High Dose Methadone Reduces Criminal Recidivism in Opiate Addicts

Abstract

Inmates accepting high dose (>/=60 mg) and low dose methadone therapy were identified between 1/1/96 and 7/31/97 in New York Cities Correctional system. We studied the duration between the release to the community from the first incarceration in the study period until reincarceration or the study's end to assess the impact on the higher dose on the criminal recidivism rate. Inmates discharged on high does methadone were less likely to return to jail than were those on low does (P<.002) with the median time to reincarceration of 253 and 187 days respectively. Controlling for age, gender and race, a Cox proportional hazard model demonstrated a 13% reduction in hazard for reincarceration for those electing high does. While a fixed higher dose demostrably reduced recidivism, we advocate routine methadone plasma level monitoring to adjust doses to achieve "blocking dose plasma levels" both in the general community and in the jail.

Illicit heroin consumption has increased over the last decade with more than 600,000 people addicted to heroin in the United States. (1,2) Heroin related emergency room visits increased between 1990 and 1995 by 124%. (3) Montefiore Medical Center, the ambulatory health care provider on Rikers Island, New York City's largest correctional facility (15,000 of the City's 20,000 capacity) experienced a 23% increase in inmates requiring methadone detoxification between 1994 and 1995. In the six month period between May and October 1994, 6,819 inmate admissions were offered detoxification while in the same six month period in 1995, 8,379 inmates required detoxification. This increase was unexplained by changes in inmate census and represented a true increase in the rate of heroin addiction treated.

The Department of Mental Health of the Montefiore Rikers Island Health Service (MRIHS) is responsible for providing both psychiatric and addiction related care. Methadone detoxification for addicts manifesting withdrawal has been available in the New York City Correctional system since Vincent Dole First introduced methadone to ease the withdrawal symptoms of inmates in the Manhattan Detention Center in New York City in the early 1970's. In late 1986, the New York State Division Of Substance Abuse Services funded a pilot project called the Key Extended Entry Pro-gram (KEEP) for incarcerated women. This pilot project allowed inmates with misdemeanor charges or who were sentenced for less than 30 days to receive methadone maintenance during incarceration and guaranteed a treatment slot upon release to the community. The KEEP program has since been expanded to include men and women in six facilities on Rikers Island who have misdemeanor charges or who have been sentenced for up to one year. Inmates in these facilities are not eligible for KEEP if they will be remanded upstate for prison sentences because the New York State correctional system does not permit methadone maintenance therapy.

In 1995, the MRIHS Addiction Services Program, recognizing the increase in heroin use, undertook an extensive review of the state of the art of managing heroin addicts. This effort was significantly aided by the then recent publication by the Institute of Medicine reviewing policy issues surrounding federal regulation of methadone treatment. (4) Of major concern to the Institute of Medicine was the use of sufficiently high doses of methadone (doses of 60 mg or more) which would not only prevent acute withdrawal, but would also effectively block euphoria from self administered heroin. Cited studies (5-7) noted that patients on effective blocking doses dramatically reduced their heroin use and criminal behavior.

In response to these recommendations, MRIHS developed new methadone protocols offering high dose treatment to patients on methadone therapy and extensively reeducated its staff through the use of training manuals, seminars for medical, mental health, and nursing personnel, and a half-day symposium on November 28, 1995. The new protocols were implemented on Rikers Island in 1996. The following study reports on the criminal recidivism rate as the outcome of interest after introducing high dose methadone therapy in an urban incarcerated Population.

METHOD SECTION

All individual admissions discharged from Rikers Island between 1/1/96 and 7/31/97 who were released to the community were eligible for inclusion in the study. We identified four groups of inmates: (1) Inmates who had been in the KEEP program on a high dose of methadone (>/=60 mg daily) (2) KEEP participants on a low dose (<=30 mg.) who had never been given a high dose in the study period (3) Inmates who were detoxified with methadone and had not been in KEEP at any point in the study period; and (4) Inmates who were never given methadone. Within each of the first three groups we studied the first admission. In the no methadone group, we identified the first incarceration during the study period and then randomly selected a sample equal in size to the previous three groups combined.

Our dependent variable, time out of jail, is measured from the date of discharge for the chosen incarceration episode until the next date of admission or the date of study termination. Date of reincarceration was tracked in the Inmate Information System until November 5, 1997. The New York City Inmate Information System captures all rearrests in the NYC area. This highly censored data was analyzed using Kaplan-Meier and Cox Proportional Hazard Model Survival procedures in SPSS (8) and S-Plus 4.5. (9) A plot of rescaled Schoenfeld residuals as implemented in S-plus 4.5 was used to assess the proportional hazard assumption. Multigroup continuous variables were analyzed with ANOVA in SPSS with Bonferroni correction of post hoc comparisons. Categorical data were analyzed using the proceedures of the Chi-square test, Fisher exact test, and 95% confidence intervals for Odds ratios available in Statxact-3. (10)

RESULTS

From January 1, 1996 through July 31, 1997, we identified 1,423 high dose KEEP participants, 1,758 KEEP participants not on high dose methadone, 6,898 detox inmates, and 10,079 randomly selected inmates who were never treated with methadone. Of the 1,758 KEEP patients not on high dose methadone, 1,371 (78%) were treated with daily methadone doses of less than or equal to 30 mg. Race, gender, and mean age are summarized in Table 1. High dose inmates were discharged on a median dose of 70 mg (25th - 75th percenthe of 70-80). Low dose inmates were discharged on a median dose of 30 mg (25th-75th percenthe of 30-30 mg). Inmates discharged on high dose methadone were less likely to return to jail than those discharged on low dose methadone (P<.002) (Kaplan Meier plot - Figure 2). The median time to reincarceration for low dose methadone inmates and high dose inmates was 187 and 253 days respectively. Controlling for age (dichotomized thirty or less), race, and gender, high dose methadone patients continued to demonstrate a 13% reduction in the hazard rate for recidivism (Table 2) as compared to low dose methadone patients.

TABLE 1: Demographics of Study Population

A random sample of 200 inmates in the study (50 from each group) showed a statistically significant difference in the number of previous arrests for inmates in each group (P<.002). The mean number of previous arrests in High dose KEEP participants, non-high dose KEEP participants, detox patients, and no methadone inmates were 3.6, 3.2, 2, and 1.6 previous arrests respectively.

DISCUSSION

The reduced recidivism rate observed for the high dose methadone patients in our study is consistent with previous observations on the utility of methadone maintenance. (6, 11, 12) Our study, however, has the advantage of including more than five times the number of patients studied in the cited references. We also drew our patients from the highest risk group of opiate using patients - opiate users whose site of enrollment is evidence of chronic involvement in crime and addiction. The patients chosen are selected because their antisocial activity has brought them to jail. We believe that these individuals are the hard core - neither the ideal study patients of the research center nor the more heterogeneous patients found in community based clinics. (12)

Despite finding a statistically significant reduction in recidivism in the high dose compared with the low dose methadone group, we were disappointed by the magnitude (13%). We believe that a number of factors reduced the observed effect and that these considerations should inform future studies as well as future public health interventions. Due to differences of' opinion with the New York City Health and Hospitals Corporation Correctional Health Services, we were unable to obtain permission to draw blood for the determination of plasma levels of methadone as standard practice for patients electing high dose therapy. We believe that this restriction hampered our efforts to reach adequate blocking doses for all the high dose patients within our program. It is well established that maintenance of blocking blood level (levels between 150-400 ng/ml (13)) is associated with better outcomes. (5, 11, 14) There is no guarantee that dosing at our fixed higher dose achieved the therapeutically meaningful "blocking serum levels". Even "high" oral doses can be undone by interactions with concurrent abuse of other drugs, absorption interference, or metabolic variations among patients. Observed oral doses of 80 mg/day (14) failed to achieve the desired 200 ng/ml at twenty-four hours, in a cohort of 18 alcoholic opiate users, who also used cocaine and benzodiazepines. (14) Patients complained of the drug wearing off before 24 hours elapsed. The impact of increasing purity of street heroin may also be of importance in determining the plasma levels required to achieve blockade in the present era. Failure to monitor methadone levels at methadone initiation, when the patient returns to prior street habits with other drugs, or when the patient is reincarcerated results in our failure to appreciate the contribution of non-blocking levels to recidivism.

We believe that each individual admitted to the jail with evidence of opiate withdrawal who is participating in a methadone maintenance program should have baseline and routine methadone plasma levels drawn to pharmacokinetically guide dosage to achieve effective heroin blockade. Rou-tine screening of blood and urine should be performed to detect the presence of other drugs which might affect methadone metabolism. Community based methadone programs should also be required to measure methadone plasma levels regularly. As this information is crucial for the medical management of addiction, it should be solely available to medical care providers and should be made inadmissable as evidence against the patient. The medical and legal professions must join forces as they did to redefine civil protections for tuberculosis patients in New York City. It was only with the strengthening of individual civil liberty protections that it became socially acceptable to implement orders of the Commissioner of Health to incarcerate patients who failed to complete tuberculosis therapy. With the described legal guarantees in place, we could maximize the effectiveness of methadone therapy. At present, the capitated reimbursement of Medicaid to methadone programs is a strong disincentive to the routine monitoring of methadone plasma levels. Monitoring should be explicitly funded. Once plasma level testing becomes commonplace, it will be possi-ble to determine the benefits of a true "blocking dose" program.

Those labeled by our study as high dose patients received this designation solely on the administered fixed dose in jail of greater than or equal to 60 mg. We have no way of knowing whether the individual patients achieved twenty-four hours of 200 ng/ml levels of methadone or even if they were Continued on the discharge dose upon release to the community.

We were also surprised at the extent to which the detox population and "no methadone" population differed from the KEEP participants in terms of recidivism. Ball (11) reported a 79% reduction in annual criminal acts among patients who remain in methadone maintenance. The detox population and no methadone population in our Study are probably very different from patients on chronic methadone therapy. We have some hint of these differences from the younger age, the shorter duration of incarceration, the percent of each group that was bailed out, and the average number of pre-vious incarcerations in a random sample from each group. All suggest a shorter history of criminal behavior and better available social supports for the detox and no methadone groups (Table 1). Patients receive tapering methadone detox at Rikers when a physician observes signs or symptoms of opiate withdrawal. Withdrawal can be manifest after the use of opiates three times a week for a month. Therefore, the detox group contains many more non-chronic opiate abusers as compared to the KEEP program, which requires evidence of chronic opiate addiction as a pre-condition of enrollment.

Methadone pharmacotherapy for heroin addiction is most appropriate for the hard core heroin addicted who have not been able to cease their use even with other interventions. Not all who have used a self administered opiate like heroin progress to substantial dependence with inability to voluntary end their use. There are occasional users and those who undergo a brief period of dependence and cease without treatment. (15) There are those who become addicted in environmental contexts which, when changed, no longer provide the conditioned cues associated with drug use. Studies in Vietnam Veterans (16) revealed that only 12% of chronic users of heroin in Vietnam became lifelong addicts upon their-- return to the United States. The chronically addicted are probably biologically different (17) from the majority who use heroin but do not become lifelong addicts. We believe that the KEEP methadone maintenance patients in this study are both more biologically altered by their heroin use and more heavily enmeshed in their sociopathologic behavior than are the other two populations.

The study design had several short-comings. We did not follow the patients into their community based program to determine whether they were maintained on their discharge dose. It is possible that some of the former inmates discharged to the community on methadone did not successfully seek and obtain Medicaid support. Community methadone programs will maintain a patient on methadone for 45 - 120 days while Medicaid or other funding is being sought. However, should the individual fail to obtain funding, the patient is severed from his/her supply of methadone. The classification of patients as high dose who were not continued on methadone at all would have weakened our study's ability to show efficacy of high dose in recidivism reduction. This implies that high dose when actually continued is even more effective than the demonstrated 13%. The study's design, however, does not preclude the possibility of self-selection bias. As the high dose methadone option was gradually provided to the different clinics in the jail many of the low dose methadone patients were low dose because they declined dose escalation despite being counseled about the advantages of blocking dose therapy. We can not exclude the possibility that the more motivated inmates elected high dose and that this motivation rather than the high dose itself was somewhat determinative of the differential recidivism rate.

CONCLUSION

This study demonstrated a statistically significant difference in criminal recidivism between inmates electing high and low dose methadone maintenance. Those patients who were discharged from the correctional system on higher methadone doses (approaching the blocking dose) remained in the community longer than those discharged on low doses. We believe that an adequately designed methadone maintenance program should substantially decrease the criminal recidivism of hard core heroin addicts. Such a program would include: 1) availability of high doses for all participants; 2) monitoring of plasma levels to achieve therapeutic levels; and 3) incorporation of psychosocial support systems both in the correctional facilities and in the community inclusive of prompt Medicaid access, and help in securing employment. (18) Coordinated efforts by both the legal and medical community to change the practice of methadone therapy management as well as ongoing monitoring of outcomes such as that performed in this study are essential if the "societal side effects of heroin addiction" - crime and incarceration are to be mitigated.

Acknowledgements

The authors thank the New York City Department of Correction for their significant support in implementing and evaluating the high dose methadone therapy program of the Montefiore Medical Center. We would also like to thank the New York State Office of Alcohol and Substance Abuse (OASAS) for their long standing support and funding of the KEEP Program. It is the effective collaboration of many agencies that will ultimately help those trapped in the web of drugs and crime escape the bondage their addiction.

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