Amy E. Boutwell

Attitudes and practices regarding the use of methadone in US State and federal prisons

In the United States, vigorous enforcement of drug laws and stricter sentencing guidelines over the past 20 years have contributed to an expanded incarcerted population with a high rate of drug use. One in five state prisoners reports a history of injection drug use, and many are opiate dependent. For over 35 years, methadone maintenance therapy has been an effective treatment for opiate dependence; however, its use among opiate-dependent inmates in the United States is limited. In June 2003, we conducted a survey of the medical directors of all 50 US states and the federal prison system to describe their attitudes and practices regarding methadone. Of the 40 respondents, having jurisdiction over 88% (n=1,266,759) of US prisoners, 48% use methadone, predominately for pregnant inmates or for short-term detoxification. Only 8% of respondents refer opiate-dependent inmates to methadone programs upon release. The results highlight the need to destigmatize the use of methadone in the incarcerated setting, expand access to methadone during incarceration, and to improve linkage to methadone treatment for opiate-dependent offenders who return to the community.

Opportunities to Address the Hepatitis C Epidemic in the Correctional Setting

An estimated 15%-40% of incarcerated persons in the United States are infected with hepatitis C virus (HCV). Approximately 1.4 million HCV-infected persons pass through the corrections system annually, accounting for one-third of the total number of HCV-infected persons in the United States. This high prevalence of HCV infection is due to the substantial increase in drug-related arrests over the past 2 decades. Although the hepatitis C epidemic in the corrections system may be viewed as a burden on correctional health systems, it is an important public health opportunity and an obligation. Research on the implementation of cost-effective HCV screening, prevention, and treatment programs among incarcerated persons is essential. Testing, education, and, when appropriate, treatment of prisoners should be a cornerstone of the public health response to the hepatitis C epidemic in the United States.

Integrating Correctional And Community Health Care For Formerly Incarcerated People Who Are Eligible For Medicaid

Under the Affordable Care Act, up to thirteen million adults have the opportunity to obtain health insurance through an expansion of the Medicaid program. A great deal of effort is currently being devoted to eligibility verification, outreach, and enrollment. We look beyond these important first-phase challenges to consider what people who are transitioning back to the community after incarceration need to receive effective care. It will be possible to deliver cost-effective, high-quality care to this population only if assistance is coordinated between the correctional facility and the community, and across diverse treatment and support organizations in the community. This article discusses several examples of successful coordination of care for formerly incarcerated people, such as Project Bridge and the Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS) program in Rhode Island and the Transitions Clinic program that operates in ten US cities. To promote broader adoption of successful models, we offer four policy recommendations for overcoming barriers to integrating individuals into sustained, community-based care following their release from incarceration.

Analysis of a Social Work-Based Model of Transitional Care to Reduce Hospital Readmissions: Preliminary Data.

Efforts to reduce readmissions after hospital discharge are increasingly being made to better identify and address social and logistical needs in addition to attending to posthospital clinical challenges. A transitional care model based in the social work professional skill set may be well matched to assess and address social and logistical needs during the posthospital transitional care period. The effect of a social work–based transitional care intervention on all‐cause 30‐day readmission rates for Medicare fee‐for‐service (FFS) beneficiaries discharged from an urban medical center was analyzed. Analyses revealed a 20% relative reduction in readmissions for 1,546 Medicare FFS discharges to home, with or without home care (a 4.5% absolute rate reduction). This model may be of interest to entities that are accountable for the care of individuals with complex social needs, such as dually eligible individuals (those eligible for Medicare and Medicaid) and adults who are newly eligible for Medicaid coverage.

Managing Opioid Use Disorder During and After Acute Hospitalization: A Case-Based Review Clarifying Methadone Regulation for Acute Care Settings.

OBJECTIVE Treatment with an opioid agonist such as methadone or buprenorphine is the standard of care for opioid use disorder. Persons with opioid use disorder are frequently hospitalized, and may be undertreated due to provider misinformation regarding the legality of prescribing methadone for inpatients. Using a case-based review, this article aims to describe effective management of active opioid withdrawal and ongoing opioid use disorder using methadone or buprenorphine among acutely ill, hospitalized patients. METHODS We reviewed pertinent medical and legal literature and consulted with national legal experts regarding methadone for opioid withdrawal and opioid maintenance therapy in hospitalized, general medical and surgical patients, and describe a real-life example of successful implementation of inpatient methadone for these purposes. RESULTS Patients with opioid use disorders can be effectively and legally initiated on methadone maintenance therapy or buprenorphine during an inpatient hospitalization by clinical providers and successfully transitioned to an outpatient methadone maintenance or buprenorphine clinic after discharge for ongoing treatment. CONCLUSIONS Inpatient methadone or buprenorphine prescribing is safe and evidence-based, and can be used to effectively treat opioid withdrawal and also serves as a bridge to outpatient treatment of opioid use disorders.

A comparison of syringe prescription and syringe exchange in Rhode Island, USA

Prior to the year 2000, strict laws regulated the purchase and possession of syringes in Rhode Island, USA. More than 50% of the state’s AIDS cases were related to injection drug use, and injecting drug users (IDUs) in Rhode Island reused each syringe, on average, over 20 times. Rhode Island’s syringe exchange programme began in 1995, and has served over 1700 clients. In 2001, the programme exchanged almost 45,000 syringes. Participation in the syringe exchange programme is anonymous, and the programme provides education, outreach, and referral to substance abuse treatment. A syringe prescription programme for IDUs began in Rhode Island in 1999; it has served over 350 patients and prescribed more than 72,000 syringes. In addition to expanding access to sterile syringes, the syringe prescription programme also expanded patients’ access to disease screening and treatment, vaccination, primary medical care, and referral to specialists. Since 1995, there have been three major programmatic and policy approaches adopted in Rhode Island to address the issue of syringe access for injection drug users: syringe exchange, legal reform, and syringe prescription. Each approach offers different ancillary services and appears to appeal to different populations of IDUs. Adopting multiple approaches to syringe access may best serve this high-risk population.