Impact of methadone maintenance treatment on women offenders' post-release recidivism

Interventions to reduce harms related to drug use among people who experience incarceration: systematic review and meta-analysis

BACKGROUND

Mortality, suicide, self-harm, and substance use are elevated among people who are incarcerated. There is a wide range of heterogeneous interventions aimed at reducing these harms in this population. Previous reviews have focused on specific interventions or limited their findings to drug use and recidivism and have not explored interventions delivered after release from prison. Our aim is to examine the effect of interventions delivered to people who use drugs during incarceration or after release from incarceration, on a wide range of outcomes.

METHODS

In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO databases up until Sept 12, 2023 for studies published from Jan 1, 1980 onwards. All studies evaluating the effectiveness of any intervention on drug use, recidivism outcomes, sexual or injecting risk behaviours, or mortality among people who use psychoactive drugs and who were currently or recently incarcerated were included. Studies without a comparator or measuring only alcohol use were excluded. Data extracted from each study included demographic characteristics, interventions, and comparisons. Pooled odds ratios and risk ratios were calculated using random-effects meta-analyses.

FINDINGS

We identified 126 eligible studies (47 randomised controlled trials and 79 observational studies) encompassing 18 interventions; receiving opioid-agonist treatment (OAT) in prison reduced the risk of death in prison (one study; hazard ratio 0·25; 95% CI 0·13-0·48), whereas receiving OAT in the first 4 weeks following release reduced risk of death in the community (two studies; relative risk 0·24; 95% CI 0·15-0·37). Therapeutic community interventions reduced re-arrest at 6-12 months (six studies; odds ratio [OR] 0·72; 95% CI 0·55-0·95) and reincarceration at 24 months (two studies; OR 0·66; 95% CI 0·48-0·96). There was scarce evidence that OAT and syringe service provision are effective in reducing injecting risk behaviours and needle and syringe sharing.

INTERPRETATION

There are effective interventions to reduce mortality and recidivism for people who use drugs who have been incarcerated. Nonetheless, there are also substantial gaps in the research examining the effect of interventions on risk behaviours and mortality during incarceration and a need for randomised designs examining outcomes for people who use drugs after release.

FUNDING

Australian National Health and Medical Research Council.

Technical violations and infractions are drivers of disengagement from methadone treatment among people with opioid use disorder discharged from Connecticut jails 2014-2018

BACKGROUND

We investigated the interaction between arrests for technical violations vs. receiving new charges with receiving community-based methadone treatment on time-to reincarceration (TTR) in a cohort of men with opioid use disorder (OUD) released from custody from two Connecticut jails from 2014 to 2018.

METHODS

Hazard ratios (HR) were estimated for time to reincarceration for technical violations/infractions, misdemeanors only, felonies only, and both misdemeanors and felonies after adjusting for age, race/ethnicity, and receiving methadone treatment during incarceration or in the community following release. Moderation analyses tested the hypotheses that the benefits of receiving methadone in jail or the community on TTR were significantly different for people with only technical violations and infractions compared to misdemeanor and felony charges.

RESULTS

In the sample of 788 men who were reincarcerated, 29.4% received technical violations with no new charges (n = 232) with the remainder of the sample receiving new charges consisting of 26.9% new misdemeanor charges, 6.5% felony charges, and 37.2% both felony and misdemeanor charges. Compared to men who received new misdemeanor charges, TTR was significantly shorter among those who received technical violations and infractions with no new charges amounting to a 50% increase in TTR (334.5 days, SD = 321.3 vs. 228.1 days, SD = 308.0, p < 0.001; aHR = 1.5, 95% CI = 1.3, 1.8, p < 0.001). TTR of men who resumed methadone and were charged with a new crime was 50% longer than those who resumed methadone and received technical violations/infractions with no new charges. (230.2 days, SD = 340.2 vs. 402.3 days, SD = 231.3; aHR = 1.5, 95%CI = 1.0, 2.2, p = 0.038).

CONCLUSIONS

Reducing technical violations may enhance the benefits of providing community-based methadone following release from incarceration on extending the time between incarcerations during the vulnerable time post-incarceration and reduce the burden on correctional systems.

Burden of opioid toxicity death in the fentanyl-dominant era for people who experience incarceration in Ontario, Canada, 2015-2020: a whole population retrospective cohort study

OBJECTIVES

To describe mortality due to opioid toxicity among people who experienced incarceration in Ontario between 2015 and 2020, during the fentanyl-dominant era.

DESIGN

In this retrospective cohort study, we linked Ontario coronial data on opioid toxicity deaths between 2015 and 2020 with correctional data for adults incarcerated in Ontario provincial correctional facilities.

SETTING

Ontario, Canada.

PARTICIPANTS

Whole population data.

MAIN OUTCOMES AND MEASURES

The primary outcome was opioid toxicity death and the exposure was any incarceration in a provincial correctional facility between 2015 and 2020. We calculated crude death rates and age-standardised mortality ratios (SMR).

RESULTS

Between 2015 and 2020, 8460 people died from opioid toxicity in Ontario. Of those, 2207 (26.1%) were exposed to incarceration during the study period. Among those exposed to incarceration during the study period (n=1 29 152), 1.7% died from opioid toxicity during this period. Crude opioid toxicity death rates per 10 000 persons years were 43.6 (95% CI=41.8 to 45.5) for those exposed to incarceration and 0.95 (95% CI=0.93 to 0.97) for those not exposed. Compared with those not exposed, the SMR for people exposed to incarceration was 31.2 (95% CI=29.8 to 32.6), and differed by sex, at 28.1 (95% CI=26.7 to 29.5) for males and 77.7 (95% CI=69.6 to 85.9) for females. For those exposed to incarceration who died from opioid toxicity, 10.6% died within 14 days of release and the risk was highest between days 4 and 7 postrelease, at 288.1 per 10 000 person years (95% CI=227.8 to 348.1).

CONCLUSIONS

The risk of opioid toxicity death is many times higher for people who experience incarceration compared with others in Ontario. Risk is markedly elevated in the week after release, and women who experience incarceration have a substantially higher SMR than men who experience incarceration. Initiatives to prevent deaths should consider programmes and policies in correctional facilities to address high risk on release.

Neurorehabilitation of Offenders, Consent and Consequentialist Ethics

The new biotechnology raises expectations for modifying human behaviour through its use. This article focuses on the ethical analysis of the not so remote possibility of rehabilitating criminals by means of neurotechnological techniques. The analysis is carried out from a synthetic position of, on the one hand, the consequentialist conception of what is right and, on the other hand, the emphasis on individual liberties. As a result, firstly, the ethical appropriateness of adopting a general predisposition for allowing the neurorehabilitation of prisoners only if it is safe and if they give their consent will be defended. But, at the same time, reasons will be given for requiring, in certain circumstances, the exceptional use of neurotechnology to rehabilitate severely psychopathic prisoners, even against their will, from the same ethical perspective.

Kaum Geschlechtsunterschiede bei Opioidkonsumierenden in Haft

Hintergrund

Ein hoher Anteil inhaftierter Frauen weist eine Opioidabhängigkeit auf. Hinsichtlich der Frage, ob sich Frauen und Männer in ihrem Opioidkonsummuster unterscheiden, und ob sich empirische Belege für einen Telescoping-Effekt (späterer Einstieg in den Drogenkonsum bei beschleunigtem Verlauf der Abhängigkeit) bei den Frauen finden lassen, ist die Forschungslage uneindeutig. Dabei mangelt es an Studien zu möglichen Geschlechtsunterschieden, insbesondere im Strafvollzug.

Zielsetzung

In einer Stichprobe von n = 247 opioidabhängigen Gefangenen im bayerischen Strafvollzug wurden die weiblichen (n = 31) mit den männlichen (n = 216) Studienteilnehmenden hinsichtlich Alter, Drogenkonsum, Substitutionsbehandlung, psychischer Vorbelastung, Bildung und wirtschaftlicher Situation verglichen.

Methode

Die Daten wurden im Rahmen einer Erstbefragung der Studie „Haft bei Opioidabhängigkeit – eine Evaluationsstudie“ erhoben.

Ergebnisse

Im Drogenkonsum zeigten sich keine Unterschiede zwischen den beiden Geschlechtergruppen, es konnten folglich keine Hinweise auf einen Telescoping-Effekt bei opioidabhängigen weiblichen Gefangenen gefunden werden. Weiterhin fanden sich keine Unterschiede zwischen Frauen und Männern bezüglich der Substitutionsbehandlung, der Bildung und der wirtschaftlichen Situation. Frauen gaben häufiger an, vor der Haft an Depressionen gelitten zu haben und Opfer von sexuellem Missbrauch gewesen zu sein.

Schlussfolgerungen

Es zeigten sich Belege für eine stärkere psychische Vorbelastung bei den weiblichen im Vergleich zu den männlichen Inhaftierten mit Opioidabhängigkeit, darüber hinaus jedoch auffallend wenige Unterschiede. Bei der untersuchten Stichprobe handelt es sich um eine Gruppe, bei der möglicherweise eine besonders schwere Verlaufsform der Opioidabhängigkeit vorliegt, die etwaige geschlechtsspezifische Unterschiede in den Hintergrund treten lässt.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada

INTRODUCTION

Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada.

METHODS

This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants' release. Data were thematically analyzed.

RESULTS

The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of 'take-home' OAT medications were common barriers.

CONCLUSIONS

Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.

Opioid agonist treatment take-home doses ('carries'): Are current guidelines resulting in low treatment coverage among high-risk populations in Canada and the USA?

Opioid agonist treatment (OAT) is the primary intervention for opioid use disorder (OUD) in Canada and the USA. Yet, a number of barriers contribute to sub-optimal treatment uptake and retention, including daily-supervised medication administration. Thus, clients are eventually granted access to take-home OAT doses (i.e., ‘carries’) to reduce this burden. However, this decision is based on physician discretion and whether patients can demonstrate stability in various life domains, many of which are inextricably linked to the social determinants of health (SDOH). Current Canadian and USA OAT carry guidance documents are not standardized and do not take the SDOH into consideration, resulting in the potential for inequitable access to OAT carries, which may be the case particularly among marginalized populations such as individuals with OUD who have been released from custody. This perspective article posits that current OAT guidelines contribute to inequities in access to OAT carries, and that these inequities likely result in disproportionately low coverage for OUD treatment among some high-risk groups, including individuals on release from incarceration in particular. Relevant impacts of COVID-19 and related policy changes are considered, and suggestions and recommendations to amend current OAT guidance documents are provided.

Opioid agonist treatment (OAT) experiences and release plans among federally incarcerated individuals with opioid use disorder (OUD) in Ontario, Canada: a mixed-methods study

Background

Incarcerated populations experience an elevated prevalence of opioid use disorder (OUD). Federal correctional institutions in Canada have increasingly treated OUD among correctional populations via opioid agonist treatment (OAT) – an evidence based pharmacotherapy that works to reduce drug use and related health harms. However, there is limited evidence regarding incarcerated individuals’ experiences with institutional-based OAT, as well potential OAT-related community release prospects. This information is important for optimal treatment retention and improved health. To address this knowledge gap, we conducted a longitudinal follow-up study examining OAT-related experiences among federally incarcerated individuals before and after community release. This article focuses on the baseline (pre-release) data.

Methods

This mixed-methods study examined OAT-related experiences and release prospects among n = 46 individuals scheduled for community release, recruited from seven federal prisons located in Ontario, Canada. Participants underwent a comprehensive interviewer-administered on-site assessment, including quantitative and qualitative items. Assessment data was furthermore linked to administrative correctional data. Data were analyzed using thematic qualitative and descriptive quantitative approaches.

Results

Participants had complex histories with opioid use including related negative health outcomes. Experiences with institutional OAT were divergent and provision was not standardized; those with OAT engagement pre-admission did not experience many challenges, whereas those initiating OAT during incarceration experienced barriers such as treatment waitlists and adverse process experiences. Most participants expressed a preference for buprenorphine-naloxone over methadone, but described difficulties accessing it. Participants were keen to transition into community-based treatment, yet envisaged prospective barriers and facilitators concerning successful reintegration and treatment continuity.

Conclusions

Major barriers towards the current administration of OAT in federal correctional systems in Canada exist, including extensive waitlists, non-standardized practices, and challenges accessing preferred OAT formulations; this contributes to sub-optimal treatment. Eliminating waitlists, standardizing OAT provision, providing additional OAT options, and more comprehensive release planning may be essential for treatment retention and positive outcomes.

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.

Recidivism and mortality after in-jail buprenorphine treatment for opioid use disorder

BACKGROUND

Buprenorphine is an effective medication for opioid use disorder (MOUD) when offered in community-based settings, but evidence is limited for incarcerated populations, particularly in relation to recidivism. In Massachusetts, Franklin County jail (FCSO) was among the first to provide buprenorphine; adjacent Hampshire County jail (HCHC) offered it more recently. These jails present a natural experiment to determine whether outcomes are different between individuals who did and did not have the opportunity to receive buprenorphine in jail.

METHODS

We examined outcomes of all incarcerated adults with opioid use disorder (n = 469) who did (FCSO n = 197) and did not (HCHC n = 272) have the opportunity to receive buprenorphine. The primary outcome was post-release recidivism, defined as time from jail exit to a recidivism event (incarceration, probation violation, arraignment). Using Cox proportional hazards models, we investigated site as a predictor, controlling for covariates. We also examined post-release deaths.

RESULTS

Fewer FCSO than HCHC individuals recidivated (48.2% vs. 62.5%; p = 0.001); fewer FCSO individuals were re-arraigned (36.0% vs. 47.1%; p = 0.046) or re-incarcerated (21.3% vs. 39.0%; p < 0.0001). Recidivism risk was lower in the FCSO group (hazard ratio 0.71, 95% confidence interval 0.56, 0.89; p = 0.003), net of covariates (adjusted hazard ratio 0.68, 95% confidence interval 0.53, 0.86; p = 0.001). At each site, 3% of participants died.

CONCLUSIONS

Among incarcerated adults with opioid use disorder, risk of recidivism after jail exit is lower among those who were offered buprenorphine during incarceration. Findings support the growing movement in jails nationwide to offer buprenorphine and other agonist medications for opioid use disorder.

A systematic review of post-release programs for women exiting prison with substance-use disorders: assessing current programs and weighing the evidence

BACKGROUND

The rising rates of women in prison is a serious public health issue. Unlike men, women in prison are characterised by significant histories of trauma, poor mental health, and high rates of substance use disorders (SUDs). Recidivism rates of women have also increased exponentially in the last decade, with substance related offences being the most imprisoned offence worldwide. There is a lack of evidence of the effectiveness of post-release programs for women. The aim of this systematic review is to synthesise and evaluate the evidence on post-release programs for women exiting prison with SUDs.

METHODS

We searched eight scientific databases for empirical original research published in English with no date limitation. Studies with an objective to reduce recidivism for adult women (⩾18 years) with a SUD were included. Study quality was assessed using the revised Cochrane Risk of Bias tool for randomized trials (RoB2) and the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tools.

RESULTS

Of the 1493 articles, twelve (n = 3799 women) met the inclusion criteria. Recidivism was significantly reduced in five (42%) programs and substance-use was significantly reduced in one (8.3%) program. Common attributes among programs that reduced recidivism were: transitional, gender-responsive programs; provision of individualised support; providing substance-related therapy, mental health and trauma treatment services. Methodological and reporting biases were common, which impacted our ability to synthesize results further. Recidivism was inconsistently measured across studies further impacting the ability to compare results across studies.

CONCLUSIONS

Recidivism is a problematic measure of program efficacy because it is inconsistently measured and deficit-focused, unrecognising of women's gains in the post-release period despite lack of tailored programs and significant health and social disadvantages. The current evidence suggests that women benefit from continuity of care from prison to the community, which incorporated gender-responsive programming and individualised case management that targeted co-morbid mental health and SUDs. Future program design should incorporate these attributes of successful programs identified in this review to better address the unique challenges that women with SUDs face when they transition back into the community.

'Keeping a lid on it': Exploring 'problematisations' of prescribed medication in prisons in the UK

BACKGROUND

The non-medical use of prescription medication and risk of diversion have become policy and practice concerns within prison settings in the UK. These issues have been highlighted by the Advisory Council on the Misuse of Drugs, Her Majesty's Inspectorate of Prisons and Her Majesty's Prison and Probation Service (2019) prison drugs strategy. In 2019, new prescribing guidance was issued by the Royal College of General Practitioners for clinicians working within prison settings.

METHODS

Informed by Bacchi's (2009) What's the problem represented to be? framework, the ways in which the 'problem' of prescribed medication in prisons have been represented is interrogated through an analysis of the prescribing guidance framework for clinicians working in prisons.

RESULTS

Restrictive prescribing practices are recommended as a solution to the 'problem' of diversion and misuse of prescribed medication. Prescribers are advised to consider de-prescribing, non-pharmacological treatments and alternative prescriptions with less diversionary potential. They are represented as responsible for the 'problems' that prescribed medication bring to prisons. The guidance is underpinned by the assumption that prescribers lack experience, knowledge and skills in prison settings. People serving prison sentences are assumed to be 'untrustworthy' and their symptoms treated with suspicion. This representation of the 'problem' has a number of effects including the possibility of increasing drug-related harm, damaging the patient-doctor relationship and disengagement from healthcare services.

CONCLUSION

The representation of prescribed medication as problems of diversion and prescribing practices inhibits alternative representations of the problem which would inform different policy directions including improvements to regime and healthcare provision and would include a range of practitioners in prison settings to address the 'problem' more holistically.

Comparing characteristics and outcomes of different opioid agonist treatment modalities among opioid-dependent federal men correctional populations in Canada

BACKGROUND

Limited evidence exists in Canada on outcomes related to Opioid Agonist Treatment (OAT) and/or differences between OAT modalities among persons in correctional institutions. This study addresses this knowledge gap by examining key characteristics and outcomes of men in Canadian federal correctional institutions across treatment modalities.

METHODS

A retrospective cohort of men incarcerated in federal correctional institutions (N = 2833) were classified into four groups - three OAT participant groups: prescribed methadone (M-OAT), prescribed buprenorphine/naloxone (Suboxone®; S-OAT) and those who switched between the two OAT modalities at least once (X-OAT). The fourth group was a non-treatment comparison group (Non-OAT). Two-thirds of study participants were released and examined for post-release outcomes. Descriptive statistics and multi-variate Cox proportional hazards regression were used.

RESULTS

The X-OAT group was more likely than the other study groups to have positive urinalysis tests, disciplinary charges, or institutional security or behavioral incidents. Survival analysis indicated that the X-OAT had an adjusted hazard of a return to custody that was 57% greater than the other groups.

CONCLUSIONS

This study indicates that individuals switching OAT modalities are a more complex group needing additional supports, especially for community reintegration. Although few of the returns to custody were due to new offences, a third of participants in the OAT groups had their release revoked, indicating a high need population mostly due to their substance use.

The impact of the opioid crisis on U.S. state prison systems

BACKGROUND

Prior studies have documented limited use of medications to treat opioid use disorders (OUD) for people incarcerated within state prisons in the United States. Using the framework of the criminal justice OUD service cascade, this study interviewed representatives of prison systems in states most heavily impacted by opioid overdose regarding the provision of medications for OUD (MOUD).

METHODS

A stratified sampling strategy included states with high indicators of opioid-overdose deaths. Two sampling strata targeted states with: 1) OUD overdose rates significantly higher than the per capita national average; or 2) high absolute number of OUD overdose fatalities. Interviews were completed with representatives from 21 of the 23 (91%) targeted states in 2019, representing 583 prisons across these states. Interviews assessed service provision across the criminal justice OUD service cascade, including OUD screening, withdrawal management, MOUD availability and provision, overdose prevention, re-entry services, barriers, and needs for training and technical assistance.

RESULTS

MOUD (buprenorphine, methadone, or naltrexone) was available in at least one prison in approximately 90% of the state prison systems and all three medications were available in at least one prison in 62% of systems. However, MOUD provision was limited to subsets of prisons within these systems: 15% provided buprenorphine, 9% provided methadone, 36% provided naltrexone, and only 7% provided all three. Buprenorphine and methadone were most frequently provided to pregnant women or individuals already receiving these at admission, whereas naltrexone was primarily used at release. Funding was the most frequently cited barrier for all medications.

CONCLUSION

Study findings yield a complex picture of how, when, and to whom MOUD is provided across prisons within prison systems in states most heavily impacted by opioid overdose in the United States and have implications for expanding availability.

"That's No Longer Tolerated": Policing Patients' Use of Non-opioid Substances in Methadone Maintenance Treatment

The current overdose crisis in the United States emphasizes the importance of providing substance use treatment programs that are not only effective but tailored to meet the specific needs of the populations they serve. While Methadone Maintenance Treatment (MMT) is considered to be among the best strategies for reducing rates of opioid-involved overdose, its ability to attract and maintain patients may be hindered by a recent focus on policing the non-opioid substance use of people on the program. This paper uses interview data from treatment providers to examine how clinicians conceptualize and organize MMT in regards to patients' use of non-opioid drugs. Responses demonstrate that some treatment providers are increasingly monitoring their patients' use of non-opioid substances and punishing them for infractions, up to and including discharge from treatment. This approach will likely result in increasing rates of patient dropout and a lack of new admissions among people who use non-opioid substances. This article argues that including non-opioid substances in MMT's mandate restricts its ability to improve public health, including by preventing overdoses, and recommends instead that MMT adopt a more individualized approach, shaped by the needs and goals of the patient rather than those of the clinician.

A Scoping Review of Barriers and Facilitators to Implementation of Medications for Treatment of Opioid Use Disorder within the Criminal Justice System

BACKGROUND

Policies aimed at addressing the high rates of opioid overdose have prioritized increasing access to medications for treatment of opioid use disorder (MOUD). Numerous barriers exist to providing MOUD within the criminal justice system and/or to justice-involved populations. The aim of this study was to conduct a scoping review of the peer-reviewed literature on implementation of MOUD within criminal justice settings and with justice-involved populations.

METHODS

A systematic search process identified 53 papers that addressed issues pertaining to implementation barriers or facilitators of MOUD within correctional settings or with justice-involved populations; these were coded and qualitatively analyzed for common themes.

RESULTS

Over half of the papers were published outside of the U.S. (n = 28); the most common study designs were surveys or structured interviews (n = 20) and qualitative interviews/focus groups (n = 18) conducted with correctional or treatment staff and with incarcerated individuals. Four categories of barriers and facilitators were identified: institutional, programmatic, attitudinal, and systemic. Institutional barriers typically limited capacity to provide MOUD to justice-involved individuals, which led to programmatic practices in which MOUD was not implemented following clinical guidelines, often resulting in forcible withdrawal or inadequate treatment. These programmatic practices commonly led to aversive experiences among justice-involved individuals, who consequently espoused negative attitudes about MOUD and were reluctant to seek treatment with MOUD following their release to the community. Facilitators of MOUD implementation included increased knowledge and information from training interventions and favorable prior experiences with individuals being treated with MOUD among correctional and treatment staff. Few systemic facilitators to implementing MOUD with justice-involved individuals were evident in the literature.

CONCLUSION

Barriers to implementing MOUD in criminal justice settings and/or with justice-involved populations are pervasive, multi-leveled, and inter-dependent. More work is needed on facilitators of MOUD implementation.

Optimising opioid substitution therapy in the prison environment

PURPOSE

The purpose of this paper is to examine the current provision of opioid substitution therapy (OST) during and immediately following release from detention in prisons in England and Wales.

DESIGN/METHODOLOGY/APPROACH

A group of experts was convened to comment on current practices and to make recommendations for improving OST management in prison. Current practices were previously assessed using an online survey and a focus group with experience of OST in prison (Webster, 2017).

FINDINGS

Disruption to the management of addiction and reduced treatment choice for OST adversely influences adequate provision of OST in prison. A key concern was the routine diversion of opiate substitutes to other prisoners. The new controlled drug formulations were considered a positive development to ensure streamlined and efficient OST administration. The following patient populations were identified as having concerns beyond their opioid use, and therefore require additional considerations in prison: older people with comorbidities and complex treatment needs; women who have experienced trauma and have childcare issues; and those with existing mental health needs requiring effective understanding and treatment in prison.

ORIGINALITY/VALUE

Integration of clinical and psychosocial services would enable a joint care plan to be tailored for each individual with opioid dependence and include options for detoxification or maintenance treatment. This would better enable those struggling with opioid use to make informed choices concerning their care during incarceration and for the period immediately following their release. Improvements in coordination of OST would facilitate inclusion of strategies to further streamline this process for the benefit of prisoners and prison staff.

Opioid-related treatment, interventions, and outcomes among incarcerated persons: A systematic review

BACKGROUND

Worldwide opioid-related overdose has become a major public health crisis. People with opioid use disorder (OUD) are overrepresented in the criminal justice system and at higher risk for opioid-related mortality. However, correctional facilities frequently adopt an abstinence-only approach, seldom offering the gold standard opioid agonist treatment (OAT) to incarcerated persons with OUD. In an attempt to inform adequate management of OUD among incarcerated persons, we conducted a systematic review of opioid-related interventions delivered before, during, and after incarceration.

METHODS AND FINDINGS

We systematically reviewed 8 electronic databases for original, peer-reviewed literature published between January 2008 and October 2019. Our review included studies conducted among adult participants with OUD who were incarcerated or recently released into the community (≤90 days post-incarceration). The search identified 2,356 articles, 46 of which met the inclusion criteria based on assessments by 2 independent reviewers. Thirty studies were conducted in North America, 9 in Europe, and 7 in Asia/Oceania. The systematic review included 22 randomized control trials (RCTs), 3 non-randomized clinical trials, and 21 observational studies. Eight observational studies utilized administrative data and included large sample sizes (median of 10,419 [range 2273-131,472] participants), and 13 observational studies utilized primary data, with a median of 140 (range 27-960) participants. RCTs and non-randomized clinical trials included a median of 198 (range 15-1,557) and 44 (range 27-382) participants, respectively. Twelve studies included only men, 1 study included only women, and in the remaining 33 studies, the percentage of women was below 30%. The majority of study participants were middle-aged adults (36-55 years). Participants treated at a correctional facility with methadone maintenance treatment (MMT) or buprenorphine (BPN)/naloxone (NLX) had lower rates of illicit opioid use, had higher adherence to OUD treatment, were less likely to be re-incarcerated, and were more likely to be working 1 year post-incarceration. Participants who received MMT or BPN/NLX while incarcerated had fewer nonfatal overdoses and lower mortality. The main limitation of our systematic review is the high heterogeneity of studies (different designs, settings, populations, treatments, and outcomes), precluding a meta-analysis. Other study limitations include the insufficient data about incarcerated women with OUD, and the lack of information about incarcerated populations with OUD who are not included in published research.

CONCLUSIONS

In this carefully conducted systematic review, we found that correctional facilities should scale up OAT among incarcerated persons with OUD. The strategy is likely to decrease opioid-related overdose and mortality, reduce opioid use and other risky behaviors during and after incarceration, and improve retention in addiction treatment after prison release. Immediate OAT after prison release and additional preventive strategies such as the distribution of NLX kits to at-risk individuals upon release greatly decrease the occurrence of opioid-related overdose and mortality. In an effort to mitigate the impact of the opioid-related overdose crisis, it is crucial to scale up OAT and opioid-related overdose prevention strategies (e.g., NLX) within a continuum of treatment before, during, and after incarceration.

Effectiveness of medication assisted treatment for opioid use in prison and jail settings: A meta-analysis and systematic review

This study examined the state of the literature on the effectiveness of medication assisted treatment (MAT; methadone, buprenorphine, naltrexone) delivered in prisons and jails on community substance use treatment engagement, opioid use, recidivism, and health risk behaviors following release from incarceration. Randomized controlled trials (RCTs) and quasi-experimental studies published through December 2017 that examined induction to or maintenance on methadone (n = 18 studies), buprenorphine (n = 3 studies), or naltrexone (n = 3 studies) in correctional settings were identified from PsycINFO and PubMed databases. There were a sufficient number of methadone RCTs to meta-analyze; there were too few buprenorphine or naltrexone studies. All quasi-experimental studies were systematically reviewed. Data from RCTs involving 807 inmates (treatment n = 407, control n = 400) showed that methadone provided during incarceration increased community treatment engagement (n = 3 studies; OR = 8.69, 95% CI = 2.46; 30.75), reduced illicit opioid use (n = 4 studies; OR = 0.22, 95% CI = 0.15; 0.32) and injection drug use (n = 3 studies; OR = 0.26, 95% CI = 0.12; 0.56), but did not reduce recidivism (n = 4 studies; OR = 0.93, 95% CI = 0.51; 1.68). Data from observational studies of methadone showed consistent findings. Individual review of buprenorphine and naltrexone studies showed these medications were either superior to methadone or to placebo, or were as effective as methadone in reducing illicit opioid use post-release. Results provide the first meta-analytic summary of MATs delivered in correctional settings and support the use of MATs, especially with regard to community substance use treatment engagement and opioid use; additional work is needed to understand the reduction of recidivism and other health risk behaviors.

Only One In Twenty Justice-Referred Adults In Specialty Treatment For Opioid Use Receive Methadone Or Buprenorphine

People in the US criminal justice system experience high rates of opioid use disorder, overdose, and other adverse outcomes. Expanding treatment is a key strategy for addressing the opioid epidemic, but little is known about whether the criminal justice system refers people to the highest standard of treatment: the use of the opioid agonist therapies methadone or buprenorphine. We used 2014 data from the national Treatment Episode Data Set to examine the use of agonist treatment among justice-involved people referred to specialty treatment for opioid use disorder. Only 4.6 percent of justice-referred clients received agonist treatment, compared to 40.9 percent of those referred by other sources. Of all criminal justice sources, courts and diversionary programs were least likely to refer people to agonist treatment. Our findings suggest that an opportunity is being missed to promote effective, evidence-based care for justice-involved people who seek treatment for opioid use disorder.

Effects of medication assisted treatment (MAT) for opioid use disorder on functional outcomes: A systematic review

This systematic review synthesizes evidence on the effects of Medication-Assisted Treatment (MAT) for opioid use disorder (OUD) on functional outcomes, including cognitive (e.g., memory), physical (e.g., fatigue), occupational (e.g., return to work), social/behavioral (e.g., criminal activity), and neurological (e.g., balance) function. Five databases were searched from inception to July 2017 to identify English-language controlled trials, case control studies, and cohort comparisons of one or more groups; cross-sectional studies were excluded. Two independent reviewers screened identified literature, abstracted study-level information, and assessed the quality of included studies. Meta-analyses used the Hartung-Knapp method for random-effects models. The quality of evidence was assessed using the GRADE approach. A comprehensive search followed by 1411 full text publication screenings yielded 30 randomized controlled trials (RCTs) and 10 observational studies meeting inclusion criteria. The studies reported highly diverse functional outcome measures. Only one RCT was rated as high quality, but several methodologically sound observational studies were identified. The statistical power to detect differences in functional outcomes was unclear in most studies. When compared with matched "healthy" controls with no history of substance use disorder (SUD), in two studies MAT patients had significantly poorer working memory and cognitive speed. One study found MAT patients scored worse in aggressive responding than did "healthy" controls. A large observational study found that MAT users had twice the odds of involvement in an injurious traffic accident as non-users. When compared with persons with OUD not on MAT, one cohort study found lower fatigue rates among buprenorphine-treated OUD patients. No differences were reported for occupational outcomes and results for criminal activity and other social/behavioral areas were mixed. There were few differences among MAT drug types. A pooled analysis of three RCTs found a significantly lower prevalence of fatigue with buprenorphine compared to methadone, while a meta-analysis of the same RCTs found no statistical difference in insomnia prevalence. Three RCTs that focused on cognitive function compared the effects of buprenorphine to methadone; no statistically significant differences in memory, cognitive speed and flexibility, attention, or vision were reported. The quality of evidence for most functional outcomes was rated low or very low. In sum, weaknesses in the body of evidence prevent strong conclusions about the effects of MAT for opioid use disorder on functional outcomes. Rigorous studies of functional effects would strengthen the body of literature.

An Examination of Women Ex-Offenders With Methadone Histories

Criminal (drug and prostitution) charges, employment levels (weekly hours), recent substance use in the past 6 months, and primary sources of income were examined among a sample ( n = 106) of women ex-offenders who had opioid use disorders with and without methadone histories. A general linear model was tested to examine differences in relation to methadone use history. Results from a one-way MANCOVA found that those with methadone histories reported significantly higher levels of drug and prostitution charges than those without any methadone history, but no significant differences in terms of weekly hours of employment or recent substance use were observed between groups. Women ex-offenders with methadone histories reported various sources of income beyond employment, and proportionally, more of these women reported prostitution as a primary source of income. Findings suggest that methadone maintenance treatments are not sufficient in meeting the needs of women ex-offenders.

Impact of Medication-Assisted Treatment for Opioid Addiction on Medicaid Expenditures and Health Services Utilization Rates in Vermont

In the face of increasing rates of overdose deaths, escalating health care costs, and the tremendous social costs of opioid addiction, policy makers are asked to address the questions of whether and how to expand access to treatment services. In response to an upward trend in opioid abuse and adverse outcomes, Vermont is investing in statewide expansion of a medication-assisted therapy program delivered in a network of community practices and specialized treatment centers (Hub & Spoke Program). This study was conducted to test the rationale for these investments and to establish a pre-Hub & Spoke baseline for evaluating the additive impact of the program. Using a serial cross-sectional design from 2008 to 2013 to evaluate medical claims for Vermont Medicaid beneficiaries with opioid dependence or addiction (6158 in the intervention group, 2494 in the control group), this study assesses the treatment and medical service expenditures for those receiving medication-assisted treatment compared to those receiving substance abuse treatment without medication. Results suggest that medication-assisted therapy is associated with reduced general health care expenditures and utilization, such as inpatient hospital admissions and outpatient emergency department visits, for Medicaid beneficiaries with opioid addiction. For state Medicaid leaders facing similar decisions on approaches to opioid addiction, these results provide early support for expanding medication-assisted treatment services rather than relying only on psychosocial, abstinence, or detoxification interventions.