Dear Editor:
Over 50 percent of the incarcerated population in the United States have a history substance abuse, and it has been noted that over 200,000 of the incarcerated population have a heroin addiction history.[1] In a study by Nunn et al,[1] in which all 50 states and the District of Columbia were surveyed, 55 percent of the 51 prisons in the survey prescribed methadone to the inmates and 14 percent prescribed buprenorphine. The main reason cited for not offering opiate replacement therapy (methadone or buprenorphine/ naloxone) was that a “drug-free detoxification” was preferred.[1]
The benefits of providing opiate replacement therapy for inmates with human immunodeficiency virus (HIV) and opioid addiction have been demonstrated.2,3 In a study by Springer et al,[2] in which 69 HIV-infected inmates on antiretroviral therapy were enrolled in a randomized, controlled trial, 30 inmates were either prescribed methadone (7 subjects) or buprenorphine/ naloxone (23 subjects). Opiate-negative urine testing was above 80 percent for those who completed buprenorphine/naloxone induction. Among this group, there was also reported a significant diminished opioid craving, and nondetectable viral load and CD4 count remained lower than those inmates not on opiate replacement treatment).[2]
In a feasibility study by Zaller et al,[3] the authors investigated the practice of initiating buprenorphine/naloxone treatment to inmates prior to release and linking these inmates to community treatment providers following release. This study was a single-arm, open-label study with a six-month follow-up in the community. The study focused on the amount of time that passed from the date of inmate release to the first buprenorphine/naloxone prescriber appointment post-release. Investigators found that those individuals who were initiated buprenorphine/naloxone treatment while still in prison accessed the community treatment providers on average 3.9 days following release versus 8.8 days for those who were not intiated treatment while still in prison. The study also revealed the median post-release treatment duration in those that started buprenorphine/naloxone treatment prior to release versus after release to be 24 and nine weeks, respectively. These led to the investigators to conclude that initiating buprenorphine/naloxone prior to release from the Department of Corrections resulted in increased engagement and retention in community-based treatment.[3]
Despite the fact that legal prescription of buprenorphine/ naloxone in the correctional system is limited, there appears to be a significant and increasing diversion of the medication in correctional facilities in several states, and the drug has been the leading contraband in a number of those state correctional systems.[4] It was noted in a report that in 2010 the rate of prescribing buprenorphine/naloxone in the state of Vermont was four times the national rate, and that it was the most common illegal drug seized as contraband in that state’s correctional system.5 Innovative ways of smuggling this drug have been prevalent in the correctional system in several states, with reports of smuggling via stamps on envelopes, in posters, in children’s artwork, in balloons, and in ballpoint pens. This has led to different correctional facilities adopting several policies to address this escalating problem.[4,5]
References
1. Nunn A, Zaller N, Dickman S, et al, Methadone and Buprenorphine prescribing and referral practices in Us prison systems: results from a nationwide survey. Drug Alcohol Depend. 2009Nov 1;105(1-2):83–8.
2. Springer SA, Chen S, Altice FL. Improved HIV and substance abuse treatment outcomes for released HIV-infected prisoners: the impact of buprenorphine treatment. J Urban Health. 2010 Jul;87(4):592–602.
3. Zaller N, McKenzie M, Friedmann PD, et al. Initiation of Buprenorphine during incarceration and retention in treatment upon release. J Subst Abuse Treat. 2013 Aug;45(2):222–6.
4. Contreras R. In New Mexico, a rise in Suboxone smuggling. htpp://www.boston.com/lifestyle/health/2012/06/16/new-mexico-rise-suboxone-smuggling/c83P1HOmDCyzu80fbt7TjK/story.html
5. Suboxone abuse worries officials in Vermont. htpp://www.addictionts.com/2013/06/03/suboxone-abuse-worries-officials-in-vermont/
With regards,
Adegboyega Oyemade, MD, FAPA
Dr. Oyemade is an Addiction Psychiatrist at the Maryland Treatment Centers, Inc. in Baltimore/Emmitsburg, Maryland.
Funding/financial disclosures: No funding was received for the preparation of this article. The authors have no conflicts relevant to the content of this article.
