Icro Maremmani1,2,3, Matteo Pacini1,3 and Mercedes Lovrecic1,4
Summary
Interventions against drug addiction aim to achieve a satisfactory level of in- dividual well-being, which does not vary despite different starting conditions. Spending time in jail is a common experience in the personal history of addicts; in response, the prison system should implement medical skills that have pro- ven effective in ensuring behavioural control and health preservation for free individuals. Agonist maintenance by methadone or buprenorphine is feasible within prison walls, applying the same criteria that are adopted outside. Fir- stly, agonist drugs allow a safer relationship with the jailed addict. In addition, they improve the prospects for early release: therapies that started behind bars pave the way towards a life of freedom. Different schedules are suitable for different grades of addictive severity. Less severe patients may be forced out of an ill-chosen style of life as a free individual into an option of therapeutic parole. Hard-core addicts may benefit from the isolation of prison life, in so far as they are initiated and become stabilized on therapeutic regimens during custody. This solution will at least grant them a better quality of prison life. On this view, the prison system can play a crucial role in leading addicts towards therapy, mental health and social adjustment.
Key Words: Addiction - Methadone Maintenance - Opiate Agonist - Prison
Address for reprints: Icro Maremmani, MD; Department of Psychiatry, Neurobiology, Phar- macology and Biotechnologies - University of Pisa, Via Roma 67 - 56100 Pisa - Italy
1PISA-SIA (Study and Intervention on Addictions) Group, "Santa Chiara" University Hospital,
Department of Psichiatry NPB, University of Pisa, Italy, EU
2Association for the Application of Neuroscientific Knowledge to Social Aims, AU-CNSonlus,
Pietrasanta, Lucca, Italy, EU
3Institute of Behavioural Sciences "G. De Lisio", Pisa, Italy, EU
4Institute of Public Health of the Republic of Slovenia, Ljubljiana, Slovenia, EU
Heroin Add & Rel Clin Probl 2004; 6(2-3): 53-72 Point of View
The rationale of methadone treatment: as outside, so inside penitentiaries
To date, agonist maintenance has proved to be the most effective means of inter- vention on the core of opiate addiction. Although other treatment typologies can play worthwhile roles within a programme, they still loom as side approaches. In correctly structured programmes of intervention, they either stem from the pharmacological
core of agonist maintenance; or, more exactly, function as pathways to bring specific agonist interventions within reach. The key issue of agonist treatment is the prevention of relapse and recidivism, to be attained by suppressing craving for heroin. Agonist treatment has with further beneficial characteristics: first, doses can be administered that will prevent heroin from being sensed, even if patients continue to inject heroin in the early phase of treatment (known as ‘opioid blockade’). Eventually, in terms of therapeutic relevance, though firstly in chronological order, agonists provide prompt buffering against upcoming withdrawal.
Agonist management that aims to restore the pre-intoxication tolerance threshold can be ruled out as an effective therapy for heroin addiction. Moreover, although somatic balance is restored, psychic toxicity and tolerance to craving for heroin are anything but under control. In Italy, at present, the latter situations are what most jailed heroin addicts live in, while there is no procedure available for reaching out to them through specific agonist (methadone or buprenorphine) programmes. Differences in the thera- peutic destiny of prisoners do not mirror any actual difference on pathological grounds, as the illness is the same for jailed as for free heroin addicts, and for the same heroin addicts before, during and after imprisonment.
Those who oppose to this view can argue that anticraving therapies are pointless inside prison walls, because no control over the drive towards heroin or blockade of narcotic effects is needed, considering that street drugs are not available. Leaving aside the longstanding issue of drug availability in jail, we prefer to focus on thia question from a medical viewpoint. Agonist maintenance chiefly aims to prevent a spontaneou- sly relapsing course. At the same time, it should bear in mind exactly which cerebral functions have suffered damage from chronic heroin exposure. Otherwise, it cannot provide any heroin-like subjective effect, as the ambiguous term “substitution therapy” misleading suggests.
Transforming time spent in jail into therapeutic time offers advantages that do not stand or fall on the basis of whether addicts use drugs or not while imprisoned. As long as the ultimate criterion for assessing treatment effectiveness is the individual’s adjustment in a free setting, a therapeutic regime with a standard dose and scheduling features will work in such as way as to increase the likelihood that prisoners will stay in touch with a therapeutic setting after their release. Even if it is not completely effective, this solution at least allows patients some protection against drug-related accidents. Supporters of pharmacological intervention 50 and supporters of community-based programmes 9,18
have both assessed the feasibility and usefulness of standard addiction treatment inside prisons, on the assumption that differences in treatment approach did not cancel the shared aim of preventing recidivism. The true promise of agonist therapies for addicted detainees is that of building up a subject’s social reliability on scientific bases, while they are kept under control in a correctional institution. Otherwise, at present, released detainees usually reacquire their social freedom together with a certainty of relapse. Besides this, as long as pharmacological shielding is maintained, the individual’s free- dom continue to be linked with a guarantee of social harmlessness 38.
I. Maremmani et al: Clinical foundations for the use of methadone in jail
Towards a prison-based treatment for addiction
The 1950 OMS definition of addiction as a disease helped to ratify the changed scientific awareness of the role of psychopathology in the dynamics of drug-related phenomena. In line with the new view, imprisonment was no longer regarded as a means of intervening specifically against addictions; alternative measures were needed to allow detainees to benefit from free therapeutic settings. The law indicated drug addicts as a category that merited a therapeutic rather than a correctional solution, through what was called “therapeutic parole”: even if the prison system in itself plays no therapeutic role, it may mark a crucial stage in the history of addiction. In fact, not every case is suitable for therapeutic parole. However, the health of addicts who cannot be selected as parolees can be preserved in other ways. On one hand, the law states the need to develop therapeutic programmes while time is being served, and on the other the need for continuity between therapeutic options inside and outside prison. Generalizing, minor offenders, who make up the commonest criminal typology among drug addicts, are best handled as mentally ill people, so therapeutic needs must prevail over the need for imprisonment. Whatever their crime, addicts who are unfit for therapeutic parole, show that addiction should continue to be recognized as a medical issue, that calls for specific intervention. It has been recommended that medical facilities for drug addicts should not differ from those offered to their free peers. Moreover, treatment should not be discontinued when passing from freedom to detention or the reverse. Correctional institutions should then be cooperating with the health system for free citizens. Lastly, detained drug addicts should be approached as subjects who come from the community and are, hopefully, destined to rejoin it (Oldenburg Conference on “Jail and Drug Ad- diction”, March 12-14, 1999). A prison, just like a therapeutic community, can become a useful setting for starting subjects on treatments, the aim being to guarantee their social role in view of their future return to freedom. The control exercised by police within prison walls may help to promote the feasibility of treatments, by overcoming the lack of compliance that would cause treatment failure in a free setting. In other words, individuals who would be untreatable because of lack of compliance or would never request any treatment as long as they were ill but free, may welcome the opportunity to receive treatment as long as they are deprived of freedom.
In recent times, changes have been made to the prison system in an attempt to organize a special setting for the handling of addicted inmates. There is, however, a risk that these innovations will develop without specific instruments for curing drug addiction, simply providing environmental, recreational and rehabilitative options which may be out target.
In our opinion an effort should be made to focus on the possibility of exploiting some of the features of prison life, which are needed anyway to ensure security, to enhance the impact and feasibility of therapeutic measures that specifically target drug addiction. When the law leaves no alternative but detention, this may create an opportunity to administer treatment 38, and we could then start talking about “prison-
Effects of agonist treatment on addiction-related crime and handling of addicted detainees.
Specific treatment for addiction and the prevention of criminal recidivism.
Agonist-maintained heroin addicts have a 5% likelihood of being imprisoned at some point during a 7 year follow-up period 35 or 2% at the end of 12 years 46. To be
under methadone maintenance implies a low risk of imprisonment both with respect to untreated peers 12,20,23,25,30- 32,34,37,40,44,52, and compared with the same subjects when they
were not being treated 3,13,15,39. When treatment is discontinued, its protective value is
lost as soon as addictive behaviour re-emerges — a moment that does not necessarily occur during withdrawal and that often follows an early period of abstinence. In fact, it is over the medium to long term that craving and addictive drives re-emerge, pushing the affected individual into a spiral of relapse which can now be expected to spin faster than in the past. In Italy it has been reported that 75% of imprisoned addicts had stopped their treatment over 60 days before being arrested, while only 3% were imprisoned in the short-term after treatment discontinuation 6. It can be said that in Italy the spread
and continuance of methadone maintenance was related to changes in addiction-rela- ted crime between ’86 and ’95, due to changes in the numbers of imprisoned subjects who were attending a methadone maintenance programme. The number of imprisoned addicts rose from 6,000 in 1986 to 13,000 at the end of 1995. On the other hand, the number of methadone-maintained subjects among the population of jailed addicts followed a different course: an initial increase was documented in the late eighties, while methadone treatment was spreading nationwide; this was followed by a steep fall in the early nineties, when the percentagedwindled from 33% to 3% 4 (See table
1 for details). In France, where agonist treatment started spreading in the nineties, the percentage of agonist-treated subjects among jailed addicts gradually fell. Experts at the French Ministry of Health have tried to explain this phenomenon as a preventive
Table 1. Incarcerated methadone-treated addicts in Italy
Survey term Incarcerated addicts Methadone-treated addicts
N % 1996-12-21 6.102 252 4.13 1987-12-31 5.221 1.742 33.37 1988-12-31 7.500 750 10.00 1989-06-15 8.790 1.916 21.80 1990-12-31 7.299 184 2.52 1991-06-30 9.623 273 2.84 1991-12-31 11.540 378 3.28 1992-06-30 13.970 237 1.70 1995-12-31 13.448 391 2.90
I. Maremmani et al: Clinical foundations for the use of methadone in jail
effect of the ongoing treatment, which tended to hold addicts back from imprisonment as the outocome of criminal involvement 21,49.
Over 40% of all heroin addicts who had drug-related legal problems were imprisoned at some stages over a 20-year follow-up period 16.
The criminal career of heroin addicts who enter maintenance treatments shows a strong tendency improvement in terms of frequency of reimprisonment 3,15,35, number
of detention periods and total time served while attending the programme 20. Patients
who agree to take 60 mg/day (the standard threshold for opioid blockade) are less likely to be sent back to prison than those who refuse to take blockade dosages 2,48.
Conversely, unspecific treatments fail to affect the natural course of addiction and the addiction-related crime of former detainees 40.
The advantages of methadone maintenance for the prison environment
In Canada a heroin-addicted detainee made the first move by bringing the Kent prison system to court on a charge of therapeutic omission, because he had been denied the right to initiate a methadone maintenance programme while in jail 33. In the Republic
of Ireland it was the penitentiary police who proposed the extension of methadone maintenance inside prisons 24.
These two events should not surprise us if we consider the fact that detainees and prison guards are those closest to what happens inside penitentiaries: between 1989 and 1995 no drug-related deaths were recorded for methadone maintenance addicts: those dying from drug use were not receiving agonist treatment 14.
Dysphoria, aggressiveness and self-injuring behaviour
Aggressiveness in heroin addicts has more than one meaning. In most heavy heroin users it is closely related to the severity of addiction, and the intensity of craving. A minority of heroin addicts, who stand out as particularly violent, are characterized by extremely severe withdrawal symptoms, together with a harm-avoidant personality trait, which may be the behavioural expression of a biological predisposition to suffer great damage from chronic heroin exposure. In fact, sensitivity to heroin’s behavioural toxicity (dysphoria and aggressiveness) and a disposition to develop addiction (with a quick transition from experimental to regular use) are interrelated, which suggests that aggressiveness and addiction-proneness share the same underlying biological struc- ture. In the stereotypical heron addict, craving justifies symptoms of aggressiveness, and thereby mirrors the severity of addiction. In prisons, violent behaviour, suicidal and self-injuring acts are highly represented among the psychopathological events of heroin addicts. However, suicide and self-injuring behaviours are not most likely during withdrawal 19. It must be born in mind that the risks increase in the medium
term, so that it is malpratice to discontinue agonist treatment by tapering steeply, even if it is apparently safe to do so in the short term. The consequences of an opioidergic malfunctioning become evident over time, so that recently detoxified, un-medicated addicts may quite suddenly begin to behave aggressively. Patients benefit most from
agonist treatment, even when dosages are inadequate. Even so, higher agonist dosages are required when aggressiveness is high at treatment entrance. From another standpoint, ongoing naltrexone treatment brings with it a higher risk of aggressive and suicidal behaviours than methadone treatment does, as shown by comparing groups of patients who did not differ in aggressiveness or suicidal risk at treatment entrance. The need to act vigorously and immediately against aggressiveness, while concomitantly reducing craving and addictive behaviours was the objective that the prison officers had in mind in proposing the extension of methadone treatment inside prisons 24.
Unsafe practices
Before talking about possible pharmacological issues, it can reasonably be assumed that internal security measures against the spread of drugs are at least partly effective against drug-related events in prisons. On the other hand, given the promiscuity of the prison environment, and the grouping together of individuals riding the same craving wavelength, drug-related happenings tend to be uncontrollable, though infrequent 8,21,27,42.
Moreover, drug-related risks inside prison are heightened by what is, on average, the greater severity of addiction of those who end up in jail — individuals who often display poor impulse control or antisocial personality disorders. Methadone maintenance favours an opposite trend for drug-related behaviours: treated individuals, unlike their untreated peers, show greater even while continuing to inject, and win a better level of impulse control. Conversely, when craving-related urges coupled with low substance availability are concomitant with a lack of therapeutic coverage, the risk to health rises steeply. By contrast, even when drug-using continues in jail, and returns to pre-incarceration levels soon after discharge, unhealthy habits (such as needle exchange and unsafe sex) remain
uncommon amongst methadone-maintained heroin addicts 8,51. In a German survey,
the risk for HIV seroconversion turned out to be negligible for methadone-maintained detainees, in sharp contrast with a 5.9/100 year/person rate for the whole prison sample, and 8.9/100 year/person among methadone-free heroin addicts 45.
It is logical to conclude that a specific therapy — one that aims to prevent relapse by craving suppression — should be regarded as first choice for detained, as well as free, heroin addicts. The data even allow us to state that addicted detainees are a category of choice for methadone maintenance, because of its striking efficacy on severe and high-risk addictive subpopulations.
In some cases addiction-targeting treatments are not feasible, due to medical incom- patibility or absolute opposition by the patient, even when the consequence may be a longer prison term. In these cases, the controlled administration of heroin is justified on a scientific basis, as long as heroin-taking detainees are isolated from other prisoners with a heroin problem32.
The provision of clean injecting equipment does not encourage substance use, while it is effective in reducing infective accidents (such as seroconversion and nee- dle-exchange)32.
I. Maremmani et al: Clinical foundations for the use of methadone in jail
in the same context. In fact, harm reduction does not hamper the spread of effective treatment; on the contrary, it helps to reduce the harm deriving from residual drug- taking activities that are not covered by the agonist treatment itself.
On the whole, substance use inside prisons can be countered in two separate directions: police controls limit the spread of drugs and, therefore, the incidence of drug-using. Specific interventions, on the other hand, should boost the effectiveness of police control by acting from inside the subject, and from within the addict population (by reducing demand). In this context, agonist treatment helps to prevent leaks within the control system from causing further damage beyond the mere use of drugs. Simi- larly, in a free setting, agonist treatment is the simplest and cheapest way of curbing all drug-related phenomena.
The role of detention in the natural course of addiction and its therapeutic de- stiny.
A medical or an environmental problem?
Imprisonment necessarily impedes ongoing substance use. Nevertheless, abstinence, whether self-determined or forced, does not cause craving to dwindle, especially in the case of opiate addiction. This explains why there is a demand for narcotics from inside prisons, and why there is a need to counteract the spreading of narcotics inside prisons by police measures. The latter are undoubtedly effective in limiting drug using among detainees, but they do not hit the core of addiction. The main drive to substance use is not rooted in the prison environment: in other words, it is not a habit born inside the prison