Opinion: Medication-assisted treatment in jails
It is a mistake to confuse the treatment of opioid withdrawal with the long-term treatment of drug addiction
This column was originally posted on Jeff Keller's blog, Jail Medicine.
I recently ran across a news article on NPR about the problem of treating the large number of opioid-addicted patients in our jails.
There is a growing movement that all opioid-addicted patients should be offered medication-assisted treatment (MAT) while in jail, meaning one or more of three drugs: methadone, Suboxone or Vivitrol.
The article does a good job pointing out this is a complicated problem. Having been on the front line of this problem for many years in my own jails, I would like to present my thoughts on using MAT in jails. (MAT in prisons is a separate subject I will address later).
The difference between treating withdrawal and treating addiction
First, it is important to recognize the distinction between treating opioid withdrawal (also called detox) and the long-term treatment of addiction. These two are often confused, and that is a mistake.
Treating withdrawal is not the same thing as treating addiction. Take, for example, a patient who has been using heroin and then comes to jail. The patient is going to go through heroin withdrawal, which typically lasts for around 5-7 days, and needs to be treated for this. It is inappropriate, bad medicine and dangerous to allow the patient to suffer through a "cold turkey" withdrawal (see my thoughts about that here).
While the MAT drugs methadone or Suboxone can be used to treat withdrawal, they are no better in this setting than alpha-blockers like clonidine or lofexidine and are trickier to use. The Cochrane review analyzed the available literature on this subject and concluded: “We detected no significant difference in efficacy between (opioid withdrawal) treatment regimens based on clonidine or lofexidine and those based on reducing doses of methadone over a period of around 10 days.”
I use clonidine to treat opioid withdrawal in my jails. It works very well. But having treated the symptoms of withdrawal, the patient still has the problem of addiction. When released from jail, there is a strong likelihood the patient will relapse into heroin use. Treating the patient’s addiction is different than treating the withdrawal. Treating the addiction is a long-term process that may take years and typically involves MAT, counseling and AA-style group meetings. When the NPR article says, “(MAT) is now considered to be the most effective method of treating opioid-abuse disorders,” it is referring to the long-term treatment of addiction.
I agree with this. However, the average length of stay in a typical county jail is less than a month. Many people are released within days. This means that MAT in a jail must be coordinated with a community-based MAT program on the outside that patients can transition to when they get out.
The ideal situation is this: If a patient is in a community MAT program before they come to jail, their MAT medication should be continued while they are in jail and then again seamlessly continued when they are released. (I have written about this here.) This requires a lot of communication between the community MAT programs and the jail.
Once a strong relationship is developed between the community MAT program and the jail, then – and only then – can the jail develop a program to begin MAT treatment of heroin-addicted patients while they are in jail. Then, the patients who begin MAT therapy in jail can continue that treatment at the community program when they get out of jail. But the relationship with the community MAT program must precede such a program. In my opinion, it does no good to start someone on MAT in jail when there is no possible way to continue it when they get out.
Barriers to medication-assisted treatment
Why would it not be possible to continue MAT when a patient is released from jail? There are two main reasons.
The most common is that there is no community program! Big cities usually have one or more community MAT programs, but little cities and towns – where most county jails are located – often do not. And if there is no program in the community, it does no good to start short-term treatment in a jail that is discontinued immediately when patients are released.
The second reason why patients may not be able to continue MAT after release from jail is that they cannot afford it. MAT programs charge their patients. While insurance may cover opioid treatment programs, many, if not most, of the opioid-addicted patients in a jail do not have insurance and cannot afford the fees of a community MAT program.
Once again, in my opinion, it does no good to start someone on MAT in a jail just to leave them hanging once they are released because they cannot afford to continue.
The bottom line is that MAT opioid treatment programs must be community based. Jails should be part of the community program, by cooperating and coordinating closely with the community program, but small jails especially cannot effectively function alone. In the meantime, all jails, even small jails in rural communities, can effectively treat opioid withdrawal.
As usual, what I have written here is my opinion, based on my training, research and experience. I could be wrong! Feel free to disagree, but please say why in comments. This article deals with jails, not prisons. MAT use in prisons is a separate subject.