Opioid-dependent detainees frequently experience rapid relapse following release from jail and this relapse is associated with poor outcomes, such as continued illicit drug use, HIV infection, overdose death, crime, and re-incarceration. While community-based methadone maintenance (MM) has been proven effective and is in widespread use, to our knowledge, Rikers Island Jail in New York City is the only US jail in the past 25 years that routinely starts out-of-treatment detainees on MM and refers them to ongoing MM upon release. There are at least three barriers to starting MM programs (MMPs) in jails: (1) public officials remain unconvinced of the health, public safety, and economic benefits of MMPs, (2) a lack of funding for counselors in the jail; and, (3) the relatively low rates of entry and retention in treatment upon release reported from the Rikers program. This renewal application seeks to build on the parent grant entitled Entry into Comprehensive Methadone via Interim Treatment (2R01 DA 13636) as well as the results from two other completed NIDA- funded R01s conducted by the PI and his colleagues. The parent grant found that newly-admitted MM patients who were randomly assigned to Interim Methadone (IM; methadone alone) during the first 4 months of MM had similar outcomes at 4- and 12-month follow-up as patients assigned to receive MM + counseling. A second study demonstrated the effectiveness of starting MM prior to release for inmates in prison (not jail). A third study found numerous barriers to MM treatment entry including lack of transportation, logistical problems with the admissions process, and lack of health insurance. The present application will test the impact of two relatively low-cost interventions that could increase treatment entry and retention post-release from jail, namely, IM and Patient Navigation (PN). PN, a strengths-based case management approach based on an existing manual adapted for this study, will help to link participants to treatment upon release This is a three-group randomized clinical trial that will compare: IM+PN v. IM alone v. brief detoxification with methadone. IM will be provided in jail to opioid-dependent detainees who were not in MM treatment at the time of arrest, with transfer to 1 of 3 MMPs upon release. Participants will be assessed at baseline, 3 and 12 months post-baseline in terms of drug use, HIV risk, criminal behavior, arrest, and re- incarceration. A cost-benefit analysis will provide th information policymakers need for evidence-based decision-making. Moreover, an adequate sample of women will permit an examination of differential response by gender to the interventions. Finally, qualitative interviews will explore the specific barriers to treatment entr in the community. The proposed study will yield novel results that can be used to inform public policy in instituting more effective and cost-effective approaches to the problem of post-release relapse to opioid use in jail detainees.
The proposed study is significant because many opioid-dependent detainees leaving US jails face high rates of relapse to opioid use, risk of HIV infection, re-arrest, and overdose death. The proposed study is innovative because it seeks to overcome barriers to implementing methadone in jails by examining the effectiveness and cost-effectiveness of two innovative treatment approaches: interim methadone and patient navigation (PN). The public health impact of the proposed study is high because it may determine that these new treatment approaches can prevent relapse, HIV-risk behavior, crime and re-arrest, and overdose for opioid-dependent detainees. Results may spur the expansion of such approaches throughout the US.
