The United States has been in a serious public health crisis for well over twenty years, and one way we can help address this crisis is by expanding the implementation of medication-assisted treatment (MAT) for people with opioid use disorder (OUD) in prisons and jails.
The crisis: the opioid overdose epidemic.
In recent years, media attention to the opioid crisis faded because of another public health crisis: the COVID-19 pandemic.
Now that we’ve discovered a new normal with regards to the COVID-19 pandemic, with boosters addressing new variants and an increasing understanding of long COVID, we can return our attention to the opioid crisis. It’s critical that we return our attention to this public health crisis, because during the pandemic, it didn’t go away.
It got worse.
In 2022, the Centers for Disease Control (CDC) reported an increase in overdose deaths over 2021. In fact, the last time drug overdose deaths decreased in the U.S. was between 2018 and 2019. Since then, despite our best efforts, rates have increased each year. That means we need to redouble our efforts to help people with opioid use disorder in all areas of our society, including among individuals incarcerated in prisons and jails. That population is particularly vulnerable, because data shows high rates of opioid use disorder (OUD), and limited access to the gold-standard treatment for OUD, in the form of medication-assisted treatment (MAT) with medications for opioid use disorder (MOUD).
Trends in Overdose Death, 2001-2022
2001-2006:
- 2001: 19,394
- 2006: 34,425 drug overdose deaths
- 5-year increase: 77%
2006-2011:
- 2006: 34,415
- 2011: 41,340
- 10-year increase: 113%
2011-2016:
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- 2011: 41,340
- 2016: 63,632
- 15-year increase: 228% increase
2016-2021:
-
- 2016: 63,632
- 2021: 106,699
- 20-year increase: 450%
2022:
-
- Overdose deaths: 108,388
- Total increase, 2001-2022: 458%
That’s the big-picture situation in the U.S. right now. The crisis is real, it’s reached every corner of our society. Both the Trump and Biden presidential administrations allocated billions of dollars of federal funding to mitigate the harm caused by the opioid crisis. To learn about those efforts, please navigate to the blog section of our website and read these articles:
Trump Administration Response: The Politics of Addiction: How a Group of Cities and Counties Shaped the Federal Response to the Opioid Crisis
Biden Administration Response: The Opioid Crisis: A New National Strategy
Both aid packages included comprehensive, all-of-the-above, all-hands-on-deck approach to the opioid crisis, including provisions to enhance law enforcement prevention, increase access to treatment and support, monitor opioid prescriptions, reduce regulations around MAT with MOUD for OUD, and expand harm reduction programs nationwide.
In addition, both plans included funding for OUD treatment in prisons and jails. But in 2019, between the first and second responses, harm reduction advocates made arguments before the Supreme Court of the United States (SCOTUS) that changed the ways we approach SUD treatment – particularly OUD treatment – in prisons and jails.
MAT in Prisons and Jails: The Department of Justice Position
The advocates cited SCOTUS precedent in a simple and effective manner. In 1976, they argued, the Supreme Court of the United States (SCOTUS) issued a decision in a case called Estelle v. Gamble that addressed medical care for incarcerated individuals. The decision stated:
“Deliberate indifference by prison personnel to a prisoner’s serious illness or injury constitutes cruel and unusual punishment contravening the Eighth Amendment.”
They argued this decision implies, therefore, that adequate medical care – which, for people with OUD, includes MAT with MOUD – is a constitutionally protected right. Then, in 2022, the Department of Justice (DOJ) issued further guidance, indication incarcerated individuals have protections provided by the Americans with Disabilities Act (ADA).
Here’s the text of the DOJ guidance:
“People who have stopped illegally using drugs should not face discrimination when accessing evidence-based treatment or continuing on their path of recovery. The Justice Department is committed to using federal civil rights laws such as the ADA to safeguard people with opioid use disorder from facing discriminatory barriers as they move forward with their lives.”
– Assistant Attorney General Kristen Clarke, Civil Rights Division, U.S. DOJ
What that means is that people in recovery should not only have access to the gold-standard care for their medical condition, but that care is protected by law. This presents an immediate quandary in our prisons and jails, because the latest data indicates that a very small percentage of incarcerated individuals with OUD receive support in the form of MAT with MOUDs. With that in mind, let’s take a look at a recent study published by Johns Hopkins University called “How the Drug Enforcement Administration Can Improve Access to Methadone in Correctional Facilities and Save Lives.”
MAT and Methadone in Prisons and Jails
Before we go any further, we should encourage anyone unfamiliar with MAT or MOUD to learn the basic facts on our treatment pages:
Medication-Assisted Treatment
Office-Based Opioid Treatment
Also, please read this article by our Chief Medical Officer, Dr. Chris Johnston, published in the online magazine Medium in 2021:
The Case for Medication-Assisted Treatment (MAT) in Prisons and Jails
Now, back to the topic at hand, which is how to improve our support for incarcerated individuals with OUD. The Johns Hopkins publication lays out a blueprint for change in four areas:
- Regulations regarding medications for opioid use disorder (OUD)
- The threshold for initiating treatment for OUD
- Collaboration between corrections officers and medical staff
- How to support incarcerated individuals upon release
We’ll review their recommendations in all four of these areas below. First, however, we’ll provide information about the use of MAT in prisons and jails for people with OUD.
Facts to Know, Ideas to Understand: MAT in Prisons and Jails
Prison, Jail, and OUD
- It’s common for people with opioid use disorder (OUD) to experience incarceration.
- Over 40% of people who use heroin report recent contact with the criminal justice system
- Almost 20% of people with a prescription opioid use disorder (OUD) report recent contact with the criminal legal system.
- 20% of people in jails and prisons reported regular heroin or opioid use before incarceration
- Current data estimates show there are roughly 2 million people in prisons and jails at any given time in the U.S.
- Fewer than 1% of jails and prisons in the U.S. offer MAT with MOUD for OUD
The next to last figure means that at any given time, there’s an opportunity to help close to half a million people (400,000) initiate MAT with MOUD, and that last figure shows that we’re falling woefully short, with lifesaving treatment absent in 99% of prisons and jails in the U.S.
Increased Overdose Risk
- Evidence shows incarceration significantly increases risk of fatal overdose
- From 2013-2014, 40% of deaths among people released from incarceration were caused by overdose
- Within 2 weeks of release:
- People with OUD are 40 times more likely to die of an overdose than people in the general population
- Within 3 months of release:
- 75% of people with OUD relapsed
- Within 1 year of release:
- 45% of people with OUD are arrested for a new offense
This data shows us that initiating MAT during incarceration could reduce relapse, save lives, and prevent new offenses.
Decreased Recidivism (Repeat Offending/Reoffending)
- Treating people for addiction in jails reduces recidivism.
- For example, a study in Rhode Island showed a 60% decrease in overdose deaths, upon release, after participating in MAT in jail
- Experts estimate that initiating MAT in prisons and jails could prevent 2,000 overdose deaths per year
This data shows that MAT in prisons and jails has a dual effect: it reduces repeat offenses and decrease overdose deaths upon release.
Comprehensive Access to MOUD Recommended
- Major stakeholders endorse all three medications for opioid use disorder (MOUD), including:
- National Commission on Correctional Health Care
- National Governors Association
- American Society for Addiction Medicine
- National Academy of Medicine
- Availability of methadone in prisons and jails is inadequate, compared to buprenorphine
- Naltrexone is the most common MOUD used in prisons and jails, but it’s the least favored among people with OUD, and associated with shorter duration of treatment adherence
This information shows us that important stakeholders support MAT in prisons and jails, including those typically cautious and averse to change, such as National Commission on Correctional Health Care.
Next, let’s look at the recommendations they make in each of these four areas.
How to Expand Access to MAT in Prisons and Jails
We’ll review these Johns Hopkins recommendations one item at a time, beginning with their position on current rules and regulations. The details on these recommendations appear in the publication “Medications for Opioid Use Disorder in Jails and Prisons: Moving Toward Universal Access.”
Toward Universal Access for MAT
Changing Rules and Regulations
- The problem(s):
- Under current regulations, patients can only receive methadone through licensed opioid treatment programs (OTPs), and must visit their provider daily to receive medication. For an incarcerated person, this is impossible.
- Before the pandemic, patients could only initiate buprenorphine treatment with a provider with an X-waiver. The X-waiver is no longer necessary, but rules prevent providers from dispensing buprenorphine to more than 30 patients, which creates problems for patients in prisons and jails.
- The possible solutions:
- Reduce barriers to methadone access in prisons and jail by increasing allowable take-home doses
- Expand regulations to allow mobile methadone units to support patients in prisons and jails
- Expand regulations to allow medical personnel to prescribe buprenorphine to more than 30 patients per provider
- Expand the existing 72-hour rule to allow prison and jail medical personnel to distribute MOUDs to patients past the existing 72 hour maximum
- Lobby the Drug Enforcement Agency (DEA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Commission on Correctional Health Care (NCCHC) to publish a set of best practices for MAT in prisons and jails
Lower the Threshold for OUD Diagnosis and Treatment.
- The problem(s):
- Jails and prisons have stringent criteria for diagnosis and treatment of OUD
- They place arbitrary limits on dosage and treatment duration
- They make participation in peer support groups mandatory for receiving medication
- When incarcerated individuals break rules, consequences are punitive, and may include withholding medication
- The possible solutions:
- Lower the threshold for diagnosis and treatment. The idea is that it should not be hard for a person to get an accurate diagnosis and appropriate medication for a well-known, well-established, well-defined medical condition
- Facilitate “warm-handoff” programs for patients both entering and exiting incarceration
- Allow patients access to medication, even when they don’t participate in peer support groups or counseling
- Institute non-punitive practices for breaking program rules: denying lifesaving medication should never be a consequence
- Create appropriate dosage regimens for methadone and buprenorphine for patients in prisons and jails
Collaboration Between Corrections Officers and Medical Staff
- The problem(s):
- Stigma from prison and jail personnel prevent adequate access to evidence-based treatment with MOUD
- Officers and medical staff may think they have conflicting goals: one the one hand, officers want to ensure safety and security, while on the other hand, medical staff want to provide evidence-based treatment
- Officers are more accustomed to confiscating methadone and buprenorphine than assisting in distributing methadone and buprenorphine as medication
- The possible solutions:
- Educate corrections officers on the science of addiction
- Education corrections on the science of addiction treatment
- Teach prison staff about the benefits of MAT with MOUD for people with OUD
- Communicate with other facilities, in other locations – different counties or states – to learn about the benefits of MAT programs
- Enlist an advocate in a position of leadership who understands the pressing need for MAT in prisons and jails
Supporting Patients Upon Release
- The problem(s):
- Currently, federal law terminates Medicaid for incarcerated individuals
- Infrastructure for reenrolling incarcerated individuals upon release is inconsistent and prevents many incarcerated individuals from accessing medical care upon release from incarceration
- Rules vary state to state, county to county, jail to jail, and prison to prison, which creates confusion for everyone involved, and often results in treatment gaps for incarcerated individuals upon release
- Significant barriers to accessing social support exist for formerly incarcerated individuals, including access to support for housing, food, employment, and medical care
- The solutions:
- Expand Medicaid coverage for low-income adults upon release from prisons or jails
- Create technology infrastructure for automatic enrollment in Medicaid upon release from incarceration
- Create programs to establish continuity of care between incarceration and release
- Distribute Naloxone to patients with OUD upon release
- Invest in specific reentry clinics for patients with OUD upon release
- Eliminate the Medicaid inmate exclusion policy
- Pass the Medicaid Reentry Act, which allows Medicaid services for patients to begin 30 days before release
If we can implement those recommendations, then we’d make considerable progress in addressing the gap between the number of incarcerated people with OUD who need treatment with MAT and the number of incarcerated people with OUD who receive MAT.
MAT in Prisons and Jails: Underlying Priorities
The first priority is, of course, the health and safety of our population as a whole. It’s important for people out in the world to understand that helping people with OUD heal and grow not only helps them, it helps everyone. Individuals benefit, families benefit, and communities benefit. To learn more about MAT in prisons and jails, please refer to these resources, which explain both where we are and where we want to go:
Current Policies on MAT in Prisons and Jails
- SAMHSA: Use of Medication-Assisted Treatment for Opioid Use Disorder (OUD) in Criminal Justice Settings
- Model Access to Medication for Addiction Treatment in Correctional Settings Act
- Expanding Access To Medications For Opioid Use Disorder In Corrections And Community Settings
- Medication-Assisted Treatment for Opioid Use Disorder in Jails and Prisons: A Planning and Implementation Toolkit
We’ll end this article with a list of core values, as determined by the study team at Johns Hopkins University, for implementing future MAT programs in prisons and jails.
Core Values: Priorities for MAT in Incarcerated Populations
Patient-Driven Support
The foundation of effective treatment for substance use disorder is personal agency. This is as true for people in prisons and jails as it is for people in the general public. People should have the right to choose treatment, and have both voice and choice in what treatment they receive and how they receive it.
Racial Equality:
Rates of incarceration among Black, Latinx, and American Indian/Alaska Native/Native Hawaiian people are higher than for people in non-minority demographic groups. This impacts access to evidence-based treatment and support. It’s essential to create programs for OUD treatment that eliminate the potential for institutional racism, systemic bias, or discrimination of any sort.
Follow the Evidence
The evidence speaks: the gold-standard treatment for opioid use disorder is medication-assisted treatment (MAT) with medication for opioid use disorder (MOUD). That’s true wherever a person is: incarcerated or not incarcerated. Therefore, it’s time to recognize this fact, and scale up our MAT program in prisons and jails, in order to follow the evidence, and give everyone with OUD a chance at making a full recovery – whether they’re incarcerated or not.
Holistic, Integrated Treatment
Health is when a person thrives on all levels: physical, emotional, psychological, and relational. SUD treatment in prisons and jails needs to address the complete person in order to keep them healthy. Granted, the fact of incarceration creates challenges. However, we have a duty to provide incarcerated individuals with complete care that maximizes total health, and create systems that allow a person to engage in continuous, uninterrupted care before, during, and after incarceration.
Moving Forward: Treatment Improves Lives
When we implement these policies and practices in places where patients need them the most, we know we can improve lives. As a society, this is an achievable goal: we can help incarcerated people turn their lives around, and prepare them to live, thrive, and grow in recovery upon release. It’s not only achievable, it’s the right thing to do, and will help improve our world, one person at a time.
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