Naloxone in Correctional Facilities for the Prevention of Opioid Overdose Deaths (2020)

Introduction

Drug overdose deaths, primarily from opioids, rose nearly 30% from December 2019 to December 2020, reaching an all-time of high of 92,183.1 Emergency medical response data show that overdose-associated cardiac arrests increased by more than 40% in 2020 compared to the two previous years, with the largest percentage increases among Black and Latinx individuals.2

Drug/alcohol overdose is the third leading cause of death in jails, following illness and suicide.3 Furthermore, the risk of death from opioid overdose is high after release from prison or jail.4

Opioid overdose results in death from coma and cessation of breathing. Opioid overdose is reversible through the immediate administration of a quick-acting opioid antagonist called naloxone (Narcan®) that blocks the action of the opioid, e.g., heroin, fentanyl, or prescription opioids. Its administration typically results in return to consciousness, resumption of breathing, and, in cases of opioid dependence, onset of opioid withdrawal symptoms. Seconds matter. Immediate administration of naloxone saves lives and reduces anoxic brain damage.

Naloxone is safe, effective, and nonaddictive and has a rapid onset of action. It can be administered as an injection or through the nose (intranasally). Training in its administration is relatively simple. It can be safely used by nonmedical personnel, resulting in more lives saved.

To date, all states and the District of Columbia have enacted laws related to use of naloxone to treat opioid overdose.5 Nearly all states permit pharmacies to provide naloxone to anyone who wants it without a prescription. Importantly, all states have authorized its use by first responders, e.g., paramedics. States have developed training and educational materials to ensure naloxone is appropriately administered and the person who has overdosed is safely transported to an emergency facility.6 Simple administration procedures are available.7

Given this widespread need for and acceptance of easy access to naloxone, correctional facilities can play an important role in preventing overdose deaths. Research has shown that opioid overdose education and naloxone distribution programs in prisons and jails reduce mortality.8,9,10 At least five states have jails and prisons that have implemented overdose education and naloxone distribution programs, including providing naloxone kits to high-risk individuals at the time of release. Data from the follow-up of visitors to Rikers correctional facility showed it saved lives.11

A naloxone program that provided video training and direct access to individuals who were incarcerated saved two lives at the Los Angeles County’s North County Correctional Facility.12

The American Society of Addiction Medicine supports broadened accessibility to naloxone for individuals commonly in a position to initiate early response to suspected opioid overdose.13

Position Statement

The National Commission on Correctional Health Care supports increased access to naloxone in correctional facilities. NCCHC supports promotion of naloxone use in correctional facilities. NCCHC makes the following recommendations to prevent overdose deaths within the facility and in the community following release from incarceration:
  1. In accordance with state laws, naloxone kits should be readily available to all people in the facility – health staff, custody staff, and, optimally, people who are incarcerated.
  2. Naloxone kits should be provided upon release to people with opioid use disorder and others at elevated risk for opioid overdose, as well as visitors.13
  3. Correctional facilities should provide training to all people, including those incarcerated. This includes education on opioid overdose and its signs, correct technique for administration of naloxone, and essential related procedures, including performance of cardiopulmonary resuscitation.
  4. Policies, procedures, and training should be in place to ensure emergency transfer of the incarcerated patient to a facility equipped to treat overdose.
  5. At discharge, individuals with opioid use disorder and others at high risk for opioid overdose should receive education on overdose and naloxone use, optimally in conjunction with family/friends/visitors.
  6. People who work in correctional settings should receive education on overdose and naloxone use.
April 12, 2015 – adopted by the National Commission on Correctional Health Care Board of Directors November 1, 2020 – reaffirmed with revision October 31, 2021 – reaffirmed with revision

Resources

A Primer for Implementation of Overdose Education and Naloxone Distribution in Jails and Prisons. RIT International, 2019.

Relevant NCCHC standards from the Standards for Health Services (2018) for jails and prisons:
• C-04 Health Training for Correctional Officers
• D-01 Pharmaceutical Operations

References

1. Ahmad, F. B., Rossen, L. M., & Sutton, P. (2021). Provisional drug overdose death counts. National Center for Health Statistics. 

2. Friedman, J., Mann, N. C., Hansen, H., Bourgois, P., Braslow, J., Bui, A. A., Beletsky, L., & Schriger, D. L. (2021). Racial/ethnic, social, and geographic trends in overdose-associated cardiac arrests observed by US emergency medical services during the COVID-19 pandemic. JAMA Psychiatry, 78, 886-895.

3. Carson, E. A. (2021, April). Mortality in local jails, 2000-2018 – statistical tables (NCJ 256002). U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. 

4. Binswanger, I. A., Blatchford, P. J., Mueller, S. R., & Stern, M. F. (2013). Mortality after prison release: Opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Annals of Internal Medicine, 159, 592-600. 

5. Legislative Analysis and Public Policy Association. (2020, October). Naloxone access: Summary of state laws. 

6. National Institute on Drug Abuse. (2018, June). Medications to treat opioid use disorder research report: Is naloxone accessible?

7. National Harm Reduction Coalition. (n.d.) Opioid overdose basics: Responding to opioid overdose – 3. Administer naloxone (training guide).

8. Bennett, T. H., & Holloway, K. (2012). The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: An evaluation of the THN Project in Wales. Drugs: Education, Prevention and Policy, 19, 320-328.

9. Bird, S. M., McAuley, A., Perry, S., & Hunter, C. (2016). Effectiveness of Scotland’s national naloxone programme for reducing opioid-related deaths: A before (2006-10) versus after (2011-13) comparison. Addiction, 111, 883-891.

10. Horsburgh, K., & McAuley, A. (2018). Scotland’s national naloxone program: The prison experience. Drug and Alcohol Review, 37, 454-456.

11. Huxley-Reicher, Z., Maldjian, L., Winkelstein, E., Siegler, A., Paone, D., Tuazon, E., Nolan, M. L., Jordan, A., MacDonald, R., & Kunins, H. V. (2018). Witnessed overdoses and naloxone use among visitors to Rikers Island jails trained in overdose rescue. Addictive Behaviors, 86, 73-78.

12. Los Angeles County Sheriff’s Department. (2021, May 27). Sheriff’s naloxone custody pilot project saves inmates from overdose.

13. American Society of Addiction Medicine. (rev. 2016, October). Public Policy Statement on the Use of Naloxone for the Prevention of Drug Overdose Deaths.