The post-incarceration overdose death rates of heroin-dependent people in the U.K. are truly appalling. “Everybody knows” that drugs are readily available in prison, but this is an urban myth that has been conclusively disproved by careful research. In reality, most addicts can’t get drugs in prison and as a result their tolerance wanes. When released, they take drugs at their former dose levels, putting themselves at high risk of overdose.
The Guardian reports that widespread naloxone provision upon prison release is being considered in the U.K. Naloxone is an inexpensive opiate antagonist that will reverse the acute effects of opiate overdose (e.g., suppressed respiration). The benefits are temporary and the underlying addiction remains intact, but the extra 30-60 minutes of time (and oxygen) the drug provides to an overdosed opiate user can prove life saving. President Obama’s national drug control strategy endorsed expanding access to naloxone among public health and safety professionals, and I recently worked with some legislator friends on a bill of this sort in my home state of West Virginia. In that debate (We got through one House and made significant progress in the other), people fell into the same camps one sees in the U.K.: Some thought direct provision of naloxone to drug users is best, others wanted to expand access only to people who have contact with overdosed drug users (e.g., homeless shelter staff, firefighters) and some opposed any expansion in availability outside emergency rooms and ambulances.
A question not addressed in the Guardian article is whether extended-release naltrexone might have value in the period following incarceration. The injection lasts for a month and blocks the effect both of opiates and alcohol, and the user doesn’t need to do anything to maintain the effect. This is superior to naloxone in providing near perfect overdose protection as well as making substance use itself less rewarding, which could help the person quit permanently (it is noble to save a life, but if all you do thereby is put off a fatal overdose for a day or a week, you have not accomplished very much).
As an interesting side note, ACMD chairman Les Iverson seems to be implying in the article that people in overdose may sometimes inject themselves. I used to think the same thing, but was surprised to learn when I spent some time with the main group in the UK that is pushing this program that that had never happened in their experience. No addicted user wanted to risk ruining a high just to stop a potential overdose, so any reversals were accomplished by fellow users, friends, family or public health and safety workers. That in itself is a powerful statement of how strongly drug addiction shapes behavioral choices.
Does that last paragraph speak to the power of addiction, or of intoxication? Also, what are the issues with extended-release naltrexone? At first glance it seems like a no-brainer, except for the self-determination issues.
Paul: I think both addiction and intoxication could both be in the soup at the decisional (or non-decisional) moment.
On extended NTX there are no more self-determination issues than there are with naloxone, the person still has to decide they want to take it (sure the effects last beyond the immediate decision point, but that is true of a zillion medical treatments, e.g., surgery). Main challenge is that it’s much more expensive up front (e.g., maybe $500) but you wouldn’t need much foresight to see the great ROI from avoided overdoses and re-incarcerations.
Paul: were you thinking that the authorities would require that injection as a condition of parole, especially for prisoners with an addiction history?
Mobius: Possibly as a condition of parole, possibly just under coercive circumstances, but definitely while still in nominal custody. Of course, a parole officer could be asking people every time whether they’d taken their naloxone, and having no metabolites in your pee could be the same as failing a regular drug test…
Tech geek question:
I have tried repeatedly to open the White House Drug Policy document using Adobe Acrobat X. Each time I try, Acrobat encounters an error and has to close. This is the only pdf document that I have had this problem with. When I sent an e-mail to a friend who does not use Acrobat X, he was able to open the document with no problem; when he sent me the pdf as an attachment, again Acrobat X had to close.
Anyone else having this problem?