"Just fighting for my life to stay alive": a qualitative investigation of barriers and facilitators to community re-entry among people with opioid use disorder and incarceration histories

Non-fatal opioid overdose and unmet need for medications for opioid use disorder among recently incarcerated people who inject drugs

BACKGROUND

Medications for opioid use disorder (MOUD) are key to preventing opioid overdose. Despite the high risk of opioid overdose among recently incarcerated people who use drugs, missed opportunities for engagement in MOUD treatment persist in this population. We examined the association between unmet need for MOUD and non-fatal opioid overdose among recently incarcerated people who inject drugs (PWID) and assessed prevalence of non-fatal opioid overdose by selected characteristics.

METHODS

We analyzed 2022 data from the National HIV Behavioral Surveillance (NHBS) system among PWID from 20 large U.S. cities. Adjusted prevalence ratios (aPR) and 95 % confidence intervals (95 % CI) were calculated to examine the association between unmet need for MOUD and non-fatal opioid overdose.

RESULTS

Among 1648 recently incarcerated PWID, 28 % reported an unmet need for MOUD and 39 % reported a non-fatal opioid-involved overdose in the past 12 months. Experiencing homelessness in the last 12 months (aPR=1.43, 95 % CI=1.27-1.61) and living in the Midwest region of the U.S. (aPR=1.18, 95 % CI=1.01-1.38) were significantly associated with reporting a non-fatal opioid overdose. Recently incarcerated PWID with an unmet need for MOUD were 1.4 times as likely to report a non-fatal opioid overdose in the past 12 months (50 %; aPR=1.42, 95 % CI=1.29-1.56) compared with recently incarcerated PWID without an unmet need for MOUD (35 %).

CONCLUSIONS

Unmet need for MOUD was significantly associated with non-fatal opioid overdose among PWID who were incarcerated in the past 12 months, suggesting the need to investigate specific strategies to improve to MOUD treatment among recently incarcerated PWID.

Community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated: a review of Wisconsin legislation and regulations

Opioid use disorder (OUD) is highly prevalent among jail and prison populations in the United States, including in Wisconsin. Medications for opioid use disorder (MOUD), including long-acting injectable naltrexone, are crucial in the treatment of OUD. These medications are especially important for individuals transitioning out of jail or prison and back into the community. Unfortunately, few individuals who were formerly incarcerated continue MOUD after reentry due to a variety of barriers. Wisconsin community pharmacists are highly accessible and uniquely positioned to provide care for this population, specifically by administering injectable naltrexone. However, community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated has not been previously explored. As a first step, this legislative and regulatory review aimed to identify Wisconsin statutes and administrative codes that may impact these services for this population. Two legal databases were searched to identify relevant Wisconsin statute and administrative code subsections. Overall, 24 statute subsections (from 7 chapters) and 31 administrative code subsections (from 12 chapters) were identified that (1) highlighted a need or potential role of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated or (2) served as a potential barrier or facilitator to the availability, access, or use of these services. Future work should focus on helping community pharmacists leverage available resources and overcome existing legal barriers to providing or supporting MOUD services. Importantly, work should be done to ensure that individuals who were formerly incarcerated can be linked to these services upon reentry.

Barriers and facilitators to community pharmacist-provided injectable naltrexone for formerly incarcerated individuals during community reentry

Introduction

Medications for opioid use disorder (MOUD), including injectable naltrexone, are a key component in the treatment of opioid use disorder (OUD). These medications are especially important for individuals transitioning out of correctional facilities and back into their communities. Unfortunately, few formerly incarcerated individuals have access to MOUD upon reentry, incurring a 40-fold greater likelihood of overdose following release compared to the general population. In Wisconsin, community pharmacists have the authority to administer naltrexone injections. However, they have not been explored as a resource for improving access to this medication for this patient population.

Objective

As a first step, the goal of this study was to understand the barriers and facilitators impacting the use of community pharmacist-provided injectable naltrexone by formerly incarcerated individuals during community reentry period.

Materials and methods

The researcher conducted semi-structured interviews with 18 individuals representing five stakeholder groups, including four MOUD prescribers, three community pharmacists, four correctional staff, four community organization or non-profit staff, and three individuals or family members/caregivers of individuals with a history of OUD and incarceration. Deductive and inductive content analysis were used to identify barrier and facilitator categories across the five levels of the Socioecological Model.

Results

Overall, participants discussed factors at every level, and many barriers and facilitators confirmed findings from existing literature focused on MOUD access for formerly incarcerated individuals. Participants also identified factors more specific to community pharmacies, including 1) lack of interagency collaboration between pharmacists, prescribers, and correctional facilities and 2) lack of awareness of community pharmacist-provided injectable naltrexone services.

Conclusions

Future research should explore interventions to address the barriers identified in this study and improve connections between community pharmacists and formerly incarcerated individuals. This work can help ensure that these individuals are given the chance to successfully reintegrate into their communities.

Medication for opioid use disorder service delivery in carceral facilities: update and summary report

The opioid overdose crisis intersects critically with the criminal legal system where individuals with opioid use disorder (are significantly overrepresented. Subsequently, incarceration increases the risk of opioid overdose due to reduced tolerance, interrupted social supports, and limited access to treatment. Medications for opioid use disorder (MOUD), such as methadone, buprenorphine, and naltrexone, have been shown to reduce opioid-related mortality and improve outcomes for those in carceral settings. Despite this, access to MOUD in jails and prisons remains limited due to stigma, concerns about medication diversion, and logistical challenges. This paper reviews the current state of knowledge on MOUD in carceral settings, summarizing the prevalence of treatment programs, the role of novel formulations like injectable buprenorphine, and barriers to implementation. It also explores the continuum of care, emphasizing the importance of initiating MOUD during incarceration and ensuring continuation upon release to prevent treatment gaps. Recent policy changes, such as Sect. 1115 Medicaid waivers, offer promising avenues for expanding access, but retention in treatment and post-release outcomes remain significant challenges. The paper provides a comprehensive overview of existing literature and updates on MOUD service delivery, including the impact of recent policy shifts and research on outcomes such as recidivism and health improvement. It concludes by identifying key areas for future research, including strategies to improve treatment retention, address systemic barriers through criminal justice reform, and enhance care coordination during the transition from incarceration to the community.

Engaging the Great Circle: a qualitative study of the Confederated Tribes of Grand Ronde’s mobile medication unit

BACKGROUND

The Confederated Tribes of the Grand Ronde Community of Oregon began a Mobile Medication Unit (MMU) as part of their Great Circle Recovery Opioid Treatment Program (OTP) to address elevated rates of opioid use disorder (OUD) among American Indians and Alaska Natives in Oregon. The MMU provides methadone or buprenorphine for individuals with OUD, enrolled in the OTP, who are living either on the reservation or in surrounding rural communities. An implementation study describes the service through document review and qualitatively assesses patient and staff experiences and the perceived barriers and facilitators to mobile services.

METHODS

Semi-structured qualitative interviews with patients (n = 11), MMU staff (n = 5), and the state opioid treatment authority (n = 1) gathered details on the initiative's development and operations. Provider interviews probed implementation experiences. Patient interviews focused on their experiences with the MMU and staff, changes in quality of life and recommendations for enhancing treatment. Interviews were transcribed and analysed using a Thematic Analysis approach.

RESULTS

Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members; the catalysts for the MMU), two steps toward MMU development (i.e. Tribal approvals and support; the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers; facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Patients' themes noted the MMU's professional and 'caring' environment, accessible rural locations and general suggestions including culturally responsive ancillary services.

CONCLUSION

The Great Circle MMU enhanced access to opioid agonist therapy for people with OUD (i.e. American Indians/Alaska Natives, and non-natives) living in rural communities. The Confederated Tribes of Grand Ronde operates the first Tribally owned OTP MMU, grounded in cultural humility and committed to Tribal members and the great circle of the larger community.

Perceptions of Community Corrections and Treatment Experience: A Qualitative Study Among People With Incarceration Histories Receiving Outpatient Methadone Treatment

BACKGROUND

Community correctional experiences among individuals receiving methadone treatment (MT) for opioid use disorder (OUD) are poorly understood. We qualitatively investigated perceptions of community corrections and treatment experiences among individuals with criminal-legal system experience currently receiving outpatient MT.

METHODS

From January to December 2017, we recruited 42 individuals with history of criminal-legal system involvement enrolled in outpatient MT at a low-barrier nonprofit organization operating multiple clinics in Connecticut. An experienced qualitative research team conducted one-to-one, in-person, semistructured interviews about incarceration and treatment experiences with individuals receiving MT. Participants completed a demographics survey. The interviews were audiorecorded, transcribed, de-identified, and independently coded using NVivo.

RESULTS

Participants described the community corrections system as restrictive and abstinence-focused. Most participants described positive perceptions of and experiences with community corrections officers (CCOs), yet described negative perceptions of and experiences with the community corrections system overall. Participants perceived CCOs to have limited knowledge of OUD and MT. Participants described a range of CCO judgment toward their OUD, with some appearing understanding and nonjudgmental while others were perceived to have stigma and prejudice. Few participants noted assistance from CCOs with seeking MT or community-based substance use disorder care. Some participants desired improved treatment facilitation, but viewed forced or coercive treatment negatively.

CONCLUSION

To our knowledge, this is the first qualitative study to examine community corrections experience among people receiving outpatient medication for OUD. While individuals receiving MT have negative experiences with the community corrections system, they perceive individual CCOs positively. Interventions addressing gaps in CCOs knowledge of OUD and MT are needed to optimize support for individuals on probation or parole with OUD. Provision of OUD treatment facilitation appears desirable to some individuals in community supervision.

Barriers and Facilitators to Community Pharmacist-Provided Injectable Naltrexone for Formerly Incarcerated Individuals During Community Reentry in Wisconsin

Medications for opioid use disorder (MOUD), including injectable naltrexone, are a key component in the treatment of opioid use disorder (OUD). These medications are especially important for individuals transitioning out of correctional facilities and back into their communities, as individuals receiving MOUD are 85% less likely to die due to drug overdose in the first month post-release and have a 32% lower risk of rearrest. Unfortunately, few formerly incarcerated individuals have access to MOUD upon reentry, incurring a 40-fold greater likelihood of overdose following release compared to the general population. While 84% of Wisconsin jails offering MOUD offer naltrexone, less than half provide linkage to community treatment for reentering individuals. In Wisconsin, community pharmacists have the authority to provide naltrexone injections. However, they have not been explored as a resource for improving access to this medication for formerly incarcerated individuals. As a first step, the goal of this study was to understand the barriers and facilitators impacting access to community pharmacist-provided injectable naltrexone for this patient population during community reentry period. The researcher conducted semi-structured interviews with 18 individuals representing five stakeholder groups. Deductive and inductive content analysis were used to identify barrier and facilitator categories across the five levels of the Socioecological Model. Overall, participants discussed factors at every level, and many barriers and facilitators confirmed findings from existing literature focused on MOUD access for formerly incarcerated individuals. Participants also identified factors more specific to community pharmacies, including 1) lack of interagency collaboration between pharmacists, prescribers, and correctional facilities and 2) lack of awareness of community pharmacist-provided MOUD services. Future research should explore interventions to address the barriers identified in this study and improve connections between community pharmacists and formerly incarcerated individuals. This work can help ensure that these individuals are given the chance to successfully reintegrate into society.

Feasibility and effectiveness of extended-release buprenorphine (XR-BUP) among correctional populations: a systematic review

Background: Medications for opioid use disorder (MOUD) reduce risks for overdose among correctional populations. Among other barriers, daily dosing requirements hinder treatment continuity post-release. Extended-release buprenorphine (XR-BUP) may therefore be beneficial. However, limited evidence exists.Objectives: To conduct a systematic review examining the feasibility and effectiveness of XR-BUP among correctional populations.Methods: Searches were carried out in Pubmed, Embase, and PsychINFO in October 2023. Ten studies reporting on feasibility or effectiveness of XR-BUP were included, representing n = 819 total individuals (81.6% male). Data were extracted and narratively reported under the following main outcomes: 1) Feasibility; 2) Effectiveness; and 3) Barriers and Facilitators.Results: Studies were heterogeneous. Correctional populations were two times readier to try XR-BUP compared to non-correctional populations. XR-BUP was feasible and safe, with no diversion, overdoses, or deaths; several negative side effects were reported. Compared to other MOUD, XR-BUP significantly reduced drug use, resulted in similar or higher treatment retention rates, fewer re-incarcerations, and was cost-beneficial, with a lower overall monthly/yearly cost. Barriers to XR-BUP, such as side effects and a fear of needles, as well as facilitators, such as a lowered risk of opioid relapse, were also identified.Conclusion: XR-BUP appears to be a feasible and potentially effective alternative treatment option for correctional populations with OUD. XR-BUP may reduce community release-related risks, such as opioid use and overdose risk, as well as barriers to treatment retention. Efforts to expand access to and uptake of XR-BUP among correctional populations are warranted.

"Expected to happen": perspectives on post-release overdose from recently incarcerated people with opioid use disorder

BACKGROUND

Opioid-related overdose is the leading cause of death for people recently released from incarceration, however treatment with medications for opioid use disorder (MOUD) during incarceration can reduce the mortality risk. This study seeks to qualitatively analyze perceptions of post-release overdose risk from the perspectives of people who received MOUD while incarcerated in one of eight Massachusetts jails during 2021-2022 using the Risk Environment Framework to guide analyses.

METHODS

N = 38 participants with lived experience of MOUD treatment during incarceration who are now living in the community were interviewed on factors that may contribute to or protect against post-release overdose risk. Themes were identified inductively and deductively using the Risk Environment Framework and its domains, which organizes themes along physical, social, economic, and policy environments on both the micro- and macro- scales.

RESULTS

The physical risk environment included loss of opioid tolerance during incarceration, polysubstance use, and the toxicity of the regional drug supply as key producers of increased risk for post-release overdose. Social drivers of risk included peer group risk norms-including peer-driven harm reduction practices and interpersonal relationships between drug sellers and buyers-as well as macro-level social determinants of health such as housing insecurity and availability of mental health services. Economic drivers of post-release overdose risk included lack of income generation during incarceration and employment challenges. Participants discussed several aspects of policy that contribute to post-release overdose risk, including availability of harm reduction supplies, public health services, and broader policy around MOUD.

CONCLUSIONS

The perspectives of people with lived experience are vital to understanding the disproportionate risks of overdose for those recently released from incarceration. Our results highlight the intersectional factors that produce and reproduce the post-release overdose risk environment, providing support for interventions across each domain of the Risk Environment Framework. By capturing perspectives from people with lived experience of OUD and incarceration during this critical period of risk, we can better identify interventions that target and mitigate overdose-related harm in this population.

Access to medications for opioid use disorder for formerly incarcerated individuals during community reentry: a mini narrative review

Medications for opioid use disorder (MOUD) are especially important for formerly incarcerated individuals with opioid use disorder (OUD) and can reduce the risk of re-arrest and overdose during community reentry. Unfortunately, few formerly incarcerated individuals are able to access MOUD within the community, missing a critical tool for rehabilitation. A mini narrative review was conducted to highlight the published work that has been done to improve access to MOUD for formerly incarcerated individuals during reentry. The results yielded 15 records describing intervention evaluations, program descriptions, and research in progress. Most work is ongoing, showing promise that researchers have identified the importance of this problem. However additional research should be done to include other stakeholders and address the limitations of existing interventions and programs. Continued efforts can help ensure that formerly incarcerated individuals can safely and successfully reintegrate into society.

Medicaid Inmate Exclusion Policy and Infectious Diseases Care for Justice-Involved Populations

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs' Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

HIV Risk and Interest in Preexposure Prophylaxis in Justice-Involved Persons

Preexposure prophylaxis (PrEP) is underused in persons who use drugs and justice-involved persons. In an ongoing randomized controlled trial in 4 US locations comparing patient navigation versus mobile health unit on time to initiation of HIV medication or PrEP for justice-involved persons who use stimulants or opioids and who are at risk for or living with HIV, we assessed HIV risk factors, perceived HIV risk, and interest in PrEP. Participants without HIV (n = 195) were 77% men, 65% White, 23% Black, and 26% Hispanic; 73% reported a recent history of condomless sex, mainly with partners of unknown HIV status. Of 34% (67/195) reporting injection drug use, 43% reported sharing equipment. Despite risk factors, many persons reported their risk for acquiring HIV as low (47%) or no (43%) risk, although 51/93 (55%) with PrEP indications reported interest in PrEP. Justice-involved persons who use drugs underestimated their HIV risk and might benefit from increased PrEP education efforts.

Substance use in the correctional settings: A qualitative exploration of individual and contextual characteristics and intervention strategies using the behavior change wheel framework

BACKGROUND AND OBJECTIVES

Planning and implementing prison-based substance use disorder (SUD) interventions are challenging. We wanted to understand why and how people in correctional settings (CS) use drugs and to explore what policies, environmental, and interpersonal factors influence substance use among incarcerated people. Using the Behavior Change Wheel (BCW) framework, we proposed a thematic map with intervention functions to reduce substance use in CS.

METHODS

We used the Framework Method of qualitative analysis. We did snowball sampling for the incarcerated people with drug use (PWD) and convenience sampling for the staff. The in-depth interview sample comprised 17 adult PWD, three prison administrative, and two healthcare staff. We determined the sample size by thematic data saturation. We followed a mixed coding approach for generating categories, i.e., deductive (based on the BCW framework) and inductive. The study constructed the final theoretical framework by determining the properties of the categories and relationships among the categories.

RESULTS

We identified eleven categories aligned with the BCW framework. The themes were prison routine, interpersonal dynamics of the incarcerated population, exposure to substance use, attitude of staff towards PWD, experience with prison healthcare, willingness (to reduce drug use) and coping, compassion, drug use harms, conflict between staff and residents, stigma, and family/peer support. The BCW framework aided the identification of potential intervention functions and their interactions with the organizational policies that could influence PWD's capability-opportunity-motivation (COM) and drug use behavior (B).

CONCLUSION

There is a need to raise awareness of SUD prevention and intervention among decision-makers and revisit the prison policies.