Tuesday, July 04, 2006

What A Meth!

I'll say up front that I'm not in favor of government-sponsored addiction. When I was a medical student I did some of my rotations at a local veteran's hospital. It was the only hospital I've ever seen that had a bowling alley. It also had vending machines for cigarettes, which was very convenient for my patients with COPD (emphysema). One town I lived in sponsored a municipal liquor store. The proceeds from the liquor store went to pay for the local alcohol rehabilitation program. And then there's the issue of slot machines to pay for government services, like treatment for gambling---don't get me started.

Thus, we come to the issue of methadone. Methadone is heading our way. Methadone maintenance, long known as a staple of addiction treatment in free society, is expanding to prisons. An American survey of state and Federal prisons showed that only 48% of systems currently provide methadone to prisoners, and then only generally for detoxification or for maintenance therapy of pregnant women. However, a Canadian court recently ordered that a prison provide methadone maintenance to an inmate. Fearing that additional litigation might cause different standards for different facilities, the Canadian Correctional Services took a proactive approach and created a policy to provide methadone maintenance to those already enrolled in maintenance programs. Pressure is on to expand treatment by offering it to prisoners who were not previously on it prior to incarceration.

At this point there is little question that methadone maintenance decreases heroin use and needle-sharing behavior in free society. Preliminary evidence suggests this may also be true in prisons, although current studies are limited by the small number of available programs to study and limited program enrollment. The question remains open whether or not methadone maintenance reduces new cases of HIV and hepatitis in prisoners.

As with any healthcare program, it will add to the expense of incarceration. The cost of this program in one American facility housing 50 inmates was $5000 according to one report, although this report doesn't clarify if this is per inmate per year or an annual total program cost. In Canada the cost is $1700 per year per patient ($1500 USD). In Australia the cost of prison maintenance therapy is $3234 ($2400 USD). Assuming an average cost of $2000 per inmate per year, and a very conservative estimate of 25% of state and Federal inmates who need treatment, this would add approximately $700 million to the annual cost of incarceration in America. The true cost of drug abuse in prison, or the benefit of treatment for drug abuse, is difficult to calculate. Supporters of methadone maintenance often balance the cost of the program against the cost of therapy for HIV or hepatitis contracted within the system. Treatment costs also apparently now have to be weighed against the costs of litigation filed by inmates seeking treatment, or suing for damages for drug-related illnesses contracted while incarcerated.

I've yet to see a cost-benefit analysis on this issue that addresses the effects of methadone maintenance on institutional culture and civillian safety, or even mentions the possible unintended negative consequences of introducing a controlled substance---a free controlled substance---into a correctional facility. This is what this post is about.

Here are my concerns about prison methadone maintenance:

  • I don't want to be a drug pusher.
    When programs like this get started, administrators usually take it for granted that clinical care will be provided by existing health care professionals. I'm not a substance abuse specialist and I don't have any particular training for the prescribing and supervision of methadone. I'd be willing to bet the cost of the program will not include on-site subspecialty services for this, and the medical providers will consider this a psychiatric responsibility. For once, I'd rather not have prescribing privileges if the expectation is that I will prescribe methadone.

  • Methadone given without rehabilitation or addiction counseling
    Similar to mental health services, substance abuse treatment often requires counseling in addition to medication. A correctional system should not point to a methadone maintenance program and say they are providing substance abuse treatment if they are not also providing the relapse prevention counseling and other therapy to go along with it.

  • No expectation that inmate will ever come off maintenance therapy
    After seeing some methadone maintenance patients continue on the drug for over ten years, I think the term "maintenance" is a misnomer. At this point users see the drug as an entitlement, not a pathway to abstinence.

  • Decision-maker safety
    Programs generally have guidelines for inclusion and exclusion criteria, but these are not necessarily "bright line" rules. There is usually some room for clinical discretion. It will fall to the decision-maker or the decision-maker's representative to tell the inmate whether he is 'in' or 'out' of the program. I've seen what happens when inmates are turned down for programs or services. I don't want to be the one telling the inmate he can't have the free opiate he wants. I already have to deal with inmates who act up or make threats to act up in order to get the sedating medications they want. If inmates make threats now over Thorazine and Elavil, I don't want to think of what they'll do for methadone. I'm not goin to put my personal safety at risk over this.

  • Risk to non-enrollees
    When you work in a correctional facility, you have to remember that anything you prescribe will end up in the hands of others in the facility. It's inevitable, even for "watch take" or "directly observed" therapy. Even in free society methadone users have been known to "cheek and spit" methadone for resale. Circulating methadone will pose a risk to non-enrolled inmates and could lead to overdose deaths. It will also enhance the institutional black market.

  • Complication of psychiatric diagnosis and treatment
    I don't really need to dwell on point. Drug addiction is a common complicating factor when it comes to making an accurate psychiatric diagnosis. Up to now, one of the nice things about working in a correctional setting was that you could get a relatively good diagnostic snapshot or your patient while abstinent. I could use lower doses of medication because I wasn't fighting against illicit chemicals. And yes, I did know when my inmates were using.

  • Risk of new addiction
    Inmates have been known to experiment with lots of unusual things---anticholinergic medication, asthma inhalers, and in a worst case scenario even "pruno" (homemade alcohol brewed in toilets). Some inmates begin abusing substances while incarcerated. Circulating methadone could lead inmates to broaden their repertoire of abused substances if they get a chance to try it while they're locked up.

Of course, I could be wrong about all this. Methadone maintenance may be the answer to drug-related violence and public health problems, but within the correctional system the jury is still out. I hope I'm just watching for a falling asteroid. I just want to make sure that all of the potential consequences get considered.

Disclaimer: The opinions expressed in this blog are my own and do not represent those of my employer or the state government. Please don't shoot me.


NeoNurseChic said...
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Dinah said...

Hi Clink, happy 4th of July to you here in America. Off soon to a Barbeque, rah America...oh but it's at the home of a Brazilian. As long as they serve hot dogs.

I treat one patient who has been on methadone for over 30 years...good? bad? I often wonder if the drug hasn't zapped his motivation, he leads a rather empty life-- somedays I think the only things that get him to venture out at all are cigarettes, methadone, and therapy. On the other hand, he lives a legal lifestyle, hasn't been in jail since starting methadone, worked for years, doesn't have HIV or hepatitis.... Another patient of mine has a partner who was in and out of jail/rehab and since starting methadone has managed to resume life as a white collar professional. So my N of 2.
I have to say, it seems to me one thing to continue methadone on someone with a track record who has been invested in and participating in a program, meeting it's requirements, showing up daily, prior to incarceration, esp if they have a spot waiting for them upon release. The concept of STARTING methadone on an inmate-- and I presume it would take a few days after arrest to assess and do this, by which time the person would have finished withdrawing and been narcotic-free--seems mind boggling. Methadone clinics have a long waitlist, maybe people could short-circuit the line by getting arrested? And I do pity you the hassles of inmates coming wanting narcotics. From my narrow, free-society, non-forensic, anti-criminal point of view, I think prisons should be unpleasant places-- part of the deal with deterring crime is that people are AFRAID to go to jail and therefore try to behave in ways to avoid incarceration-- if they dispense long-acting, free of charge narcotics, maybe it won't be such a bad place to go....

And no, I don't think methadone addicted mothers should breast feed. In or out of jail.

oh, i do love to rant.

NeoNurseChic said...
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aafan said...

Great, great post.

Just found this on Google today: "How to deal with prison." I'm interested in your thoughts about it.

ClinkShrink said...

Great link, Shrinkette. And thanks for stopping by. Yeah, that's all good advice (except for the recommendation for violence or reacting 'quickly and with aggression' part). I particularly liked this part:

"Respect the prison medical staff. They are there to help you."

For the most part, that does happen.

As for the comments about breastfeeding in or out of jail, thanks for the idea. I'm working on the post now.

On the Same Page said...

I have been searching for an old article from the NYC Village Voice called "Methadone Madness," but it was sometime in the late 1980's and not to be found, yet. I worked on a hospital campus in NY that had the forensic psychiatry and chemical dependency services back-to-back with a very lucrative methadone clinic. The article accurately described what we lived through on a daily basis: addicts of a type (opiate users) were considered "different" than addiction in general, and apparently incapable of returning to abstinence. Now, one could easily argue that addiction is, by nature, the loss of the ability to live in a drug free fashion, but these individuals seemed to exist in a hell unto their own.

While I could rant for pages reagrding my experiences, I will limit comments to one issue, boosting. The theory of methadone maintenance is that the patient is in a fuctional state of tolerance (lack of opiate withdrawal), yet below a state of euphoria, with the caveat being "with the appropriate dosage." As an analgesic with a single-does conversion ratio to morphine of 10-1, a bioavailability 2-3 times greater than morphine, and a half-life of up to 190 hours (though its analgesic properties are generally not seen after 24-48 hours), no one can argue its potency as an analgesic or a euphoriant. The issue for the Methadonians is when the tolerance replaces the euphoria; after all, they weren't taking opiates for analgesia, but for euphoria. The dosages Methadonians receive can be off the charts; I've interviewed many maintained at 120 oral mg per day! This is also to say that the concomitant use of other drugs of abuse is astonishing considering they are in "treatment," but unremarkable when considering they are addicts.

The irony of the long half-life of methadone is that weekend take-home doses can be sold on Friday to purchase other drugs, particularly alcohol and methamphetamine, and the patient will still not be in withdrawal for the Monday morning dose. Other patients purchase extra weekend doses from the sellers for a binge. I have met more than a few methadone addicts who were not patients of any clinic, but purchased the "extra" methadone from registered patients. I would be happy to give purchase tours to any "official" who insists that methadone is "strictly regulated"

Finally, the admission criteria set forth by the FDA does not necessarily even include the toxicological presence of opiates in the system or "fresh needle marks." You can even get admitted if you can demonstrate you were actively using before you went into prison, or up to two years after you left a methadone clinic. Nothing like seeing your school bus driver double-park to run in and get his morning methadone...

ClinkShrink said...

Foo you have great links, thanks. I'm setting the criteria aside for a read when I have more time.

Methadonia---I think we have readers from there.

NeoNurseChic said...
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ClinkShrink said...

she got 200mg of methadone a day and still managed to do some drug while she was in the bathroom

I've heard of inmates using IV heroin every day in addition to taking other inmates' morphine and other prescribed meds. Periodically somebody gets found unconscious in the cell, but I'm surprised it doesn't happen more often. I guess the drug detection dogs are staying busy...