Addressing Opioid Use Disorder in Corrections:
The Latest Science and Evidence From the Justice Community Opioid Innovation Network
Braeden Kelly & Julia Rosenberg
Both the rate of opioid use disorder and the rate of overdose following release from jail or prison are disproportionately high in justice-involved populations.1 Individuals leaving incarceration with opioid use disorder (OUD) are also at high risk for recidivism and adverse health outcomes.2 Providing medications for OUD (MOUD) during incarceration and post-release is effective in reducing negative outcomes, yet these medications are largely underutilized in correctional facilities. 3,4
The Justice Community Opioid Innovation Network (JCOIN) is a groundbreaking initiative led by the National Institute on Drug Addiction (NIDA) at the National Institutes of Health (NIH) to study and disseminate evidence-informed approaches to ensure quality care is provided to individuals with OUD in the criminal legal system. NIDA awarded JCOIN grants to 13 clinical research centers (“Research Hubs”) and two large resource centers: the Coordination and Translation Center (CTC) and the Methodology and Advanced Analytics Resource Center (MAARC). Together, these centers engage justice settings and treatment providers in research studies to address the opioid crisis and disseminate findings to stakeholders across the country. JCOIN’s collective vision is that every justice-involved individual with a substance use disorder should have timely access to evidence-based practices and treatment(s), whether the individual is detained or residing in the community. To this end, JCOIN has become a go-to resource for both practitioners and researchers.
A vital component of JCOIN is providing rapid translation of scientific knowledge into consumable, accessible, and actionable products tailored to specific audiences. To date, JCOIN has developed over 60 products that translate JCOIN research findings and other discoveries pertinent to the field, including research summaries, video explainers, infographics, and issue briefs.
The following are must-know research findings from JCOIN studies that showcase the latest science on MOUD and their effectiveness for people involved with the criminal legal system, and best practices for preventing MOUD diversion in correctional facilities.
Offering Buprenorphine Prior to Release from Jail May Reduce Recidivism
Drs. Elizabeth Evans, Donna Wilson, and Peter Friedmann of the JCOIN’s Massachusetts Clinical Research Center (Research Hub) completed a study of the impact of offering buprenorphine in county jails on post-release recidivism events (incarceration, probation violation, arraignment). The researchers conducted a
natural experiment comparing two county jails with similar populations and locations, the Massachusetts Franklin County Jail (FCSO) and the Hampshire County Jail (HCHC). While FSCO offered incarcerated individuals buprenorphine, HCHC did yet not offer these services at the time of the study. The study found that FCSO individuals (n=197) who were provided buprenorphine were 32% less likely to recidivate during the first year after release compared to the HCHC individuals HCHC (n=272) who did not have the opportunity to receive buprenorphine.5 The study included all adults with OUD (N = 469) who were released from two participating county jails in Massachusetts between January 1, 2015, and April 30, 2019. Participants were followed for one year after their release date. Results present compelling evidence that providing buprenorphine during the period of incarceration in jail can reduce recidivism and adverse outcomes.
Extended-Release Buprenorphine in Correctional Settings Shows Increased Treatment Retention and Reduced Opioid Use
New formulations of extended-release MOUDs are some of the most recent advancements in opioid treatment and have the potential to increase medication availability in a variety of settings, including corrections. While sublingual buprenorphine (dissolved under the tongue) must be taken daily, extended-release buprenorphine is an injection given once a month.
A study led by JCOIN’s New York University Clinical Research Center researchers found improved treatment outcomes for individuals prescribed extended-release buprenorphine in jail settings.6 The study compared treatment retention of incarcerated adults following release from jail receiving daily sublingual buprenorphine compared to those receiving extended-release buprenorphine. Study participants receiving extended-release medication began treatment prior to release and continued monthly through 8 weeks after release from the Rikers Island jail in New York.
Participants taking sublingual buprenorphine continued to receive daily directly observed in-jail administration and were provided a 7-day supply at jail release, with instructions to follow up at a designated clinic.
Key results:
• Extended-release buprenorphine had greater treatment retention and lower rates of opioid use after release from jail.
• 69% of the extended-release group were still utilizing medication at 8 weeks post-release, vs 35% among the daily sublingual buprenorphine group.
• Rates of opioid-negative urine tests were also higher among the extended-release buprenorphine at 55%, compared to 38% of the daily medication cohort.
Dr. Josh Lee, a Professor at New York University’s Grossman School of Medicine, shared: “We have several hundred people receiving buprenorphine and leaving jail each year in New York City. The primary outcome we were looking for here was whether people were able to stay on medication of any type, so staying on buprenorphine of any formulation. Extended-release buprenorphine had a clear advantage in terms of more people staying on buprenorphine for the next eight weeks.”
What this means for future research:
Extended-release buprenorphine demonstrated several advantages compared to sublingual buprenorphine, including fewer clinic visits during incarceration and improved treatment retention in the weeks following release from jail. These findings support the wider use of extended-release buprenorphine as a correctional and reentry opioid use disorder treatment. The researchers call for studies that explore retention outcomes past 8 weeks and the cost-effectiveness of implementing extended-release buprenorphine in correctional settings.
Six Strategies to Prevent MOUD Diversion in Jail–Based Treatment Programs and Key Buprenorphine Dosing Recommendations
Diversion of MOUD treatment is often cited as a concern and a reason for not offering the medications in jails and prisons. Researchers from the University of Massachusetts published a study in 2023 that detailed promising practices in program design to help limit medication diversion. The study also details guidance for corrections and lawmakers as they consider implementing MOUD treatment in correctional settings.
Led by Drs. Elizabeth Evans, Ekaterina Pivovarova, Thomas Stopka, Claudia Santelices, Warren Ferguson, and Peter Friedmann, the study identified six key diversion prevention strategies based on feedback from jail based MOUD program staff.7 The recommendations were gathered from semi-structured one-on-one interviews and focus groups with senior administrators, correctional officers, and behavioral health and clinical staff in seven Massachusetts jails. Through these conversations, participants shared effective approaches utilized to prevent buprenorphine diversion or have been shown to lower the number of diversion attempts in their respective jails.
The strategies include:
1. Determine reasons for diverting medications, which enables the staff to tailor their response to different types of diversion (e.g., coerced, euphoria, split-dosing, and accidental).
2. Use standardized but flexible dosing protocols that can be adapted to patients’ needs.
3. Communicate with and educate patients about how jail staff are effective at intercepting and preventing diversion as well as medication safety.
4. Provide a sufficient staff-to-patient ratio to ensure adequate and constant supervision during MOUD initiation.
5. Conduct routine surveillance to detect potential diversion, including searching housing units, monitoring phone calls for mention of diversion or substance use, and checking urine testing results.
6. Develop strategies to respond to diversion that provide patients opportunities to continue treatment, such as changes to medication type or dose, individual counseling sessions, and being dosed individually rather than in groups.
6 Key Strategies to Prevent MOUD Diversion in Jail-based Programs (Figure 1)
The study also outlined key dosing recommendations for MOUD program treatment staff.7 The recommended protocols span the entire MOUD dispensing cycle: from dispensing preparation and process to supervision following medication initiation and ensuring proper consumption to handling suspected diversion. The researchers advocate for medical staff to assist small groups of patients at a time and implement rules requiring patients to remove their shirts and dentures and sit on their hands to mitigate diversion risks. Standardized procedures, including nurses supervising patients drinking water after taking the medication, nurses ensuring patients’ spit appears normal, and nurses conducting checks of the patient’s hands and mouth, are simple actionable steps correctional facilities can adopt to lower diversion rates.
15 Key Buprenorphine Dosing Recommendations for Jail-Based Treatment Programs (Figure 2)
The growing rates of substance use and overdose deaths, especially related to opioids, have significantly impacted the U.S. criminal legal system. Corrections practitioners can play an integral role in facilitating access to OUD treatment and other support services that can improve health, reduce justice system costs, and prevent recidivism. These studies add to the existing evidence on the effectiveness of OUD treatment in correctional facilities and provide valuable insights into actionable steps to prevent the diversion of MOUD.
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Braeden Kelly is the Managing Director of Initiatives at Addiction Policy Forum (APF), a national nonprofit organization dedicated to eliminating addiction as a major health problem. Braeden oversees several national projects that focus on collaborating with community partners to study, translate, and disseminate evidence-based approaches and information to increase the uptake of evidence-based practice to prevent and treat substance use disorders. He also works closely with thought leaders, clinicians, policymakers, and practitioners to facilitate education, training, technical assistance, knowledge sharing, and quick feedback loops to bridge the gap between research and practice. For more information, he can be reached at bkelly@addictionpolicy.org.
Julia Rosenberg is a Project Coordinator at the Addiction Policy Forum (APF) where she supports research translation and stakeholder engagement efforts for JCOIN and other APF initiatives. Prior to joining APF in 2023, Julia worked in two substance use programs in the San Francisco County jails and completed her Master of Science in Justice, Law, and Criminology at American University. For more information, she can be reached at julia@addictionpolicy.org.
References
Winkelman, T., Chang, V. W., & Binswanger, I. A. (2018). Health, Polysubstance Use, and Criminal Justice Involvement Among Adults With Varying Levels of Opioid Use. JAMA Network Open, 1(3), e180558. https://doi.org/10.1001/jamanetworkopen.2018.0558
Russ, E. N., Puglisi, L., Eber, G. B., Morse, D. S., Taxman, F. S., Dupuis, M. F., Ashkin, E., & Ferguson, W. J. (2021). Prison And Jail Reentry And Health. Health Affairs Health Policy Brief. https://www.healthaffairs.org/do/10.1377/hpb20210928.343531/
National Academies of Sciences, Engineering, and Medicine. 2019. Medications for opioid use disorder save lives. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25310.
Nunn, A., Zaller, N., Dickman, S., Trimbur, C., Nijhawan, A., & Rich, J. D. (2009). Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey. Drug and Alcohol Dependence, 105(1-2), 83–88. https://doi.org/10.1016/ j.drugalcdep.2009.06.015
Evans, E. A., Wilson, D., & Friedmann, P. D. (2022). Recidivism and mortality after in-jail buprenorphine treatment for opioid use disorder. Drug and alcohol dependence, 231, 109254. https://doi.org/10.1016/ j.drugalcdep.2021.109254
Lee, J. D., Malone, M., McDonald, R., Cheng, A., Vasudevan, K., Tofighi, B., Garment, A., Porter, B., Goldfeld, K. S., Matteo, M., Mangat, J., Katyal, M., Giftos, J., & MacDonald, R. (2021). Comparison of Treatment Retention of Adults With Opioid Addiction Managed With Extended-Release Buprenorphine vs Daily Sublingual Buprenorphine-Naloxone at Time of Release From Jail. JAMA Network Open, 4(9), e2123032. https://doi.org/10.1001/jamanetworkopen.2021.23032
Evans, E. A., Pivovarova, E., Stopka, T. J., Santelices, C., Ferguson, W. J., & Friedmann, P. D. (2022). Uncommon and preventable: Perceptions of diversion of medication for opioid use disorder in jail. Journal of substance abuse treatment, 138, 108746. https://doi.org/10.1016/ j.jsat.2022.108746