Methadone therapy can help opiate-addicted inmates recover, and many countries have embraced it. But the U.S. hasn't.

Considering the high rates of opiate dependency among American prisoners (heroin and OxyContin), short-term jails seem like an ideal place for methadone programs. Several decades' worth of evidence confirm that methadone treatment works. Also well documented is the link between opiate use and crime. According to one National Institutes of Health report, over 95 percent of heroin addicts committed a crime during an 11-year time period. In New York, 12 to 25 percent of arrested felons tested positive for opiate use upon booking in 2003. The NIH says that treating opiate dependence markedly reduces criminal activity.

But precious few correctional facilities have taken the bold step of opening methadone maintenance treatment (MMT) programs, and very few plan to. Why?

The best-known example of an in-prison methadone program is at New York City's Rikers Island Correctional Facility. The facility's Key Extended Entry Program, begun in 1987, offers methadone to addicts charged with misdemeanors and ushers them into a community methadone program upon release (after a prison stay of about 35 days). The Rikers program has led to a significant reduction in criminal recidivism—repeated similar offenses—and a high rate of continued methadone therapy upon release. A few other facilities in the U.S. have similar programs, although some offer methadone only to people who were already in treatment prior to their arrest. In contrast, most prison systems in the European Union offer these sorts of treatments, as do others throughout the world, including some countries with very conservative governments.

A common objection to in-prison methadone programs is that they simply substitute one drug for another. Methadone is a narcotic. "The criminal justice system is very leery of providing psychoactive drugs to inmates," says Stephen Magura, who, as director of The Evaluation Center at Western Michigan University, has conducted several studies of opiate dependency treatments.

But that thinking ignores the very different pharmacologic properties of methadone and other drugs like heroin. When taken on a daily basis, as methadone needs to be, the drug does not cause a high. It's true that sporadic use does confer a high, which has led some inmates to regurgitate their prescribed methadone for sale to other prisoners. But that "hasn't been a widespread issue," says Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, a nonprofit.

The objection also ignores the current assessment of opiate dependence as a medical condition. "In clinical terms, opiate addiction is a chronic disease," says Joanne Csete, of Columbia University's Mailman School for Public Health. "[It's not] a weakness of character, where if only they had the personal strength they wouldn't need methadone."  As Csete and Parrino both explain, withholding methadone from imprisoned addicts is like refusing diabetics insulin. Even if opiate dependency is a self-inflicted disease, Parrino wrote in American Jails Magazine in 2000, a comparison can be made to heart disease resulting from overeating, alcohol consumption, and smoking. "Should the cardiac surgeon deny treatment to these individuals because their cardiac disease is 'self-inflicted' through years of neglecting their own health?"

Cost is also not an issue. MMT protocols call for the drug to be taken daily in the presence of a professional, and for patients to remain under surveillance for at least 10 minutes. That approach, Csete says, combined with keeping the medication secure, is a relatively simple and low-cost measure to integrate into the established healthcare infrastructure at many correctional facilities. One comprehensive study found a cost benefit to taxpayers of $4.00 for every dollar spent on MMT. In other words, drug addicts cost the country more than recovering drug addicts. Drug use carries a high risk of hepatitis C and HIV transmission, both costly to treat, and of course takes a toll on the criminal justice system and many other taxpayer-funded services.

Treating opiate-dependent prisoners is also potentially beneficial for guards. "If people in state custody are injecting an illicit opiate with unsafe injection equipment, this is a big danger for guards searching cells or doing pat-downs," Csete says. "If those people can be helped by oral medication, it makes prison a safer place." Csete has documented prison practices in numerous countries and found that a repetitive pattern: Guards who are at first resistant to MMT programs because they coddle miscreants later become their greatest advocates. (The most extreme example of progressive measures would be Switzerland's prescription heroin program.) In some ways, Csete says, prison is the ideal setting for methadone therapy because it eliminates all the variables that lead patients to not stick with their treatment.

In-prison MMT is becoming more common, but very slowly. Single programs exist in the correctional systems of Florida (in Orange County), Baltimore, Philadelphia, Rhode Island, and Seattle. Drug researcher Magura notes that availability of buprenorphine, an alternative to methadone, as a 30- to 90-day implant (now in phase III trials by Titan Pharmaceuticals), could also help clear the way because it would eliminate concerns about daily administration and black-market resale. But the choice of medication has to be decided on an individual basis, and buprenorphine isn't a match for all addicts.

Many prison officials consider addiction treatment to be outside their purview, and prison health administrators are already stretched thin. Clearly, these reasons for avoiding MMT are understandable and legitimate. But according to Csete, Parrino, Magura, and others, the most significant barrier to in-prison MMT programs is the persistent stigma associated with opiate addiction and with methadone. (A study set to be released in April will provide concrete documentation of attitudes toward methadone throughout the correctional setting.) That stigma keeps the need for prison MMT programs out of the political spotlight and off the minds of corrections administrators. Maybe the real question, Csete notes, is how these programs got into Rikers and other facilities in spite of all the barriers.