Question Criminalizing a Medical Illness

One way I urge us to help all our citizens is to question the legality, effectiveness, and humanity of criminalizing the medical illness of addiction.

Freedom and peace

Here is a summary of my findings:

Many of our citizens with opioid use disorder are arrested, incarcerated, or given the forced choice of drug court or jail. Many receive limited or no treatment, or are denied the first-line, evidence-based treatment for opioid use disorder, methadone and buprenorphine. Some drug courts ban the use of medications for opioid use disorder. At the national level, the Department of Justice’s Civil Rights Division has begun an initiative to remove discriminatory barriers to treatment for those in the criminal justice system. Incarceration does not decrease substance misuse. Treatment is 7 times cheaper than incarceration.

Here are highlights of my literature review of research on opioid use disorder and the criminal justice system:

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”

– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

On-going, long-term maintenance on methadone or buprenorphine are the only two treatments currently known to reduce mortality from opioid addiction by 50 percent or more.

– Pierce et al., Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in EnglandAddiction, 2015

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studiesBritish Medical Journal, 2017

Naltrexone, whether oral or extended release naltrexone, branded as Vivitrol and marketed directly to drug court judges by its manufacturer, does not result in decreased mortality rates for people with opioid use disorder.

– Degenhardt et al., Excess mortality among opioid-using patients treated with oral naltrexone in Australia, Drug and Alcohol Review, 2014

– Jarvis et al., Extended-release injectable naltrexone for opioid use disorder: A systematic review, Addiction, 2018

“[H]ealthcare providers, criminal justice officials, and the media should consider the potential for overdose when prescribing or promoting Vivitrol treatment.”
– Saucier et al., Review of Case Narratives from Fatal Overdoses Associated with Injectable Naltrexone for Opioid Dependence, Drug Safety, 3/20/18

Persons recovering from, or receiving supervised treatment for addiction to alcohol or drugs, are often qualified as disabled individuals according to the American with Disabilities Act. Courts, drug courts, probation departments and prisons may not treat individuals with opioid use disorder differently from other individuals who are allowed to take medications as prescribed.

Letter to the New York State Office of the Attorney General from the U.S. Department of Justice, October 3, 2017

80% of people with opioid use disorder who attempt abstinence-based behavioral treatment or detoxification relapse.

– Gavin Bart, M.D., Maintenance Medication for Opiate Addiction: The Foundation of RecoveryJournal of Addictive Diseases, 2012

“The majority of patients who discontinued BMT [buprenorphine maintenance therapy] did so involuntarily, often due to failure to follow strict program requirements, and 1 month following discontinuation, rates of relapse to illicit opioid use exceeded 50% in every study reviewed.”

– Bentzley et al., Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes, Journal of Substance Abuse Treatment, 2015

People are more likely to fatally overdose prior to beginning maintenance medication and upon ceasing it than are those with continuous treatment. Cornish et al. caution, “Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment.”

– Sordo et al., Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studiesBritish Medical Journal, 2017

– Anders Ledberg, Mortality related to methadone maintenance treatment in Stockholm, Sweden, during 2006–2013, Journal of Substance Abuse Treatment, 2017

– Cornish et al., Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database, British Medical Journal, 2010

Individuals with opioid use disorder who are newly released from prison are at high risk of overdose death.

– Binswager et al., Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009, Annals of Internal Medicine, 2013

Incarcerated individuals with opioid use disorder should be treated with methadone and buprenorphine while they are incarcerated. “[R]esults suggest that comprehensive MAT [medication-assisted therapy] treatment in jails and prisons, with linkage to treatment in the community after release, is a promising strategy for rapidly addressing the opioid epidemic nationwide.”

– Green et al., Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System, JAMA Psychiatry, 2018

For those with opioid addiction in the criminal justice population, maintenance medication can reduce rates of re-incarceration by 20% or more.

– Larney et al., Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarcerationAddiction, 2011

To stay in remission from opioid use disorder, people must remain on methadone or buprenorphine for extended periods of time, sometimes life-long. According to SAMHSA’s guide, “Medication-assisted treatment should continue as long as the patient desires and derives benefit from treatment. There should be no fixed length of time in treatment. For some patients, indefinite medication-assisted treatment may be clinically indicated.”

– Federal Guidelines for Opioid Treatment Programs, SAMHSA, 2015

“Medication-Assisted Treatment (MAT) is an evidence-based substance use disorder treatment protocol, and BJA [Bureau of Justice Assistance, U.S. Department of Justice] supports the right of individuals to have access to appropriate MAT under the care and prescription of a physician. BJA recognizes that not all communities may have access to MAT due to a lack of physicians who are able to prescribe and oversee clients using antialcohol and anti-opioid medications. This will not preclude the applicant from applying, but where and when available, BJA supports the client’s right to access MAT. This right extends to participation as a client in a BJA-funded drug court.”

Adult Drug Court Discretionary Grant Program FY 2017 Competitive Grant Announcement, U.S. Department of Justice, 2016

“Examining any two-year post-program recidivism (defined as an arrest, conviction, or incarceration), over one third (37.6%) of graduates and almost all program terminators (95.3%) had two-year post-program recidivism ( p < .001). [my emphasis]. For the overall sample, age, outpatient treatment, marital status, number of times treated for a psychiatric problem in a hospital, substance use (i.e., past-30-day cocaine use and intravenous opiate use), number of positive drug tests, and receiving any sanction/therapeutic response were associated with two-year post-program recidivism.”

– Shannon, et al., Examining Individual Characteristics and Program Performance to Understand Two-Year Recidivism Rates Among Drug Court Participants: Comparing Graduates and Terminators, International Journal of Offender Therapy and Comparative Criminology, 4/1/18

“The analysis found no statistically significant relationship between state drug imprisonment rates and three indicators of state drug problems: self-reported drug use, drug overdose deaths, and drug arrests.”

– More Imprisonment Does Not Reduce State Drug Problems, The Pew Charitable Trusts, 3/8/18

Treatment is up to 7 times less expensive than incarceration.

– NIDA, “Is drug addiction treatment worth its costs?”, 2018

Watercolor painting by Jesi Pace-Berkeley

The above includes data I used for a talk I gave on the opioid crisis on Tuesday, March 13, 2018. I reviewed common beliefs about opioid use in the U.S., and compare those beliefs to what research reports. I published highlights from my background research for the talk as Opioid Crisis: What People Say vs. What the Research Says.

Last updated 5/15/18

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.