title: Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial.
abstract: BACKGROUND
  Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes.
  
  
  METHODS
  In this randomised, open-label trial, we randomly assigned (1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were enrolled in a methadone maintenance-treatment programme in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, to either continuation of their methadone treatment or to usual care--forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. We did the random assignments with a computer-generated random permutation, and urn randomisation procedures to stratify participants by sex and race. Participants in the continued-methadone group were maintained on their methadone dose at the time of their incarceration (with dose adjustments as clinically indicated). Patients in the forced-withdrawal group followed the institution's standard withdrawal protocol of receiving methadone for 1 week at the dose at the time of their incarceration, then a tapered withdrawal regimen (for those on a starting dose >100 mg, the dose was reduced by 5 mg per day to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose >100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, which we established in a follow-up interview with the participants at 1 month after their release from incarceration. Our study paid for 10 weeks of methadone treatment after release if participants needed financial help. This trial is registered with ClinicalTrials.gov, number NCT01874964.
  
  
  RESULTS
  Between June 14, 2011, and April 3, 2013, we randomly assigned 283 prisoners to our study, 142 to continued methadone treatment, and 141 to forced withdrawal from methadone. Of these, 60 were excluded because they did not fit the eligibility criteria, leaving 114 in the continued-methadone group and 109 in the forced-withdrawal group (usual care). Participants assigned to continued methadone were more than twice as likely than forced-withdrawal participants to return to a community methadone clinic within 1 month of release (106 [96%] of 110 in the continued-methadone group compared with 68 [78%] of 87 in the forced-withdrawal group; adjusted hazard ratio [HR] 2·04, 95% CI 1·48-2·80). We noted no differences in serious adverse events between groups. For the continued-methadone and forced-withdrawal groups, the number of deaths were one and zero, non-fatal overdoses were one and two, admissions to hospital were one and four; and emergency-room visits were 11 and 16, respectively.
  
  
  CONCLUSIONS
  Although our study had several limitations--eg, it only included participants incarcerated for fewer than 6 months, we showed that forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release. Continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviours.
  
  
  BACKGROUND
  National Institute on Drug Abuse and the Lifespan/Tufts/Brown Center for AIDS Research from the National Institutes of Health.
authors.affiliation: Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA. Electronic address: jrich@lifespan.org.
authors.forename: Josiah D
authors.initials: JD
authors.lastname: Rich
authors.affiliation: Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: McKenzie
authors.affiliation: Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA; National Drug and Alcohol Research Centre, University of New South Wales, NSW, Australia.
authors.forename: Sarah
authors.initials: S
authors.lastname: Larney
authors.affiliation: Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
authors.forename: John B
authors.initials: JB
authors.lastname: Wong
authors.affiliation: The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
authors.forename: Liem
authors.initials: L
authors.lastname: Tran
authors.affiliation: Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA; Memorial Hospital, Pawtucket, RI, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Clarke
authors.affiliation: Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
authors.forename: Amanda
authors.initials: A
authors.lastname: Noska
authors.affiliation: Brown University, Providence, RI, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
authors.forename: Manasa
authors.initials: M
authors.lastname: Reddy
authors.affiliation: Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, AR, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, Providence, RI, USA.
authors.forename: Nickolas
authors.initials: N
authors.lastname: Zaller
mesh_terms: D000328:Adult; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D008297:Male; D008691:Methadone / Q000008:administration & dosage* / Q000627:therapeutic use; D008875:Middle Aged; D058850:Opiate Substitution Treatment / Q000379:methods*; D009293:Opioid-Related Disorders / Q000534:rehabilitation*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011329:Prisoners / Q000523:psychology*; D011330:Prisons; D012237:Rhode Island; D016320:Substance Abuse Treatment Centers / Q000706:statistics & numerical data
chemical_list: D008691:Methadone