Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial

Jenna's Project: Preventing Overdose and Improving Recovery Outcomes for Women Leaving Incarcerated Settings during Pregnancy and Postpartum Periods

OBJECTIVES

For people with opioid use disorder (OUD), transitioning from pregnancy to postpartum and from incarceration to the community is a time of increased risk for opioid overdose. This prospective project evaluated the extent of Jenna's Project's success in preventing overdoses and improving recovery outcomes by coordinating postrelease care in incarcerated OUD perinatal patients.

METHODS

Participants (N = 132) were pregnant or postpartum (1 year postdelivery) with OUD during incarceration and self-referred for postrelease services. From March 2020 to October 2021, participants could receive up to 6 months of postincarceration care coordination services (eg, regular communication, transportation, emergency housing, SUD treatment), medication to treat OUD (MOUD) and other treatment services. Outcomes included verified overdose (fatal), self-reported nonfatal overdose, reincarceration, active Medicaid, receipt of MOUD, presence of children living with participants, open Child Protective Services cases, and number of referrals for services.

RESULTS

There were 0 nonfatal and 0 fatal overdoses at both 1 and 6 months postrelease, and 3 of 132 (2%) returned to incarceration. Significantly fewer participants had Medicaid at release (36%) and at 6 months postrelease (60%) than before incarceration (87%) (P < 0.001 for all 3 pairwise comparisons). At 6 months postrelease, significantly more participants reported MOUD receipt (51%) compared with before incarceration (39%) (P < 0.001). There was no significant change in the number of open Child Protective Services cases. Referrals for childcare or parenting services were the most common referrals provided.

CONCLUSION

Immediate postrelease care coordination for pregnant and postpartum women with OUD was feasible and effective in preventing overdose, reincarceration, and promoting recovery outcomes.

Higher methadone dose at time of release from prison predicts linkage to maintenance treatment for people with HIV and opioid use disorder transitioning to the community in Malaysia

BACKGROUND

Incarcerated people with HIV and opioid-dependence often experience poor post-release outcomes in the absence of methadone maintenance treatment (MMT). In a prospective trial, we assessed the impact of methadone dose achieved within prison on linkage to MMT after release.

METHODS

From 2010 to 2014, men with HIV (N = 212) and opioid dependence before incarceration were enrolled in MMT within 6 months of release from Malaysia's largest prison and followed for 12-months post-release. As a prospective trial, allocation to MMT was at random and later by preference design (predictive nonetheless). MMT dosing was individually targeted to minimally achieve 80 mg/day. Time-to-event analyses were conducted to model linkage to MMT after release.

FINDINGS

Of the 212 participants allocated to MMT, 98 (46 %) were prescribed higher dosages (≥80 mg/day) before release. Linkage to MMT after release occurred in 77 (36 %) participants and significantly higher for those prescribed higher dosages (46% vs 28 %; p = 0.011). Factors associated with higher MMT dosages were being married, on antiretroviral therapy, longer incarceration periods, having higher levels of depression, and methadone preference compared to randomization. After controlling for other variables, being prescribed higher methadone dosage (aHR: 2.53, 95 %CI: 1.42-4.49) was the only independent predictor of linkage to methadone after release.

INTERPRETATION

Higher doses of methadone prescribed before release increased the likelihood of linkage to MMT after release. Methadone dosing should be introduced into international guidelines for treatment of opioid use disorder in prisons and further post-release benefits should be explored.

FUNDING

National Institute of Drug Abuse (NIDA).

Unmet need for medication for opioid use disorder among persons who inject drugs in 23 U.S. cities

BACKGROUND

Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities.

METHODS

PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals.

RESULTS

Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23).

CONCLUSIONS

The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.

"I think we're getting better but we're still not there": Provider-based stigma and perceived barriers to care for people who use opioids (PWUO)

BACKGROUND

Despite significant efforts to improve access to medications for opioid use disorder (MOUD), uptake remains low relative to the scope of the problem in the United States. A growing body of quantitative and qualitative research has documented consistent barriers to MOUD treatment access and retention, at the level of individuals, institutions, and society at large. Stigma - surrounding both people who use opioids (PWUO) and treatment using MOUD - is among the most-cited barriers by patients and providers alike, yet few studies have examined provider-based stigma specifically, or considered its interaction with other impediments to OUD care.

METHODS

This paper employs a qualitative approach to the analysis of provider-based stigma among professionals involved in the treatment or supervision of individuals with OUD. We conducted and analyzed interviews with 19 professionals as part of a larger mixed methods study on stigma among substance use treatment providers and court personnel in Pennsylvania. Beyond capturing providers' perceptions of PWUO and MOUD, the authors asked participants to describe barriers to recovery, and the effective delivery of care within this population.

RESULTS

Interviewees enumerated multiple entrenched barriers that sometimes operated at different levels, such as criminal-legal involvement, which weakened PWUO's social networks and employment prospects, while undermining providers' attempts at continuity of care; moreover, participants cited the "War on Drugs" as an overarching impediment to effective substance use treatment, not least for its role in perpetuating stigma against PWUO.

CONCLUSIONS

Interestingly, while an overwhelming majority of participants named stigma as a barrier to treatment at every level, most also articulated stigmatizing beliefs around PWUO. Namely, providers evoked one element of stigma - blameworthiness - in their contention that many PWUO are inadequately motivated to recover. In addition to adding further complexity to MOUD barriers research, this study troubles the notion that professional training and education on the disease model of addiction serve to eradicate stigma.

Prison Buprenorphine Implementation and Postrelease Opioid Use Disorder Outcomes

Importance

Agonist medications for opioid use disorder (MOUD), buprenorphine and methadone, in carceral settings might reduce the risk of postrelease opioid overdose but are uncommonly offered. In April 2019, the Massachusetts Department of Correction (MADOC), the state prison system, provided buprenorphine for incarcerated individuals in addition to previously offered injectable naltrexone.

Objective

To evaluate postrelease outcomes after buprenorphine implementation.

Design, Setting, and Participants

This cohort study with interrupted time-series analysis used linked data across multiple statewide data sets in the Massachusetts Public Health Data Warehouse stratified by sex due to differences in carceral systems. Eligible participants were individuals sentenced and released from a MADOC facility to the community. The study period for the male sample was January 2014 to November 2020; for the female sample, January 2015 to October 2019. Data were analyzed between February 2022 and January 2024.

Exposure

April 2019 implementation of buprenorphine during incarceration.

Main Outcomes and Measures

Receipt of MOUD within 4 weeks after release, opioid overdose, and all-cause mortality within 8 weeks after release, each measured as a percentage of monthly releases who experienced the outcome. Segmented linear regression analyzed changes in outcome rates after implementation.

Results

A total of 15 225 individuals were included. In the male sample there were 14 582 releases among 12 688 individuals (mean [SD] age, 35.0 [10.8] years; 133 Asian and Pacific Islander [0.9%], 4079 Black [28.0%], 4208 Hispanic [28.9%], 6117 White [41.9%]), a rate of 175.7 releases per month; the female sample included 3269 releases among 2537 individuals (mean [SD] age, 34.9 [9.8] years; 328 Black [10.0%], 225 Hispanic [6.9%], 2545 White [77.9%]), a rate of 56.4 releases per month. Among male participants at 20 months postimplementation, the monthly rate of postrelease buprenorphine receipt was higher than would have been expected under baseline trends (21.2% vs 10.6% of monthly releases; 18.6 additional releases per month). Naltrexone receipt was lower than expected (1.0% vs 6.0%; 8.8 fewer releases per month). Monthly rates of methadone receipt (1.4%) and opioid overdose (1.8%) were not significantly different than expected. All-cause mortality was lower than expected (1.9% vs 2.8%; 1.5 fewer deaths per month). Among female participants at 7 months postimplementation, buprenorphine receipt was higher than expected (31.6% vs 9.5%; 12.4 additional releases per month). Naltrexone receipt was lower than expected (3.4% vs 7.2%) but not statistically significantly different. Monthly rates of methadone receipt (1.1%), opioid overdose (4.8%), and all-cause mortality (1.6%) were not significantly different than expected.

Conclusions and Relevance

In this cohort study of state prison releases, postrelease buprenorphine receipt increased and naltrexone receipt decreased after buprenorphine became available during incarceration.

The association between attitudes and the provision of medications for opioid use disorder (MOUD) in United States jails

Background

Opioid use disorder is prevalent among individuals who are incarcerated, yet medications for opioid use disorder (MOUD) are not widely available in United States jails and prisons. Negative staff attitudes across the criminal legal system may prevent MOUD from being provided. We sought to determine if staff attitudes are associated with the provision of MOUD in prisons or jails.

Methods

227 staff members of 43 jails and partnering community-based treatment providers answered questions on the effectiveness and acceptability of methadone, buprenorphine, and naltrexone. Response patterns were summarized with principal component analysis. Mixed-effects regression was performed to determine if attitudes toward MOUD were associated with the number of individuals screened and diagnosed with an OUD, referred to treatment, provided MOUD and referred to treatment after release.

Results

Sites whose staff had negative attitudes towards methadone and positive attitudes towards naltrexone were associated with fewer people being screened (Mean ratio [MR] = 0.84, 95 % CI: [0.72, 0.97]), diagnosed (MR = 0.85, 95 % CI: [0.73, 0.99]), referred (MR = 0.76, 95 % CI: [0.65, 0.89]), provided MOUD (MR = 0.70, 95 % CI: [0.58, 0.84]), and referred after release (MR = 0.82, 95 % CI: [0.72, 0.94]). Sites with overall positive attitudes towards all MOUD were associated with more people being screened (MR = 1.16, 95 % CI: [1.01, 1.34]), diagnosed (MR = 1.37, 95 % CI: [1.18, 1.60]), and referred to treatment (MR = 1.41, 95 % CI: [1.20, 1.65]).

Conclusions

Attitudinal barriers exist in the criminal legal system and are associated with the provision of MOUD.

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences

INTRODUCTION

The United States has experienced substantial increases in opioid use for more than two decades. This growth has impacted rural areas where overdoses have risen drastically during this time period and more often involve prescription opioids than in urban areas. Medications for opioid use disorders (MOUDs) are highly underutilized in rural settings due to lack of access, inadequate prescribing, and stigma.

METHODS

The study collected data using a cross-sectional online survey of nonprescribing clinicians (NPCs) involved in the treatment of substance use disorders (SUDs) in the United States. The study used multiple recruitment methods to obtain a purposive sample of NPCs from a variety of geographical contexts across the nation. The survey assessed demographic and practice characteristics including rurality of practice location, exposure and training related to MOUDs, treatment orientation, treatment preferences for opioid use disorder (OUD), and attitudes toward MOUDs. The study compared treatment preferences for OUD and attitudes toward MOUDs based on rurality of practice location. We tested a mediation model to determine whether the relationship between rurality of practice setting and attitudes toward MOUDs is mediated by treatment orientation.

RESULTS

Most of the 636 NPCs surveyed favored a combination of MOUDs and psychosocial treatment. Compared to clinicians practicing in suburban or urban areas, self-identified rural clinicians were more likely to favor MOUDs alone as most effective and less likely to endorse a combination of MOUDs and psychosocial treatment. Although most NPCs were supportive of MOUDs overall, many endorsed misconceptions related to MOUDs. Rural clinicians were less likely to perceive MOUDs as effective or acceptable compared to those in urban settings. Results of a mediation analysis indicated that practicing in a rural location compared to in an urban location directly and indirectly influenced attitudes toward MOUDs through an effect on treatment orientation.

CONCLUSIONS

NPCs play important roles in the implementation of MOUDs, and while efforts to increase their knowledge of and exposure to MOUDs have contributed broadly to more favorable attitudes toward MOUDs among NPCs, this study's findings indicate that additional efforts are still needed, particularly among NPCs who work in rural settings. Findings also indicate that, among rural clinicians, increasing knowledge of and exposure to harm reduction principles may be a necessary prerequisite to engaging them in the implementation of specific harm reduction strategies such as MOUDs.

Diversion of medications to treat opioid use disorder: Qualitative findings from formerly incarcerated adults in Massachusetts

BACKGROUND

Carceral officials often cite diversion of medication for opioid use disorder (MOUD) (e.g., buprenorphine) as a reason for not offering MOUD treatment in jails and prisons with little understanding of patient perspectives. We aimed to understand patient perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and reduce diversion.

METHODS

We conducted thematic analyses of semi-structured interviews held in 2021-22 with 38 adults who received MOUD treatment and were released from eight Massachusetts jails that had implemented a MOUD program on or after September 2019.

RESULTS

Consistent with prior reports from carceral staff, patients perceived MOUD diversion to happen less frequently than expected, which they attributed to dosing protocols that have effectively reduced it. Patients reported that MOUD availability reduced the contraband buprenorphine market, although other contraband substances have entered jails (fentanyl, oxycodone, K2). Patients perceived Subutex to have greater misuse potential and added diversion risks. Patients valued graduated consequences and other efforts to reduce MOUD diversion and contraband for making jails safer and for enabling patients to receive treatment. Nearly all participants reported having heard about, witnessed, or been involved in actual or attempted diversion, with variation in reports by jail. Patients suggested that dispensing MOUD to all who need it immediately upon intake would be the most effective way to reduce MOUD diversion and contraband.

CONCLUSION

Formerly incarcerated patients perceived MOUD diversion within jail medication programs as occurring less often than expected and that it can be reduced with appropriate protocols. To help limit medication diversion, patients recommended provision of MOUD upon intake to all individuals with opioid use disorder who need it. Findings have implications for MOUD program adaptation, successful routinization, and diffusion in carceral settings.

Preferences in medications for patients seeking treatment for opioid use disorder: A conjoint analysis

INTRODUCTION

The opioid epidemic continues to be a public health crisis that has worsened during the COVID-19 pandemic. Medications for opioid use disorder (MOUD) are the most effective way to reduce complications from opioid use disorder (OUD), but uptake is limited by both structural and individual factors. To inform strategies addressing individual factors, we evaluated patients' preferences and trade-offs in treatment decisions using conjoint analysis.

METHOD

We developed a conjoint analysis survey evaluating patients' preferences for FDA-approved MOUDs. We recruited patients with OUD presenting to initiate treatment. This survey included five attributes: induction, location and route of administration, impact on mortality, side effects, and withdrawal symptoms with cessation. Participants performed 12 choice sets, each with two hypothetical profiles and a "none" option. We used Hierarchical Bayes to identify relative importance of each attribute and part-worth utility scores of levels, which we compared using chi-squared analysis. We used the STROBE checklist to guide our reporting of this cross-sectional observational study.

RESULTS

Five-hundred and thirty participants completed the study. Location with route of administration was the most important attribute. Symptom relief during induction and withdrawal was a second priority. Mortality followed by side effects had lowest relative importance. Attribute levels with highest part-worth utilities showed patients preferred monthly pick-up from a pharmacy rather than daily supervised dosing; and oral medications more than injection/implants, despite the latter's infrequency.

CONCLUSION

We measured treatment preferences among patients seeking to initiate OUD treatment to inform strategies to scale MOUD treatment uptake. Patients prioritize the route of administration in treatment preference-less frequent pick up, but also injections and implants were less preferred despite their convenience. Second, patients prioritize symptom relief during the induction and withdrawal procedures of medication. These transition periods influence the sustainability of treatment. Although health professionals prioritize mortality, it did not drive decision-making for patients. To our knowledge, this is the largest study on patients' preferences for MOUD among treatment-seeking people with OUD to date. Future analysis will evaluate patient preference heterogeneity to further target program planning, counseling, and decision aid development.

Health disparities in ethnic and racial minority populations with pain and opioid use disorder

Healthcare providers are not prepared to address health disparities among ethnic and racial minority populations with either persistent and chronic pain or substance use disorder (SUD). Recognizing biases from policies to provide pain management and treatment for SUD in our healthcare systems, from our individual state laws and federal guidelines, is necessary. Biases are embedded in the screening and treatment of patients with chronic pain through the use of screening tools, opioid treatment agreements, and prescription drug monitoring programs. Additionally, the punitive treatment of people of ethnic and racial minority populations who experience persistent and chronic pain, opioid use disorders, or other SUDs needs to be redirected to facilitate solutions rooted in equity.

Exploring mental health comorbidities and opioid agonist treatment coverage among people in prison: A national cohort study 2010-2019

INTRODUCTION

Despite a high prevalence of opioid use disorder (OUD) among people in prison, there is little knowledge of how many receive the recommended opioid agonist treatment (OAT) and what characterizes those who receive OAT and those who do not when it comes to mental health comorbidities. We aimed to describe people with OUD in Norwegian prisons over a ten-year period and their OAT status, and to investigate comorbidity of mental health disorders stratified by gender.

METHODS

Data from the PriSUD study, including all people (≥19 years old) imprisoned in Norway between 2010 and 2019, linked to national patient registry data, including ICD-10 codes. We calculated the prevalence (1-year and 10-year) of OUD and OAT, and mental health comorbidity stratified on OAT-status and gender.

RESULTS

Among the cohort (n=51,148), 7 282 (14.2%) were diagnosed with OUD during the period of observation. Of those, 4 689 (64.4%) received OAT. People with OUD had high levels of comorbidity, including other drug use disorders (92.4% OAT, 90.3% non-OAT), alcohol use disorder (32.1% OAT, 44.4% non-OAT) and any other mental health disorders (61.6% OAT, 68.2% non-OAT). The proportion receiving OAT among people with OUD increased markedly during the ten years of observation; from 35.7% in 2010-70.9% in 2019.

CONCLUSION

People with OUD, both receiving OAT and not, had substantially more mental health comorbidities than the non-OUD population. Understanding how the prison population changes over time especially in terms of mental health needs related to OUD, is important for correctional health service planning.

Recent modifications to the US methadone treatment system are a Band-Aid-not a solution-to the nation's broken opioid use disorder treatment system

For 5 decades, US federal regulations have segregated methadone treatment for opioid use disorder from the rest of the health care system, confining its availability to specialty treatment programs that are highly regulated. These regulations have led to severe shortages in the availability of methadone and grave underutilization of this lifesaving medication despite a worsening overdose crisis. In this commentary, we discuss current barriers to methadone in the US opioid treatment system and how recent changes to federal regulations fall short of the reforms needed to significantly expand access to this treatment. Instead, we propose the urgent need to expand methadone to mainstream health care settings by allowing for office-based prescribing and pharmacy dispensing of methadone, the norm in many other developed countries.

Perceived access to opioid agonist treatment in prison among people with a history of injection drug use: A qualitative study

INTRODUCTION

Opioid agonist treatment (OAT) is associated with a reduced likelihood of hepatitis C incidence, nonfatal overdose, and (re)incarceration among people who inject drugs (PWID), yet factors underpinning decisions to access OAT in prison and postrelease are not well understood. The aim of the qualitative study was to explore the perspectives of OAT access while in prison among PWID recently released from prison in Australia.

METHODS

Eligible participants enrolled in the SuperMix cohort (n = 1303) were invited to take part in a semi-structured interview in Victoria, Australia. Inclusion criteria were informed consent, aged ≥18 years, history of injection drug use, incarcerated for ≥3 months, and released from custody <12 months. The study team analysed data via a candidacy framework to account for macro-structural influences.

RESULTS

Among 48 participants (33 male; ten Aboriginal), most injected drugs in the prior month (n = 41), with heroin most frequently injected (n = 33) and nearly half (n = 23) were currently on OAT (primarily methadone). Most participants described the navigation and permeability of OAT services in prison as convoluted. If not on OAT pre-entry, prison policies often restricted access, leaving participants to withdraw in cells. In turn, some participants commenced OAT postrelease to ensure OAT continuity of care if reincarcerated. Other participants who experienced delayed access to OAT in prison stated no need to initiate while in prison or postrelease as they were now "clean". Last, implementation of OAT delivery in prison (e.g., lack of confidentiality) frequently led to changes in OAT type to avoid peer violence (pressure to divert OAT).

CONCLUSION

Findings draw attention to simplistic notions of OAT accessibility in prisons, illuminating how structural determinants influence choice in PWID decision-making. Suboptimal access and acceptability of OAT delivery in prisons will continue to place PWID at risk of harm postrelease (e.g., overdose).

Fatal and nonfatal opioid overdose risk following release from prison: A retrospective cohort study using linked administrative data

INTRODUCTION

Among individuals who are released from prison, opioid overdose is a leading cause of death with a risk more than ten-fold the general population. Although the epidemiology of opioid-related fatalities has been described, few studies have characterized both fatal and nonfatal opioid-related poisonings. The objective of this study was to estimate risk of fatal and nonfatal opioid overdose among adults released from prison.

METHODS

The study estimated fatal and nonfatal opioid overdose rates using linked corrections, Medicaid, hospital discharge, and vital statistics from the state of Oregon from 2014 to 2018. Multivariable proportional hazards models identified demographic and prison-related factors associated with overdose.

RESULTS

Between 2014 and 2017, 18,258 individuals were released from prison. A majority of individuals were male (87 %) and ages 26 to 64 (83 %). Two-thirds had a documented substance use disorder treatment need and 20 % demonstrated mental health treatment need. Following prison release, 579 opioid overdose events occurred; 65 (11 %) were fatal. The rate of opioid overdose was 1085.7 per 100,000 person-years (PY). Rates were highest in the first two weeks (2286.7 per 100,000 PY), among women (1582.9 per 100,000 PY), and those with mental health (1624.3 per 100,000 PY) or substance use disorder treatment needs (1382.6 per 100,100 PY). Only mental health (adjusted hazard ratio [aHR] 1.54, 95 % CI 1.24 to 1.90) and substance use need (aHR 2.59; 95 % CI 2.01 to 3.34) remained significant in multivariable models.

CONCLUSIONS

The rate of opioid overdose is markedly elevated after prison release, particularly in the first two weeks. In women, the higher rate of opioid overdose is mediated by a greater mental health burden.

Medication-Assisted Treatment in Problem-solving Courts: A National Survey of State and Local Court Coordinators

Problem-solving courts (PSCs) are a critical part of a societal effort to mitigate the opioid epidemic's devastating consequences. This paper reports on a national survey of PSCs (N = 42 state-wide court coordinators; N = 849 local court coordinators) and examines the structural factors that could explain the likelihood of a local PSC authorizing medication-assisted treatment (MAT) and MAT utilization. Results of the analyses indicate that MAT availability at the county level was a significant predictor of the likelihood of local courts authorizing MAT. The court's location in a Medicaid expansion state was also a significant predictor of local courts allowing buprenorphine and methadone, but not naltrexone. Problem-solving courts are in the early stages of supporting the use of medications, even when funding is available through Medicaid expansion policies. Adoption and use of treatment innovations like MAT are affected by coordinators' perceptions of MAT as well as structural factors such as the availability of the medications in the community and funding resources. The study has important implications for researchers, policymakers, and practitioners.

Medications for opioid use disorder during incarceration and post-release outcomes

BACKGROUND

Continuation or initiation of MOUDs during incarceration could improve post-release outcomes by preventing return to opioid use and reducing risk of overdose. People with OUD involved in the criminal legal system are a vulnerable population, yet little research has comprehensively examined post-release outcomes associated with receiving MOUDs in jail and prison settings.

METHODS

The authors conducted a review of published peer-reviewed literature on post-release outcomes associated with the use of MOUDs in correctional settings to determine implications for further research and policy.

RESULTS

Results showed compelling evidence supporting the use of MOUDs for currently incarcerated populations, with almost all studies showing that MOUDs provided during incarceration increased community-based treatment engagement post-release. There is also evidence that initiating or continuing MOUDs during incarceration is associated with decreased opioid use and overdoses post-release, without increasing criminal involvement.

CONCLUSIONS

Findings indicate that forcing tapering and withdrawal during incarceration can have dire consequences upon release into the community. Initiating or continuing MOUDs during incarceration reduces the risk for opioid use and overdose upon release by maintaining opioid tolerance and increasing community treatment engagement.

Characteristics of Substance Use Screening at Intake in a Sample of U.S. Jails

BACKGROUND

Despite high rates of substance use among justice-involved populations, the use of substance screening tools in justice settings varies.

METHODS

Data are from the National Jail Health Care Study, which surveyed jails across the U.S. about their health care practices (n=371). Jails were asked to voluntarily submit their medical intake forms. A content analysis of intake forms (n=63) specific to questions about substance use was completed.

RESULTS

Seventy-three percent (73%) of intake forms used non-standardized questions to assess current substance use, and 27% did not ask any questions about substance use. Alcohol use was most assessed (52%), followed by tobacco (30%), and marijuana (22%). Less than 11% of jails asked about use of opioids and 40% of forms asked about withdrawal history.

CONCLUSIONS

The lack of adequate substance use screening in jails hinders identification of substance use disorders, potential for withdrawal symptoms, and appropriate connection to treatment resources.

Incarceration status at buprenorphine initiation and OUD treatment outcomes during pregnancy

Introduction

Opioid use disorder (OUD) is a leading cause of pregnancy-associated deaths. OUD treatment with buprenorphine (BUP) reduces overdose risk and improves perinatal outcomes. Incarceration can be a barrier to receipt of OUD treatment during pregnancy and postpartum. The objective of this study was to examine differences in BUP continuation at delivery by patients' incarceration status at the time of BUP initiation.

Methods

This is a secondary analysis of a retrospective cohort study of pregnant patients with OUD who delivered at an academic medical center and initiated BUP between January 1, 2018, and March 30, 2020. The primary outcome was BUP continuation at delivery, abstracted from the state prescription monitoring program and electronic medical record, along with incarceration status. Bivariate analysis was used to assess the relationship between BUP continuation and incarceration status.

Results

Our sample included 76 patients, with 62% of patients incarcerated at BUP initiation (n = 47). Among the entire sample, 90.7% (n = 68) received BUP at delivery. Among patients who were incarcerated at BUP initiation, 97% remained on BUP at delivery; among patients who were not incarcerated at BUP initiation, 79% remained on BUP at delivery (p = 0.02).

Conclusion

In our sample from a health system housing a care model for pregnant and parenting people with OUD with local jail outreach, BUP continuation rates at delivery were high, both for patients who were and were not incarcerated at BUP initiation. Findings are intended to inform future work to develop and evaluate evidence-based, patient-centered interventions to expand OUD treatment access for incarcerated communities.

A meta-analysis on the effects of incarceration-based opioid substitution treatment

Objective: Opioid substitution treatment (OST) is a common treatment for individuals who use opioids; however, empirical evidence on the effects of OST during incarceration is scarce. Our aim was to conduct a meta-analysis on the effects of incarceration-based OST on substance use, treatment engagement post-release and re-incarceration. Method: We searched for studies on individuals who were incarcerated and treated with OST, compared to a comparison group. Studies were only included if they reported data post-release. Results: N = 15 studies met the inclusion criteria. We found less opioid use, less other drug use, higher treatment engagement post-release and less re-incarceration among treated individuals compared to the comparison group. Moderator analyses showed some influence of length of follow-up period and study quality. Conclusions: Incarceration-based OST reduces drug use, re-incarceration and leads to higher treatment engagement after release. More research is needed on the effects of incarceration-based OST on secondary outcomes (e.g. health and social integration) and on factors that moderate these effects.

Availability of best practices for opioid use disorder in jails and related training and resource needs: findings from a national interview study of jails in heavily impacted counties in the U.S

BACKGROUND

Jails are optimal settings in which to screen individuals for opioid use disorders (OUD) and provide needed services, especially medications for OUD (MOUD). This study sought to assess the availability of OUD "best practices" in jails located in counties heavily impacted by opioid overdose in the U.S. and their related training and resource needs. Counties were selected for study inclusion using two indicators of OUD severity: the absolute number and population rate of opioid overdose deaths. Structured interviews were completed with representatives from 185/244 (76%) of targeted counties and 185/250 (74%) of targeted jails in these counties. Ten OUD best practices were identified based on current treatment and practice guidelines. These include: screening for OUD; clinical assessment; medically managed withdrawal; MOUD administration; MOUD for pregnant people; counseling and wrap-around services; collaboration with community providers; assistance with Medicaid/insurance; re-entry services; and overdose prevention. Descriptive analyses examined the provision of any services and average percentage of services endorsed within best-practice categories, association of best-practice availability with community and jail characteristics, and related needs for training and resources.

RESULTS

Over 70% of jail respondents indicated that some aspects of each of the ten OUD best practices were available within their jails, ranging from 71% using clinical assessment to 96% providing overdose prevention. However, there was considerable variability in the average percentage of items endorsed within each best-practice category, ranging from 38% of items regarding re-entry services to 88% of items regarding medically managed withdrawal. Availability of OUD best practices in jails also varied by community and jail characteristics. Jails reported the highest needs for funding for medication and clinical staff.

CONCLUSIONS

Policies are needed to address the identified gaps in availability of OUD best practices within jails. Training, technical assistance, and funding are needed to improve clinical capacity of jails to administer MOUD and to ensure continuity of care from jail to community, which are essential to reducing the risk of opioid-related overdose following release.

The impact of COVID-19 on the treatment of opioid use disorder in carceral facilities: a cross-sectional study

While the COVID-19 pandemic disrupted healthcare delivery everywhere, persons with carceral system involvement and opioid use disorder (OUD) were disproportionately impacted and vulnerable to severe COVID-associated illness. Carceral settings and community treatment programs (CTPs) rapidly developed protocols to sustain healthcare delivery while reducing risk of COVID-19 transmission. This survey study assessed changes to OUD treatment, telemedicine use, and re-entry support services among carceral and CTPs participating in the National Institute on Drug Abuse (NIDA)-funded study, Long-Acting Buprenorphine vs. Naltrexone Opioid Treatments in Criminal Justice System-Involved Adults (EXIT-CJS) study. In December 2020, carceral sites (n = 6; median pre-COVID 2020 monthly census = 3468 people) and CTPs (n = 7; median pre-COVID 2020 monthly census = 550 patients) participating in EXIT-CJS completed a cross-sectional web-based survey. The survey assessed changes pre- (January-March 2020) and post- (April-September 2020) COVID-19 in OUD treatment, telemedicine use, re-entry supports and referral practices. Compared to January-March 2020, half of carceral sites (n = 3) increased the total number of persons initiating medication for opioid use disorder (MOUD) from April-September 2020, while a third (n = 2) decreased the number of persons initiated. Most CTPs (n = 4) reported a decrease in the number of new admissions from April-September 2020, with two programs stopping or pausing MOUD programs due to COVID-19. All carceral sites with pre-COVID telemedicine use (n = 5) increased or maintained telemedicine use, and all CTPs providing MOUD (n = 6) increased telemedicine use. While expansion of telemedicine services supported MOUD service delivery, the majority of sites experienced challenges providing community support post-release, including referrals to housing, employment, and transportation services. During the COVID-19 pandemic, this small sample of carceral and CTP sites innovated to continue delivery of treatment for OUD. Expansion of telemedicine services was critical to support MOUD service delivery. Despite these innovations, sites experienced challenges providing reintegration supports for persons in the community. Pre-COVID strategies for identifying and engaging individuals while incarcerated may be less effective since the pandemic. In addition to expanding research on the most effective telemedicine practices for carceral settings, research exploring strategies to expand housing and employment support during reintegration are critical.

Impact of prerelease methadone on mortality among people with HIV and opioid use disorder after prison release: results from a randomized and participant choice open-label trial in Malaysia

INTRODUCTION

Mortality is elevated after prison release and may be higher in people with HIV and opioid use disorder (OUD). Maintenance with opioid agonist therapy (OAT) like methadone or buprenorphine reduces mortality in people with OUD and may confer benefits to people with OUD and HIV leaving prison. Survival benefits of OAT, however, have not been evaluated prospectively in people with OUD and HIV leaving prison.

METHODS

This study prospectively evaluated mortality after prison release and whether methadone initiated before release increased survival after release in a sample of men with HIV and OUD (n = 291). We linked national death records to data from a controlled trial of prerelease methadone initiation conducted from 2010 to 2014 with men with HIV and OUD imprisoned in Malaysia. Vital statistics were collected through 2015. Allocation to prerelease methadone was by randomization (n = 64) and participant choice (n = 246). Cox proportional hazards models were used to estimate treatment effects of prerelease methadone on postrelease survival.

RESULTS

Overall, 62 deaths occurred over 872.5 person-years (PY) of postrelease follow-up, a crude mortality rate of 71.1 deaths per 1000 PY (95% confidence interval [CI] 54.5-89.4). Most deaths were of infectious etiology, mostly related to HIV. In a modified intention-to-treat analysis, the impact of prerelease methadone on postrelease mortality was consistent with a null effect in unadjusted (hazard ratio [HR] 1.3, 95% CI 0.6-3.1) and covariate-adjusted (HR 1.2, 95% CI 0.5-2.8) models. Predictors of mortality were educational level (HR 1.4, 95% CI 1.0-1.8), pre-incarceration alcohol use (HR 2.0, 95% CI 1.1-3.9), and lower CD4⁺ T-lymphocyte count (HR 0.8 per 100-cell/mL increase, 95% CI 0.7-1.0).

CONCLUSIONS

Postrelease mortality in this sample of men with HIV and OUD was extraordinarily high, and most deaths were likely of infectious etiology. No effect of prerelease methadone on postrelease mortality was observed, which may be due to study limitations or an epidemiological context in which inadequately treated HIV, and not inadequately treated OUD, is the main cause of death after prison release.

TRIAL REGISTRATION

NCT02396979. Retrospectively registered 24/03/2015.

State level variation in substance use treatment admissions among criminal legal-referred individuals

BACKGROUND

Individuals involved in the criminal legal system face unique challenges to accessing substance use disorder (SUD) treatment, yet state-level variation in referrals for treatment remains largely unknown. To address disparities in the overdose crisis among individuals with criminal legal involvement, it is important to understand variation in SUD treatment across states.

METHODS

We conducted a retrospective comparison of substance use treatment referrals from the criminal legal system and other sources across participating states. Using data from the 2018-2019 Treatment Episode Dataset-Admissions, we characterized treatment referral rates from the criminal legal system, the substances most commonly leading to treatment, and rates of treatment with medication for opioid use disorder (MOUD) across states.

RESULTS

Across all states, criminal legal referral rates were higher than non-criminal legal rates. Criminal-legal referral rates, adjusted for state overdose deaths, were highest in the Northeast and Midwest. Methamphetamine use was the most common substance leading to treatment referral from the criminal legal system in 24 states while opioid use was the most common reason for non-criminal legal referrals in 34 states. In over half the states analyzed, fewer than 10% of opioid treatment referrals from the criminal legal system received MOUD. In almost all states, MOUD was more common in treatment referred from non-criminal legal settings.

CONCLUSION

State-specific policies and practices shape drug policy and the SUD treatment landscape for people with criminal legal involvement. Standards and ongoing monitoring for substance use treatment referrals from the criminal-legal system should be considered by federal agencies charged with addressing the ongoing overdose crisis.

Use of long-acting injectable buprenorphine in the correctional setting

BACKGROUND

As overdoses due to opioids rise, medications for opioid use disorder (MOUD) continue to be underemployed, resulting in limited access to potentially life-saving treatment. Substance use disorders are prevalent in individuals who are incarcerated, and these individuals are at increased risk for death postrelease due to overdose. Few jails and prisons offer MOUD and most limit access. Extended-release buprenorphine (XR-BUP), a novel monthly injectable MOUD formulation, could be uniquely poised to address treatment access in correctional settings.

METHODS

This study linked a retrospective cohort design of statewide datasets to evaluate the real-world use of XR-BUP. The study included individuals (N = 54) who received XR-BUP while incarcerated from January 2019 through February 2022. The study was conducted at the Rhode Island Department of Corrections, with the nation's first comprehensive statewide correctional MOUD program.

RESULTS

Fifty-four individuals received a combined total of 162 injections during the study period. The study found no evidence of tampering with the injection site, indicating no attempts by participants to remove, hoard, or divert the medication. Sixty-one percent reported at least one adverse effect after injections were received, with an average of 2.8 side effects. Sixty-one percent of those released on XR-BUP engaged in MOUD after release, 30 % continued with XR-BUP.

CONCLUSIONS

XR-BUP is feasible and acceptable in correctional settings. XR-BUP addresses administrative concerns of diversion that obstruct lifesaving MOUD and offers another safe and effective treatment option. Further studies and trials should continue to assess this novel medication's ability to treat opioid addiction in the correctional setting and upon release to the community.

Jail-based reentry programming to support continued treatment with medications for opioid use disorder: Qualitative perspectives and experiences among jail staff in Massachusetts

BACKGROUND

Individuals with opioid use disorder released to communities after incarceration experience an elevated risk for overdose death. Massachusetts is the first state to mandate county jails to deliver all FDA approved medications for opioid use disorder (MOUD). The present study considered perspectives around coordination of post-release care among jail staff engaged in MOUD programs focused on coordination of care to the community.

METHODS

Focus groups and semi-structured interviews were conducted with 61 jail staff involved in implementation of MOUD programs. Interview guide development, and coding and analysis of qualitative data were guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Deductive and inductive approaches were used for coding and themes were organized using the EPIS.

RESULTS

Salient themes in the inner context focused on the elements of reentry planning that influence coordination of post-release care including timing of initiation, staff knowledge about availability of MOUD in community settings, and internal collaborations. Findings on bridging factors highlighted the importance of interagency communication to follow pre-scheduled release dates and use of bridge scripts to minimize the gap in treatment during the transition. Use of navigators was an additional factor that influenced MOUD initiation and engagement in community settings. Outer context findings indicated partnerships with community providers and timely reinstatement of health insurance coverage as critical factors that influence coordination of post-release care.

CONCLUSIONS

Coordination of MOUD post-release continuity of care requires training supporting staff in reentry planning as well as resources to enhance internal collaborations and bridging partnerships between in-jail MOUD programs and community MOUD providers. In addition, efforts to reduce systemic barriers related to unanticipated timing of release and reinstatement of health insurance coverage are needed to optimize seamless post-release care.

Emergency department utilization by individuals with opioid use disorder who were recently incarcerated

INTRODUCTION

Individuals with opioid use disorder (OUD) are highly represented among the incarcerated population and are frequent utilizers of the emergency department (ED). Medications for opioid use disorder (MOUD) are a recognized treatment option for individuals with OUD. Although the field recognizes the benefits of MOUD, we know little about what mitigating effects MOUD offered in jail might have on post-release ED utilization.

METHODS

In this retrospective cohort analysis, we searched electronic medical records (EMR) for incarcerations in the Santa Clara County jail between 8/1/2019 and 8/31/2021 for individuals with OUD (N = 4352) and collected demographic and medication administration data for these individuals. Individuals are considered as having received MOUD if they have at least one administration of methadone, naltrexone, or extended release (XR) buprenorphine during their incarceration. We also collected ED visit data from the same EMR for the 28 days following release from the identified incarcerations. Using logistic regression, we compared ED use within 24 h and 28 days for individuals who are incarcerated and treated with MOUD with those not receiving treatment.

RESULTS

Individuals who received methadone or XR buprenorphine during their incarceration were less likely to present at the 28 days following release than those not receiving treatment, after controlling for age, race, sex assigned at birth, preferred language, and housing status. Most individuals accessing the ED within 28 days of release do so within the first seven days, and the greatest volume occurred in the first 24 h. Individuals released before noon had a lower likelihood of ED presentation within 24 h than those released in the afternoon.

CONCLUSIONS

Offering methadone and XR buprenorphine to individuals with OUD who are incarcerated is beneficial in mitigating ED utilization within 28 days of release, although further research is needed to understand what other contributing variables, especially those related to follow-up care, could be influencing these results. If possible, release times for individuals could be shifted to the morning to maximize reduction in ED use within 24 h of release. Alternatively, further research should investigate why release times appear to influence ED utilization.

Development and use of a checklist for the implementation of medication for opioid use disorder in jails

Background:

In light of short lengths of stay and proximity to communities of release, jails are well-positioned to intervene in opioid use disorder (OUD). However, a number of barriers have resulted in a slow and limited implementation.

Methods:

This paper describes the development and testing of a Medication for Opioid Use Disorder (MOUD) Implementation Checklist developed as part of a Building Bridges project, a two-year planning grant which supported 16 US jail systems as they prepared to implement or expand MOUD services.

Results:

Although initially developed to track changes within sites participating in the initiative, participants noted its utility for identifying evidence-based benchmarks through which the successful implementation of MOUDs could be tracked by correctional administrators.

Conclusions:

The findings suggest that this checklist can both help guide and illustrate progress toward vital changes facilitated through established processes and supports.

Plain Language Summary:

People incarcerated in jails are more likely to have opioid use disorder than the general population. Despite this, jails in the United States (U.S.) often offer limited or no access to Medication for Opioid Use Disorder (MOUD). The Building Bridges project was designed to address this gap in 16 U.S. jail systems as they prepared to implement or expand MOUD services. This article addresses the use of a MOUD checklist that was initially designed to help the jails track changes toward evidence-based benchmarks. The findings suggest that this checklist can both help guide and illustrate progress toward vital changes facilitated through established processes and supports.

Treatment preference for opioid use disorder among people who are incarcerated

INTRODUCTION

The devastating overdose crisis remains a leading cause of death in the United States, especially among individuals involved in the criminal legal system. Currently, three classes (opioid agonist, partial agonist-antagonist, and antagonist) of FDA-approved medications for opioid use disorder (MOUD) exist, yet few correctional settings offer any medication treatment for people who are incarcerated. Facilities that do often provide only one medication.

METHODS

We conducted 40 semi-structured qualitative interviews with individuals receiving MOUD incarcerated at the Rhode Island Department of Corrections.

RESULTS

Results from this study indicate that people who are incarcerated have preferences for certain types of MOUD. Individuals' preferences were influenced by medication side effects, route of administration, delivery in the community, and stigma.

CONCLUSION

MOUD programs in the community and in correctional settings should use a patient-centered approach that allows choice of medication by offering all FDA-approved MOUD treatment options.

Methadone within prison and linkage to and retention in treatment upon community release for people with opioid use disorder in Kyrgyzstan: Evaluation of a national program

BACKGROUND

HIV incidence in Eastern Europe and Central Asia (EECA) continues to increase, primarily among people who inject drugs (PWID) and people in prisons. In Kyrgyzstan, an estimated 35% of people in prison are PWID, and 10% have been diagnosed with HIV. In 2008, Kyrgyzstan became the first country in EECA to provide free and voluntary methadone in prisons. We examine the impact of this national program on methadone within prison as well as linkage to and retention in treatment upon release to the community.

METHODS

Administrative data from a national methadone registry with de-identified information were assessed retrospectively. We examined the delivery of methadone services, including the duration of treatment both within prison and after release, for all prisoners who were prescribed methadone in Kyrgyz prisons from 2008 to 2018. Reasons for discontinuing methadone, HIV status and methadone dose are also analyzed.

RESULTS

Between 2008 and 2018, nine of Kyrgyzstan's 16 prisons offered methadone, and 982 incarcerated people initiated methadone within prison. Prisoners prescribed methadone were mostly male (96.2%), in their mid-30s (mean=34.9 years), and had been incarcerated for a relatively long time (mean = 44.1 months); their mean treatment duration in prison was 12.5 months, and 31.6% had HIV. A subsample (N = 645; 65.7%) of these were released to the community. Of these 645 people, 356 (55.2%) were not taking methadone at the time of release, 128 (19.8%) were on methadone and continued it after release, and the remainder (N=161, 25.0%) were on methadone at the time of release, but subsequently discontinued it, most within the first 7 days after release. Among those continuing methadone, 14.8% (N=19) remained on treatment ≥ 12 months. Independent correlates of linkage to methadone after release included positive HIV status (adjusted hazard ratio (aHR)=1.55; p = 0.033), receipt of methadone before their incarceration (aHR=2.01; p = 0.039), and receipt of methadone at the time of release (aHR = 20.81; p<0.001).

CONCLUSION

This is the first evaluation of within-prison methadone treatment in EECA. Uptake of methadone within prison and retention in treatment after release were both low. Continuous maintenance of treatment throughout incarceration is an opportunity to optimize HIV prevention and link patients to methadone post-release.

Opioid-specific medication-assisted therapy and its impact on criminal justice and overdose outcomes

BACKGROUND

The overlap between justice system involvement and drug use is well-documented. Justice-involved people who misuse opioids are at high risk for relapse and criminal recidivism. Criminal justice policymakers consider opioid-specific medication-assisted therapies (MATs) one approach for improving outcomes for this population. More research is needed that explores the impacts of opioid-specific MATs for justice-involved people.

OBJECTIVES

This study sought to assess the effects of opioid-specific MAT for reducing the frequency and likelihood of criminal justice and overdose outcomes for current or formerly justice-involved individuals.

SEARCH METHODS

Records were searched between May 7, 2021 and June 23, 2021. We searched a total of sixteen proprietary and open access databases that included access to gray literature and conference proceedings. The bibliographies of included studies and relevant reviews were also searched.

SELECTION CRITERIA

Studies were eligible for inclusion in the review if they: (a) assessed the effects of opioid-specific MATs on individual-level criminal justice or overdose outcomes; included (b) a current or formerly justice-involved sample; and (c) a randomized or strong quasi-experimental design; and c) were published in English between January 1, 1960 and October 31, 2020.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures as expected by The Campbell Collaboration.

MAIN RESULTS

Twenty studies were included, representing 30,119 participants. The overall risk of bias for the experimental studies ranged from "some" to "high" and for quasi-experimental studies ranged from "moderate" to "serious." As such, findings must be interpreted against the backdrop of less-than-ideal methodological contexts. Of the 20 included studies, 16 included outcomes that were meta-analyzed using mean log odds ratios (which were reported as mean odds ratios). Mean effects were nonsignificant for reincarceration (odds ratio [OR] = 0.93 [0.68, 1.26], SE = .16), rearrest (OR = 1.47 [0.70, 3.07], SE = 0.38), and fatal overdose (OR = 0.82 [0.56, 1.21], SE = 0.20). For nonfatal overdose, the average effect was significant (OR = 0.41 [0.18, 0.91], SE = 0.41, p < 0.05), suggesting that those receiving MAT had nearly 60% reduced odds of a nonfatal overdose.

IMPLICATIONS FOR POLICY PRACTICE AND RESEARCH

The current review supports some utility for adopting MAT for the treatment of justice-involved people with opioid addiction, however, more studies that employ rigorous methodologies are needed. Researchers should work with agencies to improve adherence to medication regimens, study design, and collect more detailed information on participants, their criminal and substance use histories, onset, and severity. This would help clarify whether treatment and control groups are indeed comparable and provide better insight into the potential reasons for participant dropout, treatment failure, and the occurrence of recidivism or overdose. Outcomes should be assessed in multiple ways, if possible (e.g., self-report and official record), as reliance on official data alone may undercount participants' degree of criminal involvement.

Medications for opioid use disorder during pregnancy: Access and continuity in a state women's prison facility, 2016-2019

BACKGROUND

Although medications to treat opioid use disorder (MOUD) are the standard of care during pregnancy, there are many potential gaps in the cascade of care for pregnant people experiencing incarceration.

METHODS

We conducted a retrospective cohort study of pregnant people with opioid use disorder incarcerated in a Southeastern women's prison from 2016 to 2019. The primary outcomes were access to MOUD during incarceration and continuity in the community. We used descriptive statistics to summarize aspects of our sample and logistic regression to identify predictors of MOUD receipt during incarceration.

RESULTS

Of the 279 pregnant people with OUD included in the analysis, only 40.1% (n = 112) received MOUD during incarceration, including 67 (59.8%) who received methadone and 45 (40.1%) who received buprenorphine. Less than one-third of the participants were referred to a community MOUD provider (n = 83, 30%) on return to the community. Significant predictors of MOUD receipt included medium/close custody level during incarceration, incarceration during the latter portion of the study period, pre-incarceration heroin use, and receipt of pre-incarceration MOUD.

CONCLUSIONS

Although prisons can serve as an important site of retention in MOUD for some pregnant people, there were substantial gaps in initiation of MOUD and retention in MOUD among pregnant people with OUD imprisoned in the Southeast during the study period.

Availability of Medications for the Treatment of Opioid Use Disorder Among Pregnant and Postpartum Individuals in US Jails

Importance

Thousands of pregnant people with opioid use disorder (OUD) enter US jails annually, yet their access to medications for OUD (MOUD) that meet the standard of care (methadone and/or buprenorphine) is unknown.

Objective

To assess the availability of MOUD for the treatment of pregnant individuals with OUD in US jails.

Design, Setting, and Participants

In this cross-sectional study, electronic and paper surveys were sent to all 2885 identifiable US jails verified in the National Jails Compendium between August 19 and November 7, 2019. Respondents were medical and custody leaders within the jails.

Main Outcomes and Measures

The primary outcome was the availability of MOUD (methadone and/or buprenorphine) for the treatment of pregnant people with OUD in US jails. Availability of MOUD was assessed based on (1) continuation of MOUD for pregnant incarcerated individuals (if the individual was receiving MOUD before incarceration), with or without initiation of MOUD; (2) both initiation and continuation of MOUD for pregnant individuals; (3) only continuation of MOUD for pregnant individuals; and (4) management of opioid withdrawal for pregnant individuals. Secondary outcomes included MOUD availability during the postpartum period and logistical factors associated with the provision of MOUD. Multivariate logistic regression analysis was used to assess factors associated with MOUD availability during pregnancy.

Results

Among 2885 total surveys sent, 1139 (39.5%) were returned; of those, 836 surveys (73.4%; 29.0% of all surveys sent) could be analyzed, with similar proportions from metropolitan (399 jails [47.7%]) and rural (381 jails [45.6%]) settings. Overall, 504 jails (60.3%) reported that MOUD was available for medication continuation, with or without medication initiation, during pregnancy. Of those, 267 jails (53.0%; 31.9% of surveys included in the analysis) both initiated and continued MOUD, and 237 jails (47.0%; 28.3% of surveys included in the analysis) only continued MOUD; 190 of 577 jails (32.9%; 22.7% of surveys included in the analysis) reported opioid withdrawal as the only management for pregnant people with OUD. Among the 504 medication-providing jails, only 120 (23.8%) continued to provide MOUD during the postpartum period. Methadone was more commonly available at jails that only continued MOUD (84 of 123 jails [68.3%]), whereas buprenorphine was more commonly available at jails that both initiated and continued MOUD (73 of 119 jails [61.3%]). In an adjusted model, jails with higher odds of MOUD availability were located in the Northeast (odds ratio [OR], 10.72; 95% CI, 2.43-47.36) or metropolitan areas (OR, 1.92; 95% CI, 1.31-2.83), had private health care contracts (OR, 1.49; 95% CI, 1.03-2.14) and a higher number of women (≥70) reported in the female census (OR, 1.69; 95% CI, 1.02-2.80), and provided pregnancy testing within 2 weeks of arrival at the jail (OR, 2.66; 95% CI, 1.69-4.17).

Conclusions and Relevance

In this cross-sectional study, a substantial proportion of US jails did not provide access to MOUD to pregnant people with OUD. Although most jails reported continuing to provide MOUD to individuals who were receiving medication before incarceration, few jails initiated MOUD, and most medication-providing jails discontinued MOUD during the postpartum period. These results suggest that many pregnant and postpartum people with OUD in US jails do not receive medication that is the standard of care and are required to endure opioid withdrawal, signaling an opportunity for intervention to improve care for pregnant people who are incarcerated.

Legal System Involvement and Opioid-Related Overdose Mortality in U.S. Department of Veterans Affairs Patients

INTRODUCTION

Opioid-related overdose risks are elevated after incarceration. The rates of opioid-related overdose mortality have risen in recent years, including among Veterans Health Administration patients. To inform Veteran overdose prevention, this study evaluates whether opioid-related overdose risks differ for Veterans Health Administration patients with versus those without indicators of legal system involvement.

METHODS

This retrospective national cohort study, conducted in 2019-2021, used Veterans Health Administration electronic health records and death certificate data from the Department of Veterans Affairs/Department of Defense Mortality Data Repository to examine opioid-related overdose mortality from January 1, 2013 through December 31, 2017. The cohort included 5,390,902 Veterans with Veterans Health Administration inpatient or outpatient encounters in 2012 who were alive as of January 1, 2013, of whom 32,284 (0.60%) patients had legal system involvement in 2012, indicated by Veterans Justice Programs outpatient encounters. Cox proportional hazards regression models assessed the associations between legal involvement and risk of opioid-related overdose mortality.

RESULTS

There were 4,670 opioid-related overdose deaths, including 295 (6.31%) among legal-involved Veterans. Veterans with legal involvement had a higher opioid-related overdose mortality rate per 100,000 person-years (191.22, 95% CI=169.40, 213.04 vs 17.76, 95% CI=17.23, 18.29, p<0.001) and an elevated risk of opioid-related overdose mortality (adjusted hazard ratio=1.38, 95% CI=1.22, 1.57, p<0.001) compared with those without.

CONCLUSIONS

Among Veterans receiving Veterans Health Administration care in 2012, documented legal system involvement was associated with an increased risk of opioid-related overdose mortality. Targeting overdose education and naloxone distribution programs and integrating opioid overdose prevention efforts into mental health care may reduce opioid overdose deaths among Veterans with legal involvement.

Injecting Opioid Use Disorder Treatment in Jails and Prisons: The Potential of Extended-release Buprenorphine in the Carceral Setting

ABSTRACT

As the opioid overdose cases rise, policy-makers and researchers should target interventions to populations at highest risk. Incarceration serves as a risk factor for opioid overdose (Gan et al. Addiction 2021) and a large portion of recent overdose deaths have had encounters in the criminal justice system.Medications for opioid use disorder in the criminal justice system can save lives, though unique administrative barriers in jails and prisons hinder access. As facilities expand medications for opioid use disorder access (due to new legislation and court rulings across states), extended-release buprenorphine offers an opportunity to overcome these barriers including logistics of administration, diversion concern, patient stigma, and an increased bridge of treatment during re-entry to the community.As extended-release buprenorphine has practical advantages in correctional health delivery, future research and policy discussions should investigate its optimal role in treating opiate addiction in a carceral setting.

Medications for opioid use disorder in state prisons: Perspectives of formerly incarcerated persons

Background: Opioid use disorder (OUD) is common among incarcerated persons and risk of overdose and other adverse drug-related consequences is high after release. Recognizing their potential to reduce these risks, some correctional systems are expanding access to medication for opioid use disorder (MOUD). This study explored the experiences and perspectives of formerly incarcerated individuals on MOUD use while incarcerated and after release. Methods: We interviewed 53 individuals with self-reported OUD who were released from New Jersey state prisons. Interviews explored motivations to use MOUD while incarcerated and after release, and experiences with prison-based MOUD and transition to community-based care. We performed cross-case analysis to examine common and divergent perspectives across participants. Results: A common reason for accepting prerelease MOUD was recognition of its effectiveness in preventing drug use, overdose, and other drug-related consequences. Participants who chose not to use MOUD often were focused on being completely medication-free or saw themselves as having relatively low-risk of substance use after a prolonged period without opioid use. A few participants reported challenges related to prison-based MOUD, including logistical barriers, stigma, and once-daily buprenorphine dosing. Most participants effectively transitioned to community-based care, but challenges included insurance lapses and difficulty locating providers. Conclusions: Many formerly incarcerated persons with OUD recognize the value of MOUD in supporting recovery, but some hold negative views of MOUD or underestimate the likelihood that they will return to drug use. Patient education on risks of post-release overdose, the role of MOUD in mitigating risk, and MOUD options available to them could increase engagement. Participants' generally positive experiences with MOUD support the expansion of correctional MOUD programs.

Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings : Harm Reduction in Outpatient Addiction Treatment

Opioid use disorder (OUD) is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. However, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many outpatient, primary care-based treatment programs. This presents a barrier to engagement for patients who continue to use substances and who may be at high risk for complications of ongoing substance use such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), superficial and deep tissue infections, and overdose. Harm reduction aims to reduce the negative consequences of substance use and offers an alternative to abstinence as a singular goal. Incorporating harm reduction principles into primary care treatment settings can support programs in engaging patients with ongoing substance use and facilitate the delivery of evidence-based screening and prevention services. The objective of this narrative review is to describe strategies for the integration of evidence-based harm reduction principles and interventions into outpatient, primary care-based OUD treatment settings. We will offer specific tools for providers and programs including strategies to support safer injection practices, assess the risks and benefits of continuing medications for opioid use disorder in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations with ongoing substance use including adolescents, parents, and families.

Post-incarceration outcomes for individuals who continued methadone treatment while in Connecticut jails, 2014-2018

PURPOSE

To assess post-release outcomes associated with continuation of methadone treatment in correctional centers.

METHODS

This case-control study of the post-incarceration impact of pilot methadone programs operating in jails in New Haven and Bridgeport, Connecticut, USA was conducted in 2014-18. The study compared non-fatal overdose, fatal overdose, reincarceration, and resumption of methadone in the community experienced by 1564 eligible men, 660 (42.2 %) of whom continued treatment while incarcerated.

RESULTS

Continuation of methadone was associated with a significant decrease in non-fatal overdose (OR:0.55; 95 % CI: 0.36, 0.85) and a greater likelihood of resuming methadone treatment in the community post-release (OR:2.56; 95 % CI: 2.07, 3.16). Time to resumption of methadone was shortened by treatment while time to non-fatal overdose was increased. Treatment while incarcerated resulted in a modest but not significant decrease in fatal overdoses and no difference in reincarceration between those who did and did not receive methadone. However, resumption of methadone after release did significantly reduce fatal overdoses (OR = 0.26, 95 % CI: 0.11, 0.62, p = 0.002).

CONCLUSION AND RELEVANCE

Improvements in post-release outcomes of non-fatal overdose and treatment reengagement emphasize the benefits of continuing medication-based treatment for opioid use disorder within the criminal justice system for those receiving it prior to being incarcerated.

Suicide Rates in Nordic Prisons 2000-2016

OBJECTIVE

To compare suicide rates of people in prison and the general population in the Nordic countries.

METHODS

Data on deaths by suicide and person-years for people in prison and the general population were obtained for the Nordic countries during 2000-2016. Age-standardized rate ratios were calculated.

RESULTS

The suicide rate in the Nordic countries overall was 110.1 (95% CI = 98.1, 122.2) per 100,000 person-years for people in prison. A significant decline was noted for the suicide rate of people in prison between 2000 and 2016 (p < 0.0001). The age-standardized mortality ratio was 7.4 (95% CI = 5.9-8.2) for males and 17.8 (95% CI = 7.3-33.2) for females in Denmark, Iceland, and Norway.

CONCLUSION

Despite a decreasing trend over time, excess suicide mortality was noted for people in prison.

Fentanyl-related overdose during incarceration: a comprehensive review

BACKGROUND

Fentanyl and related compounds have recently saturated the illicit drug supply in the United States, leading to unprecedented rates of fatal overdose. Individuals who are incarcerated are particularly vulnerable, as the burden of opioid use disorder is disproportionately higher in this population, and tolerance generally decreases during incarceration.

METHODS

We conduct a systematic search for publications about fentanyl overdoses during incarceration in PubMed and PsycINFO, as well as lay press articles in Google, from January 1, 2013 through March 30th, 2021.

RESULTS

Not a single fentanyl overdose was identified in the medical literature, but 90 overdose events, comprising of 76 fatal and 103 nonfatal fentanyl overdoses, were identified in the lay press. Among the 179 overdoses, 138 occurred in jails and 41 occurred in prisons, across the country.

CONCLUSIONS

Fentanyl-related overdoses are occurring in correctional facilities with unknown but likely increasing frequency. In addition to the need for improved detection and reporting, immediate efforts to 1) increase understanding of the risks of fentanyl and how to prevent and treat overdose among correctional staff and residents, 2) ensure widespread prompt availability of naloxone and 3) expand the availability of medications to treat opioid use disorder for people who are incarcerated will save lives.

Treating Opioid Use Disorder and Related Infectious Diseases in the Criminal Justice System

This article provides an overview of the diagnosis and management of opioid use disorder and its infectious complications among populations with criminal justice involvement. Opioid use disorder and chronic infections such as human immunodeficiency virus and hepatitis C virus are highly prevalent among incarcerated individuals and some of the unique features of correctional facilities present challenges for their appropriate medical management. We outline evidence-based strategies for integrated, patient-centered treatment during incarceration and the potentially hazardous transition back to the community upon release.

Opioid Use and Chronic Infections: The Value of Addressing the Syndemic in Correctional Settings Via Telemedicine Guidance and Broader Use of Long-Acting Medications

In the United States, we are experiencing linked epidemics (a syndemic) of substance use disorders (SUDs) and infections associated with drug use, including unsafe injecting and unsafe sex in exchange for drugs or money. Current drug laws, together with risk-taking behavior among persons with SUDs, contribute to disproportionately high prevalences of these conditions in correctional settings. Detection and treatment of diseases with a high impact on public health are best addressed in the settings where such conditions are most prevalent (ie, jails and prisons for SUDs and chronic infections). The effectiveness, safety, cost of care. and public health impact of these conditions can be improved by means of broader screening and expanded access to specialty consultations through telemedicine/telehealth, along with broader use of long-acting medications for the treatment of human immunodeficiency virus and SUDs. Expanding telemedicine/telehealth, first for specialties which do not require advanced technology (eg, infectious diseases, addictions), can eventually lead to further advancements in correctional healthcare.

Frequency and Duration of Incarceration and Mortality Among US Veterans With and Without HIV

BACKGROUND

Exposure to incarceration is associated with increased risk of mortality, and HIV is cited as a leading cause of death. Yet, few studies have examined the association between incarceration and mortality among people with HIV (PWH), specifically whether and how increasing exposure to incarceration increases risk of mortality. We compared mortality by different incarceration exposures and HIV status.

METHODS

We conducted a prospective cohort study of participants in the Veterans Aging Cohort Study from January 2011 to August 2017 (N = 5367). The primary exposure was incarceration by 3 measures: (1) any (ever/never); (2) frequency; and (3) cumulative duration. Stratifying by HIV status and controlling for age, race, and sex, we used Cox Proportional Hazard models to estimate adjusted hazard ratios (AHRs) and 95% confidence intervals (CIs).

RESULTS

Incarceration was associated with increased risk of mortality compared with those never incarcerated for PWH (AHR 1.37; 95% CI: 1.13 to 1.66) and those uninfected (AHR 1.24; 95% CI: 0.99 to 1.54), but the association was only statistically significant among PWH. Increasing frequency of incarceration was associated with higher risk of mortality in both groups: for PWH, AHRs 1.13, 1.45, and 1.64 for 1, 2-5; 6+ times, respectively, for uninfected, AHRs 0.98, 1.35, and 1.70 for 1, 2-5, and 6+ times, respectively.

CONCLUSIONS

PWH were at increased risk of mortality after incarceration, and repeated exposure to incarceration was associated with mortality in both groups in a dose-response fashion. This increased risk of mortality may be mitigated by improving transitional health care, especially HIV care, and reducing incarceration.

Care for Incarcerated Pregnant People With Opioid Use Disorder: Equity and Justice Implications

With the simultaneous rise in maternal opioid use disorder (OUD) and the incarceration of pregnant people in the United States, we must ensure that prisons and jails adequately address the health and well-being of incarcerated pregnant people with OUD. Despite long-established, clear, and evidence-based recommendations regarding the treatment of OUD during pregnancy, incarcerated pregnant people with OUD do not consistently receive medication treatment and are instead forced into opioid withdrawal. This inadequate care raises multiple concerns, including issues of justice and equity, considerations regarding the legal and ethical obligations of the provision of health care, and violations of the medical and legal rights of incarcerated people. We offer recommendations for improving care for this often-ignored group.