Written by Michael A. Mitcheff, DO, MBA, CHCQM
While medications for opioid use disorder (MOUD) programs are considered the gold standard for treating such disorders, they remain widely misunderstood by the correctional community. Denying MOUD to the justice-involved population can have deadly consequences and fuel the opioid crisis.
Approximately 85% 1,2 of the incarcerated population meets the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria for substance use disorder or were incarcerated for a crime involving drugs or drug use. Furthermore, approximately 25% 3 of the incarcerated population has an opioid use disorder that would qualify for MOUD.
The American Society of Addiction Medicine (ASAM) states that substance use disorders are treatable, chronic medical diseases involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. It recommends that all three forms of FDA-approved treatment be made available to incarcerated individuals. The National Commission on Correctional Health Care (NCCHC) has also published a position paper that encourages the use of all forms of MOUD and provides valuable information on programming. 4
This paradigm shift in correctional health care’s treatment of addiction diseases—i.e., approaching opioid use disorder like any other chronic illness and using a harm reduction model—makes sense and has been proven in the medical literature as highly successful. Like many other chronic diseases, there is no cure for substance use disorders.
Physicians treat diabetes with medications even if the patient has a sedentary routine, has an elevated BMI, smokes, or is poorly compliant with insulin. The goal to reduce the harm resulting from the diabetes. Regardless of the patient’s lifestyle choices, clinicians continue to non-judgmentally address the patient’s risk factors and update his or her treatment plan. This model applies to many chronic diseases, such as coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), lung cancer, peripheral vascular disease (PVD), etc. Why not treat substance use disorder the same way?
Imagine a patient presenting to the Emergency Department with persistent chest pain (a heart attack); and the treatment team gives the patient a list of cardiac catheter labs to contact, suggests it is the patient’s own fault that he/she is there, and tells the patient they would be happy to provide medication and treatment if the patient agrees to undergo behavioral therapy. This seems ludicrous. But unfortunately, this scenario occurs all too often with substance use disorders.
Per the U.S. Department of Justice, substance use disorder patients who are not using illicit substances are a covered group under the Americans with Disabilities Act (ADA). In fact, choosing not to treat substance use disorders is not only an ADA violation but has also been confirmed by case law to constitute a violation of the 8th amendment (civil rights).
Among incarcerated patients with an opioid use disorder, there is an 87% increase3 in the fatality (overdose and suicide) rate for individuals not on MOUD compared to those who are receiving MOUD. Data also shows that MOUD treatment corresponded with a 75% reduction3 in overdose deaths during justice-involved patients’ first few weeks of release from incarceration.
There are currently three medications approved by the Food and Drug Administration (FDA) for use in MOUD programs. Methadone, which has been used for decades, is an agonist, i.e., it stimulates opiate receptors in the patient’s brain, producing the same effects as morphine and suppressing the patient’s cravings and withdrawal symptoms. Methadone is a Schedule II controlled substance and can only be prescribed at a certified opioid treatment program. Correctional facilities can apply to become opioid treatment programs. Universal screening of all people entering a correctional facility is recommended.5
Buprenorphine, the most commonly used MOUD, is a partial agonist, activating the patient’s opioid receptors to a lesser extent than full agonists like methadone. Partial agonists cannot stimulate the brain as strongly as other opioids and lose effectiveness at higher doses. Because of this, there is a “ceiling effect” on its respiratory depression and any euphoria it may induce, making overdose much less likely.
An active opioid user can be treated with buprenorphine to avoid going through a painful withdrawal process. The drug is a Schedule III controlled substance, available in multiple formats (stand-alone, in combination with naloxone, and as an injectable) and no longer requires an X-waiver to be prescribed. Because of the way it is metabolized, buprenorphine cannot be taken orally but needs to be given transmucosally (inside the cheek or on/under the tongue) or subcutaneously. Transmucosal buprenorphine products are cost-effective and available in generic forms.6
Naltrexone is an antagonist, blocking the effects of opiates by binding to the opiate receptors in the brain without causing stimulation. The drug is not a controlled substance and has no abuse potential. Naltrexone is FDA-approved for the treatment of both opioid use and alcohol use disorders. However, the patient must be completely withdrawn from all opioids and refrained from using them for seven to 14 days prior to starting the drug.
Naltrexone is available in an oral form (with a generic) as well as a long-acting injectable (Vivitrol). ASAM does not recommend the oral form for use in a community setting, but recognizes its benefit in a controlled environment where the drug can be administered through directly observed therapy. Many correctional facilities have chosen to treat with oral naltrexone, followed by an injection prior to the patient’s release to the community.
Most opioid-related overdose deaths now result from a combination of high-potency synthetic opioids (such as fentanyl) combined with a stimulant, such as methamphetamines. Fentanyl is a high-potency synthetic opioid that is currently replacing or being mixed with a wide variety of other drugs including methamphetamines, cannabinoids, cocaine, and MDMA. Individuals may mistakenly think they are using heroin, MDMA, or another drug; but in reality, they are taking pure fentanyl, which is fifty times more potent than heroin.
Naloxone—brand name Narcan—is a life-saving medication that can reverse a heroin, fentanyl, or other opioid overdose when given in time. Individuals with an opioid use or stimulant use disorder should be given intranasal naloxone—a pure agonist “antidote” medication—at the time of their release. Naloxone should also be readily available within correctional facilities.
In patients with substance use disorders, the reward center essentially holds the patient’s cortex hostage. The patient views the drug as essential for survival, just like water, food, and shelter. This survival instinct can cause substance use disorder patients to act in ways that are completely out of character for an individual.
Furthermore, addiction and mental illness often co-exist, so it is important to evaluate patients in each group for the other condition. It is difficult to successfully treat addiction in a mentally unstable patient and vice versa. Patients with substance use disorders are best managed in a multidisciplinary manner.
Even if a patient is using multiple drugs (cannabinoids, stimulants, tobacco, etc.), by treating the opioid use disorder first and using motivational interviewing to move them along the recovery spectrum, patients do very well. In fact, they often feel a state of clarity after stabilizing on MOUD. Success rates for treating substance use disorder are equal to, and often better than, other chronic diseases.
Substance use disorder is an equal opportunity destroyer. The disease has no preference for socioeconomic status, race, religion, or gender. By practicing evidence-based addiction medicine, correctional health care professionals can advocate for patients and improve their lives.
Written by Michael A. Mitcheff, DO, MBA, CHCQM, Corporate Medical Director for UM, Addiction Medicine & Clinical Services for Wexford Health Sources, Inc.
- For more information on MOUD, visit the Substance Abuse and Mental Health Services Administration at http://www.samhsa.gov/medication-assisted-treatment.
- NCCHC’s position statement on Naloxone in Correctional Facilities for the Prevention of Opioid Overdose Deaths: https://www.ncchc.org/naloxone-for-the-prevention-of-opioid-overdose-deaths.
- ACLU’s Report “How the Failure to Provide Treatment for Substance Use
in Prisons and Jails Fuels the Overdose Epidemic: https://www.aclu.org/report/report-over-jailed-and-un-treated
- NCCHC’s Opioid Treatment Program Accreditation Information: https://www.ncchc.org/opioid-treatment-programs-accreditation
- American Society of Addiction Medicine’s Treatment in Correctional Settings Toolkit: https://www.asam.org/advocacy/advocacy-in-action/toolkits/treatment-in-correctional-settings
- By law, buprenorphine is the only opioid agonist-type drug that physicians can prescribe (outside of an OTP) to treat opioid dependence in any patient, regardless of pregnancy. The law allows for prescribers to write for up to three days as a bridge to MOUD.
Current clinical guidelines are available from the following sources:
- National Center on Substance Abuse and Child Welfare. Treatment for Opioid Dependence During Pregnancy. https://www.ncsacw.samhsa.gov/resources/resources-mat.aspx
- American College of Obstetricians and Gynecologists. Committee on Obstetric Practice. Opioid Use and Opioid Use Disorder in Pregnancy. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy