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).Â Â To some policymakers, advocates, and treatment marketers, it’s all about picking a top opiate rehab center, but in fact the rate of relapse post-rehab is depressingly high, no matter how fancy the program.
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.