Opioid Use Disorder Treatment in Correctional Settings (2021)

Deaths from opioid overdose reached an all-time high, estimated at more than 83,000 in 2020 (Centers for Disease Control and Prevention, 2020). These deaths are largely preventable. Opioid use disorder (OUD) is a chronic treatable illness and disability that is best treated in the community. Drug courts and attorneys should be educated about alternatives to incarceration that can better promote recovery and be more appropriate than incarceration for certain individuals (Cruzado-Quinones et al., 2016).

Nevertheless, there is a high prevalence of OUD among people in prisons, jails, and detention centers, and thus correctional facilities have important roles to play in ensuring appropriate treatment for people with this chronic illness (Bronson et al., 2017). Scientific evidence has firmly established that medications to treat opioid use disorder (MOUD) save lives (National Academies of Sciences, Engineering, and Medicine [National Academies], 2019). By providing access to MOUD and behavioral treatment based on national standards, prisons, jails, and detention facilities can reduce deaths, improve long-term health outcomes, interrupt the cycle of recidivism (National Academies, 2019), and minimize litigation.

MOUD treatment (also referred to as “MAT,” medications for addiction treatment) improves medical and mental health outcomes and reduces relapses and recidivism (Amato et al., 2005; Bird et al., 2015; Egli et al., 2009). The FDA-approved treatments are methadone (for patients ≥ 18 years), buprenorphine (for patients ≥ 16 years), and extended-release naltrexone (for patients ≥ 18 years). The American Society of Addiction Medicine (ASAM, 2020a, 2020b), National Academies (2019), and National Governors Association (2021) recommend that all three FDA-approved MOUD be available within corrections.

While medication treatment alone is effective for the treatment of OUD, its efficacy is enhanced when used in combination with appropriate behavioral interventions that address underlying psychological contributors to OUD, as well as co-occurring mental health conditions. Assessment and treatment of people’s mental health and social resource needs are a critical part of comprehensive treatment plans for people with OUD. Basic support groups such as Narcotics Anonymous can also provide benefit for people’s recovery. Such counseling and support are important parts of treatment, but if counseling is not available, provision of medication alone is still recommended (see ASAM national practice guideline, 2020, and National Academies, 2019). Appropriate screening for opioid use and OUD, along with thorough counseling on treatment options by appropriately trained health care professionals, can help identify those who would benefit most from engaging in medication and behavioral treatment.

A robust body of evidence has demonstrated the feasibility and benefits of providing MOUD in correctional settings. There is a striking mortality benefit of providing MOUD in corrections. People leaving prison without MOUD have up to 40 times higher risk of dying from overdose in the first 2 weeks following their discharge than the general population (Merrall et al., 2010; Ranapurwala et, 2018). MOUD significantly reduces postdischarge overdose deaths (Bird et al., 2015; Gisev et al., 2015); one state showed a two-thirds reduction in statewide opioid overdose deaths when its correctional system made MOUD available in custody (Green et al., 2018). A modeling study showed that 1,840 lives could be saved annually if all people with OUD received appropriate MOUD in jails and prisons (Macmadu et al., 2020). While the prevalence of OUD is similar by race and ethnicity (Shearer et al., 2020), Black and Brown people are more often incarcerated and more often have their treatment interrupted by incarceration (Pro et al., 2020), thus exposing people of color to higher death rates.

Providing treatment in custody also promotes engagement in and continuity of treatment in the community after incarceration, especially when linkages to community treatment and services are facilitated (Brinkley-Rubinstein et al., 2018; Krawczyk et al., 2020; Moore et al., 2018; Rich et al., 2015). It also provides an opportunity to assess for untreated mental health conditions that may be contributing to OUD. While both methadone and buprenorphine treatment pose some risk for diversion in prisons and jails, evidence suggests that overall rates of illicit drug use decline following introduction of MOUD and reduce disciplinary problems (Larney et al., 2014).

Incarcerated people with OUD should not be forced to undergo withdrawal, nor should they be forced to be on MOUD if they decline or otherwise do not meet criteria. Forced withdrawal discourages engagement in community treatment, increases the risk for substance use during incarceration, and increases the risk death for after discharge (Brinkley-Rubinstein et al., 2018; Moore et al., 2018; Rich et al., 2015). If, after education about the benefits of treatment, patients decline MOUD and choose withdrawal, then withdrawal (if moderate or greater) should be accomplished using buprenorphine in tapering doses using an opioid withdrawal scale (World Health Organization, 2009). Pregnant people in particular should have timely access to MOUD and avoid withdrawal due to maternal and fetal risks of opioid withdrawal for this population.

Correctional facilities should also consider provision of intranasal naloxone (IN)2 at discharge (in the person’s property or via e-prescribing) to prevent overdose death, accompanied by training in its use to patients and their family/friends. Partnering with local public health agencies may offset costs of IN and offer opportunities to provide IN training and medication to visitors. Discharge planning should begin at admission to facilitate linkages to MOUD treatment in the community. Correctional health advocates/liaisons can facilitate access to MOUD in community settings through direct referral or by setting up a contact person in correctional health. Evidence-based models for coordinating care have demonstrated workflows and offer job descriptions and approaches.

Adolescents with OUD are a special population in juvenile corrections. While the use of MOUD remains off-label for youth (methadone and extended-release naltrexone are approved for patients ≥ age 18 and buprenorphine for those ≥ 16) and has limited evidence compared to the extensive research conducted with adults, it still represents an effective and accepted treatment option. Considerations for the treatment of adolescents include the importance of including family in treatment as much as possible, incorporating psychosocial interventions alongside any pharmacological interventions, understanding and addressing complex issues of confidentiality and consent especially in the juvenile justice system, recognizing and treating the likely co-occurring psychiatric conditions, and accessing developmentally appropriate interdisciplinary treatment programs whenever possible. ASAM’s National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use includes treatment in correctional facilities and options for using MOUD with adolescents (2020a).

Providers in correctional settings should follow ASAM guidelines when treating people with OUD. From a legal perspective, OUD is a protected disability under federal law. Recent court rulings have affirmed the right of people with OUD in jails and prisons to receive MOUD. A useful guide for implementation is Medication-Assisted Treatment for Opioid Use Disorder in Jails and Prisons: A Planning and Implementation Toolkit (Mace et al., 2020). Despite the established benefits and feasibility of providing MOUD in custody, available evidence shows that many correctional facilities do not provide access to MOUD, in some cases do not even continue community-initiated MOUD, or provide MOUD only in limited circumstances (Vestal, 2018). To facilitate community return, the Assess, Plan, Identify, and Coordinate (APIC) model offers a model for transitional care and care coordination (Osher, 2007).