Buprenorphine Pilot Programs in Rural Jails
The opioid crisis in the U.S. did not go away during the COVID-19 pandemic.
It got worse.
The latest data on opioid overdose shows the numbers before and during the pandemic, so we can now compare 2019 and 2021 and determine the effect of COVID-19 on overdose.
Unfortunately, although most of us want the pandemic to be over and many of us feel like it is over, the fact is that people are still dying from COVID-19, which means we can’t say we have numbers for after the pandemic. The Centers for Disease Control (CDC) shows a rate 267 deaths per day, down from a peak of 3,722 a day in January 2021, and further, that over 106,000 people test positive for COVID-19 per day, down from a peak of 424,000.
The COVID-19 pandemic is not over – and the opioid crisis never went away.
As we mention above, it got worse. Here are the before and during COVID-19 figures for opioid overdose:
- In 2019, 67,697 people died from overdose.
- 50,178 of those deaths were opioid-related.
- 2020, 78,056 people died from drug overdose.
- 69,061 of those deaths were opioid-related.
- 2021, 107,622 people died from drug overdose.
- 80,826 of those deaths were opioid-related.
The increasing overdose death rates from opioid overdose are hard for those of us working in addiction treatment to accept. We have to accept them, because that’s the reality. But we know we have lifesaving medication ready to help people who need help. The problem is getting that medication to the people who need it, when they need it.
Medication for Addiction? Yes – And it Works
If you’re new to reading about the opioid crisis, you may be surprised that we have an FDA approved medication designed to treat people with opioid use disorder (OUD), a.k.a. opioid addiction. In fact, we have more than one: we have three. Collectively, they’re called medications for opioid use disorder (MOUD), and they include methadone, buprenorphine, and naltrexone. When an individual with OUD enters a program that uses one of these medications, they participate in what’s known as medication-assisted treatment (MAT).
Evidence collected since the launch first official MAT program – a methadone clinic in New York City in 1973 – shows that for people with opioid use disorder, MAT can:
- Reduce overall mortality for people with OUD
- Reduce opioid use
- Reduce opioid-related overdose deaths
- Reduce likelihood of drug-related criminal activity
- Reduce likelihood of injection-related infectious disease spread
- Improve ability to participate in social, family, and work life
- Improve treatment retentions, i.e. stating in treatment, which increases likelihood of treatment success
MAT works. The data are clear and unmistakable. It improves the lives of individuals, families, and communities. That brings us to the subject of this article: there’s one community of people in the U.S. for whom opioid addiction is a serious problem, yet this community does not have sufficient access to the benefits of MAT.
The group of people in the U.S. incarcerated in rural jails.
MAT in Rural Jails: Can it Help?
A study published in February 2022 called “Recidivism and Mortality After In-Jail Buprenorphine Treatment for Opioid Use Disorder” leveraged a set of circumstances that created a natural experiment in the use of MAT in rural jails. Two jails, in two different counties in rural Massachusetts, located 23 miles apart – one in Franklin County and one in Hampshire County – had an opportunity to offer MAT with buprenorphine to inmates with OUD who were incarcerated in their local jail.
One county chose to offer MAT with buprenorphine, and one did not.
That’s when researchers got involved. They realized that if they could measure rates of recidivism – i.e. “additional probation violations, reincarcerations, or court charges after release” – among those who received MAT and those who did not, they could determine whether MAT in rural jails reduced harm or increased harm for the individuals involved and the communities where they live.
The researchers observed the outcomes of:
- 469 adults total incarcerated adults, all diagnosed with opioid use disorder:
- 197 individuals in Franklin County
- 272 in Hampshire County
- Majority white males, average age 35
- Exited one of the two participating jails between January 2015 and April 2019
Applying statistical models to analyze data on jail bookings during the research period, the researchers found that:
- 48% of individuals from the Franklin County jail recidivated
- 63% of individuals in Hampshire County recidivated
- 36% of the people incarcerated in Franklin County faced new criminal charges after release
- 47% of people in Hampshire County faced new criminal charges after release
- The rate of re-incarceration in the Franklin County group was 21%
- The rate of re-incarceration in the Hampshire County group was 39%
We have a question: can you guess which county offered MAT to their local jail inmates, and which county didn’t?
We’ll tell you:
Franklin County offered MAT with buprenorphine, and Hampshire County did not. Franklin county officials also reported a 32 percent reduction in overall recidivism during the study period.
A Treatment Model to Mitigate Harm Caused by OUD
When we write the words “MAT improves the lives of individuals, families, and communities,” the scenario we describe in rural Massachusetts is exactly what we mean. In an area like Franklin County, any reduction in recidivism can have an impact, and a 32 percent overall reduction in recidivism can have a significant impact.
That’s one way MAT can improve life in a small community. It can reduce crime related to OUD. That’s not all, though. The individuals who received MAT may experience the benefits listed above, and their family members may experience the benefit of a loved one in treatment and on the road to recovery. Those are all improvements, and they apply to the individual, the family, and the community.
That’s what we mean when we say MAT can help.
Evidence shows that it can help on a bigger scale, too. Our Chief Medical Officer, Dr. Chris Johnston, published an article for the online magazine Medium in November 2021 called “The Case for Medication-Assisted (MAT) Treatment in Jails and Prisons.” Dr. Johnston’s article makes a strong case for the expanded use of MAT in prisons and jails across the country. In that article – which we recommend – he included detailed data on OUD and OUD treatment in both federal prisons and local jails.
A National Perspective With a Local Focus
We’ll include the data on local jails only, extracted from a report published by the U.S. Department of Justice that analyzed nationwide data on rates of OUD and treatment for OUD. This large-scale research effort included information collected on 1.5 million inmates incarcerated between 2007 and 2009.
Here’s what the researchers found:
- 63.3% of prisoners in local jails met criteria for drug addiction/dependence/abuse
- 47.2% met criteria for dependence
- 16.1% met criteria for abuse
- 15% of prisoners in local jails met criteria for opioid abuse
- 19.4% of prisoners who met criteria for addiction received treatment
- 0.6% who met criteria of opioid abuse receive medication-assisted treatment
[Note: This research occurred before the transition away from terms like addiction/abuse/dependence to terms like substance use disorder (SUD) and opioid use disorder (OUD).]
Researchers also found that:
- 21% of inmates in local jails committed crimes to obtain money for drugs
- 14% of inmates in local jails for violent crimes committed those crimes to obtain money for drugs
Let’s follow through on some of those numbers to bring the point home. According to the Prison Policy Initiative and other non-profit inmate advocacy groups, there are around 750,00 inmates in local jails at any given time in the U.S. Fifteen percent of those – the number who met criteria for OUD – is 112,500. The percentage of those who received MAT for OUD is 0.6%, which works out to 675.
And that’s based on a high estimate of current inmates, taken from 2019, before COVID-19.
That’s an absurdly low number by any metric. When we consider the available resources, and weigh their expenditure against the harm caused by untreated OUD, the case for expanded use of MAT in rural jails seems makes practical sense in human, economic, and medical terms. It made sense to officials in Hampshire County, Massachusetts, who initiated an MAT program for local inmates in 2019.
We think it would make sense to local authorities around the country, who can initiate MAT programs in rural jails in their communities using federal funds allocated to harm reduction programs. If it makes sense to them, then we’re sure we, as a nation, can help more than 675 inmates per year. The more people we help, from any walk of life, the more our communities thrive. That’s what Hampshire County learned from Franklin County, and that’s what all of us can learn from both.