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How to Stop the Opioid Epidemic Breaking the Cycle

The Bottom Line

Current responses to the opioid epidemic are inadequate. Effective treatments are underutilized, and the result is a cycle of drug use, inadequate treatment, and return to drug use. Breaking this cycle will require a lot of individual and community effort.

The Full Story

Approximately 65% of the 2.2 million Americans in prison at the end of 2016 met the criteria for substance use disorder (drug-induced impairment or addiction). In 2009, the World Health Organization recommended that prisons offer inmates the same medical treatments that are available to the general public, including treatments for drug use disorders. However, only 11% of inmates in need of addiction treatment receive it. 

During the first 2 weeks after release, former inmates are at greater risk of death from homicide, suicide, lapse in treatment for chronic medical conditions, and drug overdose, with drug overdose being the leading cause of death in this population. The risk of death from drug overdose is 129 times higher in the 2 weeks after release compared to the general public. Former inmates who received treatment for their substance use disorders while they were in prison are more likely to stay in treatment programs longer or complete treatment for addiction after their release and are less likely to relapse. Opioid-dependent patients who are allowed to continue opioid addiction treatment with medications like methadone while they are in prison are less likely to be rearrested than those who are simply detoxified in jail.

The use of medication-assisted treatments (MATs) is an effective method for treating opioid abuse. Medications used to treat opioid abuse include buprenorphine, methadone, and extended-release naltrexone. These medications block euphoria in order to reduce opioid cravings and withdrawal symptoms so the brain recovers from the addiction.

In spite of ample evidence of the benefits of medication-assisted opioid withdrawal treatments, these tools are greatly underused. Only 28 state prison systems (56%) in the US offer methadone treatment, and half of those limit treatment to pregnant women or inmates with chronic pain. Only 7 state prison systems (14%) have programs using buprenorphine treatment. Nearly 75% of prisoners with opioid use disorder relapse back into drug use within 3 months of their release.

Barriers to opioid use disorder treatment for current and former inmates and the general public are similar. These include poor social support systems, inadequate resources, stigmatization, marginalization, and restrictive drug and healthcare policies. The more we stigmatize and marginalize patients suffering from opioid use disorder, the more we impede progress. For example, communities have opposed the opening of MAT centers in their neighborhoods. Officials have proposed zoning changes that would make the opening of MATs illegal in some areas, health insurers have proposed treatment time limits on opioid use disorder medications, and there is still a widespread belief that the drugs used for treatment are just as bad and just as abused as opioids.

As a society, we must take collective ownership of the opioid epidemic and understand how each of us can make a difference by being aware of critical points of intervention. This requires recognizing our biases and fears and making the conscious decision to make a change in how we choose to move forward. Where in the cycle of addiction, prison, release, relapse into addiction, criminal activity, and return to prison can we intervene? Have a conversation about opioid use and misuse with your family and friends, identify risk factors in your home and community, be engaged in your patient/healthcare provider relationship, and support the people and programs around you that are in need of help.

Lindsy Liu, PharmD
Certified Specialist in Poison Information

Diana N. Pei, PharmD
Certified Specialist in Poison Information

Pela Soto, PharmD, BSHS, BS
Certified Specialist in Poison Information


For More Information

Drug addiction (substance use disorder). Rochester MN: Mayo Clinic; 27 Oct 2017 [accessed 3 Jun 2018].

Substance use disorders. Rockville MD: Substance Abuse and Mental Health Services Administration; 27 Oct 2015 [accessed 3 Jun 2018].

Understanding drug use and addiction. Bethesda MD: National Institute on Drug Abuse; Aug 2016 [accessed 3 Jun 2018].


References

Behind bars II: substance abuse and America's prison population. New York: The National Center on Addiction and Substance Abuse at Columbia University; Feb 2010 [accessed 3 Jun 2018].

Binswanger IA, Stern MF, Yamashita TE, Mueller SR, Baggett TP, Blatchford PJ. Clinical risk factors for death after release from prison in Washington State: a nested case control study. Addiction 2016;111:499-510.

Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. Geneva: World Health Association; 2009 [accessed 3 Jun 2018].

Kinlock TW, Gordon MS, Schwartz RP, et al. A randomized clinical trial of methadone maintenance for prisoners: results at one-month post-release. Drug Alcohol Depend 2007;91:220-7.

Merrall ELC, Kariminia A, Binswanger IA, et al. Meta-analysis of drug-related deaths soon after release from prison. Addiction 2010;105:1545-54.

Gordon MS, Kinlock TW, Schwartz RP, Fitzgerald T, O'Grady KE, Vocci FJ. A randomized controlled trial of prison-initiated buprenorphine: prison outcomes and community treatment entry. Drug Alcohol Depend 2014;142:33-40.

Westerberg VS, McCrady BS, Owens M, Guerin P. Community-based methadone maintenance in a large detention center is associated with decreases in inmate recidivism. J Subst Abuse Treat 2016;70:1-6.

Nunn A, Zaller N, Dickman S, Trimbur C, Nijhawan A, Rich JD. Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey. Drug Alcohol Depend 2009;105:83-8.

Rich JD, Boutwell AE, Shield DC, et al. Attitudes and practices regarding the use of methadone in US state and federal prisons. J Urban Health 2005;82:411-9.

Nurco DJ, Hanlon TE, Kinlock TW. Recent research on the relationship between illicit drug use and crime. Behav Sci Law 1991;9:221-42.

Olsen Y, Sharfstein JM. Confronting the stigma of opioid use disorder--and its treatment [editorial]. JAMA 2014 Apr 9;311:1393-4.

Poisoned?

Call 1-800-222-1222 or

HELP ME online

Prevention Tips

  • Recognize and respond to drug misuse in your family and community.
  • Support drug abuse treatment in your area.
  • Encourage those misusing drugs like opioids to seek treatment.

This Really Happened

A mother called Poison Control because she was worried about her child getting into her methadone bottle. She had been on a maintenance program for a while and was doing well. She went every day to the methadone clinic to get a refill. Patients are instructed to rinse out the bottle after taking the dose, which she always did. She normally put it away to take back to the clinic the next day, but this time she left it out and the child picked it up.

Mom was concerned that her child might have swallowed some of the rinse water. Poison Control consulted its staff toxicologist because there is little information on the effects of methadone in children. The mother was told that it was unlikely that a dangerous amount of drug was left in the rinsed bottle, but mom was told to check on the child through the night. The following day, Poison Control followed up and learned that the child had no symptoms.