Effects of Providing Medications for Opioid Use Disorder During Incarceration on Post-Release Health Outcomes

LIZA BECKER, BA

Drexel University College of Medicine

SUMMARY POINTS

• Incarcerated individuals face a significantly increased risk of death from drug overdose after release from prison.

• Provision of Medications for Opioid Use Disorder (MOUD) during incarceration is associated with a decrease in fatal overdose post-release from prison.

• Provision of methadone, but not buprenorphine or naltrexone, during incarceration is associated with decreased illicit and injection drug use post-release from prison.

• Provision of MOUD during incarceration is associated with decreased visits to the emergency department, increased MOUD uptake, and increased medicaid outpatient and pharmacy claims post-release from prison.

• Future research should explore barriers to establishment of MOUD programs in carceral settings to increase availability of life-saving treatment to incarcerated individuals.

ANALYSIS

Background

The war on drugs has encouraged a punitive approach towards illicit drug use, resulting in the incarceration of more people in the United States with Substance Use Disorders (SUD) in recent decades (1). Of the nearly two million incarcerated people within the U.S. today, two thirds have a substance use disorder (SUD) and roughly one fifth report lifetime use of opioids (2,3). A subset of these individuals meet diagnostic criteria for Opioid Use Disorder (OUD). OUD is defined as a “pattern of opioid use leading to problems or distress” (4). Thus, there is a significant illness burden of people suffering from OUD in our nation's jails and prisons. 

In contrast to a punitive approach towards opioid use, the medical community has come to understand OUD as a biopsychosocial disease treated effectively with medications for Opioid Use Disorder (MOUD). MOUD, as the standard of care for OUD, involves medical provider administration of buprenorphine, methadone, or naltrexone under a harm-reduction philosophy (5).

Legally, the United States Supreme Court has concluded that deprivation of healthcare from incarcerated people constitutes cruel and unusual punishment (6). Nevertheless, only an estimated 5% of incarcerated people have access to MOUD during their incarceration (7). Sudden disruption of opioid use or MOUD in a person with OUD poses the potential for severe and life-threatening opioid withdrawal syndrome (8). 

This analysis will review studies that compare post-release health outcomes for individuals receiving and individuals not receiving MOUD during their incarceration. These data demonstrate how provision of MOUD during incarceration affects post-release outcomes, including rates of fatal overdose, continued illicit and injection drug use, and healthcare service utilization.

Analysis

In the first two weeks following release, formerly incarcerated people faced an adjusted relative risk of death from overdose 129 times greater than that of the general population. Researchers postulate that a diminished physiological tolerance to drugs during incarceration  could be responsible for this increased risk of death (9). Consequently, multiple studies have examined the effects of provision of MOUD during incarceration on rates of post-release fatal overdose.

One retrospective cohort analysis from Rhode Island found a 60.5% reduction in overdose mortality among people released from incarceration after implementation of a comprehensive MOUD program in a statewide correctional facility. This result was found to still be significant in the face of a worsening illicit fentanyl-driven overdose epidemic (10). While this study is limited in its sample size and lack of longitudinal, prospective design, it still contributes to the growing body of evidence suggesting that provision of MOUD during incarceration helps prevent overdose deaths post-release in varying sociocultural contexts (10, 11).

Researchers have also examined the effects of provision of MOUD during incarceration on rates of illicit and injection drug use post-release. One meta-analysis found, via four original randomized-controlled-trials (RCTs), that individuals who received methadone during incarceration were less likely to use illicit opioids and inject drugs following release than controls. Separate RCTs comparing buprenorphine and naltrexone groups with controls, however, did not find a significant reduction in illicit opioid use and injection of drugs post-release (12). Further research should be conducted to explore the mechanisms of post-release relapse and specific characteristics of successful MOUD programs.

Other studies have examined the effects of MOUD uptake during incarceration on healthcare service utilization rates post-release. One meta-analysis found, via six separate RCTs, that incarcerated individuals who received methadone, buprenorphine, or naltrexone during incarceration were more likely to engage in treatment immediately and up to six months post release (12). 

A separate retrospective cohort analysis of medicaid beneficiaries who received MOUD while incarcerated in Rhode Island observed several healthcare utilization patterns. Individuals receiving MOUD demonstrated a significant reduction in emergency department (ED) visits per year compared to controls. While medicaid costs overall did not increase for individuals in the MOUD group following treatment, medicaid costs specifically for non-acute outpatient services and pharmacy claims for MOUD increased; this change suggests an increase in MOUD uptake post-release. The shift away from ED services and towards outpatient and pharmacy services allows for earlier detection and treatment of chronic disease, which may increase healthcare costs in the short term but reduce costs and healthcare system burden in the long run (13). 

In alignment with the medicaid beneficiary analysis conducted in Rhode Island, a retrospective cohort analysis from Santa Clara, CA found a significant reduction in ED visits post-release for individuals receiving methadone or buprenorphine during incarceration. Notably, individuals released after 12PM were more than twice as likely to present at the ED within the first day post-release than those released before 12PM, possibly due to lacking availability of nonemergency healthcare services after non-business hours (14). 

Discussion

Prisons and jails in the U.S. are important touchpoints between individuals, who may not receive routine care from a primary care physician, and the healthcare system. More research is needed to explore the multitude of post-release outcomes-- including mortality rates, morbidity, and economic outcomes-- following administration of MOUD during incarceration. Additionally, policy and implementation science research should be carried out in parallel to public health studies  to better understand systemic factors impeding the widespread implementation of MOUD programs in prisons and jails. 

Furthermore, Black and Latinx individuals interact with the criminal legal system at higher rates than other population groups (2). Thus, reducing drug-overdose mortality post-incarceration may help reduce health outcome disparities in incarcerated black/latinx  populations, and among non-black/latinx incarcerated populations with OUD. Acquiring a better understanding of barriers to widespread MOUD implementation in correctional healthcare settings will allow incarcerated people to move towards more favorable survival and recovery outcomes. 

Additionally, future research should focus on the feasibility of implementing MOUD programs in more jails and prisons across the U.S. to reach more individuals with treatment. Finally, researching the effects of diversion programs, which allow individuals to receive MOUD instead of facing jail or prison time, has potential to decrease drug-related incarceration rates, post-incarceration overdose deaths, and ED visits while increasing MOUD uptake and recovery. 

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