April 27

Addiction to Prescription Opioids Reaches Epidemic Proportions

With the rising tide of addiction to prescription opioids, addiction medicine specialists will be called upon to apply their expertise in treating its myriad presentations. Hear leading experts address the range of issues from treating chronic pain effectively to avoiding addiction during Symposium 6, “Pain Treatment in the Setting of the Prescription Opioid Epidemic” from 10 am to noon Saturday in Continental C, Lobby Level of the Hilton Chicago.

“There were more deaths from prescription drug overdoses than motor vehicle accidents in the past year,” said symposium organizer and speaker Mel Pohl, MD, FASAM, Medical Director, Las Vegas Recovery Center. “As a society, we need to step up our efforts to help manage and deal with the fallout of the epidemic. The primary purpose of this session is to inform addiction medicine specialists about the current thinking regarding chronic pain.”

Two key aspects best characterize the problem, he said. The first is that there are people addicted to prescription opioid pain medications. The second is that many people depend on prescription opioid medications for pain relief, but the causative condition for their pain is not getting better. They are experiencing an inadequate response to treatment.

Symposium 6 will cover three components, Dr. Pohl said. One component will address the psychological aspects of pain with commentary on the current state of prescription opioid addiction. “There is a tendency to over-prescribe medications for chronic pain, but there are alternative, non-medication solutions, and we will cover those bases,” he said.

The second component will feature a discussion of what to do with patients who are dependent on opioids but not doing well with their chronic pain. “This component will be instructive on detoxification and medically managed withdrawal, and the disposition of patients who have chronic pain and are not doing well on opioids,” Dr. Pohl said.

The third component will provide an overview of the non-opioid medications and other interventions to relieve chronic pain. “There are a lot of alternative medications that will be helpful for pain that are not dependence-inducing,” he said. “We tend to treat chronic pain as if it is a unilateral phenomenon that is treated by one medication. That approach has proven to be ineffective.”

Symposium 6 will apply state-of-the-art data, statistics, and evidence-based treatment to the critical problem of prescription opioid addiction, Dr. Pohl said. Some attention also will be paid to issues of the families of people in chronic pain. What can be done to support them in the course of their family member’s treatment?

He will introduce and moderate the panel, while Herb Malinoff, MD, FACP, FASAM, Medical Director, Pain Recovery Solutions, PC, and Faculty Member at the University of Michigan Department of Anesthesiology, Ann Arbor, will address opioid detoxification; Ross Halpern, PhD, a private practice pain consultant, Ann Arbor, will discuss epidemiologic and psychological aspects; and Ed Covington, MD, Director, Neurological Center for Pain, Cleveland Clinic, will present issues surrounding appropriate and alternative treatment for pain.

“I hope the audience takes away a broader understanding of the problem of chronic pain and the magnitude of over-prescribing opioid medications for it,” Dr. Pohl said. “Too many people are receiving prescriptions for opioids for pain with very negative outcomes, and that is supported by Centers for Disease Control and Prevention data and Food and Drug Administration attention. I believe the audience will learn some practical tools to implement in their practices to manage chronic pain for patients and the issues that their families encounter.”

Symposium 5 to Clarify Benzodiazepine Use and Misuse

Much mystery surrounds the appropriate use of benzodiazepines, and Symposium 5 “Benzodiazepine Use, Misuse, Addiction and Treatment” will clear the air about the indications, practice guidelines, outcomes, and limitations of prescribing these medications during this session from 10 am to noon today in Continental B on the Lobby Level of the Hilton Chicago.

“We want to present the latest data about long-term efficacy, or lack of efficacy, of benzodiazepines and their use for various types of anxiety and behavioral disorders,” said symposium organizer Gregory Bunt, MD, Clinical Assistant Professor of Psychiatry, New York University School of Medicine, New York, and President of the New York Society of Addiction Medicine.

During the symposium, Dr. Bunt will present an overview of the issues. Christopher Holden, MD, Director of Addiction Services, Department of Psychiatry, Maimonides Medical Center, New York, will discuss efficacy of benzodiazepines prescribed on a long-term basis. Faye Chao, MD, Unit Chief of Inpatient Detoxification and Rehabilitation, Addiction Institute of New York, St. Luke’s and Roosevelt Hospitals, New York, will address clinical challenges in managing benzodiazepine misuse alone or in conjunction with misuse of other prescription opioid drugs. A town-hall style question-and-answer period will follow where addiction medicine specialists and the expert panel can actively engage in conversation about the issues.

“There are no certain answers to a number of questions,” Dr. Bunt said. “It depends on clinical perspective and opinion about whether to prescribe benzodiazepines to patients. Many addiction medicine specialists believe they should limit or not prescribe benzodiazepines to patients with a history of addiction, whether it’s to alcohol or other drugs. Others believe that benzodiazepines can be prescribed selectively and can be therapeutic for certain patients, even if they have a history of an addictive disorder.”

The symposium also will address benzodiazepine use in light of the epidemic of prescription opioid use, he said. Benzodiazepines are often prescribed in addition to opioids, which often leads to serious adverse, or even fatal, events.

“While not considered of epidemic proportion right now in terms of prescription abuse compared to opioids, benzodiazepines are still prescription drugs that can lead to morbidity and mortality, particularly if they are combined with prescription opioids or with alcohol,” Dr. Bunt said. “It’s important for addiction physicians to learn the cutting-edge of the data, both efficacy and the management of misuse, with benzodiazepines because it correlates with the prescription opioid epidemic. There have been celebrities in recent years who evidently took an overdose of medications, and toxicology showed several benzodiazepines in their systems.”

Conversely, it’s important to have a real command of the efficacy of benzodiazepines prescribed on a long-term basis.

“We need to understand the long-term efficacy, or lack of efficacy, for the different disorders, and that is going to be a valuable part of the symposium in presenting an update on the latest data,” Dr. Bunt said. “For some conditions, there may be good efficacy data, and for others, not good data.”

In addition to gaining insight about efficacy or misuse issues from the symposium, he also said he hoped the audience would learn the value of tapering.

“When individuals get into trouble with benzodiazepines, there are strategies for tapering and discontinuing their use,” Dr. Bunt said. “I hope the audience will learn this effective method of tapering down doses in patients who are already being prescribed benzodiazepines.”

Potential Is Great to Detect, Successfully Treat Hepatitis C Virus

With new treatments that can eliminate the hepatitis C virus in most cases, addiction medicine specialists are in a unique position to help their patients prevent the debilitating downstream consequences of the virus. Learn how you can make a difference by attending Symposium 7 from 2 to 4 pm today in Continental B, lobby level of the Hilton Chicago. Leading experts will address the question, “Hepatitis C in 2013: Where Are We, Who Should We Treat and With What Should We Treat?”

“We now have a much better ability to treat the most common genotype of hepatitis C, which is genotype 1, with a new class of drugs, hepatitis C protease inhibitors. These drugs bring cure rates as high as 70 to 75 percent,” said symposium organizer and speaker Michael Fingerhood, MD, Associate Professor of Medicine, Johns Hopkins University, Baltimore. “Hepatitis C is the No. 1 cause of patients needing a liver transplant in the United States. It especially afflicts people with a history of drug use and addiction, and we have a chance to have an amazing impact on hepatitis C.”

The goal of the symposium is not for audience members to learn how to prescribe treatment for hepatitis C but rather to gain a basic understanding of hepatitis C, he said. What is hepatitis C? How do people get it? What is the epidemiology? Who is at risk? What is its ultimate impact on patients? What are its costs? How do we screen for it?

Discovering answers to these questions will equip addiction medicine specialists to respond to patients’ questions and to encourage them to obtain the blood test for hepatitis C, Dr. Fingerhood said. Additionally, it will be important to understand what patients will go through in taking complicated protease inhibitor treatment injections and how to support patients in this process.

“We will also address a newer class of medications that will be available by the end of 2014, which will make hepatitis C treatment even easier for patients to tolerate,” Dr. Fingerhood said. “Moving forward, treatment regimens will be pills, not injections.”

Symposium 7 also will feature discussion about models of care for treating hepatitis C. Delivery models range from direct, in-office urban care for patients to physicians in rural settings collaborating with experts in large tertiary centers to provide state-of-the-art treatment.

Sharing their perspectives will be symposium speakers Dr. Fingerhood, who will address hepatitis C basics; Andrew Talal, MD, MPH, Chief, Division of Gastroenterology, Hepatology and Nutrition, University at Buffalo, The State University of New York, who will discuss new medications to treat the virus; and Sanjeev Arora, MD, professor of medicine, University of New Mexico, Albuquerque, who will present various care models for treating infected patients.

“It is estimated that as many as 25 percent of people in the United States have hepatitis C and don’t know it,” Dr. Fingerhood said. “Certainly every patient with a history of substance abuse should be tested. For reasons we don’t understand, 25 percent of individuals with alcohol addiction test positive to hepatitis C, and there is the sexual transmission route component as well. With better treatments available, it’s particularly important learn patients’ hepatitis C virus status.”

Women and Substance Abuse Disorders Group to Meet

ASAM’s Action Group on Women and Substance Use Disorders will review its activities in the past year and discuss current issues in women and addiction during Component Session 6, “Women and Substance Use Disorders—An Action Group Update,” at 2 pm today in Williford A, on the third floor of the Hilton Chicago.

Action Group Chair Jacquelyn Starer, MD, FACOG, FASAM, President-elect of ASAM’s Massachusetts chapter, said she will review the public policy statement on women, alcohol and other drugs, and pregnancy that the group worked on with ASAM’s Public Policy Committee; a joint committee opinion on opioid abuse, dependence and addiction in pregnancy that was written in conjunction with the American College of Obstetricians and Gynecologists (ACOG); and a patient brochure for opioid-dependent pregnant women that is in development.

The opinion paper developed with ACOG, which was published in 2012, covers the pharmacology and physiology of opioid addiction, its effects on pregnancy, and outcomes, screening, and treatment.

“The purpose of the session is to let people know what the action group is doing and to get people’s input on what else needs to be done in this area,” said action group co-chair Catherine Friedman, MD, an Assistant Professor in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School at Brown University.

The annual session also provides an opportunity for attendees to hear about relevant academic events, legislation, and the group’s plans for future. Dr. Friedman said the session will feature a short lecture, but primarily is an open discussion that allows ASAM Med-Sci attendees to provide input and feedback to the action group.

Addiction medicine and regional policy vary greatly in the United States by geography, she said. This session offers an opportunity to hear different perspectives on treating women with substance use disorders.

“It’s useful for people to get together and find out how things are being done in different parts of the country,” Dr. Friedman said.

New Research Helps Integrate AA Program into Treatments

Research on how Alcoholics Anonymous (AA) operates and can be integrated into addiction treatment will be presented during two two-hour sessions today. Symposium 4, “AA and Twelve-Step Recovery: New Findings for the Clinician,” will be presented in two parts, from 10 am to noon and from 2 to 4 pm in Continental A on the lobby level of the Hilton Chicago.

“Although many members refer people to AA, they often don’t know how it can be most effectively used, and there are recent developments that improve on members’ capacity to use it productively,” said Marc Galanter, MD, FASAM who helped organize the two-part symposium, sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Speakers will review recent research into how AA and other 12-step programs operate, and how addiction specialists can use AA in their practices. Dr. Galanter organized the symposium with Joan Zweben, PhD, and it will feature four speakers, including Drs. Galanter and Zweben.

“A lot of ASAM members run clinical programs, and optimally they employ medications like naltrexone for alcoholism and use cognitive behavioral approaches for counseling. Research has shown that to the extent the patients additionally attend AA, even if only on a limited basis, their outcomes are much improved,” said Dr. Galanter, Professor of Psychiatry and Director of the Division of Alcoholism and Drug Abuse, New York University Medical Center.

Co-occurring mental health and substance use disorders are the norm, not the exception. Because12-step programs focus on a single theme, such as alcohol or stimulants, people attending them often look elsewhere for mental health support, said Dr. Zweben, Clinical Professor of Psychiatry at the University of California, San Francisco, and Executive Director of the East Bay Community Recovery Project, Oakland, CA.

“Many people do just fine with going to 12-step meetings, and they just deal with their psychiatric issues in a different way,” she said, adding that it is important to understand that mutual-help in 12-step meetings is different from mutual-help in the mental health system. “I will talk about what is available in the mental health system and what is available in integrated meetings, which are often called ‘double-trouble meetings’ or meetings where substance abuse and mental health issues are discussed.”

Another speaker is Lee Kaskutas, PhD, Senior Scientist and the Director of Training at the Alcohol Research Group of the Public Health Institute, Emeryville, Calif. She has focused her research on mutual-help programs and is the co-author of Making Alcoholics Anonymous Easy as well as numerous research papers. She will discuss how to help patients make better use of 12-step meetings.

The final speaker is John Kelly, PhD, Associate Professor in Psychiatry at Harvard Medical School. The moderator is Robert B. Huebner, PhD, Acting Director of the NIAAA Division of Treatment and Recovery Research.

“This represents an opportunity greater than we have had in recent years to update the members on what will be useful for them in their own treatment in relation to AA,” Dr. Galanter said.

Never Say ‘Never’ to Medication Use in Breastfeeding Women

To breastfeed or not to breastfeed, that is often the question women ask themselves about taking medications during lactation, particularly when it involves substances such as methadone and buprenorphine. Debra L. Bogen, MD, FAAP, FABM, will shed light on what to advise these women when she presents Course 3, “Breastfeeding and Margaritas, Marijuana, Methadone, and More,” from 2:30 to 4:30 pm today in Continental C, on the lobby level of the Hilton Chicago.

“Physicians are often ill-equipped to answer questions about whether it is OK for women to breastfeed while taking these medications, and there is a lot of misinformation out there,” said Dr. Bogen, Associate Professor of Pediatrics, Psychiatry, and Clinical and Translational Sciences, the University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC.

Approximately 80 percent of women who breastfeed take at least one medication. Some women will choose to stop breastfeeding to take medications while others will forego treatment to breastfeed, she said. The 6-8 percent of American women prescribed antidepressants during pregnancy face this decision. Study findings show that women taking antidepressants are more likely to select formula to feed despite evidence that for most antidepressants, the transfer of drug into breast milk is very low.

During the course, Dr. Bogen will review lactation pharmacology and provide resources to review when facing questions about medications or other substance use during lactation. Medications and substances she will address specifically are tobacco, methadone, buprenorphine, cannabis, and antidepressants. Her goal is to emphasize the importance of breastfeeding for the health of mothers and children, and how to support the breastfeeding decision-making process among women taking medications or those with substance-use disorders.

When asked if women taking methadone can breastfeed, Dr. Bogen said, “It depends where they are in their treatment. If they have been adherent to their drug treatment program and they have no other contraindications to breastfeeding, then women taking methadone should be supported to breastfeed.” Evidence shows that women who were prescribed methadone or buprenorphine can breastfeed their infants, she said.

The American Academy of Pediatrics indicates that women who smoke can breastfeed, although these mothers are encouraged to smoke as little as possible during lactation. However, cocaine, methamphetamine, and heroin use by the breastfeeding mother is as dangerous to the infant as it is to her.

“Physicians should make breastfeeding and medication choices part of their repertoire when they talk to women who are pregnant,” Dr. Bogen said. “Women often assume they can’t breastfeed if they are taking medications if no one talks to them about it.”

She recommends that physicians be proactive and take the first step in raising these issues.

“I am hoping to increase the number of providers who will give thoughtful comments to their patients and not just give a knee-jerk response such as ‘no medications with breastfeeding’ or ‘don’t breastfeed,’” Dr. Bogen said. “When they understand the benefits of breastfeeding for the mother and the child, they should understand that it is important to raise the issue with their patients and have an open and educated conversation about it.”

Journal of Addiction Medicine Now Available on iPad

iPadThe Journal of Addition Medicine (JAM) is taking steps to improve the publication, including making it available as an iPad application. The free application became available on iTunes earlier this month. To download the app, go to iTunes and search for “Journal of Addiction Medicine.” The app offers a print-like reading experience but also improves the ability of readers to share information and will use multimedia links.

“With the app, we are going to be able to associate videos with articles. If the author would like to augment their presentation using visual illustration, that will be possible. For example, with patient permission, some of the signs of alcohol or opioid withdrawal could be easily taught by filming the physical examination. The app is great for presenting to readers in another medium,” said Martha J. Wunsch, MD, FASAM, JAM founding Co-Editor.

The development of the app is just one of the JAM‘s recent upgrades. Starting this year, it is published every two months; previously it had been published each quarter, and the page count in each issue has increased, said founding Co-Editor Shannon Miller, MD, FASAM, DFAPA. Submissions to JAM had been steadily increasing, as has the rejection rate. Thus, it made sense to move to a more regularly available print offering, in addition to publishing it electronically ahead of print. To better manage the increasing submission rate, Frank Vocci, PhD was recruited as a third Co-Editor upon the completion of his time at NIDA.

“Dr. Vocci is a key addition to better support our long-term goal to increase the number of original research papers involving clinical trials,” Dr. Miller said.

The Journal also is now cited in PubMed, a goal of all medical publications. PubMed is a library of more than 22 million citations for biomedical literature and is part of the U.S. National Library of Medicine of the National Institutes of Health.

“Our impact factor has been increasing for the last three years, even though the numbers by which that impact factor is calculated did not include PubMed exposure. We hope that now that we are on PubMed that the impact factor will climb further,” Dr. Miller said. The impact factor is a measure reflecting the average numbers of citations to recent articles published in a journal.

Readers also will note a different look to the JAM. Its cover now includes artwork tracked by volunteer Patricia G. Pelizarri and selected by the editorial team. She has degrees in art history and arts management from the University of Michigan and The American University. The cover also now includes a list of papers published in that issue.

“The redesigned cover includes artistic works, both current and historical, that portray the drug and alcohol abuse and addiction,” Dr. Wunsch said. “It is much more attractive.”

Adding Naloxone to Prevention Programs Reducing Fatalities

Nearly 40,000 Americans died from drug overdoses in 2010, the 11th consecutive year the number of fatalities increased. A Centers for Disease Control and Prevention report issued earlier this year said the steady rise started with 16,849 deaths in 1999.

More than half of the overdose deaths in 2010 involved prescription drugs. Of those, opioids played a role in 75 percent (16,651) of fatalities. Developing programs to reverse that trend will be discussed during Course 7, “Implementing Overdose Death Prevention Programs With Naloxone,” at 2 pm today in Continental B at the Hilton Chicago.

The course will help addiction treatment providers implement overdose prevention services with naloxone in their programs said Sharon Stancliff, MD, Medical Director of the Harm Reduction Coalition, New York. It will include a summary of the epidemiology of overdose, a review of the literature on the feasibility and efficacy of naloxone programs, and the tools for evaluating the regulatory environment in different states. Participants will learn how to prescribe naloxone to their patients and how to train patients and colleagues about overdose prevention and naloxone.

At least 17 states have passed legislation or initiated pilot programs that allow people at risk of witnessing a drug overdose—including drug users, and the parents and spouses of drug users—to carry and administer naloxone to someone suffering an overdose. Nearly a dozen other states have similar legislation pending, she said.

“It’s spreading like wildfire,” Dr. Stancliff said. “It’s happening incredibly fast. Different states will have different ways of implementing it. It’s on the road to becoming a standard of care. Providers need to understand what is happening in their state. Should this be in your treatment program?”

Alex Walley, MD, Medical Director of the Massachusetts Department of Public Health’s Opioid Overdose Prevention Pilot, will present the course with Dr. Stancliff. The number of opioid-related deaths in Massachusetts increased from less than 100 a year in the 1990s to more than 600 a year by the mid-2000s, he said.

“We have more overdoses than traffic accident fatalities in Massachusetts,” Dr Walley said. “It’s the leading cause of accidental death in Massachusetts.”

Inspired by the work Dr. Stancliff and others were doing in New York—as well as programs in Chicago and San Francisco—Massachusetts implemented a naloxone program in Boston and Cambridge in 2006, and the program has been expanded to over 14 communities. More than 17,000 people have been trained to use a naloxone rescue kit, and 1,700 rescues have been documented, Dr. Walley said.

“Overdose is the No. 1 killer of people with addiction, and overdoses are increasing,” he said. “We don’t have many tools to address it. Educating patients about overdoses and giving them rescue kits is one innovative and promising intervention we can do.”

New Drugs, Approaches May Improve Hepatitis C Treatments

Hepatitis C is prevalent among substance users, and many barriers prevent these patients from receiving treatment. A symposium today will look at new treatments and treatment models that have the potential to break down these barriers and improve outcomes.

Symposium 8, “Addressing Care for Hepatitis C Virus Infection in the Addicted Patient,” will be presented from 4:30 to 6:30 pm in Continental B, on the lobby level of the Chicago Hilton.

“The main focus of the session is medications for hepatitis C infected patients, how do we take care of them, how do we improve their health outcomes by treating them with newer medications, and how do we integrate this treatment?” said session organizer Jag Khalsa, PhD, MS, Chief of the Medical Consequences Branch, National Institute on Drug Abuse.

Help is on the way because the long-time treatments for hepatitis C—pegylated interferon and ribavirin—are now being supplemented by two new protease inhibitors, boceprevir and telaprevir, which have been approved by the Food and Drug Administration.

“The drug-abusing population that has hepatitis C are able to be treated with newer, safer, less-toxic medications. Pegylated interferon and ribavirin are effective but pretty toxic and have a profile that includes depression and suicidal ideation,” Dr. Khalsa said. “We will be discussing these two newer and safer medications, especially for treating injection drug users. We are in a better situation to treat people with hepatitis C infection than before.”

The efficacy of boceprevir and telaprevir has been proven, he said, but only prolonged use will show if one is better than the other.

“The sustained virologic response is pretty good in both drugs,” Dr. Khalsa said. “They have not been tested extensively in drug-abusing populations, and that is what we want to bring to the attention of addiction experts. We want to tell them that if they come across patients with hepatitis C infection, send them for referral and let the infectious disease people, who are experts, take care of them. That is the purpose of this session.”

The referral to a specialist is just one of the barriers preventing these patients from receiving treatment. A better model may be the integrated care offered in Canada and Europe, which allows patients to receive treatment for addiction and hepatitis C at the same time. Speakers in the session who will address these issues are Jeffrey Samet, MD, MA, MPH, Professor of Medicine at Boston University School of Medicine; Alain Litwin, MD, MPH, Associate Professor of Clinical Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine; Lynn Taylor, MD, AAHIVS, Assistant Professor of Medicine in the Division of Infectious Diseases, Brown University; and Judith Tsui, MD, MPH, Assistant Professor of Medicine, Boston University School of Medicine.

Treating Substance Abuse in Prisons Presents Challenges

Sixty-eight percent of prison inmates have a diagnosis of drug and alcohol abuse or dependence, but treatment is relatively rare. Only about 17 percent of those with problems are treated while they’re in jail or prison, said Frank J. Vocci, PhD, President and Senior Research Scientist, Friends Research Institute, Inc.

Dr. Vocci, will discuss the benefits of pharmacologic treatment for incarcerated populations during Workshop 7, “Treatment of Substance Use Disorders in the Criminal Justice System,” from 4:30 to 6:30 pm today in Williford A on the third floor of the Hilton Chicago. The other speakers will be Robert Schwartz, MD, Medical Director and Senior Research Scientist at Friends Research Institute, Inc., and Terrence Fitzgerald, MD, Medical Director at Glenwood Life Center, Baltimore.

The results of nonintervention are stark. A study in Washington state showed that the mortality rate for former prisoners in their first two weeks after release was more than 10 times the mortality rate of the general population—with many of those deaths coming from drug overdoses.

“That’s an incredible signal,” Dr. Vocci said. “This is a period of time when these individuals are especially vulnerable to going back to using, overdosing. If they don’t overdose, then they’re at risk to be re-addicted, re-arrested, and incarcerated. There’s an opportunity here to treat people at a point when you can turn things around.”

The speakers will talk about treating opioid dependence with methadone, buprenorphine, or naltrexone. Dr. Schwartz said opioid agonists such as methadone and buprenorphine are “rarely” used in U.S. prisons. “It’s a challenge, even though these medications are used in prisons throughout the world.”

Despite a recent meta-analysis showing that treatment with opioid agonist medications is more effective than non-pharmacologic treatment, many corrections officials are hesitant to use agonists. Medications often are not used because of philosophical concerns about treating drug addiction with more drugs or because officials simply don’t understand the treatments, he said, calling the lack of treatment a “missed opportunity.”

“My issue is, as in other areas of medicine, people with opioid addiction should be informed of treatment options, and their risks and benefits by their physicians. They should have all the options available to them, and then decide with their physicians which one they want to use at that particular time.” Dr. Schwartz said.

Additionally, some prisoners balk at the idea of being treated with agonists, Dr. Vocci said. “They feel it cuts their edge, and they feel vulnerable. They’re feeling that someone’s going to take advantage of them.”

Another consideration with pharmacologic treatment of prisoners is funding. Researchers rely on grants and pharmaceutical companies for support. But even though prison officials won’t foot the bill for new studies, Dr. Vocci said they are watching for results.

“They’re interested,” he said. “They want to see if there’s something that we should be doing in terms of changing the system.”