injection drug use Desire to enter methadone treatment upon release and plans to secure funding for methadone treatment after study completion History of prior tolerance to methadone History of at least one drug-related incarceration Speaks English or Spanish Plans to remain in Rhode Island for the duration of the study (24 months) Ability to provide at least two names of individuals who can verify participant information Exclusion Criteria: Currently receiving methadone at the Rhode Island Department of Corrections Currently undergoing a non-narcotic detoxification from illicit opiates at the Rhode Island Department of Corrections Plans to leave Rhode Island within the two years following enrollment

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Pre-Release Initiation MMT<br>Participants assigned to this arm will undergo extensive assessment (physical, medical history, drug use and treatment history) prior to initiating treatment. MMT will begin 1-30 days prior to release from incarceration. MMT first dose will begin at 5 mg with 2 mg increase per day until release or therapeutic dose of 60-120 mg is achieved. Daily observation by dosing nurses and twice weekly symptom review by Research Assistant will occur. Additionally, participants assigned to Arm 1 will have all logistical arrangements made for entry into a community methadone clinic program within 24 hours of release from incarceration. The study will fully pay for MMT for 12 weeks and half the costs of treatment for the next 12 weeks. | Behavioral: Pre-release Initiation of MMT<br>* Participants assigned to arm 1 will undergo extensive assessment (physical, medical history, drug use and treatment history) prior to initiating treatment. MMT will begin 1-30 days prior to release from incarceration. MMT first dose will begin at 5 mg with 2 mg increase per day until release or therapeutic dose of 60-120 mg is achieved. Daily observation by dosing nurses and twice weekly symptom review by Research Assistant will occur. Additionally, participants assigned to Arm 1 will have all logistical arrangements made for entry into a community methadone clinic program within 24 hours of release from incarceration. The study will fully pay for MMT for 12 weeks and half the costs of treatment for the next 12 weeks.<br>|
| Experimental: Post Release Initiation of MMT<br>Participants assigned to this arm will have all logistical arrangements made for entry into a community methadone clinic program within 24-48 hours of release from incarceration. The study will fully pay for MMT for 12 weeks and half the costs of treatment for the next 12 weeks. | Behavioral: Post Release Initiation of MMT.<br>* Participants assigned to Arm 2 will have all logistical arrangements made for entry into a community methadone clinic program within 24-48 hours of release from incarceration. The study will fully pay for MMT for 12 weeks and half the costs of treatment for the next 12 weeks.<br>|
| Active Comparator: Standard of Care Plus<br>Participants assigned to this arem will not begin treatment prior to release from incarceration or have treatment paid for by the study. However, study staff will work with participants to identify ways to pay for treatment, including assisting with medicaid applications, etc. Further, the study will make the logistical arrangements for entering treatment if participant has a means to finance MMT. | Behavioral: Standard of Care Plus<br>* Participants assigned to Arm 3 will not begin treatment prior to release from incarceration or have treatment paid for by the study. However, study staff will work with participants to identify ways to pay for treatment, including assisting with medicaid applications, etc. Further, the study will make the logistical arrangements for entering treatment if participant has a means to finance MMT.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Treatment Engagement | Participants are considered to have successfully initiated community methadone maintenance treatment only if they make their first clinic appointment within 30 days after being released from incarceration. This outcome is measured by frequency - yes, participant attended initial clinic appointment within 30 days post release or no, participant did not attend clinic appointment within 30 days post release. Data source was methadone clinic chart review. | within 30 days post release of incarceration | 
| Time to MMT Initiation Post Release Based on Clinic Chart Review | Participants are considered to have successfully initiated community methadone maintenance treatment only if they make their first clinic appointment within 30 days after being released from incarceration. This outcome measures number of days from release to the first day of clinic attendance, only for those participants who successfully entered methadone treatment post release. Data source was methadone clinic chart review. | within 30 days post release from incarceration | 
| HIV Risk Behaviors - Self Report | Participants who self-reported injecting illicit drugs in the past 30 days, based on responses to face-to-face administration of the 6 month interview. | 6 month follow-up interviews | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Drug Use | Participants who self-reported heroin use in the past 30 days, based on responses to face-to-face administration of the 6 month interview. | 6 month follow-up interviews | 
| Fatal Overdose | Number of participants who died as the result of drug poisoning within six months of release of incarceration. This outcome was based on review of death records. | Within six months from release of incarceration | 
| Non-fatal Overdose | Participants who self-reported experiencing an overdose within the past six months, based on responses to face-to-face administration of the 6 month interview. | 6 month follow-up interviews | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HIV Prevention, Opioid-Related Disorders, Medication Assisted Treatment, Methadone