Probationers and parolees who are addicted to heroin may soon have a new treatment option--one researchers hope will help them to kick the habit and leave their criminal lifestyles behind.  Some people believe that naltrexone, an anti-opiate drug, which may soon be approved by FDA in an injectable form, could benefit the criminal justice system in a big way, by reducing recidivism.

"[Addiction] seems to be the reason that so many [offenders] have this revolving door.  They get re-addicted after they hit the streets and they have to start committing crimes in order to support that habit," said Dr. Charles O'Brien, a psychiatrist at the University of Pennsylvania, who has been studying naltrexone for the past 30 years.  "This could break the cycle."

O'Brien and his colleagues propose that naltrexone be given to some drug-addicted offenders who are on probation and parole as a way to help them stay clean and get their lives back together.  According to O'Brien, taking naltrexone on a regular basis will prevent these people from feeling the effects of heroin, morphine, oxycontin, or the like, even if they take those drugs.

In order for an opiate, like heroin or morphine, to have an effect on the body, O'Brien said, the drug must attach to opiate receptors on the brain.  Naltrexone targets those same receptors, but doesn't excite them the way an opiate would, he explained.

If people who have been taking naltrexone then add heroin or morphine into their system, they won't be able to feel the effects of the drug, O'Brien said, because it can't attach to the receptor.

"If we block that receptor, then we basically [take away] the ability for a person to get high and to feel any effect from the opiate," said Dr. James Cornish, a psychiatrist, who works closely with O'Brien at the University of Pennsylvania

And, if a person already has an opiate tagged onto those receptors, naltrexone will overpower the drug, O'Brien said.

"[It] will displace it from the receptor if it's already there first," O'Brien said.

Because of naltrexone's ability to block heroin, and other opiates, from having an effect on a person's body, both O'Brien and Cornish see potential for the drug in the criminal justice arena, especially with probationers and parolees whose freedom is at stake if they relapse and fall back into a life of crime.

O'Brien explained that the drug, which was originally approved in pill form by the FDA in 1985, has traditionally worked well with drug-addicted members of the medical profession, who really want to get clean because their careers are on the line. 

"The reason that it works so well with doctors who are addicts is because they have so much to lose.  They are highly motivated," O'Brien said.  "My colleagues and I decided that maybe people who are on parole would also be highly motivated."

With this inclination, O'Brien and his fellow researchers at Penn conducted a study, funded by that National Institute on Drug Abuse (NIDA), over a decade ago to determine how taking naltrexone would impact the rearrest rates of probationers and parolees.

"[When] we did the initial study, our feeling was that this medication would allow people who are on parole or probation to stay away from their drug of abuse and, thereby, have less drug use and have a better opportunity to complete their parole or probation," said Cornish.  "[It] clearly showed exactly that; people who were on naltrexone were rearrested at half the rate of those not on naltrexone."

In 2000, O'Brien and Cornish kicked off yet another NIDA-funded study to further examine the issue.

"This was a study that was a follow-up of our original work," said Cornish.  "The basic study was to randomize people to either take naltrexone or no medication, combined with the standard mandated treatment by the courts."

Now in its fifth year, the study has included about 100 drug-addicted probationers and parolees in Philadelphia County, Cornish said.  People who volunteer for the program are either given naltrexone twice a week or become part of the control group, which receives no medication.  Both groups, however, receive the same amount of counseling.

According to O'Brien, counseling may just not be enough for people who are involved in the criminal justice system and have serious substance abuse problems.

"Everyone talks about giving drug counseling to these people, but drug counseling, by itself, is not enough," said O'Brien.  "The track record is that they almost always relapse."

Counseling combined with naltrexone can benefit this population, O'Brien said.

But O'Brien also pointed out one problem with the current pill form of naltrexone that is approved by the FDA; people might just stop taking it, he said, especially when they want to get high.  That is why he is hopeful that an injectable form of the drug will be approved by the FDA this fall.

"This opens up some really interesting possibilities," he said.

With a naltrexone shot, probationers and parolees would only have to receive the drug every 30 to 40 days in order for it to continuously work in their system.  If the shot becomes available, O'Brien and his colleagues believe it could be a useful way to let drug-addicted offenders out of prison sooner, if they agree to take the drug.

"We think that it would be worth a try to offer people naltrexone in lieu of prison or [they] get an early release if they are to take the naltrexone injection every month," said O'Brien. 

He said that he and his colleagues are currently trying to get funding from NIDA to conduct a national study involving the injectable form of naltrexone in a variety of trial sites, including Providence, R.I. and Charlottesville, Va.

"To get this more widely used, we have to demonstrate that it really works and that takes a large, complicated study," O'Brien said.

He added that, traditionally, folks in the criminal justice field are timid about anything that feels like research.

"Even though it has potential for doing a lot of good in the criminal justice system, there is tremendous reluctance to do anything that feels like research," O'Brien said.  "People are very shy about this."

To try to allay some fears about the use of naltrexone, O'Brien held a symposium last January to give corrections professionals, lawyers, judges and ethicists an opportunity to debate the concept of using the drug with probationers and parolees.

"The vast majority of people felt this was an effort to help the prisoners, to prevent them from relapsing," said O'Brien.  "It's not an experimental drug.  There is nothing unethical about this.  We are not using the people- convicted parolees - as guinea pigs.  We are essentially trying to help them stay [clean]."

While there are questions about involving offenders in the study of the drug, there are is also the issue of its cost when it comes to using naltrexone in the criminal justice system.  Although O'Brien hopes that the shots will cost about the same as the pills would if they were taken on a daily basis for a month- which equates to about $150 per shot.

That price tag may be too high for the cash-strapped criminal justice system, but O'Brien hopes that corrections and criminal justice officials will look at the big picture when it comes to spending money on naltrexone.

"The cost of [putting] each person in a prison bed is just astronomical," said O'Brien.  "It's way more than the cost of treatment."

O'Brien hopes to get his next study off the ground shortly after the FDA approves the injectable form of naltrexone.  But, in the meantime, he just wants to get the word out to the criminal justice community about what naltrexone has to offer.

"It's something that is a benefit," O'Brien said.  "I want people to know about it and I want them to see that this can be helpful."

Resources:

O'Brien obrien@mail.trc.upenn.edu