Enrollment in community methadone maintenance programs is a major step on the hard road to recovery from opiate dependence.

But of the 140,000 to 170,000 individuals who participate in such programs across the country, about 10% are arrested and jailed each year. What happens to them? How often is methadone continued? How is methadone stopped, and how is their opiate dependency managed during their incarceration?

Since there are no reliable data to address these important questions, several colleagues and I conducted a national survey of U.S. jails to find out. (See a summary of study methods below.)

We found that very few jails provided continuous treatment to inmates on methadone, except in the case of pregnancy. Few jails contacted programs to determine dose. Most stopped methadone abruptly rather than tapering it over time. Roughly half of jails provided clonidine for withdrawal symptoms, 30% used only ibuprofen or acetaminophen and 20% reported providing no symptomatic treatment!

These findings are troubling. Forced interruption of methadone maintenance often is associated with painful withdrawal symptoms and significant health risks, including lethal overdose. It also is associated with a very high relapse rate and risk for rearrest. National standards for management of these arrestees would help to stop this costly and dangerous revolving door of arrest, detox, relapse, rearrest.

Areas of Inquiry
The study’s objective was to assess how jails manage individuals who are enrolled in community methadone programs at the time they are admitted to jail. In addition to inquiring whether a methadone program existed in the local community, the self-completed questionnaire asked whether the jail routinely...
•  Assessed opiate dependence of incoming inmates
•  Used a specific standardized treatment protocol to detoxify inmates on methadone
• Contacted the community methadone program to determine the inmate’s methadone dose
•  Continued methadone during incarceration
•  Used clonidine to treat withdrawal
•  Used methadone to treat withdrawal
•  Used any other opiates to treat withdrawal
The survey also asked for the percentage of inmates dependent on methadone, the jail’s daily census and the respondent’s job title.

Reported Practices
This table summarizes key findings about the practices taking place in the jails that responded to the survey. The results reported here are weighted to account for oversampling of larger jails as measured by daily inmate census.

In brief, 62% of the respondents said there was a methadone maintenance program in the community; only 56% routinely asked inmates whether they are opiate dependent.

However, most (85%) of the jails did not continue methadone for these inmates, nor did most (77%) use a specific standardized treatment protocol for opiate detoxification. Only 27% of jails routinely contacted the community program about the inmates now under their care.

Closer examination of the data reveals disparities in the findings, though the reasons often are unclear. Not surprisingly, compared to jails that reported no local methadone maintenance program, those jails that did report such a program were more likely to seek information about program enrollees. Yet these jails were not significantly more likely to continue methadone maintenance.

Even jails that had a written protocol for methadone management did not necessarily continue the treatment. On the other hand, these respondents were more likely to detoxify inmates using recommended protocols.

In terms of jail size, those with more than 2,000 inmates were most likely to report use of appropriate detoxification protocols, yet continuation of treatment was more common in jails with 1,000 to 2,000 inmates.

Furthermore, while jails in the South and Midwest were more likely than those in other regions to continue treatment, the Northeast produced significantly more respondents who reported use of appropriate detoxification protocols.

Drawing Conclusions
Halting treatment of individuals who receive methadone maintenance carries many risks, not only for the inmate but also for public health and safety. Thus, jails should consider options that would provide for continuity in opiate treatment and minimize the risks associated with treatment interruption.

Options include:
1. Becoming a satellite of a community-based methadone program.
2. Arranging for the local program to deliver methadone.
3. Substituting buprenorphine, which was approved for office-based use in 2002.
4. A last option, one that has become more feasible now that NCCHC offers accreditation for opioid treatment programs based in correctional facilities, is to become legally certified to operate a methadone maintenance program.

While each of these options presents challenges, they warrant consideration given the risk associated with current practices.

Furthermore, poor or nonexistent coordination between jails and community-based methadone programs exacerbates the problems of managing program enrollees admitted to jail. Without accurate information about current dosing, correctional health care providers cannot make informed decisions about methadone management.

Looking at use of “appropriate detoxification,” most of the respondents who said they used standard protocols reported using clonidine for this purpose. While studies conflict as to clonidine’s efficacy and ability to relieve withdrawal symptoms, it is well-established that methadone is safe and effective, and is known to reduce opiate usage in jails.

Of far greater concern, however, is the widespread use of “detoxification” practices, such as use of nonnarcotic analgesics, that do not meet community standards, or allowing inmates to go “cold turkey.” Such practices are inhumane and violate the hypocratic oath taken by physicians: “First do no harm.”