Medications for Opioid Use Disorder in State Prisons: A Look at Current Delivery Status
As the United States battles a growing opioid epidemic, corrections professionals face the considerable demands of managing a population increasingly dependent on opioids. Although substantial information about best practices for treating opioid use disorder exists, there is little information about how correctional systems and prisons within them are actually responding to the epidemic. And despite widespread evidence that medications to treat opioid use disorder are effective – and strong recommendations for the use of MOUD in criminal justice settings – the corrections field is not always current regarding what treatments are available for and accessible to incarcerated people with OUD.
In 2019, the research team at Chestnut Health Systems, a nonprofit organization that offers comprehensive behavioral health and human services in Illinois and Missouri, received funding from the National Institute on Drug Abuse to conduct a study of health care practices currently being implemented by correctional facilities and organizations to address the opioid epidemic, particularly in areas hard hit by the crisis. Working with Carnevale Associates, a Washington, DC-based consulting firm specializing in substance use, behavioral health, and criminal justice research, we hoped to learn what types of resources, training, and technical assistance corrections staff need to improve their capacity to mitigate the effects of the opioid crisis within their state systems.
CHS conducted in-depth interviews with representatives from 21 prison systems representing 538 prisons in states with the highest number or rates of opioid-overdose fatalities. Participants were asked about the types of MOUD available in their state system and/or their facility, the criteria for determining which individuals are eligible to receive MOUD over the course of their incarceration, and any barriers to implementation. We also asked about their future plans and needs to address the challenges of the opioid epidemic, including efforts to link individuals to community-based treatment upon release.
What we found paints a complex picture of how, when, and to whom MOUD is provided across prison systems in the states most heavily impacted by opioids. We believe our findings have implications for policies related to expanding MOUD availability by addressing funding and regulatory barriers, expanding clinical capacity, and reducing stigma associated with treatment for OUD.
Availability and Delivery of Medications for OUD
All 21 participating state prison systems reported that one or more of their prisons provide at least one of the three types of MOUD currently authorized by the Food and Drug Administration (i.e., methadone, buprenorphine, and/or naltrexone). However, only 62% reported that one or more of their prisons provide all three types of MOUD, and 61% of the 538 individual prisons do not provide any MOUD.
Almost all (19 of 21) prison systems reported that treatment with buprenorphine is available in at least one prison within their system, provided specific conditions are met. Slightly over half (52%)provide buprenorphine to individuals already being treated with it at the time of admission. Further, buprenorphine is only used in a relatively small proportion of the prisons within these state systems (15%). Given the need for specialized medical staff to administer buprenorphine, it may be that states opt to use it in a few select facilities within their systems, perhaps due to resource limitations.
Methadone also is available in at least one prison within most state systems surveyed (19 of 21). Its use, however, is largely restricted to specific subgroups, such as pregnant women, those who were being treated with methadone before being admitted to prison, and those close to release. Despite the fact that methadone is widely available, only 9% of the 538 prisons surveyed reported that they are equipped to provide it. Given the need for licensure to dispense methadone, regulatory barriers were most often cited as restricting prison capacity to administer this medication more broadly.
Most state prison systems surveyed (18 of 21) report that injectable or oral naltrexone is available to individuals with OUD in one or more of their prisons. It is more widely available than buprenorphine or methadone in that it is used in over one-third (36%) of the 538 prisons in these systems. In addition to providing naltrexone to individuals who are already being treated with it at the time of admission, most state systems (86%) dispense it to individuals at release. Because its effects last for approximately one month, the injectable form (Vivitrol®) is often used at release, which helps facilitate the individual’s transition to community-based treatment.
Since only a small subset of prisons provide these medications, most individuals being treated with MOUD when they enter prison do not receive continuing care. Moreover, they are unlikely to be linked to community treatment providers upon release, exacerbating the risk of relapse and overdose when they return to the community.
Respondents cited a variety of barriers to linking individuals to community treatment at the time of release, most often a lack of available providers, as well as a lack of transportation to community facilities. That lack of treatment capacity was particularly true in remote, rural areas. In fact, many respondents discussed the ethics of providing MOUD to individuals while incarcerated, knowing they will not be able to maintain treatment once they are released due to such barriers.
Addressing Barriers to Implementation
When asked about ways to assist the expansion of MOUD within their system, 75% of respondents identified a need for training on how to prevent MOUD diversion, screen for OUD, determine which type of MOUD to prescribe, and coordinate with community providers. There is a need, perhaps national in scope, for prison-specific training materials and technical assistance with implementation.
Nearly all survey respondents (over 90%) agreed with the statement that more resources are necessary to address stigma and negative attitudes about MOUD treatment. Additionally, over one-third of the 21 prison systems identified the state’s “preference for abstinence” as a barrier to incorporating MOUD into treatment plans.
To expand state prison systems’ capacity to provide treatment, respondents strongly endorsed the need for education for a wide range of audiences regarding OUD, addiction, and MOUD. Those audiences include judges, health care professionals, probation and parole staff, corrections administrators, church leadership, and the general community.
The most frequently cited barrier to expanding prison capacity to all three types of MOUD was lack of funding. This includes funding for medical staff, resources to prevent diversion, and funding to cover the medications’ cost. Staffing needs include physicians trained and certified to prescribe the medications, nurses to dispense the medications, and social workers to assist with reentry planning for linkages to community-based treatments at discharge. Additional funding is needed for resources to expand the availability and accessibility of MOUD across all prisons to a wider range of individuals.
Our study demonstrates that more forms of medications for opioid use disorder are available across state prison systems than reported in prior studies. Many previously identified challenges still exist, however. Awareness of commonly cited barriers is key to guiding future policies and initiatives designed to expand MOUD use in state prisons. The survey results provide a basis to help states pinpoint common challenges when expanding their systems for treating individuals with OUD, identify the resources needed to address those challenges, and build a foundation to develop enhanced MOUD policies.
For More Information
Scott, C.K., Dennis, M.L., Grella, C.E., Mischel, A.F. & Carnevale, J. (2021). The Impact of the Opioid Crisis on U.S. State Prison Systems. Health and Justice. https://doi.org/10.1186/s40352-021-00143-9.
Author information: Christy K. Scott, PhD, is director of research and development at Lighthouse Institute, the applied behavioral research division of Chestnut Health Systems. Lauren Duhaime, MA, is a research associate and Erika Ostlie, MA, is chief operating officer at Carnevale Associates LLC. The opinions expressed here are those of the authors and do not represent official positions of the United States government.