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Keywords:

  • Incarceration;
  • methadone;
  • opiate replacement therapy

Methadone maintenance therapy (MMT) is an opiate replacement therapy (ORT) that has been used in the United States for nearly 50 years to treat chronic opiate addiction [1]. Methadone prevents withdrawal symptoms and drug cravings; blocks the euphoric effects of other opiates; and reduces the risk of relapse to illicit use of opiates, infectious disease transmission, crime and overdose death [2-4].

In spite of its demonstrated public and individual health benefits, methadone is associated with tremendous social stigma. Frequently, not-in-my-backyard (NIMBY) campaigns block development of methadone treatment centers (MTCs) in communities most heavily impacted by opiate dependence due to the common misperception that MTCs are associated with increased crime. In this paper, Boyd et al. provide compelling new evidence that debunks myths that geographic areas surrounding methadone treatment centers are associated with crime [5]. Instead, they find the inverse is true: MTCs are associated with lower crime rates. In the case of methadone, US federal regulations require that individuals receiving MMT be seen and dosed on a daily basis, at least initially. It follows logically that if MMT reduces crime, having MMT in close proximity might also be associated with reduced crime in areas surrounding methadone clinics. However, this phenomenon has historically been difficult to measure, and the creative, interdisciplinary, geospatial techniques that Boyd et al. utilize provide robust scientific evidence to debunk the popular myth that MTCs are associated with crime.

Although Boyd's analysis was limited to Baltimore, MD, Baltimore has among the highest rates of injecting drug users and opiate dependence of any city in the country. The geospatial coding technique employed by Boyd et al. helps to frame the importance of methadone treatment in a broader social context by focusing less on individuals who struggle with addiction and more on the environments in which they live and are served. This geographic approach will be important for advancing evidence-based interventions in neighborhoods with an unmet need for ORT.

This exemplary analysis that combats stigma about addiction treatment with robust scientific analysis has important public policy implications for Baltimore and elsewhere, and could not be more timely. The United States is currently experiencing an epidemic of opiate addiction, much of which is fueled by increased access to prescription opiates [2]. Increased use of prescription opiates has been associated with high rates of overdose, and prescription painkillers are now the second most prevalent type of abused drug after marijuana [4]. The new wave of opiate use affects more young people than ever before and has contributed to a dramatic upsurge in overdose deaths; unintentional drug overdoses are now the second leading cause of accidental death in the United States [3].

Prisoners are at particularly high risk for heroin addiction; approximately 24–36% of all heroin addicts, or more than 200 000 individuals, pass through the US criminal justice system each year [6, 7]. Other research highlights limited access to ORT in places where individuals addicted to heroin need it most, including in correctional settings across the United States [8]. Given the paucity of addiction services available in many correctional settings, offering methadone in community settings with high rates of opiate dependence is critical for reducing drug-related health harms.

It is unreasonable to expect that a medication alone will be a panacea for opiate dependence without addressing the complex social, behavioral and structural factors that contribute to rising rates of opiate dependence in the United States. However, if the Affordable Care Act is upheld by the Supreme Court of the United States, millions of uninsured people with opiate dependence may have access to health insurance that pays for pharmacological treatment for opiate dependence. That may be a game changer for addiction treatment by allowing for more widespread use of ORT.

Moreover, access to ORT is critically important for reducing morbidity and mortality, particularly for those involved in the criminal justice system. Boyd's study underscores that offering treatment in community settings is not associated with increased crime; rather, MMTs were associated with lower crime rates. In order to combat the new wave of opiate addiction in the United States, we need as many treatment options as possible. It is no longer acceptable to limit the availability of methadone maintenance therapy because of fear of crime. This important finding should contribute to important public policy discussions about how best to expand methadone and other ORT treatments in the communities with greatest unmet need for addiction treatment.

Declarations of interest

This manuscript was supported by grant P30-AI-42853 from the National Institutes of Health (NIH) and grant 1K01AA020228 from the National Institute on Alcohol Abuse and Alcoholism, NIH. AN receives grant support from Gilead Sciences, Inc. HIV FOCUS Program and consulting fees from Mylan, Inc.

  • Amy Nunn & Jody Rich

  • Department of Infectious Diseases, Warren Alpert Medical School of Brown University and the Miriam Hospital, Providence, RI, USA. E-mail: amy_nunn@brown.edu

References

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  2. References
  • 1
    McLellan A. T., Arndt I. O., Metzger D. S., Woody G. E., O'Brien C. P. The effects of psychosocial services in substance abuse treatment. JAMA 1993; 269: 19531959.
  • 2
    Centers for Disease Control and Prevention (CDC). Emergency department visits involving nonmedical use of selected prescription drugs—United States, 2004–2008. Morb Mortal Wkly Rep 2010; 59: 705709.
  • 3
    Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med 2010; 363: 19811985.
  • 4
    Substance Abuse and Mental Health Services Administration (SAMHSA). Substance Abuse Treatment Admissions Involving Abuse of Pain Relievers: 1998 and 2008. Washington, DC: Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA); 2010 15 July.
  • 5
    Boyd S., Fang L. J., Medoff D., Dixon L., Gorelick D. Use of a ‘microecologic technique’ to study crime incidents around methadone maintenance treatment centres. Addiction 2012; 107: 16321638.
  • 6
    Rich J. D., Boutwell A. E., Shield D. C., Key R. G., McKenzie M., Clarke J. G. et al. Attitudes and practices regarding the use of methadone in US state and federal prisons. J Urban Health 2005; 82: 411419.
  • 7
    Rich J. D., McKenzie M., Shield D. C., Wolf F. A., Key R. G., Poshkus M. et al. Linkage with methadone treatment upon release from incarceration: a promising opportunity. J Addict Dis 2005; 24: 4959.
  • 8
    Nunn A., Zaller N., Dickman S., Trimbur C., Nijhawan A., Rich J. D. Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey. Drug Alcohol Depend 2009; 105: 8388.