Giving former inmates with histories of addiction monthly injections of a medication that blocks the effects of opioids cuts relapse rates by a third, according to research at five medical centers.
Release from prison is among the riskiest times for former addicts, with the loss in physical tolerance and behavioral control so common that often "they relapse the same day," said Charles P. O'Brien, senior author of the study and founding director of the University of Pennsylvania's Center for Studies of Addiction.
Over the 11/2 years of the comparison study, seven participants in the non-treatment group overdosed, three of them fatally, compared with none in the medication group.
The paper, published online Wednesday evening in the New England Journal of Medicine, comes amid a slew of federal actions aimed at stemming an epidemic of opioid abuse that is blamed for 78 deaths a day.
The Centers for Disease Control and Prevention last week issued guidelines for primary care physicians to reduce prescriptions for narcotic painkillers, which are responsible for most of the deaths; others die from heroin. On Tuesday, President Obama announced a series of moves to expand treatment, improve physician training, and cut illegal access to the drugs.
Large numbers of people in the criminal justice system have histories of substance abuse, and O'Brien said that he had been urging for years that a medication to prevent relapse be issued upon release. Some systems treat prisoners with maintenance opioids such as methadone and buprenorphine under certain circumstances, but few issue the newer, long-lasting opioid blocker tested in the new study.
The researchers recruited volunteers with a history of incarceration and substance abuse who did not want to be on the better-known opioid maintenance therapies. They were assigned randomly to two groups.
The 155 people in the control group received the "usual treatment": substance-abuse counseling and referrals to community treatment programs.
The 153 in the treatment group were also given monthly injections of extended-release naltrexone, a non-narcotic opioid "antagonist" that works by blocking opioid receptors. Heroin or any other opioid would have no effect while the person is using the blocker medication, sold under the brand name Vivitrol.
The injections ended after six months. At that point, 43 percent of the treated group had relapsed compared with 64 percent of the controls, and the median amount of time before relapse was 101/2 weeks as against five weeks. It also calculated that five people had to be treated in order to prevent one relapse. Many public health initiatives, such as vaccines and screenings, require treating hundreds of people to save one individual from disease.
The participants were tracked for an additional year, with the effects of the medication waning over time until the two groups were roughly equal. That suggested continuing treatment longer might be more effective.
Research shows that the three main kinds of medication-assisted therapy - methadone, buprenorphine, and Vivitrol - are far more effective than programs such as Narcotics Anonymous or even residential treatment that is based entirely on counseling without medication. But the counseling is critical to the drug therapy's success; adding medication helps former users to focus more intently on changing their lives. That may be even more important for people getting out of prison.
"They have no family support," said Akia Feggans, director of behavioral health for Philadelphia Fight, an AIDS services organization that works with recently released prisoners. "It's more than just willpower," Feggans said. "It's learning, 'how do I deal with being angry, how do I deal with a family that is dysfunctional.' " The usual reaction, she said, would be to "go back to what you know": using drugs.
O'Brien said there were two key messages in the study findings.
"If someone is scheduled to get out of prison with a history of opioid addiction, you could give them one injection, and at least for the next month, they cannot relapse," he said. A colleague at Penn is just starting a study with prisoners in Philadelphia that will give Vivitrol before release.
The second message, he said, is that doctors must be trained in pain management, as well as dealing with addiction to pain medicine. O'Brien said many physicians have never heard of naltrexone.
Among the announcements made by the Obama administration on Tuesday was the agreement by 60 medical schools to include instruction on prescribing opioids. The list includes just two schools in Pennsylvania: Penn, which has required instruction for decades based on O'Brien's work, and the Philadelphia College of Osteopathic Medicine. On the list in New Jersey: Rowan University School of Osteopathic Medicine and the Rutgers Robert Wood Johnson Medical School.
Laura Bamford, a physician who prescribes substance-abuse treatment at Fight and another clinic, said that release from prison is "a perfect time" to give extended-release naltrexone but cautioned that it would not be appropriate for everyone.
Because it blocks the effects of opioids, for example, someone must be clean for one to two weeks, depending on the opioids they had been abusing, or the medication will send them into withdrawal. Methadone and buprenorphine, on the other hand, contain substitute opioids that are tightly controlled.
For someone who has not used opioids, Bamford said, it is hard to understand the challenges of stopping. The brain must be retrained.
Most addicts "don't want to be using heroin or pills," she said. "It is not a conscious decision to go out and get high every day, like it is not a conscious decision for someone with diabetes to have high blood sugar."
Both are slip-ups, and medication helps people avoid them.