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Yale Prison Health Initiative - State

Op-Ed from The Hartford Courant, January 25, 2004

A Better Way To Treat Heroin Users

The National Drug Intelligence Center recently made a dramatic statement: "Heroin has surpassed cocaine as the greatest drug threat in Connecticut." Heroin is now related to about half of all new HIV cases in Connecticut, in addition to contributing directly to more than 100 deaths and 2,000 drug-related incarcerations annually at last record.

Connecticut taxpayers, public health advocates and correction officers are all interested in reducing heroin use in our state, but the task has been difficult, especially because of the inadequate numbers of slots available for state-sponsored methadone treatment.

Untreated heroin use will continue to spread disease, lead to social destabilization and homelessness, and increase unemployment and commercial sex work in this state unless we find an approach to tackle the problem quickly.

A new medication called buprenorphine might be the answer we've been searching for.

Traditional approaches toward heroin dependency have included detoxification with methadone therapy. Methadone has been successful in reducing or eliminating heroin use and reducing the transmission of HIV. But methadone is only available through tightly regulated programs with limited numbers of slots; its use is restricted by the DEA because of its potential to be diverted into illegal street use and because users can overdose on it.

Methadone is also not given to the incarcerated population, even though the presence of HIV and heroin abuse in prison is several times greater than in the population outside prison. Upon release from prison, these people usually return to a life of dependency.

In October 2002, buprenorphine, or "bup," was approved by the FDA for use by trained physicians. Unlike methadone, bup can be formulated with another drug, naloxone, to minimize its potential for abusive street use. In this formulation, it induces withdrawal if users try to crush and snort it.

The formulation is also chemically constructed to avoid problems of overdose, and because of this, the DEA has decided to place far fewer restrictions on bup's dispensation than on methadone.

Doctors ought to explore the use of bup in a population that has not fully benefited from drug treatment - soon-to-be-released prisoners. Physicians could use bup to stabilize patients prior to release from prison and to keep them healthy upon release. Young opiate users who are early in their addiction cycle might especially benefit from bup treatment as an alternative to incarceration or in community-based clinical care.

There is an initial investment in prescribing bup, but this cost appears small when compared to the price of lack of treatment: overdose, hospitalization, criminal activity, homelessness, HIV, hepatitis and death.

Compared to the $10 per day that bup treatment costs, recidivism to prison costs Connecticut taxpayers $72 per person per day. Each HIV case averted by bup would save taxpayers a lifetime medical treatment cost of $175,000.

It seems reasonable, prudent and humane to reduce the social burdens on our state by enhancing access to bup treatment for heroin addicts. Bup is now available on formulary for Medicaid recipients. It is not, however, available to prisoners or people living with HIV/AIDS who receive their medications from the Connecticut AIDS Drug Assistance Program. This is a shortsighted approach that limits access to an important, scientifically tested and rigorously evaluated medical treatment.

We've been presented with the opportunity to treat heroin addiction in Connecticut. We had better take that opportunity before the consequences prove too difficult to bear.