Overcoming obstacles to implementing methadone maintenance therapy for prisoners: implications for policy and practice

Knowledge, experiences, and perceptions of medications for opioid use disorder among Black Kentuckians

BACKGROUND

Opioid overdoses have continued to increase at higher rates among Black Americans compared to people from other racial groups. Despite demonstrated effectiveness of MOUD in reducing risk of opioid overdose, Black Americans face decreased access to and uptake of MOUD. The current study aimed to examine the knowledge, perceptions, and experiences with MOUD among a sample of Black adults who use prescription opioids nonmedically in order to inform tailored efforts to improve MOUD uptake.

METHODS

Data were derived from a larger study assessing cultural and structural influences on drug use and drug treatment among people who use prescription opioids nonmedically. Semi-structured qualitative interviews were conducted with 34 Black men and women across four generational cohorts: born 1955-1969; 1970-1979; 1980-1994; and 1995-2001. Participant responses were analyzed using thematic analysis.

RESULTS

Nearly half of participants (44.1%) reported no knowledge or experience with MOUD. Among participants who had any knowledge about MOUD, four major themes regarding their perceptions emerged: MOUD Helps with Recovery; Not Needed for Level of Drug Use; Side Effects and Withdrawal; Equivalence with Illicit Drug Use. The majority reported negative perceptions of MOUD (52.6%), and the youngest cohort (born 1995-2001) had a higher proportion of negative perceptions (80%) relative to other age cohorts (born 1980-1994: 50%; 1970-1979: 75%; 1955-1969: 16.6%).

DISCUSSION

Findings indicate a significant knowledge gap and clear points of intervention for improving MOUD uptake. Interventions to improve communication of health information in ways that are culturally relevant and tailored by age group can be used in conjunction with efforts to improve MOUD access among Black individuals who use opioids nonmedically.

Perceived access to opioid agonist treatment in prison among people with a history of injection drug use: A qualitative study

INTRODUCTION

Opioid agonist treatment (OAT) is associated with a reduced likelihood of hepatitis C incidence, nonfatal overdose, and (re)incarceration among people who inject drugs (PWID), yet factors underpinning decisions to access OAT in prison and postrelease are not well understood. The aim of the qualitative study was to explore the perspectives of OAT access while in prison among PWID recently released from prison in Australia.

METHODS

Eligible participants enrolled in the SuperMix cohort (n = 1303) were invited to take part in a semi-structured interview in Victoria, Australia. Inclusion criteria were informed consent, aged ≥18 years, history of injection drug use, incarcerated for ≥3 months, and released from custody <12 months. The study team analysed data via a candidacy framework to account for macro-structural influences.

RESULTS

Among 48 participants (33 male; ten Aboriginal), most injected drugs in the prior month (n = 41), with heroin most frequently injected (n = 33) and nearly half (n = 23) were currently on OAT (primarily methadone). Most participants described the navigation and permeability of OAT services in prison as convoluted. If not on OAT pre-entry, prison policies often restricted access, leaving participants to withdraw in cells. In turn, some participants commenced OAT postrelease to ensure OAT continuity of care if reincarcerated. Other participants who experienced delayed access to OAT in prison stated no need to initiate while in prison or postrelease as they were now "clean". Last, implementation of OAT delivery in prison (e.g., lack of confidentiality) frequently led to changes in OAT type to avoid peer violence (pressure to divert OAT).

CONCLUSION

Findings draw attention to simplistic notions of OAT accessibility in prisons, illuminating how structural determinants influence choice in PWID decision-making. Suboptimal access and acceptability of OAT delivery in prisons will continue to place PWID at risk of harm postrelease (e.g., overdose).

Association between jail-based methadone or buprenorphine treatment for opioid use disorder and overdose mortality after release from New York City jails 2011-17

BACKGROUND AND AIMS

Opioid overdose is a leading cause of death during the immediate time after release from jail or prison. Most jails in the United States do not provide methadone and buprenorphine treatment for opioid use disorder (MOUD), and research in estimating its impact in jail settings is limited. We aimed to test the hypothesis that in-jail MOUD is associated with lower overdose mortality risk post-release.

DESIGN, SETTING AND PARTICIPANTS

Retrospective, observational cohort study of 15 797 adults with opioid use disorder who were released from New York City jails to the community in 2011-2017. They experienced 31 382 incarcerations and were followed up to 1 year.

MEASUREMENTS

The primary outcomes were death caused by accidental drug poisoning and all-cause death. The exposure was receipt of MOUD (17 119 events) versus out-of-treatment (14 263 events) during the last 3 days before community re-entry. Covariates included demographic, clinical, behavioral, housing, health-care utilization and legal characteristics variables. We performed a multivariable, mixed-effect Cox regression analysis to test association between in-jail MOUD and deaths.

FINDINGS

The majority were male (82%) and their average age was 42 years. Receiving MOUD was associated with misdemeanor charges, being female, injection drug use and homelessness. During 1 year post-release, 111 overdose deaths occurred and crude death rates were 0.49 and 0.83 per 100 person-years for in-jail MOUD and out-of-treatment groups, respectively. Accounting for confounding and random effects, in-jail MOUD was associated with lower overdose mortality risk [adjusted hazard ratio (aHR) = 0.20, 95% confidence interval (CI) = 0.08-0.46] and all-cause mortality risk (aHR = 0.22, 95% CI = 0.11-0.42) for the first month post-release.

CONCLUSIONS

Methadone and buprenorphine treatment for opioid use disorder during incarceration was associated with an 80% reduction in overdose mortality risk for the first month post-release.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada

INTRODUCTION

Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada.

METHODS

This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants' release. Data were thematically analyzed.

RESULTS

The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of 'take-home' OAT medications were common barriers.

CONCLUSIONS

Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.

Opioid agonist treatment (OAT) experiences and release plans among federally incarcerated individuals with opioid use disorder (OUD) in Ontario, Canada: a mixed-methods study

Background

Incarcerated populations experience an elevated prevalence of opioid use disorder (OUD). Federal correctional institutions in Canada have increasingly treated OUD among correctional populations via opioid agonist treatment (OAT) – an evidence based pharmacotherapy that works to reduce drug use and related health harms. However, there is limited evidence regarding incarcerated individuals’ experiences with institutional-based OAT, as well potential OAT-related community release prospects. This information is important for optimal treatment retention and improved health. To address this knowledge gap, we conducted a longitudinal follow-up study examining OAT-related experiences among federally incarcerated individuals before and after community release. This article focuses on the baseline (pre-release) data.

Methods

This mixed-methods study examined OAT-related experiences and release prospects among n = 46 individuals scheduled for community release, recruited from seven federal prisons located in Ontario, Canada. Participants underwent a comprehensive interviewer-administered on-site assessment, including quantitative and qualitative items. Assessment data was furthermore linked to administrative correctional data. Data were analyzed using thematic qualitative and descriptive quantitative approaches.

Results

Participants had complex histories with opioid use including related negative health outcomes. Experiences with institutional OAT were divergent and provision was not standardized; those with OAT engagement pre-admission did not experience many challenges, whereas those initiating OAT during incarceration experienced barriers such as treatment waitlists and adverse process experiences. Most participants expressed a preference for buprenorphine-naloxone over methadone, but described difficulties accessing it. Participants were keen to transition into community-based treatment, yet envisaged prospective barriers and facilitators concerning successful reintegration and treatment continuity.

Conclusions

Major barriers towards the current administration of OAT in federal correctional systems in Canada exist, including extensive waitlists, non-standardized practices, and challenges accessing preferred OAT formulations; this contributes to sub-optimal treatment. Eliminating waitlists, standardizing OAT provision, providing additional OAT options, and more comprehensive release planning may be essential for treatment retention and positive outcomes.

Criminal problem-solving and civil dependency court policies regarding medications for opioid use disorder

Background: Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. Methods: An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's Q was used to make within-group comparisons between policies and MOUDs. Results: We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Conclusion: Because respondents rarely chose "never" or "always" for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.

Methadone and buprenorphine treatment in United States jails and prisons: lessons from early adopters

AIMS

To identify implementation barriers and facilitators to the adoption and implementation of programs that provide opioid agonist treatments (OAT) with methadone and buprenorphine to treat opioid use disorder in jails and prisons in the United States.

DESIGN

Qualitative analysis: semi-structured interviews were conducted and thematic analyses of transcripts and notes were performed using a hybrid inductive/deductive coding approach.

SETTING

Jails and prisons in the United States.

PARTICIPANTS

From August 2019 to January 2020, we conducted 20 key informant interviews with 35 individuals representing 19 carceral systems that both initiate and maintain OAT.

MEASUREMENTS

Interviews covered four domains: (1) program adoption; (2) policy influence on implementation; (3) program structure; and (4) program outcomes.

FINDINGS

Stigma among staff, particularly medical staff, challenged program adoption, but reduced over time as staff were exposed to the program. Regulations on OAT dispensation, such as licensing requirements and prescribing limits, were key challenges to program implementation and shaped program structure. Dispensing medication required significant staff, time and space. Facilities were further challenged to overcome stigma and concerns about diversion, as OAT medication is often treated as contraband in carceral settings. Some systems deviated from evidence-based treatment by limiting OAT dosage to low levels, requiring counseling for participation and requiring detoxification before medication initiation. Despite these challenges, early adopters felt strongly that other jails and prisons in the United States should provide OAT and that legislation and litigation may soon force OAT expansion in these carceral settings.

CONCLUSIONS

Despite identifying regulatory and logistical challenges, early adopters of opioid agonist treatment (OAT) programs in US jails and prisons demonstrate that OAT programs can successfully be implemented in carceral settings with tailoring to the specific context.

Post-incarceration outcomes for individuals who continued methadone treatment while in Connecticut jails, 2014-2018

PURPOSE

To assess post-release outcomes associated with continuation of methadone treatment in correctional centers.

METHODS

This case-control study of the post-incarceration impact of pilot methadone programs operating in jails in New Haven and Bridgeport, Connecticut, USA was conducted in 2014-18. The study compared non-fatal overdose, fatal overdose, reincarceration, and resumption of methadone in the community experienced by 1564 eligible men, 660 (42.2 %) of whom continued treatment while incarcerated.

RESULTS

Continuation of methadone was associated with a significant decrease in non-fatal overdose (OR:0.55; 95 % CI: 0.36, 0.85) and a greater likelihood of resuming methadone treatment in the community post-release (OR:2.56; 95 % CI: 2.07, 3.16). Time to resumption of methadone was shortened by treatment while time to non-fatal overdose was increased. Treatment while incarcerated resulted in a modest but not significant decrease in fatal overdoses and no difference in reincarceration between those who did and did not receive methadone. However, resumption of methadone after release did significantly reduce fatal overdoses (OR = 0.26, 95 % CI: 0.11, 0.62, p = 0.002).

CONCLUSION AND RELEVANCE

Improvements in post-release outcomes of non-fatal overdose and treatment reengagement emphasize the benefits of continuing medication-based treatment for opioid use disorder within the criminal justice system for those receiving it prior to being incarcerated.

The impact of the opioid crisis on U.S. state prison systems

BACKGROUND

Prior studies have documented limited use of medications to treat opioid use disorders (OUD) for people incarcerated within state prisons in the United States. Using the framework of the criminal justice OUD service cascade, this study interviewed representatives of prison systems in states most heavily impacted by opioid overdose regarding the provision of medications for OUD (MOUD).

METHODS

A stratified sampling strategy included states with high indicators of opioid-overdose deaths. Two sampling strata targeted states with: 1) OUD overdose rates significantly higher than the per capita national average; or 2) high absolute number of OUD overdose fatalities. Interviews were completed with representatives from 21 of the 23 (91%) targeted states in 2019, representing 583 prisons across these states. Interviews assessed service provision across the criminal justice OUD service cascade, including OUD screening, withdrawal management, MOUD availability and provision, overdose prevention, re-entry services, barriers, and needs for training and technical assistance.

RESULTS

MOUD (buprenorphine, methadone, or naltrexone) was available in at least one prison in approximately 90% of the state prison systems and all three medications were available in at least one prison in 62% of systems. However, MOUD provision was limited to subsets of prisons within these systems: 15% provided buprenorphine, 9% provided methadone, 36% provided naltrexone, and only 7% provided all three. Buprenorphine and methadone were most frequently provided to pregnant women or individuals already receiving these at admission, whereas naltrexone was primarily used at release. Funding was the most frequently cited barrier for all medications.

CONCLUSION

Study findings yield a complex picture of how, when, and to whom MOUD is provided across prisons within prison systems in states most heavily impacted by opioid overdose in the United States and have implications for expanding availability.

A Scoping Review of Barriers and Facilitators to Implementation of Medications for Treatment of Opioid Use Disorder within the Criminal Justice System

BACKGROUND

Policies aimed at addressing the high rates of opioid overdose have prioritized increasing access to medications for treatment of opioid use disorder (MOUD). Numerous barriers exist to providing MOUD within the criminal justice system and/or to justice-involved populations. The aim of this study was to conduct a scoping review of the peer-reviewed literature on implementation of MOUD within criminal justice settings and with justice-involved populations.

METHODS

A systematic search process identified 53 papers that addressed issues pertaining to implementation barriers or facilitators of MOUD within correctional settings or with justice-involved populations; these were coded and qualitatively analyzed for common themes.

RESULTS

Over half of the papers were published outside of the U.S. (n = 28); the most common study designs were surveys or structured interviews (n = 20) and qualitative interviews/focus groups (n = 18) conducted with correctional or treatment staff and with incarcerated individuals. Four categories of barriers and facilitators were identified: institutional, programmatic, attitudinal, and systemic. Institutional barriers typically limited capacity to provide MOUD to justice-involved individuals, which led to programmatic practices in which MOUD was not implemented following clinical guidelines, often resulting in forcible withdrawal or inadequate treatment. These programmatic practices commonly led to aversive experiences among justice-involved individuals, who consequently espoused negative attitudes about MOUD and were reluctant to seek treatment with MOUD following their release to the community. Facilitators of MOUD implementation included increased knowledge and information from training interventions and favorable prior experiences with individuals being treated with MOUD among correctional and treatment staff. Few systemic facilitators to implementing MOUD with justice-involved individuals were evident in the literature.

CONCLUSION

Barriers to implementing MOUD in criminal justice settings and/or with justice-involved populations are pervasive, multi-leveled, and inter-dependent. More work is needed on facilitators of MOUD implementation.

The Accessibility of Opioid Agonist Treatment and Its Forced Discontinuation in Swiss Prisons-Attitudes, Perceptions and Experiences of Defense Lawyers in Dealing With Detained Persons Using Opioids

BACKGROUND

Opioid agonist treatment (OAT) is an important pillar in the treatment of individuals using opioids and its continuation during imprisonment is recommended. Despite this knowledge access to and continuation of OAT is still limited in many countries. The forced discontinuation during pre-trial detention can cause severe withdrawal symptoms, which in turn may significantly impair the defendant's ability to exercise granted procedural participation rights. Furthermore, it can be argued that forced discontinuation of a desired treatment represents a form of a compulsory intervention.

AIMS

The present study was developed against the backdrop of a recent ruling by the European Court of Human Rights (Wenner vs. Germany). It intended to examine how defense lawyers dealing with detained persons using opioids view and assess the accessibility of OAT in pre-trial detention as well as during imprisonment in different parts of Switzerland.

METHODS

Using a qualitative approach, we interviewed 11 defense lawyers from three different cantons of Switzerland with multiple years of experience in providing legal representation to more than 220 defendants using heroin. The interviews were analyzed with QSR NVIVO 11 for Windows. A qualitative content analysis approach was used to evaluate findings.

RESULTS

Defenders who had been exposed to the opioid crisis during the course of their legal career had adopted a positive attitude towards OAT and associated it with a stabilizing influence on their clients, an improvement in criminal prognosis, and a reduction in recidivism. They were generally of the opinion that access to OAT had improved, however identified a considerable variance in different penitentiaries, which were mediated by attitudes of staff and authorities. Based on the assessments of the defense lawyers, it can be estimated that the initiation of OAT especially during pre-trial detention is challenging. The predominant aim of OAT in a variety of Swiss prisons still seems to focus on a discontinuation, mediated by a forced reduction of medication. Some of the interventions reported are not in line with the principle of equivalence and strongly contrast the recommendations of the Council of Europe.

An ethical analysis of medication treatment for opioid use disorder (MOUD) for persons who are incarcerated

Opioid use disorder (OUD) is highly prevalent among persons who are incarcerated. Medication treatment for opioid use disorder (MOUD), methadone, buprenorphine, and naltrexone, is widely used to treat OUD in the community. Despite MOUD's well-documented effectiveness in improving health and social outcomes, its use in American jails and prisons is limited.Several factors are used to justify limited access to MOUD in jails and prisons including: "uncertainty" of MOUD's effectiveness during incarceration, security concerns, risk of overdose from MOUD, lack of resources and institutional infrastructure, and the inability of people with OUD to provide informed consent. Stigma regarding MOUD also likely plays a role. While these factors are relevant to the creation and implementation of addiction treatment policies in incarcerated settings, their ethicality remains underexplored.Using ethical principles of beneficence/non-maleficence, justice, and autonomy, in addition to public health ethics, we evaluate the ethicality of the above list of factors. There is a two-fold ethical imperative to provide MOUD in jails and prisons. Firstly, persons who are incarcerated have the right to evidence-based medical care for OUD. Secondly, because jails and prisons are government institutions, they have an obligation to provide that evidence-based treatment. Additionally, jails and prisons must address the systematic barriers that prevent them from fulfilling that responsibility. According to widely accepted ethical principles, strong evidence supporting the health benefits of MOUD cannot be subordinated to stigma or inaccurate assessments of security, cost, and feasibility. We conclude that making MOUD inaccessible in jails and prisons is ethically impermissible.

Ambiguous identities of drugs and people: A scoping review of opioid-related stigma

BACKGROUND

Human beings have long consumed opiates and opioids for pleasure and as a treatment for numerous ailments, most notably pain. North America is currently in the grips of a crisis of opioid-related overdoses, and stigma is considered a major driver of the harms. While it is well established that substance use in general is highly stigmatized, stigma is a complex concept and opioid-related stigma is not well understood. A lack of clarity on opioid-related stigma has practice and policy implications in terms of understanding the sources of opioid stigma, how it manifests in various contexts, its impact on affected groups, and the development of effective strategies to redress it.

METHODS

We performed a scoping review of the academic literature to develop a typology of opioid-related stigma. A charting process identified the type, agent, and recipient of stigma as well as the methodology and substances considered.

RESULTS

Our search yielded 8,543 articles, from which 49 were included in the analysis. Based on the findings, we developed a typology of four main themes: (1) interpersonal and structural stigma toward people accessing opioid agonist therapy (OAT); (2) stigma related to opioids for the treatment of chronic pain; (3) stigma in healthcare settings; and (4) self-stigma.

CONCLUSION

How opioid-stigma is (re)produced depends on the context of opioid use, the social identity and networks of the person who is consuming the opioid, and what type of opioid is being consumed, including medically-sanctioned forms of treatment. Opioid-related stigma permeates intrapersonal, interpersonal, structural, and societal levels, and people who consume opioids are marginalized at all levels. Our review describes our typology of stigma and illuminates multi-level considerations for reducing opioid-related stigma in healthcare settings.

Opioid-related treatment, interventions, and outcomes among incarcerated persons: A systematic review

BACKGROUND

Worldwide opioid-related overdose has become a major public health crisis. People with opioid use disorder (OUD) are overrepresented in the criminal justice system and at higher risk for opioid-related mortality. However, correctional facilities frequently adopt an abstinence-only approach, seldom offering the gold standard opioid agonist treatment (OAT) to incarcerated persons with OUD. In an attempt to inform adequate management of OUD among incarcerated persons, we conducted a systematic review of opioid-related interventions delivered before, during, and after incarceration.

METHODS AND FINDINGS

We systematically reviewed 8 electronic databases for original, peer-reviewed literature published between January 2008 and October 2019. Our review included studies conducted among adult participants with OUD who were incarcerated or recently released into the community (≤90 days post-incarceration). The search identified 2,356 articles, 46 of which met the inclusion criteria based on assessments by 2 independent reviewers. Thirty studies were conducted in North America, 9 in Europe, and 7 in Asia/Oceania. The systematic review included 22 randomized control trials (RCTs), 3 non-randomized clinical trials, and 21 observational studies. Eight observational studies utilized administrative data and included large sample sizes (median of 10,419 [range 2273-131,472] participants), and 13 observational studies utilized primary data, with a median of 140 (range 27-960) participants. RCTs and non-randomized clinical trials included a median of 198 (range 15-1,557) and 44 (range 27-382) participants, respectively. Twelve studies included only men, 1 study included only women, and in the remaining 33 studies, the percentage of women was below 30%. The majority of study participants were middle-aged adults (36-55 years). Participants treated at a correctional facility with methadone maintenance treatment (MMT) or buprenorphine (BPN)/naloxone (NLX) had lower rates of illicit opioid use, had higher adherence to OUD treatment, were less likely to be re-incarcerated, and were more likely to be working 1 year post-incarceration. Participants who received MMT or BPN/NLX while incarcerated had fewer nonfatal overdoses and lower mortality. The main limitation of our systematic review is the high heterogeneity of studies (different designs, settings, populations, treatments, and outcomes), precluding a meta-analysis. Other study limitations include the insufficient data about incarcerated women with OUD, and the lack of information about incarcerated populations with OUD who are not included in published research.

CONCLUSIONS

In this carefully conducted systematic review, we found that correctional facilities should scale up OAT among incarcerated persons with OUD. The strategy is likely to decrease opioid-related overdose and mortality, reduce opioid use and other risky behaviors during and after incarceration, and improve retention in addiction treatment after prison release. Immediate OAT after prison release and additional preventive strategies such as the distribution of NLX kits to at-risk individuals upon release greatly decrease the occurrence of opioid-related overdose and mortality. In an effort to mitigate the impact of the opioid-related overdose crisis, it is crucial to scale up OAT and opioid-related overdose prevention strategies (e.g., NLX) within a continuum of treatment before, during, and after incarceration.

Brief video intervention to improve attitudes throughout medications for opioid use disorder in a correctional setting

OBJECTIVES

Medications for opioid use disorder (MOUD) in the criminal justice setting is an effective way to address opioid use disorder and prevent associated deaths in the community. The Rhode Island Department of Corrections (RIDOC) is the first statewide correctional system in the United States to offer comprehensive MOUD services to incarcerated individuals.However, due to stigma, eligible individuals may be reluctant to engage with MOUD. This study aims to 1) evaluate the efficacy of an educational video intervention about MOUD and 2) characterize MOUD-related attitudes in a general incarcerated population.

METHODS

Participants were recruited from eight elective classes offered to soon-to-be-released incarcerated individuals at RIDOC. Participants viewed an eight-minute video featuring incarcerated individuals speaking about their experiences using MOUD, designed to reduce MOUD-related stigma. Participants were administered surveys prior to and after watching the video to assess changes in MOUD knowledge (MOUD-K) and MOUD attitudes (MOUD-A).

RESULTS

This evaluation of the intervention included 80 incarcerated participants (median age = 35, 93% male, 36% non-Hispanic White, and 26% non-Hispanic Black). Forty percent indicated non-medical opioid use within six months prior to incarceration; 13% had previously used MOUD. Significant improvements in MOUD-K scores (t(65) = -7.0, p < 0.0001) and MOUD-A scores (t(69) = -5.8, p < 0.0001) were detected after participants viewed the video. The intervention yielded greater ΔMOUD-A scores among those identifying as non-Hispanic Black, compared to non-Hispanic Whites (β = 2.6, CI = 0.4, 4.8).

CONCLUSION

The educational video improved both knowledge and positive attitudes towards MOUD, with changes in MOUD attitudes being influenced by race. These findings may inform future MOUD educational programs, thereby helping to reduce opioid use disorder-related morbidity and mortality.

Health, Polysubstance Use, and Criminal Justice Involvement Among Adults With Varying Levels of Opioid Use

IMPORTANCE

Health profiles and patterns of involvement in the criminal justice system among people with various levels of opioid use are poorly defined. Data are needed to inform a public health approach to the opioid epidemic.

OBJECTIVE

To examine the association between various levels of opioid use in the past year and physical and mental health, co-occurring substance use, and involvement in the criminal justice system.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional analysis used the 2015-2016 National Survey on Drug Use and Health to assess the independent association of intensity of opioid use with health, co-occurring substance use, and involvement in the criminal justice system among US adults aged 18 to 64 years using multivariable logistic regression.

EXPOSURES

No opioid use vs prescription opioid use, misuse, or use disorder or heroin use.

MAIN OUTCOMES AND MEASURES

Self-reported physical and mental health, disability, co-occurring substance use, and past year and lifetime involvement in the criminal justice system.

RESULTS

The sample consisted of 78 976 respondents (42 495 women and 36 481 men), representative of 196 280 447 US adults. In the weighted sample, 124 026 842 adults reported no opioid use in the past year (63.2%; 95% CI, 62.6%-63.7%), 61 462 897 reported prescription opioid use in the past year (31.3%; 95% CI, 30.8%-31.8%), 8 439 889 reported prescription opioid misuse in the past year (4.3%; 95% CI, 4.1%-4.5%), 1 475 433 reported prescription opioid use disorder in the past year (0.8%; 95% CI, 0.7%-0.8%), and 875 386 reported heroin use in the past year (0.4%; 95% CI, 0.4%-0.5%). Individuals who reported any level of opioid use were significantly more likely than individuals who reported no opioid use to be white, have a low income, and report a chronic condition, disability, severe mental illness, or co-occurring drug use. History of involvement in the criminal justice system increased as intensity of opioid use increased (no use, 15.9% [19 562 158 of 123 319 911]; 95% CI, 15.4%-16.4%; prescription opioid use, 22.4% [13 712 162 of 61 204 541]; 95% CI, 21.7%-23.1%; prescription opioid misuse, 33.2% [2 793 391 of 8 410 638]; 95% CI, 30.9%-35.6%; prescription opioid use disorder, 51.7% [762 189 of 1 473 552]; 95% CI, 45.4%-58.0%; and heroin use, 76.8% [668 453 of 870 250]; 95% CI, 70.6%-82.1%). In adjusted models, any level of opioid use was associated with involvement in the criminal justice system in the past year compared with no opioid use.

CONCLUSIONS AND RELEVANCE

Individuals who use opioids have complicated health profiles and high levels of involvement in the criminal justice system. Combating the opioid epidemic will require public health interventions that involve criminal justice systems, as well as policies that reduce involvement in the criminal justice system among individuals with substance use disorders.

Methadone maintenance treatment and mortality in people with criminal convictions: A population-based retrospective cohort study from Canada

BACKGROUND

Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality.

METHODS AND FINDINGS

We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23-0.33]) and external (AHR 0.41 [95% CI 0.33-0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13-0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30-0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution.

CONCLUSIONS

Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths.

Balancing the Rights to Protection and Participation: A Call for Expanded Access to Ethically Conducted Correctional Health Research

Incarcerated individuals, over 95% of whom are eventually released, experience high burdens of chronic disease and behavioral health and social risk factors. Understanding the health needs of this population is critical to ensuring that general medicine physicians in prisons and in the community are adequately prepared to meet those needs. However, people in prison are significantly underrepresented in health research. In response to historical exploitation of prisoners in medical experimentation, federal guidelines appropriately require additional oversight for, and limit the scope of, research in prisons. Yet, according to a 2006 Institute of Medicine report, these requirements have produced inconsistent local regulations that often limit opportunities for incarcerated individuals to participate in research, and can slow the development of innovative medical interventions to improve their health. In this article, we describe the historical context surrounding regulations on research involving individuals in prison, the harms that can arise from excessive limitations to research in such settings, and the benefits of greater access to ethically conducted research in prison. We conclude with recommended actions that can be taken by general medicine researchers, correctional leaders, and policymakers to achieve consistent access to health research for incarcerated populations.

A randomized, open label trial of methadone continuation versus forced withdrawal in a combined US prison and jail: Findings at 12 months post-release

Recently, incarcerated individuals are at increased risk of opioid overdose. Methadone maintenance treatment (MMT) is an effective way to address opioid use disorder and prevent overdose; however, few jails and prisons in the United States initiate or continue people who are incarcerated on MMT. In the current study, the 12 month outcomes of a randomized control trial in which individuals were provided MMT while incarcerated at the Rhode Island Department of Corrections (RIDOC) are assessed. An as-treated analysis included a total of 179 participants-128 who were, and 51 who were not, dosed with methadone the day before they were released from the RIDOC. The results of this study demonstrate that 12 months post-release individuals who received continued access to MMT while incarcerated were less likely to report using heroin and engaging in injection drug use in the past 30 days. In addition, they reported fewer non-fatal overdoses and were more likely to be continuously engaged in treatment in the 12-month follow-up period compared to individuals who were not receiving methadone immediately prior to release. These findings indicate that providing incarcerated individuals continued access to MMT has a sustained, long-term impact on many opioid-related outcomes post-release.

Exploring Healthcare Experiences for Incarcerated Individuals Who Identify as Transgender in a Southern Jail

Purpose: To document the health-related experiences and needs of jail detainees who self-identified as transgender women.

Methods: Semistructured interviews with 10 transgender women of color were conducted in a county jail in a mid-sized southern city between 2015 and 2016. Interviews were recorded and transcribed, and later analyzed using a general inductive approach.

Results: Participants experienced high levels of abuse and harassment, solitary confinement, mental health issues, and lack of access to hormone treatment. Participants described discrimination (both by other inmates—particularly while in special housing units—and correctional officers); harsh correctional conditions, which exacerbated mental health issues; and a marked lack of access to healthcare, including hormone treatments.

Conclusion: Policy changes are needed to address housing and placement issues, and to increase access to healthcare for transgender women jail detainees. Training is needed for jail staff and medical care professionals in correctional settings to better understand the unique needs and experiences of transgender people.

A randomized clinical trial of buprenorphine for prisoners: Findings at 12-months post-release

BACKGROUND

This study examined whether starting buprenorphine treatment prior to prison and after release from prison would be associated with better drug treatment outcomes and whether males and females responded differently to the combination of in-prison treatment and post-release service setting.

METHODS

Study design was a 2 (In-Prison Treatment: Condition: Buprenorphine Treatment: vs. Counseling Only)×2 [Post-Release Service Setting Condition: Opioid Treatment: Program (OTP) vs. Community Health Center (CHC)]×2 (Gender) factorial design. The trial was conducted between September 2008 and July 2012. Follow-up assessments were completed in 2014. Participants were recruited from two Baltimore pre-release prisons (one for men and one for women). Adult pre-release prisoners who were heroin-dependent during the year prior to incarceration were eligible. Post-release assessments were conducted at 1, 3, 6, and 12-month following prison release.

RESULTS

Participants (N=211) in the in-prison treatment condition effect had a higher mean number of days of community buprenorphine treatment compared to the condition in which participants initiated medication after release (P=0.005). However, there were no statistically significant hypothesized effects for the in-prison treatment condition in terms of: days of heroin use and crime, and opioid and cocaine positive urine screening test results (all Ps>0.14) and no statistically significant hypothesized gender effects (all Ps>0.18).

CONCLUSIONS

Although initiating buprenorphine treatment in prison compared to after-release was associated with more days receiving buprenorphine treatment in the designated community treatment program during the 12-months post-release assessment, it was not associated with superior outcomes in terms of heroin and cocaine use and criminal behavior.

Extended-release naltrexone for pre-release prisoners: A randomized trial of medical mobile treatment

BACKGROUND

Extended-release naltrexone (XR-NTX), is an effective treatment for opioid use disorder but is rarely initiated in US prisons or with criminal justice populations. Mobile treatment for chronic diseases has been implemented in a variety of settings. Mobile treatment may provide an opportunity to expand outreach to parolees to surmount barriers to traditional clinic treatment.

METHODS

Male and female prisoners (240) with pre-incarceration histories of opioid use disorder who are within one month of release from prison will be enrolled in this randomized clinical trial. Participants are randomized to one of two study arms: 1) [XR-NTX-OTx] One injection of long-acting naltrexone in prison, followed by 6 monthly injections post-release at a community opioid treatment program; or 2) [XR-NTX+ MMTx] One injection of long-acting naltrexone in prison followed by 6 monthly injections post-release at the patient's place of residence utilizing mobile medical treatment. The primary outcomes are: treatment adherence; opioid use; criminal activity; re-arrest; reincarceration; and HIV risk-behaviors.

RESULTS

We describe the background and rationale for the study, its aims, hypotheses, and study design.

CONCLUSIONS

The use of long-acting injectable naltrexone may be a promising form of treatment for pre-release prisoners. Finally, as many individuals in the criminal justice system drop out of treatment, this study will assess whether treatment at their place of residence will improve adherence and positively affect treatment outcomes. ClinicalTrials.gov: NCT02867124.

Attitudes Toward Addiction, Methadone Treatment, and Recovery Among HIV-Infected Ukrainian Prisoners Who Inject Drugs: Incarceration Effects and Exploration of Mediators

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

Interim methadone and patient navigation in jail: Rationale and design of a randomized clinical trial

BACKGROUND

Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs.

METHODS

This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period. An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions.

RESULTS

We describe the background and rationale for the study, its aims, hypotheses, and study design.

CONCLUSIONS

Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach. ClinicalTrials.gov: NCT02334215.

Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial

BACKGROUND

Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes.

METHODS

In this randomised, open-label trial, we randomly assigned (1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were enrolled in a methadone maintenance-treatment programme in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, to either continuation of their methadone treatment or to usual care--forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. We did the random assignments with a computer-generated random permutation, and urn randomisation procedures to stratify participants by sex and race. Participants in the continued-methadone group were maintained on their methadone dose at the time of their incarceration (with dose adjustments as clinically indicated). Patients in the forced-withdrawal group followed the institution's standard withdrawal protocol of receiving methadone for 1 week at the dose at the time of their incarceration, then a tapered withdrawal regimen (for those on a starting dose >100 mg, the dose was reduced by 5 mg per day to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose >100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, which we established in a follow-up interview with the participants at 1 month after their release from incarceration. Our study paid for 10 weeks of methadone treatment after release if participants needed financial help. This trial is registered with ClinicalTrials.gov, number NCT01874964.

FINDINGS

Between June 14, 2011, and April 3, 2013, we randomly assigned 283 prisoners to our study, 142 to continued methadone treatment, and 141 to forced withdrawal from methadone. Of these, 60 were excluded because they did not fit the eligibility criteria, leaving 114 in the continued-methadone group and 109 in the forced-withdrawal group (usual care). Participants assigned to continued methadone were more than twice as likely than forced-withdrawal participants to return to a community methadone clinic within 1 month of release (106 [96%] of 110 in the continued-methadone group compared with 68 [78%] of 87 in the forced-withdrawal group; adjusted hazard ratio [HR] 2·04, 95% CI 1·48-2·80). We noted no differences in serious adverse events between groups. For the continued-methadone and forced-withdrawal groups, the number of deaths were one and zero, non-fatal overdoses were one and two, admissions to hospital were one and four; and emergency-room visits were 11 and 16, respectively.

INTERPRETATION

Although our study had several limitations--eg, it only included participants incarcerated for fewer than 6 months, we showed that forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release. Continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviours.

FUNDING

National Institute on Drug Abuse and the Lifespan/Tufts/Brown Center for AIDS Research from the National Institutes of Health.

Methadone maintenance treatment program in prisons from the perspective of medical and non-medical prison staff: a qualitative study in Iran

BACKGROUND

As one of the most important components of harm reduction strategy for high-risk groups, following the HIV epidemics, Methadone Maintenance Treatment (MMT) has been initiated in prisoners since 2003. In this paper, we aimed to assess the advantages and shortcomings of the MMT program from the perspective of people who were involved with the delivery of prison healthcare in Iran.

METHODS

On the basis of grounded theory and through conducting 14 Focus Group Discussions (FGDs), 7 FGDs among physicians, consultants, experts, and 7 FGDs among directors and managers of prisons (n= 140) have been performed. The respondents were asked about positive and negative elements of the MMT program in Iranian prisons.

RESULTS

This study included a total of 48 themes, of which 22 themes were related to advantages and the other 26 were about shortcomings of MMT programs in the prisons. According to participants' views "reduction of illegal drug use and high-risk injection", "reduction of potentially high-risk behaviors" and "making positive attitudes" were the main advantages of MMT in prisons, while issues such as "inaccurate implementation", "lack of skilled manpower" and "poor care after release from prison" were among the main shortcomings of MMT program.

CONCLUSION

MMT program in Iran's prisons has achieved remarkable success in the field of harm reduction, but to obtain much more significant results, its shortcomings and weaknesses must be also taken into account by policy-makers.

The impact of opioid substitution therapy on mortality post-release from prison: retrospective data linkage study

AIMS

Release from prison is a high-risk period for mortality. We examined the impact of opioid substitution therapy (OST), for opioid dependence during and after incarceration, upon mortality post-release.

DESIGN

A cohort was formed of all opioid-dependent people who entered OST between 1985 and 2010 and who, following first OST entry, were released from prison at least once between 2000 and 2012. We linked data on OST history, court and prison records and deaths.

SETTING

New South Wales (NSW), Australia.

PARTICIPANTS

A total of 16,453 people released from prison 60,161 times.

MEASUREMENTS

Crude mortality rates (CMRs) were calculated according to OST retention; multivariable Cox regressions for post-release periods were undertaken to examine the association between OST exposure (a time-dependent variable) and mortality post-release, for which covariates were updated per-release.

FINDINGS

There were 100,978 person-years (PY) post-release; 1050 deaths occurred. Most received OST while incarcerated (76.5%); individuals were receiving OST in 51% of releases. Lowest post-release mortality was among those continuously retained in OST post-release CMR 4 weeks post-release = 6.4 per 1000 PY; 95% confidence interval (CI) = 5.2, 7.8, highest among those with no OST (CMR = 36.7 per 1000 PY; 95% CI = 28.8, 45.9). Multi-factorial models showed OST exposure in the 4 weeks post-release reduced hazard of death by 75% (adjusted hazard ratio 0.25; 95% CI = 0.12, 0.53); OST receipt in prison had a short-term protective effect that decayed quickly across time.

CONCLUSION

In New South Wales, Australia, opioid substitution therapy in prison and post-release appears to reduce mortality risk in the immediate post-release period.

Opioid substitution therapy as a strategy to reduce deaths in prison: retrospective cohort study

OBJECTIVES

To describe deaths in prison among opioid-dependent people, and examine associations between receipt of opioid substitution therapy (OST) and risk of death in prison.

DESIGN

Retrospective cohort study.

SETTING

Adult prisons in New South Wales (NSW), Australia.

PARTICIPANTS

16 715 opioid-dependent people who were received to prison between 2000 and 2012.

INTERVENTIONS

Opioid substitution therapy.

PRIMARY OUTCOME MEASURES

Natural and unnatural (suicide, drug-induced, violent and other injury) deaths in prison.

RESULTS

Cohort members were in prison for 30 998 person-years (PY), during which time there were 51 deaths. The all-cause crude mortality rate (CMR) in prison was 1.6/1000 PY (95% CI 1.2 to 2.2/1000 PY), and the unnatural death CMR was 1.1/1000 PY (95% CI 0.8 to 1.6/1000 PY). Compared to time out of OST, the hazard of all-cause death was 74% lower while in OST (adjusted HR (AHR): 0.26; 95% CI 0.13 to 0.50), and the hazard of unnatural death was 87% lower while in OST (AHR: 0.13; 95% CI 0.05 to 0.35). The all-cause and unnatural death CMRs during the first 4 weeks of incarceration were 6.6/1000 PY (95% CI 3.8 to 10.6/1000 PY) and 5.5/1000 PY (95% CI 2.9 to 9.4/1000 PY), respectively. Compared to periods not in OST, the hazard of all-cause death during the first 4 weeks of incarceration was 94% lower while in OST (AHR: 0.06; 95% CI 0.01 to 0.48), and the hazard of unnatural death was 93% lower while in OST (AHR: 0.07; 95% CI 0.01 to 0.53).

CONCLUSIONS

Mortality of opioid-dependent prisoners was significantly lower while in receipt of OST.

Methadone treatment providers' views of drug court policy and practice: a case study of New York State

BACKGROUND

Specialized drug treatment courts are a central part of drug-related policy and programs in the United States and increasingly outside the U.S. While in theory they offer treatment as a humane and pragmatic alternative to arrest and incarceration for certain categories of drug offenses, they may exclude some forms of treatment-notably methadone maintenance treatment (MMT). We sought to understand from the perspective of treatment providers whether this exclusion existed and was of public health importance in New York State as a case example of a state heavily committed to drug courts and with varying court-level policies on MMT. Drug courts have been extensively evaluated but not with respect to exclusion of MMT and not from the perspective of treatment providers.

METHODS

Qualitative structured interviews of 15 providers of MMT and 4 NGO advocates in counties with diverse court policies on MMT, with content analysis.

RESULTS

Courts in some counties require MMT patients to "taper off" methadone in an arbitrary period or require that methadone be a "bridge to abstinence". Treatment providers repeatedly noted that methadone treatment is stigmatized and poorly understood by some drug court personnel. Some MMT providers feared court practices were fueling non-medical use of prescription opiates.

CONCLUSIONS

Drug court practices in some jurisdictions are a barrier to access to MMT and may constitute discrimination against persons in need of MMT. These practices should be changed, and drug courts should give high priority to ensuring that treatment decisions are made by or in close consultation with qualified health professionals.

Mobile opioid agonist treatment and public funding expands treatment for disenfranchised opioid-dependent individuals

The New Jersey Medication Assisted Treatment Initiative (NJ-MATI) sought to reduce barriers to treatment by providing free, opioid agonist treatment (OAT, methadone or buprenorphine) via mobile medication units (MMUs). To evaluate barriers to OAT, logistic regression was used to compare opioid dependent patients enrolled in NJ-MATI to those entering treatment at fixed-site methadone clinics or non-medication assisted treatment (non-MAT). Client demographic and clinical data were taken from an administrative database for licensed treatment providers. The MMUs enrolled a greater proportion of African-American, homeless, and uninsured individuals than the fixed-site methadone clinics. Compared to non-MAT and traditional methadone clients, NJ-MATI patients were more likely to be injection drug users and daily users but less likely to have a recent history of treatment. These observations suggest that the patient-centered policies associated with NJ-MATI increased treatment participation by high severity, socially disenfranchised patients who were not likely to receive OAT.

Unmet need for treatment for substance use disorders across race and ethnicity

BACKGROUND

The objective was to analyze disparities in unmet need for substance use treatment and to observe variation across different definitions of need for treatment.

METHODS

Data were analyzed from the 2002 to 2005 National Survey of Drug Use and Health and the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regressions estimated the likelihood of specialty substance use treatment across the two data sets. Parallel variables for specialty, informal and any substance abuse treatment were created. Perceived need and normative need for substance use treatment were defined, with normative need stratified across lifetime disorder, past twelve month disorder, and heavy alcohol/any illicit drug use. Treatment rates were analyzed, comparing Blacks, Asians and Latinos to non-Latino whites across need definitions, and adjusting for age, sex, household income, marital status, education and insurance.

RESULTS

Asians with past year substance use disorder had a higher likelihood of unmet need for specialty treatment than whites. Blacks with past year disorder and with heavy drinking/illicit drug use had significantly lower likelihood of unmet need. Latinos with past year disorder had a higher likelihood of unmet need for specialty substance abuse treatment. Asians with heavy drinking/illicit drug use had lower likelihood of unmet need.

CONCLUSIONS

The findings suggest that pathways to substance abuse treatment differ across groups. Given high rates of unmet need, a broad approach to defining need for treatment is warranted. Future research to disentangle social and systemic factors from factors based on diagnostic criteria is necessary in the identification of need for treatment.

Rate of community methadone treatment reporting at jail reentry following a methadone increased dose quality improvement effort

The Rikers Island Key Extended Entry Program (KEEP) has offered methadone treatment for opioid dependent inmates incarcerated in New York City's jails since 1986. In response to a trend toward low-dose methadone maintenance prescribing, a quality improvement (QI) protocol trained KEEP counselors, physicians, and pharmacists in the evidence base supporting moderate-to-high methadone maintenance doses in order to maximize therapeutic effects and rates of successful reporting to community methadone treatment programs (MTPs) post release. Discharge dose level and length of incarceration data were analyzed for 2 groups of KEEP patients discharged pre/post-QI. Among patients incarcerated for 21 or more days, the proportion of those on moderate-to-high doses of methadone increased significantly. Patients who reached a moderate-to-high methadone dose demonstrated higher rates of reporting to community MTP versus lower doses, both pre- and post-QI. Overall, a higher proportion of all patients reported to community MTP post-QI.

A randomized trial of methadone initiation prior to release from incarceration

Individuals who use heroin and illicit opioids are at high risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens, as well as incarceration. The purpose of the randomized trial reported here is to compare outcomes between participants who initiated methadone maintenance treatment (MMT) prior to release from incarceration, with those who were referred to treatment at the time of release. Participants who initiated MMT prior to release were significantly more likely to enter treatment postrelease (P < .001) and for participants who did enter treatment, those who received MMT prerelease did so within fewer days (P = .03). They also reported less heroin use (P = .008), other opiate use (P = .09), and injection drug use (P = .06) at 6 months. Initiating MMT in the weeks prior to release from incarceration is a feasible and effective way to improve MMT access postrelease and to decrease relapse to opioid use.

Standards for opioid treatment in the criminal justice system: implications for nurses

The delivery of health care is based on the theory that patients have timely access to qualified clinicians who will render a professional clinical judgment that is ordered and received. This article describes traditional barriers to opioid treatment and care to incarcerated populations. With 60 to 80 percent of current and former prisoners convicted on drug-related charges, the need to provide drug abuse treatment in jails and prisons remains a high social and clinical priority. The medical, economic, and social burden of opioid addiction can be alleviated with the expansion of addiction treatment programming in the criminal justice system. This article presents arguments why this programming should be implemented and describes national standards on how services should be organized. The article concludes with a description of the nursing role in a criminal justice substance abuse program highlighting key tasks that correctional nurses perform. The article concludes with a discussion of the future challenges and directions to opioid treatment in the criminal justice system.

Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions

Medication-assisted treatment (MAT) is underutilized in the treatment of drug-dependent, criminal justice populations. This study surveyed criminal justice agencies affiliated with the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) to assess use of MAT and factors influencing use of MAT. A convenience sample (N = 50) of criminal justice agency respondents (e.g., jails, prisons, parole/probation, and drug courts) completed a survey on MAT practices and attitudes. Pregnant women and individuals experiencing withdrawal were most likely to receive MAT for opiate dependence in jail or prison, whereas those reentering the community from jail or prison were the least likely to receive MAT. Factors influencing use of MAT included criminal justice preferences for drug-free treatment, limited knowledge of the benefits of MAT, security concerns, regulations prohibiting use of MAT for certain agencies, and lack of qualified medical staff. Differences across agency type in the factors influencing use and perceptions of MAT were also examined. MAT use is largely limited to detoxification and maintenance of pregnant women in criminal justice settings. Use of MAT during the community reentry period is minimal. Addressing inadequate knowledge and negative attitudes about MAT may increase its adoption, but better linkages to community pharmacotherapy during the reentry period might overcome other issues, including security, liability, staffing, and regulatory concerns. The CJ-DATS collaborative MAT implementation study to address inadequate knowledge, attitudes, and linkage will be described.

A multi-level analysis of counselor attitudes toward the use of buprenorphine in substance abuse treatment

Despite evidence that buprenorphine is effective and safe and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling to examine National Treatment Center Study data to identify counselor characteristics (attitudes, training, and beliefs) and organizational factors (accreditation, caseload, access to buprenorphine, and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate-dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) was associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.

Linkage to care for HIV-infected heterosexual men in the United States

In the United States, the human immunodeficiency virus (HIV) epidemic among heterosexual men disproportionately affects individuals involved with the criminal justice system, injection drug and other substance users, and racial and ethnic minorities. These overlapping populations confront similar social and structural disparities that contribute to HIV risk and limit access to HIV testing, treatment, and care. In this review, we discuss barriers to linkage to comprehensive HIV care for specific subpopulations of heterosexual men and examine approaches for enhancing linkage to care for this diverse population.

Development of a nursing practice guideline for pre and post-operative care of gastric cancer patients

OBJECTIVES

The aim of this study was to develop nursing practice guidelines and algorithms for the pre- and postoperative care of gastric cancer patients.

METHODS

The guidelines and algorithms were developed based on a literature review and subject-matter experts' knowledge. The usefulness and applicability of the developed guidelines and algorithms were evaluated by the expert group.

RESULTS

The guidelines comprised 64 recommendations and algorithms for admission care, preoperative care on the day before the operation, preoperative care on the operation day, immediate postoperative assessment, postoperative care, and discharge care of gastric cancer patients. After appropriate evaluation, the experts declared the guidelines to be both useful and applicable.

CONCLUSIONS

The guidelines developed in this study can be used for patient care and for training nursing students and novice nurses. In addition, these guidelines can be integrated into the electronic nursing record system for clinical decision support in the future. This will improve the quality of clinical nursing and the expertise of nurses.